The Language

of Prevention

The Language of Prevention

Introduction

The concept of prevention

The levels of prevention

Prevention and public health

Benefits of prevention

Tables
Copyright: National Public Health
Partnership 2006
Copies of this publication can be
obtained from the National Public
Health Partnership website:
www.nphp.gov.au
ISBN (print ): 0-9775144-5-5
ISBN (online): 0-9775144-6-3
Suggested citation:
National Public Health Partnership
(2006). The Language of Prevention.
Melbourne: NPHP.

Table 1: Levels of prevention

Table 2: Examples of primary, secondary and tertiary

prevention related to selected diseases and national
health priority areas

Figures
Figure 1: The Dahlgren Whitehead model of health

Figure 2: Comprehensive model of chronic disease

prevention and control

The Language of Prevention

This brief explanation of the language of prevention
from a public health perspective, aims to foster a
common understanding of prevention terminology
across the continuum of prevention and care. Effective
communication amongst health professionals and
policy makers is essential to a strengthened integrated
capacity for preventive action and improved community
health and wellbeing. Recent national initiatives to
improve the health status of the population have
emphasised the opportunities for the health system and
society in providing an increased focus on the prevention
of disease and disability, concurrent with the on-going
need for quality health care. The following overview of
the concept of prevention should facilitate integrated
preventive action across the continuum of prevention
and care and better enable workforce participation in
financial and structural reforms for improved health
outcomes.

Introduction
A description of the concept of prevention is provided
as the term is used to refer to the efforts of society
to promote, protect and sustain the health of the
population. This description is based on the customary
public health categorisation of primary prevention,
secondary prevention and tertiary prevention.
Preventive actions are developed and implemented
by a wide range of health disciplines to address many
facets of disease, disability and injury control and
management. With this diversity of use has come
differences in the way in which prevention is categorised
and communicated within the health sector. A shared
understanding of frameworks of prevention can facilitate
coordination of effort, collaboration on new solutions,
effective use of valuable resources and sharing of
experiences and expertise.
The National Public Health Partnership has previously
developed a strategic framework for chronic disease
prevention that presents the case for prevention and
clarifies the various contributions of the health sector

The Language of Prevention

within the context of the continuum of care and the

lifecourse of the population.1 Building on this resource,
The Language of Prevention aims to reinforce and
stimulate the broader opportunities for prevention across
the health system and to provide a guide to the public
health terminology of prevention.

The concept of prevention

Prevention can be simply defined as action to reduce or
eliminate or reduce the onset, causes, complications or
recurrence of disease.2
In general, the concept of prevention is characterised by
activities that are designed to reduce the likelihood that
something harmful will occur, or to minimise that harm if
it does occur.
Prevention is an important component of many aspects
of public policy (for example crime prevention, child
abuse prevention, road safety), many of which also
contribute, directly or indirectly, to health. The health
sector can play a lead role in preventive initiatives or
a supporting role when it is more appropriate for other
sectors to provide leadership. The familiar model shown
in Figure 1 illustrates the breadth of individual, social,
socioeconomic, cultural and environmental conditions
affecting the health of individuals and communities.
These conditions are both proximal (direct) and distal
(indirect), highlighting the potential for public policy
to influence the determinants of health and the
opportunities for prevention by stakeholders in health
and other sectors.
In the health arena, prevention is seen as one of the
core responsibilities of organised health systems
alongside the curative, restorative and palliative
functions and is an increasingly important element in
societal efforts to improve health.
1

National Public Health Partnership (2001). Preventing Chronic

Disease: A Strategic Framework. Background Paper, NPHP.

Australian Institute of Health and Welfare (2004). Australias Health

2004. Canberra, AIHW Cat. No. AUS 44, p.496.

Figure 1: The Dahlgren Whitehead model of health

ltural and environ

men
mic, cu
o
n
o
tal c
ec
i
c
ond
o
s
Living
and
l
i ti o
a
r
ns
ne
working
e
G
conditions
Work
Unemployment
environment

d community netw
ork
s
o
S
l lifestyle fac
a
u
tor
ivid
nd

l an
cia

Education

Water and
sanitation

Agriculture
and food
production

Age, sex and

constitutional
factors

Preventive activities focus on those major health

problems, which are known to be amenable to
intervention. For many other health conditions, treatment
and care is the mainstay and prevention may have less
relevance. The prevention of illness or disability requires
the identification of modifiable risk and protective
factors and the implementation of strategies to eliminate
or reduce these risk factors and/or maximise and
increase the protective factors. An example would be the
reduction of harmful/hazardous consumption of alcohol
(risk) and the increasing of self-efficacy, social support
and resilience (protective).

The levels of prevention

It has previously been noted that there are several ways
of categorising preventive measures, according to the
stage in the natural history of disease at which they
are introduced; the determinants of disease which are
being addressed; the target groups to which they are
applied; and the setting or level of delivery of preventive
measures.3
3

Sindall C and Stratton J (2003). Unpublished discussion paper:

Perspectives on Prevention Terminology. Department of Health
and Ageing.

Health care
services

Housing

In public health it has been common practice to

categorise the different goals or levels of prevention
across a stages of disease continuum in terms of
primary, secondary and tertiary prevention.
The goal of primary prevention is to limit the incidence
of disease and disability in the population by measures
that eliminate or reduce causes or determinants of
departures from good health, control exposure to risk,
and promote factors that are protective of health.
Secondary prevention aims to reduce progression of
disease through early detection, usually by screening at
an asymptomatic stage, and early intervention.
The goal of tertiary prevention is to improve function
and includes minimisation of the impact of established
disease, and prevention or delay of complications and
subsequent events through effective management and
rehabilitation.
Further explanation of the levels of prevention is
provided in Table 1.
A fourth, more fundamental level of prevention is
sometimes described as primordial prevention. This
term is used to refer to preventing the emergence of
predisposing social and environmental conditions that
can lead to causation of disease. Because of the many
The Language of Prevention

Table 1: Levels of prevention

Level of
Prevention
Primary

Aim
Widespread changes
that reduce the
average risk in the
whole population
Reduction of
particular exposures
among identified
higher risk groups or
individuals

Phase of
Disease
Specific
causal factors
associated
with the onset
of disease
Specific and
non-specific
factors
associated
with protection
against
disease.

Target
Total
population,
selected
groups and
healthy
individuals

Secondary

Prevent progression
to disease through
early detection and
intervention

Early stage
of disease
period
between
departure
from good
health and
onset of
symptoms

Asymptomatic
individuals
with early
disease or
established
high risk
factors

Tertiary

Reduce the
consequences of
established disease
through effective
management of the
patient to reduce
the progress or
complications of
established disease
and improve patient
well-being and
quality of life

Later stages
of disease
involving
treatment and
rehabilitation

Patients

Intervention Examples
Measures that eliminate or reduce the
causes or determinants of departures from
good health, control exposure to risk, and
promote factors that are protective of health:
Air quality guidelines leading to reduction
of urban air pollution
Systematic immunisation to eliminate
communicable disease
Education programs to increase awareness
of the risks of physical inactivity and poor
diet to reduce the burden of preventable
chronic disease
Legislation to require wearing of seat belts
to reduce the incidence of death and
disability associated with road trauma
Tobacco control programs
Measures available to individuals
and populations for early detection of
asymptomatic biological changes, disease
precursors or asymptomatic disease, and
prompt and effective intervention to address
the departures from good health:
Pre-diabetes programs
Breast screening to reduce the death rate
from breast cancer
Blood pressure measurements and
treatment of hypertension in middle-aged
and elderly people to reduce progression
to associated diseases
Testing for hearing loss and advice
concerning protection against noise in
industrial workers
Measures to reduce impairments and
disabilities, prevent or delay subsequent
events (including prevention of recurrences),
minimise suffering and promote the patients
adjustment to chronic conditions:
Rehabilitation of patients with strokes,
injuries, blindness and so on
Good glycaemic control in diabetics
Self-management programs for persons
living with chronic conditions
Relapse prevention in mental health

Source:
Adapted from Beaglehole R, Bonita R, Kjellstrom T (1993). Basic Epidemiology. Geneva, World Health Organization.
Brownson, R, Remington, P & Davis J (Eds) (1998). Chronic Disease Epidemiology and control, (2nd Edition) American Public Health Association,
Washington DC.

The Language of Prevention

different interpretations of primary prevention and the

association of primary prevention with a disease-focused
approach, some commentators suggest the use of the
primordial prevention level to address upstream (distal)
determinants. However, this term has not gained much
currency and is usually embraced within the level of
primary prevention.
Public health is defined as the organised response
by society to protect and promote health, and to
prevent injury, illness and disability. Public health is a
particular set of measures and activities, most of which
have primary prevention as their goal; that is, public
health aims to prevent through an organised effort, the
occurrence of health problems in whole populations
before they occur. However, in many circumstances
organised and systematic secondary prevention activities
such as breast screening programs also form part of
the public health effort.
Generally speaking public health efforts try to focus
on the upstream determinants (environmental, social
and behavioural determinants) of preventable health
problems.
A distinction is made between the goals of the different
levels of prevention and the type of measures required
to achieve the goals. For example, measures that reduce
the development of risk factors for heart disease (such
as physical activity interventions) may be implemented
at both a population and an individual level and can
both be considered primary prevention.
It is also necessary to distinguish between a type
of intervention (for example, aimed at a particular
risk or protective factor) and level of prevention. For
example, promotion of physical activity can be aimed at
primary prevention, secondary prevention (for example,
where physical activity is used in the management of
borderline hypertension or impaired glucose tolerance),
or tertiary prevention (where physical activity is part of
the management regime for a chronic condition, such as
arthritis).
Frameworks for conceptualising prevention continue
to evolve and respond to the needs of different fields

of health. In the mental health field, the concept of

prevention is divided into approaches designated as
universal, selective or indicated prevention, depending
on whether they are applied to the whole population
(universal) or sub-groups at a higher risk (selective) or
those people at an early stage of high risk (indicated).
This model largely encompasses the concepts of primary
and secondary prevention in the traditional public health
model and separately defines the remainder of the
spectrum dealing with treatment and maintenance
(although it does comprehend that the indicated group
effectively overlaps with the treatment group, in the
case of mental health).4 A similar approach was used
by the Australian Institute of Health and Welfare in
development of the indicator framework for monitoring
the National Health Priority Areas.5
While the prevention terminology used can vary in
different fields, the basic concepts and objectives
are essentially the same, but allow for differences of
emphasis and expanded interpretation, especially in the
non-medical context.
What is most important is the understanding that all of
the levels and approaches to prevention form part of a
holistic health system response to the patterns of health
and disease in a particular society, and to formulate the
most cost effective and feasible options for health gain
accordingly.
The examples in Table 2 illustrate how a range of
preventive measures, delivered at both the population
and individual levels, can contribute to health gain.
For example the spectrum of prevention measures
for cancer might include primary prevention through
tobacco control legislation, secondary prevention
through screening those at higher risk of the disease and
tertiary prevention through provision of care that delays
complications of the disease.
Increased capacity for the health workforce to identify
appropriate prevention interventions complements
initiatives to drive improvements in health services, such
as the National Service Improvement Frameworks.6

6
4

Australian Health Ministers (2003). National Mental Health Plan

20032008. Canberra: Australian Government.

Australian Institute of Health and Welfare and Commonwealth

Department of Health and Family Services (1997). First Report
on National Health Priority Areas 1996. AIHW Cat. No. PHE 1.
Canberra: AIHW and DHFS.

The National Service Improvement Frameworks have been

developed for the national health priority chronic conditions
of cancer, diabetes, asthma, cardiovascular health and
musculoskeletal conditions. The Frameworks accompany the
National Chronic Disease Strategy and are designed to guide the
delivery of the most appropriate care for these conditions and
cover the continuum of care encompassing prevention, detection,
screening, management, treatment, rehabilitation and palliation.

The Language of Prevention

Table 2: Examples of primary, secondary and tertiary prevention related to selected diseases
and national health priority areas*
Communicable
Diseases
Cancer

Cardiovascular
Health

Diabetes

Injury

Mental Health

General socioeconomic, cultural and environmental conditions

Agriculture and food production, education, work environment, unemployment,
living and housing conditions, transport, water and sanitation
Primary
prevention

Vector control
Tobacco
control
(environmental
tobacco
smoke and
meningococcal
disease)
Immunisation

Tobacco
control and
smoking
cessation
Nutrition
Physical
activity
Responsible
use of alcohol

Secondary
prevention

Testing
of at-risk
individuals
or groups
(eg STIs)
Prophylactic
antibiotics (eg
antimalarials)
Needle
and syringe
availability
programs

Tertiary
prevention

Isolation
Quarantine
Infection
control
Treatment

Nutrition
Physical
activity

Road safety
engineering
(road design,
traffic calming,
railway
crossing boom
gates etc)
Vehicle design
(structural
features, seat
belts, air bags
etc)
Road safety
awareness
Responsible
use of alcohol

Social capital
Self-esteem
Responsible
use of alcohol
MindMatters
program
Positive
Parenting

Early detection Hypertension

and screening management
programs
Hypercholesterolaemia
treatment

Early detection
Weight loss
Dietary
management

Mandatory
accredited
education
program
for first
drink driver
offenders

Suicide
prevention
through early
intervention in
at-risk groups
Kids in Mind
program

Treatment and
care
Psychosocial
support

Rigorous blood Road trauma

glucose control rescue
services
Selfmanagement
Foot care
Diet and
physical
activity advice

Tobacco
control and
smoking
cessation
Nutrition
Physical
activity

Cardiac
rehabilitation
programs
Antiplatelet
drugs
Diet and
physical
activity advice

Relapse
prevention

* The examples provided in this table are purely indicative for the purposes of demonstrating the principles and scope of preventive measures,
and do not purport to be a complete representation, nor do the listed preventive measures necessarily apply to all communicable diseases or
manifestations of the National Health Priority Areas disease states.

The Language of Prevention

Prevention and public health

Public health is characterised by planning and
intervening for better health in populations rather
than focussing exclusively on the health of identifiable
individuals.7,8
Where public health cannot control health problems
through upstream environmental measures (removing
the cause), efforts focus on modifying behaviour. Where
neither avenue is available or likely to be effective, the
focus is on raising community resistance (passively
or actively) for example, through immunisation, and
preventing the spread of transmission of infectious
agents. The use of drugs (for example, chemoprophylaxis
for malaria) and vaccines administered to individuals
can therefore also be seen as a public health measure,
where this is part of an organised effort to prevent a
wider impact on population health.
Public health typically uses a range of intervention
strategies mostly in combination to achieve effective
outcomes.9 These strategies might utilise legislative or
financial levers, multi-sectoral and multi-disciplinary
collaborations, immunisation, information analysis and
communication, and development of healthy public
policies to mobilise resources and promote evidencebased actions.

At present, an increasing number of government health

departments in Australia have shown a preference for use of the
term population health over the more traditional term public
health. What lines up under these structural labels will vary
between organisations and reflects the on-going debate about
whether these concepts are interchangeable or whether they reflect
different but overlapping domains.

National Public Health Partnership (2006). Public Health

Classifications Project Phase One: Final Report. Melbourne: NPHP.

National Public Health Partnership (2000). Public Health Practice

in Australia Today: A statement of core functions. Melbourne: NPHP.

In cases where neither upstream measures, behaviour

change nor raising host resistance are possible, but
where a condition can be detected sufficiently early by
screening asymptomatic individuals on a population
basis to change the course of disease progression,
organised early detection programs become part of a
public health response. Where early stage disease is
detected, the health response is then provided by the
treatment and care sector to an identified individual.
The role of public health is illustrated in Figure 2 in the
context of a model for prevention and management of
chronic conditions.

Benefits of prevention
The imperative to maintain and sustain healthy
communities derives from the need for a well functioning
society. A society that is healthy will also prosper
economically.10 The health challenges threatening to
undermine the future capacity of the nation are largely
preventable. All parts of the health system have an
important role in the prevention of health problems.
The greatest long-term contribution to high-quality
and affordable prevention measures can come from
investment in the implementation of population based
public health approaches that are largely focused at the
level of primary prevention.

10

Thomas, D. (2001). Health Nutrition and Economic Prosperity: A

Microeconomic Perspective. Commission on Macroeconomics and
Health, CMH Working Paper Series Paper No. WGI: 7.

The Language of Prevention

Figure 2: Comprehensive model of chronic disease prevention and control

Whole Population
Stage of
disease continuum
Level of prevention

Well population

At risk

Primary Prevention

Secondary Prevention/
Early Detection

Promotion of healthy

Nature of intervention

behaviours and
environments across
the lifecourse
Universal and
targeted approaches

Controlled
chronic disease

Established disease

Screening
Case finding
Periodic health

Disease Management and Tertiary Prevention

Treatment and

Acute Care
Complications
management

examinations

Continuing Care
Maintenance
Rehabilitation
Self management

Early intervention
Control risk

factors lifestyle
and medication
Responsible sectors
Represents promotion of
health and well being and
health related quality of life
acorss continuum of care

Public health
Primary health care
Other sectors

Primary health care

Public health

Specialist services
Hospital care
Primary health care

Health Promotion

Health Promotion

Health Promotion

Prevent movement to the

at risk group

Intervention objectives

Prevent progression to
established disease and
hospitalisation

Primary health care

Community care

Health Promotion

Prevent/delay progression
to complications and
prevent readmissions

Each stage requires critical assessment of: workforce requirements, resource allocation, data requirements, evidence base for
intervention (incl cost effectiveness), quality measures, guidelines and standards, monitoring and evaluation, roles and
responsibilities, (Commonwealth/State, public/private), equity impact, consumer involvement etc

Source: Preventing Chronic Disease: A Strategic Framework.

The Language of Prevention