Anticipatory Care: Importance, Levels of Prevention, and Screening Principles

2. Anticipatory Care & health promotion Prof. Sulaiman Al-Shammari Department of Family & Community Medicine , College of Medicine King Saud University , Riyadh, Saudi Arabia 2

3. Anticipatory Care Learning Objectives At the end of this session students would be able to: Define anticipatory care Recognize its importance. Recall levels of prevention with appropriate examples. Define screening. Recognize its principles. Recall criteria of screening.

4. Content Introduction. Definition. PHC and anticipatory care. Level of preventive intervention. Screening: - Definition - Principles - Ethics Conclusion.

5. Case • A 45-year-old man is presented to the clinic with C/O mild cough, fever & general body ache of one day duration. O/E : • Temp 39C, congested throat, & he is obese. • Possibility of flue like viral infection What should be done for this man?

6. Case • A 40-year-old healthy man on routine checkup he found to have: • BMI: 31 • FBS: 6.2 What should be done for this healthy man?

7. BMI Categories: • Underweight = <18.5 • Normal weight = 18.5–24.9 • Overweight = 25–29.9 • Obesity = BMI of 30 or greater

8. Awareness:Women and Heart Disease • 1 in 2-3 women die of CHD, but only 4% fear of dying of CHD • 1 in 27 women die of breast cancer, but 40% fear of dying of breast cancer • 2/3 of women have at least 1 CHD risk factor, • 52% over age 45 have hypertension, • 40% over age 55 have high cholesterol

9. Some EBM Facts Changing pattern of mortality and morbidity. Geographical variation in disease occurrence. Migrants and development of diseases. Stopping of smoking: Decreasing death due to all types of Ca-33%. Decreasing death due to all types of IHD 25%. etc. Early detection of hypertension Helps in 50% of stroke prevention. Prevention of DM ??

10. 50% of patients with “Impaired Fasting Glucose” will go on to become diabetic within 10 years

12. Does Treating The Metabolic Syndrome Make a Difference? Finnish Diabetes Prevention Study • Design • 522 middle-aged overweight/obese patients (mean BMI 31 kg/m2) • 172 men and 350 women • Mean duration 3.2 years • Intervention group: individualized counseling • Reducing weight, total intake of fat and saturated fat • Increasing intake of fiber, physical activity • Tuomilehto J et al. N Engl J Med 2001;344:1343-1350

13. Benefit of Treating The Metabolic Syndrome:Finnish Diabetes Prevention Study • After 4 years, risk of diabetes reduced by 58% 25% 20% 15% 10% 5% 0% Intervention Control With Diabetes (%) Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350.

14. Levels of Risk Associated with Smoking, Hypertension and Hypercholesterolaemia Hypertension (SBP 195 mmHg) x3 x9 x4.5 x16 x1.6 x4 x6 Smoking Serum cholesterol level (8.5 mmol/L, 330 mg/dL) Poulter N et al., 1993

15. ½ Known treated and controlled ½ of those Treated Not controlled ½ not known ½ of those known Not treated The Rule of Halves in Hypertension

16. Cost ?Less attention on prevention??

17. About six cents of every health dollar in the U.S. is spent on medical and health research. Source: America Speaks: Poll Data, Vol. 5, Research!America, 2003.

18. Less than one cent of every health care dollar in the U.S. is spent on prevention research. Source: America Speaks: Poll Data, Vol. 5, Research!America, 2003.

19. “There I am standing by the shore of a swiftly flowing-river and I hear a cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then, just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in”. Zola, I.K. “Helping – does it matter? The problems and prospects of mutual aid groups”.

20. What is anticipatory care? It include all measures which promote good health and prevent or delay the onset of diseases or their complications. This care aims to: Improve the quality of life Reduce the premature disability Increased life expectancy So it denotes “the essential union of prevention with care and curve” (RCGP-1981).

21. Level of prevention Primordial prevention. Primary prevention. Secondary prevention. Tertiary prevention.

22. Table 6.1. Levels of prevention.

24. Special groups • Pregnancy • * oral contraception. • * developmental screening of infants and children. • *elderly • *known family history of IHD, cancer, glaucoma 24

25. The optimum setting for anticipatory care: Primary Health Care. Frequent contacts. Defined population. Primary-care team. Dr.-Pt. relationship. Holistic approach.

26. Screening

27. Screening The iceberg of disease Self care and Medical treatment Symptomatic disease The surface Screening Pre-symptomatic disease Health (Last 1963)

28. Screening Definition: It is broadly defined as the questioning, examination, or investigation of an asymptomatic individual to determine the presence or absence of disease. Is it diagnostic?? Screening is not usually diagnostic and it requires appropriate investigative follow-up and treatment.

29. Screening Types: Mass screening. Multiple or multi-phasic screening. Targeted screening. Case-finding ??

30. Case – Finding Case-finding or opportunistic screening: It is the term used when it is undertaken opportunistically for patients who consult their doctors for some other purpose. Example??

31. Criteria for Assessment of a screening test. Validity - Sensitivity Specificity Reliability Predictive Value

32. predictive value a measure used by clinicians to interpret diagnostic test results. (The likelihood that a positive test result indicates disease or that a negative test result excludes disease..) positive predictive value the probability that a patient with a positive test result really does have the condition for which the test was conducted. negative predictive value the probability that a patient with a negative test result really is free of the condition for which the test was conducted.

33. Principles of Screening The criteria for screening: (Wilson 1976) The disease: An important problem Recognized latent or early symptomatic stage. Natural history of disease adequately understood. Facilities for Dx. And treatment available. The treatment: Agreed policy on whom to treat. Acceptable treatment for patients recognized. The test: Suitable test or exam. Acceptable to population. The cost should be economically balanced. Continuous process and not a “once for all” project.

34. Principles of Screening The criteria for screening: (Wilson 1976) The disease: An important problem Recognized latent or early symptomatic stage. Natural history of disease adequately understood. Facilities for dgx. And treatment available. The treatment: Agreed policy on whom to treat. Acceptable treatment for patients recognized. The test: Suitable test or exam. Acceptable to population. The cost should be economically balanced. Continuous process and not a “once for all” project.

35. Principles of Screening The criteria for screening: (Wilson 1976) The disease: An important problem Recognized latent or early symptomatic stage. Natural history of disease adequately understood. Facilities for dgx. And treatment available. The treatment: Agreed policy on whom to treat. Acceptable treatment for patients recognized. The test: Suitable test or exam. Acceptable to population. The cost should be economically balanced. Continuous process and not a “once for all” project.

36. Principles of Screening The criteria for screening: (Wilson 1976) The disease: An important problem Recognized latent or early symptomatic stage. Natural history of disease adequately understood. Facilities for dgx. And treatment available. The treatment: Agreed policy on whom to treat. Acceptable treatment for patients recognized. The test: Suitable test or exam. Acceptable to population. The cost should be economically balanced. Continuous process and not a “once for all” project.

37. Ethics of Screening Safe? Beneficial? The “cost” to patient of screening: Disadvantages? Inconvenience Anxiety Discomfort Risk that screening Procedure may be harmful Risk of labeling as “sick” or “at risk”.

39. Conclusion: Anticipatory care is the integration of prevention and cure. PHC service is the optimal place to apply this care and observe. Every opportunity to be utilize to deliver this care. Case finding V/S formal screening.

40. Health Promotion

41. What is Health Promotion1? • Concept was first introduced in USA 1979 • Has evolved to include the educational, organizational, procedural, environmental, social, and financial supports that help individuals and groups reduce negative health behaviors and promote positive change among various population groups in a variety of settings

42. What Is Health Promotion2? • Health promotion programs are designed to help people who are healthy, but engaging in • risky behaviors (i.e., smoking, drinking, risky sexual behaviors) • or actions that increase their susceptibility to negative health consequences (i.e., physical inactivity, unhealthy diets) • to change their behaviors

43. Behavior Change – Is It An Easy Task? • Can we expect people to adopt a healthy lifestyle after they have been exposed to a health promotion program? • Can we force people to participate in sport and physical activities because we believe they are good for their health and soul? • No … Getting people to engage in health behavior change is a complex process that is very difficult even under the best of conditions..

44. Effective Health Promotion1 • Does saying, “Just do it!” work? • No … Health promotion is not simply an information campaign or just providing opportunities. • Information campaign is the easiest and most common form of program, yet least effective • “Just do it!” sounds ‘good’, but doesn’t work.

45. Effective Health Promotion2 • Effective health promotion programs • help people: • modify behaviors, increase skills, change attitudes, increase knowledge, influence values, and improve health decision making • maintain healthy lifestyles • provide: • educational, organizational, environmental, financial, and social support • e.g., worksite smoke cessation program

46. Need for Health Promotion1 • Physical Inactivity is a Global Problem • In developed countries: • Industrialization, modern technologies, automation, and a global food market have taken away the need and opportunity for physical exertion • In developing countries: • Over crowding, poverty, crime, traffic, low air quality, plus lack of parks, sports and recreation facilities, and sidewalks make physical activity a difficult choice • Result: 60% ~ 85% global population fails to achieve 30 minute moderate intense physical activity daily

47. Need for Health Promotion2 • Physical movement and activity are essential for the human organism to grow, develop, and maintain health. • Consequences of physical inactivity • increased levels of obesity, diabetes, cardiovascular disease (the leading cause of death in most countries)

48. Need for Health Promotion4 • Physical inactivity: • second greatest threat to U.S. public health • a major public health problem affecting huge numbers of people in all regions of the world • Effective health promotion programs are urgently needed to promote physical activity and improve public health around the world.

49. A sedentary lifestyle increases the risk of overall mortality (2 to 3-fold) cardiovascular disease (3 to 5-fold) The effect of low physical fitness is comparable to that of hypertension, high cholesterol, diabetes, and even smoking. Physical activity Sources: Wei et al., JAMA 1999; Blair et al., JAMA 1996

50. Need for Health Promotion3 • Chronic diseases associated with unhealthy behaviors, such as unhealthy diets, caloric excess, inactivity, and obesity are the greatest public health problems in most countries of the world • The increasing incidence of chronic diseases • causing ~60% of the 56.5 million reported deaths globally • contributing ~46% to the spread of disease worldwide • These estimates are expected to rise to 73% and 60%, respectively, by 2020