University of Applied Sciences , Utrecht, The Netherlands
The basic understanding in health is prevention. Prevention is concerned with preventing health problems by optimizing the conditions for health and preventing adverse factors from affecting it. In prevention, the promotion and protection of health is an important means of arriving at an optimal state of health for patients. This chapter discusses concepts that are used within prevention. We describe in Sects. 3.1–3.3 the various forms of prevention. Within professional nursing practice, we distinguish universal, primary prevention; selective and indicated secondary prevention; and, care-related, tertiary prevention. We describe the importance of the involvement of the patient in prevention. Section 3.6 describes the levels of prevention (individual- and collective-oriented prevention). Prevention is focused on health behavior and Sect. 3.7 is about the complexity of behavior. Section 3.8 is dedicated to health protection. Section 3.9 describes health promotion together with health education and in Sect. 3.10 the focus is on disease prevention, together with patient education and self-management. The effectiveness of prevention, among other things by combining intervention strategies, is discussed in Sect. 3.11. Finally, Sect. 3.12 reports the intertwining of cure and care, and the way to the future with care leading to prevention.
What is the purpose of prevention? In prevention, one tries to optimize the conditions for health and to minimize the factors that affect health. With prevention one tries to prevent health problems, and to outsmart “disease.” The point about prevention is to make the conditions of health for the patient as favorable as possible. Prevention is also aimed at ensuring that people stay healthy. Prevention can be described as the total measures, both within and outside health care, that aims to monitor and promote health by preventing health problems and diseases. Of great importance to prevention is achieving changes in lifestyle behavior whereby people become and remain healthier. Prevention is carried out both in general health care and in mental health care. Prevention covers the whole area of the nursing profession. Prevention in mental health is defined as preventing – in the broadest sense – serious mental health problems.
For nursing professionals, prevention is both a part of the daily care given to patients and a specific activity. Together with other professional groups in the health care system, they try to prevent health problems. When health problems still arise, nursing activities are targeted at minimizing the consequences. Both nursing professionals and patients recognize the need for and the importance of prevention. For example, in the elderly – with an increase in life expectancy – the number of years that are spent in ill health has increased. Therefore, preventive activities aimed at this target group are important. Caregivers often see that extending their preventive activities aimed at promoting health leads to more health benefits than the limited focus on health care after damage that has already been incurred. Prevention includes all activities that are aimed at the prevention of health problems that affect the quality of life. Prevention can be classified into different forms of prevention (Fig. 3.1). The nursing practice consists of an intertwining of these different forms of prevention, ranging from universal, primary prevention to tertiary, care-related prevention. Apart from this format, there are other forms of prevention in the nursing profession. Prevention may be classified according to the health problem (for example, cardiovascular diseases), or the disease category (chronic diseases), and the risk factors or symptoms may also be the starting point for the format.
3.1 Universal, Primary Prevention
Universal, primary prevention: to promote health and healthy behavior.
Individual behavioral approach and environment-oriented approach by nudging.
What is universal, primary prevention? Universal, primary prevention is prevention focused on the health of the general population or a part thereof. The goal of universal, primary prevention is to prevent diseases and illnesses and so decrease the incidence and prevalence of diseases and illnesses. Universal, primary prevention is concerned with promoting health and healthy behavior. To target the creation of a health problem that may occur, we need to know the causes of that health problem. Causes of a health problem may be personal characteristics and/or risk factors. In practice, this means that one must have insight into the personal characteristics and/or risk factors showing that there is a relationship with the health problem. If there is a demonstrated link between a personal characteristic and/or risk factor and a health problem, this can be the input for prevention. Except for exposure to the risk factor itself, prevention is focused on the effects of exposure.
For universal, primary prevention, the nursing professional chooses the individual, behavioral perspective as an angle, but reasoning from an environmental perspective is increasingly gaining attention. The environment-oriented approach to prevention is becoming more prominent. An environment-oriented approach to prevention also involves the social and physical environment of the patient in nursing activities aimed at the promotion of health and the prevention of health damage. Environmental interventions directed at promoting health should be nudging, this means that interventions should give people a friendly nudge toward a healthy lifestyle (van den Berg and Schoemaker 2012). Examples of environmental interventions that are nudging is a domestic environment that invites you to take the bike, or a social environment at work or school that encourages you to eat more healthily, or persuades you to be physically active.
What are relevant examples of universal, primary prevention for nursing professionals? Examples of universal, primary prevention are youth vaccinations, attention to oral hygiene, safe sexual behavior and (passive) smoking. Infants and young children should be vaccinated against diphtheria, whooping cough, typhoid, polio, and measles. Caries prevention focused on good oral hygiene is necessary for children aged 0–4 years, because at least 50% of 5- to 7-year-old children have caries in their deciduous teeth. When in a learning package, attention is driven toward brushing teeth in primary education (for children in the age that the permanent dentition develops), we call this universal, primary prevention. Another example is the prevention of sexual violence in children, by increasing the resilience of children. In an education program, resistance of children can be enhanced to better monitor their own borders, possibly by learning through role play and theater. A second goal is the prevention of secondary victimization, i.e., preventing feelings of guilt in children because they were unable to prevent the abuse. Also, countering unwanted intimate behavior and unprotected sex by promoting condom use, is a form of universal, primary prevention. Universal, primary prevention is also preventing children from passive smoking. In about 45% of the households, children are exposed to one or more smokers. Preventive activities of nursing professionals should be aimed at informing parents about the health risks associated with passive smoking. If parents themselves do not want to quit smoking, the intervention should be aimed at not smoking in the proximity of the child.
An example of universal, primary prevention for the elderly is to optimize movement and feeding behavior. Physical activity has a positive effect on, for example, osteoporosis, cardiovascular diseases, and diabetes. If people move moderately, but especially when they are moving at a high intensity level, risk factors for cardiovascular diseases and type 2 diabetes, such as high blood pressure, high cholesterol and glucose levels in the blood and abdominal obesity, are improved (Sassen et al. 2009). A physically active lifestyle further limits the risk of falls in older people, by improving muscle strength. A physically active lifestyle not only reduces physical limitations, but also promotes sleep and improves mood and the overall sense of well-being. Exercise has a beneficial effect on the maximum lung capacity and muscle strength. Universal, primary prevention can also focus on preventing chronic health problems. Healthier dietary behavior is aimed at decreasing the calorie intake, reducing the consumption of saturated fats, and boosting fruit and vegetable consumption.
3.2 Selective, Indicated, Secondary Prevention
Secondary prevention is the early search for and detection and treatment of diseases and disorders.
Selective prevention is aimed at people who are at a high risk, the so-called high-risk group.
Indicated prevention is aimed at people who do not meet the diagnostic criteria for a disease or condition, but have limited symptoms.
What is secondary prevention? Secondary prevention is the early search for and detection and treatment of diseases and disorders.
What is selective prevention? Selective prevention is on the cutting edge of primary and secondary prevention. Selective prevention is focused on that part of the population who are at a high risk, a so-called high-risk group.
What is indicated prevention? Indicated prevention is secondary prevention aimed at people who do not meet the diagnostic criteria for a disease or condition, but have limited symptoms that give an indication of a health problem. Selective and indicated prevention are aimed at the discovery and early treatment of diseases and disorders and the search for diseases and disorders at an early stage. In selective prevention, the starting point is a high-risk group; for indicated prevention, there is already a limited indication for a health problem. Selective and indicated prevention may be aimed at diseases and disorders, but also includes the detection of risky behavior. Examples of selective prevention with a “high-risk”-approach are the detection of familial high blood pressure or diabetes type 2. Examples of indicated prevention, i.e., the detection of diseases and disorders at an early stage, are tracking down people in the first stages of a venereal disease such as gonorrhea, the early detection of dementia and other age-related diseases. An example of the detection of risky behavior is the use of food rich in saturated fat in people with high cholesterol levels. By detecting the health problem earlier, one tries to ensure a better prognosis. This is because an early start with medical and nursing activities will probably improve the health situation. Selective, indicated prevention involves favoring the prognosis of the health problem; it may reduce the treatment load, or it may reduce the sequelae.
An important tool for indicated prevention is screening. By using screening, one tries to investigate at an earlier stage the presence of a disease or condition, or behavior that harms health. The diagnosis is established at an earlier point in time, which means that treatment can be started earlier. The effects of the disease or condition or behavior with an adverse impact on health may be limited or delayed.
What are relevant examples of screening for nursing professionals? Examples include breast cancer screening, screening for language development, screening for eye diseases, and screening on oral health. Breast cancer screening is the only way to reduce mortality from breast cancer and to achieve health gains. Because the risk factors for breast cancer are unknown, universal, primary prevention is not possible. In the screening for language development, a delay in language development can be detected. This is shown frequently in children, and causes serious problems in social and emotional development later in life. Dyslexia is an example of a problem in language development, i.e., the inability to learn to read at a certain level and often also to write, despite normal intelligence. For screening, a language signaling instrument for 0- to 3-year-old children with delayed and/or different language development can be used, to detect any problems early, and early intervention has been shown to prevent a language deficiency. In the screening for eye diseases, early detection by screening of strabismus is important, and can be solved in most children with this condition (Dickey 1999). For strabismus, the early detection and deployment of treatment by alternate taping of the eyes at a very young age delivers a significant improvement and gives a good chance of obtaining a monocular image. In oral health screening for children in primary schools, the detection and treatment of dental plaque and dental erosion can optimize the status of children’s teeth. Children are taught to brush and floss their teeth daily to remove dental plaque, and to drink less soft and fruit drinks.
3.2.2 Patients’ Delay and Doctors’ Delay
For screening, the diagnosis can be highlighted in time in two ways. In the first way, people are screened that do not show any symptoms of disease. We call this the screening of asymptomatic people. In those individuals where symptoms of disease are detected, one starts treatment to achieve health gains. In the second way, screening is directed at preventing the setting of the diagnosis from being delayed.
What patients’ delay? Delay can arise because a patient with obvious symptoms is not diagnosed, because he has not visited a doctor in time. An example is that a patient with changes in a nevus or mole on his skin does not visit the general practitioner or family doctor. This delay in diagnosis is called patient’s delay.
What is doctors’ delay? Delayed diagnosis may also arise because a doctor does not establish the diagnosis in time, or incorrectly. An example is that a doctor may have insufficient knowledge about abnormalities in the skin and skin diseases. This delay in obtaining a diagnosis is called doctor’s delay. Delayed diagnose counteracts appropriate medical treatment and nursing care. Both patients’ and doctors’ delay can be alleviated by targeted education.
Patients’ delay. After a community screening for hypertension, it was found that for half of the patients with high blood pressure, the reference was not followed and no doctor was visited. Of the people who have visited a doctor, it was found that a third of the patients discontinued the treatment of hypertension within a few months (Hynes in: Lerman 2005).
Case-finding is a type of screening in which a specific group of people (and not a whole population) is conducted for a risk factor, risky behavior, and/or health problem. Case-finding is a high-risk approach and is called selective prevention. Case-finding is aimed at people who have more impacting aspects (risk factors, risk behaviors, and/or health problems) at the same time. An example of case-finding by general practitioners and practice nursing professionals is the screening of people with high cholesterol levels in the blood and present familial hypercholesterolemia. Case-finding is concerned with healthy people with a particular risk profile. In the screening for high cholesterol levels, cholesterol-lowering drugs are often prescribed. Because the risk profile in cases of hypercholesterol can also result from lifestyle factors, lifestyle advice can be offered in addition to medication prescription. Another example of case-finding by general practitioners and practice nursing professionals is the screening for diabetes mellitus. By considering fasting blood glucose levels and present familial diabetes, diabetes can be detected in an early stage, or the case-finding of diabetes in people with abdominal obesity and high blood pressure. After case-finding, diabetes treatment is started and directed at the early detection of symptoms. The screening for diabetes mellitus will possibly be extended in the future. Currently, there is insufficient evidence that large-scale screening of persons without any complaints is effective and efficient.
Case-finding is in fact the counterpart of the population approach. In population surveys, a population-oriented approach is used in which (a clearly defined part of) the healthy population is systematically examined. The population research can focus on a risk factor, risky behavior and/or health problem. By using case-finding, screening of nonhealthy people with a particular risk profile is undertaken. The case-finding is focused on a risk factor, risky behavior and/or health problem. Treatment is known to be efficient and effective.
A question that is becoming increasingly important is whether the screening of high-risk groups should be imposed because of general interest or should always be the choice of an individualhimself. The screening of high-risk groups from imposing a general interest to people is called the public health imperative. The screening of high-risk individuals is described as an individual informed choice, as the screening of high-risk groups is an individual choice, with the prerequisite that a person is well informed about the screening.
The main stumbling block for the effectiveness of case-finding or the high-risk approach is the involvement of the medical profession. For the medical profession, case-finding leads to a higher work load in the short term, with only possible health benefits in the long term. For some reason (working pressure, financing structure), the medical profession does not include prevention in care and treatment, whereas prevention would produce significant health gains.
In screening, the positive and negative effects that an intervention may have should always be weighed up. On the one hand, the early detection of a health problem (for example, in breast cancer screening) gives the possibility of an earlier and thus more successful treatment. On the other hand, screening may and often does cause anxiety. Another factor is that screening may give rise to uncertainties and false-positive results may emerge. As a result, further testing is sometimes necessary.
Can people cope well with the symptoms they experience? For secondary prevention, it is important that people cope well with the symptoms they experience. For 10–25% of the times that people experience symptoms of a disease, this results in contacting a doctor. Many people use over-the-counter medication before they visit a doctor. Older people often have one or more symptoms of a disease, but are less likely to report this because they see them as related to older age. Is this a case of patient’s delay? Elderly people typically underestimate general symptoms, such as headache, nausea, coughing and fatigue, which everyone experiences from time to time and that can be attributed to physical, mental or social conditions. However, elderly people do recognize specific symptoms of a particular disease as being important because of the knowledge they have obtained through health care providers, the media, social observation, and analysis based on life events.
People seem to become increasingly better able to recognize early symptoms. Also, those people with mental health problems (such as anxiety disorders and depression) are becoming better at recognizing early symptoms and search for help; in addition, people with diabetes mellitus contact health care professionals earlier than in the past.
Can people cope well with symptoms of cancer? Do people with symptoms of cancer exhibit the desired help-seeking behavior? In an investigation of the relationship between knowledge about cancer-related symptoms and whether to consult the doctor, we see some differences. The question in one study was, for what kind of symptoms would patients decide to consult a doctor. Most people have little knowledge of symptoms related to cancer and do not have the desired help-seeking behavior. Even if people do know what symptoms are indicative of cancer, it turns out this is not enough to proceed with seeking help. The reason for this seems to be that cancer causes anxiety and other negative feelings. Recognizing symptoms makes people afraid that they may indeed have cancer. This results in them avoiding screening programs (Sheikh and Ogden 1998).
3.3 Care-Related, Tertiary Prevention
Care-related, tertiary prevention, optimizing health, even though people have a disease or health problem.
Patients meet the criteria to be diagnosed with a health problem.
The goal is to optimize the health situation with given physical and/or mental disorders, limitations or handicaps.
What is care-related, tertiary prevention? Care-related, tertiary prevention is aimed at people who meet the criteria to be diagnosed with a health problem, and optimizing the health situation, even though a person has an existing disease or condition. This includes optimizing the health situation within the possibilities and with the restrictions imposed by the disease or condition. With health care-related tertiary prevention, one seeks to prevent the manifestation of the health problem, leading to complications and the emergence of persistent disorders, limitations or handicaps. Care-related, tertiary prevention consists of care and treatment for patients.
What are nursing-relevant examples of care-related, tertiary prevention? An example is to physically and mentally activate (bedridden) people with a (severe) mental disability. Rehabilitation after stroke is another example, or learning to pick up the threads of life after a severe depression. It is always directed at optimizing the health situation with given physical and/or mental limitations. Health care-related, tertiary prevention is often an important element of the care for patients with chronic health problems and is aimed at promoting self-management of the patient.
Strictly speaking, care-related, tertiary prevention has little to do with the prevention of diseases. Care-related, tertiary prevention is specifically intended to assist patients to be as care-independent as possible. For nursing professionals, the starting point of their care delivery concerns this care independence of the patient.
What is casuistic prevention? Care-related, tertiary prevention is closely linked with casuistic prevention. Casuistic prevention is closely linked to the care of the patient and his environment. This form of prevention is called casuistic, because it is directly associated with the individual care situation of the patient, and in that sense, with the provision of specific care. An example of casuistic prevention is an intervention to optimize self-management for patients with COPD. Adults with COPD are offered an intervention to better cope with the condition, to optimize their health situation and to prevent the improper use of health care facilities. The intervention in this example consists of a self-help book combined with various interventions to optimize cognitive skills and patient compliance, with the goal of reaching appropriate medication use, in addition to learning to seek social support.
What is the role of the patient in prevention? For prevention to be successful, the involvement of the patient is of utmost importance. In the case of universal, primary prevention, the role of the patient as the receiver of prevention can be limited. But in selective and indicated, secondary prevention, and certainly in care-related, tertiary prevention, this is not possible. Without the involvement of the receiver, prevention is often doomed to failure.
3.4 Classifications of Prevention
The forms of prevention (primary prevention, secondary prevention, and care-related, tertiary prevention) that have been described in the previous paragraphs, can be differentiated, but not usually separated, as the professional practice of nursing professionals shows. In sexually transmitted diseases, for example, successful secondary prevention using screening and (early) treatment is of great importance. However, there should also be a focus on universal, primary prevention, which is aimed at changing the risky behavior so that transmission does not take place. Another example is depression in the elderly. For the long-term prevention of depression, secondary prevention, with the screening of early symptoms of depression, and care-related, tertiary prevention in the form of treatment are important, but should also include changing lifestyle factors and behavior, such as increasing self-management, improving medication use, teaching appropriate coping strategies to deal with loneliness, and to learn to seek social support.
Combining the different forms of prevention (primary prevention, indicated prevention, and care-related, tertiary prevention) gives the best chance of health benefits. Within the professional practice of nursing professionals, the various forms of prevention can be seen at the same time, even at the level of the individual patient. An example of this is dental caries prevention in a seriously ill child with leukemia. For primary prevention, the focus is on the prevention of tooth decay, and for care-related, tertiary prevention the focus is on dealing with the physical and mental limitations that result from living with a major disease such as leukemia, improving self-management, incorporating desired lifestyle changes, such as maintaining a healthy rest and school rhythm, drug use, etc. The various forms of prevention are clearly aligned and, certainly within the nursing profession, inextricably linked.
Figure 3.1 shows the different forms of prevention schematically placed in relation to each other, with primary prevention, secondary prevention and tertiary prevention (care) in the first column. When one starts looking at the individual level of a disease in the second column, they range from healthy people, people with risk factors and/or symptoms, to people with (chronic) disease. The International Classification of Functions (ICF) is shown in the third column, running from being healthy to having restrictions in functions, activities or participation. Universal prevention is the starting point and is usually aimed at the whole population or at larger parts of the population (see columns 4 and 5). Then, selective and indicated prevention describes in the figure the transition to care and care-related prevention. Selective prevention, at the interface between primary and secondary prevention, focuses on high-risk groups. Indicated prevention is aimed at people who have limited symptoms of a health problem. Finally, it is clear from the figure that care-related prevention is focused on the individual, often the individual patient, who meets the criteria for being diagnosed with a health problem. Universal prevention runs right on with primary prevention. Selective and indicated prevention is (almost) the same as secondary prevention. Finally, care-related prevention as a whole is also equal to tertiary prevention.
The forms of prevention as they are described above may also be seen as stages in the disease process. In Fig. 3.2, the disease process in time is displayed (Gunning-Schepers et al. 1995). From a nursing point of view, it starts with universal, primary prevention. Universal, primary prevention is followed by secondary prevention and finally by care-related, tertiary prevention. In the first stage, universal, primary prevention is aimed at preventing health problems in a person (with a possibly increased risk). In the second stage, the phase of the early detection of a health problem, the goal is aimed at setting therapy to improve the prognosis of the health problem. The third stage, with care-related, tertiary prevention, starts if the health problem has become manifest. The goal at this stage is to prevent the existing disorder from becoming chronic and complications and/or restrictions resulting from the health problem from arising.
Finally, the objective tree of prevention (Fig. 3.3) (van den Berg and Schoemaker 2012) shows a way of keeping the various forms of prevention clear. The objective tree of prevention offers a schematic representation of prevention and health. On the one hand, healthy people and on the other hand, sick people with the consequences of sickness. The tree firmly anchors health in the soil. Focused on health and health determinants, universal and selective prevention are offered, more often at a collective, population level. If health problems have arisen, health problems and the consequences of sickness are the starting point for indicated prevention and for care-related prevention, more often at anindividual level.
3.5 Levels of Prevention, Individual, and Collective Prevention
Levels of prevention:
Individual prevention is offered to a person with an individual (high) risk, to prevent, to reduce or treat the risk – high-risk approach.
Collective prevention is offered to a specific group in the population or to the population as a whole, directed at a health risk with a common character. Detecting the risk factor decreases the chance that the risk factor in the entire population leads to diseases or conditions – population approach.
Anonymity of prevention.
Prevention should improve the state of health of the individual, of groups, and eventually of the whole population. We make a distinction between individual prevention and collective prevention, where the starting point is the scale.
What is individual prevention? We speak of individual prevention in an individual person with an individual (high) risk who is using health care facilities to prevent a risk, to reduce the risk, or to treat the risk. In this case, the nursing professional provides care to an individual patient with a health risk related to his physical, mental, and/or social situation. The goal of individual prevention is to prevent threatening factors from acting on human health, to limit further damage to the health or to supply specific care. An example is the targeted prevention of allergies in infants, or oral care in the elderly.