Saudi Cultural Missions Theses & Dissertations
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Item Restricted Assessment of Immunotherapy-Related Adverse Events Among Patients with Cancer in Saudi Arabia: A Mixed Methods Study(Queensland university of techonology, 2024) Alquzi, Fatimah; Bradford, NatalieThis thesis contributes significantly to cancer care by focusing on patients undergoing immunotherapy in Saudi Arabia. it is the first study to explore the challenges these patients face, offering valuable insight into their experience. the research translated and validated an immunotherapy assessment tool and assessed its real world use by evaluating its acceptability, feasibility, and clinical utility. this study deepens the understanding of immune related adverse events and provide critical perspectives for clinicians, patients, and researcher. Ultimately, it contributes to improving the management of adverse events in cancer immunotherapy. Background: Cancer is a rapidly growing healthcare system challenge, with more than 19.3 million incidences recorded globally in 2020; this is projected to surpass 29.5 million by 2040. The emergence of immunotherapy has positively changed many advanced cancer outcomes and improved survival rates. Despite immunotherapy being an efficacious and reliable treatment option for cancer, its success is tempered by associated immune-related adverse events (irAEs). Limited understanding of proactive irAE assessment further complicates this issue. Patient Reported Outcome (PRO) measures are standardised tools used to systematically collect data from patients about their health status, symptoms, functioning, and well-being, and are increasingly advocated for use in routine clinical care. However, their use in clinical care, and more specifically to assess irAEs and symptoms, is an understudied area. Objectives: To investigate the feasibility, acceptability, and usefulness of systematic assessment of irAEs from the perspectives of patients with cancer living in Saudi Arabia. Methods: The doctorate project involved five inter-related studies, underpinned by the theory of Symptoms Experience in Time (SET), a conceptual framework aimed at understanding the temporal dynamics of symptom manifestation and progression. In Study 1, a systematic literature review was completed. A comprehensive search strategy was employed to identify relevant literature on symptom assessment and management strategies related to irAEs in cancer patients. The review identified a PRO tool developed specifically for irAEs to assess 20 symptom and six interference items. In Study 2, the PRO tool identified for irAEs assessment from the review underwent robust translation from English into Arabic using the Brislin translation method. This involved forward and backward translations, consensus committees with health experts and linguists, and iterative adjustments to ensure linguistic accuracy and cultural appropriateness. Study 3 was an observational study undertaken in Saudi Arabia to evaluate the psychometric properties of the tool among Saudi Arabian cancer patients undergoing immunotherapy. The assessment involved mixed methods, including cognitive interviewing to assess item clarity and relevance, content validity and test–retest reliability analysis, and a post-assessment feedback survey to assess acceptability. Study 4 was a prospective observational cohort study over four weeks that investigated the feasibility, acceptability, and usefulness of the translated tool to assess irAEs and symptom experiences of patients undergoing immunotherapy for cancer in Saudi Arabia. Finally, in Study 5, a subset of participants from Study 4 participated in in-depth semi-structured interviews, which were analysed using qualitative content analysis. Results: Study 1: The systematic literature review identified a suitable PRO tool for assessing diverse irAEs among cancer patients undergoing immunotherapy. The review also identified gaps in evidence, including the unclear frequency of symptom assessment and the role of non-pharmacological approaches for managing mild irAEs. In Study 2, the PRO tool was translated, creating the Arabic version of the tool: the Arabic Immunotherapy Symptom Assessment Inventory (AISAI). Study 3 evaluated the psychometric properties of the AISAI, which demonstrated content validity, reliability, linguistic precision, and cultural relevance. The Cronbach’s alpha coefficients for the internal consistency were calculated as 0.90 for the 20 symptom items and 0.88 for the interference scale, indicating satisfactory reliability. The test–retest reliability, assessed through intraclass correlation coefficients (ICC), showed excellent agreement between Time 1 and Time 2, with ICC values above 0.90. In Study 4, a real-world, 4-week evaluation involving a cohort of 69 patients undergoing cancer immunotherapy treatment was completed. The feasibility and acceptability of administering the AISAI were high, with 97.1% affirming its acceptability and applicability. The five most prevalent and severe symptoms, based on mean scores, were: numbness or tingling; pain; rash or skin change; interference with general activity; and impaired walking. Over the 4- week immunotherapy period, there was a notable increase in the severity of symptoms, with statistically significant changes observed. The number of participants with moderate (score 4–6) and severe (score 6–10) symptoms increased, indicating a worsening pattern over time. In Study 5, a qualitative evaluation affirmed that the AISAI was perceived as a valuable tool for early recognition and assessment of irAEs, with a preference for routine usage. The evaluation also highlighted knowledge gaps, emphasising the need for educational interventions to enhance comprehension and management capabilities among patients. Conclusion: This thesis represents a novel contribution to the field, particularly in the context of cancer patients undergoing immunotherapy treatment in Saudi Arabia. It introduces an innovative approach by incorporating PROs in Saudi Arabia. This marks a significant advancement in the assessment practices related to irAEs. Notably, it is the first study to explore the experience of irAEs in Saudi Arabia using PRO, providing a comprehensive understanding of the challenges faced by these patients. Moreover, this research pioneers the investigation of the use of the AISAI in real-world settings for cancer patients undergoing immunotherapy. It assesses the tool’s acceptability, feasibility, and usefulness, shedding light on its practical implications in the clinical setting. The research contributes a valid and comprehensive tool, the AISAI, designed specifically for assessing irAEs in Arabic cancer patients. This research makes a valuable contribution to clinicians, patients, and researchers, enhancing the overall understanding and approach to assessment of adverse events in the context of cancer immunotherapy.13 0Item Restricted Novel Approaches to the Assessment and Management of Granulomatous Lymphocytic Interstitial Lung Disease (GLILD)(University College London, 2024) Bintalib, Heba; Hurst, John; Burns, SiobhanIntroduction: Granulomatous-lymphocytic interstitial lung disease (GLILD) is generally considered a manifestation of systemic immune dysregulation occurring in up to 20% of people with common variable immunodeficiency disorders (CVID). GLILD is associated with increased morbidity and mortality and presents a significant diagnostic and management challenge. There is a lack of evidence-based guidelines of GLILD despite its clinical significance. This thesis aimed to bridge knowledge gaps, offering new insights and methods to improve GLILD assessment and management. Methods: Several methods are employed. First, an international research prioritization exercise was conducted based on methodology developed by the James Lind Alliance. Subsequently, a systematic review was undertaken to summarise the current literature on diagnostic approaches in GLILD. Additionally, a national data analysis focusing on non-infectious complications (NICs) in CVID patients with and without GLILD was conducted to assess the variation in clinical features and the risk factors associated with this condition. Moreover, a clinicians survey was conducted to evaluate the current practice regarding lung biopsy in the work up of GLILD. A retrospective analysis was undertaken to assess three treatment regimens at our centre. Finally, a prospective study was conducted to evaluate the utility of the 6-minute walk test (6MWT) in GLILD. Results: The international research prioritization exercise identified key areas for future research. The systematic review suggested that high-resolution computed tomography (HRCT) and lung biopsy were required for definitive diagnosis of GLILD, emphasizing the need for standardized diagnostic criteria. In the CVID cohort with NICs, chronic lung diseases, particularly GLILD, were predominant, with lymphadenopathy associated with GLILD. The clinician survey underscored the complexity of diagnosing GLILD and highlighted varied opinions on the necessity and effectiveness of lung biopsies. Treatment outcomes varied, with corticosteroids demonstrating inducing remission but presenting challenges in long-term management, while mycophenolate showed promise in disease stabilization and corticosteroid sparing. Functional assessments, particularly the 6MWT and the King's Brief Interstitial Lung Disease (K-BILD) questionnaire, were valuable measures with good reproducibility in GLILD patients. Conclusion: This thesis contributes significantly to the understanding and management of GLILD in CVID. By addressing critical research priorities, elucidating diagnostic challenges, evaluating treatment modalities, and integrating functional assessments. Our findings inform clinical practice and guide future research. Ultimately, our efforts aim to improve patient outcomes and promote international collaboration.13 0Item Restricted Pronunciation assessment: Investigating the role of lexical stress error categories in distinguishing proficiency and comprehensibility levels(Iowa State University of Science and Technology, 2024-06-19) Alnafisah, Mutleb; Levis , John; Ockey, GaryLexical stress has been shown to be a good predictor of proficiency levels and raters’ comprehensibility ratings, as higher levels of proficiency and higher ratings of comprehensibility tend to show fewer lexical stress errors. Yet, there is psycholinguistic evidence to suggest that not all lexical stress error categories are equal insofar as nonstandard shifts inducing a change in vowel quality are more impactful than mis-stress with only suprasegmental alterations, and rightward shifts are more damaging than leftward shifts. To date, however, assessment practices and research have generally treated lexical stress as a static and unitary feature. To address this gap, this dissertation study quantitatively investigates the degree of association between IELTS spoken proficiency levels and comprehensibility ratings with the English Word Stress Error Gravity Hierarchy (Ghosh & Levis, 2021), a predictive model of lexical stress error categories and comprehensibility that considers vowel quality and directionality of misplaced lexical stress. It also compares three groups of raters (native English speakers vs. non-native English speakers from a stress-based language vs. non-native English speakers from a tonal language) to examine if the L1 stress phonological system is a source of variance in compressibility ratings. Qualitatively, the study employed raters’ retrospective written reports to assess the saliency of lexical stress when assigning scores and a think-aloud protocol to examine what categories of lexical stress errors raters perceive as problematic. Fifty-seven L2 speakers completed IELTS-style and summary-argument tasks. Four trained raters rated their performances using the IELTS rubric for spoken proficiency, and 15 experienced raters (5 Chinese, 5 Native, and 5 Saudi) rated their comprehensibility and provided written reports regarding the salient features that affected their comprehensibility scoring. Following the rating sessions, three raters participated in a think-aloud protocol. L2 speakers’ performances were annotated using a hybrid approach incorporating Praat acoustic cues of lexical stress and human visual inspection of these cues to identify which syllable received primary stress. Evidence from correlational analyses revealed that categories of errors encompassing vowel changes were more severely linked to deterioration of proficiency and comprehensibility ratings, and while stress categories encompassing no segmental alterations were not associated with proficiency, they correlated with comprehensibility but with a small magnitude. The importance of directionality was found to be only contingent upon the presence of a vowel change. Subsequent univariate ANOVA analyses showed that the measures significantly correlated with proficiency and comprehensibility differentiated High- from Mid- and Low-level speakers but not Mid- and Low-level speakers, a pattern that held for both constructs. Additionally, results showed that raters, to a good extent, uniformly reacted to measures of lexical stress errors. Qualitatively, raters’ written reports indicated that lexical stress was a salient feature to all rater groups, and the think-aloud protocols generally supported quantitative findings. To this end, a modification of the Hierarchy for assessment purposes is presented.21 0Item Restricted Investigating Computer Aided Assessment of Mathematical Proof by Varying the Format of Students’ Answers and the Structure of Assessment Design by STACK(University of Edinburgh, 2024-03-18) Alarfaj, Maryam Khalid H; Sangwin, ChristopherStudents are increasingly being expected to use Computer Aided Assessment (CAA) systems as support for traditional courses. Assessing a full mathematical proof in an educational context and providing feedback and other outcomes to students is currently well beyond the capabilities of CAA systems. One possible approach to assessing students’ answers has been to break up larger tasks into smaller individual steps to which automatic assessment can then be applied. However, the method of marking depends on the format of a mathematical response. This thesis aims to investigate the effectiveness of different formats in computer aided assessment of mathematics. A format effect occurs when the format of an exercise affects the rate of successful outcomes of the exercise. Having established the need to study the format effect when writing mathematical arguments particularly online, I consider three formats for writing open-ended questions: two-column, typing, and Separated Concerns. The first of three studies explored the impact of the two-column format in writing simple mathematical arguments. In conducting this research, I developed a coding scheme to describe and analyse the structure of individual mathematical arguments. The second study focused on the difference and the format effects between uploading handwritten and typing in writing mathematical responses. Another outcome of this study is to provide a further application of using the coding scheme on analysing students’ arguments. The third study focused on updating STACK potential response tree based on Separated Concerns. STACK is a System for Teaching and Assessment using a Computer algebra Kernel, is an open source computer aided assessment system for mathematics, and other STEM subjects. Separated Concerns is a phrase used to describe materials in which potential misconceptions are addressed directly. In this study, I focused exclusively on students’ responses, and misconceptions in learning proof by induction using STACK. Mathematical induction is used as a vehicle to illustrate the idea of Separated Concerns. The main goal of the third study is to understand how engagement with learning materials packaged into online quizzes to replace live lectures, a “lecture quiz”, related to success on the weekly assessed quiz, and the course total. A second goal of the third study is to explore the common mistakes made by students when using online materials to prepare for mathematical induction. This study also illustrates how to use research to update the algorithms which assess students’ answers, known as “STACK potential response trees”, in questions written to support learning mathematical induction based on Separated Concerns.64 0Item Restricted Assessment of Clinical Competence: Implementation of the Objective Structured Clinical Examination (OSCE) in Saudi Medical Schools(University of Leeds, 2023-02-08) Almisnid, Khaled; Homer, MatthewAssessment of clinical skills is essential in determining the competency of health professionals. The Objective Structured Clinical Examination (OSCE) is a performance assessment tool that is widely adopted for this purpose. Despite its widespread use in Saudi medical schools, the implementation and impact of the OSCE in Saudi Arabia (SA) have not been widely investigated. The aim of this research is to provide an in-depth understanding of OSCE usage in Saudi medical schools, the opportunities and challenges offered by its adoption, and to develop recommendations to improve implementation. Using a qualitative constructivist philosophy, this research employs a case study design in two different Saudi medical schools, integrating document review with interviews and focus groups with medical school leaders and their Faculty. Reflexive thematic analysis and codebook methods were applied to interviews/focus groups and documents, respectively. The analysis generated a series of key themes that impacted the OSCE implementation in Saudi medical schools. These themes constitute a conceptual framework that requires careful consideration in order for them to function harmoniously to produce a high-quality OSCE. This research also highlights that each stage of OSCE implementation in the investigated medical schools involves a series of dilemmas and compromises. Analysis suggests that funding sources (public or private schools), accreditation status, faculty experience, and resource availability all influence the quality of OSCE implementation. The research findings are consistent with the international OSCE literature; however, this work brings new insights into the use of the OSCE in SA, a non-western culture, and sheds light on the integrative nature of the factors that contribute to successful implementation. It concludes with a series of recommendations that individual medical schools and organisational networks can employ to improve the OSCE in SA, and beyond.37 0Item Restricted IDENTIFYING SUBJECTIVITY AND ENHANCING OBJECTIVITY WITHIN MERCHANT MARITIME SIMULATION-BASED SCENARIO TRAINING(Saudi Digital Library, 2023-12-16) Sendi, Yaser; Audette, Michel; Weisel, Eric; Crompton, Helen; Shen, YuzhongThe main idea behind the Kingdom of Saudi Arabia's vision of 2030 is to be an exemplary and leading nation in all aspects of life, especially in the education and training sectors. Therefore, this project tries to achieve one part of numerous ways to develop the Maritime Educational and Training (MET) scheme by providing seafarers with higher competencies to overcome future hindrances and challenges in less time, lower costs, and prevent loss of lives. The gap in knowledge about subjectivity and objectivity in maritime training is the lack of a suitable methodology for maritime simulation training assessments based on objective assessment approaches, which may decrease assessment accuracy, invalidity, unfairness, unreliability, and misjudgment. This project studies the subjectivity and objectivity in simulation training assessments. It develops objective assessment methodologies for identifying subjectivity and enhancing objectivity using maritime merchant simulators and biometric sensors for thorough, objective assessment processes. Currently, there is limited research on identifying subjectivity in assessments. In addition, there needs to be more focus on the advantages of objective assessment within the merchant maritime simulation training industry to uncover the capabilities of the apprentices in keeping on Situational Awareness (SA) and Decision-Making (DM). Due to unforeseen occurrences during maritime operations, SA and DM are affected by several psychophysiological conditions. The methodological training strategies that comply with the competency levels set forth by the International Maritime Organization (IMO) and The International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers (STCW) to develop competency assessment objectively. The distillation of this project draws attention to the effectiveness of utilizing the proposed methodologies across Maritime Education and Simulation Training Centers (MESTCs) for objective and rigorous training assessment. It provides scenarios with valuable insight into eliminating subjective assessment instances and increasing objective assessment prototypes.18 0Item Restricted Assessment of Interprofessional Education for Undergraduate health-care students: a systematic review and intervention study(Hailah Almoghirah, 2023) Almoghirah, Hailah Abdulrahman A; Illing, Jan; Nazar, HamdeIntroduction: Interprofessional education (IPE) provides health care students and practitioners with the training necessary to be ready to collaborate, and to work effectively in interprofessional teams. It is widely believed that interprofessional working improves the healthcare system and reduces medical errors, thus improving patient safety. Furthermore, it has been suggested that interprofessional training for undergraduates is a useful strategy to improve staff wellbeing and patient care in the future. Aim: The overall aim of this thesis was to design, and test an IPE educational intervention and improve IPE assessment for undergraduate students. Method: A systematic review was conducted to critically appraise IPE assessment tools used for undergraduate IPE. From this review, an IPE Assessment Decision Aid was then developed to help educators select the appropriate IPE assessment tool. The next phase involved the development of a robust, authentic intervention and an evidence based assessment approach based on the systematic review findings. Final year medical students and final and third year pharmacy students were recruited via email to participate in this intervention. Medical and pharmacy students were assigned in pairs to work together online to undertake a hospital discharge process. The IPE intervention was repeated three times using three different patient scenarios. A multi-modality approach to assessment of students was taken to gain a better understanding of student learning and improvement. Quantitative and qualitative data were collected from different sources. Data collected included: a validated scale completed by an interprofessional assessment team, discharge letters completed by students, written feedback provided by the assessment team, student reflections on their performance, and focus groups conducted with the students and the assessment team. Results: Eighteen students (nine from each professional programme) completed the study and a total of 27 IPE sessions were conducted. The assessment team completed 54 Interprofessional Professionalism Assessments (IPA) of the students’ performance, evaluated 27 discharge letters and 31 student reflections, which were received from the eighteen students who participated. Additionally, nine focus groups were conducted with students, and one focus group was conducted with the assessment team. The third IPE iteration showed a statistically significant improvement in students’ interprofessional behaviour. The discharge letter, used as a proxy for patient outcome, also improved over the IPE iterations. Students found the educational sessions useful and relevant. Conclusion: The selection of an appropriate assessment tool is a decision to be taken alongside the conception and design of the IPE intervention. No single IPE tool is suited to all IPE interventions. This PhD project provides educators with a decision aid about which tools might be most appropriate for the purpose of their planned IPE intervention. The developed and implemented intervention and assessment approach illustrated the benefits of repeating the same IPE intervention for students to develop skills and assess improvement. In the assessment, having the opportunity to provide qualitative feedback is important to provide a more global assessment of student performance. This IPE study was distinguished from other IPE studies in its ability to capture the impact of interdependence, as students worked with different partners across each iteration.64 0Item Restricted Diagnostic Validity of Clinical Observations for Detecting Physiologic Swallowing Impairment(2023) Alkhuwaiter, Munirah; Martin-Harris, BonnieThe act of swallowing is characterized as a complex synergy of coordinated movements that serve to protect the airway, generate pressures on and propel a bolus (liquids and foods) through the upper aerodigestive tract from mouth to stomach. Dysphagia, or swallowing problem(s) commonly occur in diseases and conditions that involve the central or peripheral control of swallowing function, or when there is direct injury to the muscles and structures involved in swallowing movement. The incidence of dysphagia in hospitalized patients is high and has shown to be a critical factor in the duration of hospital length of stay and patient survival (Attrill et al., 2018; D. A. Patel et al., 2018). The importance of early identification through timely, accurate and reliable assessment is highly significant to the overall health and well-being of patients who suffer from dysphagia. The clinical assessment of swallowing function involves observational measures of swallowing behavior used as surrogate markers of swallowing impairment. Information obtained from swallowing assessments are life changing for patients. It is essential that we have assessment tools with rigorous methodological quality to optimize the accuracy of our clinical judgement. The results obtained from these tools in combination with medical, social, and environmental factors allow clinicians to make critical decisions about patients’ health and quality of life. Thus, it is crucial that the tools assess what they propose to assess (validity) in a reproducible and consistent manner (reliability) to avoid reporting ambiguity, potential inaccuracies in assessment and selection of treatment and management plans, and gaps in service delivery.7 0