Chapter 9: Levels of Disease Prevention

In addition to using the continuum to describe how an individual's health can fluctuate over time, the continuum can be used to identify what else?

subsets of the population that are at increased risk of poor health or disease.

Relationship between Continuum and Health Promotion and Disease Prevention: Disease Prevention

a. Disease prevention targets more specific populations. i. This specificity tends to increase as you go towards the RIGHT side of the continuum. b. In addition, the interventions tend to vary quite a bit as you target the different populations. i. This has led to describing prevention activities as three levels of prevention: primary, secondary, and tertiary.

Three Levels of Prevention: Tertiary Prevention

a. Goal: i. Reduce number of complications, deaths b. Rationale: i. By reducing disease severity and increasing recovery, can reduce number of premature deaths or complications c. Target population: i. Those who have disease and need treatment d. Typical activities: i. Treatment tailored to the patient ii. Rehabilitation to promote recovery e. Outcome measure: incidence of death and long-term disability

Relationship between Continuum and Health Promotion and Disease Prevention: A. Explaining the circles in terms of population.

1. In a population, the circles represent different at-risk groups that may be targeted by an intervention. a. This explicit grouping underscores the idea that we would create interventions for folks who have lifestyle risks like tobacco use differently than we would approach folks who have advanced respiratory illnesses like COPD or emphysema.

Role of Pharmacists in Prevention: A. Traditionally involved in? B. Pharmacists can expand their role into?

A. Traditionally involved in: a. Tertiary prevention for individuals b. Secondary prevention for individuals B. Pharmacists can expand their role into: a. Primary prevention for individuals or populations b. Tertiary or secondary prevention for populations

Health-to-Death Continuum: B. Continuum

a. At any given time, a person's state of health lies somewhere on this continuum. i. Throughout their lifetime, their health may fluctuate between states of health and states of disease. ii. Most people fall into the moderate health area of the continuum for most of their lives. b. Aging does not automatically mean a person will develop disease; however, many diseases do appear as people age. i. This may be in part to lifestyle choices, exposures over time to harmful chemicals, genetics, or other diseases. ii. Diseases often shorten the lifespan; some may be treated successfully and a person is considered healthy again (e.g., cancer that is in remission). c. Death may occur at any time. i. If a person lives a long life and their death comes in old age that may be considered a natural lifespan. ii. However, deaths that occur earlier than the average lifespan are considered premature. Premature deaths that can be avoided will be one of the targets of prevention activities.

Three Levels of Prevention: Define levels by: a. Goal b. Rationale c. Target Population d. Typical Activities e. Outcome Measure

a. Goal i. What is the goal of the intervention? 1. Goals are related to the ultimate outcomes - prevent new cases of disease (morbidity) and premature death (mortality) b. Rationale i. What is the implicit rationale of the intervention? ii. Or - how will interventions at this level ultimately reduce morbidity and mortality? 1. Rationales will center on avoiding new cases of the disease, reducing the time people with the disease are sick, reducing the severity of illness to increase survival, and returning the ill back to health. All of these will contribute to lower incidence (new cases) and prevalence (all cases) of a disease and its related mortality. c. Target Population i. As level of prevention progresses from those at risk of exposure to those with late disease, the size of the population tends to get smaller. d. Typical Activities i. These can overlap some, but there do tend to be some distinctive interventions based on level. 1. This makes sense - would you provide education about seasonal flu vaccine to individuals who are currently experiencing influenza or risks of lung disease from tobacco use to people who are dying from lung cancer or chronic lung disease? Looked at another way, you would not take every person who smoked and treat them for lung cancer or a chronic lung disease. e. Outcome Measure i. These outcome measures will trend from reducing the number of new cases (incidence rates) to reducing overall number of cases (prevalence rates) and mortality rates in the populations at risk or with the disease.

Three Levels of Prevention: Primary Prevention

a. Goal: i. Reduce number of new cases b. Rationale: i. By reducing exposure rates and increasing resistance, can reduce number of new cases c. Target population: i. Those who are most likely to be exposed and/or could increase their resistance d. Typical activities: i. Remove or reduce source of the risk ii. Educate and make aware of disease risk 1. Include behavioral changes to reduce exposure iii. Improve general health e. Outcome measure: incidence of exposure; incidence of disease

Three Levels of Prevention: Secondary Prevention

a. Goal: i. Reduce number of new cases; reduce number of severe cases b. Rationale: i. By reducing number of exposures and early disease that progress to more severe disease, mortality and morbidity can be reduced c. Target population: i. Those who have been exposed to the disease-causing agent or have early symptoms of the disease d. Typical activities: i. Screening for exposure and/or disease ii. Post-exposure prophylaxis iii. Early treatment to reduce impact of disease/reverse course e. Outcome measure: incidence of disease

Disease Prevention Overview

a. Prevention is a cornerstone concept in public health i. "If it can be prevented, it should be." ii. This concept is applied to disease, injury, and premature death. 1. It is the central theme of many public health interventions, policies, and laws. a. Examples: seatbelt and helmet laws for automobiles and motorcycles; mandatory vaccinations for school children, and safety caps on prescription vials. iii. If it cannot be prevented, try to reduce its impact 1. If disease or injury cannot be avoided, disease prevention will focus on reducing its impact on the individual and the community. This is usually done with early diagnosis, treatment, and rehab. b. Often tailored to a specific disease or risk i. A difference between health promotion and disease prevention is this specificity. 1. While general measures to improve health can be used (e.g., better nutrition, exercise, sleep), prevention activities are often tailored to the disease that is being targeted. a. A prevention program for skin cancer will have very different activities than one designed to reduce injuries from medication errors, yet both are technically disease prevention programs. c. Prevention may occur at individual or population levels i. Interventions or policies may target individuals in an at-risk population or the entire community where the at-risk populations are found. 1. Unlike pharmacy, where we often focus on the individual and their risks, a public health approach could also focus on an entire community, or communities across the nation or world. a. Text has examples including one about sun exposure and skin cancer risk that may be worth emphasizing. This will also be emphasized in subsequent slides. • Disease prevention is focused on specific disease states while health promotion is focused on overall improvement in health and not specific disease states.

Relationship between Continuum and Health Promotion and Disease Prevention: General Health Improvement vs. Specific Disease Prevention

a. Recall that the goal of health promotion is to optimize overall health. i. This may involve some reduction of lifestyle or exposure risks, but should focus mainly on improving health in general (e.g., good nutrition, exercise, sleep) ii. Because it is a general approach, it will tend to focus on larger populations than the more disease-specific prevention interventions. (There can still be subsets such as health needs by age or gender.)

Health-to-Death Continuum: A. Introduction

a. This is the big picture: i. Disease prevention will focus on the RIGHT hand side of the continuum. ii. Health promotion tends to focus on the LEFT side of the continuum. 1. Activities for both tend to overlap in the middle where exposures and lifestyle risks are found.

Example of Three types of Prevention: Infectious Disease-Disease is Seasonal Influenza B. Secondary Prevention: • Interventions at the individual level? • Interventions at the community/population level?

a. target population - everyone who has been exposed to the virus b. Goal - reduce number and severity of cases of flu c. Rationale - early treatment to reduce severity of disease d. Actions: i. Screening: identify those who are most likely exposed from those who are not ii. Early treatment iii. Immunization: vaccination to develop antibodies • Interventions at the individual level: - Post flu symptoms and suggestions for self-care - Provide antiviral within 48 hours of symptom onset • Interventions at the community/population level: - Use quarantine(those EXPOSED) or isolation (those INFECTED) measures; ban gatherings of large groups; travel restrictions

Example of Three types of Prevention: Infectious Disease-Disease is Seasonal Influenza C. Tertiary Prevention: • Interventions at the individual level? • Interventions at the community/population level?

a. target population - everyone who has influenza b. Goal - reduce number and severity of flu-related complications and deaths c. Rationale - treatment and rehabilitation can reduce deaths and help return individual to a normal lifestyle d. Actions: i. Provide supportive care and early treatment of complications ii. Use rehabilitation to increase recovery of normal lifestyle • Interventions at the individual level: o Tailor treatment to symptoms; monitor and treat complications • Interventions at the community/population level: o Ensure access to treatment (health insurance, local clinics available) o Protect employees who are out sick from losing jobs o Research to find better treatments; monitor resistance patterns

Example of Three types of Prevention: Infectious Disease-Disease is Seasonal Influenza A. Primary Prevention • Interventions at the individual level? • Interventions at the community/population level?

a. target population - everyone; all ages b. Goal - reduce number of cases of flu c. Rationale - reduce exposures; bolster immune system d. Actions: i. Education: cough and sneeze etiquette, hand washing, know risk groups ii. Immunization: vaccination to develop antibodies o vaccinate; good nutrition, sleep, and exercise to optimize health; good cough/sneeze etiquette; frequent hand washing; avoid others who are sick o Provide access to vaccines o Use Public Service Announcements (PSAs) to educate public o Prepare plans for schools, worksites, and hospitals/clinics for outbreak

Relationship between Continuum and Health Promotion and Disease Prevention

• Health Promotion (Left side) - optimize overall health. • Disease Prevention (Right side)- reduce occurrence and impact of specific diseases.

Health-to-Death Continuum

• Think about various levels of healthiness, sickness, and death o Activities to reduce disease and increase health by where they are initiated on the continuum