Review Levels of Prevention and Describe Examples of Each Level Using a Chart

Bones Concepts in Prevention and Health Promotion

Afterwards completing this affiliate, the reader will be able to:

• Talk over the concept of life course and the natural history of illness, specially with respect to possible public health and clinical interventions;
• Understand the four levels of prevention (primordial, primary, secondary, and third);
• Appreciate the office that physicians can play in promoting wellness and preventing diseases at the individual and community level, including health protection and health promotion;
• Draw the five strategies of health promotion equally defined in the Ottawa Charter and employ them to relevant situations.

Linking these topics to the Medical Council examination objectives, especially sections 78-3 and 78-4.

Catherine's diabetes

Catherine Richards, Paul's lxx year-erstwhile mother, was diagnosed with diabetes ii years agone and is experiencing increasing cerebral impairment. Dr. Rao is concerned that this volition reduce her power to monitor her diet and proceed up with the exercise program they had devised for her. He wonders if there is a fashion to slow the progression of her disease and continue her contained.

Natural History of Disease and the Stages of Prevention

Capacity i and 2 introduced the NATURAL HISTORY of a disease, from exposure to causal agents through its progression to final outcomes. Agreement the characteristic natural history of a affliction enables physicians to anticipate the patient'southward prognosis and to place opportunities for prevention and command.^one For instance, based on his knowledge of Type 2 diabetes, Dr. Rao tin can be concerned that Catherine Richards may face visual harm, kidney failure, fifty-fifty possible amputation, if she does not have measures to control her affliction. The natural history likewise suggests the time frame inside which he has to arbitrate to alter the clinical class of her diabetes and prevent the development of more than serious consequences.

Ideally, prevention occurs earlier people contract a disease, and then preventive programs are often delivered to currently good for you people in the general population. Merely at what stage in the natural history should nosotros arbitrate? The metaphor of the "iceberg of disease" reminds usa that for every case that comes to a clinician, there are likely to exist many more than people with pre-clinical disease in the community, and even more with gamble factors for the condition. For some conditions (water-borne parasitic diseases, respiratory disease due to air pollution) about everyone in the population is susceptible, so prevention can justifiably target the entire population. For other atmospheric condition (e.1000. breast cancer) some groups are at higher chance, so prevention tin focus on those. Chapter ii distinguished population health approaches, which target unabridged populations, from public wellness programmes which often target identifiable groups. To pattern such a plan we must, therefore, sympathise the distribution of the condition in the population and know how to identify future cases.

Figure 4.1 links the phases in the natural history and clinical course of a disease to preventive strategies, or "stages of prevention". Different groups of experts, in different locations, will evangelize the various preventive strategies.

Effigy 4.1: Clinical class of a disease: four prevention stages

Chapters ane and 2 illustrated how a patient's affliction follows a natural history that tin, for convenience, exist broken into a series of stages. Preventive measures can be applied at any stage along the natural history, with the goal of preventing further progression of the condition (see PREVENTION, defined in Glossary). For the purposes of introduction it is convenient to think of preventive deportment at iv master stages, just in reality the stages blur i into the next.

Primordial prevention consists of actions to modify population health determinants and inhibit the institution of factors (environmental, economical, social, behavioural) known to increase the hereafter run a risk of disease.² It addresses determinants at the systemic level rather than modifying personal take a chance factors, which is the goal of main prevention. Thus, outlawing alcohol in certain countries would stand for primordial prevention, whereas a campaign against drinking and driving would be an instance of primary prevention.

Other examples of primordial prevention include improving sanitation (and so that exposure to infectious agents does non occur), establishing good for you communities, promoting a good for you lifestyle in childhood (for case, through prenatal diet programs and supporting early on childhood development programmes), or developing light-green free energy approaches. Starfield et al. gave more than examples.³ So, in preventing Catherine Richards'due south diabetes, subsidized fitness programmes at the sports centre should make such activities more affordable for women like her, and could aid to make exercise a norm for women in her community. As these are population-level programmes, primordial prevention is conceptually linked to population wellness and health promotion, simply clinicians tin play a part in bringing problems to public attention and in advocating for action on determinants.

Salubrious communities

During the early on 1980s the European regional role of the World Wellness System proposed actions to improve the quality of life in cities by making the urban environment conducive to salubrious living: providing recreational resource, improved transportation, cleaner environments, more pleasant housing and so on. Toronto was an early on participant in the healthy cities movement.⁴

Primary prevention aims to prevent the onset of specific diseases via gamble reduction: by altering behaviours or exposures that tin lead to illness, or by enhancing resistance to the effects of exposure to a disease agent. Examples include smoking cessation and vaccination. Primary prevention reduces the incidence of disease by addressing affliction take chances factors or by enhancing resistance. Some approaches involve active participation, as with regular tooth brushing and flossing to forbid dental caries. Other approaches are passive: calculation fluoride to the municipal drinking water to harden molar enamel and prevent caries. Principal prevention often targets specific agents and the risk factors for specific diseases, but may as well aim to promote good for you behaviours, improve host resistance, and foster safe environments that reduce the risk of illness in general, for instance, thorough cleaning of operating rooms to foreclose mail-operative infection. Principal prevention fits well into the agent-host-environment model of causation introduced in Chapter 2.

Secondary prevention includes procedures to detect and abort pre-clinical pathological changes and thereby command the progression of a particular affliction. Screening procedures (such equally mammography to detect early phase breast cancer) are oft the showtime step, leading to early interventions that are more cost effective than intervening in one case symptoms appear. Routine blood sugar testing for people over 40 would be an instance relevant to detecting Catherine'southward diabetes early. Screening is unremarkably undertaken past wellness professionals, either in individual doctor-patient encounters every bit with routine blood pressure checks, or via public health screening programs (e.m., population mammography screening programmes). The criteria for implementing a screening programme are described in Affiliate 9.

One time a disease has developed and has been treated in its acute clinical phase, tertiary prevention seeks to soften the touch on of the disease on the patient's function, longevity, and quality of life. Examples include modifying behavioural adventure factors, such as profitable a cardiac patient to lose weight, or making environmental modifications to reduce an asthmatic patient's exposure to allergens. In the example of Catherine Richards, it might include ensuring regular bank check-ups to monitor her condition, including eye exams to check for possible adverse outcomes of her diabetes. Where the condition is non reversible, tertiary prevention focuses on rehabilitation, profitable the patient to accommodate to his disability. For reversible weather condition, such as many types of heart illness, tertiary prevention will reduce the population prevalence, whereas for incurable conditions information technology may increase prevalence if it prolongs survival. The cardinal goal for tertiary prevention is to enhance quality of life.

Table iv.1: Examples of master, secondary, and tertiary prevention interventions targeting individuals and populations

Disease	Intervention level	Primary	Secondary	Tertiary
Colorectal cancer	Private	Counselling on healthy lifestyles: dietary counselling for people at take chances of colorectal cancer, etc.	Hemoccult stool testing to detect colorectal cancer early on	Follow-upward exams to place recurrence or metastatic affliction: concrete examination, liver enzyme tests, breast ten-rays, etc.
	Population	Publicity campaigns alerting the public to the benefits of lifestyle changes in preventing colorectal cancers; promotion of loftier fibre diets; subsidies to help people access practice programmes; anti-smoking campaigns	Organized colonoscopy screening programs	Reorganizing health services to improve admission to high-quality follow-up care
Infectious diseases: hepatitis C	Individual	Counselling on safe drug use to prevent hepatitis C virus (HCV) transmission; counselling on safer sex	Screening for HCV infection of patients with a history of injection drug use	HCV therapy to cure infection and preclude manual
	Population	Education on safer sex practices; programmes to discourage needle sharing among intravenous drug users, etc.	Constitute a universal testing arrangement for HCV in high take chances groups	(Similar to primary prevention); ensuring close command of high take chances sites such as tattoo parlours that have been associated with outbreaks
Metabolic syndrome	Private	Nutrition and practise counselling	Screening for diabetes	Referral to cardiac rehabilitation clinics
	Population	Build environments conducive to active send (walking or bicycling rather than using a automobile)	Community level weight loss and exercise programs to command metabolic syndrome	Implementation of multidisciplinary clinics

Secondary confusion

Beware: you may encounter the term secondary prevention mistakenly used in reference (for example) to preventing a 2d stroke in a patient who has had a first one. This is incorrect, for this would exist an example of 3rd prevention, in terms of preventing farther damage to the patient's vascular system.

Bodies in the river

A passer-by sees a body floating down a river and calls 911. Firemen arrive and haul the person out. Paramedics start resuscitation and rush the victim to the ER; subsequently the hospital public relations function announces that while everything possible was done to salvage the victim, sadly he died. Suicide is presumed.

The metaphor of "upstream" and "downstream" interventions was introduced in Chapter 2. Applying this to the case of the body in the river, tertiary prevention would include efforts at resuscitation at the scene and in infirmary. Apparently these may exist judged as "also little, too late." Secondary prevention activities might focus (metaphorically) further upstream and include attempts to identify suicidal people before they brand an endeavor, perhaps by screening for low in primary intendance practices. Those who requite indications of depression could be more than fully evaluated, mayhap by referral to a psychologist. The pocket-sized success of such counselling, and its limited availability, limit its touch on on preventing suicide. Therefore, principal or primordial preventive approaches may exist more effective. They represent a transition from identifying individual solutions to grouping and environmental approaches.

Chief prevention might include social programs for loftier-take a chance youth in areas of high suicide rates, or installing rubber nets to prevent the human action of suicide (which probably only moves the problem elsewhere). Primordial prevention falls in the domain of population wellness approaches; these involve a wide range of government agencies and focus on developing healthy public policies and altering underlying determinants of health. Applied to the bodies in the river, primordial prevention might include improving youth employment training, attracting small industries to boondocks, or programmes to improve the congenital environment

More on the stages of prevention

Our presentation of prevention as discrete stages offers a useful introduction to the topic, but classifying a preventive action into a stage depends profoundly on the context.

For example, checking and then controlling claret pressure may represent primary prevention if the condition you aim to prevent is a eye attack. But BP control may be seen as secondary prevention if the person has a family history of hypertension and you are screening for this. It may even exist 3rd prevention if the patient has already had a heart attack and the goal is to forbid a recurrence.  Bother!

Fifty-fifty more confusing: secondary prevention has been defined as slowing the progression of a disease or its sequelae at any indicate after its inception. From this perspective, treating a disease can be seen as prevention if information technology slows the progression of the disease or prevents adverse outcomes. From a public wellness perspective, treating an infectious disease might fifty-fifty authorize every bit master prevention because it reduces the gamble of manual of the virus.

Conversely, backlog use of antibiotics may be viewed equally the opposite of prevention if it contributes to the development of resistant organisms. Clinicians should always weigh the costs and benefits of treating against those of not treating in much the aforementioned way every bit they do in prevention. Reflecting this theme, you may also hear the term 'quaternary prevention': where a patient is at hazard of over-medication, quaternary prevention protects them from new medical invasion, promoting interventions that are ethically acceptable, and assuring quality of the care process.⁵

Implementing Prevention, Health Protection and Health Promotion Programmes

Prevention programmes may exist delivered by public health agencies, by individual clinicians (ofttimes past general practitioners, nurses or nurse practitioners), or by community agencies (including volunteer groups such as students against drunkard driving, or non-profit groups). Ideally, programmes should be coordinated between these providers; while we have many good programs in Canada, they tend to be delivered in relative isolation by the single agencies responsible for them, resulting in gaps and overlaps betwixt programs. Programmes besides need to be tailored to the local situation: i size does not fit all. This theme is discussed in programme planning in Chapter 12.

Wellness protection

Wellness PROTECTION refers to a broad range of activities undertaken by public health departments and by regime agencies such as the Public Health Agency of Canada (PHAC). Health protection spans primordial and chief prevention, and includes "food hygiene, water purification, environmental sanitation, drug rubber, and other activities in which the emphasis is on actions that can be taken to eliminate as far equally possible the risk of adverse consequences for health owing to environmental hazards, unsafe or impure nutrient, h2o, drugs, etc."⁶ Public health protection besides includes reducing environmental threats such as biological, chemical, or physical agents that could cause an epidemic if non controlled.

Public health agencies are required by constabulary to deal with specified threats that tin can be detected by SURVEILLANCE systems, equally described in Chapter 7. The arroyo to health protection will vary according to the nature of the biological, chemical, or physical risk involved. For example, federal, provincial and local inspectors work to limit the spread of infectious disease such as those associated with contamination of water or food. Legislation and regulations address chemic hazards, such as risks due to ecology tobacco smoke, and fines may be applied. Warning signs are often used to brand hazards visible and raise public awareness. A traditional public health protection or risk reduction approach to the problem of the bodies in the river might involve adding protective netting to the bridge. Even though nets might not deter a determined suicide endeavour, they could reduce impulse suicides and information technology would assistance to make the problem visible by reminding passers-by that suicides have occurred in that spot. This recognition may help indirectly, past raising vigilance in the public and encouraging people to take early warning signs seriously.

Health promotion

While health protection focuses on removing negative influences on health, health promotion aims to enhance wellness in terms of developing salubrious public policies, good for you environments and personal resiliency; this reflects a philosophy of supporting communities and individuals to take charge of their own health. Starting time in the 1970s and 1980s, health promotion built on health teaching (offering pamphlets, posting signs, patient pedagogy classes, etc.), which had been criticized every bit beingness insufficient (see "Pamphlets may not be enough", below). The aims of health promotion include, just also get beyond, preventing illness: "Health promotion includes strengthening the skills of individuals to encourage healthy behaviours, and it as well includes edifice the salubrious social and physical environments to support these behaviours."⁷ It involves "any combination of health pedagogy and related organizational, economic, and political interventions designed to facilitate behavioural and ecology changes conducive to wellness."⁸

While a wellness promotion programme might focus on a specific issue such every bit smoking cessation, it would typically approach this within a broader set of interrelated interventions including environmental and lifestyle changes that support non-smoking. Enhancing supportive environments and encouraging healthy behaviours contribute to primary prevention of disease, but also have the broader aim of encouraging people to accept responsibility for their wellness. This approach reflects concerns over the erosion of individual responsibility for health that may upshot from relying on the availability of therapy once illness develops, which was discussed in Chapter 1. Practical to the bodies in the river, a health promotion arroyo might begin past asking what was causing people to throw themselves into the water, and so attempt to correct this cause. Information technology would typically focus on programs aimed at helping people to cope with stress in their lives, such as arranging common-support groups.

Pamphlets may not be enough

Dr. Rao has some pamphlets alerting diabetic patients to the demand for careful monitoring and control of their condition in order to avoid serious adverse outcomes but he recognizes that these are not helpful for Catherine, given her increasing memory difficulties. He sees the need for a broader support program, involving her family members and other community members. He encourages her son Paul and his wife Julie to go Catherine to join a diabetic support group that he is planning to set up. He hopes that they tin contribute by leading some concrete activities that would get them actively engaged and exist practiced for all of them.

The philosophy of health promotion

Health promotion reflects a characteristic fix of liberal values, such every bit self-responsibility for health, that characterize much of the WHO thinking: "Wellness promotion is the procedure of enabling people to increase control over, and to improve, their health." This definition derived from the WHO formulation of health described in Chapter i: "The extent to which an individual or group is able to realize aspirations and to satisfy needs, and to change or cope with the surround.^eight" Along with self-responsibility, other cadre values of wellness promotion include many 'upstream' factors, such as:

• Promoting equity and social justice;
• Applying a holistic definition of health;
• Consideration of the total range of health determinants;
• Addressing ecology influences on health;
• Empowering people and building individual and collective capacity;
• Seeking to enhance people'southward social participation; and
• Fostering collaboration between agencies.

Population health promotion starts from a recognition that health behaviours are unlikely to change in a lasting manner unless environmental factors that give rise to them are likewise changed. This implies mounting a campaign that focuses on community date and ecology change in improver to modifying individual behaviours. Merely as individuals change what they consider a priority, communities have a more or less well-voiced set of priorities that may support or inhibit efforts to promote health. A survey of perceived customs needs is therefore oftentimes the first stage in a local health promotion campaign: what does this community perceive every bit its priorities and how do these match the goals of the wellness promotion team? A community needs cess will collect information, typically from surveys and interviews with opinion leaders, on the health and social problems of individuals, families and the community as a whole. Community Health Centres usually apply a needs-based approach to planning wellness promotion programmes; these centres typically accept community representation on their board of directors and plan programmes based on customs input. Engaging community members in the planning procedure non only ensures that the programme is likely to exist relevant to local needs, but likewise helps to ensure customs back up for the programme and participation in it. The bodily design of the programme may be developed following a instance conference of experts in relevant specialties who suggest approaches designed to lucifer the particular local situation.

The principles on which health promotion strategies are designed were described in the Ottawa Charter for Health Promotion.

The Ottawa Charter for Health Promotion

In 1986, Ottawa was the venue for an international briefing sponsored by the WHO to constitute the bones design principles for health promotion programmes.⁸ The resulting charter congenital on a 1981 Global Strategy to attain health for all by the year 2000.⁹ The lease sets out a range of upstream and downstream approaches outlined in the box below.

The Ottawa Lease for Health Promotion

The Ottawa Lease and the Health for All 2000 manifesto included the post-obit strategies:

• Building healthy public policy. The aim is to put health on the agenda for all policymakers, and to ensure that they consider the health implications of their decisions. A good for you public policy is one that avoids the side effect of damaging health while pursuing some other goal.
• Creating supportive environments. The emphasis on environs reflects an awareness of the bear upon of natural, congenital, and social environments on health, and proposes a socio-ecological approach to wellness.
• Strengthening customs action. Wellness promotion requires community empowerment and interest in setting priorities and in planning and implementing strategies to achieve better wellness.
• Developing personal skills. Health promotion supports personal and social development through providing information and enhancing life skills.
• Re-orienting health services. Health promotion argues for shifting health resources towards a more equal distribution between treating disease and preventing information technology. Essentially, health services should be expanded to include the four strategies above in addition to conventional medical care. Responsibleness for health promotion services should be shared among individuals, community groups, health professionals, wellness services, and governments.

The Charter likewise identified seven prerequisites for health: peace, shelter, instruction, food, income, a stable eco-system, and sustainable resources. These prerequisites are closely related to the macro-social determinants of wellness and are essential in understanding why we accept failed to accomplish the goal of 'health for all past the yr 2000' (HFA 2000) even though it is xv years past the deadline.^{10, 11}

Discussion points: to what extent has the world failed in this goal, and why? How can a dr. influence these factors in his or her do?

An awarding of the Ottawa Charter

A public health programme in Glasgow, Scotland, illustrated an application of the Ottawa Charter in an experiment to amend the dental health of 5-year-old children living in deprived neighbourhoods.¹² The oral wellness of Glasgow children had been documented equally being among the worst in Western Europe.

A 'from nascence' caries prevention programme addressed early lifestyle determinants of dental caries, and oral health action teams in each of the metropolis's 15 health care administrative areas led the interventions.

Here are some examples of the activities they undertook:Building healthy public policy: staff education in all nursery schools; healthy snacks policies introduced in plant nursery schools; subsidised utensils and food blenders; provided gratuitous fluoride toothpaste;
Supportive environments: customs oral wellness promotion events were organized; facilities in nursery schools were improved; they held community consultations; arranged 'get cooking' classes;
Developing personal skills: literature was translated into jargon-free language; children were taught molar brushing skills; dental health song books were developed;
Strengthening community action: there was a stiff accent on community appointment. This included creating networks of voluntary community activists to give outreach into the communities, leading community groups in identifying means to promote caries-protective events and behaviours; they trained the trainers.
Reorienting health services: the oral health action teams promoted perinatal oral health sessions in doctors' offices; created dental registration programmes.

The plan included an evaluative component that will be summarised in Chapter seven.

Self-test questions

1. Distinguish between the natural history and the clinical class of a disease.

Natural history refers to the sequence of changes and progression in a illness that is untreated. Treatment may alter this, producing the clinical course. If handling is ineffective (as in using antibiotics for a viral illness) the 2 may be the same.

ii. The Pap smear test detects cervical cancer in women at an early on stage of the affliction when in that location are no symptoms and the disease is non evident on visual examination. Which of the post-obit statements applies to a woman with no history of cervical cancer who undergoes a Pap smear?

A. She is practicing primordial prevention.

B. She is practicing main prevention.

C. She is practicing secondary prevention.

D. She is practicing tertiary prevention.

E. This is a screening examination, not a preventive process.

C) Secondary Prevention

Rationale:

A. Primordial prevention acts early in the causal chain, to change general social or economic circumstances that give rise to risk factors. The Pap test does not accost general circumstances, merely a specific affliction process.

B. Primary prevention is defined as the avoidance of disease – having a Pap smear would not foreclose the disease from occurring.

C.  Secondary prevention is divers as the interruption of any disease procedure before the emergence of recognized symptoms or diagnostic findings of the disorder. The Pap smear test forms an essential step in this process: it identifies the disease process before the emergence of symptoms.

D. Third prevention is defined every bit the avoidance of negative sequelae of a affliction process, once the disease has been diagnosed and treated. The Pap smear concerns early detection; information technology has nothing to do with subsequent effects of the affliction.

E. Yep, it is a screening test, only that forms an integral component of an arroyo to prevention. Then this response is splitting definitional hairs and presumably the physician's intent in administering the test was to foreclose further progression of the cancer.

3. Contrast the underlying philosophies of health promotion and wellness protection.

Health promotion seeks to foster the chapters for self-responsibility in a community, enabling it to ameliorate its health via collective action. Health protection is set of actions, ofttimes supported by legislation, applied by an external say-so to avoid adverse health consequences. Involvement of the customs may be limited.

4. Summarize the elements in the Ottawa Charter for Health Promotion

Building healthy public policy; Creating supportive environments; Strengthening community activeness; Developing personal skills, and Re-orienting health services. Now requite examples of how these might be put into do in a typical family medicine centre in the city where you lot live.

References

1. Bhopal RS. Concepts of epidemiology. Oxford: Oxford University Press; 2002.
2. Porta G, editor. A dictionary of epidemiology. New York (NY): Oxford Academy Printing; 2008.
3. Starfield B, et al. The concept of prevention: a good idea gone off-target? J Epidemiol Community Health. 2008;62:580-three.
4. Beaglehole R, Bonita R, Kjellström T. Basic epidemiology. Geneva, Switzerland: WHO; 1993.
5. Flynn BC. Salubrious cities: toward worldwide health promotion. Annu Rev Public Wellness. 1996;17:299-309.
6. Last JM. A lexicon of public health. New York: Oxford Academy Printing; 2007.
7. Green L. National policy on the promotion of wellness. Int J Wellness Educ. 1979;22:161-8.
8. World Wellness Organisation. Ottawa lease for health promotion. Geneva: WHO; 1986 [cited 2011 June]. Available from: http://www.euro.who.int/en/who-nosotros-are/policy-documents/ottawa-charter-for-health-promotion,-1986.
9. Earth Health Organization. Global strategy for health for all by the year 2000. Geneva: WHO; 1981 [cited 2015 Dec]. Available from: http://apps.who.int/iris/bitstream/10665/38893/1/9241800038.pdf.
10. Bryant JH, Zuberi RW, Thaver IH. Alma Ata and health for all by the yr 2000. The roles of academic institutions. Infec Dis Clin Due north Am. 1991;5(2):403-xvi.
11. Gunning-Schepers LJ. "Health for all by the yr 2000": a mere slogan or a workable formula? Wellness Policy. 1986;vi(3):227-37.
12. Blair Y, Macpherson L, McCall D, McMahon A. Dental health of 5-year olds post-obit community-based oral wellness promotion in Glasgow, Great britain. Int J Paediatric Dentistry. 2006;16:388-98.

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Source: https://phprimer.afmc.ca/en/part-i/chapter-4/

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