Saudi Cultural Missions Theses & Dissertations
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Item Restricted Prevalence of Prediabetes and Type 2 Diabetes Among Undiagnosed Schoolteachers in Riyadh, Saudi Arabia(Saudi Digital Library, 2025) Aldekhayel, Ghassan; Farragher, Tracey; Verma, Arpana; Greenhalgh, Christine; Azmi, ShazliBackground: Diabetes Mellitus (DM) is an important public health issue in the Middle East region because of its high prevalence. In Saudi Arabia, the prevalence of type 2 DM among adults is 23.1%, and is one of the top ten causes of mortality. Patients with type 2 DM may remain undiagnosed for many years, due to its asymptomatic nature especially in the early stages. It is estimated that nearly half of adults with type 2 DM in Saudi Arabia are undiagnosed, which indicates the importance of early detection to understand the true burden of the disease. In addition, early detection and management of type 2 DM prevents complications related to diabetes. Also, identifying prediabetes cases helps prevent or delay the onset of type 2 DM. Methods: This study included both observational cross-sectional and longitudinal study designs. Schoolteachers in Riyadh were randomly selected from the Ministry of Education database and invited to complete the Saudi diabetes risk score questionnaire. Those identified as high risk underwent diabetes diagnostic tests, such as fasting plasma glucose and glycated haemoglobin (HbA1c), at collaborating primary healthcare centres. Participants diagnosed with type 2 DM or prediabetes were followed up after 3 months to assess risk factors associated with changes in HbA1c. Additionally, participants completed health-related quality of life (HRQoL) questionnaires at baseline, 3 months, and 6 months, to assess the quality of life of participants over time and compare HRQoL outcomes between low and high risk participants. Results: Among 945 recruited participants, 387 (41%) were female, the mean age was 42.5 years (SD ± 7.1), and 372 (39.4%) were classified as high risk. Out of 109 high risk participants who attended diabetes diagnostic testing, 7 (6.4%) were diagnosed with type 2 DM, and 19 (17.4%) were diagnosed with prediabetes. Population weighted estimates indicated that 1.8% of teachers in Riyadh had undiagnosed type 2 DM or prediabetes (95% CI: 0%, 6.91%). Among participants diagnosed with type 2 DM or prediabetes greater reductions in HbA1c levels at the 3-month follow-up was associated with higher baseline HbA1c levels (Coefficient: -0.63, 95% CI: [-0.79, -0.47]). Additionally, high risk participants reported lower HRQoL scores across physical, psychological, social relationships, and environment domains compared to low risk participants, with statistically significant differences observed in the physical (Coefficient: -5.57, 95% CI: [-8.65, -2.48]) and psychological (Coefficient: -4.40, 95% CI: [-7.47, -1.33]) domains. Conclusion: The study found a high prevalence of teachers at high risk of type 2 DM in Saudi Arabia. Early identification and intervention for participants with higher baseline HbA1c levels were associated with greater HbA1c reductions after 3 months, which may lead to better health outcomes and reduce the burden of diabetes-related complications. These findings highlight the feasibility and potential benefits of systematic prediabetes and type 2 DM case finding programmes in Saudi Arabia.22 0Item Restricted Adult Foster Homes in an Aging America: Trends, Effects, and Operational Challenges (2017–2023)(Oregon Health and Science University, 2024) Albalawi, Wafi; Chair, Paula Carder; Tunalilar, Ozcan; Messer, Lynne; Carlson, BryantBackground: As the aging U.S. population grows, the demand for long-term care services (LTCS) is rising. Adult Foster Homes (AFHs), small residential care settings providing personalized support for older adults, play a critical role in meeting this demand. However, limited research has focused on AFHs compared to other LTCS options. This dissertation examines Oregon’s AFH holistically by assessing home characteristics, resident’s status and health needs, and the experiences of operators, particularly during the COVID-19 pandemic. Methods: Utilizing data from the Oregon Community-Based Care study (2017–2023), this mixed methods research integrates quantitative trend analyses and qualitative content analysis. It explores three key aims: (1) identifying trends in residents' health conditions, service utilization, and medication use; (2) assessing associations between AFH characteristics and healthcare outcomes; and (3) capturing operators' perspectives on rewards and challenges during the pandemic. Results: Findings reveal high prevalence rates of dementia and polypharmacy among residents, with increasing medication use and stable trends in ADL needs. Family involvement significantly declined during the pandemic but showed partial recovery post-restrictions. Operators highlighted meaningful rewards, such as resident care and autonomy, alongside challenges like regulatory burdens and low Medicaid reimbursement rates. Conclusion: By highlighting the unique attributes, resident health needs, and operational challenges of AFHs in Oregon, this study brings critical attention to an often-overlooked long-term care option19 0Item 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.23 0Item Restricted Enhancing Colorectal Cancer Screening Participation via Text Message Interventions(King's College London, 2024-09) Almoallem, Ghader; Round, Thomas; Hamad, WasimBackground: Colorectal cancer (CRC) ranks as the third most frequently diagnosed cancer globally and is a significant contributor to cancer-related deaths. Early detection through regular screening is crucial, as it greatly improves treatment outcomes and survival rates. However, screening participation for CRC remains insufficient, especially among minority groups. Text message interventions have been proposed as a cost-efficient and scalable solution to increase screening adherence. Objective: This systematic review and meta-analysis aimed to assess the effectiveness of text messaging interventions in enhancing CRC screening participation. Methods: A comprehensive search was conducted across four major databases Embase, PubMed, MEDLINE, and Cochrane up to August 2024. The review included randomized controlled trials (RCTs), observational studies, mixed-methods studies, and qualitative research that evaluated the impact of text message reminders on CRC screening rates. Data were extracted on study characteristics, intervention specifics, and screening outcomes. Meta-analyses were carried out to calculate pooled effect sizes of text message interventions compared to usual care. Results: Eighteen studies met the inclusion criteria, consisting of 12 RCTs, two observational studies, two mixed-methods studies, and two qualitative studies. The meta-analysis indicated that text message interventions significantly improved CRC screening uptake compared to usual care (pooled relative risk: 1.23, 95% CI: 1.12–1.36, p < 0.001). Sensitivity analyses validated the robustness of these results across different study designs and populations. Text message interventions were especially effective in low-income and underserved groups, where traditional outreach methods tend to be less successful. Furthermore, cost analysis from the reviewed studies highlighted that text messaging is a highly cost-effective method for promoting CRC screening. Conclusion: Text message interventions offer a scalable and effective approach to increasing participation in CRC screening programs. Their affordability, wide reach, and simplicity make them an ideal tool for public health systems, particularly those operating in resource-constrained settings. Despite these encouraging results, further research is needed to refine the content, timing, and cultural relevance of messages to ensure maximum impact across diverse populations. Incorporating text messaging into broader public health strategies could be crucial in alleviating the global burden of colorectal cancer.48 0Item Restricted Investigating the Role of Zinc in Manganese-induced Hepatotoxicity(Florida International University, 2024) Alandanoosi, Afnan; Liuzzi, Juan; Palacios, Cristina; Narayanan Vijaya; George, FlorenceThe objective of this study was to investigate the role of zinc (Zn) status in manganese (Mn) -induced hepatotoxicity using epidemiological data and vitro experiments. First, we conducting epidemiological study using the National Health and Nutrition Examination Survey (NHANES) to determine the relationship between Zn status and blood Mn levels on enzymatic markers of liver damage. The findings indicated that without the regression interaction of Zn intake or serum Zn, blood Mn exhibits a direct (positive) association with Alkaline Phosphatase (ALP) and Aspartate Amino transferase (AST). The results however showed that with the interaction of blood Mn and Zn intake at the second quartile (Q2) (marginal low Zn intake), a negative association was found with ALP in model 1,model 2 (corrected by age and gender), and model 3 (corrected by age, gender, race, education, BMI, alcohol, smoking and diabetes ). A similar association was found between Q4 (adequate/high Zn intake) and Lactate Dehydrogenase (LDH) activity in all three models of the study. Second, the effect of Zn deficiency and adequacy on Mn toxicity and the expression level of the cellular Mn efflux transporter SCL30A10 in human hepatocytes was evaluated. Mitochondria oxidative stress, apoptosis, and cell death and proliferation studies showed that exposure to elevated levels of Mn increased oxidative stress, apoptosis, and cell death. Mn exposure also decreased cell proliferation. Noteworthy, Zn depletion was found to enhance Mn induced apoptosis and cell death. Lastly, the mRNA expression of SLC30A10 was significantly decreased by Mn exposure (p < 0.05). However, no significant difference in the protein expression level of SCL30A10 was found. This suggests that there was no compensatory regulatory response of this transporter expression to either Zn deficiency or Mn exposure for the time point analyzed. Overall, the results from the epidemiological data and in vitro studies indicate that Zn deficiency could enhance the toxic effects of Mn. The results underscore the importance of having an adequate Zn intake in mitigating Mn induced cytotoxicity.67 0Item Restricted Satisfaction, utilization, and willingness to pay for primary care services(Queen's University Belfast, 2023-12) Aljohani, Motab; Donnelly, Michael; O’Neill, CiaranThis thesis investigates the nature of stated and revealed preferences on the part of the public for primary care services. It examines the relationship between satisfaction, willingness-to-pay (WTP), and use of primary care services in Britain and Saudi Arabia. The thesis used three measures to triangulate these concepts: satisfaction, WTP, and utilisation of primary care services. Satisfaction provided an ordinal measure of stated preference, while WTP provided a cardinal measure of stated preference. Use (utilisation) provided a measure of revealed preference. Using these measures across various contexts, the thesis explores how preferences and the relationships between preferences and respondent characteristics vary depending on the context and the measure used. The thesis findings indicate that satisfaction, WTP, and use of primary care services provide distinct but complementary insights into variations in preferences between socio-demographic groups; points in time; regions and; the location in which data are collected. Observed variations are grounded in a variety of factors that include needs and the nature of service provision. The thesis provides an appreciation of the complexity of stated and revealed preferences and the challenges inherent in using such data to inform policy using examples drawn from Britain and Saudi Arabia and identifies a number of avenues for future research in this area.34 0Item Restricted Childhood Obesity and Weight Stigma: A Public Health Nutrition Approach(University of Glasgow, 2024-04-20) Abuznada, Salma; Combet, Emilie; Garcia, AdaPoor understanding of obesity, its causes and consequences contribute to weight-related stigma in the UK. Children’s understanding of obesity shapes their views and perceptions towards obesity as a disease, body image, and weight stigma behaviours. Exploring children’s and adolescents’ knowledge, perceptions and views of obesity, weight stigma, and nutrition is essential to establishing effective health promotion programmes that cater to young people’s needs, understanding and perspectives. Successful programmes also need continuous monitoring and evaluation, which are currently lacking in the UK. Perceptions and views around obesity among the public vary in different cultures and among healthcare professionals. These different perspectives lead to debates on defining, managing and treating obesity. Weight stigma research in adults tends to focus on weight stigma due to the poor understanding of obesity both among the public (especially women of white ethnicity) and healthcare professionals rather than children and adolescents. This thesis uses systematic reviews and a mixed-methods approach to explore weight stigma across the age spectrum, including children, adolescents and adults. Furthermore, the research investigates children’s and adolescents’ views on obesity and nutrition knowledge. Study 1 systematically reviewed existing observational, quantitative and qualitative studies focusing on the sources, frequency and implications of weight stigma on children’s and adolescents’ mental health, well-being and eating behaviours. The Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) were followed for study selection, screening and data extraction. Synthesis Without Meta-Analysis (SWiM) guidelines were applied to report the synthesis and results. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Heart, Lung, and Blood Institute (NHLBI) was used to assess the quality of the included studies. Twenty observational studies were included in the final text analysis. Synthesised evidence highlighted that bullying and victimisation play a fundamental role in developing and perpetuating weight-related stigma. Weight-related bullying was correlated with participants’ low self-esteem. Most of the included studies (N=15/20) were of fair quality (average score 5 to 8), although two were of poor quality (average score 0 to 4), and most of the quality criteria were not met. One of the main gaps identified during the literature search in Study 1 was children and adolescents were poorly represented in the studies, with an overemphasis on white adult women. After identifying existing gaps in the literature (e.g., the overemphasis on recruiting white women), Studies 2, 3 and 4 were developed to explore underrepresented groups and gain a deeper understanding of their views and opinions of obesity and weight stigma. Children’s and adolescents’ views and opinions of obesity and nutrition knowledge were explored in Study 2, using a cross-sectional questionnaire and phone interviews. The questionnaire was structured in six sections, exploring sociodemographic characteristics, anthropometric measurements, views and perceptions of obesity, nutrition knowledge, general health, and eating habits and lifestyle. Online interviews followed a narrative focusing on obesity knowledge and experience, obesity perception and the relationship between nutrition and obesity. Study 2 recruited a total of n=317 participants, 54% boys, 72% White/British, with a median age of 16 years (interquartile range (IQR) 15- 18). There was an overall lack of understanding of obesity and its causes and consequences. There was also a lack of consensus and agreement about whether obesity is a sign of disease, a disease, or merely a body shape. There was agreement that obesity can be a personal responsibility (median=4: likely, IQR 3: neutral – 4: likely). Food knowledge was low, with 83% correctly answering three questions or fewer out of six. Although participants reported and believed that they knew what obesity was, most participants linked obesity to body image and placed the responsibility of having obesity on the individuals or their parents. This can lead to increased stigmatising behaviours and isolation of children and adolescents with obesity. Proper education about obesity is imperative to help support children in understanding the general concepts behind obesity’s complexity as a disease. Study 3 used a cross-sectional questionnaire and phone interviews to explore weight stigma and its implications on weight stigma attitudes and body image perceptions in children. In Study 3 (n=667, 62% boys, 70% White/British, median age 16 years (IQR 15-18)), 50% of participants who experienced weight stigma had a BMI ≥30 kg/m². Almost two-thirds of participants who experienced weight stigma (n=259) said it happened at local community places (e.g., clubs, during extracurricular activities) (n=149, 58%). Over a quarter (n=67,26%) reported that it was extremely harsh. Participants who self-reported having obesity (n=214) experienced more weight stigma (n=114, 53%) than those who believed they have overweight (n=87, 41%) or underweight (n=13, 6%). More than half of the sample (n=408, 61%) were dissatisfied with their body image. Most participants who self-reported having obesity were dissatisfied with their body image, demonstrating a significant relationship between self-reported weight problems ‘underweight, overweight, obesity’ and body image satisfaction levels ‘dissatisfied, neutral and satisfied’". In summary, unsurprisingly, most participants who reported weight stigma had a BMI ≥30 kg/m2. Interestingly, more boys than girls who reported experiencing weight stigma believed there was weight stigma in society. To better understand the contribution and impact of childhood lived experiences of weight stigma on adult perceptions and beliefs around overweight and obesity, Study 4 employed similar methods to Study 3. In Study 4 (n=738, 52% men, 76% White/British, 39% BMI ≥30 kg/m2, median age=26 years (IQR=24-31)), less than a quarter of participants had experienced weight stigma as children (n=154, 21%). More women (n=108/154, 70%) experienced weight stigma during childhood than men (n=46/154, 30%, p≤0.001). Participants were mostly undecided about whether obesity is a disease (median=3: undecided, IQR=1: strongly disagree – 3: undecided). Experiencing weight stigma in childhood was positively associated with parents reporting their children’s weight stigma experiences. Parents dissatisfied with their body image (n=62) were more likely to be dissatisfied with their children’s body image (n=23/62, 37%) than satisfied (n=17/62, 24%). Understanding and awareness of obesity are essential in developing public health strategies and health education programmes that are child-oriented and specific to children and adolescents regarding location and intervention tools. The findings in this thesis highlight the negative impact of weight stigma on children and adolescents' physical and mental health. Moreover, a poor understanding of obesity was evident in this research. The work of this research is beneficial in informing programs explicitly targeting the gaps explored and found. This thesis attempts to improve the knowledge of public and academic domains in elements surrounding perceptions, views, and attitudes regarding obesity and weight stigma, the reasonings behind perceptions, and strategies to address obesity stigmatising behaviour.18 0Item Restricted Biomedical and Public Health Studies on Susceptibility to Post-Traumatic Stress Disorder(Saudi Digital Library, 2023-05) Al Jowf, Ghazi Ibrahim Abdurahman; Rutten, BartTraumatic stress exposure can induce the development of mental disorders such as post-traumatic stress disorder (PTSD), resulting in a decreased quality of life and increased disease burden. This thesis investigated and addressed the gaps of knowledge in the understanding of the association between epigenetic mechanisms, gene activity, and differential susceptibility to PTSD. It also identified the public health measures that can be effectuated for the prevention of PTSD and how biomarkers may support these measures. Accordingly, it discusses the possible ways that can aid in the early identification and detection of PTSD resulting from traumatic stress, and the possibility of developing biomarkers of increased susceptibility. It also discusses how this early detection can help with early intervention, and if early enough, prevention. Application of such models, with findings from future research to establish cost-effective measures, can greatly enhance the patient’s quality of life and decrease the disease burden.12 0Item Restricted Investigation of Existing and New Human Resources Practices on Public Health Eemployee Retention During the Covid-19 Pandemic in Saudi Arabia(Saudi Digital Library, 2023-07-30) Alattas, Mohsen Mohammed; Jang, Hee Soun; Andrew, Simon; Benavides, Abraham; Shi, KellyThis research investigates existing and new HR practices that have impacted public health employee retention in Saudi Arabia during the COVID-19 pandemic. It builds on social support theory and social exchange theory to better understand the relationships between HR practices and retention, and uses quantitative methods to examine the hypotheses based on a conceptual framework. While OLS regression is employed to analyze the relationships between HR practices and retention, path analysis (bootstrapping) is used to examine the mediator variable. Based on 417 valid questionnaires distributed to public health employees in Saudi Arabia’s central, western, and eastern regions, the analysis illustrates that while training and emphasis on work-life-balance as existing HR practices had a positive effect on retention, social support (supervisory support) and promotion of mental well-being as new HR practices also had a positive effect on retention during the COVID-19 pandemic. However, the hypothesis that compensation and occupational health and safety would improve retention was not supported. These results indicate that financial benefits and providing safety materials did not lead to employee retention. Meanwhile, safety training programs, psychosocial support, and promotion of well-being have been essential HR practices during the pandemic. Regarding the mediation hypotheses, interestingly, the results show that organizational commitment has mediated relationships between safety training and mental (psychological) well-being on one hand and public health retention on the other during the pandemic.41 0Item Restricted Investigating Ohio Health Commissoners' Perceptions and Experiences with Respect to Decision-Making During the COVID-19 Pandemic(2023-05-01) Alsaheil, Nouf; Hoornbeek, JohnBackground: Public Health (PH) leaders debate the effectiveness of their decisions on controlling the COVID-19 pandemic. Varying decisions across states and localities illustrate the difficulty of decision-making when confronted with complex and unexpected challenges in PH. Psychologists often frame decision-making as reflecting one of two systems. System 1 is based on experience and instinct. System 2 is based on data and analysis. In PH, many efforts are directed toward supporting evidence-based decision-making; however, scholars confirm that skills and experience play a substantial role in shaping decisions. Skills and experiences appear to become more influential in decisions associated with high-stakes situations, where individuals will depend more on their cognitive, interpersonal, and behavioral skills and less on data because of uncontrollable constraints, such as time, information, and uncertainty. The purpose of this study is to generate a better understanding of the decision-making processes used by Ohio local health commissioners (HCs) as they were dealing with COVID-19 high-stakes situations. Study aims include: examining the thinking styles of expert and novice Ohio HCs regarding decision-making in the context of COVID-19-associated high-stakes situations; identifying factors that impact the decision-making preferences and practices during these situations; and exploring the contextual factors that HCs consider when faced with COVID-19 decisions. Methods: The study applied a convergent mixed-method approach. Quantitative methods were applied to a cross-sectional survey data where the Rational-Experiential Inventory-40 survey was used to measure individual differences and their relationships with expressed preferences for using System 1 and 2 thinking. An ANOVA and paired t-test were used to assess differences between Public Health Officials’ (PHOs) experience levels and preferred decision-making systems. Multiple linear regression analysis was used to identify factors associated with preferred system thinking. The Critical Decision Method, a semi-structured interview protocol, was used to discover contextual factors that influence the decision-making process of HCs in COVID-19 situations. A thematic analysis was used to analyze the qualitative data. Findings: This study found that Ohio HCs prefer using rational over experiential thinking during COVID-19 situations. There were no consistent documented differences between novices and experts except for the reported status of their networks and relationships. The study also identified contextual factors that appeared to influence HCs’ decision-making processes. Themes that emerged from the interviews in relations to these factors included vagueness and uncertainty, senses of urgency, regulation and guidance, autonomy and sense of responsibility, prior experience, networks and relationships, effective communication and teamwork, cognitive skills, and personality traits. Implications: The results inform scientific knowledge and can be used to aid development of hazard-focused training programs and PH curricula. Equipping the PH workforce with necessary leadership competencies to face high-stake situations is an important protective factor to help counteract other uncontrollable factors that arise within the PH sector, including lack of information, time, and budget. The work presented here may be used to improve PHOs' performance, which can lead to better service delivery. Results from this study are also available to preparedness planners to assist in LHDs’ After-Action Reviews/Improvement Plans.9 0