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Population Health for Nurses

2.5 Levels of Prevention

Population Health for Nurses2.5 Levels of Prevention

Learning Outcomes

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

  • 2.5.1 Identify and differentiate between the five levels of prevention in public health.
  • 2.5.2 Differentiate public health efforts according to one of the three levels of prevention.

Much of public health focuses on prevention—preventing injuries, preventing acute illnesses, preventing chronic conditions, even preventing unexpected death. The five levels of prevention in public health are primordial, primary, secondary, tertiary, and quaternary (Figure 2.6). Not all public health professionals or nurses may consider primordial and quaternary prevention in their work; the concepts of primordial and quaternary prevention entered the health care lexicon in 1978 and 1986, respectively, while the other three levels of prevention are familiar to generations of clinicians (Kisling & Das, 2023; Martins et al., 2018).

A diagram uses a triangle divided into 4 sections to show the different levels of prevention in public health. The base of the triangle is primordial prevention, which affects populations by reducing overall risk. 16 stick figures in this section represent the broad number of people affected by this level of prevention. The next level is primary prevention, which affects at-risk populations or environments by preventing problems. 8 stick figures in in this section represent the relative number of people affected by this level of prevention. The third section is secondary, which affects individuals by detecting conditions or needs. 4 stick figures in this section relative number of people affected by this level of prevention. The final, smallest section, is tertiary, which affects individuals by preventing or lessening negative impact. 1 stick figure in this section represents the relative number of people affected by this level of prevention.
Figure 2.6 Levels of prevention in public health focus on different strategies to improve population health outcomes. (See U.S. Department of Health and Human Services, 2023a; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
  • Primordial prevention focuses on risk factor reduction for an entire population and is usually carried out through large social changes and national policy (Falkner & Lurbe, 2020).
    • The American Heart Association has emphasized following the DASH diet (dietary approaches to stop hypertension), participating in physical activity, keeping a healthy body mass index, avoiding smoking, and consuming low or no alcohol as primordial prevention strategies to avoid risk factors for poor cardiac health (Lloyd-Jones et al., 2021).
  • Primary prevention involves interventions to prevent an adverse health outcome from occurring. Primary prevention interventions may target the population, groups, and communities at high risk of a particular condition. Immunizations and education on healthy lifestyle factors are two examples of primary prevention strategies.
    • Medication overuse headache occurs when those who experience headaches take medications to address their pain but then have rebound headaches from using medications too often. A group of researchers designed and implemented an education campaign and guidance for primary care providers and clients on stopping overused medications to prevent this type of headache (Diener et al., 2019).
  • Secondary prevention focuses on early disease detection to diagnose conditions early and promptly treat them to stop or slow progression and minimize impact. Screening is the primary activity in secondary prevention, but other activities may be conducted.
    • During an ischemic stroke, blood flow to part of the client’s brain is blocked. Following identification of an ischemic stroke, a secondary prevention strategy includes surgical placement of a stent to help restore blood flow (Diener & Hankey, 2020).
  • Tertiary prevention strategies aim to lessen the negative impact of a health condition and prevent complications. Treatment through medications, surgical procedures, complementary modalities, therapies, and rehabilitation approaches are tertiary prevention activities.
    • Researchers studied an intervention to help individuals who are unhoused during the transition to becoming housed. Over six months, youth who were unhoused received outreach-based case-management services, individual and group mental health support, and peer support. Following program participation, the youth displayed gains in employment, education, and connection to mental health services (Kidd et al., 2019).
  • Quaternary prevention aims to protect clients from health interventions that might cause more harm than good (Martins et al., 2018). To carry out quaternary prevention, clinicians attempt to avoid conducting tests and exams that are not essential to the client’s plan of care or well-being. For social problems, public health professionals address the risks and harm associated with excessive intervention.
    • For example, if a client presented to the urgent care clinic with a runny nose, cough, and no fever for three days with clear lung sounds, the clinician may reason that the client has a viral upper respiratory infection instead of a bacterial upper respiratory infection. Antibiotics would not be needed given the likely viral cause. Additionally, a viral panel to determine the causative agent would yield interesting results but would not change the client’s plan of care. Regardless of the virus, the client would be asked to avoid other people and public spaces, possibly wear a surgical mask when around others, hydrate, get rest, and use over-the-counter medications as needed.

Table 2.2 provides some examples of the levels of prevention applied to different health conditions. Of note, quaternary prevention is not included in the table, as the quaternary activities are generally focused on what clinicians should not do.

Condition Primordial Primary Secondary Tertiary
Cervical cancer Mandating health plan coverage of cervical cancer screening tests HPV vaccine administration Cervical cancer screening tests Electrosurgical excision to remove diseased tissue from the cervix
Preeclampsia Mandating health plan coverage of prenatal visits Blood pressure monitoring and urine testing during pregnancy Medications to control blood pressure Immediate delivery of the baby on conversion to eclampsia
Migraine Promoting migraine-friendly schools and offices Educating individuals about migraine triggers Medications for symptom relief and prevention Specialized infusions for chronic pain management
Influenza Use of masks, handwashing, and cough courtesy Annual vaccine administration Rapid influenza testing Antiviral treatments
Food insecurity Funding of social safety nets to reduce poverty and food inaccessibility Food assistance programs and community gardens Referrals to food banks and government assistance programs Employment assistance, financial literacy, and budget training
Gun violence Comprehensive gun control policies Safe firearm storage education Early identification of perpetrators and deployment of crisis response Emergency care and support for victims
Youth social media and mental health Positive digital citizenship and online behavior guidelines for students Cyberbullying, privacy, safety, and screen time education Twice-yearly mental health screenings in schools Therapy programs to address mental health and promote coping strategies
Table 2.2 Levels of Prevention Examples

Case Reflection

Levels of Prevention

Read the scenario, and then respond to the questions that follow.

You are working with the Lee family and focusing on the health of the children, Sunshine and Woody.

  • Sunshine, life-threatening allergy: Sunshine just started kindergarten and has an epi-pen for a life-threatening nut allergy. She attended an after-school arts and crafts program twice a week but stopped going when Christopher lost his job. Her parents are considering home-schooling due to the increased incidence of school-based gun violence in America.
  • Woody, toddler who is generally healthy and attends the daycare where Alexandra works.
  • Sunshine and Woody love going to the park near their home with their parents. Both are excited to see their paternal grandparents, who will soon visit from South Korea.
  1. What adverse health outcomes may occur but have not yet affected Sunshine and Woody? What are some related primary prevention interventions?
  2. Based on their ages, what secondary prevention activities should be completed?
  3. How may tertiary prevention activities be implemented for Sunshine’s life-threatening allergy?
  4. What primordial prevention efforts in the Lee family’s city, state, or nation could positively impact their health?
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