School of Health and Psychological Sciences Doctoral Studentships

Project Title

Addressing inequities in maternity outcomes for Black and Asian Mothers requires better understanding of experiences and potential

Supervision team

• Professor Christine McCourt 
• Dr Marina Daniele
• Dr Diana Yeh

Centre for Maternal and Child Health Research

Project description

This project will contribute to addressing the paucity of research on equity of access, quality, and outcomes of maternity care for black and South Asian women in the UK. The UK’s maternal and infant enquiries system has identified a significantly higher rate of maternal and neonatal deaths, highlighting a combination of vulnerability factors but also sub-optimal care.

There is surprisingly little research on the experiences of maternity care among black and South Asian women in the UK given the known inequity in outcomes.

Research conducted by psychologists Bowes and Domokos over two decades ago identified a problem of professional stereotypes negatively influencing care for women of South Asian heritage and a range of studies have identified barriers to accessing maternity care amongst migrant women, despite our universal health system.

This is a highly topical issue. On 23rd February, the Department of Health and Social care announced creation of a Maternity Disparities Taskforce. In 2021, the advocacy organisation Birthrights conducted a national enquiry into racial injustice in maternity services, and the user organisation Fivexmore conducted a national survey of black women’s experiences of care.

These reflect the level of public concern but such enquiries, while important to raise awareness, depend on social media networks and will not provide the more in-depth and theoretically informed analysis that is also required.

In addition, more clarity is needed in relation to definitions of vulnerability and risk categorisation in maternity care and attention is needed to systemic and societal factors influencing both health and healthcare.

While it is important that risk is addressed, the concerns about disparity in outcomes has also prompted a tendency to define black and South Asian women as a ‘risk group’, with proposed solutions being to provide routine clinical interventions targeted at people with high risk pregnancies; yet routine intervention use has been associated with poor care experiences and psychological outcomes and is not associated with improved clinical outcomes.

For example, the 2021 NICE Induction of Labour guidelines update consultation proposed that all black and South Asian women should be routinely offered induction of labour at 39 weeks of pregnancy, despite a lack of evidence that this would have clinical benefit for them. This issue highlighted further the need for a research base to understand more fully the issues influencing these disparities and thus how they may be addressed more effectively.

Proposed design and methods

A systematic review and mixed methods study is considered suitable for this topic and for a doctoral project. A strong PPI and co-design approach would also be important, working with relevant community organisations and user organisations with particular focus on maternity experiences of black and minority ethnic women in the UK.

We would expect the student to engage with a PPI advisory group at all stages, through from commenting on analysis in the systematic review, helping to plan the qualitative study and support engagement and contributing to the development of questions for the quantitative analysis phase.

The work will benefit from an inter-disciplinary perspective, including application of historical, sociological and physiological knowledge.

The systematic review should identify and analyse existing research literature relevant to understanding potential factors influencing the disparity of outcomes. It is likely to require a mixed methods approach as a wide range of study designs and methods may be relevant. Alternatively, two systematic reviews may be proposed, looking at different aspects of the topic, such as experiences of maternity care and research into potential risk factors.

Methods will include, in two main phases of empirical work:

• Interviews and/or focus groups with women from relevant communities with experience of maternity care, and possibly with birth partners
• Secondary analysis of routine maternity and infant datasets and/or large longitudinal birth cohorts (such as Born In Bradford)

Analysis of the qualitative data collection will be synthesised with a meta-synthesis of the literature to formulate hypotheses about potential pathways to poorer outcomes. These will be used to generate focused questions for secondary analysis of large databases.

Who should apply?

Applicants with good Bachelor’s and Master’s level qualifications in social or political science, midwifery or anthropology would be suitable applicants. Applicants without quantitative analysis skills would be expected to enrol in the MRes module in advanced data analysis skills.

Feasibility of project

Three main pieces of work are proposed and this is highly suitable for doctoral work. Systematic review can be conducted without delays in HRA or comparable access and without need to travel. We also now have very positive experience of interviewing service users via online platforms, enabling us to offer choice to participants.

We have excellent service user, community and advocacy organisation links to draw on. We have potential advisors available in the centre with expertise in data linkage and analysis of large datasets, to support the quantitative phase. The secondary analysis work is also less affected by possible restrictions on face to face research.

Alignment with research centre expertise and activities

Prof McCourt and colleagues conducted some of the earliest research in the UK on black and minority ethnic women’s experiences of maternity care and Prof Macfarlane conducted some of the early analyses of disparities in outcomes.

McCourt’s work has identified that contrary to popular stereotypes, continuity of midwifery carer was particularly valued by black and minority ethnic women for providing more personalised care and informed choice. Further work has identified that the lower uptake of midwifery unit care is linked to unequal information provision to women from black, minority ethnic or more socioeconomically disadvantaged backgrounds.

The REACH pregnancy programme, led by Harden and colleagues in the Centre, was funded by NIHR to identify and test ways of improving access and early uptake and experience of antenatal care in underserved groups.

The proposed project will complement the work of this ongoing programme. The student would also benefit from links with the ongoing European Union funded GC1000 programme that is evaluating how group care, which has benefits for those from underserved communities, can be implemented effectively.

The Centre has a strong inter-disciplinary approach, which is needed for this project, including midwifery, epidemiology and social sciences.

Project title

Intersectionality and identity: Race and gender in autism and personality disorder

Proposed supervisory team

• Professor Rose McCabe 
• Dr Kirsten Barnicot

Background & Significance

Concerns have been raised that autism spectrum disorder (ASD) may frequently be missed in some people currently diagnosed with borderline personality disorder (BPD), which is a specific type of personality disorder characterised by emotional and interpersonal regulation difficulties and identity disturbance (Lai & Baron-Cohen 2015).

Missed or misdiagnoses could lead to people being offered inappropriate explanations for their experiences, being offered unhelpful or distressing treatment, and being denied access to needed support. The reasons for this are complex but may intersect with at least three marginalised identities: female birth sex; non-cis gender identities; and ethnic minority status.

Rationale

1. Female sex. ASD has stereotypically been viewed as a male diagnosis with a 4:1 male: female diagnostic ratio (Fombonne et al. 2005). Recent evidence suggests female autism may be hugely misunderstood and underdiagnosed. Conversely, at least 75% of people diagnosed with BPD in clinical services are female (APA 2000), despite BPD features being equally common in men in the general population (Busch et al. 2016).

Gendered biases may lead clinical services to view female emotional dysregulation and interpersonal difficulties through the lens of personality disorder whilst similar difficulties in men are viewed through the lens of autism (Lai & Baron-Cohen 2015). Our proposed PhD will investigate differences between autism and personality disorder in people assigned a female sex at birth.

2. Non-cis gender identity. Autistic people are more likely than the general population to identify as trans or non-binary gendered; people with BPD are not (DeWinter et al. 2017, Kourti & MacLeod 2019; Singh et al. 2011). Historically, some clinicians have erroneously linked such gender identity differences with BPD, for which “identity disturbance” is a diagnostic criterion (Hepp et al. 2005).

There is evidence that this has been used to discriminate against and undermine people who experience transgender or non-binary feelings, by dismissing their experiences as reflecting a psychiatric “disorder” (Beatrice 1985, Lothstein 1984). Our proposed PhD will investigate how gender identity affects the labelling of women's experiences as autism or personality disorder.

3. Ethnicity. In the UK, black and ethnic minority individuals are under-represented amongst adults diagnosed with a personality disorder, relative to the general population (Hossain et al. 2018). Conversely, whilst black and ethnic minority individuals are hugely over-represented amongst autistic children (Keen et al. 2010), how ethnic status and cultural biases affect adult autism diagnosis is unknown.

Our proposed PhD will investigate how ethnicity affects the labelling of women's experiences as autism or personality disorder.

The PhD will also investigate how autistic people and people with a diagnosis of BPD identify themselves in relation to their diagnosis and experience their sense of self. Identity confusion is a diagnostic criterion for BPD and yet how this is experienced in people’s everyday lives is poorly understood (Wilkinson-Ryan & Westen 2000).

Autistic people often see autism as a positive and central aspect of their identity, preferring an identity-first label as an autistic person, not "a person with autism" (NHS England 2020). By contrast, the stigma linked to the personality disorder label is huge and people with this diagnosis are unlikely to see this in the same way as a central part of their identity (Chartonas et al. 2017).

Research Questions

1. How do race and gender identity affect the labelling of women's experiences as autism or personality disorder?
2. How do autistic women¹ and women¹ with a diagnosis of personality disorder experience their sense of self and identify themselves in relation to their diagnosis?

Design

Mixed-methods, cross-sectional, drawing on audit data, survey data and qualitative interviews, including primary and secondary data analysis.

Methods & Analysis

1. Audit of diagnostic rates of women¹ referred to adult autism and personality disorder services, by ethnicity and gender identity.
2. Survey of N = 88 autistic women¹ and N = 88 women¹ diagnosed with a personality disorder. Ethnic group and gender identity will be assessed and related to diagnostic status and to differences in autistic and personality disorder traits, assessed via validated questionnaires and diagnostic interviews (e.g., AQ-10, SAPAS, SCID-PD, ADOS module 4), using logistic and linear regression as appropriate.
3. Qualitative interviews with N= 5 autistic women¹ identifying as black and minority ethnic; N = 5 autistic women¹ identifying as non-cis gendered; N= 5 women¹ with a personality disorder diagnosis identifying as black and minority ethnic; N = 5 women¹ with a personality disorder diagnosis identifying as non-cis gendered. Interviews will explore how they feel their race and gender identity affected the labelling of their experiences as autism or personality disorder, how they experience their sense of self, and how they identify themselves in relation to their diagnosis.

Who should consider applying

• Applicants should have a Bachelor’s degree with 2.1 honours degree or merit level Masters degree in Psychology, Mental Health or a related subject (or international equivalent).
• Lived or family experience of autism and/or personality disorder, and previous experience of clinical or research work in mental health services, will be an advantage.
• Experience and skills in quantitative and qualitative research, a strong interest in the PhD topic and a solid commitment to co-produced research.

Feasibility of project

We already have NHS ethical approval for a highly related project (Improving Understanding of Autism and Personality Disorder (I-RAP), IRAS 307912), including approval to collect the survey data that will be used for this project (method 2 above), planned for Nov 2022 to Nov 2023. Further approvals will be sought as a substantial amendment. Other proposed data collection is small-scale and achievable and can be undertaken remotely.

Research Centre Expertise

Excellent tie-in with the Centre for Mental Health Research existing work on autism and personality disorder (I-RAP). Joint meetings and training would be held to share expertise and learnings and to dovetail data collection.

This is excellent: important, pertinent, feasible and succinctly detailed. There are clear learning/ skill development strengths in the breadth of coverage of research methods -  and great synergies - using/building on links with ongoing study and collaborations with health services partners.

Project title

Co-creating culturally competent maternity service recommendations with and for women with history of Female Genital Cutting.  A community participation and mobilization, maternal health project in London and the Midlands

Proposed supervisory team

• Dr Mandie Scamell 
• Further supervisor TBD from within SHPS and/or SASS
• External supervisor Dr Yana Richens (HoM Whittington NHS Trust)

Project description

Background:

The World Health Organization’s (WHO) first policy document aimed at integrating female genital mutilation/cutting (notwithstanding the debates around language and this topic, for the purpose of this application the abbreviation FGC will be used) into midwifery curricula, was launched in February 2022.

This international, maternal health initiative rests upon an understanding that the complex maternal health needs of women who have undergone FGC, are not being met. Recently published systematic reviews on the maternity care experienced by migrant women in receiving countries, sadly endorse this understanding.

Turkmani, Homer, and Dawson (2019) for example, show that these women often feel ‘traumatised by the negative judgments and racist comments they received, as well as disrespectful reactions by care providers’ p7. While Scamell and Ghumman (2019) talk about birth experiences in host countries as being a time of ‘re-victimisation’, a finding echoed in Wood, Richens and Lavender (2021) literature review where maternity care is a time when, ‘a picture comes to me. I remember what she did to me long ago back in Somalia, when I was only 7 years old.’

Significance

Within a context where migration from countries that routinely practice FGC is increasing, the evidence indicating that the current maternity service provision, and clinical recommendations, may intensify the women’s potential vulnerability rather than mitigate against it is becoming more pressing.

It is estimated that 200 million girls and women worldwide are affected by FGM. In England, a total of 24,420 women and girls have attended the NHS in England between 2015 and 2020, according to the NHS FGM Advanced Data Set. Most cases of FGC recorded in England have been identified by midwives, with London and Midlands having the highest incident rates.

Despite these growing numbers, just two studies on women’s experience of maternity care in England have been published in the last ten years.

Rationale

With the recent WHO call for the integration of FGC into midwifery curricula across the world, now is the moment when a thorough understanding of what a culturally sensitive maternity care service might look like for migrant women who have experienced FGM is needed.

What is known is that this group of potentially vulnerable women experience a range of obstacles and prejudices when trying to access the maternity services in migrant receiving countries. What is less clear is how a woman centred maternity service should be organised.

This PhD aims to tackle this maternal health problem and is underpinned by two propositions:

1. Failure of the England maternity services to provide women who have undergone FGC with sensitive care that meets their complex health needs, is unacceptable.
2. An emancipatory project co-led by women who have personally undergone FGC will provide a robust basis for training and service improvements in this country.

Study design

Following an emancipatory research design, this PhD will take a qualitative, participatory-led approach. The aim of this approach will be to work collaboratively with women from affected communities to co-develop culturally sensitive, woman-centred maternity care training and practice recommendations.

The aim of this research design is to move beyond the concept of research done on a community, to research done with and for the community.

Methods

Using a range of emancipatory methods, the aim of this PhD will be to mobilize women from the affected communities to engage in a participatory-led, grass-roots discussion on how maternity care should be provided for migrant women living in England with a history of FGC.

Analysis

Consistent with emancipatory research design, the analysis will form an integral part of the community mobilization. Identification and support of community representatives to co-produce initial analysis that will be tested/validated through a wider community mobilization network will be undertaken.

Empowering women from the community to take ownership of the data analysis process will be central to ensuring an authentic voice in this PhD data analysis and the PhD candidate will be responsible for this participatory empowerment including facilitation of necessary training

Who should consider applying?

Given the sensitive nature of this PhD and the research design proposed, suitable candidates would ideally identify – although not exclusively - with an ethnic communities known to practice FGC. For example, having family heritage from Kenya, Somali, Sudan, Sierra Leone, Egypt, Nigeria, or Eritrea would be advantageous.

This candidature profile would help to address the under-representation of black and ethnic minority PhD students in the School of Health and Psychological Sciences. Although being a qualified midwife would be advantageous, applications for this studentship would also be welcomed from those with anthropology, sociology, community mobilization and other health backgrounds.

Feasibility of achieving project within timeframe

The prevalence profile of migrant populations dictate that this PhD will involve mobilizing work with communities from two geographical areas: the Midlands and London.

The Maternal and Child Health Research Centre benefits from a robust network of London-based NGOs set up to support migrant women, including those from communities who traditionally practice FGC. Drawing from these established contacts will be a crucial part of the community mobilization in both London and the Midlands and will facilitate completion within the maximum timeframe of three years.

Alignment with research centre expertise and activities

This PhD proposal aligns with the Centre for Maternal and Child Health Research.

Project title

Developing and testing a strategy to address Post Intensive Care Syndrome (PICS)

Proposed Supervisory Team

• Professor Leanne Aitken 
• The second supervisor will be determined based on the specific focus of the project, e.g., cognitive function, psychological function etc.

Project Description

Survivors of critical illness experience a range of challenges after discharge home, with between one quarter and half of all survivors experiencing compromise in one or more areas of physical, cognitive and psychological function.

The problems associated with recovery after critical illness are now collectively referred to as Post Intensive Care Syndrome (PICS). Over the past 15 years there has been a range of studies conducted to better understand the challenges associated with recovery, and to test potential interventions. Despite this, few effective interventions have been identified.

The proposed PhD project will be tailored to the specific interest and expertise of the successful applicant but will focus on developing or adapting an intervention to address either physical, cognitive or psychological compromise in critical illness survivors.

Multiple different options exist for a successful PhD, depending on how much is already known within the specific area of interest, but examples of options include:

1. A systematic review of relevant evidence to date regarding the effectiveness of physical rehabilitation commencing in intensive care and extending beyond discharge home, development of an intervention to aid physical recovery based on the findings that have shown most promise in the systematic review, and feasibility and acceptability testing of the intervention in a small cohort of participants to provide baseline information for later large-scale testing in a randomised controlled trial.

2. Exploration of an area of current practice within critical care that influences long term recovery. Some suggested areas of practice to focus on might include:

• delirium assessment and management
• mobility practices
• sleep assessment and improvement for critically ill patients

Methods of exploration might incorporate observation, database analysis, interviews and/or surveys with relevant stakeholders, including patients, family members and/or clinicians of all disciplines to develop an understanding of current practice.

Additional information should outline barriers and enablers to optimal practice in this area and be informed by appropriate theoretical underpinnings such as the Theoretical Domains Framework. Based on findings from this exploration, a draft intervention to improve practice and subsequent patient outcome will be developed for initial testing of feasibility and acceptability.

All projects will incorporate appropriate patient and public involvement throughout the process and be conducted in collaboration with clinicians in relevant critical care settings.

Who should consider applying?

The successful PhD applicant for this project will ideally have knowledge of care provided to critically ill patients, or alternatively, knowledge of physical, cognitive or psychological interventions that might be delivered to critical illness survivors.

They therefore might be from a range of health care disciplines such as nursing, physiotherapy, social work, psychology, occupational therapy. Potential applicants might include current clinicians as well as those working in clinical research or academic positions.

Feasibility to complete project in timeframe

All potential projects will be able to be undertaken within a three-year (full time) timeframe, or equivalent part time. Where extensive development work is required, only initial feasibility and/or acceptability work will be undertaken.

In contrast, if minimal development work is required, more extensive testing of the intervention will be undertaken to ensure the overall project is suited to the available timeframe.

Alignment with expertise and activities

This project has strong alignment with the Centre for Health Services Research, with content related to the Acute and Critical Care Group, with methodological training and support from the other groups within this Centre. Some projects may also align to the work within the Centre for Mental Health Research.

Project title

Eye Heroes: Evaluating a model of raising awareness about eye health by training children to be eye health champions

Supervision Team

• Professor David Crabb (City SHPS)
• Dr Deanna Taylor (City SHPS)
• Dr Ahalya Subramanian (City SHPS)
• Dr Mark Haddad (City SHPS)
• Ms Yusrah Shweikh (Eye Heroes and Consultant Ophthalmic Surgeon at Sussex Eye Hospital)

Aims

To design and implement a trial to evaluate the effectiveness of an established volunteer led public health intervention called Eye Heroes., testing the specific hypothesis that this will improve optometric examination uptake.

Background

Many people live with sight loss that could have been prevented by having regular optometric examinations. Raising awareness about the purpose of eye examinations, in terms of preventable sight loss, and not just need for spectacles, is an important public health message. [1,2]. In addition, an inequality exists in the level of access to eye care services in people with greater socioeconomic deprivation.[3]

Moreover, people may not attend for eye tests due to language barriers, social isolation, perceived costs, learning disabilities and fears. [4,5] The intervention to be examined in this studentship project has been designed with this evidence in mind.

Eye Heroes is an established volunteer led, low-cost public health intervention designed to reduce preventable sight loss; it empowers schoolchildren (8 – 11 years), to become champions of eye health, and inform adults in their families and communities about the importance of having regular eye tests. Eye Heroes is delivered by volunteers (mostly medical and allied healthcare professionals) as interactive workshops for children (see figure).

Prior to workshops, volunteers receive training before downloading standardised workshop material including digital media. Workshops use activities, animations, role-plays, and games in order to enable children to learn about the importance of eye testing and inform people in their family/communities about the importance of eye health.

A precedent exists for an approach using children as instigators of health behaviour change with an effective national anti-smoking campaign and a scheme to raise awareness about oral health. [6,7] We propose to examine the effectiveness of Eye Heroes with a studentship project that will design/plan (year 1) and then implement (year2/3) a school-based intervention trial. A strong evidence base is necessary for the potential scaling up of the Eye Heroes intervention and this is the main idea for this project.

Methodology and Outcomes

The PhD student (Year 1) will complete a systematic review on barriers to eye examination take-up and on estimates of asymptomatic glaucoma and macular disease detected by routine eye examinations.

The student (Year 1) will work with collaborators who have expertise in intervention trials in schools (Haddad; co-investigator City); public health intervention trials Burton; collaborator; ethics for studies involving children (Drey; collaborator City and NSPCC Research Ethics Committee).

The student will also interact closely with Shweikh (co-investigator; Eye Heroes and Sussex Eye Hospital) and Lydamore (collaborator; Camden Schools Nurse Team leader). A committee of these collaborators will oversee trial planning and R&E submission and will include patients with eye conditions (Ms Bronze and Ms Langley).

What follows is a draft plan for the trial (years 2-3), subject to change as the student works with the planning committee in year 1.

A school cluster randomised trial will be based in the London Borough of Camden (45 primary schools invited). The RNIB indicates this area to have a high proportion of under-represented individuals including migrant ethnic groups, people living in areas with high deprivation scores and social isolation.

Each school (cluster) will be randomised (1:1) to the Eye Heroes programme (intervention) or comparator (no intervention; a wait-list control group - meaning these schools will eventually receive the intervention after the trial data has been collected, thus overcoming ethical issues about withholding an educational opportunity).

The intervention will be delivered to Year 4 and 5 classes. The cluster RCT design will minimise potential for contamination and consequent dilution of intervention effects. Schools will be stratified by key indicators of attainment and free school meal eligibility.

Primary Outcome

Self-reported visits to an eye health professional by child’s main caregiver. At 6 months post intervention, named caregivers for each pupil will receive an electronic message from the school/research team asking questions, to be translated as needed when caregivers do not have English as their first language.

[a.] “Can you recall your child discussing eye health with you?” [b.] “How many people in your family, including grandparents, have had an eye exam in the last 6 months?”

Emailing/SMS caregivers is ubiquitously used in Camden schools. Yet we will assume a response rate of only 33%. (Detailed sample size calculations are available)

Note reference to grandparents; the intervention will potentially reach older adults (>60 years) who would likely benefit most from an eye exam because an estimated 93% of families rely on grandparents for childcare.

Data and analysis

The PhD student will be trained in multilevel modelling to determine difference in self-reported optometrist visits between intervention and comparator. Analyses will include associations with index of multiple deprivation.

Data collection will be paperless, facilitated by experience in web-based data collection and secure handling of large datasets within the Crabb Lab, including trial data. [8,9]

Importance - Potential clinical benefit

Sight loss costs our economy an estimated £15-28 billion annually, yet only ~£2 million is spent on prevention and awareness.[10] Preventable sight loss is an increasing problem and the need for effective prevention is pressing. Eye Heroes is a low-cost intervention designed for rapid scalability and is worthy of scrutiny in a trial of its effectiveness.

A trial is important because public health interventions have been subject to controversy from lack of evidence from trials to support their scalability in the first place. Results from our trial will be published in high impact open-access journals and disseminated at international meetings for ophthalmology and public health.

With in-house expertise, we will publish interactive web-based maps to highlight socioeconomic and geodemographic results. Finally, as an evidence-based intervention to prevent sight loss, Eye Heroes has enormous potential for being adopted as a flagship low-cost eye health programme.

PhD Studentship Training:

The student will be trained in ophthalmic public health, systematic reviews, informatics and statistics. The student will also be exposed to experts in design of intervention trials at LSHTM.

The Lab currently has several postdoctoral and PhD level researchers with different backgrounds in optometry, computer science, psychology and health economics, providing a unique interdisciplinary peer-to-peer, day-to-day training environment.

The lab collaborates with top national/international institutions and is a partner on a prestigious Marie-Curie EU funded early stage researcher training programme. Crabb Lab has graduated at least one PhD a year for the last ten years.

References

[1] Shickle D. What proportion of sight loss is preventable? The need for a confidential enquiry for the eye care pathway. Ophthalmic Physiol Opt. 2015;35(5):591-4.

[2] Leamon S, et al. Improving access to optometry services for people at risk of preventable sight loss: A qualitative study in five UK locations. J Public Heal (United Kingdom). 2014;36(4):667-673.

[3] Shickle D. Geographical inequalities in uptake of NHS funded eye examinations: Poisson modelling of small-area data for Essex, UK. J Public Health (Oxf). 2018;40(2):e171-e179.

[4] Shickle D, Griffin M. Why don't older adults in England go to have their eyes examined? Ophthalmic Physiol Opt. 2014;34(1):38-45.

[5] Johnson M et al. A Review of Evidence to Evaluate Effectiveness of Intervention Strategies to Address Inequalities in Eye Health Care. UK: RNIB (RNIB/CEP/01, 2011)

[6] Thailand’s anti-smoking campaign. Accessed 8/8/18

[7] Colgate®campaign.    Accessed 8/8/18.

[8] Lee CS…Crabb DP et al.The United Kingdom Diabetic Retinopathy Electronic Medical Record Users Group: Report 3: Baseline Retinopathy and Clinical Features Predict Progression of Diabetic Retinopathy. Am J Ophthalmol. 2017;180:64-71.

[9] Garway-Heath DF, Crabb DP et al.Latanoprost for open-angle glaucoma (UKGTS): A randomised, multicentre, placebo-controlled trial. Lancet. 2015;385(9975):1295-1304.

[10] Pezzullo L, et al. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res. 2018 30;18(1):63

Project Title

How good are my wobbly eyes?  Understanding visual function and support needs for those with infantile nystagmus

Supervisory team

• Professor Chris Hull (specialises in the interaction between the retinal image and vision and has lived experience of infantile nystagmus)
• Dr Ahalya Subramanian (clinician and specialist in visual impairment)
• Professor John Barbur (vision scientist and developer of the Eye Movements and Intrinsic Latencies (EMAIL) test)

Brief project description

Background:

Nystagmus is an eye disorder that results in involuntary, rhythmic movements of the eyes. As a result, it is sometimes referred to as ‘wobbly eyes’. Nystagmus can occur in early childhood (infantile) or be acquired subsequent to neurological or vestibular disease (latent). Both forms have a combined prevalence estimated at 24 per 10,000 population (Sarvananthan et al., 2009).

Infantile nystagmus syndrome (INS) develops within the first few months of birth and is a lifelong condition It occurs in around 6 per 10,000 births (Hvid et al., 2020) and can be idiopathic or related to pathology of the visual system. There is no known cure and treatment usually involves careful investigation for any underlying cause, optimising visual acuity with refractive correction, correcting squint or abnormal head posture with prisms or surgery (if appropriate) and support for patients and carers.

INS produces an unstable image on the retina leading to reduced vision even when refractive error has been corrected. People with INS may report having difficulty with face recognition, picking out objects in low lighting conditions and carrying out tasks involving moving objects and/or judging depth.

Although visual function in nystagmus has some similarities with other forms of visual impairment, there are some aspects that are unique to nystagmus such as being “slow to see,” particularly when interacting with moving objects. Although research has indicated that post-saccadic visual processing time is not slower in those with INS (Dunn et al., 2015), pilot data from our lab as well as earlier research have indicated that crowding, discriminability, contrast and timing in the nystagmus waveform could have an impact on the time needed to process and respond to a peripheral target.

Early results also indicate a possible ‘tuning effect’ where unlimited viewing time can be detrimental. Although these investigations will help understand the neural processes in INS, the primary aim of this arm of our research is to understand better the link between visual function and daily visual tasks.

Diminished visual function in INS has been shown to be associated with poor social function (Pilling et al., 2005) and has more recently been linked to negative experiences of living (McLean et al., 2012).  Support and information are critical for patients and carers to help manage expectations and reduce the negative impact of nystagmus.

A recent survey demonstrated variability in the information and support provided across the UK but also the important role charities and social media play (Gummer et al., 2020).  We are currently not aware of research that has investigated how well the available information from professionals, charities and social media supports those with INS and their caregivers.

There is anecdotal evidence that social media can have a negative impact by emphasising differences; without this input, those with INS are better able to normalise their condition.  This second arm to our work therefore aims to evaluate, from a patient and their care giver’s perspective, the quality of information currently available and to define missing areas of support.

Our overarching aim is to improve the lived experience of those with INS by providing informed support that helps manage expectations.  It therefore combines the two areas of research described above by linking visual function to daily living.  A better understanding will help advise those with INS how they can expect to perform in daily visual tasks.

Significance

The area of research described above addresses the negative experiences of those living with INS, something that has become increasingly apparent in recent years (Pilling et al., 2005; McLean et al., 2012; Gummer et al., 2020).

Rationale

INS has been noted as an under-researched area even though it leads to negative visual and social impact. This is likely because it is a lifelong condition with limited treatment options that improve visual performance and cosmetic appearance.  It has been listed as a “Top 10” priority by the James Lind Alliance.

Research questions

For the visual function element: (i) what role does visual timing within the nystagmus waveform play in the ‘slow to see’ phenomenon? (ii) what role do crowding, contrast and discriminability have on visual processing times at fixation and for peripheral targets?

For the patient support element: (i) does current information about nystagmus help patients and their caregivers cope with the condition? And (ii) what information/support could improve their daily lives?

Study design

Experimental design comparing cases and controls for visual performance and a purposive sample of those with infantile nystagmus and their caregivers to recruit to the qualitative arm of the study.

Methods and Analysis

Exploring aspects of visual performance in nystagmus will use a standard experimental psychophysical paradigm for those with INS and controls.

The methods will employ a variation of the Eye Movements and Intrinsic Latencies (EMAIL) test that has already been developed and tested on normal observers (Llapashtica, 2019).  Data will be analysed using bespoke Matlab code developed for the EMAIL test.

Two-sample comparisons between normals and those with INS will be made using parametric statistics when assumptions are met. We will use questionnaires to determine the impact of nystagmus on daily life (for example, the Nystagmus-specific QoL, McLean et al., 2016) and semi-structured interviews, with thematic analysis, to explore:

1. difficulties with visual tasks
2. appropriateness of support available from professionals, charities and social media.

Who should consider applying?

This area of research would appeal to a wide range of disciplines interested in translational vision research.  This includes optometrists, ophthalmologists, orthoptists, psychologists, neuroscientists. It would most closely align with optometry and psychology students at City.

Project Title

Investigating Decisions to Refer to Mental Health Services for People Attending the Emergency Department for Self-Harm and the Impact on Subsequent Mental Health Trajectories: A Mixed Methods Enquiry

Supervisory team

• Professor Rose McCabe
• Professor Steve Gillard 

Co-Leads, Centre for Mental Health Research (CMHR)

Background & Significance

Self-harm, defined as self-poisoning or self-injury irrespective of intent, is the strongest predictor of death by suicide. In England, around 220,000 people present to the Emergency Department (ED) with self-harm each year (Hawton, et al., 2007). A comprehensive psychosocial assessment is routine care for these people.

In the assessment, mental health practitioners assess the person’s needs and risks (of harm to self or others) and decide on immediate care (discharge or inpatient admission) and referral to mental health services.

However, there are systemic barriers to accessing mental health services. For example, people with a diagnosis of personality disorder or alcohol misuse are often excluded from services (Allsopp & Kindeman, 2021). They are bounced between services without receiving the support they need (Flynn et al., 2020).

Negative and stigmatising attitudes towards  ‘frequent attenders/ frequent flyers’ are prevalent. This patient group presents regularly in crisis because they do not get the support they need in the community, with the mental health system described as a “fortress” designed to keep them out (Fisher 2022).

Limited access to appropriate services in the community is linked to a deterioration in mental health and repeated crisis attendances to the ED (O’Keeffe et al., 2021). Approximately 20% of those presenting to the ED for self-harm re-attend within a year (Carroll et al., 2014) contributing to the £162 million hospital costs for self-harm annually (Tsiachristas et al., 2017). Service users report help-seeking as ‘futile’ (De Leo et al., 2022) with some subsequently dying by suicide after repeated contacts with services (Flynn et al., 2020).

Mental health practitioners navigate systemic barriers in services, taking on the role of ‘gatekeepers’. They can recommend services that are most available rather than most appropriate, and may block access to services by citing a person’s risk (too high/too low), needs (too complex) or ‘readiness for change’ (Beale, 2021).

Other research has shown how clinicians make decisions based on ‘tacit knowledge’ acquired through their practice - knowledge they have acquired about ‘types’ of cases and who is likely to benefit from care - alongside technical knowledge informed by their training (Brummell et al. 2016).

The psychosocial assessment in the ED is a key point in the care pathway to investigate how practitioners make decisions not to refer people (Bergen, McCabe et al. in prep). Video recordings of psychosocial assessments, medical notes and discharge letters offer rich sources of data reflecting how practitioners make and justify decisions not to refer people to mental health services.

Aim

To better understand clinical decision making by mental health practitioners in the ED and the impact on subsequent mental health trajectories for people presenting to the ED with self-harm.

Research Questions (RQs)

1. What is the existing evidence on how mental health practitioners make decisions to refer people to mental health services after they present to the ED with self-harm?
2. How do mental health practitioners decide whether or not to refer to mental health services, and how is that recorded in the patient’s medical records and in the psychosocial assessment in the ED?
3. What is the impact of practitioner decisions not to refer to mental health services on patient mental health trajectories?

Methods & Analysis

RQ1 Existing Evidence: WP1 will be a systematic review of quantitative and qualitative research synthesising mental health practitioner decision-making in the ED (excluding studies examining effectiveness of decision aids). The review protocol will be registered on PROSPERO and will follow Popay’s guidance on conducting narrative synthesis (2005) and PRISMA 2020 reporting guidelines (Page et al., 2020).

RQ2 Decisions Not to Refer: In WP2 (a) Psychosocial assessments undertaken by mental health practitioners with patients presenting with self-harm in the ED will be video recorded (n=12). Discussions about referrals will be analysed along with patients’ requests for further support. Based on Bergen, McCabe et al. (in prep.), verbal and non-verbal communication in the video recordings will be analysed using conversation analysis to identify how patients report their needs, how practitioners respond to them and how they justify not referring the patient to requested mental health services.

In WP2 (b), Medical records of the same 12 patients will be analysed to document reasons for not referring and how these correspond to the reasons discussed in the psychosocial assessment. Practitioners participating in the video recordings (n=12) will be interviewed and data will be analysed using a knowledge framework (Collins 2007) to understand decision-making processes in the context of referral criteria, service capacity and clinical formulations.

RQ3 Patient Mental Health Trajectories: WP3 will involve longitudinal narrative interviews with the same 12 patients, 1-week and 3 months after attending the ED. At 1-week, interviews will explore participants’ perspectives on treatment options and decisions about not referring them to mental health services. The 3-month interview will explore the patient’s service journey before presenting to the ED and 3 months after attending the ED along with their mental health. This will be guided by a timeline of the participant’s service use taken from their medical records. Narratives will be analysed using ideal-type analysis, a method of forming typologies of patient journeys (Stapley et al., 2021).

Who should consider applying?

Applicants should have a Bachelor's degree with 2:1 honours (or Overseas equivalent) and ideally a Master's in psychology, sociology, or related field.  Relevant experience with those with people who harm themselves is desirable. Experience and skills in quantitative and qualitative research, Commitment to working with people with lived experience

Feasibility of project

This PhD will be embedded in a NIHR programme grant led by McCabe (ASSURED – Improving outcomes in patients who self-harm), supporting its feasibility. The project will run alongside the ASSURED trial, recruiting from a number of EDs with whom the team have established partnerships with clinical staff, enabling access to participants and video data of psychosocial assessments collected as part of the trial. Ethical approval has been granted in McCabe’s previous studies (and ASSURED) to video-record psychosocial assessments in the ED.

Alignment of project to research centre expertise and activities

The candidate will be mentored and supported in regular CMHR meetings every 2 weeks with other PhD students, early career researchers (ECRs) and faculty. They will develop their skills in patient and public involvement, research skills and transferable skills across the CMHR, SHPS, City Doctoral College, NIHR Applied Research Collaboration (ARC) North Thames and external organisations as appropriate.

They will be encouraged to present their work at e.g., the Annual Doctoral Conference, the 3-Minute Thesis competition, the NIHR ECR Summer Researcher Showcase and international conferences. We will encourage the candidate to apply for post-doctoral fellowships.

The student will be embedded with staff in complementary projects in CMHR (e.g., Gillard leads the NIHR DECISION study on referral to mental health crisis care from the ED and a NIHR programme development grant on trauma informed care; McCabe leads studies worth over £3.5m on self-harm in adults and young people).

Both supervisors have an extensive background in literature reviews and mixed methods research. People with lived experience of seeking help for self-harm will be involved from the outset. This project arises from their experiences and the ASSURED Lived Experience Advisory Panel.

Project title

Ethnographic case study of the implementation of the Midwifery Unit Self-Assessment (MUSA) Toolkit: a case study in three Midwifery Units, Gloucestershire Hospitals NHS Foundation Trust

Supervision Team

• Professor Christine McCourt
• Dr Lucia Rocca-Ihenacho

Project description

The Midwifery Unit Self-Assessment (MUSA) toolkit aims to provide a structured framework to guide the self-assessment and improvement of midwifery units. This toolkit has been developed from the European Midwifery Unit Standards, in collaboration with City, University of London and international expert stakeholders.

The toolkit is a step-by-step framework supporting service self-evaluation and improvement, emphasising co-production, stakeholder engagement and interdisciplinarity, including strong service user input.

The toolkit involves establishing a partnership between midwifery units and key stakeholders, supported by the Midwifery Unit Network (MUNet). This type of stakeholder engagement is highly effective because it combines insider knowledge with the benefit of gaining the fresh eye of an external facilitator (MUNet).

The approach involves partnership to create a local community of practice to improve MU standards using the MUSA-Toolkit as a resource and guide.

As part of this initiative, Gloucestershire Hospitals NHS Foundation Trust have co-funded a PhD Scholarship with City, University of London’s School of Health and Psychological Sciences to support an in-depth ethnographic case study to explore the impact of the implementation of the MUSA-Toolkit.

Proposed design and methods

The aims of the ethnographic case study will be to explore the use of the MUSA toolkit in conducting an analysis of current service provision, to inform and develop a service improvement project.

The objectives will be to:

1. Conduct a context analysis of the maternity services in this NHS Trust including the three MUs and two OUs.
2. Explore staff, leadership, and service users’ experiences of involvement with the MUSA-Toolkit
3. Explore the experience of the setting up of the community of practice via the MUSA process
4. Explore the impact of the implementation of the MUSA-Toolkit
5. Explore the impact of the role of external facilitation in this process.

The PhD student will design the detail of the evaluation, including the theoretical and analytical approach.

Methods could include

• Observation of activities within the improvement project at of Gloucestershire Hospitals NHS Foundation Trust
• Focus groups with those involved
• Interviews with community of practice participants and stakeholders and service users
• Analysis of routine clinical data in a time series

The student will be supported by integration with a collegial wider team of researchers and opportunity to learn about a broad range of methods, design for complex interventions evaluation and implementation science.

Who should apply?

Applicants should have good prior educational qualifications, knowledge, and interest in the subject. Relevant disciplines include midwifery, anthropology, psychology, and other social sciences.

Alignment with research centre expertise and activities

The successful applicant will benefit from the collective expertise within the Centre for Maternal and Child Health Research https://researchcentres.city.ac.uk/maternal-and-child-health.

Project Title

Sustainable diets for under-represented populations in the UK

Proposed supervisory team

• Dr Christian Reynolds
• Dr Swrajit Sakar 
• Dr Honglin Dong

Brief project description

Background:

Unhealthy and unsustainably produced food poses a global risk to people and the planet. More than 820 million people have insufficient food and many more consume an unhealthy diet that contributes to premature death and morbidity (Walter Willett et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet, Volume 393, Issue 10170, 2019,Pages 447-492,).

The existing accounting of the so-called diet gap (DG) between the current food system and the healthy reference diet at the regional scale fails to address the heterogeneity of diet patterns among different levels of socio-economic development (Tuninetti, M., Ridolfi, L. & Laio, F. Compliance with EAT–Lancet dietary guidelines would reduce global water footprint but increase it for 40% of the world population. Nat Food 3, 143–151 (2022).

There is a lack of evidence regarding environmental impacts of dietary patterns of the main ethnic minorities and other under-represented populations in the UK. Ethnical minorities have health inequalities and often underrepresented in clinical research. South Asians and African & Caribbeans  in the UK have worse health outcomes in many areas than the general population.

For example, South Asian males and females have 10% and 5% higher mortality from cardiovascular disease (CVD) respectively than Caucasians, while the rates are 3% and 4% higher respectively in African & Caribbean males and females (ref. patient.info). Although multiple factors have been identified to account for these ethnic health inequality differences, such as socio-economic standing, culture and attitude, and biological diversity, the association to the dietary habit is much under-investigated.

Significance

There is a need for ethnic minorities and other under-represented populations in the UK to be considered in the sustainable diets policy. This PhD will provide insight into dietary gaps and policy support for these communities.

Research questions and Objectives

• To investigate the diet gap between dietary patterns of different ethnic groups including White, Black and South Asians and the reference diet intakes of food in the UK
• To investigate the environmental impacts of different eating patterns of underrepresented populations.
• To investigate the knowledges, perceptions and barriers of sustainable diet between different ethnic groups, e.g., White, Black, South Asians in the UK
• To formulate policy, advice and interventions to reduce the diet gap and encourage healthy sustainable diets

Methods and analysis

Depending on the PhD candidate there are multiple approaches that can be used in this PhD. These includes (but is not limited to) secondary data analysis (such as dietary pattern analysis) using data from the Living Cost and Food Survey, and/or the National Diet and Nutrition Survey, linking this dietary data (analysed using Diet Quality Index) to Life Cycle Analysis databases (LCA).

Methods may also include primary data collection using interviews, focus groups, etc. An online survey may be used to investigate the knowledges, perceptions and barriers of sustainable diet among different ethnic groups, e.g., White, Black, South Asians in the UK via the Qualtrics software.

Depending on the candidate, analysis of existing policy documents may also be within this PhDs methodological scope. Evidence synthesis methods may also be used.

Variables derived from LCA and Diet Quality Index will be compared among different ethnic groups using Mann-Whitney or Chi-square test for continuous or categorical variables respectively. Pearson’s correlation is used for two continuous variables. SPSS will be used to statistically analyse data. P value is set at 0.05 with two tail as significant level.

We highlight that this is an “open” project description to allow potential applicants the flexibility to adapt the project and align it with their relevant research interests – e.g., focusing on specific under-represented populations or sustainability/nutrition issues.

Who should consider applying?

Due to this being an “open” flexible project, we encourage highly motivated individuals from a wide range of academic or career backgrounds including STEM and social science backgrounds to apply. This may include applicants with backgrounds in consumer behaviour, diets, nutrition and health, as well as applicants with knowledge related to food systems, policy analysis, environmental sustainability, data science, economics, life cycle analysis, and climate change.

The supervisory team values equality, diversity, inclusion and we welcome applications from anyone regardless of age, disability, race/ethnicity, religion, sex, gender identity or sexual orientation. We encourage individuals who have had worked in relevant sectors (or with relevant communities), a change in disciplines or career paths, or career breaks, e.g., caring responsibilities, to apply."

Feasibility to complete proposed research project in time frame

(3 years plus 1 year writing up or PT equivalent)

Due to being focused on secondary data analysis, this thesis can be completed within the standard 3+1 model.

Alignment of project to research centre expertise and activities

This proposal builds on the world leading sustainable diets research of Dr Christian Reynolds (Centre for Food Policy), and links this to the research specialisms (nutrition of under-represented populations) of Dr Swrajit Sakar, Dr Honglin Dong in HSRM. The candidate would have the option of enhancing their food policy skills through the auditing of additional MSc Food Policy courses.

Project Title:

The impact of sexual violence on birth and mental health

Supervisory team:

• Professor Susan Ayers
• Dr Becca Webb 

Centre for Maternal and Child Health Research

Project description

Background

Worldwide there are over 130 million births every year(1) Research has established that a substantial proportion of women find birth traumatic(2–5)and that 1 in 25 women develop post-traumatic stress disorder (PTSD) as a result of birth(6,7). This means over 5 million women every year develop PTSD following childbirth and many more (~17%) will have sub-clinical symptoms(8).

Sexual violence is experienced by 1 in 4 women living in Western societies(9,10,11). Globally, sexual violence towards girls ranges from 11 to 23%.(12) Furthermore, sexual violence against adult women affects between 1 and 20% of women in lower-middle income countries(13), 18% in the USA(14), and between 25 and 35% in European countries(15).

Research suggests experiencing sexual violence can impact on women’s experiences of birth. Women describe their birth experience as “being back in the rape”(16,17) or “being controlled by another person” again(18). However, this has not been widely studied(19) and most research has been qualitative. The impact of sexual violence on women’s experiences of birth and becoming a mother is therefore not clear.

Significance

The prevalence of sexual violence is high and a large proportion of women who have experienced sexual violence may be re-traumatised during birth. The lack of research in this area means understanding the interplay between sexual trauma and women’s experiences of birth is a scientific imperative.

Results have the potential to inform changes to maternity care provision, funding and policy at national and international levels, informing initiatives such as the WHO’s campaign to prevent disrespect and abuse during childbirth(20). It can also inform initiatives such as potential screening and intervention to reduce morbidity worldwide.

Rationale

Determining the prevalence of sexual violence during childhood and adulthood, and the negative impact it may have on women’s birth experiences and mental health is important to raise awareness, increase understanding and to inform screening and interventions, such as trauma informed care(21), being implemented worldwide.

Research questions

This PhD therefore aims to examine the impact of sexual violence on women’s birth experiences and postnatal mental health. Specific research questions are:

1. What are the prevalence rates of sexual violence in childhood and adulthood in different countries?
2. How does sexual violence in childhood or adulthood affect women’s experiences of birth?
3. Is a history of sexual violence associated with greater risk of developing PTSD or depression after birth?

Study design

This PhD will be embedded in the International Survey of Childbirth-Related PTSD (INTERSECT), an international survey of birth trauma and birth-related PTSD; related outcomes of birth satisfaction and depression; and risk factors. The INTERSECT protocol is available here.

INTERSECT involves 41 low, middle, and high-income countries (see Box 1). Researchers in each country are translating the INTERSECT survey according to accepted translation procedures; obtaining local research ethics board approval; recruiting and collecting data for a minimum of 250 women in their country; and will share anonymised data for the INTERSECT dataset.

Countries collaborating in INTERSECT

• Africa: Botswana, Ghana, Malawi, Nigeria, Zimbabwe
• America: Argentina, Brazil, Chile, USA
• Asia: India, Israel, Jordan, Kazakhstan, Malaysia, Nepal, Pakistan, Russia, Saudi Arabia, United Arab Emirates
• Europe: Croatia, Czech Republic, Estonia, Germany, Iceland, Ireland, Italy, Lithuania, Norway, Poland, Portugal, Republic of North Macedonia, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, UK
• Oceania: Australia

Methods and analysis

Sample: Systematic samples of women are being recruited through universal maternity or infant health services, i.e. not services targeted at specific groups such as high risk women. Women are eligible if they are aged 16 or over, had a baby in the previous 6-12 weeks, and are able to provide informed consent. We require a minimum of 250 women from each country and asked PIs to provide their expected sample size. The current expected sample size over the 41 confirmed countries is 13,950 participants.

Measures: Participant reported measures include a measure of trauma history, which includes sexual trauma as a child, sexual trauma as an adult, and whether the perpetrator was a stranger or known person. Women also complete measures of birth trauma, PTSD, birth satisfaction, depression, psychological history, sociodemographic characteristics (e.g. age, ethnicity, relationship status, household income) and obstetric details (e.g. number of children, gestation, time since birth, type of birth, maternal or infant complications).

Analysis: Descriptive statistics will be used to examine the prevalence of sexual trauma in different countries using percentages and 95% confidence intervals. Odds ratios and logistic regression models will be used to look at whether women with a history of sexual trauma have a greater risk of poor birth experiences, postnatal PTSD and depression, compared to women with no trauma history.

Who should consider applying?

Applicants should have an undergraduate degree and a master's degree in a related subject e.g., psychology, medicine, midwifery, nursing, health sciences, sociology.

Feasibility of project to complete within timeframe

The INTERSECT study started in January 2021 and data collection is already underway in half the countries involved. The study therefore has proven feasibility and is low risk. The INTERSECT data collection ends in February 2023. The PhD student will therefore spend 2022/3 doing data screening and linkage; 2023/4 analysing; and 2024/5 writing up.

Alignment of project to research centre expertise and activities:

This project aligns with the expertise in the Maternal and Child Mental Health Group. The student will be supervised by Ayers (INTERSECT lead) and Dr Rebecca Webb who is a key member of the INTERSECT Oversight Group.

The student will be part of the International INTERSECT consortium and COST network on birth trauma so will have multiple opportunities to collaborate and disseminate their work through these networks, putting them in a strong position to develop an international research profile during and after their PhD.

They will also have the support of the School and University doctoral training structures throughout their studies.

References

1. Richie H. How many people die and how many are born each year? Our World in Data [Internet]. 2019. Available from: https://ourworldindata.org/births-and-deaths
2. Alcorn KL, O’Donovan A, Patrick JC, Creedy DK, Devilly GJ. A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events. Psychol Med. 2010;40(11):1849–59.
3. Ayers S, Harris R, Sawyer A, Parfitt Y, Ford E. Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling. J Affect Disord. 2009;119(1–3):200–4.
4. Creedy DK, Shochet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: Incidence and contributing factors. Birth. 2000;27(2):104–11.
5. Soet JE, Brack GA, Dilorio C. Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth. 2003;30(1):36–46.
6. Grekin R, O’Hara MW. Prevalence and risk factors of postpartum posttraumatic stress disorder: A meta-analysis. Clin Psychol Rev. 2014;34(5):389–401.
7. Dikmen-Yildiz P, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. J Affect Disord. 2017;208:634–45.
8. Dekel S, Stuebe C, Dishy G. Childbirth induced posttraumatic stress syndrome: A systematic review of prevalence and risk factors. Front Psychol. 2017;8:560.
9. Jewkes R, Sen P, Garcia-Moreno C. Sexual violence in world report on violence and health. Geneva; 2002.
10. Finkelhor D, Hotaling G, Lewis IA, Smith C. Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse Negl. 1990;14(1):19–28.
11. One in Four. About One in Four [Internet]. About. 2022 [cited 2022 Mar 1].
12. Stoltenborgh M, Van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreat. 2011;16(2):79–101.
13. Coll CVN, Ewerling F, García-Moreno C, Hellwig F, Barros AJD. Intimate partner violence in 46 low-income and middle-income countries: an appraisal of the most vulnerable groups of women using national health surveys. BMJ Glob Heal. 2020;5(1):e002208.
14. Black MC, Basile KC, Breidling MJ. National intimate partner and sexual violence survey (NISVS): 2010 summary report. Atlanta, GA; 2011.
15. UN Women. Violence against women prevalence data: surveys by country. New York; 2011.
16. Garratt L, Kirkham M. Survivors of childhood sexual abuse and midwifery practice: CSA, birth and powerlessness. Routledge; 2018.
17. Halvorsen L, Nerum H, Øian P, Sørlie T. Giving birth with rape in one’s past: a qualitative study. Birth. 2013;40(3):182–91.
18. Montgomery E, Pope C, Rogers J. The re-enactment of childhood sexual abuse in maternity care: a qualitative study. BMC Pregnancy Childbirth [Internet]. 2015;15(1):194. Available from: https://doi.org/10.1186/s12884-015-0626-9
19. Leeners B, Richter-Appelt H, Imthurn B, Rath W. Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women. J Psychosom Res. 2006;61(2):139–51.
20. World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth [Internet]. 2015.
21. Sperlich M, Seng JS, Li Y, Taylor J, Bradbury-Jones C. Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues. J Midwifery Women’s Heal. 2017;62(6):661–72.

Project Title

Witness skills in children with developmental language disorder

Proposed supervisory team

• Prof Lucy Henry 
• Prof Nicola Botting 
• Dr Rachel Wilcock (external, University of Winchester)

Project description

Background:

There is increasing recognition that children with developmental conditions show differing strengths and vulnerabilities as witnesses. For example, children with intellectual disabilities demonstrate witness skills broadly in line with their developmental level but vulnerabilities emerge when suggestible or repeated questions are posed.  Autistic children can remember informative forensic details about witnessed events, reaching accuracy levels that match those of non-autistic children, but may recall less information overall.

Significance:

In the current literature, there is no research on witness skills in children with developmental language disorder (DLD), a common developmental condition with 7-10% prevalence (at least two children in every UK classroom).  Witnesses and defendants with speech, language and communication needs are considerably over-represented within the criminal justice system (e.g., up to 60% of defendants have language difficulties).

Thus, our lack of understanding about witness skills in individuals with DLD has a direct impact on fair access to justice.  In an equitable modern justice system, potential communication difficulties should be understood and recognised by relevant professionals, with appropriate supports put in place.

Rationale:

The proposed doctoral research will address this urgent gap in the literature by looking at a wide range of key witness skills in children with DLD.  The overall aim will be to understand the specific strengths and vulnerabilities of witnesses with DLD compared to an appropriate comparison group.

Research questions

What are the strengths and vulnerabilities of child witnesses with DLD compared to peers of the same chronological age (and non-verbal ability) with typical development? The doctoral research programme will consider this research question in several important areas:

1. the amount recalled during investigative interviews
2. the accuracy of information recalled in investigative interviews
3. the narrative coherence of information recalled in investigative interviews
4. the accuracy of performance on mock identification line-ups (prepared by the Metropolitan Police Service)
5. the ability to resist cross-examination challenges on false information (in ‘mock cross-examinations’ by qualified criminal barristers).

Study design and methods

An empirical method will be used, namely, a ‘mock witness study’ in which participants with and without DLD view a mild crime event and are questioned later about what happened.  Video-recorded best-practice police interviews and identification line-ups for ‘mock’ perpetrators will be carried out around one week after the witnessed event, in line with current practice.

A video-recorded mock cross-examination will also be included, alongside the interview phase, again in line with current best practice to video-record investigative interviews and cross-examinations (for vulnerable witnesses such as children) at the same time.

Analysis:

The research questions will be addressed by considering whether the volume, accuracy, coherence and consistency of witness evidence in children with DLD is at a comparable level to a comparison group of typically developing children of the same age and non-verbal ability.

Group differences in performance will be assessed using hierarchical multiple regression, with group coded as a dummy variable and non-verbal ability and age included as control variables (i.e., three predictors in total).

Sample sizes will be 40-50 in each group, offering sufficient power for hierarchical multiple regression analyses: for 80% power to detect a medium or large effect, with alpha=.05, and three predictor variables, regressions require a total sample size of at least 77.

Patient and Public Involvement:

The doctoral researcher will actively engage with and work in partnership with key stakeholders throughout the life of this project by forming an Advisory Board in the first two months of the project.

The board will comprise at least:

• two caregivers of children with DLD
• one speech and language therapist with expertise in DLD
• one Registered Intermediary (a communication specialist who assists communication within the criminal justice system for vulnerable witnesses)
• one person with a policing background and interest in vulnerable witnesses (and if possible, the National Vulnerable Witness Advisor)
• one adult or young person with DLD.

Some study parameters cannot be changed (broad research questions/overall methods), but we will draw on the Advisory Board expertise for specific areas:

• study set up (recruitment; wording/presentation of information sheets/consent forms; structure/length of sessions)
• dissemination/communicating implications of results to stakeholders
• reviewing documentation.

We will take a flexible approach to how members contribute to best suit their needs and the project requirements.

Who should consider applying?

This doctoral research project will be attractive to recent graduates in Speech and Language Therapy and Psychology.

It has a strong applied focus, and the findings will have important implications for criminal justice professionals, features which will appeal to many applicants, including those considering future careers as Registered Intermediaries (this profession draws heavily from suitably qualified SLTs and Psychologists).

The involvement of key stakeholders throughout the project will also be attractive to potential applicants.

Feasibility of completing proposed research project in maximum time frame:

(3 years plus 1 year writing up or PT equivalent).

This project will involve an empirical mock witness study with 80-100 participants, which is identical in scale and complexity to a successful recently completed PhD (2020) supervised by Wilcock and Henry that involved participants with and without intellectual disabilities.

Alignment of project to research centre expertise and activities:

The research is clearly aligned with the Developmental Assessment and Intervention Research (DAIR) research grouping within the Centre for Language and Communication Science Research.

Henry and Wilcock have extensive relevant research experience looking at witness skills in children and adults with developmental conditions, having successfully completed large projects on young people and adults with intellectual disabilities, and on autistic and non-autistic primary school age children.

Botting and Henry have extensive experience in research into DLD, including large longitudinal and cross-sectional projects involving children and adults.  All three supervisors have very strong track records of publications on these topics in prestigious peer-reviewed journals.

The supervisory team has supervised 33 successful PhDs (LH=15; NB=11; RW=7) and is highly experienced in nurturing students to succeed in academic and other careers.

The team also has excellent links with several police forces, including the Metropolitan Police and Hampshire Police; the National Vulnerable Witness Advisor (Dr Kevin Smith); the Registered Intermediary profession; families of children with DLD; and individuals who have DLD.  All of these pre-existing links will facilitate PPI and dissemination activities.