One of Europe’s leading university departments of population health sciences, the Department of Public Health and Primary Care has as its mission to generate evidence to inform the prevention of premature death and disability, the promotion of health, and health policy.
Comprising over 400 members, the Department is distinctive for its multidisciplinary character and research strengths across quantitative and qualitative methods, cohort studies, genetic epidemiology, public health, primary care, and social and behavioural sciences. This diverse expertise is cross-linked in “team science” efforts that tackle grand challenges in the understanding, prediction, prevention and control of common chronic diseases. Patient and public involvement and engagement are prioritised throughout.
The Department is home to enviable population research resources, including global consortia (such as the 2.5 million-participant Emerging Risk Factors Collaboration), multi-centre cohort studies (for example, the world’s largest cardiovascular disease case-cohort study, EPIC-CVD, which is embedded in the 520,000-participant pan-European EPIC cohort), unusually deeply-characterised cohorts (for example, the 50,000-participant INTERVAL study), and a variety of community-based randomised trials.
A further notable feature of the Department is its strategic partnerships with external organisations, including NHS Blood and Transplant, Wellcome Trust Sanger Institute, RAND Europe, Health Foundation, industry, and policy-makers at local, national and international levels. These partnerships facilitate multidisciplinary research projects, ensure relevance to population and health service need, and accelerate translation of findings into policy and practice.
We have highlighted some research themes that cut across the Department’s multiple groups and units.
Biological basis of disease
Goal: To identify and evaluate causal risk factors for selected major diseases, including cardiovascular diseases, cancers, neurodegenerative diseases, diabetes, and other age-related conditions, thus providing foundations for novel prevention, early detection and therapeutic strategies.
Achievements: We have led discovery of hundreds of genetic risk factors for a range of common diseases (eg, breast, prostate, and ovarian cancers; coronary disease; type 2 diabetes) and thousands of genetic risk factors for intermediate traits (eg, blood lipids, proteins) in >50 publications in Nature, Cell, Science and Nature Genetics in the past few years alone. These findings have opened new avenues of mechanistic understanding and helped industry prioritise novel therapeutic targets.
Future plans: In an attempt to provide a more complete picture of the genetic basis of disease, our gene sequencing studies are being extended to >100,000 individuals, including tens of thousands with breast cancer or coronary disease as well as healthy controls. We have commenced large-scale “multi-omic” studies of >10,000 molecular traits to identify and understand potential predictors and determinants of disease.
Early detection of disease, risk prediction and screening
Goal: To develop and evaluate approaches that can cost effectively enhance the diagnosis, early detection, prediction and control of chronic disease outcomes.
Achievements: We have shaped clinical management guidelines by producing precise cancer risk estimates for women with genetic faults in major cancer susceptibility genes (eg, PALB2, CHEK2, BRIP1), and have shown that cancer risks for women with genetic faults in BRCA1 and BRCA2 depend on both the precise mutation and the woman’s family cancer history. We have developed widely used prognostic tools for breast and ovarian cancer, as well as electronic clinical decision support tools for general practitioners to help target cancer screening more accurately. Our work has also shaped >10 cardiovascular disease risk management guidelines, principally by suggesting approaches that simplify risk prediction without sacrificing accuracy.
Future plans: We plan to develop and implement improved cancer diagnostic testing strategies for general practitioners through the first ever Cancer Research UK Catalyst Award. We plan to introduce a new international cardiovascular risk prediction score, calibrated to populations in >180 countries, in collaboration with the World Health Organization. We aim to develop new ways to screen populations for atrial fibrillation to cut stroke risk.
Behaviour and health
Goal: To develop interventions that can be implemented at scale to target the four sets of behaviours that contribute most to premature, preventable death worldwide, years lived in poor health and health inequalities: excessive consumption of food and alcohol, smoking and low physical activity.
Achievements: For interventions that target whole populations rather than specific individuals (eg, changing cues in physical environments that shape our behaviour often without our awareness, also known as nudging), we have developed a classification of interventions for changing proximal physical environments to change behaviour, such as in relation to food portion size. For interventions that target specific individuals (eg, using digital, automated text messaging and smartphone applications), we have developed and are evaluating an intervention for smoking cessation using tailored text messaging (iQuit in Practice) and a version for pregnant smokers (MiQuit).
Future plans: We are planning a series of integrated field and laboratory studies to estimate the effect sizes of promising interventions to reduce food, alcohol and tobacco consumption. These studies will be conducted in supermarkets, bars and cafeterias; the interventions will be optimised through laboratory studies determining mechanisms.
Health services research
Goal: To provide high quality evidence for making improvements in quality, safety, and experience of care.
Achievements: We have conducted studies across a range of care settings, including primary, hospital, mental health, and community care. These include the first ever randomised trial of the impact of varying the frequency of blood donation, yielding findings that allow better management of the supply to the NHS of units of blood with in-demand blood groups. Our studies of patients’ experiences of care have revealed how specific patient populations (such as those of minority ethnicity) may have poorer experiences than others. Our research has challenged current policy orthodoxy on people’s preferences for place of death, demonstrating that dying at home may not be the universal choice it is often portrayed.
Future plans: We will establish a new institute for the study of healthcare improvement, with £42 million support provided by the Health Foundation. This institute will develop and test creative solutions to big healthcare problems by bringing together multidisciplinary expertise, strengthening the science behind the study of improvement, evaluating specific interventions and programmes to assess their effectiveness and cost-effectiveness, and figuring out how successful improvements can be replicated and scaled and where disinvestment is warranted.
Goal: To help provide context-specific solutions to control the epidemic of chronic diseases in low- and middle-income countries, and to advance understanding of disease by leveraging the striking heterogeneity of environmental, lifestyle and genetic exposures in these populations.
Achievements: We have established a portfolio of studies in various emerging economies, with a particular focus on settings with rapidly increasing rates of cardiometabolic conditions (eg, heart disease and diabetes). They include BELIEVE (a 25,000-participant household survey in Bangladesh), MAVERIK (a 5000-participant case-control study of myocardial infarction in Malaysia), and PROMIS (a 40,000-participant case-control study of myocardial infarction in Pakistan). Initial findings have highlighted the important interplay of universal risk factors (eg, blood lipids) and local factors (eg, consanguinity, toxic metal exposure).
Future plans: As part of a £8 million capacity-building effort funded by Research Councils UK, we are establishing a 100,000-person cohort in Bangladesh in urban, rural and slum contexts, using this study as a framework to develop and evaluate interventions that help control the complex set of risk factors for chronic disease.