Co-adapting and evaluating Teen Online Problem-Solving (TOPS) with adolescents with neurodevelopmental conditions (TOPS-ND) for use by Child Wellbeing Practitioners (CWPs) and Education Mental Health Practitioners (EMHPs) in primary care

Contact: Anna Adlam a.r.adlam@exeter.ac.uk

Other supervision team members: Jennifer Limond, Catherine Gallop, and Shari Wade (Cincinnati Children’s Hospital, Ohio, USA)

Health Education England have developed a new senior role for Child Wellbeing Practitioners (CWPs) and Education Mental Health Practitioners (EMHPs) to support the delivery of low intensity interventions in primary care for children and young people who have neurodevelopmental conditions. Approximately 80% of children and adolescents who have a neurodevelopmental condition experience difficulties with everyday executive functioning, and this can impact mental health and wellbeing. Despite this, there is limited research investigating low intensity interventions to support executive functions in children and adolescents with neurodevelopmental conditions. In collaboration with Prof Shari Wade, we have demonstrated acceptability and effectiveness (using randomised controlled trials; RCTs) of our web-based programme, Teen Online Problem-Solving (TOPS), with adolescents with brain injury in the USA, UK, Italy, and New Zealand (Wade et al., 2021). Building on our existing research, this PhD aims to: i) co-adapt TOPS with children and adolescents with neurodevelopmental conditions (TOPS-ND); and ii) evaluate the acceptability of TOPS-ND, and the feasibility of a randomised controlled trial (RCT) comparing TOPS-ND with treatment-as-usual (TAU) delivered by CWPs and EMHPs.

Development of educational resources to improve health care practitioners’ communication of uncertainty

Contact: Jo Butterworth, APEx j.e.butterworth@exeter.ac.uk

Other supervision team members:

Jason Hancock, Health Professionals Education and Wellbeing Research Group

Uncertainty is inherent within the practice of medicine. The skills of applying evidence, where available, and to making decisions in situations of uncertainty, are essential to being a doctor. Shared decision-making is ‘a joint process in which a healthcare professional works together with a person to reach a decision about care’ (NICE 2021). Experts suggest that shared decision-making provides the best clinical value in situations of uncertainty, however there is little evidence to support these opinions. Recent calls to educate practitioners in the communication of uncertainty, as a core component of shared decision-making training, require new research to guide the development of educational interventions. The aims of this PhD project are:

1.     To explore patient and practitioners’ experiences of the communication of uncertainty and the impact of shared decision-making on these experiences.

2.     To outline an evidence-based educational intervention to support practitioners in expressing and sharing uncertainty with patients as part of a shared decision-making process. 

3.     (To test the feasibility of delivery and evaluation of this new educational intervention in practice.)

Blood pressure and cognition

Contact: Christopher Clark

c.e.clark@exeter.ac.uk

Other supervision team members:

Jane Masoli, Sinéad McDonagh, Fiona Warren

In the UK, over 10% of people aged over 65 years are diagnosed with dementia and health and social care costs of dementia are estimated at £26 billion annually. Understanding and addressing the factors that lead to the development of impaired cognition and ultimately dementia is, therefore, an important health and research priority. Chronic hypertension, postural hypotension and inter-arm blood pressure differences are associated with increased dementia risk, independent of cardiovascular disease, but estimates of these associations with cognitive outcomes vary.

This PhD aims to further quantitatively explore the associations between blood pressure trajectories and indices with cognitive changes. The PhD programme will build on existing research, offering training and development in quantitative analysis and performing an exploratory, pilot phase study of blood pressure measures and cerebral blood flow to help to understand potential mechanisms. This exploratory analysis will complement the large-scale quantitative analysis of a large cardiovascular dataset derived from community and primary care cohorts (INTERPRESS-IPD Collaboration). The research team have a strong track record of research into blood pressure and cardiovascular frailty, as well as links with the Exeter NIHR BRC, the NHS Clinical Research Facility, NIHR SPCR Evidence Synthesis Working Group, and our Public Health and Sports Sciences department to support this research. As well as networking within APEx and the SPCR, the PhD student would benefit from peer support from other PhD students working in the field of cardiovascular frailty.

Evaluating therapy for prolonged grief disorder in a NHS Talking Therapies context

Contact: Barney Dunn, B.D.Dunn@exeter.ac.uk

Other supervision team members: Heather O’Mahen, Kathy Shear (Columbia University), Megan Colletta (AccEPT grief lead)

There are many people experiencing sustained and non-resolving grief reactions following bereavement who present to NHS Talking Therapies services (formerly Improving Access to Psychological Therapy, IAPT) with depression or anxiety. At the moment these people are either offered standard depression or anxiety protocols or referred out to voluntary sector providers for grief counselling, but they may do better with specialist treatment for prolonged grief disorder. This PhD would involve adapting “Complicated Grief Therapy” developed by collaborator Shear (CGT; see Shear 2010). Clients presenting to NHS Talking Therapies with prolonged grief features alongside anxiety and depression would be randomised to CGT versus TAU and feasibility, acceptability and proof of concept of the approach and trial design would be assessed.

Social prescribing in dementia what works and why people refuse

Contact: Chris Fox

Christopher.Fox@exeter.ac.uk

Other team members:

Jane Smith, Jane Cross (UEA-physiotherapy and co-lead SPLENDID study), Marie Pooley (NASP-national SP expert), Tony Avery GP, Nottingham), Louise Allan (Geriatrician)

Dementia affects 1 million people in England and 55 million people currently live with dementia globally, a number forecast to rise to 139 million by 2050. It places a significant burden on both families and health and social care. After care and support is limited, affected by budget restrictions. Recently the concept of social prescribing (SP) has been re-invigorated since its initial emergence a century ago and is growing internationally. SP could address social and behavioural determinants of the burden caused by dementia and potentially improve the efficient use of health and social care resources by enhancing self-care and use of community support networks. There is a lack of research on acceptability in dementia and also what works in this population given the broad nature of SP. The aim of this PhD would be to evaluate why people living with dementia and carers decline SP and what is potentially working. Methods would involve linking with the NIHR SPLENDID programme (ref: 203280) to conduct a mixed methods study comprising:

(a) a scoping review to understand what works and why people decline SP in dementia 

(b) interviews with people living with dementia, carers and those involved in SP to enhance implementation in people living with dementia. 

(c) development of guidance to overcome the reasons identified for people who decline SP and who are living with dementia

Tracking the pathways of young people with Attention Deficit Hyperactivity Disorder (ADHD)

Contact: Tamsin Newlove-Delgado, t.newlove-delgado@exeter.ac.uk

Other supervision team members: Anna Price, Sarah Bailey, Jane Smith

Young people with ADHD have historically been an under-served group who may experience gaps in care and disjointed services. This proposal involves using primary and secondary care datasets, and linked datasets where available, to understand patient pathways for young adults with ADHD and contribute to service development.

Physical activity and Attention Deficit Hyperactivity Disorder (ADHD) in young people: a mixed methods project to explore acceptability and implications for practice guidelines

Contact: Tamsin Newlove-Delgado

t.newlove-delgado@exeter.ac.uk

Other supervision team members:

Anna Price, Emma Cockcroft, Alan Barker (TBC)

Attention deficit hyperactivity disorder (ADHD) is a long-term condition with high costs for individuals and society. Despite a growing evidence base indicating that physical activity and exercise may improve ADHD-related impairments, there are no specific physical activity or exercise recommendations in the National Institute of Clinical Excellence (NICE) guideline for ADHD diagnosis and management. Therefore, this project proposes to advance understanding of the form(s) of physical activity and exercise that are acceptable and meaningful to young people with ADHD and what/how recommendations may be incorporated into practice guidance. The project will use a flexible mixed methods approach with embedded patient public engagement and involvement.

Digital Health Interventions: Addressing health inequalities in primary care for minoritized young people with ADHD

Contact: Anna Price

A.Price@exeter.ac.uk

Other supervision team members:

Jane Smith, Abby Russell

Attention deficit hyperactivity disorder (ADHD) is a long-term condition with high costs for individuals and society. Access to ADHD healthcare in the United Kingdom (UK) is limited, with waiting lists of 2 years or more to access specialist services in many areas. This places a strain on primary care providers. Developing new ways to deliver cost-effective, streamlined interventions via Primary Care is crucial to improving patient experiences, meeting unmet need, and reducing the burden of ADHD on the NHS. Digital health interventions (DHIs) are emerging therapeutics which, when delivered via primary care, may ameliorate some challenges experienced by people with ADHD and improve access to healthcare. Developing culturally sensitive DHIs is imperative to reduce widespread health inequalities and improve health, wellbeing, and digital provision for young people with ADHD from minority backgrounds. This PhD aims to understand and address inequalities and preferences in provision of DHIs for ADHD to help inform future policies and guidance on adapting interventions to the needs of minority groups.

Antimicrobial resistance (AMR): integration into health services policy, delivery and organisation in primary care

Contact: Emma Pitchforth, E.Pitchforth@exeter.ac.uk

Other supervision team members: Ruth Garside

AMR poses a huge health threat globally with significant implications for health service delivery. There is recognition of the challenges of AMR in the UK and the NHS Long Term Plan includes a commitment to support the implementation of the government’s five-year action plan on AMR. However, is not clear how plans for tacking AMR are integrated within broader health services delivery and organisation or achieved through key policies, including those driving primary care. Efforts to combat AMR often focus around surveillance, stewardship or behaviour change interventions to reduce the demand for or likelihood of prescribing antibiotics but not necessarily cutting across other policies concerning, for example, new models of care.

This PhD project would involve undertaking mapping and content analysis of key NHS and primary care policy documents, development of a conceptual framework to understand potential implications of key health service policies on AMR, conducting an evidence mapping and synthesis informed by the conceptual framework and primary research involving key stakeholders to inform the further integration of AMR in health services, organisation and delivery research and policy, with a specific focus on primary care.

Non-cancer diagnoses and their potential for missed opportunities in symptomatic cancer diagnosis

Contact: Sarah Price, S.J.Price@exeter.ac.uk

Other supervision team members potentially include: Richard Neal, Gary Abel, Luke Mounce, Bianca Wiering, Elizabeth Shephard

Cancer can be difficult to diagnose, particularly when it presents with non-specific symptoms with many differential diagnoses, of which cancer is relatively unlikely. Sometimes an initial non-cancer diagnosis is made in people who transpire to have cancer. These interim diagnoses may reflect good clinical practice, given the clinical information available at the time. However, they may also be missed opportunities to test for and diagnose cancer, leading to delayed diagnosis and poorer outcomes. Some people may be especially prone to receiving an interim diagnosis, particularly those who are 50 or younger, before the point at which the age-specific incidence of cancer starts to rise steeply. This PhD is envisaged to explore potential for interim diagnoses to be missed opportunities to diagnose cancer, and how associated delays in arriving at a cancer diagnosis could be minimised. A variety of approaches are possible, depending on the student’s preferences, including epidemiological, health economic and qualitative methods. This PhD will complement work being conducted as part of a multi-institutional SPCR-funded study examining interim diagnoses in older patients and offers the potential for collaboration with researchers from Queen Mary University of London and University of Oxford.

Climbing (e.g., indoor, outdoor, clip, bouldering) and mental health

Contact: Samantha van Beurden

S.B.vanBeurden@exeter.ac.uk

Other supervision team members: Jeff Lambert (Bath)

Evidence shows that physical activity can help reduce anxiety and depression. Climbing involves concentration and thought, as well as physical exercise, which helps to: keep you focused, clear your mind of outside worries. This studentship would aim to investigate the impact of climbing on mental health and the mechanisms of action, as well as potential primary care referral pathways (e.g., social prescribing) for scalable implementation.

Integrating primary care networks into the delivery of heart failure cardiac rehabilitation

Contact: Samantha van Beurden

S.B.vanBeurden@exeter.ac.uk

Other supervision team members: Sinead McDonagh, Jane Smith

The NHS long-term plan puts pressure on Cardiac Rehabilitation (CR) in secondary care to increase the offer (and uptake of) CR to people living with heart failure (HF). However, from our various projects involving the development, evaluation, and implementation of REACH-HF (home-based CR specifically for HF, including paper-based and digital) we are increasingly aware of the struggles the CR staff are experiencing in working towards the recommended targets due to lack of capacity (staff hours allocated in CR). The programme of work for this PhD would focus on investigating whether we could adapt the model of HF CR delivery to reduce the pressures on secondary care CR services by integrating primary care into the REACH-HF implementation model. Plans for the work might include:

(1)    a scoping of practice

a.    scoping review of literature about integrated care service models (for other conditions) where primary and secondary care are working together and progressing to a systematic review if there is sufficient literature (but a meta-analysis unlikely),.

b.    survey of integrated care boards about HF service delivery

(2) co-design of a new service model (with primary and secondary care staff (not necessarily patients) involving qualitative research and following Experience-Based Co-Design (primary care staff, nurses, GPs, pharmacist, but also newer staff in Primary Care Networks such as physiotherapists, dieticians – thus making best use of these new appointments).

(3) Potentially a feasibility study/trial, in 2-4 sites, or Case Study! working towards a clear service delivery model and improved/protocol for communication pathways between primary and secondary care.

Identifying and supporting people with Bipolar Disorder in primary care

Contact: Kim Wright, Psychology K.A.Wright@exeter.ac.uk

Other supervision team members: Barney Dunn, Psychology

People with Bipolar Disorder face, on average, a 9 year gap between onset of the condition and diagnosis. Even when diagnosed, access to psychological therapy is limited. Despite there being considerable demand and potential for delivery evidence-based therapies to this patient group at primary care level, nationally there is variation in terms of whether primary care psychological therapies (IAPT) services seek to identify, or offer interventions for, bipolar disorder. This studentship would aim to: i) develop and evaluate a screening process for people with Bipolar Disorder within primary care psychological therapies services; ii) and develop and evaluate a training and supervision intervention for primary care therapists to enable them to deliver appropriate evidence-based interventions.