http://hdl.handle.net/1893/205 Electronic theses of Faculty of Health Sciences and Sport Students. Sat, 03 Oct 2026 23:47:56 GMT 2026-10-03T23:47:56Z http://hdl.handle.net/1893/38281 Title: The use of bioelectrical impedance vector analysis in the assessment of refeeding syndrome on severely acute malnourished children Author(s): Mogase, Tshegofatso Abstract: Severe acute malnutrition remains a major cause of morbidity and mortality among children under five in low- and middle-income countries, including South Africa. Despite the existence of World Health Organisation inpatient severe acute malnutrition management guidelines, mortality in many public hospitals remains unacceptably high, and preventable complications continue to occur during the early stabilisation phase. Refeeding syndrome is a potentially fatal metabolic complication that arises when nutritional support is initiated or increased after a period of undernutrition. In routine paediatric practice, however, refeeding syndrome is often poorly recognised, inconsistently defined and rarely documented as a distinct clinical entity. Conventional anthropometric and clinical indicators may also fail to detect the rapid physiological shifts that precede clinical deterioration. This thesis addresses these gaps by examining the identification and management of refeeding syndrome in children with severe acute malnutrition. This was realised by evaluating the potential role of bioelectrical impedance vector analysis as an additional tool to assess hydration status and risk of refeeding syndrome during inpatient stabilisation. The overall aim of the thesis was to improve understanding of how refeeding syndrome is conceptualised, identified and managed in children who are undergoing severe acute malnutrition care and to explore whether bioelectrical impedance vector analysis can support early risk stratification. A three-phase, mixed-methods design was used. Phase 1 comprised a systematic review and meta-analysis of evidence on the identification and management of refeeding syndrome among hospitalised children aged 6 to 59 months with severe acute malnutrition in Sub-Saharan Africa. Phase 2 was a quantitative study conducted in public hospitals in the City of Tshwane, which admitted children with severe acute malnutrition and followed them over the first five days of stabilisation using bioelectrical impedance vector analysis, anthropometric, biochemical and clinical assessments. Phase 3 was a qualitative descriptive study that explored healthcare practitioners’ experiences of assessing and identifying refeeding syndrome in hospitalised children with severe acute malnutrition in the same setting. Phase 1 systematically reviewed published and grey literature to describe how refeeding syndrome is defined, monitored and treated in inpatient severe acute malnutrition programmes in Sub-Saharan African countries. Several electronic databases and relevant organisational websites were searched. The review demonstrated marked heterogeneity in refeeding syndrome definitions, with most studies either not defining refeeding syndrome explicitly or using non-standard criteria that did not consistently include hypophosphatemia. Biochemical monitoring during refeeding was variably reported, and routine phosphate measurement was uncommon. The review found descriptive variation in management strategies for refeeding syndrome in children with severe acute malnutrition across studies, although most adhered to the World Health Organisation guidelines for severe acute malnutrition treatment. The reported refeeding syndrome incidence varied widely, reflecting both true variation and inconsistent recognition and documentation. Overall, Phase 1 highlighted substantial evidence gaps, particularly the lack of context-appropriate operational definitions and structured monitoring strategies for refeeding syndrome in children undergoing severe acute malnutrition treatment. Phase 2 was a prospective quantitative observational longitudinal repeated-measures study involving 64 hospitalised children with severe acute malnutrition during the stabilisation phase of treatment. to selected public hospitals in the City of Tshwane. Anthropometry, clinical variables, laboratory markers and the bioelectrical impedance vector analysis-derived parameters were recorded at admission and followed over the five days of inpatient stabilisation. Refeeding syndrome risk was classified using phosphate-based criteria adapted from international guidelines and applied to the South African context of severe acute malnutrition. Clinically, vomiting and diarrhoea improved rapidly in both groups; however, children classified as at risk of refeeding syndrome had delayed oedema resolution (higher oedema grades on Days 2 to 4) and minimal net weight gain by Day 5, whereas children not at risk showed progressive weight gain with a significant between‑group difference by Day 5. Mid upper arm circumference remained comparatively stable across Days 1 to 5 in both groups, supporting the interpretation that early weight changes during stabilisation largely reflect fluid dynamics rather than true tissue accretion. At admission, the refeeding syndrome ‑risk group showed lower resistance values and shorter impedance vectors. Hydration-related indices, such as percentage total body water, were generally higher in the refeeding syndrome risk group, consistent with apparent anthropometric adequacy in oedematous or fluid-overloaded children. Multivariable logistic regression identified lower resistance as a predictor of refeeding syndrome risk. These findings suggest that bioelectrical impedance vector analysis-derived markers may help to identify children at higher risk of refeeding syndrome at admission and could complement existing anthropometric and clinical assessments. Phase 3 employed a qualitative descriptive design to explore the experiences of healthcare practitioners involved in the care of children with severe acute malnutrition. Semi-structured interviews were conducted with a purposive sample of paediatricians, medical doctors, dieticians and nurses working in paediatric wards that manage severe acute malnutrition cases in public hospitals in the City of Tshwane. Generally, participants recognised refeeding syndrome as a theoretical or textbook concept but reported that it was seldom explicitly documented in patients' records and was rarely labelled as a distinct diagnosis. Instead, refeeding syndrome was included under more general severe acute malnutrition complications such as oedema, sepsis, electrolyte imbalance or “the child collapsing/crashing”. Themes that emerged included uncertainty and variation on how refeeding syndrome and risk are defined, reliance on informal clinical cues rather than structured monitoring tools, and the perception that refeeding syndrome is “not normally recognised” despite its potential severity. Participants described significant constraints on systematic biochemical monitoring, including delayed laboratory results and limited after-hours access. Multidisciplinary team communication was highlighted as both a strength and a challenge. This is to say, where regular joint ward rounds occurred, care tended to be more consistent, but after-hours and shift-to-shift handovers were seen as vulnerable points. Practitioners emphasised the need for simple, practical tools and focused training to support early recognition, documentation and standardised management of refeeding syndrome within existing resource limitations. The integration of all three phases provides a coherent account of why refeeding syndrome remains under-recognised and difficult to manage in paediatric severe acute malnutrition settings. The systematic review showed that refeeding syndrome is poorly defined and inconsistently reported in the regional literature, reflecting the absence of clear operational guidance in many programmes. The quantitative study demonstrated that clinically important biochemical shifts compatible with refeeding syndrome are common in hospitalised children with severe acute malnutrition and identified a bioelectrical impedance vector analysis-derived indicator that signals increased risk. The qualitative findings, in turn, revealed how conceptual uncertainty, documentation practices, laboratory constraints and communication challenges limit the translation of this theoretical knowledge into consistent bedside practice. The findings across these phases highlight the importance of strengthening health‑system protocols to support clinical decision‑making, while also expanding the use of technological methods for risk assessment to improve outcomes related to refeeding syndrome. This thesis makes several contributions to paediatric nutrition and critical care. It consolidates and appraises existing evidence on refeeding syndrome in severe acute malnutrition in Sub-Saharan Africa, thereby clarifying current knowledge gaps. It provides pilot data on the feasibility and potential use of bioelectrical impedance vector analysis as a bedside method for assessing hydration status and refeeding syndrome risk in children with severe acute malnutrition during the early stabilisation phase. It also offers an in-depth account of healthcare practitioners’ perspectives on the barriers and enablers to recognising and documenting refeeding syndrome in public hospital paediatric medical wards. Based on these findings, the thesis recommends: (i) adopting clear, context-appropriate definitions and monitoring for refeeding syndrome within national and facility-level severe acute malnutrition guidelines; (ii) prioritising routine electrolyte monitoring, particularly phosphate and potassium, during the first week of inpatient stabilisation; (iii) further evaluating bioelectrical impedance vector analysis-informed risk stratification in larger, multi-centre cohorts; and (iv) implementing targeted in-service training, standardised documentation prompts and strengthened multidisciplinary communication to support earlier recognition and management of refeeding syndrome. Overall, the work supports a more proactive, physiologically informed and system-sensitive approach to preventing refeeding syndrome and improving outcomes for hospitalised children with severe acute malnutrition. Thu, 26 Feb 2026 00:00:00 GMT http://hdl.handle.net/1893/38281 2026-02-26T00:00:00Z http://hdl.handle.net/1893/38280 Title: Opportunities and Challenges of Anti-Doping Policy Harmonisation: Comparative Analysis of the Implementation and Perceived Legitimacy of Testing and Retesting between China and the United Kingdom Author(s): Deng, Ziheng Abstract: The perceived legitimacy of anti-doping policies by stakeholders plays a vital role in harmonising implementation and sustaining the legitimacy of global anti-doping regime. Despite the vast research on anti-doping policies, comparative analysis of implementation and perceived legitimacy issues across political and cultural boundaries is limited. Consequently, there remains the opportunity for conducting comparative analysis between divergent national contexts. The aim of this thesis is to compare how testing and retesting are implemented and perceived in China and the United Kingdom (the UK) to extend empirical evidence and critically examine issues related to harmonisation and perceived legitimacy based on theoretical underpinnings of implementation and legitimacy. Semi-structured interviews were conducted with 47 stakeholders, comprising officials, coaches, and athletes from China, and coaches and athletes from the UK. Following reflexive thematic analysis, results showed that although scepticism about the credibility of China’s anti-doping is persistent, its implementation strategies for testing and retesting are convergent with those of the UK and stakeholders from both countries support anti-doping in general. However, it was also identified that stakeholders raised questions about the effectiveness, consistency and fairness of testing and retesting. Through critical analysis, the understanding of harmonisation in anti-doping was reframed, a multi-layer perceived legitimacy framework was proposed, the reasons for convergence between both countries were analysed, and the potential risks of the hegemonic character of the anti-doping regime were highlighted. Recommendations for improving the implementation of anti-doping policies and enhancing legitimacy were provided. Sun, 01 Mar 2026 00:00:00 GMT http://hdl.handle.net/1893/38280 2026-03-01T00:00:00Z http://hdl.handle.net/1893/38125 Title: Evaluating Talent Selection in a Scottish Football Academy: The Role of the FA 4 Corner Model in Identifying High-Potential Players Author(s): Ireland, Ross Abstract: Talent selection in football is a complex, multifaced process with various models being developed to assess player potential across various domains. This study aimed to explore the process of identifying high potential in academy players of those between the age groups of U13- U18, using the Football Association (FA) 4 Corner model as a method for talent selection in the context of a single case study. A focus group was conducted with six key academy performance staff across all departments within the academy’s multidisciplinary structure. Insights from the data analysis of this discussion informed the development of a questionnaire which was subsequently distributed to twenty-five academy staff members within the case study, including the existing case study participants. Thematic analysis was used to identify key themes in the selection process to provide results which were representative of the study population. Findings revealed that within each sub-corner in the 4 Corner model, there was specific attributes which held greater importance than others when measuring high potential. However, accurately pinpointing these attributes and confidently predicting a player’s potential remained a complex and challenging process. Characteristics such as ‘outplaying’ , ‘game intelligence’ , ‘speed and power’, ‘movement qualities’ , ‘resilience’ and ‘self-sufficiency’ were identified as individualistic traits of a high potential player. While there was no specific order or pattern between these traits, it was concluded that high potential players typically exhibit either a distinctive super-strength within one area of the model that sets them apart or demonstrated consistently high-performance levels across at least three of the model’s corners simultaneously. The study emphasises that to truly understand a player’s high potential ability, a dynamic and flexible assessment approach is required. Balancing objective data and subjective insights is crucial to understand a player’s full potential. Sun, 01 Jun 2025 00:00:00 GMT http://hdl.handle.net/1893/38125 2025-06-01T00:00:00Z http://hdl.handle.net/1893/38068 Title: Coach-rated importance of technical performance metrics across playing positions in football: introducing the Game Performance Index (GPI) Author(s): Smyth, Andrew Abstract: Introduction: Football is a dynamic and complex sport in which player impact is not always adequately captured by traditional performance statistics. While existing research has demonstrated the value of combining expert judgement with statistical methods, limited attention has been given to how coaches themselves prioritise technical skills across different playing positions. This study addresses this gap by examining coach-rated importance of technical actions by position and introducing the Game Performance Index (GPI) as a conceptual position-specific framework for structuring these evaluations. Methods: Seven experienced coaches and analysts from Rangers Football Club participated during the 2023/24 season. Participants rated the importance of positive and negative technical skills (e.g., successful dribbles, unsuccessful progressive passes, aerial duels won) across six outfield positions (centre back, full back, defensive midfielder, attacking midfielder, winger, and centre forward) using a five-point Likert scale. The analysis focused on the Professional Development Phase (PDP), incorporating match data from 23 players across 30 fixtures. Descriptive statistics were used to assess agreement patterns, while regression modelling and analysis of variance examined differences in importance ratings by skill type and participant. Participant deviation analysis was used to explore individual differences in rating behaviour. Results: Clear positional patterns emerged in how technical actions were valued, alongside notable overlap across roles. Defensive actions such as aerial and defensive duels were prioritised for centre backs and defensive midfielders but were also rated as relevant for forwards and wingers involved in pressing and defensive transitions. Attacking actions including chance creation, dribbling, and progressive passing were highly valued for attacking roles and remained important for deeper positions such as full backs and defensive midfielders, reflecting their role in build-up play. Differences in importance ratings were driven primarily by individual coaching tendencies rather than systematic differences between skill types. These findings illustrate that coach evaluations are shaped by positional demands and individual emphasis rather than a single uniform weighting structure. Thu, 01 Jan 2026 00:00:00 GMT http://hdl.handle.net/1893/38068 2026-01-01T00:00:00Z