The Three Levels of Prevention in the Chronic Disease Context

In the U.S., chronic disease accounts for over 70% of deaths and up to 76% of healthcare expenditures ^(1-3). Never before has our society been faced with this magnitude of chronic disease burden. Although a likely result of complex interactions among genetic, behavioral, and environmental influences, the pace at which chronic disease has risen suggests that behavioral and environmental influences play a large role and as such, warrants a greater focus on disease prevention at each of its three levels; primary, secondary and tertiary. Overall, the level of prevention has less to do with the intervention itself and more to do with the progression of the disease state as described below.

Despite the emergence of the chronic disease epidemic, the U.S. healthcare system continues to function based on a fragmented acute care model. In response to this deficit, the field of disease management (DM) was born to help patients embrace a healthy lifestyle, increase their knowledge and acceptance of the condition, enhance self-efficacy and motivation in managing the condition, improve treatment adherence, and establish consistent self-regulation.

If you would like to earn CE’s and learn more about DM and behavior change, see our featured course below.

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Featured Course

Disease Management: Biopsychosocial Tools for Mental Health and Nurse Care Managers
(3 CEs) by Indira Paharia, PsyD, MBA, MS

While DM encompasses a broad scope, a significant role for the care manager/healthcare provider includes the use of empirically based interventions with the goal of empowering the patient to take responsibility for the effective and ongoing management of his or her chronic disease(s). This goal is further broken down to include helping the patient at the appropriate level of prevention. Overall, the level of prevention has less to do with the intervention itself and more to do with the progression of the disease state. The table below presents empirically supported interventions at each level of prevention for the 4 major chronic diseases in the U.S.

Levels of Prevention for the 4 Leading Causes of Death: Cardiovascular Dx (CVD), Cancer (CA), Chronic Obstructive Pulmonary Dx (COPD), Type 2 Diabetes (T2DM) ^(4-5)

As can be seen, an intervention such as tobacco cessation could be considered primary, secondary, or tertiary prevention depending on the severity of the disease progression, such as in the case of COPD. Within the framework of DM, this tailored approach could be considered the backbone of a DM program’s return on investment, as a program is only as successful as its members’ improvements in these areas.

DM programs to address and facilitate health-related change are grounded in a biopsychosocial model; informed and guided by social-cognitive theory, the transtheoretical model, and motivational interviewing, and relying heavily on cognitive-behavioral interventions ^{(e.g., 6-13)}. While DM programs show great promise, front-line providers can find themselves ill-equipped to manage the behavioral aspects of care, thereby negatively impacting outcomes. This course is designed to address this need and reviews the most effective methods for behavior change. Underlying theories and cognitive-behavioral techniques are discussed with an emphasis on application to chronic disease. Healthcare providers are left with a repertoire of assessment and intervention strategies to promote change, overcome common barriers, and optimize outcomes.

About the Author M. Indira Paharia, PsyD, MBA, MS, a licensed clinical psychologist, is the Assistant Director of Behavioral Health & Wellness for Regence Blue Cross Blue Shield serving 4 states in the Pacific Northwest. She is recognized nationally and internationally as a lecturer and researcher on topics of disease prevention and health promotion.  Her co-edited textbook, The Comprehensive Handbook of Clinical Health Psychology, was recently released by John Wiley and Sons. (See Related Events in this Newsletter). Her current clinical and research interests include: disease management, tobacco cessation, obesity, cost-effectiveness analysis, managed behavioral healthcare, and integrated primary care.

References

1. U.S. Department of Health and Human Services (2003). Promising practices in chronic disease prevention and control: A public health framework for action. Washington, DC: Author.
2. Clarke, J. L., & Meiris, D., C. (2006).  Preventive medicine: A “cure” for the healthcare crisis. Disease Management, 9(supplement1), S1-S16.
3. Pruitt, S. D., Klapow, J. C., Epping-Jordan, J.E., & Dresselhaus,  T. R. (1998).  Moving behavioral medicine to the front line: a model for the integration of behavioral and medical sciences in primary care.  Professional Psychology: Research and Practice, 29 (3), 230-236.
4. National Center for Health Statistics (2006). Deaths-leading causes. Retrieved January 10, 2007, from http://www.cdc.gov/nchs/fastats/lcod.htm
5. Paharia, M. I. (2007). Chronic disease prevention. In B. A. Boyer & M. I. Paharia (Eds.), Comprehensive handbook of clinical health psychology. New Jersey: John Wiley and Sons.
6. Bandura, A. (2000). Heath promotion from the perspective of social cognitive theory. In P. Norman, C. Abraham, & M. Conner (Eds.),Understanding and changing health behavior (pp. 299-239).  Amsterdam: Harwood Academic Publishers.
7. Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31(2), 143-164.
8. Bandura, A. (2005). The primacy of self-regulation in health promotion. Applied Psychology: An International Review, 54(2), 245-254.
9. Prochaska, J., & DiClemente, C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-288.
10. Prochaska, J., & DiClemente, C. (1983). Stages and processes of self change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390-395.
11. Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change. Applications to addictive behaviors. American Journal of Psychology, 47, 1102-1114.
12. Prochaska, J., DiClemente, C., Velicer, W., & Rossi, J. (1992). Criticisms and concerns of the transtheoretical model in light of recent research. British Journal of Addiction, 87, 825-835.
13. Miller, W. R., & Rollnick, S. (1991).  Motivational interviewing: Preparing people to change addictive behavior. NY: Guilford Press.