NRSG 780 - HEALTH PROMOTION AND

POPULATION HEALTH
Module 4: Primary , Secondary , and Tertiary
Prevention
OVERVIEW
The purpose of this module is to examine principles of primary, secondary and tertiary
prevention, to introduce clinical practice guidelines, and to showcase a community
based health promotion program that emphasizes primary, secondary and tertiary
prevention.
O BJECTIVES
At the conclusion of this module, the learner will be able to:
 Differentiate primary, secondary and tertiary prevention
 Identify characteristics of good screening tests
 Explain clinical practice guidelines
 Describe a model population-based primary, secondary and tertiary prevention
program
You may be required to use your UMSON log in to search and access these articles via
the Health Science and Human Services Library (www.hshsl.umaryland.edu).
R EQUIRED R EADINGS
 Butterfield, Patricia G. (1990). Thinking upstream: Nurturing a conceptual
understanding of the societal context of health behavior. Advances in Nursing
Science, 12(2), 1-8.
(This article is a seminal work in the field written when Patricia Butterfield was in
her doctoral program. She was the Dean at Washington State School of Nursing
and is now the Associate Dean for Research at Washington State Elson S. Floyd
School of Medicine. Advances in Nursing Science recently asked that she write a
retrospective analysis of this article)
 Butterfield Patricia G. (2017). Thinking upstream: A 25-year retrospective and
conceptual model aimed at reducing health inequities. Advances in Nursing
Science, 40(1), 2-11.
R ECOMMENDED R EADING
 Butterfield, P. B. (2002). Upstream reflections on environmental health: An
abbreviated history and framework for action. Advances in Nursing Science, 25(1),
32-49
 Puska, Pekka (2009)Fat and heart disease: Yes we can make a change—The
case of North Karelia (Finland). Annals of Nutrition & Metabolism, 54 (suppl 1)33-
38.
Available at http://www.karger.com/Article/Pdf/220825
D IRECTIONS
Read the module content and activities. Then complete the assignment for the module.

Module 4: Primary , Secondary , and Tertiary

Prev ention
LEVELS OF PREVENTION
There are three levels of prevention: primary, secondary and tertiary.
P RIMARY P REVENTION
Primary prevention describes interventions aimed at preventing occurrences of disease,
injury or disability. Primary prevention strategies focus on a population the does not
have a disease that an initiative is trying to prevent.
Immunizations are a familiar example of primary prevention. As a society, we are very
concerned with vaccine-preventable diseases.

Pediatric and family practitioners and many parents recognize the importance of and
follow the vaccine schedules for children. Proof of immunizations is required by many
institutions, such as day care, schools and health care settings. This requirement further
reinforces this primary prevention measure.
Another example of primary prevention is exercise Let's Move! is an initiative, launched
by the former First Lady, that provides parents with helpful information to help children
become more physically active, eat a healthy diet and maintain ideal weight.
Not starting smoking or early smoking cessation are also primary prevention strategies
geared toward preventing heart disease, cancer, stroke and many other diseases.
S ECONDARY P REVENTION
Secondary prevention describes initiatives aimed at early detection and treatment of
disease before signs and symptoms occur. Secondary prevention focuses on the
population that has disease, but in its earliest stage. With early detection and
intervention, secondary prevention strategies can be effective and significantly enhance
health care outcomes.
Secondary prevention is often equated with screening, but it is actually broader than
screening alone and includes early intervention.
Screening is defined in terms of What, Who and Why.

Population screening is not appropriate for all diseases. Screenings should focus
on important health problems that result in significant morbidity and mortality for the
population as a whole. This would include:
 diseases with a high incidence or prevalence rates
 disabilities that significantly decrease quality of life
 diseases that have a high mortality rate.
Criteria for screening include:
 an important health problem
 an acceptable form of treatment
 evidence that early detection and treatment improves the outcome
  an understanding of the natural history of the disease
 a recognizable latent stage
 a suitable screening test
 availability of diagnostic/treatment facilities
 an agreed upon policy on whom to treat
 a reasonable cost of screening
If there is not an acceptable form or treatment, or early detection/treatment does not
improve the outcomes, or few of the other criteria are met, then screening may be
inappropriate.

Successful screening programs are:

 Valid (accurate)—High probability of correct classification of person tested
 Reliable (precise)—Results consistent from place to place, time to time, person to
person
 Capable of large group administration—Fast and inexpensive Innocuous—
Minimally invasive and few side effects
 High yield—Ability to detect enough new cases to warrant the effort and expense
Validity is measured by sensitivity and specificity. Commit the definitions below to
memory:
 Sensitivity measures the proportion of persons with the disease correctly
identified as positive (true positives)
 Specificity measures the proportion of persons the test correctly identifies as
negative for the disease (true negatives)
Screening is appropriate when there is a significant latent phase and detecting the
problem early will lead to improved outcomes and improved survival.
Evaluation of a Screening Program - screening programs are considered
effective when they:
 reduce the burden of disease
 enhance quality of life
 reduce mortality rates.
Examples of Good Screening Tests* Examples of Bad Screening
Tests

Questions about lifestyle risk factors (e.g., diet, smoking, physical Chest X-ray
activity)

Dental exam Resting EKG

Pap smear Exercise EKG

Blood pressure measurement Urinalysis

Screening for osteoporosis in the ≥ 60 years of age PSA

Skin examination CBC

Blood cholesterol measurement Thyroid function tests

Stool hemoccult
 Sigmoidoscopy/colonoscopy ≥ 50 years of age

Mammography for women ≥ 50 years of age

Blood lead levels (in high-risk populations)

Metabolic diseases of childhood (e.g., PKU hypothyroidism)

*not all of these are appropriate for community screening settings

T ERTIARY P REVENTION
Tertiary Prevention includes interventions aimed at preventing further morbidity, limiting
disability and avoiding mortality and interventions aimed at rehabilitation from disease,
injury or disability.
Examples: insulin for diabetes, penicillin for pneumococcal pneumonia, CVD exercise
programs, drug therapy, substance abuse treatment programs.
Summary: This schematic may help in summarizing primary, secondary and tertiary
prevention in relation to disease onset and usual detection.

CLINICAL PRACTICE GUIDELINES

D EFINITION OF CPG
CPG's are systematically developed statements used to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances.
There are numerous synonyms for clinical practice guidelines including:
 practice parameters
 therapeutic guidelines
 practice policies
 management guidelines
 clinical algorithms
 standards of care
D EVELOPMENT OF CPG
Evidence-based decision making is the best foundation for clinical practice guidelines.
If evidence is not available, they can be based on a formal group consensus-generating
process.
Guidelines come from:
 professional societies (e.g., American Nurses Association)
 federal agencies (e.g., Agency for Healthcare Research & Quality)
 non-profit organizations (e.g., American Hospital Association)
 hospitals
 manage care organizations
B ENEFITS OF C LINICAL P RACTICE G UIDELINES
Benefits for patients:
 improve health outcomes
 improve consistency of care
 empower patients to make informed healthcare decisions
 influencing public policy
Benefits for healthcare professionals:
 improve quality of clinical decisions
 support quality improvement activities
 Identify key research questions
On the negative side, clinical practice guidelines may also be seen as self-serving in
terms of reimbursement, turf issues, and medico-legal issues.
Benefits for health care systems
 improve efficiency
 reduce costs
 improved public image
A TTRIBUTES OF G OOD CPG
 validity
 reliability/reproducibility
  clinical applicability
 clarity
 multidisciplinary process for development
 structured review
 documentation
U.S. P REVENTIVE S ERVICES T ASK F ORCE (USPSTF)
The U.S. Preventive Health Services Task Force is a leader in establishing CPGs
under the auspices of the Agency for Healthcare Research and Quality (AHRQ). The
Task Force is an independent panel of experts in primary care and preventive medicine
that systematically reviews the evidence of effectiveness and develops
recommendations for clinical preventive services.
The federal government has developed a number of clinical and population-based
guidelines, often stemming from the exhaustive work of expert panels. Click here to see
the USPSTG A-Z Topic Guide and the dates when each of the available guidelines was
issued.
The Office of the Surgeon General has been a leader in developing guidelines.

N ATIONAL H EART L UNG AND B LOOD I NSTITUTE

One of the earliest sets of guidelines developed by the National Heart Lung and Blood
Institute (NHLBI) was directed to nurses—Guideline on Helping Your Patients Stop
Smoking.
NHLBI’s Dietary Approaches to Stop Hypertension (DASH) diet is included as a
non-pharmocological intervention in the JNC 7 Guidelines.
NHLBI’s Landmark SPRINT study results released September 11, 2015 further
reaffirms the importance of achieving a target systolic blood pressure of 120 mm Hg.
For more information on the SPRINT study click
on http://www.nhlbi.nih.gov/news/press-releases/2015/landmark-nih-study-shows-
intensive-blood-pressure-management-may-save-lives.
NHLBI’s Adult Treatment Panel last report on the Detection, Evaluation and
Treatment of High Blood Cholesterol in Adults clearly explains what affects
cholesterol—diet, weight and physical activity, and identifies what patients need to know
in terms of LDL, HDL and triglycerides.
A DDITIONAL R ESOURCES FOR G UIDELINES
Numerous guidelines exist in other areas as well. The US Departments of Health and
Human Services and Agriculture recently issues the 2015-2020 Dietary Guidelines to
help health professionals and policy makers improve overall eating patterns of
Americans.
The newest guidelines have MyPlate replacing the Food Guide Pyramid.

For more information on the Dietary Guidelines for Americans click here.
Some of the newest guidelines are in the area of obesity. Many guidelines now include
information on the cost/benefit of primary prevention, screening and improved care as a
result of following clinical practice guidelines, all major tenants of the Affordable Care
Act.