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Population Health for Nurses

15.2 Health Promotion and Disease Prevention Interventions

Population Health for Nurses15.2 Health Promotion and Disease Prevention Interventions

Learning Outcomes

By the end of this section, you should be able to:

  • 15.2.1 Describe the five key action areas of health promotion as defined in the Ottawa Charter.
  • 15.2.2 Describe the natural history of a disease to identify opportunities for prevention and control.
  • 15.2.3 Apply the four levels of prevention (primordial, primary, secondary, and tertiary) to plan health promotion and disease prevention interventions.

Health promotion and disease prevention interventions can improve health throughout the lifespan. A nurse in most care environments can perform health promotion and disease prevention interventions at the individual, community, and population levels.

Ottawa Charter for Health Promotion, 1986

The first International Conference on Health Promotion in Ottawa, Canada, in 1986 produced the Ottawa Charter for Health Promotion with the aim of achieving (or establishing) more effective health education strategies (WHO, 2023a). The Charter provided a common definition of health promotion, three core values, a framework of three strategies, and five areas of action. The nurse plays an important role in each.

Health Promotion and the Ottawa Charter

This video describes the Ottawa Charter, a landmark document that was influential in providing guidance to the goals and concepts of health promotion for public and population health programs worldwide.

Watch the video, and then respond to the following questions:

  1. Which action area in the Ottawa Charter links most closely to the SDOH we address today?
  2. How can the nurse participate in each of the three strategies for health promotion identified by the Ottawa Charter?

The Natural History of Disease

To identify opportunities for prevention and control, it is first necessary to recognize the natural history of disease—that is, the progression of a disease process in an individual over time in the absence of treatment (Kisling et al., 2023). The five stages in the natural history of disease are underlying, susceptible, subclinical, clinical, and recovery/disability/death (see Table 15.2).

Stage Definition Example
Underlying Risk factors may lead to the development of a disease. These can include social and environmental factors. A client who is sedentary for over 8 hours daily is at risk for developing obesity. Therefore, the client is in the underlying stage of disease.
Susceptible The state of being predisposed to, or sensitive to, developing a certain disease. Genetic, environmental, or a combination of both factors may contribute to this. A client who lives in a region with very poor air quality is more susceptible to developing lung disease due to their environment.
Subclinical An illness that stays below the surface of clinical detection and has no recognizable clinical findings. In infectious diseases, this is the incubation period, or the time from exposure to onset of disease symptoms. The clinical latency period is the period for which an infection is subclinical. The results of routine bloodwork indicate a client has hypothyroidism. They have difficulty believing they have a thyroid problem because a relative with hypothyroidism gained weight, lost their hair, and experienced constipation. The client has none of these symptoms because they are in the subclinical stage of disease.
Clinical A disease with recognizable clinical signs and symptoms. The client’s relative in the above (subclinical) example is in the clinical stage of hypothyroidism.
Recovery/Disability/Death Ultimately, a disease process ends in either recovery, disability, or death. A client has an untreated HIV infection. This terminates with AIDS and death over a 10-year period.
Table 15.2 Five Stages in the Natural History of Disease (See Kisling et al., 2023.)

Recognition of each disease stage allows the nurse to identify the corresponding levels of prevention, which can then be applied to plan health promotion and disease prevention interventions.

Levels of Prevention

The five levels of prevention—primordial, primary, secondary, tertiary, and quaternary—described in Foundations of Public/Community Health correspond to the five stages of disease described in Table 15.2. Combined use of prevention strategies in a community at the macro-level (or upstream) can lead to the prevention of individual (micro-level, or downstream) complications of an exhibited disease (Kisling & Das, 2022). Table 15.3 identifies the levels of prevention as they correspond to the disease stages.

Levels of Prevention Targeted Stage of Disease Characteristics of Level of Prevention Example of Level of Prevention
Primordial Prevention Underlying
  • Risk-factor reduction targeted to an entire population through focus on social and environmental conditions
  • Prevention of the development of risk factors for disease
  • Typically promoted through laws and policy (multi-sectoral)
  • Often aimed at children to decrease as much risk exposure as possible
  • Targets the underlying social conditions that promote disease onset
Improving an urban neighborhood’s access to safe sidewalks to promote physical activity, which in turn will decrease risk factors for obesity, cardiovascular disease, and diabetes
Primary Prevention Susceptible
  • To prevent a disease from occurring
  • Target population is healthy individuals
  • Modifies existing risk factors to prevent the development of disease
  • Commonly involves activities to limit risk exposure or increase immunity of those at risk to prevent a disease from progressing in a susceptible individual to subclinical disease
Conducting an immunization campaign targeting school-aged children, with the goal of preventing the occurrence of vaccine-preventable diseases and promoting overall community health
Secondary Prevention Subclinical
  • Emphasizes early disease detection
  • Targets healthy-appearing individuals with subclinical forms of disease
Organizing a breast cancer screening program in collaboration with local community organizations, such as women’s groups and senior centers, to raise awareness about the importance of screenings and encourage women to participate
Tertiary Prevention
  • Clinical
  • Recovery, Disability, Death
  • Targets both the clinical and outcomes stages of disease
  • Implemented in symptomatic individuals
  • Aims to reduce the severity of disease and any associated sequelae
Referring community members who live with chronic joint pain and limited mobility to a local rehabilitation center, which serves as a community hub for rehabilitation service activities that encourage community members to engage with one another, share experiences, and provide mutual support throughout their rehabilitation journey
Quaternary Prevention N/A
  • Targets clients with illness but without disease
  • Action taken to protect persons from medical interventions that are likely to cause more harm than good
Cautioning a population of clients who are complete post-hysterectomy against the continuing need for Pap smears
Table 15.3 Five Levels of Prevention

Healthy People 2030


Healthy People 2030 vaccination objectives focus on increasing the proportion of children and adults who receive recommended vaccinations and maintain vaccination coverage. This objective category includes recommendations for reducing the number of children who do not get recommended vaccines by age 2 in order to reduce outbreaks of vaccine-preventable diseases like measles, pertussis, and mumps.

While primordial and primary prevention appear similar, the actual existence of risk factors is key to differentiating them. Primordial prevention prevents the development of risk factors for disease. Primary prevention modifies existing risk factors to prevent the development of disease (Weintraub et al., 2011). In addition, primordial prevention generally is intersectoral rather than limited to those within the health sector. The other levels of prevention, as noted previously, are mainly limited to the health sector. This information can be useful to the nurse in planning health promotion and disease prevention interventions.

Another important factor the nurse should consider when planning involves the approach to prevention. The high-risk approach targets prevention only to those who are identified to be at high risk for disease. This could be an individual or a group who is likely to have an increased incidence of a disease based on the presence of known risk factors for the disease or characteristics that are associated with a higher incidence of disease. Even when a group is involved, the high-risk approach focuses on the individual and their risk behaviors (Wilson et al., 2017). An example of this approach would be a smoking cessation intervention for a client.

In contrast, a population approach implements prevention strategies across an entire population, many of whom are not necessarily at high risk (Rose, 1992). An example of a population approach to prevention would be a citywide anti-smoking law inside public buildings. In most cases, a population approach requires intersectoral involvement, while the high-risk approach is usually limited to the health sector. Both approaches can be used at the primary and secondary prevention levels (Platt et al., 2017). Sometimes a combination of both approaches is used to prevent disease.

An Overview of the Levels of Disease Prevention

To address disease prevention as a whole, it is necessary to look at different levels of prevention as they apply to population health. The video “Levels of Disease Prevention and Approaches” reviews the definition of prevention, the process of prevention, the four levels of prevention, and two approaches to prevention.

Watch the video, and then respond to the following questions.

  1. A client at risk for diabetes has their blood glucose and HgA1C levels tested periodically. Which level of prevention does this describe?
  2. A public health nurse provides a presentation on healthy eating habits to first-grade children. Which level of prevention does this describe?

Unfolding Case Study

Part A: Health Screening Follow-Up

Read the scenario, and then answer the questions that follow.

After receiving education from the nurse at the community health screening, Deanna decides to call and make an appointment with her primary provider to follow up on the high blood pressure reading. The receptionist at the provider’s office provides Deanna with an appointment in a week, noting Deanna’s reason for the visit is “BP 148/88 at community screening, denies other symptoms.” The nurse in the provider’s office reviews Deanna’s file in preparation for the office visit. The nurse notes that Deanna has not seen the provider for a few years, has no high blood pressure readings documented in the past, and has a family history of hypertension.

Which stage of the natural history of disease should the nurse most likely suspect for Deanna?
  1. Susceptible
  2. Clinical
  3. Recovery
  4. Subclinical
If the provider diagnoses Deanna with hypertension and prescribes medication to treat the disease, which form of prevention will Deanna receive?
  1. Primary prevention
  2. Secondary prevention
  3. Tertiary prevention
  4. Primordial prevention

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