| Original Full Text | 1 Teesside University School of Health and Life Sciences Doctoral Thesis Volume I TITLE: What is the influence of nurse education on the Indigenous belief systems about intellectual disability and mental illness of student nurses of Southern African origin? By Christopher Zenzo Dlamini STUDENT NUMBER E5089525 Academic Supervisors Dr. Dorothy Hannis Dr. Alan E. Armstrong. Submitted as partial fulfilment of the Requirements for the Doctor of Philosophy Degree 2022 2 What is the influence of nurse education on the Indigenous belief systems about intellectual disability and mental illness of student nurses of Southern African origin? Abstract The purpose of this phenomenological study was to explore the impact of nurse education on the indigenous belief systems of student nurses of Southern African origin. The study documents their perspectives and experiences regarding beliefs about causation, management and treatment of intellectual disability and mental illness since they were children in Africa and then enquire about the influence of nurse education on those beliefs when they were in England. Semi-structured qualitative interviews lasting up to ninety minutes were held with each participant over Microsoft Teams, and thematic analysis was used to generate research themes and findings. Six themes and a variety of subthemes emerged including beliefs about intellectual disability and mental illness, cultural learning experiences in Africa, witchcraft, help-seeking ways, stigma and acculturation. Implications for both educational institutions and further research were discussed that may help nursing educators better understand the Southern African student nurse experience and assist the students to successfully complete their nursing education. Results indicated that nurse education alone did not play a role in shifting belief systems; highlighting that acculturation and employment in health and social care had a major stake in preparing students for the nursing journey. The analysis revealed that participants were as strongly motivated to integrate into British society as they were determined to maintain the attachment to their cultural values although they were equally willing to change their beliefs towards causation of intellectual disability and mental illness. More significantly, the study showed that nurse education needed to acknowledge the diversity of the university classroom and decolonise the curriculum to deliver teaching that speaks to all students. Importantly, the study adds further knowledge on a less researched area involving indigenous African belief systems in a British university delivering nurse education and calls for educators to support the student nurse who enters the classroom with a different set of beliefs. 3 Declaration I, Christopher Z. Dlamini, declare that this thesis is submitted in partial fulfilment of the requirement for the degree of Doctor of Philosophy (PhD) and is entirely my own work except where otherwise accredited. It has not at any time either in whole or in part been submitted for any other educational award. Signed: (Candidate) Christopher Z. Dlamini Date: 23rd June 2023 4 Acknowledgements First and foremost, all Glory and Honour to Almighty God for the amazing gifts He has bestowed on me throughout my life. l express my deepest and most heartfelt gratitude to the unique group of student nurses who participated in and made this thesis possible. Their knowledge, subjective experiences, and stories that they individually contributed is, not only to me, but to the entire nursing academia, a gift which will keep giving for many years to come. Secondly, there was a collective of community informants including African born nurses and academics, my sounding boards that I queried and relied on for input, feedback, and direction. To them, l am forever grateful. I would also like to thank my director of studies Dr. Dorothy Hannis for her inspiration, motivation, immeasurable support and the countless hours of feedback, direction, and mentoring she has provided me throughout the last five years. I have no doubt in my mind that she is one of the most brilliant and indeed, transformative leaders in the field of anthropology and public health in the faculty. Her unmatched ability to role model hard work, show caring, compassionate and empathetic support not only for me but all her students and colleagues and advocate for the needs of our minority ethnic communities have stood out for me. I would also like to thank Dr. Allan E. Armstrong who has been a moral compass to me in the last five years. Working alongside Dr. Hannis, Dr Armsotrong added advice on ethical issues, values and virtues which enhanced my understanding of these very important issues for my thesis. Dr. Armstrong has provided the time, guidance and mentoring and his wisdom and intelligence have left me in awe. I also extend my thanks to my colleagues who have shared their views and offered kind and encouraging words during this journey. Finally, it would not have been possible to complete this piece of work without the endless supply of kindness, love and support from my family. To my mother, the greatest teacher I have ever had, who has been my number one motivator and supporter and never failed to cheer me on with every written word, thank you. My siblings and entire family in Southern Africa, thank you. To all the people closest to my heart, whose love and encouragement l continue to appreciate, thank you ever so much. This thesis and its future reverberations that will echo into eternity is a thank you to everyone who has supported and mentored me throughout my life, and I am eternally grateful to each and every one of you. 5 Dedication This thesis is dedicated to my children, Lynden Thabiso, my son and Amelia Nanziwe, my daughter who have been my constant inspiration throughout the writing of this thesis. They know that the completion of this thesis is a cue for them to do better than me one day and l know they will. This thesis is a special dedication to my best friend, Blessing Shirichena, who passed away in January 2021. We started our journey as young and prospective academics, eager to make a difference one day and he taught me how to study and set targets in life. We were on our PhD journeys together and set to reach the ultimate goals of our academic careers when he was cruelly robbed of his life by Covid19, and l vowed to complete this PhD in his honour. The least l could do to honour his name was to make sure his name is not forgotten nor the impact he had on me as a man and now, an academic. Rest in Power my brother. To all the African born student nurses, this one is for you. I hope it speaks to you. 6 Definition of key terms Southern African student nurse A university student who was born in a country in the Southern African region on the continent of Africa, has completed at least nine years of primary and secondary education in that country, and has been in the United Kingdom with a legal status and registered on the nursing programme at the researcher’s university. Indigenous knowledge is used to mean African way of knowing African student. Sub-Saharan Africa is the sub-Saharan region of Africa which refers to the area of Africa south of the Sahara Desert. Ubuntu is a knowledge value system within the traditional Southern African communities. Traditional knowledge is employed throughout this thesis to describe the healing practices and medical understandings of Africa. Western The term “Western” or “West” refers to Europe, North America, Australia, and New Zealand in relation to the “traditions of thought and practice with a specific historical trajectory” (Durkin, 2008a, p. 16). This will at times also be identified in this study as “culturally Western” described by Tweed and Lehman (2002) as referring to “culturally Western English-speaking individuals” (p. 89). Western Medicine Psychiatrist, other mental health professionals (psychologist, psychotherapist, psychiatric social worker, a mental health nurse or mental health counsellor), a general practitioner or any other medical doctor, any other health professional, such as a nurse or physician’s assistant. Alternative Medicine Traditional healer, spiritual or religious advisor (e.g., minister, priest, or rabbi), or any other healer (e.g., chiropractor or spiritualist). A sangoma is a shaman or clairvoyant who communicates with ancestral spirits, amongst other things to diagnose illnesses or the title most generally used by patients, traditional practitioners, and biomedical doctors to describe traditional medical healers in South Africa. A witch often performs witchcraft or sorcery. 7 Traditional healers: diviner, herbalist, and faith healer/prophet (Truter, 2007). Intellectual disability a condition of arrested or incomplete development of the mind which is characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence (cognition, language, motor and social abilities). Mental illness is a health condition involving changes in emotion, thinking or behaviour (or a combination of these). Epilepsy is a common condition that affects the brain and causes frequent seizures. Seizures are bursts of electrical activity in the brain that temporarily affect how it works. Decolonising the curriculum in this thesis is taken to include a fundamental reconsideration of who is teaching, what the subject matter is and how it's being taught (Guardian 2019) Eurocentrism is a view which sees everything through the lens of European knowledge, values and attitudes. Ethnocentrism means believing that the way one’s culture does things is the only right way to do them, while seeing other cultures as doing the same thing differently and wrong. 8 Foreword The International Year of the Nurse and Midwife, 2020, the year in which Covid-19 and the murder of George Floyd occurred simultaneously, sparking debates about structural, individual, and ideological racism (SIIR) (Burnett et al. 2020) coincided with the interview stage of this thesis. Burnett et al. (2020) postulate that this and other racist murders and unprosecuted ‘deaths in custody’ of Black, Asian, and Minority Ethnic peoples internationally, catalysed calls that the underlying racism and oppression enabling such violence to occur with regularity and impunity, cannot continue. This global surge in an outpouring of emotion appeared to give a voice to Black people across the world characterised by demonstrations and destruction of statues of prominent slave traders and businessmen of the era. The wave spilled into communities, including university campuses. Charles (2019) posits that South Africa is accepted as the birthplace of the decolonising curricula movement in 2015 when the University of Cape Town students staged the #Rhodesmustfall demonstrations which was then rapidly replicated in Oxford University, England. The battle cry #RhodesMustFall sparked an international movement calling for the decolonisation of the world's universities. In the West, the movement “Why is my curriculum white, why isn’t my professor black?” simultaneously connected contemporary voices and struggles globally in the margins of academic institutions. Additionally, Burnett et al. (2020) note that the need to decolonise education and knowledge has been underwritten by such student movements in the global south. One of the responsibilities of these movements is the need to decolonise education within migrant receiving countries, particularly those with historical and contemporary links to the roots of displacement (Rutazibwa 2018). Kaur-Aujla (2021) accentuate that Covid19, and Black Lives Matter (BLM) have made unavoidable the truth that we have not achieved race equality and the urgency now must be to start to dismantle and decolonise the curriculum. In addition, the efforts of these international movements towards decolonisation including nurse education are both gathering momentum and hopefully this thesis adds further impetus and suggestions for achieving change and that nursing and midwifery educators respond to this call with insight, honesty and fierce actions that 9 eradicate all forms of discrimination in nursing, midwifery, and the whole of academia, (Burnett et al. 2020). I have no doubt in my mind that the Black African student participants in this study were enthused and inspired by the prevailing narrative. This study could not have occurred at a better time and l hope this wave continues to rise and bring about change. 10 The impact of the Covid19 pandemic on my study The start of the COVID-19 pandemic initially hindered the progress of my study; simultaneously decreasing my study wellbeing and motivation. The pandemic restricted direct access to the participants, scholarly support networks as well as reducing physical access to the library’s resources. There was a sudden increase in workload due to changes in student expectations and support coupled with the shift to online teaching. Initially, this was a monumental life change where being a senior lecturer with a full workload and a parent with caring responsibilities became two major skills l needed to execute at the same time and within one environment. Resultantly, a poor work–life balance became a major issue. It became necessary to evolve very quickly due to the unpredictable and unprecedented impact of the pandemic. Resilience levels increased and this meant learning very quickly to work smart, managing my professional and parental workloads as well as my study. Thankfully, my supervisory team was extremely supportive. I received more help and frequent supervision via both online and alternative platforms such as email, text messages and telephone. I felt that I had my supervisors’ emotional support and could not have asked for the best possible supervision during the pandemic. It was comforting for all PhD students to be given an extension of their PhD programmes due to delays caused by the pandemic. Finally, despite all the challenges, I attribute the completion of my study to my commitment to and passion for intellectual disability nursing. 11 Contents Abstract ......................................................................................................................................................... 2 Declaration .................................................................................................................................................... 3 Acknowledgements ....................................................................................................................................... 4 Dedication ..................................................................................................................................................... 5 Definition of key terms ................................................................................................................................. 6 Foreword ....................................................................................................................................................... 8 The impact of the Covid19 pandemic on my study .................................................................................... 10 Chapter 1 - Introduction and Organisation of Thesis ................................................................................. 15 1.1 Introduction ................................................................................................................................ 15 1.2 Background to the study ............................................................................................................. 15 1.3 Aims and Objectives .................................................................................................................... 19 1.4 Africa ........................................................................................................................................... 19 1.5 Sub-Saharan Africa ...................................................................................................................... 20 1.6 Ubuntu ........................................................................................................................................ 20 1.7 Rationale of the study ................................................................................................................. 25 1.8 Structure of the thesis ................................................................................................................ 30 1.9 Chapter summary........................................................................................................................ 32 Chapter 2 - Literature Review ..................................................................................................................... 33 2.1 Introduction ...................................................................................................................................... 33 2.2 Section 1 ............................................................................................................................................ 33 2.2.1 Reviewing the literature. ........................................................................................................... 33 2.2.2 Scoping review ........................................................................................................................... 34 2.3 Section 2 ............................................................................................................................................ 61 2.3.1 Indigenous Knowledge Systems ................................................................................................. 61 2.3.2 Explanatory Models ................................................................................................................... 63 2.3.3 Explanatory Belief Systems about Disease: An example of Epilepsy ......................................... 64 2.3.4 Local beliefs about ‘disability’ in Africa ...................................................................................... 66 2.3.5 The Power of Witchcraft in Africa .............................................................................................. 67 2.3.6 Help-seeking behaviours ............................................................................................................ 73 2.3.7 Stigma ........................................................................................................................................ 77 2.3.8 Chapter Summary ...................................................................................................................... 79 Chapter 3 – Methodology ........................................................................................................................... 81 12 3.1 Introduction ...................................................................................................................................... 81 3.2 Cosmology ......................................................................................................................................... 82 3.3 Ontology ............................................................................................................................................ 83 3.4 Epistemology ..................................................................................................................................... 84 3.5 Locating the researcher’s research style in the paradigmatic debate. ............................................. 86 3.6 Paradigms .......................................................................................................................................... 91 3.6.1 Positivism ................................................................................................................................... 92 3.6.2 Interpretivism............................................................................................................................. 92 3.7 Methodology ..................................................................................................................................... 94 3.7.1 Grounded theory ................................................................................................................. 94 3.7.2 Ethnography ........................................................................................................................ 96 3.7.3 Phenomenology .................................................................................................................. 96 3.7.4 Methods .............................................................................................................................. 98 3.7.5 Sampling .............................................................................................................................. 99 3.7.6 Recruitment ...................................................................................................................... 102 3.7.7 Ethical considerations ....................................................................................................... 105 3.7.8 Data Collection Process ..................................................................................................... 106 3.8 Chapter Summary ........................................................................................................................... 128 Chapter 4 - Findings and discussion .......................................................................................................... 129 4.1 Introduction .................................................................................................................................... 129 4.2 Theme 1 - Indigenous beliefs about causation and explanatory models about causes of intellectual disability or mental illness. ................................................................................................................... 132 4.2.1 Biological explanations and antenatal stress. .......................................................................... 134 4.2.2 Traditional beliefs (supernatural). ........................................................................................... 135 4.2.3 Religious beliefs (supernatural). .............................................................................................. 136 4.2.4 Beliefs combining other aspects. ............................................................................................. 137 4.3 Theme 2 - Local beliefs about causation of intellectual disability and mental illness and help-seeking behaviours ............................................................................................................................... 139 4.4 Theme 3 - Stigma, discrimination towards people with an intellectual disability and mental illness .............................................................................................................................................................. 145 4.5 Theme 4 Acculturation .................................................................................................................... 151 4.5.1 Sub-theme 3 - Route into learning disability nursing .............................................................. 162 4.5.2 Sub-theme 4 - University classroom and practice placement experiences ............................. 164 4.6 Discussion ........................................................................................................................................ 172 13 4.7 Chapter Summary ........................................................................................................................... 203 Chapter 5 – Limitations ............................................................................................................................. 204 5.1 Introduction .................................................................................................................................... 204 5.2 Impact of Covid19 outbreak in 2020 ............................................................................................... 204 5.3 Data collection ................................................................................................................................ 205 5.4 Paucity of research .......................................................................................................................... 205 5.5 Sampling and Bias ........................................................................................................................... 206 5.6 Chapter summary............................................................................................................................ 208 Chapter 6 – Implications, Recommendations and Conclusion ................................................................. 209 6.1 Introduction .................................................................................................................................... 209 6.2 Implications for nurse education .................................................................................................... 209 6.3 Recommendations .......................................................................................................................... 214 6.4 Delivering content that encompasses various belief systems to cater for a diverse student population. ............................................................................................................................................ 214 6.5 Epilogue ........................................................................................................................................... 216 References ................................................................................................................................................ 220 Chapter 7 - APPENDICES ........................................................................................................................... 290 7.1 Appendix A: Ethical Approval .......................................................................................................... 290 7.2 Appendix B: Participant information sheet..................................................................................... 305 7.3 Appendix C: Participant Invite......................................................................................................... 311 7.4 Appendix D: Informed Consent ....................................................................................................... 313 7.5 Appendix E: Survey Questionnaire.................................................................................................. 315 7.6 Appendix F: Interview Schedule...................................................................................................... 319 7.7 Appendix G: Arksey and O'Malley methodological framework ...................................................... 322 7.8 Appendix H: Spider Diagram ........................................................................................................... 324 7.9 Appendix I: Southern African Student Acculturation Assessment Scale ........................................ 325 14 List of tables and figures Table 1: PEO framework ............................................................................................................................. 38 Table 2: Search terms used in Discovery. ................................................................................................... 39 Table 3: Inclusion and exclusion criteria ..................................................................................................... 44 Table 4: Charting the data. ......................................................................................................................... 45 Table 5: CASP qualitative checklist tool ...................................................................................................... 46 Table 6: Emerging themes .......................................................................................................................... 47 Table 7: shows the charted studies. ........................................................................................................... 60 Table 8: Examples of the word disability in Bantu languages ..................................................................... 66 Table 9: Reflexivity on Methodology .......................................................................................................... 91 Table 10: Participant demographics ......................................................................................................... 103 Table 11: Educational experiences of the participants ............................................................................. 105 Table 12: Braun and Clarke’s six-phase framework for doing a thematic analysis (2006) ....................... 120 Table 13: shows how the codes were initially developed. ....................................................................... 123 Table 14: Reflexivity on Data Collection and Analysis .............................................................................. 124 Table 15: Emerging themes and sub-themes developed from the interviews. ........................................ 130 Table 16: Reflexivity item on stigma ......................................................................................................... 148 Figure 0-1: History / Alerts Search Modes .................................................................................................. 40 Figure 0-2: History / Alerts Search Modes .................................................................................................. 41 Figure 0-3: The PRISMA flow chart ............................................................................................................. 48 Figure 0-4: Indigenous beliefs about causes of intellectual disability and mental illness ........................ 133 15 Chapter 1 - Introduction and Organisation of Thesis 1.1 Introduction This chapter begins with a background to the study. This is then subsequently followed by the aims and objectives of the study in 1.2. Following this section, 1.3 introduces the African continent and the countries of Southern Africa. An introduction to Ubuntu a philosophy that originates from Southern Africa where Bantu people live and refers to the view, process, content, and quality of being a human (Mugumbate and Chereni 2019) is offered in 1.6. Subsequently, the rationale for the current study is presented in section 1.7 followed by the structure of the thesis chapters in 1.8. Finally, Chapter 1 concludes with a summary in section 1.9. 1.2 Background to the study This study explores the belief and knowledge systems of Southern African-born student nurses about intellectual disability and mental illness in a United Kingdom (UK) university. Belief systems are structures of norms that are interrelated and through which humans individually make sense of the world around them. Humans use belief systems; reinforced by culture, theology, and experience in varying degrees to cope with events in their lives (Usó-Doménech and Nescolarde-Selva 2015). More specifically, the study examines if and how the students’ indigenous belief systems are influenced by nurse education as they navigate the academic nursing curriculum amid sociocultural challenges. This is important because as a result of migration from African countries with Anglophone colonial backgrounds (Arthur 2006), universities offering nurse training in Europe, especially the UK are increasingly recruiting African students. In addition, students who have migrated to England from its former colonies in Southern Africa and legally settled can enrol on a nursing course as home students. African born student nurses who have been given British citizenship, refugee or settled status are a unique group because when they commence their nurse training, they are classed as home students, yet their backgrounds, knowledge, experiences, attitudes, and beliefs are different to those of their native counterparts. 16 This has resulted in the complexion of the nursing classroom changing rapidly meaning that more now needs to be done to meet the needs of the ever-changing student demographic. African-born student nurses are not homogenous even if they share similar tenets, such as beliefs about intellectual disability, mental illness, upholding strong family values, caring for one another intimately, and valuing education highly (Ezenowu 2019). In some instances, they are classified as and grouped with Black British students born in England and yet in others viewed as international students. They are, however, diverse in ethnicity, religion, culture, and language meaning; they enter the world of nursing with ‘unfamiliar’ cultural beliefs about the causation of intellectual disability and mental illness including interventions and treatment methods such as using lay traditional systems. This leaves them in limbo because Southern African-born student nurses have distinct backgrounds and experiences which they bring into nurse education, yet they are assumed to be on a par with native students when learning experiences are considered. Shahid et al. (2009) postulate that traditional beliefs can co-exist with but are not completely displaced by Western biomedical understanding. Additionally, Boulton et al. (2002) showed in their study of indigenous Australian and Papua New Guinean medical science students that indigenous student conceptualised health and illness in a way that accepted both traditional and Western systems, concluding that education in Western health did not alter their core philosophy towards life and their indigenous belief systems. However, a review of cultural competence literature found that there is significant evidence that curricula teaching specific cultures and worldviews may improve care provider knowledge, attitudes, and skills, and patients’ experiences of healthcare delivery (Beach et al. 2005). Several studies have highlighted the experiences of African born students in HE. For example, Lee and Opio (2011) highlighted that Black African students' experiences of acculturation and discrimination are incomparable to racial discrimination directed toward African Americans since the former group faces challenges related to cultural differences, accents, and negative stereotypes about their countries of origin. Other studies, (Fuller and Mott-Smith 2017 and Malecha et al. 2012) for example, explored language and communication issues as key stressors for foreign-born nursing students in the United States. Boafo-Arthur (2014) found that 17 adjustments to societal norms and interpersonal relationships created acculturative stress for students who arrive in the United States. Some studies have examined various aspects of minority ethnic nurse experiences in academic and professional settings. For example, Likupe et al. (2013) examined the experiences of Black African nurses working in the National Health Service in the UK, while Alicea-Planas (2017) examined the experiences of specific ethnicities such as Hispanic nursing students in the United States and international nursing students from Nepal, China, India, Iran, Nigeria, and Trinidad in the UK (De 2010). However, research studies that focus on knowledge and belief systems of students born in Southern Africa who live in the UK are scarce. Mikkonen et al. (2016) conducted a systematic review to examine culturally and linguistically diverse healthcare students’ experiences of their learning in the clinical environment. This study fills this gap in research by focusing on this topic to add to the nursing knowledge. In contrast to the rich literature concerning lay beliefs and stigma relating to mental illness, there is a dearth of research on students’ conceptualisations of intellectual disability (Scior et al. 2013). Several studies have examined stigma and attitudes of students towards disability and mental illness in various health professions, such as medicine (Tervo et al. 2002), occupational and physical therapy (Stachura and Garven 2007), rehabilitation (Wong et al. 2004; Rosenthal et al. 2006) and social work (Au Man 2006). Sheridan and Scior (2016) carried out a study in the UK, comparing the attitudes of young White British and British Asians toward individuals with intellectual disabilities and reported that British Asians had lower scores on exclusion and higher similarity scores than their White British counterparts. Benomir et al. (2016) compared students’ attitudes toward persons with intellectual disabilities in Libya and the UK, with the students in Libya recording less favourable attitudes toward persons with intellectual disabilities than their counterparts in the UK. Opoku et al. (2021) conducted a study, the purpose of which was to develop deeper insight into students’ attitudes toward individuals with intellectual disabilities using the Community Living Attitude Scale for Intellectual Disabilities (CLAS-ID) in the sub-Saharan African context, specifically Cameroon and Ghana. The findings showed no association 18 between attitudes and variables such as gender, relation, and contact with individuals with intellectual disabilities. However, there is a dearth of studies which explore both awareness of and understanding of the causation of intellectual disability and mental illness. This study captures conceptions of intellectual disability and mental illness from the perspective of Southern African student nurses. A further accentuation of this study is that it explores these views in the Western world where the participants are studying a nursing degree. Benner and Ghulom (2011) comment that in the Middle East there is limited data available about intellectual disability while Al-Rashed et al. (2009) add that belief in supernatural causes of intellectual disability is high in this area. Al-Adawi et al. (2006) accentuate that this parallels the importance of supernatural beliefs about mental illness in Arab contexts. In Africa, these beliefs are informed and reinforced by traditional, cultural and religious beliefs (Gureje et al, 2006) and have been shown to inhibit help-seeking behaviour (Segal et al. 2005). Thus, some degree of belief in witchcraft or curses as causes of mental illness and intellectual disability is not uncommon among the students, albeit less so in the context of a relative abundance of psychiatric educational resources. This reflects the ongoing influence of cultural and magico-religious beliefs associating witchcraft with mental illness and intellectual disability in much of Southern Africa (Lauber and Rossler 2007) and highlights the need to incorporate culturally relevant teaching interventions in the nursing curriculum. In summary, only a few recent studies have specifically examined the beliefs systems of Southern African born nursing students about the causation and management of intellectual disability and mental illness. There are still important gaps in current knowledge about attitudes of nursing students and the factors influencing these attitudes (White et al. 2000). This thesis contends that for nurse education to be fully supportive of the expectations of its student cohorts, the curriculum needs to expand, adjust and diversify not only for the sake of Southern African students but for its own sustainability and applicability in a multi-cultural world. 19 The responsibility for dismantling barriers to Black and minority ethnic nursing student achievement and decreasing awarding gaps cannot be placed with Black and minority ethnic staff and students who do not have sufficient power to gain the leverage necessary alone. Change is only possible with strong leadership committed to cultural, institutional, and social change, meaningful individual reflection on our own personal bias and its impact on our educational practices, harnessing and evaluating teaching and assessment methods which promote inclusivity, and valuing Black and minority ethnic student voices Godbold and Braithwaite (2021). 1.3 Aims and Objectives The aim of the study was to ascertain whether Southern African born student nurses’ indigenous belief systems about intellectual disability and mental illness changed as a result of receiving nurse education in England. In order to achieve this aim of the study, it was necessary to: a. establish themes in the scholarly literature that describe indigenous belief systems about the causation of intellectual disability and mental illness in Southern Africa. b. explore the extent to which current nursing curriculum captures the knowledge systems, beliefs and help seeking ways of other ethnicities about intellectual disability and mental illness in the Future Standards for nurses (NMC 2018). c. ascertain student nurses’ beliefs about intellectual disability and mental illness before and during receiving nurse education including their acculturative experiences when they encountered patients in intellectual disability and mental health environments. 1.4 Africa Africa is the second largest and most tropical continent with a total area of over 11 million square miles and a population of about 1.38 billion people (worldpopulationreview.com). Africa is a land of some 54 independent, multitribal nations, with varying colonial histories and with people from a variety of ethnic groups who speak different languages and have different customs (United Nations 2013; Abdullah and Brown 2011). A significant part of Sub-Saharan Africa is inhabited by 20 a collection of related ethnic groups known as Bantu people. Southern Africa refers to the southernmost region of the African continent, which includes the countries of Botswana, Lesotho, Namibia, South Africa, and Kingdom of Eswatini (United Nations 2013). There is considerable heterogeneity among people of African descent. Even among Africans, there is not just one African culture (Abdullah and Brown 2011). East Africa refers to a part of Sub-Saharan Africa bordered by the Indian ocean on the east and the Saharan desert on the north, which includes the countries of Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mayotte, Mozambique, Reunion, Rwanda, Seychelles, Somalia, South Sudan, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe (United Nations 2013). 1.5 Sub-Saharan Africa Sub-Saharan Africa is the sub-Saharan region of Africa which refers to the area of Africa south of the Saharan desert. It includes all African countries except for Algeria, Egypt, Libya, Morocco, Tunisia, and Western Sahara, (United Nations 2013). For the purpose of this study, reference to Sub Saharan Africa includes the Southern African nations of Zimbabwe, Mozambique, Kenya, Zambia, Namibia, South Africa, Lesotho, Kingdom of Eswatini, Botswana and Mozambique. 1.6 Ubuntu Bantu people who live in Southern Africa share not just similar cultural views but have similar ontologies as well. Metz (2015 p. 75-6) postulates that there is a maxim that Africans often invoke, to sum up, salient sub-Saharan ethical perspectives, namely, "a person is a person through other persons". As the prominent African philosopher John Mbiti puts it: What then is the individual and where is his place in the community? In traditional life, the individual does not and cannot exist alone except corporately. He owes his existence to other people, including those of past generations and his contemporaries. The community must therefore make, create or produce the individual. Whatever happens to the whole 21 group happens to the individual. The individual can only say: I am because we are and since we are, therefore, l am. John Mbiti (1970 p.141) In other words, Mbiti believes that the personal identity of the African is deeply embedded in the family, the clan, the tribe, and the community. The concept of Ubuntu refers to African values of collective relatedness, interdependence, communality, group solidarity, and conformity where the essence of personhood is the connectedness between the self, social, and spiritual agencies of the person (Kpanake 2018). Personhood requires the intervention of spiritual entities; God, ancestors, divinities, and spirits to secure the person’s protection against malevolent spiritual forces to constantly influence the course of the person’s life through beneficial or harmful events (Kpanake and Ndoye, 2013; Bujuwoye 2005). The concept of Ubuntu is found in diverse forms in many societies throughout Africa (Murithi 2009) and has several different definitions, some of which are contradictory and make it difficult to extract one central definition of Ubuntu that would be universally accepted (West, 2014). In summary, Ubuntu is an African worldview about relationships with others with whom one lives and exists alongside. Schreiber and Tomm-Bonde (2015) contend that all the Sub-Saharan African countries share a common philosophical stance that virtually marinates social life and Ubuntu provides an excellent grounding for the cultivation of African cultural values. Ubuntu is a practical humanist disposition towards the world and includes ethical concepts such as compassion, tolerance, and fairness (Tutu 1981). Similarly, this can be likened to Afro-Caribbeans who use the phrase ‘l and l’ meaning you and me to demonstrate their acknowledgement that we are all one. Schreiber and Tomm-Bonde (2015) comment that Ubuntu, as a value system underpins interactions from childhood onwards and includes a profound respect for all people, human dignity and all forms of life. Ubuntu is seen as a knowledge system within the African education system. Taylor (2014) suggests there are two basic aspects to Ubuntu: relationships between people and how those relationships could be conducted. Ubuntu encompasses several interrelated principles including solidarity, spirituality, and harmony (Schreiber and Tomm-Bonde (2015) where human excellence describes the quality of being human (Mugumbate and Chereni 22 2019). With one’s identity wrapped up in such tight group collectivism, one’s fortune or misfortune is also believed to be closely tied to the influences and activities of others in society. There is always someone in society, usually those marginalised, who can be pointed to or accused of whatever evil may happen to a person. Critics have suggested that the Ubuntu philosophy served as an effective framework which promoted standards for moral behaviour until eroded by Western values such as individualism (Nyaumwe and Mkabela 2007). Whereas individualism as an ideology accepts that the individual person is more important than the group, collectivism, on the other hand, posits that the group is more important than the individuals that form the group. The Western world has long been associated with individualism due to the promotion of an individual’s pursuit of success, partly because of capitalism and liberal democracies. On the contrary, collectivism has been an ideology in Africa, where humans still largely live as communities. When it comes to supporting the vulnerable such as children and the elderly, communities rally together to achieve this goal. However, with intellectual disabilities and mental illness, some communities hide their family members, which then contradicts this essence. Ubuntu has been identified as a philosophy that permeates much of Western and Sub-Saharan traditional African cultures and lifestyles (Barrett, 2008; Grosser and Lombard, 2008; Mbigi, 1997; Metz and Gaie, 2010). In other words, people reach their fullness through community. Ubuntu accentuates both the communal perspective of personhood and morality. Further, Ubuntu underscores the need for all people to be treated with respect and dignity as well as the holding the community good to a higher value than the good of the individual (Prinsloo, 2001). Ubuntu, as a worldview equal in importance to Confucianism or European American worldviews, is not necessarily to be tested. Rather, such worldviews provide a framework for understanding phenomenon within the world (Tweed and Lehman, 2002). Ubuntu is often seen as a moral philosophy, as reflected by the predominant writings regarding it within the philosophical and ethics descriptive literature (Murove, 2009; Wiredu, 2004). In its emphasis on collectivism, Ubuntu is often compared to East Asian ways of thinking in contrast to the Western worldview of individualism and provable findings (Nisbett, Peng, Choi and Norenzayan, 2001; Muwanga-Zake, 2001). 23 Contrary to Ubuntu, individualism as known in the West is rarely practised in Africa. The common saying ‘It takes a village to raise a child’ is captured in collectivism where support systems are the strength of communities. This is reflected in how attitudes, beliefs and perspectives towards people with intellectual disabilities and mental illness are viewed in the communities, positively or negatively. It is therefore imperative that the teaching of nursing ethics and values acknowledges some world views of minority communities especially in understanding how these communities function. If cultivated within higher education, it helps nursing students to understand the values and beliefs of minority ethnic communities of African origin. Completing this study from the perspective of Ubuntu is important in demonstrating value to the student’s cultural background and history. In coming to the England, African students are asked to transcend cultural boundaries and adopt Western critical thinking skills in order to be successful. Western universities may not merely be asking the African student to learn a new way of thinking, as expected of native students. Rather, African students may be expected to disregard both their former ways of thinking, as well as the values inherent in that thinking. Thus, the perspective of Ubuntu will help to see the students’ experience through their eyes. Bantu people who live in Southern Africa share not just cultural views which are similar, they have similar ontologies as well. Metz (2015 p. 75-6) postulates that there is a maxim that Africans often invoke to sum up salient sub-Saharan ethical perspectives, namely, "a person is a person through other persons" which in plain English means nothing to someone outside the fold. As the prominent African philosopher John Mbiti puts it; What then is the individual and where is his place in the community? In traditional life, the individual does not and cannot exist alone except corporately. He owes his existence to other people, including those of past generations and his contemporaries. The community must therefore make, create or produce the individual. Whatever happens to the whole group happens to the individual. The individual can only say: I am, because we are and since we are, therefore l am. John Mbiti (1970 p.141) 24 In other words, Mbiti believes that the personal identity of the African is deeply embedded in the family, the clan, the tribe, and the community. The concept of Ubuntu refers to African values of collective relatedness, interdependence, communality, group solidarity, and conformity where the essence of personhood is the connectedness between the self, social, and spiritual agencies of the person (Kpanake 2018). Personhood requires the intervention of spiritual entities; God, ancestors, divinities, and spirits to secure the person’s protection against malevolent spiritual forces to constantly influence the course of the person’s life through beneficial or harmful events (Kpanake and Ndoye, 2013; Bujuwoye 2005). The concept of Ubuntu is found in diverse forms in many societies throughout Africa (Murithi 2009) and has several different definitions, some of which are contradictory and make it difficult to extract one central definition of Ubuntu that would be universally accepted (West, 2014). In summary, Ubuntu is an African worldview about relationships with others with whom one lives and exists alongside. Schreiber and Tomm-Bonde (2015) contend that all the Sub-Saharan African countries share a common philosophical stance that virtually marinates social life and Ubuntu provides an excellent grounding for the cultivation of African cultural values. Ubuntu, as described in a seminal talk, is a practical humanist disposition towards the world and includes ethical concepts such as compassion, tolerance, and fairness (Tutu 1981). Similarly, this can be likened to Afro-Caribbeans who use the words ‘l and l’ meaning you and me to demonstrate their acknowledgment that we are all one. Schreiber and Tomm-Bonde (2015) comment that Ubuntu, as a value system underpins interactions from childhood onwards and includes a profound respect for all people, for human dignity and for all forms of life. Ubuntu is seen as a knowledge system within the African education system. Taylor (2014) suggests there are two basic aspects to Ubuntu: relationships between people and how those relationships could be conducted. Ubuntu encompasses a number of inter-related principles including solidarity, spirituality, and harmony (Schreiber and Tomm-Bonde (2015) where human excellence describes the quality of being human (Mugumbate and Chereni 2019). With one’s identity wrapped up in such tight group collectivism, one’s fortune or misfortune is also believed to be closely tied to the influences and activities of others in society. 25 There is always someone in society, usually those marginalised, who can be pointed to or accused of whatever evil may happen to a person. Critics have suggested that the Ubuntu philosophy served as an effective framework which promoted standards for moral behaviour until eroded by Western values such as individualism (Nyaumwe and Mkabela 2007). Whereas individualism as an ideology accepts that the individual person is more important than the group, collectivism on the other hand, posits that the group is more important than individuals that form the group. The Western world has long been associated with individualism due to the promotion of individual’s pursuit of success, partly as a result of capitalism and liberal democracies. On the contrary, collectivism has been an ideology in Africa, where humans still largely live as communities. When it comes to supporting the vulnerable such as children and the elderly, communities rally together to this regard. However, with intellectual disabilities and mental illness, some communities hide their family members, which then contradicts this essence. Contrary to Ubuntu, individualism as known in the West is rarely practiced in Africa. The common saying ‘It takes a village to raise a child’ is captured in collectivism where support systems are the strength of communities. This is reflected in how attitudes, beliefs and perspectives towards people with intellectual disabilities and mental illness are viewed in the communities, positively or negatively. It is therefore imperative that the teaching of nursing ethics and values acknowledges some world views of minority communities especially in understanding how these communities’ function. If cultivated within higher education, it helps nursing students to understand the values and beliefs of minority ethnic communities of African origin. 1.7 Rationale of the study In English nursing education, significant emphasis is placed on the preparation of student nurses who are culturally competent in their practice and this perspective is reinforced throughout their three-year programme. The NMC (2018) expects all universities running the nursing programme to assess student skill, knowledge, and attitude to care for people with intellectual disabilities and mental illness as part of their nurse training journey. However, nursing knowledge continues 26 to be grounded in Western biomedical hegemony and its philosophical premises in positivism (McGibbon et al. 2014) in the 21st century university. Additionally, this is evident in the values espoused in and communicated through the curriculum and those that are absent in the curriculum (Allen 2006; Scammell and Olumide 2012). This has the potential to lead to poor satisfaction with the curriculum in the future among students from Black and minority ethnic communities, poorer recruitment and retention, (Abrums et al. 2010; Beard and Julion 2016; Cortis and Law 2005; Schroeder and DiAngelo 2010) Cervasio and Fatata-Hall (2013) posit that even though curriculum in schools of nursing is focused on knowledge and skills in clinical courses, it is not clear how attitudes of nursing students are conceptualised or measured as an outcome of nursing education. Knowledge and skills are assessed through course work and laboratory-based skills teaching respectively including simulations and scenarios. However, measuring beliefs, attitudes and perspectives is not a formal requirement of the nursing programme although student nurses are expected to display respectful behaviour and compassion towards patients and communities. Cervasio and Fatata-Hall (2013) propound that the effect of disability curriculum content on the attitudes of student nurses toward disabilities is a significant research agenda, suggesting that attitude changes are activated through knowledge, skill, and attitude acquisition. To address this gap in knowledge, this thesis proposes that exploring the belief systems of Southern African born student nurses and how nurse education influences them will go some way in enriching the nursing curriculum. Theoretically, knowledge, skills, beliefs and attitudes of nursing students and faculty are intertwined in nursing education. If, due to globalisation, nurse education seeks to serve student populations who hold multiple views about disease and illness, discourse on cultural beliefs and values about intellectual disability and mental illness needs to be in the curriculum and must address issues that may be viewed as biased towards the majority and against minority ethnic student populations especially in nursing which serves the needs of diverse patient communities. Thinking and teaching along Whiteness and Eurocentrism isolates the view of the ‘foreign’ student nurse in the classroom whose views and ways of knowing are not acknowledged by both 27 the academic and peers. This thesis calls for universities and nurse educators to explore/review issues around pedagogy for Black and minority ethnic students by being aware that they hold different beliefs about health, illness and wellbeing including kinds of assumptions and stereotypes, which are compounded by issues for example of gender, culture, religion and disability (Cortis and Law 2005). I am a Black African lecturer who grew up at a time when most of Southern Africa was under White rule. Years later, living and working in Europe, Whiteness continues to surround me. Implicit in my understanding of Whiteness has been the domination of Black people and a lack of recognition of African beliefs, ideals and knowledge systems by White people. While l agree that modern education liberates one and advances one’s knowledge, I recognise that for centuries the centrality of Western ‘knowledge’ has been used as an organising principle of the modern world. This resonates in the nursing profession where calls have now been made for its decolonisation. It is within this context that Whiteness dominates the nursing curriculum even in locations where Black student nurses predominate and exist alongside White peers in classrooms. To drive forward the decolonisation, agenda, the #BlackLivesMatter and other movements, my contribution in the form of this thesis serves to promote the advancement and recognition of indigenous knowledge systems shared by the many Southern African and indeed, other minority ethnic student populations in the West. The thrust of this thesis is to heighten awareness and contribute knowledge, stir new thoughts within nursing curriculum and generate future discussion on what l believe is contained in the wealth of African Indigenous Knowledge. This thesis makes a small contribution to this knowledge gap, and to build the evidence base in this area of study by reporting findings from a qualitative study that sought the views and experiences of participants of Southern Africa as they underwent nurse education and encountered people with intellectual disabilities and mental illness in various placement areas. This thesis further suggests the need to decolonise the nursing curriculum, the concept which arises from the view that due to historical colonial power and privilege within so-called first world countries, certain groups, certain ideas, and beliefs become accepted as more important and superior and as a result dominate the curriculum (Kaur-Aujla et al. 2018). Bhambra et al. (2018) describe decolonisation as broadly concentrated on critically 28 engaging with colonialism, empire, and racism as a focus of study, and the impact of these forces on what we understand as knowledge; and in turn opening the curriculum to previously neglected ways of thinking. In a university classroom now comprised of not just native white, but Black and minority ethnic students from the many previously colonised countries worldwide, it is imperative that the curriculum does not continue to perpetuate colonialist ideologies behind the veil of education. One key approach posited by this thesis towards decolonisation is to eliminate these issues through the encouragement of a more diverse approach to knowledge creation and production as well as the opportunity to talk about the power dynamics associated with Whiteness dominating curriculum design and content. The literature on decolonisation presents some clear themes for further development through research and action. Many white academics are 'comfortably oblivious to the realities of racism' and resist efforts of their peers to move issues of Eurocentrism in the faculty forward (Hassouneh 2006 p.260). If students and academics work collegiately, it ensures that the content in the curriculum meets the needs of the whole school of nursing with academics ready and prepared to deliver it. Content on culture must not be seen to be the remit of Black lecturers and students. Also, cultural competence should be afforded more time not just taken as a tokenistic exercise to tick boxes that it has been taught. In this sense, decolonisation affords the opportunity for all students to appreciate the role of power and privilege in terms of what gets taught and by whom. It encourages students and staff to examine critically, their collective histories of the curriculum Furthermore, decolonisation is used as a curriculum development benchmark to ensure that learning and teaching affords all students the opportunity to reach their full potential (Bell 2020). Bell (2021) is highly critical of today’s nursing curricular and exposes the white dominance that pervades this field highlighting white educators that possess no cultural competencies. Bell cogitates about nursing as: an oppressive educational climate for non-white identifying people, a curriculum that does not attend to the social construction of difference, and a nursing culture that is not consciously situated in a broader socio-political context Bell (2021 p. 23) 29 This thesis considers that the curriculum previously designed for the majority white population no longer serves the interests of the white students only and needs to meet the educational expectations of other ethnicities. White, Western dominance of ideas, beliefs, authors, research, ways of knowing, accepted truths and knowledge (Kaur-Aujla 2018), now need to be revisited by actively addressing both conscious and unconscious bias. The aim is to decolonise the personal, cultural, and structural inequality that limits the true potential and inclusiveness of all individuals and to look beyond the traditional Eurocentric white male syllabus to include more women, Black and minority ethnic communities to name a few (Lokugamage et al.2020). Another consideration of this thesis is that the complexion of nurse education is no longer white not only in the composition of the classroom but the cultural representation, beliefs, and diverse knowledge systems. Burnett et al. (2020) argue that Nursing and Midwifery educators often seem more concerned to preserve a façade of harmony and homogeneity, never to be ‘upset’ by opening the proverbial ‘can of worms’ of Structural Institutional and Individual Racism. To add to the existing knowledge, this thesis premises that even though most students and patients remain white-British, through world-wide migration, it is now necessary, more than before to expand the curriculum to accommodate the expectations of the minority ethnic communities of students. This is not only for the benefit of the students, but also for the expansion of the knowledge base for the academics and decolonisation will ensure education is fair in its delivery. This thesis seeks to neither negate nor denigrate known Western methods of investigation, rather it seeks to persuade readers to consider the understanding of indigenous knowledge about intellectual disability and mental illness from the point of view of Southern African peoples, in particular student nurses in the UK higher education sector. On a larger scale, the findings will also inform the development of educational materials and nurse education proficiencies related to the formulation of intellectual disability and mental health practices for Indigenous peoples from other countries and will contribute to ongoing efforts to add to the curriculum, the diversity of the Indigenous Knowledge Systems (IKS) of students from Southern Africa and indeed many other countries in the world. 30 The pursuit of and the intellectualisation of indigenous knowledges and knowledge production, go hand in hand with the realisation that the world is composed of diverse cultures and different modes of being in the world, (Murove 2018). This means that the recognition of the world's existential realities of multiculturalism, also speaks to an acknowledgement of the reality of pluralism in the realm of knowledge. Smith and Foronda (2019) conclude that cultural humility is cultivated by diverse faculties and cohorts, and curricula developed alongside Black and Minority Ethnic/Black and Indigenous People of Colour, students and patients. Part of this includes universities playing their part by ensuring they prepare the students not just through assessments but through changing attitudes, beliefs and perspectives which may be different to the mainstream population. It is my sincere hope that nurse academics in England as well as researchers will be open and welcoming to contributing to the development and use of ‘alternative methods of studying our reality and refrain from sticking to the research pathways mapped out by Western methodologies, within which many have been trained’ Owusu-Ansahh and Mji (2013 p234). The results from this study will inform the development of theory and practice when considering how to best understand indigenous and Western belief systems so that interventions are culturally appropriate, and this will be of particular use to learning disability and mental health Trusts and organisations which support student nurse education as well as nurses from Southern African countries. 1.8 Structure of the thesis This thesis is composed of eight chapters. Chapter 1 introduces the background and study rationale in the context of the movement towards decolonising the curriculum and incorporating a nursing curriculum that is tailored towards meeting the needs of all nursing students including those from minority ethnic communities. Chapter 2 presents the search strategy used to explore the current national and international knowledge base in the area of Indigenous knowledge and belief systems of Southern African peoples. This section explores, belief systems about intellectual disability, mental illness, epilepsy and culturally competent care, and ethnocentrism. 31 Chapter Two, the review of the literature steadily builds the backdrop against which this thesis should be viewed. Chapter 3 discusses the methodological approach adopted in conducting this study. To be considered here are the philosophical assumptions underpinning the research methodology and strategy, including the specific methods and techniques deployed for the data collection. Divided into three interrelated parts, this chapter first details the philosophical assumptions underpinning the research approach, secondly, the research design and strategy adopted in the investigation and finally, the third part discusses the specific methods and techniques of data collection including the description of my role as an insider researcher, ethical considerations, validity and reliability. Chapter 4 is concerned with thematic analysis of the data and begins with an outline of the approaches to the analyses of the interview data through thematic analysis. Chapter 5 presents the discussion of the data where the chapter will review the participant results and analyses, focusing on perspectives and experiences of nurse education and the influences their belief systems about intellectual disability and mental illness. Chapter 6 considers the theoretical implications of the study in the context of the current body of evidence, addressing key strengths and limitations of the study and makes clear recommendations for future research directions. This chapter reflects on the objective of the study and the main research questions to provide the summary of the findings. In conclusion, this chapter has introduced the topic for this thesis and highlighted the need to design a curriculum that can accommodate the needs of students from minority ethnic communities such as Southern Africa. This can be achieved by universities acknowledging belief and knowledge systems, attitudes and explanatory models that have developed from diverse cultures, rather than continuously creating more scaffolding to erect extensions of Western/Eurocentric knowledge. Nurse education can decentralise Western concepts as the ‘peak of knowledge’ (Kaur-Aujla et al. 2018). To do this will involve open minds, collaboration and cooperation when diverse academics design curriculums that acknowledge difference, diversity and multifaceted aspects of world knowledge systems. 32 1.9 Chapter summary This chapter began with a brief background to the study exploring belief systems in the context of African Indigenous Knowledge followed by the aim and objectives of the study. A short appraisal of the African continent including Southern Africa, the place of origin of all the study participants was offered. A brief introduction was given about Ubuntu which was then followed by the rationale of the study. Finally, the chapter concluded with a structure of the thesis. The next chapter is the literature review detailing how the research was obtained for this study. 33 Chapter 2 - Literature Review 2.1 Introduction This chapter is divided into three main sections where section 1 (2.2) begins with a description of the search strategy used to screen and identify relevant literature and the rationale for selecting a scoping review, respectively. The second section (2.3) critically explores concepts linked to African belief systems. This section reviews the extent to which the existing research literature has evaluated Southern African peoples’ beliefs and level of knowledge and understanding of intellectual disability and mental illness. This section will address Indigenous knowledge systems of Southern African Bantu people followed by an exploration of the themes found in the literature. These are Explanatory Models with an example of an explanatory model for epilepsy. This is then followed by beliefs about disability in Africa, the power of witchcraft in Africa, help-seeking behaviours and stigma towards people with intellectual and mental illness. 2.2 Section 1 2.2.1 Reviewing the literature. In identifying what method should best answer the research question, it was important to review the literature therefore a scoping review was undertaken. First, literature focused on Indigenous belief systems held by African communities regarding intellectual disabilities and mental illness was investigated. Following that, international literature focusing on help-seeking and treatment methods awareness was explored. Subsequently, any literature looking at issues such as stigma and support systems for people with intellectual disabilities were examined. Finally, institutional websites with links to online resources were accessed for publications of interest to this study. Some of the key approaches to conducting a literature review include, but are not limited to, systematic reviews, meta-analysis, meta-synthesis, scoping review or narrative review. For purposes of this thesis, this chapter will define a systematic review and scoping review only. The 34 Cochrane Collaboration (2021) defines a systematic review as a comprehensive high-level summary of primary research on a specific research question that attempts to identify, select, synthesise, and appraise all high-quality evidence relevant to that question to answer it. Systematic reviews follow a structured and pre-defined process that requires rigorous methods to ensure that the results are both reliable and meaningful to end users (Munn et al. 2018). Additionally, systematic review uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made Cochrane (2021). Pearson (2004) and Pearson et al. (2005) conclude that if the authors have a question addressing the feasibility, appropriateness, meaningfulness or effectiveness of a certain treatment or practice, then a systematic review is the most valid approach. In short, systematic reviews ideally aim to answer specific questions, rather than present general summaries of the literature on a topic of interest. 2.2.2 Scoping review While several studies have concerned themselves with student attitudes and stigma towards disability and mental illness, there is a dearth of research on public conceptualisations of intellectual disability (Scior et al. 2013). This represents a significant gap in understanding how Southern African students understand causation of intellectual disabilities and mental illness from their cultural perspective and how nurse education influences their belief systems. This change in life brought about by migration to the UK whilst still subscribing to their indigenous belief systems has been a key justification for the need for this research. This scoping review aims to consider published studies capturing the indigenous belief systems of people of Southern African origin about intellectual disabilities and mental illness. It was important to carry out an exploratory review of the existing literature to aggregate the evidence base, assess the quality of the available studies and highlight the gaps that require further investigation (Arksey and O’Malley, 2005). 35 In the disciplines of health and social sciences, the use of scoping reviews has increased in popularity as this approach is recognised as an appropriate method of inquiry for informing new research in these areas (Pham et al. 2014; Tricco et al. 2016). Scoping review methods enable researchers to examine the existing literature, record what and how previous research has been conducted, identify key factors related to the central concepts and analyse the gaps for further research (Munn et al. 2018; Peters et al., 2020). Intellectual disability and mental illness are broad, complex and can be multifaceted in terms of their epidemiology across the world; how they are characterised and how they are experienced culturally, religiously, on an individual and at community level. As such, a scoping review is considered an appropriate methodology for examining the different types of evidence related to indigenous beliefs about the causation of intellectual disability and mental illness. When authors do not always wish to ask precise questions but are more interested in the identification of certain characteristics/concepts in papers or studies, a scoping review is the better choice. Munn et al. (2018) propose that researchers may preference the conduct of a scoping review over a systematic review where the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts, investigate research conduct, or to inform a systematic review. A scoping review tends to address broader topics where a broader range of study designs might be applicable and is useful to identify all relevant literature regardless of study design (Arksey and O'Malley 2005). While the employment of scoping reviews has become more popular across the disciplines, so too have the criticisms of the approach with some authors highlighting weaknesses in its use for synthesising evidence (Davis et al., 2009; Tricco et al., 2016). A scoping review is a method for providing a comprehensive overview of evidence, rather than a type of systematic review which seeks to synthesis qualitative or quantitative data (Munn et al., 2018) and as such, scoping reviews do not necessitate critical appraisal (Lockwood et al., 2019; Peters et al., 2020). Finally, a scoping review is preferred when research objectives or review questions involve exploring, identifying, mapping, reporting or discussing characteristics or concepts across a breadth of evidence sources (Peters et al. 2021). Khalil et al., (2016) advise that scoping reviews are particularly useful when there is a range of evidence generated from a variety of methods and are often undertaken to ensure that further 36 research in that area is a beneficial addition to world knowledge. The seminal framework for conducting scoping reviews was developed by Arksey and O’Malley, 2005, however, since it’s conception, methodological challenges in this approach with regard to the analysis of data have been highlighted. In response to this, an extension of the framework was proposed by Levac et al. (2010) and updated guidance from the JBI and the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) explicitly reference the need for increased rigour and transparency in the conduct of scoping reviews (Peters et al., 2020). While the purpose of a scoping review is to map the body of literature on a topic area (Arksey and O'Malley 2005), the purpose of a systematic review is to sum up the best available research on a specific question (Campbell Collaboration 2013). Thus, a scoping review appeared the most appropriate given my study aims and the body of literature in the area. The approach to scoping reviews taken in this study was that it considered research findings as well as drawing conclusions from the existing literature regarding the Indigenous belief systems of Southern African Bantu people. This study’s scoping review facilitated the identification of gaps in the evidence base where there is a paucity of research with the potential to summarise and convey the findings of this study. The five steps of a scoping review as outlined by Arksey and O’Malley (2005), (Appendix A) include (1) Identifying the research question; (2) Searching for and identifying the relevant studies; (3) Selecting relevant studies; (4) Charting the data; and (5) Collate, summarise and report the results to guide this review were followed. The search question for the review evolved throughout the research process into “What is the influence of nurse education on the Indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin? The five-step process is styled in a sequence direct approach; however, it is an interactive approach where each step is revisited and further developed during the review and the results are presented in the form of a narrative in addition to charts, tables and diagram illustrations (Arksey and O’Malley 2005; Colquhoun et al. 2014, Levac et al. 2010). Each step is detailed below. (1) Identifying the research question. 37 The search question for the review evolved throughout the research process into “What is the impact of nurse education on the Indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin?” (2) Identifying relevant studies. A comprehensive search was conducted by searching and reviewing the literature from multiple sources (Arksey and O’Malley, 2005; Levac et al., 2010). To achieve this, this study adopted a strategy that involved searching for research evidence via diverse sources: these included electronic databases, reference lists, hand‐searching of key journals, and existing networks. The start date of 2000 was chosen because it was felt that this covered major and contemporary research and most importantly the use of universally adopted essential terminology used in nursing care for people with intellectual disabilities and mental illness. Foreign language material was excluded because of lack of time and resources that could be incurred in translating material. Conversely, this research would be best informed by evidence from African countries, however, it had to adopt these limits for practical reasons. Wright et al. (2007) caution that reviews that limit articles to the English language may introduce bias as such it is worth pointing out that potentially relevant papers could have been missed. A University librarian assisted with the identification of relevant keywords and advised on what databases were most likely to produce the type of studies to search for. The university’s Library search engine, Discovery was used conduct multiple searches. Discovery searches the library's catalogue and many academic databases including electronic databases such as Cumulative Index for Nursing and Allied Health Literature (CINAHL), Medline, Applied Social Sciences Index and Abstracts (ASSIA), and Embase simultaneously, to quickly provide relevancy-ranked, credible library results through a single search box. When searching the literature, Population, Intervention and Outcome (PICO) incorporates the following components. Population: the persons or community affected with a specific health h condition or problem. Intervention is the process or action under investigation in a clinical study. Interventions can include pharmaceutical agents, devices, and procedures, such as education 38 about diet or exercise. Comparison is the group assessed against the intervention. Outcome is the planned measure to determine the effect of an intervention on the population under study. Alternatively, PEO: (Population, Exposure, and Outcome) centres on those affected and their problems/issue (Population). Exposure focuses on the area of interest. The Exposure viewpoint depends on the framing or wording of the research question and the goals of the project since qualitative studies can denote a broad area of research or specific sub-categories of topics (Cresswell, 2013). Since the PEO model is best suited for qualitative studies (Methley et al 20014), Outcome tends to have elements of defining a person’s experiences or discovering processes that happen in specific locations or context (Doodly and Bailey 2016). For this research, the screening of titles and abstracts was guided by the PEO (Population, Exposure, Outcome) framework to formulate qualitative literature investigating the belief systems of Southern African student nurses. This was preferred over the PIO (Population, Intervention, Outcome) framework. (Please see Table 1). “What is the influence of nurse education on the Indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin? Population Southern African AND Student Exposure Nurse education Outcome Indigenous belief AND Intellectual disability OR Mental illness PEO framework for study eligibility. Table 1: PEO framework The databases searched for studies published before March 2021 using Medical Subject Headings (MeSH) and subject index terms including the keywords, (Southern African AND Student OR Pre-registration nurse) AND (Indigenous belief AND intellectual disability* OR learning disability* OR mental handicap, OR mental retardation) AND (experience* or perceptions* or attitudes*). Please see Table 2 for the search terms. The results were crossed checked to ensure seminal academic work in the area were captured in the results. The start date of 2000 was chosen because it was felt that this covered major and contemporary research and most importantly the 39 use of universally adopted essential terminology used in nursing care for people with intellectual disabilities and mental illness. Foreign language material was excluded because of the lack of time and resources that could be incurred in translating material. Conversely, this research would be best informed by evidence from African countries, however, the search strategy had to adopt these limits for practical reasons. Wright et al. (2007) caution that reviews that limit articles to the English language may introduce bias as such it is worth pointing out that potentially relevant papers could have been missed. Population Population Exposure Outcome Southern African Nurse student Nurse education Beliefs about Intellectual disability Learning disability Mental illness Pre-registered nurse Mental retardation/handicap Perceptions about Intellectual disability Learning disability Mental illness Mental health disorder Opinions about Intellectual disability Learning disability Mental illness Values about Intellectual disability Learning disability Mental illness Table 2: Search terms used in Discovery. 40 Figure 0-1: History / Alerts Search Modes 41 Figure 0-2: History / Alerts Search Modes 42 They produced 0 results when all the search terms were combined, please see figure 0-1. A further search was performed on PsychInfo with the same search terms (Southern African AND Student OR Pre-registration nurse) AND (Indigenous belief AND intellectual disability* OR learning disability* OR mental handicap, OR mental retardation) AND (experience* or perceptions* or attitudes*) to produce 11 results. Please see Figure 0-2. Additionally, a manual search was completed using Google Scholar; African journals such as African Journal of Indigenous Knowledge Systems, Journal of Philosophy and Culture African Journal of Health Sciences, African Journal of Neurological Sciences, African Journal of Psychiatry, Annals of Health Research, Journal of the Eastern and Southern Africa Regional Branch of the International Council on Archives were scrutinised and yielded many useful studies which were otherwise unavailable on other databases. Nearly all the reference material identified from this study (n=16) were found through these journals. This also included grey literature. This process identified further references, although a saturation point was reached where no new ones were identified. Reference lists Reference lists of included studies were examined to identify additional references of relevance. Search terms were compiled based on keywords from the literature and in consultation with the institution’s reference librarian where final terms and search strings were iteratively developed. It was essential to check the reference lists of studies found through the database searches—especially systematic reviews, scoping reviews and traditional literature reviews—to ensure they were included in the scoping exercise. Hand‐searching of key journals In addition, journals were hand‐searched to identify articles that might have been missed in database and reference list searches. An Endnote library which proved invaluable for managing records was used to keep track of articles and making requests for inter‐library loans. The final total of selected studies is shown in the PRISMA flow chart on Fig 0-3 43 (3) Study selection For the scoping review an inclusion and exclusion criteria based on the specific research question was developed at the outset of the study to ensure consistency in decision‐making. Studies were included in the review if they met the following set of inclusion criteria: · Reported on indigenous belief systems of people from Southern African countries which focused on intellectual disabilities and mental illness · Included traditional healers, professionals working with and families of people with intellectual disabilities · Published in English · Published between 2000 and 2021 · Included qualitative, quantitative or mixed methods methodologies or were reviews or commentaries. The screening process is diagrammatically represented in a PRISMA-ScR flow diagram (Tricco et al., 2018) on Fig 0-3. The inclusion criteria used in the scoping study are included in Table 3 below. Criterion Inclusion Exclusion Time period 2000 to 2021 Studies outside these dates Abstracts Language Where overwhelming theme was belief systems English Abstract without this theme. Non-English studies Type of article Original research, published in a peer reviewed journal Articles that were not peer reviewed or original research Ethics clearance Studies with approved ethics notification Studies without approved ethics notification Study focus African communities including carers, African undergraduate students in higher education All other students and employment settings Literature focus Articles where the overwhelming theme relates to Indigenous belief systems about causation of intellectual disabilities, mental illness, help-seeking behaviours, stigma Articles that made a passing or token reference to flipped classroom activity. 44 Criterion Inclusion Exclusion Articles that were editorials or discussion or opinion pieces. Population and sample Southern African communities and minority societies with traditional beliefs and undergraduate students enrolled in a recognised undergraduate nursing programme of study. Communities in the West who hold scientific beliefs, all other students not enrolled in a health-related or medical study Table 3: Inclusion and exclusion criteria (4) Charting the data The fourth stage of Arksey and O’Malley (2005) scoping review framework is the charting of selected articles. Summaries were developed of each article related to the author, year, location of study, study design, study methods and sample size and a brief comment on the limitations and recommendations of the individual selected study. In the first step data were extracted by author, year and country where studies had been conducted, type of the study, participants and sample size, and the aim and objective of the study. Methodology, outcome measures and results followed. This helped with the stratification of the studies and simplify the group process according to themes or countries of origin as well as the populations studied. Also, when proceeding to the next stages of the scoping review, it was easier to locate the studies so the researcher could copy and paste them in the textboxes when collating and summarising the data in the final stages of the scoping review. Arksey and O’Malley’s (2005) framework was very useful at this stage. Table 4 shows how the articles were categorised. (Please see Table 4 below) 45 1. Author(s), year of publication, study location 2. Study type 3. Study populations 4. Aims of the study 5. Methodology 6. Outcome measures 7. Important results Table 4: Charting the data. Additionally, a charting form was constructed to facilitate the screening of the full-text studies. The extraction process took an iterative approach, and the tool was revised and adjusted where necessary. The charting of the data and the systematic recording of the studies helped the researcher to begin to identify the main themes in the literature and begin to build an emerging picture of the major themes that would form the literature review. This also helped to identify key authors in this field of research. This also meant that the researcher was able to focus on studies which focused on the research question which addressed indigenous belief systems about intellectual disability and mental illness. (Please see Table 6). The data were collected in a Microsoft Word document for validation and coding. Out of the 11 studies identified on PsychInfo, none of the papers were deemed suitable for this study, however, the hand searching and Google scholar searches including a scrutiny of the reference lists and African journals produced a total of twenty-four studies that met the inclusion criteria, and these were critically screened for methodological quality using the Critical Appraisal Skills Programme (CASP) tool (Oxford University 2013). These consist of checklists involving prompt questions to help a researcher evaluate their research study. The questions are an effective way to stimulate thinking (Oxford University 2013). This instrument consists of twelve questions to assess the quality of studies and ten questions for qualitative studies. The CASP tool is a user-friendly option for a novice qualitative researcher and is endorsed by Cochrane and the World Health Organisation for use in qualitative evidence synthesis (Long et al. 2020). For this reason, the CASP framework was preferred in addition to the fact that it was 46 devised for use with health-related research. Although the CASP tool has been compared with the evaluation tool for qualitative studies (ETQS) and the Joanna Briggs Institute (JBI) tool on five dimensions of validity and found to be the least sensitive of the three to interpretative, evaluative and theoretical validity and did not compare well as a measure of intrinsic methodological quality (Hannes et al. 2010), it was still deemed appropriate for this study due to the researcher’s inexperience in research. (Please see Table 5) The 10 questions of the CASP qualitative checklist tool. 1 Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate for the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between the researcher and participants been adequately addressed? 7. Have ethical issues been taken into consideration? 8. Was the analysis sufficiently rigorous? 9. Is there clear research finding? 10. How valuable is the research? Table 5: CASP qualitative checklist tool 47 Theme Authors Theme 1 Cultural beliefs van Dyk and van Dyk, (2015); Bunning et al., (2017); Aldersey (2012); Aldersey et al., (2014); Gona et al., (2011); Lamptey (2019); Masulani-Mwale et al., (2016); Tilahun et al., (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn, ((2007); Ajuwon and Brown (2012); Tilahun et al., (2016) Mkabile et al., (2021) Theme 2 Local understanding of disability Mkabile et al (2021) Bunning et al. (2017) Aldersey (2012); Aldersey et al. (2014); Gona et al. (2011); Lamptey (2019); Masulani-Mwale et al. (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn ((2007) Ajuwon and Brown (2012); Tilahun et al. (2016) Theme 3 Fate, nature or will of God. van Dyk and van Dyk (2015); Tilahun et al., (2016); Bunning et al. (2017) Aldersey (2012); Mkabile et al. (2021); Aldersey et al. (2014); Gona et al. (2011); Lamptey (2019); Masulani-Mwale et al. (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn ((2007) Ajuwon and Brown (2012); Tilahun et al. (2016) Theme 4 Wrongdoing Bunning et al. (2017) Mkabile et al. (2021); Aldersey (2012); Tilahun et al., (2016); Aldersey et al. (2014); Gona et al. (2011); Lamptey (2019); Masulani-Mwale et al. (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn ((2007) Ajuwon and Brown (2012); Tilahun et al. (2016) Theme 5 Plurality of beliefs. Bunning et al. (2017); Tilahun et al., (2016); Mkabile et al (2021); Aldersey (2012); Aldersey et al. (2014); Gona et al. (2011); Lamptey (2019); Masulani-Mwale et al. (2016); Tilahun et al., (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn (2007) Ajuwon and Brown (2012); Tilahun et al. (2016) Theme 6 Stigma Mitfah et al. (2015); Nota et al., (2015); Groce and McGeown (2013); Magnussen (2011); Bunning et al. (2017) Aldersey (2012); Aldersey et al. (2014); Gona et al. (2011); Lamptey (2019); Masulani-Mwale et al. (2016); Nkhosi and Menon (2015); Ntswane and Van Rhyn ((2007) Ajuwon and Brown (2012); Tilahun et al. 2016) Tilahun et al., (2016); Table 6: Emerging themes 48 “What is the influence of nurse education on the Indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin?” Figure 0-3: The PRISMA flow chart Records identified from*: PsychInfo (n = 11) Google scholar (n = 24) African journals (n=16) Records removed before screening: Duplicate records removed (n =2) Records marked as ineligible by automation tools (n =0) Records removed for other reasons (n =9) Records screened. (n =40) Records excluded** (n =10) Reports sought for retrieval. (n =30) Reports not retrieved. (n =0) Reports assessed for eligibility. (n = 30) Reports excluded:6. Reason 1 outside chosen time scale (n =3) Reason 2 unclear methodology (n =3) Studies included in review. (n =24) Identification of studies via databases and registers Identification Screening Included 49 (5) Collating, summarising and reporting the results The data extracted included details about the phenomena of interest (indigenous belief systems about intellectual disabilities and mental illness), the population at hand (student nurses of Southern African origin), the study methods and outcomes deemed significant to the review question and specific objectives. The results generated through this review were reported using the PRISMA-ScR tool (Tricco et al, 2018). The PRISMA-ScR is the most recent and innovative approach for reporting in scoping reviews. The PRISMA-ScR is not a guideline for review synthesis, rather it serves as a checklist tool to guide the comprehensive reporting of methods and findings. As approaches for evidence synthesis in scoping reviews advances, the use of the PRISMA-ScR extension is considered a reliable, practical tool for improving the quality of scoping reviews when used in conjunction with methodological guidance (Peters et al. 2021). The narrative report synthesises the study findings grounded in themes that emerged from the extracted data. The results are presented in line with the research questions and in the context of the overall scoping review objectives. Figure 0-3 presents summary information on the included articles. (Please see Figure 0-3) At this stage, data was extracted reporting on concepts of intellectual disability and mental illness causation beliefs, attitudes towards, and stigmatisation of people with intellectual disability and mental illness. Full texts of selected studies were checked for representation of sampling, quality of methods applied, and reporting strategy. This stage of a scoping study involves collating, summarising and reporting the results. The scoping study presents an overview of the material reviewed and consequently issues of how best to present this potentially large body of material are critical. Finally, the identification of research gaps in this study relied on the literature review, which was confined to identifying areas of overall weakness within the field by comparing intervention types and study designs. The final stage (6) an optional consultation exercise was not pursued as it was not pertinent to this study. All the charted studies are presented on Table 7. (Please see Table 7 below) 50 Table 7 below details all the studies found for the scoping review. The findings informed the literature review and interview schedule. Author/ year/ location Aim of study Method/ sample Key findings Tilahun et al. (2016) Ethiopia to examine the stigma experiences, explanatory models, unmet needs, preferred interventions and coping mechanisms of caregivers of children with developmental disorders in Ethiopia. A cross-sectional facility-based study was carried out using a structured questionnaire administered in a face to-face interview to caregivers of children with ASD and/or ID 1. Most caregivers reported experience of stigma: 43.1 % worried about being treated differently, 45.1 % felt ashamed about their child’s condition and 26.7 % made an effort to keep their child’s condition secret. 2. Caregivers gave a mixture of biomedical explanations (e.g., head injury (30.4 %) or birth complications (25.5 %)) and supernatural explanations (e.g., spirit possession (40.2 %) or sinful act (27.5 %)) for their child’s condition. 3. Most caregivers reported that talking to health professionals (86.3 %) and family (85.3 %) helped them to cope Lamptey, (2018) Ghana explored the health beliefs and behaviours of families towards the health needs of children with intellectual and developmental disabilities (IDD) to inform health promotion strategies for the children and their families. semi-structured interviews were the primary means of data collection. The interviews were analysed using constant comparison. 1. Challenges associated with the IDD of the children in public and attitudinal barriers when accessing health care. 2. The parents did not often patronise health facilities due to poor confidence in neighbourhood. 3. Further, many parents did not patronise religious interventions for the children. parents explained that in addition to seeking medical care to address the physical symptoms of the children's disabilities and/or illnesses, they sought religious interventions because they believed that there could be a spiritual dimension to the situation. Mkabile et al. (2017) South Africa investigate experiences of caregivers and systematic review 1. Caregivers of children with intellectual disability in Africa faced substantial challenges. 51 Author/ year/ location Aim of study Method/ sample Key findings parents of children with intellectual disability in Africa. 2. Current findings suggested that there was the need for both formal and alternative healthcare workers to work together towards an understanding and management of intellectual disability in Africa. Bunning et al. (2017) Kenya Munthali et al. (2013) Malawi Investigate local understanding of disability as a co-constructed concept. explores the health-seeking behaviour of people with epilepsy in a rural town in southern Malawi and how having a person with epilepsy impacts on the households’ productivity Focus group discussions were conducted. a total of 63 interviews were done with persons with disabilities or their guardians. Eight of the 63 interviews were with persons with epilepsy and this article is based on these interviews. 1. Local beliefs about disability to human transgression of social conventions, invoked a curse; supernatural forces; the will of God; unexplained events; and biomedical factors. 2. Perceived barriers to inclusion, Local understanding of disability in this rural part of Kenya demonstrated overlapping explanations and plurality of beliefs. 1. The study found that persons with epilepsy seek both traditional and modern medicines to treat the condition. Informants mentioned that barriers to accessing western treatment include lack of medicines, congestion at health facilities, lack of knowledge about epilepsy, misdiagnosis by health workers and the belief that epilepsy caused by witchcraft cannot be treated by western medicine. 2. The study also highlights the wider impacts of epilepsy on the household such as the failure of children to attend school, children dropping out of school, stigma and discrimination and households being driven deeper into poverty as a result of seeking care for members with epilepsy. 52 Author/ year/ location Aim of study Method/ sample Key findings Molalign et al. (2020) Canada discover the barriers and facilitators to healthcare access for CwDs in selected low to middle income Sub-Saharan African countries. scoping review 1. Sub-Saharan African countries face major barriers including stigma and negative attitudes, Aldersey (2012) Tanzania Family perceptions of ID 13 family members of people with ID Interview 1. Family members reported that Tanzanians look negatively on people with ID. 2. Family members reported their children experience stigma. Baffoe (2013) Ghana Examine societal attitudes and barriers for persons with disabilities in Ghana 80 people with disabilities, 20 family members, 20 others (1) Interviews (2) Focus groups (3) survey 1. Societal stigma, discrimination and their effects most difficult barriers for people with ID to live normal lives. 2. Myths, superstitions, negative labels contribute to social exclusion of people with ID. 3. Some parents admitted to hiding children from public view. Bayat (2014) Cote d’Ivoire Understanding ways in which Ivorians view disability 65 professionals working in the field of developmental disabilities; 29 females and 36 males. (1) Field observations, (2)2 surveys; (3)2 focus groups with 1. Professionals viewed children as ‘diseased’ in line with a medical model 2. Public viewed children as ‘cursed’. 53 Author/ year/ location Aim of study Method/ sample Key findings professionals, (4)1 focus group of parents of children with ID, (5)5 transcribed interviews and (6) examination of government document MacDonald (2012) Tanzania Examines cultural beliefs and values about disability and the influence of these on a school for children with disabilities. 32 participants compromised of families, school staff and local leaders. Observation (2) document collection (3) interviews using five strategies outlined by McMillan and Schumacher (2006) 1. Majority believe that having a child with ID is part of God’s plan 2. Negative beliefs included shame or burden that child with ID brought to the family McKenzie and Swartz (2011) South Africa and UK Examines viewpoints of two communities on disability in childhood and its implications for sexuality of people with disabilities 63 participants (community members, parents of people with disabilities, people with disabilities and teachers); 31 from East London and 32 from Eastern Cape 3. High levels of stigma and negative attitudes towards people with disabilities limit the development of sexuality. 4. Sexuality of people with disabilities seen as different and impacts on self-esteem of children with disabilities. 5. Mothers and grandmothers tend to be responsible for sexuality education of children with disabilities 54 Author/ year/ location Aim of study Method/ sample Key findings Province, South Africa Q methodological study; (1) surveys and (2) interviews Menon and Nkhosi (2015) Zambia Mothers’ perceptions of the needs of adolescent children with ID 19 mothers Focus groups (2) Observations using the Home Environment Potential Assessment (HEPA) 1. Mothers reported that adolescents with ID have social and emotional needs just like everyone else. Dangor and Ross (2006) South Africa Beliefs and practices of caregivers and traditional healers regarding Down Syndrome 10 traditional healers and 10 caregivers from South African Muslim community Individual semi-structured interviews including both open and close-ended questions adapted from Bham and Ross (2005) and Badat (2003) 1. Common beliefs were that Down syndrome was genetic and children were perceived as ‘gifts from God’ 55 Author/ year/ location Aim of study Method/ sample Key findings Hartley et al. (2005) Uganda Understand how family members cope with their disabled children 51 parents, caregivers, and families of children with disabilities (1) Key informant semi structured interviews (Britten, 1995) (2) non-participatory observation schedules (Mays and Pope, 1995) 1. Carers reported that children encountered negative attitudes, rejection from family members, peers and community. 2. Parents would like children to attend school 3. Parents and caregivers often believed that ID was God’s will, angered spirits or witchcraft was the cause Mkabile and Swartz (2020) South Africa Kiwanuka et al. (2018) Uganda. understanding and management of intellectual disability, contextual and cultural explanations used to describe and conceptualise this condition. To assess the knowledge, attitudes, and beliefs of adults on epilepsy 20 semi-structured interviews with primary caregivers and parents of children with intellectual disability Khayelitsha, a low-income setting in We used Kleinman's Explanatory Models (EMs) A cross‐sectional study was conducted Two hundred seventeen of 220 randomly selected adults 18 years or 1. Carers’ explanatory models included biomedical causes, injuries during pregnancy or birth, as well as spiritual causes. 1. Most respondents had negative beliefs such as attributing epilepsy to supernatural spirits, heredity, and preference of traditional medicine and healers to conventional medicine as a treatment for epilepsy. 2. A significant number of respondents expressed sympathetic feelings toward people living with epilepsy, specifically tolerance and kindness to those living with epilepsy. 56 Author/ year/ location Aim of study Method/ sample Key findings older participated in the study. A standardized self‐administered questionnaire (Attitudes towards persons with Epilepsy “ATPE”) was used for data collection. Ten Klooster et al. (2009) Netherlands Dutch nursing students attitudes towards people with physical or intellectual disabilities. A sample of Dutch nursing students (n = 81) and an age-matched group of non-nursing peers (n = 48) completed standardized scales measuring attitudes about physically or intellectually disabled people. Data were collected in 2006. Nursing students were more positive towards physically disabled people than their peers, and more strongly endorsed empowerment and similarity of intellectually disabled people. These attitudinal differences remained statistically significant after multivariate adjustment for demographic variables and experience and contact with individuals with disabilities. An important independent determinant of a positive attitude towards physically disabled people in the total sample was having a relative or friend with a physical disability. This association, however, was not apparent in attitudes towards intellectually disabled persons. 57 Choi and Lam (2001) South Korea insight into how different people of different cultural backgrounds view disabilities cross-cultural research 359 Korean and Korean American undergraduate and graduate students participated in this study. The Scale of Attitudes Toward Disabled Persons (SADP), with a measure of attitudes toward people with mental disabilities and another of attitudes toward people with physical disabilities, was used. In terms of physical disability and mental disability attitudinal comparison, only the Korean student group showed favourable attitudes toward people with physical disabilities compared with those with mental disabilities. However, no significant within-group difference in terms of types of disability was found in the Korean American sample. Korean students possess consistent Asian values that favour people with physical disabilities over those with mental disabilities. Sahin and Aykol (2010) Turkey The aim of this study is to assess the attitudes of students towards disabled people and provide suggestions to make necessary changes in the curricula. Cross-sectional design was used. Data were collected using the Turkish Attitudes towards Disabled Person Scale (TATDP) and demographical variables. TATDP Scale was scored according to five-point Likert Scale. Medical students acquired more prior knowledge about attitudes towards the disabled. Total attitude scores of female students were above the students’ mean attitude score when compared to those of male students. 58 Matziou et al (2009) Athens to investigate the attitudes of nurse professionals (paediatric nurses) and nursing students towards disabled children. comparative study. The sample consisted of 228 first-year nursing students, 90 post-diploma nurses attending MSc degree course and 123 nurse professionals who are employed in paediatric hospitals. Overall nurses' attitudes were poor. However, the post-diploma nurses had significantly higher ATDP scores than first-year students and paediatric nurses (P < 0.001). In addition, first-year students had significantly higher scores than paediatric nurses (P = 0.047). Across the sample, females hold significantly more positive attitudes than males (F = 9.5, P = 0.002), while age did not have any significant effect. Carefully designed curricula can influence the attitudes of nursing students towards children with disabilities. Special courses for treating disabled children should be integrated to the basic nursing studies. Moreover, continuing hospital education can change paediatric nurses' attitudes towards children with disabilities. Kritsotakis et al (2017) Greece To examine and compare undergraduate healthcare students' attitudes towards people with physical or intellectual disabilities in Greece. Descriptive cross-sectional survey. Nursing, Social Work and Medicine students (N = 1007, 79.4% female) attending three universities (Athens, Crete) completed during 2014-2016 two standardised scales regarding physical (ATDP-B) and intellectual disability (CLAS-ID). Descriptive and multivariate logistic regression analyses were performed. Attitudes towards people with physical disabilities in Greece (ATDP-B scores) were poor with scores just above the mid-point. Medical studies and higher knowledge and work with individuals with physical disabilities signified marginally more positive attitudes. Gender and age displayed no associations with attitudes. Regarding intellectual disability (CLAS-ID scores), nursing students had slightly less positive attitudes in "Similarity" but more positive attitudes in "Sheltering" subscales. Previous work and contact was related to more favourable and higher age to less favourable "Similarity" and "Sheltering" attitudes. Males had higher "Exclusion" scores. Those who knew people with intellectual disabilities had less favourable "Empowerment" attitudes. Knowledge was related to more positive attitudes in all four CLAS-ID subscales. 59 Ryan and Scior (2014). UK a review of research on medical students' attitudes to people with intellectual disabilities An electronic search of Embase, Ovid MEDLINE(R), PsycINFO, Scopus, and Web of Science was completed to identify papers published up to August 2013 The study suggested that medical students' attitudes to people with intellectual disabilities were responsive to interventions. However, the evidence is restricted due to research limitations, including poor measurement, self-selection bias, and the absence of control groups when evaluating interventions. Thus, there is a dearth of high-quality research on this topic, and past findings should be interpreted with caution. Future research directions are provided. James (2019). USA exploratory analysis of relationships between (i) attitudes towards individuals with intellectual disability, (ii) beliefs about the causes of intellectual disability, and (iii) beliefs about interventions that might be beneficial to individuals with intellectual disability with the goal of identifying trends and patterns that can be further evaluated in future research. Employees from an intermediate care facility in USA (n = 97) and undergraduate students (n = 92) completed measures on their attitudes, beliefs of etiological causes and endorsement of helpful treatments and supports. Participants reported few stigmatizing attitudes and high levels of support for interventions. Differences between employees and students emerged in regard to attitudes and causal beliefs, with employees reporting more support for sheltering and less endorsement of biomedical causes. Among students, those that reported knowing someone with intellectual disability reported less agreement with causal factors as well as differences in what supports were thought to be necessary or beneficial. Scior et al. (2013) Kuwait This study examined awareness of intellectual disability, 537 university students in Kuwait and 571 students in Medium to significant differences between the two samples were observed on seven of the causal items, and 10 of the intervention items. Against predictions, social distance did not differ. Causal beliefs 60 causal and intervention beliefs and social distance in Kuwait the UK completed a web-based survey asking them to respond to a diagnostically unlabelled vignette of a man presenting with symptoms of mild intellectual disability. mediated the relationship between recognition of intellectual disability and social distance, but their mediating role differed by sample. Iheanacho,et al 2014) Nigeria This study compared beliefs about and attitudes to mental illness among medical and nursing students at two teaching hospitals in Nigeria Factor analysis of responses to a 43-item self-report questionnaire identified three domains: social acceptance of people with mental illness; belief in non-superstitious causation of mental illness; and stress, trauma and poverty as external causes of mental illness, with entitlement to employment rights Students at the hospital with a larger, functioning psychiatry department had significantly higher scores on all three factors. Culturally enshrined beliefs and attitudes about mental illness are not uncommon among medical trainees. The availability of psychiatric education and services may have a positive effect on beliefs and attitudes. Table 7: shows the charted studies. 61 The following sections critically explore the literature following the scoping review and build the background and emerging picture which inspired this thesis. As a result of the dominance of nurse education by Whiteness, which was established in the last chapter, this chapter will critically consider African knowledge and concepts about causation of intellectual disabilities and mental illness. The first step in answering the research question; What is the influence of nurse education on the indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin? was to explore the extent to which the literature covers African belief systems about intellectual disability and mental illness. 2.3 Section 2 2.3.1 Indigenous Knowledge Systems Moachi (2007) posits that indigenous knowledge includes ideas and practices that are peculiar to a particular community and embody the community’s identity and ways of surviving and maintaining the environment they find themselves. This is further expounded by Oduro et al. (2008 p.9) who argue that ‘there is an African way of understanding the world, the visible world around us including the unseen world, the supernatural world of spirits, powers, and diseases. Owuor (2007) accentuates the term ‘Indigenous knowledge’ as referring to a process of learning and sharing social life, histories, identities, economic, and political practices unique to each cultural group. The proximity of most African communities to each other may imply that they share similar ideas, beliefs, and behaviours although this differs for larger cities due to urbanisation and digital technologies. The word ‘Indigenous’ has often been used to refer to specific groups of people defined by ancestral territories, collective cultural configuration, and historical locations (Angioni 2003; Turay 2002). Indigenous knowledge is seen as multifaceted bodies of knowledge, practices, and representations that are maintained and developed by peoples with long histories of close interaction with the local natural environment (Owour, 2007). Additionally, Mapara (2009) further asserts that it is a body of knowledge of the Indigenous people of geographical areas that 62 has survived for an exceptionally long time. These knowledge forms are known by other names, and among them are indigenous ways of knowing, traditional knowledge, indigenous technical knowledge, and rural knowledge as well as ethnoscience or people’s science (Mawere 2010). This thesis accepts all the definitions of indigenous knowledge offered here and will use indigenous, knowledge for consistency. Mapara (2009) advances that indigenous knowledge systems are bodies of knowledge of the indigenous people of particular geographical areas that have survived for an exceptionally long time, developed through the processes of acculturation and kinship relationships that societal groups form. Moreover, indigenous knowledge systems harness and spread indigenous knowledge (Mkabela 2005). Mawere (2010), identifies indigenous knowledge systems simply as pieces of knowledge originating locally and naturally. This distinction shows one to be a body of knowledge whereas the other is a system which includes the techniques and the methods used by the communities to harness that body of knowledge. As a knowledge system, African knowledge is characteristically oral and passed on from generation to generation in the context of community living and activities (Mkabela 2005). Unlike Western knowledge, which is stored in records, written and electronic, African knowledge has survived through millennia and stood the test of time despite the lack of records. In summary, indigenous knowledge systems are a process of learning and sharing social life, histories, and identities, unique to each cultural group. They are framed as the complex set of activities, values, beliefs, and practices that have evolved cumulatively over time and are active among communities, lay people and groups who are the practitioners. Indigenous knowledge and indigenous healing refer to those local, time-honoured, traditional, and cultural ways of local people employing local knowledge to survive. Even though they may be local and applicable within the Sothern African setting, Indigenous knowledge systems may be based on evidence or essential scientific processes that are measurable. It is fair to conclude that within the local context, indigenous pieces of knowledge are of global interest for their heuristic, creative practicality, application, and contextualisation especially as the world is becoming globalised and the health workforce diverse. 63 2.3.2 Explanatory Models This section examines African explanatory models of illness and disability to ascertain why and how people come to believe what or who is responsible for their illness and disability. This section will also present the themes from the literature including help-seeking ways when a child is born with an intellectual disability or when someone has a mental illness. In addition, the section will explore traditional healing and offer an illustration of what might result from the encounter between traditional healing and modern Western medicine. This is crucial in addressing the thesis's aim of ascertaining belief systems held by African peoples. Kleinman (1980), proposes that a useful way of examining illness and disorder beliefs is through the use of explanatory models as they reflect the beliefs of individuals about an episode of illness or life condition that is its aetiology, cause, and effect. In addition, Kleinman (1984) recommended that a patient’s explanatory models of illness should be elicited using a mini-ethnographic approach. These ethnographies offer rigorous and valid phenomenological descriptions of indigenous illness syndromes as cultural experiences (Lewis-Fernandes and Kleinman 1995). Additionally, Argyris and Schon (1974) theorised that people construct the meanings they give to what they experience. People construct causal theories and beliefs over time from a variety of sources such as tradition, environment, family, media and experience. Fernandes and Kleinman (1995) further contend that the relationship between symptoms and illness is complex and that finding a superficial resemblance among symptom clusters across cultures does not guarantee that the same disorder is validly identified. Furthermore, Sorsdahl et al. (2010) argue that one way of examining the role of culture in psychiatric disorders is to elicit the explanatory models of traditional healers. This approach is based on the notion that reality is socially constructed. Kleinman’s (1984) view defines explanatory models as the notions about an episode of sickness and its treatment are employed by all those engaged in the clinical process. Explanatory models are formed from a variable cluster of cultural symbols, experiences and expectations associated with a particular category of illness (Patel 1995). They reveal sickness labelling and cultural idioms for expressing the experiences of illness and have been shown to influence health-seeking 64 behaviour and health service utilisation in line with the emic approach. Additionally, explanatory models are seen as particularly notable because they acknowledge the significance of patients' points of view as complementary to health professionals' assessments. In that sense, they refer not so much to formal structural or predictive models, but to the way, people think and speak, as a way of explaining illness (Helman 2004). This includes the unwritten Indigenous knowledge systems used by African people which are usually manifested in the beliefs brought into learning environments by students of Southern African origin. 2.3.3 Explanatory Belief Systems about Disease: An example of Epilepsy This section critically discusses the literature regarding African Indigenous belief systems about the causes of epilepsy as well as help-seeking behaviours. This is because epilepsy is the most common neurological disorder globally, affecting seventy million people with up to 90% living in African countries half of whom are children (Ngugi et al. 2012; Newton and Garcia 2010). The prevalence of epilepsy as well as underreporting and misdiagnosis are highest in poor countries, particularly in Sothern Africa (Kaddumskasa et al., 2018). It is imperative for this thesis that epilepsy is discussed as it is considered a misfortune and is comorbid with an intellectual disability. Epilepsy is a neurological condition that is particularly common in people with intellectual disabilities (van Ool et al., 2016; Fitzgerald and Ring 2009). Christianson et al. (2000) define epilepsy as a history of recurrent, unprovoked seizures, occurring in the absence of an identified acute brain or systemic insult. Amongst people with intellectual disabilities, there is a reported epilepsy prevalence of 16 to 44% compared to 0.4 to 1% in the general population (Bowley and Kerr 2000; McGrother et al. 2006; Morgan et al. 2003; World Health Organisation 2012). In addition, Emmerson et al. (2012) comment that the prevalence rate of epilepsy amongst people with intellectual disabilities has been reported as at least twenty times higher than for the general population, with seizures commonly being multiple and resistant to drug treatment due to the syndromes and associated physical health conditions. It is important to investigate the 65 belief systems of student nurses because they will encounter people with both intellectual disabilities and epilepsy. Reynolds (1988) claims that historically, epilepsy was believed to be a sacred disease that is the result of the invasion of the body by a god. It was thought that only a god could deprive a healthy person of their senses, throw them to the ground, convulse them, and then rapidly restore them to their former self again. Abulaban et al. (2012) posit that in Greco-Roman antiquity, in Judeo-Christian and in Islamic tradition, epilepsy has been thought of as an infliction or possession by a supernatural power be it a god or a demon. In addition, many communities in Africa believe that epilepsy results from witchcraft or possession by evil spirits (Teferi and Shewangizaw 2015; Ba-Diop et al. 2014; Groce and McGeown 2013; Ndlovu 2016). Epilepsy is more prevalent in many African regions particularly rural areas that have limited resources for diagnosis and treatment (Wilmhurst et al. 2014). Christianson et al. (2000) comment that it is not unusual for people with epilepsy in African countries not to receive effective orthodox Western anti-epileptic management due to the limited availability of the medical workforce and deficiencies in the training of doctors. Additionally, differences in beliefs concerning causation and the management of epilepsy render the Western model of epilepsy management inappropriate. More importantly, views about causation are worth exploring especially within rural communities because they hold traditional views more than those in cities. This section culminates with a classic example of what happens when people who hold Indigenous belief systems about epilepsy have a remarkably close encounter with a hospital with professionals who are trained within the Western model. This scenario resonates with the popular book The Spirit Catches You and You Fall Down: by Anne Fadiman chronicling the life and times of a Hmong Child Lia Lee, her parents and her American doctors, which highlights the struggles of the Hmong refugee family from Houaysouy, Sainyabuli Province, and their interactions with the medical system. This article is the text of the informal talk given by Anne Fadiman at the American Epilepsy Society Symposium Epilepsy and Quality of Life: Spanning Cultures and the Life Cycle in December 1999. I attach the original excerpt from the Supplement for the reader as Appendix J. 66 This story highlights the importance of the need for professionals to think about strategies that address cultural beliefs before conveying their own scientific findings or professional beliefs. Lia’s story is a prime example of when two spheres, medical and cultural come together but yield catastrophic outcomes due to a lack of mutual understanding. For Southern Africans who observe traditional views about intellectual disability and mental illness, professionals need to offer them support to understand the benefits of accessing medical help despite their traditional beliefs. Professionals too need to be working in partnership with them to avoid raising mistrust issues between medical professionals and the services they offer. 2.3.4 Local beliefs about ‘disability’ in Africa Having explored witchcraft, the thesis will explore how disability and illness are viewed from an African perspective. This is crucial in understanding how African peoples understand disability and the beliefs they attach to it. In the family of Southern African Bantu languages, the word 'lema' or 'rema' is prefixed by the object or animal-referent 'ki', 'chi' or 'isi' (for 'it') examples of seminal works are by (Burch 1989; Devlieger 1998). Table 8 below shows some examples of how the word stem is prefixed and given meaning in the selected languages. (Please see Table 8 below) Word Language and country kilema chirema isilima Kiluba, Kisanga, Songye languages: Angola, Congo, Zambia Shona: Mozambique, Zimbabwe Ndebele or Nguni: Malawi, South Africa, Tanzania, Zimbabwe Table 8: Examples of the word disability in Bantu languages The human-referent 'mu' as in 'mulema' (for example, in Kiluba, Kisanga, and Songye languages) is used to refer to someone with a disability (Burch 1989; Devlieger 1998). It is fair to suggest that Sub-Saharan African conceptions of disability consider a person with a physical disability as at the 67 borderline between a human being and an animal (Devlieger 1998). Disability is used to refer to limitations resulting from dysfunction in individual bodies and minds but perhaps the core meaning of disability for most of us is a biopsychological one; blindness, lameness, mental deficiency, and chronic incapacitating illness (Whyte and Ingstad 2020). In most of Africa, disability is often seen in the physical or observable presentation of the person implying stupidity and an inability to function. 2.3.5 The Power of Witchcraft in Africa This section critically explores ‘witchcraft’ from the perspective of an African person. Having introduced African knowledge systems, this following section explores witchcraft to enhance how illness and misfortune are best understood within this perspective. You will note the word is in single quotation marks because this is an English word being used for an African concept. My disclaimer here is that when l explore this subject, l do so in English and yet l am thinking in ‘African’. As an adult male born and raised in Southern Africa, my worldview of ‘witchcraft’ is based on my earlier understanding of the concept. More than half of my life as an adult has happened in Europe, yet l find that my thinking about witchcraft is still based in Africa. When one is an African, witchcraft is not something to be ignored whether one believes it exists or not. There is an African way of thinking and talking about witchcraft. I will look at witches, the practitioners of witchcraft and traditional healers, the ones who undo the effects of witchcraft. The palpability of witchcraft in Africa is undeniable (Obiwuru 2019) and belief in mystical powers prevails in every African village and township. In Africa, belief in the presence and work of evil powers, especially witches, is pervasive; most African traditions conceive of the universe as alive with spirit powers, a place in which evil is hyperactive (Asamoah Gyadu 2015). Geschiere (2013) suggests that witchcraft has become so generalised in everyday language that its meaning becomes increasingly vague and limitless; yet, to impose clear definitions and categorisations would also limit the fluidity of witchcraft and falsely constrain the diffuseness of the discourse that is the secret of its power. In addition, Roxburgh (2018) comments that as researchers, we are perpetually defining and describing witchcraft because it is shifting and fluid and, as a result, 68 it is never certain that the same phenomenon is being discussed across all contexts, languages, interpretations, experiences, and cosmologies. This thesis, though keen to eventually portray witchcraft from the true African perspective, will offer some definitions from the literature not to dilute the phenomenon but to establish a mutual understanding held by researchers. Addressing the different definitions of the term 'witchcraft,' Atata (2019) argues that due to different practices and labels appended to witches from country to country, no clarification or meaning of witchcraft has been embraced. This thesis needs to establish to the reader from the outset that the concept of witchcraft is understood from the African worldview. Asamoah-Gyadu (2015) claims that supernatural evil and witchcraft are prevalent in the worldview of Africans. In its broadest sense, witchcraft is an attempt to make sense of, and deal with, the afflictions of a world dominated by unpredictable occult forces, and to secure an agreeable personal and social life. It is part of a magic worldview (Leistner 2014). Saunders (2003) views witchcraft as a construct of modernity that addresses tensions within society and provides an explanation for events, which have no logical explanation, such as illnesses, sudden death, misfortune, bad luck, and crop failure. Correspondingly, Debrunner (1959) a church historian, in his seminal work, defines witchcraft as the idea of some supernatural power of which human beings become possessed, and which is used exclusively for evil and antisocial purposes. Carter (2018) notes that witchcraft refers to the following: “worldview, “religion” and “practices” which are associated with the use of rituals that are believed to harness and focus cosmic or psychic energies to bring about some desired change. To Africans, witchcraft is seen as real and has existed for many years, to some it is a way of being, and to others a way of life while a way of seeing and viewing the world to others. This thesis accepts all the above definitions as they all point to occult forces, mystical in nature, operating within the realms of evil machinations by evil agents, usually called witches who possess powers to bring evil and misfortune. For the purpose of this thesis, witchcraft refers to ideas about dangerous occult power in social contexts where misfortune is attributed by many, if not most members of society to the alleged mystical powers of individuals referred to as “witches” (Stabell 2010). This is to help uncover the Indigenous belief systems of which witchcraft is a part and seen as a cause of intellectual disability or a mental illness or disorder. 69 Evans-Pritchard, the founding father of studies of witchcraft, set the stage for future studies of witchcraft in Africa. Evans-Pritchard (1937) is known for making the distinction between witchcraft and sorcery when he lived among the Azande of Sudan studying their witchcraft beliefs. He built up an incredible discourse on witchcraft in his work on the Azande, where witchcraft was portrayed as a social function, with the conclusion that witches do not exist. Hence, witchcraft is only imagination and not possible (Atata 2019). Azande people distinguish clearly between witches and sorcerers (Evans-Pritchard 1937). He further noted that the Azande people believe that some people are witches and can injure them under an inherent quality and that sorcerers may do them ill by performing magic rites with bad medicines. Evans-Pritchard further expresses that for the Azande community, witchcraft is viewed as an inborn quality of social function which can also be acquired (Atata 2019). Evans-Pritchard’s work, recognises the Western considerations of the unreality of witchcraft, describing it as simply an imaginary offence that cannot be proven (Pels 1998). In his seminal work on witchcraft in Africa, Evans-Pritchard (1937) does not indicate the Azande witches of Sudan as experiencing witch hunt as it was in European societies because Azande witchcraft was different from European witchcraft (Kapferer 2002). Conceptually, witchcraft differs from one African society to another hence scholars like Mesaki (1995) have argued that Evans-Pritchard never generalised his discoveries to all African societies but confined them to the Azande people. In his findings, Evans-Pritchard reported that if you take the initial premise of a belief in the supernatural, then all that follows is perfectly valid and sensible. This belief underpins a presumption among scholars that the concept of witchcraft was a Western invention, simply imposed onto Africa. Therefore, the general understanding and description of witchcraft by Western academia, colonial churches and rulers are shaped in the context of power processes in Africa. For this reason, this thesis will accept the African understanding of witchcraft because the focus is on the understanding of witchcraft beliefs by Southern African-born student nurses. The European view is strongly rejected as it does not appear to acknowledge the power of witchcraft as a phenomenon in Africa. 70 Before the rise of Christianity, beliefs in witchcraft existed at the popular level in Europe (Diwan (2004). The Cambridge International Dictionary of English (1996), definition of witches was of women believed to have magical powers and use them to harm other people. Narratives of witchcraft in European societies were mostly about evil women, and such women experienced killings on a large scale whilst at the same time such analyses exclude men as potential witches (Wyk, 2004). Nelson (2020) postulates that the fear of witches, witchcraft, and bewitchment originated in the medieval period when the Roman Catholic Church taught the dangers of witchcraft and printed texts that illustrated the horrors of witchcraft. With the rise of Christianity during the Dark Ages, popular pagan beliefs in witchcraft were frowned upon and suppressed by the church elite in the sixteenth and seventeenth centuries (Diwan 2004). Witches were women who were marginalised by their communities and the witch trials were a large-scale attempt to rid women of the powers that they held. This shows that Europe did hold beliefs in ‘witchcraft’ in its history therefore, it cannot be underestimated or disregarded from an African perspective. When modern scientific insights began to evolve, witchcraft belief and witchcraft violence prevailed in Europe no less than in Africa today (Leistner 2014). During the Middle Ages, religious institutions exploited pagan beliefs in witchcraft, constructing an organised, systematic demonisation of witchcraft giving rise to an anti-witch frenzy (Diwan 2004) with between 40 000 and 60 000 alleged witches killed, usually burned at the stake between 1450 to 1750. Diwan (2004) comments that witch-hunts in early modern Europe were an attempt by organised religion to control certain segments of the population by accusing non-conformists of practising witchcraft. During the witch hunt craze in Europe, witches were identified to be women, and witchcraft was defined as concerning the female gender. Even pre-colonial African societies had the experience of witches but knew how to live with them where witches and witchcraft were part of their everyday reality (Wyk 2004). Colonialism tried to eradicate witchcraft in Africa without success as it remains present to this day. Isiko (2018) and the World Bank (2004) affirm that in pre-colonial Africa, traditional medicine was the only healthcare system. Additionally, Leistner (2014) asserts that under colonial control, traditional medicine practice was equated to witchcraft and seen as contrary to the ideals of the pre-eminent colonial religion and Western medicine. Bauer (2017) suggests that some sceptical 71 Westerners question if there is such a thing as witchcraft, largely as a result of their secular, enlightenment worldview. Pels (1998) in his recollection of Western thought about witchcraft, states how colonial European rulers ruled out the reality of witchcraft in Africa but moved on to enact witchcraft ordinances to regulate it. There existed a defining point of difference between pre-colonial societies of Africa and medieval Europe regarding witchcraft. The former attributed witchcraft to intra-group conflicts and competition for leadership and resources, whereas the latter noted witchcraft to be the practice of magic aimed at manipulating nature for the benefit of the practitioner or his/her client (Mesaki 1995). Geschiere (2010) also discusses how the French, British and Belgians challenged the reality of witchcraft, accusing healers of defamation and disturbance of the peace. Russell and Lewis (2016) suggest that witchcraft is a mere imagination and a stereotype held by contemporaries. The belief in witchcraft was therefore categorised as irrational and unreliable and its practitioners were mere charlatans and mentally sick (Mufuzi 2014). To Africans, witchcraft is a reality of existence even in the 21st century and is a real phenomenon. Isiko (2018) posits that in several societies in Africa, there exists no dichotomy in witchcraft: with one being good and another bad. In general, witchcraft is a term used to describe the evil that some people inflict on others (Wyk 2004). The fact that African forms of witchcraft did not resonate with Western forms of civilisation, was the basis for its misconception (Isiko 2018). Europeans, now took it upon themselves to define and redefine what was African in nature, using Western models of a civilised society; this is known as a cultural imposition. It is also common to categorise all mystical African scientific practices and supernatural-influenced activities in Africa as witchcraft, whether done for the good or bad of society, transforming the erroneous categorisation of witchcraft into bad or good (Bauer 2017). As a result, the criminalisation of witchcraft became a colonial invention in Africa, a result of Western Imperialism, unheard of in pre-colonial African societies (Diwan 2004). The fear and ostracisation of witches were introduced by European colonial rulers, as an extension of the witch hunt craze prevalent in medieval Europe (Bauer 2017; Mufuzi 2014). This was Europe’s attempt to colonise the African mindset forcibly, imposing Western views in an African setting, potentially 72 introducing resistance and pain that would last for the entire colonisation process and beyond it. Diwan (2004) asserts that witchcraft was practised by cunning folk, a term for practitioners of ‘white’ magic whose practice involved the use of charms and supernatural forces for fortune telling, fertility rituals, healing, the casting of spells, the making of storms, conversing with spirits, and sympathetic magic. The second important characteristic of witchcraft is that witches operate in secrecy, their victims oblivious to it (Hutton 2004; Isiko 2018). It is the belief in its supernatural nature which gives witchcraft a ‘respected’ standing from an African perspective. Mbiti (1969) observes that when it comes to African societies, they do not often draw the rather academic distinction between witchcraft, sorcery, evil magic, evil eye, and other ways of employing mystical powers to harm anyone or their belongings. Both healers and witches draw their powers from one of three sources: (1) inheritance of abilities from ancestors, (2) training by skilled masters and (3) direct communication with higher powers such as the ancestors or spirits. Examples of these higher powers include the caul in Ireland; being struck by lightning in Latin America and sympathetic magic and epilepsy in some societies including the Hmong. Yet the line between healing and witchcraft is thin and often crossed (Leistner 2014). In Africa, the witch personifies the dark side of traditional African society with the ability to destroy human life and well-being by manipulating the evil occult forces which they embody. The witch uses harmful medicines, charms, magic and any other means or devices for causing illness, misfortune or death to persons or animals, and also for attracting hailstorms or causing a lack of rain (Leistner 2014). This thesis is concerned with the predominant negative aspect which is usually the attributable cause of intellectual disability and associated comorbid conditions such as epilepsy and mental illness. Leistner (2014) argues that whereas the terms ‘witch’ and ‘sorcerer’ are often used interchangeably, the distinction is usually made that witches operate with their inherent or inborn occult power, whereas sorcerers lack such power but apply magical means such as incantations, substances, or instruments. Correspondingly, Rain (1982) suggests that healers and witches alike utilise magic which has been defined as the manipulation of persons and things using objects, words and acts thought to give one access to supernatural powers for either good 73 or evil purposes. Conversely, the African traditional healer stands for Africa’s positive and helpful aspects taking the role of doctor, psychologist, and pastor, women practising as diviners diagnosing the ills of those seeking her/his help via the provision of treatment and remedies such as plants, herbs, powders, bones, seeds, roots, juices, leaves, liquids, minerals, charcoal, and the like. 2.3.6 Help-seeking behaviours So far, this thesis has claimed that most of the African population has for centuries relied heavily on a system of indigenous healthcare knowledge to treat physical and mental disorders. On top of that, the discussion has already offered an introduction to traditional healers and the role they play in the African healing system. This section further explicates traditional healing and will chart the impact of the practice, its regulation or lack of it, and accentuate the role of its practitioners in African communities when seeking help with intellectual disabilities and mental illness. The social and cultural milieu of African societies is surrounded and influenced by beliefs in supernatural deities, witchcraft, sorcery and magical powers, particularly concerning complex illnesses (Abasiabong et al. 2009). Miner (1956) authored the paper "Body Ritual Among the Nacirema". In this article, Miner highlights how attitudes about the body influence many institutions in Nacirema society. For the benefit of the reader, Nacirema is American spelt backwards. The magical beliefs and practices of the Nacirema, an imaginary tribe, are presented in very unusual terms when seen from an outsider’s point of view showing that the culture of these people is still very poorly understood. For the benefit of the reader, Nacirema is American spelt backwards. Miner (1955) highlighted the fundamental belief underlying the whole Nacirema system as showing the human body as ugly and that its natural tendency is to suffer debility and disease. The Nacirema believe that man's only way of avoiding these characteristics is through the use of ritual and ceremony practised in shrines devoted to this purpose. The main point of Miner's exercise is to demonstrate the presence of ritual in High-Income Countries like the USA. A lesson 74 that we learn is that if we distance ourselves and our point of view, a culture will always look peculiar to us, however, when looked at from within, even the strangest customs and practices might seem completely reasonable and justifiable. It serves to demonstrate the topic of cultural relativism, arguing that there is no one objective viewpoint from which to assess cultures and that every culture should be understood and interpreted from the native's point of view. This exercise demonstrates that even those cultures believed to be based upon rationality still have ritualistic behaviour. Traditional African medicine is often the first intervention for many people in African countries. Its practitioners form a large part of the healthcare labour force in these countries because it is built on the beliefs, values and norms which are traditional or peculiar to specific communities (WHO 2013). Due to poverty and lack of enough accessible healthcare, there is limited access to biomedical healthcare services in these countries, and the use of traditional and alternative medicine is common (Abera et al. 2015; Christianson et al. 2002; Gureje et al. 2015). In comparison to Western populations, African patients may be more likely to attribute illness to a spiritual or social cause rather than a physiological or scientific cause hence the choice of traditional medicine; a concept referred to as the Hierarchy of Resort. Romannucci-Ross (1969;1977) postulates that there exists a "hierarchy of resort" in which people first try one thing and then try another until their condition is fixed to their satisfaction. This concept claims that treatment choice can follow a hierarchical sequence, but patterns of resort often involve many treatment modalities at once. Further, people do not necessarily adhere to all the official rules related to each type of treatment as they will often combine recommendations finally creating a regimen that they feel is right for them. The importance of this is seen in health seeking as being a dynamic process; people constantly re-evaluate their symptoms and revise their healthcare plans. Nortje et al. (2016 p.156) define traditional healers as those “who explicitly appeal to spiritual, magical or religious explanations for disease and distress”. In pre-colonial Africa, traditional healing occupied an important place in socio-political systems. In Southern Africa, while most people associate traditional medicine with herbs, remedies, and the advice of the sangomas or 75 izinyangas (Richter 2003), for illnesses attributed to supernatural forces, healers frequently combine magico-religious rituals and empirical techniques in their curative strategies (Workneh et al., 2020). These empirical techniques are based on African knowledge systems. Beck (1979) suggests that in trying to establish a history of the African healer during the early years of British administration in Tanzania, one must rely on the use of raw materials. This may be extracted from valuable though isolated bits and pieces of archival sources as well as occasional articles in scientific and more general journals. In this search, one discovers with surprise that the African healer aroused quite a bit of curiosity on the part of those who met him in their medical work or as administrators. Traditional healers are an important part of the informal health system throughout Africa and in many other low-income countries (Ovuga et al.1999; Kajawu et al. 2015). It comes as no surprise that the White colonialist found it difficult to understand the mystery surrounding the traditional healer in Africa which may explain why they were viewed not only with mystery but suspicion as well. The next section discusses the regulation of traditional healers and explores ethical and safety issues associated with the practice. The need to regulate traditional healers in most African countries rose out of concern for equality which was at the root of many governments’ attempts to start reintroducing traditional practices. These practices had been dismantled by colonialism (especially by the Apartheid system in South Africa) which had labelled traditional healing as ‘witchcraft’ or ‘wizardry’ and as an inefficient tool for curing the ill (Richter 2003). This may have been viewed with disrespect for African traditional beliefs and healing systems, however, regulation is necessary for the protection of consumers. Indeed, in many African countries, most governments regulate their traditional healers and this thesis advocates for the regulation of traditional healers for the protection of the users of the practice. Moagi (2009) posits that the decision reached by governments concerning the inclusion and regulation of traditional practitioners was to preserve and protect the traditional knowledge that has been neglected by the previous regime and to respect and uphold the tradition that had been in existence for centuries. Most colonialist regimes had drafted policies to discredit traditional 76 healers and neglect the health care of the African population. This resulted in generating more doubt and general disrespect for African culture and tradition. Moreover, it discouraged the African population from consulting with traditional healers and created discriminatory health provision measures and in some cases biopiracy. This led to the insulation of traditional practices for many years, preventing the healers from obtaining professional recognition among the African people who consult with traditional health practitioners (Department of Health South Africa 2013). In South Africa firstly, the Traditional Healers Act (2007) sets out a formal legal regulation process/procedure such as the registration of healers by the South African government. This seeks to provide the patients of traditional health practitioners with protection from mistreatment and malpractice and reaffirm constitutional commitments to the promotion of cultural diversity and tolerance of difference (Hansard 2014). As with most Southern African states, this was the direction taken by governments following independence. Although there are debates about problems with the regulation and recognition of traditional healing, that argument is beyond the scope of this thesis. However, it could be argued that using the same procedures and standards that are Western based, such as how nurses and doctors are regulated will create problems in African settings. Regulation of traditional healers can prevent the unethical practices associated with faith/traditional healing, which are not widely associated with methods that rely on physical or humoral explanations (Green and Colluci 2020). Keikelame and Swartz (2015) point out that traditional and biomedical practitioners in South Africa suggested that lack of regulation was a barrier to effective collaboration while doctors who see traditional medicine as lacking scientific validity also have called for its regulation (Kayombo et al. 2007). Additionally, traditional healers themselves expressed frustration that their knowledge was not respected and some presented regulation as a means of professionalising healers so that they could be recognised as ‘legitimate partners’ in healthcare provision (Campbell-Hall 2010). Traditional healing has become state-sanctioned and offered as a training programme in higher educational settings, for example, Ayurvedic medicine, homoeopathy, Chinese Traditional 77 Medicine, Acupuncture and Zimbabwean Traditional Medicine (Ministry of Health and Child Care (online). This ensures that as a practice and system, traditional healing continues to maintain and command the respect and loyalty of its consumers. It is worth noting that in some societies there is a two-way referral system where one may need to refer to the other. The practice of traditional healing has previously been associated with abusive acts including chaining, and beating of people which are an infringement on a patient’s human rights causing severe suffering and the development of further mental and physical disabilities (Green and Colluci 2020). In some cases, there still is a widespread view of healers as charlatans in the entire traditional healing sector where the WHO. has suggested working more closely with ‘informal’ healthcare providers, including traditional healers, to widen access to care (WHO 2015). Proponents of traditional healing assert that it is important to cultural belief systems, particularly in Africa (Ashforth, 2005), and is viewed as essential for treating health problems biomedicine cannot cure (Mander et al. 2007). Besides, some societies still can neither access nor afford biomedicine where the traditional African healer is readily accessible. Additionally, W.H.O. and Alma Ata Declaration advocate for collaborative work between traditional healers and bio medics. This section has explicated traditional healing, charting the impact of the practice, its regulation and the role of its practitioners in African communities when seeking help with intellectual disabilities and mental illness. The next section will critically examine stigma. 2.3.7 Stigma Goffman (1963) assets that stigma occurs when an individual with an attribute such as intellectual disability or mental illness, which is deeply discredited by their society, is rejected as a result of the attribute. Prevailing cultural beliefs link the labelled person to undesirable characteristics and to negative stereotypes; labelled individuals are then placed into distinct categories (‘us’ and ‘them’) through the process of separating, resulting in loss of status and discrimination. These factors apply to people with intellectual disabilities (Link et al.2004). Prevailing cultural beliefs link the labelled person to undesirable characteristics and to negative stereotypes; labelled 78 individuals are then placed into distinct categories (‘us’ and ‘them’) through the process of separating, resulting in loss of status and discrimination (Kock et al. 2012). Due to their disabilities, people with intellectual disabilities face social exclusion, stigma, discrimination, and human rights violations across a multiplicity of low-resource settings, in Africa (Roy et al. 2021). Additionally, beliefs of supernatural causations of intellectual disability are persistent in many African countries, potentially triggering negative attitudes and severely affecting the life chances of persons with intellectual disabilities, as they are, for instance, hidden at home out of shame (McKenzie et al. 2013). This not only affects the collection of data about numbers of people with intellectual disabilities but will continue to perpetuate all forms of supernatural causation beliefs. In the UK, there have been several national campaigns to reduce stigma against people with intellectual disabilities. This has also been seen through the publication of ‘Valuing People’ (Department of Health, England, 2001), ‘Valuing People ‘Now’ (Department of Health, England 2009) both of which promote the principles of ‘rights, independence, control and inclusion’ of people with intellectual disabilities, including the use of mainstream services used by the general public. These are also closely linked with legislation; Equality Act (2010) and the Human Rights Act (1998) which both aim to improve equality across disability and other groups. This creates an awareness of the rights of people with intellectual disabilities so that reporting acts of discrimination and stigmatisation would be more likely. Whilst some Southern African countries may have some of the most comprehensive legislation to protect and promote the rights of disabled people in the world, policy implementation remains a challenge (Kock et al. 2011). In Zambia, for example, there is a lack of a specific national policy exclusively for people with intellectual disabilities (Mung’omba 2008). Therefore, these drivers and initiatives have yet to be driven forward in Southern Africa as there is evidence of widespread discrimination of people with intellectual disabilities and mental illness (Kock et al. 2011). There is still an active desire to segregate people with intellectual disabilities from society due to deep rooted prejudice, misconceptions and stigmatising beliefs about the causes of intellectual disability (Scior et al. 2020). This public display of stigma and discrimination is an indication that 79 the African philosophy of Ubuntu is neglected in this instance, negating the spirit of respect for other human beings. When considering stigma in Africa, studies have demonstrated the presence of such attitudes in most African countries, hypothesising that they are informed and reinforced by traditional, cultural, and religious beliefs about the causes of mental illness (Gureje et al. 2006). Stigma and cultural beliefs have been shown to inhibit help-seeking behaviour (Segal et al. 2005). Associating witchcraft with mental illness in much of Southern Africa reflects the ongoing influence of cultural and magico-religious beliefs (Lauber and Rossler 2007), highlighting the need to incorporate culturally relevant teaching interventions in the nursing curriculum. Afrocentric cultural values consist of a set of beliefs, values, and assumptions founded on African cultural traditions that relate to definitions of the self, others, and the relationship of the self with the environment (Utsey, et al. 2000). The plurality of values is considered to be a constitutive feature of modern societies therefore, different values create central issues such as prejudice and discrimination against dissimilar cultural habits; a sense of shame, conflict over religious duties, which can result in serious ethical dilemmas in medical practice and including nursing practice too (Ilkilic 2007). It is fair to suggest that when nurses are unaware of the value systems of people in their care, as well as family expectations about roles and relationships, a disconnect can occur, creating serious ethical dilemmas with deleterious outcomes. There is a need when supporting student nurses with different belief systems to be supported safely and competently by academics and educators. 2.3.8 Chapter Summary This chapter began with an outline of the literature searching process followed by a critical exploration of African Indigenous belief systems. Following that was a critical analysis of beliefs about illness causation and help-seeking ways including examples of situations when Indigenous beliefs about treatment clash with Western models. The chapter then reviewed the extent to which the existing research literature has evaluated Southern African peoples’ beliefs and level of knowledge and understanding of intellectual disability and mental illness. The third section addressed Indigenous knowledge systems of Southern African Bantu people followed by an 80 exploration of the themes found in the literature: Explanatory Models with an example of an explanatory model for epilepsy. This was followed by beliefs about disability in Africa, the power of witchcraft in Africa, help-seeking behaviours and Stigma towards people with intellectual and mental illness. The next chapter considers how the study was conducted by addressing several research processes followed for this thesis. 81 Chapter 3 – Methodology 3.1 Introduction The last chapter explored the literature to identify themes about beliefs regarding causation of intellectual disabilities and mental illness. This chapter describes the overall conduct of this study and will begin each section by examining the definitions of the key terms and then move to how they were applied to the research. The author will address several aspects namely cosmology, ontology, epistemology. The chapter introduces paradigms, further exploring concepts relating to positivism and interpretivism as the two paradigms that underpin quantitative and qualitative methodologies, respectively. The author will offer a rationale for their orientation to the research process, positioning their critical scholarship by considering epistemology and explaining the methodology used in the research, arguing that phenomenology was the most suitable approach to provide answers to the question of: What is the influence of nurse education on the indigenous belief systems about intellectual disability and mental illness on student nurses of Southern African origin? This is followed by an overview of methods, as well as a consideration of the data collection process. Furthermore, the author offers an analysis of the sampling method for the selection of research participants followed ethical reporting for this study. A consideration of triangulation will be offered followed by a critical examination of the data analysis process. The chapter further offers a detailed discussion of how data was analysed the data using thematic analysis. The chapter then concludes with a detailed discussion of insider bias. This section explores the philosophical perspectives underpinning research in general as well as this research and rationalises the methodological approaches of the qualitative methods used by the researcher in the study. If the reader understands the philosophical basis for the research and the position of a researcher this will help to recognise the way people understand and explain what they know, which is considered critical in the process of developing and designing research (Saunders et al. 2015). Collis and Hussey (2014) assert that philosophy is a system that reflects the researcher’s 82 own beliefs and worldview on the fundamental nature of knowledge, reality, and existence of the researched. This section serves as a critical review that addresses and clarifies the fundamental aspects of scientific inquiry which will culminate in the researcher’s chosen methods for this research. It is important to start by acknowledging that a research paradigm consists of several components including ontology, epistemology, methodology, and methods. ‘Researchers should begin their inquiry process with philosophical assumptions about the nature of reality, how they know what is known, the inclusion of their values, the nature in which their research emerges, and their writing structures’ (Creswell 2003 p. 238). 3.2 Cosmology Cosmology refers to one’s worldview and in essence this influences how a researcher approaches a study design (Mafuba and Gates, 2012). Cosmology is the framework of concepts and relations which man erects in satisfaction of some emotional or intellectual drive, for the purpose of bringing descriptive order into the world, including himself as one of its elements (Nwala 1985 p 7). Cosmology is understood to be about one’s worldview particularly in relation to our environment and that one’s understanding of cosmology will accordingly reflect one’s sociological, philosophical or scientific predilections (Nwala, 1985, p.7). Together, they constitute a cosmic, religious worldview and its philosophy, from which can be identified an economy of affection and the utilisation of resources that aims to provide for the people in Bantu kinship systems. Ultimately, one’s ontological perspective, and worldview, are both heavily influenced by my understanding and embodiment of African cosmology. Cosmology directly influences one’s ontology, or the claims, and assumptions the researcher makes regarding the nature of social realities, assumptions about what exists, and what that existence looks like, and how what exists interacts with each other (Blaikie, 2000). Encapsulated in this view is the Ubuntu philosophy that is captured in the inclusional phrase, “I am because we are”, prevalent across Southern Africa where the researchers sees their relationship to the world and their knowledge as directly 83 connected with those around them. Central to the African worldview is the strong orientation to collective values and harmony rooted in a collective sense of responsibility – a ‘collective ethic’ – which acknowledges that survival of the group derives from harmony through interdependence and interconnectedness (Mkabela 2005; Sarpong 2002; Sarpong 1991). 3.3 Ontology Slevitch (2011), Snape and Spencer (2003) and Scotland (2012) hold the view that ontological assumptions are concerned with what constitutes reality. Ormston et al. (2014) further postulate that ontology concerns the question of whether or not there is a social reality that exists independently from human conceptions and interpretations and closely related to this, whether there is a shared social reality or only multiple, context-specific ones. Ontology enables one to examine one’s underlying belief system and philosophical assumptions as the researcher, about the nature of being, existence and reality. Philosophical assumptions about the nature of reality are crucial to understanding how one makes meaning of the data one gathers. These assumptions, concepts or propositions help to orientate the researcher’s thinking about the research problem, its significance, and how one might approach it to answer the research question, understand the problem investigated and contribute to its solution (Kivunja 2017). It can be concluded, therefore, that ontology concerns our beliefs about the kind and nature of reality and the social world (what exists). Almeida (2013) proposes that ontology addresses the question of what it means to exist. Common in any indigenous paradigm is a relational ontology (Kovach 2012). The assumption in a relational ontology is that the reality that is investigated can be understood concerning the connections human beings have with the living and the non-living (Kovach 2012; Wilson 2008). People have connections with the land, the earth, animals and with other beings. Among the people of Southern Africa, the place of origin of all the participants in this study, the nature of ‘being’ is captured in the adage I am because we are. Aristotle was an important early influence on the development of ontology as he focused on beings rather than the idea of ‘being’ in a more general or abstract sense. However, Descartes, building on this ontological position, proposed 84 scepticism about taking the evidence of the senses at face value, and instead proposed that ‘I think, therefore I am’ should be the foundational basis for ontological thought; this led to the establishment of mind–body dualism (Descartes 1637;1641). This view premises human existence and essence on the ability to think, and thus act reflectively and reasonably (Apiah and Kodah 2020). The indigenous African society believes in the bond between the living and the ancestors and that Indigenous healers have the gift and ability to connect the consulting individual and his or her ancestors through the spirit (Scheidegger 2009; Gumede 1990 and Marsella; Yamada 2000). Predicating this principle, African reality as based on the African worldview is influenced by African ontology and epistemology, hence knowledge should consider the situation of the African (Nwogbo 2017). African ontology is concerned with the spiritual world and the forces that play a role in it because Africans regard supernatural causes as the explanation for everything. Western thought is mainly intellectual (riddled with ritualistic thought and behaviour), devoid of emotional content whilst African thought, on the contrary, is more involved, more personal, emotionally affective, and expressive (Thabede 2008). Ontology's fundamental precept is that everyone needs a theory of existence to determine their way of living in the world, of orienting oneself in the midst of things, of seeking an answer in the quest for the self (Azevedo, 2023). To sum up, ontology, from the African perspective, emphasises the view that the researcher and the participants in this study know and understand the reality of cultural values and health beliefs, which are accessible to their own lived experiences and interpretation of health, intellectual disability, mental illness, and healing. This ontological assumption explains how they all create their reality based on their own experiences of life. 3.4 Epistemology If our ontological position establishes our process of knowing, the next logical step leads me to the next term: epistemology, a theory of knowledge concerned with the nature and the scope of knowledge (Slevitch 2011). Questions of epistemology and ontology are philosophical ones about what fundamentally exists in the world and how we can know about what exists (Bender and 85 Holmes 2019). Epistemology is defined as the assumptions we make about the kind or the nature of knowledge (Richards 2003) or how it is and what is possible to find out about the world (Snape and Spencer 2006). Epistemology is important because it influences how researchers frame their research in their attempts to discover knowledge. Whereas objectivist epistemology assumes that reality exists outside, or independently, of the individual mind, constructionist epistemology rejects the idea that objective ‘truth’ exists and is waiting to be discovered (Moon and Blackman 2017). Instead, ‘truth’, or meaning, arises in and out of our engagement with the realities in our world; that is, a ‘real world’ does not pre-exist independently of human activity or symbolic language. Objectivist research is useful in providing reliability and external validity whereas the value of constructionist research is in generating contextual understandings of a defined topic or problem. This research has been conducted from a critical perspective, that is, the researcher understands that epistemology focuses on the development, identification, and validation of knowledge to answer questions about how knowledge occurs, how people develop knowledge, and methods to explore human lived experience (Bruce et al. 2014). To this end, a phenomenological study based on Husserlian philosophy was an attractive choice for my study as well as analyse them. This is largely influenced by my Ubuntu values where the creation of knowledge by participants would help both the participants and researcher build rapport on collectively shared experiences. The researcher was drawn to a phenomenological study to help them construct meanings from the participants’ stories through thematic analysis, an analysis method (Charmaz, 2006; Clarke, 2005) that assume an epistemic position similar to the researcher’s own position as well as formal theories such as social constructionism and interpretivism. In addition, epistemology is key to assessment of the quality of data and of analysis (Angen, 2000). The researcher advocates for making detailed recordings and detailed, evocative transcriptions that are carefully checked against the recordings to build a rich story as told by the participant. Additionally, the researchers also believe that epistemology profoundly shapes their conceptualisation of the participant in data collection and analysis. This would enable the researcher during interviews to build trust and mutual respect with the participants in order to have open and honest conversations during the interviews. 86 Finally, epistemology determines how the researcher communicates with his or her audience and the conceptualisation of the role of the audience, the analyst, and the participants in the work (Mantzoukas, 2004). Based on the researcher’s identity and that of the participants, it was easy to relate to each other, return for further clarification so that the findings were accurate. Finally due to the study being about cultural values and beliefs, the researcher’s epistemology was strengthened by their values, and it helped in that the knowledge that was generated by the study would be discussed, evaluated, and justified in relation to broader cultural values. 3.5 Locating the researcher’s research style in the paradigmatic debate. It has been argued that a researcher’s positionality influences not only the type of research undertaken but also the interpretation of data and findings. Dunne, Pryor and Yates (2005 p. 29) propose that ‘researcher identity is critical to the production of knowledge about the complexities of the social world’. Miller and Donner (2008) advise that when writing about issues of culture, race and/or ethnicity, it is essential to identify and locate one’s own identity. This is because categories such as gender, age, culture and so on can influence the area of inquiry. The researcher does not doubt that their research inevitably raises the issue of subjectivity. All qualitative research does due to issues of the researcher’s subjectivity as already discussed. Freshwater (2016) posits that traditional science privileges professional objectivity over subjectivity and engagement. Quantitative researchers claim that in qualitative research there is no control group or the usual standardisation of research instruments that appeals to positivist scientific objectivity (Merriam et al. 2001). The topic chosen for this research reflects a personal interest as does the selection of participants which then raises the spectre of insider ‘bias.’ This study emerged when the researcher’s daily interactions with students from Africa, particularly the Southern African region, called them to question what it is like for them to be in an English university nursing degree programme. The researcher was particularly interested in how nurse education impacted their indigenous belief systems about intellectual disabilities and mental illnesses they have held from being young children. Once an indigenous person in their own country, then having migrated to an unfamiliar cultural environment, the researcher had 87 their views about what causes a learning disability; views that were unanimously held in their country and this affected how they initially interacted, treated, and worked with people with intellectual disabilities when the researcher became a student nurse. The researcher had their views as a nurse and then as a senior lecturer who supported student nurses from Southern African countries. While there are advantages to being an insider in a study, Unluer (2012) advises that it is problematic as it includes greater familiarity, which can lead to a loss of objectivity as well as the unconscious making of wrong assumptions about the research process based on the researcher’s prior knowledge rendering it as biased. To study the participants’ lived experience means that the researcher must study the world as it is immediately experienced rather than as they theorise about it. The aim of this phenomenological study, therefore, was to come to a deeper understanding of the nature or meaning of an everyday experience, answering the question, ‘‘What is this experience like?’’; seeking to define the essential essence or nature of the experience (van Manen 2011). It was for this reason that the preferred methodology is phenomenological rather than grounded theory. A researcher’s personal experience often frames the starting point for this type of research since the researcher is integrally involved in the process of interpretation (van Manen 2011). Insider research is conducted within a social group, organisation, or culture of which the researcher is also a member (Greene 2014) and shares cultural, biological and occupational characteristics as the researched (Loxley and Seery 2008). It is important, therefore, to adopt a reflexive methodological approach that considers how similarities and differences between the researcher and the researched shape the research process and the knowledge produced (Zempi 2016). Palaglanas (2017) further advises that reflexivity makes the research process as well as decisions transparent and rigorous while Brunero et al., (2015) assert that by critically discussing the methods of data collection and the methods of data analysis. Additionally, it gives the researcher an identity, as a researcher. Dwyer and Buckle (2009) contend that being a member of the group under investigation does not unduly negatively influence the process. This is because they believe that disciplined ‘bracketing’ and detailed reflection on the subjective research process, with a close awareness 88 of one’s own biases and perspectives, might well reduce the potential concerns associated with insider membership. Although keeping a reflexive diary helped address some issues with bias, the researcher rejects the idea that bracketing, no matter how disciplined, is possible nor would the researcher want to attempt it. We enter any situation with preconceptions and locking them away to be ‘objective’ is not possible for us. This stance is supported by Lewis (2003) who asserts that a common cultural background between the researcher and participants may enrich the researcher’s understanding of participants’ accounts and the language they use. He adds that there may be instances where the researcher’s experiences mirror those of the participants in terms of oppression or imbalances of power, especially if issues of oppression and discrimination are relevant to the study for example (Lewis 2003). Heidegger (1962) rejected the concept of ‘bracketing’ or epochē, or reduction, terms which are often used synonymously to refer to researchers temporarily setting aside tacit assumptions about a phenomenon. He argued that for the researcher to fully comprehend the lived experience of the participants, they must see it as an interpretative process; meaning bracketing out preconceptions is neither possible nor desirable (LeVasseur, 2003). Heidegger adopted the position of being in the world, where contextual interpretation and meaning were sought and valued (Gearing, 2004). The researcher needs to be honest and vigilant about their perspective, pre-existing thoughts, and beliefs; engage in a self-reflective process; recognise and set aside but not abandon their a-priori knowledge and assumptions, with the analytic goal of attending to the participants’ accounts with an open mind (Starks and Trinidad 2007). However, McNarry et al. (2019) assert that as researchers, our theories and concepts are already in our minds, socialised into us as academics. Our ideas, assumptions, meanings and interpretations are always inevitably there, so these can never be neutral, ‘unknowing’ or value-free (McNarry et al. 2019). A researcher can separate subjective experiences from the phenomenon being studied by writing memos throughout data collection and analysis as a means of examining and reflecting upon their engagement with the data (Cutcliffe 2003). Berge (2015) defines reflexivity as the researcher's self-awareness and self-analysis throughout the research process. Finlay (2002) argues that reflexivity is necessary for understanding the ontological and epistemological assumptions embedded within theories and methodologies that researchers use. Skukauskaite 89 et al. (2021) add that this understanding starts with the researcher examining their worldviews and values. It was unlikely that upon entering the research arena, the researcher would be able to shut out all their perceptions, emotions, beliefs, memories, and experiences both as a student nurse, a practising nurse and in the last few years a lecturer. To address this, the researcher had to demonstrate that they kept an open mind. Miller et al. (2015) argue for the need to be critically reflexive and to interrogate assumptions that are associated with researcher subjectivities. While reflexivity is synonymous with qualitative research, the credibility of the overall study can be strengthened with researchers’ subjective positionalities influence on all aspects of the research process, from subject matter to methods to analysis to representation of the findings (Stuart 2017). Engward and Davis (2015) posit that reflexivity transcends such paradigmatic polarisations and explains, elaborates, and deliberates the way the research is contextualised theoretically. The researcher’s initial reflexivity commenced when they approached their prospective supervisory team to discuss the proposed topic. The researcher had undergone a protracted process of soul searching, reflection and sometimes being critical of their own beliefs. There was an opportunity to at least address through a PhD study. The supervisors were supportive with the construction of the research topic and since that day, it became a regular occurrence for the researcher to reflect in supervision. The researcher fondly remembers the reflexive diary being mentioned in the initial meeting and this was something they went on to develop as the study itself grew. Throughout this study, the researcher kept a reflexive diary in which they documented any thoughts or noteworthy events which if they had not documented would never have made it into this thesis. While it is appreciated that not all reflexivity will be included, the researcher believes that being honest about their thought process during the research helped keep things in perspective. Three examples from the research diary are presented to illustrate how the researcher used the reflective diary. These examples appear throughout the thesis and the researcher has referenced/labelled them accordingly for the reader. They illustrate a variety of issues which arose and interested the researcher, but which were not necessarily concerned with the stated aims and objectives of the research. The diary was like a platform used to record the researcher’s research highlights. The research supervisor impressed upon the researcher, the 90 absolute necessity of keeping a reflexive diary which was a good demonstration that reflexivity is an ongoing process with the diary enabling reflection long after the research had concluded. Dunbar et al. (2002) concur by pointing out that in most interview situations, emphasis in research is disproportionately placed on researchers obtaining information from respondents. This is problematic as it includes little or no exchange or disclosure about the background of the researcher. More importantly, Black people may regard outsiders with suspicion because of their marginalised position (Zempi, 2016). However, the researcher’s position could have put them in a privileged position and created a barrier between them and the participants where the researcher could be viewed as someone just interested in extracting data from Black Southern African student nurses without having their interests at heart. This research method helped in the construction of knowledge. Bailey and Tilley (2002) discussed the importance of recognising that participants will share stories and narratives that convey meaning as they relate to the area of focus or research. It was therefore the researcher’s belief that each participant and the researcher would collaboratively participate in the sharing and construction of stories that were meaningful and important in gaining insight into the overarching research question of this study. As the researcher would be actively participating in the co-construction of narratives and theories with the participants, it was essential to situate oneself in the research process. To conclude this section, this thesis observes that where the researcher is an insider, qualitative research calls for them to reflect on how their positionality identities, experiences and interpretations situate themselves in relation to what or whom they are studying. Reflexivity is not to be viewed as just a peremptory requirement of a qualitative study but an in-depth self-examination of the researcher's role in the construction of new knowledge. The researchers has dedicated this short section to discussing insider bias, however, the very act of acknowledging their own voice as well as threading their positionality throughout the thesis has hopefully, endorsed the inter-subjectivity paradigm of qualitative research. Table 9 below includes some reflexivity on the choice of methodology. (Please see Table 9 below) 91 Reflexivity on Methodology In choosing my methodology, I explored with critical depth the different approaches to phenomenology whilst needing to remain grounded in Ubuntu to come to a state of acceptance as well as to make an informed choice as, to what extent these philosophies best suited my study. I have made it quite clear that as a researcher interested in the experiences of student nurses from Southern Africa, l found phenomenology to be the philosophy and methodology that best described the experiences that I wished to elicit from my study. I realised that a critical point in selecting the best research approach entailed coming to terms with my own research philosophy, which I made clear when l critically explored phenomenology, highlighting my position regarding ‘reality and truth.’ Phenomenology for me was the most appropriate approach that resonated with my worldview and cognitive style whilst fitting with the goal of the research. Table 9: Reflexivity on Methodology 3.6 Paradigms Kuhn (1962) in a seminal paper defines a paradigm as underlying assumptions and intellectual structures on which research and development in a field of inquiry are based. Correspondingly, Jacob et al. (2015) accentuate that a paradigm comprises a model, an image of the domain of the study, theories, and an agreed set of methods and tools. The above definitions show that different paradigms inherently contain differing ontological and epistemological views and have different assumptions of reality and knowledge which underpin their research approach, (Scotland 2012) and this is reflected in their methodology and methods. My research question is What is the influence of nurse education on the Indigenous belief systems about mental illness and intellectual disability of Southern African nursing students? Assumptions surrounding this question are based on the researcher’s understanding of why they asked this question in the first instance and how they proceeded to obtain the answers. In the following section, the researcher will offer a consideration of Positivism and Interpretivism. 92 3.6.1 Positivism Positivism is a methodological philosophy in quantitative research which applies the methods of natural sciences to discover the study of social science. As such, understanding of phenomena must be measured and supported by evidence (Hammersley 2013). This means that knowledge management should be observable and measured based on scientific analysis (Mingers and Standing 2017) to allow scientific predictions using deductive reasoning (Brooke, 2013). Positivism leads to the production of generalisations as it relates to the importance of what is given in general, with a strict focus to consider pure data as well as facts without being influenced by interpretation and human bias (Scotland 2012; Saunders et al., 2012). Shateri and Hayat (2020) caution that while positivists show how knowledge is acquired, they do not fully explain how it is processed and shared. This is further expounded by Ryan (2018) who argues that knowledge management is intertwined with human experiences, values, beliefs and practices. Within this paradigm, it might be challenging for researchers to gain further insight into in-depth issues to be considered part of their research. Based on the nature of the research question for this thesis, the positivist paradigm will not be able to provide the most suitable framework to guide my thinking and methods to answer it. As a result, an argument arose for the necessity to examine the interpretivist paradigm to develop a deeper understanding of the philosophical roots of knowledge management (Turyahikayo 2021). 3.6.2 Interpretivism While most positivists assume that reality is not mediated by our senses, interpretivists believe that it is. Proponents of the interpretivist paradigm argue that humans interpret their world and then act based on such interpretations (Hammersley 2013). As such, knowledge of the world is based on our understanding which arises from our reflection on events rather than only on our lived experiences (Ormston et al. 2014). Whereas, in the positivist tradition, it is generally accepted that reality is unaffected by the research process and that the researcher has to distance oneself from the findings, in this opposing tradition, researchers construct meanings 93 and interpretations based on those of their participants and the research process is considered to be largely ‘inductive’ in the sense that the aim is to generate theory from the data collected rather than use the data to test an already existing theory. Unlike the positivist approach, the researcher cannot, nor would he/she want to detach him or herself from the research (Saaid 2014); they inevitably become personally engaged in the research and, as such, findings are influenced by their perspectives and values. Baggini (2017) premises that people draw different conclusions from the data, depending on their prejudices and prior beliefs. How a researcher reacts to data also depends on his or her age, sex, ethnicity, country of origin, and other things such as religion, or spiritual orientation. In addition, human behaviour is a complex interplay of socio-psychological factors (Brooke 2013). Interpretivists, therefore, view knowledge as subjective, as well as culturally and contextually situated, based on people’s experiences and their understanding (Ryan 2018). This is because, as posited by Haddadi et al. (2017), interpretivist research is value-laden and the interpretivist’s evaluation, understanding and analysis rests on their understanding of the interpretive process that led to the emergence of the view. This strengthens interpretivism as the chosen paradigm of this thesis. Saunders et al. (2012) claim that the adoption of the interpretivism paradigm can provide in depth understanding of certain contexts such as cross-cultural studies and interpretation of qualitative data leading to deep insight and conclusions. Within this paradigm, the data gathered and analysed would be less likely to be generalised through the adoption of the interpretivist paradigm given the consideration that data is dependent on a specific context, viewpoint, and values (Saunders et al. 2012). However, Cohen et al. (2011) caution that this can be seen as a limitation of this paradigm because interpretivism aims to gain a deeper understanding and knowledge of phenomena within its complexity of the context rather than generalising these results to other people and other contexts. This leaves interpretivism open to scrutiny, exposing a gap in the trustworthiness and usefulness of research outcomes without using scientific procedures which are used by positivists. This thesis does not aim to generalise the results either but seeks to discover the experiences of Southern African students which may help with transferability to other university settings. This thesis, conducted from the interpretivist 94 paradigm explored the subjective Indigenous belief systems of Southern African student nurses. Therefore, interpretivism was considered as suitable for this research. 3.7 Methodology Methodology is “the strategy, plan of action, process or design lying behind the choice and use of particular methods and linking the choice and use of the methods to the desired outcomes.” Crotty, (2003 p. 3). Methodology has been described as, “How should we study the world” (Kawulich, 2015, p. 1) where the fundamental question is “How does one go about acquiring knowledge?” (Lincoln and Guba 2013 p. 39). In other words, it is the study of the method. The methodological aspect of research must agree with the ontological and epistemological stances of the research. Within the qualitative tradition, several strategies of inquiry exist for example grounded theory and discourse analysis, but given the nature of the research question, participant sample, and the conceptual frameworks that informed this research, the researcher chose to use phenomenological inquiry as the ideal qualitative methodology for the research study. 3.7.1 Grounded theory The researcher could have chosen grounded theory instead of phenomenology for this type of study. Grounded theory methodology demands concurrent data collection and analysis, so that more individuals who display the characteristics that warrant further investigation can be recruited to the study as the research progresses and preliminary findings emerge; Grounded theory differs from phenomenology in that it premises for sampling concerned with generating data specifically related to conceptual categories that emerge as of interest to the inquiry, referred to as theoretical sampling (Conlon et al. 2020). This differs from purposive sampling which concerns itself with the identification and strategic selection of participants who are experts in the topic of interest. Whereas in purposive sampling what constitutes an information-rich case is broadly defined at the outset of a study, theoretical sampling is not bounded by the 95 limits of a priori selection (Conlon et al. 2020). Theoretical sampling entails jointly collecting and analysing data to decide what data to collect next and where to find them to develop a theory (Glasser and Strauss 2012). In theoretical sampling, the process involves identifying emergent concepts in data being generated which are then used to guide where, how, and from whom more data should be collected, and with what focus (Butler et al. 2018). Theoretical sampling is an approach associated with grounded theory and builds concepts and theory from data (Bryant 2017; Charmaz, 2014; Corbin and Strauss 2015; Glaser 1992). This thesis did not seek to generate theories but participants’ experiences of a particular phenomenon, in this case, nurse education in a country with diverse cultural views on the subject matter they were studying. The main aim of grounded theory is the generation of theory from data. It is for this reason that the researcher rejected this approach and opted for a phenomenological approach instead. Alternatively, phenomenography looks for variations in interrelated conceptions of meaning or experience from different groups (Cossam, 2017). The difference lies in that when groups are studied, the phenomenologist would attempt to highlight the individual perspective, while phenomenography looks for variation among groups (Dabengwa et al. 2023). The main purpose of phenomenography is to describe the variety of experiences regarding phenomenon in the universe (Sjöström and Dahlgren 2002), while the main purpose in phenomenology is to reach the essence or meaning of the phenomenon (Laverty, 2003). Phenomenography is the study of how people experience, understand or conceive of a phenomenon in the world around us where the investigation is not directed at the phenomenon as such, but at the variation in people's ways of understanding the phenomenon (Marton, 1981). This is referred to as a second-order perspective (Marton, 1981). Phenomenography, as opposed to phenomenology, has this distinction between first order and second-order perspectives. Marton referred to the first-order perspective as the question of “what a thing really is” and the second order perspective as the question of “how a thing is perceived” (Assarroudi and Heydari 2016). In addition, phenomenography has been criticised for its serious lack of interpretative rigour because the researcher’s presuppositions, misconceptions, biases, have not been removed from the research. Phenomenology, on the other hand offers phenomenological reduction, or the practice of bracketing (Stolz, 2019). This study focuses on 96 the influence of nurse education only and is not concerned with anything else. It was for this reason that phenomenography was not considered for this study. 3.7.2 Ethnography Another alternative for this research could have been ethnography. Reeves et al. (2008) define ethnography as the study of social interactions, behaviours, and perceptions that occur within groups and communities with the central aim of providing rich, holistic insights into people’s views and actions, as well as the nature of the location they inhabit, through the collection of detailed observations and interviews. Goodson and Vassar (2011) caution that sample size is a limitation of the ethnography method due to the time spent in participant observation and conducting long interviews. I reasoned that in a university setting this would have required careful planning and if the few participants for an ethnography study became unavailable, it would affect the study. Consequentially, this happened as a result of the lockdown caused by the Covid19 pandemic. 3.7.3 Phenomenology As a researcher interested in the experiences of student nurses from Southern Africa, the researcher found phenomenology to be the philosophy and methodology that best described the experiences that they wished to elicit from this study. Phenomenology emerged from a German philosophical movement led by Husserl (1859-1938) and sought to unveil the primary source of direct intuition of the human being concerning the essential elements of a given phenomenon (Husserl 2008). Phenomenology aims to contribute to a greater understanding of the nature and meaning of the lived experience (van Manen 2014). Although there are several schools of phenomenology, there are two main ones: the interpretative (hermeneutic) perspective (Chesnay, 2015) and the descriptive perspective (Beck 2016). 97 Interpretative phenomenology tends to reaffirm the centrality of unveiling the lived experience through the interpretation of its meaning to the human being (Munhall 2016). Heidegger (1962) argues that Dasein or ‘there-being’ in the world is well placed to shed light on human’s lived experiences. The cornerstone of Dasein is the concept of Time where there is an attachment in time (temporality) and space (spatiality) to both culture and history, which provides an understanding of beliefs and contexts, forming perspectives that colour and shed light on the phenomenon of interest (Miles et al. 2012). Van Manen (2011 p.332) states: ‘In actual phenomenological descriptions one often notices that the author uses the ‘‘I’’ form or the ‘‘we’’ form to enhance the evocative value of the truth experience expressed in this way but also to show that the author recognises both that one’s own experiences are the possible experiences of others and that the experiences of others are the possible experiences of oneself’. Miles et al. (2012) emphasise this further in stating that significant lived events or more than everyday mundane events have attached memories and/or feeling(s) and provide experiences that we can pull out and examine, to help reveal and interpret what those events meant, at deep levels. This study asks the participants to recall events in times and spaces in which they grew up and how they formed beliefs about intellectual disability and mental illness as well as in another time and space when the same beliefs need to be revisited again. Descriptive phenomenology attempts to discover what it is like to undergo a particular experience where the role of the researcher is to describe the first-hand experience being investigated (Reiners 2012). Van Manen (2011) proposes that when the interpretive phenomenological approach is chosen, researchers need to focus on gaining a deeper understanding of an experience and adds that phenomenological research becomes ‘hermeneutic’ when its method and focus is interpretive. The researcher found that hermeneutic phenomenology, employed as a research methodology, provided me with the best opportunity to ‘give voice’ to the experiences of the participants in this study. Hermeneutic phenomenology was the best philosophy and methodology to provide me with an ideal platform from which to understand the lived experiences of Southern African-born student nurses, ontologically. 98 This hermeneutic method allows the researcher to investigate the meaning of experiences and understand how participants interpret their lived experiences. Neubauer et al. (2019) caution that to expect a researcher to take an unbiased approach to the data is inconsistent with hermeneutic phenomenology’s philosophical roots. Moran (2002) advises researchers working from this tradition to openly acknowledge their preconceptions and reflect on how their subjectivity is part of the analysis process. To this regard the researcher kept a reflective diary where they openly discussed some of the preconceptions and biases. The depth and detailed focus of the research question required a qualitative methodology that emphasised co-construction and meaning-making in context hence the decision to employ phenomenological inquiry. Given the philosophical tenets of qualitative research and the conceptual frameworks underpinning this study, a central principle which governed and informed the research was that together, the participants and the researcher co-constructed the stories and narratives that were shared in the interview and research process. In addition, Heidegger’s hermeneutic phenomenological thinking works from the concept of being-in-the-world, within the milieu of human relationships, rituals, symbols and languages that constitute their shared meanings (Miles et al. 2012). 3.7.4 Methods Methods are ‘the techniques or procedures used to gather and collect data related to some research question or hypothesis’ (Crotty, 2003 p 3). Hammarberg et al. (2016 p.499) comment that qualitative research techniques include small-group discussions for investigating beliefs and attitudes; semi-structured interviews, to seek views on a focused topic with key informants; in-depth interviews to understand an experience from a personal perspective; and analysis of texts and documents to learn about distributed or private knowledge. Streubert and Carpenter (2013) assert that qualitative research seeks to understand and interpret subjective experiences, interactions, and social contexts to find the meaning of human experience. The nature of this investigation sits well within these qualitative techniques. 99 Hammarberg et al. (2016) argue that it is possible to combine quantitative and qualitative (mixed) methods, although great care should be taken to ensure that the theory behind each method is compatible and that the methods are being used for appropriate reasons. The two methods can be used sequentially where the first approach is used to facilitate the design of the second; they can be used in parallel as different approaches to the same question; or a dominant method may be enriched with a small component of an alternative method (such as qualitative interviews ‘nested’ in a large survey). 3.7.5 Sampling Cleary et al. (2014) argue that generating data in qualitative research entails strategically selecting participants who share views and experiences that can add meaning to, illuminate, and, in some cases, help explain the phenomenon under study. Participant recruitment was conducted using purposive (non-probability) sampling. Purposive sampling is different from random sampling or probability sampling in quantitative research in which the nature of the population is defined, and all members have an equal chance of being selected (Hamilton and Finley 2019). Purposive sampling refers to a group selection of participants for a study because they have characteristics needed by the researcher in the sample. This sampling method relies on the researcher’s judgment when identifying and selecting the individuals, cases, or events that can provide the best information to achieve the study’s objectives. Purposive sampling is essential for all phenomenological investigations, and all qualitative studies research as it allows the selection of participants who have rich knowledge of the phenomenon (Mapp 2008; Polit and Beck 2012). The rationale for adopting a purposive strategy assumes that, given the aims and objectives of the study, Southern African student nurses would hold different and important views about the ideas and issues at question and therefore needed to be included in the sample (Robinson, 2014). Additionally, the rationale is based on the researcher’s assumption that their a-priori theoretical understanding of the topic being studied, that certain categories of individuals may have a unique, different or important perspective on the phenomenon in question and their presence 100 in the sample should be ensured (Mason 2002). Non-probability sampling could be a drawback in commissioned health services research, such as that commissioned by the NHS as research needs to result in benefits for the largest number of the population possible (Higginbottom, 2004). However, this principle cannot necessarily be applied equitably to minority ethnic communities who may be small, such as was the case with Southern African nursing students at the researcher’s university. Merriam and Tisdell (2016) posit that when doing qualitative research, the issue of whether sampling reaches numerical significance, or the sample size underpins what researchers interpret as significant is not significant. Conlon et al. (2020) advance that in qualitative research sampling is conceptualised as focusing on the characteristics of the cases or instances identified as pertinent sources of data for the inquiry. As a result, Hamilton, and Finley (2019) assert that typical sample sizes range between 5 and 10 individuals in a qualitative study of this nature for individual interviews. Chesnay (2015) further supports this, adding that in a phenomenological study, the number of participants is small because the researcher tries to select participants with specific characteristics, that is, people who have experienced a given phenomenon of interest. This is consistent with Guest et al. (2006) who recommend that with a narrow research scope and a homogenous target audience, a sample size of 6–12 is usually adequate. The richness of the data collected takes precedence over the actual size of the sample (Mapp 2008). Before recruiting the final sample, participants were invited to take part in a survey which functioned as a pre-recruitment strategy. All participants were invited to take part in the interviews and were given the researcher’s email address. A small sample size is not seen as a limitation in phenomenological studies, since the primary objective is not generalisability, but to illuminate the lived experience and context in as much depth as possible. A small purposive sample with a homogenous sample is most coherent with phenomenological studies’ main objective of uncovering the multiple layers of the hiddenness of a phenomenon within its context. The Participant Information Sheet (PIS) (Appendix B) clarifies the recruitment process of this homogenous sample. 101 In addition to purposive sampling, the researcher was open to snowball sampling or convenience sampling. The risk of convenience sampling is that if the sample universe is broad, unwarranted generalisations may be attempted from a convenience sample therefore, ‘to counter that the best way of justifying the use of convenience samples in qualitative research is by defining the sample universe as demographically and geographically local and thus restricting generalisation to that local level, rather than attempting decontextualised abstract claims’ (Robinson, 2014 p32). Snowball sampling is a sampling method where new participants are recruited by other participants to form part of the sample. Snowball sampling was a useful way to conduct research about people with specific traits (Johnson, 2014) such as Southern African student nurses who might otherwise have been reluctant to put themselves forward for this research. After each interview was completed, the researcher asked the African nursing students to identify and refer other potential African nursing students. The snowballing method allows for the identification of additional participants who may otherwise be difficult to locate (Streubert-Speziale and Carpenter, 2007). Although snowball and purposeful sampling methods are limited in their ability to generate a representative sample of African nursing students, they are suitable for such a qualitative research design. A downside to using this approach is that it can reinforce confirmatory bias where studies that agree with the prevalent wisdom are more likely to be published and cited while studies that contest the conventional wisdom are less likely to be published or cited (Suri, 2008). Self‐selection is a non‐probability sampling method in which the researcher specifies inclusion/exclusion criteria and persons from the population choose to participate. It can be seen as timesaving and those who choose to participate are more likely to commit to the research process and provide truthful responses. A drawback of this method is that it creates sampling bias and selection bias can lead to a non‐representative sample or misleading findings (Mathe et al. 2021). Another non‐ probability sampling method is quota sampling which is based on identifying participants with shared or unique characteristics of the population. Quota sampling is quicker and easier to conduct and makes it easier to explore distinctions inn subgroups. Like self‐selection, quota sampling can create sampling bias because random sampling is not used, 102 therefore sampling error cannot be calculated. Additionally, it can also be difficult to draw conclusions about the population (Berndt 2020). 3.7.6 Recruitment Southern African students enrolled on the nursing programme at the researcher’s university with specific inclusion characteristics were approached to participate via an email sent to the whole school of nursing. The inclusion criteria were that students must be of Southern African origin by birth and be studying for a pre-registration nursing degree at a specific university in England. The participants must have had their formative education in their countries of origin. For this study, the Southern African countries were to include South Africa, Zimbabwe, Lesotho, Angola, Swaziland, Malawi, Mozambique, Botswana, Zambia, and Namibia only. Anyone who did not meet these criteria was excluded from this study. For those students who responded to the email but declined participation or did not meet the inclusion criteria, no further contact was made. If the student met the criteria and agreed to participate, a mutually agreed time and place for the completion of the critical thinking instrument and interview was established. At the beginning of the interview, the study was again explained to the student. A written informed consent form was given to the student once it was determined that the student met the inclusion criteria. All participants were African/black and were from different ethnic groups, however, the interviews were conducted in English. In total, (n=13) participants took part in the study; the age of the participants at the time of the interview ranged from 22 to 48 with a mean of 36.3. Five countries were represented by the participants including three from South Africa, five from Zimbabwe, two from Zambia and one each from Uganda, Botswana and Malawi. Participants had been in the UK from four to fifteen years with a mean of 8.13 years. Participant demographics are presented on Table 10. (Please see Table 10 below) 103 Participant Age Gender Country of birth Country where of formative education was received (including up to 18 years old) 1 28 M South Africa South Africa 2 34 F Zambia Zambia 3 35 F Zimbabwe Zimbabwe 4 41 F Zimbabwe Zimbabwe 5 45 F Zimbabwe Malawi 6 43 F Zimbabwe Zimbabwe 7 22 M Zambia Zambia 8 44 F Uganda Uganda 9 36 F Eswatini Eswatini 10 32 M South Africa South Africa 11 48 M Zimbabwe Zimbabwe 12 25 F Botswana Botswana 13 40 M South Africa South Africa Table 10: Participant demographics In Table 11 the educational experiences of the participants are delineated. All of the thirteen students attended public primary and secondary schools in Africa. Two students attended teacher training college in Africa. Ten students enrolled in courses in colleges in the UK. prior to enrolling in prerequisite Nursing courses. These courses include Health and Social Care and Access to Health and are part of the requirements to enrol onto a nursing programme depending on one’s academic qualifications. Two students, Participants 9 and 11 had completed other 104 degrees in the UK: BSc in Construction and Architecture respectively before enrolling in a nursing programme. Only one participant had attended their final year of A level in England. (Please see Table 11 below) Participant Type of Secondary School Attended in Africa Prior exposure to nurse education in Africa Work experience in Health and Social Care in the UK Education obtained in home country in Africa prior to emigration Education obtained in the UK prior to embarking on nursing. 1 Public M Yes A level Level 3 Health and Social Care 2 Public F Yes A level Level 3 Health and Social Care 3 Public F Yes A level Level 3 Health and Social Care 4 Public F Yes A level Level 3 Health and Social Care 5 Public F Yes Diploma in education Access to Health 6 Public F Yes A level Level 3 Health and Social Care 7 Public M Yes GCSE O Level A Levels 8 Public F Yes A level Level 3 Health and Social Care 105 9 Public F Yes A level BSc. Construction 10 Public M Yes A level Level 3 Health and Social Care 11 Public M Yes Diploma in Education BSc. Architecture 12 Public F Yes A level Level 3 Health and Social Care 13 Public M Yes A level Access to Health at Level 3 Table 11: Educational experiences of the participants 3.7.7 Ethical considerations Chilisa (2005) posits that ethical issues in research include codes of conduct that are concerned with protection of the researched from physical, mental, and/or psychological harm. The codes of conduct to protect the researched include ensuring anonymity of the researched and confidentiality of the responses. In conducting this research, the university’s Policy Procedures and Guidelines for Research Ethics were studied, and the author ensured the proposed research complied with the University's Principles for Research Ethics. The ethical issues underlying these principles are laid out in detail in the Appendices attached to show that these were fully adhered to. Participation in this study was voluntary and participants had signed consent forms (Appendix D) before the study commenced. The initial phase which included the questionnaire was voluntary and participants were asked if they would be happy to take part in the interviews which would follow. On the day of each interview, the researcher still checked if each participant was willing 106 to take part. Moreover, a reminder was given to each participant of their right to withdraw from the study if they so wished except after their data had been anonymised. Consent was sought before the study, allowing each participant to understand the implications of participating in the study, without the exercise of any pressure or coercion. The topic involved investigating the belief systems and had the potential to evoke feelings and memories they experienced in their respective countries of birth. The researcher ensured that during the interviews the use of offensive, discriminatory, or other unacceptable language was avoided. This was also considered in drafting my initial formulation of the interview schedule. Assurance was given that the participants’ privacy and anonymity including the guarantee that none of their documents or recorded interviews would ever be used for any other purpose other than the research itself was made. When reporting the research findings, the researcher ensured the maintenance of the highest level of objectivity in discussions and analyses throughout the research by not identifying them by their names. Only the codes used to identify them were known to the researcher. As per the university guidance, adherence to the General Data Protection Regulations UK (2018) was made. 3.7.8 Data Collection Process The use of data collection instruments for an in-depth understanding of an issue can vary considerably in projects with similar aims (Robson 2002). This study focused more on in-depth understanding rather than the breadth of the research. A phenomenological study must present the description and interpretation of the findings from research work (Atkinson and Hammersley,2007). This qualitative phenomenological research incorporates the use of semi-structured interviews for data collection. This research occurred in two phases: a survey questionnaire (Appendix E) and interviews. The rationale for using a questionnaire survey was that most survey studies are conducted to make inferences about groups of people based on data obtained from individuals representing the group and to inform the second stage (Robson 2002). The researcher was keen to identify 107 participants for the study because it was not possible to obtain demographic data for the prospective sample due to General Data Protection Regulations (2018). Furthermore, the questionnaire survey enables data to be collected in a standardised, structured, and systematic way (De Vaus 2002). A questionnaire was prepared (Appendix E) following a comprehensive search of related literature and used questions from similar questionnaires used in similar studies and adapted to the needs of this study. Piloting a questionnaire as a prelude to the main study is useful in providing triggers that generate interesting data relating to individuals’ perceptions and definitions of complex issues (Adamson et al. 2004). In this particular study, the issues were cultural beliefs on mental illness and learning disabilities which provoked detailed stories about experiences to explain and justify responses to items. The questionnaire data resulted in a chronology that added another layer of context to the preceding demographic information, providing another dimension for the interpretation of the ways in which Southern African students’ cultural beliefs were influenced by education. The information below is an outline of the statistical data gathered from the survey questionnaire. It presents the participant demographics. A justification for each question used as well as why and how this was useful for the second phase of data collection is offered. This part of the questionnaire collected quantitative data. The second part of the questionnaire presents the qualitative data. 1. Are you Male 4 Female 9 This question was used to target my main audience, but l also wanted to have wider knowledge of what other people thought. Traditionally nursing is a field that appeals to females however l was aware that this is a stereotype therefore l was eager to attract responses from males and even wider. This would also allow me to compare responses from males and females. 2. Please state your age 22-29 (4) 30-35 (5) 36-45 (4) 108 This question was used to target a wide spectrum of ages to help me capture a varied range of views, especially regarding beliefs as l believed there would be differences based on this. This would help me make links between age and traditional beliefs. 3. Which nursing field are you studying? Learning Disabilities 4 Mental Health 5 Adult 4 Child 0 Midwifery 0 This question was used to target students from all fields of nursing. Adult nursing is a field that appeals to most student nurses however l was aware that this is a stereotype therefore l was eager to attract responses from other fields other than an adult. This would also allow me to compare responses from those students who chose the learning disability pathway. 4. What is your country of birth? South Africa (2), Zimbabwe (7), Malawi (1), Kenya (1) Zambia (2) 5. Where was your father born? South Africa (2), Zimbabwe (7), Malawi (1), Kenya (1) Zambia (2) 6. Where was your mother born? South Africa (2), Zimbabwe (7), Malawi (1), Kenya (1) Zambia (2) 7. Please state your ethnicity (see below) Black / African/ Black British/Caribbean Mixed / Multiple ethnic groups African 13 White and Black African/ Caribbean 0 Any other Black/African/Caribbean/White background (please state) 0 109 8 Who else was involved in your life when you were growing up? Both parents 13 Mother 13 Father 13 Siblings 13 Grandmother 13 Stepmother 13 Stepfather 0 Step siblings 0 Grandfather 13 Both Grandparents 13 Aunt 13 Uncle 13 Cousins 13 Friends 13 9 At what age did you come to the UK? Please place a tick in the relevant box. 0-10 0 11-19 0 20-29 13 30-39 40plus 10. How long have you lived in the UK? 0-5 years 0; 5-10 years 4; 10-15 years 9 11 Who taught/told you about mental illness/learning disabilities when you were growing up? Parents 13 Grandparents 13 Teachers 13 Church 13 110 Other (please state) Quantitative data gathered from the first phase (Survey Questionnaire) With the above information available to me, I was able to use it to design the interview schedule as well as the questions and probes to enrich my conversations with the participants. It was important to have this information before the interviews. Quantitative approaches such as surveys provide a broad overview of the status of a body of research and are recommended for accountability purposes as the most appropriate way that calls for transparency and reliability (Guthrie et al 2013). The second part of the questionnaire was comprised of qualitative questions which participants had to write in a free text box. The extract below is a summary of some of the responses which were then used to inform the interview schedule. The participants’ responses were useful in informing the narrative that took place during the phenomenological interviews. I offer a summary of the responses in the questionnaire below. 1. Before you started your nurse training, what did you believe was the cause of mental illness/ intellectual disability? Please briefly state your response Responses included witchcraft, and religious views (God meant it to be that way) whilst others cited biological and medical views. 2. What are your culture’s beliefs with regard to mental illness/ intellectual disability? Please state your response Responses included witchcraft, and religious views (God meant it to be that way) whilst others cited biological and medical views. 3. During nurse training have you ever come across/cared for a patient with a mental illness/ intellectual disability? Y/N All responses were affirmative (YES) 111 4. Please write down your initial thoughts and feelings when you first cared for a patient with a mental illness/ intellectual disability. Responses included fear, tense, trepidation, nervous. 5. What services were you aware of for people with mental illness and intellectual disabilities in your country of birth? Please write them down. Responses included Specialist schools and centres. Commonest was Main Psychiatric hospitals. 6. Since starting your nurse training, do you think your views about mental illness/ intellectual disabilities have changed? If YES, in what way? If NOT, in what way? There were mixed responses here, so this was used to further the discussion during the interviews. 7. What are the attitudes towards people with mental illness/ intellectual disabilities in England compared to your country or parents’ country of origin? Most responses included stigma, discrimination, and fear of people with intellectual disabilities and mental illness. There were mixed responses here, so this was used to further the discussion during the interviews. 8. Do you feel you have been trained efficiently to work with people with mental illness/ intellectual disabilities? Please explain your answer There were mixed responses here, so this was used to further the discussion during the interviews. 9. What else would help make you work competently with people who have mental illness/ intellectual disabilities? 112 There were mixed responses here, so this was used to further the discussion during the interviews. 10. What factors would you say helped shape or form your attitudes and beliefs about mental illness and or intellectual disabilities? (Please use free text here) Here, the participants cited culture, family, school, and church. There were mixed responses here, so this was used to further the discussion during the interviews. 11. Who helped you with the above? (Please write free text here) Here, the participants cited culture, family, school, and church. There were mixed responses here, so this was used to further the discussion during the interviews. 12. How do people from your country or your parents’ country feel about you training as a nurse for or working with people who have mental illness/ intellectual disabilities? Participants reported that there was an element of surprise from family members especially if the participants had chosen intellectual disability nursing. Overall, there was a general feeling of pride that they had chosen a noble profession in the UK. 13. Any other comments? Please write them here There were no extra comments. Qualitative data from the first phase (Survey Questionnaire The primary data obtained in the open-ended questionnaire section allowed the participants to give varied discussions whilst allowing me to make critical analyses of their responses without the restricted use of numbers and calculations. This also enabled me to plan the interviews which followed once the participants had expressed their interest in the second phase. 113 The interviews began with several demographic questions. This served to establish a cooperative relationship between the participant and the interviewer. Maxwell (2005) stated that the relationship between participant and researcher is an important component to the qualitative process. Such a relationship can become the mechanism by which the deeper meaning of the phenomenon may emerge (van Manen, 1990). The interview continued with several guided questions. All interviews were audio taped and transcribed verbatim for validation and analysis. Any potential identifying information was omitted from the transcripts. The researcher used semi-structured interviews as they provide a means to explore the points of view of research participants. Cypress (2018) suggests that in a qualitative study, one-on-one interviews can be face to face, using technology, or talking over the telephone or in writing through text messaging or an online chat function. Hennink et al. (2011) comment that the method of the in-depth interview is usually used when seeking information on individual or subjective experiences from people on a specific topic, primarily to capture people’s voices and stories. Interviews are likely to provide a more complete and more in-depth picture than other forms of inquiry (Cypress 2018). Hamilton and Finley (2019) suggest that in semi-structured interviews questions are specified but can be asked in a conversational style and do not necessarily need to be asked in the exact order in which they appear in the guide. Phenomenological interviewing involves an informal interactive process that aims to elicit a personal comprehensive description of a lived experience of a phenomenon from a small number of individuals who have experienced it (Paton 2015; van Manen 1999; 2014). All the data was transcribed verbatim to immerse the researcher in the data. Data immersion involves deep and insightful interactions with data, a prerequisite for qualitative research (Maher et al 2018). Transcriptions yielded on average, 10 A4 pages worth of data per participant, the analysis of which commenced immediately. 114 3.7.8.1 Triangulation Wilson (2014) defines triangulation as using more than one approach when doing research to get richer, fuller data and/or to help confirm the results of the research. Triangulation was initially used to refer to the use of more than one method in a given inquiry. This is to avoid a situation where research results are generated exclusively using one method. This is the view advanced by many researchers (Bryman 2001; Freebody 2003). The assumption is that methods have weaknesses and exclusive reliance on one method could lead to bias or distort the researcher’s work. Flick (2002) points out four diverse types of triangulation: methodological triangulation, theory triangulation, investigator triangulation, and data source triangulation. From the commencement of this study, the researcher used a reflective diary and employed methodological data source and theoretical triangulation. Theory triangulation is used when approaching the data with multiple theories or perspectives in mind to “extend the possibilities for producing knowledge” (Flick 2002 p.227). Method triangulation involves the use of multiple methods of data collection about the same phenomenon (Polit and Beck 2012) and involves interviews, observation, member checking and field notes. Carter et al. (2014) define data source triangulation as the collection of data from several types of people, including individuals, groups, families, and communities, to gain multiple perspectives and validation of data. While data triangulation uses diverse sources of data, investigator triangulation uses at least more than one person in the data gathering and data analysis processes. The argument advanced with this approach is that the more the methods contrast with each other, the greater the researcher’s confidence in the findings. The survey in the initial phase of this study, coupled with the interviews, the extensive literature review and the reflective diary all ensured the researcher was able to use different data sources to validate and crosscheck findings. 115 3.7.8.2 Trustworthiness in qualitative research Fairhurst (2014) argues that one of the main challenges for qualitative researchers is to show the rigorous steps used to arrive at the emerging patterns in the data because the issue of picking a specific sample may raise issues with validity and reliability. Credibility concerns itself with determining the accuracy of the findings from the researcher’s and participants’ standpoint (Creswell and Miller 2000; Lincoln et al. 2013). Rose and Johnson (2020) postulate that reliability and validity are contested terms, both derived from a traditional quantitative construct in which qualitative researchers must justify the trustworthiness of their research. Conversely, qualitative researchers, also question or reject the quantitative underpinnings of validity (Lincoln et al. 2013) arguing for deep understanding, whether that be descriptive, interpretive, or theoretical (Rose and Johnson 2020). This deeper understanding can be demonstrated in several ways, some of which will now be considered below. Gunawan (2015) advises that to ensure trustworthiness, the role of triangulation must again be emphasised, in this context to reduce the effect of investigator bias. Additionally, Shenton (2004) adds that the trustworthiness of qualitative research is often questioned by positivists because their concepts of validity and reliability cannot be addressed in the same way in naturalistic work. Many naturalistic investigators have, therefore, preferred to use different terminology to distance themselves from the positivist paradigm such as Guba and Lincoln (1985), who propose four criteria that they believe should be considered by qualitative researchers in pursuit of a trustworthy study. It has been pointed out earlier that qualitative researchers defend the integrity of their work by different means: trustworthiness, credibility, dependability and confirmability are the evaluative criteria (Hammenberg et al. 2016). Four strategies to ensure trustworthiness were employed to ensure that academic rigour and credibility of findings were maintained. Credibility establishes whether the research findings represent plausible information drawn from the participants' original data and is a correct interpretation of the participants' original views (Mathe et al. 2012). Credibility was ensured through the time spent with the participants during data collection; peer debriefing during regular supervision sessions; member checking which was 116 done during interviews by clarifying and summarising the discussions with the participants. Rose and Johnson (2020) posit that dependability refers to the soundness of the research and the appropriateness, application, and implementation of the methods in a qualitative research study. Further, Miles et al. (2014) and Cresswell (2013) expand this by stating that dependability questions the consistency of the methodological process, ascertaining if it remains stable over time even when used by other researchers using the same methods. Rose and Johnson (2020) point out that the dependability of a study increases when the researcher provides a justification of the methods used as well as clarity of the analytical procedures used. Additionally, dependability also addresses the consistency and clarity associated with the actual conduct of the research, thereby increasing the likelihood that other researchers could not only discern but also undertake many of the research methods described (Creswell 2013). The dependability of a study can be achieved through a variety of consistencies that demonstrate a study’s rigorous and systematised nature such as the inspection of recordings and transcripts to account for possible mistakes (Rose and Johnson 2020). This also includes documentation of methodological procedures (Yin 2012). Additionally, themes or codes developed during analysis should be clearly defined to increase the reliability of the deductive analysis in the research project (Miles et al. 2014; Saldana 2013). The researcher has demonstrated the justification of the methods and throughout the study, demonstrates how this study has addressed issues of conduct, reflexivity, and analysis. Additionally, the researcher has highlighted how they followed these procedures in their discussion of Thematic Analysis in two sections’ time below. William and Morrow (2009) note that the researcher can establish the trustworthiness of the data by asking the participants to give feedback at multiple points along the research process. This process is referred to as ‘member checking’ Guba and Lincoln (1985) and makes the processes a collaborative one and is seen as validation of accuracy by participants (Cohen et al., 2011). Informants should be asked to review transcriptions from interviews to confirm that personal perspectives ideas were accurately and completely represented (Merriam and Tisdell, 2016). In this study, member checking was used by sending the transcripts back to each of the participants for validation. This process continued as participants also received a report which 117 presented the findings so that they could ensure that what was presented represented their individual narrative accounts. The researcher is aware that using this method means that the participants’ views are represented by themselves. This is important because limited studies exist that consider issues from the points of view of international students. (Walsh, 2010). Confirmability is a strategy that is concerned with establishing that data and interpretations of the findings are not figments of the researcher's imagination (Mathe et al. 2021), but clearly derived from the data. This strategy was ensured through keeping interview notes, a reflective diary including supervisors' feedback reports. Finally, transferability was ensured through the sampling method and provision of thick, detailed and accurate descriptions of the participants of this study. 3.7.8.3 Data Analysis Cresswell (2014) posits that analysing qualitative data involves a range of processes whereby the researcher moves from qualitative data collection to making sense of the vast amount of information, and then explaining and interpreting the views of people and situations studied. As previously mentioned above, the researcher had to analyse the quantitative and qualitative data from the questionnaires. Saunders et al. (2009) describe the process or interplay between a researcher and the collected data as data analysis. The researcher carried out verbatim transcription of the interviews following the data collection (see Appendix C). As explained to the research participants, handling of the collected data (such as interviewee details, interview recordings and field notes) would be conducted with confidentiality and anonymity to protect their identities (see Appendix B). During interviews, for example, the researcher was making notes and highlighting some poignant issues for me to reflect on. Sometimes it was necessary to write reminders such as participant codes, dates and times in the reflective diary. This helped during the transcribing later or when the researcher wrote in the reflective diary. 118 3.7.8.4 Thematic Analysis of the Interviews This section will focus on thematic analysis, the preferred method for this thesis. The researcher discusses the thematic analysis and describe the six stages of this method that l followed in making sense of the data from the participants. There are several ways of analysing qualitative data, namely: narrative analysis, discourse analysis, content analysis, ethnographic analysis, thematic analysis and conversation analysis (Silverman 2011; Creswell 2014). The analysis strategy went through a series of iterations before thematic analysis was found to be the most appropriate method to address the research questions in the given timeframe. The chapter that follows will present the results and data analysis. However, the section that follows offers a consideration of what each stage entailed. Thematic analysis was the most appropriate method for the analysis of the interview transcripts. Thematic analysis is the process of identifying patterns or themes within qualitative data (Maguire and Delahunt 2017). Kiger and Varpio (2020) postulate that the distinguishing feature of thematic analysis is its flexibility to be used within a wide range of theoretical and epistemological frameworks, and to be applied to a wide range of study questions, designs, and sample sizes. While Aronson (1995) has previously described the thematic analysis as falling within the realm of ethnography or as particularly suited to phenomenology (Joffe 2011), Braun and Clarke (2006; 2013) argue that thematic analysis can stand alone as an analytic method rather than a methodology (Braun and Clarke 2006). Researchers who are relatively unfamiliar with qualitative methods may find that thematic analysis is easily grasped and can be relatively quick to learn, as there are few prescriptions and procedures (Braun and Clarke, 2006). Braun and Clarke (2006) reason that rigorous thematic analysis can produce trustworthy and insightful findings and does provide a highly flexible approach that can be modified for the needs of many studies, providing a rich and detailed, yet complex account of data. This was the rationale for preferring thematic analysis to other methods of analysis despite the researcher’s inexperience. They further add that thematic analysis does not require the detailed theoretical and technological knowledge of other qualitative approaches 119 as it offers a more accessible form of analysis, particularly for those early in their research career (Braun and Clarke 2006). Maguire and Delahunt (2017) suggest that the goal of thematic analysis is to identify themes or patterns in the data that are important or interesting. This allows for either a rich description of the data set related to a broad research question or a detailed description of a particular theme within the data (Braun and Clarke 2006). Thematic analysis is an appropriate and powerful method to use when seeking to understand a set of experiences, thoughts, or behaviours across a data set (Braun and Clarke 2012). This is well-suited to this study in which l explore the thoughts and experiences of student nurses from Southern Africa. Braun and Clarke, (2006) and argue that thematic analysis is a useful method for examining the perspectives of different research participants, highlighting similarities and differences, and generating unanticipated insights. Thematic analysis is also useful for summarising key features of a large data set, as it forces the researcher to take a well-structured approach to handling data, helping to produce a clear and organized final report (King, 2004). Since thematic analysis is designed to search for common or shared meanings, it is less suited for examining unique meanings or experiences from a single person or data item (Kiger and Varpiro 2020), and as a result, the data set obtained from multiple participants is appropriate for this study. A drawback to using thematic analysis, however, is that its methodology is not well-described and thus it is open to interpretation, especially at higher levels of analysis (Braun and Clarke, 2006). While thematic analysis is flexible, this flexibility can lead to inconsistency and a lack of coherence when developing themes derived from the research data (Holloway and Todres, 2003). Consistency and cohesion can be promoted by applying and making explicit an epistemological position that can coherently underpin the study’s empirical claims (Holloway and Todres, 2003). Braun and Clarke (2006) provide a six-phase guide which is an especially useful framework for conducting this kind of analysis. This is designed to be a recursive, rather than a linear process in which subsequent steps may prompt the researcher to circle back to earlier steps in light of new data or newly emerging themes that merit further investigation (Kiger and Varpio 2020). Table 12 below displays the framework. (Please see Table 12 below) 120 Step 1: Become familiar with the data, Step 2: Generate initial codes, Step 3: Search for themes, Step 4: Review themes, Step 5: Define themes, Step 6: Write-up. Table 12: Braun and Clarke’s six-phase framework for doing a thematic analysis (2006) Step 1. Becoming familiar with the data. The first step in any qualitative analysis is reading and re-reading the transcripts. Kiger and Varpio (2020) posit that for audio data that needs to be transcribed, the process of transcription can be time-consuming but also serves as an excellent way to become familiar with the data. Braun and Clarke (2006) refer to immersion; as the repeated reading of the data and actively reading the data - searching for meanings, patterns and so on. Braun and Clarke (2006) recommended that researchers read through the entire data set at least once before beginning coding, as ideas and identification of possible patterns may be shaped as researchers become familiar with all aspects of their data This also involved constant revisiting of the literature review to maintain the focus on the topic under consideration; a process referred to as data immersion. During this phase, researchers are encouraged to engage with the analysis as a faithful witness to the accounts in the data, being honest and vigilant about their own perspectives (Starks and Trinidad, 2007), pre-existing thoughts and beliefs, and developing theories including their values, interests, and growing insights about the research topic as well as make notes about ideas for coding that can be returned to in subsequent phases (Lincoln and Guba 1985; Sandelowski, 1995). The researcher also read over the notes in they reflective diary to gain as full a sense of the research process as possible. In respect of familiarisation with data, the researcher internalised the emerging themes through the transcription and translation of the research interviews. This included listening to the audio recordings of the interviews of 13 respondents and translate all the research interviews into English, verbatim. Supervision time helped with the familiarisation as the researcher was able to reflect with the supervisory team on coding and theme development. Step 2. Generate initial codes. ‘Coding begins when researchers take notes on potential data items of interest, questions, connections between data items, and other preliminary ideas adding that a code is ‘the most 121 basic segment, or element, of the raw data or information that can be assessed in a meaningful way regarding the phenomenon’ (Kiger and Varpio 2020 p. 315). To this end, Richards and Morse (2007) describe initial coding as involving the creation of a mixture of descriptive codes and topic codes where descriptive coding involves storing information known about data items (Richards and Morse 2007), such as the research participants’ demographics (age, number, country of origin). This type of coding is not subject to much bias since it focuses on facts although it can be argued the researcher chooses the facts to focus upon. Topic coding (Richards and Morse 2007), on the other hand, is a far more analytical activity, as it entails creating a category or recognizing one from earlier, reflecting on where it belongs among the researcher’s growing ideas, and reflecting on the data he/she is referring to and on how they fit with the other data coded there. Furthermore, since topic coding is more analytical than descriptive coding, it is subject to more bias from the researcher’s background and preconceptions. Therefore, to minimise bias, the topic codes in the current study aimed to capture the essence of the participants’ experiences or thoughts (Richards and Morse 2007). Within the context of this study, the researcher developed the codes using a few words derived inductively from the data; that is, the language and syntax used by each participant informed the labels or codes the researcher developed. The researcher reviewed each sentence in the transcripts and used open coding; the researcher did not have pre-set codes but developed and modified the codes as they worked through the coding process. Braun and Clarke, (2006) recommended that researchers work systematically through the entire data set, giving full and equal attention to each data item, and identify interesting aspects in the data items that may form the basis of themes across the data set. Cresswell (2014) described a systematic process for coding data in which specific statements are analysed and categorised into themes that represent the phenomenon of interest. Sections of text can be coded in as many different themes as they fit, being uncoded, coded once, or coded as many times as deemed relevant by the researcher (Braun and Clarke 2006). While computer programs may be helpful to organise and examine large amounts of data, King, (2004) and Thorne (2000) advise that none are capable of the intellectual and conceptualising processes required to transform data, nor can 122 they make any kind of judgment hence the decision to not opt for any software as well as learn the process as a first-time researcher. Following initial round of coding for the transcripts, the researcher re-read the transcripts and reviewed each code that had been derived to ensure that they had captured the essence of the participants’ perspectives and experiences. All thirteen interview transcripts were coded in this manner. The process of coding is part of the analysis because the researcher is already organising data into meaningful groups (Tuckett 2005). The researcher was coding the data by writing notes on the texts during analysis, by using highlighters or coloured pens to indicate potential patterns, and by using post-it notes to identify segments of data. Finally, using Microsoft Word, the researcher highlighted sections in the text (key phrases and sentences) using assorted colours and this enabled the generation of short-hand labels or codes to describe the textual content. Rennie (2006) suggests that coding ‘meaning units’ is sometimes more appropriate than line-by-line coding. He argues that people being interviewed wish to make a point, and when they have made it, they move on to another. In this way, each ‘point’ is a ‘meaning unit,’ or an ‘envelope of meaning’ (Rennie 2006) and each can be coded. For the current study, the researcher preferred coding meaning units to line-by-line coding because some participants were keen to express themselves as soon as the questions were asked, and it was something they were enthusiastic about. Table 13 shows how the codes were initially developed. (Please see Table 13 below) Interview Extract All this started when I actually enrolled in college. Even in my adult age, I still believed that there are witches and witchcrafts because it was already ingrained in my beliefs. Going to college really exposed me to things that I otherwise wouldn’t have known back home. Back home I knew there was a place where people with mental health issues are housed. And I remember sometimes whenever you pass by, Codes Previously held belief systems Acculturation through education Public attitudes and discrimination Cultural values Acculturation through education In this example extract, I have highlighted various sentences in different colours that correspond to their different codes, with each 123 you will just see them climbing fences, some of them, not dressed, or you'll meet them in town picking things up and no one would want to associate with them, because they're just crazy and mad, something's wrong. So, in terms of health in Africa, especially where I come from in Zimbabwe, it is difficult to help those people come out of that mindset. And I think even now, still the same. My mind was really opened when I studied this degree. I discovered a lot about disability. And there are some people who actually live in mental health places that can talk to families and help. code describing the central idea that is being revealed in the text. At this stage I took time to go through each transcript thoroughly in order to highlight any key information that caught my attention in respect of this being related to the research study. Having gone through the texts, I then collated the data into ‘groups’ that could be identified by codes. The purpose of this was to enable me to have an overview of the main points that were being revealed and identify common meanings in the transcribed text that recurred throughout the data. Table 13: shows how the codes were initially developed. The researcher was constantly reflecting at this stage, going back and forth to the codes and transcripts and it was during this time that they would refine the data especially upon realising that some of the codes were vague, or did not appear as frequently in the whole of the data set. An example is the code, ‘diagnosis,’ which was not reinforced in significant ways in the whole data set, so this was discarded. Other codes were, however, generated into key themes due to their frequency of appearance and as the researcher reflected on the data, some of the codes merged to form key themes. On table 14, there is some reflexivity on this process. (Please see Table 14 below) 124 Reflexivity on Data Collection and Analysis During the interviews, the participants saw my presence and position as that of a researcher who was asking questions and probing. However, on the other hand, I am an African like them and felt like l was one of them. Having previously reflected on the fact that our similarity in ethnic identity created this sense of belonging it was easy to build relationships spontaneously with them. Upon further pondering, nevertheless, I wondered if l was the best person to be doing the research or if would they find it easier to work with researchers from other ethnic backgrounds. I saw ‘insider knowledge’ as a double-edged sword capable of helping to build an easy and immediate familiarity yet would prevent them from sharing information that they perceived could harm the rapport. My position of privilege, l found out was that they were able to confide about experiences of racism, being ‘othered;’ issues they knew l was also familiar with. In the end, l concluded it did not matter who was researching because if the questions needed to be asked, then there was no avoiding that. I figured that if l listened with sensitivity and compassion to what they shared, it would help form the building block of any relationship. Without a doubt, as a nurse, I needed to display these qualities as part of my profession. During the coding stage of data analysis, higher-level concepts are developed which explain and provide theoretical insight into increasingly larger slices of the data (Charmaz 2006). My role as a reflexive researcher left me with the responsibility of making explicit the process of interpretation – the process of analysis. Based on my philosophical understanding it was important to establish a healthy link between the data, the participants and myself as a researcher. Consequently, throughout the process of coding, there was continuous reflexivity based on this link which then served to enrich the generation of themes. In my journal l scribbled the following thoughts ‘Are these the correct codes or are they influenced by my own experiences I found myself struggling with thinking l had the wrong codes and was just producing what l wanted to see. However, through supervision, l was able to bring balance to my thought process. Table 14: Reflexivity on Data Collection and Analysis 125 Step 3 Search for themes. At this point of the research process, the researcher generated several different codes, and the next step of the research process was to enable the generation of a broader level of key research themes, and this involved using the research codes to help in amalgamating key research themes. In realising this aim, the researcher applied colour coding to sift through the initial research codes. The third step involves an examination of the coded and collated data extracts to look for potential themes of broader significance (Braun and Clarke 2006). A theme is not necessarily dependent on quantifiable measures but rather on whether it captures something important in relation to the overall research question (Braun and Clarke 2006). Themes can be classified as either semantic which address more explicit or surface meanings of data items, or latent, which reflect deeper, more underlying meanings, assumptions, or ideologies (Boyatzis 1998; Braun and Clarke 2006). In the semantic approach, the themes are detected at the surface semantic level and the researcher is not after something beyond what the participant has said or what is written in the text (Javadi and Al-Zarea 2016). They further explain that this is the simplest and the most evident type of theme where the data are explained and patterns that exist in the data are organized, summarised, or interpreted. Latent themes, on the other hand, scrutinise the researcher’s efforts in detecting and testing beliefs, presumptions, and conceptualisation for forming semantic content (Javadi and Al-Zarea 2016). This approach goes beyond description to reveal patterns in semantic content, creating theories based on the importance of the patterns and a wider framework of meanings and connotations. The researcher has great flexibility in which themes to identify, but he or she should strive to identify themes that provide important insights that address the research question (Braun and Clarke 2006). Themes should be independently meaningful but also ‘work together to form a coherent whole (Clarke and Braun 2014). An inductive approach derives codes and themes from the researcher’s data (Varpio et al. 2019). Typically, the researcher was interested in gaining a cross-section of participants’ experiences related to the research question, hence the choice of an inductive approach in which patterns and themes are linked to the data and are not 126 fundamentally driven by any of my previous theories or preconceptions (Braun and Clarke 2006). During this stage, Braun and Clarke (2006) advise that it is important not to abandon data or codes, as without looking at all the extracts in detail during the fourth phase of thematic analysis, it is uncertain whether the themes will hold, or be combined, refined, separated, or discarded. Step 4. Review the themes. During this phase some themes do not have enough data to support them, or the data are too diverse while others may collapse into each other or may need to be broken down into separate themes (Braun and Clarke 2006). Selected themes are then refined into themes that are specific enough to be discrete and broad enough to capture a set of ideas contained in numerous text segments. In addition, the data within themes should cohere together meaningfully, with a clear and identifiable distinction between themes (Braun and Clarke 2006). At the end of this phase, researchers have a good idea of the different themes, how they fit together, and the overall story they tell about the data (Braun and Clarke, 2006). Lincoln and Guba (1995) advise that returning to the raw data and comparing it to the developed themes to make sure that all conclusions are firmly grounded in the data is good practice in ensuring trustworthiness. Alternatively, some researchers are interested in a specific idea derived from reading the literature, usually from their prior research studies or from their clinical experience and tend to take a theoretical or deductive approach to their thematic analysis (Braun and Clarke, 2006). All thematic analyses include not only a description of the themes identified but also an interpretation of these themes, often concerning previous reports in the literature (Braun and Clarke, 2006). Since there were previous studies that had researched belief systems and exploratory models from Indigenous peoples, it was inevitable that these would also be raised in the research. Step 5 Define themes. Braun and Clarke (2006) describe step 4 as a two-level analytical process in which level one looks at coded data placed within each theme to ensure proper fit. The researcher reviews all relevant codes and data extracts under each theme. Here, data extracts can be re-sorted, and themes modified to better reflect and capture coded data. Themes can be added, combined, divided, or 127 even discarded. At level two the researcher here decides if individual themes fit meaningfully within the data set and whether the thematic map accurately and adequately represents the entire body of data (Braun and Clarke 2006). Kiger and Varpio (2020) advise that throughout this process, researchers should keep detailed notes, or memos, regarding their thought processes and decisions made regarding how themes were developed, modified, and/or removed. This is because these memos can help researchers make connections between themes and create an audit trail that bolsters the trustworthiness of their findings (Nowell et al. 2017). In this study, memos were written from the onset of reading the interviews, including throughout the coding process, and the identification and clarification of these stages. It was ensured that earlier memos were revisited throughout this stage to help with recollection of each research participant’s story, in terms of the points they discussed, and what the researcher was thinking during each stage of the process. The researcher here is creating a definition and narrative description of each theme, including why it is important to the broader study question (Braun and Clarke 2006). The names of themes to be included in the final report are reviewed to ensure they are brief and descriptive (Braun and Clarke 2006). This is a suitable time to select data extracts that illustrate key features of themes to be presented in the final report as well as create narratives surrounding them (Braun and Clarke 2012). By defining the themes, the researcher gave a clear definition of what each theme means and how it helps in addressing the research focus and providing context to explain its importance to the broader story. Step 6 Writing up. This last step involves writing up the final analysis and discussion of findings (Braun and Clarke 2006). This forms the next chapter of this thesis. 128 3.8 Chapter Summary This chapter has described the overall methodological conduct of this study. Key terms such as ontology, cosmology, conceptual frameworks, methodologies and methods, epistemological issues as well as concepts relating to positivism and interpretivism as the two paradigms have been reviewed. The researcher offered a rationale for using a qualitative rather than a quantitative research approach. The researcher offered a general overview of the research design, methods and techniques, sampling methods, data collection, triangulation techniques, culminating with a rationalisation of data analysis. The next chapter will focus on the Findings and Discussion. 129 Chapter 4 - Findings and discussion 4.1 Introduction The last chapter explored the overall conduct of the study and justified the decision to use thematic analysis. This chapter presents the research findings. The findings presented here relate to the research questions that guided the study. The questions were created from the questionnaire administered in the first phase of the study. The questionnaire was comprised of two sections and data generated will be presented as follows: The first section comprised demographic data such as age, gender, country of birth, field of study and number of years resident in England. The second section comprised data on the beliefs about the causes and management of intellectual disability and mental illness, how those beliefs came about and who influenced them. This chapter is concerned with the data from the interviews. In the interviews, data were analysed to identify, describe and explore the relationship between beliefs about intellectual disability and mental illness and views held in the country of birth. Data were obtained from interviews completed with student nurses (n=13). The findings are presented with thematic analysis used to discuss the research findings in answering the question What is the influence of nurse education on the indigenous belief systems about intellectual disability and mental illness of student nurses of Southern African? The study involved exploring the beliefs they held when they were still in their home countries. The researcher was interested in exploring how their nurse education and the journey itself through classroom experiences and placements had influenced their original belief systems. Using Braun and Clarke’s (2006) thematic analysis, the researcher identified six major themes that emerged through the frequency of specific participant responses. The researcher compared the most meaningful themes and patterns that emerged through data analysis of participant interviews to the transcribed data. 130 Table below 15 shows how the themes and sub themes were initially generated following the interviews. (Please see Table 15 below) Codes Ancestral and generational curses, God’s will, Witchcraft Beliefs Culture Theme 1. Indigenous beliefs about causation and explanatory models about causes of intellectual disability or mental illness Codes Lack of acceptance Rejection of people with intellectual disability and mental illness Stigma Theme3 Stigma and discrimination of people with intellectual disabilities and mental illness Codes Acculturation Education Exposure Previous work experience Classroom experiences Placements experience Shifting views Theme 4 Acculturation Sub Theme 3 Route into intellectual disability/mental health nursing Sub Theme 4 University classroom and practice placement experiences Codes Search for meaning; Something is wrong, Seeking a cure, Traditional healers, churches, hospitals. Theme 2 Local beliefs about causation of intellectual disability and mental illness and help-seeking behaviours Codes Significant adults, Siblings, Community’ Role modelling Sub-theme 1 Earlier cultural learning about intellectual disability/mental illness Table 15: Emerging themes and sub-themes developed from the interviews. 131 The major themes that emerged from the data were: • Indigenous beliefs about intellectual disability and mental illness • explanatory models about the causes of intellectual disability and mental illness. • local beliefs about intellectual disability and mental illness • Witchcraft • Help-seeking • stigma and discrimination directed at people with intellectual disabilities and mental illness. • acculturation (university/placement experiences). These were then combined according to their relationship and the final list is presented to include major and themes below: Theme 1. Indigenous beliefs about causation and explanatory models about causes of intellectual disability or mental illness. Sub-theme 1. Earlier cultural learning about intellectual disability/mental illness Theme 2. Local beliefs about causation of intellectual disability and mental illness and help-seeking behaviours Theme 3. Stigma and discrimination of people with intellectual disabilities and mental illness Theme 4. Acculturation Sub Theme 3. Route into intellectual disability/mental health nursing Sub Theme 4. University classroom and practice placement experiences The following sections will present the themes as presented by the participants in the interviews. 132 4.2 Theme 1 - Indigenous beliefs about causation and explanatory models about causes of intellectual disability or mental illness. All the participants in this study were student nurses studying in their first, second or third year of the nursing programme. All of them had had some exposure to people with a learning disability or mental-ill health either through university placements or previous employment. The first emergent theme from data analysis was beliefs about the causes of intellectual disability. When asking the questions about beliefs about causation, I emphasised that their answers had to reflect their beliefs whilst they were still in their countries of origin. The main causes of intellectual disability fall into the following categories: (1) supernatural factors such as witchcraft, spirit possession, ancestral curses, the result of a sinful act or punishment from God; (2) biomedical factors which include: head injury, birth complications, or health conditions such as Down Syndrome and epilepsy to be the causes of intellectual disability. Figure 0-4 below shows a breakdown of the causes of intellectual disability and mental illness provided by all the participants. I have produced a spider’s web diagram showing the themes and how they interconnect. The Indigenous beliefs ranged from supernatural, traditional, biological and a combination of two or all three categories above. 133 Figure 0-4 : Indigenous beliefs about causes of intellectual disability and mental illness Learning disability/ mental illness Transgressions against others Peri-natal/Biological Religious beliefs (supernatural) Traditional beliefs (supernatural) Indigenous beliefs Biological/Beliefs combining other aspects. Pre-natal Combination of above Witchcraft Birth complication God’s will Ancestral curse Mother’s behaviour Evil forces God/Ancestors/Supernatural Unexplained natural elements Possessed by demons/evil spirits. Witchcraft Post-natal Ancestral curse 134 4.2.1 Biological explanations and antenatal stress. Question: In terms of people with Down syndrome and autism and other people born with learning disabilities what again were you made to believe was the cause of learning disabilities? We were told it has something to do with genetics. (P1) Sometimes other people say it comes from genes. (P6) For most of the participants, biological reasons included stress during pregnancy, trauma exposure during pregnancy and heredity. when the child was born with a learning disability, it became a family secret. And the response was usually that the blame was sent to the mother of the child. It was always said that the mother of the child has done something which made the child to be the way that they were. (P4) obviously, the mother would be heartbroken and crying. they would start blaming the woman and say that it was obviously from the woman’s side. They would just blame the woman, maybe she has done something wrong, or the woman’s family has caused this meaning they have done something to do with witchcraft. (P7) that the mother wanted to abort this child and that is why the child turned out that way. There is a lack of knowledge around learning disabilities. (P7) In these responses above, several participants reported that everyone, including the father, avoided the mother and child and refused to give any support due to beliefs in traditional causes. 135 4.2.2 Traditional beliefs (supernatural). The most common belief was that intellectual disability could be caused by offending the ancestors in some way. All participants discussed traditional beliefs. when she had an extramarital affair the husband’s ancestors would punish her by giving her a child with a learning disability. (P9) With mental health again, people believed it was witchcraft. (P3) A lot of people believe that when somebody has a mental illness, it is because somebody else has bewitched them. (P2) maybe some sort of black magic was involved in the family or from outside the family. Some people believed they were cursed. (P3) I think the cause that everybody accepted was that the person had been bewitched. (P6) So that stigma of learning disability and mental health, remained with us, that there is a witch somewhere there, bewitching your family, that's why you're like that. (P1) back then, we would always suspect witchcraft; that somebody has been bewitched and maybe someone else needed something and had to give up someone in order to get it. (P7) Persons with intellectual disabilities in these Southern African communities in which the participants were brought up, are virtually invisible in the public sphere, neither seen nor talked about. The quotations above suggest that knowledge of intellectual disability in the communities is scarce. Many people do not know that people with intellectual disabilities exist. the terms black magic and witchcraft is an immensely popular things where I come from. If something that you can’t explain happens, all of that was categorized as black magic or witchcraft. So, these kids who we grew up 136 with, we couldn’t explain or say what was wrong with them, but we knew they were different from us because they couldn’t speak, and we couldn’t communicate with them. We just assumed that maybe it is a curse and people were talking saying it was a curse and we grew up believing that. (P3) 4.2.3 Religious beliefs (supernatural). In this category, participants reported that having an intellectual disability happened as a result of God punishing the parents for previous transgressions committed by the parents and grandparents. Additionally, God may have willed that the child be born with an intellectual disability therefore parents just had to accept it. Relying on spiritual beliefs, some accepted that giving birth to or caring for a child with an intellectual disability was God’s will. Participants reported that as a result, these caregivers would then take their children to churches to pray for deliverance. Both findings are mirrored in the following quotations: The explanation would always be rooted in what the community or the religious sects believed. (P3) Back home, they believe prayer works while in England they detach completely from religion whereas back home, they believe in a higher power and in that God loves you and has created you in His image so that is the major difference. I might be wrong, but it is a value that is ingrained in me and might be hard to get rid of. (P10) her family belonged to the church of the apostolic faith. Because they believed in the Apostles, they couldn’t even take her to the traditional healers. (P6) 137 4.2.4 Beliefs combining other aspects. In this category, some participants cited a combination of multiple causalities of intellectual disability or mental illness identified above. The data shows that the beliefs could be mixed, hence, having a certain belief did not necessarily exclude the other beliefs. Especially religious beliefs of causation did usually not stand alone but were tied to medical ones, and more of an abstract nature, while the direct causes in these cases were still often attributed to medical factors. Again, as l pointed out earlier, this was a challenge as the responses might have been more informed and detailed due to the participants being current student nurses. Notwithstanding, these results suggest that belief systems based on supernatural and biomedical causes of intellectual disability and mental illness often co-exist in Southern African societies. At times, it might be that you are kind of well off, and then maybe some of your relatives get jealous of you, and then they curse your generation, and whoever is surrounding you, so there's a release of a curse, because of jealousy, that was always what we’ve believed. (P1) It's when people use what we call juju to play with other people's minds because you don't like them and then you impose this evil spirit on them. (P2) I think it was a cultural reason because people used to say that it runs in your family or runs in your culture or because of something that your ancestors did. (P6) It was viewed as a curse in terms of something you did in your life that made you carry a child with the condition, or somebody sent a spirit to do this witchcraft and now it has turned around on you and that is why you have had a baby that has this mental issue. So, it was a matter of the parents doing something wrong or one of the family members using the child to get powers. (P9) It normally happens when you expose yourself to things like drugs and things that mess up your mind (P13). 138 I remember, growing up if someone was a thief then they developed a mental health problem, the conclusion would be that it was because of their actions. People would say that they have been bewitched and other things like that. (P8) Two of the participants also indicated that some unscrupulous parents may choose to trade their child's intellectual capacity for wealth and/or status by going to witches who are believed to make this happen: In Africa, if you are from a poor background, there's always a belief that maybe one of your parents was desiring to be rich, then end up sacrificing one of your kids or unborn children, and as a result, are born with a disability. At times, it might be that you are kind of well off, and then maybe some of your relatives get jealous of you, and then they curse your generation, and whoever is surrounding you (P6) We believed that some people are trying to get wealth and then they sacrifice one of their own. This was common among rich people. (P5) Sub-theme 1 - Earlier cultural learning about intellectual disability and mental illness Closely related to the belief systems the participants shared, is how they came to know what they thought they knew. I asked the participants who it was that taught them what they knew then about intellectual disabilities and mental illness. It was family members and people that my grandmother knew because she would spend more time explaining this to us. (P2) All the people like our older brothers and older kids in our community would be talking about that. (P3) Family members and friends and it has a very general idea that went around in the community so it's just what I would hear from time to time. From the time you are small, you would just hear people talking. (P5) 139 My parents. I never heard anything like that at school. I cannot remember if they ever taught us about people with learning disabilities. (P6) Parents and grandparents but especially my grandparents. (P7) I think it's culture in general… it becomes a way of life. (P13) It was by the way when you came across someone with mental challenges in the community that is when you would now question your parents or your teachers. (P10) 4.3 Theme 2 - Local beliefs about causation of intellectual disability and mental illness and help-seeking behaviours Some of the treatments cited included: making the patient inhale steam from boiling water mixed with medicinal plants or making the patient inhale a mixture of special herbs and seeds placed on glowing coal in order to remove the spirits or magical charms that caused the illnesses. (P4) With mental illness, I understood that they were being treated in hospitals for mentally ill people but for learning disabilities, help was only offered for physical disabilities, not the learning disabilities like the ones I have encountered in this country.’ (P6) They would go to the witch doctors to try and find out who is causing this and if anything can be done and it would end there. (P7) The majority of the community was Christian so they would call pastors and bishops so that they pray for this individual to cast out the spell found on this person. If they were a traditional family, they would be taken to traditional healers and be given concoctions and some traditional rites to follow. (P10) 140 in the village, people just think it's madness and so when you were in the village, they did not bother to take you to the hospital, or they would give you herbs and everything else that they use. In this city, it's different because they at least take you to the hospital. (P7) even if you went to the doctor will tell you to go to the traditional healers, and they would refer you to go to the witch doctors. (P5) Witch doctors are everywhere and that was their only answer back home. They believed in that, especially the Black community. They believed in going to the witch doctor for everything they had which was wrong with them. (P13) Yeah, it was just witchcraft, all the way. Sometimes they will use some smoke or incense and put the child to see if they are possessed because that's all they understand. That's why we understood that if you burn incense, and maybe every night, you just put your child there, all those evil demons do leave him or go. (P1) They would look for a person that was thought to have performed some witchcraft on the child and that's what the community would think. They would say someone within the family had been sending those spirits to that person when they were pregnant which is why they had the result of a child who had mental health problems. (P6) We just knew that he was born like that. Whether it was a complicated birth or anything like that, we never knew. (P3) from the stories that I have heard and the ones that were described when I was young and when I was in primary school that they had crowns of feathers on their heads. They used a lot of charms and would throw bones and use a lot of traditional medicine. They would go into the forest and look for traditional medicine. (P9) 141 Witch doctors. People would go to a traditional healer and religious leaders, particularly the Apostles and that is how people tried to treat those people. (P5) I think that was the only option that they would take people to traditional healers. (P6) Oh, yeah. They are taken to witch doctors using African herbs and medicines, depending on if the family has money. And the next thing they'll tell you is to bring a chicken and kill it in the bushes, or a few dozen eggs and oh, my goodness, crazy stuff, man. You know, get a black cloth or a white cloth and just tie the child on their hand. It's depressing. It’s just African culture, it's crazy. Yeah, it was just witchcraft, all the way. Sometimes they will use some smoke or incense and put the child to see if they are possessed because that's all they understand. That's why we understood that if you burn incense, and maybe every night, you just put your child there, all those evil demons do leave him or go. (P12) That was the answer back home because they have got witch doctors everywhere in South Africa. If something is remotely wrong with you, they would go and see a witch doctor and the witch doctor would use herbs or medicine… and then tell you to take this before you go to bed, make sure you drink this and when you wake up or go to a shower, use this to shower yourself with it. Witch doctors are everywhere and that was their only answer back home. They believed in that, especially the Black community. They believed in going to the witch doctor for everything they had which was wrong with them. (P2) Traditional healers are there but when we were growing up as young people, we were not allowed to have anything or any associations to know about traditional healers because this was mainly adult stuff. Luckily in my family, they didn't practice with traditional healers. (P12) 142 ‘I think a lack of knowledge played a part as well because people used to believe them. They would seek traditional healers or religious leaders over formal hospital and support services. (P13) So, when the child was born with a mental disability, the parents would go to Sangomas to try and get help. The family would have to pay to get that help.’ (P4) ‘With the sangomas and the churches, especially the apostolic church, people could get help but with actual hospitals, (P4) .and religious leaders particularly the Apostles and that is how people tried to treat those people (P7) One participant commented that they knew of a child to have been chained to manage their problems. They acknowledged that chaining is done not as a punishment, but to protect the child from harming themselves or others when there is no one to look after the child: Yeah, I know, one case. In South Africa, there was a child with Autism, and the family was using chains, just to keep him inside. They would lock his leg with a chain so that he doesn’t stray away. He would always be chained...People think putting someone in chains is for their own good but it’s torture. You know, they don’t understand this, they don’t understand better how to treat this, because there’s no help at all. You see an autistic child, and you think, Oh, my God. (P1) In addition to the help-seeking models l have discussed above, some of the participants acknowledged that as well as looking for answers, families still had to look after their relative with an intellectual disability or mental illness. The burden of looking after the person was so immense that it was difficult to manage them all day every day and there was no external or formal support available in the communities. Some of the participants’ responses regarding support were: No, I don't think there was any help at all, the only thing that was there was to take them and lock them up. Sometimes the person will just be left to live on the street because the family will also be struggling. (P2) 143 It is very acceptable in Europe that some individuals within our community may live with a condition. The community is also educated about those through advertisements on TV and in Newspapers. So that allows everyone to understand the illness, and that is a big difference. Financial help also plays a key role. The financial budget for mental health is there. Unlike in Africa, such funds are often misdirected to other things, and that is the reason why there is a lack of awareness. That is the reason why we end up concluding that it is witchcraft because we don’t have any sort of awareness. Nurse professionals should take that responsibility to teach the masses about mental health. The country does not even have a mental health ministry. How's that? You know, that's so crazy. (P1) Mainly it was families who looked after their own. If a family member has a learning disability, there were no facilities where they could take them like a day centre as they have here in the UK. Families were the ones who supported them. The only thing you would find was that most of them would end up in the streets or prison or they would be dead. (P3) I don't think there was anything because, for most of them, their families used to keep them at home. (P4) They never got supported. They would be left as they were. I remember another woman who used to walk around all over the place in dirty clothes and she was scruffy. To everyone, she was crazy, but she was living in a family with very well-to-do people, and no help was given to her. (P5) She used to live with family, but she would just go from place to place and when she was lucid, she would go back home and then she would start again moving from one farm to another. She would just come and sit outside, and people would give her food, especially at our place. My mum would give her food and water and clothes because she would be dressed in tatters and my mom would give her clothes but the next time you would find her naked again. (P6) 144 It's the same as well, they are just disregarded and treated like people with no value at all. We didn't want to associate yourself with that person. And if a family has somebody who has a learning disability, or mental health issues, those people usually struggle, because even the government cannot even help. The government should chip in, support, and raise awareness but if the government, with people that are elected officials, are not able to raise issues like that, then what will the community do? (P3) I also asked the participants to make comparisons between support available in their home countries and that which they had become aware of since having become aware in England: I have done placements in... There are people with mental health issues, but they actually live in their own apartments like a massive institution. It's not liked a locked-up place whereby they're told, “Go to bed now “. They’ve got their own house; they've got their own rooms there where families visit them. They also have TVs in their rooms, eating food, whatever they want to eat and are well looked after. So that that struck me, that was so unbelievable. The other thing is that back home, this thing was not spoken about, so we didn't know what it was. We only knew the reason why they were locked up is that they were mentally disturbed. No education whatsoever, but mental health with only one channel, which is a government TV channel, you won't get anything like anything like teachings. (P3) Through this, they receive support and are able to live their own lives. I'm surrounded by all that now and we learn with people living with disabilities and some of them are smarter than us. Well, some of them are very smart. I think if people in Africa could be exposed to that. Knowing that this thing can be managed, and people can live a normal life with the condition. That will help and with the input of the government will go a long way. (P3) 145 4.4 Theme 3 - Stigma, discrimination towards people with an intellectual disability and mental illness Communities tended to ignore the parents who had a child with intellectual disability. Some community members seemed to disapprove of intellectual disability, mostly the severe and profound forms of disability. To ascertain this, I asked the participants to describe public perceptions of people with intellectual disabilities or mental illness. Some of their responses were: I remember where I used to live, there was one guy who had a learning disability and we used to laugh at him. He would go around the house-to-house opening people’s taps then he would leave. Nothing was done for him. The family felt fine with it, and everyone just accepted the situation but at the same time not being helpful to him in any way because no one knew or understood what was going on with him. (P5) I remember sometimes whenever you pass by you will just see them climbing fences, some of them, not dressed, or you'll meet them in town picking things up and no one would want to associate with them, because they're crazy and mad, something's wrong (P1) Back then, I remember one who would sing and follow the road. He used to sing songs of liberation and as children, we would imitate those songs and make fun of him. We did not understand what was going on. So yes, I did come across people with mental illnesses that I still remember. (P10) Oh, yes, we were running away from them. Because they were always regarded as just mentally disturbed, and you cannot associate yourself with that? Because that thing might jump from them into you. That's the belief that we've always had. (P12) Given the participants’ active experiences with stigma and discrimination at an early age, in some cases where they were the instigators, it would be of benefit to explore the impact of stigma and 146 discrimination on their own growth as nurses who will be working with people with intellectual disabilities and mental illness. The behaviours the participants identified in relation to the experience of stigma and discrimination, included insults, mocking, staring and fear of people with mental illness and intellectual disabilities. In what follows, I will cite a few examples of African beliefs concerning mental illness that depict psychological and neurological impairment in a negative light. Some of the ethnic names are included in the participant’s responses below. They use Shona names like “akadzungaira” which means someone is very confused. (P4) the term that we used for them was very derogatory. I think it stemmed from the English word scum and we called them SASCAM. (P5) Culturally in Zimbabwe, even the mad people are treated the same. There was one woman who was from my primary school, and she was a mad woman we used to call her “abenzi” which means mad woman and she would respond to it. (P6) For example, when dealing with something with epilepsy she would always tell me to move away when someone was having a fit because she was scared that I too would get it. She believed that everybody who had a mental illness or learning disability could spread to two other people (P4) There was a stigma when someone has mental problems because they were being pushed away from the community and they could not be associated with other people in society. (P10) There was still a stigma and social isolation and even at church, you could see them being treated differently from everybody else. (P7) In my study, there was no indication that intellectual disability could be cured as evidenced by one participant’s testimony: 147 the explanation was that this cannot be undone or changed because you do not choose who you want to become, it has already been ordained by God that this is the outcome of this person (P13) Those that endorsed fate and environmental causes, however, supported more religious/spiritual help and lifestyle changes, possibly to address the causes they perceived to influence intellectual disability. Conversely, some families either did not believe in taking their family members to hospitals or could not access them either due to distance or financial reasons especially in more remote and rural areas. To summarise, this included the influence of stigma and beliefs, help-seeking, and a general lack of knowledge about intellectual disability and mental illness. This leads to the refusal to acknowledge that the biological causes of an intellectual disability and mental illness require biomedical approaches. They used to go to religious leaders and some of them used to go to sangomas to try and get help. The family would have to pay to get that help. (P2) That was the answer back home because they have got witch doctors everywhere in Southern Africa. If something is remotely wrong with you, they would go and see a witch doctor and the witch doctor would use herbs or medicine (P12) I offer some reflexivity in Table 16 (Please Table 16 below). 148 Table 16: Reflexivity item on stigma Most of the participants in this study cited either possessing or having witnessed strong cultural beliefs related to stigma towards people with intellectual disabilities and mental illness. These findings aligned with those found in reviewed studies investigating caregivers and parents of people with intellectual disabilities and mental illness who reported being stigmatised because of others’ negative cultural beliefs. In this study, participants described how some families worried about taking their child out of the house; felt ashamed or embarrassed about their child’s condition; felt a need to hide the problem from people in the community and tried to keep their child’s condition a secret Stephenson (2008) posits that arising from the evolving meanings of ‘culture’ and ‘values’, cultural values are taken to be those values that are shared by a group or community or are given legitimacy through a socially accepted way of assigning value. Related to values are cultural values although these are more than what is important to individuals. Ludwick and Silva (2000) refer to cultural values as enduring ideals or belief systems to which a person or a society is committed. Cultures, and by extension cultural values, are defined as the ‘‘shared The stigma associated with intellectual disability and mental illness is strongly associated with witchcraft beliefs from an African perspective and belief system. My discussion of Witchcraft earlier in the thesis highlighted the African view of witchcraft. The participants, even as adults now, vividly remembered how fearful they were of people with intellectual disabilities and mental illness especially if it was believed that witchcraft was the cause. If the participants and l as Africans had this profound fear of people with intellectual disabilities and mental illness, l wondered how they overcame this fear when they started encountering them in England. I wondered if it was possible that because they were now living in a culture where witchcraft was not a feared phenomenon that their fear dissipated. This left me questioning what the outcome would have been had this research been conducted in Africa. The everyday lived experience of the participants coupled with my own experiences as a student and a nurse when we first encountered people with intellectual disability and mental illness led to the construction of another layer of belief systems. Again, l was interested in exploring, maybe, in a future study, whether in years to come, Southern African nurses would encounter families of people with intellectual disabilities and mental illness with the same belief systems and how they would manage them in a country such as England. 149 way of life of a group of people’’ (Berry 2004, p. 167) or as the ‘‘rich complex of meanings, beliefs, practices, symbols, norms, and values prevalent among people in a society’’ (Schwartz 2014 p.6). Ohara (2018) asserts that cultural and religious attitudes, understanding and beliefs all play their part in how care is sought, planned, accepted, and delivered. Cultural values are inclusive not only of attributes traditionally considered to be part of the culture such as Indigenous beliefs and knowledge systems but also of attributes that might be considered to be part of the causation of intellectual disability and mental illness which are valued culturally (Stephenson 2007). Southern African students schooled in these cultural values develop a sense of loyalty to their communities and as they navigate the nursing arena, some of these may need to be completely overhauled. The time it takes for these to change may present challenges to the students. Cultural values may be seen as underpinning, shaping, and justifying individuals’ affect, behaviours, and cognitions (Hofstede 1980, 2001; Schwartz 2003). Culturally determined value systems are crucial for understanding the perception of notions such as ‘health’ and ‘illness,’ and lead to fundamental differences in assessing medical interventions and therapeutic objectives (Ilkilic 2007). I think it was a cultural reason because people used to say that it runs in your family or runs in your culture or because of something that your ancestors did. (P6) I might be wrong, but it is a value that is ingrained in me and might be hard to get rid of. (P12) The explanation would always be rooted in what the community or the religious sects believed. (P13) So, the stigma of learning disabilities and mental health remained with us. (P1) ‘If something that you can’t explain happens, all of that was categorised as black magic or witchcraft. So, these kids who we grew up with, we couldn’t explain or say what was wrong with them, but we knew they were different from us because they couldn’t speak, and we couldn’t 150 communicate with them. We just assumed that maybe it is a curse and people were talking saying it was a curse and we grew up believing that. (P13) The explanation would always be rooted in what the community or the religious sects believed. (P3) Sub-theme 2 - Encountering a person with a learning disability for the first time in England. Having encountered people with learning disabilities, especially those with severe and profound and multiple learning disabilities, participants shared their perceptions and thoughts about the fragility of life. For some, it was not always easy and some of their experiences were negative; openly sharing feelings about fear and stigma. What made it more poignant for some of them was the previous feelings and stigma they had held as casual observers back home whereas now they were in positions of responsibility as carers or students. In a sense, it was overwhelming to think that someone could live and go through all that or they have all these complications and still be alive. I have come across people who have got an extensive list of people with syndromes which I have never heard of before (P13) It was overwhelming, to tell the truth, because I wanted to understand and listen to these people and see how they are like and what is involved in their day-to-day life. (P4) my first reaction was that it was surprising to me because back home, we did not see much of them. (P5) The first job that I got was as a learning disability support worker and I landed on this residential home with one guy who was one to two (staffing). If you were not careful, he would jump on you, and it was scary. I just felt deeply sorry for them because there were so many people with different conditions. (P6) I was scared, and this was back home. In the community, you see one or two people but when you go to a facility where there are so many of them, it’s different. I 151 remember being very scared, especially of those that can't even speak but all they do is make these expressions and you don't understand them. It's scary.’ (P7) So, the first time I saw that it affected me. I was on placement. A young woman was banging her head against the wall. I had heard about it, but I had never seen it myself. It was so emotional for me because when you hear something but have never seen it you don't believe it the way that other people do. (P8) 4.5 Theme 4 Acculturation Some of the participants indicated that education contributed to the shift that had occurred in themselves. Classroom discussions, individual study, and the desire to fit into the new culture through self-teaching changed their cultural beliefs. This included social media which entailed active participation on Twitter, Facebook, and other social media platforms. Throughout our education, we understand British values, especially when you want to get British citizenship and because I was in the army. Also now in nursing, there is a diverse group of people whom I work with so in one way or the other, there has been a lot of cultural education. But the important thing is that it's difficult to change someone’s values and beliefs, but within professionalism, you need to be respectful but at the back of your mind, you still have your values and beliefs. (P10) …now those beliefs have been crushed because I now have my own values and beliefs and with studying nursing at the university… (P12) Oh, yes, definitely. Through access to the internet, books, teachings, and lectures, like you guys -learning disability nurses, you’ve really opened up our minds. I’m now well-versed in the causes and management of such cases, and I can help those people live a better life. It is through that exposure and awareness, from the government's support, the NHS, the community, people, the neighbours, and access to resources like wheelchairs. (P1) 152 All the strategies used by the participants in their experiences of learning about intellectual disabilities and mental illness on their way to becoming nurses suggest an active engagement with mainstream society and a prominent level of motivation to become competent practitioners. The findings reflect the acculturation experience that sustained contact and interaction with people with intellectual disabilities and mental illness by the participants helped to create the enabling learning environment. At the end of the interviews, l asked the participants to comment about whether their views or beliefs had changed, and their quotations below summarise their views: It's both really. I reject witchcraft, obviously, because I'm a Christian, and I now have more awareness. (P1) Of course, it's changed especially when it comes to labelling people because I did not like that even in Zimbabwe because even back then, I would ask why they would call somebody like that because I did not like it. (P6) Again, I am a nurse, and I am a Christian, so the belief is still there but when I am practising, I put my beliefs aside and in my private life, I become a Christian. (P5) ‘Being here (in England) has helped with my thinking differently…Exposure has helped my path of understanding so that I know that there might be something that causes all this. (P7) Most of my beliefs have certainly changed. (P10) Yes, I do think so. Because of the programmes that have been set already. In the modules you get, people with learning disabilities coming in to address us as students in terms of how they are treated and their feelings. And so, all those things are awareness, isn't it? Because you tend to hear from the people living with autism themselves expressing themselves on how they are treated and how they are received, and how the community is benefiting from them, at the same time. So yes, there is a lot of awareness. … University, like I've mentioned, and obviously, 153 access to some placements where you've got an opportunity to go and learn. So, all those things, they play a vital role.’ (P13) This study has shown that there is a relationship between prior employment experiences which exposed student nurses to people with intellectual disabilities and mental illness and accessing nurse education. Employment as support workers and health care assistants appeared to inspire them to socialise into the future nursing role through their daily interactions with patients in these environments. Additionally, the study found that these experiences with patients in both intellectual disability and mental health environments and the professional values which student nurses have acquired during their education interact to influence how they react to and treat the people they are caring for. While this study focused on student nurses from Southern Africa, it will resonate with universities, researchers and practitioners that work with other immigrant groups. This study provides some evidence for specific factors involved in the reshaping of attitudes, including education, previous work experience in learning disability and mental health settings, placements, and intrinsic motivation to learn the phenomena under study. The study provides qualitative reflections and suggestions from participants. It is to be envisaged that as Western education deepens and gains wider spread coupled with development in science and technology, there would be corresponding increased awareness of and interest in the scientific and traditional causal models in African-born students. So far this study’s analysis of the data has shown that when ascertaining traditional beliefs, attention must be paid to changes in belief systems that are likely to occur over time, therefore, beliefs are not viewed as static. However, what was evident in the data was that the participants’ beliefs about disability and mental illness per se are often exceptionally long-standing and intricately woven into many other aspects of the traditional culture (Glover and Blankenship 2007). With most of the participants having lived in the UK for at least five years, it was clear that their beliefs changed when there was an intersection with Western ideas, especially in education. All the participants expressed shock and surprise at seeing the high numbers of people with intellectual disabilities in England, a direct contrast to the exceedingly small numbers in Africa 154 since many were hidden in family homes. The nature of the cause of the intellectual disability or mental illness back in Africa influenced help-seeking models they chose between traditional or biomedical. Assumptions of lay people derived from the literature review (Stone-McDonald and Butera 2006; Botts and Owusu 2013) about beliefs about the causation of intellectual disability and mental illness research were hence mirrored in the data reported by the participants. Even in my adult age, I still believed that there are witches and witchcrafts because it was already ingrained in my beliefs (P1) it was because of something that was done wrong in your family (P2) I think the majority of it was the thought of witchcraft- that is what I was told (P6) So, some of the things we sort of believed in our community are that when someone is born like that, maybe some sort of black magic was involved in the family or from outside the family. (P7) Seven of the participants became acculturated in intellectual disability and mental illness whilst others admitted that they were still stuck in their old beliefs. However, those who admitted to being stuck in their old ways reported that they accepted the new belief systems they had now come to know. This usually happened during their earlier employment, equivalent to the integration stage of the acculturation model (Berry 1980). This shows that acculturation is not linear, and people do not acculturate at the same time. The next section will offer a consideration of acculturation on the belief systems of the participants. Due et al. (2015) posit that even if there are benefits associated with international and immigrant students in a university setting, there are a range of issues faced by this cohort of students at all levels, including acculturation stress, language difficulties, challenges in meeting and forming friendships with local students and discrimination. Acculturation accounts for many of the stressors as it involves a shift in cultural beliefs and perspectives. This study will be of interest to researchers, especially in nurse education who observe immigrant nursing students’ acculturation in higher education contexts and who raise questions about their experiences in the learning environment. 155 While Handy et al. (2010) suggest that nursing students are likely to present value-based motivators for volunteering, this thesis proposes that employment opportunities such as working as support staff are helpful in compassion building. In addition, Newbanks et al. (2018) indicate that religious beliefs affect the perception of care. As some of the students identified as Christian, there was a determination to help others including people with intellectual disabilities. Despite their indigenous beliefs, they were able to show the fundamental tenets of Christianity and Ubuntu, treating others with respect at all times. Qualitative data from the participants supported the findings, showing that eight out of the thirteen participants were affected by strong traditional beliefs and stigma. When aiming to explain how beliefs about causation and stigma changed in the participants, it became apparent that for some, this process started before the participants had become student nurses. Grainger and Bolan (2006) suggest that many students enter training with an idealised view of nursing. As well as meeting financial needs, employment has also been viewed as an opportunity to expose students to the reality of nursing practice (Rhodes and Bouic 2005). There was an interplay between acculturation, employment experiences and education, although it can be argued that the latter two are part of the former. It could be argued that acculturation was the overarching phenomenon. Employment may not have been in an intellectual disability or mental health setting therefore the beliefs and stigma may have remained unchanged. Previous education undertaken in the UK may not have been in a health-related profession either. In terms of acculturation, the participants may have chosen not to interest themselves in intellectual disability and mental illness and opted to remain in the same mindset. For this research, all the factors favoured the process of a shift in the participants’ beliefs because they made the decision to be nurses and aligned acculturation, employment, and education to suit their decisions. However, the degree to which phenomenon was more influential in the shift in beliefs was beyond the scope of this thesis. Given the existing literature on the transitioning experiences of African students engaging in higher education (Smith and Khawaja 2011; Harvey and Park 2012), I decided to focus this aspect 156 of my research on a key component of this transition: cultural shock. This is because all thirteen participants confirmed that they immediately experienced culture shock when they arrived in England and started working with or encountering people with intellectual disabilities and mental illness. Some of the responses were: In a sense, it was overwhelming to think that someone could live and go through all that or they have all these complications and still be alive. I have come across people who have got a long list of people with syndromes which I have never heard before’ (P3) It was overwhelming, to tell the truth… I wanted to understand and listen to these people and see how they are like and what is involved in their day-to-day life.’ (P4) my first reaction was that it was surprising to me because back home, we did not see much of them. (P5) I was scared... I remember being very scared, especially of those that can't even speak but all they do is make these expressions and you don't really understand them. It's scary.’ (P7) So, the first time I saw that it really affected me. It was so emotional for me because when you hear something but have never seen it you don't really believe it the way that other people do. (P8) The term culture shock was first used by Oberg (1960) in his seminal work, to describe the feelings experienced by people immersed in an unfamiliar culture where individuals were removed from the everyday cues, they relied upon to engage in daily life. However, Harvey and Park, (2012) have defined culture shock as maladaptive psychological reactions and mental disorders that occur in response to the transition from one cultural setting to another. Students reported that a comparison between diverse cultures requires approaching each with the desire to see a different point of view, valuing diversity (Randon et al. 2020). Heidegger (1962) in his seminal work on phenomenology asserts that the experience of time and space is not a situation-less experience because we are located in our own temporospatial 157 context, because of being in the world. For the participants, encountering a person with an intellectual disability or mental illness in England meant a change of the context and changed the meaning of the event. For example, placing the same event back or forward in time would influence the meaning of that event in that when they encountered a person with an intellectual disability back home, the meaning of that experience changed when they did so in England. In my study, I posed the question to the participants ‘What was the experience of meeting a person with an intellectual disability or mental illness like?’ This invitation to speak of their lived experiences revealed both temporal and spatial aspects of student nurses’ experiences of encountering a person with an intellectual disability or mental illness both at home and in England. This encouraged the participants to bring forward a deep telling of their experiences, including the mind, body and spirit of those experiences, at the same time revealing more about themselves as future nurses. All the participants in this study expressed having experienced culture shock and through their encounters with a different culture, they had an opportunity to analyse their values, allowing them to gain an awareness of their cultural system, which is the starting point to be able to recognise and appreciate others’ cultural diversity (Foronda 2008). The participants all attested to having entered a process of questioning these values and beliefs affirming this stage as part of acculturation. The study participants reported that they found it difficult to adapt to more fundamental cultural differences that challenged their beliefs having to do with the position of people with intellectual disabilities in society. Through this, they receive support and are able to live their own lives. I'm surrounded by all that now and we learn with people living with disabilities and some of them are smarter than us. Well, some of them are very smart. I think if people in Africa could be exposed to that. Knowing that this thing can be managed, and people can live a normal life with the condition. That will help and with the input of the government will go a long way. (P1) I went back then to get a feel because that’s where my next placement was- in personal care and that's when I got into the nitty gritty of nursing and that really 158 changed my perspective. And in terms of reasonable adjustment, because when I went with one of the clients to get a haircut that was really such a struggle to get the person to do the haircut. The assets were there but just the attitude and everything that I saw there. That was when I thought we had to do something about it so that's when I realised, I was in the right post. (P2) Coming to terms with this led them to immediately start questioning their previously held beliefs. Kokko (2011 p. 679) explained culture shock as an “encounter with difference that confuses the nursing students because they had to face their own prejudices, stereotypes and systems of values”. This is what the participants were going through, some of them long before they were students because they were in paid employment. For the participants, a lack of knowledge about the new culture appeared to exacerbate culture shock. All thirteen participants experienced cultural nursing shock as they tried to adapt their nursing practice to fit with the professional standards and the culture of the new country of settlement. Particularly difficult for one participant were issues related to the offending behaviour of patients with mild to moderate intellectual disabilities cared for in forensic services. I couldn't understand why they were defending and protecting people with mental disabilities and advocating that they fit into the community despite all the damage that they would have done. But it was so hard for me because when you look at the things that these people had done, you couldn't make it up, you couldn't understand why you are looking after somebody who's done such things. And then still these guys are covered up and protected. In Africa, they would have been killed, there's no chance for a person like that. So, when I looked at that and looked at where I was coming from, it was so tough. But I began to read about it and the people that I was working with were understanding and were sharing their feelings with me. So, I would ask them how they are feeling, and they would say, you know, what, man, this is just a disability, this is what happens to a person, sometimes they might not know, or understand what they are doing. Sometimes they behave like children, sometimes they behave crazy, and they just want to do things that 159 you might not understand. That's why they're under strict orders of medication (P1) Research has shown that the experience of culture shock also negatively impacts students’ psychological and sociocultural adaptation (Presbitero 2016). Merry et al. (2021) postulate that due to their cultural differences, foreign-born African nursing students often face cultural adaptation and cultural shock, issues not experienced by students from the dominant culture. Professionals may have personal feelings and reactions to a patient’s previous offences, current behaviours or beliefs (Hammarström et al. 2020), however, it is fundamental that these are not communicated or acted upon and do not affect care delivery. The students encountered people with profound and multiple intellectual disabilities, autism, epilepsy, and mental illness in their capacity as carers which placed a level of close contact and care. Having never been in this position before, it served to raise their anxiety levels. Irungu (2013) points out that African students can find the cultural gap between their own country and the host country overwhelming. Some of the participants in this study found it difficult to change their deeply embedded cultural beliefs. A part of me still believes what I knew before I came to the UK. A small fraction of me still believes, especially with mental illness, there could be something sinister that would be going on. (P13) I believe that what you were told or taught as a young child growing up will stay with you for the rest of your life. How you are taught to live your life, how to approach people, and the beliefs you have will always stay with you for the rest of your life. So even if I move to a different country and they had an unusual way of doing things, what I believe will never change because that is embedded in my mind. I have these conversations with my mother about what I have seen at work. (P3) 160 Maringe and Carter (2007) found that the mature students they studied were concerned about the erosion of their cultural heritage while in the United Kingdom. This is consistent with some studies of Black-African students abroad who also show a reluctance to relinquish their former identity, in favour of embracing the host country’s culture. Beoku-Betts (2006) posits that the concept of relinquishing an identity to integrate into a new culture is especially challenging for many African students because of the legacy of cultural marginalisation and destruction left by the colonial period. This highlights the importance of exploring participants’ previous beliefs and their Indigenous knowledge, so they do not impact their new learning. Previous studies have shown that cultural background can impact the provision of practical care to patients, for example, patients of the other sex (Abu-Arab and Parry 2015). This study identifies that students’ cultural background for example norms, values and beliefs impacted their clinical and classroom learning experiences. Some of the participants indicated that education contributed to the shift that had occurred in themselves. Classroom discussions, individual study, and the desire to fit into the new culture through self-teaching changed their cultural beliefs. This included social media which entailed active participation on Twitter, Facebook, and other social media platforms. ‘But the important thing is that it's difficult to change someone’s values and beliefs, but within professionalism, you need to be respectful but at the back of your mind, you still have your values and beliefs. (P10) …now those beliefs have been crushed because I now have my own values and beliefs and with studying nursing at the university… (P11) Heidegger (1962) suggested that the process of understanding a phenomenon exists before theorising that humans find out what is acceptable behaviour, thoughts and relationships by the everyday interaction they have with others and things. As they encountered people with a learning disability and mental illness, the participants’ understanding of intellectual disability and mental illness began to develop whilst the shedding off of their original understandings simultaneously occurred. Therefore, when introducing a new experience, knowledge or 161 phenomenon, our existing understandings and experiences are challenged to make sense of and accommodate new meanings (Miles et al. 2012). Although it initially brings about confusion, the experience itself is a learning process. However, this initial confusion and frustration develop into cultural awareness that can be viewed as a precondition of the learning process (Kokko 2011). Support has been identified by Charles et al. (2014) as playing a major part in overcoming the culture shock experienced by students. Preparation requires an acknowledgement and identification of one’s own values, beliefs and cultural practices and reflection on how these may be challenged in another culture and without the comfort of the normal cues associated with everyday life to provide culturally responsive care (Harvey and Park 2012). Universities must support students as they undergo these emotional and intellectual transformations. Hermeneutically, understanding comes from a process of deconstructing and reconstructing, from not understanding to coming to a moment when new meanings and understandings are developed, merging both preunderstanding and new phenomena, to come to a significant new understanding of-being-in-the-world (Miles et al. 2012). This thesis adds that acculturation, as a process, involves an exchange in the flow of belief systems from the unknown to the known in terms of culture. When African-born student nurses assimilate, it will involve some discomfort as they battle to reject their childhood teachings about intellectual disability and mental illness. It may feel like a rejection of their culture to some or seen by others as entering a new belief system. Moreover, Waters and Himenez (2005) suggest that during the process of assimilation, migrants are expected to conform to the current norms of the state through a process that Berry (1997) refers to as culture shedding, which is unlearning or undoing previous customs or traditions. Additionally, hermeneutics is also one of constant change, as life is an ongoing cycle of actions that constantly construct and reconstruct ‘life-worlds (Liamputtong and Ezzy 2005). To further accentuate my assertion, I agree with Heidegger’s argument that interpretation occurs in every encounter and this interpretation is influenced by the individual’s background or history. 162 4.5.1 Sub-theme 3 - Route into learning disability nursing Due to the beliefs held by the participants about intellectual disabilities and mental illness, I was interested to find out what made them choose to pursue intellectual disability or mental health nursing. Some of the participants were following the adult pathway, however, they had worked in mental health and intellectual disability settings before enrolling as student nurses. I asked them the question ‘What made you choose learning disability or mental health nursing?’ if they were following this pathway. Alternatively, I asked them ‘How did you get into nursing?’ and ‘What was your experience of intellectual disability or mental illness before becoming a student nurse?’ Following the responses about beliefs regarding intellectual disabilities and mental illness previously held by the participants, the overall finding was that they were more positive about people with intellectual disabilities and/or mental illness. I also found that the participants held favourable attitudes towards people with mental illness and intellectual disabilities. This finding is concordant to the study by Schwartz and Armony (2001) which investigated and concluded that students had a positive attitude towards people with intellectual disabilities and mental illness. Iwakuma et al. (2012) and Julia-Sanchis et al. (2020) posit that a positive attitude towards people with intellectual disabilities is achievable with a combination of education, information, support and contact with people who have disabilities in this study, the participants cited personal employment experience in mental health and/or intellectual disabilities as factors that had an impact on their decision making when considering nursing as a profession. This phenomenon has been observed in students in other studies who describe a desire to make a difference, consistent with existing literature (Nadler-Moody and Loucks 2011; Ng et al. 2010). This finding demonstrates that the participants’ interest in choosing intellectual disability or mental health nursing as a future career had been influenced by exposure to intellectual disability or mental health nursing and non-nursing roles. It's the learning disability side to be honest because like I said I have seen very little learning disabilities back home like this kid from my neighbourhood, but I never 163 quite understood what the problem was with them. So, when I came to the UK, it was something I probably wanted to know more about and I knew with a learning disability, you could learn the mental health side of it as well. It all comes together in a sense. For example, recently my recent placement is a mixture of mental health and learning disabilities. So, it was a wonderful experience to find out more about learning this more than mental health. So, coming to do my undergraduate was a great opportunity to learn more about learning disabilities. (P3) I used to work in a nursing home before I went to LD. (P4) Because I have worked with people with learning disabilities. I never wanted to be a nurse. I didn't know there was a learning disability nurse because all I knew was General Nursing. I worked as a support worker for people with learning disabilities for a long time. (P5) I did a degree in learning disabilities and the reason why I went for that degree is I wanted to understand what was going on with the people that I was looking after… and I saw that it has nothing to do with witchcraft. (P6) When I came to England, I was working as a healthcare assistant in a nursing home...but I didn't feel like it was what I wanted until they suggested I move to Learning Disability. From that time, I have loved it because every day is different and for me because my nephew had Cerebral Palsy, it was something that I had a personal connection with…and that is how I came to settle for learning disability.’ (P7) I am amazingly comfortable because since 2014, I have worked with people with Autism and after that, in 2016 I joined the NHS as a support worker. Through that, I have had experience working with people with Mental illness, learning disabilities and Dementia as well. (P10) 164 4.5.2 Sub-theme 4 - University classroom and practice placement experiences There were some positive responses reported about the classroom experience. Participants cited positive experiences in the classroom and commented about their learning. I had to probe them further to clarify whether they had received any cultural competency learning or not. As can be seen above, some did not feel that they had covered this. Bearing in mind that this was a sample consisting of students in their first, second or third years, their level of education was different. Some of the content had been covered by some cohorts already whilst the others were yet to learn them: The school has been brilliant. Everyone has been given a chance. If you don't understand anything, guys are given ample time sometimes I cannot believe it myself, but they are given so much time and there's so much help to get around it and they are achieving. There is so much help within the university. (P1) It's been brilliant because you do get some placements, preferred options, where you choose where you want to go. There you meet learning disability patients, and you have that opportunity to meet and actually seeing, what is it about. And it's amazing. (P1) With what we have had so far.... because I believe in is that the basics are the most important. That's fundamental: if you get the fundamentals right, you'll get everything else correct. So, what they have given us is a basis and if we get that right, we will not go wrong. They have already prepared us in the way that they want things to happen with what they have taught us so far. We are good to go, we just need a bit more. We have been given the basics which are the foundation of everything so we started on a solid foundation so as we progressed, we can always do better. (P2) In my first year, they taught us the history of mental health in terms of the Western perspective. They mention that in ancient times, they believed that mental health was the cause of it. It was the history of mental health. This goes back to what we 165 believe mental health issues were possessed by spirits. It was an interesting side even though over the years it has changed, they no longer believe that, but we still do. So, in that sense, it was great to hear those views even though they are not relevant today because those things have changed. But I wouldn’t say our curriculum is from outside the UK or from a different background. (P3) Although the participants attributed problems faced by Black and minority ethnic students to cultural differences or students’ individual characteristics, student participants tended to attribute this more bluntly to institutional racism within the practice-learning field. Godbold and Braithwaite (2020) recommend that there needs to be an acknowledgement and redressing of the ongoing impact of white power and Eurocentrism in nurse education; a crucial step towards dismantling structures that allow the awarding gap to continue. Scammell and Olumide (2012 p. 545), comment that ‘Whiteness is a source of power and is normalised within nursing education and seen through a white lens, without recognising this racism cannot be challenged’. For many years, people have been raising these issues and no one else seems to be interested so we leave it and keep quiet. For others, it’s the fear of speaking out about decolonising, you don’t know what’s going to happen after that. They just want to get their degree and go (P1). Yeah, especially African students, who are in the UK look at Nigeria, Cameroon, Congo, you look at all Africans, and this way witchcraft is practised as well as South Africa and Zimbabwe. If the university can introduce something, just for those people that come from those areas. At times it might be difficult for us to express ourselves with our white colleagues in the class because you just don't know how they will view you when you start talking about witchcraft in class. After all, they don't understand anything like that. So that's why you just have to walk back and say, you know what, they don't even know where I come from. So let me just keep quiet because we will scare them away.’ (P1). Diverse cultures and beliefs about learning disability and not just the Western way, because it is only focused on the Western way and learning disability, is worldwide. 166 It is not just America, UK, cultures like in China, and Africa also have learning disabilities as well. So, it would be nice to see any research around those areas and what they believe learning disability is and maybe try and put that in the curriculum for different people and different students. (P3). We need to help fellow African people to understand more about what causes these conditions so as to not blame women because they end up being blamed for giving birth to a child with a disability. If that one is made clear in your research that it is not about women giving birth to a child with a disability, that women need support because already 9 months is not a joke; everything in your body has changed and to give birth to the child and having people be against you is like a prison sentence. (P6). This finding about the rigidity of the nursing curriculum and its constant refusal to evolve raises the need for consideration to be given to understanding the effect that existing curriculums and content might be having on student inclusivity (Bell 2021). Greater understanding and recognition of white privilege is needed in the UK such as in universities giving a voice to their students from Black and minority ethnic backgrounds. Student nurses need to be represented equally in forums that address and evaluate their learning experiences. If these forums do not exist, then they need to be created. Black and minority-ethnic student nurses need to see a genuine desire for change behind any reviews and have a chance to share their views and experiences as part of the process (Bouattia, 2015). Thompson et al. (2000) argue that the need for nursing students to have an acute awareness of the influence of cultural factors on health and healthcare is central if they are to respond appropriately to the cultural diversity that exists in society. Several theoretical frameworks have been developed to guide research and practice. These include Leininger's (1978) Grand Theory of Cultural Care Diversity and Universality, Purnell and Paulanka's (1998) Model for Cultural Competence, Giger and Davidhizar's (2004) Transcultural Assessment Model, and Campinha-Bacote's (1998) Model of Cultural Competence. Cultural competence is defined as a process, not 167 an endpoint, in which the nurse strives to achieve the ability to work within the cultural context of an individual, family and community from a diverse cultural background provided within the historical and daily context of clients (Campinha- Bacote, 2000). Culturally competent care is also defined as care that is responsive and reactive to the diversity of the patient population and cultural factors that can affect health and healthcare, such as languages, communication styles, beliefs, attitudes, and behaviours (Murphy 2011). The most comprehensive definition of cultural competence in nursing practice is stated as being an ongoing process to achieve the ability to work effectively with culturally diverse persons. Additionally, it encompasses caring for these individuals with a keen awareness of diversity, a strong knowledge base and skills in transcultural nursing, and a strong personal and professional respect for others from various cultures (Leininger 2002). This thesis adds that nurse education itself needs to develop a curriculum that meets the needs of a diverse student body by being culturally competent and not taking it for granted that it is. African students encounter problems with negative perceptions of African cultures, which are often seen as backward, and some participants gave examples of some uncomfortable classroom experiences. Some participants alluded to having experienced racial discrimination or fearing low-level racial undertones especially when issues about cultural beliefs were concerned (Beoku-Betts 2006). The participants also reported experiencing negative stereotypes about their African culture and traditions. As nurse academics, there should be the active dismantling of nursing's history of ‘transcultural’ or ‘multicultural’ practices, where proficiency is measured by gaining more “Eurocentric knowledge” (Grant and Guerin 2018 p. 2836). Gaining Eurocentric knowledge at the expense of other knowledge continues to perpetuate the colonial narrative, and dominance in a culturally diverse classroom is detrimental to nursing practice. here the lecturers and our colleagues do not pay attention to what we know from our backgrounds, they don’t pay attention to how we can change. I feel like sometimes we are suppressed, and people don't want to understand where we come from. Yes, we are in England, we have left our home, but they need to follow up as to how then can we be helped. Instead of exploring this, we are being told to 168 simply follow a certain way of thinking. And when you get to work you have to put your feelings aside but on occasion, it comes up and you think about it. (P7) In the curriculum that they present, all that they want us to learn is more about the majority of the people that we will be able to care for and it’s rare to get for example cultural education about African values or Asian values or any minority group so basically, you learn values about the dominant groups. Apart from that, there is no education about other cultures. (P10) Through culturally sensitive care, cultural competence is seen as an essential foundation for reducing, if not eradicating, health disparities in healthcare facilities (Cruz et al. 2016). Culturally competent nursing care encompasses adequate knowledge, skills and values that ensure appropriate care for patients with varied linguistic and cultural backgrounds (Seeleman et al 2009). Cultural care itself has also been discussed under several different titles such as 'Cultural Competence,' 'Transcultural Nursing,' 'Culturally Sensitive Care,' or 'Cultural Safety.' With so much variety in the way cultural care is labelled, there is also a great deal of controversy about the way that cultural care is applied (Vandenberg and Kalischuk 2014). Understanding the influence of culture on health, having an awareness of the impact of one’s own ethnic background in interacting with others and being sensitive towards the ethnicity of others should be central concepts in nursing curricula (Thompson et al. 2000). Cultural competence is widely seen as a foundational pillar for reducing disparities through culturally sensitive and unbiased quality care (American Association of Colleges of Nursing 2008) and contributes to improving patient satisfaction and health outcomes (Shen 2015). When teaching transcultural care, it is imperative that as many cultures around the world are addressed and issues of diversity of beliefs considered as well. In addition, the notion of cultural competence has not been extensively examined in a multicultural nursing workforce where nurses are not only culturally diverse from the patients, they care for but also culturally different from each other (Almutairi et al. 2015). The provision of culturally sensitive care to patients is an expectation from each healthcare worker to ensure prominent levels of quality care (Cruz et al. 2016). Matziou et al. (2009), in their study of 169 paediatric nurses’ attitudes towards children with disabilities, further advocate for special integration of courses on treating children with disabilities to the basic nursing studies. Their study was included in the scoping review. However, mastering the art of delivering culturally competent care presents great challenges to the members of the healthcare team, such as controlling if not eradicating prejudices and biases (Hart and Mareno 2014; Heer et al. 2016). This highlights the urgent need for the curriculum to address the needs of the diverse student cohorts to teach cultural competence. Thus, it is noticeably clear that culturally relevant care is at the heart of all nursing care. This means culturally competent nurses are sensitive to issues related to culture, race, ethnicity, gender, and sexual orientation (Dauvrin and Lorant 2016). To understand ethically adequate transcultural care, it is necessary to have good knowledge of illnesses and what they mean to people. Furthermore, culturally competent nurses have achieved efficacy in communication skills, cultural assessments, and knowledge acquisition related to health practices of diverse cultures (Dauvrin and Lorant 2016). If they are not supported to develop cultural competence students miss out on opportunities to self-identify knowledge and skills gaps that arise in practice, and to become curious about those gaps, they miss out on opportunities to develop the reflexive and academic acumen to fulfil on their responsibility – we set them up to fail, not flourish (Collier-Sewell et al. 2023). The NMC (2018) assumes that culturally competent care is sensitive to issues related to diversity, marginalisation, and vulnerability due to disability, ethnicity, gender, and mental illness. However, Burnett et al. 2020) comment that attaining this cannot be tackled in classrooms only by learning more about ‘other’ cultures because it effectively reinforces racialised stereotypes and perpetuates nursing as colonised care. Culturally competent care can be achieved by reflecting on unconscious and conscious biases that can result in blind teaching and learning (Lokugamage 2019). Classroom learning should accommodate the student nurse who was born and raised in a distinct cultural environment. Collier-Sewell et al. (2023) posit that as a profession, if we want to consistently communicate that person-centred approaches are what the public needs and expects, then we would do well to apply person-centred approaches to learning as we 170 claim to do with patient care. This further strengthens this study’s argument to accommodate the needs of the diversified student population within HE. Nurses encounter difficult ethical situations in daily practice. These situations may be even more challenging for nurses when the patients involved are from various cultural backgrounds (Dauvrin and Lorant 2016). Dogan et al. (2009) suggest that ethical responsibility includes a certain curiosity, a desire to understand a person or situation better, and the capacity to push out a personal boundary of understanding on the part of nurses, and thus enlarge the ‘space’ or personality of patients. Although previous studies have focused on the investigation of cultural competence among nurses (Almutairi et al. 2015; Castro and Ruiz 2009; Gözüm et al. 2015), the critical role of cultural competence in ensuring the quality of care, remains a non‐shared behaviour among healthcare professionals (Dauvrin and Lorant 2016). Labun (2001) comments that nurses have repeatedly expressed a lack of education necessary to provide culturally competent care for a diverse mix of patients from other cultures. They further acknowledged their limitations in caring for these individuals because they do not have enough transcultural knowledge and skills to enable them to deliver culturally sensitive nursing care (Labuan 2001). Within health care systems, care is regularly provided to individuals whose ethnicity, language, religion, and culturally based beliefs about health and illness are quite different from those of the care provider (Delgado et al. 2013). Nowadays, healthcare professionals, including learning disabilities and mental health nurses are increasingly required to interact with families whose ethnicity and culture are different from their own due to the increasing multiracial and multi-ethnic populations in England. The NMC released new standards for pre-registration student education developed to cope with the ever-changing NHS, and to future-proof these standards for several years (NMC 2018). These were felt to be more explicit to ensure nurses were trained with higher level skills. This mirrored the recommendations from the Council of Deans of Health, (Clarke, 2016; Council for Deans for Heath, 2016; NMC 2018) with the acknowledgement that the health and care landscape is changing at an unprecedented speed. Additionally, these statements for each platform were designed to apply across all four fields of nursing practice—adult, 171 children, intellectual disabilities, mental health, as well as all care settings, with the expectation that all fields will consider the lifespan approach of the patient and their family. A lifespan approach is person-centred, holistic care that promotes the prevention of illness and promotion of health for people at different stages of life. This lifespan approach that is demonstrated throughout the NMC standards, states: ‘Understand and explain the contribution of social influences, health literacy, individual circumstances, behaviours and lifestyle choices to mental, physical and behavioural health outcomes’ (NMC 2018). Amongst these populations, there are families with views of mental illness and learning disabilities that are quite distinct from those of the clinicians responsible for making decisions about their care. Interestingly too, the university classroom in England is now comprised of students who come from these same populations. For example, in Southern African countries, attitudes towards intellectual disability and mental illness remain strongly influenced by traditional beliefs in supernatural causes and natural remedies (Alegria et al. 2009). All approved educational institutions across the UK are compelled by the NMC to adhere to standards embedded in the Quality Assurance Framework (Glasper 2015). However, the institutions and their practice learning partners have ownership and accountability for the development, delivery, and management of pre-registration nursing programme curricula (NMC 2018). The Standards framework for nursing and midwifery education and these programme requirements give universities in partnership with practice partners the flexibility to design their own curriculum (NMC 2018). Curriculum development and design in universities is a role for course or programme leaders, partners, patients and carers and other stakeholders. This thesis argues that curriculum design is influenced by the ethnic composition of these groups and that cultural beliefs and values play a critical role in the design of educational programmes. It is relevant to investigate whether underlying beliefs and values that are unexamined because everyone shares them may result in curriculum designs that are biased towards the mainstream culture. Choi and Kim (2018) claim that the current cultural education in nursing curricula is not sufficient to improve students' cultural competence and that little is known about how nursing students' 172 subjective experiences of other cultures may impact their cultural competence (Choi and Kim 2018, Gallagher and Polanin 2015, and Von Ah and Cassara, 2013). Nursing education has been widely recognised as an essential component in the development of cultural competence among nurses (Repo et al. 2016). Various efforts have been conducted to ensure the incorporation of the topic of cultural competence in the nursing curricula around the world including in the United States and Europe, (American Association of Colleges of Nursing 2008; Sairanen et al. 2013). Dogan et al. (2009) point out that as a result of cultural variation in many countries, the orientation of ethical care requires different components. Cultural competence refers to the ability of health systems to provide care to patients with diverse values, beliefs, and behaviours, and to tailor the delivery of health care services to meet patients’ sociocultural and linguistic needs (American Hospital Association 2006). 4.6 Discussion The study sought to answer the question What is the influence of nurse education on the Indigenous belief systems of student nurses of Southern African origin towards intellectual disability and mentally illness. The objectives were to: a. establish themes in the scholarly literature that describe indigenous belief systems about the causation of intellectual disability and mental illness in Low to Middle Income Countries. b. explore the current nursing curriculum in terms of how it captures the knowledge systems and beliefs of other ethnicities about intellectual disability and mental illness. c. ascertain student nurses’ beliefs about intellectual disability and mental illness before receiving and during receiving nurse education including their acculturative experiences when they encountered patients in intellectual disability and mental health environments. So far, the thesis has explored the literature describing African Indigenous knowledge and belief systems about intellectual disability and mental illness in Chapter 2 presented and discussed the results in Chapter 4. This chapter will now critically discuss the emerging theory of the ‘new’ 173 understanding of mental illness and intellectual disability through the participants’ perspective and presents some explanations for their behavioural presentations when they finally encountered people with intellectual disability and mental illness in the UK. This thesis seeks to advance the scholarship around Southern African immigrant students and broaden conceptualisations of culturally relevant teaching by examining their negotiations of cultural knowledge, values, and ideologies as they make sense of their identities as future practitioners in a new cultural space. The discussion interprets the significance of the study’s findings considering what was already known about Southern African people’s views about intellectual disability and mental illness. It also presents new understandings regarding the views of the participants as they encounter people with intellectual disability and mental illness as well as being consumers of nurse education in the UK. The chapter also shows how the new knowledge in this area can now be advanced by this study. My study has shown that there is a relationship between prior employment experiences which exposed student nurses to people with intellectual disability and mental illness and accessing nurse education. Employment as support workers and health care assistants appeared to inspire them to socialise into the future nursing role through their daily interactions with patients in these environments. Additionally, the study found that these experiences with patients in both intellectual disability and mental health environments and the professional values which student nurses have acquired during their education interact to influence how they react to and treat the people they are caring for. While this study focused on student nurses from Southern Africa, it will resonate with universities, researchers and practitioners that work with other immigrant groups. This study provides some evidence for specific factors involved in the re-shaping of attitudes, including education, previous work experience in learning disability and mental health settings, placements, and intrinsic motivation to learn the phenomena under study. The study provides qualitative reflections and suggestions by participants. It is to be envisaged that as Western education deepens and gains wider spread coupled with development in science and technology, there would be corresponding increased awareness of and interest in the scientific and traditional causal models in African-born students. 174 Seven of the participants became acculturated in intellectual disability and mental illness whilst others admitted that they were still stuck in their old beliefs. However, those who admitted to being stuck in their old ways reported that they accepted the new belief systems they had now come to know. This usually happened during their earlier employment, equivalent to the integration stage of the acculturation model (Berry 1980). This shows that acculturation is not linear, and people do not acculturate at the same time. The next section will offer a consideration of acculturation on the belief systems of the participants. Acculturation accounts for much of the stressors as it involves a shift in cultural beliefs and perspectives. This study will be of interest to researchers, especially in nurse education who observe immigrant nursing students’ acculturation in higher education contexts and who raise questions about their experiences in the learning environment. Given the existing literature on the transitioning experiences of African students engaging in higher education (Smith and Khawaja 2011; Harvey and Park 2012), I decided to focus this aspect of my research on a key component of this transition: cultural intellectual disability and mental health nursing shock. This is because all thirteen participants confirmed that they immediately experienced culture shock when they arrived in England and started working with or encountering people with intellectual disability and mental illness. Some of the responses were: In a sense it was overwhelming to think that someone could live and go through all that or they have all these complications and still be alive. I have come across people who have got a long list of people with syndromes which I have never heard before’ (P3) It was overwhelming to tell the truth… I wanted to understand and listen to these people and see how they are like and what is involved in their day-to-day life.’ (P4) my first reaction was that it was surprising to me because back home, we did not see much of them. (P5) I was scared... I remember being very scared especially of those that can't even speak but all they do is make these expressions and you don't really understand them. It's scary.’ (P7) 175 So, the first time I saw that it really affected me. It was so emotional for me because when you hear something but have never seen it you don't really believe it the way that other people do. (P8) The term culture shock was first used by Oberg (1960), to describe the feelings experienced by people immersed in an unfamiliar culture where individuals were removed from the everyday cues, they relied upon to engage in daily life. However, Harvey and Park, (2012) have defined culture shock as maladaptive psychological reactions and mental disorders that occur in response to the transition from one cultural setting to another. Students reported that a comparison between diverse cultures requires approaching each with the desire to see a different point of view, valuing diversity (Randon et al. 2020). Heidegger (1962) asserts that the experience of time and space, is not a situation-less experience because we are located in our own temporo-spatial context, because of being-in-the world. For the participants, encountering a person with an intellectual disability or mental illness in England meant the change of the context also changed the meaning of the event. For example, placing the same event back or forward in time would influence the meaning of that event in that when they encountered a person with an intellectual disability back home, the meaning of that experience changed when they did so in England. In this study, I posed the question to the participants What was the experience of meeting a person with a learning disability/mental illness like? This invitation to speak of their lived experiences revealed both temporal and spatial aspects of student nurses’ experiences of encountering a person with an intellectual disability or mental illness both at home and in England. This encouraged the participants to bring forward a deep telling of their experiences, including the mind, body and spirit of those experiences, at the same time revealing more about themselves as future nurses. All the participants in this study expressed having experienced culture shock and through their encounters with a different culture, they had an opportunity to analyse their values, allowing them to gain an awareness of their cultural system, which is the starting point to be able to recognise and appreciate others’ cultural diversity (Foronda 2008). The participants all attested to having entered a process of questioning these values and beliefs affirming this stage as part of acculturation. The fear the participants were referring to had to do with the sheer numbers of 176 people with learning disabilities they came across and in some cases being attacked by those whose behaviours were unpredictable. Bearing in mind that some of the participants had not had close encounters or even met a person with a learning disability or seen them in public spaces, it was a shock for them to learn that people with a learning disability were cared for like any other person. The study participants reported that they found it difficult to adapt to more fundamental cultural differences that challenged their beliefs having to do with the position of people with intellectual disability in society. Through this they receive support and can live their own lives. I'm surrounded by all that now and we learn with people living with disabilities and some of them are smarter than us. Well, some of them are very smart. I think if people in Africa could be exposed to that. Knowing that this thing can be managed, and people can live a normal life with the condition. That will help and with the input of the government will go a long way. (P1) I went back then to get a feel because that’s where my next placement was- in personal care and that's when I got into the nitty gritty of nursing and that really changed my perspective. And in terms of reasonable adjustment, because when I went with one of the clients to get a haircut that was really such a struggle to get the person to do the haircut. The assets were there but just the attitude and everything that I saw there. That was when I thought we had to do something about it so that's when I realised, I was in the right post. (P2) Coming to terms with this led them to immediately start questioning their previously held beliefs. Kokko (2011 p. 679) explained culture shock as an “encounter with difference that causes confusion among the nursing students because they had to face their own prejudices, stereotypes and systems of values”. This is what the participants were going through, some of them long before they were students because they were in paid employment. For the participants, a lack of knowledge about the new culture appeared to exacerbate culture shock. All thirteen participants experienced cultural nursing shock as they tried to adapt their nursing practice to fit with the professional standards and the culture of the new country of settlement. 177 Particularly difficult for one participant were issues related to offending behaviour of patients with intellectual disability cared for in forensic services. I couldn't understand why they were defending and protecting people with mental disabilities and advocating that they fit into the community despite all the damage that they would have done. But it was so hard for me because when you look at the things that these people had done, you couldn't make it up, you couldn't understand why you are looking after somebody who's done such things. And then still these guys are covered up and protected. In Africa, they would have been killed, there's no chance for a person like that. So, when I looked at that, and looked at where I was coming from, it was so tough. But I began to read about it and the people that I was working with were understanding and were sharing their feelings with me. So, I would ask them how they are feeling, they would say, you know, what, man, this is just a disability, this is what happens to a person, sometimes they might not know, or understand what they are doing. Sometimes they behave like children, sometimes they behave crazy, they just want to do things that you might not understand. That's why they're under strict orders of medication (P1) Research has shown that the experience of culture shock also negatively impacts students’ psychological and sociocultural adaptation (Presbitero 2016). Merry et al. (2021) postulate that due to their cultural differences, foreign-born African nursing students often face cultural adaptation and cultural shock, issues not experienced by students from the dominant culture. Professionals may have personal feelings and reactions to a patient’s previous offences, current behaviours or beliefs (Hammarström et al. 2020), however it is fundamental that these are not communicated or acted upon and do not affect care delivery. The students encountered people with profound and multiple intellectual disabilities, autism, epilepsy, and mental illness in their capacity as carers which placed a level of close contact and care. Having never been in this position before, it served to raise their anxiety levels. Heidegger (1962) suggested that the process of understanding a phenomenon exists before theorising that humans find out what is acceptable behaviour, thoughts and relationships by the 178 everyday interaction they have with others and things. As they encountered people with a learning disability and mental illness, the participants’ understanding of intellectual disability and mental illness began to develop whilst shedding off their original understandings simultaneously occurred. Therefore, when introducing a new experience, knowledge or phenomena, our existing understandings and experiences are challenged to make sense of and accommodate new meanings (Miles et al. 2012). Although it initially brings about confusion, the experience itself is a learning process. However, this initial confusion and frustration develops into cultural awareness that can be viewed as a precondition of the learning process (Kokko 2011). Support has been identified by Charles et al. (2014) as playing a major part in overcoming the culture shock experienced by students. Preparation requires an acknowledgement and identification of one’s own values, beliefs and cultural practices and reflection on how these may be challenged in another culture and without the comfort of the normal cues associated with everyday life to provide culturally responsive care (Harvey and Park 2012). It is important that universities support students as they undergo these emotional and intellectual transformations. Hermeneutically, understanding comes from a process of deconstructing and reconstructing, from not understanding to coming to a moment when new meanings and understandings are developed, merging both preunderstanding and new phenomena, to come to a significant new understanding of-being-in-the-world (Miles et al. 2012 p412). This thesis adds that acculturation, as a process, involves an exchange in the flow of belief systems from the unknown to the known in terms of culture. When African born student nurses assimilate, it will involve some discomfort as they battle to reject their childhood teachings about intellectual disability and mental illness. It may feel like a rejection of their culture to some or seen by others as entering a new belief system. Moreover, Waters and Himenez (2005) suggest that during the process of assimilation migrants are expected to conform to the current norms of the state through a process that Berry (1997) refers to as culture shedding, which is unlearning or undoing previous customs or traditions. Additionally, hermeneutics is also one of constant change, as life is an ongoing cycle of actions that constantly construct and reconstruct ‘life-worlds Liamputtong and Ezzy (2005). To further accentuate this assertion, I agree with Heidegger’s 179 argument that interpretation occurs in every encounter and this interpretation is influenced by the individual’s background or history. The next section will now offer a comprehensive conclusion wrapping up all the themes and findings from the study before the presentation of the study’s limitations. This thesis has shown that in Southern African communities, views about what causes intellectual disability and mental illness are associated with stigmatising attitudes towards people with intellectual disability and mental illness. While Southern African people’s viewpoints of treatment of illness have changed over time following the addition of Western views via colonisation and education, there has been less change in beliefs regarding the cause of illness. This may be because Africans look for a meaning behind every event to help them cope with it. While the study shows that general knowledge about the nature of intellectual disability and mental illness is uniformly poor whether the views are biopsychosocial or religious-magical, the overall significance between the two views is the underlying stigma towards people with intellectual disability and mental illness. The findings are harmonious with those of others who have observed that views about causation are strongly associated with stigmatising attitudes to intellectual disability mental illness (Scior and Furnham 2011; Strydom et al 2008; Mak and Cheung 2008) The findings suggest student nurses of Southern African origin hold cultural beliefs linked to the causation of intellectual disabilities and mental illness (van Dyk and van Dyk 2015; Tilahun et al., 2016; Bunning et al., 2017; Aldersey 2012; Mkabile et al. 2021; Aldersey et al., 2014; Gona et al., 2011; Lamptey 2019; Masulani‐Mwale et al., 2016; Nkhosi and Menon 2015; Ntswane and Van Rhyn 2007; Ajuwon and Brown 2012; Tilahun et al. 2016). It can be postulated that such beliefs may reflect a lack of understanding of clinical subtleties of intellectual disability and mental illness. The findings suggest that religion did play a significant role in explaining Southern African born student nurses’ beliefs about the causes of learning disability and mental illness. This should be understood as an external attribution as well as a culturally shared and familiar explanation. With regard to supernatural causation, both the questionnaire and interview results were in concordance with previous research. The findings suggest that supernatural causation is 180 considered as a culturally acceptable explanatory approach and its role cannot be overstated. This is important for academics supporting student nurses to better understand this group of students. However, on a more positive outcome of this study, student participants who cared for people with intellectual disability and mental illness had developed clinical knowledge of their causation and therefore showed less stigmatising attitudes as a result of this new understanding. The participants called for more awareness raising in Southern Africa about intellectual disabilities and mental illness. Belief in supernatural causation is a well-documented phenomenon in studies reporting societal beliefs in the supernatural (Botts and Owusu 2013; Botts and Evans 2010; Reynolds 2010; Anthony 2009; Agbenyega, 2003 and 2007; Avoke 2002). Corroborating the participants’ responses with existing literature, they reported physiological or biological causes of intellectual disability which include genetic conditions and maternal behaviour during pregnancy (Harris 2006; Foreman 2009; Inclusion Ghana 2011; de la Rocha 2011; Oasis Association 2013). Some studies have reported participants believed that intellectual disability occurred because of perceived wrongdoing (Ha et al. 2014), or negligence on the mothers' part (Blum 2007 and Gammeltoft, 2008). My study also records various opinions from research participants that affirm their beliefs about the supernatural causes of intellectual disability. Rashid and Ibrahim (2007) found a relationship between culture, religiosity, and ethical decision-making. White et al. (2019) postulate that religion and religiosity, or religious orientation, are related but are not identical constructs. Religion is defined as an organised set of beliefs, practices, and rituals while religiosity is the strength of religious faith (Prois and Prois 2017). A study found that South Asian understandings of disability based on cultural and religious beliefs can become an issue when people encounter services, as their needs may not be matched (Azmi et al. 1997; Hatton et al. 1998; Hensel et al. 2005). It is fair to suggest that cultural beliefs, including religion, need to be explored in the teaching of ethics to help African students understand help seeking behaviours of minority ethnic communities. 181 In my study exploring beliefs held by students from Southern Africa, curses and spells were the dominant examples of supernatural factors which, according to research participants, caused intellectual disability and mental illness. In addition, African studies (Bunning et al. 2017; Etieyibo and Omiegbe 2016; Kromberg et al. 2008; Stone-MacDonald and Butera 2014) also reported beliefs in mercenary spirits, jealousy, and envy, as well as ancestral displeasure or curses as supernatural factors which could result in intellectual disability. All thirteen participants discussed having held superstitious beliefs and curses as the cause of intellectual disability in the past. This confirms what Aldersey et al. (2014) reported in their study that the causes and meanings of intellectual disability were founded on the belief that everything, happens for a reason including superstition and mysticism, punishment from God, superstition about bewitchment and demon possession. The findings cited above are consonant with those from previous studies (Aldersey et al. 2014; Scior and Furnham 2011; Scior et al. 2015; Treloar 2002) from various parts of the world, showing, in multiple contexts, that there is a range of explanations for the causes of intellectual disability. A study in the United States of America (Schnittker et al. 2000) compared African American and White American student nurses' beliefs about the causation of mental illness and found that Black Americans were less likely to ascribe to genetic causes of mental illness and more likely to believe ‘god's will’ is a factor in the aetiology of mental health problems and intellectual disability. Several studies describing belief in supernatural causes of intellectual disability and societal response to persons with intellectual disabilities have been published from various parts of the world however, the interpretations offered vary from place to place (Huang et al. 2009; Lamichhane 2013; Miles 2002). Mkabile and Swartz (2020) point out that intellectual disability is more common in poorer countries than in wealthier countries for a range of reasons. These include increased risk factors such as poor nutrition, poverty, violence, increased exposure to environmental toxins, poor access to pre-natal screening, lack of skilled birth attendants and the use of Traditional Birth Attendants and substance use during pregnancy. In Africa, however, these factors are overshadowed by supernatural causation which results in difficulty in accurate records and 182 diagnoses being officially categorised. In addition, this might be linked to the explanatory models of disability, especially in Southern African countries included as part of this study. Messa et al. (2021) suggest that the prevalence of intellectual disability is difficult to determine due to differences in epidemiological and diagnostic practices around the world. Conditions and impairments in turn may be caused in many ways, including genetic causes, infectious disease, and malnutrition (Guralnick 2005; Maulick and Darmstadt 2007). As well as intellectual disability, there was a similar pattern to attributing the prevalence of mental illnesses to the machinations of witches and ancestral spirits as some of the major causes of insanity also referred to as madness. Conversely, Capri et al., (2018) identify a widespread problem in South Africa where people with an intellectual disability are regarded as mentally ill. These findings are in concordance with those found during the scoping review including James (2019); Scior et al. (2013). The 24 studies in this scoping review clearly show that people in Southern Africa and Africa in general hold strong negative attitudes towards people with intellectual disabilities and mental illness as a result of their strong indigenous beliefs about causation (Mkabile et al. 2021 ; Bunning et al. 2017); Aldersey 2012; Aldersey et al., 2014; Gona et al. 2011; Lamptey 2019; Masulani‐Mwale et al. 2016; Nkhosi and Menon 2015; Ntswane and Van Rhyn 2007; Ajuwon and Brown 2012; Tilahun et al. 2016) . These negative attitudes are widespread in the participants’ countries of origin mainly found in Southern Africa. Those negative attitudes are held by student nurses as well and arise precisely because people of Southern African origin hold misperceptions on intellectual disabilities and mental illness based on their indigenous knowledge systems (van Dyk and van Dyk, 2015; Bunning et al., 2017; Aldersey 201; Aldersey et al.,2014; Gona et al., 2011; Lamptey 2019; Masulani‐Mwale et al., 2016; Tilahun et al., 2016; Nkhosi and Menon 2015; Ntswane and Van Rhyn, 2007; Ajuwon and Brown 201); Tilahun et al., 2016 Mkabile et al., 2021, Odongo et al. 2023. It became clear that supernatural beliefs (witchcraft, sorcery, evil spirits, act of God) play an important role in explaining behaviours of people with intellectual disabilities and mental illness living in Southern Africa and they influence people’s concepts on causation. 183 Segrave et al. (2017) comment that regarding causes, the emphasis that is placed on the mother's behaviour during pregnancy further reiterates the view of intellectual or mental disorders because of negligence or a punishment for wrongdoing. They further explain that this also speaks to the expected behaviours of pregnant women in most of the African context as can be seen from the participants’ responses. There are previous studies (Scior et al. 2013; Ryan and Scior 201; Iheanacho, et al. 2014; Bunning et al. 2017; Etieyibo and Omiegbe 2016; Kromberg et al. 2008; Stone-MacDonald and Butera 2014) that have discussed the taboos and behaviours associated with pregnancy in African communities, which seek to prevent congenital conditions such as intellectual disability. Following the quotations and statements of the participants, the evidence suggests that these beliefs are the root causes of stigma towards people with intellectual disabilities. Stone-MacDonald and Butera (2006) classify beliefs about the causes of disability in three categories, of which several can be held at the same time: Previous studies on developmental disorders have generally focused on parents or caregivers with a developmentally delayed child or traditional healers who were asked to treat the child (Altiere and von Kluge 2009; Brown et al. 2012; DePape and Lindsay 2015; Divan et al. 2012), examining their views on the causes of intellectual disability and most of them suggested spiritual machinations. Some of the traditional healers and pastors suggested that curses which ran through families could affect the child and he/she would develop an intellectual disability from birth. Traditional beliefs refer for instance to witchcraft; Christian beliefs considering disabilities as God’s will; and medical beliefs accepting explanations of modern medicine. Traditionalist Zimbabweans and South Africans believe in an avenging spirit: the spirit of a person whose death is known or suspected to have been caused by another person. Most Indigenous Zimbabweans and indeed most Southern Africans believe that the avenging spirit can express its displeasure by causing a disability in a member of the offending family. Most of the participants believed that people with mental illness are possessed by an evil spirit sent to the person seeking vengeance. Consequently, it is not surprising that participants’ understanding of the cause of mental illness and intellectual disability was rooted in African traditional religion, spirituality, and culture (Chidarikire et al. 2020). 184 In addition, the participants also indicated a link in supernatural circumstances leading to intellectual disability. These findings are also in concordance with what has been reported in other African cultures for example in South Africa, (Kromberg et al. 2008) and Tanzania (Stone-MacDonald and Butera 2014). These African studies also reported beliefs in mercenary spirits, jealousy, and envy, as well as ancestral displeasure or curses as supernatural factors which could result in intellectual disability. Indigenous African religions, like other human traditions worldwide that objectify and stigmatise disability punishment from divinities, or the ancestors, or as the embodiment of sin or social deviance depict people with mental impairment as victims of either witchcraft or ancestral anger (Sait et al. 2011). Similarly, when conceptualised as spiritual or supernatural ailments, mental illness is understood in terms of sin, supernatural powers, or evil spirits (Ae-Ngibise et al. 2010). A major theme identified for spiritual causality pertained to intellectual disability or mental illness operating as a mechanism of spiritual retribution or punishment (Opare-Henaku 2014). This belief supports the idea that an individual or their family is in some way personally responsible for their intellectual disability and mental illness. This suggests that traditional beliefs not only show the attitude of seeing people with intellectual disabilities or mental illness as a negative deviance from the normal, but they are also seen as being the product of a violation of norms, or witchcraft. Parents experience shock, loss, disappointment, bereavement and self-blame when children with intellectual disabilities are born, leading to denial, anxiety, parental and family conflicts and conflicts between professionals and agencies (Mafuba 2015). Also, the presence of intellectual disabilities in children is more likely to result in extended parental needs that are correlated to the degree of their level of intellectual disability, social and cultural background and economic status of the family (Mafuba 2021). This heightens stigma and public perceptions of individuals with mental disabilities and intellectual disabilities. Regarding help-seeking ways and interventions attempted to address intellectual disability and mental illness in their home countries, this theme considers the time when the participants were children themselves. Previous studies on developmental disorders have generally focused on 185 parents or caregivers with a developmentally delayed child or traditional healers who were asked to treat the child (Altiere and von Kluge 2009; Brown et al. 2012; DePape and Lindsay 2015; Divan et al. 2012), examining their views on the causes of intellectual disability and most of them suggested spiritual machinations. Some of the traditional healers and pastors suggested that curses which ran through families could affect the child and he/she would develop an intellectual disability from birth. Participants in my study cited both the use of Western and indigenous health systems to explain the cause of intellectual disability and mental illness. This is not a specific feature of African parents because, throughout the world, people seek to understand intellectual disability or mental illness in a range of ways and may make use of a range of help, including services based on spiritual beliefs quite at odds with biomedical services (Sango and Forrester-Jones 2017). One qualitative study conducted participant observation and semi-structured interviews with family members of people with intellectual disabilities and community members in Kinshasa, Republic of Congo (Aldersey et al. 2014). They reported that the cause and meaning of intellectual disability is a result of punishment from God and demon possession. In my study, the participants observed that they were aware of families seeking cures from traditional practitioners as the first form of treatment following an admission that someone had a mental illness or when they sought to understand how to address intellectual disabilities. Other participants cited seeking help from a hospital, while across the whole sample, many responded with various alternative sources such as religious and faith healing, churches, and traditional healers. Again, this is consistent with findings from a study conducted in Ethiopia (Tilahun et al. 2016). Societies believe that these people must be ritually, morally, and physically cleansed of their affliction before they can be reintegrated into human society (Ndlovu 2016). There was a general sense that mental illness was curable, however, concerning intellectual disability it was more of hoping for a cure rather than confidence in it happening. Shoko (2007) observes that among the Karanga of Zimbabwe, for example, mental illness is a serious disease that is best treated by a diviner or a herbalist because there was a strong belief that insanity is caused by an arch-rival 186 through witchcraft. What was striking in this research was that there was a supernatural explanation for a biological cause further reinforcing evidence of medical pluralism and movement through the hierarchy of support. For example, if a child was born with Down Syndrome, there was a supernatural explanation for it such as an act of God or an ancestral curse. Mkabile et al. (2021) assert that beliefs regarding the causes of intellectual disability do occur and need to be taken seriously. I was also interested in their experiences or encounters with traditional healers. Based on the responses concerning traditional healers, l was keen to gather their views and hear what they understood about the role of traditional healers in ‘curing’ intellectual disabilities and mental illness. As can be gleaned from the findings above, the participants in this study indicated that when a child was born with an intellectual disability, families used a combination of traditional and biomedical interventions to help them, affirming the findings from the literature review on the use of medical pluralism. My study found rituals related to the prevalent religions and traditional belief systems in Southern Africa to be common and this is consistent with the findings of the Ethiopian study by Tilahun et al. (2016). Kbopi and Swartz (2018) comment that despite the popularity of traditional medicine usage, there is surprisingly little research on explanatory models for intellectual disability in countries outside the West, particularly from Africa. Nkosi (2012) argues that for many Black Africans, beliefs about the spiritual world are inextricably linked to how illness is understood and that pleasing ancestral spirits is the most powerful force for promoting health (Bogopa 2010). Mokgobi (2014) highlights that many Africans are still divided between Western and traditional African philosophies due to issues like gender, religion, medicine, ceremonies, and other practices that affect our daily lives. In addition, Kasaye et al. (2006) assert that indigenous medicine is concerned not only with curing diseases, but also with the protection, promotion, and/or the manifestation of human physical, spiritual, social, mental, and material well-being. Folk language is still prevalent in every culture, for example even today the saying ‘An apple a day keeps the doctor away’ is still in use. Even among Africans living a more Westernised lifestyle, many still see merit in performing rituals in times of uncertainty or tragedy (Bogopa 2010). It is difficult for most Africans to separate or abandon traditional views as it has been part of the African ontology for many years. 187 Chavhunduka (2001) makes a compelling defence of the existence of African religion in Zimbabwe long before colonisation; asserting that consulting traditional healers, spirit mediums and an African interpretation of illness predated Christianity. He highlights that the Shona of Zimbabwe believe that illnesses may be caused by agents such as witches and spirits requiring people to seek remedy from traditional healers who can communicate with ancestral spirits and God, a higher power. In Malawi, traditional healing has been practised for centuries even before colonisation took hold in Africa (Simwaka 2007). To address help-seeking ways, some student participants in Cameroon recommended prayers or traditional healers or both a medical doctor and prayers, and lastly both a medical doctor and a traditional healer (Niamnshi et al. 2010). Gureje et al. (2005) reported that student nurse respondents in Nigeria had exclusive beliefs in religious-magical views of the causation of mental disorders. The findings of my study are consilient with those of Niamnshi et al. (2010) and Gureje et al. (2005). A study conducted in Ethiopia also showed that parents from urban areas are more likely to prefer modern treatment modalities for adults with mental illness compared with their rural counterparts (Nicole and Shyngle 2013). Again, the results of my study are congruous with the findings from the above studies (Nicole and Shyngle 2013; Niamnshi et al. (2010); Gureje et al. 2005). In my study, six of the participants lived in rural areas, one lived on a farm and five in cities. Moshabela et al. (2017), define medical pluralism as the use of more than one medical system for health; in Southern Africa, it involves ‘shopping and switching’ between multiple modalities of care available, including traditional and faith-based healthcare systems. This is known as the Hierarchy of Resort. Ribera (2007) further asserts that in Africa, as elsewhere, medical pluralism is the rule rather than the exception, and people tend to use the various medical traditions to which they have access in ways that may be exclusive, sequential, or complementary. Any study focusing on medical traditions in themselves, as if their histories, development, and qualities were independent of interactions with other therapeutic resources, is necessarily incomplete (Ribera 2007). Medical subsystems may coexist in a cooperative or collaborative relationship with one another (Baer 2018). Western medical views were introduced during colonialism and ran alongside African traditional systems and despite attempts to outlaw anything African, medical pluralism continued to exist during these times. 188 Ribera (2007) propagated that medical pluralism means that different representations of health and illness, but also of understanding and practising the therapeutic arts, coexist within the same geographic space. In addition, Baer (2018) referred to medical pluralism as the coexistence of medical subsystems, particularly in states or complex societies. Medical pluralism, therefore, is broad and varied and includes a wide range of themes which include formal and informal relations between biomedical institutions and traditional medicine; illness representations understood as combinations of elements from a variety of origins; and the issues that come into play when people choose one medical system over another. Helman (2014) observed that in most societies, one form of health care, such as scientific medicine in the West, is elevated above the other forms, and both its cultural and social aspects are upheld by law. In modern capitalist and postrevolutionary societies, biomedicine is the most dominant system used. However, other systems such as homoeopathy, osteopathy, chiropractic, naturopathy, religious healing systems, and various ethnomedical systems find themselves in a subordinate status (Baer 2001). In Southern Africa, medical pluralism is defined as having used both public healthcare and traditional healers where both are available, whereas exclusive public healthcare use is defined as having used public healthcare and not having used traditional healers (Pantelic et al. 2015). The three sectors of the healthcare model cover: the popular sector, the folk sector, and the professional sector, (Kleinman 1978). Many Indigenous groups often consult both traditional healers and Western health professionals (Kleinman 1979; Shimoji, 1991; Zoller 1997). Patients recognise that different practitioners can fulfil diverse needs. Lipsedge (2015) suggests that patients are not motivated to choose healthcare systems based on single consistent theories but seek practical help from a range of practitioners regardless of the practitioners’ theoretical background. The wide range of interventions tried by caregivers may reflect the fact mental illness and intellectual disability are lifelong conditions, so caregivers keep looking for answers and treatments by navigating both Western biomedicines to treat the symptoms and traditional medicine to treat the cause. The belief in the reversibility of intellectual disability could contribute to explaining why families from some minority ethnic communities are not keen to access services that do not share this view as they provide a more negative prognosis. For example, it could be explained to be due to the fallibility of parents, such as the innate inferiority 189 of the mother, bad sexual practices, wrongdoings during pregnancy, or to external causes, such as curses or the evil eye (O’Hara and Bouras 2007). Overall, the beliefs held by all the participants were reflective of the African worldview regarding the causation of intellectual disability and mental illness. Due to their disabilities, people with intellectual disabilities face social exclusion, stigma, discrimination, and human rights violations across a multiplicity of low-resource settings, in particular in African countries (Roy et al. 2021). Also, these negative perceptions were triggered by fear of becoming subject to discriminating behaviour by other persons. This could be referred to as anticipated stigma. Additionally, another type of stigma presented is public stigma. This manifested in families being afraid of seeking help because of shame and harassment. The participants reported that parents and their children with intellectual disability, faced challenges of being neglected and rejected by the communities and experienced social isolation and stigma (Chauke et al. 2019). Stigma and discrimination surrounding mental illness and intellectual disability are common in most Southern African communities as also noted in studies by Ae-Ngibise et al. (2015; Baffoe (2013); Tawiah et al. (2015). Ae-Ngibise et al. (2015) assert that stigma operates as a major barrier in this context as it limits the amount of social support given to families. Due to the beliefs held in those communities and the fear associated with having a child with an intellectual disability, it made it difficult for families to expose their loved ones in public. Consistent with literature from the UK, the use of derogatory terms and labels used for intellectual disability and mental illness was cited by the participants in my study. Agbenyega (2003) and Avoke (2002) suggest that mental retardation and mentally handicapped are widely used labels in Africa however, others cited labels include mentally impaired, mental, slow learner, idiot, moron, and fool (Gates and Mafuba 2016). Masulani-Mwale et al. (2016) reported that some people were called derogatory names such as ‘retard,’ ‘Downey,’ ‘moron,’ ‘Mongol’ and ‘fool’ used in many countries to reflect the fundamental disrespect of people with intellectual disabilities (Scior et al. 2015, p. 5). Different ethnic groups are known to label individuals with intellectual disabilities differently. 190 Much of the existing literature provides little assistance to Western-trained professionals in understanding how Indigenous names for mental illness are used by African psychiatric patients. For example, Zulu beliefs about illness and suffering in South Africa are intimately bound up with their beliefs concerning religion, history, social relationships, and cosmology (Crawford and Lipsedge 2004). Such illnesses are seen as common to all societies and may either be treated with medicines from any society or are completely untreatable. Biomedical doctors are thought to be capable of understanding and treating these conditions. However, whilst those illnesses are seen as specific to the African people-referred to as ‘diseases of Africans’- are thought to be understood only within the African concepts of illness and therefore only recognised and treated by traditional healers (Crawford and Lipsedge 2004). Many types of mental illness and psychological distress are considered to be African-specific conditions. The indigenous peoples of Southern Africa are made up of various cultural groups with their own explanations of illness. Mabunda (2001) proposes that disease and illness are common to all human societies including the societies above. These are illness categories that were believed to be specific to certain societies (Kayser and Weaver 2019) as well as culture-bound syndromes. Dangor and Ross (2006) believe that within traditional medicine, the terms diseases, disorders, disabilities, and ailments are often used interchangeably and are seen as arising from natural, social, spiritual, or psychological disturbances that create disequilibrium expressed in the form of physical or mental ill health. However, the types of diseases that occur, and the ways they are diagnosed and treated depend on how people regard them, and these vary from one society to another. Cultural stigmas helped strengthen the participants’ beliefs that there were many ways of viewing intellectual disability and mental illness and firmly influenced the help-seeking behaviours cited above. Additionally, some participants commented mental illness was considered and viewed with fear and shame and those exhibiting symptoms were stigmatised. This is in concordance with the studies found during the scoping review including in Nigeria (Iheanacho, et al. 2014) South Africa (Scior et al. 2013) and Korea (Kuwait et al. 2001). As a result, families, and communities preferred to look after their own because of the fear of being 191 stigmatised when a family member displayed psychological symptoms or was born with an intellectual disability. They did not seek any clinical interventions; hence most of them remained hidden away. Ku (2007) asserts that stigma related to mental illness is an international concern, and research is needed to understand its basis, mechanisms, and consequences to formulate means by which stigma and its impact may be ameliorated. Stigma signifies a mark indicating that someone is of lesser value than others, and this attitude also abounds among health workers in most cultures (Crisp et al. 2000). Additionally, stigmatisation denies psychiatric patients and those with an intellectual disability the empathy and understanding traditionally bestowed on the sick in the African society (Gureje et al. 2009; Ewhrudjakpor 2009). Goffman (1963) put forward a theory to explain the mechanisms that cause and perpetuate stigma in which he argued that individuals rely on stereotypes to interact effectively with strangers and categorise them. Goffman comments that stigmatisation is when an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute. These categories have a set of expectations about a person which form a ‘virtual social identity’ (how others see them) as well as their ‘actual reality’ (how they see themselves). Attributes such as intellectual disability or mental illness, or external attributes such as the way a person looks or behaves can render a person the subject of stigmatisation. Thus, according to Goffman, the roots of stigma lie in the perceived discrepancy between a person’s virtual and actual social identities. Goffman identifies a group of people called ‘The Wise’ who rise above everyone else and have less stigmatised views due to being better positioned by knowledge, sympathy, insight and education. These are professionals who work with stigmatised people including nurses, social workers and teachers (Bates and Stickley 2013). Student nurses who stigmatise their patients are in danger of entering the profession with these preconceptions if unchecked during university training. In many African societies, people with mental illness are typified as dangerous, dirty, unpredictable, and worthless. The history of social psychiatry shows that cultural conceptions of learning disabilities and mental illness have dramatic consequences for help-seeking, 192 stereotyping, and the kinds of treatment structures created for people with learning disabilities and mental illness. In relation to the use of asylums in Africa to ‘treat’ mental illness, Oyebode (2006) asserts that although asylums were developed in response to a perceived need to restrain and control the mentally ill, as in other parts of the world, the actual facilities were both poorly resourced and maintained. The introduction of psychiatry in Africa during colonial times represented a period of rapid change in African societies with the attempts by colonisers to eradicate African belief systems, rituals, practices, and ways of healing. The African who was unwell had to be treated biomedically, symptoms and causation included. Oyebode (2006), further accentuates that the development and expansion of asylums, the responses of society to the problem of the vagrant psychotic, and the potential abuses of psychiatry for political purposes left a lasting impact on psychiatry services. The comments from the participants did not portray a positive image of institutions further reinforcing the stigma that asylums were made for dangerous and mad people. While Ubuntu as a philosophy dictates that these people are cared for, there is a negative view attached to causation which then leads to discrimination and stigma. Additionally, Western psychiatry’s introduction of asylums in Africa inaugurated a care system that led to unmeaningful treatment regimes, the remnants of which are still being felt today. The perceived cause of intellectual disability and mental illness could be attributed, in some cultures, to non‐biological causes and therefore, not amenable to medical treatment as has already been seen within Southern African communities. As a result, these negative beliefs result in psychiatric patients being seen as outcasts and people who should be hidden away from public view (Gureje et al. 2005). Ndetei et al. (2011) posit that in many African societies, psychiatric illness is believed to be either an outcome of a familial defect or the 'handiwork of evil machinations' (demons, evil spirits) and that psychiatric patients are responsible for their illness, especially when it is an alcohol and/or substance-related problem. Yohani et al. (2020) add that most African immigrants view the concept of mental health as synonymous with being cognitively incapacitated, disconnected from reality, and exhibiting behaviours incongruent with acceptable behavioural norms. Robertson (2006), Nortje et al. 193 (2016) and Abbo (2011) contend that the focus on magico-religious healers was due to the widespread belief in African countries that mental illness is caused by spiritual/magical factors, and to a large amount of published literature that highlights that these healers tend to be specifically sought out for mental complaints. In addition to most African communities, traditional medicine includes not only herbal medicine for specific diseases but also folk knowledge, traditions and values, health behaviour rules and patterns, identified personnel and structures for delivery and restoration therapy. Religious beliefs, customs, and health-related values tend to perpetuate the utilisation of traditional healing systems also, reflecting the compatibility of Indigenous medicine with deeply ingrained traditions (Fasil 2013; Kloos et al. 2006; Kloos and Kaba 2006). Traditional medicine, having dominated the African healing system for many years has proved difficult to eradicate despite colonialism’s unrelenting attempts to do so. A study by Edge and Rogers (2005) with African immigrants, found that beliefs about the relationship between evil spirits, devil possession and mental illness carried with them implicit assumptions about moral failings on the part of individuals experiencing psychological distress. Social psychiatry suggests that cultural beliefs play a key role in shaping societal responses to people with mental illnesses, influencing stereotyping, service provision and help‐seeking (Link et al. 1999). Changing these collective views takes concerted efforts from different methods of which nurse education is a suitable start. It is likely that within Southern African‐descended communities, this finding relates not only to serious mental illnesses which are sometimes linked with violence in the minds of the general public but extends to more common mental disorders (Edge and Rogers 2005; Edge 2013). When viewed with such attitudes, people with intellectual disabilities and mental illness become devoid of their humanity. This is in direct opposition to the spirit of Ubuntu but there appears to be a level of fear arising out of supernatural attribution being attached to the condition. Based on these findings it can be concluded that people possessing these traditional beliefs appear to be influenced in their understanding of intellectual disabilities and mental illness, regardless of whether they live in Southern Africa or in England. This study has shown that 194 experience of working with people with intellectual disabilities and mental illness is crucial in influencing the aetiology of these conditions. This study has also shown that acculturation of student nurses’ is crucial in the shifting of belief systems about intellectual disabilities and mental illness. Together with work experience and acculturation, exposure to nurse education can be seen as indicators for biological models of causation, reducing supernatural explanations for such diseases (Mavundla et al. 2009, Ofori et al. 2010). As revealed by the student participants, there is a strong and urgent need to increase awareness of intellectual disabilities and mental illness to help lessen stigmatisation and minimise exclusion of people with intellectual disabilities and mental illness and those who care for them. Acculturation Berry (1999) defines acculturation as the process of cultural change that results when two or more cultural groups encounter each other; the changes occur in both groups, but usually one (the dominant group) changes less than the other(s). Similarly, Bhugra and Becker (2005) define acculturation as the process by which a minority group assimilates the cultural values and beliefs of the majority community. These definitions emphasise changes in the minority group when they encounter the host group. Acculturation is further defined as changes that take place as a result of contact with culturally dissimilar people, groups, and social influences (Schwartz et al. 2010, p. 237). More recently, acculturation is defined as a process of adaptation to a culture that is different from the culture owned by the individual in which the individual lives and socialises (Aini 2021). Acculturation can also be seen as a process that involves conflict and negotiation, taking individuals through states of culture shedding and culture learning, the process varying depending on the sociocultural, political, economic, and religious backgrounds of individuals and the age at which they migrate (Berry, 2005). This thesis accepts all the above definitions which acknowledge a change of cultural mindsets; however, the focus of interest is on minority groups having to cope with that change. On an individual level, acculturation refers to how individuals change and adapt because of the longer term, continuous contact with a new culture (Ward and Geeraert 2016). Organista et al. 195 (2010) accentuate that a more modern conceptualisation of acculturation is that it is a continuous and fluctuating process of change that occurs when distinct cultures are in sustained contact allowing for the maintenance of original cultural identity and acquisition of new culture. On this view, an individual’s acculturation is impacted by various and unique combinations of events and factors, for example, personal factors such as voluntariness of migration (Berry 2004). Student nurses of Southern African origin were of interest in this thesis as they experience acculturation on an individual level involving their indigenous beliefs about intellectual disability and mental illness. Lewis (2021) posits that contact between an immigrant minority ethnic group and the dominant mainstream culture group triggers this process for psychological and sociocultural adaptation to the new society. Ward et al. (2001) further extend that psychological adaptation concerns affective responses including a sense of well-being and self-esteem, as well as physical well-being. They then add that sociocultural adaptation is based on behavioural responses related to how effectively an individual links into the new society, such as competence in managing tasks required for daily intercultural living (Ward et al. 2001). While the contact impacts both groups, it significantly confronts the values, beliefs, and behaviours of the immigrant group (Lewis, 2021; Kunst et al., 2021). It is fair, therefore, to conclude that the process of acculturation is influenced by an individual’s motivation and attitude towards cultural integration. Many stages and processes are known to occur during the process of migration such as ‘cultural bereavement’, ‘culture shock,’ ‘adjustment’ (Brown and Holloway, 2008; Campbell 2010; Erichsen and Bollinger 2011; Gornisiewicz and Bass 2011; Khaway and Stallman 2011) and ‘culture learning’ adaptations (Zhou et al. 2008). This thesis is interested in the individual level, particularly attitudes, beliefs and perspectives held by the student nurses from Southern Africa. Syed (2013) postulates that the idea of assimilation is characterised by an extreme form of cultural change. In assimilation, there is an atmosphere of intolerance of external norms, attitudes, values or beliefs, xenophobia and intense pressure for individuals or racial, ethnic, or linguistic minorities to adapt to the cultural or religious norms of the dominant group. To further expand this sentiment, Alba and Nee (2003) define assimilation as the decline of an ethnic distinction and its corollary cultural and social differences. However, Ovando (2014), defines 196 assimilation as a voluntary or involuntary process by which individuals or groups completely take on the traits of another culture, leaving their original cultural and linguistic identities behind. Assimilation occurs when people adopt local cultural values and identity while maintaining day-to-day interactions with members of the local community while rejecting or having little interest in their home cultures (Aini 2021). To truly assimilate means to let go of all that one was before a point in time and to become something or someone else while discouraging the retention of their tribal customs, beliefs, and language (Hickey 2015). Aini (2021) states that the assimilation strategy is to let go of the cultural identity of origin and choose to live with the majority culture somewhere. Following that, separation is defined by negative responses to the question of cultural contact and positive responses to cultural maintenance. Finally, marginalisation is the label applied where negative responses are obtained for both questions. Furthermore, it has been by establishing relationships between ‘positive psychological adaptation’ and ‘integration’ that integration has come to be privileged as the optimal acculturation strategy (Bowskill et al. 2010). In summary, separation is characterised by individuals only wanting to cling to their original culture while avoiding interaction with the host group. Individuals exhibit attitudes of integration when they attempt both to maintain their traditional way of living and to seek daily interactions with the host group. Marginalisation refers to the attitude of incoming individuals who have little interest in maintaining their own culture and in interacting with others from the host group. Eventually, they are pushed aside because their beliefs do not reflect the mainstream's. It has to be pointed out though that these stages do not occur at the same time and some people may reach them at different phases. This study reported on the experiences of Southern students training to be nurses. Study findings replicate and provide support for some findings that have already been identified; specifically, that acculturation is important for the study experiences of foreign-born student nurses. The study showed that immigration results in acculturation, a process which involves students finding themselves in a position where they review their traditions, beliefs, and way of life. In their home countries, these are issues they took for granted, yet in a new country they come to the fore; 197 once they were absolute and mostly invisible, and yet under the spotlight, they are the subject of persistent questioning, reviewing, analysing and at times rejection. Wang (2012) noted that the international student can help academic members of staff to recognise the influence of their own cultural background on their values and those of home students and, as Lee and Rice (2007) highlight, increase tolerance, understanding and appreciation of different countries and cultures around the world. It is fair therefore to suggest that the contribution of nursing students born outside England, such as the participants in this study adds to the diversity of the student population and brings fresh perspectives during classroom discussion. Students from Black and minoritised ethnic communities need to see themselves reflected in the curriculum as legitimate creators of The international student also referred to as the foreign-born student contributes to the diversity of the student population and in doing so adds fresh perspectives during classroom discourse (Charles-Toussaint and Crowson 2010; Lee and Rice 2007). Wang (2012) notes that the international student can help academic members of staff to recognise the influence of their own cultural background on their values and those of home students. Lee and Rice (2007) highlight, increasing tolerance, understanding and appreciation of different countries and cultures around the world. Like international students, home students can benefit from the mixed cultural experiences that they might be less likely to gain from an all-home student group, and this may help prepare home students for future encounters with diversity (Andrade 2006). If they are giving us lectures, they need to acknowledge that we exist so that our counterparts recognise us... If tutors could support us, we could get support from our friends as well. (P8) my suggestion is that if they could open such areas so that people can understand and bring people from divergent backgrounds who have experienced discrimination in one way or another not because of the mental challenges but because of the characteristic that that would be an eye-opener because a lot of people don’t understand that we as nurses try to treat everybody fairly, but we 198 may not be equipped to see things differently. We would be able to improve how we care about people, particularly Black people, and other minorities. (P10) Several factors were found to affect participants’ attitudes toward people with intellectual disabilities and mental illness including cultural and religious beliefs. Since an attitude can be defined as a multidimensional concept involving affection, behaviour and cognition, it is susceptible to change and variation (De Laat et al. 2013). This study has shown that for student nurses of Southern African origin, exposure to a person with an intellectual disability and mental illness during prior employment and practice placements helped them appreciate the patients. Given that all but one participant had had no contact with a person with a learning disability when they were back home, the participants felt that employment and placement provided them with the exposure. As an educational environment, placement has a direct impact on the students’ learning and with the support of practice assessors, students can build therapeutic relationships with patients. Additionally, acculturative experiences couched in nurse education including practice placements, helped to bolster the changes in beliefs previously held when they were younger. These experiences have resulted in an increase in intellectual disability and mental illness literacy with the acceptance and endorsement of biomedical factors and reduced endorsement of psychosocial and supernatural factors as causes of intellectual disability and mental illness. Markey and Okantey (2019) suggest that cultural factors, including the diversity between the students’ cultural background and the nursing programme context, have been reported as a source of the difficulty. Moreover, differences in ethics and values systems have been reported as a source of misunderstanding and fear of compromising one’s own cultural values (Gilligan and Outram 2012; O’Reilly and Milner 2015). Malapela et al. (2017) argue that student nurses are at a crucial stage of learning about their profession and if they are not properly educated or oriented on the specialised care needs of people with intellectual disabilities, then there are likely to be profound challenges and shortcomings when they care for people with intellectual disabilities. Although African-born nursing students in higher education constitute a small subset of students, the implications of this study's findings extend beyond this population and speak to 199 the broader experiences of higher education for minority ethnic and other marginalised populations. African-born nurses represent diversity in the profession, the UK health system and in academia. To understand the aspect of intellectual disability and mental illness one needs to understand the cosmological assumptions that shape the cultural values and perceptions of people, particularly concerning notions of cause and effect. The focus of this discussion is based on the Afrocentric perspective, examining topics from the perspective of Southern African people. The discussion views the participants as subjects of historical experiences that relate to them as well as seeking to re-locate the African person as an agent in human history to eliminate the illusion of the fringes (Asante 2003). How intellectual disability and mental illness are viewed from a Southern African person’s perspective is determined by how their culture has shaped their understanding and changing their perspectives takes a lot of effort. During the interviews, l asked the participants about their experiences of studying nursing and how their previous beliefs interacted with their present belief systems. All the respondents acknowledged considerable differences related to the time it took to lose their previous beliefs. As children, they learned the beliefs quicker and naturally. They contended that at the university level and as adults, shedding the beliefs involved making conscious and deliberate efforts to make the experience more difficult. The quotations below summarise the learning experiences about cultural competence for those who had already covered the topic: It's the first thing that we did- to explore people's beliefs and what they think about having a learning disability and we talked about it. (P5) The first positive thing that I have found about learning culture is that during our first year, we brought in people who were having immigration challenges and were from diverse backgrounds and there was a big change in my colleagues and fellow student. (P10) 200 Irungu (2013) points out that African students can find the cultural gap between their own country and the host country overwhelming. Some of the participants in this study found it difficult to change their deeply embedded cultural beliefs. A part of me still believes what I knew before I came to the UK. A small fraction of me still believes, especially with mental illness, there could be something sinister that would be going on. (P3) I believe that what you were told or taught as a young child growing up will stay with you for the rest of your life. How you are taught to live your life, how to approach people, and the beliefs you have will always stay with you for the rest of your life. So even if I move to a different country and they had an unusual way of doing things, what I believe will never change because that is embedded in my mind. I have these conversations with my mother about what I have seen at work. (P3) It has changed because I have been educated but at the same time, I'm saying I'm also a Christian and there can be a dilemma sometimes. (P5) I will say that my Africanness has not left me, but I think that some of it has been replaced. It is the same belief but only differs in how we treat it. In the church, we believe that it is an evil spirit, in African culture, it is also an evil spirit. In African culture, we go to traditional healers, in church, we pray, in Europe, we go to the doctor. I believe they are evil spirits but because I'm now a Christian I react to them in an unusual way. (P5) Maringe and Carter (2007) found that the mature students they studied were concerned about the erosion of their cultural heritage while in the UK. This is consistent with some studies of Black-African students abroad who also show a reluctance to relinquish their former identity, in favour of embracing the host country’s culture. Beoku-Betts (2006) posits that the concept of relinquishing an identity to integrate into a new culture is especially challenging for many African students due to the legacy of cultural marginalisation and destruction left by the colonial period. This highlights the importance of exploring participants’ previous beliefs and their Indigenous 201 knowledge, so they do not impact their new learning. Previous studies have shown that cultural background can impact the provision of practical care to patients for example patients of the other sex (Abu-Arab and Parry 2015). This study identifies that students’ cultural background for example norms, values and beliefs impacted their clinical and classroom learning experiences. People living in Western societies and are from traditional ethnic or minority populations within high-income countries do not abandon everything they know and practice to unquestioningly adopt a new system of thoughts, beliefs and behaviours; rather, new and old ideas often co-exist and frequently co-mingle– producing hybrid belief systems that are neither wholly old nor new (Groce 2000). Usher et al. (2005) in their study involving student nurses in Australia learnt that the exclusion of indigenous content was not helpful to them and advocated for the inclusion of relevant Indigenous content in the nursing courses. Additionally, Foxall (2013) found that the content failed to show the cultural understanding of Indigenous students in New Zealand. As a result, Schafer et al. (2010) suggest that incorporating cultural diversity seminars positively and creatively facilitates deeper learning and greater awareness and challenges the students' assumptions and attitudes concerning mental illness and intellectual disability understanding by providing a safe, explorative environment through skilled facilitation. Conversely, Lewis and Stenfert-Kroese (2010) caution that nurse training alone is not sufficient to improve attitudes towards people with intellectual disabilities and that more specific training and teaching on this subject are required due to the lack of education student nurses receive about intellectual disability. They advise that future research needs to focus on improving attitudes amongst nursing staff and student nurses. Additionally, Beacock et al. (2015), recommended nursing curricula should include attitudes, health issues and the role of carers among others to meet the healthcare needs of people with intellectual disabilities and mental illness. Ways of knowing vary across the world and include intuition, authority and rationalism (Gladwell 2007). This thesis contends that incorporating such issues in the curriculum helps students with strong cultural views to accept that those alone are not helpful as diagnoses without scientific and empirical 202 evidence. However, ignoring or excluding such content reinforces the ongoing argument for decolonising the curriculum. This study also identified that following their attendance at university, the participants now hold more positive attitudes toward caring for people with intellectual disabilities and mental illnesses. This is due to the placements they had attended and the content of the curriculum helping them examine their belief systems. Although gaps were identified in exactly what they were taught, there is a need for the curriculum to be culturally inclusive. Some participants did not feel they had been prepared because they felt the curriculum was still biased towards the mainstream population. The participants also reported that some lecturers need to acknowledge that they (students) exist in the classroom and not expect them to hold back if they wanted to share their beliefs and views. In addition, they also commented that most of the time, they were expected to just go along with the teaching even if it was Eurocentric. This is supported by McCrae (2012) who observed that educators and practitioners struggle to both teach and assess behaviour, values, and attitudes because of the difficulties associated with developing activities that address affective domain development and measuring the effect scientifically and empirically. Hall and Guidry (2013 p.6) posit that founded on evidence-based teaching practices; nursing education has a responsibility to ‘build the capacity of students through experiences that foster cultural understanding. Being Southern African as well as tribal members in their own respective countries means that each one of the participants subscribed to a general culture of social and cultural practice, including that of culture, health and healing. This also points to the existing beliefs about intellectual disability and mental illness they bring with them into nurse training. The endorsement of the conclusions of my study by students in a similar position presents an argument for studying how student nurses born and raised outside the host country manage this dual allegiance to both cultures. These findings are broadly in harmony with those of researchers such as Mikkonen et al. (2016), who found that foreign-born student nurses experienced a cultural difference in the nursing programme and their own, which was dealt with by a process of progressive integration. I have discussed this in the acculturation section but must reiterate that this process included: an acceptance that they had a profound attachment to their own 203 culture; an immediate acknowledgement of detachment from their beliefs and the desire to learn those of the new culture; and thirdly, the expression to integrate the two cultures and be able to practise safely in the new culture. 4.7 Chapter Summary The chapter began with a presentation of and critical analysis of the findings of the study followed by an exploration of acculturation and acculturative experiences of the participants. This included a critical analysis and review of the acculturation theory and how this links with the participants’ experiences. This next chapter will include the limitations of this qualitative, phenomenological study as well as the recommendations for nurse education. 204 Chapter 5 – Limitations 5.1 Introduction The previous chapter presented the findings of the study and critically discussed them from an educational perspective arguing how they can be applied for the benefit of both students and academics supporting them. This chapter critically examines and discusses the limitations of this study. It is important to be open and honest about my study so that l highlight where the limitations may have impacted on the outcomes of my study. I identified several limitations in this study. 5.2 Impact of Covid19 outbreak in 2020 • The interview phase which was due to commence in March was delayed by over three months because it coincided with the national lockdown which resulted from the outbreak of the Covid 19 pandemic. Due to the new government regulations on social distancing, interviews were then moved to online platforms including Microsoft Teams, the university's preferred platform of remote working and communication via video link. Again, due to the ongoing pandemic and constant changes being made and policies reviewed regularly, timescales for the completion of interviews were further impacted by the programme structures being adjusted which meant interviews were dependent of the availability of students. In addition, the pandemic disrupted family lives and this additional interruption l caused meant that the interviews were sometimes conducted when some participants had their young children at home. 205 5.3 Data collection The research method uses only interviews to capture the lived experience of the participants and even though this is proven to be the most reliable data collection method for a phenomenological study, the questions required recall of earlier childhood experiences. It can be argued that while beliefs can and do change over time, people can still remember them. Additionally, l conducted single interviews with the participants in which some participants described personal and emotionally charged situations that were visibly painful. Five participants highlighted experiences of racism in the classroom or placement areas. I chose not to pursue these situations further based on the desire to be sensitive to their emotions. A second interview could have provided the opportunity for building a deeper rapport between the participants and the researcher with the hope of gaining further understanding of the students’ experience. However, l was able to go back to the participants during member-checking to verify any issues encountered during data analysis. There were no interview questions specifically relating to discrimination and racism, for example, issues which, upon analysing the data, appear to be concepts of some importance in the study. This is a limitation of the study, even though it was not the intention of the study to explore them. However, l did not ignore these responses as l have reflected on them in the data analysis and description chapters. Additionally, l have acknowledged previous research on acculturation experiences which include discrimination and racism. 5.4 Paucity of research There is a paucity of research on African student nurses’ belief systems about intellectual disability and mental illness when they have become citizens of their host countries. There is, however, an abundance of research on international students’ experiences of acculturation. Obtaining statistics and research was, therefore, a limiting factor because when students commence a nursing course as home students, they do not have to disclose their country of birth. 206 For research purposes, it may be difficult to identify gaps in practice and learning experiences of this group if they choose not to disclose their countries of origin. 5.5 Sampling and Bias The chosen methodology necessitated a small sample size; meaning that the findings cannot be generalised. Resultantly, this study cannot be taken as representative of a complete Southern African students’ perspective, given the size of the African continent at large as well as the Southern African region chosen for this study as well as the biases inherent in my role as an African researcher. The possibility of bias existed since I worked at the university. However, I have been transparent about this, and I believe that the participants were very honest in what they said. I should stress that my study has been primarily concerned with the lived experience of student nurses of Southern African origin. This analysis has concentrated on this group of students who were represented by thirteen willing participants; therefore, the findings of my study are limited to this number only. I have addressed only the influence of nurse education on their belief systems about intellectual disability and mental illness, a process which opened other concepts such as acculturation, discrimination, racism to name a few, some of which were beyond the scope of this thesis. In addition, aside from the sample size, I utilised convenience and purposive sampling from my own university because of the easily available and accessible population from which to select my sample. Miles and Huberman (1994) identified 16 strategies for purposeful sampling in which convenience sampling was seen as the least desirable (Maxwell, 2005, p. 88). The limitation of convenience sampling lies in both the utility of the data as well and generalisability. However, such external generalisability is not the purpose of qualitative research (Maxwell 2005). From a phenomenological research perspective, the interpretation of the transcripts attempted to capture the essence and meaning of the experience of nurse education among the thirteen students who participated. 207 Selection bias may have occurred in this study because of the purposive sampling strategy used to recruit the study participants. I acknowledge that selection bias can negatively affect the credibility of a study resulting in inaccurate generalisation and invalid conclusions about the phenomenon under study. However, a strength of the study was that the sampling strategy decreased selection bias as the study participants were recruited through the ethics processes regulated by the university. The advantage of this phenomenological study is that it helped to develop a rich understanding of vital educational issues impacting a specific group of student nurses allowing the researcher to identify a range of previously unidentified issues and the narratives behind them. Thus, future studies can build on the findings from this study. I should make clear that I have intentionally not included the rest of Africa as my target sample and only focused on Southern Africa due to my lineage and connections with this part of the world. Definite conclusions should not be drawn in relation to other foreign-born students because they may hold the same beliefs as those found in the Western world. Correspondingly, this thesis has shown that in general, most African students hold similar beliefs, however, the findings of my study do not imply that this experience is the same for all Southern African students. In addition to the identified potential sampling bias, the findings are from within one university and thus may not readily generalise to other universities. As a result, my findings should not be taken as evidence for all Southern African students training to be nurses in England and indeed any Western country. A further limitation involves the inability to represent the whole of Africa and the vast diversity among both students and countries in Africa. Africa is a large continent with many and wide-ranging histories and cultures. It is clear from the interview transcripts that differences existed in student educational experiences in my university even among the thirteen participants. As part of the data analysis, narrative summaries were written to capture both a summary of each interview, as well as the essence of the individual student’s experiences with nurse education at the university. The final limitation of this study involves my role in the qualitative research process, both in performing the interview process as well as interpreting the transcripts through the identification of themes and thematic analysis. The role of the researcher becoming part of the research has 208 been widely discussed, most notably by Heidegger (Lopez and Willis, 2004; Streubert Speziale and Carpenter, 2007). While performing the interviews, reading and rereading the transcripts, writing narrative summaries, analysing and categorising elements of the transcripts into themes, and interpreting the themes for the significant essence of the Sub-Saharan African students’ experience. My inexperience as a researcher was a major factor and while this experience was overwhelming, it was totally rewarding. This study aimed to provide the Southern African students a voice as they reflected how, at times, they felt powerless and voiceless. The sense that students were highly interested in participating and sharing their experience provided validation of the researcher’s focus on both the personal and the academic experience of the participants – thus providing them a voice. During the interviews, I found myself being transformed by the richness of the student stories and the student willingness to share those stories, becoming less of a researcher and more of a listener in the research process. As interview transcripts were read multiple times, new stories were found in the transcripts that did not stand out in the earlier thematic analysis process. Part of the researcher becoming part of the research emerged near the final stages of the analysis and writing process. “Phenomenological projects and their methods often have a transformative effect on the researcher himself or herself” (Van Manen 1990 p. 163). 5.6 Chapter summary This chapter has critically explored the study’s limitations, identifying the impact of the Covid19 pandemic and the sampling and data collection issues. Implications and recommendations derived from the study’s findings on Southern African students’ educational experiences and how nurse education can enhance their experiences will follow in the next chapter. 209 Chapter 6 – Implications, Recommendations and Conclusion 6.1 Introduction This study explored the participants’ beliefs they held about intellectual disability and mental illness. The participants described their beliefs about causation, attitudes, and stigma towards people with intellectual disability and mental illness and reflected on their acculturative experiences which were characterised by shock, fear, discomfort, and guilt. They did not readily or openly report any prejudicial or discriminating attitudes towards patients with intellectual disabilities and mental illness in England as compared to their honest admissions about their stigmatising attitudes they openly shared when they were back in Africa due to their beliefs. This final chapter is the culmination of the study and will concern itself with implications and recommendations for nurse education and conclude the study. 6.2 Implications for nurse education The participants outlined their journeys into nursing and how this process prepared them for university education. Their experiences as support workers and healthcare assistants in England helped to ease the transition process. Although not all of them were training to be learning disability nurses, most of them had at some point either worked with people with learning disabilities or mental illness. Having made the decision to become nurses, they joined the health and social care sector to gain experience which would boost their chances of gaining a place on the nursing programme. It was not the intention of this study to explore their experiences in this sector apart from establishing what it was like to meet a person with an intellectual disability or mental illness for the first time in England. It was important for this study to establish the participants’ initial reactions upon meeting a person with an intellectual disability or mental illness as this would have been in a caring role. This thesis also offered a consideration of globalisation, immigration, and the rapidly growing culturally diverse populations of student nurses worldwide. More importantly, in the UK HE, 210 globalisation, immigration and cultural diversity have resulted in a diverse composition of cultural and ethnic groups including those from Southern Africa. Additionally, with the evolving student demographics in the UK it is paramount that HE reflects on its ability to deliver teaching that does not exclude minority ethnic groups by what it includes in its curricular. Schools of health and academics are expected to teach students how diversity can affect health care outcomes. In this chapter, l argue for the critical need for a curriculum that incorporates culturally competent teaching throughout the educational process because with the widening sociocultural diversification of the student nurse population, it is now imperative that nurse educators establish cultural competence as a graduate capability as evidence does not yet exist regarding the best way to educate culturally competent student nurses (Cuellar et al. 2008). The participants described the stigma they had towards people with intellectual disabilities and mental illness and how they had to change them to prepare for the nursing profession. They also expressed frustration resulting from a lack of knowledge and experience of caring for people with intellectual disabilities and mental illness due to the stigma they witnessed back home and the lack of facilities there. This thesis argues for future research to examine the attitudes, beliefs, and emotions of student nurses raised outside the UK towards the phenomena that is intellectual disability and mental illness. With the rising numbers of diverse minority ethnic populations, there is a need for academics and nurses to equip themselves with knowledge to support this population of students. This will achieve the advantage of equipping native students with knowledge about belief systems of minority ethnic communities who also hold the same views as those of the participants in this study. This research has shown that understanding of intellectual disability and mental illness needs to reflect the African students’ perspectives which differ in certain ways from Western notions. As students from Southern African countries enter UK, HE, they bring with them their own value systems and beliefs about intellectual disabilities and mental illness. Some of those beliefs especially around causation, treatment and how to respond to them from an attitudinal perspective will be different to those which nursing care advocates for. Markey and Okantey (2019) suggest that cultural factors, including the diversity between the students’ cultural background and the nursing programme context, have been reported as a source of difficulty. 211 Moreover, differences in ethics and values systems have been reported as a source of misunderstanding and fear of compromising their own cultural values (Gilligan and Outram 2012; O’Reilly and Milner 2015). When student nurses of African origin are supported to face these phenomena and adjust their values and beliefs, they can develop personally and professionally. The research further highlights the presence of fear and stigma attached to intellectual disability and mental illness. Malapela et al. (2017) argue that student nurses are at a crucial stage of learning about their profession and if they are not properly educated or oriented on the specialised care needs of people with intellectual disabilities, then there are likely to be profound challenges and shortcomings when they care for people with intellectual disabilities. Although African-born nursing students in HE constitute a small subset of students and subsequently the nursing workforce, the implications of this study's findings extend beyond this population and speak to the broader experiences of HE for minority ethnic and other marginalised populations. African-born nurses represent diversity in the profession, the UK health system and in academia. The conclusions to be drawn from this study are threefold. Firstly, health educators and their institutions need to be trained to be culture-sensitive and to acknowledge that diverse students have different value and beliefs systems. Secondly, cultural education raises student nurses’ awareness about the diversity of beliefs among communities, yet this study shows that it does not acknowledge the diverse views held in the classroom. Thirdly, the study showed that some beliefs may delay the formal support given to children and eventually, adults with intellectual disabilities due to the cultural beliefs held in their communities. Based on the above assertions, the study gives two main impulses for further research. First, it is necessary to better understand processes that evolve over time, including beliefs and stigma which should be investigated in more detail. This is necessary because the participants did acknowledge that it was difficult for them to give up and forget their beliefs. Second, collecting data from other health and social care students and qualified staff of Southern African origin is crucial to further explore how beliefs and stigma affect their interactions with people with intellectual disability and mental illness. The question remains as to what degree 212 factors identified in this study are valid among caregivers from Southern Africa who do not seek Western medical help because understanding the influence of beliefs and stigma has shown to be crucial in understanding and supporting caregivers to seek help. Future research should also focus on interactions between students and caregivers of Southern African origin regarding their beliefs and help seeking ways while living in a country where these views may not be viewed in a positive light. The participants, during their initial training, hold beliefs about intellectual disability and mental illness from two domains, that of their culture and that of Western biomedicine. There is an opportunity, due to this dual belief system, and of course that the participants are training to be nurses, to place them in the role of change agents and primary ‘brokers’ between families who subscribe to traditional culture and biomedicine. This may serve the purpose of shifting traditional beliefs and increase access to health services for minority ethnic communities with the foreign-born nurses acting as ambassadors. This study also identified that following their attendance at university, the participants now hold more positive attitudes toward caring for people with intellectual disability and mental illness due to the placements they had attended and the content of the curriculum helping them examine their belief systems. Although gaps were identified in exactly what they were taught, there is need for the curriculum to be culturally inclusive. Some participants did not feel they had been prepared because they felt the curriculum was still biased towards the mainstream population. The participants also reported that some lecturers need to acknowledge that they (students) exist in the classroom and not expect them to hold back if they wanted to share their beliefs and views. In addition, they also commented that most of the time, they were expected to just go along with the teaching even if it was Eurocentric. Being Southern African as well as tribal members in their own respective countries means that each one of the participants subscribes to a general culture of social and cultural practice, including that of culture, health and healing. This also points to the existing beliefs about intellectual disability and mental illness they bring with them into nurse training. The endorsement of the conclusions of my study by students in a similar position presents an argument for studying how student nurses born and raised outside the host country manage this dual allegiance to both cultures. 213 This study has shown that Southern African born student nurses face challenges as learners over and above those encountered by native students. Due to the beliefs that they bring into nursing, they must grasp the content and practice of nursing education within an educational and cultural context radically different from their own and do this quickly. The participants in this study reported having each undergone a transformative lived experience which included cultural bereavement, culture shock, reflection on beliefs and an acceptance of the new knowledge. This study argues that Southern African student nurses’ beliefs can have a profound impact on their care for and attitudes to patients. The study explored the belief systems held by Southern African student nurses and identified their shared perspectives and viewpoints on intellectual disability and mental illness causation, which are influenced by culture, nursing education as well as the geographical environment through acculturation. Student nurses’ indigenous beliefs influence their patient care and are an important matter for nursing education. African people's beliefs are deeply influenced by traditional culture. The findings of this study emphasise the importance of influence of African culture and scientific evidence. Student nurses should be supported to critically think about the influence of their cultural health beliefs. This study argues for the need for African born student nurses to be supported to evaluate their beliefs. It cannot be denied that students of Southern African origin arrive with pre-set belief systems and those remain a part of their daily lives as they continue to navigate the cultural field of nursing. However, exposure to nurse education alone is not enough to reshape the beliefs which must align with the scientific, non-traditional views about intellectual disability and mental illness. This has been partly explained by considering occupational socialisation such as employment within health and social care environments where the participants experienced caring for people with intellectual disability and mental illness. In addition, exposure to media, educational materials and the ongoing process of acculturation all had a part to play in impacting on their Indigenous belief systems. The process of nurse education should promote and support the Southern African and indeed international student nurses to portray and preserve the scientific and empirical views of the profession while supporting them to shed off the cultural, intuitive belief systems and perspectives they arrive with. 214 6.3 Recommendations This study has shown that indigenous beliefs of student nurses of Southern African origin heavily influence misconceptions of causes of intellectual disabilities and mental illness (van Dyk and van Dyk 2015; Tilahun et al., 2016; Bunning et al., 2017 ; Aldersey 2012; Mkabile et al. 2021; Aldersey et al., 2014; Gona et al., 2011; Lamptey 2019; Masulani‐Mwale et al., 2016; Nkhosi and Menon 2015; Ntswane and Van Rhyn 2007; Ajuwon and Brown 2012; Tilahun et al. 2016) . Hence, such perceptions also influence people’s concepts on conditions such as epilepsy and other physical disabilities. The study has shown that these misconceptions promote stigmatising attitudes towards people living with such conditions (Mitfah et al. 2015; Nota et al., 2015; Groce and McGeown 2013; Magnussen 2011; Bunning et al. 2017; Aldersey 2012; Aldersey et al. 2014; Gona et al. 2011; Lamptey 2019; Masulani‐Mwale et al. 2016; Nkhosi and Menon 2015; Ntswane and Van Rhyn 2007 Ajuwon and Brown 2012; Tilahun et al. 2016; Tilahun et al., 2016). This study also showed that student nurses, some of whom had been working in professional services prior to becoming students also often believe in causes such as witchcraft, God’s will and ancestral curses for intellectual disabilities and mental illness. 6.4 Delivering content that encompasses various belief systems to cater for a diverse student population. My study offers suggestive evidence for the introduction of new and creative ways of teaching that tap into the diverse tapestry of beliefs, attitudes, and cultural values. The expectation is not that nurse education must turn to a cultural show, but that teaching standards and subsequent writing of curriculums continuously reflects the ever-changing student demographic and provides an opportunity to revisit and re-evaluate how teaching is facilitated and that academics are comfortable and confident doing this. Part of this agenda must involve what Scammell and Olumide (2012 p.545) propose, that nursing students should be educated about the social and historical landscapes which have led to the unchallenged ‘whiteness’ of both nursing practice and education to equip them to deal with its impacts. 215 Participants in this study reported that they had to challenge their cultural assumptions and stereotypes through direct contact with people with intellectual disabilities and mental illness. Regarding future curriculum development, for nurse education to be transcultural, this thesis premises that it must prepare students to acknowledge and understand their own cultural values and beliefs as well as those of others. HEIs providing nurse education must be sensitive to the needs and expectations of student nurses from different cultural backgrounds by addressing the unique Indigenous beliefs they bring with them. For Southern African born students, it is imperative that the teaching of culturally competent care will help them explore their own cultural biases, reshape their initially held beliefs and remodel them based on nursing values, professional values, and ethical behaviour to avoid further cases of abuse based on ignorance of the new cultural spaces they now exist in. Nurse education needs to address health and illness beliefs held by student nurses from various cultural backgrounds in order to create greater awareness and knowledge on such conditions and their causes and to help eliminate the unhelpful beliefs that may impact students’ attitudes towards people with intellectual disabilities and mental illness. It will be useful to address these cultural influences in the nursing curricula. This study proposes acculturation work with students who were born in Africa to help with the shift in these beliefs and help reduce stigmatisation influenced. Teachers of nursing students raised outside England, both academic and clinical, need to be cognizant of the ‘otherness’ of international nursing students, develop cultural competence and a willingness to advocate for an equitable environment that is appropriately resourced for international nursing students' learning opportunities. Nurse academics are advised to develop strategies that are inclusive of international nursing students to negate discriminatory practices, with cultural humility being not only studied but also demonstrated and practiced so that students, both international and domestic, can develop the necessary skills to address discrimination in a professional manner and enhance learning opportunities. Nursing educators can role model for students through their own efforts to expand the scope and depth of cultural competence and demonstrate the ongoing quest for excellence that needs to be part of professional nursing practice Berdnaz et al. (2010) 216 While it is important that we spend time teaching students the cultural norms of the host country, we should acknowledge that some of our students may still be acculturating and therefore experiencing the difficult stages of the process. Areas for further investigation include the absolute necessity for schools of health and faculty working with not just Southern African but foreign-born students to frame a relevant curriculum, which includes course content which help students express their own cultural beliefs and challenge them safely. Beyond the remit of this thesis, it is worthwhile considering training packages for nurses arriving from African and Asian countries to boost nursing numbers to prepare them for these possible cultural challenges. 6.5 Epilogue For me as a researcher in this study, seeing the participants through this phenomenological lens has been an invaluable learning experience. Hearing about their experiences through the interviews revealed unique aspects of negotiating the cultural context and taught me to be reflective and attentive to their needs. Through undertaking this research, I have gained some understanding of the nature of research and of the messiness, difficulties and rewarding nature of the research process. Regardless of the plans, targets, and deadlines that l set myself, I have learned that things do not fit neatly into categories, of course, and that research can be and is a frustrating and tedious process. As a qualitative researcher, the application of Hermeneutic phenomenological concepts as research methods in my study enabled a deeper understanding of the lived experiences of student nurses than may have been achieved through a different methodology and research methods such as experiments and questionnaires. Through phenomenological interviewing, for example, when mutual understandings were revealed through the deep telling of lived experiences by the participants, and by listening to their stories that resonate with others found in the literature, the aims of Hermeneutic phenomenological research were achieved in this study. The philosophy based on being-there; including concepts of beliefs, culture, and more importantly time and space were all conducive to bringing to light the many intricacies of the student nurses’ experiences of navigating an unfamiliar cultural environment to that of their own. 217 The participants suggested that a module that addresses cultural issues including beliefs and attitudes towards health would be helpful and should be offered to all students not just foreign-born students. They also discussed the transcultural nursing lecture in their first year which they felt was useful, however, was not fully followed up across all modules. My study supports the argument for a change in how cultural competence is taught. Cultural competence must not be seen as an add-on or a preference by only a few academics with an interest in it. This research adds to the nursing field that academics need to maintain competence in teaching cultural education especially with respect to addressing the expectations of students from minority ethnic backgrounds. On the face of it, this suggests that cultural training for academics is a key factor in Continuous Professional Development. Through my study, I am contributing to knowledge by joining the conversation about acculturation, experiences of foreign student nurses and decolonising the curriculum, claiming a voice and a stance, and being brave enough to argue for it. Additionally, for me as a researcher, it is crucial that I show how my study builds on, extends, and definitely critiques the current arguments dominating the conversation about the experiences of African students in the field of Higher Education in the UK. By extending the conversation to include Indigenous belief systems about intellectual disability and mental illness and the lived experiences of Southern African origin, my research has identified and reviewed five acculturation measurement scales that have been used with international students. For student nurses, nurse education can be a useful vehicle for changing attitudes to intellectual disability and mental illness. For student nurses who hold beliefs based on religious and cultural views, nurse education, through targeted modules, holds the promise of challenging those who have stigmatising views to reflect on their feelings and lead to some circumspection. The challenge for universities is, therefore, to devise strategies that will increase the general knowledge of the student cohorts regarding the link between intellectual disability and mental illness with indigenous beliefs with the intention of changing their attitudes to people with intellectual disability and mental illness can be improved. 218 In this study, l have shifted the focus of acculturation as a phenomenon seen as a series of stages an immigrant goes through to one that involves cognition, reflection and a conscious effort to make personal changes to their beliefs. This has led to the idea for the creation of a yet to be substantiated and validated acculturation model that places the student at the centre of acculturation and proposing a series of stages to be followed when supporting them to acculturate rather than expecting them to proceed unsupported. Following this study, I am actively working on substantiating and validating the phenomenological acculturation interview framework whose idea came about after the participants highlighted spatial and temporal contributions about their lived experiences in nurse education. Once these tools have been tried and tested, they will be used to support students with their acculturation process (Please see Appendix I). The study adds to knowledge, the experiences of acculturation which can further be explored in the three-year nursing course of not just African born student nurses but others from different countries as well. The contribution l make through this interview framework and acculturation model enables me to find and claim a researcher identity and voice. I am in the field now, and I have shown in my thesis that I can do research at this level and of growing further. I know that there is also value in adding new perspectives such as new and innovative ways of supporting student born and bred abroad who decide to train and work in a different country. I understand that all the existing work before my study commenced is a resource for substantiating my own claims to knowledge. My research also opens a whole new perspective on pedagogical development in nurse education. It raises an acknowledgement that white nurse academics need to become aware of their assumptions regarding teaching which is based on colonial and Western-dominated ideologies. To this regard, there should be a willingness to critically reflect on those biases in order to enhance a rich and all-encompassing student learning experience. The ongoing conversation and actions on decolonising the curriculum will be made rich by my study and further considerations suggested here, including the acculturation model contributed by my study. While l do not expect this to lead to an immediate and fundamental paradigm shift in the field, the significance of my research is recognisable to those in my field. 219 Thanks to my supervisory team and supportive colleagues, l also found that at the best of times, doing a PhD study is immensely rewarding and even exhilarating. The phenomenological approach allowed me to see the participants’ determination to be competent nurses of the future despite having to navigate the turbulence of cultural terrains. I sensed a tremendous determination to show growth over time as they cautiously underwent personal and professional transformation over time. This research study transported me back to my days as a student nurse and reminded me of my own experiences. Having had the privilege to do this research has also provided some key ideas which have helped me examine my own professional values, reflect on my practice, and start making changes to my own future practice. I recognise my role in influencing future policy and practice by adding my contributions. I am more than determined to explore further the impact nurse education programmes have on the belief systems of the practitioners of the future who will be working with the ever-diverse populations since I now have a growing awareness of the impact of belief systems on the students’ lived experience. I have also started speaking to colleagues and begun to question how they individually, and how we, collectively, come across as course academics, in our daily interactions with students who may be experiencing the issues l have identified in my study. It is essential that we are aware of how much attention we pay to our participants’ beliefs about intellectual disability and mental illness and support them in the three years they are with us. 220 References Abasiubong, F., Ekott J.U., Bassey, E.A., Nyong E.E. 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(2017) “If You Say You Have Mental Health Issues, Then You Are Mad”: Perceptions of Mental Health in the Parenting Practices of African Immigrants in Canada. 52.(3) 290 Chapter 7 - APPENDICES 7.1 Appendix A: Ethical Approval REQUEST FOR ETHICAL APPROVAL EthApp V 9.0 2019 - CONFIDENTIAL Please fully answer every Section as the SRESC may not be able to review any incomplete forms. The academic supervisor (or the Chief Investigator for non-student projects) submits by emailing the completed form and any supplementary documents, to sohsc-ethics@tees.ac.uk. Before submitting this form: Please read the TU ‘Policy Procedures and Guidelines for Research Ethics’ and ensure the proposed research complies with the University's six Principles for Research Ethics. The ethical issues underlying these principles are laid out in detail in the Guidelines section. If this project will require Health Research Authority Approval after TU Ethical Clearance has been confirmed, then do not complete this form. You must apply for TU Ethical Clearance by submitting a form generated through the Integrated Research Application System (IRAS https://www.myresearchproject.org.uk/). You must not apply for HRA review, nor any other external approvals or permissions, until after TU Ethical Clearance has been confirmed. If you are in any doubt about which Approvals/Permissions your project requires, use please contact the Chair of SRESC before applying. SECTION A: To be completed by the Chief Investigator (CI) NB – for student projects the Academic Supervisor is the CI 1) Project title: Indigenous Knowledge Systems about Intellectual Disability and Mental Health: A Phenomenological study of the experiences of Southern African students studying nursing in the UK. 291 2a) Name, job title and address* of the Chief Investigator: Dr Dorothy Hannis, Senior Lecturer 2b) Name, job title, employer and address of all other people involved with this project other than student(s) or researcher(s): Dr Alan E Armstrong, Senior Lecturer * For TU employees do not give address 3a) Name(s) of researcher(s)/student(s) working on this project: Chris Dlamini, Senior Lecturer 3b) Please initial below to indicate which category of project this is: Taught Postgraduate PG Research Student Staff - higher degree Staff - other research √ Final Year Undergrad Student 4) Expected duration of this project: From: October 2018 To: October 2025 5) Research Question(s), Aim(s) and/or any Hypotheses being tested: Due to world-wide migration and growing immigrant populations, nursing students in the United Kingdom need to possess a high level of cultural competence to provide nursing care to patients from various cultural backgrounds (Choi and Kim 2018). Cultural competence is defined as an individual's ability to rapidly learn different cultures and convert this knowledge into action and to draw on his/her cultural knowledge to effectively interact with people of different cultural backgrounds (Selmeski 2007). Additionally, it is seen as a process, not an endpoint, in which the nurse strives to achieve the ability to work within the cultural context of an individual, family and community from diverse cultural backgrounds. Interestingly, it has been reported that the current cultural education in nursing curricula is not sufficient to improve students' cultural competence and that little is known about how nursing students' personal experiences of other cultures may impact their cultural competence (Choi and Kim 201; 292 Gallagher and Polanin, 2015, Von Ah and Cassara 2013). Providing culturally competent care can reduce malpractice claims for healthcare organisations, whilst increasing the efficiency of service and improving quality of care (Brussin, 2012; Truong et al 2014). Some students lack exposure to the art of understanding peoples’ specific principles, beliefs, and caring patterns, which in turn affects quality of care and when patient’s quality of care is in question, the nurse’s role as a caregiver is jeopardized, for one’s profession is “essential to curing and healing, for there can be no curing without caring” (Leininger, 2001, p.45) The overall aim of this project is: To explore the impact of nursing education on the Indigenous Knowledge Systems of student nurses of Southern African descent. This will be achieved through: Establishing the Indigenous Knowledge Systems of the participating students of Southern African descent. An exploration of how student nurses from Southern Africa respond to the cultural needs of patients with mental illness or learning disabilities. To incorporate cultural competency training in the nursing curriculum that acknowledges the Indigenous knowledge of foreign nurses. Murove (2018) asserts: there is a realisation among academics that knowledge production should link to the experiential world of Indigenous communities, whereby social and cultural contexts play an academically indispensable role in the formation of discourses. There is a global consciousness among academics that terms used, and examples generated with regard to particular phenomena in knowledge production, should be determined by cultural context and history, not least, Africa (Masolo 2010 pg 20). 6) Please give full details of who the participants in this project will be (i.e., what are the things which make a person eligible to take part in this project) *: Kpobi and Swartz (2018) suggest that traditional healing methods are considered central to mental health care in low-income countries because they are perceived to be more easily accessible, more affordable and generally ascribe similar causal beliefs to those of the patients. Following years of colonization which in turn led to ‘discreditation’ of certain and specific beliefs held by colonized communities in relation to illness 293 causation, treatment and healing, the discourse of indigenisation has given impetus to the intellectualisation, and promotion of the study and development of African Indigenous knowledge systems, across all the disciplines in the humanities and the natural sciences (Murove, 2018). Based on the indigenous knowledge and belief systems of the communities of contemporary Africa, south of the Sahara which includes the Zulu, Xhosa tribes of South Africa, the Ndebele, Tonga and Karanga-speaking groups of Zimbabwe, the research will seek to understand how students of sub-Saharan descent cope with their beliefs taught to them as young people and those with which they find themselves confronted in a western education and placement system in their journeys to become nurses. Kpobi and Swartz (2018) assert that Indigenous beliefs and the use of traditional methods for mental health care have been documented in several African countries. Kimwanga (2010) suggests that African Indigenous societies have, for centuries, developed their own sets of experiences and explanations relating to the environments they live in. Oliver (2013) further contends that African Traditional medical practitioners use Indigenous knowledge, theories, beliefs, practices and experiences of health and healing in the diagnosis, treatment and prevention of physical and mental illnesses. This is affirmed by Edwards (2011) who postulates that African forms of indigenous healing are informed by Indigenous knowledge systems, beliefs and practices which are both perennial and changing in relation to various factors and contexts. Students must be of Southern African origin* by birth. Those individuals who immigrated to the United Kingdom as young children/teenagers or later in life, will be considered as first-generation immigrants (Shaw 2012). First generation immigrants are a starting point because they are likely not to have fully acculturated into British culture and maintain the cultural beliefs of their country of origin (Barata et al, 2005) as their cultural background has to be taken into consideration when studying how they assimilate into the mainstream culture of the United Kingdom. Schneider (2016) contends that the term second generation, includes persons who were actually born in the country of immigration. Kraymijn and Kraykamp (2017) predicate that members of the second generation are exposed to competing pressures: they experience liberal values from their peers, the media, and the schools and workplaces they encounter, but they may also be socialised into conservative values by their parents and in their ethnic community. Additionally, whilst there are potential parental influences on children’s outcomes, whether immigrant or native, one would not expect all gaps to be eliminated but one would expect them to be reduced. Students must be of Southern African origin by birth and be studying for a pre-registration nursing degree at Teesside University’s School of Health and Life Sciences and aged 18 and above. Southern African 294 countries include South Africa, Zimbabwe, Lesotho, Angola, Swaziland, Malawi, Mozambique, Botswana, Zambia and Namibia *Please note - If you plan to recruit Teesside University staff in this project, please refer to TU's Policy, Procedures, and Guidelines for Research Ethics No Teesside University staff will be recruited for this project. 7) Please give full details of how you will recruit the participants: Please state who will identify the potential participants (i.e., the people who can take part), how they will know a person is eligible and how they will obtain the potential participants' contact details? Please ensure all processes are compliant with the General Data Protection Regulations (GDPR) and the Data Protection Act (DPA) (2018). Formal approval will be sought from the Associate Dean (Research and Innovation) in the School of Health and Life Sciences following which, the Director of Studies will contact the Head of Department of Nursing and Midwifery in the School of Health and Life Sciences via email requesting permission to contact all cohorts. (See email draft from DoS in Appendix A). The email will have links to the Participation Information Sheet (Appendix B). The Head of Department as gatekeeper, will then email all cohorts inviting the potential participants who meet the inclusion criteria above. Personal data including special category data obtained for the purposes of this research project is processed lawfully in the necessary performance of scientific or historical research or for statistical purposes carried out in the public interest. Processing of personal data including special category data is proportionate to the aims pursued, respects the essence of data protection and provides suitable and specific measures to safeguard the rights and interests of the data subject in full compliance with the General Data Protection Regulation and the Data Protection Act (2018). How and by whom will the potential participants first be contacted and find out that this project is running, that they are eligible and that they are invited to consider taking part? An email will be sent to all nursing students with clear details of the study and the eligibility criteria so participants can self-determine their eligibility. Those who self-determine as potential participants will have access to links on the email that will take them to a contact form (appendix a), the participant information sheet (appendix c) and a consent form (appendix d). If a potential participant would like to volunteer for the study, they will then be required to either phone or email the primary researcher to declare their interest in the study. After reading the PIS if 295 participants are happy to continue, they will be formally asked to participate in the study. The study will be explained to individual participants via Microsoft Teams due to government guidance on social distancing as a result of Covid19, and they will be given the opportunity to ask any questions before the interviews take place. A signed informed consent form will need to be signed by each participant before the interviews will take place. Who will potential participants be able to contact to ask any questions they may have before they decide whether or not they wish to take part? If a potential participant would like to volunteer for the study, they will then be required to either phone or email the primary researcher to declare their interest in the study. How many participants do you hope to recruit and how did you decide on that number? In the survey conducted in the phase of the research project, it was not possible to obtain the demographic information of students due to General Data Protection Regulations. Currently, there is no information available to the research team of the total number of students of Southern African origin largely due to Data Protection regulations on confidentiality. As a result, it is not known exactly how many students from Southern Africa are enrolled on the pre-registration programme, however, the survey indicated that there are at least ten. For the purpose of this study, there are approximately 550 student nurses on the undergraduate programme. Dworkin (2012) suggests that anywhere between 5 to 50 participants is adequate for a qualitative study. Most scholars argue that the concept of data saturation (the point at which the data collection process can no longer offer any new or relevant data) is the most important factor when deciding about sample sizes in qualitative research (Mason 2010). Additionally, Malterud (et al 2016) contend that sample size can be determined in relation to the ‘information power’ that a sample holds for example the aim of the study, the specificity of the characteristics of the participants in relation to the study aims will require a very small sample size. It was decided that 8 participants would provide enough data to fully explore the topic. For a study of this kind 8 participants have been shown to be an appropriate sample size to explore the topic in the appropriate level of depth. While some authors have recommended smaller sample sizes, Smith et al (2011) stated that for PhD studies where there is more time to explore data in more depth a sample size of 8 participants it advantageous. 296 How many people will you contact and invite to take part? All students on the pre-registration nursing programme will be contacted initially via email. Those who feel that they meet the criteria will then contact the researcher to express interest. Following this, they will then be invited to meet the researcher virtually while not engaging in any face-to-face meetings due to government guidance on social distancing as a result of Covid19. The university’s recommended virtual platform is Microsoft Teams which is accessible on student iPad devices issued by the university. Only those who self-determine as meeting the criteria will make up the sample for the research project. How long will the potential participants have to decide whether or not they wish to take part? As per standard university procedure, a second Reminder e mail will be sent again after two weeks to remind potential participants about taking part in the study. No further emails will be sent after this. How will a potential participant indicate that they would like to take part? Those who indicate that they would like to take part in the study will email the primary researcher to express interest. The same process will be explained in the email from the Head of Department of Nursing and Midwifery asking potential participants to contact the primary researcher via email. When and how will you obtain and document the participant's Informed Consent/Consent & Assent* to take part? Potential participants would have emailed the primary researcher expressing interest in taking part in the study. The primary researcher will meet with each potential participant virtually while not engaging in any face-to-face meetings due to government guidance on social distancing as a result of Covid19. The university’s recommended virtual platform is Microsoft Teams which is accessible on student iPad devices issued by the university. The researcher will then explain the purpose of the study during this online meeting, give them the opportunity to ask any questions and formally ask for consent. A signed informed consent form (Appendix) will 297 need to be signed by each participant before the interviews take place. This will be shared with the student by email, and they will sign and return to the researcher as soon as possible, preferably within a week. *If young person's under the age of 16 are eligible how will the Informed Consent of their parents/guardians (Informed Consent for their child to be asked if they would like to take part and to take part if they wish to) be obtained and documented? Not Applicable *How will the young person's Assent be obtained and documented after parents/guardians Informed Consent is confirmed? If the young person's Assent will not be obtained and documented, then please justify this choice. Not Applicable Will participants be given any monetary or other inducements to/rewards for taking part? NO 8) Please give full details of the methods; please detail all the procedures, activities and equipment involved in the proposed project from when Informed Consent is obtained and documented (i.e., where Section 7 stops) through to the end of the project and the destruction (or archiving) of the data collected. Please include copies of all materials or documents you will use (e.g., Invitation Letter/email, Participant Information Sheet, Consent/Assent Form, Questionnaire, Interview Schedule, Focus Group topic guide etc) as cross-referenced appendices. Potential participants will be given an Initial Contact form (Appendix b), the Participant Information Sheet (PIS) (Appendix) and a Consent Form (appendix d) all with a with a unique identifying number. If a potential participant would like to volunteer for the study, they will then be required to email the primary researcher to declare their interest in the study. After reading the PIS if participants are happy to continue, they will be asked to participate in 298 the study virtually while not engaging in any face-to-face meetings due to government guidance on social distancing as a result of Covid19. The university’s recommended virtual platform is Microsoft Teams which is accessible on student iPad devices issued by the university. The study will be explained to participants, and they will be given the opportunity to ask any questions before the interviews will take place. A signed informed consent form will need to be signed by each participant and the researcher before the interviews take place. An Interview Schedule (Appendix) will be issued to potential participants so they can familiarise themselves with the questions prior to the interview taking place. Due to the current pandemic resulting in restrictions such as travel, social contact and sharing of facilities, online platforms such as Microsoft Teams will be utilised. University employees are currently expected to work from home to stop the spread of the coronavirus outbreak, virtual interactions are taking the place of in-person research interviews. The university recognises that Microsoft Teams is the safest platform and unless the restrictions are lifted, it is likely that all of the interviews will be conducted online. Documentation will be sent out to via email and participants will also confirm their willingness to take part in the study as well as the recording of the interview. 9a) What (if any) risks do you feel there will be to anyone who decides to take part in the research as a result of their choice? As the research is exploring Indigenous belief systems, there is a likelihood the questions could evoke emotions based on nostalgic longing for previously held beliefs which may seem to have been abandoned or shelved due to being in a new country. This could be distressing for participants. If participants begin to get distressed, they may pause the interview and resume when ready. However, if they choose to not continue on that day, they will be offered an alternative time if they still want to but if they wish to withdraw completely, arrangements will be put in place for them to contact a counsellor via Student Support 9b) What (if any) risks do you feel there will be to the people who are involved in running the project and/or the University? None anticipated however, if participants are interviewed at their own home the Teesside University Lone Worker Policy (Appendix F) will be adhered to. 299 10): Will participants be allowed to withdraw their data after it has been collected? YES Why have you chosen to allow this? Participants have the right to withdraw at any point during the study; however, cannot withdraw after the data analysis process has started. This is because at that point, all data would have been anonymised and it would be difficult to identify any participant-specific data. If participants would like to withdraw their data up until the point before data analysis has commenced, then they would have to email or telephone the primary researcher. Once data analysis has commenced, they will not be allowed to withdraw their data. This will be clarified in the PIS. How will this be made possible (i.e., will the data be person identifiable or pseudonymised [link-anonymised] during the period when withdrawal of data is allowed)? From the interview stage onwards, each participant will be referred to using a pseudonym and will not be referred to using any identifiable label. However, there will be a linking document identifying each participant’s interview information before data analysis occurs, therefore anyone who wishes to withdraw their data will be easily identifiable. After this, all data becomes pseudonymised so no one can be linked to the data. What (if any) time limit will be set on the period when withdrawal of data is allowed? After the completion of data collection, participants will be given 3 days in which to withdraw their data. Schaefer and Wertheimer (2011) advise that this is an acceptable cooling off period for participants to withdraw their data. If any time limit will be set on how long people have to withdraw their data how will the data be rendered non-person identifiable after that point in time has passed? (i.e., how will the linkage of the data be broken, and the data rendered non-identifiable - or - if that will not occur will the data then be destroyed or retained, if 300 retained for how long, where and in what format will it be retained e.g., non or person identifiable, pseudonymised [link anonymised], as electronic files or hard copies etc and why) From the interview stage onwards, each participant will be referred to using a pseudonym and will not be referred to using any identifiable label. The data will be transcribed by the primary researcher and after transcribing the recordings will be destroyed. Any identifiable data will be stored either as a hard copy in a filing cabinet the primary researchers work office at Teesside University or as an electronic copy on Teesside University's password protected server. All electronic data will be stored on a Teesside University password protected server. Participant information sheets and informed consent forms will be stored in a locked filing cabinet in the primary researcher’s office at Teesside University. 11a) What steps and procedures will be taken to preserve the confidentiality and privacy of any people and/or organisations involved in, and/or data or information collected as part of this project? All identifiable information will be kept secure at all times. From the interview stage onwards, each participant will be referred to using a pseudonym and will not be referred to using any identifiable label. The data will be transcribed by the primary researcher and after transcribing the recordings will be destroyed Any identifiable data will be stored either as a hard copy in a filing cabinet the primary researchers work office at Teesside University or as an electronic copy on Teesside University's password protected server. All electronic data will be stored on a Teesside University password protected server. Participant information sheets and informed consent forms will be stored in a locked filing cabinet in the primary researcher’s office at Teesside University. 11b) Please detail what, where and in what format people's data will be stored from the point at which is collected to when it is destroyed or archived. From the interview stage onwards, each participant will be referred to using a pseudonym and will not be referred to using any identifiable label. The data will be transcribed by the primary researcher and after transcribing the recordings will be destroyed Any identifiable data will be stored either as a hard copy in a filing cabinet the primary researchers work office at Teesside University or as an electronic copy on Teesside 301 University's password protected server. The data will be retained by the researcher for five years, and then disposed of securely at the end of the five-year period. The stored data will only be accessed by the researcher’s office. 11c) Do you foresee any circumstances under which that confidentiality and privacy may need to be breached? (For example - what actions (if any) would be taken if any previously unknown factors become known during the course of the research which may require disclosure (e.g., medical or health problem(s), criminal confession or intention to commit crime, abusive or unprofessional behaviours or actions by any person etc). YES If YES, please detail and justify these circumstances and explain what will happen? In circumstances where the participants bring discussions with concerns of potential harm to individuals, others or patients in their care, information will be shared with supervisors in the first instance. If any relevant professional and safeguarding body are required, then they will be notified accordingly. This will be made explicit in the participant information sheet. If confidentiality has to be breached as a result of a disclosure this will be discussed with the participant fully beforehand. The possible participants and the researcher practise within a Professional Code of Practice, (NMC, 2018); therefore, maintaining confidentiality and anonymity will be priority. 12) Will any secondary analysis of data occur during the project (i.e., will you be using any data which was collected separately from this project)? NO (delete as appropriate) Submit a separate Release Form application that details the Secondary Analysis which will occur, - or - 302 Refer to the Release Form and give both: 1. Full details of how the use of that data complies with the requirements of the GDPR and DPA (2018) (in particular the derogations contained in Article 89 of the GDPR and Section 19 of the DPA) and any other relevant legislation, - and - 2. Include verification of the statements, required on the Release Form, here. 3. Personal data including special category data obtained for the purposes of this research project is processed lawfully in the necessary performance of scientific or historical research or for statistical purposes carried out in the public interest. Processing of personal data including special category data is proportionate to the aims pursued, respects the essence of data protection and provides suitable and specific measures to safeguard the rights and interests of the data subject in full compliance with the General Data Protection Regulation and the Data Protection Act (2018). 13) Will the research involve the use of any of the following: 13a) Human Tissue of any kind (e.g.) blood, semen, saliva, urine, bodily fluids etc? NO 13b) Radioactive materials? NO 13c) Any other potentially dangerous or hazardous materials, such as chemicals or other agents? 303 NO 14) Will the project receive financial support from outside Teesside University? YES If YES, Please detail the nature and source of the support: The research is being sponsored by Teesside University Have any restrictions/conditions been imposed upon the conduct of research? NO 15) Will any restrictions have been placed on the dissemination, or use of the results and/or findings? NO 16) Does the project require any external approvals or permissions after TU ethical clearance has been granted? NO 17) Is there anything which has not already been included on this form, or in any supporting documents that you would like SRESC members to be aware of when reviewing this application? NO 304 18) I confirm that have read the University’s ‘Policy Procedures and Guidelines for Research Ethics’ and confirm that my project will conform to the University’s six Principles for Research Ethics contained therein. I am aware of University procedures on Health & Safety. I understand that the ethical propriety of this project may be monitored by the School’s Research Ethics Sub-Committee and that my project may be audited by the University Research Ethics and Integrity Committee at any time during the course of the project or after it is completed. (Please complete the following as appropriate by putting your initials or explanatory text in the boxes) ▪ I have appropriate experience of the research area of the project ▪ I have undertaken any research ethics training required by my School. Note: having undertaken training is not a condition of application for ethical Approval unless a School requires that training be completed. √ ▪ I confirm that as Supervisor I will monitor progress of the project. • I confirm that the project complies with the Code of Practice of the following Professional Body (state N/A, if this is not applicable): The possible participants and the researcher practise within a Professional Code of Practice, (NMC, 2018); 19: Signature of Staff Researcher: ___ ____________________________ Date: _10/07/2020________ OR: For any student projects Signature of Academic Supervisor or Director of Studies _________________________ Date: _________ 305 7.2 Appendix B: Participant information sheet PhD research title: Indigenous Knowledge Systems about Intellectual Disability and Mental Health: A Phenomenological study of the experiences of Southern African students studying nursing in the UK. Primary researcher: Dr Dorothy Hannis, Teesside University, School of Health and Life Sciences, Centuria Building, Middlesbrough. TS13BA Research team: Dr Alan E. Armstrong, Teesside University, School of Health and Life Sciences, Centuria Building, Middlesbrough. TS13BA Chris Dlamini, Teesside University, School of Health and Life Sciences, Centuria Building, Middlesbrough. TS13BA We would like to invite you to take part in this research study however before you decide please read the following information. Please discuss any aspects of this study with anyone that you wish and please contact the research team and ask any questions that you may have. Why am I being invited to take part? As a pre-registration nursing student, you have been asked to participate as you are among the student population group whose experiences we would like to explore. The inclusion criteria for this study are that participants must be of Southern African origin either by birth or have a parent or both who originate from there, live in England and be aged over 18. These countries are South Africa, Zimbabwe, Lesotho, Angola, Swaziland, Malawi, Mozambique, Botswana, Zambia and Namibia What is the purpose of the study? The aim of this study is to explore the impact of professional nursing education on the Indigenous knowledge systems (IKS) of student nurses of Southern African descent working with patients with mental illness or learning disabilities in order to understand how they respond to the cultural 306 needs of those patients. (IKS refers to knowledge systems embedded in the cultural traditions of regional, Indigenous, or local communities). Ouwor (2007) postulates that Indigenous knowledge systems represent a multifaceted body of knowledge, practices, and representations that are maintained and developed by peoples with long histories of close interaction with the local natural environment. Additionally, Mapara, (2009) further asserts that it is a body of knowledge of the Indigenous people of particular geographical areas that has survived for a very long time. In summary, therefore, Indigenous knowledge systems are a process of learning and sharing social life, histories, and identities, unique to each cultural group and framed as the complex set of activities, values, beliefs and practices that have evolved cumulatively over time and is active among communities and groups who are its practitioners. Giger et al (2007) postulate that culturally competent care is sensitive to issues related to diversity, marginalization, and vulnerability due to ethnicity, gender, and sexual orientation. If student nurses are to provide care that meets the needs of people from many cultures and if providing this type of care is to be a reality then education and training programmes will need to provide a learning environment where existing beliefs about age, ethnicity, culture, disability, gender, spirituality and sexuality can be examined and challenged. Currently, evidence does not yet exist regarding the best way to educate culturally competent nurses (Campinha-Bacote, 2006; Grant and Letzring, 2003). Smith (2017) asserts that although nursing students and nursing graduate diversity has improved, cultural competence is still a long way off from being achieved. However, little is known about how migrant nursing students' personal experiences of other cultures may impact their cultural competence (Safipur et al 2017). This study will explore how your Indigenous knowledge systems and nurse education interact during your time at university. What is involved in this study? This study will involve one to one interview lasting between 45minutes and 60 minutes either at your own home or at Teesside University. In this interview you will be asked to discuss your understanding and beliefs about mental illness and learning disability from your home country and whether or not those have altered following education and training at university in England. 307 This is not a test and there are no right or wrong answers, the study is designed to try and establish your understanding. Do I have to take part? No. You do not need to take part. Participation in this study is completely voluntary and you should only participate if you feel happy with what is involved with the research and that you are happy for information about your understanding of mental health and learning disability to be used for this study. Any information that is collected will be completely anonymised and any identifiable data will be kept by the researcher only. What will happen if I do take part? If you are happy to participate in the study, you will be asked to provide written consent. Following this the interview will take place. either at Teesside University or your own home. Before the interview begins the study will be explained to you and you will be offered the opportunity to ask any questions. If the interview is conducted at ……. then this will be in a private room. The interviews will be conducted by Chris Dlamini. This will involve the researcher asking questions to try and guide the interview on the topic of your understanding of mental illness and learning disabilities. You can terminate the interview at any point. You have the right to withdraw from the study, however, after the data has been anonymised or written up, you can no longer withdraw your data. Once the data from all the interviews has been analysed the study will be written up. In the event that you share something during the interview to suggest that a vulnerable person in your care such as a patient with a mental illness or learning disability has been treated differently because of their illness, then confidentiality may need to be breached. This will be fully discussed with the research team first before being shared with the relevant persons responsible for safeguarding. This will be discussed with you fully beforehand. What are the possible advantages and disadvantages and benefits of taking part? There are no direct benefits for you as an individual for taking part in this study however we will use your data to try and provide a better understanding of your own beliefs and understanding 308 of mental illness and learning disability from your point of view. The very nature of this study is about listening to your voice. Your thoughts, whatever they are, are what we would like to hear. Additionally, this study will ensure that culturally competent care is included in the nursing curriculum including acknowledgement of your traditional beliefs and behaviours as well as those among the communities you will serve as a nurse. There are no disadvantages of taking part in this study. If there are any questions that are raised which you do not want to discuss, then you do not have to. If any topics/ questions are upsetting, the interview can be paused or terminated and if you decide that after the interview you do not want your data to be analysed you can withdraw. There is a university counsellor on hand if one is needed therefore, you will be provided with contact details if you would like to speak to one. Expenses and payments? There are no payments or expenses paid out for taking part in this study. What will happen to the information that is collected about me? Your interview will be audiotaped and then transcribed. Once your interview has been transcribed, for the purpose of analysis and the write up of the study you will be referred to using a pseudonym such as participant 1, 2. The research team will look for repeated themes across the interviews. As part of this process the three other academics named at the start of this document will assist in the analysis. This is to maintain the objectivity during the analysis of the data. Any identifiable data that will be collected as part of this study will be kept in a locked filing cabinet or on a password protected university server then, all identifiable data will be destroyed. No identifiable data will be shared with anybody, and only non-identifiable data will be used in the data analysis and write up of this study. Who has approved the study? This research study has been approved by Teesside University School of Health and Life Sciences Ethics board. 309 What if I am not happy about something? If anything goes wrong, firstly please do accept my apologies for this, and if you want to complain then please contact an independent member, who knows about, but is not involved with this project: Dr Alasdair MacSween the Chair of Teesside University School of Health and Life Sciences Research Ethics Committee and Principal Lecturer in Research Governance; email: a.macsween@tees.ac.uk tel: 01642 34 2965. Who can I contact for more information/ who do I contact if I want to take part? If you would like more information or you would like to participate in this study, please contact. Chris Dlamini Senior Lecturer in Learning Disabilities Nursing School of Health and Life Sciences Care Teesside University Email: c.dlamini@tees.ac.uk Tel: 01642 (38) 4948 Director of Studies Dr Dorothy Hannis School of Health and Life Sciences Teesside University Email: d.hannis@tees.ac.uk Tel: 01642 (384526) Dr Alan E. Armstrong 310 Teesside University, School of Health and Life Sciences Centuria Building, Middlesbrough. TS13BA Email: a.e.armstrong@tees.ac.uk For independent advice about this study or if you have any concerns about this study please contact: Dr Alasdair MacSween, Principal Lecturer in Research Governance; email: a.macsween@tees.ac.uk; tel: 01642 34 2965. 311 7.3 Appendix C: Participant Invite Participant Invitation E-Mail You are being invited to participate in a research study. Before you agree it is important that you understand what your participation would involve. Please take time to read the following information carefully. My name is Chris Dlamini, I am a PhD student in the School of Health and Life Sciences Teesside University. As part of my studies, I am conducting the research you are being invited to participate in. The research title is: Indigenous Knowledge Systems about Intellectual Disability and Mental Health: A Phenomenological study of the experiences of Southern African students studying nursing in the UK. My research has been approved by the School of Health and Life Sciences Research Ethics Committee. This means that my research follows the standard of research ethics set by Teesside University. Why have you been asked to participate? I am contacting you because you meet the criteria for this research You have told me that you are of Southern African origin by birth or descent, aged at least eighteen and studying for a pre-registration nursing degree at………. Southern African countries include South Africa, Zimbabwe, Lesotho, Angola, Swaziland, Malawi, Mozambique, Botswana, Zambia and Namibia. Thank you for agreeing to take part. I emphasise that I am not looking for ‘experts’ on the topic I am studying. You will not be judged or personally analysed in any way, and you will be treated with respect. You are quite free to decide whether or not to participate and should not feel coerced. What will your participation involve? If you agree to participate you will be asked to • engage for 45-90 minutes in a one-to-one interview on the topic on your beliefs about learning disability and mental health and what it means to you as a student from Southern Africa 312 • agree to the interview being recorded on a dictaphone • agree on a mutually agreeable location to meet I will not be able to pay you for participating in my research, but your participation would be very valuable in helping to develop knowledge and understanding of my research topic and will be of benefit for the future of nurse training. Your taking part will be safe and confidential. Your privacy and safety will be respected at all times. The link below will direct you to the Participant Information Sheet 2020.doc Thank you. 313 7.4 Appendix D: Informed Consent Informed Consent Form Indigenous Knowledge Systems about Intellectual Disability and Mental Health: A Phenomenological study of the experiences of Southern African students studying nursing in the UK. Primary researcher: Chris Dlamini Please put your initials in the boxes to indicate your agreement with the corresponding statements. • I have read and understood the Participant Information Sheet for the above study and have had the opportunity to ask questions. • I meet the inclusion criteria for participation in the study. • I know that I have the right to withdraw at any time without giving reasons, or without any of my rights being affected • I understand and agree that the interview will be audio recorded. • I understand that anonymised quotes will be used from the audio. recording and that my data will be kept confidential and stored for up to 5 years after which it will be confidentially destroyed. 6 I understand that my data will not have my name or anything identifiable. 314 in it but will be linked to me by a participant number which will be stored separately from the data. After that, all identifiable data will be destroyed. 7 I agree to take part in this study. ---------------------------- -------------------- -------------------- Name of Participant Date Signature ---------------------------- ------------------- -------------------- Name of Researcher Date Signature 315 7.5 Appendix E: Survey Questionnaire Survey Questionnaire 14. Are you. Male Female 15. Please state your age 16. Which nursing field are you studying in? Learning Disabilities Mental Health Adult Child Midwifery 17. What is your country of birth? 18. Where was your father born? 19. Where was your mother born? 20. Please state your ethnicity (see below) Black / African/ Black British/Caribbean Mixed / Multiple ethnic groups African White and Black African/ Caribbean Any other Black/African/Caribbean/White background (please state) 21. Did you go to school in your country of birth? Y/N 22. How long did you remain in school/education in your country of birth? 316 23. If you did not attend school in your country of birth, please state where you did? 24. Were you taught in English? Y/N 25. Did you attend school in the UK? 26. How long did you attend school in the UK? 27. Was this Primary or Secondary School? Please state. 28. How long did you live with your parents? 29. Who else engaged in your life when you were growing up? Both parents Mother Father Siblings Grandmother Stepmother Stepfather Step siblings Grandfather Both Grandparents Aunt Uncle Cousins Friends 30. At what age did you come to the UK? Please place a tick in the relevant box. 0-10 11-19 20-29 30-39 40plus 31. How long have you lived in the UK? 32. Who taught/told you about mental illness/learning disabilities when you were growing up? 317 Parents Grandparents Teachers Church Other (please state) 33. Before you started your nurse training, what did you believe was the cause of mental illness/learning disability? Please briefly state your response 34. What are your culture’s beliefs with regards to mental illness/learning disability? Please state your response 35. During nurse training have you ever come across/cared for a patient with mental illness/learning disability? Y/N 36. Please write down your initial thoughts and feelings when you first cared for a patient with mental illness/learning disability. 37. What services were you aware of for people with mental illness and learning disabilities in your country of birth? Please write them down. 38. Since starting your nurse training, do you think your views about mental illness/learning disabilities have changed? If YES, in what way? If NOT, in what way? 39. What are the attitudes towards people with mental illness/learning disabilities in England compared to your country or parents’ country of origin? 40. Do you feel you have been trained efficiently to work with people with mental illness/learning disabilities? Please explain your answer 318 41. What else would help make you work competently with people who have mental illness/learning disabilities? 42. What factors would you say helped shape or form your attitudes and beliefs about mental illness and or learning disabilities? (Please use free text here) 43. Who helped you with the above? (Please write free text here) 44. How do people from your country or your parents’ country feel about you training as a nurse for or working with people who have mental illness/learning disabilities? 45. Any other comments? Please write them here Thank you for completing this questionnaire. 319 7.6 Appendix F: Interview Schedule Interview Schedule PARTICIPANT NAME............................................................................ QUESTIONNAIRE NUMBER...................................................... DATE OF INTERVIEW................................................................ The Knowledge and Attitudes Towards Depression (KATD) Questionnaire (Almanz et al. 2014) was used to develop the interview questions for this study. The questionnaire consists of demographic questions and closed-ended statements, to which respondents can indicate their level of agreement with a 5-point Likert scale, however, for the purpose of the Interview Schedule, these were further expanded into open ended questions. This study sought to explore the knowledge and belief systems about intellectual disability and mental illness from the perspective of student nurses of Sub-Saharan African origin studying nurses in England the questions were felt to be appropriate for the current study. In addition, some of the questions have been developed in line with The Ten Essential Shared Capabilities (Department of Health 2004). QUESTIONS ABOUT INDIGENOUS BELIEF SYSTEMS 1. Based on your traditional beliefs as a (country participant identifies with), what do you believe to be the cause of mental illness? 2. In a similar way, based on your traditional beliefs, please tell me what you believe to be the cause of learning disability? 3. What was your first experience of meeting a person with a learning disability/mental illness like? 4. What factors would you say have helped shape your attitudes and beliefs about mental illness and 5. What factors would you say have helped shape your attitudes and beliefs about learning disabilities? 6. How do people in your country support someone who is mentally ill? 7. How do people in your country support someone who has a learning disability The following probes will be used to guide the participants. 1. Who taught you about mental health/learning disabilities? 2. Who did you consult when the somebody got mentally ill? 3. Who did you consult when a child was born with a learning disability? 4. How was mental illness/ a learning disability viewed by traditional healers or religious leaders? 320 QUESTIONS ABOUT EXPERIENCES IN COUNTRY OF ORIGIN 1 What treatment was given to a person with a mental illness? 2. When it was suspected that a person had a mental illness, what was the help seeking behaviour of the person and their family? 3. When it was believed that a person had a learning disability, how did the community explain this? 4. When it was believed that a person had a mental illness, how did the community explain this? 5. Was there any treatment for mental illness? 6. Was a learning disability viewed as an illness? If so, was there any treatment followed? 4. Was taking the patient to hospital an option? If it was, what was the name of the illness given by the nurses and doctors? QUESTIONS ABOUT STUDENT PLACEMENTS 1. What was it like for you when you met a person with a mental illness or learning disability in England? 2. What do you think are the causes of mental illness or learning disability and communication difficulties? 3. 1: Have you had an encounter with a person with a mental illness or learning disability? What kind of a person was s/he? What were the difficulties? What could s/he do? 4. Have you had communication problems with a person who has a mental illness or a learning disability? What were their difficulties? What could s/he do? 5. What do you think are the causes of mental illness or learning disability and communication difficulties? 6. What can the community do about mental illness or learning disabilities and difficulties experienced by such individuals? 7. Have you ever associated with patients from a different cultural region? 8. Do you have any relatives living in a foreign country? 9. Do you have friends or neighbours from another culture? 10. Have you received cultural education? 11. What do you think about indigenous healing in general? 12. Have you ever had any experience, personally or professionally, with Indigenous healers? • If yes, how did you find the experience? Is there a role for Indigenous healers in the mental health care system? 321 • If no, why? • If yes, what do you think is that role? • Are there any cases where you think an acknowledgement of Indigenous beliefs will be helpful during your studies? If yes, what skills or knowledge do you think you or others need to obtain to enable you to work as a culturally competent practitioner? 322 7.7 Appendix G: Arksey and O'Malley methodological framework Arksey and O'Malley Framework (2005) Overview of the Arksey and O'Malley methodological framework for conducting a scoping study. Stage Description 1: Identifying the research question Identifying the research question provides the roadmap for subsequent stages. Relevant aspects of the question must be clearly defined as they have ramifications for search strategies. Research questions are broad in nature as they seek to provide breadth of coverage. 2: Identifying relevant studies This stage involves identifying the relevant studies and developing a decision plan for where to search, which terms to use, which sources are to be searched, time span, and language. Comprehensiveness and breadth is important in the search. Sources include electronic databases, reference lists, hand searching of key journals, and organizations and conferences. Breadth is important; however, practicalities of the search are as well. Time, budget, and personnel resources are potential limiting factors and decisions need to be made upfront about how these will impact the search. 3: Study selection Study selection involves post hoc inclusion and exclusion criteria. These criteria are based on the specifics of the research question and on new familiarity with the subject matter through reading the studies. 4: Charting the data A data-charting form is developed and used to extract data from each study. A 'narrative review' or 'descriptive analytical' method is used to extract contextual or process-oriented information from each study. 323 5: Collating, summarizing, and reporting results An analytic framework or thematic construction is used to provide an overview of the breadth of the literature but not a synthesis. A numerical analysis of the extent and nature of studies using tables and charts is presented. A thematic analysis is then presented. Clarity and consistency are required when reporting results. 6: Consultation (optional) Provides opportunities for consumer and stakeholder involvement to suggest additional references and provide insights beyond those in the literature. 324 7.8 Appendix H: Spider Diagram Spider Diagram Element Definition Example Sample Who is the group of people being studied? Sub-Saharan student nurses Phenomenon of Interest What are the reasons for behavior and decisions? University education Design How has the research been collected (e.g., interview, survey)? interviews Evaluation What is the outcome being impacted? Indigenous belief systems about intellectual disability and mental illness Research type What type of research (qualitative or mixed methods)? Qualitative studies 325 7.9 Appendix I: Southern African Student Acculturation Assessment Scale Southern African Student Acculturation Assessment Scale. ❖ Anticipatory observation In the anticipation dimension scenario, the participant discusses their desire to adapt their traditional beliefs about mental illness and intellectual disability to be more like the local beliefs, stating that they do everything possible to match the cultural behaviours used or held by British people. This is the stage when the participants decide to enrol on a nursing programme and is aware they will be working with people with mental illness and learning disabilities. ❖ Assertive interaction In the interaction dimension, the participant regards their cultural beliefs as essential grounding which defines their identity and now that they live, work and study in a country with more than just one homogenous community, they begin adjusting their cultural, psychological, and behavioural traits. They strive to maintain their cultural, psychological, and behavioural heritage by being non-judgmental and practicing diversely but also participate in and embrace English cultural beliefs about mental illness and learning disability. ❖ Bold Resolution In the resolution dimension, the participant refuses to change their beliefs, neither attempting nor desiring to match the cultural beliefs and behaviours used by the English. They are reluctant to relinquish their cultural, psychological, and behavioural heritage, stating that they feel more connected to her heritage culture. They claim that their values will be difficult to shift, however, they accept that they adopt a professional code and respect the position that they have chosen. ❖ Transformation In the transformation dimension, the participant acknowledges that they are now part of a system. They realise that fighting this system will impact their ability to function as a culturally competent professional. Eventually, they agree to be flexible with their beliefs but acknowledge that in the new cultural space these may no longer be required. 326 This model of acculturation identifies important, yet previously unexplored aspects of acculturation experienced by immigrant student nurses from Sub Saharan Africa. These include acknowledgement of their beliefs and their attitude toward these beliefs; discussion of the degree to which they wanted to maintain their cultural beliefs about intellectual disabilities and mental health, to what extent their beliefs had shifted and develop connections with fellow native students. Furthermore, the multidimensional aspect offers the added advantage of an inclusive scale incorporating the multi-cultural realities inherent in African traditional and religious worldviews relevant to the research population. |
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