The antibacterial activities of different thin films (TiO2/CuO, Cu/SiO2 and Ag/SiO2) prepared by flame-assisted chemical vapour deposition (FACVD) and atmospheric pressure thermal (APT-FCVD) for TiO2/CuO films, were investigated against standard strains of bacteria used for disinfectant testing and against multi-antibiotic resistant bacteria that have been shown to persist in the hospital environment. These included; MRSA strains (EMRSA15 and two recent clinical isolates MRSA 1595 and MRSA 1669), extended spectrum β-lactamase (ESBL) producing Escherichia coli, a second (ESBL- 2 ) producing Escherichia coli, KPC+ (carbapenemase producing) Klebsiella pneumoniae, Stenotrophomonas maltophilia, Acinetobacter baumannii, Listeria monocytogenes, Salmonella enterica ser typhimurium, and vancomycin resistant Enterococcus faecium (VRE) . The Antimicrobial activity of the above coatings (Cu/SiO2 and Ag/SiO2) was investigated based on the BS ISO 22196:2009 and 2011 Plastics – Measurement of antibacterial activity on plastics and other porous surfaces. The activity of TiO2/CuO films was investigated based on the BS ISO 27447:2009 Test method for antibacterial activity of semiconducting photocatalytic materials. On the TiO2/CuO films, the bacteria were killed by UVA irradiation of the photocatalyst with a >5 log kill within 4-6 h except for the MRSA where a 2.3 log kill was obtained after 6 h increasing to >5 log after 24 h. There was antimicrobial activity in the dark which was enhanced by irradiation with fluorescent light. There was also activity at 5ºC under UVA but activity was lower when fluorescent light was used for illumination. The Cu/SiO2 coating showed a >5 log reduction in viability after 4 h for the disinfectant test strain (E.coli) and for some pathogenic strains include; Acinetobacter baumannii, Klebsiella pneumoniae and Stenotrophomonas maltophilia. However, their activity against the other hospital isolates was slower but still gave a >5 log reduction for extended spectrum β-lactamase producing Escherichia coli and Salmonella enterica typhimurium, and > 2.5 log reduction for vancomycin resistant Enterococcus faecium, Listeria and methicillin resistant Staphylococcus aureus within 24 h. The coating was also active at 5ºC but was slow compared to room temperature. The highest activity of copper /silica films was seen at 35ºC, but bacterial cells were also killed on the control surfaces. The Ag/SiO2 coating was also active against pathogenic bacteria; however the coating was not hard or durable as other coatings used. The activity on natural contamination in an in use test in a toilet facility was also determined for coated ceramic tiles (Cu/SiO2 and Ag/SiO2) and coated steel. The results demonstrated that the tiles were highly active for the first 4 months period and the contamination was reduced by >99.9%. However, tiles lost some of their activity after simulated ageing and washing cycles. The Cu/SiO2 coated ceramic tiles placed in Manchester Royal Infirmary also showed antimicrobial activity and no indicator organisms were detected. The coatings had a good activity against both standard test strains and clinical isolates. The coatings (copper surfaces in particular), may have applications in health care by maintaining a background antimicrobial activity between standard cleaning and disinfection regimes. They may also have applications in other areas where reduction in microbial environmental contamination is important, for example, in the food industry. However, the optimum composition for use needs to be a balance between activity and durability. Keywords: TiO2, CuO, Ag, Antimicrobial; Chemical vapour deposition; Copper; Disinfection surface; Pathogenic bacteria (hospital pathogen).

The research in this thesis investigated the independent effects of changing heel height, forefoot shoe volume and upper material stiffness on plantar pressures and comfort in ladies raised heel shoes. Plantar pressure is widely associated with comfort and foot pain including conditions such as subchondral bone microfractures, cartilage degeneration, osteoarthritis, hallux valgus, plantar calluses, metatarsalgia, morton’s neuroma, and hammer toe. Reducing peak plantar pressure at localised foot regions is therefore an aspiration of footwear manufacturers and health professionals alike. As a precursor to the primary investigations, protocols for measuring plantar pressure were investigated. Specifically, how long it takes for a participant to acclimatise to new footwear and how many steps must be measured to provide valid plantar pressure data are research design issues not thoroughly resolved by prior research. In the first study within this thesis it was found that 166 steps per foot were required to acclimatise to unfamiliar footwear. Also, that data from 30 steps should be collected to ensure sufficient data for a representative step could be accurately calculated (within error of +/-2.5%) assumed The second study investigated the effects of incremental increases in heel height and upper material stiffness on comfort and plantar pressure. It was found that an increase in heel height of 20mm was required for a significant 19% increase in plantar pressure at MTP1 in shoes which have a heel height under 55mm. A significant increase in pressure was observed with just a 10mm increase in heel height for shoes over 55mm. Similar, though smaller, effects were observed for perceived comfort in different heel heights. The third study investigated the effects of shoe volume and upper stiffness on comfort and plantar pressure. It was found that an increase in shoe volume increased the pressure at the MTP1 and reduced it at the heel. There was also a volume, the medium volume shoe, which clearly produced the significantly lowest pressure at the MT24 (275kPa medium shoe compared to 289kPa and 305 kPa in the smallest and largest volumes respectively). A significant interaction between shoe volume and material stiffness was also observed: when the material stiffness is changed the amplitude of the effect due to volume is magnified. Of the three footwear features investigated heel height has the greatest significant effect on both comfort (74% increase in overall discomfort for 35mm to 75mm heel height) and plantar pressure (33% increase at MTP1 between 35 and 75 mm heel height), followed by shoe volume then upper stiffness. There was a clear relationship between plantar pressure and comfort and the results suggest that shoes with an effective heel height over 55mm should be considered different from those with heel height less than 55mm. This serves to define a “high heeled“shoe. To ensure that set measurements could be defined investigations into the effects of heel height were completed with only one shoe size. Thus for other shoe sizes scaling may be required. The results of this thesis will improve the quality of future investigations because it has provided guidelines on the required number of steps to acclimatise to unfamiliar footwear, and the number of steps required to produce an average representative step. Also, to the benefit of researchers, the results of this thesis have highlighted the difficulty in controlling features of footwear such as the stiffness of the upper material whilst simultaneously demonstrating the importance of controlling this feature. For both shoe manufactures and research these results have shown the effect of a systematic increase in heel height which has enabled the first pressure and comfort based definition of a high heeled shoe. From this information designers will have a greater understanding of how their designs will have an effect on the plantar pressure and comfort experienced by the wearer.

This study aims to design a practice-based, culturally sensitive model of health education for hospital nurses. The theoretical and literature background to the meaning of practice-based, culturally sensitive models indicates that designing such models requires consideration of theoretical assumptions and evidence-based findings related to both health education practice and cultural sensitivity. Hence, the study has to use the study findings to create the final model design. The study objectives that needed to be answered using mixed methods include:1) Identify which health education skills are most valued by hospital nurses in Saudi Arabia; 2) Explore the self-perceived competence levels of Saudi hospital nurses when delivering health education; 3) Identify which aspects of health education knowledge are most valued by hospital nurses in Saudi Arabia; 4) Identify any organisational barriers that might impact on the delivery of health education in Saudi Arabian hospitals; 5) Identify any strategies that might impact on improving the delivery of culturally sensitive health education in Saudi hospitals. The results have found several important skills and subjects of knowledge related to health education, low confidence levels for the majority of measured skills among nurses, the presence of culture, nursing, the workplace and educational barriers to health education practice, and also recommended several culturally sensitive strategies able to help to deal with Saudi cultural norms and values. Therefore, from the discussion of theoretical assumptions, literature and evidence-based findings of the study results, the final model is created and indicates that practice-based, culturally sensitive health education requires several interventions at two levels. The model consists of two dimensions including internal and external dimensions. The internal dimension reflects actions inside hospitals, which include continuous education, barrier removal and motivational interventions. Actions outside hospitals include updating nursing policies, cooperation with community organisations and use of the media.

Middle-distance athletes are faced with a unique challenge to generate high running velocities (between 6.00 and 8.00 m∙s-1) while making movements as economical as possible (Williams & Cavanagh, 1987). Research suggests that 54% of the variation in running economy can be attributed to gait and spring-mass characteristics. The aims of this thesis were to establish a valid means of measuring gait and spring-mass characteristics away from the laboratory environment and then to provide a biomechanical evaluation of middle-distance running during competition and training in order to identify gait and spring-mass characteristics that influence performance time. Accordingly this thesis has demonstrated that high-speed, Optojump and laser distance measurement (LDM) device all provided a valid measurement of gait and spring-mass characteristics. Spring-mass characteristics obtained through mathematical modelling (estimations based on high-speed video data only) during running were comparable to the gold standard direct measurement (using a force platform). These mathematical models allow for estimations of Kvert and Kleg to be reported away from the laboratory environment on an outdoor 400 m synthetic athletics track. During outdoor track competition international-level athletes achieved a lower performance time as a consequence of a longer step length and lower Kvert¬ and Kleg. For the first time this suggests that a longer step length, greater knee flexion, lower Kvert and Kleg are differentiating factors associated with a reduced middle-distance performance time. Whereas, over a single training session and training block regional-level athletes maintained running velocity by significantly increased step frequency and a reduction in Kvert/BW. Overall, this thesis implies that middle-distance training should monitor how athletes sustain a high running velocity with more emphasis placed on step length to develop competitive performance by increasing flight distance. To increase the travel during flight it is suggested that athletes increase vertical ground reaction forces through plyometric exercises (e.g. stretch-shortening cycle) and continual development of middle-distance training history.

AIMS: The thesis explored influences on emergence of toothbrushing as a dyadic process through infancy with influences conceptualised throughout using Bronfenbrenner’s ecological model. Influences were used to develop methods to support novice mothers to establish and maintain toothbrushing routines with infants. METHODS: Study One: Qualitative interview study with novice mothers of infants exploring influences on emergence of dyadic toothbrushing routines (n=16). Study Two: Using collected qualitative data to develop and standardise a psychometric scale measuring parental self-efficacy (PSE) for enforcing toothbrushing routines with infants (n=91). Study Three: Cross-sectional observational study of dyadic interactions during toothbrushing episodes, using three age groups of infant, 12-months, 18-months and 24-months (each n=12). Study Four: Development and evaluation of an intervention to increase maternal control of the brush dyadic toothbrushing using three study groups (each n=11). RESULTS: Study One: A total of 25 influences on emergence of dyadic toothbrushing were identified. Many of these influences were identified as lying within the mother-infant dyad. Study Two: Scale items were generated from the 25 sub-themes identified from the qualitative study. Overall reliability of the scale was α= .934 and it was found to contain five components. Study Three: Significant differences (p < .001) were found between the three groups in frequency and duration of maternal and infant control of holding and using the toothbrush during observed episodes. Study Four: The picture book intervention did not significantly affect frequency and duration of either maternal or infant control of holding and using the toothbrush during observed episodes. Conclusion: Many influences on emergence of dyadic toothbrushing come from the mother-infant dyad. Some may pose challenges, such as infant drive for self-toothbrushing. However, some influences such as PSE may facilitate the routine. Further work should focus on supporting caregivers to maintain control of holding and using the toothbrush during dyadic toothbrushing.

Background: Understanding the biomechanical function of the normal human foot is essential so to be able to determine the parameters of what is the abnormal or pathological foot. The current model used in podiatry to describe the normal biomechanical function and assessment of the foot presents many key difficulties. Such as the poor reliability and questionable validity of many of the examinations used in the assessment of the foot and the incorrect assumption that all normal feet will display exactly the same biomechanical function during walking. Although technological advancements in gait analysis have improved our understanding of foot biomechanics this new information has not yet not yet significantly changed clinical practice. Objectives: The aim of this investigation was a. Derive a consensus on what podiatrists currently use for conducting a static biomechanical assessment of the foot, b. To test the Root et al (1971, 1977) description of the function of the foot during gait cycle and c. To determine if the measurements obtained from a static biomechanical assessment of the foot as described by Root et al (1971, 1977) can predict the movement of the foot during the gait cycle. Methods: Data was collected from 100 asymptomatic participants and included a static biomechanical assessment of the foot developed from the consensus agreement in part a. and the measurement of the three dimensional kinematic function of the foot during the gait cycle using a six segment foot model. XVI Results: The results indicate that there is a large variation in the kinematic function of feet during walking and the results of a static biomechanical assessment of the foot cannot predict the dynamic function of the foot. Conclusions: This suggests that the key principles of the current model used to describe the biomechanical function of the normal foot in podiatry are incorrect and the methods used by podiatrists in clinical practice are not valid.

We aim to develop a methodology to determine individual optimum cadences for competitive cyclists using field data. Cadence is the number of pedal crank revolutions per minute or pedalling rate. Currently athletes tend to select a cadence intuitively (choosing a gear that permits a cadence that feels comfortable), with some advice from coaches. Literature defines optimum cadence based on gross efficiency. However only power output, heart rate and cadence measurements from the field are available to us. Hence we determine an optimum cadence as the cadence that minimises heart rate for a given power output. In so doing we consider heart rate a reasonable proxy for gross efficiency. We fit statistical models of power output, heart rate amd cadence, with heart rate lagged behind changes in power output, at various lags (though we believe 30 seconds is appropriate). We consider the effect of fatigue on optimum cadence through calculation of training impulses or TRIMPs, but do not consider the effects of fitness, gradient, or whether athletes are standing or sitting. Optimum cadences are found for two athletes (83 and 70 revolutions per minute respectively); these cadences are similar to athletes’ preferred cadences (82-92 and 65-75 rpm respectively). Optimum cadences do not vary by power output or heart rate in our study, and are relatively insensitive to TRIMP. Power output reduces by approximately 2% for cadences 10 rpm above or below optimum. The methodology we propose can be implemented by a wide range of competitive cyclists to calculate optimum cadence; cyclists need to collect power output, heart rate and cadence measurements from training sessions over an extended period (>6 months), and ride at a range of cadences within those sessions. Cyclists and their coaches can re-calculate optimum cadence, say every 6 months, to take account of possible changes in fitness.

Background: Introduction of nationwide breast and cervical screening programmes in Poland (2006) created an unprecedented opportunity to explore the predictors of breast and cervical cancer prophylactic behaviours in a society unexposed to population screening. The study aims to add to the body of knowledge on predictors that could be common for other countries in a similar geo-political situation, aiming to introduce nationwide breast and cervical screening programmes. Methods: A data subset (N=4,290) from a large representative survey (N=7,948) on cancer knowledge and prophylaxis, conducted by the Cancer Oncology Institute in Warsaw close to the introduction of nationwide breast and cervical cancer screening, was used in this thesis. Behaviours and knowledge were described and logistic regression used to identify predictors of mammography and cytology uptake. Results: Women’s level of cancer knowledge was evenly distributed (49.2% low and 50.8% high scores). However, knowledge on cervical cancer was lower than for breast. Higher knowledge was linked to higher education, better material conditions, cancer diagnosis, or practicing any type of the studied prophylaxis and lower levels of knowledge was associated with being aged 18-24 or ≥70 y.o., being widowed, and living in village. Even though 93% (N=3,970) of respondents were aware of the need for breast self-examination (BSE), only 32.3% regularly practiced BSE. Majority (92.3%, N=3,943) knew that mammography can allow early cancer detection but only 52.5% ≥ 50 y.o. (32.1% all ages) declared ever having it. Similarly, 90.7% (N=3,871) knew that cytology allows early detection of cancer and 78.8% have ever undertaken it cytology but only 53.6% had it done every 1-3 years. Up to 4% indicated test unavailability of either test as the reason for non-attendance. The most common barriers included: feeling of no need for such test (37.9-44.9%) and lack of referral (28.7%-39.2%). Women with the highest education levels, the 3 ones living in cities above 100,000 inhabitants, or with highest cancer knowledge were the most likely to ever get screened for breast and cervical cancers. Additionally BSE was found to predict mammography whilst cytology was also predicted by: household size, marital status, having a family member or a friend with cancer. Conclusions: Low screening uptake could be reflective of the fact that there was no nationally available screening but only a small proportion reported non-attendance due to unavailability of tests. This suggests that the uptake was driven by other factors (e.g., cancer knowledge, education) than population screening availability. Particular attention should be paid to the provision of cancer related knowledge. A follow up study is recommended to assess whether women’s knowledge and screening behaviours improved since the conduct of this survey.

Introduction: Foot ulceration and re-ulceration are a serious problem in people with diabetes as the outcome can be lower limb amputation, reducing quality of life and increasing mortality. The pathogenesis of foot ulceration is multifactorial with neuropathy, alterations in foot structure, callus formation and increased plantar foot pressure. The most effective intervention for reducing plantar pressure is the curved rocker outsole. To date this design has been prescribed from clinical intuition rather than scientific evidence. Therefore the studies within this thesis aimed to improve our understanding of how to best to design, and also prescribe, a rocker sole. Methods: Ethical approval was obtained from the University of Salford and the NHS. Study 1 investigated the independent effect of varying the three outsole design features (apex angle, apex position and rocker angle) on plantar pressure in 24 people with diabetes and healthy participants. In-shoe pressure data was collected using Pedar-x and analysed using Matlab. Study 2 investigated the effect of varying apex position in combination with rocker angle, in 87 people with diabetes, and aimed to establish how many people would receive sufficient offloading when wearing a pre-defined rocker design. Study 3 investigated a new method of prescribing a rocker sole using artificial neural networks with an input of gait variables on 78 people with diabetes. Gait data was collected using Vicon and analysed using Visual-3D and Matlab. Results: The results of Study 1 suggested that fixing apex angle at 95° would be a suitable compromise to offload the high risk areas (medial forefoot). It also suggested that apex position and rocker angle needed more investigation. Therefore, in Study 2 the combined effect of two rocker angles and four apex positions were investigated. Despite some inter-subject variability, this study showed that over 60% of participants received sufficient offloading when walking in a mean optimal design. Furthermore, over 60% of people received sufficient offloading with the smaller rocker angle of 15°. The results in Study 3 showed there was low accuracy when predicting an individual optimal shoe using gait variables as inputs (34-49%). Conclusions: This project has shown it is possible to significantly reduce plantar pressures in people with diabetes with a well-designed rocker shoe (95° apex angle, individual apex position and 15° rocker angle). This finding paves the way for future clinical trials which could provide robust clinical evidence for the use of rocker shoes.

Echinococcosis is highly endemic in northwestern China. In order to improve sero-testing in support of community screening and for hospital use, a dot immunogold filtration assay (DIGFA) for rapid serodiagnosis of human CE and AE was developed. DIGFA incorporated four antigen preparations: crude E. granulosus cyst fluid, crude extract of E. granulosus protoscoleces, E.granulosus native antige and a metacestode extract (Em2) from E. multilocularis. The overall sensitivity of DIGFA in a hospital diagnostic setting using archived sera was 80.7% for human CE (n=857 samples) and 92.9% for human AE (n=42 samples). In endemic communities (Qinghe, Hobukersaier, Wenquan, Xinyuan County and Bayanbulak Pasture in Xinjiang; Xiji County in Ningxia; Ganzi County in Sichuan; Dangxiong and Dingqing County in Tibet AR) in northwest China screened for echinococcosis, the sensitivity of DIGFA ranged from 71.8% to 90.7% in comparison to abdominal ultrasound as the gold standard; specificity for CE using AgB was 94.6% and for AE using Em2 was 97.1%. This simple eye-read rapid test was judged useful for both clinical diagnostic supports, as well as in conjunction with ultrasound for mass screening in endemic CE and AE areas. An immunochromatographic assay (ICA) test for rapid E.granulosus antigen detection showed AgB detection in human cyst fluid biopsy samples had a sensitivity of 93.6%. Application of ICA for rapid coproantigen detection in dog faeces, indicated a test sensitivity and specificity generally lower (66.7%) than for coproELISA (72.2%) after 20 days post infection (dpi). A faecal sample time-course from experimental E.granulosus in dogs (n=9) indicated ICA coproantigen detection by 16 dpi and coproDNA detection by 20dpi. Epidemiological results also showed the overall ultrasound prevalence of human echinococcosis was 3.28% (615/18766), with cystic echinococcosis (CE) 2.73% (513/18766) and alveolar echinococcosis (AE) 0.54% (102/18766) respectively. Meanwhile the DIGFA serological positive rate was 22.4% (2388/10684), females had a relative higher seropositive rate (p<0.05). Relative risk factors for human CE were dog and livestock ownership, occupation as herdsman, ethnic groups as Mongolian and Kazakh. Another risk factor for seropositive might be involved with the gender as a female. This research has implications for further development of rapid tests in support of human and canine echinococcosis diagnosis and for surveillance of transmission in China and elsewhere.