Public Health High Risk Prevention Strategies
by
Andrew Wilson, Pippy Barnett, Samantha Rowbotham, Sonia Wutzke
  • LAST MODIFIED: 30 March 2017
  • DOI: 10.1093/obo/9780199756797-0159

Introduction

Simply stated, high risk prevention strategies aim to identify individuals or groups who are likely to have an increased incidence of a disease, based on the presence of modifiable risk factors known to be causal for the disease (e.g., high blood pressure), or characteristics of individuals or groups that are associated with a higher incidence of disease. Once identified, interventions are targeted to these individuals or groups to modify their risk of illness or disease. In The Strategy of Preventative Medicine, published in 1992 (Introductory Works), Geoffrey Rose argued that prevention strategies that focused solely on those at higher risk have less impact than strategies that focused on the whole population, because for many common conditions most cases will occur among those not at high risk. However, strategies that impact on whole populations frequently require action beyond the health care sector and are politically more difficult to achieve. Moreover, shorter-term benefits may be easier to achieve by focusing on those at highest risk. They have more to be gained from changing behavior and, where the preventive intervention involves some risk (for example, side effects of medications), the risk-benefit ratio is more favorable. The notion of high-risk preventive interventions is consistent with the training and practice orientation of most Western-trained health professionals. It is focused on the individual and their risk behaviors. This has driven approaches focused on better identification of those at risk (searching for additional risk factors, more accurate measurement of risk factors, and requirements for randomized trials of evidence of efficacy). As in the rest of medicine, genomic profiling of risk will further drive this concern. Prevention practice however has increasingly recognized that at least when it comes to behavior change, the family, community, and broader social and cultural environment is critical to achieving sustainable risk behavior change in individuals. Consequently, public health practice is a mix of population-based and high-risk prevention strategies. The balance between these approaches is rarely determined empirically but arises through a mix of politics, industry, and public-interests lobbying and precedence. However, for any given population or community, methods exist to determine a mix of interventions that will achieve the best benefits for any given overall investment. This article provides key resources and publications that highlight these key elements of high-risk prevention strategies.

Introductory Works

Rose 1981 first described the high-risk prevention theory based on work in the prevention of cardiovascular disease. Rose then went on to describe this approach to prevention in more detail in his frequently cited paper (Rose 1985) and text book (Rose 1992), where both the advantages and disadvantages are considered, and specialities (other than cardiology) that have embraced this strategy are listed. An updated text published by Rose’s colleagues after his passing highlights the ongoing relevance of his ideas, despite scientific advances that have transformed approaches to medicine and public health (Rose, et al. 2008). As a result of such advances, Manuel, et al. 2006 discusses an extension on this original theory to distinguish the single raised risk factor strategy from the high baseline risk strategy, also referred to as assessing absolute risk. The World Health Organization (WHO) Global Burden of Disease (GBD) project provides consistent and comparative reports on the burden of disease and causative risk factors. To become familiar with known risk factors and their impact on death and disability-adjusted life years (DALYs) since the late 20th century, the paper published in The Lancet, Lim, et al. 2012, provides useful comparisons. For a one-document summary of the elements of this topic, including the application in addition to the theory, the 2002 World Health Report (World Health Organization 2002) is a recommended read.

  • Lim, S. S., T. Vos, A. D. Flaxman, et al. 2012. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet 380:2224–2260.

    DOI: 10.1016/S0140-6736(12)61766-8Save Citation »Export Citation »E-mail Citation »

    This is a detailed analysis of the burden of disease attributable to risk factors between 1990 and 2010. This information can be used to inform high-risk prevention strategies.

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    • Manuel, D. G., J. Lim, P. Tanuseputro, et al. 2006. Revisiting Rose: Strategies for reducing coronary heart disease. British Medical Journal 332:659–662.

      DOI: 10.1136/bmj.332.7542.659Save Citation »Export Citation »E-mail Citation »

      This is a practical introduction to the baseline risk strategy from the New Zealand national guidelines for the assessment and management of cardiovascular risk. Canadian data from 1990 is used to highlight the different number of individuals that would be treated, and expected outcomes using the population health, high baseline risk, and single risk factor prevention strategies.

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      • Rose, G. 1981. Strategy of prevention: Lessons from cardiovascular disease. British Medical Journal 282:1847–1851.

        DOI: 10.1136/bmj.282.6279.1847Save Citation »Export Citation »E-mail Citation »

        This is the first paper where high-risk prevention is explained in the context of medicine. The place for both high risk and population or “mass” strategies for prevention are explained, with reference to the “prevention paradox” using cardiovascular disease examples in developed countries.

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        • Rose, G. 1985. Sick individuals and sick populations. International Journal of Epidemiology 14.1: 32–38.

          DOI: 10.1093/ije/14.1.32Save Citation »Export Citation »E-mail Citation »

          Rose discusses high-risk prevention strategies in more detail here by outlining the inherent advantages and disadvantages of this approach to prevention. This paper further discusses the place for high-risk prevention strategies, noting that high-risk prevention should not been seen as competing with the population approach, rather complementary of each other.

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          • Rose, G. 1992. The strategy of preventive medicine. Oxford and New York: Oxford Univ. Press.

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            Comprehensive coverage of the elements of prevention including the objectives of prevention, what needs to be prevented, relation of risk to exposure, the high-risk strategy, individuals and populations, some implications of population change, the population strategy, and in search for health as chapter headings. This text is useful for students seeking an introduction to prevention.

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            • Rose, G., K. -T. Khaw, and M. Marmot. 2008. Rose’s strategy of preventive medicine. Oxford and New York: Oxford Univ. Press.

              DOI: 10.1093/acprof:oso/9780192630971.001.0001Save Citation »Export Citation »E-mail Citation »

              Chapter 4 titled “Prevention for Individuals and the High-Risk Strategy” provides a summary of continuous risk factors related to different health outcomes (other than cardiovascular disease), for which high-risk criteria have been established. Policy guidelines for screening to assess risk and a summary of strengths and weaknesses of this approach are also included.

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              • World Health Organization. Global Burden of Disease.

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                Since 1990 this project has provided regular reports on the burden of disease and injuries and related risk factors. The most comprehensive estimates have been since 2000, which have allowed for comparisons overtime to be published with a focus on ensuring this information can be used in public health planning and decision making. More recently this work has continued through the Institute for Health Metrics and Evaluation.

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                • World Health Organization. 2002. The world health report: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization.

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                  Provides a summary of identified risk factors and their effect on health outcomes, highlights current interventions used for reducing risk, and discusses the benefits of combining multiple interventions to simultaneously reduce risk. This refers to the mix of both high-risk and population approaches to prevention and the contribution of both, highlighting the “prevention paradox.”

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                  Bibliographies

                  The Cochrane Database of Systematic Reviews provides the best available summary of evidence for the use of tools for identifying high-risk individuals, and for the effectiveness of interventions for the prevention of disease. Other large medical and public health databases such as PubMed, Embase, and Global Health will undoubtedly return a wealth of quality publications on preventive strategies for a given condition. Due to the exponential growth in this field of research, however, policymakers, public health workers, and clinicians will likely find the Screening Tools and Management Guidelines sections more practical.

                  • Cochrane Database of Systematic Reviews.

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                    A leading resource for systematic reviews with access to published protocols in addition to editorials. Searches can be conducted by topic, Cochrane review group (CRG), or advanced search. This is a useful database for agencies considering the implementation of high-risk implementation strategies to determine evidence of effectiveness.

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                    • Embase.

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                      Embase provides unparalleled coverage of the biomedical literature, with more than thirty million records from over 8,500 currently published journals. Embase includes more than six million records and over 2,900 journals that are not covered by MEDLINE. Also, Embase Classic provides access to data going back to 1947.

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                      • Global Health.

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                        This database covers all aspects of public health at both international and community levels, as well as a wealth of material from other biomedical and life science fields. Content includes over 2.6 million scientific records, publications from over 100 countries in fifty-two languages and over 4,480 journals, of which more than 3,600 are unique to Global Health.

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                        • PubMed.

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                          PubMed comprises more than twenty-six million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher websites.

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                          Journals

                          High-risk prevention strategies call upon a number of different fields of public health from the conception of the theory to the implementation and evaluation of strategies among different high-risk groups. Articles covering the topic more broadly, including the theoretical background, advantages, disadvantages, and use in the context of other preventive strategies, can be found in journals covering all areas of public health and epidemiology such as American Journal of Public Health, Annual Review of Public Health, International Journal of Epidemiology, and American Journal of Epidemiology. In addition to these journals, the implementation and evaluation of specific high-risk prevention strategies can be found in Preventive Medicine, American Journal of Health Promotion, and in journals targeting specific disease states, notably European Journal of Preventive Cardiology and Cancer Prevention and Control.

                          High Risk vs. Population Approaches to Prevention

                          One of the first examples of the relationship between the individual and population approach was published in Rose and Day 1990 discussing the Intersalt study, an international, multi-center study on the determinants of blood pressure. Most papers and texts included in this article make reference to the two approaches to prevention together; however, Emberson, et al. 2004; Zulman, et al. 2008; Mackenbach, et al. 2013; and Manuel, et al. 2013 make specific comparisons. Chiolero, et al. 2015 provides a useful editorial on the more recent application of prevention strategies with reference to the widening of high-risk criteria and the apparent “pseudo high risk approach.” Doyle, et al. 2006 revisits the original paper by Rose and highlights that despite advances in public health practice twenty years on, both the individual and population approach are needed. Health technology assessment using decision analytic modeling is the primary method used to synthesize evidence for multiple strategies with regard to cost effectiveness to establish the best mix of strategies. Philips, et al. 2006 provides a review of existing guidelines for this method.

                          • Chiolero, A., G. Paradis, and F. Paccaud. 2015. The pseudo-high-risk prevention strategy. International Journal of Epidemiology 44.5: 1469–1473.

                            DOI: 10.1093/ije/dyv102Save Citation »Export Citation »E-mail Citation »

                            This paper is a useful comparison between the high risk and population prevention approaches. Since Rose originally published these theories, the criterion used to identify high-risk individuals has been widened. This has been named the “pseudo-high-risk prevention approach” and is explained alongside Rose’s two original theories.

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                            • Doyle, Y. G., A. Furey, and J. Flowers. 2006. Sick individuals and sick populations: 20 years later. Journal of Epidemiology and Community Health 60.5: 396–398.

                              DOI: 10.1136/jech.2005.042770Save Citation »Export Citation »E-mail Citation »

                              Revisits Rose’s theory and examines how both the high risk and population strategies have been implemented over the prior two decades. This discussion is a useful introduction to the concept of how both approaches are needed for successful prevention.

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                              • Emberson, J., P. Whincup, R. Morris, M. Walker, and S. Ebrahim. 2004. Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. European Heart Journal 25.6: 484–491.

                                DOI: 10.1016/j.ehj.2003.11.012Save Citation »Export Citation »E-mail Citation »

                                In the context of cardiovascular disease prevention via blood pressure and cholesterol-lowering strategies, this study utilizes data from the British Regional Heart Study and estimates of risk reduction from meta-analyses to predict and compare outcomes both of high risk, and population approaches to prevention. A practical example of how the two approaches can be applied.

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                                • Mackenbach, J. P., H. F. Lingsma, N. T. van Ravesteyn, and C. B. Kamphuis. 2013. The population and high-risk approaches to prevention: Quantitative estimates of their contribution to population health in the Netherlands, 1970–2010. European Journal of Public Health 23.6: 909–915.

                                  DOI: 10.1093/eurpub/cks106Save Citation »Export Citation »E-mail Citation »

                                  A summary of both population and high-risk prevention strategies implemented in the Netherlands over a forty-year period to compare the contribution of each to prevention of death and disease. This paper demonstrates how and why the two strategies should be used together.

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                                  • Manuel, D. G., L. C. Rosella, M. Tuna, C. Bennett, and T. A. Stukel. 2013. Effectiveness of community-wide and individual high-risk strategies to prevent diabetes: A modelling study. PLoS One 8.1: e52963.

                                    DOI: 10.1371/journal.pone.0052963Save Citation »Export Citation »E-mail Citation »

                                    Using data from the Canadian Community Health Survey in 2003, this study modeled the impact of both a community and a high-risk strategy on reducing the incidence of diabetes in Ontario over five years. This study provides a useful comparison of the different interventions used for the two approaches, and how successful they are likely to be.

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                                    • Philips, Z., L. Bojke, M. Sculpher, K. Claxton, and S. Golder. 2006. Good practice guidelines for decision-analytic modelling in health technology assessment. Pharmacoeconomics 24.4: 355–371.

                                      DOI: 10.2165/00019053-200624040-00006Save Citation »Export Citation »E-mail Citation »

                                      This guideline introduces the use of decision-analytic modeling for health technology assessment commonly used to help prioritize health programs or interventions. The main purpose of this paper is to review existing decision-analytic modeling guidelines and to provide a framework to assess the quality of a model.

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                                      • Rose, G., and S. Day. 1990. The population mean predicts the number of deviant individuals. British Medical Journal 301:1031–1034.

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                                        This paper highlights the importance of considering and understanding individuals that are classified as being at high risk in the context of the whole population. This is based on the finding that the population mean is associated with the prevalence of deviation in risk factors.

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                                        • Zulman, D. M., S. Vijan, G. S. Omenn, and R. A. Hayward. 2008. The relative merits of population-based and targeted prevention strategies. Milbank Quarterly 86.4: 557–580.

                                          DOI: 10.1111/j.1468-0009.2008.00534.xSave Citation »Export Citation »E-mail Citation »

                                          A study that compares the population-based strategy, and both a single risk strategy and an absolute high-risk strategy for the prevention of cardiovascular events. Using survey data, a population was simulated to estimate the risk of cardiovascular events.

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                                          Identifying High-Risk Individuals

                                          High-risk individuals can be identified via systematic or opportunistic screening. The different approaches to screening and principles for selecting an appropriate screening tool are outlined in the text Wilson and Jungner 1968, which focuses only on screening for disease. Since the recognition of the need for screening tools to help prevent disease, and other advances such as genetic screening, these criteria have been reviewed and updated (Andermann, et al. 2008; Andermann, et al. 2011). Law and Wald 2002 explains the important distinction between the assessment of individual risk factors and an individual’s absolute risk, with a preference for using the latter. Rather than setting thresholds for each individual risk factor, the use of multicomponent risk assessments provides a more accurate assessment of absolute risk given the contribution of multiple risk factors on disease. Examples of such assessments are provided under the Screening Tools and Management Guidelines heading. Most of the work in this space has focused on cardiovascular disease and cancer, with Powles, et al. 2010; Doust, et al. 2012; and Wardle, et al. 2015 providing examples and further discussion on assessing absolute risk and the practicalities of screening. Overdiagnosis is a significant issue in identification of individuals at high risk. Risk factors such as blood pressure vary within the same individual and are subject to significant measurement error. Where the risk factor is a continuous variable, the cut points that define high risks are not absolute and may change according to different local norms or lower treatment harms. For the individual, the risk associated with any one risk factor needs to be weighed up against their overall risk as determined by other factors such as age, family history, presence of other risk factors, and personal preferences. Moynihan, et al. 2012 provides a discussion on the rates, causes, and potential solutions to the issue of overdiagnosis from high-risk screening.

                                          • Andermann, A., I. Blancquaert, S. Beauchamp, and I. Costea. 2011. Guiding policy decisions for genetic screening: Developing a systematic and transparent approach. Public Health Genomics 14.1: 9–16.

                                            DOI: 10.1159/000272898Save Citation »Export Citation »E-mail Citation »

                                            Reviews the initial screening criteria published in Wilson and Jungner 1968 using a systematic approach to propose a revised set of criteria considering the need for patient education, informed choice, quality assurance, evaluation, citizen involvement, and equity. This paper also acknowledges the need for screening tools targeting prevention, rather than just the identification of disease.

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                                            • Andermann, A., I. Blancquaert, S. Beauchamp, and V. Dery. 2008. Revisiting Wilson and Jungner in the genomic age: A review of screening criteria over the past 40 years. Bulletin of the World Health Organization 86.4: 317–319.

                                              DOI: 10.2471/blt.07.050112Save Citation »Export Citation »E-mail Citation »

                                              A succinct summary of the gold standard screening criteria proposed in Wilson and Jungner 1968 to assist with selecting diseases that are appropriate for screening. These criteria are then reviewed, with new emerging criteria proposed. This is a useful resource for anyone looking to develop new or critique existing screening tools. This has since been republished in Andermann, et al. 2011.

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                                              • Doust, J., S. Sanders, J. Shaw, and P. Glasziou. 2012. Prioritising CVD prevention therapy. Australian Family Physician 41.10: 805–809.

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                                                An analysis of an Australian cohort to compare the number of individuals identified for targeted prevention using the individual risk factor and absolute risk approach. This is a useful example of the difference between and application of both methods.

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                                                • Law, M. R., and N. J. Wald. 2002. Risk factor thresholds: Their existence under scrutiny. British Medical Journal 324:1570–1576.

                                                  DOI: 10.1136/bmj.324.7353.1570Save Citation »Export Citation »E-mail Citation »

                                                  This is a useful discussion of the key points to consider when determining the appropriateness of using thresholds to label individuals at high risk for targeted prevention. In particular the need to assess an individual’s absolute risk, rather than the level of individual risk factors.

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                                                  • Moynihan, R., J. Doust, and D. Henry. 2012. Preventing over-diagnosis: How to stop harming the healthy. British Medical Journal 344.7859: 19–23.

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                                                    Discusses the issues and drivers of overdiagnosis in relation to screening, and provides examples and data on the rates of overdiagnosis for various conditions.

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                                                    • Powles, J., A. Shroufi, C. Mathers, W. Zatonski, C. la Vecchia, and M. Ezzati. 2010. National cardiovascular prevention should be based on absolute disease risks, not levels of risk factors. European Journal of Public Health 20.1: 103–106.

                                                      DOI: 10.1093/eurpub/ckp067Save Citation »Export Citation »E-mail Citation »

                                                      An analysis of World Health Organization data from twenty-five member states to apply the absolute risk approach to populations, to argue that the high risk approach should also be applied to population-level prevention. Relevant to those interested in prevention on a global scale.

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                                                      • Wardle, J., K. Robb, S. Vernon, and J. Waller. 2015. Screening for prevention and early diagnosis of cancer. American Psychologist 70.2: 119–133.

                                                        DOI: 10.1037/a0037357Save Citation »Export Citation »E-mail Citation »

                                                        This article considers different cancers and the current screening options, in addition to highlighting practical considerations with screening programs such as equality, balancing the benefits and risk of screening, optimizing screening participation, and risk-stratified approaches. This is a useful overview of current methods used to identifying patients at risk of cancer.

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                                                        • Wilson, J. M. G., and G. Jungner. 1968. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization.

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                                                          First assessment criteria to guide policy decision making for the selection of tools to screen for disease and considered widely as the gold standard. Covers the different forms of screening and evaluating screening tools, and provides individual versus population approach examples.

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                                                          Targeted Prevention Strategies

                                                          The meta-analyses of blood pressure and cholesterol-lowering interventions in Sundstrom, et al. 2014 and the Cholesterol Treatment Trialists’ Collaborators 2005 respectively provide two examples from cardiovascular disease prevention that are illustrative of the key features and issues in targeting individuals. In addition to controlling an intermediate variable such as blood pressure or cholesterol, targeted strategies can focus on reducing the level of exposure to a cause. Suk and Mishamandani 2016 provides a summary on environmental exposures and interventions, and Halpin, et al. 2010 outlines behavioral-based strategies. Beyond the evidence for effective and worthwhile interventions, the ability to implement strategies on a national or international scale often adds complexity to achieving targeted prevention. Mangham and Hanson 2010 and Yamey 2011 provide an overview of what is referred to as “scaling-up,” with specific examples of barriers and methods to implementation of cardiovascular disease strategies provided in Zannad, et al. 2011.

                                                          • Cholesterol Treatment Trialists’ Collaborators. 2005. Efficacy and safety of cholesterol-lowering treatment: Prospective meta-analysis of data from 90?056 participants in 14 randomised trials of statins. The Lancet 366.9493: 1267–1278.

                                                            DOI: 10.1016/s0140-6736(05)67394-1Save Citation »Export Citation »E-mail Citation »

                                                            This meta-analysis assesses the effect of cholesterol lowering treatment as an intervention to prevent cardiovascular disease. This analysis is a good demonstration of how individuals with a higher absolute risk receive a higher absolute benefit, supporting the high-risk prevention approach for this particular prevention strategy.

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                                                            • Halpin, H. A., M. M. Morales-Suarez-Varela, and J. M. Martin-Moreno. 2010. Chronic disease prevention and the new public health. Public Health Reviews 32.1: 120–154.

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                                                              A summary of chronic disease epidemiology, shared lifestyle related risk factors and interventions used to address these factors at the policy, community, and individual level. A useful resource for effective prevention strategies with supporting evidence.

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                                                              • Mangham, L. J., and K. Hanson. 2010. Scaling up in international health: What are the key issues? Health Policy Plan 25.2: 85–96.

                                                                DOI: 10.1093/heapol/czp066Save Citation »Export Citation »E-mail Citation »

                                                                This paper provides a definition of the term “scaling-up” and highlights four key concerns surrounding application at the international level. A useful resource for those unfamiliar with the concept of scaling-up, and key information for anyone interested in prevention on a national or international scale.

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                                                                • Suk, W. A., and S. Mishamandani. 2016. Changing exposures in a changing world: Models for reducing the burden of disease. Reviews on Environmental Health 31.1: 93–96.

                                                                  DOI: 10.1515/reveh-2015-0049Save Citation »Export Citation »E-mail Citation »

                                                                  This provides a brief summary of the environmental exposures contributing to the chronic disease burden. The inherent difficulty with getting prevention interventions off the ground and a proposed solution is discussed.

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                                                                  • Sundstrom, J., H. Arima, M. Woodward, et al. 2014. Blood pressure-lowering treatment based on cardiovascular risk: A meta-analysis of individual patient data. The Lancet 384.9943: 591–598.

                                                                    DOI: 10.1016/s0140-6736(14)61212-5Save Citation »Export Citation »E-mail Citation »

                                                                    As an example of a targeted prevention strategy, this analysis demonstrates that like cholesterol lowering, blood pressure lowing medication can achieve higher absolute risk reduction of cardiovascular disease in individuals with a higher baseline risk.

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                                                                    • Yamey, G. 2011. Scaling up global health interventions: A proposed framework for success. PLoS Medicine 8.6: e1001049.

                                                                      DOI: 10.1371/journal.pmed.1001049Save Citation »Export Citation »E-mail Citation »

                                                                      This is a proposed framework consisting of six categories to incorporate all the elements necessary to adopt or “scale up” health interventions on a global scale. This framework has been built from a literature review and interviews with experts in the field.

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                                                                      • Zannad, F., J. Dallongeville, R. J. Macfadyen, et al. 2011. Prevention of cardiovascular disease guided by total risk estimations—challenges and opportunities for practical implementation: Highlights of a CardioVascular Clinical Trialists (CVCT) Workshop of the ESC Working Group on CardioVascular Pharmacology and Drug Therapy. European Journal of Preventive Cardiology 19.6: 1454–1464.

                                                                        DOI: 10.1177/1741826711424873Save Citation »Export Citation »E-mail Citation »

                                                                        This is a useful discussion paper for those involved with or wanting to understand more about the practicalities of implementing preventive interventions for cardiovascular disease. The information presented comes from a CardioVascular Clinical Trialists workshop where experts in the field provided their insights.

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                                                                        Screening Tools and Management Guidelines

                                                                        The identification of cardiovascular risk factors and subsequent screening tools can largely be attributed to outcomes of the Framingham study, one of largest longitudinal studies (see Framingham Heart Study). A number of these screening tools are summarized and compared in Zhao, et al. 2015. International and national health bodies provide online recommendations and resources for the screening and management of high-risk individuals, based on their own synthesis of scientific evidence and expert recommendation. The World Health Organization provides a wide scope of approved guidelines for both screening tools and preventive interventions for a range of health outcomes. Some of the most comprehensive national screening and intervention recommendations and guidelines include those published by the US Preventive Services Taskforce’s Recommendations for Primary Care Practice, Johns Hopkins Medicine’s Prevention Guidelines, the UK National Screening Committee’s Current UK NSC Recommendations, the National Institute for Health and Care Excellence’s (NICE) Guidance, and the Canadian Task Force on Preventive Health Care’s CTFPHC Guidelines.

                                                                        • Canadian Task Force on Preventive Health Care. 2016. CTFPHC Guidelines.

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                                                                          This taskforce was established by the Public Health Agency of Canada (PHAC) to support primary health providers through the provision of preventive healthcare guidelines. These guidelines, updated continuously, can be searched by medical condition, with links to additional tools such as risk calculators and clinical algorithms. This information is also relevant to other health care and public health professionals, program developers, policymakers, and the general public.

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                                                                          • Framingham Heart Study.

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                                                                            A project of the National Heart, Lung, and Blood Institute and Boston University. Producing over three thousand publications since the initiation of this research in 1948, this website provides a full bibliography in addition to interactive risk calculators to evaluate absolute risk of atrial fibrillation, cardiovascular disease, congestive heart failure, coronary heart disease, diabetes, hypertension, intermittent claudication, and stroke by assessing multiple risk factors.

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                                                                            • Johns Hopkins Medicine. 2016. Prevention Guidelines.

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                                                                              This resource, updated continuously, can be used to search prevention guidelines by age and gender to see a full list of conditions to screen for. Tools are often referenced from the US Preventive Services Taskforce, and specific information on individuals at high risk of certain conditions is linked to information provided by the Centers for Disease Control and Prevention.

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                                                                              • National Institute for Health and Care Excellence. 2016. Guidance.

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                                                                                Screening and management guidelines, updated continuously, can be searched via the clinical guidelines section. The aim of these regularly reviewed evidence-based UK guidelines is to promote integrated care.

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                                                                                • UK National Screening Committee. 2016. Current UK NSC Recommendations.

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                                                                                  This screening committee advises UK ministers and the National Health Service (NHS) about all aspects relating to population screening and the implementation of screening programs. There are over one hundred published recommendations that are reviewed every three years. Where possible links to the clinical practice guidelines published by NICE are provided.

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                                                                                  • US Preventive Services Taskforce. 2016. Recommendations for Primary Care Practice.

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                                                                                    This taskforce is an independent panel made up of experts in the fields of primary health care and prevention. There are currently around one hundred published recommendations, updated continuously, on both screening and preventive interventions such as counseling and medication use for a variety of health conditions. Links to additional tools, facts sheets, and other supplementary resources are also provided.

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                                                                                    • World Health Organization. WHO guidelines approved by the Guidelines Review Committee.

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                                                                                      These published evidence-based guidelines can be searched by topic or year of publication and cover a wide range of public health areas with some pertaining to prevention. These recommendations can be used to influence health policies or clinical interventions.

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                                                                                      • Zhao, D., J. Liu, W. Xie, and Y. Qi. 2015. Cardiovascular risk assessment: A global perspective. Nature Reviews Cardiology 12.5: 301–311.

                                                                                        DOI: 10.1038/nrcardio.2015.28Save Citation »Export Citation »E-mail Citation »

                                                                                        This paper provides a detailed comparison of different available cardiovascular disease risk assessments to demonstrate that not all are suitable for use outside of the region they were developed for. Differences in clinical guidelines are also reviewed and the potential impact this may have on clinical practice. The authors state that this work could potentially assist with the development of validated tools and guidelines in low- to middle-income countries.

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                                                                                        Future Considerations

                                                                                        There is a concern that population-based strategies may increase or maintain health inequalities and that this is an additional justification for high-risk approaches (Frohlich and Potvin 2008; McLaren, et al. 2010; Capewell and Graham 2010; Adams, et al. 2016). It has however been acknowledged in Nishi, et al. 2016 that as the field of molecular pathology continues to expand, the same disparities could be realized in the identification of high-risk individuals. Holtzman and Marteau 2000 provides a useful introduction to some of the key considerations as public health moves into the use of genotypes for prevention, and Burton, et al. 2012 revisits Rose’s concepts and proposes that levels of risk be stratified, to improve outcomes for high-risk individuals using genetic risk of breast cancer as an example.

                                                                                        • Adams, J., O. Mytton, M. White, and P. Monsivais. 2016. Why are some population interventions for diet and obesity more equitable and effective than others? The role of individual agency. PLoS Medicine 13.4: e1001990.

                                                                                          DOI: 10.1371/journal.pmed.1001990Save Citation »Export Citation »E-mail Citation »

                                                                                          Discusses population-based strategies with reference to the prevention of obesity and how the reliance on individual agency creates inequalities. This paper highlights a range of different strategies that are used, and emphasizes that the focus should move more to interventions requiring low individual agency.

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                                                                                          • Burton, H., G. S. Sagoo, P. Pharoah, and R. L. Zimmern. 2012. Time to revisit Geoffrey Rose: Strategies for prevention in the genomic era? Italian Journal of Public Health 9.4: e8665–8661.

                                                                                            DOI: 10.2427/8665Save Citation »Export Citation »E-mail Citation »

                                                                                            This paper builds on scientific advances in the realm of genomics to provide a conceptual analysis of stratified prevention using genetic risk of breast cancer as an example. An important concept for anyone interested in or involved with risk profiling for targeted prevention.

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                                                                                            • Capewell, S., and H. Graham. 2010. Will cardiovascular disease prevention widen health inequalities? PLoS Medicine 7.8: e1000320.

                                                                                              DOI: 10.1371/journal.pmed.1000320Save Citation »Export Citation »E-mail Citation »

                                                                                              This discussion covers the different methods of cardiovascular disease prevention in relation to health inequalities. This includes the use of structural population approaches to reduce inequality, and the risk of inequality with high-risk prevention strategies.

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                                                                                              • Frohlich, K. L., and L. Potvin. 2008. The inequality paradox: The population approach and vulnerable populations. American Journal of Public Health 98.2: 216–221.

                                                                                                DOI: 10.2105/AJPH.2007.114777Save Citation »Export Citation »E-mail Citation »

                                                                                                In light of inequalities associated with the high risk and population approaches to prevention, this paper presents a vulnerable populations approach. This would theoretically complement population level prevention strategies and is a useful consideration for those working in this field.

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                                                                                                • Holtzman, N. A., and T. M. Marteau. 2000. Will genetics revolutionize medicine? New England Journal of Medicine 343.2: 141–144.

                                                                                                  DOI: 10.1056/NEJM200007133430213Save Citation »Export Citation »E-mail Citation »

                                                                                                  This sounding board piece discusses the use of genetic testing to assess risk of disease. This piece provides a realistic scope of the progression in this space and the evidence gaps that are likely to persist and delay the realization of the genetic revolution.

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                                                                                                  • McLaren, L., L. McIntyre, and S. Kirkpatrick. 2010. Rose’s population strategy of prevention need not increase social inequalities in health. International Journal of Epidemiology 39.2: 372–377.

                                                                                                    DOI: 10.1093/ije/dyp315Save Citation »Export Citation »E-mail Citation »

                                                                                                    A useful introduction to the issues of health inequalities in prevention approaches. A distinction between agentic and structural population approaches is provided and discussed in relation to Rose’s high-risk prevention strategy, and the vulnerable population approach in Frohlich and Potvin 2008.

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                                                                                                    • Nishi, A., D. A. Milner Jr., E. L. Giovannucci, et al. 2016. Integration of molecular pathology, epidemiology and social science for global precision medicine. Expert Review of Molecular Diagnostics 16.1: 11–23.

                                                                                                      DOI: 10.1586/14737159.2016.1115346Save Citation »Export Citation »E-mail Citation »

                                                                                                      The authors here propose a model that encompasses molecular pathology, epidemiology, and social science to help ensure equality in the use of advances in medicine for targeted prevention. The future challenges and the need for an integrative approach are highlighted.

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