Welcome to the last session for the course on disease screening in public health. In this course, we have presented you with the general concepts and metrics that are essential to screening. We then provided several modules that explore different types of disease screening at different times during the life course and in different environments. We concluded with essential information needed for the evaluation, planning, and implementation of screening programs. The general purpose of the course was to increase the competency of people involved in the scientific field of screening and to put screening into the public health perspective. You should now understand that you cannot consider only a screening test in isolation, but must consider screening as an entire program that is complex and requires careful evaluation and considered decisions by patients, providers, and policymakers. In this final part of the last module, I'll be interviewing several experts on what they feel will be the future focus of disease screening and public health. This will include an interview on the use of genomics and screening for nutritional risk factors. The second interview will address the use of qualitative research to generate important evidence for evaluation, planning, and implementation of screening programs. The third and final interview will cover the interactions between public health and primary care and how this relates to screening programs. For our first interview. We have Dr. Murielle Boshud, who is the new head of the Institute for Social and Preventive Medicine. Dr. Boshud will be speaking with us about the role of genomics in screening as it relates to assessing nutritional risk factors. Please tell us a little bit about yourself. I am a public health physician and a genetic epidemiologist. I do both public health research and services, and my expertise is primarily in the field of genetic epidemiology and nutrition epidemiology as well as cardiometabolic epidemiology. Can you tell us what is meant by nutrigenomics? Nutrigenomics is a field that looks at the interface between diet and health while taking into account genomic information or other omics information such as epigonomics, transcriptomics. It is in the classical case, the study of how genetic determinant influence the effect of diet on human health and we can also envisage these fields. Nowadays, with novel technological developments, has a study of how nutrition influences health through modifications of how the genome is expressed and what are the consequences on health. How do you envision this being used in public health screening programs? We are not yet ready for personalized nutrition recommendations. Global recommendations that are targeted to the general population still remain valid. That is, for instance, to recommend people to eat plenty of fruits and vegetables regardless of their genetic background. However, we do know from recent research findings that when given the same standardized meal, different individuals will provide or display different metabolic responses. It is possible that in the future, nutrition recommendations become more personalized and targeted to their genetic background. But at the time being, the evidence is not sufficient to do so. What do you think will be the major challenges. The major benefits? I think the major challenges to implement the knowledge from nutrigenomics into public health screening programs will be first to be able to handle the huge amount of data that is needed to adequately interpret this information. Another challenge is that diet is known to influence health but it is likely that we need to consider exposure to diet during many years or even many decades before it has an impact on health. So that we need to capture these long-term exposure to diet during a very long period of time. So one of the challenges to adequately capture long-term diet and long-term exposure to selected nutrients for instance. Current tools have important limitations. For instance, food frequency questionnaires or 24-hour recalls, as they are based on the fact that people do remember what they ate usually or what they ate during the day before. And if we want to have a long-written assessment, we would need to repeat the use of such tools at regular intervals and this would present a substantial burden to participants and also a high research cost. So one of the challenge will be to develop methods that are not too cumbersome for participants and that do not cost too much money, so that we have a good assessment of exposure to diet and can evaluate or analyze the impact on health. Another challenge is that the relationship between diet and human diseases is very complex and that there is still a lot of knowledge that need to be acquired so that we can then design and develop interventions that are efficient in improving an individual's health status and prognosis. It is also important to consider the entire food chain that is not only what people eat but also how the food came to to the individuals, and to ensure that the entire food production chain is sustainable and also safe for people to consume. So the relationship between nutrition and human health is a very complex entity that will require the multidisciplinary teams able to digest a huge amount of data and also to get a better understanding of how human health can influence, sorry, a better understanding of how nutrition can influence human health. Currently many diseases are known to be strongly influenced by diet, such diseases are cancer, cardiovascular disease, metabolic diseases such as obesity and type 2 diabetes. I'm convinced that when our knowledge will have improved, we will be able to target nutritional interventions to the needs of the individuals and therefore be more efficient in fighting and better preventing those diseases. We would like to thank Dr. Boshud for taking this time to share her views on this interesting topic that we are sure to hear more about in the future. For our next interview, we have Professor Brenda Spencer, who is the senior academic at the Institute for Social and Preventive Medicine. Professor Spencer will be speaking with us about the role of qualitative research and how it can contribute to the generation of needed evidence for screening program evaluation, planning, and implementation. Please tell us a little bit about yourself. My name is Brenda Spencer. I originally trained in psychology and from then onwards, I've spent on my professional life in public health. I've specialized quite a lot in sexual and reproductive health and in health promotion and then over recent years, in fact for about the past 15 years, I've developed a speciality in our institution to help people conduct qualitative research in the field of clinical research. Can you give us a short explanation of what qualitative research methods are? Qualitative research is destined to answer questions such as why and to explore issues as opposed to quantitative research which we're more looking at the questions of how many. So the things we know about in terms of methods that we usually use interviewing and this is open interviewing, be it on structured or semi-structured. A lot of people have heard of the techniques of focus groups which are a kind of collective interview and then observation whether it's a participant or non-participant observation. These are the main methods that we think about when we talk about qualitative research methods. Qualitative methods are often critical for implementation and program evaluation. Can you provide some examples of how you think qualitative research could improve public health screening programs? When we set up a public health screening program, we need to know that the program is accessible to the target population and that it is acceptable to the target population. To me, it's very difficult to answer these questions if we don't do qualitative research because otherwise we're assuming what the public see as being accessibility. We're assuming that we know how they're thinking about things, what will be their fears, what will be their expectations, all of these things we actually need to push them directly to understand these issues. And we have learnt in the past from many screening programs, over a number of years, that sometimes we assume we know what the problem is when there's low uptake was, in fact if we actually go and find out from the people that we're working with and that we're hoping to attract, the answers can be very different. Many years ago, in pioneering days of screening programs, I was involved in setting up what we called provider-initiated, consumer-orientated screening program. And for this, we needed to check how people were seeing what was being offered to them, and examine exactly why people were not attending when they were attending. And in that particular situation, we learnt the problems that we thought were to do with fears in the mind of the public were, in fact, sometimes quite banal problems such as the fact that the screening service was not open at the right kind of times, and that it wasn't simply accessible to them. In particular, in this case, it was a question of accessibility to busy mothers. So, in fact, what we need to do is go into these situations in order to check out what is happening really directly rather than projecting our own ideas and our own notions from the situation, which, in fact, are very much related to our own perspective of the world. We need to see what their perspective of the world is. What do you think will be the major challenges? The major benefits? The major challenges to establishing qualitative research in constructing screening programs. Our field are actually challenges that come from the inside rather than from the outside. And that we work in a field where the biomedical perspective is very much preponderant. And in these situations, very often, it is our own colleagues who don't understand what qualitative research can do and the fact to establish a certain amount of resistance or see these things as not very serious. See them as not scientific. And, in fact, they're the challenges that in fact we very often meet for the researches that are involved in this kind of approach. And there's the major benefit. Well, I see qualitative research is being totally complementary to quantitative research. The two work together and I think if we have a vision of integrating the two, then this will carry substantial benefits, which we can't have by just having one approach or the other. So far, the issues that I've mentioned have been very much in terms of thinking about how to implement programs. In my institution, we're involved very heavily in evaluating programs, and what we find is that systematically, it's necessary to have a number of different approaches and to triangulate questions in order to really get answers in complex situations. In these complex situations, very often, we have to look at what's happening with a number of different stakeholders. And, in order to do this, it's necessary to go and find out quite simply. It's necessary to go and ask the questions and to strip to the research around the answering of complex questions and evaluation. I really don't feel that you can get the necessary answers with just simple questionnaires and with simple counting. I think you really have to dig underneath and find out what's going on, find out what the problems are, and find out how we can better meet the challenges at this level. We'd like to thank Professor Spencer for taking the time to share her views on this key research methodology that can help to provide a solid evidence based for making decisions about screening programs in the future. For our final interview, we have Dr. Jacques Cornuz, who is the head of the University Medical Polyclinic. Dr. Cornuz will be speaking with us about the intersection of primary care and public health and how this is important for screening. Please tell us a little bit about yourself. First, I got a degree in political sciences here in the University of Lausanne. Then, I got MD degree also here in Lausanne and I decided then to get the internal medicine training in a hospital in ambulatory care settings in Switzerland. Then I moved to the US to get MPH at the Harvard School of Public Health in the concentration of clinical effectiveness, clinical epidemiology. And then I decided to came back to Lausanne to get the faculty position here at the university hospital, first as associate professor. And from 2011 as full professor of medicine and chief medical officer of the Department of Ambulatory Care and Community Medicine. I'm now deeply involved in teaching preventive medicine, evidence-based medicine, and also general internal medicine here in Lausanne. Can you give us a short explanation of primary care and how it current relates to public health? Primary care is the health care setting where the vast majority of health issues are addressed among citizens for the general population. And I do believe that primary care professionals and public health officers have a complementary role to provide care for citizens and patients. And, for me, all primary care professionals like GPs or nurses should have a very solid background on public health and public health officer should also have a good connection with the primary care providers. Primary care and public health often have overlapping mandates and this can clearly be seen for screening. Can you provide some examples of how you think primary care or primary care providers could better contribute to public health screening programs? Based on the new data coming from the literature, based on the new perspective in the healthcare setting, I do believe that primary care providers especially GPs, family physician have a crucial role in promoting public health screening programs. But, at the same time, we have to shift, I would say, we have to have a new paradigm regarding the final goal of public health screening program. The final goal is not anymore very high level of participation rate. The major goal is to have a high-level of information regarding screening programs. For me, the big issue around this topic is to be sure that primary care providers will explain carefully with neutral objective information to the patient and the citizens, the pro and the cons of each screening program, the advantage and the disadvantage of having screening tests or screening procedures. And, in the future, this type of professionals, primary care providers, public health officials, should work altogether to be sure that all citizens are well informed about the issues regarding screening. What do you think will be the major challenges? The major benefits? I do believe that the major challenge right now is the quality of the information that we provide to the patient and the citizens regarding screening issues. I do believe that the past, there was too much emotion in the pamphlet or the brochures explaining the advantages of screening especially for breast cancer screening, but for other types of screening also. Now, we have to address the issue of overdiagnoses and other well-documented issues of screening. But, at the same time, we have also to explain the benefit for the population and for an individual to perform a screening test. So, for me, the major challenge will be the quality of the information and the major benefit should be the percentage of the population very well informed regarding screening issues. We would like to thank Dr. Cornuz for taking the time to share his expertise and views on this important intersection between primary care and public health as this will undoubtedly become more and more important for the success of future screening programs. We hope you have enjoyed this course for the theoretical training, which might have been a refresher for some of you who have had public health training as well as the substantive content that should have provided an up-to-date perspective on screening programs. You should now have a good understanding of what compromises disease screening and public health and a framework for making decisions on current and future screening programs. You should also now have the basis for understanding how important empirical evidence is for determining harms and benefits, and how this is different from the public perception of good. A special edition on current issues and screening has been published with the journal Public Health Reviews. I encourage you to read these open-access articles and to continue your training and education in the field of disease screening. The link is in the list of reading materials that accompany this module. I would like to acknowledge the Institute of Social and Preventive Medicine in Lausanne and the University of Lausanne in producing this MOOC as well as the support from the school of public health of South West Switzerland, and the University of Geneva. Thank you for your time and congratulations on completing the course.
