SUBSTANCE ABUSE PREVENTION PROGRAMMES AND THE ROLE OF AUDIOVISUAL MEDIA

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CHAPTER 3 ADOLESCENCE SUBSTANCE ABUSE

INTRODUCTION

In the previous chapter a literature review on the conceptual framework of the study was presented. It was indicated that consideration of SCT/SET in programmes to prevent or address adolescent substance abuse may be useful in cases where adolescents do not need professional treatment.
It is important that teachers be well-informed about drugs and drug abuse, and the reasons why adolescents turn to drugs in order to select prevention resources that can address the mild use of drugs. Thus, this chapter highlights these issues. Adolescent substance abuse epidemiology is discussed with a focus on alcohol, cannabis, and study drugs in particular, considering the aims of this study. Various theories and models of substance use and abuse are explained as well as risk and protective factors. Next, the types and effects of adolescents’ substance abuse development are described. Finally, the role of the teacher in supporting adolescents is elucidated.

EPIDEMIOLOGY OF SUBSTANCE USE AND ABUSE

In chapter one, section 1.1, adolescent substance abuse epidemiology was introduced in general. From a review of the literature it would appear that the most commonly abused substances by adolescents are alcohol, nicotine, marijuana (dagga), ‘study drugs’ including Ritalin, depressants, inhalants and hallucinogens. In this study, the focus is not on addressing substance abuse for which professional health care is needed. Thus, the focus is on alcohol, nicotine, marijuana and study drugs.
In sections 3.2.1 to 3.2.3, the epidemiology of adolescent substance use and abuse is presented in greater detail with particular reference to findings from the USA (as influential country in the Western world) and South Africa.

Alcohol

The USA’s National Survey on Drug Use and Health (NSDUH) report (2007) indicates that alcohol use has been linked to delinquent behaviours such as stealing, illicit drug use, and problems in school. Early drinkers are more likely than non-drinkers to engage in delinquent behaviours (Isralowitz & Reznik, 2006:845-849; Lambie & Sias, 2005:266). According to Wisdom (2008) in 2006, 28.3 percent (10.8 million) 12- to 20-year-olds in the USA reported drinking alcohol in the previous month. Heavy drinking (five or more drinks on the same occasion on five or more days in the previous month), including binge drinking (five or more drinks within a couple of hours), are significant concerns because of associated health problems. About 18.8 percent (7.2 million) of 12- to 20-year-olds reported binge drinking and 6 percent (2.3 million) were heavy drinkers.
Drinking and driving is a chief cause of serious and fatal road accidents and is the greatest danger associated with the use of alcohol. In research by Facy and Rabaud (2006:139-149) the mortality rates of young French adults due to alcohol abuse is reported. The risk of accidents was higher for alcohol users, on road accidents in particular. Society and the media encourage the perception that alcohol is used by everyone and that alcohol is an essential for pleasant social interactions. Consequently, it is not surprising that adolescents widely use alcohol.
Burger et al. (2000:173) state that alcohol is usually the first drug adolescents try, sometimes before they reach high school. The use of alcohol is so embedded in everyday life that many people do not think of alcohol as a drug. According to Pretorius (in Burger et al., 2000:174) alcohol abuse starts between the ages of 14 and 15. Alcohol and drug abuse has reached crisis proportions in the Cape metropole, with devastating effects on the lives of thousands (City of Cape Town, 2010). The City of Cape Town (2010) reports that the Western Cape has the highest proportion of binge drinkers in high school: 34 percent versus 23 percent for the national average. A third of adolescents aged 11 to 17 from nine districts in Cape Town report having been drunk at least once in their lifetime.

Cannabis

Wicks-Nelson and Israel (2003:201) state that cannabis, including hashish and marijuana, is the most frequently used psycho-active substance by adolescents in the USA other than alcohol. In 2007, the Monitoring the Future survey (Wisdom, 2008) found that 14 percent of 8th graders, 31 percent of 10th graders and 42 percent of high school seniors in the USA reported lifetime use. Cannabis use was then twice that of the early 1990s. The reported use of marijuana by 12 to 17 year-olds declined significantly from 8.2 percent in 2002 to 6.7 percent in 2006. The majority of marijuana possession arrests were composed of young people, with half of arrestees under age 21. It has been estimated that more than one million teenagers in the USA sell marijuana.
In South Africa, according to SACENDU (2011b), marijuana is the most often used illegal drug in this country, and the most primary substance of abuse in adolescents younger than 20 years of age. Cannabis was also the most common primary substance of abuse among patients seen at specialist treatment centres in the Northern Region, accounting for 37 percent of all patients. It was the second most primary substance of abuse in Gauteng (27 percent) and KZN (32 percent).

Ritalin and ‘study drugs’

According to Schetchikova (in Miller, Pentz, Spruijt-Metz & Sussman, 2007:136), from 1990 to 2000, use of Ritalin (methylphenidate) increased five-fold in the USA, which consumes approximately 90 percent of all Ritalin. As many as four million Americans take these medications, primarily prescribed by a physician for attention deficit disorders. Johnston, Bachman, O’Malley and Schulenberg (in Miller et al., 2007:136) state that the annual prevalence of use of Ritalin among 8th, 10th and 12th graders has averaged about 2.7 percent, 4.3 percent, and 4.5 percent, respectively, over the period from 2001 to 2004. Amphetamines, which may also be used as study drugs, showed a National annual prevalence of 4.9 percent, 8.5 percent, and 10.0 percent among 8th, 10th and 12th graders, respectively in 2004 (Johnston et al., in Miller et al., 2007:136).
According to Truter (2009:413-417), epidemiological data on the prescribing of methylphenidate (Ritalin) in the private health sector in South Africa is scarce. However, there are numerous claims being made of Ritalin overuse and even abuse in South African adolescents of school-going age. Nevertheless, in this investigation overuse could not be established among adolescents aged 18 years and younger in the private health care sector in South Africa.

THEORIES AND MODELS OF FACTORS RELATED TO ADOLESCENT SUBSTANCE USE AND ABUSE

A number of research projects have led to theories on factors that are related to adolescent substance use and abuse (Antidrugs Civil Union, 2010; Bethea, 2008; Borsos, 2008; Cavaiola, 2008a; Cavaiola, 2008b; Cook, 2006:145; NIDA, 2010a; Oetting & Beauvais, in Schuld 2006:54; Thombs, 2006:6-8; Wicks-Nelson & Israel, 2003:203).

Gateway theory

The gateway theory suggests that adolescents start using cigarettes and alcohol and then move on to illegal or harder substances. The hypothesis of the gateway drug theory is that the use of less deleterious drugs may lead to a future risk of using more dangerous hard drugs and/or crime. However, according to Wicks-Nelson and Israel (2003:204), as well as Wisdom (2008), drug use in adolescence is not necessarily highly predictive of drug use in adulthood. The view of adult and adolescent drug disorders as fundamentally the same disorder has been questioned as most drug use peaks in late adolescence. There is also controversy regarding whether tobacco and alcohol may be ‘gateway’ drugs that lead to the useof marijuana and other illicit drugs.
In a study identifying Russian and Finnish adolescents’ problem behaviours, the authors (Jokela, Kemppainen, Pantelejev, Puska, Tossavainen, Uhanov & Vartiainen, 2007:81-98) show that a syndrome of problem behaviours, including early substance abuse, school and family problems and sexual promiscuity impairs normal development in adolescents. The findings were that unhealthy dietary habits, use of illegal drugs, psychosomatic disorders and problems with parents were common among early experimenters. According to Jokela et al. (2007:82), the earlier adolescents experiment with alcohol or tobacco, the more likely they are to be involved in risky behaviours. This is in accordance with the gateway theory, as indicated in section 3.3.1 above.

The disease model of addiction

The Antidrugs Civil Union (2010) states that for most of the 20th century addiction as a disease was a favoured viewpoint. It is still in favour and has been adopted by 12-step groups like Alcoholics Anonymous (AA) and Narcotics Anonymous. Addiction is viewed as an illness and the addict is considered as the victim of this disease. The person can have a lifelong remission if they take certain steps, but can never be cured (Borsos, 2008; Thombs 2006:6-8).

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The genetic model of addiction

The Antidrugs Civil Union (2010) emphasises that according to this viewpoint, addiction itself is not something that is inherited but the genetic predisposition for developing the problem is. A genetic component of addiction is evidence-supported to some extent in that addiction seems to run in families and this may be due to nurture as well as nature (Borsos, 2008).

The moral model of addiction

The Antidrugs Civil Union (2010) views addiction as a choice arising because the addict is morally weak. The medical and scientific community largely do not support this viewpoint although many individuals and groups do (Borsos, 2008; Thombs, 2008). Authors such as Cook (2006:1-221), however, demonstrate that Christian ethics can make a significant contribution to the moral debate. Cook (2006:ix) states that a proper sense of humility can help us to see that some experience of addiction, whether it involves shopping, food, alcohol, sex or drugs is an everyday reality in which each of us experiences a divided self. In addition, he argues that the need for grace is an essential component in any adequate response to addictive disorders, whether it is the explicit Christian concept of God’s grace or the notion of the need for the ‘Higher Power’ of AA. In his commentary on Paul’s theology of sin, Cook (2006:145) explains that the subjective experience of the divided self described in Romans 7:14-25, would together appear to describe subjective phenomena very similar to those experienced as part of the alcohol dependence syndrome.

The opponent-process model

With this model of addiction NIDA (2010a) explains that every psychological event A, will be followed by its opposite psychological event B. For example, the pleasure one experiences from a hard drug is followed by an opponent process of withdrawal. In the nervous system there are many examples of opponent processes including hearing, vision, taste, touch and motor movement. Addiction follows from our wanting to avoid withdrawal symptoms (Antidrugs Civil Union, 2010).

Psychological theory

With emotional distress theory and psychological theory, substances are regarded as a means of coping with depression and anxiety. According to authors such as Borsos (2008) and Cavaiola (2008a), psychological theories tend to focus on compulsive, continual use, whereby substance use is related to personality traits such as low self-esteem.
Pipher (in Zervogiannis, 2003:113) indicates that drug use may sometimes be symptomatic of other problems such as social anxiety, despair, problems with family or friends, a lack of support or guidance, pressure to achieve, a low self-image, negative sexual experiences or difficulty in finding a positive identity (see 3.3.13). Krenek and Maisto (2009:51), Stockwell (2005:20-21) and Wisdom (2008) emphasise the bi-directional causal impact of drug use and co-occurring psychiatric disorders. Adolescents with particular temperamental traits, such as being shy, aggressive, or highly novelty-seeking, may have fewer childhood experiences of success or mastery. Adolescents with these childhood experiences who also have poor social skills, family problems or self-regulation difficulties, may associate with a peer group that is supportive of drug use (found by Wicks-Nelson & Israel, 2003:203). For example, according to Wicks-Nelson and Israel (2003:203) as well as Wisdom (2008), many adolescents experience dysfunctions in the maintenance of a safe environment, which may include poor family communication, poor adult supervision, a deviant peer group, poor academic performance, and overt conflict or violence. Drug use then contributes to further marginalization of adolescents from potentially positive school or family associations and increased involvement with deviant peers (see 3.3.11).

The cultural model of addiction

In a discussion on this theory, Cavaiola (2008b) states that addiction is seen as arising from the environment in which an individual grows up. For example, alcoholism is rare among Saudi Arabians, where obtaining alcohol is difficult and using alcohol is prohibited (Antidrugs Civil Union, 2010).

Social theory

Social theories are theoretical frameworks which are used to study and interpret social phenomena within a particular school of thought. Substance abuse would be explained in terms of a symptom of underlying social problems (Keel, 2010). Various types of social theories are differentiated, including normative, definitional, structural and process theories.
The social control theory
According to Keel (2010), this theory proposes that exploiting the process of socialisation and social learning builds self-control and reduces the inclination to indulge in behaviour recognised as anti-social. The long-term impact of basic parental values or parental drug use may open up the potential for adolescent substance abuse.
The influence of peers and peer drug use is also a very important factor in social control theory. Adolescents usually associate with each other based on similarities of life styles and are also most likely to share drug using patterns and type of drug use. Thus, peer cluster theory emphasises the role of the peers in convincing adolescents to use substances. According to Oetting and Beauvais (in Schuld, 2006:54) the peer cluster initiates the adolescent into the use of drugs, helps to provide drugs and models drug behaviour. This helps to shape the adolescents’ attitude about drugs and drug using behaviour.

Social cognitive learning theory

This theory of addiction emphasises that adolescents may model the behaviour of significant others. Attitudes in the initiation and development of substance abuse are emphasised. Chassin et al. (in Wicks-Nelson & Israel, 2003:203) state that since older siblings and parents are potential models for such behaviour, the child of a parent who is a substance abuser or alcoholic may be at particular risk. When older siblings or parents use alcohol, tobacco or marijuana, adolescents are more likely to initiate use of these substances. The parents’ attitude displayed can also affect the young person’s behaviour. Adolescents are more likely to use alcohol or other substances when they perceive parental approval for use. According to Lubbers (2005) the cognitive mediators of refusal self-efficacy and outcome expectancies are important determinants of adolescent alcohol use and the more distal influence of anti-social behaviour. Increased refusal self-efficacy beliefs and positive peer group social behaviour were found to be related to decreased drinking.

Psycho-social theory

In his discussion of personality development, Corey (2001:73-81) describes how personal characteristics and social environments may play a role in psycho-social theory. In terms of Erik Erikson’s stages of psycho-social development, eight stages are identified through which a healthy human should pass from infancy to late adulthood. In each stage the person confronts, and needs to master, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.
Botvin, Diaz, Griffin and Ifill-Williams (2001a:1-13; 2001b:360-365) found that when adolescents have poor social skills this led to increased alcohol use. However, with increased social competency, adolescents are less likely to be pressured into using substances. Causal factors in the psycho-social sphere include peers, family, school, neighbourhood and community influences (Wicks-Nelson & Israel, 2003:203).

The bio-psychosocial model

According to Bethea (2008) the bio-psychosocial model, unlike traditional models of addiction, is a-theoretical in that it does not attempt to explain the causality of addiction. However, this model presents a holistic, systems approach and identifies the influence as well as interaction of various dimensions of the biological, social, psychological, spiritual, and cultural environment on the adolescent. The different causes and stages of drug development are also most significant as these are indicative of the various ages to start with a prevention programme, whom to target, as well as where the focus of the programme should be.

General factors

In addition to the factors related to adolescent drug use (as explained above), McKeown (in Zervogiannis, 2003:112) found that young people may be influenced to use drugs as a result of complex and interrelated factors. These may include advertising, boredom, the need to experiment, and the excitement of risk taking (Wicks-Nelson & Israel, 2003:203).

RISK AND PROTECTIVE FACTORS OF ADOLESCENT SUBSTANCE ABUSE

The inter-relationship of factors

According to David et al. (2003:6) and Stockwell (2005:21) many factors have been identified that help differentiate those more likely to abuse drugs from those less vulnerable to drug abuse. These are termed ‘risk’ and ‘protective’ factors. David et al. (2003:10) as well as Cavell, Ennet and Meehan (in Wicks-Nelson & Israel, 2003:203) suggest that ‘risk’ factors are associated with a greater potential for drug abuse whereas ‘protective’ factors are those associated with reduced potential for abuse. Risk factors can affect students in a developmental risk trajectory (David et al., 2003:6). This path captures how risks become evident at different stages of a child’s life. Risk and protective factors are characterised in five domains, or settings as shown in Table 3.1 (David et al., 2003:6) below.
As shown in Table 3.1 above the domains can serve as a focus for prevention. Some risk and protective factors are mutually exclusive, where the presence of one means the absence of the other, as the first two examples suggest. For example, in the Individual domain, early aggressive behaviour, a risk factor, indicates the absence of impulse control, a key protective factor. Helping students to control impulsive behaviour is a focus of some prevention programmes.
David et al. (2003:7) explain that other risk and protective factors are independent of each other and not mutually exclusive as in the peer, school, and community domains. For example, in the school domain, drugs may be available, even though the school has anti-drug policies. Hawke and Kaminer (2009:354-355) as well as Sambrano, Szapocznik and Tolan (2007:242) indicate that an intervention might strengthen enforcement so that school policies create the intended school environment. An adolescent’s social, emotional, and academic development can be challenged by these risk factors for drug abuse. Depending on the adolescent’s attributes, personality traits, phase of development, and environment these risk factors can produce different effects (Hawke & Kaminer, 2009:354-355; Sambrano et al., 2007:242). For instance, poor academic achievement and early aggressive behaviour may indicate that a student is headed toward problem behaviour. Early intervention and treatment, however, can help reverse or reduce these risks and change that student’s developmental path (also see sections 3.3.10 and 3.3.12).
According to David et al. (2003:7), the more risks a student is exposed to, the more likely the child will abuse drugs. Some risk factors are particularly potent, yet may not influence drug abuse unless certain conditions prevail. Having a family history of substance abuse, for example, puts a student at risk for drug abuse (also see section 3.3.10). In an environment with no drug-abusing peers and strong antidrug norms, that student is less likely to become a drug abuser (also see sections 3.3.7 and 3.3.9). According to this understanding, protective factors can lessen the impact of a few risk factors (David et al., 2003:7; Wicks-Nelson & Israel, 2003:203). For example, strong protection, such as parental involvement and support can significantly reduce the influence of strong risks, such as having substance-abusing peers (see also sections 3.3.4 and 3.3.9).

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Intrinsic risk and protective factors

Intrinsic risk and protective factors of substance use involvement include personality and gender. I discuss these briefly here.

Personality

According to David et al. (2003:8) and Wicks-Nelson and Israel (2003:215) a student’s personality traits or temperament can place them at risk for later drug abuse. Aggressive and withdrawn boys, for example, often exhibit problem behaviours in interactions with their families, peers, and others they encounter in social settings. If these behaviours continue, they will likely lead to other risks. These risks can include early peer rejection, academic failure, and later affiliation with deviant peers, often the most immediate risk for drug abuse in adolescence (see section 3.5.1).

Gender

According to David et al. (2003:8) research on family relationships indicates that adolescent girls respond positively to parental support and discipline, while adolescent boys sometimes respond negatively. Wicks-Nelson and Israel (2003:203) found that aggressive behaviour in boys and learning difficulties in girls are the primary causes of poor peer relationships. These poor relationships, in turn, can lead to a negative school experience, social rejection, and problem behaviours including drug abuse (see section 3.3.12).

Extrinsic risk and protective factors

In this section I briefly report on some of the extrinsic or environmental causes/risk and protective factors of adolescent involvement in substance use and abuse. These may include the media, the family and the community as follows.

Media

Burger et al. (2000:182) and Zervogiannis (2003:110) reported that attitudes have changed among young people about drug use. Their perception of the risks have diminished, at least in part, as a result of popular media and entertainment portrayals of drugs, drinking and smoking in an acceptable or even in a positive light. The media contributes towards this illusion by linking sophistication with self-destructive and impulsive behaviour (Pipher in Zervogiannis, 2003:112). Characters with self-control and thoughtful reasonable behaviour are often portrayed in a negative light (see also section 3.3.9).

Family

Burger et al. (2000:174-175) indicate that when parents are inclined to swallow a pill for every minor complaint, their children may become only too ready to resort to some sedative or other to relieve their stress. Barbiturates and sedatives are commonly used among adolescents, although barbiturates are illegal to obtain without a medical prescription. Adolescents sometimes have little difficulty in obtaining supplies of these drugs from their parents’ medicine cabinets. The sedatives include alcohol-based barbiturates and tranquillizers that induce a feeling of relaxation in the user (Cross & Gulmatico-Mullin, 2008a; Cross & Gulmatico-Mullin, 2008b; Gallon, Martino-McAllister & Wessel, 2008; NIDA, 2010a).
In addition to the above, drug-addicted adolescents often come from divided families (Burger et al., 2000:182; Wicks-Nelson & Israel, 2003:203) (see also sections 3.3.7, 3.3.8 and 3.3.9). However, there are also some adolescents who are cared for and cherished by loving parents yet still become addicted to hard drugs. Positive or negative interactions within the family can affect early adolescent development. David et al. (2003:8) explains that risk is more likely to be experienced when there is:
lack of mutual attachment and nurturing by parents or caregivers;
ineffective parenting;
a chaotic home environment;
lack of a significant relationship with a caring adult and
a caregiver who abuses substances, engages in criminal behaviour or suffers from mental illness.
When parents and other caregivers abuse drugs and other substances this can impede bonding with the family and threaten feelings of security needed for healthy development. According to Sambrano et al. (2007:xi-xii) a protective function on the other hand, is served when there is:
a strong family bond and loving support;
parental involvement and open communication;
supportive parenting that meets cognitive, emotional, financial, and social needs; and
clear limits, disapproving of tobacco, alcohol, or drug use, and consistent enforcement of discipline.
In findings by Bellamy, James, Matthew and Wang (2005:531) empirical evidence is provided indicating that family protective factors can significantly influence adolescents’ substance use, based on the social ecological model. According to the writers, these factors should be adopted into substance use prevention interventions Research by Alvarez-Nemegyei, Nuno-Gutierrez and Rodriguez-Cerda (2006:649) investigated Mexican teenage illicit drug users in rehabilitation to determine their drug use debut. They propose that teenagers’ drug use debut may be linked to subjects’ emotional vulnerability which originates in the family image (see section 3.3.3 and section 3.3.8). This vulnerability renders the adolescents more susceptible to the influence of others. This kind of reasoning points to a more passive than active, and a more social than personal dynamic in drug use debut. These are important factors for developing preventive measures.

TABLE OF CONTENTS
CHAPTER 1: ORIENTATION AND OVERVIEW
1.1 INTRODUCTION AND BACKGROUND
1.2 PROBLEM FORMULATION
1.3 RESEARCH QUESTION AND AIMS OF THE RESEARCH
1.4 RESEARCH PARADIGM
1.5 RESEARCH DESIGN AND METHODOLOGY
1.6 CLARIFICATION OF CONCEPTS
1.7 RESEARCH PROGRAMME – DIVISION OF CHAPTERS
1.8 CONCLUSION
CHAPTER 2: SOCIAL COGNITIVE THEORY AND SELFEFFICACY THEORY
2.1 INTRODUCTION
2.2 SCT KEY ASPECTS
2.3 SET OVERVIEW
2.4 SELF-EFFICACY AND THE ADDICTIVE BEHAVIOURS
2.5 CONCLUSION
CHAPTER 3: ADOLESCENCE SUBSTANCE ABUSE
3.1 INTRODUCTION
3.2 EPIDEMIOLOGY OF SUBSTANCE USE AND ABUSE
3.3 THEORIES AND MODELS OF FACTORS RELATED TO ADOLESCENT SUBSTANCE USE AND ABUSE
3.4 RISK AND PROTECTIVE FACTORS OF ADOLESCENT SUBSTANCE ABUSE
3.5 TYPES, SIGNS AND EFFECTS OF ADOLESCENT SUBSTANCE ABUSE
3.6 THE ROLE OF THE TEACHER REGARDING ADOLESCENT DRUG USE
3.7 CONCLUSION
CHAPTER 4: SUBSTANCE ABUSE PREVENTION PROGRAMMES AND THE ROLE OF AUDIOVISUAL MEDIA
4.1 INTRODUCTION
4.2 WHAT IS PREVENTION?
4.3 INTERVENTION LEVEL OF A PREVENTION PROGRAMME
4.4 EFFECTIVE PREVENTION PROGRAMME CORE ELEMENTS
4.5 PRINCIPLES OF EFFECTIVE PREVENTION PROGRAMMES
4.6 EVIDENCE-BASED PREVENTION PROGRAMMES
4.7 RECENT INNOVATION IN PREVENTION – BEHAVIOURAL HEALTH AND SOCIAL MEDIA
4.8 INTEGRATING BEHAVIOURAL HEALTH AND SOCIAL MEDIA TOGETHER WITH AUDIO-VISUAL MEDIA
4.9 CRITERIA FOR EVALUATION OF AUDIO-VISUAL MEDIA
4.10 PREVENTION INITIATIVES IN SOUTH AFRICA
4.11 REFLECTIONS AND RECOMMENDATIONS FOR AN INTERVENTION PROGRAMME RESOURCE IN THE LIGHT OF SCT AND SET
4.12 THE PSYCHO-EDUCATIONAL PROGRAMME TO PREVENT ADOLESCENT DRUG ABUSE
4.13 CONCLUSION
CHAPTER 5: RESEARCH DESIGN
5.1 INTRODUCTION
5.2 RESEARCH APPROACH AND DESIGN
5.3 DATA COLLECTION METHODS
5.4 DATA ANALYSIS
5.5 CONCLUSION
CHAPTER 6: FINDINGS AND DISCUSSION
6.1 INTRODUCTION
6.2 THE FOCUS GROUP PARTICIPANTS
6.3 THE INDIVIDUAL INTERVIEW PARTICIPANTS
6.4 FINDINGS AND DISCUSSION
6.5 SUMMARY
CHAPTER 7: CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS
7.1 INTRODUCTION
7.2 CONCLUSIONS
7.3 RECOMMENDATIONS
7.4 LIMITATIONS
7.5 SUMMARY
BIBLIOGRAPHY
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