Saudi Cultural Missions Theses & Dissertations
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Item Restricted Knowledge and Acceptability of HPV Vaccination in Countries in the Eastern Mediterranean Region: A Systematic Review(University College London, 2024) Aboalaz, Amirah; Sonnenberg, PamBackground: Human Papillomavirus (HPV) is a significant cause of cervical cancer and may cause other cancers, including anal and penile cancers. Despite the availability of effective vaccines, the level of knowledge and acceptability of HPV vaccination varies widely across different regions. This systematic review focuses on the Eastern Mediterranean Region (EMR) to evaluate the current state of awareness and vaccine acceptability. Methods: A systematic review was conducted following PRISMA guidelines, with a comprehensive search across Embase, Scopus, PubMed, and Web of Science for studies published between January 1, 2008, and March 30, 2024. Inclusion criteria were cross-sectional studies conducted in the EMR that included questions on HPV awareness, vaccine awareness, the link between HPV and cervical cancer, and vaccine acceptability. Studies were assessed for quality using the Joanna Briggs Institute (JBI) critical appraisal checklist. Results: A total of 815 studies were identified and after screening and quality appraisal, a total of 36 studies from 14 countries in the EMR were included. The review revealed low levels of awareness about HPV and its vaccine, with median awareness levels at 35.05% for HPV infection and 31.8% for the HPV vaccine. The median acceptability level for the HPV vaccine was higher, at 54.05%. Knowledge about HPV was found to be correlated with higher vaccine acceptability. Conclusion: The findings highlight the need for targeted public health interventions to improve HPV vaccination knowledge and acceptability in the EMR. Strategies may include robust educational campaigns, integration of HPV education into school curricula, community engagement, and training of healthcare providers. Policy interventions to make the vaccine more accessible and affordable are also crucial. Addressing these challenges through comprehensive and multi-faceted approaches can significantly enhance vaccine uptake and reduce the burden of HPV-related diseases in the region.21 0Item Restricted Economic Evaluations of Sickle Cell Disease-Modifying Therapies in Adult Patients(Howard University, 2024-07) Algatan, Razan; Wingate, La'Marcus T.Throughout history, sickle cell disease (SCD) has faced unequal healthcare treatment, impacting African Americans disproportionately due to difficulties in obtaining high-quality medical services. Although advancements in medicine have resulted in longer lifespans, these improvements may not fully meet the complex requirements of the growing number of elderly individuals dealing with the illness. Objectives: The objectives of this study are to (1) to investigate how the type of insurance influences the use of crizanlizumab and voxelotor in adult patients with SCD; (2) to evaluate the financial burden and therapeutic benefits of SCD therapies in mature individuals; and (3) to determine the financial impact and feasibility of using SCD treatments in U.S. Medicaid programs that have the highest rates of SCD. Methods: A comprehensive review of patient records was undertaken at the adult SCD clinic at Howard University Hospital, spanning from 2019 to 2023. The review focused on patients prescribed crizanlizumab and voxelotor, and extracted demographic data and insurance information. Logistic regression used to predict crizanlizumab or voxelotor usage A cost-utility analysis compared the cost-effectiveness of SCD-modifying therapies to automated red blood cell exchange in adult patients, using a lifetime horizon and taking into account societal costs. This model was then used to estimate the total budgetary impact of these therapies versus automated red blood cell exchange over a one-year period, from the perspective of U.S. Medicaid programs with the highest incidence of SCD, and exploring the potential benefits of an annuity payment model. Results: A total of 54 patients with were included, SCD, with an average age of 39.4 years, and the vast majority were single (90.7%). Notably, patients with dual eligibility had a significantly higher average age (43 years) compared to those with only Medicaid coverage(40 years). After controlling for other factors, the results showed that patients with Medicare coverage were nearly 10 times more likely to receive crizanlizumab compared to those with Medicaid coverage. The cost utility analysis indicated that automated red blood cell exchange (aRBCX) may be a cost-effective strategy compared to other SCD-modifying therapies, with a cost per quality-adjusted life-year (QALY) below $100,000, depending on the severity of SCD and the likelihood of death due to vaso-occlusive crisis. The cost-utility model predicted that hydroxyurea had the lowest lifetime costs, approximately $1,039,311, while voxelotor had the highest, approximately $3,252,674. Also, aRBCX resulted in the highest QALY and the fewest acute pain episodes over a lifetime. In terms of cost-effectiveness, l-glutamine had the lowest incremental cost-effectiveness ratio compared to aRBCX. Furthermore, the analysis demonstrated that voxelotor had the largest annualized budget impact, adding approximately $95,702.40 per patient compared to aRBCX, while hydroxyurea offered significant short-term cost savings of approximately $41,519.23 per patient relative to aRBCX. Conclusions: Medicaid serves as a vital safety net for individuals afflicted with SCD, with roughly half of adult sufferers relying on Medicaid or similar programs for their health insurance needs. Despite this, the adoption of interventions that can alter the course of SCD remains surprisingly limited. In stark contrast, aRBCX has consistently shown more favorable results in adult patients compared to these disease-modifying therapies.18 0Item Restricted Body Weight and Mortality Risk in Community-Dwelling Older Adults(Monash University, 2024-02-21) Alharbi, Tagrid Abdullah; Owen, Alice; Freak Poli, Rosanne; Ryan, Joanne; Gasevic, DanijelaBackground: Overweight and obesity, generally defined by body mass index (BMI) ≥ 25 kg/m² or large waist circumference (abdominal obesity), is increasingly prevalent among older adults worldwide, however studies of excess weight and the link with mortality risk in older adults have reported mixed findings. Weight change may be a better indicator of mortality risk in older individuals, but large community-based longitudinal studies of older individuals are needed. Aims: To systematically review the association between weight change and all-cause mortality risk in adults aged ≥ 65 years, and to examine the association of weight status, abdominal obesity and weight change with the risk of mortality in community-dwelling older adults aged ≥ 65 years. Methods: A systematic review and meta-analysis conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to examined the evidence that weight change (loss, gain and fluctuation, measured by weight or BMI) is associated with all-cause mortality. Secondary data analysis was performed using longitudinal data on community-dwelling individuals from the ESPIRIT (France, N=2,017) and ASPREE/ALSOP sub-studies (Australia, N=14,853). The association of self-reported weight loss, objectively measured weight change (loss and gain), weight status, and abdominal obesity with all-cause mortality over a 17-year follow-up period in the ESPIRIT study was explored using Cox proportional-hazard regression. To broaden understanding of the association between BMI in early (at age 18 years) and later (age ≥70 years) adulthood, and their impact on later-life mortality (over a median of 4.7 years in the ASPREE/ALSOP sub-study), Cox proportional-hazard regression was applied. Furthermore, the socio-demographic, lifestyle, and clinical characteristics associated with change in weight status between early (age 18 years) and late (age ≥ 70 years) adulthood were identified. Results: From the systematic review, weight change, particularly weight loss, was found to be associated with a 59% increased risk of mortality compared to stable weight. Longitudinal data analyses found that abdominal obesity was linked to a 49% increased mortality risk compared to non-abdominal obesity, but being overweight was associated with a 20% decreased risk compared to a normal BMI. Self-reported weight loss of >3 kg at baseline was associated with a 52% increase in mortality risk for men only; but both men and women with ≥ 5% objectively measured weight loss had a 24% increased risk of all-cause mortality. Obesity at 18 years, but not in older age, was associated with a 35% increased risk of mortality in later life. Compared to participants with a normal BMI, obesity at both early adulthood and later life was associated with 99% increase in the risk of all-cause mortality. Obesity in early and/or late adulthood was also associated with a higher risk of adverse clinical risk characteristics. Conclusion: Weight change and weight status are important predictors of mortality risk in older adults. These results highlight the importance of healthcare providers monitoring weight in older adults to detect weight loss at it is early stages, enabling more effective interventions aimed at maintaining stable weight and reducing risk of premature mortality.45 0Item Restricted The interactive effects of juvenile hormone analogs and environmental factors on mosquito phenotypic traits and susceptibility to arbovirus infection(Saudi Digital Library, 2023-09-10) Alomar, Abdullah Abdulaziz; Alto, Barry WilmerEmerging arthropod-borne viruses (arboviruses) are among the most important global public health concerns. Arboviruses, such as Zika virus (ZIKV) have caused explosive epidemics affecting thousands of people worldwide. In the absence of effective antiviral medications, prevention measures rely largely on reducing the number of adult mosquito vectors by targeting juvenile stages. However, a full understanding of the interactive effects of these measures and environmental factors in determining mosquito phenotypic traits and interactions between arboviruses and mosquito vectors is poorly understood. Pyriproxyfen is a juvenile hormone analog (JHA) that primarily blocks adult emergence, by mimicking the natural insect juvenile hormone, and minimally affects larval growth and development. This mechanism of JHA has the potential to act in combination with other larval sources of mortality in nature to affect mosquito populations. Here, we designed a series of experimental manipulations to determine the influence of juvenile exposure to JHA on the Ae. aegypti life-history traits and susceptibility to infection with ZIKV under different environmental factors, including predation and variation in temperature. Concentrations of JHA that cause over 50% inhibition in adult emergence of Ae. aegypti had no effect on adult emergence and lifespan of predatory mosquito Tx. rutilus. Weights of adult Ae. aegypti and Tx. rutilus were not influenced by JHA exposure. The combination of the presence of JHA and Tx. rutilus heavily lowered Ae. aegypti emergence to adulthood more than the independent effects of JHA or Tx. rutilus. Lifespan of adult Ae. aegypti was shortened by exposure to JHA and Tx. rutilus. The effects of JHA on mosquitoes were modulated by temperature. Phenotypic traits (development time, wing size, and adult emergence) and susceptibility to ZIKV infection, dissemination, and transmission were differently influenced by JHA and temperature interactions. These findings suggest that the use of JHA to control mosquito vectors may have low effects on mosquito biocontrol agents, but it may influence adult susceptibility to arboviruses under different environmental conditions. Understanding the ultimate consequences of juvenile mosquito control measures on subsequent adults’ ability to transmit viral pathogens is critical to fully understanding their overall impacts on the epidemiology of arboviruses.22 0Item Restricted Effectiveness and safety of apixaban compared to warfarin in atrial fibrillation by BMI: a non-interventional cohort study using the UK’s Clinical Practice Research Datalink (CRPD)(2022-08-30) Bin Hammad, Turki; Wing, KevinBackground: Current guidelines recommend starting anticoagulation therapy for patients with non-valvular atrial fibrillation (NVAF) and an increased risk of stroke. Warfarin was the anticoagulant of choice for a long period before apixaban showed superiority in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study on the prevention of stroke/systemic embolism and bleeding. However, little is known about their effects on overweight and obese patients compared to normal weight populations, with concerns that obesity might undermine apixaban’s effects because of its fixed dosing across body mass index (BMI) groups. Methods: I emulated a target trial mirroring the ARISTOTLE study using data from the Clinical Practice Research Datalink (CPRD) linked to secondary databases. I estimated the BMI-stratum-specific hazard ratios to investigate the non-inferiority or superiority of apixaban compared to warfarin in NVAF patients in rates of a composite of stroke/systemic embolism (SE) (primary effectiveness outcome) and their individual components or superiority in major bleeding (primary safety outcome) and all-cause mortality. Results: In 51,520 patients, apixaban was non-inferior in all groups of BMI on the composite of stroke/SE with multivariable adjusted hazard ratios (HRs) of 1.11 (95% CI: 0.93, 1.32; p:0.257) in the normal weight, 1.06 (95% CI: 0.90, 1.25; p:0.459) in the overweight and 0.98 (95% CI: 0.83, 1.17; p:0.857) in the obese groups with no evidence of statistical interaction (interaction-p: 0.563). In major bleeding, apixaban was superior in normal weight (HR: 0.79; 95% CI: 0.67, 0.94; p:0.008), overweight (HR: 0.75; 95% CI: 0.64, 0.87; p:<0.001) and obese groups (HR: 0.79; 95% CI: 0.68, 0.91; p:<0.001) with no evidence of interaction (interaction-p: 0.797). Conclusion: In NVAF, BMI was not an effect modifier of the effectiveness and safety of apixaban compared to warfarin. BMI-stratum-specific estimates were consistent in overweight and obese compared to normal weight patients.14 0Item Restricted TOBACCO, ALCOHOL AND HIGH FAT, SALT AND SUGAR FOOD AUDIO-VISUAL CONTENT IN VIDEO ON DEMAND ORIGINAL FILMS AND POPULAR TELEVISED SPORTING EVENTS: IMPLICATIONS FOR PUBLIC HEALTH(Khaldoon Alfayad, 2023-05-12) Alfayad, Khaldoon; Murray, RachaelBackground: Research on the impact of different media is continually developing within the public health field, and audio-visual content has been identified as having potential negative outcomes on viewers through possible contribution to the prevalence of lifestyle behaviours, such as tobacco smoking, alcohol consumption and high fat, sugar and salt (HFSS) food consumption in adults and children. The UK has developed policies to control the accessibility of tobacco and alcohol products since the 1930s, ranging from increased taxes to more stringent advertising restrictions, smoke-free legislation, reinforced health warnings, managing the drinking environment, reducing drunk-driving, and brief interventions and treatment among others. Efforts continue to be made today to lower the number of individuals who engage in harmful use of tobacco and alcohol, including age and marketing controls to reduce advertising exposure to young people. Following these policy interventions, the UK has seen general decreases in tobacco and alcohol consumption among young people. However, the increasing role of media in alcohol and tobacco content exposure is a cause for concern to regulators and public health supporters. The UK government has, however, proposed fewer policies to address increasing levels of obesity in the UK, apart from the Soft Drink Industry Levy and the recently announced watershed ban prohibiting the advertisement of junk food online and before 9pm on TV. The few policies could be because obesity is a multifaceted health issue with no specific contributing factor. Researchers have outlined potential interventions that could help tackle HFSS food consumption, including restrictions on the number of fast-food outlets, reformulation of foods and drinks, and stricter regulation on the advertising of junk food. Limiting advertising on junk food is more important today than ever as HFSS food promotions become increasingly popular on traditional media, such as television and movies, and non-traditional media channels, including sponsored webpages, third-party sites, and social media among related channels. Research on alcohol, tobacco, and HFSS imagery exposure has been previously undertaken. However, limited studies have compared exposure to alcohol, tobacco, and HFSS imagery within the UK-wide population and there is no contemporary data. The aim of this study was to investigate the extent of broadcast media exposure (specifically television, films, and sports sponsorship) of tobacco, alcohol, and HFSS foods in adults and children. Objectives: Specific objectives of the study were to analyse and evaluate tobacco, alcohol, and HFSS contents, as well as estimating population exposure to this content (where viewing data is available). Three content analyses were completed: (1) Netflix and Amazon Prime Video original films released and viewed in 2017. (2) FIFA 2018 Men’s World Cup broadcast by the British Broadcast Corporation (BBC) and Independent Television Network (ITV). (3) FIFA 2019 Women’ World Cup broadcast by the British Broadcast Corporation (BBC) and the Independent Television Network (ITV). Methods: The study started by sampling films on Netflix and Amazon Prime Video for analysis. The study selected the most popular movies on Netflix and Amazon Prime Video watched by audiences across the UK in 2017, according to IMDb rating statistics. Data collected from Netflix and Amazon Prime Video included instances of tobacco, alcohol, and HFSS imagery appearing in 5-minute intervals. Instance of tobacco use were coded based on imagery, or tobacco appearance in the form of outright use, display of tobacco paraphernalia, inferred tobacco use, or brand appearance. The coding categories for alcohol included actual alcohol use which was defined as on-screen consumption of alcohol products. The type of alcohol product, whether beer, wine, champagne, or spirit was recorded during the coding process. The study was also interested in implied use of alcohol, which was interpreted as visible appearance of alcoholic products without outright consumption. The study also coded implied use of alcohol, which referred to verbal references to alcohol, drunken behaviour, and other appearances depicting alcohol use in the films. The coding process documented the type of HFSS product based on the ‘Big Five’ categories: pre-sugared breakfast cereals, confectionery, savoury snacks, soft drinks, and fast-food outlets. All episodes of tobacco, alcohol or HFSS consumption within the 5-minute period were recorded as one event irrespective of the number of appearances within that interval. However, where one episode appeared over a transition between one 5-minute periods to another 5-minute period, it was counted as two separate episodes. However, multiple branding information appearing within a 5-minute interval were counted separately. Data collected were initially recorded using Microsoft Excel prior to analysis using SPSS or Graph Pad Prism statistical software. Cumulative frequencies were used during statistical analysis. The cumulative frequencies were used to determine the number of observations above or below a certain value in the collected data set. The study calculated cumulative frequencies for visuals occurring in five-minute intervals within the selected Netflix and Amazon Prime Video films. Next, the study selected matches for the FIFA 2018 Men’s World Cup and the 2019 Women’s World Cup. For the FIFA 2018 Men’s World Cup, matches involving England, Saudi Arabia, Russia, and the final match were selected for analysis. The matches involving England and the final game were selected since they had the potential of high viewership and were relevant to the UK. Saudi Arabia and Russia were selected due to the strict alcohol promotion regulations in the countries; Russia was also the host country of the FIFA World Cup 2018. For the 2019 Women’s World Cup, all matches from Group D, which included England and the final match were selected for coding due to the likelihood that they would draw high viewership. Group A matches featuring France, except three that were not available, were also selected for coding. After selecting the men’s and women’s matches, all billboard advertisements which occurred during the two halves as well as during the period between the first and the second halves were coded. After watching the matches and encountering the adverts the data has been collected, including the appearance of logos for the selected brands “McDonald’s”, “Coca-Cola”, “Powerade” and “Budweiser”, which were indications of advertisements for these brands in the men’s and women’s matches. For each appearance, the start and end time (in minutes and seconds i.e., 6:30-6:54) and match period (first half, second half, extra time and penalties) were recorded. Visual occurrences of each brand that appeared in clear, uninterrupted view on the screen received a single count in each instance. The duration of each continuous visual appearance was timed to the nearest second. Population exposure estimates of imagery content in the selected matches were used to approximate gross and per capita impressions. Per capita gross impressions were derived based on the frequency and duration of appearances (to the nearest second) of branding within the selected matches. Appearances overlapping between intervals were coded in the two intervals. To estimate UK population exposure to branding content, this study analysed the distribution of branding appearances and used that distribution to compute cumulative gross and per capita impressions. Gross impressions were determined by multiplying the estimate of the UK population who had watched the men’s and women’s FIFA World Cup matches by the number of branding occurrences in each match. Per capita gross impressions of were obtained by dividing the total number of gross HFSS branding appearances across all the matches in the sample by the total population in the UK. Results: Results of the study provided evidence that original films on VOD services, such as Netflix and Amazon Prime Video, are likely to be a source of potential exposure to alcohol in the UK. Potential harmful exposure refers to the extent to which the target audience in the UK encountered certain alcohol, tobacco, or HFSS imagery in the selected movies, likely to have contributed to increased used of these products. There was no major difference in alcohol, tobacco and HFSS imagery observed in movies selected from Amazon Prime Video and Netflix. The total percentage of alcohol and HFSS intervals were the same on each service, but the proportion of tobacco content on Amazon Prime Video was slightly higher. The most frequently consumed tobacco product were cigarettes (14.8%), represented in most films containing tobacco. Findings on the 2018 FIFA World Cup showed about 3.7 billion gross branded alcohol impressions to UK viewers. The study also revealed that an estimated 354 million alcohol impressions were delivered to children in the UK. Upon analysing the films and sporting events, the findings confirmed the presence of high HFSS content. HFSS brands were also evident in the 2018 FIFA men’s World Cup (1806 brand appearances) with popular advertising brands being Coca Cola (25.7% of the total brand appearances), McDonald’s (33.3% of total brand appearances), Budweiser (30.4% of total brand appearances) and Powerade (10.5% of total brand appearances), as well as in the 2019 women’s FIFA World Cup (1104 brand appearances) with the main advertising brands being Coca Cola (62.04% of the brand appearances) and Powerade (37.95% of brand appearances). The 13 matches analysed in the men’s game delivered an estimated 6.7 billion gross branded HFSS impressions, with the estimated total HFSS food impressions delivered to viewers varying across the selected matches. The highest per capita impressions (1.8 billion) were in the game between Tunisia and England, and the lowest per capita impressions (7.9 million) were in the match between Panama and Tunisia. Gross per capita impressions delivered to children across the entire 13 matches was 852 million. The 10 matches in the women’s game delivered an estimated 2.5 billion gross branded HFSS of total impressions. The highest HFSS food impressions (532.67 million) were in the match between England and Scotland, and the lowest (74.26 million) were in the match between Scotland and Argentina. The total of the branded HFSS child impressions was 164 million over the 10 matches. Study findings show that VOD services and the 2018 Men’s and 2019 Women’s World Cup are a significant source of exposure to alcohol, tobacco, and HFSS imagery to all age groups of individuals in the UK and are likely to aid HFSS consumption. Conclusion: The current study found that instances of alcohol, tobacco, and HFSS imagery were prevalent in original Netflix and Amazon Prime Video films, as well as the 2018 and 2019 FIFA World Cup. Potential regular and prolonged exposure to alcohol, tobacco, and HFSS imagery is a major risk factor likely to influence behaviour towards the consumption of these products among the young people. Specifically, the frequency of display and the proportion of programming time containing such imagery represents a source of exposure to alcohol, tobacco, and HFSS products. The possibility that being exposed can lead to behaviour change is supported by the heuristic model and the social learning theory, which theorize that people learn or acquire new patterns of behaviour by either observing or imitating other people. These findings show that stricter regulations need to be applied to prohibit alcohol, tobacco, and HFSS imagery. In view of the changing viewing habits of adolescents, there is a need for the regulation of tobacco, alcohol and HFSS imagery in original content from VOD services, whether this be updating the European audio-visual media services directive to ensure that regulations specifically include alcohol, tobacco and HFSS content, or ensuring that the current UK regulations which cover Amazon Prime Video are applied across Europe. Given the potential influence of brand appearances in FIFA World Cup events on food choices and alcohol consumption among children and young adults, it is important that the current regulations on alcohol and HFSS advertisement include televised sporting events, which are currently unregulated.33 0