The principles of public health provide a useful framework for both continuing to

investigate and understand the causes and consequences of violence and for preventing
violence from occurring through primary prevention programmes, policy interventions
and advocacy. The activities of VPA are guided by the scientifically-tested and proven
principles and recommendations described in the World report on violence and health.
This public health approach to violence prevention seeks to improve the health and safety
of all individuals by addressing underlying risk factors that increase the likelihood that an
individual will become a victim or a perpetrator of violence.

The approach consists of four steps:

• To define the problem through the systematic collection of information about the
magnitude, scope, characteristics and consequences of violence.
• To establish why violence occurs using research to determine the causes and
correlates of violence, the factors that increase or decrease the risk for violence,
and the factors that could be modified through interventions.
• To find out what works to prevent violence by designing, implementing and
evaluating interventions.
• To implement effective and promising interventions in a wide range of settings.
The effects of these interventions on risk factors and the target outcome should be
monitored, and their impact and cost-effectiveness should be evaluated.

By definition, public health aims to provide the maximum benefit for the largest number
of people. Programmes for the primary prevention of violence based on the public health
approach are designed to expose a broad segment of a population to prevention measures
and to reduce and prevent violence at a population-level.

The steps of the public health approach

Public health is "the science and art of preventing disease, prolonging life and promoting
health through the organized efforts and informed choices of society, organizations,
public and private, communities and individuals" (1920, C.E.A. Winslow).[1] It is
concerned with threats to the overall health of a community based on population health
analysis. The population in question can be as small as a handful of people or as large as
all the inhabitants of several continents (for instance, in the case of a pandemic). Public
health is typically divided into epidemiology, biostatistics and health services.
Environmental, social, behavioral, and occupational health are other important subfields.

The focus of public health intervention is to prevent rather than treat a disease through
surveillance of cases and the promotion of healthy behaviors. In addition to these
activities, in many cases treating a disease may be vital to preventing it in others, such as
during an outbreak of an infectious disease. Hand washing, vaccination programs and
distribution of condoms are examples of public health measures.

The goal of public health is to improve lives through the prevention and treatment of
disease. The United Nations' World Health Organization defines health as "a state of
complete physical, mental and social well-being and not merely the absence of disease or
infirmity."[2]

Objectives
The focus of a public health intervention is to prevent rather than treat a disease through
surveillance of cases and the promotion of healthy behaviors. In addition to these
activities, in many cases treating a disease can be vital to preventing its spread to others,
such as during an outbreak of infectious disease or contamination of food or water
supplies. Vaccination programs and distribution of condoms are examples of public
health measures.

Most countries have their own government public health agencies, sometimes known as
ministries of health, to respond to domestic health issues. In the United States, the front
line of public health initiatives are state and local health departments. The United States
Public Health Service (PHS), led by the Surgeon General of the United States, and the
Centers for Disease Control and Prevention, headquartered in Atlanta, are involved with
several international health activities, in addition to their national duties.

There is a vast discrepancy in access to health care and public health initiatives between
developed nations and developing nations. In the developing world, public health
infrastructures are still forming. There may not be enough trained health workers or
monetary resources to provide even a basic level of medical care and disease prevention.
As a result, a large majority of disease and mortality in the developing world results from
and contributes to extreme poverty. For example, many African governments spend less
than USD$10 per person per year on health care, while, in the United States, the federal
government spent approximately USD$4,500 per capita in 2000.

Many diseases are preventable through simple, non-medical methods. For example,
research has shown that the simple act of hand washing can prevent many contagious
diseases.[3]

Public health plays an important role in disease prevention efforts in both the developing
world and in developed countries, through local health systems and through international
non-governmental organizations.

The two major postgraduate professional degrees related to this field are the Master of
Public Health (MPH) or MSc in Public Health or allied fields. Doctoral studies in this
field include Doctor of Public Health (DrPH) and PhD in a subspeciality of greater Public
Health disciplines. DrPH is regarded as a leadership degree and PhD is more an academic
degree.

History of public health

In some ways, public health is a modern concept, although it has roots in antiquity. From
the beginnings of human civilization, it was recognized that polluted water and lack of
proper waste disposal spread communicable diseases (theory of miasma). Early religions
attempted to regulate behavior that specifically related to health, from types of food
eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual
relations. The establishment of governments placed responsibility on leaders to develop
public health policies and programs in order to gain some understanding of the causes of
disease and thus ensure social stability prosperity, and maintain order.

The term "healthy city" used by today's public health advocates reflects this ongoing
challenge to collective physical well-being that results from crowded conditions and
urbanization.
Notes
1. ^ C.-E. A. Winslow, “The Untilled Fields of Public Health,” Science, n.s. 51
(1920), p. 23
2. ^ WHO Definition of Health Preamble to the Constitution of the World Health
Organization as adopted by the International Health Conference, 1946
3. ^ http://www.globalhandwashing.org/Publications/Lit_review.htm
4. ^ Cuter, David; Grant Miller (February 2005). "The Role of Public Health
Improvements in Health Advances: The Twentieth Century United States". Project Muse.
Demography 42 (1).
5. ^ The Solid Facts: Social Determinants of Health edited by Richard Wilkinson
and Michael Marmot, WHO, 2003
6. ^ a b c d e Patel, Kant; Rushefsky, Mark E.; and McFarlane, Deborah R. The
Politics of Public Health in the United States, M.E. Sharpe, 2005, p. 91. (ISBN
076561135X)
7. ^ Fee and Acheson, A History of education in public health: Health that mocks
the doctors' rules, OUP, 1991. (ISBN 0192617575 )
8. ^ Brandt, A. M., and M. Gardner. 2000. Antagonism and Accommodation:
Interpreting the Relationship Between Public Health and Medicine in the United States
During the Twentieth Century. American Journal of Public Health 90:707 – 715.
9. ^ White, K. L. (1991). Healing the schism: Epidemiology, medicine, and the
public's health. New York: Springer-Verlag.
10. ^ a b http://www.cdc.gov/mmwr/PDF/wk/mm4850.pdf
11. ^ "Schools of Public Health and Public Health Programs". Council on Education
for Public Health. 19 November 2009.
http://www.ceph.org/files/public/Master_List.v.11.pdf. Retrieved 12 January 2010.[dead link]
12. ^ ASPH
13. ^ http://www.ceph.org
14. ^ http://www.deltaomega.org/
15. ^ Gillam Stephen; Yates, Jan; Badrinath, Padmanabhan. Essential Public Health.
Cambridge University Press 2007.
16. ^ Pencheon, David; Guest, Charles; Melzer, David; Gray, JA Muir. Oxford
Handbook of Public Health Practice. Oxford University Press 2001.
17. ^ Smith, Sarah; Sinclair, Don; Raine, Rosalind; Reeves, Barnarby. Health Care
Evaluation (Understanding Public Health). Open University Press 2006.
18. ^ Sanderson, Colin; Gruen, Reinhold. Analytical Models for Decision Making
(Understanding Public Health). Open University Press 2006.

References
• Breslow, Lester, ed (2002). Encyclopedia of Public Health. New York:
Macmillan Reference USA. ISBN 9780028653549. OCLC 469905883.
• Heymann, David L., ed (2008). Control of Communicable Diseases Manual.
Washington, D.C.: American Public Health Association. ISBN 9780875531892.
OCLC 232981417.

Levels
Preventive medicine strategies are typically described as taking place at the primary,
secondary, tertiary and quaternary prevention levels. In addition, the term "primal
prevention" has been used to describe all measures taken to ensure fetal well-being and
prevent any long-term health consequences from gestational history and/or disease.[2] The
rationale for such efforts is the evidence demonstrating the link between fetal well-being,
or "primal health", and adult health.[3][4] Primal prevention strategies typically focus on
providing future parents with: education regarding the consequences of epigenetic
influences on their child,[5] sufficient leave time for both parents, and financial support if
required.

Simple examples of preventive medicine include hand washing and immunizations.

Preventive care may include examinations and screening tests tailored to an individual's
age, health, and family history. For example, a person with a family history of certain
cancers or other diseases would begin screening at an earlier age and/or more frequently
than those with no family history. On the other side of preventive medicine, some non-
profit organizations, such as the Northern California Cancer Center, apply
epidemiological research towards finding ways to prevent diseases.

Doctor’s side
Prevention levels[6] Disease
absent present
Primary prevention Secondary prevention
absent (illness absent (illness absent
Patient’s disease absent) disease present)
Illness
side Quaternary prevention Tertiary prevention
present (illness present (illness present
disease absent) disease present)
Level Definition
Primary prevention strategies intend to avoid the development of disease.
Primary [7]
Most population-based health promotion activities are primary
prevention
preventive measures.
Secondary Secondary prevention strategies attempt to diagnose and treat an existing
prevention disease in its early stages before it results in significant morbidity.[8]
Tertiary These treatments aim to reduce the negative impact of established disease
prevention by restoring function and reducing disease-related complications.[9]
This term describes the set of health activities that mitigate or avoid the
Quaternary
consequences of unnecessary or excessive interventions in the health
prevention
system.[10]

Footnotes

1. ^ MeSH Preventive+Medicine
2. ^ Primal Research Centre, London
3. ^ Primal Health Research Databank
4. ^ Effect of In Utero and Early-Life Conditions on Adult Health and Disease, by
P.D.Gluckman et al., N ENGL J MED 359;1
5. ^ Origins: How the Nine Months Before Birth Shape the Rest of Our Lives, by
Annie Murphy Paul, Free Press, september 2010
 6. ^ Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoule M. Quaternary
prevention: a task of the general practitioner. PrimaryCare. 2010; 10(18):350-4.
7. ^ MeSH Primary+Prevention
8. ^ MeSH Secondary+Prevention
9. ^ MeSH Tertiary+Prevention
10. ^ Gofrit ON, Shemer J, Leibovici D, Modan B, Shapira SC. Quaternary
prevention: a new look at an old challenge. Isr Med Assoc J. 2000;2(7):498-500.
11. ^ Gordon, R. (1987), ‘An operational classification of disease prevention’, in
Steinberg, J. A. and Silverman, M. M. (eds.), Preventing Mental Disorders, Rockville,
MD: U.S. Department of Health and Human Services, 1987.
12. ^ Kumpfer, K. L., and Baxley, G. B. (1997), 'Drug abuse prevention: What
works?', National Institute on Drug Abuse, Rockville.
13. ^ How should influenza prophylaxis be implemented?
14. ^ de Oliveira JC, Martinelli M, D'Orio Nishioka SA, et al. (2009). "Efficacy of
antibiotic prophylaxis prior to the implantation of pacemakers and cardioverter-
defibrillators: Results of a large, prospective, randomized, double-blinded, placebo-
controlled trial". Circ Arrhythmia Electrophysiol 2 (1): 29–34.
doi:10.1161/CIRCEP.108.795906. PMID 19808441.
15. ^ Lars Bo Andersen et al. (June 2000). "All-cause mortality associated with
physical activity during leisure time, work, sports, and cycling to work.". Arch Intern
Med. 160 (11): 1621–8. doi:10.1001/archinte.160.11.1621. PMID 10847255.
16. ^ Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (May 2006).
"Global and regional burden of disease and risk factors, 2001: systematic analysis of
population health data". Lancet 367 (9524): 1747–57. doi:10.1016/S0140-
6736(06)68770-9. PMID 16731270.
17. ^ Mokdad AH, Marks JS, Stroup DF, Gerberding JL (March 2004). "Actual
causes of death in the United States, 2000". JAMA 291 (10): 1238–45.
doi:10.1001/jama.291.10.1238. PMID 15010446. http://www.csdp.org/research/1238.pdf.

Levels of Prevention

1. Primary -concerned with health promotion activities that prevent the actual
occurence of a specific illness or disease
2. Secondary -promotes early detection or screening and treatment of disease and
limitation of disability. This level of prevention is also called HEALTH
MAINTENANCE.
3. Tertiary -directed towards recovery or rehabilitation of a disease or condition after
the disease has been developed.

Read more: http://wiki.answers.com/Q/3_levels_of_prevention#ixzz1GsBYSBw3

LEVELS OF PREVENTION IN COMMUNITY NURSING

Many of the most serious disorders treated in health care practice can be
prevented or postponed by immunizations, chemoprophylaxis and healthier
lifestyles, or detected and treated early with various screening and intervention.
Health care professionals, like nurses, now have the opportunity, skills and
resources to prevent disease and promote health, as well as cure disease.
Community nursing care oriented to health promotion, wellness, and illness
prevention can be understood in terms of health activities the levels of
prevention. These levels of prevention are primary, secondary, and tertiary levels
which are formulated by Leavell & Clark. Each level of prevention corresponds to
specific nursing and medical interventions.
Primary prevention is true prevention. It is also referred to as specific
protection. It precedes disease or dysfunction and is applied to clients considered
physically and emotionally healthy. It comprises of measures applicable to a
particular disease or group of diseases in order to intercept their causes before
they involve the individual (World Health Organization, 2001).
Primary prevention aimed at health promotion for the community includes
health education programs, immunization for the children, and physical and
nutritional fitness activities. It can be provided to an individual or to a general
population, or it can focus on individuals at risk for developing specific diseases
(Potter & Perry, 2004).
Wellness activities are synonymous with the activities identified for primary
prevention. Primary prevention includes all health promotion efforts, as well as
wellness activities that focus on maintaining or improving the general health of
individuals, families, and communities (Edelman & Mandle, 2002).
For health promotion, activities includes health education, good standard
of nutrition adjusted to developmental phase of life, attention to personality
development, provision of adequate housing and recreation as well as agreeable
working conditions in communities, marriage counseling and sex education,
genetic screening and periodic selective examinations. Activities geared towards
specific protection include the use of specific immunizations, use of
environmental sanitation, protection against occupational hazards, protection
from accidents, use of specific nutrients, protection from carcinogens, and
avoidance of allergens (Potter & Perry, 2004).
Primary level of prevention could be used to address issues in a
community experiencing increasing level of family violence. Educating the
individuals in the community regarding violence, how to stop them and how to
avoid them could largely help in decreasing the levels of violence in the
community. Activities that could help individuals occupy their time could shift
thought of violence behavior to a more productive one. Thus by using primary
prevention, individuals could be directed to do more productive activities than
produce violence. Other than that, marriage counseling could help minimize the
levels of family violence in communities. When couples and other family member
would undergo counseling, issues and problems could be solved and violence
prevented.
Secondary prevention focuses on individuals who are experiencing health
problems or illnesses and who are at risk for developing complications or
worsening conditions. This is basically the level of prevention that focuses on
treatment. It refers to measures to arrest a disease process already initiated, in
order to prevent further complications and sequelae, limit disability, and prevent
death (World Health Organization, 2001). Activities are directed at diagnosis and
prompt intervention, thereby reducing severity and enabling the client to return to
a normal level of health as early as possible (Potter & Perry, 2004).
A large portion of nursing care related to secondary prevention is
delivered in homes, hospitals, or skilled nursing facilities. It includes screening
techniques and treating early stages of disease to limit disability by averting or
delaying the consequences of advanced disease.
Early diagnosis and prompt treatment for secondary prevention include
case-finding measures and selective examinations to cure and prevent disease
process, prevent spread of communicable disease, prevent complication and
sequelae, and to shorten an individual's period of disability. Activities for disability
limitations include adequate treatment to arrest disease process and prevent
further complications and sequelae, and the provision of facilities to limit disability
and prevent death (Potter & Perry, 2004).
Tertiary prevention occurs when a defect or disability is permanent and
irreversible. This level of rehabilitation involves measures aimed at disabled
individuals, restoring their previous situation or maximizing the use of their
remaining capacities (World Health Organization, 2001). It also involves
minimizing the effects of long-term disease or disability by interventions directed
at preventing complications and deterioration (Edelman & Mandle, 2002). It
therefore comprises both interventions at the level of the individual and
modifications of the environment.
Activities are directed at rehabilitation rather than diagnosis and treatment.
Care at this level aims to help clients achieve as high a level of functioning as
possible, despite the limitations caused by illness or impairment. This level of
care is preventive care because it involves preventing further disability or
reduced functioning (Potter & Perry, 2004).
Examples of activities that focus on tertiary prevention includes provision
of hospital and community facilities for retraining and education to maximize use
of remaining capacities, education of public and industry to use rehabilitated
persons to fullest possible extent, selective placement, work therapy in hospitals,
and use of sheltered colony (Kozier & Erb, 2004).
 Preventive care cannot be delivered effectively without active client
involvement. At the most basic level, clients must consent to receive preventive
care. In the case of family members in the community that agree to undergo
preventive treatment in order to reduce levels of violence, they must
wholeheartedly consent to such an intervention. Every effort should be made to
foster patient knowledge and interest in preventive care with the use of various
educational materials. Members of communities must be thoroughly educated
and health care professionals should come up with strategies that gauge if these
individuals have indeed learned something, and if the intervention is indeed
successful. These may be made conspicuously available at strategic locations
throughout the office or clinic, as well as actively distributed to clients with special
needs.
A comprehensive health care program should address all three levels of
prevention. The nurse should develop a health care program that would focus on
(1) health promotion and protection against specific disease problems and
decrease probability of diseases, (2) early identification of health problems and
prompt intervention to alleviate health problems and include specific screening
programs and illness care, and (3) chronic disease rehabilitation to an optimal
level of functioning and relates to situations where a disability is already present
in an individual. Granting the fact that communities comprise of very diverse
individuals with different demographic, sociopsychological and structural
variables, nurses and other health care professionals must come up with a health
care program that is comprehensive enough to cover such a diverse population
and the diverse levels of illness and disease that come with them.
Addressing a health concern at this level of prevention is cost effective
since it is like hitting three birds with one stone. By preparing for whatever could
possibly happen to an individual in a community, the nurse could save time, effort
and money in the prevention of illness and diseases. Perhaps in the primary level
of prevention alone, this could help stop the spread and development of illness
and diseases in the members of the community. Identifying risk factors, attempts
to eliminate the stressor, focuses on protecting and strengthening defenses could
help individuals from developing diseases and illness. If that is the case, not only
will the health care professionals save on time and effort but the individuals in
communities could also save costs on treatment for secondary prevention and
even rehabilitation for tertiary prevention.
In conclusion, health care professionals most especially nurses must
develop health care plans and strategies geared on prevention and taking into
account the three levels of preventive care. A comprehensive health care
program should address all three levels of preventive care. Aside from being an
advantage since it could be used on any individual in the community, it is also
cost effective. Individuals in communities and health care professionals must
always remember that prevention is still better than cure.

REFERENCES
Edelman, C.L. & Mandle, C.L. (2002). Health Promotion Throughout the Life

Span. Mosby.

Kozier, B. and Erb, G. (2004). Fundamentals of Nursing: Concepts, Process, and

Practice 7th Edition. Pearson Education Inc.

No Author. (2006). Transition to Professional Nursing: Health

Promotion/Wellness. Retrieved from:

http://chua2.fiu.edu/faculty/phillips/NUR3055/TransHealthPro.htm

Potter, P. and Perry, A. (2004). Fundamentals of Nursing. Mosby.

World Health Organization. (2001). The World Health Report 2001 – Mental

Health: New Understanding, New Hope. Retrieved from:

http://www.who.int/whr/2001/chapter3/en/index3.html

Disease prevention is the deferral or elimination of specific illnesses and conditions by

one or more interventions of proven efficacy. While the term is generally applied to
human health, the principles apply to other plant and animal species.

It is useful to distinguish among three levels of prevention—primary, secondary, and

tertiary— although the boundaries between these levels are not always perfectly
understood. "Primary prevention" refers to the prevention of diseases before their
biological onset. For example, pasteurizing milk essentially eliminates bacterial
pathogens that could cause illnesses, and measles immunization prevents clinical illness
before it can get started. Another kind of primary prevention occurs when 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,
as are the provision of uncontaminated food and water. Routine searching for genetic
abnormalities is usually a form of primary prevention, in that abnormal genes that are
associated with various diseases can often be detected before any disease occurs. An
example is newborn screening for phenylketonuria, a metabolic disease that can be
subverted with an appropriate diet. There are many logistical and ethical difficulties in
routine searching for genetic abnormalities, however, and appropriate approaches are still
being developed.

A term sometimes used, related to primary prevention, is "primordial prevention," which

refers to creating an environment where certain challenges to health are eliminated, and
thus no other preventive interventions are necessary. Two examples of primordial
prevention are the global elimination of smallpox, so that no immunization is necessary;
and the potential for eliminating added salt from all foods, which would, if achieved, be
quite effective in preventing hypertension.

"Secondary prevention" refers to the prevention of clinical illness through the early and
asymptomatic detection and remediation of certain diseases and conditions that, if left
undetected, would likely become clinically apparent and harmful. This is often referred to
as "screening." There are many examples of secondary disease prevention, including
routine bacteriological culturing for sexually transmitted organisms in asymptomatic
persons; routine serological testing for preclinical infections such as syphilis; screening
for high blood pressure, which may indicate clinical hypertension; screening for early
breast cancer using mammography or for early cancers or precancerous lesions of the
colon using sigmoidoscopy or colonoscopy. 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. One variation
of secondary prevention is to screen for conditions that might be clinically overt but have
gone undetected, such as clinical depression or other mental illnesses. This is also quite
useful because such conditions are often quite treatable. Sometimes it may be possible to
apply primary preventive interventions to diseases that are already developing: smoking
cessation and increasing exercise may prevent the emergence of heart attack or stroke,
even though some atherosclerotic lesions (hardening of the arteries) are already
developing.

"Tertiary prevention" refers to the prevention of disease progression and additional

disease complications after overt clinical diseases are manifest. This is generally the
province of physicians and other health professionals, who manage acute and chronic
conditions. While the distinction between disease treatment and tertiary prevention may
be sometimes uncertain, many examples exist— lowering a high blood cholesterol level
after a heart attack can prevent the occurrence of further heart attacks and related
conditions such as stroke and angina pectoris (chest pain with activity). Similarly,
treating high blood pressure after a stroke may decrease the risk of subsequent strokes.
For persons with diabetes mellitus, eye examinations to detect diabetic retinal disease,
and steps taken to prevent its progression, are routinely undertaken. Routine podiatric
care can deter the effects of diabetic vascular disease on the feet. Among persons who are
severely disabled, provision of special mattresses and other interventions can prevent
some chronic skin ulceration. Providing handrails in the homes of persons at high
likelihood of repeated falling can prevent fractures and other injuries. Tertiary prevention
is perhaps the least well developed of the three domains, and is ripe for considerable
prevention research.

The construct of primary, secondary, and tertiary prevention considers preventive

intervention in the context of the onset and natural history of specific human diseases and
their outcomes. Another way to view disease prevention is to consider where particular
preventive interventions are carried out. Some of the most important disease prevention is
carried out by environmental modification. This includes all sanitary services, such as the
provision of safe food and water; adequate housing; and a general environment free of
diseasecausing physiochemical and biological pollutants. Many work environments
require substantial environmental protections, since they would otherwise be extremely
hazardous. There are countless other environmental modifications that yield disease
prevention, such as highway engineering to control speeds and dangerous road segments,
the elimination of overhanging building cornices, and the removal of sharp edges or
provision of shielding devices on consumer products.

Another general source of disease prevention is through appropriate individual and group
behavior. Part of the disease-prevention burden lies with the individual, who must
practice behaviors that minimize disease risk and occurrence, and maximize health states.
Some obvious examples are maintaining an appropriate weight, never taking up or
ceasing the use of tobacco products, avoiding exposures that may lead to unwanted
pregnancy or passage of sexually transmitted diseases, avoiding carcinogenic sun
exposure, maintaining active exercise habits appropriate for one's health status,
appropriately using prescription drugs or other substances, refusing to drive a vehicle
after consuming alcohol, and discouraging participation in social behaviors that may lead
to disease or injury. Some persons are more prone to risk-taking behaviors in general, but
there are currently not many interventions for these situations. It is clearly important that
individuals have sufficient and accurate information in order to assist in initiating and
maintaining disease-preventing behaviors. Thus, a related source of appropriate disease
prevention is wherever health education and behavioral training takes place. This may
include educational institutions, medical care sites, the Internet, and all other venues
where health information and knowledge are offered, including the media and marketing
activities.

Another important source of disease prevention lies largely with health-professional

practice. In general, only health professionals can conduct and interpret many screening
procedures, administer immunizations, or prescribe chemopreventive interventions and
provide tertiary preventive services for persons with existing medical conditions. A
substantial amount of health counseling and education is done by health professionals.
Thus, it is important that health professionals provide clinically appropriate and
comprehensive preventive services in the practice setting—as well as at other community
locales, where the entire population can acquire access to them. In recent years, the extent
of clinical preventive services provision has served as a key indicator of the general
quality of health professional practice.
Underlying preventive-intervention delivery, no matter the source, is the need for
political action. The citizens of every community or jurisdiction must provide the
political impetus and the resources to assure that modern prevention is available, whether
in regulating and policing the general or workplace environment, assuring high-quality
sanitary procedures, furnishing effective educational programs and services, or providing
fiscal and geographical access to clinical services. Provision of suitable research
programs and prevention professionals is also critical. Prevention interventions may vary
considerably in the evidence of their efficacy, the proportion of the population that will
be positively affected by the intervention, and intervention delivery costs. Thus, some
prioritization of the universe of potential interventions will often be necessary; methods
to conduct such prioritization are often lacking, however, and more research is needed in
this area.

Disease prevention may not be equally applied to all persons in the community. While
many clinical and environmental interventions, such as routine childhood immunizations,
air pollution control, and public health sanitary measures, are appropriately intended for
all persons, individuals may differ dramatically in their risk of various diseases for
genetic, behavioral, or environmental reasons. If groups with varying risks can be
effectively discerned and efficiently identified, then some disease prevention activities
may be differentially targeted for high-risk groups, both for reasons of efficacy and cost.
For example, screening for blood-lead levels in children may only be useful for those
who reside in older housing, where lead paint exposure is much more likely. Persons with
a clear family history of some chronic conditions, such as coronary heart disease and
cancer, may benefit from more intensive screening and intervention programs.

Applying disease-preventing interventions requires the same care and consideration as

any clinical treatment, for several reasons. There should be evidence of efficacy—that the
intervention has sufficient scientific basis to know that it works. Some interventions
proffered under the guise of prevention have insufficient evidence of benefit, and more
systems to monitor and provide evidence summaries are needed—existing systems
include the United States Preventive Task Force, the Task Force on Community
Preventive Services, and the Cochrane Collaboration. Also, it is important to note that
most direct preventive interventions, even when appropriately applied, do not prevent
disease in all persons. Thus, routine mammographic testing results in only a 20 to 30
percent reduction in breast cancer mortality, and physician counseling for smoking
cessation has only a small effect on the smoking behavior of patients. The effect of these
interventions will only be enhanced by new research and more efficient delivery
programs. On the other hand, some preventive interventions are highly effective, such as
many vaccines, food safety procedures, and other public health environmental activities.
A related problem for some disease-prevention interventions is that long-term efficacy
may be uncertain.

As in the case of clinical treatments, preventive interventions may have actual or

potential adverse effects, some of which may be undetected. It is often pointed out that
disease prevention has a greater moral burden to be free of adverse effects than do
treatments, since they target individuals who are generally healthy. Some adverse effects
are clearly and immediately identifiable, such as acute allergic reaction to a vaccine or a
perforated colon during an endoscopic procedure. Others require longer term
surveillance. For example, a long-term randomized trial of an early cholesterol-lowering
drug revealed that the drug caused lower rates of nonfatal heart attacks but higher overall
mortality rates. Similarly, a particular intervention may have an effect in a definitive
randomized trail that was not predicted from epidemiological studies. For example, while
consuming beta-carotene-containing vegetables has been associated with lower cancer
incidence rates, randomized trials of beta-carotene in smokers have been associated in
some studies with higher incident lung cancer rates. Also an intervention may have varied
effects on different disease outcomes. A recent clinical trial for stroke prevention using a
newer cholesterol-lowering agent found that overall strokes were prevented, but
hemorrhagic strokes were significantly more frequent in the intervention group.

Behavioral and psychological adverse effects of the disease-prevention activities may be

more subtle, but they are still important. An individual who has undergone a screening
test may conceivably abandon health-promoting behaviors, incorrectly feeling that he or
she is disease-free. Since most screening tests are not 100 percent sensitive in detecting
the presence of the target disease, a false sense of security may occur. Similarly, an
individual may not understand that many screening interventions must be done repeatedly
to be effective, and thus may fail to participate at appropriate intervals. Some individuals
may not be emotionally or educationally prepared for dealing with a disease that might be
detected by screening, and this poses additional challenges for health professionals and
health systems.

ROBERT B. WALLACE

(SEE ALSO: Behavior, Health-Related; Behavioral Change; Environmental

Determinants of Health; Prevention; Preventive Medicine; Primary Prevention, Risk
Assessment, Risk Management; Secondary Prevention; Social Determinants; Tertiary
Prevention; and articles on specific diseases mentioned herein)

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