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.

Echinococcus granulosus is a canid cestode species that causes hydatid disease or cystic echinococcosis (CE) in domestic animals or humans. Echinococcus equinus formerly recognised as the ‘horse strain’ (E.granulosus genotype G4) is not known to be zoonotic and predominantly involves equines as its intermediate host. The domestic dog is the main definitive host for both species, which are also both endemic in the UK but data is lacking especially for E.equinus. An E.equinus-specific PCR assay was designed to amplify a 299bp product within the ND2 gene and expressed 100% specificity against a panel of 14 other cestode species and showed detection sensitivity up to 48.8pg (approx. 6 eggs). Horse hydatid cyst isolates (n = 54) were obtained from 14 infected horse livers collected from an abattoir in Nantwich, Cheshire and hydatid cyst tissue was amplified using the ND2 PCR primers to confirm the presence of E.equinus and used to experimentally infect dogs in Tunisia from which serial post-infection faecal samples were collected for coproanalysis, and indicated Echinococcus coproantigen and E.equinus DNA was present in faeces by 7 and 10 days post infection, respectively. Canine echinococcosis due to E.granulosus appears to have re-emerged in South Powys (Wales) and in order to determine the prevalence of canine echinococcosis a coproantigen survey was undertaken. The Welsh Assembly Government also funded a 2 year hydatid disease eradication campaign (2008-10) as a preventative public health measure and faecal samples were tested from farm dogs in the control area. In addition 8 foxhound packs (5 from Wales and 3 from England) were sampled and screened for echinococcosis infection using an Echinococcus genus-specific coproantigen ELISA that was optimised against a panel of known Echinococcus and control faecal samples. Farm dogs and foxhounds were also screened using two coproPCR assays (predominantly E.granulosus G1 or E.equinus G4 specific). In the Welsh farm dog study, 609 dog faecal samples were collected at baseline (pre-treatment) of which 10.8% (66/609) were found to be coproantigen positive, 5.1% (31/609) were G1 E.granulosus coproPCR positive, and 1.8% (12/609) were E.equinus ND2 coproPCR positive. A total of 742 farm dog samples were tested after 3 quarterly deworming treatments and showed a coproantigen decrease to 0.7% (5/742). One year after the last dosing round 4.2% (45/1076) of farm dogs were found to be coproantigen positive; of these only 123 were tested with the G1 primers of which 15.4% (19/123) were positive for E.granulosus DNA. Of 8 foxhound packs screened by the Echinococcus genus specific coproantigen ELISA and by the two coproPCR tests (E.granulosus, E.equinus) 3 of the 4 Welsh hunts had copropositive dogs (hunt prevalence 30.9%, 9.7%, 61.2%) and 2 of the 3 English hunts (hunt prevalence 17.5%, 44.5%). Hounds in 6 of the 8 hunts were coproPCR positive for E.granulosus DNA and 2 of the 8 hunts were positive for E.equinus coproDNA. Additional foxhound data was collected in the form of a survey questionnaire to hunt staff which suggested that there may be a link between increased Echinococcus coproantigen prevalence and inadequate worming protocols and unsafe feeding practices. The study showed that canine echinococcosis due to E.granulosus and E.equinus occurred in farm dogs and foxhounds in Wales and England and that an intervention programme in mid-Wales reduced canine echinococcosis in farm dogs after four dosing rounds, but coproprevalence increased by 12 months after cessation of dosing. The data are discussed with reference to potential human infection, risk factors and optimal intervention approaches. The study showed that the distribution of canine echinococcosis in farm dogs and foxhounds was not homogenous and also confirms the continued presence of both E.granulosus and E.equinus in foxhounds in England and Wales.

This thesis presents a programme of nine key published works, as well as twelve published supporting works focusing on two areas. Firstly, an investigation of how non-technical skills education in healthcare can be used to enhance outcomes for patients. Secondly, an exploration of how evidence synthesis be used as a tool to direct educational innovation and, in this context, enhance patient safety. Non-technical skills are the interpersonal, communication, team working and decision making skills that support safe patient care. Existing theory was applied to build new conceptual frameworks to understand how non-technical skill learning occurs. Educational innovations were developed, allowing outcomes for patients to be enhanced and the theory to be refined. Ultimately, this has led to the proposal of the SECTORS model, combining three key elements: The generic knowledge and skills in core areas that contribute to and support learning in non-technical skills (Systems and technology use, Error awareness, Communication, Team working), a situated cognition approach to formal and experiential learning that develops these skills (Observation and simulation) and developments in analytical skills that can integrate these and support decision making (Risk assessment and situational awareness). SECTORS can support curricula design, educational innovation and design of assessments. SECTORS will support future scholarly research, allowing the field to move from theory generation to theory testing and refinement. Additionally, synthesis of educational evidence to support the development of this new knowledge has been employed. Building on existing guidance and in response to calls for more theoretical generation in primary educational research, a complete method for health education evidence synthesis has been developed and applied. This method allows clarification of educational questions through generation of conceptual frameworks and new theory within a systematic framework that employs qualitative synthesis techniques such as thematic generation and meta-ethnography, representing a significant contribution to the field.