Ohio prevention basics June 2014 What is prevention? Prioritizing health and safety overall community so that healthy behaviors are Prevention addresses health problems before they expected and supported, and people have clean occur, rather than after people have shown signs of water to drink, safe places to walk and play and disease, injury or disability.1 In order to be effective other conditions that contribute to wellbeing. in reaching large numbers of people before they become sick, prevention strategies are implemented Prevention is best understood in contrast to medical in a wide variety of settings, including clinics, treatment. Treatment is defined as “what a health schools, workplaces and neighborhoods. Prevention care provider does to relieve, reduce or eliminate strategies focus on both individual and community harm once it has become manifest in an ailment.”2 wellness. Prevention programs often help individuals Prevention, on the other hand, keeps harm from engage in healthier behaviors, such as driving safely occurring in the first place or detects a health or not smoking. Many also focus on improving the problem early enough to cure or ameliorate it.
Figure 1. Prevention, treatment and rehabilitation
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Maximizing remaining function Ohio’s prevention
eliminate harm once disease or after a disease has been diagnosed infrastructure and
injury is fully present. workforce 17 or an injury has occurred. Includes inpatient and outpatient care
Includes: rehabilitative and (including some tertiary prevention)
habilitative services, chronic disease Appendix A.
self-management, recovery Key prevention
support and follow-up/aftercare frameworks and
(including some tertiary additional prevention terms 20 prevention)
Appendix B.
Sources of evidence
of effectiveness 22
Glossary 23
Af ter health problem
PB 1 Figure 1 displays the relationship between classifying and defining levels of prevention, prevention, treatment and a third level the classic framework is primary, secondary of intervention called rehabilitation and and tertiary prevention. These levels are based recovery. Rehabilitation and recovery helps upon the timing of prevention activity relative people transition from illness to wellness. This to the onset of a health problem (see Figure 2). framework can be applied to both physical and behavioral health and is relevant to Primary prevention keeps people well and, for both public health and healthcare system purposes of this publication, includes health delivery and payment models. It is important promotion. Secondary prevention identifies an to recognize that relationships between these emerging health problem and seeks to slow four categories can be non-linear, fluid and or stop its progression. Primary and secondary overlapping in real-life situations. prevention activities are generally applied to entire populations and often reach people Primary, secondary and tertiary prevention before they become patients within a clinical Although there are several models for healthcare system.
Figure 2. Levels of prevention Level Audience Examples Primary prevention Total population in • Providing healthy foods and physical activity occurs when there is no a geographic area opportunities for all children in school in health problem present and/or healthy order to reduce diabetes rates and aims to prevent a people • Safe Sleep campaigns to prevent infant disease, injury or other mortality
Prevention health problem from • Immunizations occurring in the first • School-based drug and alcohol prevention place. programs designed to increase student knowledge and avoidance skills • Home visits for expectant parents to promote healthy pregnancy and positive parenting skills Secondary prevention Individuals with • Fitness and nutrition education programs for occurs at the first signs early-stage disease pre-diabetic teenagers of a health problem and but no symptoms • Breast and colorectal screenings to identify aims to detect health and/or those with cancer in early stages problems at an early high risk factors • Hearing and vision screenings for young stage and/or to slow or children halt the progress of an • Suicide and depression risk screenings existing disease or injury. • A Matter of Balance classes for seniors identified as high-risk for falls due to poor balance or strength • Early intervention programs for children who have missed developmental milestones Tertiary prevention Patients • Diabetes self-management classes to occurs after a health prevent complications from diabetes problem has developed • Programs to help parents identify and and aims to reduce remove asthma triggers in the home the negative impact • Ear tube surgery to prevent recurring ear of a disease, injury or infections other health problem • Provision of naloxone to individuals with and to prevent or delay opioid addiction to prevent overdose
Treatment complications and deaths subsequent harm.
2 3 Tertiary prevention is targeted to the person a healthcare setting and are usually paid for who already has symptoms and seeks to by health insurance plans. Screenings help to reduce further complications, increasing detect health problems before they become pain or death. Because tertiary prevention more severe, while other clinical preventive is often difficult to distinguish from traditional services like immunizations and dental sealants clinical treatment or rehabilitation, this provide long-lasting protections from disease. publication focuses on and refers only to With the notable exception of immunizations, primary and secondary prevention activities as most clinical preventive services are secondary “prevention.” prevention.
Universal, selected and indicated prevention Community-based prevention programs Universal, selected and indicated is another School-based drug and alcohol prevention useful framework for describing levels of programs and home visits for newborns are prevention that refers to the level of risk in the examples of community-based prevention population. Universal prevention strategies programs. Rather than being administered in a are directed at an entire population and are healthcare setting by a traditional healthcare likely to provide some benefit to all. Examples provider, these programs typically are include social skills training for all children in delivered by health educators, public health a school district to prevent bullying and teen professional, certified prevention professionals dating violence, and building sidewalks and or community health workers outside the crosswalks to promote safe physical activity walls of a doctor’s office. These community- for all residents of a community. Selective based programs often aim to increase the prevention activities are targeted to specific awareness, knowledge and skills of individuals populations with above-average risk for a to help them engage in healthy behaviors problem. Examples include needle exchange and/or to promote healthy social norms about programs for intravenous drug users to health issues, such as marketing campaigns prevent HIV transmission, and healthy food to promote using a designated driver to retail initiatives in poor neighborhoods with avoid drunk driving. Some community-based high rates of obesity. Indicated prevention prevention programs are primary prevention interventions are targeted at individuals and others are secondary prevention or with increased vulnerability or early signs of include a combination of the two. a problem, disease or condition. Examples include tobacco cessation, early intervention Population-based policy change for middle school students who have The third type of prevention strategy— experimented with tobacco, or strength and population-based policy change (also referred balance exercise classes for the frail elderly. to as policy, system, and environmental Most primary prevention activities are aimed change, or PSEC)—aims to modify the at overall populations and can therefore be environment so that everyone in the considered universal prevention. community has the opportunity to be healthy. The policy change approach focuses on See Appendix A for additional prevention making healthy behaviors feasible and terms and framework. affordable for everyone, and on changing community conditions to ensure that residents Prevention strategies have access to things like clean air and water, There are several types of prevention strategies safe schools, safe homes and places to be that can be distinguished by the setting in physically active. Examples of population- which they are delivered and the audience based policy strategies include Ohio’s smoke- they reach. free workplace law; the Ohio Automated Rx Reporting System (OARRS) data system Clinical preventive services that helps to prevent “doctor shopping” for Clinical preventive services, such as opiates; and zoning requirements for sidewalks. mammograms and flu shots, often come Strategies include public policy changes at to mind as examples of prevention. These the local, state and federal levels, as well forms of prevention are typically provided in as organizational policies implemented by
2 3 employers and other private organizations. Most change, although this work involves multiple sectors policy and environmental change strategies are (including education, transportation, housing, primary prevention. etc.) and can be done by any organization that wants to improve health. For example, staff from Public health professionals and local or state-level a county health department might lead efforts to health coalitions often take the lead in planning increase access to healthy food by setting up a and advocating for policy and environmental “farm to school” program in a local elementary Figure 3. Types of health improvement activities Prevention Treatment and rehabilitation
Population- Community- Clinical Treatment Disease based policy based preventive management, change prevention services rehabilitation, (Policy, System programs recovery supports and Environmental Change) Setting School, child Home, school, Primary care Hospital, physician’s Rehabilitation care, workplace, child care, office/clinic, office/clinic, facility, community neighborhood, workplace, local hospital, behavioral health organization city, county, state community behavioral provider, nursing or country health provider, home or other in- local health patient and out- department or patient healthcare other healthcare settings setting Delivered All residents in a Program Individual patients, Individual patients, Individual patients, geographic area, participants clients and clients and consumers clients and consumers to… or for all students as individuals, consumers or employees families, or groups in a school or workplace Examples • Smoke-free • Home visiting • Screening • Diagnostic tests • Housing program workplace laws programs for (mammograms, • Pharmaceuticals for persons • Changes new parents colonoscopies, • Surgery recovering from to the built • Community blood pressure • In-patient and out- opiate addiction environment to health workers checks, suicide patient addiction • Diabetes self- promote safety helping families risk, etc.) and mental health management and physical to remove • Nutrition counseling program activity (such asthma triggers counseling • Cancer survivor as lighting, in the home • Immunizations support group sidewalks, • School-based • Dental sealants • Physical, speech crosswalks and programs and occupational bike lanes) to prevent therapy • Safe Routes to violence School initiatives and alcohol, • Healthy school tobacco and lunch guidelines other drug use • Impaired driving • Workplace laws wellness • Restaurant programs inspections • Marketing • Clean air campaign and water about the regulations dangers of distracted driving Level of Mostly primary Primary and Mostly secondary Mostly treatment Rehabilitation and prevention secondary prevention (includes some tertiary recovery (includes prevention prevention prevention) some tertiary prevention)
Community Healthcare setting
4 5 school, or by arranging for local famer’s markets to accept WIC vouchers in partnership with farmers, the school district and the Personal responsibility: Everyone local chamber of commerce. A local heroin has a role to play to improve prevention coalition might partner with law health enforcement, addiction treatment agencies Healthcare providers share some of the and healthcare providers to set up drop-off responsibility for improving health, but sites for unused prescriptions and to advocate good health starts long before we get to for changes in prescribing practices. the doctor’s office.
Figure 3 displays settings and audiences for the Every individual is responsible for keeping three types of prevention strategies, as well as themselves healthy by doing things like for treatment and rehabilitation. eating healthy, being physically active and not smoking. People also have Linking clinical and community a responsibility to protect others, for Unlike clinical preventive services, community- example by refraining from texting while based prevention programs and policies have driving, keeping immunizations up to traditionally been separate from the health date, and treating family members with care system and are typically not paid for dignity and respect. by health insurance. Public health agencies often play a role in delivering all three of these types of prevention, while traditional These daily decisions about how to health care providers focus on clinical services stay healthy are heavily influenced by and treatment. Going forward, many health the world around us. Evidence-based leaders acknowledge the importance of prevention strategies can help to make better linking clinical preventive services and it more likely that people will engage other aspects of primary care with prevention in healthier behaviors. Children are less strategies outside the doctor’s office. Calling likely to walk to school if their parents for a change in the way that primary care feel it is unsafe, for example. Walking and public health sectors have historically school bus programs and infrastructure operated independently of each other, a improvements like sidewalks and 2012 Institute of Medicine report identifies a crosswalks can make walking to school set of core principles for successful integration an easier choice, leading kids to be and provides a framework for state and more active as a part of their daily local efforts to better coordinate clinical and routine. community-based prevention.3
Population health and upstream outcomes. Community-based prevention prevention programs and policy-change strategies Population health is defined as the “health are critical aspects of the population-level outcomes of a group of individuals, including approach to health improvement. the distribution of such outcomes within the group.”4 Population health strategies include While population health is part of the Institute both prevention and treatment services. for Healthcare Improvement’s widely- Primary and secondary prevention are used Triple Aim framework, there has been important components of population health, widespread variation in how population and the term “population health” is broader health is defined and pursued by Triple Aim than the term “prevention.” initiatives.5 The term has traditionally been used differently by the public health system and Like prevention, population health the clinical care system.6 Within public health, approaches go beyond the doctor’s office; “population” refers to the total population they may include clinical services, but also go of a geographic area (such as a county or “upstream” to address the social, economic state), or to a specific sub-population (such and physical environments that impact health as low-income families or adults over age 65).
4 5 Within the clinical care system, “population” is Roadmaps (see Figure 5) distinguish between usually defined as a group of individuals who health outcomes (such as mortality and quality are receiving care within a health system or are of life) and health determinants, defined as covered by a specific health plan. Examples the factors that impact health outcomes. include members of a managed care plan Determinants can be non-modifiable, such as or all patients of a specific hospital or health genetics8 and individual biology, or modifiable, system (see Figure 4). such as clinical care, behaviors, social environment, and physical environment. The In a 2012 paper commissioned by the National impact of clinical care on health outcomes Quality Forum, researchers propose use of the is direct and well recognized. Health policy term total population health to refer to the experts recognize increasingly that social, health outcomes of a group of individuals within economic and physical environments are also a specific geographic area, as distinct from a key driver of health outcomes. the more narrow use of the term “population” within the clinical care system.7 A 2002 study estimated that behavior patterns (40 percent), environmental exposures The total population health framework (5 percent), and social circumstances emphasizes three related concepts: (15 percent) together contribute more than half • Determinants of health of the causes of premature death (see figure • Health disparities 11).9 Taken together, these non-clinical factors • Health equity are referred to as the social determinants of health. Examples of social determinants Determinants of health include: Total population health models, such as the • Safe and affordable housing framework used by County Health Rankings and • Access to education
Figure 4. Total population health
Public health and Total population total population of a geographic area health approach Example: State of Ohio focus on improving health of the overall population or subpopulations Subpopulation Example: Low- income parents
Population within the clinical care system Example: Members of Clinical care a Medicaid managed care plan system focuses on individual health improvement for patients who use their provider- based services
Source: Adapted from “An Environmental Scan of Integrated Approaches for Defining and Measuring Total Population Health by the clinical care system, the government public health system, and stakeholder organizations.” Public Health Institute and County of Los Angeles Public Health, 2012.
6 7 • Income and employment The term health disparities is defined as • Public safety “differences in health status among distinct • Built environment (roads, sidewalks, parks, segments of the population including etc.) differences that occur by gender, race or • Availability of healthy foods ethnicity, education or income, disability, or • Environments free of life-threatening living in various geographic localities.”11 Some toxins10 health disparities may result from random variation and individual biology, making them Prevention professionals often use the phrases difficult to prevent. Other disparities, however, “health begins where we live, learn, work, and may result from modifiable economic or social play” and “health beyond the doctor’s office” conditions or poor access to health care.12 to describe the social determinants of health. For example, disparities in breast cancer prevalence among men and women are Health disparities and health equity biologically-based, while high rates of breast Assessing and addressing differences in health cancer mortality among African American outcomes across groups is an important women compared to white women are largely component of population health. Population rooted in differences in access to and quality health strategies aim to improve the health of health care and social and economic of everyone, including groups that have poor conditions. health outcomes and historically have had fewer opportunities to be healthy. Health equity is the absence of differences in health that are caused by social and
Figure 5. Total population health model used by County Health Rankings
Source: County Health Rankings and Roadmaps, University of Wisconsin Population Health Institute and Robert Wood Johnson Foundation
6 7 economic factors. Achieving health equity means that all people have the opportunity “It is no longer sufficient to expect to achieve their full health potential, with no that reforms in the medical care one at a disadvantage because of social or delivery system (for example, 13 economic circumstances. changes in payment, access and quality) alone will improve the Going upstream The term upstream prevention (or upstream public’s health.” medicine) is increasingly being used in the — Institute of Medicine public health, health care and health policy sectors to describe approaches that address the causes of health problems rather than For example, interventions toward the top just the symptoms. As stated by the Institute of the pyramid include educational sessions of Medicine, the upstream approach about how to reduce fall hazards in the home acknowledges that “it is no longer sufficient and fitness classes such as A Matter of Balance to expect that reforms in the medical care which help older people make changes delivery system (for example, changes in to protect themselves from falls. These payment, access and quality) alone will types of programs can be highly effective improve the public’s health.”14 for individuals who follow through and make changes in their behavior and home The term “upstream” comes from a commonly- environment, but they only reach those with told story, sometimes called the “river story” access to the program. Toward the base of or the “public health parable.” Here is one the pyramid, general improvements to housing version of the story: conditions for low-income seniors, policies
requiring grab bars and hand rails, and built Two friends are standing at the edge of environments that make it easy for seniors to a rapidly-flowing river that is filled with remain active in their daily lives (such as safe drowning people. The friends work very sidewalks and crosswalks near grocery stores), hard to rescue as many of the people as are examples of strategies that impact a possible, but are not able to save everyone broad reach of the general population. These in the seemingly never-ending stream of types of strategies do not necessarily require drowning victims. Seeking a better solution, individuals to be connected or compliant with one of the friends walks upstream and finds a specific service or program. Comprehensive a bridge with a large hole in it. She gathers approaches that include strategies at each the people together to repair the hole and level of the pyramid are most likely to achieve they stop falling into the river. sustainable improvements in population health. Upstream approaches are typically primary prevention strategies implemented in a In addition to the Health Impact Pyramid, community or population-level setting and the National Prevention Strategy, Social- often address the social determinants of Ecological Model and Spectrum of Prevention health. are prominent frameworks that provide guidance to policymakers on how to design Key prevention frameworks effective prevention strategies and lay out The Health Impact Pyramid provides a useful foundational concepts in public health, total framework for the types of public health population health, and upstream prevention. interventions that are most likely to “move the Each of these frameworks emphasizes the needle” for total population health outcomes. importance of designing comprehensive As shown in Figure 6, activities toward the prevention strategies that not only educate base of the pyramid require minimal individual individuals about the importance of behavior effort and have the greatest leverage for change, but also go beyond the individual to improving health for large numbers of people, address other factors that shape wellbeing, while activities toward the top of the pyramid including family relationships, social norms require increased individual effort and reach and economic conditions. Risk and protective smaller segments of the population.15 factors, asset development, and resiliency are
8 9 Figure 6. Health Impact Pyramid
Examples Counseling and education • Dietary counseling • Public education about drunk driving, physical activity, youth violence, etc.
less population impact • Treatment of hypertension and hyperlipidemia more individual effort needed Clinical • Screening for fall risk interventions
• Immunizations • Tobacco cessation services Long-lasting protective • Dental sealants interventions • Grab bars and hand rails to prevent falls
• Clean water • Flouridation Changing the context to make • Elimination of lead paint and asbestos exposure • Smoke-free workplaces individuals’ default decisions healthy • Impaired driving and helmet laws • Built environment redesign to promote physical activity
• Poverty reduction • Improved education Socioeconomic factors less individual effort needed • Improved housing and sanitation
more population impact
Source: Frieden, Thomas R., “A framework for public health action: The Health Impact Pyramid.” American Journal of Public Health 100, no, 4 (2010).
additional approaches that are critical to designing public and private decision-making”). effective prevention strategies. See Appendix A for a • Fairness and opportunity (“everyone has access to more detailed description of these frameworks. affordable, quality health care;” “individuals and families have the means and the opportunity to 16 New ways to think about health and wellbeing make choices that lead to healthy lifestyles”). Culture of health The Robert Wood Johnson Foundation (RWJF), a Health in All Policies national philanthropy, has begun to use the term Over the past decade, the Health in All Policies “culture of health” to describe a way of looking at approach has emerged as a public health strategy what it takes for an entire community to be healthy to address the social determinants of health. Health in and stay healthy. This term is useful because it All Policies is a “collaborative approach to improving combines the following concepts: the health of all people by incorporating health considerations into decision-making across sectors and • Broad definition of health that includes community 17 conditions, health behaviors, access to healthcare, policy areas.” and physical, mental and emotional wellbeing. • Prioritization of health and wellbeing (“being The Health in All Policies approach uses tools such as healthy and staying healthy is valued by our entire Health Impact Assessments to identify the ways that society;” “the health of the population guides policy decisions in sectors such as transportation,
8 9 education, and regional planning may affect some prevention activities may increase costs. population health outcomes. This approach aims This section provides background on the US to break down government agency silos in order to healthcare system’s twin problems of high costs and raise awareness about the connections between poor outcomes, and describes available evidence for health and other sectors, and to address these the role of prevention strategies in addressing these connections by embedding health and health equity problems. considerations into public decision-making processes at the local, state and federal level. High costs, poor outcomes The US leads the world in medical research and In Ohio, for example, health departments in advanced clinical care, and spends far more on Cincinnati and Columbus have partnered with their health care than any other country (see Figure 7). Yet local school districts and the Ohio Department of our population health outcomes indicate that we are Transportation to look at the relationships between not getting a good return on our health care dollar. In school transportation policies and health outcomes its 2013 report Shorter Lives, Poorer Health, the Institute for children and to design school travel plans that of Medicine reviewed population health outcomes for improve safety and promote physical activity. the US in comparison to other high-income countries and concluded that the US is at a distinct “health The value of prevention disadvantage.” The report found that although life Keeping people healthy and improving quality of life expectancy and health have improved in the US over are the most obvious benefits of prevention. Though the past century, these gains have lagged behind not all prevention activities are effective, countless more significant improvements in most peer countries studies demonstrate the effectiveness of specific in recent years. The result is comparatively shorter life prevention strategies to achieve positive health expectancy (see Figure 8), as well as higher rates of many diseases, injuries, and disability across all age outcomes. Research on the cost savings brought by 18 prevention is more mixed. Many studies indicate that groups. prevention is cost-effective, although, like treatment,
Figure 7. Health care spending per capita, by source of funding, 2011
$8,508 $987 Out-of-pocket spending
$3,454 Private spending Public spending
$5,643 $1,455
$4,522 $4,495 $4,495 $4,118 $666 $593 $593 $3,925 $3,800 $527 $75 $307 $4,066 $465 $635 $672 $3,827 $650 $733 $3,405 $3,661 $3,213 $3,182 $3,436 $86 $338 $3,204 $464 $348 $3,183 $3,161 $490 $246 $2,821 $111 $203 $2,578 $2,638 $2,631
U.S. Swiz Can Den* Ger Fra Swe Aus* UK Jpn* NZ * 2010 Source: Commonwealth Fund analysis of Organization for Economic Cooperation and Development Health Data 2013
10 11 Ohio shares in this Figure 8. Seventeen high-income countries ranked by life health disadvantage. expectancy at birth, 2007 Among the states, Ohio ranks 37 in life Males Females expectancy19 and Average Average 42 in overall health length length outcomes,20 and Rank Country of life Rank Country of life spends more per 1 Switzerland 79.33 1 Japan 85.98 capita than 32 other states on health care.21 2 Australia 79.27 2 France 84.43 3 Japan 79.20 3 Switzerland 84.09 Preventable sickness 4 Sweden 78.92 3 Italy 84.09 and death Many causes of illness, 5 Italy 78.82 5 Spain 84.03 disability and death 6 Canada 78.35 6 Australia 83.78 are preventable. 7 Norway 78.25 7 Canada 82.95 The 2013 IOM report 8 Netherlands 78.01 7 Sweden 82.95 referenced above identified four likely 9 Spain 77.62 9 Austria 82.86 explanations for the US 10 United Kingdom 77.43 9 Finland 82.86 health disadvantage. 11 France 77.41 11 Norway 82.68 Prevention strategies directly address the 12 Austria 77.33 12 Germany 82.44 last three: 13 Germany 77.11 13 Netherlands 82.31 • Health systems. 14 Denmark 76.13 14 Portugal 82.19 High number of 15 Portugal 75.87 15 United Kingdom 81.68 uninsured people and lapses in 16 Finland 75.86 16 United States 80.78 accessibility, 17 United States 75.64 17 Denmark 80.53 affordability, Source: Institute of Medicine analysis of World Health Organization data quality and safety • Health behaviors. Higher rates Similarly, the US Centers for Disease Control of drug abuse, alcohol-involved traffic and Prevention have identified four modifiable crashes and firearm violence, and lower risk behaviors that are responsible for much of rates of seat belt use the illness, poor quality of life, and premature • Social and economic conditions. Higher death related to chronic diseases: lack of rates of poverty and income inequality, physical activity, poor nutrition, tobacco use, 23 lower social mobility and poorer education and excessive alcohol consumption. Effective outcomes prevention strategies to address each of these • Physical environments. Built environment risks are available (see next section). may discourage physical activity and contribute to obesity While much of the discussion around the value of prevention centers on chronic A similar analysis of the burden of diseases, physical health conditions such as diabetes, injuries, and risk factors in the US and peer heart disease, cancer and obesity, and to nations published in the Journal of the a lesser extent on injuries and violence, it is American Medical Association (JAMA) in important to note that many behavioral health 2013 concluded that “in many cases, the best conditions are also preventable. A large investments for improving population health body of research demonstrates that mental, would likely be public health programs and emotional and behavioral disorders among multisectoral action to address risks such as young people (including depression, conduct physical inactivity, diet, ambient particulate disorder and substance abuse) have negative pollution, and alcohol and tobacco life-long consequences for psychological, consumption.”22 physical and economic wellbeing, and that many of these disorders are preventable,
10 11 particularly when addressed in childhood and 24 adolescence. For example, children with Early Childhood: A critical untreated aggressive behavior are at risk for criminal activity and unemployment as they window of opportunity age into adulthood. Although prevention can be effective at improving health at all stages of life, Prevention’s impact on health outcomes prevention strategies that reach young Research suggests that, over time, prevention children have the greatest potential strategies can have a significant positive impact for improving total population impact on total population health, but that it health. From Neurons to Neighborhoods, can often take many years for those benefits a landmark study on the science of to be realized on a broad scale. A 2011 early childhood development from the study published in Health Affairs modeled Institute of Medicine, concluded that the impact of three different strategies most critical human brain development for reducing deaths and improving cost- takes place in the early years of life. effectiveness for the overall US population: expanding health insurance coverage, Infants and toddlers can thrive if they delivering better preventive and chronic have the benefits of an enriched environment and positive relationships care (including secondary prevention), and 25 “protection,” defined as “enabling healthier as they grow. These early experiences behavior and safer environments” (i.e., last a lifetime. Conversely, damaging primary prevention). The study found that early childhood experiences can have each of these approaches alone can save detrimental impacts that also last a lives, but that they are much more effective lifetime, including all of the leading in combination, and that the preventive causes of death and disability. For “protection” approach had the most example, the Adverse Childhood sustained positive impact over time. Expanded Experiences (ACE) Study conducted by insurance coverage and improved healthcare Kaiser Permanente found that children were found to reduce deaths within the short- who had been abused or neglected or term, followed by a plateau in health effects witnessed domestic violence were more likely to suffer from depression and heart after about 10 years. The impact of improved 26 behavioral and environmental conditions, disease later in life. however, saved many more lives through year 25 compared to expanded coverage and Experts from many different fields now improved care.28 Another study found local recognize that prevention strategies, public health spending was associated with such as evidence-based home visiting reduced mortality from leading preventable and violence prevention programs, and causes of death over a 13-year period. For multi-sector efforts to provide enriched every 10 percent increase in local public cognitive and social environments for health spending, there was an 6.9 percent disadvantaged young children, are powerful tools for improving health, reduction in infant mortality and a 3.2 percent 27 reduction in heart disease deaths.29 wellbeing, and self-sufficiency.
These studies provide evidence for the potential of prevention and public health evidence registries. See Appendix B for a list of strategies to save lives. Numerous other these resources. studies provide evidence of the effectiveness of specific prevention strategies to achieve Potential adverse effects of prevention reductions in the prevalence of conditions Recent controversies over screening for like heart disease or low birth weight and breast and prostate cancers point to risk factors like smoking or distracted driving, potential adverse effects and unintended and increases in protective behaviors like consequences of some clinical preventive physical activity or breastfeeding. Figure 9 lists services. For example, in 2009, the US examples of these evaluation results. Other Preventive Services Task Force (USPSTF) evidence-based prevention strategies can declined to recommend routine biennial be found in systematic reviews and online mammography for women under age 50,
12 13 Figure 9. Examples of effective community-based prevention strategies Policy change strategies Prevention programs Delivered to overall populations in Delivered to individuals, families or groups communities, schools and workplaces in community settings Tobacco taxes. Raising unit price of tobacco products, LifeSkills Training (LST). School-based program that such as increased excise taxes on cigarettes, leads to: teaches skills needed to build resilience and resist
Overall tobacco use alcohol and drug use leads to:
Initiation of tobacco use among young people Use of alcohol, tobacco, marijuana, and other drugs Tobacco-related morbidity and mortality30 Violence and delinquency Substance abuse refusal skills34 Smoke-free policies. Smoke-free policies (such as Ohio’s Smoke-free Workplace Act) have many benefits, Early childhood home visiting. Visitors provide parents including: with information and support regarding child health and
Overall tobacco use development. Shown to:
Initiation of tobacco use among young people Child abuse and neglect Improve birth outcomes Hospitalizations for heart attacks (acute Improve cognitive and social-emotional cardiovascular events) and asthma31 development 35
Safe Routes to School. Promoting walking and biking Safe Dates program. School-based curriculum that to school through education, incentives and safety teaches dating conflict-resolution skills and addresses
improvements has been shown to: dating violence and gender-role norms leads to: Pedestrian crashes Psychological and sexual abuse 32 36 Physical activity among children Violence against a dating partner Competitive pricing for school lunches. Assigns higher Good Behavior Game. Classroom intervention designed
costs to non-nutritious foods and lower costs to nutritious to help children stay on task and engaged in school
foods: work has been found to: Sales of healthy foods Children’s behavior problems
Consumption of healthy foods33 Need for mental health services
Drug or alcohol abuse or dependence disorders (at 14-year follow-up) Academic success37
instead stating that it should be an individual body of research that assesses whether decision based on “patient context and prevention activities are “cost saving,” “cost values.” The reluctance to recommend effective,” or simply drive up costs without mammography for women under age 50 improving health. Prevention activities that is based partly on the potential harms of decrease costs compared to waiting for screening, such as over-diagnosis resulting in treatment are cost saving. Prevention activities over-treatment, and false-positive tests that that cause significant health improvements lead to unnecessary procedures and anxiety.38 compared to waiting for treatment are cost Similarly, in 2012 the USPSTF recommended effective, even if they do not save very much against routine Prostate-Specific Antigen money.40 (PSA) testing for prostate cancer because it concluded that the harms caused by false- There is overwhelming evidence that many positives and long-term adverse effects of prevention strategies help people live longer treatment outweighed the benefits.39 and healthier lives, and strong evidence for the cost-effectiveness of many—but not Prevention’s impact on health costs all—prevention activities; in other words, Like medical treatment, the goal of prevention prevention generally increases health value. is to improve health. Given that “bending Evidence for cost savings is more mixed the cost curve” is a major goal of health and varies for different types of prevention reform, policymakers are also very interested activities. For example: in determining whether increased investment • An analysis of 20 evidence-based clinical in prevention will pay off in terms in reduced preventive services found that some failed or slowed healthcare costs and improved to yield net medical cost savings (including health value. Health value is defined as the cholesterol and osteoporosis screening), combination of improved health outcomes while others resulted in significant savings and controlled health costs. There is a growing (including childhood immunizations and
12 13 smoking cessation advice and assistance). Ohio Medicaid of $23.9 million within 1-2 Overall, the package of 20 preventive years and $76.7 million within five years.45 services was estimated to save many lives • Analysis by the Trust for America’s Health and result in modest cost savings.41 concluded that Ohio could save $686 • A review of cost-effectiveness studies million in healthcare costs (all payers) found that preventive measures were within five years if it invested $10 per person slightly more likely than treatments for per year in community-based prevention existing conditions to save money, but that strategies to increase physical activity, most preventive measures and treatments improve nutrition, and prevent tobacco alike actually increased costs.42 use. This represents a return on investment • A similar review of cost-effectiveness (ROI) of 6 to 1.46 studies categorized prevention activities into three types: environmental How do we pay for prevention? interventions (i.e., population-based Paying for clinical preventive services policy strategies), nonclinical person- Most clinical services, including clinical directed interventions (i.e., community- preventive services and medical treatment, based prevention programs delivered are paid for by health insurance (including to individuals and families), and clinical Medicaid and Medicare) or out of pocket by interventions (i.e. clinical preventive individual consumers. Providers are typically services). The study concluded that reimbursed for these clinical services on a population-based environmental strategies fee-for-service basis, although payment and were generally more cost-effective than delivery models designed to pay for outcomes clinical preventive services or community- 43 rather than volume of individual services based prevention programs. (such as managed care, Accountable Care • A study comparing the impact of better Organizations, or ACOs, bundled payments, preventive and chronic care (including and episode-based payments) are becoming secondary prevention) and primary more common. prevention strategies (“protection”) on healthcare costs over 10-year and 25-year The Affordable Care Act, or ACA, requires time horizons, estimated that better care most health insurance plans to cover a would actually increase costs. Primary package of clinical preventive services prevention, on the other hand, would that have been rated “A” or “B” by the increase costs for the first six years and then USPSTF, indicating that an independent would decrease total costs through year 44 panel of experts has determined that the 25. services have substantial or moderate net benefit. This package includes services Overall, this research suggests that prevention such as immunizations and screenings for services delivered in the healthcare system are colorectal cancer and depression, and it less likely to produce cost savings than those greatly increases access to clinical preventive directed at the population level, and that services.47 Insurers must provide these services primary prevention may be more cost-saving without charging patients for copayments, than secondary prevention in the long term. deductibles or co-insurance.
The studies presented above focused on Paying for population-based and community- the cost-effectiveness of specific prevention based prevention activities. Additional research looks at the Community-based prevention programs broader impact of increasing investment in and population-based policy strategies prevention more widely and makes projections have traditionally been separate from the about state-level cost savings. For example: clinical healthcare system and are not • A study published in the American Journal covered by health insurance. As shown in of Public Health found that Ohio could Figure 10, community-based programs are save $531.6 million in the short run and typically funded by federal, state or local $1,232.9 million in the medium term in government or private philanthropy in the medical costs (all payers) by reducing the form of grants. Funding for population-level prevalence of diabetes and hypertension policy strategies is spread across many by 5 percent. This translates to savings to different sectors. For example, transportation
14 15 Figure 10. Current payment sources and mechanisms for prevention and treatment Prevention Treatment and rehabilitation Population- Community- Clinical Treatment Disease based policy based preventive management, strategies prevention services rehabilitation, programs recovery supports • Federal, state, • Federal, state, • Medicaid and • Medicaid and • Medicaid and and local and local Medicare Medicare Medicare government government • Private • Private • Private • Philanthropy • Philanthropy insurance insurance insurance • Non-health • Individual • Individual • Individual sectors consumers consumers consumers (transportation, • Hospital charity • Federal, state, education, care and local
Payer/ Funder regional government planning, housing, etc.)
• Grants • Grants Reimbursement Reimbursement • Reimbursement • Inspection (fee-for-service (fee-for-service (some services) fees (for model, managed model, managed • Grants or environmental care, etc.) care, etc.) federal, state, health) and local • Public funding funding for non- for non- reimbursable health sectors services (transportation, mechanism education,
Dominant payment regional planning, housing, etc.)
See Figure 3 for description of these prevention and treatment categories.
spending on sidewalks and bike trails helps for population-based policy changes. These to increase physical activity, and school new approaches include payment reform district and U.S. Department of Agriculture mechanisms that allow for reimbursement spending on school lunches improves child for community-based prevention programs, nutrition. Health departments and other delivery models such as Accountable Care prevention organizations are often involved Communities and Community-Centered in coordinating these funding streams and Health Homes, wellness trusts, social impact advocating for multi-sector investments that bonds, employer wellness programs and improve health. leveraging hospital community benefit requirements to support upstream initiatives. Emerging models to finance prevention HPIO will explore these approaches in more Recognizing the need to establish more detail in a future publication. The following stable and coordinated investments in a reports provide an introduction to these broader range of evidence-based prevention concepts: strategies, policymakers around the country • Financing prevention: How states are are exploring new ways to link community- balancing delivery system and public based prevention with clinical preventive health roles, report prepared by National services and develop new sources of funding Academy for State Health Policy for ChangeLab Solutions, 2014
14 15 • How can we pay for a healthy population?: Innovative new ways to Emerging payment and delivery models redirect funds to community prevention. take patient care further upstream Prevention Institute, 2013. A Patient Centered Medical Home (PCMH) is an enhanced model of primary care in which a practice How much do we spend on is paid a care coordination fee (often per member prevention? per month) to attend to the multi-faceted needs The proportion of health expenditures that go of patients and provide comprehensive care that includes prevention, treatment and rehabilitation. toward prevention is a matter of debate and PCMHs, often through establishment of care teams, hinges upon the definition of prevention and coordinate physical and mental health care for the type of prevention strategies and sectors patients, including links to community services and included in the calculation. Estimates in the supports. For example, if a child with asthma has literature range from 1 percent to 5 percent.48 frequent emergency room visits, the pediatrician in a PCMH may reach out to a child’s school or child A frequently-cited statistic points out the care provider to make sure that everyone who is mismatch between spending on medical caring for the child understands how to manage the care (95 percent) and prevention (5 percent) child’s medications. in light of the primary drivers of premature death (behavior patterns, environmental The Community-Centered Health Homes (CCHH) model takes PCMHs one step further by actively exposure, and social circumstances) which addressing factors outside the healthcare are best addressed through upstream system that impact patient health outcomes by prevention rather than downstream “sick advocating for population-level policy change. care” (see Figure 11). For example, a CCHH that is treating children with lead poisoning or asthma may get involved in advocating for housing code enforcement to A more recent analysis of National Health improve housing quality, and have community Expenditure data estimated that 8.6 percent health workers on staff who go into homes and of 2008 US healthcare expenditures went help families to remove lead paint or asthma to prevention, including public health, triggers. prevention research and medical and dental preventive services. The estimate drops An Accountable Care Organization (ACO) is a to 4.4 percent if only primary prevention is network of providers that collectively assumes included.49 responsibility for the care of a defined patient population and shares in payer savings if set quality and cost performance metrics are met. The provider How much do we spend on network may also be at risk and bear financial prevention in Ohio? responsibility for spending that exceeds target Existing studies on this topic focus on metrics. For example, a primary care physician in an ACO may identify an individual who is at risk for healthcare expenditures for the US overall, diabetes due to obesity. The physician provides and do not include state-specific data counselling on prevention of diabetes and referral or the contributions of sectors outside the to a nutritionist in the ACO to help the individual healthcare system (such as transportation lose weight. If the ACO is successful in reaching set or education). In order to gain a better performance metrics targeted at managing and preventing diabetes, they are rewarded financially understanding of state-level public spending and the patient foregoes other complications of on prevention in Ohio, HPIO will report on diabetes such as amputations and kidney failure. state agency expenditures that support primary and secondary prevention in a future The Accountable Care Community (ACC) model publication. The Ohio departments of Health, takes the ACO one step further by holding Aging, Mental Health and Addiction Services, entities outside the healthcare system (such as Job and Family Services, Developmental community-based prevention organizations, local health departments, or social service providers) Disabilities and Medicaid will be included in accountable for the health outcomes of a this analysis. community along with health care providers. For example, the Live Healthy Summit County ACC Additional research like this is needed to partners with local YMCA Diabetes Prevention establish a clearer understanding of how Programs that help people diagnosed with prediabetes to adopt healthy eating and physical Ohio currently invests in prevention in order activity habits, and with the Cuyahoga Valley to move toward an appropriate balance National Park to promote active living. between prevention and treatment that will improve health value for Ohioans. 16 17 Ohio’s prevention Figure 11. Estimated contributions to causes of premature death infrastructure and vs. national health expenditures workforce For the most part, prevention activities in Ohio are carried out by three sectors: the clinical healthcare system, governmental public health and human service agencies and private nonprofit organizations. In some cases, organizations collaborate across these sectors, such as YMCAs working with healthcare providers and health insurers to implement the Diabetes Prevention Program. Some prevention strategies also involve partnerships with representatives from sectors such as education, transportation, regional planning, faith- based organizations, public safety and criminal justice, agriculture and housing. Employers are also increasingly involved causes expenditures in prevention, particularly Source: McGinnis, Williams-Russo, and Knickman. Health Affairs. 2002. larger employers that invest in comprehensive infrastructure for prevention in Ohio. Prevention employee wellness programs. Examples of injuries and communicable and chronic include incentives for healthy behaviors and diseases is a high priority for public health changes to the workplace environment, such agencies, and public health professionals as healthier foods in cafeterias and meetings, are trained to plan, implement and evaluate onsite fitness facilities, and policies that support prevention strategies. It is important to note, breastfeeding. however, that public health agencies are also responsible for some activities that may not be Clinical healthcare system considered prevention, such as emergency Clinical preventive services are delivered preparedness and disaster response. by community health centers, hospitals and health systems, private doctor’s and dentists’ Governmental public health’s role in providing offices and behavioral health clinics, employing clinical preventive services is in transition and professionals such as nurses, physicians, varies widely by location. Traditionally, local community health workers, dental hygienists, health departments have been responsible dieticians and social workers. In 2013, there for administering immunizations, although as were 686,884 people working in the healthcare more Ohioans gain access to health insurance sector in Ohio, making up 14 percent of the that is required to cover vaccinations, this total workforce.50 It is unknown, however, what responsibility is shifting to the clinical healthcare proportion of that overall healthcare workforce sector. Many local health departments conduct is delivering preventive services. screenings, such as for high blood pressure, tuberculosis and sexually transmitted disease. Public health system Only a small number of health departments The Ohio Department of Health (ODH) and local provide comprehensive primary care services.51 health departments provide the backbone Changes in the healthcare landscape as a result
16 17 of the ACA will likely alter further the extent developments in the city in order to promote to which local health departments provide active living. clinical preventive services. At the state level, ODH is the primary public As more Ohioans gain insurance coverage health agency. About 70 percent of ODH’s through expanded Medicaid eligibility and the funding comes from federal sources and health insurance marketplace, there may be much of that funding is passed through to less demand on local health departments to local health departments and other local provide clinical services. Regardless of a health organizations. Ohio’s 88 counties are home to department’s role in directly providing care, 125 local health departments. Sixty-five Ohio “linking people to needed personal health counties have one local health department (74 services” is one of the 10 Essential Public Health percent), while the remaining 23 counties have Services and health departments will likely two or more LHDs. About three-quarters of LHD continue to assist people with accessing health funding comes from local sources. See HPIO’s insurance and healthcare services. Ohio Public Health Basics for more information about the structure and funding of public Governmental public health is heavily health in Ohio. involved in communicable disease prevention, largely through disease surveillance and In 2014, ODH had 1,155 employees, down 20 environmental health services, such as percent from 1,442 in 2007 (see Figure 12). restaurant inspections, body art regulation Ohio’s 125 local health departments had and mosquito control. Health departments 4,789 total Full Time Equivalent staff positions also implement community-based prevention in 2013.52 Added together, the size of Ohio’s programs, such as tobacco education in governmental public health workforce is schools, the Help Me Grow home visiting roughly 5,900 employees. program, and public awareness campaigns to prevent drunk driving. Public health agency Health and human services agencies staff often lead policy change efforts, such In addition to ODH, several other state as Columbus Public Health’s work reviewing agencies carry out or fund prevention zoning applications and advocating for activities. Like ODH, these agencies have local- inclusion of sidewalks and bike racks for new level counterparts that also implement some
Figure 12. Total number of Ohio Department of Health employees, 2007 to 2014 1,442 1,422
1,380
1,285 1,282
1,245
1,165 1,155
2007 2008 2009 2010 2011 2012 2013 2014 Note: Includes full-time, part-time and intermittent employees Source: Ohio Department of Health 18 19 prevention activities: Some Ohio counties have chronic disease • Ohio Department of Mental Health and prevention coalitions supported by grants from Addiction Services and 53 local behavioral ODH’s Creating Healthy Communities program health boards (16 communities), Ohio Alliance of YMCAs’ • Ohio Department of Aging and 12 Area Pioneering Healthier Communities program Agencies on Aging (nine communities), or the federally-funded • Ohio Department of Developmental Community Transformation Grants (three Disabilities and 88 local Developmental communities). Disabilities boards • Ohio Department of Job and Family Services Each county also has a Family and Children First and 88 local County Departments of Job Council (FCFC) which brings together partners and Family Services from education, health, and juvenile justice • Ohio Department of Medicaid in order to coordinate services for children and families. FCFCs are required to develop Private nonprofit organizations a “Shared Plan” that aligns all local plans that Ohio is home to many private organizations address priorities for children and families. Many that promote health, such as the American of these plans include prevention activities. Heart Association, American Cancer Society, YMCAs, Big Brothers Big Sisters, Drug Free Action Training and certification Alliance, Buckeye Healthy Schools Alliance and There is no specific degree or certification the Ohio Suicide Prevention Foundation. Visit required to implement prevention activities. the Ohio Wellness and Prevention Network’s Academic public health programs do, however, “family tree” of prevention organizations for a list provide specialized training in assessing of statewide prevention organizations, including population health needs and identifying, nonprofit organizations, statewide coalitions, implementing and evaluating prevention and academic research centers. strategies. Ohio is home to one accredited school of public health and five accredited Nonprofit hospitals are increasingly involved Master of Public Health programs. There are in planning and implementing prevention also several certifications targeted to specific strategies, largely through the Community prevention skill sets. For example: Health Needs Assessment (CHNA) process • Health education: National Commission and other community benefit activities. for Health Education Credentialing issues The ACA requires all nonprofit hospitals to Certified Health Educator Specialists and conduct a CHNA every three years and to Master Certified Health Education Specialists adopt an implementation strategy. Many of certification (Ohio had 442 certified these implementation strategies may include individuals in 2014) prevention activities. • Alcohol or other drug prevention: Ohio Chemical Dependency Professionals Board Local coalitions issues Ohio Certified Prevention Specialist Local coalitions play an important role in (OCPS) and Certified Prevention Specialist planning and implementing prevention Assistant (CPSA) credentials (Ohio had strategies. These coalitions are typically led a total of 410 certified individuals in 2014 by a health department, United Way or (CPSA and OCPS I & II) other nonprofit organization or agency, and • Environmental health: State Board of bring together partners from multiple sectors. Sanitarian Registration (Ohio had 1,227 Examples include Our Futures in Licking County, active registered sanitarians in state fiscal which brings together the superintendents of year 2013) all school districts in the county with health and social service organizations with the goal of improving academic outcomes and reducing substance abuse, and the Greater Columbus Infant Mortality Task Force convened by the City Council in partnership with Columbus Public Health and Nationwide Children’s Hospital.
18 19 Appendix A. Key prevention frameworks and additional prevention terms
National Prevention Strategy Policy, system, and environmental change Released by the National Prevention Council strategies are aimed at the community and in 2011, the National Prevention Strategy lays societal levels. out four strategic directions to serve as the foundation for a “prevention-oriented society” Figure 14. Social-Ecological Model (see Figure 13). Organized around seven priority areas that emphasize a positive “health promotion” approach, this document compiles evidence-based recommendations and a set of measurable indicators and targets (cross- referenced with Healthy People 2020) designed individual relationship community societal to reduce the leading causes of preventable death and major illness in the U.S. Figure 13. National Prevention Strategy Framework
Spectrum of Prevention The Spectrum of Prevention builds upon the Social-Ecological Model and provides prevention practitioners with guidance about how to design effective and sustainable primary prevention strategies that address individual as well as environmental factors.54 The six levels shown in Figure 15 are complementary and are meant to reinforce one other.
There are strong parallels between the Spectrum of Prevention, the Social-Ecological Model and the Health Impact Pyramid. Each of these frameworks emphasize the importance of designing comprehensive prevention strategies that educate individuals about the importance Source: Centers for Disease Control and Prevention of behavior change, but also go beyond the individual to address other factors that shape wellbeing, including family relationships, social Social-Ecological Model norms and economic conditions. The Social-Ecological Model describes Figure 15. Spectrum of Prevention interaction between individual and contextual factors that impact wellbeing, suggesting that Influencing policy and legislation effective prevention strategies must address each of these factors.53 Initially used in the fields of child maltreatment, youth violence, Changing organizational practice and intimate partner violence, this model is now being used to inform a wide range of Fostering coalitions and networks health fields. As shown in Figure 14, the model includes four levels. The individual level refers to biological and personal history factors, while the Educating providers relationship level refers to family relationships, social interaction, and connections with peers and mentors. Community environments include Promoting community education schools, neighborhoods, and workplaces, and societal factors include social norms, cultural Strengthening individual knowledge and skills values, economic conditions, and policies. Source: The Prevention Institute
20 21 Risk and protective factors, asset Figure 16. Mental health intervention spectrum development, and resiliency Prevention strategies often aim to decrease risk factors and increase protective factors. Risk factors are individual, family or community conditions that increase the likelihood of a bad outcome for an individual, while protective factors are associated with a lower likelihood of a bad outcome. For example, easy access to drugs and alcohol, poor academic performance and family conflict are risk factors for teen substance abuse, while parental monitoring and a strong sense of belonging at school Source: Adapted from IOM, Reducing Risks for Mental Disorders, protect youth from drug and alcohol Frontiers for Preventive Intervention Research, 1994. use.
The Search Institute’s 40 Developmental Assets Additional prevention terms for Adolescents identify a set of protective Health promotion focuses on the positive factors often used by local prevention coalitions state of wellness, rather than on preventing to design initiatives to help children successfully a specific disease. Although the term health transition to adulthood. Examples of these promotion has different connotations for different developmental assets include positive family groups, it is often used to refer to strategies communication, caring school climate, adult that support healthy behaviors and healthy 55 role models, and resistance skills. Resiliency is a community conditions, and de-emphasize related concept that focuses on nurturing one’s a focus on preventing harm or sickness. For ability to overcome risk factors and cope with example, a health promotion approach to life’s stressors and challenges. Youth resiliency preventing domestic violence would be to help strategies, such as Ohio’s Start Talking: Building young people develop positive relationship a Drug-Free Future—Resilience Programming communication skills, rather than focusing solely in Schools initiative, aim to help young people on “red flags” for relationship abuses. develop good decision-making skills, cope with adversity, and develop other social-emotional Primordial prevention is defined as “an approach competencies that will help them to be healthy to prevention that targets underlying health 56 and successful as adults. Ohio’s Youth-Led determinants via modifying social policies so Figure 15. Spectrum of Prevention Prevention Network, a coalition of peer-led as to improve health in general.”57 Examples of substance abuse prevention groups, is another primordial prevention include sanitation system example of a program centered around positive improvements and economic reforms. For the youth development and resiliency. sake of simplicity and clarity, this publication considers the term primary prevention to Mental health intervention spectrum include both health promotion and primordial Prevention professionals within the behavioral prevention. health field use the Institute of Medicine’s Mental Health Intervention Spectrum, which includes the Quaternary prevention refers to the avoidance of universal/selected/indicated prevention levels unnecessary or excessive medical interventions. described on page 3. This framework broadens For the purposes of this publication, quaternary the context of prevention by including health prevention is included within the category of promotion, treatment, and maintenance (see treatment. Figure 16). This prevention typology focuses on varying levels of risk for population groups and is seen as particularly useful for describing strategies to prevent mental, emotional, and Source: The Prevention Institute behavioral disorders.
20 21 Appendix B. Sources of evidence of effectiveness There are several systematic reviews,58 online Because prevention strategies delivered in a evidence registries, and recommendations from community setting are more difficult to evaluate expert panels that identify evidence-based than clinical practices delivered in a healthcare prevention strategies. The US Preventive Services setting, the evidence base for community-based Task Force (USPSTF) Recommendations and programs and policy approaches is evolving the Center for Disease Control and Prevention’s and not all prevention topics are covered by the Guide to Community Preventive Services Community Guide. Figure 17 includes additional (“Community Guide”) are two systematic reviews sources that are credible and user-friendly, and that are considered “gold-standard” sources can supplement the USPSTF recommendations for prevention evidence. The USPSTF focuses on and the Community Guide. For more information clinical preventive services, while the Community about how to find evidence-based prevention Guide includes community-based programs and strategies, visit HPIO’s Online Guide to Evidence- population-level policy change strategies. Based Prevention.
Figure 17. Sources of evidence for effective prevention strategies: Systematic reviews and evidence registries Systematic reviews and evidence registries (click for link) Sponsoring organization Approach and topics US Preventive Services Task Force Agency for Healthcare Research and Clinical preventive services (screening, (USPSTF) Recommendations* Quality (AHRQ) counseling, and preventive medication) for broad range of health topics The Guide to Community Preventive US Centers for Disease Control and Community-based programs Services (Community Guide)* Prevention (CDC) and population-based policies; Comprehensive range of health topics What Works for Health University of Wisconsin Population Community-based programs Health Institute and the Robert Wood and population-based policies; Johnson Foundation Comprehensive range of health topics National Registry of Evidence-based Substance Abuse and Mental Health Clinical and community-based Programs and Practices (NREPP) Services Administration (SAMHSA) programs; Mental health promotion, substance abuse prevention, mental health and substance abuse treatment Research-tested Intervention Programs National Cancer Institute (NCI) and Clinical and community-based (RTIPs) Substance Abuse and Mental Health programs; Cancer screening, nutrition, Services Administration (SAMHSA) physical activity, tobacco, sun safety and other aspects of cancer control Public Health Law Research- Evidence Temple University and the Robert Wood Population-based policies; Physical and Briefs Johnson Foundation mental health and housing Cochrane Reviews* Cochrane Collaboration Clinical preventive services; Physical health Promising Practices Network RAND Corporation Community-based programs; Child and adolescent physical and mental health, school success, juvenile justice and poverty Top Tier Evidence* Coalition for Evidence-Based Policy Community-based programs; Early childhood, education, employment/ training, youth development, crime/ violence, health care, obesity, substance abuse, housing What Works Clearinghouse Institute for Education Sciences, US Community-based programs; Department of Education Education Campbell Library Systematic Reviews* Campbell Collaboration Library Community-based programs and population-based policies; Crime, education, social welfare *Systematic review (comprehensive literature reviews that appraise and synthesize empirical evidence)
22 23 Glossary
Accountable Care Community (ACC) — A and mental wellbeing, and not merely the broadened concept of accountable care absence of disease or infirmity.61 organizations (see below) that includes other entities, such as community-based prevention Health disparities — Differences in health status organizations, local health departments, or among distinct segments of the population social service providers, in addition to health including differences that occur by gender, care providers, in the group held accountable race or ethnicity, education or income, for performance.59 disability, or living in various geographic localities.62 Accountable Care Organization (ACO) — A network of providers that collectively assumes Health equity — The absence of differences responsibility for the care of a defined patient in health that are caused by social and population and shares in payer savings if set economic factors. Achieving health equity quality and cost performance metrics are met. means that all people have the opportunity The provider network may also be at risk and to achieve their full health potential, with no bear financial responsibility for spending that one at a disadvantage because of social or exceeds target metrics. economic circumstances.63
Backbone organization — Described as part Health Impact Assessment (HIA) — A of the Collective Impact Model, “backbone” systematic process that uses an array of organizations provide supporting infrastructure data sources and analytic methods, and for collaborative efforts through meeting considers input from stakeholders to determine facilitation, fundraising, data collection and the potential effects of a proposed policy, reporting, administration and communications plan, program, or project on the health of support.60 a population and the distribution of those effects within the population. An HIA provides Clinical preventive services — Prevention recommendations on monitoring and services provided to individual patients in a managing those effects.64 healthcare setting. Health promotion — The process of enabling Community-based prevention programs people to increase control over, and to — Prevention programs delivered in a improve, their health.65 community setting (such as home, school, child care, workplace, or neighborhood) to Health in All Policies — A collaborative program participants as individuals, families or approach to improving the health of all communities. people by incorporating health considerations into decision-making across sectors and policy Community-Centered Health Homes — An areas.66 emerging health model to bridge clinical services with community-based prevention Hospital community benefit requirements — programs and population-level policy Federal Internal Revenue Service requirements strategies. A provider practice that addresses that nonprofit hospitals must meet to maintain the factors outside the healthcare system their nonprofit status. that impact patient health outcomes by advocating for policy, system and Indicated prevention — Prevention environmental change. interventions targeted to high-risk individuals with increased vulnerability or early signs of a Environmental change — Physical or material problem, disease, or condition. changes to the economic, social, or physical environment (such as water fluoridation, Patient Centered Medical Home (PCMH) — A removing lead from paint, and improving the provider practice that receives additional built environment with sidewalks and bike payments in exchange for the delivery of care lanes). coordination services that are not currently provided or reimbursed. Health — A state of complete physical, social,
22 23 Glossary (cont.)
Policy — Laws, regulations, rules, protocols, determinants via modifying social policies so as mandates, resolutions, and ordinances to improve health in general.70 designed to guide or influence behavior. Public policy refers to legislative (laws, ballot Public health — The science and art of measures), legal (court decisions), fiscal promoting health, preventing disease, and (government budgets), and regulatory actions prolonging life through the organized efforts of (including administrative rules and executive society.71 Public health organizations include orders). Organizational policy refers to internal government agencies at the federal, state, standards and protocols established by public and local levels, as well as nongovernmental or private organizations, such as workplace or organizations that are working to promote school wellness policies. health and prevent disease and injury within entire communities or population groups. Policy, systems, and environmental change (PSEC) — Policy, systems, and environmental Quaternary prevention — The avoidance change is a way to modify the environment to of unnecessary or excessive medical make healthy choices practical and available interventions. For the purposes of this to all community members.67 publication, quaternary prevention is included within the category of treatment. Population-based prevention policies — Policy change strategies designed to reach all Secondary prevention — Efforts to detect residents of a geographic area or all people health problems at an early stage and/or to in a community setting (such as a school or slow or halt the progress of an existing disease, workplace) in order to modify the environment injury, or other problem. to make healthy choices practical and available to all community members. See also, Social determinants of health — Conditions in policy, systems and environmental change. the environments in which people are born, live, learn, work, play, worship, and age that Population health — The health outcomes of a affect a wide range of health, functioning, group of individuals, including the distribution and quality-of-life outcomes and risks. In of such outcomes within the group.68 The addition to the social, economic, and physical field of population health focuses on the conditions of a person’s environment, social determinants of health (including medical determinants also include patterns of social care, public health interventions, social engagement and sense of security and environment, physical environment, genetics, well-being. Examples of resources that can and individual behavior) and the policies and influence (or, “determine”) health outcomes programs that influence those determinants include safe and affordable housing, access to and reduce health disparities among education, public safety, availability of healthy population groups. foods, local emergency/health services, and environments free of life-threatening toxins.72 Prevention — A systematic process that promotes healthy behaviors and reduces the likelihood or frequency of an incident, condition, or illness. Ideally, prevention Selective prevention — Prevention activities addresses health problems before they occur, targeted to specific populations with above- rather than after people have shown signs of average risk for a problem. disease or injury.69 Systematic review — A literature review that Primary prevention — Efforts to prevent a attempts to identify, appraise and synthesize disease, injury, or other heath problem from all the empirical evidence that meets pre- occurring in the first place. specified eligibility criteria. Systematic reviews of randomized controlled trials are considered Primordial prevention — An approach to to the “gold standard” of evidence. prevention that targets underlying health
24 25 Glossary (cont.)
Systems change — Systems change involves change made to rules and practices within an organization, institution, or system (such as school, transportation, park, food distribution, or health care systems).
Tertiary prevention — Prevention activities targeted to the person who already has symptoms and seeks to reduce further complications, increasing pain, or death.
Treatment — What a health care provider does to relieve, reduce, or eliminate harm once it has become manifest in an ailment.73
Triple Aim — A term used to describe an approach for enhancing health system performance. The goals of the Triple Aim, as conceptualized by the Institute for Healthcare Improvement are: improve the patient experience of care, improve health of populations, and reduce the per capita cost of health care.74
Wellness — Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the full potential of the individual physically, psychologically, socially, spiritually, and economically, and the fulfillment of one’s role expectations in the family, community, place of worship, workplace and other settings.75
Universal prevention — Prevention activities that are directed at an entire population and are likely to provide some benefit to all.
Upstream prevention — Health improvement approaches that address the causes of health problems rather than just the symptoms. Upstream strategies often involve non-clinical/ community-based programs and policies that address the social determinants of health.
24 25 Notes 1. Adapted from: National Public Health live if current mortality rates continue to 37. U.S. Department of Health and Human Services, Partnership. “The language of prevention.” apply.”Accessed May 27, 2014. http://www. Substance Abuse and Mental Health Services Melbourne: NPHP, 2006. And, Cohen, Larry, rwjf.org/en/research-publications/research- Administration, National Registry of Evidence- and Sana Chehimi. “The Imperative for Primary features/rwjf-datahub/national.html#q/scope/ based Programs and Practices. “PAX Good Prevention.” Prevention is Primary: Strategies for national/ind/31/dist/29/char/119/time/14/viz/ Behavior Game and Good Behavior Game Community Wellbeing. The Prevention Institute, rankings/cmp/brkdwn Intervention Summary.” Accessed May 2007. 20. America’s Health Rankings. “2013 Annual 30, 2014. http://www.nrepp.samhsa.gov/ 2. Faust, Halley S. and Paul T. Menzel, eds. Report.” http://www.americashealthrankings. SearchResultsNew.aspx?s=b&q=good%20 Prevention vs. Treatment: What’s the Right org/reports/annual behavior%20game Balance? Oxford University Press, 2012. 21. Kasier Family Foundation, State Health Facts, 38. U.S. Preventive Services Task Force. “Screening 3. Institute of Medicine. “Primary Care and “Health Care Expenditures per Capita by State for Breast Cancer.” Accessed May 30, 2014. Public Health: Exploring Integration to Improve of Residence.” Accessed May 29, 2014. http:// http://www.uspreventiveservicestaskforce.org/ Population Health.” Washington, DC: The kff.org/other/state-indicator/health-spending- breastcancer.htm National Academies Press, 2012. per-capita/ 39. U.S. Preventive Services Task Force. “Screening 4. Kindig, David, Asada Yukiko, and Bridget 22. U.S. Burden of Disease Collaborators. “The for Prostate Cancer.” Accessed May 30, 2014. Booske. “A population health framework for state of U.S. health, 1990-2010: Burden of http://www.uspreventiveservicestaskforce.org/ setting national and state health goals.” Journal diseases, injuries, and risk factors.” Journal of the prostatecancerscreening.htm of the American Medical Association 299, no. American Medical Association 310, no. 6 (2013): 40. Goodell, S., JT Cohen and PJ Neuman. “Cost 17 (2008): 2081-2083. 591-608. savings and cost-effectiveness of clinical 5. Institute of Medicine Roundtable on Population 23. U.S. Centers for Disease Control and Prevention. preventive care.” Robert Wood Johnson Health Improvement. “A working definition of “The power of prevention: Chronic disease… Foundation. The Synthesis Project Policy Brief population health.” Accessed May 23, 2014. the public health challenge of the 21st No. 18., 2009. http://iom.edu/~/media/Files/Activity%20Files/ century,” 2009. 41. Maciosek, Michael V., et al. “Greater use of PublicHealth/PopulationHealthImprovementRT/ 24. Institute of Medicine. Preventing Mental, preventive services in US health care could Population%20Health%20RT%20Working%20 Emotional, and Behavioral Disorders Among save lives at little or no cost.” Health Affairs 29, Definition.pdf Young People Progress and Possibilities. no. 9. (2010): 1656-1660. 6. Jacobson, Dawn Marie, and Steven Teutsch. Washington, D.C.: The National Academies 42. Cohen, Joshua T., Peter J. Neumann, and “An Environmental Scan of Integrated Press, 2009. Milton C. Weinstein. “Does preventive care Approaches for Defining and Measuring Total 25. Institute of Medicine. From Neurons to save money?: Health economics and the Population Health by the clinical care system, Neighborhoods: The Science of Early Childhood presidential candidates.” New England Journal the government public health system, and Development. Washington, DC: The National of Medicine 358, no 7. (2008): 661-663. stakeholder organizations.” Public Health Academies Press, 2000. 43. Chokshi, Dave A. and Thomas A. Farley. Institute and County of Los Angeles Public 26. U.S. Centers for Disease Control and Prevention. “The cost-effectiveness of environmental Health, 2012. “Adverse Childhood Experiences (ACE) Study.” approaches to disease prevention.” New 7. Ibid. http://www.cdc.gov/violenceprevention/ England Journal of Medicine 367, no. 4. (2012): 8. Although genetics have been traditionally acestudy/about.html 295-297. considered to be “nonmodifiable,” emerging 27. Robert Wood Johnson Foundation Commission 44. Milstein, B., et. al. “Why behavioral and evidence suggests that environmental to Build a Healthier America. “Time to act: environmental interventions are needed to conditions can impact genes. Investing in the health of our children and improve health at lower cost.” Health Affairs 30, 9. McGinnis, J. Michael, Pamela Williams-Russo, communities,” 2014. no. 5. (2011): 823-832. and James R. Knickman. “The case for more 28. Milstein, B., et. al. “Why behavioral and 45. Ormond, Barbara, et. al. “Potential National active policy attention to health promotion.” environmental interventions are needed to and State Medical Care Savings from Primary Health Affairs 21, no. 2 (2002). improve health at lower cost.” Health Affairs 30, Disease Prevention.” American Journal of Public 10. Healthy People 2020. “Social Determinants of no. 5. (2011). 823-832. Health 101, no. 1. (2011): 157-164. Note: Cost Health.” Accessed May 19, 2014. http://www. 29. Mays, Glen P., Sharla A. Smith. “Evidence links savings to Medicaid include state and federal healthypeople.gov/2020/topicsobjectives2020/ increases in public health spending to declines portions. overview.aspx?topicid=39 in preventable deaths.” Health Affairs 30, no. 8. 46. Trust for America’s Health. “Prevention for 11. Virginia Department of Health. “What is (2011): 1585-1593. a healthier America: Investments in disease health inequity?” Last modified March 29, 30. Guide to Community Preventive Services. prevention yield significant savings, stronger 2014. Accessed May 19, 2014. http://www. “Reducing tobacco use and secondhand communities,” 2008. vdh.virginia.gov/OMHHE/healthequity/ smoke exposure: interventions to increase the 47. “Preventive Services Covered by Private Health unnaturalcauses/healthequity.htm unit price for tobacco products.” Accessed Plans under the Affordable Care Act.” Focus 12. Rudolph, Lisa, Julia Caplan, Karen Ben-Moshe, May 30, 2014. www.thecommunityguide.org/ on Health Reform fact sheet. Kaiser Family and Lianne Dillon, “Health in All Policies: A guide tobacco/increasingunitprice.html. Foundation. September 2011. Accessed for state and local governments.” Washington, 31. Guide to Community Preventive Services. 6/12/14. http://kaiserfamilyfoundation.files. D.C. and Oakland, C.A.: American Public “Reducing Tobacco Use and Secondhand wordpress.com/2013/01/8219.pdf Health Association and Public Health Institute, Smoke Exposure: Smoke-Free Policies.” 48. Miller, George, et. al., “What is currently spent 2013. Accessed May 30, 2014. http://www. on prevention as compared to treatment?” 13. Whitehead, Margaret and Goran Dahlgren, thecommunityguide.org/tobacco/ In Prevention vs. Treatment: What’s the Right “Levelling up part 1: concepts and principles smokefreepolicies.html. Balance?, edited by Halley S. Faust and Paul for tackling social inequities in health.” 32. County Health Rankings and Roadmaps. Safe T. Menzel, 37-55, New York: Oxford University Copenhagen, Denmark: World Health Routes to School, as reviewed by What Works Press, 2012. Organization (2006). Accessed May 19, 2014. for Health. Accessed June 4, 2014. http://www. 49. Miller, George, et. al., “What is currently spent http://www.euro.who.int/__data/assets/pdf_ countyhealthrankings.org/policies/safe-routes- on prevention as compared to treatment?” file/0010/74737/E89383.pdf schools-srts. In Prevention vs. Treatment: What’s the Right 14. Institute of Medicine. “For the Public’s Health: 33. County Health Rankings and Roadmaps. Balance?, edited by Halley S. Faust and Paul Investing in a healthier future.” Washington, Competitive pricing in schools, as reviewed by T. Menzel, 37-55, New York: Oxford University D.C.: The National Academies Press, 2012. What Works for Health, Accessed June 4, 2014: Press, 2012. 15. Frieden, Thomas R., “A framework for public http://www.countyhealthrankings.org/policies/ 50. Census Bureau Quarterly Workforce Extraction health action: The Health Impact Pyramid.” competitive-pricing-schools Tool. Quarterly average for first two quarters of American Journal of Public Health 100, no, 4 34. U.S. Department of Health and Human Services, 2013. Includes public and private sector. http:// (2010). Substance Abuse and Mental Health Services ledextract.ces.census.gov/ 16. “Building a culture of health: A message from Administration, National Registry of Evidence- 51. Health Policy Institute of Ohio. “Ohio Public Risa Lavizzo-Mourey, President and CEO” based Programs and Practices. “LifeSkills Health Basics,” 2013. Robert Wood Johnson Foundation, 2014. http:// Training (LST) Intervention Summary.” Accessed 52. Ohio Department of Health, 2014. www.rwjf.org/en/about-rwjf/annual-reports/ June 4, 2014. http://www.nrepp.samhsa.gov/ 53. Krug, Etienne G., et. al., eds. “World report on presidents-message-2014.html. ViewIntervention.aspx?id=109. violence and health.” Geneva, Switzerland: 17. Rudolph, Lisa, Julia Caplan, Karen Ben-Moshe, 35. County Health Rankings and Roadmaps. 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Geneva, Switzerland: World Health Oakland, C.A.: American Public Health 74. Institute for Healthcare Improvement. “The Organization, 1998. Association and Public Health Institute, IHI Triple Aim.” http://www.ihi.org/Engage/ 62. Virginia Department of Health. “What is 2013. Initiatives/TripleAim/Pages/default.aspx health inequity?” Last modified March 29, 67. Communities Putting Prevention to 75. The WHO Health Promotion Glossary: New 2014. Accessed May 19, 2014. http://www. Work. “What is Policy, Systems, and Terms. Geneva, Switzerland: World Health vdh.virginia.gov/OMHHE/healthequity/ Environmental Change?” Cook County Organization, 2006. unnaturalcauses/healthequity.htm Department of Public Health and the
Author Amy Bush Stevens, MSW, MPH, Director of Prevention and Public Health Policy, HPIO
Contributors Anne Harnish, Consultant Stephanie Gilligan, HPIO Policy Assistant Allison Gollon, HPIO intern Sarah Bollig Dorn, HPIO intern
Acknowledgements We thank the Ohio Prevention Basics Advisory Committee for guiding the development of this publication: • Elaine Borawski, Director, Prevention Research Center and Professor, Department of Epidemiology and Biostatistics, Director, Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University • Rebecca Cline, Prevention Programs Director, Ohio Domestic Violence Network • Phyllis Pirie, Professor, College of Public Health and Prevention Research Center, The Ohio State University • Robin Seymour-Hicks, Board of Directors, Alcohol and Drug Abuse Prevention Association of Ohio • Michele Shough, Coordinated Chronic Disease Manager, Bureau of Healthy Ohio, Ohio Department of Health • Andy Wapner, Chief Medical Officer, Ohio Department of Health
26 27 We want to hear from you Please take a few minutes to let us know what you think of this policy brief. https://www.surveymonkey.com/s/prevbasics
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