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.
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.
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.
Manuel, D. G., J. Lim, P. Tanuseputro, et al. 2006. Revisiting Rose: Strategies for reducing coronary heart disease. British Medical Journal 332:659–662.
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.
Rose, G. 1981. Strategy of prevention: Lessons from cardiovascular disease. British Medical Journal 282:1847–1851.
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.
Rose, G. 1985. Sick individuals and sick populations. International Journal of Epidemiology 14.1: 32–38.
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.
Rose, G. 1992. The strategy of preventive medicine. Oxford and New York: Oxford Univ. Press.
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.
Rose, G., K. -T. Khaw, and M. Marmot. 2008. Rose’s strategy of preventive medicine. Oxford and New York: Oxford Univ. Press.
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.
World Health Organization. Global Burden of Disease.
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.
World Health Organization. 2002. The world health report: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization.
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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