Identification of factors contributing to recurrence of venous leg ulcers

Background and Significance Venous leg ulcers are a significant cause of chronic ill-health for 1–3% of those aged over 60 years, increasing in incidence with age. The condition is difficult and costly to heal, consuming 1–2.5% of total health budgets in developed countries and up to 50% of community nursing time. Unfortunately after healing, there is a recurrence rate of 60 to 70%, frequently within the first 12 months after heaing. Although some risk factors associated with higher recurrence rates have been identified (e.g. prolonged ulcer duration, deep vein thrombosis), in general there is limited evidence on treatments to effectively prevent recurrence. Patients are generally advised to undertake activities which aim to improve the impaired venous return (e.g. compression therapy, leg elevation, exercise). However, only compression therapy has some evidence to support its effectiveness in prevention and problems with adherence to this strategy are well documented. Aim The aim of this research was to identify factors associated with recurrence by determining relationships between recurrence and demographic factors, health, physical activity, psychosocial factors and self-care activities to prevent recurrence. Methods Two studies were undertaken: a retrospective study of participants diagnosed with a venous leg ulcer which healed 12 to 36 months prior to the study (n=122); and a prospective longitudinal study of participants recruited as their ulcer healed and data collected for 12 months following healing (n=80). Data were collected from medical records on demographics, medical history and ulcer history and treatments; and from self-report questionnaires on physical activity, nutrition, psychosocial measures, ulcer history, compression and other self-care activities. Follow-up data for the prospective study were collected every three months for 12 months after healing. For the retrospective study, a logistic regression model determined the independent influences of variables on recurrence. For the prospective study, median time to recurrence was calculated using the Kaplan-Meier method and a Cox proportional-hazards regression model was used to adjust for potential confounders and determine effects of preventive strategies and psychosocial factors on recurrence. Results In total, 68% of participants in the retrospective study and 44% of participants in the prospective study suffered a recurrence. After mutual adjustment for all variables in multivariable regression models, leg elevation, compression therapy, self efficacy and physical activity were found to be consistently related to recurrence in both studies. In the retrospective study, leg elevation, wearing Class 2 or 3 compression hosiery, the level of physical activity, cardiac disease and self efficacy scores remained significantly associated (p<0.05) with recurrence. The model was significant (p <0.001); with a R2 equivalent of 0.62. Examination of relationships between psychosocial factors and adherence to wearing compression hosiery found wearing compression hosiery was significantly positively associated with participants’ knowledge of the cause of their condition (p=0.002), higher self-efficacy scores (p=0.026) and lower depression scores (p=0.009). Analysis of data from the prospective study found there were 35 recurrences (44%) in the 12 months following healing and median time to recurrence was 27 weeks. After adjustment for potential confounders, a Cox proportional hazards regression model found that at least an hour/day of leg elevation, six or more days/week in Class 2 (20–25mmHg) or 3 (30–40mmHg) compression hosiery, higher social support scale scores and higher General Self-Efficacy scores remained significantly associated (p<0.05) with a lower risk of recurrence, while male gender and a history of DVT remained significant risk factors for recurrence. Overall the model was significant (p <0.001); with an R2 equivalent 0.72. Conclusions The high rates of recurrence found in the studies highlight the urgent need for further information in this area to support development of effective strategies for prevention. Overall, results indicate leg elevation, physical activity, compression hosiery and strategies to improve self-efficacy are likely to prevent recurrence. In addition, optimal management of depression and strategies to improve patient knowledge and self-efficacy may positively influence adherence to compression therapy. This research provides important information for development of strategies to prevent recurrence of venous leg ulcers, with the potential to improve health and decrease health care costs in this population.

Characterisation of the tritrophic interactions between tobacco yellow dwarf virus, its vector and host-plants

Tobacco yellow dwarf virus (TbYDV, family Geminiviridae, genus Mastrevirus) is an economically important pathogen causing summer death and yellow dwarf disease in bean (Phaseolus vulgaris L.) and tobacco (Nicotiana tabacum L.), respectively. Prior to the commencement of this project, little was known about the epidemiology of TbYDV, its vector and host-plant range. As a result, disease control strategies have been restricted to regular poorly timed insecticide applications which are largely ineffective, environmentally hazardous and expensive. In an effort to address this problem, this PhD project was carried out in order to better understand the epidemiology of TbYDV, to identify its host-plant and vectors as well as to characterise the population dynamics and feeding physiology of the main insect vector and other possible vectors. The host-plants and possible leafhopper vectors of TbYDV were assessed over three consecutive growing seasons at seven field sites in the Ovens Valley, Northeastern Victoria, in commercial tobacco and bean growing properties. Leafhoppers and plants were collected and tested for the presence of TbYDV by PCR. Using sweep nets, twenty-three leafhopper species were identified at the seven sites with Orosius orientalis the predominant leafhopper. Of the 23 leafhopper species screened for TbYDV, only Orosius orientalis and Anzygina zealandica tested positive. Forty-two different plant species were also identified at the seven sites and tested. Of these, TbYDV was only detected in four dicotyledonous species, Amaranthus retroflexus, Phaseolus vulgaris, Nicotiana tabacum and Raphanus raphanistrum. Using a quadrat survey, the temporal distribution and diversity of vegetation at four of the field sites was monitored in order to assess the presence of, and changes in, potential host-plants for the leafhopper vector(s) and the virus. These surveys showed that plant composition and the climatic conditions at each site were the major influences on vector numbers, virus presence and the subsequent occurrence of tobacco yellow dwarf and bean summer death diseases. Forty-two plant species were identified from all sites and it was found that sites with the lowest incidence of disease had the highest proportion of monocotyledonous plants that are non hosts for both vector and the virus. In contrast, the sites with the highest disease incidence had more host-plant species for both vector and virus, and experienced higher temperatures and less rainfall. It is likely that these climatic conditions forced the leafhopper to move into the irrigated commercial tobacco and bean crop resulting in disease. In an attempt to understand leafhopper species diversity and abundance, in and around the field borders of commercially grown tobacco crops, leafhoppers were collected from four field sites using three different sampling techniques, namely pan trap, sticky trap and sweep net. Over 51000 leafhopper samples were collected, which comprised 57 species from 11 subfamilies and 19 tribes. Twentythree leafhopper species were recorded for the first time in Victoria in addition to several economically important pest species of crops other than tobacco and bean. The highest number and greatest diversity of leafhoppers were collected in yellow pan traps follow by sticky trap and sweep nets. Orosius orientalis was found to be the most abundant leafhopper collected from all sites with greatest numbers of this leafhopper also caught using the yellow pan trap. Using the three sampling methods mentioned above, the seasonal distribution and population dynamics of O. orientalis was studied at four field sites over three successive growing seasons. The population dynamics of the leafhopper was characterised by trimodal peaks of activity, occurring in the spring and summer months. Although O. orientalis was present in large numbers early in the growing season (September-October), TbYDV was only detected in these leafhoppers between late November and the end of January. The peak in the detection of TbYDV in O. orientalis correlated with the observation of disease symptoms in tobacco and bean and was also associated with warmer temperatures and lower rainfall. To understand the feeding requirements of Orosius orientalis and to enable screening of potential control agents, a chemically-defined artificial diet (designated PT-07) and feeding system was developed. This novel diet formulation allowed survival for O. orientalis for up to 46 days including complete development from first instar through to adulthood. The effect of three selected plant derived proteins, cowpea trypsin inhibitor (CpTi), Galanthus nivalis agglutinin (GNA) and wheat germ agglutinin (WGA), on leafhopper survival and development was assessed. Both GNA and WGA were shown to reduce leafhopper survival and development significantly when incorporated at a 0.1% (w/v) concentration. In contrast, CpTi at the same concentration did not exhibit significant antimetabolic properties. Based on these results, GNA and WGA are potentially useful antimetabolic agents for expression in genetically modified crops to improve the management of O. orientalis, TbYDV and the other pathogens it vectors. Finally, an electrical penetration graph (EPG) was used to study the feeding behaviour of O. orientalis to provide insights into TbYDV acquisition and transmission. Waveforms representing different feeding activity were acquired by EPG from adult O. orientalis feeding on two plant species, Phaseolus vulgaris and Nicotiana tabacum and a simple sucrose-based artificial diet. Five waveforms (designated O1-O5) were observed when O. orientalis fed on P. vulgaris, while only four (O1-O4) and three (O1-O3) waveforms were observed during feeding on N. tabacum and the artificial diet, respectively. The mean duration of each waveform and the waveform type differed markedly depending on the food source. This is the first detailed study on the tritrophic interactions between TbYDV, its leafhopper vector, O. orientalis, and host-plants. The results of this research have provided important fundamental information which can be used to develop more effective control strategies not only for O. orientalis, but also for TbYDV and other pathogens vectored by the leafhopper.

Availability of advance visual information constrains association-football goalkeeping performance during penalty kicks

A pressing concern within the literature on anticipatory perceptual-motor behaviour is the lack of clarity on the applicability of data, observed under video-simulation task constraints, to actual performance in which actions are coupled to perception, as captured during in-situ experimental conditions. We developed an in-situ experimental paradigm which manipulated the duration of anticipatory visual information from a penalty taker’s actions to examine experienced goalkeepers’ vulnerability to deception for the penalty kick in association football. Irrespective of the penalty taker’s kick strategy, goalkeepers initiated movement responses earlier across consecutively earlier presentation points. Overall goalkeeping performance was better in non-deception trials than in deception conditions. In deception trials, the kinematic information presented up until the penalty taker initiated his/her kicking action had a negative effect on goalkeepers’ performance. It is concluded that goalkeepers are likely to benefit from not anticipating a penalty taker’s performance outcome based on information from the run-up, in preference to later information that emerges just before the initiation of the penalty taker’s kicking action.

Corneal sensitivity as an ophthalmic marker of diabetic neuropathy

Purpose. The objective of this study was to explore the discriminative capacity of non-contact corneal esthesiometry (NCCE) when compared with the neuropathy disability score (NDS) score—a validated, standard method of diagnosing clinically significant diabetic neuropathy. Methods. Eighty-one participants with type 2 diabetes, no history of ocular disease, trauma, or surgery and no history of systemic disease that may affect the cornea were enrolled. Participants were ineligible if there was history of neuropathy due to non-diabetic cause or current diabetic foot ulcer or infection. Corneal sensitivity threshold was measured on the eye of dominant hand side at a distance of 10 mm from the center of the cornea using a stimulus duration of 0.9 s. The NDS was measured producing a score ranging from 0 to 10. To determine the optimal cutoff point of corneal sensitivity that identified the presence of neuropathy (diagnosed by NDS), the Youden index and “closest-to-(0,1)” criteria were used. Results. The receiver-operator characteristic curve for NCCE for the presence of neuropathy (NDS ≥3) had an area under the curve of 0.73 (p = 0.001) and, for the presence of moderate neuropathy (NDS ≥6), area of 0.71 (p = 0.003). By using the Youden index, for an NDS ≥3, the sensitivity of NCCE was 70% and specificity was 75%, and a corneal sensitivity threshold of 0.66 mbar or higher indicated the presence of neuropathy. When NDS ≥6 (indicating risk of foot ulceration) was applied, the sensitivity was 52% with a specificity of 85%. Conclusions. NCCE is a sensitive test for the diagnosis of minimal and more advanced diabetic neuropathy and may serve as a useful surrogate marker for diabetic and perhaps other neuropathies.

Response shift, recall bias and their effect on measuring change in health-related quality of life amongst older hospital patients

Background: Assessments of change in subjective patient reported outcomes such as health-related quality of life (HRQoL) are a key component of many clinical and research evaluations. However, conventional longitudinal evaluation of change may not agree with patient perceived change if patients' understanding of the subjective construct under evaluation changes over time (response shift) or if patients' have inaccurate recollection (recall bias). This study examined whether older adults' perception of change is in agreement with conventional longitudinal evaluation of change in their HRQoL over the duration of their hospital stay. It also investigated this level of agreement after adjusting patient perceived change for recall bias that patients may have experienced. Methods: A prospective longitudinal cohort design nested within a larger randomised controlled trial was implemented. 103 hospitalised older adults participated in this investigation at a tertiary hospital facility. The EQ-5D utility and Visual Analogue Scale (VAS) scores were used to evaluate HRQoL. Participants completed EQ-5D reports as soon as they were medically stable (within three days of admission) then again immediately prior to discharge. Three methods of change score calculation were used (conventional change, patient perceived change and patient perceived change adjusted for recall bias). Agreement was primarily investigated using intraclass correlation coefficients (ICC) and limits of agreement. Results: Overall 101 (98%) participants completed both admission and discharge assessments. The mean (SD) age was 73.3 (11.2). The median (IQR) length of stay was 38 (20-60) days. For agreement between conventional longitudinal change and patient perceived change: ICCs were 0.34 and 0.40 for EQ-5D utility and VAS respectively. For agreement between conventional longitudinal change and patient perceived change adjusted for recall bias: ICCs were 0.98 and 0.90 respectively. Discrepancy between conventional longitudinal change and patient perceived change was considered clinically meaningful for 84 (83.2%) of participants, after adjusting for recall bias this reduced to 8 (7.9%). Conclusions: Agreement between conventional change and patient perceived change was not strong. A large proportion of this disagreement could be attributed to recall bias. To overcome the invalidating effect of response shift (on conventional change) and recall bias (on patient perceived change) a method of adjusting patient perceived change for recall bias has been described.

Increasing underwater vehicle autonomy by reducing energy consumption

In this paper, we concern ourselves with finding a control strategy that minimizes energy consumption along a trajectory connecting two given configurations. We develop an algorithm, based on our previous work with the time optimal problem, which provides implementable control strategies that are energy efficient. We find an interesting correlation between the duration of these trajectories and the optimal duration. We present the algorithm, control strategy and experimental results from our test-bed vehicle.

Autonomous underwater vehicles: development and implementation of time and energy efficient trajectories

Autonomous underwater vehicles (AUVs) are increasingly used, both in military and civilian applications. These vehicles are limited mainly by the intelligence we give them and the life of their batteries. Research is active to extend vehicle autonomy in both aspects. Our intent is to give the vehicle the ability to adapt its behavior under different mission scenarios (emergency maneuvers versus long duration monitoring). This involves a search for optimal trajectories minimizing time, energy or a combination of both. Despite some success stories in AUV control, optimal control is still a very underdeveloped area. Adaptive control research has contributed to cost minimization problems, but vehicle design has been the driving force for advancement in optimal control research. We look to advance the development of optimal control theory by expanding the motions along which AUVs travel. Traditionally, AUVs have taken the role of performing the long data gathering mission in the open ocean with little to no interaction with their surroundings, MacIver et al. (2004). The AUV is used to find the shipwreck, and the remotely operated vehicle (ROV) handles the exploration up close. AUV mission profiles of this sort are best suited through the use of a torpedo shaped AUV, Bertram and Alvarez (2006), since straight lines and minimal (0 deg - 30 deg) angular displacements are all that are necessary to perform the transects and grid lines for these applications. However, the torpedo shape AUV lacks the ability to perform low-speed maneuvers in cluttered environments, such as autonomous exploration close to the seabed and around obstacles, MacIver et al. (2004). Thus, we consider an agile vehicle capable of movement in six degrees of freedom without any preference of direction.

Low intensity CBT by mail

Introduction: There are many low intensity (LI) cognitive behavoural therapy (CBT) solutions to the problem of limited service access. In this chapter, we aim to discuss a relatively low-technology approach to access using standard postal services-CBT by mail, or M-CBT. Bibliotherapies including M-CBT teach key concepts and self-management techniques, together with screening tools and forms to structure home practice. M-CBT differs from other bibliotherapies by segmenting interventions and mailing them at regular intervals. Most involve participants returning copies of monitoring forms or completed handouts. Therapist feedback is provided, often in personal letters that accompany the printed materials. Participants may also be given access to telephone or email support. ----- ----- M-CBT clearly fulfills criteria for an LI CBT (see Bennett-Levy et al., Chapter 1, for a definition of LI interventions). Once written, they involve little therapist time and rely heavily on self-management. However, content and overall treatment duration need not be compromised. Long-term interventions with multiple components can be delivered via this method, provided their content can be communicated in letters and engagement is maintained.

Brief motivational interviewing for depression and anxiety

Motivational interviewing (MI)can be applied as a brief, low intensity (LI) intervention of 1-4 individualised sessions (typically 45-60 minutes in duration), including screening, assessment feedback, and psycho-education. MI is a client-centred, directive therapeutic style that enhances readiness for change by helping clients explore and resolve ambivalence (Miller and Rollnick 2002). A summary of the key components of brief MI interventions is provided in Table 16.1. There is a well-established evidence base for MI in the treatment of substance misuse (particularly alcohol misuse; Moyer et al. 2002), as well as a growing evidence for the use of MI in the treatment of other mental disorders (e.g. depression, PTSD, OCD), as well as suicidality and physical health problems (Hettema et al. 2005). Brief MI intervention can be delivered as a standalone treatment or as a motivational prelude to pharmacological and/or other psychological treatments (Hettema et al. 2005). MI has been used as an accompaniment to cognitive behavioural therapy (CBT) in the treatment of both depression and anxiety for resolving ambivalence about change and developing strategies for responding to resistance (e.g. treatment attendance, homework/medication compliance; Arkowitz et al. 2008a, 2008b). This chapter will describe how to apply brief MI interventions to the treatment of depression and anxiety as applied to the case of Megan (see Box 16.1) along with some of the challenges and potential solutions to applying MI in practice.

The impact of changes to the graduated driver licensing program in Queensland, Australia on the experiences of learner drivers

Purpose: Graduated driver licensing (GDL) has been introduced in numerous jurisdictions in Australia and internationally in an attempt to ameliorate the significantly greater risk of death and injury for young novice drivers arising from road crashes. The GDL program in Queensland, Australia, was extensively modified in July 2007. This paper reports the driving and licensing experiences of Learner drivers progressing through the current-GDL program, and compares them to the experiences of Learners who progressed through the former-GDL program. ----- ----- Method: Young drivers (n = 1032, 609 females, 423 males) aged 17 to 19 years (M = 17.43, SD = 0.67) were recruited as they progressed from a Learner to a Provisional driver’s licence. They completed a survey exploring their sociodemographic characteristics, driving and licensing experiences as a Learner. Key measures for a subsample (n = 183) of the current-GDL drivers were compared with the former-GDL drivers (n = 149) via t-tests and chi-square analyses. ----- ----- Results: As expected, Learner drivers progressing through the current-GDL program gained significantly more driving practice than those in the former program, which was more likely to be provided by mothers than in the past. Female learners in the current-GDL program reported less difficulty obtaining supervision than those in the former program. The number of attempts needed to pass the practical driving assessment did not change, nor did the amount of professional supervision. The current-GDL Learners held their licence for a significantly longer duration than those in the former program, with the majority reporting that their Logbook entries were accurate on the whole. Compared to those in the former program, a significantly smaller proportion of male current-GDL Learners reported being detected for a driving offence while the females reported significantly lower crash involvement. Most current-GDL drivers reported undertaking their supervised practice at the end of the Learner period. ----- ----- Conclusions: The enhancements to the GDL program in Queensland appear to have achieved many of their intended results. The current-GDL learners participating in the study reported obtaining a significantly greater amount of supervised driving experience compared to former-GDL learners. Encouragingly, the current-GDL Learners did not report any greater difficulty in obtaining supervised driving practice, and there was a decline in the proportion of current-GDL Learners engaging in unsupervised driving. In addition, the majority of Learners do not appear to be attempting to subvert logbook recording requirements, as evidenced by high rates of self-reported logbook accuracy. The results have implications for the development and the evaluation of GDL programs in Australia and around the world.

The low-affinity site of the β1-adrenoceptor and its relevance to cardiovascular pharmacology

β-Adrenoceptor blocking agents (β-blockers) that at low concentrations antagonize cardiostimulant effects of catecholamines, but at high concentrations also cause cardiostimulation, have been appearing since the late 1960s. These cardiostimulant β-blockers, coined non-conventional partial agonists, antagonize the effects of catecholamines through a high-affinity site (β1HAR), but cause cardiostimulation mainly through a low-affinity site (β1LAR) of the myocardial β1-adrenoceptor. The experimental non-conventional partial agonist (−)-CGP12177 increases cardiac L-type Ca2+ current density and Ca2+ transients, shortens action potential duration but augments action potential plateau, increases heart rate and force, as well as causes arrhythmic Ca2+ transients and arrhythmic cardiocyte contractions. Other β-blockers, which do not cause cardiostimulation, consistently have lower affinity for β1LAR than β1HAR. These sites were verified and the cardiac pharmacology of non-conventional partial agonists confirmed on recombinant β1-adrenoceptors and on β1-adrenoceptors overexpressed into the heart. A targeted mutation of Asp138 to Glu138 virtually abolished the pharmacology of β1HAR but left intact the pharmacology of β1LAR. Non-conventional partial agonists may be beneficial for the treatment of peripheral autonomic neuropathy but probably due to their arrhythmic propensities, may be harmful for the treatment of chronic heart failure.

MobileMums: A randomized controlled trial of an SMS-based physical activity intervention

Background Postnatal women (<12 months postpartum) are at increased risk of physical inactivity. Purpose To evaluate the efficacy and feasibility of a theory-based physical activity (PA) intervention delivered to postnatal women primarily via mobile telephone short message service (SMS). Methods Eighty-eight women were randomized to the intervention (n=45) or minimal contact control (n=43) condition. The 12-week intervention consisted of a face-to-face PA goal-setting consultation, a goal-setting magnet, three to five personally tailored SMS/week and a nominated support person who received two SMS per week. SMS content targeted constructs of social cognitive theory. Frequency (days/week) and duration (min/week) of PA participation and walking for exercise were assessed via self-report at baseline, 6 and 13 weeks. Results Intervention participants increased PA frequency by 1.82 days/week (SE±0.18) by 13 weeks (F(2,85)=4.46, p=0.038) and walking for exercise frequency by 1.08 days/ week (SE±0.24) by 13 weeks (F(2,85)=5.38, p=0.02). Positive trends were observed for duration (min/week) of PA and walking for exercise. Conclusions Intervention exposure resulted in increased frequency of PA and walking for exercise in postnatal women.

Reliability analysis and economic equipment replacement appraisal for substation and sub-transmission systems with explicit inclusion of non-repairable failures

The modern society has come to expect the electrical energy on demand, while many of the facilities in power systems are aging beyond repair and maintenance. The risk of failure is increasing with the aging equipments and can pose serious consequences for continuity of electricity supply. As the equipments used in high voltage power networks are very expensive, economically it may not be feasible to purchase and store spares in a warehouse for extended periods of time. On the other hand, there is normally a significant time before receiving equipment once it is ordered. This situation has created a considerable interest in the evaluation and application of probability methods for aging plant and provisions of spares in bulk supply networks, and can be of particular importance for substations. Quantitative adequacy assessment of substation and sub-transmission power systems is generally done using a contingency enumeration approach which includes the evaluation of contingencies, classification of the contingencies based on selected failure criteria. The problem is very complex because of the need to include detailed modelling and operation of substation and sub-transmission equipment using network flow evaluation and to consider multiple levels of component failures. In this thesis a new model associated with aging equipment is developed to combine the standard tools of random failures, as well as specific model for aging failures. This technique is applied in this thesis to include and examine the impact of aging equipments on system reliability of bulk supply loads and consumers in distribution network for defined range of planning years. The power system risk indices depend on many factors such as the actual physical network configuration and operation, aging conditions of the equipment, and the relevant constraints. The impact and importance of equipment reliability on power system risk indices in a network with aging facilities contains valuable information for utilities to better understand network performance and the weak links in the system. In this thesis, algorithms are developed to measure the contribution of individual equipment to the power system risk indices, as part of the novel risk analysis tool. A new cost worth approach was developed in this thesis that can make an early decision in planning for replacement activities concerning non-repairable aging components, in order to maintain a system reliability performance which economically is acceptable. The concepts, techniques and procedures developed in this thesis are illustrated numerically using published test systems. It is believed that the methods and approaches presented, substantially improve the accuracy of risk predictions by explicit consideration of the effect of equipment entering a period of increased risk of a non-repairable failure.

The role of mother-centered factors influencing the complex social behaviour of breastfeeding : social support and self-efficacy

This research investigated the role of mother-centred issues that influence breastfeeding behaviours. The need for social marketing research for breastfeeding is indicated by the fact that despite evidence of the health benefits to both the infant and mother of longer breastfeeding duration, rates in developed countries have failed to increase in recent decades. Breastfeeding is a complex behaviour that for many women involves barriers that influence their commitment to continue breastfeeding. Structural equation modelling was used on a sample of 405 respondents to an online survey. The analysis revealed that personal social support had a significant impact on breastfeeding self-efficacy, which in turn had a significant impact on breastfeeding behaviour. The findings and implications for both social marketing theory and practice are discussed.

An assessment system for evaluation of driving competencies

Automobiles have deeply impacted the way in which we travel but they have also contributed to many deaths and injury due to crashes. A number of reasons for these crashes have been pointed out by researchers. Inexperience has been identified as a contributing factor to road crashes. Driver’s driving abilities also play a vital role in judging the road environment and reacting in-time to avoid any possible collision. Therefore driver’s perceptual and motor skills remain the key factors impacting on road safety. Our failure to understand what is really important for learners, in terms of competent driving, is one of the many challenges for building better training programs. Driver training is one of the interventions aimed at decreasing the number of crashes that involve young drivers. Currently, there is a need to develop comprehensive driver evaluation system that benefits from the advances in Driver Assistance Systems. A multidisciplinary approach is necessary to explain how driving abilities evolves with on-road driving experience. To our knowledge, driver assistance systems have never been comprehensively used in a driver training context to assess the safety aspect of driving. The aim and novelty of this thesis is to develop and evaluate an Intelligent Driver Training System (IDTS) as an automated assessment tool that will help drivers and their trainers to comprehensively view complex driving manoeuvres and potentially provide effective feedback by post processing the data recorded during driving. This system is designed to help driver trainers to accurately evaluate driver performance and has the potential to provide valuable feedback to the drivers. Since driving is dependent on fuzzy inputs from the driver (i.e. approximate distance calculation from the other vehicles, approximate assumption of the other vehicle speed), it is necessary that the evaluation system is based on criteria and rules that handles uncertain and fuzzy characteristics of the driving tasks. Therefore, the proposed IDTS utilizes fuzzy set theory for the assessment of driver performance. The proposed research program focuses on integrating the multi-sensory information acquired from the vehicle, driver and environment to assess driving competencies. After information acquisition, the current research focuses on automated segmentation of the selected manoeuvres from the driving scenario. This leads to the creation of a model that determines a “competency” criterion through the driving performance protocol used by driver trainers (i.e. expert knowledge) to assess drivers. This is achieved by comprehensively evaluating and assessing the data stream acquired from multiple in-vehicle sensors using fuzzy rules and classifying the driving manoeuvres (i.e. overtake, lane change, T-crossing and turn) between low and high competency. The fuzzy rules use parameters such as following distance, gaze depth and scan area, distance with respect to lanes and excessive acceleration or braking during the manoeuvres to assess competency. These rules that identify driving competency were initially designed with the help of expert’s knowledge (i.e. driver trainers). In-order to fine tune these rules and the parameters that define these rules, a driving experiment was conducted to identify the empirical differences between novice and experienced drivers. The results from the driving experiment indicated that significant differences existed between novice and experienced driver, in terms of their gaze pattern and duration, speed, stop time at the T-crossing, lane keeping and the time spent in lanes while performing the selected manoeuvres. These differences were used to refine the fuzzy membership functions and rules that govern the assessments of the driving tasks. Next, this research focused on providing an integrated visual assessment interface to both driver trainers and their trainees. By providing a rich set of interactive graphical interfaces, displaying information about the driving tasks, Intelligent Driver Training System (IDTS) visualisation module has the potential to give empirical feedback to its users. Lastly, the validation of the IDTS system’s assessment was conducted by comparing IDTS objective assessments, for the driving experiment, with the subjective assessments of the driver trainers for particular manoeuvres. Results show that not only IDTS was able to match the subjective assessments made by driver trainers during the driving experiment but also identified some additional driving manoeuvres performed in low competency that were not identified by the driver trainers due to increased mental workload of trainers when assessing multiple variables that constitute driving. The validation of IDTS emphasized the need for an automated assessment tool that can segment the manoeuvres from the driving scenario, further investigate the variables within that manoeuvre to determine the manoeuvre’s competency and provide integrated visualisation regarding the manoeuvre to its users (i.e. trainers and trainees). Through analysis and validation it was shown that IDTS is a useful assistance tool for driver trainers to empirically assess and potentially provide feedback regarding the manoeuvres undertaken by the drivers.