Saudi Cultural Missions Theses & Dissertations
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Item 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.9 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.1 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.27 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.14 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.2 0Item Restricted Quality of Accounting Information, Corporate Governance, and Economic Crises: Evidence from the Asia-Pacific Countries(Saudi Digital Library, 2025) Basahi, Ahmed; Chand, ParmodEconomic crises pose significant challenges to financial systems, affecting corporate performance, accounting practices, and governance structures globally. During crises, accounting information’s relevance and earnings quality often come under scrutiny as firms face financial stress and managers grapple with meeting performance expectations. This amplifies the importance of reliable and transparent financial reporting. This thesis explores the multifaceted impact of such crises on the quality of accounting information, corporate governance mechanisms, and firm value, focusing on the Asia-Pacific region. Specifically, it delves into how economic disruptions, like the COVID-19 pandemic, influence the value relevance of accounting information and earnings quality, as well as how corporate governance can serve as a stabilising factor, influencing firm value and mitigating the adverse effects of economic shocks. By examining the Asia-Pacific, the thesis provides a unique perspective on a region marked by institutional diversity and significant economic influence. The overarching aim of this thesis is to enhance the understanding of how economic crises impact accounting, with a particular focus on the Asia-Pacific region. This region, with its diverse institutional frameworks, regulatory environments, and financial systems, provides a fertile ground for examining this issue. The first paper investigates the effects of economic crises on the value relevance of accounting information in 14 major Asia-Pacific economies. Using a comparative analysis of pre-pandemic and pandemic periods, the study reveals a significant decline in the explanatory power of accounting information during the pandemic. Institutional factors, such as investor protection, legal systems, and financial systems, are shown to moderate this relationship. The findings underscore the importance of regional diversity in shaping how accounting information is utilised by investors during periods of economic instability, offering actionable insights for policymakers and regulators. The second paper provides a comparative analysis of earnings quality during two major economic crises: the 2008 global financial crisis (GFC) and the COVID-19 pandemic. The results reveal that earnings quality deteriorated during both crises. Interestingly, the results also reveal that the GFC had a more significant impact on accrual-based earnings management when compared with COVID-19, although COVID-19 had a more severe effect on economies. This highlights the role of improved regulatory reforms and accounting standards in recent years in the Asia-Pacific region in limiting accounting manipulation. By comparing these distinct crises, the paper advances the understanding of how financial and operational challenges impact earnings quality in diverse economic contexts. The final paper examines the influence of corporate governance on firm value in the Asia- Pacific region, emphasising the moderating effect of economic conditions. The findings demonstrate that robust country-level governance and firm-level corporate governance, including board size, board independence, and audit committee independence, positively affect firm stock performance. Furthermore, their positive effects become more evident during times of economic uncertainty, such as during COVID-19. By illustrating the protective role of governance mechanisms during economic downturns, this paper offers critical insights for fostering resilience in firms facing volatile environments. Taken together, the findings of the three papers collectively emphasise the critical interplay between economic crises and accounting information quality and the important role of governance systems in enhancing firm resilience during periods of economic uncertainty. By conducting a comprehensive cross-country analysis, the thesis enhances our understanding of the implications of economic conditions on the accounting profession and provides valuable insights into the broader implications of economic uncertainty on corporate decision-making, investor behaviour, and financial transparency.28 0Item Restricted Assessing Dental Patients' Acceptance and Trust of Dentists in COVID-19-related Services: A Cross-Sectional Study(Saudi Digital Library, 2025) Alzunaydi, Ayoub; Aguilar, Maria L; Psoter, Walter JBackground: Dentists have traditionally been underutilized in public health crises, despite their clinical expertise and trusted role within communities. The COVID-19 pandemic highlighted the need for an expanded healthcare workforce, yet the extent to which dental patients trust and accept dentists providing pandemic-related services remains unclear. Objective: This study aimed to assess dental patients’ acceptance and trust in dentists conducting COVID-19 testing, vaccination, and public health communication while examining the influence of demographic and insurance-related factors. Materials and Methods: A cross-sectional, self-administered, structured questionnaire-based study was conducted at multiple clinics within the University of Florida College of Dentistry. A total of 150 adult dental patients participated, providing self-reported responses on their trust in dentists discussing COVID-19 topics and their acceptance of dentists administering COVID-19 services. Data were analyzed using descriptive statistics and logistic regression to identify associations between demographic variables and trust levels. Results: Trust in dentists discussing COVID-19 topics was high, particularly for face masking (85.4%) and COVID-19 disease (76.4%), but was lower for discussing vaccination (70.2%). Patient acceptance of dentists administering COVID-19 vaccines was divided, with 51% expressing comfort and 49% expressing hesitancy. Private insurance holders were significantly less trusting of dentists in administering COVID-19-related services, while Medicare recipients exhibited the highest levels of trust. Age trends suggested older individuals were more trusting, while demographic variables such as sex, race, and ethnicity were not statistically significant predictors of trust. Conclusion: These findings highlight the potential role of dentists in public health crises beyond traditional oral healthcare. While dentists are trusted for public health communication, hesitancy in accepting them as vaccine providers suggests a need for further public education and policy reinforcement. Recognizing dentists as part of the frontline healthcare workforce could enhance healthcare system resilience in future crises.23 0Item Restricted Impact of the COVID-19 pandemic on labour market outcomes in the UK(University of Leeds, 2025-03) Abugamza, Amwaj; Howdon, Daniel; Martin, Adam; Charlwood, AndyThis thesis investigates changes in labour market outcomes and their links to physical and mental health. It uses the exogenous nature of the COVID-19 pandemic as a unique opportunity to compare pre- and post-pandemic periods through four studies. Study One, a systematic review, assessed international literature up to January 2022 on COVID-19's effects on employment. It critically evaluated the methodological tools used in prior research and provided recommendations for improved study design. The review identified key moderators, mediators, and confounders using a theoretical diagram (DAG). Following these recommendations, Study Two employed Interrupted Time Series analysis using UK Office for National Statistics (ONS) data (up to June 2023) to investigate changes in key labour market outcomes following two policy interventions: the COVID-19 lockdown and the final stage of easing lockdown restrictions. The results show that the initial disruption caused by the lockdown was followed by a recovery in employment as restrictions were lifted, but a persistent rise in economic inactivity, which became the focus of the two final studies. Study Three used the UK Household Longitudinal Study (UKHLS), showing that being aged 50–66 (OR= 2.18, 95% CI: 1.53, 3.10) and reporting long-standing illness (OR= 1.44, 95% CI: 1.12, 1.84) were statistically significant predictors of transitioning from pre-pandemic employment to post-pandemic economic inactivity. This transition was associated with higher psychological distress. Study Four focused on individuals aged 50–66 and explored why economic inactivity has risen. It found that the prevalence of reported poor health increased among this age group post-pandemic, suggesting that rising economic inactivity is driven by deteriorating health rather than changes in propensities of healthy or unhealthy people leaving the labour force after the pandemic. It also compared ONS and UKHLS data to explore concerns about the reliability of government statistics. This thesis identified key drivers of economic inactivity in the UK post-COVID-19 and their links to health, highlighting policy interventions to support people in remaining in or returning to work.10 0Item Restricted RISK MANAGEMENT IN THE HOSPITALITY SECTOR DURING TIMES OF CRISIS.(Saudi Digital Library, 2025-07-17) Alanazi, Abdulrahman; Samaradheera, AmaThis research explores how the Ritz-Carlton Hotel in Saudi Arabia managed risks during the COVID-19 pandemic. The study investigates the effectiveness of health and safety protocols, identifies operational challenges, and evaluates risk management strategies implemented during the crisis. Using a qualitative methodology based on interviews with hotel managers, the study highlights the role of emergency response teams, digital innovations, and employee welfare in maintaining operational resilience. Key findings emphasize the importance of crisis communication, proactive scenario planning, and mental health support in the hospitality sector. Recommendations are made to enhance future preparedness and sustainability in hotel operations during crises.16 0