Public Health


Theme 1: Health behaviour and health promotion

Prof. dr. Frank J. van Lenthe

Our society faces an epidemic of unhealthy life behaviours, as evidenced by the strong increase in obese children and adults. An unhealthy lifestyle not only leads to increased morbidity and mortality, but also to adverse consequences among those with a chronic disease. The research in this theme varies from identifying the relative importance of lifestyle and coping strategies on morbidity among different populations, such as school children and elderly persons, developing and evaluating interventions aimed at changing health behaviours, and evaluating the consequences of health behaviour for functioning and participation, for the role of physical activity in frailty among older persons. Projects can accommodate a large variety of interest, such as active data collection on health behaviour and physical activity patterns among elderly persons in relation to the physical environment, studying the role of social and cultural determinants of health behaviour, and investigating how to reach and encourage persons with unhealthy behaviour to participate in health intervention programmes.

Theme 2: Infectious disease control

Prof. dr. Sake J. de Vlas, Dr. Wilma A. Stolk

Infectious diseases are still an important problem worldwide and in many cases systematic preventive control is needed. The theme infectious disease control aims at studying the public health consequences of infectious diseases and evaluating the cost-effectiveness of their control. The core activity is the development and application of simulation models describing the transmission and natural history of infectious diseases in human populations and the impact of control measures. However, we also perform epidemiological data collection or carry out literature reviews.

Most of the ongoing research is in collaboration with active control projects, and has a strong focus on global infectious diseases that have a chronic course with secondary complications. Examples of work over the past years concern parasitic worm infections, tuberculosis, leprosy, visceral leishmaniasis, and HIV/Aids. The research network includes various scientists and scientific institutes in the developing and developed world, including the WHO and the World Bank. Special collaborations exist with sub-Sahara Africa (worm infections and HIV/Aids), Bangladesh (leprosy), India (lymphatic filariasis, leprosy, and visceral leishmaniasis) and Indonesia (tuberculosis and leprosy). The department is a key partner within the Neglected Tropical Diseases (NTD) Modelling Consortium, funded by the Bill & Melinda Gates Foundation. Within the Huisman Research Centre for Infectious Diseases and Public Health, Erasmus MC and the Municipal Public Health Service (GGD) of Rotterdam work together in the area of infectious disease surveillance and control in the Rotterdam region. Here, emphasis is on diseases that are closely related to the immigrant population of the city, and to the public health aspects of antibiotic resistance. An important new area of research concerns the epidemiology and control of emerging infectious diseases, in particular Covid-19.

Theme 3: Screening for disease

Prof. dr. Harry J. de Koning, Dr. Iris Lansdorp-Vogelaar

Cancer is a major cause of death worldwide. Several strategies have been implemented to prevent cancer death, such as screening. Everybody in the Netherlands is invited to participate in several screening programs at a certain age, for example breast cancer screening, cervical cancer screening and colorectal cancer screening. Screening can either prevent cancer or detects cancer in an earlier stage, thereby saving many lives. However, early detection also means a longer period of life during which a person is aware of having the disease, and false-positive test results will induce unnecessary diagnostic interventions.

Our research quantifies the health benefits, unfavourable side-effects, impact on quality of life, and the cost consequences of introducing screening and is used to guide national cancer screening guidelines, both in the Netherlands and abroad. Our team, consisting of modelers, epidemiologists, statisticians, economists and doctors, performs calculations for policy makers, for example to inform the National Institute for Health and Environment and the United States National Cancer Institute. Another large project is EU-TOPIA: towards imporved screening for breast, cervical and colorectal cancer in all of Europe. We closely collaborate with our partners from all around the world to improve our understanding of the impact of cancer screening on population trends in cancer mortality. Our mission is to conduct eminent quantitative research with a discernable impact on population health.

Theme 4: Inequalities in health

Prof. dr. Frank J. van Lenthe

All high-income countries have substantial inequalities in health within their populations. People with a lower level of education, a lower occupational class, or a lower level of income tend to die at a younger age, and to have, within their shorter lives, a higher incidence and prevalence of almost all diseases (cardiovascular, cancer, respiratory, injuries, …). Other important disparities in health are found between men and women, between ethnic groups, between people with a different marital status, and residents of deprived and affluent neighborhoods. At the Department of Public Health of Erasmus MC we aim to understand international variation in health inequalities, to investigate specific explanations of inequalities in health and health behaviour, and to evaluate interventions and policies aimed at reducing health inequalities.

We are engaged in international comparative studies, prospective cohort studies, natural (policy) experiments and intervention studies, and apply state-of-the-art quantitative methods. Our research provides important input into health policy at the local, regional, national and international level, and offers excellent opportunities for public health research training.

Theme 5: Medical Decision making

Dr. Hester F. Lingsma

Diagnostic and therapeutic options continue to increase, both in number and in complexity. The science of medical decision making considers decision problems in individual patient care. Our research considers diagnostics (what is wrong?), therapy choice (what can be done about it?) and prognosis (what will happen?). Special interest is in prognosis and prediction modeling. We frequently use regression analysis for prediction of the presence of disease (diagnosis) or the outcome of a disease process (prognosis) given patient and/or care characteristics. Recent interest is expanding from development and validation of prediction models to assessment of impact in clinical practice, that is, do patients have better outcomes when decisions are based on a prognostic model than without? A specific issue here is the contribution of novel markers to the improvement of prognostic models. Another line of research is on quality of care, where we consider differences between health care providers, such as differences in mortality between hospitals. We study a wide scope of medical problems, including patients with various cancers (e.g. bladder, prostate, colorectal), cardiovascular disease, neurological disorders (including stroke, Guillain – Barre syndrome), gastrointestinal disease (e.g. Barrett oesophagus), surgical interventions, and acute diseases (e.g. patients with traumatic brain injury). The research is done in close collaboration with various clinical groups at Erasmus MC, in the Netherlands, and internationally.

Theme 6: Health, work, and participation

Prof. dr. Alex Burdorf, Dr. Suzan Robroek

With growing life expectancy in developed countries, workers are encouraged to remain in work longer. There is ample evidence that among older workers, especially those 50-65 years, ill health contributes to selection out of the workforce due to early retirement, unemployment, and permanent disability. For chronic diseases, such as rheumatoid arthritis and low back pain, the average working life expectancy may be reduced by up to 4 years. We seek interested students to study the influence of poor health on paid employment and participation in available datasets of cohort studies across European countries, such as SHARE, SILC, and EHIS. With statistical analysis techniques for longitudinal data, we want (i) to determine how particular aspects of health problems, e.g. particular chronic diseases or functional limitations, predict leaving paid employment, (ii) to assess how lifestyle behaviours and working conditions mediate these associations, and (iii) estimate the number for working years lost due to poor health during a working career (life course perspective).

Theme 7: Cancer surveillance

Valery Lemmens PhD (cancers of the GI-tract, cancer in general, treatment, quality of care)

Project: Cancer surveillance examines the various cancer epidemics, elucidating determinants of changes in incidence and prognosis

The Cancer surveillance section at the department of Public Health of Erasmus MC entertains excellent relations with the renowned South Netherlands cancer registries at Eindhoven and Rotterdam, each with impressive extra data- collections on clinical aspects of cancer detection and care, co-morbidity, and strongly involved in a variety of regional , national and European studies of cancer incidence and prognosis.

Besides close collaborations across Europe, a.o with IARC (Int Agency for Research of Cancer in Lyon) there is close collaboration with most clinical oncological departments at Erasmus MC and in the large southern community hospitals where most older cancer patients are being treated.

In our research special emphasis exists on the following topics:

skin cancer epidemics of melanoma and non-melanoma skin cancer including basal cell skin carcinoma gastro-intestinal cancer epidemics with special emphasis on oesophageal and colorectal cancer obesity, alcohol and smoking related epidemics of cancer in the (very) elderly, allowing for studies of the role of co-morbidity of which there is a unique data collection since 1995 cancer in migrants. Most likely we can accommodate your own ideas.

Theme 8: Care and decision making at the end of life

Prof. dr. Agnes van der Heide and Dr. Judith Rietjens

During the last decades, the end of life has emerged as a new field of practice and research in health care, due to demographic changes, cultural developments, and medical progress. In our group, we study this fascinating topic in two lines of research.

The first line focuses on palliative care and medical decision making at the end of life. Goals of medical care need to be re-aligned for patients who have a limited life expectancy. Quality of life may become more important than postponing death. Care at the end of life often involves many different formal and informal caregivers and complex decisions about whether or not to use life-prolonging interventions, or about far-reaching interventions to alleviate severe suffering. Research in this line inventorizes epidemiological, clinical and societal aspects of care at the end of life and includes quantitative and qualitative studies.

The second line of research focuses on self-management and advance care planning. Patients’ autonomy and self-determination are increasingly valued, and patients and their family caregivers are more and more expected to be co-responsible for their health and care. Examples are that patients and their family caregivers increasingly need to self-manage care at home, that they are expected to take up co-responsibility for decision-making regarding care and treatment (advance care planning), and that they need to navigate the increasingly complex arena of care providers and other professionals who can support in the disease trajectory. Nevertheless, self-management in care is not always self-evident, especially in the last phase of life where care needs are high. In this research line, qualitative and quantitative studies are performed to gain insight in the determinants, outcomes and underlying mechanisms of self-management and advance care planning.

Theme 9: Preventive Health Care for youth and families, and other vulnerable populations (people with multi-morbidity or frailty)

Prof. dr. Hein Raat

Healthy growth and development of babies, even before birth, and of children and youth is essential for public health. Even in high income countries, persistent differences in health potential are present between children of various social and ethnic backgrounds. These differences show up in pregnancy and continue during childhood, leaving their marks throughout life. The aim of this theme is to unravel the mechanisms that cause childhood health inequalities, to contribute to effective prevention in day-to-day practice of professionals dedicated to support parents and to promote child health. Moreover, methodologies and lessons learned are applied in health promotion research among other vulnerable populations, such as the older population. Four types of studies are conducted.

Firstly, studies regarding the origins of socio-economic and ethnic differences in growth and development. They primarily use the framework of the Generation R cohort of almost 10.000 Rotterdam children, most of which were included in early pregnancy, with extensive measurements throughout pregnancy and after birth. The theme focuses on assessing how adverse circumstances of the mother affect pregnancy, birth outcomes and child health. Furthermore, we have a project on the origins of social and ethnic differences in overweight in childhood.

Secondly, studies that develop and evaluate new preventive interventions in preventive youth health care. For example we developed E-health4Uth, an interactive, web-based approach that supports monitoring and prevention in preventive Youth Health Care (YHC) and with an application for obstetric care. Several applications in day to day practice are being evaluated.

Thirdly, we conduct studies, in collaboration with others, to evaluate established or new Youth Health Care interventions by applying rigorous designs such as large cluster-Randomised Controlled Trials (c-RCTs). Examples are multi-center studies to evaluate the nation-wide protocols for Overweight Prevention, a new Internet-based Home-safety Promotion intervention, and early detection of emotional/behavioural problems.

Fourthly, studies regarding lifestyle improvement in combination with technological solutions are being conducted. Examples are the SEFAC and ValueCare project. In SEFAC a training was developed and evaluated to improve self-management for citizens with (a risk for) chronic conditions. In ValueCare we aim to deliver efficient outcome-based integrated (health and social) care for older people facing cognitive impairment, frailty and multiple chronic health conditions in order to improve their quality of life (and of their families) as well as the sustainability of the health and social care systems in Europe.

Theme 10: International Health

Dr. Tanja AJ Houweling

At the start of the 21st century profound health inequalities persist globally between countries and between socio-economic groups within countries. These inequalities are not due to a lack of technical or medical knowledge on how to improve health. Within countries, they are due to a lack of knowledge on how to reach the most in need with effective interventions. Our projects focus on three main areas: (1) What works, where, and why to reach the most in need with effective interventions and reduce health inequalities. We evaluate health interventions –such as participatory women’s groups to reduce newborn mortality, and conditional cash transfer and performance-based financing schemes in Asia and Africa– in terms of (a) the socio-economic groups that these interventions reach and (b) their health impact among lower and higher socio-economic groups.

We mainly use observational and experimental study designs, including large randomised trials, but we also explore the role that experiential knowledge of policy makers and practitioners can play in understanding what works, where and why to reach lower socio-economic groups. (2) Understanding societal contexts that are conducive to reducing or increasing health inequalities.

Building on the work of the WHO Commission on Social Determinants of Health, we use ecological designs, contrasting case studies and natural experiments to study the effects of factors like state strength and rapid economic growth on the magnitude of health inequalities within countries in Asia, Africa, and Latin America. Students can explore these issues using Demographic and Health Survey (DHS) data. (3) Measurement and monitoring of health inequalities in low and middle income countries. Socio-economic inequalities in a wide range of health outcomes, in particular for newborns, children and women, can be studied using DHS data and data collected in large demographic surveillance sites in Asia and Africa.

Theme 11: Cost-effectiveness of health care

Dr. Suzanne Polinder, Dr. Juanita A. Haagsma, Dr. V. Erasmus

How can we improve cost effectiveness without compromising quality of care? Over the last 40 years health care costs have been rising in most countries. Several factors have played a role in this growth, including ageing of the population and health technology advancements. To continue progress in health care delivery, improve health outcomes of patients and meet new challenges, monetary resources must be deployed effectively. Research on cost-effectiveness of health care generates information that is used to guide effective allocation of resources to health. The research in theme 11 covers cost-effectiveness of health care studies as well as many aspects that are linked to cost-effectiveness studies, such as determining how much certain interventions cost, assessing health outcomes of patients by employing health-related quality of life instruments, collecting information to assess if an intervention actually works and which process and contextual factors prevent a proven intervention to become part of routine health care workflow. Projects can accommodate a large variety of interest, such as active data collection on health care consumption and health outcomes of patients, researching health-related quality of life of certain patient groups and identifying determinants of health-related quality of life and comparing the costs and effects between an existing and new health care interventions.