Shaping the future of workforce of applied health research

The Unit has been actively supportive in helping individuals to gain doctoral degrees and research experience.

Below are some study details of our current doctoral students and recent graduates.

Dr Jennifer Airlie

PhD status: Awarded
PhD title: The measurement of physical activity and sedentary behaviour in older adults residing in care homes

Study Overview: Evidence supports the implementation of physical activity (PA) as a therapeutic intervention for older care homes residents. Nevertheless, few studies to date have actually measured PA or sedentary behaviour,  instead choosing to focus on examining the effect of PA on another outcome, typically physical function. As a result little is known about the levels of PA and sedentary behaviour in this population.  The preference to utilise measures of physical function rather than PA may be attributed in part to the unique challenges surrounding the measurement of PA and sedentary behaviour in a care home population. Thus, this thesis aims to explore the methodological issues and practical feasibility of using accelerometers with older care home residents. It also aims to use an accelerometer to objectively measure the levels and patterns of PA and sedentary behaviour this population.

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Background
While policy and service developments have emphasised alternatives to long-term care (LTC), projected demographic changes mean the number of dependent older adults residing in LTC facilities such as care homes will remain high. Accordingly, it is important to explore factors which may help slow the progression in functional decline and also maintain or improve quality of life.

There is an established body of evidence concerning the health and social benefits of engaging in PA for older adults. Moreover, evidence from interventional studies that supports the implementation of PA as a preventative and therapeutic intervention for residents of care homes is emerging. Nevertheless, few studies to date have actually measured PA or sedentary behaviour, instead choosing to focus on examining the effect of PA on another outcome, typically physical function. The preference to utilise measures of physical function rather than PA may be attributed in part to the unique challenges surrounding the measurement of sedentary behaviour and PA in a care home population.
The ability of accelerometers to objectively and unobtrusively measure both sedentary behaviour and differing intensities of PA mean they have great potential in terms of their use with older care home residents. Still, there remains a limited number of studies which have utilised these devices to objectively measure the habitual PA behaviours of this population. As a result little is known about the levels and patterns of sedentary behaviour and PA typical of care home residents. Understanding the PA behaviour of this population is critical to inform the development of interventions and advise on appropriate recommendations in a care home environment.

Aims and Objectives
This thesis aims to explore issues pertaining to the use of accelerometers with older care home residents. It also aims to use an accelerometer to objectively measure the levels and patterns of PA and sedentary behaviour of this population. Additionally, the influence of intra- and inter-personal factors on PA and sedentary behaviour will be explored

Academic Supervisors:
Professor Karen Birch
Professor Anne Forster

Dr Nicola Cornwall

PhD status: Awarded
PhD title: Exploring sedentary behaviour in stroke survivors with severe mobility disability living at home

Study Overview: The study aims to investigate sedentary behaviour in stroke survivors with severe mobility disability (need the help of at least one person to stand or walk) living at home. It also aims to identify the next steps needed for research into sedentary behaviour in stroke survivors with severe mobility disabilities and develop recommendations to help reduce sedentary behaviour in this population.

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Background
Sedentary behaviours are defined as any behaviour that involves sitting or reclining postures with low energy expenditure and have recently been found to have deleterious health effects.
Stroke survivors are often more sedentary than aged matched controls, with severe stroke associated with associated with greater sedentary behaviour. The current limited literature indicates that stroke survivors who have a mobility disability or are severely disabled are often excluded or under-represented in research studies, especially in relation to sedentary behaviour. There is also little known about the activity levels and energy costs of activity in stroke survivors who require help to stand or walk.
Because stroke survivors with severe mobility disability are more sedentary than other stroke survivors, there is a need for research into sedentary behaviour in this population. It is not only important to determine the significance of sedentary behaviour in this population but also to gain the patient’s perspective of what being sedentary means to them.
The overall aim of the project is to investigate sedentary behaviour in stroke survivors with severe mobility disability living at home, using different methods including systematic review, qualitative and quantitative research methods. The main outcomes will be to develop recommendations to help reduce sedentary behaviour in stroke survivors with severe mobility disability and to speculate the next steps needed for research into sedentary behaviour in this population.

Aims and Objectives
The overall aim of the project is to investigate sedentary behaviour in stroke survivors who have a severe mobility disability and are living at home.

The project has five sub-aims, each with objectives:

1. To review the existing literature of sedentary behaviour in stroke survivors
a. Update an existing systematic review by (English et al., 2014).
b. Explore the inclusion and exclusion of stroke survivors with severe mobility disability in the included studies.

2. To review the existing literature to assess the effectiveness, appropriateness and acceptability of interventions to reduce sedentary behaviour in disabled people through a mixed method systematic review using the Evidence for Policy and Practice Information and Co-ordinating centre (EPPI) approach.
a. Undertake a systematic review to identify, describe and assess the effectiveness of interventions aimed at reducing sedentary behaviour in disabled people.
b. Undertake a systematic review of qualitative ‘views’ studies to explore the individuals’, carers’ and health care professionals’ perspectives and experiences of sedentary behaviour in people who are disabled.
c. Conduct a meta-synthesis to synthesise the findings from the two systematic reviews.

3. To explore sedentary behaviour from the perspectives of stroke survivors with severe mobility disability, their carers and professionals involved in their care.
a. Conduct a Q-methodology study with stroke survivors with severe mobility disability, their carers and professionals involved in their care, to explore their perspectives of sedentary behaviour and assess their priorities in terms of mobility, sitting, movement and exercise.

4. Characterise sedentary behaviour in stroke survivors with severe mobility disability.
a. Characterise the sedentary behaviour patterns of a sample of stroke survivors with severe mobility disabilities.
b. Investigate the energy expenditure required when completing different activities in this group of stroke survivors with severe mobility disabilities.

5. To develop advice, guidance and recommendations to help reduce sedentary behaviour in stroke survivors with severe mobility disability.
a. Draw upon findings from aims one to four and their objectives to develop advice and guidance for patients, carers and professionals to reduce sedentary behaviour.
b. Develop recommendations regarding the design and content of a possible intervention to reduce sedentary behaviour in stroke survivors with severe mobility disability.

Academic Supervisors:
Professor Anne Forster
Dr David Clarke
Dr Karen Birch

Funding: University of Leeds. 110 Anniversary Scholarship – £14,057(per annum). October, 2015 – October 2018

Dr Jessica Hall

PhD status: Awarded
PhD title: The development of an intervention for carers of stroke survivors using an Intervention Mapping approach

Study Overview: The aim of the study was to use an Intervention Mapping approach (Bartholomew et al. 2011) to develop a proposed theory- and evidence-based intervention to reduce burden in carers of stroke survivors. In conjunction with stakeholder involvement, Intervention Mapping stages one to four guided intervention development: needs assessment; identifying outcomes and objectives; selecting theoretical methods and practical applications; and creating a programme plan. The needs assessment included three components: A systematic review of systematic reviews established the factors that influence burden in carers of stroke survivors and other longer-term conditions; a thematic synthesis of qualitative studies and a qualitative interview study established carers’ needs, how and whether they change over time, and the barriers and facilitators to addressing needs. Findings influenced subsequent stages of intervention development where a proposed intervention comprised of multiple components was developed.

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Background: Burden is well documented among carers of stroke survivors, yet current evidence is insufficient for determining the best strategies for reducing negative outcomes. The Medical Research Council (MRC) framework advocates using theories in intervention development, but lacks guidance on how this can be achieved. Interventions targeting carers of stroke survivors often lack theory or provide inadequate descriptions of the active ingredients determining their effects.

Aims: This research aimed to develop a proposed theory and evidence-based intervention to reduce burden in carers of stroke survivors.

Academic Supervisors:
Professor Anne Forster
Dr David Clarke

Funding: University of Leeds. 110 Anniversary Scholarship – £14,057(per annum). October, 2017 – October 2017

Ms Liz Graham

PhD status: On-going
PhD title: The feasibility of undertaking a complex intervention trial in English care homes

Study Overview: The PATCH feasibility trial will inform the design of a definitive cluster RCT. It will also provide a platform for detailed exploration of recruitment (barriers and facilitators to care home, staff and resident involvement), factors influencing intervention uptake, and the feasibility and best methods of collecting data from and about residents. It is already known that conducting trials in care homes is difficult. The aim of this research is to explore recruitment, retention, intervention delivery and data collection in this setting in more detail.

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Background: The urgent need to improve the health and quality-of-life of care home residents is being addressed by an increase in research activity in this setting. In line with Department of Health and Social Care priorities the collective and much needed goal is to optimise care for residents, but generating evidence is difficult. I have experience of the challenges involved in the implementation of clinical trials in the care home setting and there is much published literature detailing similar complexities. Such limitations include low participant engagement, poor intervention uptake and poor quality data.

Aims and objectives
The aim of this research is to explore recruitment, retention, intervention delivery and data collection in more detail, through a review of the literature, engagement with PATCH care home staff and residents, and through wider work with care home partners. This will lead to recommendations for the conduct of future trials in this setting, with a particular focus on the collection of appropriate outcome data.

Academic Supervisors
Professor Anne Forster
Dr David Owens

Dr Seline Ozer

PhD status: Awarded
PhD title: An Evaluation of Brief Cognitive Tests for the Identification of Mild Cognitive Impairment

Study Overview: The aim of the study was to investigate the effectiveness of a range of brief cognitive tests to be used for the purpose of identifying people with mild cognitive impairment (MCI) in an efficient and accurate manner. The study involved conducting a systematic review to identify the brief cognitive tests that have been used to identify people with amnestic MCI and to evaluate the evidence for their accuracy. In addition, experimental work was conducted to assess the validity of two brief memory tests (the Memory Alteration Test (M@T) and Test Your Memory (TYM) test) as well as some reaction time task derived measures to identify MCI within a cohort of older people recruited from the community.

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Background: Mild cognitive impairment (MCI), a term used to describe the transitional state between normal aging and established dementia, has been identified as a potentially effective time point at which to target interventions to prevent or slow the decline into dementia. An efficient way of identifying people with MCI is required as a first step in conducting large scale studies to develop and evaluate interventions targeted at this high risk population.

Aims and Objectives: The overall aim was to investigate the effectiveness of a range of brief cognitive tests to be used for identifying people with MCI in an efficient and accurate manner. This aim was met by addressing four research questions:

  • What brief cognitive tests have been used previously to identify people with amnestic MCI (aMCI) and what is the evidence for their accuracy?
  • Can people with MCI be identified and recruited from the community in an efficient and timely manner?
  • Are candidate brief cognitive tests (namely the Memory Alteration Test (M@T) and the Test Your Memory (TYM) test) accurate, reliable and usable in identifying people with aMCI from the community?
  • Are reaction time (RT) derived measures accurate in identifying MCI?

Publications:

  • Ozer S, Young J, Champ C, Burke M: A systematic review of the diagnostic test accuracy of brief cognitive tests to detect amnestic mild cognitive impairment. International journal of geriatric psychiatry 2016, 31(11):1139-1150.
  • Ozer S, Noonan K, Burke M, Young J, Barber S, Forster A, Jones R: The validity of the Memory Alteration Test and the Test Your Memory test for community-based identification of amnestic mild cognitive impairment. Alzheimer’s & dementia: the journal of the Alzheimer’s Association 2016, 12(9):987-995.

Academic Supervisors:
Professor John Young
Dr Melanie Burke

 

Dr Oliver Todd

PhD status: On-going
PhD title: Optimising blood pressure management for older people with frailty

Study Overview: Oliver’s PhD aims to identify the optimal blood pressure in frail older people. His work includes a big data study which will apply the electronic frailty index (eFI) to large primary care data sets, alongside interviews to establish with older people themselves the goals of treatment and how they might change with frailty. He will be supervised at the University of Leeds by Dr Andy Clegg, Prof John Young and Mary Godfrey (from the Academic Unit of Elderly Care and Rehabilitation) and Prof Chris Gale and Dr Marlous Hall from the Division of Epidemiology, Leeds Institute of Cardiovascular and Metabolic Medicine. Oly will also be collaborating with researchers from the Nuffield Department of Primary Care Health Sciences, Oxford University and the Division of Geriatric Medicine, Dalhousie University, Canada.

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Objectives and brief methodology
We know that tight blood pressure control in young and middle age reduces future stroke and heart attack risk. We don’t know if therapy is as effective for frail older people as they have been excluded from large clinical trials. Yet there is growing evidence that in some of the frail elderly, treatment may do harm.

Current practice focuses just on BP as a number. But clearly there are trade-offs: sacrificing short term adverse effects for long term vascular risk prevention. Considering frailty could inform treatment.

We need to know whether and how frailty modifies BP management on the net effect on quality of life, independent living and mortality.

The overarching aim of this fellowship is to investigate the association between frailty, hypertension and clinical outcomes to inform optimisation of blood pressure management for people with well-defined frailty. This will be done through four linked studies:

Study 1 will take stock of the available literature to provide context for my primary study and to inform the type of outcomes I should be looking at.

Study 2 will involve use interviews to identify from patients and their carers emergent themes concerning studies 3 and 4.

Study 3 will apply the electronic frailty index (eFI) to large primary care data sets (approx. 1.5million older people). Here I will ascertain whether frailty has a modifying effect on the association between blood pressure and outcomes derived from Hospital episode statistics. I will use multivariable regression techniques. This analysis will be highly statistically powered, but limited in the granularity of BP and frailty measurements.

Therefore, Study 4 will use a prospective cohort highly characterized in terms of BP and frailty measures to determine whether similar patterns exist in this richer data set.

Together, the results of these 4 linked studies will provide key generalizable knowledge to inform and guide clinical decision making on the treatment of blood pressure in older people.

Academic Supervisors
Dr Andy Clegg
Prof Chris Gale
Dr Marlous Hall
Ms Mary Godfrey
Prof John Young

Funding: Dunhill Medical Trust Research Training PhD Fellowship

Further information
Follow @ToddOly on Twitter
For more information email oliver.todd@bthft.nhs.uk

Dr Faye Wray

PhD status: Awarded
PhD title: Developing a self-management intervention for stroke survivors with communication difficulties living in the community.

Study Overview: The study aims to understand how best to support stroke survivors with communication difficulties in the longer-term and to make recommendations for a longer-term support strategy.

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Background
Up to one third of stroke survivors will experience communication difficulties which may cause difficulty speaking, understanding speech or difficuly with reading and writing. These difficulties have an extensive impact upon daily life and may persist for many years following stroke. We wish to understand how stroke survivors with communication difficulties might be better helped to manage in the longer-term and to make recommendations about the type of support which is needed.

Aims and Objectives
The overall aim of the project is to develop an in-depth understanding of the requirements for longer-term care for stroke survivors with communication difficulties and to use this knowledge to make recommendations for a longer-term care strategy.

Publications 
Wray F, Clarke D, Forster A. Post-stroke self-management interventions: a systematic review of effectiveness and investigation of the inclusion of stroke survivors with aphasia. Disability and Rehabilitation. 2017:1-15. DOI: http://dx.doi.org/10.1080/09638288.2017.1294206

Academic Supervisors:
Professor Anne Forster
Dr David Clarke

Funding: Funded by the David and Anne-Marie Marsden scholarship for stroke rehabilitation (University of Leeds)

Ms Louisa-Jane Burton

PhD status: On-going
PhD title: Talking about recovery after stroke: How do we do it, and how can we do better?

Study Overview: Patients and their relatives describe dissatisfaction with information about recovery outlook following stroke, including how much recovery might take place and when it might be expected. These issues often arise during rehabilitation, but research suggests that stroke unit staff lack the confidence and skills to discuss recovery and may avoid doing so. However, information about recovery is important for stroke survivors and their families, because it helps them make decisions about their life after stroke and future care. Louisa-Jane’s research aims to develop an intervention involving strategies for staff to help them to discuss recovery with stroke survivors and families in a way that meets their needs.

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Aims and Objectives
The aim of the Louisa-Jane’s research is to develop an intervention to enable multidisciplinary team members (including therapists, nurses and doctors) to discuss recovery in a format that meets the needs of stroke survivors and their families, and is feasible to deliver in clinical practice.  The project will involve two systematic reviews to identify what can be learned from other neurological conditions; the first will identify strategies to discuss recovery in neurological conditions, and their effectiveness; the second systematic review will explore stroke survivors’, caregivers’ and healthcare professionals’ views relating to discussing recovery and prognosis in acquired neurological conditions.  A qualitative study will explore current practice in two stroke units, using observations and interviews to understand the views and experiences of stroke survivors, their caregivers and staff.  The information collected from the systematic reviews and qualitative study will be summarised and presented to groups of former patients, caregivers and stroke staff.  In these groups, stroke survivors, caregivers and staff will be facilitated to work together using coproduction methods, to develop an intervention designed to support staff to engage more effectively in discussions about recovery.  The intervention may include guidance on how to identify how much information about recovery the stroke survivor and their family may wish to receive, the timing of information provision, and how to frame conversations.  Overall, the project will develop an evidence-based and patient-informed intervention to guide staff to discuss recovery effectively.  Louisa-Jane is supervised at the University of Leeds by Dr David Clarke, Dr Tom Crocker and Prof Anne Forster from the Academic Unit of Elderly Care and Rehabilitation, and Dr Judith Johnson from the School of Psychology.

Academic Supervisors: 
Dr David Clarke
Dr Judith Johnson
Dr Tom Crocker
Prof Anne Forster

Funding: This study is funded by The Stroke Association’s Postgraduate Fellowship Scheme (ref:  TSA PGF 2017-02).  September 2017- March 2021.

Further information:  For further information, please visit:  https://www.stroke.org.uk/research/how-can-we-improve-talking-about-recovery-stroke-unit
Or e-mail:  louisa.burton@bthft.nhs.uk

Mrs Sarah Batt

PhD status: On-going
PhD title: An in-depth inquiry into how stroke patients are supported with eating and drinking in stroke units.

Study Overview: The aim of the study is to develop an in-depth understanding and explanation of the observed and perceived level of support with eating and drinking for stroke patients during their stroke unit care. This knowledge will be used to make recommendations to inform a future intervention for supporting stroke patients with eating and drinking.

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Background
It is reported that up to a third of patients admitted to hospital with stroke are undernourished, for some stroke patients their nutritional status deteriorates further whilst in the hospital setting. Sub optimal nutritional status is linked  to poor outcomes following stroke including: increased co – morbidities (infection, aspiration – pneumonia), poorer outcomes during and  following rehabilitation and increased incidence of death.

Study Objectives:

  1. To determine how and by whom a requirement for support with eating and drinking is identified.
  2. To identify how and by whom support is prescribed when a requirement for support is identified.
  3. To investigate how and by whom prescribed and unprescribed support is delivered and monitored.
  4. To explore how support with eating and drinking is perceived by patients, informal carers and MDT members.
  5. To understand how organisational and contextual factors influence provision of support with eating and drinking.
  6. To develop and pilot test recommendations developed from study findings.

Supervisors:
Professor Anne Forster
Dr David Clarke
Dr Julia Hackett

Ms Alison Ellwood

PhD status: On-going
PhD title: Working with people living with coexistent physical frailty and cognitive impairment

Study Overview: Frailty may be classed as a biological syndrome, distinct from, yet associated with ageing. Individuals with coexistent physical frailty and cognitive impairment may be at increased risk of dependency and poor outcomes. Multidimensional models of frailty emphasise the interplay of biopsychosocial factors in contributing to frailty status and related adverse outcomes. Psychosocial factors feature less in research and are not prioritised, although appear to influence wellbeing and quality of life. Further exploration is required to understand the experiences of those living with coexistent physical frailty and cognitive impairment, and the extent to which psychosocial factors may impact on their capacity to live well in later life.

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Background:

In an ageing population the prevalence of age-related decline has proven problematic for medicine and society. Both nationally and internationally the response to this has been to increasingly promote healthy ageing. However, some functional decline in later life appears inevitable for many. Over the past 20 years there has been a growing interest in frailty as a biological syndrome. Frail individuals experience reduced resilience and reserve leading to increased vulnerability to stressor events. Evidence suggests individuals with co-existent physical frailty and cognitive impairment experience more severe adverse health outcomes than those with physical frailty alone.
Defining and measuring frailty has proven complex. Primarily research has a biological focus, however researchers are increasingly moving towards a more multi-dimensional model of frailty. This approach seeks to consider the complex interplay of biological, psychological and social components which contribute to frailty status and the adverse outcomes individuals experience. Vulnerability to stressor events and anticipated reduced capacity to return to previous function may be more evident in individuals with cognitive impairments.
The potential impact of psychosocial factors on the vulnerability of individuals living with coexistent physical frailty and cognitive impairment has not been a primary focus of exploration. Whilst the relationship of such factors on frailty is likely to be bi-directional and complex, emerging research suggests psychosocial factors may have an effect on quality of life for individuals, as well as healthcare resource and social care use. Further investigation is required to establish what factors might predispose individuals to a higher level of dependency, decreased wellbeing and poor quality of life; and how these can be mediated against.

Aims & Objectives

This PhD is aiming to understand more of the experiences of people with coexistent physical frailty and cognitive impairment. An improved awareness of the potential impact of psychosocial factors on the specific current, and anticipated future, needs of these people to promote healthier ageing and improve quality of life is sought.

 

Academic Supervisors:
Professor Gail Mountain
Dr. Catherine Quinn
Dr. Elizabeth Teale

Funding: University of Bradford, Supported by NIHR Applied Research Collaborations Yorkshire and Humber