Saudi Cultural Missions Theses & Dissertations
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Item Restricted Maternal Awareness and Feeding Strategies for Picky Eating in Children Aged 2-5 Years in Al-Madinah(Saudi Digital Library, 2025) Badi, Reem; Toumpakari, ZoiIntroduction Picky eating is a widespread concern in early childhood, with implications for children’s nutritional status and parental stress. There is concern that poor maternal awareness and inappropriate feeding strategies may reinforce picky behaviours over time. This concern is supported by studies linking parental beliefs to children’s eating patterns and dietary variety. The current study investigates maternal awareness of picky eating and examines the feeding strategies employed by mothers of children aged 2 to 5 years in Al-Madinah, Saudi Arabia. Methods This research followed a cross-sectional design. A total of 204 mothers living in Al-Madinah, Saudi Arabia, completed an online questionnaire. The participants all had children aged between two and five years. The link was shared through WhatsApp, Telegram, and Snapchat. The questionnaire included questions about demographics, understanding of picky eating, feeding routines, mealtime difficulties, and where mothers seek advice. Answers in Sections 2 to 4 were rated using a fivepoint Likert scale. Ethical approval was obtained from the University of Bristol. Data analysis was carried out in SPSS using descriptive and non-parametric tests to assess patterns in maternal awareness and feeding strategies. Results Most mothers held a bachelor’s degree and were caring for more than three children. Approximately 80% reported that their child was at least somewhat picky. The mean awareness score was relatively high (M = 3.43). Reoffering the same food was the most common strategy. No significant associations were found between awareness and education, number of children, or dietitian consultation. Maternal stress showed a weak positive correlation with picky eating. Conclusions This study highlights the importance of supporting mothers in addressing picky eating in children, particularly by reducing stress and promoting effective strategies. While awareness was generally high, no strong predictors emerged. Future research should explore tailored approaches based on maternal well-being and children’s eating behaviours.21 0Item Restricted Children’s Reading Engagement and Social Reading Experiences: Exploring the Influence of Augmented Reality (AR) Books(Saudi Digital Library, 2025) Alhamad, Kawla; Manches, Andrew; McGeown, SarahThe quality of children’s reading experiences plays a significant role in their opportunity to thrive, and these reading experiences can be shaped by different text types (Krcmar & Cingel, 2014). Over the last decade, the nature of reading has been evolving, and Augmented Reality (AR) represents a step change in bringing together the physical book with digital enhancements (Panchenko et al., 2020; Polyzou et al., 2023). Augmented Reality (AR) books represent a hybrid reading experience, where print books are augmented with digital features (e.g., animations, sounds, comprehension questions). This offers opportunities for new research questions focusing on children’s reading experiences and how different reading mediums could shape and support their reading practices. This research adopted a mixed-methods exploratory sequential design to i) provide in-depth insights into children’s reading engagement with AR books, focusing on behavioural, cognitive, affective, and social dimensions and ii) explore the social reading experiences (shared reading and book-talk) afforded by AR books for children with reading difficulties. Previous research highlights that the quality of children’s reading experiences and outcomes is associated with their reading engagement (McGeown & Conradi-Smith, 2023); however, research to date has only examined children’s reading engagement within the context of print books or digital texts. Therefore, Study 1 examined children’s perspectives and experiences of AR books, within the context of reading engagement. In total, 38 demographically diverse children (aged 8–10, 21 boys, 17 English as an Additional Language, 14 ethnicities, and nine with teacher-reported reading difficulties) from the UK participated. After reading an AR book, children participated in interviews to learn about their reading engagement. Deductive (themes) and inductive (subthemes) approaches to thematic analysis were used (Braun & Clarke, 2006), examining children’s AR reading experiences within the context of their behavioural, cognitive, affective and social engagement (Lee et al., 2021a). The majority of children found AR books easy to use, and provided examples of how AR books supported their behavioural engagement (e.g., desire to read more/extend reading practices), altered their cognitive engagement (e.g., reading strategies, visual representation/use of imagination, comprehension monitoring), influenced their affective engagement: (e.g., diverse positive feelings), and social engagement (e.g., prompted interaction and discussion), providing examples suggesting similarities and differences with print books. In addition, class teachers from the classes participating in this project took part in interviews (n = 2), and their perceptions of the usability of AR books in the classroom are discussed (e.g., time restrictions and availability), as these issues could complicate the implementation of AR books within classrooms. Shared reading and book talk are common activities used to engage primary school readers, yet can be anxiety-provoking for those with reading difficulties. Study 2 examined whether, and how, AR books could foster more positive social reading experiences for children with reading difficulties by comparing children’s book-talk and reading experiences with an Augmented Reality (AR) and non-AR (matched in content and format, except for the number of pages) book. In total, 32 children (aged 8–10, 17 girls, 3 English as an Additional Language, 7 ethnicities, and all with reading difficulties) from the UK participated. Children participated in dyads in two shared book reading sessions (AR/non-AR book, counterbalanced), with book-talk after each session, followed by a general discussion to learn of their perceptions of the similarities and differences in their AR/non-AR reading experiences. It was found that AR books were associated with significantly higher levels of book talk following the reading session (both in number of words spoken and sentence length), while many similarities and differences were found in children’s experiences with the AR and non-AR books. For example, shared reading in both conditions could support reading progress (e.g., positive peer support) and foster positive social reading experiences (e.g., enjoying reading together and feeling connected); however, differences were also found in relation to the AR book shared reading (e.g., ease of use). The findings of this thesis have contributed to the very limited research literature on AR books and reading experiences. Given the increase in the use of technology among children, this research reported how this new form of technology can potentially support and extend children’s reading practices and experiences. For AR books to be used optimally within the classroom, it is essential to raise teachers’ awareness of AR books, and how they influence children’s reading engagement, so that teachers can make informed decisions about their use. Moreover, previous research has demonstrated the importance of talking about text with peers (Gambrell, 2011), and its positive influence on readers’ social engagement (Lee et al., 2021a). Enabling positive social reading experiences for children who have difficulties with reading is essential, and AR books offer promise in this regard. This research provides novel and educationally important insights which can inform the reading practices of children with reading difficulties, as it is the first research to explore the potential impact of AR books on the book-talk and reading experiences of children with reading difficulties. Finally, AR does offer a new direction for book publishing (Gudinavičius & Markelevičiūtė, 2020; Lai et al., 2015) and the findings of this research could develop our understanding of how best to integrate AR into books to facilitate positive engaging and enriching reading experiences for children.12 0Item Restricted Beyond Words: Understanding Pain in Children with Intellectual Disabilities in Saudi Arabia Through the Eyes of Mothers and Providers: Reflexive Thematic Analysis.(Saudi Digital Library, 2025) Alghoriby, Shahd; Lee, Elaine; Croudace, Tim; Buell, SusanBackground: Children with intellectual disabilities frequently experience significant pain due to specific health conditions and increased susceptibility to everyday accidents. They may require specialised medical and rehabilitative interventions, and their limited communication abilities make it challenging to express and describe pain, leading family members and healthcare providers to rely on behavioural cues. In Saudi Arabia, where disability presents substantial medical, social, and economic challenges, no prior study has explored pain assessment in children with intellectual disabilities from the perspective of parents and healthcare providers. Aim: This study aimed to examine pain assessment practices for children with intellectual disabilities in Saudi Arabia, focusing on the experiences and perspectives of parents and healthcare providers. Methods: Qualitative data was generated through interviews with 20 mothers and focus groups with 16 healthcare providers. Reflexive thematic analysis was employed to interpret the data. Results: The data analysis revealed that the mother's experience with pain assessment for her child with intellectual disabilities was multifaceted and influenced by several interconnected factors. Healthcare providers demonstrated notable gaps in knowledge, attitudes, and practices, highlighting challenges in pain detection, professional development, and the paradox of parental engagement. Issues extended beyond standard clinical practices, reflecting systemic barriers. Conclusion: This study is the first of its kind in Saudi Arabia to examine pain experiences in children with intellectual disabilities from the perspectives of mothers and healthcare providers. The findings reveal the influence of cultural norms, healthcare policies, and resource limitations on pain assessment, offering insights into the complex challenges within this context and emphasising the need for culturally informed, supportive pain assessment strategies.3 0Item Restricted A systematic Review of the Consequences of Parents’ Divorce and Challenges of Raising Children between Saudi Arabia and the United Kingdom(Bangor University, 2024) Qahtani, Wasmmih Nayef; Margiad, WilliamsAbstract Purpose: The objective of this study is to assess the emotional, psychological, and social effects of parental divorce on children in the United Kingdom and Saudi Arabia as well as the challenges parents face in parenting after divorce in the two cultures. Methodology: A pragmatic research paradigm was adopted for conducting a systematic review. Literature relevant to the project was then identified, screened, and assessed in line with the PRISMA framework. The approach was a mixed-methods one, using qualitative findings, and supported with quantitative data. The assessment of key themes was conducted through narrative analysis. Results: The children in the UK brought up in an emotionally expressive climate have significant emotional and behavioural issues post-divorce. Saudi children, especially girls, however, are taught to suppress emotions as a cultural norm. Co-parenting challenges are different, with UK laws favouring shared custody but lacking emotional safeguards, and Saudi laws favouring paternal custody and limiting involvement. Conclusion: The experiences children have after a divorce are shaped by cultural values and legal systems and therefore need context specific support strategies. Keywords: Divorce, children, co-parenting, UK, Saudi Arabia, culture, emotional impact20 0Item Restricted Investigating opportunities to provide behaviour change conversations to promote child oral health in non-dental settings(University of Manchester, 2024) Alshammari, Dalil; Peters, Sarah; Goldthorpe, Joanna; Coupe, NiaBackground: In 2022, almost a quarter of 5-year-old children in England had at least three untreated teeth with deep tooth decay. This is partly due to limited access to dentists, suggesting a need for additional ways to support children's oral health. Therefore, this PhD project sought to investigate opportunities to provide behaviour change conversations (BCC) to reduce children's oral health problems in early years settings (EYS). Method: The thesis aim was addressed through three stages using a mixed-method approach. In the first stage, a secondary analysis was conducted of electronic records of children referred to general dental anaesthesia in northwest England for tooth extraction. In the second phase,14 parents and 11 EYS staff were interviewed to explore their views regarding delivering and receiving messages to promote children's oral health. Sampling of participants sought to include those from varied backgrounds and 8 (57%) of parent interviews were conducted in Arabic. A systematic approach was developed to ensure accurate translation of non-English data, which preserved cultural and linguistic nuances during analysis. In the final stage, the behaviour change wheel approach was used to design an intervention to address the barriers and challenges identified in the previous stages. Results: Stage one revealed that despite an increased need, there were 90% fewer referrals to general anaesthesia during lockdown than in the corresponding period in the previous year. These findings indicate the need to explore the potential for non-clinical settings to address children’s oral healthcare. Stage two revealed that parents have limited awareness of oral health activities in EYS. They acknowledged that EYS staff could influence children's oral health behaviours, but identified several limitations, such as staff credibility. EYS staff recognised the need to address child oral health yet viewed the inclusion of oral health activities as overwhelming and reported how they avoid difficult conversations about oral health with parents. In response to the challenges of translating non-English data, a framework consisting of six stages was developed to ensure accurate translation and to guide researchers through the translation process. In stage three, the ToothTalk toolkit intervention was developed to facilitate communication between EYS staff and parents regarding children's oral health. This comprised a booklet for staff with information and behaviour change techniques to support their conversations, and an accompanying parents’ interactive workbook. Conclusion: The thesis provides timely and important evidence to support the existing rollout and proposals for expanding oral health practice at EYS in England, which may have potential also for other geographical localities. It found that oral health is considered a delicate conversation where staff need training to develop the necessary communication skills and confidence to initiate and hold tooth-kind conversations. Parents need support to trust and engage more in these conversations. The ToothTalk intervention was developed to address the identified barriers, which aim to increase the frequency and quality of oral health-related discussions initiated by EYS staff with parents. Further research is necessary to evaluate its effectiveness and acceptability in the EYS context. As well as its potential to be tailored to other contexts both within the four nations of the UK, and beyond.22 0Item Restricted UNRAVELING THE LINK BETWEEN ANTI-INFLAMMATORY DIET, ZINC, AND CADMIUM TOXICITY IN INFLAMMATION REGULATION AMONG CHILDREN AND ADOLESCENTS(Florida International University, 2024-10-29) Mobarki, Huda; Liuzzi, JuanZinc (Zn) possesses antioxidant and anti-inflammatory properties essential for regulating the body’s inflammatory response. However, the interplay between diet, heavy metal toxicity, and Zn status in influencing inflammation in children remains poorly understood. This study examined the associations among diet, Zn levels, cadmium (Cd) toxicity, and inflammation, using high-sensitivity C-reactive protein (hsCRP) and white blood cell count (WBCs) as biomarkers. Data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES), comprising 3,507 U.S. children aged 2–19 years, were analyzed. Linear regression models assessed the relationships between serum Zn, the Anti-inflammatory Diet Score (ADS), Cd levels, and inflammatory markers. Of the participants, 49.4% were male and 50.6% female. Serum Zn was inversely associated with inflammation (β = -0.236, p = 0.008 for WBCs; β = -0.223, p = 0.035 for hsCRP) after adjusting for covariates. Although ADS showed an inverse relationship with inflammation, the associations were not statistically significant. Blood Cd levels were positively associated with WBCs (β = 0.436, p = 0.008), but not hsCRP. Interestingly, adjusting for Zn reversed the association between Cd and inflammation, though the results were not significant, suggesting Zn may counteract Cd’s pro-inflammatory effects. Complementary studies in C. elegans were conducted to further explore these findings. Survival assays showed that Cd exposure significantly reduced worm survival, whereas co-incubation with equal concentrations of Zn (100 µM) mitigated this toxic effect, as demonstrated by two-way ANOVA and Tukey tests. Overall, this study highlights that serum Zn is a more reliable marker of inflammation than dietary Zn intake in children. Zn appears to partially neutralize Cd's toxic effects, with findings supported by both epidemiological data and experimental models. Maintaining adequate Zn levels may reduce inflammation and counteract Cd toxicity. These results underscore the importance of dietary strategies to enhance Zn status, potentially mitigating the adverse health effects of environmental Cd exposure in children.24 0Item Restricted The Psychosocial Impact on Families of Paediatric LT-MCS Patients During In- Hospital Bridge to Transplant: A Modified Systematic Review(University of Nottingham, 2024-09) Alawami, Sakinah; Hemingway, PippaIntroduction: End-stage heart failure children waiting for heart transplants have better survival rates with long-term mechanical circulatory support (LT-MCS). However, the shortage of donor hearts prolongs the transplant bridging period, extending hospitalisation, disrupting family life, and adding uncertainty. While a previous mixed-method systematic review has explored the home experience of these families, understanding their in-hospital experiences remains limited. Therefore, this review aims to examine the psychosocial impact on these families during their LT-MCS children’s in-hospital bridged to transplant, illuminating their challenges and resilience. Methods: This review employed the SPIDER framework searching for PubMed, CINAHL, ASSIA, Embase, and ProQuest (dissertations and theses) for English-published and non-published qualitative studies according to the pre-defined inclusion criteria. Findings: Six qualitative studies matched the pre-defined inclusion criteria. The review synthesised four themes using Braun and Clarke reflexive thematic analysis: (1) Commencing the families' journey with LT-MCS discussing the diagnosis and LT-MCS implantation’s impact. (2) Navigating the LT-MCS paediatric patients’ families through Bridging: addressing LT-MCS children-mother role changes, caregiver's daily life, complications, and grief. (3) Crossroads of blessings and challenges: LT-MCS children's families await a new heart, highlighting donor heart uncertainty. (4) The power stations of LT-MCS children’s families focus on supporting systems. After synthesising themes, findings were examined through Dr. Mishel’s Uncertainty in Illness Theory, Theor yielding recommendations aligned with Advanced Nursing Practice's pillars. Conclusion: This systematic review highlights the profound psychosocial impact and uncertain experience on LT-MCS children’s families during diagnosis, hospitalisation, complications, grieving, and the waiting period for a new heart. It calls for urgent tailored educational and supportive interventions by clinicians for sudden and previously diagnosed heart failure children's families, robust policy initiatives, and innovative research. Additionally, it points out the role and potential needs of healthcare providers in helping families mitigate the stresses associated with the in-hospital bridging period.23 0Item Restricted UNRAVELING THE LINK BETWEEN ANTI-INFLAMMATORY DIET, ZINC, AND CADMIUM TOXICITY IN INFLAMMATION REGULATION AMONG CHILDREN AND ADOLESCENTS(Florida International University, 2024) Mobarki, Huda; Liuzzi, JuanZinc (Zn) is known for its antioxidant and anti-inflammatory properties and is important in regulating the body’s inflammatory response. However, there is limited evidence on how factors such as diet and heavy metal toxicity contribute to inflammation in children, and whether these effects are influenced by Zn status. This study aimed to investigate the links between diet, Zn, and cadmium (Cd) toxicity with inflammation, using high-sensitivity C-reactive protein (hsCRP) and white blood cell count (WBCs) as biomarkers. Using data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES), which included 3,507 children in the U.S. aged 2-19 years, we explored the associations between the main exposure variables (Zn, Anti-inflammatory Diet Score (ADS), and Cd) and inflammatory biomarkers. Statistical analysis was conducted using a linear regression model. Of the participants, 49.4% were male and 50.6% female. We observed an inverse relationship between serum Zn and inflammation (β = -.236, p = .008 for WBCs, and β = -.223, p = .035 for hsCRP) after adjusting covariates. Although ADS was inversely associated with inflammation, the relationship was not significant (β = -.006, p = .186 for WBCs, and β = -.003, p = .210 for hsCRP). Significant associations were found between blood Cd and WBCs (β = .436, p = .008), but not for hsCRP. After adjusting for Zn, the relationship between Cd and inflammation became inversely associated (β = -.083 for WBCs, β = -.099 for hsCRP), although these results were not significant, suggesting that Zn may mitigate Cd’s inflammatory effects. To further support the epidemiological findings, we conducted studies using young C. elegans. The experiment consisted of two studies analyzing the effects of Zn and Cd on the survival of the worms using two-way ANOVA and Tukey tests. The results showed that Cd treatment significantly decreased the survival of worms; however, co-incubation with Zn attenuated this effect when the concentration of Cd and Zn were equal (100 µM). In conclusion, the epidemiological data indicate that serum Zn is a more reliable indicator of inflammation in children than Zn intake. The study also suggests zinc status neutralizes Cd's pro-inflammatory effects on inflammatory biomarkers. Additionally, C. elegans model demonstrated that Zn supplementation mitigated Cd-induced toxicity. These findings highlight the importance of maintaining adequate Zn status to mitigate the harmful effects of Cd exposure in children. Therefore, dietary interventions that improve Zn status could potentially reduce inflammation and counteract the adverse impact of Cd exposure on a population level.16 0Item Restricted THE ASSOCIATION BETWEEN HOUSING CHARACTERISTICS AND DENTAL CARIES AMONG CHILDREN IN THE USA(King's College London, 2024-08) Alsaeed, Lina; Sabbah, Waelassociation between housing characteristics and dental caries among children. Objectives: To examine the association between housing characteristics and caries experience among 2-6 years American children. Methods: Data from the National Health and Nutrition Examination Survey 2017-18 was used. Children aged 2-6 were included. The association between housing characteristics and the sum of decayed and filled primary teeth was assessed adjusting for family income, ethnicity, age, gender, and dental visits. Results: A total of 861 child were included in the analysis. The mean number of decayed and filled primary teeth was 1.28. Compared to those who lived in owned home, Children living in rented homes or homes with other arrangement had higher rate ratios for decayed and filled teeth with rate ratios 1.98 (95% Confidence Interval “CI” 1.25, 3.12) and 2.60 (95%CI:1.14, 5.93), respectively. Higher family income was also associated with lower rates of decayed/filled teeth. Conclusion: The analysis highlighted the importance of housing characteristics as a social determinant of children caries.16 0Item Restricted THE ASSOCIATION BETWEEN HOUSING CHARACTERISTICS AND DENTAL CARIES AMONG CHILDREN IN THE USA(King's College London, 2024) Alsaeed, Lina; Sabbah, WaelBackground: Despite the strong evidence on the role of the social determinants in dental caries, there is limited research on association between housing characteristics and dental caries among children. Objectives: To examine the association between housing characteristics and caries experience among 2-6 years American children. Methods: Data from the National Health and Nutrition Examination Survey 2017-18 was used. Children aged 2-6 were included. The association between housing characteristics and the sum of decayed and filled primary teeth was assessed adjusting for family income, ethnicity, age, gender, and dental visits. Results: A total of 861 child were included in the analysis. The mean number of decayed and filled primary teeth was 1.28. Compared to those who lived in owned home, Children living in rented homes or homes with other arrangement had higher rate ratios for decayed and filled teeth with rate ratios 1.98 (95% Confidence Interval “CI” 1.25, 3.12) and 2.60 (95%CI:1.14, 5.93), respectively. Higher family income was also associated with lower rates of decayed/filled teeth. Conclusion: The analysis highlighted the importance of housing characteristics as a social determinant of children caries.33 0