Levels of Prevention

• Primary
• Secondary
• Tertiary
 Intervention

Any attempt to intervene or interrupt the usual

sequence in the development of disease.
• This may be provision of:
– Treatment
– Education
– Help or
– Social support
 Five Modes of Intervention
1. Health promotion
2. Specific Protection
3. Early Diagnosis and treatment
4. Disability Limitation
5. Rehabilitation
 PERIOD OF PRE-PATHOGENESIS PERIOD OF PATHOGENESIS
Human (Host) is not
Course of Disease in Humans
infected
NATURAL HISTORY OF DISEASE

DEATH
Environment Chronic State
Defect
Disability
Epidemiological Clinical Horizon
Illness
Triad Asymptomic Symptoms & Signs
Agent Host Tissue & Physiological
Changes
Immunity & Resistance
bringing Agent, host and Stimulus or agent becomes
established & multiplies RECOVERY
Environment together
Interaction of
results in the stimulus Host Reaction
Host & stimulus
In the Early Discernible Advanced Convalesce
Human Pathogenesis early Lesions disease nce
Host
Levels of
Secondary
Prevention Primary Prevention Tertiary Prevention
prevention
Modes of Health Specific Early diagnosis Disability
nterventionPromotion Rehabilitation
Protection & Treatment Limitation
 Health Promotion
• Process of enabling people to increase control
over and to improve health.
It is not directed against any particular disease
But is
Intended to strengthen the host
through a variety of interventions.
 Interventions to Promote Health
1. Health Education
2. Environmental Modification
3. Nutritional Interventions
4. Lifestyle and behavioral changes
 Health Education
• The most cost-effective intervention.
• A large number of diseases could be prevented
with no or little medical intervention if people
are informed about them and if they are
motivated to take necessary precautions in time.
 Health education : Definitions
• A translation of what is known about health, into desirable
behavior, individual and community pattern by
educational process.
• The process by which individuals and groups of people
learn to behave in a manner conducive to the promotion,
maintenance or restoration of health.
• A process that informs, motivates and help people to
adopt and maintain healthy practices and lifestyles,
advocates environmental changes as needed to facilitate
this goal and conduct professional training and research
to the same end.
 Communication for Health
• Communication and education are interwoven.
• Communication is more than mere exchange of
information.
• Communication is a two-way process of
exchanging or shaping ideas, feelings and
information.
• The ultimate goal of all communication is to
bring about a change in the desired direction of
the person who is receives the communication.
 Patterns of Change in Person
as a result of communication

• There are three (3) levels of change:

– Cognitive: increase in knowledge
– Affective: changing existing patterns of behavior
and attitudes
– Psychomotor: acquiring new skills
 Communication Process

Sender Message Channel Receiver

Feed back
 Channels of Communication
• By Channel is implied the “ physical bridges’ or
the media of communication between sender
and the receiver.
• Media Systems:
– Interpersonal Communication
– Mass Media
– Traditional or Folk Media
 Types of communication
• One-way communication (Didactic method)
• Two-way communication ( Socratic method)
• Verbal communication
• Non-verbal communication
• Formal and informal communication
• Visual communication
• Telecommunication and Internet
 One-way communication
(Didactic method)

• The flow of communication is “one-way” from

the communicator to the audience. E.g.,
Lectures in class rooms.
• Drawbacks:
– Knowledge is imposed
– Learning is authoritative
– Little audience participation
– No feedback
– Does not influence human behavior
 Two-way communication
( Socratic method)

• Both communicator and the audience take

part.
• The audience may raise questions, and add
their own information, ideas and opinions to
the subject.
• The process of learning is active and
democratic.
• More likely to influence behavior
 Verbal communication
• The traditional way of communication is by
“word of mouth’.
• May be loaded with hidden meanings
• It is persuasive than indirect or written
communication
 Non-verbal communication
• Includes a wide range of bodily movements,
postures, gestures, facial expressions (e.g.,
smile, raised eye-brows, frown, staring, gazing
etc.)
• Silence is non-verbal communication and is
louder than words
 Barriers of Communication
Types Examples
Physiological Difficulties in hearing, expression
Psychological Emotional disturbance
Environmental Noise, invisibility, congestion
Cultural Illiteracy
Levels of knowledge and understanding
Customs
Beliefs
Religion
Attitudes
Socio-economic disparities
Language
Cultural gaps between indigenous and immigrants and
foreigners
Rural-urban divide
 Approaches to Health Education
• Regulatory Approach (Managed Approach)
based on government intervention
• Service Approach
based on provision of services at the door step (do not reflect felt
needs)
• Health education approach
Based on the assumption informed people make good decisions
themselves
• Primary health care approach
Based on active community participation
 Contents of Health Education
• Human Biology
• Nutrition
• Hygiene
• Family health
• Disease prevention and control
• Mental health
• Prevention of Accidents
• Use of health services
 Principles of Health Education
• Credibility
• Interest
• Participation
• Motivation
• Comprehension
• Reinforcement
• Learning by doing
• Setting an example
• Good human relations
• Feedback
• Leaders
 Health Promotion
2. Environmental Modification

A comprehensive approach to health promotion

requires environmental modification which
includes:
– Provision of safe water
– Installation of sanitary latrines
– Control of insects and rodents
– Improvement of housing ; etc, etc.
 Health Promotion
3. Nutritional Intervention
• Food distribution and nutrition improvement
of vulnerable groups
• Child feeding programs
• Food fortification
• Nutrition education
 Health Promotion
4. Lifestyle and Behavioral Changes
• Denotes “ the way people live”.
• Reflects a whole range of social values, attitudes
and activities.
• Composed of cultural and behavioral patterns
and lifelong personal habits (e.g., smoking and
alcoholism developed through socialization.
• Lifestyles are learnt through social interaction
with parents, peer groups, friends and siblings
and through school and mass media
• Many health problems e.g., coronary heart
disease, obesity, lung cancer, drug addiction)
are associated with lifestyle changes.
• In developing countries, risks of illness and
health are associated with lack of sanitation,
poor nutrition, personal hygiene, elementary
human habits, customs and cultural patterns.
• Health is both a consequence of an
individual’s lifestyle and a factor in
determining it.
 Primary Prevention
Specific Protection

• Immunization
• Use of specific nutrients
• Chemoprophylaxis
• Protection against occupational hazards
• Protection against accidents
• Protection from carcinogens
• Avoidance of allergens
• Control of specific hazards in environment, e.g., air pollution,
noise pollution
• Control of consumer product quality and safety of foods, drugs,
cosmetics, etc.
 Health Protection
• The provision of conditions for normal mental and
physical functioning of human beings individually and
in the group.
• It includes the promotion of health, the prevention of
sickness and curative and restorative medicine in all
aspects.
Health protection is conceived as an integral part of an
overall community development programs, associated
with activities such as literacy campaigns, education and
food production.
Immunization
 Biological Shield
• A large proportion of infants remain free from
potent infections up to 3 months , or even
longer.
• Due to IgM and IgG in cord blood and plasma
of infants born immuneto mothers.
• Active Immunity
– Humoral immunity
– Cellular immunity
– Combination of both
• Passive Immunity
– Normal Human Ig
– Specific human Ig
– Animal antitoxins or antisera
 Immune response to antigens
• Primary response:
– There is a latent period of induction of 3-10 days before
antibodies appear in the blood. (the antibody elicited is
entirely of IgM type.
– IgG appears after few days , reaches peak in 7-10 days and
then gradually fall over a period of weeks and months.
• Secondary (booster)response
– Differs from primary response:
• Short latent period
• Antibody more abundant
• Antibody response maintained at higher level for a
longer period of time.
• Antibody elicited have more avidity for antigens
 Who is Immune?
• A person is said to be immune when he
possesses “ specific protective antibodies
or cellular immunity as a result of previous
infection or immunization, or is so
conditioned by such previous experiences as
so to respond adequately to prevent infection
and/or clinical illness following exposure to a
specific infectious agent” .
 Immunization
• The process by which an individual's immune
system becomes fortified against an agent
(known as the immunogen).
• When this system is exposed to molecules that
are foreign to the body (non-self), it will
orchestrate an immune response, and it will also
develop the ability to quickly respond to a
subsequent encounter (through 
immunological memory).
 • Any substance, usually proteins or polysaccharides that
causes immune system to produce antibodies against it.
Antigen
•This includes parts (coats, capsules, cell walls, flagella,
fimbrae, and toxins) of bacteria, viruses, and other microorganisms.
• At the molecular level, an antigen is characterized by its
ability to be "bound" at the antigen-binding site of an antibody.

• also known as an immunoglobulin, is a large Y-shaped

proteins produced by  B- cells that is used by the immune
Antibody system to identify and neutralize foreign objects such as
bacteria and viruses.
• The antibody recognizes a unique part of the foreign target,
called an antigen.
 Immunity

Active Immunity Passive Immunity

Natural Artificial Natural Artificial

• Colostrum
Infection Vaccines • Placental • Anti-toxins
• Live attenuated organisms antibodies • Anti-sera
• Killed organisms
• Extracted cellular fractions • Human Ig
• Toxoids
Passive versus Active Immunization
• Passive immunity is:
– Rapidly established
– Immunity produced is only temporary.
– No education of reticulo-endothelial system
(immunological memory)
 Prophylactic versus therapeutic
immunization
• Most vaccines are given prophylactically, i.e. prior to exposure to the pathogen.
• However, some vaccines can be administered therapeutically, i.e. post
exposure (e.g., rabies virus). The effectiveness of this mode of immunization
depends on the rate of replication of the pathogen, incubation period
and the pathogenic mechanism. For this reason, only a booster shot with
tetanus is sufficient if the exposure to the pathogen is within less than 10 years
and if the exposure is minimal (wounds are relatively superficial).
• In a situation where the pathogen has a short incubation period, only a small
amount of pathogenic molecules could be fatal (e.g., tetanus and diphtheria);
therefore both passive and active post exposure immunization are essential.
This is also the case when a bolus of infection is relatively large.
 Herd Immunity
• “The resistance of a group to invasion and spread of an
infectious agent, based on the immunity of a high proportion
of individual of the group”.
• During the course of an epidemic a number of susceptible
people come down with the disease, thus providing multiple
sources of infection to others.
• As the epidemic progresses the proportion of non-
susceptible ones increases and the likelihood of effective
contact between patients with the disease and remaining
susceptible declines.
• Herd Immunity can be quoted as an example of Public Good.
 Secondary Prevention

Early Detection & Treatment

 Early Detection of Health Impairment

“The detection of disturbances of homeostatic

and compensatory mechanism
while
biochemical, morphological, and functional
changes are still reversible.”
• In order to prevent overt disease or disablement, the
criteria of diagnosis should be based on early
biochemical, morphological and functional changes that
precede the occurrence of manifest signs and symptoms.
(This is of particular importance in chronic diseases.)
• Early Diagnosis and treatment , though not as cost-effective
as primary prevention, may be critically important:
– in reducing the high morbidity and mortality in certain diseases
such as essential hypertension, cancer of cervix and breast.
– the only effective mode of intervention for many diseases
like tuberculosis, leprosy and STD,
• Effective therapy shortens considerably
– the period of communicability &
– reduce the mortality from acute communicable diseases.
 Mass Treatment
• Mass treatment approach is used in the control of
certain diseases such as yaws, pinta, bejel, trachoma
and malaria.
• The rationale for a mass treatment is the existence
of at least 4-5 cases of latent infection for each
clinical case of active disease in the community.
• Variants of mass treatment:
– Total mass treatment
– Juvenile mass treatment
– Selective mass treatment
Screening of Disease
 Concept of Screening

The active search of disease among apparently

health is a fundamental aspect of prevention.
 Definition
The presumptive identification of
unrecognized disease or defect
by the application of
tests, examination or other procedures
which can be applied rapidly.
• Screening tests sort out apparently well
person who probably have disease from those
who probably do not.
• A screening test is not intended to be
diagnostic.
• Persons with positive or suspicious findings
must be referred to their physicians for
diagnosis and necessary treatment
• Screening is an initial examination only, and
positive responders require a second,
diagnostic examination.
• The initiative for screening usually come form
the investigator or the person or agency
providing care rather than from a patient with
a complaint.
• Screening is usually concerned with chronic
illness and aims to detect disease not yet
under medical care.
 Principles/Criteria of Screening
(WHO Guidelines:1968)
• The condition should be an important health problem.
• There should be a treatment for the condition.
• Facilities for diagnosis and treatment should be available.
• There should be a latent stage of the disease.
• There should be a test or examination for the condition.
• The test should be acceptable to the population.
• The natural history of the disease should be adequately
understood.
• There should be an agreed policy on whom to treat.
• The total cost of finding a case should be economically balanced
in relation to medical expenditure as a whole.
• Case-finding should be a continuous process, not just a "once and
for all" project.
Concept of Lead Time
 Screening versus Diagnostic
Screening test
Done on apparently healthy
Applied on groups
Test results are arbitrary and final
Based on one criterion or cut-off point
Less accurate
Less expensive
Not a basis for treatment
The initiative comes from investigator or
agency
Diagnostic test
Done on those with indications or sick
Applied on single patients, all diseases
are considered
Diagnosis is not final but modified in
light of new evidence
Based on evaluation of a number of
symptoms, signs and laboratory findings
More accurate
More expensive
Used as a basis for treatment
The initiative comes from a patient with
a complaint
 Uses of Screening
• Case Detection
– Also known as “Prescriptive Screening”
– The presumptive identification of unrecognized disease, which does
not arise from a patient’s request, e.g., neonatal screening.
– Since disease detection is initiated by medical and public health
personnel, they are under special obligation to make sure that
appropriate treatment is started early .

• Control of disease
– Also known as “Prospective Screening
– People are examined for the benefit for the others, e.g., screening of
immigrants to protect home population

• Research purposes
• Educational opportunities
 Types of Screening
• Mass Screening:
– whole population, all adults etc, etc,.
• High risk screening:
– Low socio-economic women for screening CA
Cervix
• Multiphase screening:
– Application of two or more screening tests in
combination
 CONDITIONS FOR WHICH SCREENING
HAS PROVED COST-EFFECTIVE
• Phenylketonuria (neonatal period)
• Hypothyroidism congenital (neonatal period)
• Iron deficiency anemia (at 9 months old)
• Lead poisoning (in preschoolers)
• Tuberculosis (regularly during childhood)
• Vision impairment (in children 3-4 years of age)
• Assessment of physical growth & developmental status
• Measurement of BP (in children 3 years of age & older)
• Hearing assessment
• identification of Sickle cell anemia
 Sensitivity (true-positive rate)
• The proportion ofTrue Status
truly diseased Total
persons(True
Screening
Positives)
test results who are identified by screening
Diseased Not
test. -Diseased
A
• A measure of the
Sensitivity= A probability of correctly
Positive B A+B
diagnosing a case, or the probability that any
A+C
given case will be
Negative C identified.D C+D
Total A+C B+D A+B+C+D
 Sensitivity (true-positive rate)
• The proportion ofTrue Status
truly diseased Total
persons(True
Screening
Positives)
test results who are identified by screening
Diseased Not
test. -Diseased
A
• A measure of the
Sensitivity= A probability of correctly
Positive B A+B
diagnosing a case, or the probability that any
A+C
given case will be
Negative C identified.D C+D
Total A+C B+D A+B+C+D
 Sensitivity (true-positive rate)
• The proportion ofTrue Status
truly diseased Total
persons(True
Screening
Positives)
test results who are identified by screening
Diseased Not
test. -Diseased
A
• A measure of the
Sensitivity= A probability of correctly
Positive B A+B
diagnosing a case, or the probability that any
A+C
given case will be
Negative C identified.D C+D
Total A+C B+D A+B+C+D
 Specificity (true-negative rate)
True Status Total
• TheScreening
proportion of truly non-diseased
test results
persons(True Negative)
Diseased
whoNot
are identified by
screening test. -Diseased
D
• A measure of the
Specificity= A probability of correctly
Positive B a screening
A+B
identifying a non-diseased with
B+D
test.
Negative C D C+D

Total A+C B+D A+B+C+D

Positive Predictive Value/ Precision
True Status Total
• The Screening
probability that a person with a positive test
test results
is a true positive (i.e., does have a disease).
Diseased Not
• Precision is sometimes stratified into:
-Diseased
A A
– Repeatability — the variation arising when all efforts
NPV=
PPV=
Positive A
are made to keep conditions B by using
constant A+Bthe
same instrument and A+B A+B and repeating during a
operator,
short time period;
Negative C variation arising
D using theC+Dsame
– Reproducibility — the
measurement process among different instruments
and operators,
Total and over longer B+D
A+C time periods.
A+B+C+D
 Negative Predictive Value
True Status Total
• TheScreening
probability that a person with a negative
test results
test does not have a
Diseased
disease).
Not
-Diseased
D
Positive NPV= A B A+B
C+D

Negative C D C+D

Total A+C B+D A+B+C+D

 Accuracy
True Status Total
• TheScreening
extent to which a measurement, or an
test results
estimate based on measurements,
Diseased Not
represents
the true value of the variable being measured.
-Diseased
A+D
Positive
Accuracy= A B A+B
A+B+C+D
Negative C D C+D

Total A+C B+D A+B+C+D

True positive Sick people
correctly diagnosed as sick

False positive Healthy people

incorrectly identified as sick

True negative Healthy people

correctly identified as healthy

False negative Sick people

incorrectly identified as healthy
 YIELD
• The amount of the previously unrecognized
disease that is diagnosed and brought to
treatment as a result of screening
• Factors that affect the yield:
– Sensitivity of the test
– Prevalence of unrecognized disease
– Multiphase screening
– Frequency of screening
– Participation in screening & follow-up
 Validity
• The degree to which an instrument measures
what it is intended to measure
• The degree to which a Research design allows
for a reasonable interpretations from the data,
based on the controls (internal validity),
appropriate definitions (construct validity),
appropriate analysis procedures (statistical
conclusion validity), and generalizibility
(external validity)
 INTERNAL VALIDITY
• The degree to which the relationship between
the independent and dependent variables is
free from the effects of extraneous factors;
 EXTERNAL VALIDITY
• A study is externally valid or generalizable if it
can produce unbiased inferences regarding a
target population (beyond the subjects in the
study).
• This aspect of validity is only meaningful with
regard to a specified external target
population
 RELIABILITY
• The extent to which a measurement is consistent and
free from error.
• The degree of stability exhibited when a
measurement is repeated under identical conditions.
• The degree to which the results obtained by a
measurement procedure can be replicated.
• Conceptualized as dependability or predictability
• A reliable instrument is one that will perform with
predictable consistency under set conditions.
 INTER-RATER RELIABILITY
• The reliability between measurements made
by two different raters on a given variable.
• The degree to which two or more raters can
obtain the same ratings for a given variable.
 INTRA-RATER RELIABILITY
• The reliability between measurements made
by the same person (or rater) at two different
points in time;
• The degree to which one rater can obtain the
same rating on multiple occasions of
measuring the same variable.
Disability Limitation & Rehabilitation
 Disability
Magnitude of Problem
• About a billion people in the world have some form of
disability as a result of movement, hearing, seeing, or
mental impairment.
• 110-190 million encounter significant difficulties in their
daily lives.
• 50% of disabled persons cannot afford health care.
• A lack of attention to their needs means that they are
confronted with barriers at every turn. These include
stigma and discrimination; lack of adequate health care
and rehabilitation services; and inaccessible transport,
buildings and information.
DALYs= Disability Adjusted Life Years

The sum of years of potential life lost due to

premature mortality and the years of
productive life lost due to disability.
 Definitions
( according to ICIDH)
Any loss or abnormality of
Impairment psychological, physiological or anatomical
structure or function
Any restriction or lack (resulting from an impairment) of
Disability ability to perform an activity in the manner or within the
range of normal for a human being

• A disadvantage for a given individual, resulting from impairment

or disability, that limits or prevents the fulfillment of a role that is
Handicap normal (depending on age, sex, social and cultural factors) for
that individual. (Disability is associated with social exclusion.)
• The concept of handicap also includes the role of society in
creating barriers and limit opportunities for people with
disabilities
These are useful in planning for rehabilitation within healthcare
services because they bring attention to the continuum needed
between disability prevention and rehabilitation.
 Examples explaining terms
Accident Disease or Disorder

Impairment
Loss of Foot (Extrinsic or Intrinsic)

Cannot walk Disability

(Objectified)

Unemployed Handicap
(Socialized)
 Disability Limitation
• Late in pathogenesis phase, the mode of intervention is
Disability limitation.
• The objective is to prevent or halt the transition of the
disease process from impairment to handicap.
• Intervention in disability is often Social or
Environmental as well as Medical.
• Impairment which is earlier stage has large medical
component.
• Disability and Handicap which are later stages have
large social and environmental components in terms of
dependence and social cost.
 Disability Prevention
• It relates to all levels of prevention:
– Reducing the occurrence of impairment, e.g.,
immunization against polio (primary prevention)
– Disability limitation by appropriate treatment
(secondary prevention)
– Preventing the transition of disability into
handicap (tertiary prevention)
 Major causes of Disabling Impairments
(in developing countries)
• Communicable diseases
• Malnutrition
• Low quality of perinatal care
• Accidents
 Rehabilitation
• The combined and coordinated use of medical,
social, education and vocational measures for
training and retraining the individual to the
highest possible level of functional ability.
• Includes all measures aimed at:
– Reducing the impact of disabling and handicapping
conditions and
– Enabling the disabled and handicapped to achieve
social integration
 Social Integration
• Active participation of disabled and
handicapped people in the mainstream of
community life.
 Domains of Rehabilitation
Medical Restoration of function
Rehabilitation

Vocational Restoration of the capacity to earn livelihood

Rehabilitation

Social Restoration of family and social relationship

Rehabilitation

Psychological Restoration of personal dignity and confidence

Rehabilitation
 Disciplines of Rehabilitation
• Physical medicine or Physiotherapy
• Occupational therapy
• Speech therapy
• Audiology
• Psychology
• Education
• Social work
• Vocational guidance
• Placement services
 Examples of Rehabilitation
• Establishing schools for blondes
• Provision of aids for crippled
• Reconstructive surgery in leprosy
• Muscle re-education and graded exercises in
neurological disorders
• Change of profession for a more suitable one
• Modification of life in general