Saudi Cultural Missions Theses & Dissertations
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Item Restricted A Mixed Methods Study to Determine the Organisational and Health Care Professionals’ Barriers and Facilitators of Timely Initiation of Insulin Among People Living with Type 2 Diabetes Mellitus in Saudi Arabia(Saudi Digital Library, 2026) Alsayed, Shatha; Winkley, Kirsty; Duaso, MariaBackground: Delayed initiation of insulin therapy is a recognised clinical challenge for People living with type 2 diabetes mellitus (PLWT2D) worldwide, including in the Kingdom of Saudi Arabia (KSA), where 23.1% of adults have diabetes (IDF, 2024). Despite clinical need, insulin initiation is frequently delayed by up to five years (Gavin et al., 2023). Organisational and professional drivers of this delay are poorly understood in KSA. Aim: To investigate organisational and healthcare professional (HCP) barriers and facilitators to timely insulin initiation for PLWT2D in KSA and identify priority areas for improvement. Methods: A sequential exploratory mixed-methods design, underpinned by the Theoretical Domains Framework (TDF), was employed across three phases: (1) systematic review of 14 studies from the Middle East and North Africa (MENA) region; (2) qualitative multiple-case study involving semi-structured interviews (n=28) and document analysis (n=13) at two Saudi hospitals; and (3) national cross-sectional survey of HCPs (n=287). Qualitative data were analysed using the Framework method. Quantitative data were analysed using descriptive statistics, one-way ANOVA, independent samples t-tests and multiple linear regression. All findings were integrated and aligned to TDF domains. Results: Three consistent barriers emerged across all phases: insufficient HCP training, time and educational constraints, and patient adherence concerns. The survey identified educational and time constraints (mean [M]=3.35, standard deviation [SD]=1.30) and patient adherence concerns (M=3.34, SD=1.13) as the most prominent barriers. Regression analysis revealed that working in a private hospital (β = 0.311, p< 0.001), male gender (β=0.135, p=0.018) and higher patient load (β=0.140, p=0.045) were associated with perceived barriers. Facilitators, including institutional support and diabetes specialist access, were rated low across settings. Conclusion: Barriers to timely insulin initiation in KSA operate across individual, interpersonal and systemic levels. Interventions addressing HCP training, standardised clinical pathways and institutional support are needed to optimise insulin initiation for PLWT2D in KSA.11 0Item Restricted Biochemical changes of the insulin molecule due to functionalized surfaces: An investigation from a therapeutic perspective(Saudi Digital Library, 2025) Fagihi, Megren; Bhattacharjee, SouravInsulin therapeutics is the cornerstone in current diabetes management, especially while treating Type I diabetes. However, being a protein, insulin is known to demonstrate agglomeration when subjected to alterations in its biochemical environment, such as acidity, temperature fluctuation, coming in contact with hydrophobic surfaces, and agitation. This thesis describes a detailed and systematically designed study to investigate the curious case of insulin agglomeration, understand the mechanism(s) that drive such agglomeration, and realize the therapeutic impacts of such insulin agglomeration. To begin with, a detailed literature survey was conducted on insulin agglomeration, with or without fibrillation, and converge the available knowledge into a single discourse, which is presented as the Chapter 1 (introduction) of this thesis. This literature survey was followed by four experimental chapters (Chapters 2–4) where through a range of systematic and consistent experimental approach the phenomena of acidity-, heating-, and hydrophobic surface-induced insulin agglomeration was investigated. To characterize the insulin agglomerates, a broad range of analytic platforms, such as transmission and scanning electron microscopy, circular dichroism, nanoparticle tracking analysis, and zeta potential were used. Additionally, this thesis work also exploited the promise of advanced optical microscopy platforms, such as the confocal laser scanning microscopy and fluorescence lifetime imaging microscopy to probe the agglomerates and identify the varied segments of fluctuating acidity inside them. Taken together, the data was able to provide vital information on insulin agglomeration with a mechanistic understanding of what drives such agglomeration. An in vitro study was also conducted (Chapter 3) to find out if the insulin agglomerates generated due to heating at high temperatures (50°C and 65°C) were bioactive, and the results came positive. The Chapter 5 then explains another in vitro study where fluorophore-labeled insulin uptake in human hepatocellular carcinomaderived HepG2 cells was investigated with confocal microscopy. Finally, Chapter 6 summarized the findings, provide a few additional perspectives on overall realizations made through these studies, and prioritized some lines of research for future explorations.11 0Item Restricted Nurses’ Competency in the Provision of Diabetes Self-Management Education to Hospitalised Patients in Saudi Arabia(Saudi Digital Library, 2025) Algharash, Hassan; Lynette, Cusack; Rebecca, MuntDiabetes is a significant chronic condition, and one of the ten most common causes of mortality globally. The population of Saudi Arabia has a high rate of diabetes, placing an enormous burden on the healthcare system. Therefore, when the Saudi Arabian government launched the 2030 Vision, one of the main components was to improve the quality of life of people with diabetes. People with diabetes need to self-manage their chronic condition by maintaining their blood glucose levels within a target range to reduce the risk of developing diabetes-related complications. Therefore, it is essential that they receive diabetes self- management education. Nurses in acute care settings, such as medical and surgical wards, are in a position to provide opportunistic diabetes self-management education to inpatients with diabetes. Specialist diabetes educators are not available to inpatients in many hospitals within Saudi Arabia. Therefore, nurses in hospitals must be competent in both diabetes management and patient education to enhance patients’ quality of life. The aim of this study was to understand the attitudes, knowledge and skills of nurses working in Saudi Arabian Ministry of Health hospitals to undertake diabetes self-management education for inpatients, and the facilitators and/or barriers to providing diabetes self- management education to inpatients. The competency in delivering health and patient education framework was employed to guide the study. This framework brings together nurses’ knowledge, skills and attitudes in both their management of diabetes and in delivering patient education. A sequential explanatory mixed- methods design was utilised where quantitative data were collected and analysed first, informing the qualitative data collection and analysis. In the first phase, a paper-based questionnaire was distributed to nurses working in medical and surgical wards in four Saudi Arabian hospitals, attracting 157 responses. The data were analysed using descriptive statistics and multiple linear regression. In the second phase, 12 nurses participated in semi- structured interviews. The qualitative data were analysed using inductive content analysis. The results from both phases were then integrated using a joint display approach. The survey results focused on diabetes management revealed that nurse respondents have outdated knowledge and skills. However, nurse respondents indicated they felt confident and had a positive attitude towards managing inpatients with diabetes. The study also found nurse respondents had a good understanding of and a positive attitude towards inpatient education. In the qualitative phase three main categories were identified: 1) barriers to providing inpatient education, 2) barriers to acquiring diabetes management knowledge, and 3) enablers of providing diabetes self-management education. Data integration highlighted that there are significant environmental factors that are barriers to nurses providing diabetes self-management education to inpatients, such as lack of access to continuing professional development, limited time, an absence of higher management support and lack of patient education resources. To ensure nursing care aligns with the 2030 Vision, nursing leaders must be proactive to address the suboptimal diabetes knowledge and skills, and the environmental barriers to providing effective patient education. Without addressing the current barriers, the quality of care of patients with diabetes will continue to be compromised.44 0Item Restricted The Association of Patient Portal Engagement with Critical Diabetes Care Indicators and Healthcare Utilization Among Adults with Type 2 Diabetes(Saudi Digital Library, 2025) Altamimi, Mujahid M; Imes, Christopher CType 2 diabetes mellitus (T2DM) remains a significant health problem that is increasing in prevalence. Despite recent advances in drug development and well-publicized guidelines for glycemic, blood pressure (BP), and cholesterol management, achieving the major goals of T2DM remains suboptimal. Patient portals can facilitate disease self-management by allowing patients to access and interact with their health records and communicate with their health care providers. Patient portals provide patients with T2DM the information and tools needed to achieve goal hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-c), and BP measurements. Methods This project aimed to comprehensively evaluate the long-term effects of patient portal use on critical T2DM care indicators (HbA1c, LDL-c, and BP assessed using mean arterial pressure [MAP]) and healthcare utilization metrics over four years of follow-up. A retrospective observational cohort study of patients with T2DM treated at UPMC was conducted. Propensity score matching was used to create comparable high and low portal engagement groups. Linear mixed-effect modeling was used to examine the longitudinal association between portal engagement and critical T2DM care indicators. Further, a comprehensive portal feature analysis and its association with improved HbA1c over time were completed using linear mixed-effect modeling. Negative binomial regression modeling was employed to evaluate the association of patient portal use with the utilization of the healthcare system. Results The study included 96,391 patients and identified 10,573 (11%) high-engagement users. This group, compared to 21,146 matched low-engagement users, was predominantly female (53 vs 51%), White (90 vs 82%), and exhibited a more favorable socioeconomic profile. Engaged portal users presented with lower baseline HbA1c (7.4 vs 7.7%) and a greater number of prescriptions (27 vs 25). The longitudinal analysis revealed a modest yet statistically significant negative association between portal engagement and HbA1c affecting both the baseline and the rate of change over time (P<0.01). The analysis of LDL-c showed an association between higher portal engagement and improved LDL-c trajectories (P<0.01). No significant association was found between MAP and portal use. The portal features of clinical data review and patient-provider communication had the strongest associations with better glycemic control. Portal use was also associated with significantly higher outpatient encounters but lower emergency visits. Discussion Patient portal engagement can lead to modest but meaningful improvements in HbA1c and LDL-c for patients with T2DM. These improvements assist patients in meeting treatment goals and potentially reduce the risk of complications. The proactive care pattern among engaged users can lead to consistent management of T2DM, limit complications, and ultimately lead to potential cost savings for both patients and the healthcare system. Future research should explore the development and testing of new portal functionalities and include patients and nurses in the process of design and implementation of new portal features.25 0Item Restricted Understanding the influence of ethnicity on medicines adherence(Newcastle University, 2025-05) Asiri, Rayah; Husband, Andy; Todd, Adam; Robinson-Barella, AnnaDiabetes is a significant global public health issue, resulting in serious and costly complications and reduced life expectancy. Adherence to prescribed medication is an essential component of diabetes management to obtain optimal outcomes. Understanding the factors influencing adherence is key to optimising adherence to antidiabetic medication. One factor that has yet to be studied in this context is ethnicity and given the increased incidence of diabetes in certain ethnic groups, it is important to establish if or how adherence to diabetes medication varies by ethnic group (Chapter 1). A systematic review of the existing quantitative literature was conducted to explore whether medication adherence to antidiabetic medications in people with diabetes varied by ethnicity (Chapter 2). Most of the included studies showed statistically significant disparities in adherence among different ethnic groups, with minority ethnic groups in high-income countries often reporting the lowest rates. A second systematic review (meta ethnography) was undertaken to synthesise the existing qualitative data to explore the barriers to and facilitators of adherence to antidiabetic medications experienced by people from minority ethnic communities in high-income countries (Chapter 3), revealing a gap in the literature concerning ethnicity-related factors from the perspectives of both minority ethnic communities and the majority within the context of socioeconomic deprivation. Chapters 4 and 5 detail two qualitative studies conducted in socioeconomically deprived settings in the United Kingdom and Saudi Arabia. The UK study (Chapter 4) explored the perspectives of people from South Asian and White British ethnic backgrounds in the North East of England. The results identified a range of barriers and facilitators, with some shared by both groups and others unique to the South Asian participants, including a preference for alternative medicine, certain religious-related beliefs and practices, social stigma associated with the condition, and unawareness of free prescription availability. The Saudi Arabian study (Chapter 5) involved participants from South Asian and Saudi Arabian backgrounds, highlighting a range of barriers and facilitators—some shared across both groups and others unique to each ethnic community. This research identified several factors influencing adherence, including ethnicity related and socioeconomic influences, as well as personal and healthcare system-related factors; these findings should inform the development of tailored interventions (Chapter 6).29 0Item Restricted Blood Glucose Monitoring Devices and Digital Biomarkers in Diabetes: Effectiveness, Utilisation and Challenges: A Systematic Review(King's College London, 2024-10-09) Al Hamdan, Janah Abdullah; Lu, LeiAbstract Introduction: Diabetes management has advanced with the introduction of digital biomarkers and blood glucose monitoring (BGM) devices, offering new avenues for improving glycemic control. This systematic review evaluates the effectiveness, utilisation, and challenges of these technologies in diabetes management. Methodology: A comprehensive search was conducted in PubMed, Medline, and Embase for studies published between 2014 and 2024. Eligible studies involved adult patients (aged ≥18) with diabetes using wearable or body-mounted devices for glucose monitoring. The review included continuous glucose monitoring (CGM) systems (e.g., Dexcom, Medtronic), flash glucose monitoring (FGM) systems (e.g., Freestyle Libre), and self-monitoring of blood glucose (SMBG) devices. A total of 27 studies were included, comprising RCTs, observational studies, pilot studies, interventional studies, and quasi-experimental studies. Results: CGM systems demonstrated significant improvements in glycemic control, with reductions in HbA1c ranging from 0.6% to 1.1% and improvements in time in range (TIR) from 43% to 59%. FGM systems showed an average HbA1c reduction of 0.44% and a significant decrease in hypoglycemic events, particularly nighttime hypoglycemia (a 0.29-hour reduction, p=0.0001). While SMBG proved effective for real-time glucose monitoring, it showed lower adherence rates and a limited impact on long-term glycemic outcomes compared to CGM and FGM. Across studies, CGM outperformed FGM and SMBG in minimising glycemic variability (GV) (27% vs 29%, p=0.05) and improving patient satisfaction. However, challenges related to device cost, accessibility, and adherence, particularly for SMBG, remain prevalent. Conclusion: CGM and FGM offer substantial benefits over traditional SMBG, particularly in reducing HbA1c, improving TIR, and decreasing hypoglycemic events. While these advanced glucose monitoring systems provide significant clinical advantages, barriers such as cost and complexity must be addressed to ensure broader adoption and improved health outcomes for diabetes patients globally27 0Item Restricted Understanding Lipohypertrophy in Diabetes(King's College London, 2024) Almunif, Dina; Jha, PrashantLipohypertrophy (LH) is a significant complication of insulin therapy affecting approximately 25-41.8% of diabetes mellitus patients. This qualitative study investigates patients' and healthcare professionals' (HCPs) attitudes toward LH and insulin injection practices. Through online focus groups and interviews involving 11 patients and 10 HCPs, the research explores the prevalence and risk factors LH. Key findings reveal that modifiable risk factors, including improper injection practices like site non-rotation and needle reuse, significantly contribute to LH development. The research emphasizes the critical need for comprehensive patient education, improved HCP training, and technological advancements in insulin delivery. Recommendations include developing structured education programs, investing in advanced delivery technologies, conducting large-scale research, and creating targeted interventions for high-risk populations. This study provides crucial insights into LH management, advocating for a proactive approach to prevent complications, improve patient outcomes, and reduce healthcare system costs.19 0Item Restricted Physiological and Biochemical Differences between Diabetes Type 1 and Diabetes Type 2(University of New England, 2017-10-20) Almutairi, Majed; Farlane, JimThe expression "diabetes" is gotten from the ancient Greek word 'diabainen', which means ‘go through’, to show the too much passage of urine from the kidney. Until the 1600s it was not included, nonetheless, that Willis included the expression "mellitus" ('sweet') to recognize this condition from an unreasonable production of non-sweet urine (diabetes 'insipidus')(Poretsky, 2010). Just about 200 years after the fact (1776), Dobson showed that sweet taste of urine wasbecause of an abundance of sugar in blood and urine. Another 100 more years were needed to demonstrate the pathogenesis of diabetes mellitus. In 1889, von Mering and Minkowski showed that pancreatectomised dogs created manifestations of diabetes, thus first time connecting diabetes surprisingly to a particular organ. In 1910, Sharpey-Schafer recommended that diabetic peoples were inadequate in a substance created in the pancreatic islets (found in 1869 by Langerhans) and called it 'insulin'; in this manner, a connection between the pancreas, insulin and diabetes was begun to develop and thus modern period of diabetes study started. It was just in 1921, in any case, that a more exact picture developed: Banting, Macleod and Best demonstrated that diabetes in pancreatectomised dogs could be turned around after the intravenous organization of the "islet" extracted from typical canine ancreata. Then, Best, Banting and Collip refined this substance from bovinepancreata, and the first patient was effectively treated in 1922, bringing about a decrease in blood glucose as well as glycosuria. In 1926, MacLean recommended a difference between 'hepatic glycosuria' and 'genuine diabetes'. After ten years, Himsworth, compressing his past research, recognized 'insulin-dependent' and 'insulin-independent' diabetes mellitus, with the last more treacherous condition portrayed by less serious hyperglycaemia. In the 1950s, a solid estimation of circling insulin with a radioimmunoassay system permitted a reasonable difference between 'insulin-dependent' and 'insulin-independent' diabetes mellitus, and the worldview of two pathophysiologically distinct disordersturned out to be increasingly clear in the folowing years (Zaccardi, Webb, Yates, & Davies, 2016).48 0Item Restricted Platelet glucose metabolism-impact of diabetes(University of Leeds, 2023-12-21) Alotaibi, Reem; Naseem, KhalidGlucose metabolism is crucial for providing platelets with adequate ATP to do their functions properly. Little is known about platelet glucose uptake and the role of the first rate-limiting glycolytic enzyme, hexokinase (HK), in the regulation of platelet activation. Glucose uptake in response to platelet agonists, thrombin and convulxin (CVX), increased in a dose and time-dependent manner. Focusing on signalling downstream of glycoprotein VI (GPVI), it was found that inhibition of signalling enzymes SFKs, Syk, or PI3K linked to this receptor significantly decreased platelet glucose uptake, combined with reduced P-selectin expression. Glucose uptake was found to be independent to integrin activation, but interestingly required ADP signalling and, to a lesser extent, TxA2 signalling. Using immunoblotting and immunoprecipitation, we found that HK I and II are expressed in human and murine platelets, with HK I equally localised in cytosol and mitochondria and HK II was exclusively found in membrane fraction. Blocking HK activity with three different HK inhibitors revealed that HK plays an important role in glucose transport into platelets upon platelet activation with CVX. Functional studies have shown that HK may play a role in GPVI-mediated platelet aggregation and activation, αIIbβ3, and P-selectin expression. Platelet activation with CVX caused an increase in HK activity, which required SFKs, Syk, and PI3K/Akt pathways. These data suggest that HK plays a key, but poorly defined, role in GPVI-mediated platelet activation. Next, the effect of diabetes on platelet glucose uptake was examined. Type1 diabetes mellitus was induced in mice using Streptozotocin (STZ) injection. C57BL/6J male mice aged 8-12 weeks received STZ intraperitoneally (50 mg/kg body weight;3 days). After confirming diabetes, glucose uptake studies demonstrated that glucose uptake was basally high in diabetic mice compared to vehicle control. Further, this increase in glucose uptake was also associated with increased mitochondrial membrane potential in diabetic mice compared to vehicle group (hyperpolarisation). Correlation analysis revealed a strong positive association between fasting blood glucose levels and platelet glucose uptake upon activation in STZ mice. These data suggest that glucose metabolism is altered in diabetes. In conclusion, these studies suggest that platelet activation regulates platelet glucose metabolism by regulating GLUT3 expression and HK activity.34 0Item Restricted Adherence Therapy Intervention for People with Type 2 Diabetes(Saudi Digital Library, 2022-12) Alenazi, Fatimah; Gray, Richard; Peddle, Monica; Bressington, DanielBackground: Adults with type 2 diabetes (T2D) mellitus encounter several challenges during treatment, including inconsistent medication taking. Many interventions addressing medication taking and treatment plans are safe and effective; however, none is more effective than others. Adherence therapy (AT), a brief structured psychological intervention, is a promising candidate for improving medication taking in people with T2D. The primary aim of this PhD thesis was to establish the feasibility of a randomised controlled trial of AT in the Middle Eastern context. Methods: This thesis consists of five studies adopting different methodologies. Two systematic reviews focusing on people with T2D were conducted; the first was on adherence interventions, and the second was on the effectiveness of AT in improving the consistency of medication taking. Considering the Middle Eastern context, a cultural adaptation study and a feasibility trial of AT for people with T2D were conducted. Finally, qualitative research as a component of the feasibility trial was performed. Results: A range of adherence interventions was identified during the first systematic review, but none was the most effective. No trials met the inclusion criteria. However, for the second systematic review, four trials evaluating interventions with components similar to AT were identified. These components were positively associated with improved medication use and sticking to treatment plans for diabetes. Culturally, AT was shown to be generally appropriate in the Middle Eastern context, but modifications are needed to improve its acceptability and effectiveness. Finally, a full-scale trial of AT in people with T2D was shown to be feasible after adopting the recommended amendments. Conclusions: This study contributes to knowledge by establishing a sound scientific basis for conducting a randomised controlled trial of AT; however, the protocol for such a trial conducted within a Middle Eastern context requires careful consideration.16 0