Primordial prevention

1. Primordial prevention by Sorin Ursoniu, MD, PhD I am a public health specialist and lecturer in the Department of Public Health & History of Medicine at the �Victor Babes� University of Medicine & Pharmacy, Timisoara, Romania. I am also a qualified dermatologist.I am a public health specialist and lecturer in the Department of Public Health & History of Medicine at the �Victor Babes� University of Medicine & Pharmacy, Timisoara, Romania. I am also a qualified dermatologist.

2. Why is primordial prevention important? Nowadays more people than ever before are exposed to products and patterns of living imported or adopted from other countries that pose serious long-term risks to their health. Tobacco, alcohol and some processed foods are being increasingly marketed by multinational companies, with low and middle income countries as their main targets for expansion. Cigarette smoking is increasing rapidly in developing countries while the overall consumption of cigarettes in many developed countries is dropping. It has been estimated that by the year 2010 there will be over two million deaths each year in China from smoking-related diseases unless a major effort is made to reduce smoking. Nowadays more people than ever before are exposed to products and patterns of living imported or adopted from other countries that pose serious long-term risks to their health. Tobacco, alcohol and some processed foods are being increasingly marketed by multinational companies, with low and middle income countries as their main targets for expansion. Cigarette smoking is increasing rapidly in developing countries while the overall consumption of cigarettes in many developed countries is dropping. It has been estimated that by the year 2010 there will be over two million deaths each year in China from smoking-related diseases unless a major effort is made to reduce smoking.

3. Learning & Performance Objectives Learning Objectives - to understand the concept and the importance of primordial prevention - to understand that a high level of government commitment is required for effective primordial prevention Performance Objectives - to be able to identify the various inter-related approaches which can be used to modify health behaviourLearning Objectives - to understand the concept and the importance of primordial prevention - to understand that a high level of government commitment is required for effective primordial prevention Performance Objectives - to be able to identify the various inter-related approaches which can be used to modify health behaviour

4. Prevention Disease prevention includes measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established. Historical medical records as early as 2500 BC referred to the practice of Prevention. References to the importance of prevention are found in the writings of Hippocrates, thus rendering the prevention concept important and certainly not new in the practice of medicine. The continuously changing patterns of mortality and morbidity over time indicate that major causes of disease are preventable. Other evidence comes from the geographical variation in disease occurrence within and between countries, and from the observation that migrants slowly develop the patterns of disease of host populations. Disease prevention is considered to be action which usually emanates from the health sector, dealing with individuals and populations exhibiting identifiable risk factors, often associated with different risk behaviours.Historical medical records as early as 2500 BC referred to the practice of Prevention. References to the importance of prevention are found in the writings of Hippocrates, thus rendering the prevention concept important and certainly not new in the practice of medicine. The continuously changing patterns of mortality and morbidity over time indicate that major causes of disease are preventable. Other evidence comes from the geographical variation in disease occurrence within and between countries, and from the observation that migrants slowly develop the patterns of disease of host populations. Disease prevention is considered to be action which usually emanates from the health sector, dealing with individuals and populations exhibiting identifiable risk factors, often associated with different risk behaviours.

5. Levels of prevention (I) Primordial prevention deals with underlying conditions leading to exposure to causative factors. The target of this approach is either the total population or selected groups from the population. It aims to modify the conditions that generate and structure the unequal distribution of health damaging exposures, susceptibilities and health protective resources among the population. The purpose of primary prevention is to limit the incidence of disease by controlling causes and risk factors. It involves two strategies that are often complementary and reflect two views of etiology. It can focus on the whole population with the aim of reducing average risk (the population strategy) or on people at high risk as a result of specific exposure (the high-risk individual strategy). Primordial prevention deals with underlying conditions leading to exposure to causative factors. The target of this approach is either the total population or selected groups from the population. It aims to modify the conditions that generate and structure the unequal distribution of health damaging exposures, susceptibilities and health protective resources among the population. The purpose of primary prevention is to limit the incidence of disease by controlling causes and risk factors. It involves two strategies that are often complementary and reflect two views of etiology. It can focus on the whole population with the aim of reducing average risk (the population strategy) or on people at high risk as a result of specific exposure (the high-risk individual strategy).

6. Levels of prevention (II) Secondary prevention aims to cure patients and reduce the more serious consequences of disease through early diagnosis and treatment. It is directed at the period between onset of disease and the time of diagnosis, and aims to reduce the prevalence of disease. Secondary prevention can be applied only to disease with a natural history including an early period when the disease is easily identified and treated, so that progression to a more serious stage can be stopped. The purpose of tertiary prevention is to reduce the progress or complications of established disease and is an important aspect of therapeutic and rehabilitative medicine.Secondary prevention aims to cure patients and reduce the more serious consequences of disease through early diagnosis and treatment. It is directed at the period between onset of disease and the time of diagnosis, and aims to reduce the prevalence of disease. Secondary prevention can be applied only to disease with a natural history including an early period when the disease is easily identified and treated, so that progression to a more serious stage can be stopped. The purpose of tertiary prevention is to reduce the progress or complications of established disease and is an important aspect of therapeutic and rehabilitative medicine.

7. Definition Primordial prevention is defined as prevention of risk factors themselves, beginning with change in social and environmental conditions in which these factors are observed to develop, and continuing for high risk children, adolescents and young adults. In 1978, Strasser suggested that prevention of cardiovascular diseases should go beyond programmes encompassed under the idea of primary prevention. He coined the term �primordial prevention� to mean activities that prevented the penetration of risk factors into populations. The basic idea is to intervene in order to stop the appearance of risk factors in the population. In some sense, this is similar to traditional public health immunization efforts for infectious conditions, aiming to prevent the appearance of the risk factor or condition before it takes hold in the population.In 1978, Strasser suggested that prevention of cardiovascular diseases should go beyond programmes encompassed under the idea of primary prevention. He coined the term �primordial prevention� to mean activities that prevented the penetration of risk factors into populations. The basic idea is to intervene in order to stop the appearance of risk factors in the population. In some sense, this is similar to traditional public health immunization efforts for infectious conditions, aiming to prevent the appearance of the risk factor or condition before it takes hold in the population.

8. Primordial prevention, a relatively new concept, is receiving special attention in the prevention of chronic diseases. For example, many adult health problems (e.g. obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed. While Strasser�s idea of primordial prevention was originally concerned with controlling the penetration of risk factors like smoking in developing countries, the concept has important implications regarding the way we think about the relationship between lifecourse socio-economic circumstances and adult risk factors. While Strasser�s idea of primordial prevention was originally concerned with controlling the penetration of risk factors like smoking in developing countries, the concept has important implications regarding the way we think about the relationship between lifecourse socio-economic circumstances and adult risk factors.

9. General access to energy-dense diets coupled with typically sedentary urban lifestyles creates a trend toward obesity and chronic disease. The term 'epidemiological transition' describes the shift in disease patterns from a dominance of infectious and deficiency diseases to a dominance of chronic diseases (accompanied by a decrease in fertility and population aging), as played out around the world. Mortality from infectious disease is declining in many developing countries and life expectancy is increasing. Consequently, noncommunicable conditions, especially coronary heart disease, cancer and unintentional injuries, take on a greater relative importance even before the infectious and parasitic diseases have been fully controlled. The term 'epidemiological transition' describes the shift in disease patterns from a dominance of infectious and deficiency diseases to a dominance of chronic diseases (accompanied by a decrease in fertility and population aging), as played out around the world. Mortality from infectious disease is declining in many developing countries and life expectancy is increasing. Consequently, noncommunicable conditions, especially coronary heart disease, cancer and unintentional injuries, take on a greater relative importance even before the infectious and parasitic diseases have been fully controlled.

10. It is important to change the milieu that promotes major risk factor development. Primordial prevention calls for changing the socio-economic status of society. A better socio-economic status correlates inversely with lifestyle factors like smoking, abnormal food patterns and exercise. Changes in attitudes, behaviour and social values are important for primordial prevention. They include encouragement of positive health behaviour, prevention of adopting risk behaviour, elimination of established risk behaviour and promotion of the concept of health as a social value. Established principles and practices of health and general education should be included in public health programmes. Healthy behaviour should be made socially acceptable and encouraged by improved community facilities. Changes in attitudes, behaviour and social values are important for primordial prevention. They include encouragement of positive health behaviour, prevention of adopting risk behaviour, elimination of established risk behaviour and promotion of the concept of health as a social value. Established principles and practices of health and general education should be included in public health programmes. Healthy behaviour should be made socially acceptable and encouraged by improved community facilities.

11. Primordial prevention begins in childhood when health risk behaviour begins. Parents, teachers and peer groups are important in imparting health education to children. The decisive role of health education in schools should be stressed through new social and behavioural values. Close co-operation between the health and teaching profession at all levels is needed. Special target groups are: children and adolescents, the family unit, the under-privileged and other high risk groups. The mass media should play a major role in health education programme. Promotion of dietary restriction, physically active lifestyle and avoidance of tobacco use beginning from childhood is important for primordial prevention. All adults should know their blood pressure and blood cholesterol levels, should not smoke, should monitor their salt and fat intake and should engage in at least moderate exercise.The decisive role of health education in schools should be stressed through new social and behavioural values. Close co-operation between the health and teaching profession at all levels is needed. Special target groups are: children and adolescents, the family unit, the under-privileged and other high risk groups. The mass media should play a major role in health education programme. Promotion of dietary restriction, physically active lifestyle and avoidance of tobacco use beginning from childhood is important for primordial prevention. All adults should know their blood pressure and blood cholesterol levels, should not smoke, should monitor their salt and fat intake and should engage in at least moderate exercise.

12. Cost-effectiveness of primordial prevention Governments should recognize that major savings in health care costs will be realized by the avoidance of mass behaviours such as smoking, and by achieving positive changes in food consumption patterns. Primordial prevention that is, preventing risk factors from appearing in the first place, is likely to be highly cost-effective. In both the developing and the industrialized world, economic constraints limit the governments' ability to provide state-of-the-art treatment and prevention programmes to all who might benefit. Governments must accept responsibility for the influence of their policies on public health. To improve nutrition, promote physical activity and reduce smoking, coordinated approaches, involving all sectors, are needed. Now that we have been able to study many of the disease related genes, we may soon be able to engineer them to prevent disease in those susceptible. We may also be able to identify individuals with the �bad� genes to be targeted for primordial prevention of disease, long before primary and secondary prevention begin to give any benefit to mankind. Governments should recognize that major savings in health care costs will be realized by the avoidance of mass behaviours such as smoking, and by achieving positive changes in food consumption patterns. Primordial prevention that is, preventing risk factors from appearing in the first place, is likely to be highly cost-effective. In both the developing and the industrialized world, economic constraints limit the governments' ability to provide state-of-the-art treatment and prevention programmes to all who might benefit. Governments must accept responsibility for the influence of their policies on public health. To improve nutrition, promote physical activity and reduce smoking, coordinated approaches, involving all sectors, are needed. Now that we have been able to study many of the disease related genes, we may soon be able to engineer them to prevent disease in those susceptible. We may also be able to identify individuals with the �bad� genes to be targeted for primordial prevention of disease, long before primary and secondary prevention begin to give any benefit to mankind.

13. The cost of prevention: can we afford it? can we afford not to do it? Primordial prevention actions should reflect economic impacts and value from a societal perspective. As such, a society with limited resources should determine which interventions have the most value. Cost-effectiveness analysis is the most often used approach for economic evaluation of a medical or health care strategy. In concert with this and a �fixed� monetary allocation for health, policy makers want the greatest return on their investment. For example, studies of smoking cessation intervention suggest that cost per year of saved life is small compared with other interventions. Prevention of death from one disease may not be a valuable outcome if overall life expectancy is not changed because of another significant illness. An obstacle in an investment in prevention is the public expectation that such an investment should pay for itself.Primordial prevention actions should reflect economic impacts and value from a societal perspective. As such, a society with limited resources should determine which interventions have the most value. Cost-effectiveness analysis is the most often used approach for economic evaluation of a medical or health care strategy. In concert with this and a �fixed� monetary allocation for health, policy makers want the greatest return on their investment. For example, studies of smoking cessation intervention suggest that cost per year of saved life is small compared with other interventions. Prevention of death from one disease may not be a valuable outcome if overall life expectancy is not changed because of another significant illness. An obstacle in an investment in prevention is the public expectation that such an investment should pay for itself.

14. Examples of primordial prevention actions (I):National policies and programmes on nutrition involving the agricultural sector, the food industry, and the food import-export sector  For nutrition, strategies should include the development of methodologies to encourage healthy eating and policies that support social, economic and marketing environments conducive to healthy eating. For nutrition, strategies should include the development of methodologies to encourage healthy eating and policies that support social, economic and marketing environments conducive to healthy eating.

15. Examples of primordial prevention actions (II):Comprehensive policies to discourage smoking Activities on smoking prevention should be based on a national plan for tobacco control that includes strategies for data collection, development of health education and information systems and other appropriate policies and legislation. Activities on smoking prevention should be based on a national plan for tobacco control that includes strategies for data collection, development of health education and information systems and other appropriate policies and legislation.

16. Examples of primordial prevention actions (III):Programmes to promote regular physical activity  Physical activity programmes should be based on policy, public information, education and training supported by standardized research and evaluation components. All strategies should aim at increasing physical activity in the population as a whole with special emphasis on children and women. Physical activity programmes should be based on policy, public information, education and training supported by standardized research and evaluation components. All strategies should aim at increasing physical activity in the population as a whole with special emphasis on children and women.

17. Responsibilities for primordial prevention: Government Professional and non-governmental organisations Industry Hospitals, health clinics, health practitioners and health-care workers The responsibility for primordial prevention is shared by the following parties: Government - to legislate (e.g. anti-tobacco advertising), develop and fund intervention programmes. A high level of government commitment is required for effective primordial prevention. Professional and non-governmental organisations - to develop targets in conjunction with government, advise and provide educational resources to government and the community, educate health-care providers. Industry - to support recommendations from government and professional bodies (e.g. food processing, tobacco advertising), health promotion, funding. Hospitals, health clinics, health practitioners and health-care workers - for health promotion, risk assessment. The responsibility for primordial prevention is shared by the following parties: Government - to legislate (e.g. anti-tobacco advertising), develop and fund intervention programmes. A high level of government commitment is required for effective primordial prevention. Professional and non-governmental organisations - to develop targets in conjunction with government, advise and provide educational resources to government and the community, educate health-care providers. Industry - to support recommendations from government and professional bodies (e.g. food processing, tobacco advertising), health promotion, funding. Hospitals, health clinics, health practitioners and health-care workers - for health promotion, risk assessment.

18. Making major changes in lifestyle (I) Individuals should be taught practical skills on how to adopt and follow healthy practices, such as what sort of food to buy and how to prepare meals. People and communities should also be taught the skills for support measures needed for such lifestyles. However, providing information is not enough. People's health-related lifestyles in any community are closely related to the general lifestyles of the community and to the general beliefs, norms and social values. Thus, it is often difficult for the individual to make major changes in lifestyle, if respective changes do not take place in the community and, more generally, in society as a whole. Therefore, successful large-scale preventive programmes attempt to change, not so much the individuals, but the whole community and many of its social and environmental factors. This involves decisions and actions that make healthy choices possible and easy. Individuals should be taught practical skills on how to adopt and follow healthy practices, such as what sort of food to buy and how to prepare meals. People and communities should also be taught the skills for support measures needed for such lifestyles. However, providing information is not enough. People's health-related lifestyles in any community are closely related to the general lifestyles of the community and to the general beliefs, norms and social values. Thus, it is often difficult for the individual to make major changes in lifestyle, if respective changes do not take place in the community and, more generally, in society as a whole. Therefore, successful large-scale preventive programmes attempt to change, not so much the individuals, but the whole community and many of its social and environmental factors. This involves decisions and actions that make healthy choices possible and easy.

19. Making major changes in lifestyle (II) People are responsible for themselves, but intervention programmes and decision-makers should ensure that people can make informed choices and that following healthy lifestyles is an acceptable option. Government departments other than the ministry of health need to be involved in a highly coordinated manner. Non-governmental organizations should also be involved and, ultimately, mobilization of the whole community is needed. Carefully designed community programmes should form a link between the basic health research and the large-scale public health programmes and governmental policies. Such community programmes thus form a "model" for testing the approach for nationwide use. From an epidemiological point of view, the strength of the community approach (population approach) is that it is more effective in reducing disease rates in the community than restricted, but more intensive, interventions among high-risk individuals alone. People are responsible for themselves, but intervention programmes and decision-makers should ensure that people can make informed choices and that following healthy lifestyles is an acceptable option. Government departments other than the ministry of health need to be involved in a highly coordinated manner. Non-governmental organizations should also be involved and, ultimately, mobilization of the whole community is needed. Carefully designed community programmes should form a link between the basic health research and the large-scale public health programmes and governmental policies. Such community programmes thus form a "model" for testing the approach for nationwide use. From an epidemiological point of view, the strength of the community approach (population approach) is that it is more effective in reducing disease rates in the community than restricted, but more intensive, interventions among high-risk individuals alone.

20. Perspectives: Socioeconomic conditions over the lifecourse do influence adult risk factor profiles. Behavioural and social science research has a vital role in bringing the issues of lifecourse development and primordial prevention to the forefront of our efforts to improve public health in the 21st century. Primordial prevention should be recognized as a priority at the policy and programme level, with the necessary investment of resources.Socioeconomic conditions over the lifecourse do influence adult risk factor profiles. Behavioural and social science research has a vital role in bringing the issues of lifecourse development and primordial prevention to the forefront of our efforts to improve public health in the 21st century. Primordial prevention should be recognized as a priority at the policy and programme level, with the necessary investment of resources.