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Anticipatory Care & health promotion
Prof. Sulaiman Al-Shammari
Department of Family & Community Medicine ,
College of Medicine King Saud University ,
Riyadh, Saudi Arabia
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Anticipatory Care
Learning Objectives
At the end of this session students would be able
to:
Define anticipatory care
 Recognize its importance.
Recall levels of prevention with appropriate examples.
 Define screening.
 Recognize its principles.
 Recall criteria of screening.

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Content

Introduction.

Definition.

PHC and anticipatory care.

Level of preventive intervention.

Screening:
- Definition
- Principles
- Ethics

Conclusion.
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Case
 A 45-year-old man is presented to
the clinic with C/O mild cough,
fever & general body ache of one
day duration. O/E :
Temp 39C, congested throat, & he is
obese.
 Possibility of flue like viral infection
What should be done for this man?

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Case

A 40-year-old healthy man on
routine checkup he found to have:
BMI: 31
 FBS: 6.2

What should be done for this healthy
man?
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BMI Categories:




Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
Awareness:
Women and Heart Disease





1 in 2-3 women die of CHD, but only 4%
fear of dying of CHD
1 in 27 women die of breast cancer, but
40% fear of dying of breast cancer
2/3 of women have at least 1 CHD risk
factor,
52% over age 45 have hypertension,
40% over age 55 have high cholesterol
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Some EBM Facts
Changing pattern of mortality and morbidity.
 Geographical variation in disease occurrence.
 Migrants and development of diseases.


Stopping of smoking:
•
•
•

Early detection of hypertension
•

Decreasing death due to all types of Ca-33%.
Decreasing death due to all types of IHD 25%.
etc.
Helps in 50% of stroke prevention.
Prevention of DM ??
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50% of patients with “Impaired
Fasting Glucose” will go on to
become
diabetic within 10 years
10
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Does Treating The Metabolic Syndrome
Make a Difference?
Finnish Diabetes Prevention Study
• Design
– 522 middle-aged overweight/obese patients
(mean BMI 31 kg/m2)
– 172 men and 350 women
– Mean duration 3.2 years
• Intervention group: individualized counseling
– Reducing weight, total intake of fat and saturated fat
– Increasing intake of fiber, physical activity
Tuomilehto J et al. N Engl J Med 2001;344:1343-1350
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Benefit of Treating The Metabolic Syndrome:
Finnish Diabetes Prevention Study
25%
20%
After 4 years,
risk of diabetes
reduced by 58%

15%
10%
5%
0%
Intervention
Control
With Diabetes (%)
Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350.
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Levels of Risk Associated with Smoking,
Hypertension and Hypercholesterolaemia
Hypertension
(SBP 195 mmHg)
x3
x9
x4.5
x16
Smoking
x1.6
x6
x4
Serum cholesterol level
(8.5 mmol/L, 330 mg/dL)
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Poulter N et al., 1993
The Rule of Halves in Hypertension
½ Known treated
and controlled
½ of those
Treated
Not controlled
½ not known
½ of those known
Not treated
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•Cost ?
Less attention on
prevention??
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About six cents of every health dollar in the U.S. is spent
on medical and health research.
Source: America Speaks: Poll Data, Vol. 5, Research!America, 2003.
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Less than one cent of every health care dollar in the
U.S. is spent on prevention research.
Source: America Speaks: Poll Data, Vol. 5, Research!America, 2003.
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“There I am standing by the shore of a swiftly flowing-river and I
hear a cry of a drowning man. So I jump into the river, put my
arms around him, pull him to shore and apply artificial respiration.
Just when he begins to breathe, there is another cry for help. So I
jump into the river, reach him, pull him to shore, apply artificial
respiration, and then, just as he begins to breathe, another cry for
help. So back in the river again, reaching, pulling, applying,
breathing and then another yell. Again and again, without end,
goes the sequence. You know, I am so busy jumping in, pulling
them to shore, applying artificial respiration, that I have no time to
see who the hell is upstream pushing them all in”.
Zola, I.K. “Helping – does it matter? The problems and prospects
of mutual aid groups”.
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What is anticipatory care?

It include all measures which promote good health
and prevent or delay the onset of
diseases or their
complications.
 This care aims to:
Improve the quality of life
 Reduce the premature disability
 Increased life expectancy

So it denotes “the essential union of prevention with
care and curve”
(RCGP-1981).

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Level of prevention




Primordial prevention.
Primary prevention.
Secondary prevention.
Tertiary prevention.
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Levels of prevention. Table 6.1.
Level of
prevention
Phase of disease Target
Primordial
Underlying conditions
leading to causation
Total population and
selected groups
Primary
Specific causal factors
Total population,
selected groups and
healthy individuals
Secondary
Early stage of disease
Patients
Tertiary
Late stage of disease
(treatment,
rehabilitation)
Patients
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Routine
Care
V/S
Preventive
Care
Patient-initiative
Doctor-initiative
Immediate-type
Non-urgent
Usually involve the doctor
Easily delegated to other PHC team
Focused on individual
Focused on high-risk groups
Good record are a help but audit is
difficult
Good record are essential, audit is
straightforward
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Special groups
•Pregnancy
•* oral contraception.
•* developmental screening of infants and
children.
•*elderly
•*known family history of IHD, cancer,
glaucoma
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The optimum setting for anticipatory care:
Primary Health Care.





Frequent contacts.
Defined population.
Primary-care team.
Dr.-Pt. relationship.
Holistic approach.
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Screening
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Screening
The iceberg of disease
Self care and
Medical treatment
Symptomatic
disease
The surface
Screening
Pre-symptomatic
disease
Health
(Last 1963)
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Screening
Definition:
It is broadly defined as the questioning,
examination, or investigation of an asymptomatic
individual to determine the presence or absence of
disease.
Is it diagnostic??

Screening is not usually diagnostic and it
requires appropriate investigative follow-up
and treatment.

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Screening
Types:

Mass screening.

Multiple or multi-phasic screening.

Targeted screening.

Case-finding ??
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Case – Finding
Case-finding or opportunistic screening:
It is the term used when it is undertaken
opportunistically for patients who consult their
doctors for some other purpose.
Example??
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II.
Criteria for Assessment of a
screening test.

Validity -

Reliability
Predictive Value

Sensitivity
Specificity
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predictive value



a measure used by clinicians to interpret diagnostic
test results. (The likelihood that a positive test result
indicates disease or that a negative test result
excludes disease..)
positive predictive value the probability that a
patient with a positive test result really does have the
condition for which the test was conducted.
negative predictive value the probability that a
patient with a negative test result really is free of the
condition for which the test was conducted.
Principles of Screening
The criteria for screening:
(Wilson 1976)
A.
The disease:




B.
The treatment:


C.
An important problem
Recognized latent or early symptomatic stage.
Natural history of disease adequately understood.
Facilities for Dx. And treatment available.
Agreed policy on whom to treat.
Acceptable treatment for patients recognized.
The test:




Suitable test or exam.
Acceptable to population.
The cost should be economically balanced.
Continuous process and not a “once for all” project.
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Principles of Screening
The criteria for screening:
(Wilson 1976)
A.
The disease:



B.

The treatment:


C.
An important problem
Recognized latent or early symptomatic stage.
Natural history of disease adequately understood.
Facilities for dgx. And treatment available.
Agreed policy on whom to treat.
Acceptable treatment for patients recognized.
The test:




Suitable test or exam.
Acceptable to population.
The cost should be economically balanced.
Continuous process and not a “once for all” project.
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Principles of Screening
The criteria for screening:
(Wilson 1976)
A.
The disease:




B.
The treatment:


C.
An important problem
Recognized latent or early symptomatic stage.
Natural history of disease adequately understood.
Facilities for dgx. And treatment available.
Agreed policy on whom to treat.
Acceptable treatment for patients recognized.
The test:




Suitable test or exam.
Acceptable to population.
The cost should be economically balanced.
Continuous process and not a “once for all” project.
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Principles of Screening
The criteria for screening:
(Wilson 1976)
A.
The disease:




B.
C.
An important problem
Recognized latent or early symptomatic stage.
Natural history of disease adequately understood.
Facilities for dgx. And treatment available.
The treatment:

Agreed policy on whom to treat.

Acceptable treatment for patients recognized.
The test:




Suitable test or exam.
Acceptable to population.
The cost should be economically balanced.
Continuous process and not a “once for all” project.
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Ethics of Screening
Safe? Beneficial?
The “cost” to patient of screening: Disadvantages?
Inconvenience
Anxiety
Discomfort
Risk that screening Procedure may be harmful
Risk of labeling as “sick” or “at risk”.
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Conclusion:




Anticipatory care is the integration of
prevention and cure.
PHC service is the optimal place to
apply this care and observe.
Every opportunity to be utilize to deliver
this care.
Case finding V/S formal screening.
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Health Promotion
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What is Health Promotion1?

Concept was first introduced in USA 1979

Has evolved to include the educational,
organizational, procedural, environmental,
social, and financial supports that help
individuals and groups reduce negative health
behaviors and promote positive change among
various population groups in a variety of
settings
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What Is Health Promotion2?

Health promotion programs are designed to
help people who are healthy, but engaging in


risky behaviors (i.e., smoking, drinking, risky
sexual behaviors)
or actions that increase their susceptibility to
negative health consequences (i.e., physical
inactivity, unhealthy diets)
to change their behaviors

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Behavior Change
– Is It An Easy Task?



Can we expect people to adopt a healthy lifestyle
after they have been exposed to a health promotion
program?
Can we force people to participate in sport and
physical activities because we believe they are good
for their health and soul?
No … Getting people to engage in health behavior
change is a complex process that is very difficult even
under the best of conditions..
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Effective Health Promotion1


Does saying, “Just do it!” work?
No … Health promotion is not simply an information
campaign or just providing opportunities.
 Information campaign is the easiest and most
common form of program, yet least effective
 “Just do it!” sounds ‘good’, but doesn’t work.
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Effective Health Promotion2
Effective health promotion programs
help people: 
modify behaviors, increase skills, change attitudes, 
increase knowledge, influence values, and improve
health decision making
maintain healthy lifestyles 
provide: 
educational, organizational, environmental, financial, 
and social support
e.g., worksite smoke cessation program 

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Need for Health Promotion1
Physical Inactivity is a Global Problem
In developed countries:
Industrialization, modern technologies, automation, and a global
food market have taken away the need and opportunity for physical
exertion


In developing countries:
Over crowding, poverty, crime, traffic, low air quality, plus lack of
parks, sports and recreation facilities, and sidewalks make physical
activity a difficult choice



Result: 60% ~ 85% global population fails to achieve 30 minute

moderate intense physical activity daily
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Need for Health Promotion2
Physical movement and activity are essential
for the human organism to grow, develop, and
maintain health.
Consequences of physical inactivity
increased levels of obesity, diabetes, 
cardiovascular disease (the leading cause of
death in most countries)


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Need for Health Promotion4
Physical inactivity:
second greatest threat to U.S. public health 
a major public health problem affecting huge 
numbers of people in all regions of the world
Effective health promotion programs are urgently
needed to promote physical activity and improve
public health around the world.


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Physical activity
A sedentary lifestyle increases the risk of
overall mortality (2 to 3-fold) •
cardiovascular disease (3 to 5-fold) •

The effect of low physical fitness is comparable
to that of hypertension, high cholesterol, diabetes,
and even smoking.

Sources: Wei et al., JAMA 1999;
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Blair et al., JAMA 1996
Need for Health Promotion3
Chronic diseases associated with unhealthy behaviors, such as
unhealthy diets, caloric excess, inactivity, and obesity are the
greatest public health problems in most countries of the world
The increasing incidence of chronic diseases 
causing ~60% of the 56.5 million reported deaths 
globally
contributing ~46% to the spread of disease worldwide 
These estimates are expected to rise to 73% and 60%, 
respectively, by 2020

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Deaths by broad cause group
Cardiovascular disease –
heart disease, stroke
Cancer
Chronic respiratory diseases
Diabetes
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60% of all deaths are due to chronic diseases
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What Has Been Done3?
In the past three decades:
widespread interest in good health, wellness, and health
behaviors,
recognized for its potential to improve quality of
lives,longevity & adaptation healthy lifestyle,
programs to promote good health among general
population.



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
What Has Been Done1?
WHO Annual Global Move for Health initiative
to promote healthy diets and physical activity 
among the world population, both male and
female, of all ages and conditions including
disabilities worldwide.
WHO Global Strategy on Diet, Physical Activity and
Health


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What Has Been Done2?
In the United States, physical activity, overweight and obesity:
are the top two leading health indicators listed in the 
government document, Healthy People 2010 - the U.S.
National Goals and Objectives in Health Promotion and
Disease Prevention
are two of the six priority health behaviors used by the U.S. 
Centers for Disease Control and Prevention to monitor the
population risk behaviors in the U.S.
will lower life expectancy by 5 years unless obesity rate is 
reduced significantly by 2010.

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Overweight
Increasing weight associated with:
 risk of overall mortality (up to 2.5-fold in the 
30-44 age group, less at older ages)
 risk of cardiovascular mortality (up to 4-fold 
in the 30-44 age group, less at older ages)
 risk of diabetes (up to 5-fold) 
 risk of hypertension 
 risk of some cancers 
 risk of gall bladder disease 
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Source: Willett et al., New Eng J Med, 1999
Why Aren’t We Effective?
Programs not based on sound health behavior theories or
outcomes assessment
The program planners may:
not have the necessary knowledge of health promotion 
program planning, implementation, evaluation, and
lack adequate training in health behavior theories. 
Having good intentions and the knowledge in exercise and
sports are not enough.
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


What Can Sport Do to Promote
Health1
Competitive sports events inspire and motivate
people to participate.
Non-competitive sports activities provide
opportunities for mass participation and
involvement.


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What can Sport do to Promote Health2?
Participation help people become more physically
active and develop healthier lifestyle habits, thus
reduce :
obesity, BP ,cholesterol 
burden illness and premature death. 

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What Can Sport Do to Promote Health3?
build social bonds and social support,
reduce feelings of depression and anxiety,
promote psychological well-being, and
prevent risky behaviors, especially among children
and young people
tobacco, alcohol or other substance abuse 
unhealthy diet or violence 




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What Can Sport Do to Promote
Health5?
Detailed sport plans provide procedural support for
behavioral change.

Incentives eg discounted,free gym, reduced insurance
premiums for regular exercise and healthy body weight =
provide financial support for behavioral change.

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What Can Sport Do to Promote
Health6?
Building fields, sidewalks, bike lanes, and
organize events = environmental support for
behavioral change.

Participating in sport, instill the value of sport in
all aspect of our lives, and involve families,
friends, and coworkers = social support for
behavioral change.

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Plan Sport-Related
Health Promotion Programs1
Practitioners and scholars in sport field:
are experts in theories and skills of sports,
have a desire to help people live a healthier life,
and
already possess the basic program planning and
implementation skills.




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Plan Sport-Related
Health Promotion Programs2
Procedures that are similar to health promotion
programming:
identifying a planning committee,
obtain support of decision makers,
develop goals and objectives,
design or select health intervention activities,
identify and allocate resources,
market the program, and
implement the program.








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Plan Sport-Related
Health Promotion Programs5
Health promotions: 
conduct various forms of evaluations 
throughout the implementation phase to ensure
that the program is carried out as planned.
Process evaluation - to control, assure, or 
improve the quality of program activities
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Plan Sport-Related
Health Promotion Programs6
Impact evaluation - to judge the immediate 
impact of the program:
awareness of consequences of physical 
inactivity,
knowledge of benefits of healthy body 
weight,
attitudes toward exercise, 
skills of certain sports, and 
behaviors of healthy diet. 
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Plan Sport-Related
Health Promotion Programs7
Outcome evaluation - to assess the ultimate goal of 
the program is achieved:
improved BMI, 
reduced CVD, 
reduced deaths due to chronic disease. 
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How Do We Change Culture?
In some culture, “plump” used to be a sign of
health and wealth.
In the Middle East, “round” is seen as
successful.
Some Africans view “heavy” women as a sign
of having rich husbands?



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WHO Global Strategy on Diet, Physical
Activity and Health (DPAS) Goal
"Promote and protect health by guiding the
development of an enabling environment for
sustainable actions at individual, community,
national and global levels, that, when taken
together, will lead to reduced disease and death
rates related to unhealthy diets and physical
inactivity"
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Objectives of DPAS
Reduce risk factors through essential public action
actions, health-promoting and disease prevention
measures
Increase awareness and understanding of importance
of diet and physical activity and health
Develop, strengthen, implement global, regional,
national policies, plans etc to improve diets, physical
activity
Monitor science and promote research




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Foundations of WHO Global Strategy on Diet,
Physical Activity and Health
Prevention of chronic, noncommunicable
diseases (NCDs)

Multisectoral action 
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Activities in CHILE
1.Integrated healthy lifestyle guide on healthy
diet, PA and tobacco
2.Directed at the public in general
3.Transmitted by the health and education
sectors
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Activities in Spain
Spanish Strategy for Nutrition, Physical Activity and the
Prevention of Obesity (NAOS)
AIM:
To improve the diet and encourage 
the regular practice of physical
activity by all citizens, with special
emphasis on children

Produced by:
Spanish Ministry of Health and 
Consumer Affairs (General Directorate
of Public Health)
Coordinated by the Spanish Food Safety Agency 

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Activities in Sweden
The Action Plan for Healthy Dietary Habits and Increased
Physical activity
Aim: 
To introduce measures to improve the prerequisites for healthy dietary
habits and physical activity in order to contribute to the overall public
health aim
To create societal conditions which ensure good health on equal terms
for the entire population


Produced by:
The Swedish Government commissioned the National Food
Administration and the National Institute of Public Health to develop
the national action plan.


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Germany – Platform for Diet and
Physical Activity
Partnership with public and private sector,
NGO's, …
Focus obesity prevention in preschool children
Funding projects
Use of the logo by initiatives that follow the
established requisites
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



ISSUES AND
CHALLENGES:
The Global Evidence Debate in
Health Promotion
77
Issues in urbanization: major public
health concern of an urbanizing world
Population
Pollution
Degradation (environment)
Migration
Destruction
Desertification






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Ozone health effects
Susceptible subgroups include:
Asthmatics 
Children 
The elderly 
Those with certain underlying diseases 
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Evidence Iceberg in Health Promotion
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dvmcq 2001
Conclusions I
Implementation well underway in most regions,
credible response but inadequate
Global and national investment well short of
requirements
National strategies developed in various countries but
not universal
Commendable actions seen in the private sector,
especially food and drink
Physical activity programmes remain weak in many
countries – capacity limited





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Conclusions II
WHO will continue to develop and disseminate
suitable tools and evidence-based guidelines in
various areas e.g. monitoring framework.
Member States are encouraged to fully utilize the
opportunity created by DPAS to make progress and
strengthen their national capacities for action to
prevent and control chronic diseases and their
common risk factors.


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ACCOMMULATION OF
HAZARDS
Risk behavior
Unbalanced diet 
Inactivity 
Obesity 
Smoking 
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Successful Health Promotion
Regular Exercise
Balanced Diet
Ideal Body Weight
No Smoking




84
Thank you
85