School of Health Sciences
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Item Tutor motivation and retention in public health training institutions in Ghana: An exploration sequential mixed methods study(Queen Margaret University, Edinburgh, 2019) Beyere, Christopher BaasongtiPolicymakers in the health sector continue to look for ways to improve the staffing of rural health facilities. However, only when they are equitably distributed and accessible by the population, when they possess the required competency, and are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the society (WHO, 2016). Extensive research has been conducted on health worker motivation and retention in the clinical settings, but relatively little is known of the situation of staff in the Ministry of Health training institutions. Health-training institutions play a significant role in strengthening the health workforce of the country by training all the middle-level cadres of health professions like Nurses, midwives, and other affiliated health professionals (MoH, 2015). This thesis reports on a mixed-methods study of health tutors in some selected public health training schools in the northern part of the country, predominantly rural-based and some in the southern region, primarily urban-based. Focus group discussions engaged 100 health tutors from across rural and urban schools. Five in-depth interviews and five key informant interviews were conducted with past health tutors and principals, respectively. Focus group discussions and interviews informed the development of a structured questionnaire comprising closed and opened ended questions. The quantitative study used a representative sample of 329 health tutors. Non-parametric (Spearman ranked correlation, Pearson Chi-Square, and Wilcoxon-Mann Whitney) and parametric (t-test and ordered logistic regression) statistical tests were run. Findings suggest that most tutors actively compare their income, benefits, qualification to that of their colleagues in other schools, and with other general health workers in the clinical area and lecturers within the ministry of education. From the findings of the results, personal characteristics of the health tutors, such as his or her place of origin, rural or urban, gender, age, and family background, have a significant impact on their employment decisions. There was evidence from this research demonstrating that rural upbringing increases the chances of rural practice. While rural and urban health tutors equated motivation with money, those working in urban settings ranked accommodation as a significant factor influencing employment choice. In conclusion, the study examined differences in health tutors’ motivation and retention and some recommendations.Item The effects of English proficiency on the processing of Bulgarian-accented English by Bulgarian-English bilinguals(Queen Margaret University, Edinburgh, 2019) Dokovova, MarieThis dissertation explores the potential benefit of listening to and with one’s first-language accent, as suggested by the Interspeech Intelligibility Benefit Hypothesis (ISIB). Previous studies have not consistently supported this hypothesis. According to major second language learning theories, the listener’s second language proficiency determines the extent to which the listener relies on their first language phonetics. Hence, this thesis provides a novel approach by focusing on the role of English proficiency in the understanding of Bulgarian-accented English for Bulgarian-English bilinguals. The first experiment investigated whether evoking the listeners’ L1 Bulgarian phonetics would improve the speed of processing Bulgarian-accented English words, compared to Standard British English words, and vice versa. Listeners with lower English proficiency processed Bulgarian-accented English faster than SBE, while high proficiency listeners tended to have an advantage with SBE over Bulgarian accent. The second experiment measured the accuracy and reaction times (RT) in a lexical decision task with single-word stimuli produced by two L1 English speakers and two Bulgarian-English bilinguals. Listeners with high proficiency in English responded slower and less accurately to Bulgarian-accented speech compared to L1 English speech and compared to lower proficiency listeners. These accent preferences were also supported by the listener’s RT adaptation across the first experimental block. A follow-up investigation compared the results of L1 UK English listeners to the bilingual listeners with the highest proficiency in English. The L1 English listeners and the bilinguals processed both accents with similar speed, accuracy and adaptation patterns, showing no advantage or disadvantage for the bilinguals. These studies support existing models of second language phonetics. Higher proficiency in L2 is associated with lesser reliance on L1 phonetics during speech processing. In addition, the listeners with the highest English proficiency had no advantage when understanding Bulgarian-accented English compared to L1 English listeners, contrary to ISIB. Keywords: Bulgarian-English bilinguals, bilingual speech processing, L2 phonetic development, lexical decision, proficiencyItem FOOT DROP AND FATIGABILITY IN PEOPLE WITH MULTIPLE SCLEROSIS(Queen Margaret University, Edinburgh, 2019) Andreopoulou, GeorgiaPeople with Multiple Sclerosis (pwMS) often experience walking impairments such as foot drop which can lead to trip and falls. Foot drop can be either transient and is often induced by exercise (fatigability) in pwMS whose walking ability is not affected and can become more fixed with disease progression. The overall aim of this PhD was to explore foot drop, its presence in pwMS with different disability levels and the psychometric properties of outcomes used to evaluate walking impairments. The first study in this thesis was a systematic review into the level of evidence for the psychometric properties of walking measures that have been used to evaluate the effect of assistive technology such as FES for foot drop in MS. Moderate to strong psychometric evidence was found for the Multiple Sclerosis Walking Scale, Timed 25 Foot Walk, 6 minute and 10 meter walk tests. There were no psychometric studies for three-dimensional (3D) gait kinematics in pwMS even though it was one of the most frequently used outcome measures. The second study assessed the test-retest reliability of 3D ankle kinematics and spatiotemporal parameters in pwMS, with low Expanded Disability Status Scale (EDSS < 3.5) and in those with moderate to high EDSS (EDSS: 4-6). Reliability was excellent for ankle kinematics and spatiotemporal parameters in both groups, with lower minimal detectable change (MDC95%) values in the low EDSS group compared to the higher EDSS group. The third study investigated transient exercise induced foot drop in highly physically active pwMS (EDSS < 3.5) and health controls using 3D kinematics. It was found that 6 out of 15 pwMS and none of the healthy controls presented this phenomenon. The fourth study examined the direct orthotic effect of FES during dual-tasking (i.e. walking combined with a cognitive task) and after inducing fatigability. Low to moderate effect sizes indicated that the direct orthotic effect was higher under dual-task and fatiguing conditions but this needs to be confirmed in appropriately powered studies. In conclusion, the studies in this thesis have contributed to the psychometric evidence of gait kinematics in pwMS, have objectively documented the presence of transient foot drop in highly physically active pwMS and orthotic effect of FES under a variety of conditions simulating the perceived benefits in ‘real life’ reported by FES users. Key words: multiple sclerosis, foot drop, fatigability, FES, psychometric properties, 3D gait kinematicsItem Humanitarian workers in South Sudan: Mental health, gender, and organizational staff support(Queen Margaret University, Edinburgh, 2019) Strohmeier, HannahThis study focused on humanitarian workers in South Sudan and the interrelation of mental health, gender, and organizational staff support. Based on the propositions of Job Demands- Resources (JDR) theory, I applied mixed methods research in three research phases to 1) investigate prevalence and predictors of common mental health problems among national and international humanitarian workers; 2) examine international humanitarian workers’ lived experiences, particularly with respect to gender; and 3) crystallize implications of these findings for humanitarian stakeholders, particularly with respect to organizational staff support. The survey phase estimated prevalence rates of post-traumatic stress disorder (24%), depression (39%), anxiety disorder (38%), hazardous alcohol consumption in men (35%) and women (36%), and the burnout components emotional exhaustion (24%) and depersonalization (19%). Chronic stress was most consistently associated with mental health problems. Dysfunctional coping predicted mental health problems among humanitarian workers, but emotion-focused and problem-focused coping were neither protective nor predictive of the outcomes studied. Surprisingly, gender was significantly associated with anxiety only, with women being more likely to experience symptoms associated with anxiety diagnosis. However, the focused qualitative phase indicated that gender substantially influenced international humanitarian workers’ lived experiences. Men perceived Juba as a convenient duty station. Women experienced a feeling of loneliness on site, and considered it challenging to combine their profession with family life. There was a gap between international humanitarian workers’ needs for psychosocial support, and the attention paid to these needs by themselves and their organizations. The evaluation phase showed that organizational staff support provided by NGOs was insufficient to address employees’ needs. As expected, national staff had less access to services than international staff, and organizations neglected gender in their staff support programs. This study provides tailored recommendations to address the identified challenges and gaps in staff support. It demonstrates that a more nuanced version of JDR theory is required to be applicable to humanitarian settings.Item Agency and wellbeing in the context of early marriage: A qualitative inquiry into the northern Nigerian context(Queen Margaret University, Edinburgh, 2018) Zasha, DoosuurAccording to the literature, early marriage remains a problem due to the limitations it places on the educational and economic opportunities of the young girls involved, as well as the variety of health complications they suffer as a result of this. Although early marriage is prevalent in Nigeria, regional differences indicate the northern part of the country as having a higher percentage of girls who marry before the age of 18 compared to the south. Most research and advocacy efforts, as well as related programmes and policies, rightfully focus on the prevention of early marriage but neglect the adolescent girls who are already married. This study focuses on the lives of young married girls, highlighting the process through which they get married as told from their own perspective, and explores their accounts of life after marriage particularly illuminating their health needs and overall wellbeing. Using semi-structured interviews, focus group discussions participatory techniques, and participant observations, 24 young married girls between the ages of 15-25 from Nasarawa state in Nigeria, were recruited for this study, adopting a mixture of principles borrowed from ethnography and grounded theory. The analysis highlights the personal agency exercised by some of the girls in their decisions to get married but also demonstrates how said agency is constrained by the context in which it is exercised. Analysis further reveals the underlying influences behind the constructions of health and illness held by young girls and explores ways in which they primarily seek to address their health and wellbeing. The accounts of these girls also point to strong associations between their wellbeing, economic factors, relationships and experiencing self-worth. This dissertation will contribute to knowledge around early marriage in Nigeria and Sub-Saharan Africa and highlight nuances around the decision-making process at the time of marriage. It also offers insights as to how young girls construct wellbeing in the context of marriage hereby contributing to knowledge around wellbeing in poorer populations in Nigeria and arguably, similar African contexts.Item FRAILTY, CARDIOVASCULAR FUNCTION AND RISK OF FALLING AMONGST PATIENTS WITH STAGE 5 CHRONIC KIDNEY DISEASE ON HAEMODIALYSIS(Queen Margaret University, Edinburgh, 2019) Zanotto, TobiaThis PhD thesis explores the risk of falling of stage 5 chronic kidney disease (CKD-5) patients receiving haemodialysis (HD) therapy. Previous research has suggested that multiple risk factors such as older age, comorbidities, polypharmacy, and frailty contribute primarily to the increased risk of falling in this clinical population. However, HD patients are also characterised by severe cardiovascular disease burden that often manifests with symptoms of orthostatic intolerance, impaired blood pressure control and syncope, all of which may be implicated in the aetiology of falling. The aim of this thesis was to address important research questions, such as: Are frailty and its physical function/activity components associated with falling in CKD-5 patients on HD? Are baroreflex function and the cardiovascular responses to orthostasis also associated with falling? What is the relative importance of frailty and cardiovascular function as potential exercise-modifiable risk factors for falls in this patient group? A prospective observational study involving 76 prevalent HD patients (61.1±14 years) confirmed previous observations that CKD-5 patients on HD are at higher risk of falls compared to the non-uraemic population, as 37.7% of research participants experienced at least one fall during a 12-month follow-up, and the incidence of falls recorded was 1.16 falls/person-year. Although participants classified as fallers did not appear to differ from non-fallers in single physical function measures such as timed-up and go (TUG), 5 repetitions chair sit to stands (CSTS-5), or muscle strength, frailty and lower postural balance were associated with increased odds of falling. In addition, baroreflex function indices reflecting frequency of baroreflex activation, as well as the blood pressure response to a five-minute 60° head-up tilt test (HUT-60°) were associated with increased odds of falling and a greater number of falls. More importantly, we showed that modelling the risk of falling by adding a cardiovascular function variable to a frailty-only model improved significantly the prediction of number of falls experienced by CKD-5 patients on HD. Overall, this PhD thesis revealed that cardiovascular mechanisms implicated in the short-term regulation of blood pressure showed a greater relative importance than frailty in predicting falls in the study participants. These findings challenge the current assumption that frailty is the primary factor involved in the aetiology of falls in CKD-5 patients on HD. The clinical implications of this novel observation are also discussed from a preventive and rehabilitative perspective. Key words: Stage 5 chronic kidney disease, haemodialysis, falls, frailty, cardiovascular function.Item ENHANCING KINEMATIC SHOULDER FUNCTION EVALUATION THROUGH A VALID, SIMPLE AND CLINICALLY APPLICABLE SCORE(Queen Margaret University, Edinburgh, 2019) Pichonnaz, ClaudeIntroduction Controversies surrounding Patient-Reported Outcome Measures (PROMs) and the cumbersome-nature of movement analysis-based (MAB) methods for shoulder function evaluation make the exploration of alternatives needed. Research aimed at the simplification of MAB outcome measures had demonstrated previously that the B-B Score, which relies on two movements only, was valid for out-of-laboratory evaluations of shoulder function. Nevertheless, further investigations were needed to optimise testing procedures, test the B-B Score’s capability of acquisition using a user-friendly device, and critically evaluate its measurement properties in comparison to current methods. Objective The aim of this thesis was to develop and assess the simplest possible MAB shoulder function scoring procedure for clinical measurement. Methods The research included four steps: 1) Optimisation of the B-B Score testing procedure (Phase 1 study [data-driven]), 2) Comparison of measurements using a smartphone or an inertial sensor system (Phase 2 study [data-driven]), 3) Validation in frequentlyoccurring pathologies (rotator cuff conditions, instability, fracture, capsulitis) (Phase 3 study [data-driven]), 4) Benchmarking of the new approach with concurrent MAB outcome measures and PROMs (literature review). Results Amongst the tested methods, the B-B score was optimised by using the mean of three replicates in the computation of the range of accelerations by angular velocities. The comparison of easily-used smartphone and reference device showed non-significant differences and excellent relationships between measurements (Intraclass Correlation Coefficient [ICC=0.97]). The smartphone’s B-B Score intra-rater and inter-rater reliability was excellent (ICC=0.92), but limits of agreement could reach up to ±19.4%. The score was responsive (area under the curve [AUC≥0.70]) and demonstrated excellent discriminative power between patients and controls (AUC≥0.90), except for shoulder instability (AUC=0.67). The correlations with PROMs were moderate to high. The benchmarking established that the measurement properties of the B-B Score compared equivalently with those of PROMs and MAB outcome measures, except for shoulder instability. Conclusion Shoulder function can be efficiently evaluated using a simple scoring procedure performed with a smartphone, which facilitates its objective assessment. Further research is needed to understand how best to reduce the effects of variability associated with single measurements in order to optimise clinical applicability and to explore the B-B Score’s properties in other situations requiring functional assessments of the shoulder. . Keywords: shoulder, shoulder function; outcome assessment; validation studies, reliability and validity; inertial sensors; smartphone sensors; body-worn sensors; kinematics; sensitivity and specificity.Item QUANTILE REGRESSION AS A METHODOLOGY FOR UNDERPINNING PROPORTIONATE UNIVERSALISM(Queen Margaret University, Edinburgh, 2019) Rush, RobertIn the social sciences, and beyond, we are often interested in the impact of factors on some outcome. These research questions of interest are traditionally addressed with linear regression, which informs on those factors impacting on the average. Frequently though the interest is not in the ‘average’ but with those in the tails of the outcome distribution, where for example the low performing or high scoring are contained. This is particularly the case when these analyses are to inform policies to improve on those low performing and the identification and targeting of possible interventions for this. Focusing solely on the average and applying interventions across the board can only widen the gap between those low scoring and better performing. These traditional modelling methods will not provide information on differential impact of a factor across the distribution and indeed can fail to identify important factors. In addition to the analysis suitable to the research question there are inherent linear regression model assumptions which must be met. To try and address this using traditional techniques by segmenting the data to assess factor impact is inefficient and can have power implications. Also a logistic regression approach provides a cut-point with those on either side, regardless of their proximity to that cut-point being in one group or the other. Therefore to understand the effect of factors across the outcome distribution we must use different techniques and a quantile regression approach offers an assessment across the outcome distribution and can identify those factors which are influential at different locations on that distribution and is also robust to the assumptions which dog those other traditional methods. Thus with a principled method such as quantile regression analysis, there exists an enormous potential to inform not just basic policy questions, as to relationships amongst factors and outcome, but with the resulting more nuanced answers provide those key policymakers with a more complete evidence base with robust informative estimates on those mediating factors and on who to target.Item MEASURING PRE-SPEECH ARTICULATION(Queen Margaret University, Edinburgh, 2019) Palo, PerttiAbstract: What do speakers do when they start to talk? This thesis concentrates on the articulatory aspects of this problem, and offers methodological and experimental results on tongue movement, captured using Ultrasound Tongue Imaging (UTI). Speech initiation occurs at the start of every utterance. An understanding of the timing relationship between articulatory initiation (which occurs first) and acoustic initiation (that is, the start of audible speech) has implications for speech production theories, the methodological design and interpretation of speech production experiments, and clinical studies of speech production. Two novel automated techniques for detecting articulatory onsets in UTI data were developed based on Euclidean distance. The methods are verified against manually annotated data. The latter technique is based on a novel way of identifying the region of the tongue that is first to initiate movement. Data from three speech production experiments are analysed in this thesis. The first experiment is picture naming recorded with UTI and is used to explore behavioural variation at the beginning of an utterance, and to test and develop analysis tools for articulatory data. The second experiment also uses UTI recordings, but it is specifically designed to exclude any pre-speech movements of the articulators which are not directly related to the linguistic content of the utterance itself (that is, which are not expected to be present in every full repetition of the utterance), in order to study undisturbed speech initiation. The materials systematically varied the phonetic onsets of the monosyllabic target words, and the vowel nucleus. They also provided an acoustic measure of the duration of the syllable rhyme. Statistical models analysed the timing relationships of articulatory onset, and acoustic durations of the sound segments, and the acoustic duration of the rhyme. Finally, to test a discrepancy between the results of the second UTI experiment and findings in the literature, based on data recorded with Electromagnetic Articulography (EMA), a third experiment measured a single speaker using both methods and matched materials. Using the global Pixel Difference and Scanline-based Pixel Difference analysis methods developed and verified in the first half of the thesis, the main experimental findings were as follows. First, pre-utterance silent articulation is timed in inverse correlation with the acoustic duration of the onset consonant and in positive correlation with the acoustic rhyme of the first word. Because of the latter correlation, it should be considered part of the first word. Second, comparison of UTI and EMA failed to replicate the discrepancy. Instead, EMA was found to produce longer reaction times independent of utterance type.Item THE AUDITORY BRAINSTEM RESPONSE IN HEALTHY ADULTS AND ADULTS WITH ALCOHOL DEPENDENCE SYNDROME(Queen Margaret University, Edinburgh, 2018) Johnson, ChristineThe Auditory Brainstem Response (ABR) assesses brainstem function. This thesis explores the click and speech ABR in both healthy adults and adults with alcohol dependence syndrome (ADS). Experiment One undertook auditory-cognitive assessment including ABRs, of 60 healthy adults (30 women), aged 18-30 years. For waves III and V of the click ABR, women’s responses were earlier than men’s by 0.14ms and 0.19ms. For the speech ABR, onset and offset measures were earlier in women by at least 0.43ms. No effect for left vs. right ear was found in either case. Inter-rater reliability was found to be high (ICC2,1 ≥0.89) for the click ABR and good (ICC2,1 ≥0.75) for six of the seven peaks of the speech ABR. A comparison of ABRs to those from an older group of 12 adults aged 31-49 years (six women, matched control group for Experiment Two) found the stimulus to response lag for the speech ABR, was earlier (0.78ms) in the older women but within the expected range. Click and speech ABRs were repeated after 12 weeks and the representation of F0 for women was greater by 4.8 μV at the second recording. Experiment Two assessed the auditory-cognitive profile and ABRs of 16 adults (six women) aged 29-49 years, undergoing a treatment and rehabilitation programme for people with ADS. All participants had hearing thresholds within normal limits, but exhibited deficits in auditory-cognitive profiles compared to matched, healthy adults, including their click and speech ABRs. For the click ABR, men had significant delays in wave III (0.18ms) and wave V (0.22ms). For women there were significant delays for wave I (0.11ms) and wave V (0.22ms). For the speech ABR, men had significant delays in the onset measures of waves V (0.40ms) and A (0.36ms). Women had significant delays in waves V (0.45ms), A (0.48ms) E (0.66ms) and O (0.42ms). Testing was repeated after 12 weeks of abstinence and significant improvements in the click and speech ABR were observed. For men, average click ABR latencies improved for wave III (0.12ms) and wave V (0.22ms) and for women, wave V (0.08ms) improved. Significant improvements were also found for discrete peak and onset measures of the speech ABRs for both men and women. For men, average speech ABR latencies improved for wave A (0.23ms) and the duration of the VA complex (0.15ms). For women there were improvements in wave V (0.10ms), A (0.12ms) and E (0.33ms). These results add to the body of knowledge about the ABR and support its value as a clinical tool. They also provide new information about auditory-cognitive function in adults with ADS, for whom beneficial effects of abstinence are demonstrated. The ABR has a potential role in identifying people most at risk of alcohol related brain damage and in monitoring recovery with abstinence. Keywords Auditory Brainstem Response, Frequency Following Response, Speech ABR, Reliability, Alcohol Dependence Syndrome, Abstinence.