GENERAL ARTICLES

 

The nature of decolonisation in health sciences curricula: a scoping review

 

 

R. Koch^I; J. Pool^II; Y. Heymans^III

^ICentre for Higher Education Professional Development (CHEPD), Faculty of Education. North-West University. Potchefstroom, South Africa. https://orcid.orq/0000-0003-2398-9475
^IICentre for Health Professions Education (CHPE), Faculty of Health Sciences. North-West University. Potchefstroom, South Africa. https://orcid.org/0000-0002-6839-4419
^IIICentre for Health Professions Education (CHPE), Faculty of Health Sciences. North-West University. Potchefstroom, South Africa. https://orcid.org/0000-0003-4459-2266

 

 

---

ABSTRACT

The amassed momentum from recent student protests applied pressure on Higher Education to respond to the calls for curriculum transformation. While decolonisation is viewed as an opportunity to create an inclusive and diverse learning environment, decolonising health curricula seems unachievable because the concept is not clearly defined, resulting in curricula that continue to marginalise and exclude certain groups. This scoping review explores the nature of decolonisation within Health Sciences. Online databases were used to identify 21 sources addressing the nature of decolonisation in Health Sciences. The findings indicate that decolonisation in Health Sciences is described as the process of acknowledging the impact of colonialism; combatting injustice and inequities; reclaiming and revaluing heritage; and interrogating knowledge to find alternative ways. This review added to understanding the nature of decolonisation in the Health Sciences field and its potential as a vehicle for transformation in HE (Higher Education).

Keywords: higher education, decolonisation, health sciences, curriculum, scoping review

---

 

 

INTRODUCTION

The topic decolonisation has gained significant importance, especially in the context of Higher Education (HE). Despite the long history of the term decolonisation, dating back to anti-colonial struggles in the 1950s, recent student protests have reinvigorated discussions and debates around the topics of decolonisation (Jansen 2019; Le Grange et al. 2020; Shay 2016). A significant increase in global student-led activism has been observed, as demonstrated by movements such as the #RhodesMustFall and #Feesmustfall in South Africa in 2015 and 2016, and the 2015 "Why is My Curriculum White?" campaigns in the UK (Pimblott 2020, 210). Due to the pressure applied by the above-mentioned student-led movements, the HE sector has been challenged to respond to the demands of these student (Behari-Leak et al. 2020; Osman and Maringe 2019).

In order to respond to the demands, it is important to recognise that the demands of students have gone beyond the elimination of fees only and now encompass the decolonisation of knowledge as well as the necessity for a complete transformation of the curriculum (Osman and Maringe 2019; Sathorar and Blignaut 2021). Students advocated for curricula to be diversified and more focused on social responsiveness (Mbaki, Todorova, and Hagan 2021). Although the issue of free education has been partially addressed by the National Student Financial Aid Scheme (NSFAS), the decolonisation of HE curricula remains an elusive and challenging issue (Griffiths 2019, 147). Büyüm et al. (2020, 4) argue that while student-led decolonisation movements are important, they are merely a preliminary step in achieving a more equitable and unbiased curriculum. These authors expressly emphasise that the abovementioned movements must continue to result in evidence of actual change towards a decolonised curriculum. Zappas et al. (2021) agree that intentional efforts to decolonise curricula are needed to create sustainable policies and programs.

Despite the growing awareness of the importance of decolonisation and an increasing effort to explore how global teaching can move beyond its colonial past, many institutions still lack an understanding of the nature of decolonising curricula in HE (Griffiths 2019; Osman and Maringe 2019; Timmis et al. 2019). Recognising the impact of colonialism is highlighted as an important aspect of the literature. The concept of coloniality is employed to describe the inclination of previously colonised states to revert to their past status quo, perpetuating deficit-based ideologies, and imposing knowledge through imperial relations. Within the framework of coloniality, development was measured by the degree to which local communities deserted their traditional ways and embraced Western lifestyles (Goodman et al. 2015; Maringe, Ndofirepi, and Osman 2021; Rodney 2016). This inclination to reject local culture and values in favour of Western culture and values is described by the term the coloniality of being (Behari-Leak and Chetty 2021; Behari-Leak et al. 2020; Maringe et al. 2021). The decoloniality of being is about creating a new way of thinking about who the colonised person is and undoing the adverse impact of colonisation. This means embracing and valuing one's own identity and culture instead of trying to imitate the coloniser (Behari-Leak et al. 2020).

An exploratory literature review revealed that literature is loaded with calls to "decolonise" the curriculum, "decolonise" knowledge, "decolonise" assessment, "decolonise" teaching etc., but simultaneously there is hardly any consensus as to what "decolonisation" actually means. While there have been discussions and debates about the definitions and implementation of decolonization in HE, in South Africa and other countries, Behari-Leak et al. (2017, 2) emphasize that the crucial aspect lies in establishing a shared understanding of the nature of decolonisation and its specific processes, rather than solely focusing on its definition. Decolonising HE is further complicated by the fact that different disciples in HE perceive decolonisation differently (Le Grange et al. 2020; Shahjahan et al. 2022).

The legacy of colonialism persists and has a far-reaching impact on Health Sciences (Büyüm et al. 2020). The colonial practices of acquiring control over other territories or countries often resulted in the marginalisation of indigenous health knowledge and practices, perpetuating unequal health outcomes (Griffiths 2019; Lawrence and Hirsch 2020). The field of Health Sciences views decolonisation as an opportunity to create an inclusive and diverse learning environment (Finn et al. 2022) and as a process of eliminating mechanisms that contribute to inequities (Chandanabhumma and Narasimhan 2020). Curricula may unintentionally perpetuate colonising practices (Goodman et al. 2015) and decolonisation may offer a means to examine and challenge the persistent colonial legacy within pedagogies and practices (Castell et al. 2018). However, as pointed out by Lawrence and Hirsch (2020), the concept of decolonising Health Sciences curricula is not clearly defined and therefore seems unachievable. Without a clear understanding of the concept, there is an absence of institutional processes and sustainable policies (Neden 2021; Zappas et al. 2021). Consequently, HE institutions (HEi) have not fully embraced opportunities to decolonise, resulting in Health Sciences curricula which remain imbued with colonialism and are irrelevant to the requirements of development in the local contexts (Lawrence and Hirsch 2020; Maringe et al. 2021; Timmis et al. 2019).

Calls for decolonisation can only be answered effectively if stakeholders involved in teaching and learning have a clear understanding of what "decolonisation" is and how the process of decolonisation should be approached (Hoadley and Galant 2019). This lack of understanding of what the nature of a decolonised curriculum in the field of Health Sciences entails, necessitates this research. It is important that the field of Health Sciences first explore the understanding of the nature of decolonisation in Health Science disciplines before decisions can be made about what in curricula needs redress, redesign, and development. Hence this study aims to explore the nature of decolonisation in Health Sciences curricula. Findings from this research may provide an evidence-based foundation for policy and practice changes related to decolonising curriculum within Health Sciences. Addressing decolonisation in Health Sciences can potentially lead to transformation and create a more equitable and inclusive curriculum, which can ultimately result in better health outcomes for marginalised communities (Büyüm et al. 2020; Lawrence and Hirsch 2020).

The next section of this article focuses on the method of the study.

 

METHOD

A scoping review is a methodological approach that can be especially useful when the research questions are broad and complex, and when the existing literature is diverse and heterogeneous (Pham et al. 2014). In the case of the proposed research question related to the nature of decolonisation in Health Sciences, a scoping review can assist in identifying the extent and range of available literature on this topic. A scoping review aims to answer a broader question and summarise existing evidence on a given topic (Pollock et al. 2021). Given that the nature of decolonisation is a complex and multifaceted concept, a scoping review can offer a rigorous and transparent method for mapping the research (Munn et al. 2018; Peters et al. 2020). A scoping review was therefore chosen to explore the nature of decolonisation in the field of Health Sciences. This scoping review was conducted following the Joanna Briggs Institute guidelines (Peters et al. 2020).

This scoping review will be discussed under the following five stages (Arksey and O'Malley 2005):

• Stage 1 : Identifying the research question

• Stage 2: Identifying relevant studies

• Stage 3 : Study selection

• Stage 4: Charting the data

• Stage 5: Collating, summarising, and reporting the results

Stage 1: Identifying research question

This scoping review aims to systematically explore and map the current research on the following research question: What is the nature of decolonisation in Health Sciences?

Stage 2: Identifying relevant studies

To fully explore objectives for the eligibility criteria for study selection, the concept of interest and context approach was followed when preparing the search as recommended by Peters et al. (2020). The concept examined in this study is the nature of decolonisation as a vehicle for transformation. The context for this review is studies performed in Health Sciences.

A three-step search strategy is recommended in all JBI types of review (Peters et al. 2020). Step one was conducted in collaboration with a research librarian exploring two databases relevant to the topic (Pollock et al. 2021). Keywords were identified from the aims of this study. From these keywords, a set of search terms were derived. Both scientific and common terminology were used, and British and American spelling, synonyms and plurals were accounted for. An initial search was conducted on the database "Scopus". This step was followed by an analysis of the text words contained in the title and abstract of retrieved papers and index terms to develop a full search strategy. A second search using all identified search terms (see Appendix A) was then undertaken. See Appendix B for the final search strategy. This was followed by the third step in which the reference list of identified reports and articles was searched with a view to obtain more sources relevant to this study. The researchers subsequently submitted additional relevant sources to be considered for inclusion.

Since the concept of decolonisation only came to occupy prominence in HE succeeding the students' movements and calls to decolonise HE (Jansen 2019), only publications from 2015 onwards were considered for inclusion. In addition to this, publications written in English and consisting of literature reviews, book chapters and peer-reviewed scholarly articles were considered for inclusion.

The following databases were searched from 2015 to July 2022: EbscoHost, ERIC, Proquest, Pubmed, Scopus, and Web of Science. Following the database searches, 540 results were identified and imported into EndNote (a commercial reference management software package), where sources were combined, and duplicates removed. The 396 remaining results were then imported into Covidence (an online screening and data extraction tool), by means of which a further 88 duplicates were removed, whereafter 308 studies remained.

Stage 3: Study selection

The 308 remaining studies underwent screening through which the selection was performed based on the pre-specified inclusion criteria summarised in Table 1. Source selection was performed independently by the researchers. Ten articles were randomly selected, and the titles and abstracts were screened independently by the researchers to test the reliability of the inclusion criteria. Discrepancies were discussed to ensure clarity and consistency in the application of the inclusion and exclusion criteria. Any disagreements were solved through discussion, and on agreement the screening process commenced. Potentially relevant sources were retrieved in full. The researchers independently reviewed the full text of selected citations. For sources that did not meet the inclusion criteria during the full-text screening, the reason for exclusion was recorded and reported.

 

 

The title and abstract screening marked 209 of the 308 remaining studies irrelevant because they did not meet the inclusion criteria. 99 studies went through to the full-text review where full-text articles were retrieved and tested for eligibility. Of these sources, 78 were excluded, see Figure 1: PRISMA 2020 flow diagram for exclusion reasons. The 21 studies remaining were considered eligible for this review. Table 1 presents the inclusion and exclusion criteria for this research.

 

 

Stage 4: Charting the data

In this stage, data were mapped and summarised based on the research question and aim of this study. To ensure that relevant results were extracted in full, this research made use of a calibration exercise to familiarise the researchers with the source results and to test the usability and appropriateness of the data extraction form (see Appendix C). The data extraction form was then refined further and updated to provide a logical and descriptive summary of the results that align with the objectives of this study (Peters et al. 2020).

General data on article characteristics were abstracted such as title, lead author, country of origin and year of publication. The aim, methodology and findings of the study were also briefly noted as well as the academic discipline or subject on which the research is based. The aim was to explore the nature of decolonisation in Health Sciences. Therefore, the following information was collected for each study: the definition of decolonisation in Health Sciences and the reasons mentioned as to why decolonisation is needed in Health Sciences (Appendix E).

Stage 5: Collating, summarising, and reporting the results

The final stage of the process is the analysis of the results. As suggested in the JBI Manual for Evidence Synthesis, the ultimate purpose of data charting is to identify, characterise and summarise the evidence, including identifying research gaps (Peters et al. 2020).

A total number of 21 sources addressing the nature of decolonisation within the field of Health Sciences were included in this study. The extracted data were thematically analysed and descriptively mapped in tabular form by grouping the data in accordance with the main themes that emerged while exploring the nature of decolonisation within Health Sciences (see Table 2).

 

 

RESULTS

The included sources originated from various countries, namely Australia, the United States, the United Kingdom, Canada, South Africa, Gaza, Nigeria, Botswana, and China. The disciplines range from HE in general to transdisciplinary, Education, Health Sciences Education, Pharmacy, Medicine, and Psychology. The individual characteristics of the sources are presented in Appendix D.

The following sections offer a nuanced reflection of the results of this scoping review and the themes that emerged from it.

The nature of decolonisation in Health Sciences

This scoping review aimed to understand the nature of decolonisation in the field of Health Sciences. The results of the sources were thematically analysed, and from the data, five main themes emerged as illustrated in Table 2.

 

DISCUSSION

This scoping review identified 21 studies which described the nature of decolonisation within Health Sciences. The nature of decolonisation within Health Sciences could be grouped into five thematic categories as described below.

Theme 1: Acknowledge and challenge the impact of colonialism

As described in the subthemes below, the sources define decolonisation in Health Sciences as the process of recognising and acknowledging the impact of colonialism. Decolonisation is also described as the process of challenging these assumptions and practices that currently persist in education.

Subtheme 1: Recognise and acknowledge the impact of colonialism

It is emphasised in literature that recognising and acknowledging the impact of colonialism is a crucial aspect of the decolonisation process (Chandanabhumma and Narasimhan 2020; Goodman et al. 2015; Mbaki et al. 2021; Zidani 2021). This involves acknowledging how colonising practices can perpetuate deficit-based ideologies and impose knowledge on others through imperial relations (Goodman et al. 2015; Rodney 2016). Added to this, decolonisation is a process of understanding and unpacking the core assumptions of domination, racism, patriarchy and ethnocentrism still prevalent (Swidrovich 2020). Finally, Wong, Gishen, and Lokugamage (2021) highlight the importance of acknowledging how colonialism has influenced the systems that we participate in daily. To delink from colonial thinking it is necessary to recognise the problems created by Western epistemic hegemony (Zidani 2021).

Subtheme 2: Challenge the legacy of colonialism.

Decolonisation is a critical reflective process of resisting and challenging the oppressive forces of colonialism (Chandanabhumma and Narasimhan 2020). Decolonisation can also be described as a process of confronting the colonising practices that have influenced education and a means to challenge these practices (Castell et al. 2018; Finn et al. 2022). Furthermore, decolonisation can be described as the establishment of widespread movements capable of dismantling settler-colonialism, white supremacy, and capitalism (Bhandal 2018).

Theme 2: Combat injustice and strive for socially just, culturally diverse, and inclusive education

This theme discusses decolonisation as a tool for achieving social justice with the aim to address historical and ongoing cycles of oppression, injustices, and inequities. The decolonisation of Health Sciences curricula is needed for creating a socially just learning environment that values equity, diversity, and inclusivity.

Subtheme 1: Voice to underrepresented

Within a Western discourse, Indigenous groups often lack representation that may lead to their perspectives being invisible (Castell et al. 2018). The decolonial turn challenges this trend by advocating for the inclusion of Indigenous perspectives. Decolonisation is about more than acknowledging historical injustices; it involves creating spaces where underrepresented groups have a voice and an active role (Diab et al. 2020). The goal of decolonisation is to enable these underrepresented groups to advocate for themselves, and have more influence and leadership in a decolonised pedagogical space that provides them with more power for accurate representation and visibility (Diab et al. 2020; Mbaki et al. 2021).

Subtheme 2: A tool for social justice

Decolonisation is a tool for working towards social justice, which involves actively addressing historical and ongoing cycles of oppression (Goodman et al. 2015; Narasimhan and Chandanabhumma 2021). Curriculum reform, as a part of the decolonisation process, requires a shift away from the Western-centric perspective towards addressing local inequalities and challenges (Joosub 2021). One critical area where decolonisation can have a significant impact is in combatting injustice and inequities. Zappas et al. (2021) argue that decolonisation in the field of Health Sciences necessitates that educators, community advocates, health care providers, liaisons, and individuals listen, learn, and relearn because quality and equal health care is a fundamental human right for everyone. In summary, decolonisation serves as a crucial tool for addressing inequities towards social justice, particularly in fields like health care where disparities are prevalent.

Subtheme 3: Diversity and inclusivity

Decolonisation embraces cultural diversity and promotes inclusion (Goodman et al. 2015; Nazar et al. 2015). A decolonised curriculum aims to provide a more inclusive education by incorporating diverse perspectives and promoting cultural understanding, which implies recognising and respecting the cultural differences of students and ensuring a learning environment that values diversity, promotes understanding, and fosters inclusion (Lokugamage, Ahillan, and Pathberiya 2020; Neden 2021).

Theme 3: Re-embrace cultural heritage

In this theme, decolonisation involves reclaiming African heritage and centring the perspectives of historically oppressed groups. It requires co-constructing understanding with Indigenous peoples, integrating Indigenous knowledge, and centring African values in a redesigned curriculum. To achieve this, partnering with those impacted by the colonial legacy and including more diverse authors in curricula are essential steps.

Subtheme 1: Recentring indigenous perspectives and values

The articles by Nibafu, Du Plessis, and Abrahams (2021) and Wong et al. (2021) share the perspective that decolonisation involves recentring the perspectives and values of historically oppressed and marginalised populations. However, they differ in their specific focus. According to Nibafu et al. (2021), decolonisation in the South African context means placing African values and ideas at the centre of the education curriculum, with European ideas and values being secondary or supplemental. This approach reflects the idea that colonised societies have historically been forced to adopt the values and beliefs of colonising powers, often at the expense of their own cultural heritage and traditions. Decolonisation is about recentring the perspectives of the populations who have been historically subjugated and marginalised (Wong et al. 2021).

Subtheme 2: Restoring indigenous knowledge

Nibafu et al. (2021) argue for the restoration of Indigenous knowledge in curricula to challenge the dominance of European epistemology. This aligns with the view of Van der Westhuizen, Greuel, and Beukes (2017) who suggest that decolonisation requires active engagement with processes that prioritise the revaluing and reclaiming of African heritage and culture. Universities should embrace African heritage and culture (Witthuhn and Le Roux 2017). This perspective complements the arguments of Nibafu et al. (2021) and Van der Westhuizen et al. (2017), as all three sources emphasise the importance of actively engaging in processes that aim to reclaim and revalue African heritage and culture.

Subtheme 3: Include locals by partnerships

The literature suggests that a crucial aspect of decolonisation involves collaborating with Indigenous peoples to incorporate their knowledge, traditions, and values with services, programs, and policies. Chandanabhumma and Narasimhan (2020) emphasise the importance of partnering with people affected by the colonial legacy, and Lokugamage et al. (2020) suggest that including more diverse authors in curricula is essential to decolonisation. Van der Westhuizen et al. (2017) recommend that Indigenous voices should be prioritised in shaping future practices, and Neden (2021) argues that co-constructing understanding with Indigenous peoples and integrating their knowledge are essential aspects of decolonisation.

Theme 4: Challenge conventional knowledge and explore alternative perspectives

According to the literature on this theme and subthemes, decolonisation requires challenging conventional knowledge, interrogating power dynamics and valuing subordinated knowledge. It involves rearranging practices of knowing and exploring alternative ways of thinking.

Subtheme 1: Challenge conventional knowledge

The nature of knowledge has been a topic of discussion in decolonisation efforts. Bhandal (2018) maintains that knowledge is partial, incomplete, and always changing. Castell et al. (2018) suggest that decolonising knowledge within disciplines can broaden the scope of knowing by incorporating diverse perspectives and worldviews. Chandanabhumma and Narasimhan (2020) argue that decolonisation challenges conventional knowledge systems and assumptions. Rodney (2016) adds that decolonisation involves a discursive approach to interrogating why certain forms of knowledge are privileged over others. Disrupting conventional knowledge systems is not limited to the removal of colonial power and the breaking down of colonial structures. Eichbaum et al. (2021) note that it reaches beyond this to encompass decolonisation of the mind. Joosub (2021) adds that disrupting the power dynamics of knowledge is necessary for decolonisation to take place.

Subtheme 2: Explore alternatives

To decolonise knowledge, it is important to realign our practices of knowing by incorporating subordinated knowledge and surpassing the boundaries of exclusion and marginalisation, as suggested by Zidani (2021). This involves recognising and valuing knowledge systems that have been historically excluded or marginalised. Wong et al. (2021) add that decolonisation is a movement that offers alternative ways of thinking about reality. This movement can encourage the questioning and challenging of the dominant narratives and power structures that have shaped our worldview. By valuing subordinated knowledge, and embracing alternative ways of knowing, being and doing we can move towards a more inclusive and equitable knowledge system that represents diverse perspectives and experiences.

Theme 5: Reasons to decolonise

There are multiple reasons why the decolonisation of Health Sciences curricula is important. In this theme, five subthemes will be discussed, namely: the growing momentum and demand for culturally responsive and equity-focused curricula, diverse student needs, the persistence of colonialism, the potential of decolonisation, and serving a diverse health population.

Subtheme 1: Seizing the moment

The findings of this study emphasise the growing momentum and demand from students for more culturally and socially responsive curricula, particularly in the field of Health Sciences. Mbaki et al. (2021) highlight this call for action and suggest that the time is ripe for institutions to respond to these demands and take active steps towards decolonising their curricula. There is a need for intentional efforts to dismantle the forces of colonialism to deliver quality care to diverse populations (Zappas et al. 2021).

Subtheme 2: Diverse student needs

Despite the presence of international and non-White-identifying students and academics, the current curricula remain centred around a Western perspective, neglecting the diversity and transnationalism that is present in the classroom (Zidani 2021). Joosub (2021) points out that students are resisting the hierarchical academic structures inherited from colonial education systems which hinder their natural inquisitiveness and need for autonomy in the educational process. In response to these challenges, decolonisation can provide a way to address the needs of students.

Subtheme 3: The persistence of colonialism

The influence of colonial policies and practices on Higher Education (HE) is undeniable. The perpetuation of power disparity between the global North and South in teaching and health professions education is a clear example of this (Rodney 2016). Even if countries are no longer colonies, the impacts of colonial policies and practices continue to influence HE, as highlighted by Bhandal (2018). It is therefore crucial to be aware of current conversations about globalisation and critical social justice.

Universities play a crucial role in perpetuating colonial practices through their pedagogies and practices, both intentionally and unintentionally (Goodman et al. 2015). Universities are inclined to reproduce colonial methodologies and practices that may not relevant to the context (Nibafu et al. 2021). These practices may be unintentional, but they nonetheless have a detrimental impact on students and reinforce the legacy of colonialism in academia.

Colonial legacy perpetuates inequities that affect marginalised groups, particularly Indigenous Peoples, globally. Eichbaum et al. (2021) highlight the heritage of former colonial associations and their impact on global health initiatives, promoting structural drivers of discrimination and obstacles to self-determination. Colonialism continues to shape considerable inequities in the mental, physical, and emotional health and well-being of marginalised people (Narasimhan and Chandanabhumma 2021). The persistence of colonial legacy reinforces the perception of superiority among colonisers and inferiority among the colonised, perpetuating power imbalances and inequities.

Subtheme 4: The potential of decolonisation

The process of decolonisation can illuminate and address the forces of colonialism. Castell (2018) argues that decoloniality can expose how epistemic violence is inflicted upon indigenous knowledge and practices. Similarly, Chandanabhumma and Narasimhan (2020) highlight the need to address the colonial legacy and its contributions to health inequities. Decolonisation offers a means to challenge and eliminate the mechanisms leading to these inequities by providing an opportunity to examine and challenge the status quo and incorporate diverse perspectives and knowledge in education and health care systems (Castell et al. 2018). Decolonised models challenge standard practices that underpin a Western way of knowing that may be disconnected from the complexity of cultural phenomena in particular contexts (Diab et al. 2020).

Decolonisation can also contribute to creating a diverse and inclusive learning environment, that recognises and respects the various cultural practices and traditions (Finn et al. 2022). By incorporating diverse knowledge and perspectives, decolonised models can foster participatory and inclusive approaches (Diab et al. 2020).

Galvaan et al. (2022) argue that it is essential to bridge the divide between health education and health care systems to produce a health care workforce. Decolonisation can facilitate collaboration and knowledge exchange between education and health care systems, creating more culturally sensitive and responsive health care systems.

Subtheme 5: Serving a diverse health population

To promote sustainable human development, health education and training should be grounded in the realities of the contexts in which service beneficiaries operate (Van der Westhuizen et al. 2017). Shifting the focus of Health Science education holds the potential to prompt students to think more holistically, critically, and reflexively about the interconnected inequalities within clinical settings, health systems, and the broader society (Wong et al. 2021). By considering the specific contexts in which health care services are delivered, health care training can be designed to be more effective and culturally relevant.

The education system needs to address equity and diversity, and graduates should be equipped with the skills and knowledge to address the unique challenges presented by a diverse population (Lokugamage et al. 2020). This means that Health Sciences students should graduate with an awareness of how the diversity of patient populations may impact health behaviours and outcomes (Nazar et al. 2015). Meeting the health care needs requires a decolonised approach to health education for graduates to be better equipped to provide care that is sensitive to the unique needs of diverse populations (Swidrovich 2020).

Subtheme 6: Decolonisation should be formalised

Institutional processes and procedures must be put in place to address and dismantle inequities in the health care system. Zappas et al. (2021) highlight the need to establish sustainable policies and programs that can help remove inequities and foster the ability to deliver quality healthcare to diverse patients, families, communities, and health professionals. Neden (2021) continues to argue that such processes should demand a decolonising agenda in research and education, as well as the recognition of Indigenous rights. Witthuhn and Le Roux (2017) emphasise that it is essential to fore-front curriculum transformation and the formalisation of decolonisation processes through policy changes and capacity building.

 

CONCLUSION

Our findings indicate that decolonising curricula in Health Sciences is important for several reasons. These reasons include the growing demand for culturally responsive and equity-focused curricula, the fact that current curricula often neglect the diversity in the classroom and the lingering presence of colonial policies and practices in HE. Meeting the health care needs of the diverse population requires a decolonised approach to health education, because decolonisation offers a means to challenge the status quo and incorporate diverse perspectives and knowledge in the curriculum. Addressing decolonisation in Health Sciences education can result in better health outcomes for all populations by aiming to bridge the gap between Health Education and the Healthcare system.

This scoping review aimed to explore the nature of decolonisation within the field of Health Sciences by mapping the available research. Through this process, a more nuanced understanding of the key concepts regarding the nature of decolonisation in Health Sciences was obtained. It became clear that decolonisation of Health Sciences curricula is a complex and multifaceted movement that encompasses many different aspects as indicated in Table 3.

 

 

It is crucial that inclusive transformation should take place. It is only after critical engagement and the co-construction of an understanding about the nature of decolonisation in Health Sciences, that we can start to decolonise curricula and other teaching and learning-related elements within the field of Health Sciences. By adding to the understanding of the complex concept of decolonisation within Health Sciences, this study hopes to contribute to a shared understanding thereof, making the decolonisation of Health Sciences curricula both attainable and achievable.

By embracing decolonisation in Africa, Health Sciences Education can foster a more inclusive, culturally sensitive, and contextually relevant approach to healthcare. It recognises the richness of African cultures, promotes local solutions to health challenges, and aims to address the historical injustices that have shaped healthcare systems on the continent.

For academics to effectively implement decolonisation on a practical level, further research is necessary to establish how decolonisation can be used as a vehicle for transformation and to gauge academics' perspectives within Health Sciences to develop practical guidelines for evaluating and improving curricula. Despite the progress made thus far, much work still needs to be done in the ongoing effort to decolonise HE.

 

STRENGTHS AND LIMITATIONS

Scoping reviews have certain limitations that can impact their accuracy and usefulness. Scoping reviews have a defined focus, so they can miss out on other important information that falls outside the scope. Scoping reviews are designed to provide a broad overview of the literature but may lack the depth and detail that can make it difficult to fully understand individual studies. Even with established procedures in place the potential for bias exists, as the selection of studies and the interpretation of findings can be influenced by the researcher's biases and perspectives. Additionally, scoping reviews can be time-consuming, particularly when searching for and evaluating a large number of studies and may be limited by the quality and availability of the relevant literature, which may not provide a comprehensive overview of the available evidence.

Furthermore, scoping reviews can be outdated quickly due to their time constraints, as new research and data may be published after the completion of the review, making it important to conduct regular updates. All these limitations highlight the need to consider scoping reviews as just one step in a larger evidence-based process and to complement them with other methods such as systematic reviews or meta-analyses when possible.

 

FUNDING

This research did not receive funding.

 

DECLARATION STATEMENT

The authors declare that they have no conflict of interest.

 

SUPPLEMENTAL MATERIAL

• Appendix A: Search term

• Appendix B: Search strategy

• Appendix C: Data extraction form

• Appendix D: Results of individual sources of evidence

• Appendix E: Charted data

 

REFERENCES

Arksey, H. and L. O'Malley. 2005. "Scoping studies: Towards a methodological framework." International Journal of Social Research Methodology 8(1): 19-32. https://doi.org/10.1080/1364557032000119616.         [ Links ]

Behari-Leak, K., L. Masehela, L. Marhaya, M. Tjabane, and N. Merckel. 2017. "Decolonising the curriculum: It's in the detail, not just in the definition." The Conversation. https://theconversation.com/decolonising-the-curriculum-its-in-the-detail-not-just-in-the-definition-73772        [ Links ]

Behari-Leak, Kasturi and Rajendra Chetty. 2021. "Drawing a line in the sand: Social mapping of responses to calls to 'decolonise the university'." Journal of Decolonising Disciplines 3: 1-24. https://doi.org/https://doi.org/10.35293/jdd.v3i1.26.         [ Links ]

Behari-Leak, K., Sisanda Nkoala, G. Mokou, and H. Binkowski. 2020. "Exploring disruptions of the coloniality of knowledge, power and being to enable agency as disciplinary activists for curriculum change." Journal of Decolonising Disciplines 2(2): 1-31. https://doi.org/https://doi.org/10.35293/jdd.v2i2.25.         [ Links ]

Bhandal, T. 2018. "Ethical globalization? Decolonizing theoretical perspectives for internationalization in Canadian medical education." Canadian Medical Education Journal 9(2): e33-e45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044296/pdf/CMEJ-9-e033.pdf.         [ Links ]

Büyüm, A. M., C. Kenney, A. Koris, L. Mkumba, and Y. Raveendran. 2020. "Decolonising global health: If not now, when?" BMJ Global Health 5(8): e003394. https://doi.org/10.1136/bmjgh-2020-003394.         [ Links ]

Castell, E., J. Bullen, D. Garvey, and N. Jones. 2018. "Critical Reflexivity in Indigenous and Cross-cultural Psychology: A Decolonial Approach to Curriculum?" Am J Community Psychol 62(3-4): 261-271. https://doi.org/10.1002/ajcp.12291.         [ Links ]

Chandanabhumma, P. P. and S. Narasimhan. 2020. "Towards health equity and social justice: An applied framework of decolonization in health promotion." Health Promot Int 35(4): 831-840. https://doi.org/10.1093/heapro/daz053.         [ Links ]

Diab, M., G. Veronese, Y. Abu Jamei, and A. Kagee. 2020. "The interplay of paradigms: Decolonizing a psychology curriculum in the context of the siege of Gaza." NORDIC PSYCHOLOGY 72(3): 183-198. https://doi.org/10.1080/19012276.2019.1675087.         [ Links ]

Eichbaum, Q. G., L. V. Adams, J. Evert, M.-J. Ho, I. A. Semali, and S. C. van Schalkwyk. 2021. "Decolonizing Global Health Education: Rethinking Institutional Partnerships and Approaches." Academic Medicine: Journal of the Association of American Medical Colleges 96(3): 329-335. https://doi.org/10.1097/ACM.0000000000003473.         [ Links ]

Finn, G. M., A. Danquah, and J. Matthan. 2022. "Colonization, cadavers, and color: Considering decolonization of anatomy curricula." The Anatomical Record (Hoboken) 305(4): 938-951. https://doi.org/10.1002/ar.24855.         [ Links ]

Galvaan, R., L. Peters, L. A. Richards, M. Francke, and M. Krenzer. 2022. "Pedagogies within occupational therapy curriculum: Centering a decolonial praxis in community development practice." CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL-BRAZILIAN JOURNAL OF OCCUPATIONAL THERAPY 30. https://doi.org/10.1590/2526-8910.ctoAO24023133.         [ Links ]

Goodman, R. D., J. M. Williams, R. C.-Y. Chung, R. M. Talleyrand, A. M. Douglass, H. G. McMahon, F. Bemak, R. D. Goodman, and P. C. Gorski. 2015. "Decolonizing traditional pedagogies and practices in counseling and psychology education: A move towards social justice and action." In Decolonizing 'multicultural' counseling through social justice, edited by R. D. Goodman and P. C. Gorski, 147-164. https://doi.org/10.1007/978-1-4939-1283-4_11.         [ Links ]

Griffiths, D. 2019. "#FeesMustFall and the decolonised university in South Africa: Tensions and opportunities in a globalising world." International Journal of Educational Research 94: 143-149. https://doi.org/https://doi.org/10.1016/j.ijer.2019.01.004.         [ Links ]

Hoadley, U. and J. Galant. 2019. "What Counts and Who Belongs? Current Debates in Decolonising the Curriculum." In Decolonisation in Universities: The Politics of Knowledge, ed. J. Jansen, 101- 114. Wits University Press. https://www.cambridge.org/core/books/decolonisation-in-universities/on-the-politics-of-decolonisation-knowledge-authority-and-the-settled-curriculum/4A165FE51DAC0E90686A4F534EB8F844.         [ Links ]

Jansen, J. D. 2019. "Introduction and Overview: Making Sense of Decolonisation in Universities." In Decolonisation in Universities: The Politics of Knowledge, ed. J. Jansen, 1 -12. Wits University Press. https://doi.org/DOI: undefined.         [ Links ]

Joosub, N. 2021. Becoming African psychologists: Decolonisation within a postgraduate psychology module at the University of Johannesburg. South African Journal of Higher Education 35(1): 192- 208. https://doi.org/10.20853/35-1-4003.         [ Links ]

Lawrence, D. S. and L. A. Hirsch. 2020. "Decolonising global health: Transnational research partnerships under the spotlight." International Health 12(6): 518-523. https://doi.org/10.1093/inthealth/ihaa073.         [ Links ]

Le Grange, L., P. du Preez, L. Ramrathan, and S. Blignaut. 2020. "Decolonising the university curriculum or decolonial-washing? A multiple case study." Journal of Education 80: 25-48. https://doi.org/10.17159/2520-9868/i80a02.         [ Links ]

Lokugamage, A. U., T, Ahillan, and S. D. C. Pathberiya. 2020. "Decolonising ideas of healing in medical education." JOURNAL OF MEDICAL ETHICS 46(4): 265-272. https://doi.org/10.1136/medethics-2019-105866.         [ Links ]

Maringe, F., A. Ndofirepi, and R. Osman. 2021. "Clash of ideologies in post-colonial education systems: Convergences and divergences." In Higher Education in the melting pot: Emerging discourses of the Fourth Industrial Revolution and decolonisation (Vol. 1), ed. F. Maringe, 1-27. AOSIS. https://doi.org/https://doi.org/10.4102/aosis.2021.BK305.01.         [ Links ]

Mbaki, Y., E. Todorova, and P. Hagan. 2021. "Diversifying the medical curriculum as part of the wider decolonising effort: A proposed framework and self-assessment resource toolbox." Clin Teach 18(5): 459-466. https://doi.org/10.1111/tct.13408.         [ Links ]

Munn, Z., M. D. J. Peters, C. Stern, C. Tufanaru, A. McArthur, and E. Aromataris. 2018. "Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach." BMC Medical Research Methodology 18(1): 143-143. https://doi.org/10.1186/s12874-018-0611-x.         [ Links ]

Narasimhan, S. and P. P. Chandanabhumma. 2021. "A Scoping Review of Decolonization in Indigenous-Focused Health Education and Behavior Research." Health Educ Behav 48(3): 306-319. https://doi.org/10.1177/10901981211010095.         [ Links ]

Nazar, M., K. Kendall, L. Day, and H. Nazar. 2015. "Decolonising medical curricula through diversity education: Lessons from students." Med Teach 37(4): 385-393. https://doi.org/10.3109/0142159x.2014.947938.         [ Links ]

Neden, J. 2021. "Decolonizing digital learning design in social work education. A critical analysis of protocol practice for cultural safety and cultural capability." SOCIAL WORK EDUCATION. https://doi.org/10.1080/02615479.2021.1998426.         [ Links ]

Nibafu, E. Q. F., M. du Plessis, and F. Abrahams. 2021. "Contextual relevance and decolonisation of South African Industrial Psychology training: An exploratory case study." JOURNAL OF PSYCHOLOGY IN AFRICA 31(2): 203-208. https://doi.org/10.1080/14330237.2021.1903155.         [ Links ]

Osman, R. and F. Maringe. 2019. Transformation in Higher Education in South Africa Toward the Decolonization of South African Universities. Oxford University Press. https://doi.org/10.1093/acrefore/9780190264093.013.202.         [ Links ]

Peters, M., C. Godfrey, P. McInerney, Z. Munn, A. Tricco, and H. Khalil. 2020. "Chapter 11: Scoping reviews." In JBI Manual for Evidence Synthesis, ed. E. Aromataris and Z. Munn, 407-452. https://synthesismanual.jbi.global. https://doi.org/10.46658/JBIMES-20-12.         [ Links ]

Pham, M. T., A. Rajic, J. D. Greig, J. M. Sargeant, A. Papadopoulos, and S. A. McEwen. 2014. A scoping review of scoping reviews: Advancing the approach and enhancing the consistency. Res Synth Methods 5(4): 371-385. https://doi.org/10.1002/jrsm.1123.         [ Links ]

Pimblott, K. 2020. "Decolonising the University: The Origins and Meaning of a Movement." Political Quarterly 91(1): 210-216. https://doi.org/10.1111/1467-923X.12784.         [ Links ]

Pollock, D., A. C. Tricco, M. D. J. Peters, P. A. McInerney, H. Khalil, C. M. Godfrey, L. A. Alexander, and Z. Munn. 2021. "Methodological quality, guidance, and tools in scoping reviews: A scoping review protocol." JBI Evidence Synthesis 20(4): 1098-1105. https://doi.org/10.11124/jbies-20-00570.         [ Links ]

Rodney, R. 2016. "Decolonization in health professions education: Reflections on teaching through a transgressive pedagogy." Canadian Medical Education Journal 7(3): e10-e18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5342882/pdf/cmej-07-10.pdf.         [ Links ]

Sathorar, H. and S. Blignaut. 2021. "A Critical Approach to Curriculum Implementation: Reflecting on Lecturer Preparedness to be Transformative Intellectuals." Interchange 52(3): 415-431. https://doi.org/10.1007/s10780-021-09437-1.         [ Links ]

Shahjahan, R. A., A. L. Estera, K. L. Surla, and K. T. Edwards. 2022. "'Decolonizing' Curriculum and Pedagogy: A Comparative Review Across Disciplines and Global Higher Education Contexts." Review of Educational Research 92(1): 73-113. https://doi.org/10.3102/00346543211042423.         [ Links ]

Shay, S. 2016. "Decolonising the curriculum: It's time for a strategy." The Conversation. https://theconversation.com/decolonising-the-curriculum-its-time-for-a-strategy-60598.         [ Links ]

Swidrovich, J. 2020. "Decolonizing and Indigenizing pharmacy education in Canada." Curr Pharm Teach Learn 12(2): 237-243. https://doi.org/10.1016/j.cptl.2019.11.018.         [ Links ]

Timmis, S., E. Mgqwashu, K. Naidoo, P. Muhuro, S. Trahar, L. Lucas, G. Wisker, and T. de Wet. 2019. "Encounters with coloniality: Students' experiences of transitions from rural contexts into higher education in South Africa." CriSTal 7(2) (Special Issue). https://doi.org/10.14426/cristal.v7iSI.195.         [ Links ]

Van der Westhuizen, M., T. Greuel, and J. W. Beukes. 2017. "Are we hearing the voices? Africanisation as part of community development." HTS TEOLOGIESE STUDIES-THEOLOGICAL STUDIES 73(3). https://doi.org/10.4102/hts.v73i3.4512.         [ Links ]

Witthuhn, J. and C. S. le Roux. 2017. "Factors that enable and constrain the internationalisation and Africanisation of Master of Public Health programmes in South African higher-education institutions." AFRICAN JOURNAL OF HEALTH PROFESSIONS EDUCATION 9(4): 208-211. https://doi.org/10.7196/AJHPE.2017.v9i4.839.         [ Links ]

Wong, S. H. M., F. Gishen, and A. U. Lokugamage. 2021. "'Decolonising the Medical Curriculum': Humanising medicine through epistemic pluralism, cultural safety and critical consciousness." LONDON REVIEW OF ED UCATION 19(1). https://doi.org/10.14324/LRE.19.1.16.         [ Links ]

Zappas, M., B. Walton-Moss, C. Sanchez, J. A. Hildebrand, and T. Kirkland. 2021. "The Decolonization of Nursing Education." JNP-JOURNAL FOR NURSE PRACTITIONERS 17(2): 225-229. https://doi.org/10.1016/j.nurpra.2020.11.006.         [ Links ]

Zidani, S. 2021. "Whose pedagogy is it anyway? Decolonizing the syllabus through a critical embrace of difference." MEDIA CULTURE and SOCIETY 43(5): 970-978. https://doi.org/10.1177/0163443720980922.         [ Links ]

 

 

APPENDICES

APPENDIX A: SEARCH TERMS

 

 

APPENDIX B: SEARCH STRATEGIE

DATABASE 1 : Scopus (Results: 89)

(TITLE-ABS-KEY (decolonise OR decolonize OR decolonisation OR decolonization OR decolonising OR decolonizing OR Africanisation OR Africanization OR decolonial OR democratization OR democratisation) AND ALL (transform OR transformation OR renew OR renewal OR renewing OR change OR revision OR intervention OR mediate OR deconstructing OR revolution OR transition OR diversity OR development OR adjustment OR reversal OR modification OR diversification OR remodelling OR reconstructing OR reconstruction OR change) AND ALL (curriculum OR curricula OR pedagogy OR pedagogic OR pedagogical OR pedagogies OR educational AND program OR syllabus OR module OR course OR program AND strategy OR guideline OR guidelines OR framework OR action OR approach OR blueprint OR design OR tactics OR method OR planning AND higher AND education OR college OR university OR post-secondary OR postsecondary OR undergraduate OR graduate OR tertiary AND health AND science OR health AND sciences OR health) AND TITLE-ABS-KEY (health AND science OR health AND sciences OR health OR education) AND PUBYEAR > 2014 AND PUBYEAR > 2014

DATABASE 2: EBSCOhost Research Databases (56 Results)

https://nwulib.nwu.ac.za/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=eric&bquery=TI+(+Decolonise+or+decolonize+or+Decolonisation+or+decolonization+or+Decolonising+or+Decolonizing+or+Africanisati on+or+Africanization+or+decolonial+or+democratization+or+democratisation+)+AND+(+Transform+or+Transformation+or+renew+or+renewal+or+renewing+or+change+or+revision+or+intervention+or+mediate+or+deconstructin g+or+revolution+or+transition+or+diversity+or+development+or+adjustment+or+reversal+or+modification+or+diversification+or+remodelling+or+reconstructing+or+reconstruction+or+change+)+AND+(+Curriculum+or+curricula+ or+pedagogy+or+pedagogic+or+pedagogical+or+pedagogies+or+educational+program+or+syllabus+or+module+or+course+or+program+)+AND+(+Strategy+or+guideline+or+guidelines+or+framework+or+action+or+approach+ or+blueprint+or+design+or+tactics+or+method+or+planning+or+model+)+AND+(+Higher+education+or+college+ or+university+or+post-secondary+or+postsecondary+or+undergraduate+or+graduate+or+tertiary+)+AND+AB+(+Health+Science+or+Health+Sciences+or+health+or+education+)&cli0=DT1&clv0=201501-000001&type=1&searchMode=Standard

DATABASE 3: Web of science (Results 168)

decolonised or decolonized or Decolonisation or decolonization or Decolonising or Decolonizing or Africanisation or Africanization or decolonial or democratization or democratisation (Title) and Transform or Transformation or renew or renewal or renewing or change or revision or intervention or mediate or deconstructing or revolution or transition or diversity or development or adjustment or reversal or modification or diversification or remodelling or reconstructing or reconstruction or change (All Fields) and Curriculum or curricula or pedagogy or pedagogic or pedagogical or pedagogies or educational program or syllabus or module or course or program (All Fields) and Strategy or guideline or guidelines or framework or action or approach or blueprint or design or tactics or method or planning or model (All Fields) and Higher education or college or university or post-secondary or postsecondary or undergraduate or graduate or tertiary (All Fields) and Health Science or Health Sciences or health or education (Abstract) | 168 results

| Timespan: 2015-01-01 to 2022-07-07 (P

DATABASE 4: Pubmed (Results 48 results)

((((((Decolonise[Title] OR decolonize[Title] OR Decolonisation[Title] OR decolonization[Title] OR Decolonising[Title] OR Decolonizing[Title] OR Africanisation[Title] OR Africanization[Title] OR decolonial[Title] OR democratization[Title] OR democratisation[Title]) AND (Transform or Transformation or renew or renewal or renewing or change or revision or intervention or mediate or deconstructing or revolution or transition or diversity or development or adjustment or reversal or modification or diversification or remodelling or reconstructing or reconstruction or change)) AND (Curriculum or curricula or pedagogy or pedagogic or pedagogical or pedagogies or educational program or syllabus or module or course or program)) AND (Strategy or guideline or guidelines or framework or action or approach or blueprint or design or tactics or method or planning or model)) AND (Higher education or college or university or post-secondary or postsecondary or undergraduate or graduate or tertiary)) AND (Health Science[Title/Abstract] OR Health Sciences[Title/Abstract] OR health[Title/Abstract] OR education[Title/Abstract])) AND (("2015"[Date - Publication] : "3000"[Date - Publication]))

DATABASE 5: EBSCOhost

Searching: APA PsycArticles, APA PsycInfo, Applied Science & Technology Source, CINAHL with Full Text, eBook Collection (EBSCOhost), E-Journals, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition, MEDLINE, Newspaper Source, Teacher Reference Center

Results 122, EBSCOhost removes duplicates before downloading: Results 96

https://nwulib.nwu.ac.za/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=pdh&db=psyh&db=aci&db=c8h&db=nlebk&db=eoah&db=eric&db=hxh&db=hch&db=cmedm&db=nfh&db=trh&bquery=TI+(+Decolonise+or+decolonize+or+Decolonisation+or+decolonization+or+Decolonising+or+Decolonizing+or+Africanisation+or+Africanization+or+decolonial+or+democratization+or+democratisation+)+AND+(+Transform+or+Transformation+or+renew+or+renewal+or+renewing+or+change+or+revision+or+intervention+or+mediate+or+deconstructing+or+revolution+or+transition+or+diversity+or+development+or+adjustment+or+reversal+or+modification+or+diversification+or+remodelling+or+reconstructing+or+reconstruction+or+change+)+AND+(+Curriculum+or+curricula+or+pedagogy+or+pedagogic+or+pedagogical+or+pedagogies+or+educational+program+or+syllabus+or+module+or+course+or+program+)+AND+(+Strategy+or+guideline+or+guidelines+or+framework+or+action+or+approach+or+blueprint+or+design+or+tactics+or+method+or+planning+or+model+)+AND+(+Higher+education+or+college+or+university+or+post-secondary+or+postsecondary+or+undergraduate+or+graduate+or+tertiary+)+AND+AB+(+Health+Science+or+Health+Sciences+or+health+or+education+)&cli0=DT1&clv0=201501-000001&type=1&searchMode=Standard

DATABASE 6: ProQuest (Results 83)

ti(Decolonise OR decolonize OR Decolonisation OR decolonization OR Decolonising OR Decolonizing OR Africanisation OR Africanization OR decolonial OR democratization OR democratisation) AND (Transform OR Transformation OR renew OR renewal OR renewing OR change OR revision OR intervention OR mediate OR deconstructing OR revolution OR transition OR diversity OR development OR adjustment OR reversal OR modification OR diversification OR remodelling OR reconstructing OR reconstruction OR change) AND (Curriculum OR curricula OR pedagogy OR pedagogic OR pedagogical OR pedagogies OR educational program OR syllabus OR module OR course OR program) AND (Strategy OR guideline OR guidelines OR framework OR action OR approach OR blueprint OR design OR tactics OR method OR planning OR model) AND (Higher education OR college OR university OR post-secondary OR postsecondary OR undergraduate OR graduate OR tertiary) AND ab(Health Science OR Health Sciences OR health OR education)

 

APPENDIX C: DATA EXTRACTION FORM

 

 

APPENDIX D: RESULTS OF INDIVIDUAL SOURCES OF EVIDENCE

 

 

APPENDIX E: CHARTED DATA