HLN004 Lecture 4 Prevention Works - Frameworks, strategies and approaches

HLN004 Chronic Conditions
Prevention and Management

Lecture 4: Prevention Works –
Frameworks, Strategies and
Approaches

Semester 1, 2013
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CRICOS No. 00213J
Queensland University of Technology

Outline
• Prevention stages
• Population approach & life-course approach
• Prevention in clinical practice
• Prevention works? Where can we find the evidence?
• Global strategies for the prevention of chronic health
conditions
• Prevention in Australia – Recent developments
• Prevention in Queensland – Recent developments

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a university for the real world CRICOS No. 00213J

Prevention

‘Approaches and activities aimed at reducing the
likelihood that a disease or disorder will affect an
individual, interrupting or slowing the progress of the
disorder or reducing disability’ (WHO)

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Clinical course of a chronic condition:
Four prevention stages

AFMC Primer on Population Health, Canada

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a university for the real world CRICOS No. 00213J 4

Prevention targeting individuals and
populations


a university for the real world
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CRICOS No. 00213J
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Prevention
• Is the key to reducing the prevalence of chronic
conditions

• Can reduce the personal, family and community burden
of disease, injury and disability

• Can allow better use of health system resources

• Can generate substantial economic benefits, which,
although not immediate, are tangible and significant over
time

• Can produce a healthier workforce, which in turn boosts
economic performance and productivity
(National Preventative Health Taskforce, 2008)

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a university for the real world CRICOS No. 00213J 6

Population approach
• Population approaches seek to reduce the risks
throughout the entire population

• Address causes rather than consequences

• Small reductions in the exposure of the
population to risk factors such as tobacco use,
unhealthy diet and physical inactivity can lead to
population-level reductions in cholesterol, blood
pressure, blood glucose and body weight
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Life-course Approach
• The impact of risk factors of chronic conditions increases
over the life-course

• Emerging body of evidence that points to the need to take
greater account of the impact of cumulative and interactive
exposures to both risk and protective factors (biological,
behavioural, social and environmental) over the life-course

• Successful interventions in middle and older age will reap
major short term benefits

• In the LONGER term, interventions EARLY in life have the
potential to reduce substantially the chronic conditions
pandemic
(WHO, 2005)
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Evidence for a lifecourse
approach
• Adverse events such as foetal exposure to tobacco smoke,
low birth weight, malnutrition, repeated infections and
abuse and neglect in the early years of life help establish
predispositions to a range of chronic conditions in
adulthood

• Social support is an independent aetiological and
prognostic factor for CHD and may also be protective to
diabetes and depression

• Social relationships or lack thereof constitute a major risk
for health- rivaling the effects of smoking, high blood
pressure, blood lipids and obesity 9
(National Public Health Partnership, 2001)
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Chronic diseases across the
lifespan

(Darnton-Hill, Nishida and James, 2004) 10
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Socioeconomic influences on CVD
from a life-course perspective
Socioeconomic position

Intra-uterine Educational and Working Income and
conditions Environmental Conditions and Assets
Conditions Income

Birth Childhood and Adulthood Old Age
Adolescence

Low Birth Job Stress Inadequate
Weight Smoking
Smoking Medical care
Growth Diet
Exercise Diet
Retardation
Exercise
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Atherosclerosis CVD Reduced
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Function
(National Public Health Partnership, 2001,p.27)

Lifecourse perspective

Three main messages for the prevention of chronic
conditions are:

1. The earlier the intervention the better
2. Intervene at strategic points in time
3. Intervene whenever there is an effective
intervention
(Hertzman & Power, 2003; Queensland Health, 2008, p.69)

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Prevention in clinical practice

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R AFMC Primer on Population Health, Canada:
a university for the real world Influences on clinical practice (adapted from CRICOS No. 00213J

Walsh & McPhee)

Office systems for improving prevention
in practice
• Preventive care flow sheets
• Reminders for patients
• Visual prompts in office
• Patient information and patient-held preventive records
• Chart reminders
• Prevention prescriptions
• Health risk appraisal
• Computerized tracking systems

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Where can we find the evidence?

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Levels of evidence

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Useful websites

• Cochrane Library:
http://www.thecochranelibrary.com/view/0/index.
html
• Health Evidence (McMaster University, Canada):
http://www.healthevidence.org/
• The Guide to Community Preventive Services
(the Community Guide):
www.thecommunityguide.org
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Some examples

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Community guide example

• The Community Preventive Services About the Intervention
Task Force recommends team-based • Team members who most often worked with
care to improve blood pressure control patients and primary care providers were
on the basis of strong evidence of pharmacists and nurses.
effectiveness in improving the • Medication management roles for team
members were implemented in three
proportion of patients with controlled
different ways. Team members could:
blood pressure and in reducing systolic
– Change medications independent of
(SBP) and diastolic (DBP) blood
the primary care provider
pressure. Evidence was considered
– Change medications with primary care
strong based on findings from 77 provider approval or consultation
studies of team-based care organized – Provide only adherence support and
primarily with nurses and pharmacists hypertension-related information, with
working in collaboration with primary no direct influence on prescribed
care providers, patients, and other medications
professionals.
www.thecommunityguide.org
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Prevention of Chronic Conditions:
Global Response

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Global response to address Chronic Conditions
2000 Global Strategy for the prevention and Control of
Noncommunicable Diseases

2003 WHO Framework Convention on Tobacco Control

2004 Global Strategy on Diet, Physical Activity and Health

Resolution WHA60.23 on Prevention and control of
noncommunicable diseases: implementation of the global
2007
strategy

WHO Report on the Global Tobacco Epidemic, 2008

2008 Resolution WHA61.4 on Strategies to reduce the harmful use of
alcohol

Action Plan for the Global Strategy for the Prevention and
2008-2013 Control of Noncommunicable Diseases

2010-2011 Global Status Report on NCDs – NCDs Country Profiles

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WHO and the prevention of chronic conditions

• WHO recommends development of integrated
approach targeting all major common risk
factors for CVD, DM, cancer, and chronic
respiratory diseases (CRD)
– most cost-effective way to prevent and control
– responds to need of intervention to address common
risk factors and need to integrate health promotion,
primary, secondary and tertiary prevention, and
related programs across sectors and different
disciplines.
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WHO and the prevention of chronic conditions
WHO has proposed a range of population
based strategies to address chronic disease
• Laws and regulations
• Tax and price interventions
• Improving the built environment
• Advocacy
• Community based interventions
• School-based interventions
• Workplace interventions
• Screening
(WHO, 2005)

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Strategies/ interventions to address
tobacco consumption
• Increased tobacco taxes
– Broaden and extend integrated tobacco cessation system
– Build upon existing resources in hospitals, primary care and
community settings to increase access to services equitably

• Sustained social marketing campaign
– Motivate tobacco users to quit
– Informs tobacco users of the dangers of all types of tobacco use
– Inform about different options and resources available

• Smoke-free public areas/ places
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Strategies to decrease alcohol
consumption
• Maintain and reinforce socially-responsible pricing
– Establishing minimum pricing per standard drink across all
alcoholic beverages indexed to inflation
– Maintaining average prices at or above the consumer price index
– Adopting disincentive pricing policies for higher alcohol content
beverages to create disincentives for the production and
consumption of higher strength alcoholic beverages, and to
reduce the overall per capita level consumption of ethyl alcohol

• Strengthen targeted controls on alcohol marketing and
promotion
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Strategies to decrease alcohol
consumption
• Ensure effective controls on alcohol availability
– Ensuring that there is no increase in hours of sale
– Ensuring that the overall population density of on- and
off - premise outlets per capita does not increase
– Not undertaking further privatization of “off -premise”
alcohol retail sales

• Increase access to brief counseling interventions

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Strategies to increase physical activity
• Physical education in school curriculum

• Evaluate/ monitor physical activity within context
of national recommendations

• Support active transport
– Provide funding for dedicated infrastructure

• Workplace based physical activity policy
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Strategies to improve nutrition
• National food and nutrition strategy

• Compulsory food skills in education curriculum

• Support healthy eating in publically funded
institutions

• Mandatory menu labelling in food service
organisations
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Meanwhile, in Australia

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Prevention in Australia –
Recent Developments
• 2008 – National Preventative Health Taskforce
(NPHT) established to advise on the actions
needed in preventative health for Australia
• 2009 – NPHT produced the National
Preventative Health Strategy (“Australia: The
healthiest country by 2020”)
• 2010 – Government response: “Taking
preventative action – A response to Australia:
The healthiest country by 2020”
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National Preventative Health
Strategy - Goals
By 2020:
• Halt and reverse the rise in overweight and
obesity
• Reduce the prevalence of daily smoking to 10%
or less
• Reduce the proportion of Australians who drink
(short-term risky/high risk levels to 14%; long-
term risky/high risk levels to 7%)
• Contribute to the ‘Close the Gap’ target for
Indigenous people, reducing the life expectancy
gap between indigenous and non-indigenous
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Why obesity, tobacco and
alcohol?
Keys to prevention: Top seven selected risk factors and the burden of disease

Tobacco

Blood Pressure

Overweight/obesity

Physical Inactivity

Blood Cholesterol
In total modifiable risk
factors cause:
Alcohol
32% of burden of disease
Low fruit and
Vegetables

0 1 2 3 4 5 6 7 8 9
% DALYS

(National Preventative Taskforce, 2008- Adapted from AIHW, Australia’s Health 2008, Table 4.1)

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CRICOS No. 00213J
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National Preventative Health
Strategy – How?
1. Shared responsibility – developing strategic
partnerships
2. Act early and throughout life
3. Engage communities
4. Influence markets and develop coherent
policies
5. Reduce inequity
6. Working with Indigenous Australians to close
the gap
7. Refocus primary healthcare towards prevention
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Government’s response to National
Preventative Health Strategy
• Critical infrastructure
• World’s strongest tobacco crackdown
• Addressing alcohol misuse, especially binge
drinking
• Tackling obesity
• Building on broader government support for
children and low income communities
• Prevention for Indigenous Australians
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What about Queensland?

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Previous Queensland Initiatives
Strategic documents for the prevention of Chronic Conditions in
Queensland include:
- Queensland Strategy for Chronic Disease 2005–2015
- The Health of Queenslanders: Prevention of Chronic Disease 2008
- Strategic Directions for Chronic Disease Prevention 2009-2012

Around $16 million was invested into the health of Queenslanders in
the areas of nutrition, physical activity and healthy weight
• Over 100 co-ordinated nutrition and physical activity initiatives
undertaken as part of:
- Eat Well Be Active - Healthy Kids for Life Action Plan
- Eat Well Queensland 2002-2012
- Be Active Queensland 2006-2012
- Queensland Aboriginal and Torres Strait Islander Food and Nutrition
Strategy
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(Queensland Health, 2005; Queensland Health 2009)

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Strategic Directions for Chronic Disease
Prevention 2009-2012

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(Queensland Health 2009)
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Prevention in Queensland:
2012 onwards...
• Queensland Health Strategic Plan 2012–2016
http://www.health.qld.gov.au/about_qhealth/docs
/strategic-plan-12-16.pdf

• Blueprint for better healthcare in Queensland
(February 2013)
http://www.health.qld.gov.au/blueprint/docs/print.
pdf
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Queensland Health Strategic Plan
2012–2016
• Outcome relevant to Prevention: (1) Health services
emphasise keeping people well, and avoiding
unnecessary hospitalisations through:
– Develop funding strategies that promote increased activity by
service providers in health promotion, screening/monitoring of
high-risk cohorts and early intervention
– Improving quality and use of evidence base for individual and
community health promotion and reducing rates of chronic
disease
– Protect the population’s health by providing services that
manage preventable environmental health hazards as well as
the prevention and control of communicable diseases.
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Blueprint for better healthcare in
Queensland (2013)
• Stronger focus on delivery of healthcare (treatment)
rather than on preventative services
• Individual’s responsibility to manage their own health
• Broad media & community campaigns (i.e. education)
• Cost (and responsibility) shifting of preventative services
from State Government to Federal Government through
Medicare Locals
• Health Partnerships: engaging community groups in the
provision of preventative healthcare (outsourcing of
preventative services)
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Blueprint for better healthcare in
Queensland (2013)
• “Ultimately, people are responsible for managing their own health”
(p.17)
• “Queenslanders will be encouraged to take responsibility for their
own health through broad-based community messaging” (p.17)
• “There is a need to re-align the day-to-day delivery of preventative
health services at the local level. Experience over many years has
demonstrated that these measures should be more closely aligned
with the activities of community-based practitioners. Increasingly,
Medicare Locals will address this opportunity (...) The Australian and
State Governments will collaborate on disease prevention and mass
media strategies.” (p.17)

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Prevention policies and strategies in
your country of origin?

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Reclaimingmyfuture.com

Additional References
• AFMC, Primer on Population Health (http://phprimer.afmc.ca/inner/primer_contents)
• Australian Government. (2010) . Taking Preventative Action – A Response to Australia: The Healthiest Country by
2020 – The Report of the National Preventative Health Taskforce. Commonwealth of Australia, Canberra
• Darnton-Hill, I., Nishida, C. and James, W. (2004). A lifecourse approach to diet, nutrition and the prevention of
chronic diseases. Public Health Nutrition. 7(1A), 101-121.
• National Preventative Health Taskforce. (2008). Australia: The Healthiest Country by 2020. Commonwealth of
Australia, Canberra.
• National Preventative Health Taskforce. (2008). Technical Report 1. Obesity in Australia: a need for urgent action.
Commonwealth of Australia, Canberra.
• National Health Priority Action Council. (2006). National Chronic Disease Strategy. Australian Government
Department of Health and Ageing, Canberra.
• National Public Health Partnership. (2001). Preventing Chronic Disease: A Strategic Framework. National Public
Health Partnership, Melbourne.
• Queensland Health. (2009). Strategic directions for chronic disease prevention 2009-2012. Division of the Chief
Health Officer, Brisbane
• Queensland Health. (2008). The Health of Queenslanders 2008: Prevention of Chronic Disease. Second Report of
the Chief Health Officer Queensland. Queensland Health, Brisbane.
• Queensland Government. (2012). Queensland Health Strategic Plan 2012-2016. Queensland Government,
Brisbane.
• Queensland Health. (2013). Blueprint for better healthcare in Queensland. Queensland Government, Brisbane
• WHO. (2005). Preventing Chronic Disease: a vital investment. WHO, Geneva.
• WHO. (2008a). 2008-2013 Action Plan for the Global Strategy for the prevention and control of Noncommunicable
Diseases. WHO, Geneva.
• WHO. (2008b). Prevention and Control of noncommunicable diseases: Implementation of the global strategy.
WHO, Geneva.

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HLN004 Lecture 4 Prevention Works - Frameworks, strategies and approaches

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