3. Relate the different stages of the development of
a disease to the phases of prevention.
Describe the advantages and disadvantages of population and high-risk prevention strategies.
Understand the role and limitations of screening regarding the early detection of disease. Overhead 6.1 PRIMORDIAL PREVENTION
Prevention of the emergence of living patterns that contribute to increased risk of disease (e.g., maintenance of low fat diet in Asian countries). Overhead 6.2 PRIMARY PREVENTION
Prevention of disease by controlling risk factors (e.g., non-smoking promotion).
STRATEGIES : Population High-risk Overhead 6.3 PRIMARY PREVENTION : The Population Strategy
Advantages Radical Large potential for population Behaviourally appropriate
Disadvantages Small benefits to individuals Poor motivation of subject Poor motivation of physician Benefit-to-risk ratio may be low
Overhead 6.4 PRIMARY PREVENTION : The High-risk Strategy
Advantages Appropriate to individuals Subject motivation Physician motivation Benefit-to-risk ratio is favourable Disadvantages High screening costs Temporary effect Limited effect Behaviourally inappropriate
Overhead 6.5
PREVENTION PARADOX
A preventive measure which brings much benefit to the population often offers little to each participating individual.
(Rose, 1985) Overhead 6.6 SECONDARY PREVENTION
Reduction in consequences of disease by early diagnosis and treatment (e.g., cervical cancer screening)
TERTIARY PREVENTION
Reduction of complications of disease (e.g., MV crashes and ICU) Overhead 6.7 SCREENING
The organized attempt to detect, among apparently health people in the community, disorders or risk factors of which they are unaware. Table 6.1. Levels of prevention Level of prevention Phase of disease Target Primordial Underlying conditions leading to causation Total population and selected groups Primary Specific causal factors Total population, selected groups and healthy individuals Secondary Early stage of disease Patients Tertiary Late stage of disease (treatment, rehabilitation) Patients Table 6.2. Advantages and disadvantages of strategies for primary prevention Population strategy High-risk individual strategy Advantages Radical Large potential for whole population Behaviourally appropriate Appropriate to individuals Subject motivation Physician motivation Favourable benefit-to-risk ratio Disadvantages Small benefit to individuals Poor motivation of suject Poor motivation of physician Benefit-to-risk ratio may be low Difficulties identifying high-risk individuals Temporary effect Limited effect Behaviourally inappropriate Table 6.3. Criteria for instituting a screening programme Disease Serious High prevalence of preclinical stage Natural history understood Long period between first signs and overt disease
Diagnostic test Sensitive and specific Simple and cheap Safe and acceptable Reliable
Diagnosis and Facilities are adequate Treatment Effective, acceptable, and safe treatment available Table 6.4. Validity of a screening test Disease status Present Absent Total Positive Negative Screening test a b c d a + b c + d a + c Total b + d a + b + c + d KEY : a : no. of true positives c : no.of false negatives b : no. of false positives d : no. of true negatives Sensitivity = probability of a positive test in people with the disease = a/(a + c) Specificity = probability of a negative test in people without the disease = d/(b + d)
Positive predictive value = probability of the person having the disease when the test is positive = a/(a + b)
Negative predictive value = probability of the person not having the disease when the test is negative = d/(c + d)