|Year : 2014 | Volume
| Issue : 2 | Page : 254-256
Changing concept of disease prevention: From primordial to quaternary
Harshal Tukaram Pandve
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, Maharashtra, India
|Date of Web Publication||11-Nov-2014|
Harshal Tukaram Pandve
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pandve HT. Changing concept of disease prevention: From primordial to quaternary
. Arch Med Health Sci 2014;2:254-6
"Prevention is better than cure" or "an ounce of prevention worth a pound of cure." Both these sayings are undoubtedly true. Research underlines that prevention is necessary. Through high-quality prevention, we can create community environments that foster good health. Prevention is our best hope for reducing unnecessary demand on the healthcare system. This review article discusses historical aspects related to concept of prevention and change in this concept over period years.
| Disease Prevention|| |
Disease prevention covers 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. 
Prevention has several meanings. When many physicians talk about prevention, they refer to screening tests, vaccinations, and prescribing medication. Prevention may also refer to a more fundamental, perhaps truer way to avoid disease, unrelated to prescription drugs or devices, a subject that has drawn insufficient interest from evidence-based medicine so far. This includes what the patient can do personally to delay disease or risk factors, behavioral lifestyle measures that applied sufficiently over the anticipated incubation period of a disease can avoid the appearance of risk factors entirely.  Preventive measures can be applied at any stage along the natural history of a disease, with the goal of preventing further progression of the condition. 
| Levels of Prevention|| |
Levels of prevention or preventive actions can be broadly divided in terms of few main categories, but in reality, the stages blur one into the next. Over period of many years, the concept of prevention has advanced from primordial to quaternary.
The term primary prevention was coined in the late 1940s by Leavell and Clark and was used to describe 'measures applicable to a particular disease or group of diseases to intercept the causes of disease before they involve man. 
Although Leavell and Clark's definition is mostly disease-oriented, the applications of primary prevention extend beyond medical problems and include the prevention of other societal concerns. Primary prevention seeks to prevent the onset of specific diseases via risk reduction, by altering behaviors or exposures that can lead to disease, or by enhancing resistance to the effects of exposure to a disease agent. Primary prevention reduces the incidence of disease by addressing disease risk factors or by enhancing resistance. 
In 1978, Strasser suggested that prevention of cardiovascular disease (CVD) should go beyond the concept of primary prevention. Strasser coined the term 'primordial prevention' to denote activities that prevented the penetration of risk factors into the population by intervening to stop the appearance of the risk factors. He suggested that prevention of CVD should go beyond the concept of primary prevention.  Primordial prevention prevents the appearance of the mediating risk factors in the population, focusing on aspects of social organization and aiming to modify the conditions that generate and structure the unequal distribution of health-damaging exposures, susceptibilities and health-protective resources among the population.  It addresses broad health determinants rather than preventing personal exposure to risk factors, which is the goal of primary prevention. 
Terms secondary prevention and tertiary prevention were also coined by Leavell and Clark. Secondary prevention includes procedures that detect and treat pre-clinical pathological changes and thereby control disease progression. Screening procedures are often the first step, leading to early interventions that are more cost effective than intervening once symptoms appear.  It is also known as "Health Maintenance."
Once a developed disease has been treated during its acute clinical phase, tertiary prevention seeks to soften the impact caused by the disease on the patient's function, longevity, and quality of life. Tertiary prevention can include modifying risk factors. Where the condition is not reversible, tertiary prevention focuses on rehabilitation, assisting the patient to accommodate to his disability. The key goal for tertiary prevention is to enhance quality of life. 
New knowledge points to the fact that prevention can also do harm. Under the concept of "quaternary prevention," efforts are currently focused on finding the right measure of preventive care, true to the old medical tenet "primum non nocere." 
This level of prevention, however, has recently been suggested. This is termed as quaternary prevention that was first proposed by Jamoulle and Roland in 1986 as a conceptual framework for family practice.  Quaternary prevention is defined as "action taken to identify patient at risk of over medicalization, to protect him from new medical invasion, and to suggest him interventions that are ethically acceptable."
The concept of quaternary prevention makes it easier to "identify patient at risk of over medicalization." This phrase is one, which has never been as necessary as today.  The strongest means to accomplish this is to listen better to the patients. This is what has been termed "Narrative-based Medicine," which means to adapt the medically possible to the individual needs and wants. The other important means is called "Evidence-based Medicine". The knowledge of the probable predictive values of diagnostic tests and the probabilities of effect sizes of benefit and harm of therapy and preventive measures give us the opportunity to leave out many useless procedures.
| Spectrum of Prevention|| |
The Spectrum of Prevention was originally developed by Larry Cohen in 1983, which is based on the work of Marshall Swift (1975) in preventing developmental disabilities. The first level of the Spectrum, strengthening individual knowledge and skills, emphasizes enhancing individual skills that are essential in healthy behaviors.
The second level of the spectrum, promoting community education, entails reaching people with information and resources to promote their health and safety. The third level of the spectrum is educating providers. Because healthcare providers are a trusted source of health-related information, they are a key group to reach with strategies for prevention. Level four of the spectrum, fostering coalitions and networks, focuses on collaboration and community organizing. The fifth level of the spectrum, changing organizational practices, deals with organizational change from a systems perspective. The sixth level of the spectrum, influencing policy and legislation, has the potential for achieving the broadest impact across a community. 
| Conclusion|| |
Strasser suggested primordial prevention to stop the appearance of the risk factors. Leavell and Clark defined primary and secondary prevention as health measures before and after the disease in question comes into existence. Secondary prevention was confined to early disease stages, for example disease detected by screening. Tertiary prevention was related to avoiding complications of already clinically manifested diseases and was used for rehabilitation measures. All these have been driven by doctor-centered approaches to health care. Quaternary prevention concept introduces a new strategy, combining patient and doctor's views and elaborating on a prevention concept based on this relationship. Its new way of dealing with the prevention concept breaks away from the former chronological way.  To conclude, concept of prevention has advances over the years from primodial to quaternary and from doctor driven to patient centered as well.
| References|| |
|1.||Glossary Terms used in Health for All series (N°9). Geneva: WHO; 1984. |
|2.||Kones R. Is prevention a fantasy, or the future of medicine? A panoramic view of recent data, status, and direction in cardiovascular prevention. Ther Adv Cardiovasc Dis 2011;5:61-81. |
|3.||The stages of prevention. Chapter 4: Basic Concepts in Prevention, Surveillance, and Health Promotion from AFMC Primer on Population Health. A virtual textbook on Public Health concepts for clinicians. Available from: http://phprimer.afmc.ca/Part1-TheoryThinkingAboutHealth/Chapter4 Basic Concepts In Prevention Surveillance And Health Promotion/Thestages of prevention [Last accessed on 2014 Jul 22]. |
|4.||Leavell H, Clark E. Preventive medicine for the doctor in his community an epidemiologic approach. 1 st edition, New York: McGraw-Hill; 1958. |
|5.||Strasser T. Reflections on cardiovascular diseases. Interdiscip Sci Rev 1978;3:225-30. |
|6.||Giampaoli S. Primordial prevention of cardiovascular diseases-the role of blood pressure. Eur Cardiol Rev 2007;3:20-1. |
|7.||Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoulle M. Quaternary prevention: A task of the general practitioner. Available from: http://www.primary-care.ch/docs/primarycare/archiv/de/2010/2010-18/2010-18-368_ELPS_engl.pdf [Last accessed on 2014 Jul 22]. |
|8.||Jamoulle M, Roland M. Quaternary prevention. Paper presented at the Hong-Kong Meeting of the Wonca Classification Commitee, June 1995. |
|9.||Kalra S, Baruah MP, Sahay R. Quaternary prevention in thyroidology. Thyroid Res Pract 2014;11:43-4. |
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