Language disorders or language impairments are disorders that involve the processing of linguistic information. Problems that may be experienced can involve grammar (syntax and/or morphology), semantics
(meaning), or other aspects of language. These problems may be
receptive (involving impaired language comprehension), expressive
(involving language production), or a combination of both. Examples
include specific language impairment, better defined as developmental language disorder, or DLD, and aphasia, among others. Language disorders can affect both spoken and written language, and can also affect sign language; typically, all forms of language will be impaired.
Current data indicates that 7% of young children display language disorder, with boys being diagnosed twice as often as girls.
Preliminary research on potential risk factors have suggested biological components, such as low birth weight, prematurity,
general birth complications, and male gender, as well as family history
and low parental education can increase the chance of developing
language disorders.
For children with phonological and expressive language difficulties, there is evidence supporting speech and language therapy. However, the same therapy is shown to be much less effective for receptive language difficulties.
These results are consistent with the poorer prognosis for receptive
language impairments that are generally accompanied with problems in
reading comprehension.
Note that these are distinct from speech disorders, which involve difficulty with the act of speech production, but not with language.
Language disorders tend to manifest in two different ways:
receptive language disorders (where one cannot properly comprehend
language) and expressive language disorders (where one cannot properly
communicate their intended message).
Receptive language disorders
Receptive language disorders can be acquired—as in the case of receptive aphasia,
or developmental (most often the latter). When developmental,
difficulties in spoken language tend to occur before three years of age.
Usually such disorders are accompanied by expressive language
disorders.
However, unique symptoms and signs of a receptive language
disorder include: struggling to understand meanings of words and
sentences, struggling to put words in proper order, and inability to
follow verbal instruction.
Treatment options include: language therapy, special education classes for children at school, and a psychologist if accompanying behavioral problems are present.
Expressive language disorders
Expressive aphasia
is characterized by partial loss of the ability to produce language,
although comprehension generally remains intact; it is typically a
result of stroke, trauma, or tumors. Other expressive language disorders
may impair not only voice and articulation, but also the mental
formation of language, itself.
Expressive language disorders can occur during a child's
development or they can be acquired. This acquisition usually follows a
normal neurological development and is brought about by a number of
causes such as head trauma or irradiation.
Features of an expressive language disorder vary, but have
certain features in common such as: limited vocabulary, inability to
produce complex grammar, and more lexical errors.
If it is a developmental disorder, the child will have difficulty
acquiring new words and grammatical structures. The child will often
begin speaking later than his/her peers and progress at a slower rate
linguistically. Due to the very nature of these disorders, the child may
struggle with academics and socializing with peers.
Experts that commonly treat such disorders include speech pathologists and audiologists.
Psychopathology of language
A special class of language disorders is studied by the psychopathology of language. Its topics of interest range from simple speech error to dream speech and schizophasia.
Childhood language disorders
During childhood the most common type of disruption in communication is a language disorder.
In most cases, language development is predicable and referrals for
evaluation may be needed in cases where a child's language development
is atypical.
Language disorders among children are present when a child is
experiencing substantial difficulty regarding their language
development. Among young children, language disorders have been associated with higher rates of social difficulties and anxiety.
Specific language impairment
Specific language impairment
(SLI) is a developmental language disorder among children that has no
known cause and cannot be attributed to any physical or intellectual
disability, environmental factors such as deprivation, hearing loss, or
any other underlying etiology.
SLI is characterized by abnormal development of language that includes a
delay in the onset of language, simplification of grammatical
structures and difficulty with grammatical morphology, limited vocabulary, and problems understanding complex language. Children with SLI tend to begin speaking at a later age and have a smaller vocabulary than their peers.
Among the language disorders that are present during childhood, SLI is
one of the most prevalent, affecting roughly 7% of children.
While children with specific language impairment have difficulty with
language production, they are noted to have normal levels of
intelligence.
Autism spectrum disorder
Autism
spectrum disorder (ASD) is a term used to define a group of
developmental disorders that are characterized by disruption in
communication and social abilities, limited eye contact, exhibiting
repetitive behaviors, and having limited interests.
Due to the impact that autism has on communication and social
interactions, verbal language is affected in most instances though not
in the presentation formally known as Asperger's.
Acquired neurogenic language disorders
Language disorders that are neurogenic affect the nervous system and result in disruption in language production. The type of language dysfunction that occurs is dependent upon the site, extent, and cause of the brain damage.
Aphasia
Aphasia is a language disorder that is caused by damage to the tissue in the language center in the brain.
The type of incident that most often causes Aphasia is stroke but can
also occur due to traumatic brain injury, infection, tumors, and
degenerative brain disorders.
Aphasia is a disorder that is acquired, therefore it occurs in
individuals that have already developed language. Aphasia does not
affect a person's intellect or speech but Instead affects the
formulation of language. All areas of language are affected by aphasia including expressive and receptive language abilities.
Symptoms of aphasia vary widely but generally are defined by language
deficits that affect fluency, the ability to talk, reading, writing, and
comprehension.
There are many types of aphasia that vary in symptoms depending upon
where in the language center of the brain the damage occurred.
The aphasias can be categorized as different aphasic syndromes
depending upon the location of lesion and the symptoms that
differentiate the aphasias from one another.
Global aphasia is a type of aphasia that occurs in people where a large
portion of the language center of the brain has been damaged and
results in deficits in all modalities of language.
Broca's aphasia, also referred to as expressive aphasia, is an aphasic
syndrome in which there is damage in left hemisphere, specifically in
the Broca's area, of the brain. Broca's aphasia may affect an individual's ability to produce speech while comprehension remains intact.
Traumatic brain injury
Traumatic brain injury (TBI) is caused by neurological damage due to an open or closed head injury. The most frequent causes of head injury include motor vehicle accidents, assault, gun related incidents, and falls, TBI is categorized as either mild, moderate or severe and can affect cognitive, psychosocial, and linguistic skills. Language skills that may be affected include comprehension, motor output, word finding, and difficulties with reading.
Classification
In
order to help distinguish between language disorders, they are often
categorized as either primary disorders of language, secondary disorders
of language, acquired or developmental. A primary language disorder is
one that cannot be attributed to an underlying disorder and is solely
responsible for the language disturbance while a secondary language
disorder is the result of another disorder.
Language disorders can also be categorized as developmental or
acquired. A developmental language disorder is present at birth while an
acquired language disorder occurs at some point after birth. Acquired
language disorders can often be attributed to injuries within the brain
due to occurrences such as stroke or Traumatic brain injury.
A vocal register is a range of tones in the human voice produced by a particular vibratory pattern of the vocal folds. These registers include modal voice (or normal voice), vocal fry, falsetto, and the whistle register.
Registers originate in laryngeal
function. They occur because the vocal folds are capable of producing
several different vibratory patterns. Each of these vibratory patterns
appears within a particular range of pitches and produces certain characteristic sounds.
In speech pathology,
the vocal register has three components: a certain vibratory pattern of
the vocal folds, a certain series of pitches, and a certain type of
sound. Although this view is also adopted by many vocal pedagogists,
others define vocal registration more loosely than in the sciences,
using the term to denote various theories of how the human voice
changes, both subjectively and objectively, as it moves through its
pitch range. There are many divergent theories on vocal registers within vocal pedagogy, making the term somewhat confusing and at times controversial within the field of singing. Vocal pedagogists may use the term vocal register to refer to any of the following:
A labeled anatomical diagram of the vocal folds or cords.
a particular part of the vocal range such as the upper, middle, or lower registers
a region of the voice defined or delimited by vocal breaks
Manuel Garcia II
in the late nineteenth century was one of the first to develop a
scientific definition of registers, a definition that is still used by
pedagogues and vocal teachers today.
"A register is a series of homogeneous sounds produced by one
mechanism, differing essentially from another series of equally
homogeneous sounds produced by another mechanism."
Another definition is from Clifton Ware in the 1990s.
"A series of distinct, consecutive, homogeneous vocal tones that
can be maintained in pitch and loudness throughout a certain range."
A register consists of the homogeneous tone qualities produced by the
same mechanical system, whereas registration is the process of using
and combining the registers to achieve artistic singing. For example: a
skilled singer moves through their range and dynamics smoothly, so that
you are unaware of register changes. This process could be described as
good or clean registration.[7]
The term "register" originated in the sixteenth century. Before then, it
was recognized that there were different "voices". As teachers started
to notice how different the ranges on either side of the passaggi or
breaks in the voice were, they were compared to different sets of pipes
in an organ. These clusters of pipes were called registers, so the same term was adopted for voices.
Vibratory patterns
Vocal
registers arise from different vibratory patterns produced by the vocal
cords. Research by speech pathologists and some vocal pedagogists has
revealed that the vocal cords
are capable of producing at least four distinct vibratory forms,
although not all persons can produce all of them. The first of these
vibratory forms is known as natural or normal voice; another name for it is modal voice,
which is widely used in both speech pathology and vocal pedagogy
publications. In this usage, modal refers to the natural disposition or
manner of action of the vocal cords. The other three vibratory forms are
known as vocal fry, falsetto, and whistle. Each of
these four registers has its own vibratory pattern, its own pitch range
(although there is some overlap), and its own characteristic sound.
Arranged by the pitch ranges covered, vocal fry is the lowest register, modal voice is next, then falsetto, and finally the whistle register.
While speech pathologists and scholars of phonetics recognize
four registers, vocal pedagogists are divided. Indiscriminate use of the
word register has led to confusion and controversy about the number of
registers in the human voice within vocal pedagogical circles. This
controversy does not exist within speech pathology and the other
sciences, because vocal registers are viewed from a purely physiological
standpoint concerned with laryngeal function. Writers concerned with
the art of singing state that there are anywhere from one to seven
registers present. The diversity of opinion is wide with no consensus.
The prevailing practice within vocal pedagogy is to divide both
men and women's voices into three registers. Men's voices are designated
"chest", "head", and "falsetto" and women's voices are "chest",
"middle", and "head". This way of classifying registers, however, is not
universally accepted. Many vocal pedagogists blame this confusion on
the incorrect use of the terms "chest register" and "head register".
These professionals argue that, since all registers originate in
laryngeal function, it is meaningless to speak of registers being
produced in the chest or head. The vibratory sensations which are felt
in these areas are resonance phenomena and should be described in terms related to resonance, not to registers. These vocal pedagogists prefer the terms "chest voice" and "head voice"
over the term register. Many of the problems described as register
problems are actually problems of resonance adjustment. This helps to
explain the multiplicity of registers which some vocal pedagogists
advocate. For more information on resonance, see Vocal resonation.
Various types of chest or head noises can be made in different
registers of the voice. This happens through differing vibratory
patterns of the vocal folds and manipulation of the laryngeal muscles. "Chest voice" and "head voice"
can be considered the simplest registers to differentiate between.
However, there are other sounds other than pure chest voice and head
voice that a voice can make. These sounds or timbres
exist on a continuum that is more complex than singing purely in chest
voice and head voice. The vocal timbres created by physical changes in
the vocal fold vibrations and muscular changes in the laryngeal muscles
are known as glottal configurations. These configurations happen as a result of adduction and abduction of the glottis.
A glottal configuration is the area in which the vocal folds come
together when phonating. Glottal configurations existing on this
continuum are adducted chest, abducted chest, adducted falsetto, and
abducted falsetto. In this case, falsetto could also be referred to as
head voice as it applies to females as well. Vocally, the process of
adduction is when the posterior of the glottis is closed. Abduction is
when the posterior of the glottis is open. An example of adducted chest
is belting as well as bass, baritone, and tenor classical singing.
Abducted falsetto, on the opposite end of the spectrum, sounds very
breathy and can possibly be a sign of a lack of vocal fold closure.
However, in styles like jazz and pop, this breathy falsetto is a
necessary singing technique for these genres. Abducted chest is a lower,
breathier phonation occurring in the chest register, also occurring in
jazz and pop styles. Abducted falsetto is treble classical singing.
Chestmix and headmix lie on this continuum as well with chest mix being
which is more adducted than headmix.
These different vocal fold vibratory patterns occur as the result
of certain laryngeal muscles being either active or inactive. During
adducted and abducted chest voice, the thyroarytenoid muscle
is always activated while during falsetto this muscle is not activated.
When the posterior of the glottis is closed the interarytenoid muscle
is engaged. This occurs in both adducted falsetto and adducted chest.
The confusion which exists concerning the definition and number
of registers is due in part to what takes place in the modal register
when a person sings from the lowest pitches
of that register to the highest pitches. The frequency of vibration of
the vocal folds is determined by their length, tension, and mass. As
pitch rises, the vocal folds
are lengthened, tension increases, and their thickness decreases. In
other words, all three of these factors are in a state of flux in the
transition from the lowest to the highest tones.
If a singer holds any of these factors constant and interferes with their progressive state of change, their laryngeal
function tends to become static and eventually breaks occur, with
obvious changes of tone quality. These breaks are often identified as
register boundaries or as transition areas between registers. The
distinct change or break between registers is called a passaggio or a ponticello.
Vocal pedagogists teach that, with study, a singer can move
effortlessly from one register to another with ease and consistent tone.
Registers can even overlap while singing. Teachers who prefer the
theory of "blending registers" usually help students through the
"passage" from one register to another by hiding their "lift" (where the
voice changes).
However, many pedagogists disagree with this distinction of
boundaries, blaming such breaks on vocal problems which have been
created by a static laryngeal adjustment that does not permit the
necessary changes to take place. This difference of opinion has affected
the different views on vocal registration.
The vocal fry register is the lowest vocal register and is produced through a loose glottal closure
which will permit air to bubble through with a popping or rattling
sound of a very low frequency. The chief use of vocal fry in singing is
to obtain pitches of very low frequency which are not available in modal voice.
This register may be used therapeutically to improve the lower part of
the modal register. This register is not used often in singing, but male
quartet pieces, and certain styles of folk music for both men and women
have been known to do so.
The modal voice is the usual register for speaking and singing, and
the vast majority of both are done in this register. As pitch rises in
this register, the vocal folds are lengthened, tension increases, and
their edges become thinner. A well-trained singer or speaker can phonate
two octaves or more in the modal register with consistent production,
beauty of tone, dynamic variety, and vocal freedom. This is possible
only if the singer or speaker avoids static laryngeal
adjustments and allows the progression from the bottom to the top of
the register to be a carefully graduated continuum of readjustments.
The falsetto register lies above the modal voice register and overlaps the modal register by approximately one octave.
The characteristic sound of falsetto is flute-like with few overtones
present. The essential difference between the modal and falsetto
registers lies in the amount and type of vocal cord
involvement. The falsetto voice is produced by the vibration of the
ligamentous edges of the vocal cords, in whole or in part, and the main
body of the fold is more or less relaxed. In contrast, the modal voice
involves the whole vocal cord with the glottis
opening at the bottom first and then at the top. The falsetto voice is
also more limited in dynamic variation and tone quality than the modal
voice.
The whistle register is the highest register of the human voice.
The whistle register is so called because the timbre of the notes that
are produced from this register are similar to that of a whistle or the
upper notes of a flute, whereas the modal register tends to have a warmer, less shrill timbre.
The Passaggio is a bridge or transition point between the different
registers of the voice. Singers are often trained to navigate this area
in the voice. Instabilities often happen in this bridge while the voice
is phonating on pitches within this location. When a singer does not
navigate this area sufficiently the voice folds temporarily lose the
mucosal wave pattern resulting in an audible crack. These cracks can be
navigated often through changing vowel. The female voice has two
passaggios, primo and secondo passaggio.
The male voice has two passaggios as well, however the points of
transition lie differently than those of a treble singer and are also
navigated in a different manner.
The minority stress
model takes into account significant stressors that distinctly affect
the mental health of those who identify as lesbian, gay, bisexual,
transgender, or another non-conforming gender identity. Some risk factors that contribute to declining mental health are heteronormativity, discrimination,
harassment, rejection (e.g., family rejection and social exclusion),
stigma, prejudice, denial of civil and human rights, lack of access to
mental health resources, lack of access to gender-affirming spaces
(e.g., gender-appropriate facilities), and internalised homophobia.
The structural circumstance where a non-heterosexual or gender
non-conforming individual is embedded in significantly affects the
potential sources of risk. The compounding of these everyday stressors increase poor mental health outcomes among individuals in the LGBT community.
Evidence shows that there is a direct association between LGBT
individuals' development of severe mental illnesses and the exposure to
discrimination.
In addition, there are a lack of access to mental health
resources specific to LGBT individuals and a lack of awareness about
mental health conditions within the LGBT community that restricts
patients from seeking help.
Limited research
There
is limited research on mental health in the LGBT community. Several
factors affect the lack of research on mental illness within
non-heterosexual and non-conforming gender identities. Some factors
identified: the history of psychiatry with conflating sexual and gender
identities with psychiatric symptomatology; medical community's history
of labelling gender identities such as homosexuality as an illness (now
removed from the DSM); the presence of gender dysphoria
in the DSM-V; prejudice and rejection from physicians and healthcare
providers; LGBT underrepresentation in research populations; physicians'
reluctance to ask patients about their gender; and the presence of laws
against the LGBT community in many countries. General patterns such as the prevalence of minority stress have been broadly studied.
There is also a lack of empirical research on racial and ethnic
differences in mental health status among the LGBT community and the
intersection of multiple minority identities.
Stigmatization of LGBT individuals with mental illness
There is a significantly greater stigmatization of LGBT individuals
with more severe conditions. The presence of the stigma affects
individuals' access to treatment and is particularly present for
non-heterosexual and gender non-conforming individuals with
schizophrenia.
Disorders
Anxiety
LGBT individuals are nearly three times more likely to experience anxiety compared to heterosexual individuals. Gay and bisexual men are more likely to have generalized anxiety disorder (GAD) as compared to heterosexual men.
Depression
Individuals
who identify as non-heterosexual or gender non-conforming are more
likely to experience depressive episodes and suicide attempts than those
who identify as heterosexual.
Based solely on their gender identity and sexual orientation, LGBT
individuals face stigma, societal bias, and rejection that increase the
likelihood of depression. Gay and bisexual men are more likely to have major depression and bipolar disorder than heterosexual men.
Transgender youth are nearly four times more likely to experience depression, as compared to their non-transgender peers.
Compared to LGBT youth with highly accepting families, LGBT youth with
less accepting families are more than three times likely to consider and
attempt suicide.
As compared to individuals with a level of certainty in their gender
identity and sexuality (such as LGB-identified and heterosexual
students), youth who are questioning their sexuality report higher
levels of depression and worse psychological responses to bullying and
victimization.
Transgender youth who report higher feelings of internalized
transphobia are found to be more likely to meet the diagnostic criteria
for depression. On the other hand, those who report their perceived
physical appearance are consistent with their internal gender identity
are less likely to be diagnosed with depression.
31% of LGBT older adults report depressive symptoms. LGBT older
adults experience LGBT stigma and ageism that increase their likeliness
to experience depression.
Post-traumatic stress disorder
LGBT
individuals experience higher rates of trauma than the general
population, the most common of which include intimate partner violence,
sexual assault and hate violence.
Compared to heterosexual populations, LGBT individuals are at 1.6 to
3.9 times greater risk of probable PTSD. One-third of PTSD disparities
by sexual orientation are due to disparities in child abuse
victimization.
Suicide
As
compared to heterosexual men, gay and bisexual men are at a greater
risk for suicide, attempting suicide, and dying of suicide. In the United States, 29% (almost one-third) of LGBT youth have attempted suicide at least once.
Compared to heterosexual youth, LGBT youth are twice as likely to feel
suicidal and over four times as likely to attempt suicide. Transgender individuals are at the greatest risk of suicide attempts.
One-third of transgender individuals (both in youth and adulthood) has
seriously considered suicide and one-fifth of transgender youth has
attempted suicide.
LGBT youth are four times more likely to attempt suicide than heterosexual youth.
Youth who are questioning their gender identity and/or sexuality are
two times more likely to attempt suicide than heterosexual youth. Bisexual youth have higher percentages of suicidality than lesbian and gay youth.
As compared to white transgender individuals, transgender individuals
who are African American/black, Hispanic/Latinx, American Indian/Alaska
Native, or Multiracial are at a greater risk of suicide attempts. 39% of LGBT older adults have considered suicide.
Substance abuse
In
the United States, an estimated 20-30% of LGBT individuals abuse
substances. This is higher than the 9% of the U.S. population that abuse
substances. In addition, 25% of LGBT individuals abuse alcohol compared
to the 5-10% of the general population.
Lesbian and bisexual youth have a higher percentage of substance use
problems as compared to sexual minority males and heterosexual females. However, as young sexual minority males mature into early adulthood, their rate of substance use increases. Lesbian and bisexual women are twice as likely to engage in heavy alcohol drinking as compared to heterosexual women. Gay and bisexual men are less likely to engage in heavy alcohol drinking as compared to heterosexual men.
Substance use such as alcohol
and drug use among LGBT individuals can be a coping mechanism in
response to everyday stressors like violence, discrimination, and
homophobia. Substance use can threaten LGBT individuals' financial
stability, employment, and relationships.
Eating disorders
The average age for developing an eating disorder is 19 years old for LGBT individuals, compared to 12–13 years old nationally. In a national survey of LGBTQ youth conducted by the National Eating Disorders Association, The Trevor Project
and the Reasons Eating Disorder Center in 2018, 54% of participants
indicated that they had been diagnosed with an eating disorder. An additional 21% of surveyed participants suspected that they had an eating disorder.
Various risk factors may increase the likelihood of LGBT
individuals experiencing disordered eating, including fear of rejection,
internalised negativity, post-traumatic stress disorder (PTSD) or pressure to conform with body image ideals within the LGBT community.
42% of men who experience disordered eating identify as gay. Gay men are also seven times more likely to report binge eating and twelve times more likely to report purging than heterosexual men. Gay and bisexual men also experience a higher prevalence of full-syndrome bulimia and all subclinical eating disorders than their heterosexual counterparts.
Research has found lesbian women to have higher rates of
weight-based self-worth and proneness to contracting eating disorders
compared to gay men. Lesbian women also experience comparable rates of eating disorders compared to heterosexual women, with similar rates of dieting, binge eating and purging behaviours. However, lesbian women are more likely to report positive body image compared to heterosexual females (42.1% vs 20.5%).
Transgender individuals are significantly more likely than any
other LGBT demographic to report an eating disorder diagnosis or
compensatory behaviour related to eating. Transgender individuals may use weight restriction to suppress secondary sex characteristics or to suppress or stress gendered features.
There is limited research regarding racial differences within LGBT populations as it relates to disordered eating.
Conflicting studies have struggled to ascertain whether LGBT people of
colour experience similar or varying rates of eating disorder proneness
or diagnosis.
Coping mechanisms
Each
individual has its own way to deal with difficult emotions and
situations. Oftentimes, the coping mechanism adopted by a person,
depending on whether they are safe or risky, will impact their mental
health. These coping mechanisms tend to be developed during youth and
early-adult life. Once a risky coping mechanism is adopted, it is often
hard for the individual to get rid of it.
Safe coping-mechanisms, when it comes to mental disorders,
involve communication with others, body and mental health caring,
support and help seeking.
Because of the high stigmatization they often experience in
school, public spaces and society in general, the LGBT community, and
more especially the young people among them are less likely to express
themselves and seek for help and support, because of the lack of
resources and safe spaces available for them to do so. As a result, LGBT
patients are more likely to adopt risky coping mechanisms then the rest
of the population.
These risky mechanisms involve strategies such as self-harm,
substance abuse, or risky sexual behavior for many reasons, including;
"attempting to get away from or not feel overwhelming emotions, gaining a
sense of control, self-punishment, nonverbally communicating their
struggles to others."
Once adopted, these coping mechanisms tend to stick to the person and
therefore endanger even more the future mental health of LGBT patients,
reinforcing their exposure to depression, extreme anxiety and suicide.
Immunization against diseases is a key preventive healthcare measure.
Preventive healthcare, or prophylaxis, is the application of healthcare measures to prevent diseases. Disease and disability are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices,
and are dynamic processes that begin before individuals realize they
are affected. Disease prevention relies on anticipatory actions that can
be categorized as primal, primary, secondary, and tertiary prevention.
Each year, millions of people die of preventable causes. A 2004
study showed that about half of all deaths in the United States in 2000
were due to preventable behaviors and exposures. Leading causes included cardiovascular disease, chronic respiratory disease, unintentional injuries, diabetes, and certain infectious diseases. This same study estimates that 400,000 people die each year in the United States due to poor diet and a sedentary lifestyle. According to estimates made by the World Health Organization (WHO), about 55 million people died worldwide in 2011, and two-thirds of these died from non-communicable diseases, including cancer, diabetes, and chronic cardiovascular and lung diseases. This is an increase from the year 2000, during which 60% of deaths were attributed to these diseases.)
Preventive healthcare is especially important given the worldwide
rise in the prevalence of chronic diseases and deaths from these
diseases. There are many methods for prevention of disease. One of them
is prevention of teenage smoking through information giving.
It is recommended that adults and children aim to visit their doctor
for regular check-ups, even if they feel healthy, to perform disease screening,
identify risk factors for disease, discuss tips for a healthy and
balanced lifestyle, stay up to date with immunizations and boosters, and
maintain a good relationship with a healthcare provider.
In pediatrics, some common examples of primary prevention are
encouraging parents to turn down the temperature of their home water
heater in order to avoid scalding burns, encouraging children to wear
bicycle helmets, and suggesting that people use the air quality index
(AQI) to check the level of pollution in the outside air before
engaging in sporting activities. Some common disease screenings include
checking for hypertension (high blood pressure), hyperglycemia (high blood sugar, a risk factor for diabetes mellitus), hypercholesterolemia (high blood cholesterol), screening for colon cancer, depression, HIV and other common types of sexually transmitted disease such as chlamydia, syphilis, and gonorrhea, mammography (to screen for breast cancer), colorectal cancer screening, a Pap test (to check for cervical cancer), and screening for osteoporosis. Genetic testing can also be performed to screen for mutations that cause genetic disorders or predisposition to certain diseases such as breast or ovarian cancer.
However, these measures are not affordable for every individual and the
cost effectiveness of preventive healthcare is still a topic of debate.
Overview
Preventive healthcare strategies are described as taking place at the primal, primary, secondary, and tertiary prevention levels.
Although advocated as preventive medicine in the early twentieth century by Sara Josephine Baker,
in the 1940s, Hugh R. Leavell and E. Gurney Clark coined the term
primary prevention. They worked at the Harvard and Columbia University
Schools of Public Health, respectively, and later expanded the levels to
include secondary and tertiary prevention. Goldston (1987) notes that
these levels might be better described as "prevention, treatment, and
rehabilitation", although the terms primary, secondary, and tertiary
prevention are still in use today. The concept of primal prevention has
been created much more recently, in relation to the new developments in
molecular biology over the last fifty years,
more particularly in epigenetics, which point to the paramount
importance of environmental conditions, both physical and affective, on
the organism during its fetal and newborn life, or so-called primal
period of life.
Level
Definition
Primal and primordial prevention
Primal prevention has been propounded as a separate category of health promotion
based on the evidence that epigenetic processes start at conception
(see below: Primal and primordial preventions). Primordial prevention
refers to measures designed to avoid the development of risk factors in
the first place, early in life.
Primary prevention
Methods to avoid occurrence of disease either through eliminating disease agents or increasing resistance to disease. Examples include immunization against disease, maintaining a healthy diet and exercise regimen, and avoiding smoking.
Secondary prevention
Methods to detect and address an existing disease prior to the appearance of symptoms. Examples include treatment of hypertension (a risk factor for many cardiovascular diseases), and cancer screenings.
Tertiary prevention
Methods to reduce the harm of symptomatic disease, such as disability or death, through rehabilitation and treatment. Examples include surgical procedures that halt the spread or progression of disease.
Primal prevention is health promotion par excellence. New knowledge in molecular biology, in particular epigenetics, points to how much affective as well as physical environment during fetal and newborn life may determine adult health. This way of promoting health consists mainly in providing future
parents with pertinent, unbiased information on primal health and
supporting them during their child's primal period of life (i.e., "from
conception to first anniversary" according to definition by the Primal
Health Research Centre, London). This includes adequate parental leave,
ideally for both parents, with kin caregiving and financial help where
needed.
Primordial prevention refers to all measures designed to prevent
the development of risk factors in the first place, early in life, and even preconception, as Ruth A. Etzel
has described it "all population-level actions and measures that
inhibit the emergence and establishment of adverse environmental,
economic, and social conditions". This could be reducing air pollution or prohibiting endocrine-disrupting chemicals in food-handling equipment and food contact materials.
Primary prevention
Primary prevention consists of traditional health promotion and "specific protection". Health promotion activities include prevention strategies such as health education and lifestyle medicine, and are current, non-clinical life choices such as eating nutritious meals and exercising often, that prevent lifestyle-related medical conditions, improve the quality of life, and create a sense of overall well-being. Preventing disease and creating overall well-being prolongs life expectancy.
Health-promotional activities do not target a specific disease or
condition but rather promote health and well-being on a very general
level. On the other hand, specific protection targets a type or group of diseases and complements the goals of health promotion.
Food
Food
is the most basic tool in preventive health care. Poor nutrition is
linked to various chronic illnesses. Because of this, having a healthy
diet and proper nutrition can be used to prevent illnesses.
Access
The
2011 National Health Interview Survey performed by the Centers for
Disease Control was the first national survey to include questions about
ability to pay for food. Difficulty with paying for food, medicine, or
both is a problem facing 1 out of 3 Americans. If better food options
were available through food banks,
soup kitchens, and other resources for low-income people, obesity and
the chronic conditions that come along with it would be better
controlled. A food desert
is an area with restricted access to healthy foods due to a lack of
supermarkets within a reasonable distance. These are often low-income
neighborhoods with the majority of residents lacking transportation. There have been several grassroots movements since 1995 to encourage urban gardening, using vacant lots to grow food cultivated by local residents.
Mobile fresh markets are another resource for residents in a "food
desert", which are specially outfitted buses bringing affordable fresh
fruits and vegetables to low-income neighborhoods.
Food education and guidance
It has been proposed that healthy longevity diets are included in standard healthcare as switching from a "typical Western diet" could often extend life by a decade.
Specific protective measures such as water purification, sewage treatment, and the development of personal hygienic routines, such as regular hand-washing, safe sex to prevent sexually transmitted infections,
became mainstream upon the discovery of infectious disease agents and
have decreased the rates of communicable diseases which are spread in
unsanitary conditions.
Scientific advancements in genetics have contributed to the
knowledge of hereditary diseases and have facilitated progress in
specific protective measures in individuals who are carriers of a
disease gene or have an increased predisposition to a specific disease.
Genetic testing has allowed physicians to make quicker and more accurate
diagnoses and has allowed for tailored treatments or personalized medicine.
Preventive measures like vaccines and medical screenings are also important.
Using PPE properly and getting the recommended vaccines and screenings
can help decrease the spread of respiratory diseases, protecting the
healthcare workers as well as their patients.
Secondary prevention
Secondary prevention deals with latent diseases and attempts to prevent an asymptomatic disease from progressing to symptomatic disease.
Certain diseases can be classified as primary or secondary. This
depends on definitions of what constitutes a disease, though, in
general, primary prevention addresses the root cause of a disease or injury whereas secondary prevention aims to detect and treat a disease early on.
Secondary prevention consists of "early diagnosis and prompt treatment"
to contain the disease and prevent its spread to other individuals, and
"disability limitation" to prevent potential future complications and
disabilities from the disease.
Early diagnosis and prompt treatment for a syphilis patient would
include a course of antibiotics to destroy the pathogen and screening
and treatment of any infants born to syphilitic mothers. Disability
limitation for syphilitic patients includes continued check-ups on the
heart, cerebrospinal fluid, and central nervous system of patients to
curb any damaging effects such as blindness or paralysis.
Tertiary prevention
Finally,
tertiary prevention attempts to reduce the damage caused by symptomatic
disease by focusing on mental, physical, and social rehabilitation.
Unlike secondary prevention, which aims to prevent disability, the
objective of tertiary prevention is to maximize the remaining
capabilities and functions of an already disabled patient.
Goals of tertiary prevention include: preventing pain and damage,
halting progression and complications from disease, and restoring the
health and functions of the individuals affected by disease.
For syphilitic patients, rehabilitation includes measures to prevent
complete disability from the disease, such as implementing work-place
adjustments for the blind and paralyzed or providing counseling to
restore normal daily functions to the greatest extent possible.
The general use of machinery that has adequate ventilation and
airflow is suggested for these patients in order to halt progression and
complications of disease. A study conducted in nursing homes to prevent
diseases concluded that the use of evaporative humidifiers to maintain
the indoor humidity within the range 40–60% can reduce respiratory risk.
Certain diseases thrive in different humidities, so the use of the
humidifiers can help kill the particles of diseases.
Leading causes of preventable death
United States
The leading preventable cause of death
in the United States is tobacco; however, poor diet and lack of
exercise may soon surpass tobacco as a leading cause of death. These
behaviors are modifiable and public health and prevention efforts could
make a difference to reduce these deaths.
Leading causes of preventable deaths in the United States in 2000
The leading causes of preventable death worldwide share similar trends to the United States.
There are a few differences between the two, such as malnutrition,
pollution, and unsafe sanitation, that reflect health disparities
between the developing and developed world.
Leading causes of preventable death worldwide as of the year 2001
However, several of the leading causes of death – or underlying contributors to earlier death – may not be included as "preventable" causes of death. A study concluded that pollution was "responsible for approximately 9 million deaths per year" in 2019. And another study concluded that the global mean loss of life expectancy (a measure similar to years of potential life lost) from air pollution
in 2015 was 2.9 years, substantially more than, for example, 0.3 years
from all forms of direct violence, albeit a significant fraction of the
LLE is considered to be unavoidable (such as pollution from some natural
wildfires).
A landmark study conducted by the World Health Organization and the International Labour Organization
found that exposure to long working hours is the occupational risk
factor with the largest attributable burden of disease, i.e. an
estimated 745,000 fatalities from ischemic heart disease and stroke
events in 2016.
With this study, prevention of exposure to long working hours has
emerged as a priority for prevention healthcare in workplace settings.
Child mortality
In 2010, 7.6 million children died before reaching the age of 5. While this is a decrease from 9.6 million in 2000, it was still far from the fourth Millennium Development Goal to decrease child mortality by two-thirds by 2015. Of these deaths, about 64% were due to infection including diarrhea, pneumonia, and malaria. About 40% of these deaths occurred in neonates (children ages 1–28 days) due to pre-term birth complications. The highest number of child deaths occurred in Africa and Southeast Asia. As of 2015 in Africa, almost no progress has been made in reducing neonatal death since 1990.
In 2010, India, Nigeria, Democratic Republic of the Congo, Pakistan,
and China contributed to almost 50% of global child deaths. Targeting
efforts in these countries is essential to reducing the global child
death rate.
Child mortality is caused by factors including poverty, environmental hazards, and lack of maternal education.
In 2003, the World Health Organization created a list of interventions
in the following table that were judged economically and operationally
"feasible," based on the healthcare resources and infrastructure in 42
nations that contribute to 90% of all infant and child deaths. The table
indicates how many infant and child deaths could have been prevented in
2000, assuming universal healthcare coverage.
Leading preventive interventions as of 2003 reducing deaths in children 0–5 years old worldwide
Obesity is a major risk factor for a wide variety of conditions including cardiovascular diseases, hypertension, certain cancers, and type 2 diabetes.
In order to prevent obesity, it is recommended that individuals adhere
to a consistent exercise regimen as well as a nutritious and balanced
diet. A healthy individual should aim for acquiring 10% of their energy
from proteins, 15-20% from fat, and over 50% from complex carbohydrates,
while avoiding alcohol as well as foods high in fat, salt, and sugar.
Sedentary adults should aim for at least half an hour of moderate-level
daily physical activity and eventually increase to include at least 20
minutes of intense exercise, three times a week.
Preventive health care offers many benefits to those that chose to
participate in taking an active role in the culture. The medical system
in our society is geared toward curing acute symptoms of disease after
the fact that they have brought us into the emergency room. An ongoing
epidemic within American culture is the prevalence of obesity. Healthy
eating and regular exercise play a significant role in reducing an
individual's risk for type 2 diabetes. A 2008 study concluded that about
23.6 million people in the United States had diabetes, including 5.7
million that had not been diagnosed. 90 to 95 percent of people with
diabetes have type 2 diabetes. Diabetes is the main cause of kidney failure, limb amputation, and new-onset blindness in American adults.
Sexually transmitted infections
U.S. propaganda poster Fool the Axis Use Prophylaxis, 1942
Sexually transmitted infections (STIs), such as syphilis and HIV, are common but preventable with safe-sex
practices. STIs can be asymptomatic, or cause a range of symptoms.
Preventive measures for STIs are called prophylactics. The term
especially applies to the use of condoms, which are highly effective at preventing disease, but also to other devices meant to prevent STIs, such as dental dams and latex gloves. Other means for preventing STIs include education on how to use condoms or other such barrier devices, testing partners
before having unprotected sex, receiving regular STI screenings, to
both receive treatment and prevent spreading STIs to partners, and,
specifically for HIV, regularly taking prophylactic antiretroviral
drugs, such as Truvada. Post-exposure prophylaxis,
started within 72 hours (optimally less than 1 hour) after exposure to
high-risk fluids, can also protect against HIV transmission.
Malaria prevention using genetic modification
Genetically modified mosquitoes are being used in developing countries to control malaria. This approach has been subject to objections and controversy.
Thrombosis
is a serious circulatory disease affecting thousands, usually older
persons undergoing surgical procedures, women taking oral contraceptives
and travelers. The consequences of thrombosis can be heart attacks and
strokes. Prevention can include exercise, anti-embolism stockings,
pneumatic devices, and pharmacological treatments.
In recent years, cancer
has become a global problem. Low and middle income countries share a
majority of the cancer burden largely due to exposure to carcinogens
resulting from industrialization and globalization.
However, primary prevention of cancer and knowledge of cancer risk
factors can reduce over one third of all cancer cases. Primary
prevention of cancer can also prevent other diseases, both communicable
and non-communicable, that share common risk factors with cancer.
Lung cancer
Distribution of lung cancer in the United States
Lung cancer is the leading cause of cancer-related deaths in the United States and Europe and is a major cause of death in other countries. Tobacco is an environmental carcinogen and the major underlying cause of lung cancer.
Between 25% and 40% of all cancer deaths and about 90% of lung cancer
cases are associated with tobacco use. Other carcinogens include
asbestos and radioactive materials. Both smoking and second-hand exposure from other smokers can lead to lung cancer and eventually death.
Prevention of tobacco use is paramount to prevention of lung
cancer. Individual, community, and statewide interventions can prevent
or cease tobacco use. 90% of adults in the U.S. who have ever smoked did
so prior to the age of 20. In-school prevention/educational programs,
as well as counseling resources, can help prevent and cease adolescent
smoking. Other cessation techniques include group support programs, nicotine replacement therapy
(NRT), hypnosis, and self-motivated behavioral change. Studies have
shown long term success rates (>1 year) of 20% for hypnosis and
10%-20% for group therapy.
Cancer screening
programs serve as effective sources of secondary prevention. The Mayo
Clinic, Johns Hopkins, and Memorial Sloan-Kettering hospitals conducted
annual x-ray screenings and sputum cytology tests and found that lung
cancer was detected at higher rates, earlier stages, and had more
favorable treatment outcomes, which supports widespread investment in
such programs.
Legislation can also affect smoking prevention and cessation. In
1992, Massachusetts (United States) voters passed a bill adding an extra
25 cent tax to each pack of cigarettes, despite intense lobbying and
$7.3 million spent by the tobacco industry to oppose this bill. Tax
revenue goes toward tobacco education and control programs and has led
to a decline of tobacco use in the state.
Lung cancer and tobacco smoking are increasing worldwide,
especially in China. China is responsible for about one-third of the
global consumption and production of tobacco products.
Tobacco control policies have been ineffective as China is home to 350
million regular smokers and 750 million passive smokers and the annual
death toll is over 1 million.
Recommended actions to reduce tobacco use include decreasing tobacco
supply, increasing tobacco taxes, widespread educational campaigns,
decreasing advertising from the tobacco industry, and increasing tobacco
cessation support resources.
In Wuhan, China, a 1998 school-based program implemented an
anti-tobacco curriculum for adolescents and reduced the number of
regular smokers, though it did not significantly decrease the number of
adolescents who initiated smoking. This program was therefore effective
in secondary but not primary prevention and shows that school-based
programs have the potential to reduce tobacco use.
Skin cancer
An image of melanoma, one of the deadliest forms of skin cancer
Skin cancer is the most common cancer in the United States. The most lethal form of skin cancer, melanoma, leads to over 50,000 annual deaths in the United States.
Childhood prevention is particularly important because a significant
portion of ultraviolet radiation exposure from the sun occurs during
childhood and adolescence and can subsequently lead to skin cancer in
adulthood. Furthermore, childhood prevention can lead to the development
of healthy habits that continue to prevent cancer for a lifetime.
The Centers for Disease Control and Prevention
(CDC) recommends several primary prevention methods including: limiting
sun exposure between 10 AM and 4 PM, when the sun is strongest, wearing
tighter-weave natural cotton clothing, wide-brim hats, and sunglasses
as protective covers, using sunscreens that protect against both UV-A
and UV-B rays, and avoiding tanning salons.
Sunscreen should be reapplied after sweating, exposure to water
(through swimming for example) or after several hours of sun exposure.
Since skin cancer is very preventable, the CDC recommends school-level
prevention programs including preventive curricula, family involvement,
participation and support from the school's health services, and
partnership with community, state, and national agencies and
organizations to keep children away from excessive UV radiation
exposure.
Most skin cancer and sun protection data comes from Australia and the United States.
An international study reported that Australians tended to demonstrate
higher knowledge of sun protection and skin cancer knowledge, compared
to other countries.
Of children, adolescents, and adults, sunscreen was the most commonly
used skin protection. However, many adolescents purposely used sunscreen
with a low sun protection factor (SPF) in order to get a tan.
Various Australian studies have shown that many adults failed to use
sunscreen correctly; many applied sunscreen well after their initial sun
exposure and/or failed to reapply when necessary.
A 2002 case-control study in Brazil showed that only 3% of case
participants and 11% of control participants used sunscreen with SPF
>15.
Cervical cancer
The presence of cancer (adenocarcinoma) detected on a Pap test
Cervical cancer ranks among the top three most common cancers among women in Latin America, sub-Saharan Africa, and parts of Asia.
Cervical cytology screening aims to detect abnormal lesions in the
cervix so that women can undergo treatment prior to the development of
cancer. Given that high quality screening and follow-up care has been
shown to reduce cervical cancer rates by up to 80%, most developed
countries now encourage sexually active women to undergo a Pap test
every 3–5 years. Finland and Iceland have developed effective organized
programs with routine monitoring and have managed to significantly
reduce cervical cancer mortality while using fewer resources than
unorganized, opportunistic programs such as those in the United States
or Canada.
In developing nations in Latin America, such as Chile, Colombia,
Costa Rica, and Cuba, both public and privately organized programs have
offered women routine cytological screening since the 1970s. However,
these efforts have not resulted in a significant change in cervical
cancer incidence or mortality in these nations. This is likely due to
low quality, inefficient testing. However, Puerto Rico, which has
offered early screening since the 1960s, has witnessed almost a 50%
decline in cervical cancer incidence and almost a four-fold decrease in
mortality between 1950 and 1990. Brazil, Peru, India, and several
high-risk nations in sub-Saharan Africa which lack organized screening
programs, have a high incidence of cervical cancer.
Colorectal cancer
Colorectal cancer is globally the second most common cancer in women and the third-most common in men, and the fourth most common cause of cancer death after lung, stomach, and liver cancer, having caused 715,000 deaths in 2010.
It is also highly preventable; about 80 percent of colorectal cancers begin as benign growths, commonly called polyps, which can be easily detected and removed during a colonoscopy. Other methods of screening for polyps and cancers include fecal occult blood
testing. Lifestyle changes that may reduce the risk of colorectal
cancer include increasing consumption of whole grains, fruits and
vegetables, and reducing consumption of red meat.
Dementia
The prevention of dementia involves reducing the number of risk factors for the development of dementia, and is a global health priority needing a global response. Initiatives include the establishment of the International Research Network on Dementia Prevention (IRNDP) which aims to link researchers in this field globally, and the establishment of the Global Dementia Observatory
a web-based data knowledge and exchange platform, which will collate
and disseminate key dementia data from members states. Although there is
no cure for dementia, it is well established that modifiable risk
factors influence both the likelihood of developing dementia and the age
at which it is developed.Dementia can be prevented by reducing the risk factors for vascular disease such as diabetes, high blood pressure, obesity, smoking, physical inactivity and depression.
A study concluded that more than a third of dementia cases are
theoretically preventable. Among older adults both an unfavorable
lifestyle and high genetic risk are independently associated with higher
dementia risk. A favorable lifestyle is associated with a lower dementia risk, regardless of genetic risk.
In 2020, a study identified 12 modifiable lifestyle factors, and the
early treatment of acquired hearing loss was estimated as the most
significant of these factors, potentially preventing up to 9% of
dementia cases.
Health disparities and barriers to accessing care
Access
to healthcare and preventive health services is unequal, as is the
quality of care received. A study conducted by the Agency for Healthcare
Research and Quality (AHRQ) revealed health disparities
in the United States. In the United States, elderly adults (>65
years old) received worse care and had less access to care than their
younger counterparts. The same trends are seen when comparing all racial
minorities (black, Hispanic, Asian) to white patients, and low-income
people to high-income people.
Common barriers to accessing and utilizing healthcare resources
included lack of income and education, language barriers, and lack of
health insurance. Minorities were less likely than whites to possess
health insurance, as were individuals who completed less education.
These disparities made it more difficult for the disadvantaged groups to
have regular access to a primary care provider, receive immunizations,
or receive other types of medical care.
Additionally, uninsured people tend to not seek care until their
diseases progress to chronic and serious states and they are also more
likely to forgo necessary tests, treatments, and filling prescription
medications.
These sorts of disparities and barriers exist worldwide as well.
Often, there are decades of gaps in life expectancy between developing
and developed countries. For example, Japan has an average life
expectancy that is 36 years greater than that in Malawi.
Low-income countries also tend to have fewer physicians than
high-income countries. In Nigeria and Myanmar, there are fewer than 4
physicians per 100,000 people while Norway and Switzerland have a ratio
that is ten-fold higher.
Common barriers worldwide include lack of availability of health
services and healthcare providers in the region, great physical distance
between the home and health service facilities, high transportation
costs, high treatment costs, and social norms and stigma toward
accessing certain health services.
Economics of lifestyle-based prevention
With
lifestyle factors such as diet and exercise rising to the top of
preventable death statistics, the economics of healthy lifestyle is a
growing concern. There is little question that positive lifestyle
choices provide an investment in health throughout life. To gauge success, traditional measures such as the quality years of life method (QALY), show great value. However, that method does not account for the cost of chronic conditions or future lost earnings because of poor health.
Developing future economic models that would guide both private
and public investments as well as drive future policy to evaluate the
efficacy of positive lifestyle choices on health is a major topic for
economists globally. Americans spend over three trillion a year on
health care but have a higher rate of infant mortality, shorter life expectancies, and a higher rate of diabetes than other high-income nations because of negative lifestyle choices. Despite these large costs, very little is spent on prevention for lifestyle-caused conditions in comparison. In 2016, the Journal of the American Medical Association estimated that $101 billion was spent in 2013 on the preventable disease of diabetes, and another $88 billion was spent on heart disease. In an effort to encourage healthy lifestyle choices, as of 2010 workplace wellness programs were on the rise but the economics and effectiveness data were continuing to evolve and develop.
Health insurance coverage impacts lifestyle choices, even
intermittent loss of coverage had negative effects on healthy choices in
the U.S. The repeal of the Affordable Care Act
(ACA) could significantly impact coverage for many Americans as well as
"The Prevention and Public Health Fund" which is the U.S. first and
only mandatory funding stream dedicated to improving public health including counseling on lifestyle prevention issues, such as weight management, alcohol use, and treatment for depression.
Because in the U.S. chronic illnesses predominate as a cause of
death and pathways for treating chronic illnesses are complex and
multifaceted, prevention is a best practice approach to chronic disease
when possible. In many cases, prevention requires mapping complex
pathways to determine the ideal point for intervention. Cost-effectiveness
of prevention is achievable, but impacted by the length of time it
takes to see effects/outcomes of intervention. This makes prevention
efforts difficult to fund—particularly in strained financial contexts.
Prevention potentially creates other costs as well, due to extending the lifespan
and thereby increasing opportunities for illness. In order to assess
the cost-effectiveness of prevention, the cost of the preventive
measure, savings from avoiding morbidity, and the cost from extending
the lifespan need to be considered. Life extension costs become smaller when accounting for savings from postponing the last year of life, which makes up a large fraction of lifetime medical expenditures and becomes cheaper with age.
Prevention leads to savings only if the cost of the preventive measure
is less than the savings from avoiding morbidity net of the cost of
extending the life span. In order to establish reliable economics of
prevention for illnesses that are complicated in origin, knowing how
best to assess prevention efforts, i.e. developing useful measures and
appropriate scope, is required.
Effectiveness
There is no general consensus as to whether or not preventive healthcare measures are cost-effective, but they increase the quality of life
dramatically. There are varying views on what constitutes a "good
investment." Some argue that preventive health measures should save more
money than they cost, when factoring in treatment costs in the absence
of such measures. Others have argued in favor of "good value" or conferring significant health benefits even if the measures do not save money.
Furthermore, preventive health services are often described as one
entity though they comprise a myriad of different services, each of
which can individually lead to net costs, savings, or neither. Greater
differentiation of these services is necessary to fully understand both
the financial and health effects.
A 2010 study reported that in the United States, vaccinating
children, cessation of smoking, daily prophylactic use of aspirin, and screening of breast and colorectal cancers had the most potential to prevent premature death.
Preventive health measures that resulted in savings included
vaccinating children and adults, smoking cessation, daily use of
aspirin, and screening for issues with alcoholism, obesity, and vision
failure.
These authors estimated that if usage of these services in the United
States increased to 90% of the population, there would be net savings of
$3.7 billion, which comprised only about -0.2% of the total 2006 United States healthcare expenditure.
Despite the potential for decreasing healthcare spending, utilization
of healthcare resources in the United States still remains low,
especially among Latinos and African-Americans.
Overall, preventive services are difficult to implement because
healthcare providers have limited time with patients and must integrate a
variety of preventive health measures from different sources.
While these specific services bring about small net savings, not
every preventive health measure saves more than it costs. A 1970s study
showed that preventing heart attacks by treating hypertension early on
with drugs actually did not save money in the long run. The money saved
by evading treatment from heart attack and stroke only amounted to about a quarter of the cost of the drugs. Similarly, it was found that the cost of drugs or dietary changes to
decrease high blood cholesterol exceeded the cost of subsequent heart
disease treatment.
Due to these findings, some argue that rather than focusing healthcare
reform efforts exclusively on preventive care, the interventions that
bring about the highest level of health should be prioritized.
In 2008, Cohen et al. outlined a few arguments made by
skeptics of preventive healthcare. Many argue that preventive measures
only cost less than future treatment when the proportion of the
population that would become ill in the absence of prevention is fairly
large.
The Diabetes Prevention Program Research Group conducted a 2012 study
evaluating the costs and benefits in quality-adjusted life-years or QALYs
of lifestyle changes versus taking the drug metformin. They found that
neither method brought about financial savings, but were cost-effective
nonetheless because they brought about an increase in QALYs.
In addition to scrutinizing costs, preventive healthcare skeptics also
examine efficiency of interventions. They argue that while many
treatments of existing diseases involve use of advanced equipment and
technology, in some cases, this is a more efficient use of resources
than attempts to prevent the disease.
Cohen suggested that the preventive measures most worth exploring and
investing in are those that could benefit a large portion of the
population to bring about cumulative and widespread health benefits at a
reasonable cost.
Cost-effectiveness of childhood obesity interventions
There are at least four nationally implemented childhood obesity
interventions in the United States: the Sugar-Sweetened Beverage excise
tax (SSB), the TV AD program, active physical education (Active PE)
policies, and early care and education (ECE) policies.
They each have similar goals of reducing childhood obesity. The effects
of these interventions on BMI have been studied, and the cost-effectiveness analysis (CEA) has led to a better understanding of projected cost reductions and improved health outcomes.
The Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES)
was conducted to evaluate and compare the CEA of these four
interventions.
Gortmaker, S.L. et al. (2015) states: "The four initial
interventions were selected by the investigators to represent a broad
range of nationally scalable strategies to reduce childhood obesity
using a mix of both policy and programmatic strategies... 1. an excise
tax of $0.01 per ounce of sweetened beverages,
applied nationally and administered at the state level (SSB), 2.
elimination of the tax deductibility of advertising costs of TV
advertisements for "nutritionally poor" foods and beverages seen by
children and adolescents (TV AD), 3. state policy requiring all public
elementary schools in which physical education (PE) is currently
provided to devote ≥50% of PE class time to moderate and vigorous
physical activity (Active PE), and 4. state policy to make early child
educational settings healthier by increasing physical activity,
improving nutrition, and reducing screen time (ECE)." The CHOICES found
that SSB, TV AD, and ECE led to net cost savings. Both SSB and TV AD
increased quality adjusted life years and produced yearly tax revenue of
12.5 billion U.S. dollars and 80 million U.S. dollars, respectively.
Some challenges with evaluating the effectiveness of child obesity interventions include:
The economic consequences of childhood obesity are both short
and long term. In the short term, obesity impairs cognitive achievement
and academic performance. Some believe this is secondary to negative
effects on mood or energy, but others suggest there may be physiological
factors involved.
Furthermore, obese children have increased health care expenses (e.g.
medications, acute care visits). In the long term, obese children tend
to become obese adults with associated increased risk for a chronic condition such as diabetes or hypertension. Any effect on their cognitive development may also affect their contributions to society and socioeconomic status.
In the CHOICES, it was noted that translating the effects of these
interventions may in fact differ among communities throughout the
nation. In addition it was suggested that limited outcomes are studied
and these interventions may have an additional effect that is not fully
appreciated.
Modeling outcomes in such interventions in children over the long
term is challenging because advances in medicine and medical technology
are unpredictable. The projections from cost-effective analysis may need
to be reassessed more frequently.
Economics of U.S. preventive care
As
of 2009, the cost-effectiveness of preventive care is a highly debated
topic. While some economists argue that preventive care is valuable and
potentially cost saving, others believe it is an inefficient waste of
resources.
Preventive care is composed of a variety of clinical services and
programs including annual doctor's check-ups, annual immunizations, and
wellness programs; recent models show that these simple interventions
can have significant economic impacts.
Clinical preventive services and programs
Research
on preventive care addresses the question of whether it is cost saving
or cost effective and whether there is an economics evidence base for
health promotion and disease prevention. The need for and interest in
preventive care is driven by the imperative to reduce health care costs
while improving quality of care and the patient experience. Preventive
care can lead to improved health outcomes and cost savings potential.
Services such as health assessments/screenings, prenatal care, and telehealth and telemedicine can reduce morbidity or mortality with low cost or cost savings. Specifically, health assessments/screenings have cost savings
potential, with varied cost-effectiveness based on screening and
assessment type. Inadequate prenatal care can lead to an increased risk of prematurity, stillbirth, and infant death. Time is the ultimate resource and preventive care can help mitigate the time costs.
Telehealth and telemedicine is one option that has gained consumer
interest, acceptance, and confidence and can improve quality of care and
patient satisfaction.
Economics for investment
There
are benefits and trade-offs when considering investment in preventive
care versus other types of clinical services. Preventive care can be a
good investment as supported by the evidence base and can drive
population health management objectives.
The concepts of cost saving and cost-effectiveness are different and
both are relevant to preventive care. Preventive care that may not save
money may still provide health benefits; thus, there is a need to
compare interventions relative to impact on health and cost.
Preventive care transcends demographics and is applicable to
people of every age. The Health Capital Theory underpins the importance
of preventive care across the lifecycle and provides a framework for
understanding the variances in health and health care that are
experienced. It treats health as a stock that provides direct utility.
Health depreciates with age and the aging process can be countered
through health investments. The theory further supports that individuals
demand good health, that the demand for health investment is a derived
demand (i.e. investment is health is due to the underlying demand for
good health), and the efficiency of the health investment process
increases with knowledge (i.e. it is assumed that the more educated are
more efficient consumers and producers of health).
The prevalence elasticity of demand for prevention can also
provide insights into the economics. Demand for preventive care can
alter the prevalence rate of a given disease and further reduce or even
reverse any further growth of prevalence.
Reduction in prevalence subsequently leads to reduction in costs. There
are a number of organizations and policy actions that are relevant when
discussing the economics of preventive care services. The evidence
base, viewpoints, and policy briefs from the Robert Wood Johnson Foundation, the Organisation for Economic Co-operation and Development (OECD), and efforts by the U.S. Preventive Services Task Force
(USPSTF) all provide examples that improve the health and well-being of
populations (e.g. preventive health assessments/screenings, prenatal
care, and telehealth/telemedicine). The Affordable Care Act
(ACA) has major influence on the provision of preventive care services,
although it is currently under heavy scrutiny and review by the new
administration. According to the Centers for Disease Control and Prevention
(CDC), the ACA makes preventive care affordable and accessible through
mandatory coverage of preventive services without a deductible,
copayment, coinsurance, or other cost sharing.
The U.S. Preventive Services Task Force (USPSTF), a panel of national experts in prevention and evidence-based medicine, works to improve health of Americans by making evidence-based recommendations about clinical preventive services.
They do not consider the cost of a preventive service when determining a
recommendation. Each year, the organization delivers a report to
Congress that identifies critical evidence gaps in research and
recommends priority areas for further review.
The National Network of Perinatal Quality Collaboratives (NNPQC),
sponsored by the CDC, supports state-based perinatal quality
collaboratives (PQCs) in measuring and improving upon health care and
health outcomes for mothers and babies. These PQCs have contributed to
improvements such as reduction in deliveries before 39 weeks, reductions
in healthcare associated bloodstream infections, and improvements in
the utilization of antenatal corticosteroids.
Telehealth and telemedicine has realized significant growth and
development recently. The Center for Connected Health Policy (The
National Telehealth Policy Resource Center) has produced multiple
reports and policy briefs on the topic of Telehealth and Telemedicine
and how they contribute to preventive services.
Policy actions and provision of preventive services do not guarantee
utilization. Reimbursement has remained a significant barrier to
adoption due to variances in payer and state level reimbursement
policies and guidelines through government and commercial payers.
Americans use preventive services at about half the recommended rate and
cost-sharing, such as deductibles, co-insurance, or copayments, also
reduce the likelihood that preventive services will be used.
Despite the ACA's enhancement of Medicare benefits and preventive
services, there were no effects on preventive service utilization,
calling out the fact that other fundamental barriers exist.
Affordable Care Act and preventive healthcare
The
Patient Protection and Affordable Care Act, also known as just the
Affordable Care Act or Obamacare, was passed and became law in the
United States on March 23, 2010.
The finalized and newly ratified law was to address many issues in the
U.S. healthcare system, which included expansion of coverage, insurance
market reforms, better quality, and the forecast of efficiency and
costs.
Under the insurance market reforms the act required that insurance
companies no longer exclude people with pre-existing conditions, allow
for children to be covered on their parents' plan until the age of 26,
and expand appeals that dealt with reimbursement denials. The Affordable
Care Act also banned the limited coverage imposed by health insurances,
and insurance companies were to include coverage for preventive health
care services.
The U.S. Preventive Services Task Force has categorized and rated
preventive health services as either A or B, as to which insurance
companies must comply and present full coverage. Not only has the U.S.
Preventive Services Task Force provided graded preventive health
services that are appropriate for coverage, they have also provided many
recommendations to clinicians and insurers to promote better preventive
care to ultimately provide better quality of care and lower the burden
of costs.
Health insurance
Healthcare
insurance companies are willing to pay for preventive care despite the
fact that patients are not acutely sick in hope that it will prevent
them from developing a chronic disease later on in life. Today, health insurance plans offered through the Marketplace, mandated by the Affordable Care Act are required to provide certain preventive care services free of charge to patients. Section 2713 of the Affordable Care Act,
specifies that all private Marketplace and all employer-sponsored
private plans (except those grandfathered in) are required to cover
preventive care services that are ranked A or B by the U.S. Preventive
Services Task Force free of charge to patients.
UnitedHealthcare insurance company has published patient guidelines at
the beginning of the year explaining their preventive care coverage.
Evaluating incremental benefits
Evaluating
the incremental benefits of preventive care requires a longer period of
time when compared to acutely ill patients. Inputs into the model such
as discounting rate and time horizon can have significant effects on the
results. One controversial subject is use of a 10-year time frame to
assess cost effectiveness of diabetes preventive services by the
Congressional Budget Office.
Preventive care services mainly focus on chronic disease.
The Congressional Budget Office has provided guidance that further
research is needed in the area of the economic impacts of obesity in the
U.S. before the CBO can estimate budgetary consequences. A bipartisan
report published in May 2015 recognizes the potential of preventive care
to improve patients' health at individual and population levels while
decreasing the healthcare expenditure.
Economic case
Mortality from modifiable risk factors
Chronic
diseases such as heart disease, stroke, diabetes, obesity and cancer
have become the most common and costly health problems in the United
States. In 2014, it was projected that by 2023 that the number of
chronic disease cases would increase by 42%, resulting in $4.2 trillion
in treatment and lost economic output. They are also among the top ten leading causes of mortality.
Chronic diseases are driven by risk factors that are largely
preventable. Sub-analysis performed on all deaths in the United States
in 2000 revealed that almost half were attributed to preventable
behaviors including tobacco, poor diet, physical inactivity and alcohol
consumption. More recent analysis reveals that heart disease and cancer alone accounted for nearly 46% of all deaths.
Modifiable risk factors are also responsible for a large morbidity
burden, resulting in poor quality of life in the present and loss of
future life earning years. It is further estimated that by 2023, focused
efforts on the prevention and treatment of chronic disease may result
in 40 million fewer chronic disease cases, potentially reducing
treatment costs by $220 billion.
Childhood vaccinations
Childhood
immunizations are largely responsible for the increase in life
expectancy in the 20th century. From an economic standpoint, childhood
vaccines demonstrate a very high return on investment.
According to Healthy People 2020, for every birth cohort that receives
the routine childhood vaccination schedule, direct health care costs are
reduced by $9.9 billion and society saves $33.4 billion in indirect
costs.
The economic benefits of childhood vaccination extend beyond individual
patients to insurance plans and vaccine manufacturers, all while
improving the health of the population.
Health capital theory
The
burden of preventable illness extends beyond the healthcare sector,
incurring costs related to lost productivity among workers in the
workforce. Indirect costs related to poor health behaviors and
associated chronic disease costs U.S. employers billions of dollars each
year.
According to the American Diabetes Association (ADA),
medical costs for employees with diabetes are twice as high as for
workers without diabetes and are caused by work-related absenteeism ($5
billion), reduced productivity at work ($20.8 billion), inability to
work due to illness-related disability ($21.6 billion), and premature
mortality ($18.5 billion). Reported estimates of the cost burden due to
increasingly high levels of overweight and obese members in the
workforce vary,
with best estimates suggesting 450 million more missed work days,
resulting in $153 billion each year in lost productivity, according to
the CDC Healthy Workforce.
The health capital model explains how individual investments in
health can increase earnings by "increasing the number of healthy days
available to work and to earn income."
In this context, health can be treated both as a consumption good,
wherein individuals desire health because it improves quality of life in
the present, and as an investment good because of its potential to
increase attendance and workplace productivity over time. Preventive
health behaviors such as healthful diet, regular exercise, access to and
use of well-care, avoiding tobacco, and limiting alcohol can be viewed
as health inputs that result in both a healthier workforce and
substantial cost savings.
Quality-adjusted life years
Health benefits of preventive care measures can be described in terms of quality-adjusted life-years
(QALYs) saved. A QALY takes into account length and quality of life,
and is used to evaluate the cost-effectiveness of medical and preventive
interventions. Classically, one year of perfect health is defined as 1
QALY and a year with any degree of less than perfect health is assigned a
value between 0 and 1 QALY.
As an economic weighting system, the QALY can be used to inform
personal decisions, to evaluate preventive interventions and to set
priorities for future preventive efforts.
Cost-saving and cost-effective benefits of preventive care
measures are well established. The Robert Wood Johnson Foundation
evaluated the prevention cost-effectiveness literature, and found that
many preventive measures meet the benchmark of <$100,000 per QALY and
are considered to be favorably cost-effective. These include screenings
for HIV and chlamydia, cancers of the colon, breast and cervix, vision
screening, and screening for abdominal aortic aneurysms in men >60 in
certain populations. Alcohol and tobacco screening were found to be
cost-saving in some reviews and cost-effective in others. According to
the RWJF analysis, two preventive interventions were found to save costs
in all reviews: childhood immunizations and counseling adults on the
use of aspirin.
Minority populations
Health
disparities are increasing in the United States for chronic diseases
such as obesity, diabetes, cancer, and cardiovascular disease.
Populations at heightened risk for health inequities are the growing
proportion of racial and ethnic minorities, including African Americans,
American Indians, Hispanics/Latinos, Asian Americans, Alaska Natives
and Pacific Islanders.
According to the Racial and Ethnic Approaches to Community Health
(REACH), a national CDC program, non-Hispanic blacks currently have the
highest rates of obesity (48%), and risk of newly diagnosed diabetes is
77% higher among non-Hispanic blacks, 66% higher among
Hispanics/Latinos and 18% higher among Asian Americans compared to
non-Hispanic whites. Current U.S. population projections predict that
more than half of Americans will belong to a minority group by 2044.
Without targeted preventive interventions, medical costs from chronic
disease inequities will become unsustainable. Broadening health policies
designed to improve delivery of preventive services for minority
populations may help reduce substantial medical costs caused by
inequities in health care, resulting in a return on investment.
Chronic disease
is a population level issue that requires population health level
efforts and national and state level public policy to effectively
prevent, rather than individual level efforts. The United States
currently employs many public health policy efforts aligned with the
preventive health efforts discussed above. The Centers for Disease
Control and Prevention support initiatives such as Health in All
Policies and HI-5 (Health Impact in 5 Years), and collaborative efforts
that aim to consider prevention across sectors and address social determinants of health as a method of primary prevention for chronic disease.
Obesity
Policies
that address the obesity epidemic should be proactive and far-reaching,
including a variety of stakeholders both in healthcare and in other
sectors. Recommendations from the Institute of Medicine in 2012 suggest
that "concerted action be taken across and within five environments
(physical activity (PA), food and beverage, marketing and messaging,
healthcare and worksites, and schools) and all sectors of society
(including government, business and industry, schools, child care, urban
planning, recreation, transportation, media, public health,
agriculture, communities, and home) in order for obesity prevention
efforts to truly be successful."
There are dozens of current policies acting at either (or all of)
the federal, state, local and school levels. Most states employ a
physical education requirement of 150 minutes of physical education per
week at school, a policy of the National Association of Sport and
Physical Education. In some cities, including Philadelphia, a sugary
food tax is employed. This is a part of an amendment to Title 19 of the
Philadelphia Code, "Finance, Taxes and Collections", Chapter 19-4100,
Sugar-Sweetened Beverage Tax that was approved 2016, which establishes
an excise tax of $0.015 per fluid ounce on distributors of beverages
sweetened with both caloric and non-caloric sweeteners.
Distributors are required to file a return with the department, and the
department can collect taxes, among other responsibilities. These
policies can be a source of tax credits. Under the Philadelphia policy,
businesses can apply for tax credits with the revenue department on a
first-come, first-served basis. This applies until the total amount of
credits for a particular year reaches one million dollars.
Recently, advertisements for food and beverages directed at
children have received much attention. The Children's Food and Beverage
Advertising Initiative (CFBAI) is a self-regulatory program of the food
industry. Each participating company makes a public pledge that details
its commitment to advertise only foods that meet certain nutritional
criteria to children under 12 years old.
This is a self-regulated program with policies written by the Council
of Better Business Bureaus. The Robert Wood Johnson Foundation funded
research to test the efficacy of the CFBAI. The results showed progress
in terms of decreased advertising of food products that target children
and adolescents.
Childhood immunization policies
Despite
nationwide controversies over childhood vaccination and immunization,
there are policies and programs at the federal, state, local and school
levels outlining vaccination requirements. All states require children
to be vaccinated against certain communicable diseases as a condition
for school attendance. However, only 18 states allow exemptions for
"philosophical or moral reasons." Diseases for which vaccinations form
part of the standard ACIP vaccination schedule are diphtheria tetanus
pertussis (whooping cough), poliomyelitis (polio), measles, mumps,
rubella, haemophilus influenzae type b, hepatitis B, influenza, and
pneumococcal infections. The CDC website maintains such schedules.
The CDC
website describes a federally funded program, Vaccines for Children
(VFC), which provides vaccines at no cost to children who might not
otherwise be vaccinated because of inability to pay. Additionally, the
Advisory Committee on Immunization Practices (ACIP) is an expert
vaccination advisory board that informs vaccination policy and guides
on-going recommendations to the CDC, incorporating the most up-to-date
cost-effectiveness and risk-benefit evidence in its recommendations.
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