Saudi Cultural Missions Theses & Dissertations
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Item Restricted The Experiences of Psychological Well-Being Amongst Paramedics During The COVID-19 Pandemic(Saudi Digital Library, 2025) Alalhareth, Musalli; Peters, RosemaryParamedics are critical frontline healthcare providers during emergencies. However, they often work in high-stress environments with a myriad of challenges, which affect their psychological wellbeing. The COVID-19 pandemic intensified these challenges, potentially worsening the paramedics’ mental health. Yet paramedics’ psychological experiences remain underexplored compared to other healthcare workers. This study sought to systematically review literature on the psychological wellbeing of paramedics during the COVID-19 pandemic to identify stressors, coping mechanisms, and assess the role of organizational support. The review synthesized four analytical themes. On the theme of psychological issues, it emerged that paramedics faced high rates of stress, anxiety, PTSD, emotional exhaustion, and depersonalization. Major stress and risk factors included fear of infection, inadequate PPE, long shifts, social stigma, leadership failures, and poor communication. The study identified various protective factors and coping mechanisms including personal resilience, humor, exercise, therapy, supportive leadership, peer support, and incentives. However, some used maladaptive strategies like alcohol overuse. There was substantial variation of experience by role and context. Student and less-experienced paramedics, and older staff faced more severe impacts while frontline paramedics experienced higher distress compared to second responders. This study makes several recommendations for improving the mental wellbeing of paramedics during emergencies. Organizations should improve communication, ensure PPE supply, provide psychological screening, promote healthy coping strategies, and tailor support by role and demographic. Educational institutions should integrate stress management and ethics training into paramedics’ curricula. Strategic interventions are vital for enhancing resilience and reducing attrition in future public health crises.13 0Item Restricted Machine Learning Accelerated Antibody Ranking and Extracellular Vesicle Engineering for Antiviral and Anticancer Immunotherapeutics(Saudi Digital library, 2025) Almubarak, Hannah; Liu, HuipingOne of the most pressing challenges in modern medicine is the development of therapeutics that can effectively counter rapidly evolving biological threats, including infectious pathogens and cancer cells. In response to the growing need for adaptable and potent treatments, we present a series of innovations that leverage machine learning and extracellular vesicle (EV) engineering to overcome therapeutic resistance and enhance immune targeting. To address the challenge of viral escape in fast-mutating pathogens like SARS-CoV-2, we have developed a machine learning-assisted antibody generation pipeline (AbGen) powered by an antibody language model (AbLM). AbGen enables high-throughput screening and redesign of IgGs with broad neutralization capacity against wildtype and emerging variants, including Delta and Omicron. To further overcome variant-mediated antibody evasion, we have engineered EV- presented IgG (evIgG), an innovative EV-based therapeutic platform that displays anti-spike IgG antibodies on the EV surface, achieving exceptionally high loading efficiency. evIgG shows over 150-fold enhanced neutralization efficacy against Omicron BA.5 compared to soluble IgG through maintaining ultra-high binding affinity and resisting dissociation due to multivalent cooperative interactions. Notably, evIgG effectively blocks pulmonary BA.5 viral amplification in hACE2- transgenic mice, highlighting its therapeutic potential in vivo. Extending this EV-based engineering strategy to oncology, we have explored the use of tumor-derived extracellular vesicles (TEVs) as cancer vaccines. TEVs, enriched with tumor- specific neoantigens, elicit robust anti-tumor immune responses in a murine melanoma model, significantly reducing tumor burden and prolonging survival. These findings highlight the potential of TEVs as a promising platform for anticancer immunotherapies. Together, these studies establish a transformative framework for therapeutic development combining AI-driven prioritizations with EV-based delivery systems to combat immune evasion in infectious diseases and cancer. This integrative approach offers precision-targeted solutions to some of the most complex challenges in clinical medicine.11 0Item Restricted Impact of Social Isolation During the COVID-19 Pandemic on Student Stress Levels(Saudi Digital Library, 2025) Altukhaifi, Abdulaziz Mohammed; Busch, RobertAims: The COVID-19 pandemic led to global restrictions, creating a long period of isolation that significantly impacted the mental health of people, particularly students. This study focused on investigating whether increased social isolation during the COVID-19 lockdown was associated with elevated stress levels among students, with a specific focus on perceived loneliness. It also examined whether living situations during lockdown influenced these experiences. Methods: A cross-sectional, quantitative survey design was employed. Fifty-nine students from the University of Roehampton retrospectively completed an online questionnaire assessing their experiences during the 2020-2021 lockdown period. The COVID-19 student stress questionnaire (CSSQ) and UCLA Three-Item Loneliness Scale (TILS) were used to measure perceived stress and loneliness. Descriptive statistics, Pearson correlation, Linear regression, and one-way ANOVA were used to analyse the data. Results: There was a significant positive correlation between loneliness and stress (r = 0.562, p < 0.0001), with loneliness accounting for approximately 31.6% of the variance in stress scores. However, one-way ANOVA showed that there are no statistically significant differences in stress or loneliness based on the living situation. Conclusions: the study demonstrates that perceived loneliness, rather than living situations, was a strong predictor of stress in students during lockdown. These findings highlight the importance of emotional support over social conditions and suggest that schools should prioritise and apply strategies that enhance social belonging and emotional support, especially during crises. This research enriches the available literature on student wellbeing and adds valuable insights into future mental health interventions.16 0Item Restricted Visual Public Health Communication Strategies: A Case of The Saudi Ministry of Health During The COVID-19 Pandemic(Saudi Digital Library, 2025-08-26) Omar, Afnan; Osman, IdilThis study investigates the visual public health communication strategies employed by the Saudi Ministry of Health (MoH) during the COVID-19 pandemic, focusing on how cultural elements such as traditional Saudi values and collective cultural norms influenced the interpretation of visual messaging. It also examines the impact of Saudi Arabia’s broader national development Vision 2030 on these visual communications. This study explores how the MoH’s strategies not only addressed the immediate health crisis but also conveyed cultural and political messages. It analyses how visual representations of COVID 19 messages reflected and interacted with prevailing cultural norms and ideological perspectives. The study relies on two main data sources: content from the official Twitter account of the Saudi MoH, and semi-structured interviews with key MoH personnel, including decision-makers, elites, and designers. A qualitative research methodology was adopted. The multimodal social-semiotic (MSS) approach was applied to the visual Twitter content, while thematic analysis was used for the interview data. The dataset comprised nine visual Twitter posts and interviews with 20 Ministry of Health participants. Findings reveal that the MoH used visual communication not only for public health messaging but also to promote sociocultural values such as tradition, social responsibility, and community cohesion supporting Saudi Arabia’s collectivist cultural framework. Political figures were prominently featured as “role models” visually reinforcing hierarchical state authority and limiting the emphasis on participatory public engagement. Additionally, the study uncovers the strategic use of imagery associated with modernisation and social reform, particularly gender representation and women’s empowerment, reflecting alignment with Vision 2030’s goals for national transformation. The study concludes that sociocultural visual elements were deliberately employed during the pandemic to advance both health awareness and broader national agendas, contributing to an understanding of visual public health communication in a sociocultural context.10 0Item Restricted A quantitative and qualitative analysis of medicines use by care home residents with dementia during the COVID-19 pandemic(Saudi Digital Library, 2025) Alsulami, Nawaf; Barry, Heather; Hughes, CarmelThe COVID-19 pandemic disproportionately affected residents with dementia, and may have exacerbated existing medication challenges for them, due to restrictions on visiting, staff absences, and an increased prevalence of non-cognitive symptoms. The aim of this thesis was to examine medicines use by care home residents with dementia during the COVID-19 pandemic. Care home managers’ experiences of optimising medicines for residents with dementia were explored through semi-structured interviews (n=14), followed by cross-sectional, questionnaires (n=215). A documentary analysis of medicines management inspection reports (n=278) was conducted to assess the extent to which care homes met the arrangements and measures of medicines management. A retrospective observational study was conducted using the Enhanced Prescribing Database and other data sources to investigate the prevalence and patterns of dispensing of psychotropic medications, over a five-year period (2018 – 2022) among residents with dementia (n=7,544). Care home managers described an overwhelming sense of isolation for them and their residents during the pandemic with increased burden on their staff and residents. Medication reviews were disrupted and issues with communication were reported. Survey data highlighted the dissatisfaction that care home managers felt when accessing health services, lack of medication review and face-to-face contact with healthcare professionals, and changes in modes of communication and consultation. Inspection reports highlighted that robust arrangements were not in place in some care homes with respect to prescribing, administration, monitoring and review of medicines. Changes in dispensing of some classes of psychotropic medications among residents with dementia were observed during the pandemic: dispensing of antipsychotic medications increased, particularly in males and those aged ≥85 years, whilst dispensing of antidepressant medications decreased. The research presented in this thesis has provided an understanding of the short-term effects of the COVID-19 pandemic on medicines optimisation for residents with dementia, and adds to the growing evidence base in this area.10 0Item Restricted Quality of life among brain injury patients before, during, and after COVID-19 pandemic(Saudi Digital Library, 2025) Alkhthiri, Shaden; Seiss, EllenIntroduction: Acquired Brain Injury (ABI) has many physical, cognitive, and emotional difficulties. The COVID-19 pandemic significantly disrupted rehabilitation services for ABI patients. This research project is aimed at studying the impact of the pandemic on quality of life for ABI patients, specifically the effect of injury type (TBI vs. mTBI) and sex. Method: The current study was a retrospective cohort study, which utilised secondary data from 767 patients with an acquired brain injury (ABI) who were referred to ABI rehabilitation services (ABIRS) in Dorset (UK) from 2018 to 2024. Patients completed a quality of life questionnaire using a 36-item short-form health survey (SF-36). The data were grouped into three time periods: pre, during, and post-pandemic, and were analysed descriptively using ANOVA and non-parametric pairwise comparisons. Results: Throughout the pandemic, patients with ABI had notable improvements in physical and social functioning, and a reduction in pain level, as opposed to the periods before and after the pandemic. However, once societal restrictions were lifted, these improvements returned to pre-pandemic levels. Female patients reported lower quality of life in all domains except role limitation physical and emotional. mTBI patients faced more challenges with energy and pain compared to TBI patients. No meaningful interactions were determined between injury type, sex, and COVID-19. Discussion: The pandemic provided a temporary opportunity for an improved quality of life, likely to a decrease in social pressures and obligations, but this was short-lived after the end of the pandemic, highlighting the need for flexible rehabilitation service options. Female and mTBI patients had worse outcomes, emphasising the importance of considering injury type and sex in intervention plans. The current study suggests developing tele-rehabilitation options and a flexible care model, which could lead to better outcomes after ABI rehabilitative services.5 0Item Restricted Understanding Breathlessness Including Breathing Pattern Disorder in Adults Following a Hospital Admission With COVID-19(Saudi Digital Library, 2025) ٍAlmulhim, Saja; Evans, RachaelUnderstanding breathlessness including breathing pattern disorder in adults following a hospital admission with COVID-19 Saja Abdulaziz Almulhim Introduction SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection caused a global pandemic in March 2020 to May 2023. This resulted in a syndrome termed Long COVID. Long COVID is a patient derived term for ongoing symptoms for greater than four weeks after SARS -Cov-2 infection. Breathlessness is one of the most prevalent persistent symptoms of Long COVID. It has been hypothesized that some breathlessness after COVID-19 could be related to Breathing Pattern Disorder (BPD). Aims This thesis aims to understand breathlessness including breathing pattern disorder in adults following a hospital admission with COVID- 19. Three main study designs were undertaken. 1. A systematic review and meta-analysis to explore interventions for breathlessness. 2. A prospective cross-sectional study to investigate the contribution for BPD in people with and without breathlessness post COVID -19. 3. An exploratory study to investigate the underlying physiology contributing to exertional breathlessness in adults with and without breathlessness post COVID -19 hospital admission using Cardiopulmonary Exercise Testing (CPET) with Optoelectronic polysomnography (OEP). Results The systematic review showed that breathing exercises has no significant benefit over usual care whereas uncontrolled studies that involved rehabilitation programs demonstrated a positive impact on breathlessness outcomes. The overall evidence from RCTs was inconclusive due to heterogeneity in study design and interventions. Breathlessness in participants with long COVID is associated with higher prevalence of BPD and higher levels of anxiety, and depression symptoms compared to the non-breathless group. However, pulmonary function test was similar in both groups. Breathlessness was also associated with reduced exercise capacity measured by CPET and considerable desynchronization between the ribcage and abdomen compartments detected by OEP during exercise. Conclusion Breathing pattern disorder is a major contributor to breathlessness in patients with long COVID, particularly among those with normal lung function. This emphasizes the importance of a comprehensive rehabilitation approach that addresses both the physical and psychological dimensions of breathlessness to enhance outcomes for patients with long COVID.8 0Item Restricted Visual Public Health Communication Strategies: A Case of The Saudi Ministry of Health During The COVID-19 Pandemic(Saudi Digital Library, 2025) Omar, Afnan; Osman, IdilThis study investigates the visual public health communication strategies employed by the Saudi Ministry of Health (MoH) during the COVID-19 pandemic, focusing on how cultural elements such as traditional Saudi values and collective cultural norms influenced the interpretation of visual messaging. It also examines the impact of Saudi Arabia’s broader national development Vision 2030 on these visual communications. This study explores how the MoH’s strategies not only addressed the immediate health crisis but also conveyed cultural and political messages. It analyses how visual representations of COVID 19 messages reflected and interacted with prevailing cultural norms and ideological perspectives. The study relies on two main data sources: content from the official Twitter account of the Saudi MoH, and semi-structured interviews with key MoH personnel, including decision-makers, elites, and designers. A qualitative research methodology was adopted. The multimodal social-semiotic (MSS) approach was applied to the visual Twitter content, while thematic analysis was used for the interview data. The dataset comprised nine visual Twitter posts and interviews with 20 Ministry of Health participants. Findings reveal that the MoH used visual communication not only for public health messaging but also to promote sociocultural values such as tradition, social responsibility, and community cohesion supporting Saudi Arabia’s collectivist cultural framework. Political figures were prominently featured as “role models” visually reinforcing hierarchical state authority and limiting the emphasis on participatory public engagement. Additionally, the study uncovers the strategic use of imagery associated with modernisation and social reform, particularly gender representation and women’s empowerment, reflecting alignment with Vision 2030’s goals for national transformation. The study concludes that sociocultural visual elements were deliberately employed during the pandemic to advance both health awareness and broader national agendas, contributing to an understanding of visual public health communication in a sociocultural context.30 0Item Restricted The application of the Necessity-Concerns Framework in understanding inappropriate demand for antibiotics in upper respiratory tract infections and COVID-19 vaccine hesitancy(Saudi Digital Library, 2024) Almeshal, Nouf; Horne, Rob; Chan, Amy; Foot, HollyThe National Institute for Health and Care Excellence (NICE) Medicines Adherence Guidelines recommend personalised support to address both practical issues, enhancing patients’ abilities and perceptions that influence motivation to engage with, and adhere to treatment. The perceptions and practicalities approach (PaPA) operationalises key adherence-related beliefs through the Necessity-Concerns Framework (NCF). The NCF proposes that adherence is influenced by patients’ perceptions of their personal need for medication relative to concerns about adverse consequences. Studies across diseases, cultures, and healthcare systems have demonstrated the validity of the NCF in explaining variation in treatment engagement. This PhD thesis aims to examine the application of the NCF to address two behavioural challenges related to respiratory illnesses: vaccine hesitancy and demand for antibiotics to treat upper respiratory tract infections (URTIs). The research includes a scoping review of determinants influencing patients’ demand for antibiotics, a qualitative study involving patients with URTIs, a cross-sectional survey investigating beliefs about antibiotics and AMR, a review of COVID-19 vaccine hesitancy literature, a cross-sectional cohort survey examining differences in beliefs between COVID-19-vaccinated and unvaccinated individuals, and an exploratory analysis of the antecedents of beliefs about COVID-19 vaccine necessity and concerns. The scoping review identified patient demand as an important driver of unnecessary antibiotic prescriptions, influenced by factors that shape the perceived need for antibiotics and are associated with low concerns regarding their use. The qualitative study (n=32) identified determinants influencing perceived need for antibiotics (e.g., type and severity of symptoms) and concerns (e.g., frequent administration of antibiotics), impacting inappropriate demand for and unnecessary use of antibiotics. The cross-sectional study (n=1105) found that intention to request antibiotics was significantly predicted by beliefs about antibiotic necessity (β=0.475, p<0.001), and concerns (β=-.133, p<0.001). The COVID-19 vaccine hesitancy literature review was suggestive of the applicability of the NCF as an effective framework to understand and address this public health issue. The following cohort cross-sectional survey (n = 1012) reported that beliefs about vaccine necessity outweighed concerns about the vaccine and strongly predicted vaccination decisions [OR=1.616, 95% CI (3.001, 8.440)]. This research highlighted the adaptability of the NCF as a theoretical framework for comprehending inappropriate demand for antibiotics and COVID-19 vaccine hesitancy. The findings indicate the potential applicability of a reverse NCF approach in understanding and addressing inappropriate antibiotic demand. It further identified that COVID-19 vaccine hesitancy demonstrated patterns commonly observed in medication non-adherence, specifically characterised by low perceived necessity and increased concerns regarding treatment. The thesis findings potentially laid the foundation that the NCF can effectively inform the design of interventions targeting vaccine hesitancy and patients’ inappropriate demand for antibiotics in the management of URTIs.17 0Item Restricted The application of the Necessity-Concerns Framework in understanding inappropriate demand for antibiotics in upper respiratory tract infections and COVID-19 vaccine hesitancy(Saudi Digital Library, 2024) Almeshal, Nouf; Rob, Horne; Amy, Chan; Holly, FootThe National Institute for Health and Care Excellence (NICE) Medicines Adherence Guidelines recommend personalised support to address both practical issues, enhancing patients’ abilities and perceptions that influence motivation to engage with, and adhere to treatment. The perceptions and practicalities approach (PaPA) operationalises key adherence-related beliefs through the Necessity-Concerns Framework (NCF). The NCF proposes that adherence is influenced by patients’ perceptions of their personal need for medication relative to concerns about adverse consequences. Studies across diseases, cultures, and healthcare systems have demonstrated the validity of the NCF in explaining variation in treatment engagement. This PhD thesis aims to examine the application of the NCF to address two behavioural challenges related to respiratory illnesses: vaccine hesitancy and demand for antibiotics to treat upper respiratory tract infections (URTIs). The research includes a scoping review of determinants influencing patients’ demand for antibiotics, a qualitative study involving patients with URTIs, a cross-sectional survey investigating beliefs about antibiotics and AMR, a review of COVID-19 vaccine hesitancy literature, a cross-sectional cohort survey examining differences in beliefs between COVID-19-vaccinated and unvaccinated individuals, and an exploratory analysis of the antecedents of beliefs about COVID-19 vaccine necessity and concerns. The scoping review identified patient demand as an important driver of unnecessary antibiotic prescriptions, influenced by factors that shape the perceived need for antibiotics and are associated with low concerns regarding their use. The qualitative study (n=32) identified determinants influencing perceived need for antibiotics (e.g., type and severity of symptoms) and concerns (e.g., frequent administration of antibiotics), impacting inappropriate demand for and unnecessary use of antibiotics. The cross-sectional study (n=1105) found that intention to request antibiotics was significantly predicted by beliefs about antibiotic necessity (β=0.475, p<0.001), and concerns (β=-.133, p<0.001). The COVID-19 vaccine hesitancy literature review was suggestive of the applicability of the NCF as an effective framework to understand and address this public health issue. The following cohort cross-sectional survey (n = 1012) reported that beliefs about vaccine necessity outweighed concerns about the vaccine and strongly predicted vaccination decisions [OR=1.616, 95% CI (3.001, 8.440)]. This research highlighted the adaptability of the NCF as a theoretical framework for comprehending inappropriate demand for antibiotics and COVID-19 vaccine hesitancy. The findings indicate the potential applicability of a reverse NCF approach in understanding and addressing inappropriate antibiotic demand. It further identified that COVID-19 vaccine hesitancy demonstrated patterns commonly observed in medication non-adherence, specifically characterised by low perceived necessity and increased concerns regarding treatment. The thesis findings potentially laid the foundation that the NCF can effectively inform the design of interventions targeting vaccine hesitancy and patients’ inappropriate demand for antibiotics in the management of URTIs.4 0