This is note on Preventive Health based on Pokhara University Syllabus (BPH Fourth Semester- IPH II)

1. UNIT II:
Preventive Health
(BPH Fourth Semester, Pokhara University Syllabus)
Isha Karmacharya
MPH (PHSM)
Lecturer
CiST College

2. Concept
• Preventive is best described as avoiding diseases.
• It is intended to try to stop the causes of problems or
difficulties in the health.
• It is a process of making small regular decisions and
taking positive action on health, diet, exercise and
lifestyle.
• Removal or elimination of a single known essential cause
is known as preventive health
• The prevention of disease helps to promote health,
maintain health, restore health and alleviate the sufferings
during illness.
2

3. Concept
• Refers to any measure taken to prevent disease rather
than curing them or treating their symptoms
• Simple examples: hand washing, breast feeding,
immunization, disease screening etc.
3

4. • The notion of prevention in populations has a long
history of discovering and eliminating the causes of
disease.
- For example, in the 1840s Hungarian physician Ignaz
Phillipp Semmelweis reduced the rates of puerperal sepsis
among pregnant women through attendant hand washing.
- In the 1850s, British physician John Snow helped abort an
outbreak of cholera in London that was due to a
contaminated water supply.
- Eradication of Small pox in 1980 due to mass vaccination
globally.
4

5. Prevention of health problems depends
upon:
• Knowledge of transmission
• Dynamics of transmission
• Identification of risk factors and risk groups
• Availability of prophylactic or early detecting
and treatment measures
• An organization for applying preventive
measures
• Continuous evaluation of and development of
procedures applied
5

6. Where does prevention take place???
Prevention takes place at almost all important societal venues,
which may be considered in a few major categories (although
there is overlap among them):
1. Prevention that is facilitated by a healthful
environment;
2. Prevention optimized by healthful personal behaviors;
3. Preventive interventions delivered by health
professionals—so called clinical prevention; and
4. Prevention that occurs through social actions, including
political, policy, economic, educational, and other
group behaviors.
6

7. Continue…
1. Healthful personal behaviors, such as regular, appropriate
exercise programs and avoiding risk taking behaviors, such as
tobacco or illicit drug use, will add measurably to positive
preventive outcomes.
2. Clinical preventive interventions, such as cancer screening,
clinical health counseling, and routine immunizing practices,
will add important elements of prevention to individuals and
families.
3. Social and administrative activities provide some of the best
prevention available in communities like providing laws that
deter underage alcohol and tobacco consumption, health
system policies that promote early disease detection, and
taxation policies that deter purchase of harmful products such
as cigarettes and firearms etc.
7

8. 8

9. 9

10. 10
I. The patient is not sick and you are in a health
promotion process or in immunization campaign,
II. The patient is not sick and you are screening for
diseases,
III. Unfortunately you find the disease and now the
patient knows that he is sick (but sometimes doesn't
accept it).
IV. The fourth, is not the easy. The patient feels sick and
you find nothing or you were wrong in finding
something. Health promotion, screening and medical
activities could throw the patient into the fourth field

11. WHY PREVENTION OF
DISEASES???
• Early Death
• Economic Burden
• China is expected to lose roughly $558 billion in national
income between 2005 and 2015 due to early deaths. In
2005, heart disease, stroke and diabetes caused an
estimated loss in international dollars of national income
of 9 billion in India and3 billion in Brazil.
"Preventing Chronic Diseases is a
Vital Investment".
11

12. Levels of Prevention
1. Primordial Prevention
2. Primary Prevention
3. Secondary Prevention
4. Tertiary Prevention
12

13. 1. Primordial Prevention
• This is primary prevention in its purest sense
• The early stage of primary prevention
• Prevention of emergence of risk factors in population
groups in which they have not yet occurred.
• Main intervention is through individual and mass
education (target is whole population or special group)
• Applied in prevention of chronic diseases like diabetes,
lung cancer, hypertension etc.
• E.g. Discouraging children from adopting harmful
lifestyle (smoking, drinking etc.)
13

14. According to John M Last’s dictionary
Primordial prevention… aspires to establish and
maintain conditions to minimize hazards to health…it
consists of actions and measures that inhibit the
emergence and establishment of environmental,
economic, social and behavioral conditions, cultural
patterns of living known to increase the risk of
disease.
14

15. Continue…
• Childhood is the period when lifestyles are
formed which ultimately cause adult health
problems like diabetes, HTN etc.
• Efforts of primordial prevention are directed
towards discouraging children from adopting
harmful lifestyles like smoking, dietary
habits, physical exercise etc.
15

16. Continue…
• Examples of primordial prevention actions:
- National policies and programmes on nutrition
involving the agricultural sector, the food
industry, and the food import-export sector
- Comprehensive policies to discourage smoking
- Programmes to promote regular physical activity
16

17. Continue…
Application in prevention of Hypertension
• Modification of lifestyles including diet (reduced
intake of sodium and increased intake of
potassium),
• physical activity (increased physical activity for the
control and prevention of overweight), and
• drinking (reduction of excessive alcohol intake)
17

18. 2. Primary Prevention
• Primary prevention can be defined as “action
taken prior to the onset of disease which removes
the possibility that a disease will ever occur”
• Intervention in pre pathogenesis phase of disease
or health problem
• The concept is applied to prevention of chronic
disease like CHD, HTN, Cancer etc based on
elimination or modification of risk factors of a
disease
18

19. • Success in eliminating and controlling different
communicable disease like cholera, plague, small pox,
tuberculosis, leprosy, etc was not only by medical
intervention but also by different primary prevention
measures
• The application of primary prevention in the control
of chronic disease is a recent development.
• The main modes of interventions can be:
- Health Promotion (Raising the standard of living)
- Specific Protection (Vaccination against diseases)
19

20. For the conditions where risk factors are established
following are the approaches for primary prevention of
chronic disease
1. Population strategy
• Directed towards socio-economic, behavioral or
lifestyle changes
• Applied to all population irrespective of their level of
risk
2. High risk strategy
• Directed towards the group or individual at special
risk
• requires the detection of individual at high risk
through the use of clinical methods
20

21. Continue…
• Primary prevention generally involves the prevention of
diseases and conditions before their biological onset.
This can be done in a variety of ways, such as preventing
environmental exposures, improving human resistance to
disease, or education to diminish risk-taking behaviors.
• Thus, general environmental and sanitary measures, such
as maintaining safe water and food supply, promoting the
use of condoms to prevent sexually transmitted diseases,
and application of safe and effective vaccines are
examples of primary prevention, fluoridation of water ,
boiling water etc. whereby diseases and injuries do not
obtain a foothold in the body.
- ROBERT B. WALLACE
21

22. Examples
• Pasteurizing milk essentially eliminates bacterial
pathogens that could cause illnesses,
• Measles immunization prevents clinical illness
before it can get started.
• Older persons with osteoporosis wear hip protectors,
which absorb the shock of a fall and are capable of
preventing hip fracture
• Behavioral interventions such as smoking cessation,
preventive dental care, and maintaining physical
exercise are also examples of primary prevention.
22

23. Application in prevention of childhood
blindness
• Expanded program on Immunization (rubella vaccine)
• Vitamin A supplementation to
- All children with measles, diarrhoea, RTI, HIV/AIDS
and babies < 6 months that are not breastfeed
- To all children from communities where vitamin A
deficiency is high
- To malnourished children who show signs of
Marasmus, Kwashiorkor and growth faltering
- To all infants with birth weight with less than 2.5 kg
23

24. Prevention of Road Traffic Accidents
• Training and education to drivers in proper
maintenance of vehicles and safe driving
• Promotion of safety measures: seat belts, safety
helmets etc.
• Improvement of roads, imposition of speed limits etc.
• Regular inspection of vehicles, driving license,
examination of age >50 years, vision test of drivers etc.
24

25. 3. Secondary Prevention
• Secondary prevention can be defined as “action which
halts the progress of a disease at its incipient stage and
prevents complications”.
• Intervention in pathogenesis phase of disease
• It is largely the domain of clinical medicine
• It is not as effective as primary prevention
• Also includes the check of spread by contact investigation
in case of infectious disease
• The main modes interventions can be:
- Early diagnosis (e.g. screening tests, case finding
program)
- Treatment
25

26. • Secondary prevention emphasizes early detection
of disease, prompt intervention and health
maintenance of individuals experiencing health
problems.
• Its purpose is to cure disease, slow its progression,
or reduce its impact on individuals or
communities.
• A common approach to secondary prevention is
screening for disease for its early detection
26

27. Example of screening:
- noninvasive computerized scan to look for calcium
deposition in the arteries which can signal
previously undetected heart disease
- mammography for breast cancer detection;
- eye tests for glaucoma;
- blood tests for lead exposure;
- the Pap test for cervical cancer;
- the Prostate-Specific Antigen(PSA) test for
prostate cancer etc.
27

28. Screening can also be primary prevention
in some cases…
An example of a form of screening that is actually a
primary prevention is to routinely examine the paint
on walls of older homes, where lead contamination
and its exposure to children may be a problem.
28

29. Other examples of secondary prevention
• treatment of hypertension to prevent further
complications;
• telling people to take daily, low-dose aspirin to
prevent a first or second heart attack or stroke;
• providing suitably modified work for injured
workers etc.
29

30. 4. Tertiary Prevention
• Tertiary prevention can be defined as “all measures
available to reduce or limit impairments and
disabilities, minimize suffering caused by existing
departures from good health and to promote the
patient’s adjustment to irremediable conditions”
• Intervention in late pathogenesis phase of disease (i.e.
disease process has advanced beyond its early stage)
• The main modes interventions can be:
- Disability limitation
- Rehabilitation (e.g. establishing school for the
blind, reconstructive surgery in leprosy etc.)
30

31. • The goals include preventing further physical
deterioration, prevent sequela, limit disability
and maximizing quality of life
• Tertiary prevention extends the concept of
prevention into rehabilitation
• Examples of Secondary Prevention:
- cardiac or stroke rehabilitation programs
- chronic pain management programs
- patient support groups
31

32. Application in cancer prevention
Tertiary prevention is an approach to control the cancer
and prevention of disease-related complications. It
involves a variety of aspects of patient care such as quality
of life, surgical intervention and palliative care.
32

33. 33

34. Quaternary Prevention
• This term describes the set of health activities that
mitigate or avoid the consequences of unnecessary
or excessive interventions in the health system.
• Example: Naming the illness properly, prevention
from over-medicalisation, physicians unable to
diagnose disease(referring more tests), informed
choice to patients, addressing the physician needs,
ethics in health research etc.
34

35. Modes of Intervention
• “Intervention” can be defined as any attempt to
intervene or interrupt the usual sequence in the
development of disease in man
• Intervention may be by the provision of treatment,
education, help or social support
• There are five modes of intervention
35

36. 1. Health Promotion
• The process of enabling people to increase control over,
and to improve health
• Not directed against any particular disease, but is intended
to strengthen the host through a variety of approaches
(interventions):
- Health Education
- Environmental modifications
- Nutritional interventions
- Lifestyle and behavioral changes
36

37. 2. Specific Protection
Some currently available interventions aimed at specific
protection:
- Immunization
- Use of specific nutrients
- Chemoprophylaxis
- Protection against occupational hazards
- Protection against accidents
- Protection from carcinogens
- Avoidance of allergens
- Control of specific hazards in the general environment e.g.
air pollution, noise control
- Control of consumer product quality and safety of foods,
drugs, cosmetics etc.
37

38. 3. Early Diagnosis and Treatment
• The earlier a disease is diagnosed and treated the
better it is from the point of view of prognosis and
preventing the occurrence of further cases (secondary
cases) or any long term disability.
• To be exact early diagnosis and treatment cannot be
called prevention because the disease has already
commenced in the host
• But since it intercepts the disease process, it is
included in prevention
• Mass treatment: e.g. for trachoma, worm infestation
etc.
38

39. 4. Disability Limitation
Concept of disability:
Disease --- Impairment --- Disability --- Handicap
Disease: Accident
Impairment: Loss of foot
Disability: Cannot walk
Handicap: Unemployed
39

40. 5. Rehabilitation
• The combined and coordinated use of medical,
social, educational and vocational measures for
training and retraining the individual to the highest
possible level of functional ability
• Includes all measures aimed at reducing the impact
of disabling and handicapping conditions and at
enabling disabled and handicapped to achieve social
integration
• Social integration is the active participation of
disabled and handicapped people in the mainstream
of community life
40

41. Rehabilitation Continue…
a. Medical Rehabilitation: Restoration of function
b. Vocational Rehabilitation: Restoration of the
capacity to earn a livelihood
c. Social Rehabilitation: Restoration of family and
social relationship
d. Psychological Rehabilitation: Restoration of
personal dignity and confidence
41

42. Good to Know
• 1983 Re-Classification by Gordon:
 Universal,
 Selective, and
 Indicated Prevention
• Prevention measures can be classified on the
basis of population groups among which they are
optimally used.
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424415/ 42

43. Good to Know
• 1983 Re-Classification by Gordon: Universal, Selective,
and Indicated Prevention
“…Universal, is a measure that is desirable for everybody. In
this category fall all those measures which can be advocated
confidently for the general public and which, in many cases, can
be applied without professional advice or assistance.
Maintenance of an adequate diet, dental hygiene, use of
seatbelts in automobiles, smoking cessation, and many forms of
immunization would fall clearly into the universal category for
which benefits outweigh costs and risks for everyone.” (Gordon,
1983; p. 108).
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424415/ 43

44. Good to Know
• 1983 Re-Classification by Gordon: Universal, Selective,
and Indicated Prevention
Selective “…the balance of benefits against risk and cost is such
that the procedure can be recommended only when the
individual is a member of a subgroup of the population
distinguished by age, sex, occupation, or other obvious
characteristics whose risk of becoming ill is above average.”
“Examples would be active rabies immunization for
veterinarians, annual influenza immunization for the elderly, use
of safety goggles by machinists, and the avoidance of alcohol
and many drugs by pregnant women.” (Gordon, 1983; p. 108).
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424415/ 44

45. Good to Know
• 1983 Re-Classification by Gordon: Universal, Selective, and Indicated
Prevention
“…Indicated, encompasses those that are advisable only for persons
who, on examination, are found to manifest a risk factor, condition,
or abnormality that identifies them, individually, as being at
sufficiently high risk to require the preventive intervention. The
majority of these measures have been called secondary under the
classical scheme, since in most cases the observable indication is
related to the biologic origin of disease.
Preventive interventions in this class include control of hypertension,
dietary measures to reduce hypercholesterolemia, anti-tuberculous
drugs for recent skin test converters, the use of uricosuric drugs by
persons with asymptomatic hyperuricemia, and frequent, careful
reexamination of persons from whom a basal cell skin cancer or a
colonic polyp has been removed.” (Gordon, 1983; p. 108).
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424415/ 45

46. Good to Know
Trade Offs
• Universal approaches are low risk and have a low
expense per person.
• Selective and indicated approaches are more
expensive and carry greater risks for the individual.
However, the potential benefits and savings per
individual are also greater than universal
approaches.
Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1424415/ 46

47. SCOPE of
PREVENTIVE HEALTH
47

48. E.g. Prevention of malnutrition
• Generally, malnutrition is caused by lack of nutritional
components.
• It can be prevented by providing special diet such as
fruit, vegetable, milk product, oils, meat and beans etc
with sufficient amount in timely.
• There are primary prevention, secondary prevention
and tertiary prevention for malnutrition.
48

49. Preventive measures
The preventive measures can be described in following
ways:
Prevention at family level:
– Encourage exclusive breast feeding of infants for first 6 months
completely.
– Additional nutritive supplementation introduce by age of 6
months, As much as milk, meat, eggs, or foods of biological
value as family can afford should be offered.
– Adequate immunization.
49

50. Prevention at family level continue…
• Maternal care and ANC & PNC visit also plays a
role to minimize or prevent malnutrition.
• Equal distribution of nutritive foods among male &
female children.
• Minimize or keep far from maternal malnutrition &
other infectious diseases such as malaria, TB,
diarrhea etc.
50

51. Prevention at community level
• Promotion of health through health intervention &
education in community to reduce the malnutrition.
• Non formal education for pre- school age children,
lactating mother and pregnant women.
• Nutritional education & mass communicative
approaches.
• Early detection of malnutrition and intervention.
• Vigorous promotion of family planning.
• Income generation activities, kitchen-gardening
promotion
51

52. Prevention at community level
• Food fortifications: Iodination of salts,
Supplementation of vitamin A
• Distribution of iron-folic acid tablets.
• Anthropometric assessment of the developing children
such as:
a. Height Weight
b. Mid upper arm circumference
c. Head circumference
d. Weight for height etc.
52

53. Prevention at national level
• Good nutritional planning, implementation & also evaluate the
success.
• Nutritional rehabilitation services
• Nutritional intervention programs such as distribution of iron
and folic acid tablet to pregnant mother.
• Good Nutritional supplementation strategy
• Rural development & stabilization of population
• Diet and nutrition surveys should be carried out
• Increase agricultural/ food production & appropriate
fortification & formulations
• Nutritional surveillance to detect the cause, character &
magnitude of nutritional problems
53

54. Prevention at International level
• Food & nutrition are global problems. International
cooperation in solving problems of malnutrition.
• Plays important role in mitigating the effect of acute
emergencies caused by floods & droughts.
• Multilateral coordination with organizations such as:
WHO, FAO, UNICEF, WORLD BANK, UNDP etc.
54

55. Practices of Preventions of Malnutrition at different
Prevention Levels
Primary prevention
1. Health promotion
⁃ Health education to mothers about good nutrition and food
hygiene health workers
⁃ Distribution of supplements (distribution of iron, folic acid and
vitamin A).
⁃ Promotion of breastfeeding
⁃ Development of low cost weaning foods
⁃ Measures to improve family diet
⁃ Nutritional education
⁃ Home economics
⁃ Family planning and birth spacing
⁃ Family environment
55

56. Primary prevention
2. Specific protection
₋ Specific protein diet, eggs, milk, fresh fruit
₋ Immunization
₋ Fortification of food
56

57. 57

58. Secondary prevention
Secondary prevention; early diagnosis and adequate
treatment
• Periodic nutrition surveillance .
• Early diagnosis of any lag of growth .
• Early diagnosis and treatment of infection including diarrhea.
• Developing the program for early dehydration of children
with diarrhea.
• Developing supplementary feeding program during
epidemics.
• Regular de-worming of school and preschool children
58

59. Tertiary prevention
• Tertiary prevention; nutritional rehabilitation
• Nutritional rehabilitation services.
• Hospital treatment .
• Follow up of cases
59

60. Scope of Prevention
60
Societal ( Population) level Individual level
Physical
Aspects
Environmental planning,
monitoring,
regulation
Responsible use of
environmental
resources
Social
Aspects
Public advocacy, community
mobilization
Promotion of
solidarity
Health
services
Aspects
Resource mobilization/deployment
Information systems: collection,
analysis and dissemination for
early identification of problems
and iatrogenesis (Physician
induced infection)
Early recognition of
problems regardless
of their genesis
Personal
Aspects
Genetic engineering Responsible
stewardship
of one’s health

61. Preventive Health Behavior
61

62. CATEGORIES OF
HEALTH BEHAVIOR
We can define three categories of health behavior:
• Preventive health behavior: any activity undertaken by an individual
who believes himself (or herself) to be healthy, for the purpose of
preventing or detecting illness in an asymptomatic state.
• Illness behavior: any activity undertaken by an individual who perceives
himself to be ill, to define the state of health, and to discover a suitable
remedy.
• Sick-role behavior: any activity undertaken by an individual who
considers himself to be ill, for the purpose of getting well. It includes
receiving treatment from medical providers, generally involves a whole
range of dependent behaviors and leads to some degree of exemption
from one’s usual responsibilities.
62

63. Preventive Health Behavior
• Preventive health behavior is "any activity undertaken
by an individual who believes himself to be healthy for
the purpose of preventing or detecting illness in an
asymptomatic state" (Kasl and Cobb 1966, p.246).
Example:
- Quitting smoking to reduce the chances of early
morbidity and mortality.
- Eating healthful foods, exercising regularly,
moderation in the use of alcohol, and the avoidance
of tobacco and tobacco products
• Preventive actions can reduce, but not eliminate, the
chances of acquiring a disease or illness.
63

64. Preventive health behavior include both primary prevention
and early detection.
• Primary prevention behaviors aim to prevent the incidence of disease
(the number of new cases occurring within a given time frame).
Exercise to improve aerobic fitness and prevent cardiovascular
disease is an example of a primary preventive behavior. People who
increase their levels of physical activity have been found to have
reduced levels of risk factors such as high blood pressure, high blood
cholesterol, and excess body fat.
• Early detection (or secondary prevention) behaviors aim to prevent
early forms of disease from progressing. This involves people who
have already developed preclinical disease or risk factors for disease
but in whom the disease has not yet become clinically apparent.
Behaviors such as having a breast screen (mammogram) or a pap test
for cervical cancer are intended to detect disease early so it can be
treated promptly.
64

65. • Sociocultural and environmental aspects of a person's
life influence preventive health behavior, and these
factors can have minimal to great effect in
determining whether a preventive health behavior is
performed.
• Cultural traditions, attitudes, and beliefs can play an
important role in the ways in which people behave.
• Social, economic, and cultural determinants of
behaviors are closely linked.
65

66. Factors affecting preventive health behavior
• Biological,
• Social,
• Environmental, and
• Economic factors
66

67. PREVENTION
is BETTER
&
COST EFFECTIVE
than CURE!!!
Thank you…
67