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THE PUBLIC HEALTH DEVELOPMENT THEORY OF FOUR STAGES OF

PREVENTION
By: Professor Winston G. Mendes Davidson
Head, School of Public Health and Health Technology
University of Technology
INTRODUCTION:
The terms primary, secondary and tertiary prevention were first documented
in the late 1940s by Hugh Leavell and E. Guerney Clark from the Harvard and
Columbia University Schools of Public Health, respectively. Pioneers in Public Health
thinking at that time, Leavell and Clark described the principles of prevention within
the context of the Public Health triad of Host, Agent and Environment commonly
referred to as the 1epidemiologic triangle model of Causation of diseases. This
paradigm has served the development of public health practice in the Caribbean
and indeed throughout the World very well, as it has been the standard framework
which has informed the strategic development of policies plans and programs in the
delivery of the health services in most jurisdictions throughout the world.
LEAVELL AND CLARKS THREE LEVELS OF PREVENTION
Primary Prevention
Seeks to prevent a disease or condition at a pre-pathologic state;
To stop something from ever happening, Health Promotion, health education,
marriage counseling, genetic screening, good standard of nutrition, adjusted to
developmental phase of life, Specific, Protection, use of specific immunization,
attention to personal hygiene, use of environmental sanitation, protection against
occupational hazards, protection from accidents, use of specific nutrients,
protections from carcinogens, avoidance to allergens
Secondary Prevention
Also known as Health Maintenance: Seeks to identify specific illnesses or
conditions at an early stage with, prompt intervention to prevent or limit disability;
to prevent catastrophic effects that could occur if proper attention and treatment
are not provided, Early Diagnosis and Prompt Treatment, Case finding measures,
individual and mass screening survey, prevent spread of communicable disease,
prevent complication and sequelae, shorten period of disability, Disability
Limitations, Adequate treatment to arrest disease process and prevent further
complication and sequelae, Provision of facilities to limit disability and prevent
death.
Tertiary Prevention
Occurs after a disease or disability has occurred and the recovery process has
begun; Intent is to halt the disease or injury process and assist the person in
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Principles of Epidemiology, 2nd ed. Atlanta U.S Dept. of H&H Serv. CDC 1992

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obtaining an optimal health status. To establish a high-level wellness. To maximize
use of remaining capacities, Restoration and Rehabilitation, Work therapy in
hospital, Use of shelter colony
Is the principle of prevention only applicable as an external intervening event? Is
prevention only relevant and applicable in dysfunctional situations of diseases or
conditions? Is primary, secondary and tertiary prevention as defined by Leavell and
Clark the limit to which the principle of prevention is applicable? Is the principle of
prevention applicable whenever there is a state of wellness and Health?
THE THEORY OF THE FOUR STAGES OF PREVENTION
This paper will present the theory of four stages of prevention: 1. Adaptation or Preprimary prevention, 2. Primary Prevention, 3. Secondary Prevention, 4. Tertiary
Prevention. This will embody a wider scope and continuum which involves both the
health and disease paradigms, where health is defined as the harmonious
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adaptation of man within his environment. In this context health is linked both to
the development of human society, as this society evolves in harmony with the
evolution of the planet.
To the extent that this process of adaptation of man and the society which he
creates evolves in disharmony (maladaptation) with the planet, is the extent to
which the impact of human society on the process of development of the earth
influences changes in the earth's evolution. A process of maladaptation invariably
renders human society on the planet non-sustainable. The manifestation of this
reality is the evidence of the cause effect relationship between the development of
human society and climate change of the planet.
The theory is also based on the principle that prevention may for all practical
purposes be seen both as an event and as a process and that this event and
process is optimally manifested in the process of adaptation of man within the
environment in a harmonious way. It is this process of adaptation and harmony
which represents prevention at work in its most efficient, effective and sustainable
form.
The theory also asserts that the fundamental characteristic of the nature of the
relationship between mankind and the planet earth (man in his environment) is the
manifestation of an inextricable organic relationship underpinned by a 3dialectical
process (See paper on "The Law of Accommodation and Rejection" by Professor W.
G. Mendes Davidson).
The Public Health practice of prevention is therefore an essential and necessary part
of the process of adaptation (internal or endogenous health development) and also
part of the continuum of data driven intervention measures (external or exogenous
health development) as formulated by the work of Leavell and Clarke.

Adaptation is defined as a dialectical process in the paper "The Law of Accommodation and
Rejection" by Professor Mendes Davidson.
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"The Law of Accommodation and Rejection" by W.G. Davidson also documents the basic
Laws of Dialectics.

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In that context Health development is derived as a consequence of a process of
harmonious adaptations between man and his environment throughout the Ages,
which may be a process which is quite independent of formal Public health theory or
practice. This more expansive framework of health as a process of harmonious
adaptation of man in his environment when combined with a series of interventions
derived from Public health practice (exogenous) as manifested by the Leavell and
Clark "disease model paradigm" create the complete framework for
understanding the fundamental relationship between health and disease. It
therefore expresses greater clarity and a more comprehensive understanding of the
continuum of the principles of prevention, the process of health development and
the inextricable link between health, disease, the environment, and risks and
threats to man's survival on the planet.
The four stages model of prevention, therefore establishes the unity between Health
and Disease as an inescapable continuum within the context of the natural history
of health and disease in man. This paradigm therefore presents new opportunities
and challenges, for new approaches and analytical methods of research, especially
related to very complex health questions derived from present day community
health development challenges which are invariably located within the community
development setting.
PREVENTION AND CHANGE
The introduction of prevention intervention measures will occur only in so far as
there is a need to change not only the course of an event, but also the processes
underlying the course of events. The objective is always to effect favorable and in
most cases desired outcomes. This may be done by introducing a series of discrete
or interconnected measures, in such a manner as to prevent the occurrence of an
undesirable event or to change the course of an unfavorable process.
The context:
Prevention always takes place within a context. A prevention measure may be
introduced as a discrete activity only to alter the course of an event. On the other
hand there are prevention measures which may comprise a complex series of
interconnected, integrated, intervening activities along a chain or process of selfpropelling dynamic changes.
These two extremes are introduced within contexts which vary from the
simple to the complex. In order for these prevention measures to be applied, the
context and the natural history of the process must be established otherwise the
outcome of the intervention may not be in keeping with what is desired or desirable.
It is only under these conditions that the scope, content and form of the preventive
measures may be ascertained.
What is Prevention?
Against that background the following is the definition used in this instance to
define the phenomenon "Prevention":

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Prevention is any activity or process (or series of activities or processes)
which avoids, deters, averts or reverses the development of an event or
process which leads to an undesirable outcome
The Natural History of Health and Disease
THE NATURAL HISTORY OF ANY UNDESIRABLE PUBLIC HEALTH OUTCOME
(e.g. Disease, or Injurious Condition etc.)
Every undesirable outcome has a natural history which follows the sequence /
process below. Every preventive activity is located along the path of this sequence
of events or continuous process (the continuum).
THE PREVENTION CONTINUUM

Adaptation-----------> risk exposure------> risk contact-------> early nondiscernable disease /injury----->

<--------A---------------> <------------------------------B------------------------------------------------------------------------> <--early
discernable disease / injury---------> late discernable injury------> advanced
disease injury----->
<--------------------------------------------------------------------- C
--------------------------------------------------------------> <------------------------Chronicity / Rehabilitation / recovery ---------> death
<----------------------------------- D------------------------------------------------>
The sequence of this natural history is a dynamic and continuous process which is
segmented purely for organizational purposes using Health represented by
adaptation or 4Pre-Primary Prevention; and Disease, represented by
epidemiologic principles of: exposure, risk and therefore new cases (hence
incidence reduction or Primary Prevention intervention measures)---> Early
and late cases: old and new, (hence prevalence reduction or Secondary
Prevention intervention measures )------------> Averting chronicity ( hence
rehabilitation or Tertiary Prevention intervention measures).
HEALTHY LIFESTYLE, WELLNESS, SUSTAINABLE DEVELOPMENT AND
CLIMATE CHANGE.
This paradigm of Prevention is therefore a fundamental break from that of
Leavell and Clarke of the past which emphasized the disease paradigm only,
ignoring the inextricable link between HEALTH / ADAPTATION and therefore
DISEASE, DEVELOPMENT and CLIMATE CHANGE. This new paradigm therefore
locates health and disease in a continuous dialectical relationship, expressing itself
in outcomes which are manifestations of the struggles between man and his
environment, between societys growth and differentiation and the impact of this
growth and differentiation on the Planet. The paradigm explains the relationship
4

This theory was developed by Prof. W. Davidson to describe the essential goal of prevention
and its measures which are guided by the frame of reference in our understanding that the
relationship between health and disease is a continuum in the process of prevention and
adaptation.

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between man and his environment, the well-being of man and the sustainable
development of the planet.
Finally this paradigm presents Prevention as a universal paradigm
applicable to all aspects of human development, whether this development is
adaptable and therefore functional and sustainable or non-adaptable and therefore
dysfunctional and non-sustainable. In this connection Prevention establishes its
relevance to the process of functional development and therefore sustainable
development of the planet and dysfunctional development and therefore nonsustainable development of the planet which outcome are the consequences of
climate change.

A.
ADAPTATION / HARMONISATION = PRE-PRIMARY PREVENTION
Pre-primary prevention or adaptation in this context refers to the
process from which wellbeing is always the outcome. This process of adaptation is
a continuous unrelenting process of man within his environment. When man is in
harmony with his environment, he is in a state of mental, physical, social and
spiritual wellbeing i.e. health. A healthy lifestyle is one of the strategies for
achieving adaptation, whether this is achieved by conscious or programmed effort
or it is achieved spontaneously as an expression or manifestation of sustainable
socio-cultural practices. This state of health, or adaptation, or pre-primary
prevention must be understood, and defined, within the particular context,
circumstance or condition, if the goals of the stages and processes of disease
prevention / intervention measures are to achieve best practices and outcomes.
The state of adaptation/ harmonization is linked to relative perceptions of
human values and attitudes which have to be clarified within a given context and at
a particular point in time. This context is invariably culture bound and is determined
by deeply embedded relatively stable core values, influenced by the rapidly
changing nascent values5 of the times.
Adaptation is Primary preventions antecedent
In the absence of an understanding of the context, content and forms of
adaptation within the diverse areas of social space, the application of preventive
measures is open to serious errors. Indeed whenever the application of preventive
strategies occur in the context of lack of adequate information or analysis, these
5

Prof. W. Davidson defines nascent values as the new things people strive for, or attach
meaning or significance to e.g. popular cultural forms and expressions, fashion,
contemporary lifestyles and fetishes, etc.

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circumstances are more likely to lead to discrete, isolated, incoherent initiatives
because they lack the knowledge and understanding of critical core values which
have evolved from the process of adaptation over time.
Deeply embedded core values form the basis, the essence of adaptation and
are the antecedents of a rational and sustainable preventive strategy. In this
connection, values clarification together with the identification of norms and
standards of human behavior within the existing culture at a particular point or
period of time are necessary criteria for meaningful planning of preventive
measures and strategies.
How can values be determined or clarified, and what methods may be used to
establish this on a consistent basis? This evidence is best derived from Qualitative
research methods. However 6Stones framework for analyzing values in relation to
behavior, social forces and social space is both instructive and valuable.
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RELATIONSHIP BETWEEN VALUES AND HUMAN BEHAVIOR

This framework presents a starting point for understanding the relationship between
values and social norms, the relationship between the evolution of institutions and
their role in shaping values and how both of these created the conditions for drives
and motivations manifested by human behaviours in society. Dysfunctional values
6

The late Professor Carl Stone, a political sociologist at the University of the West Indies
developed this framework for analyzing values etc. in his paper values Norms and
personality development in Jamaica (1992).
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Source: Values Norms and personality development in Jamaica by the late Prof Carl Stone

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lead to dysfunctional institutions, dysfunctional institutions lead to dysfunctional
drives and motivations and dysfunctional human behaviours and maladaptation to
the environment. In this instance, development is non-sustainable

RELATIONSHIP BETWEEN SOCIAL FORCES AND HUMAN BEHAVIOUR

ibid

Social forces are the primary determinants in the development of human values.
These forces shape our norms and their impact is reflected in the evolution of our
institutions. These institutions influence the development of our values and the
drives and motivations of our citizens. They also function as points of reference for
standards of social behavior and their absence lead to behaviors which reflect
fragmentation of norms, standards and social and behavioral cohesion.

RELATIONSHIP BETWEEN DOMAINS OF SOCIAL SPACE AND CORE VALUES

This diagram above presents an insight into the scope of some of the categories
which Professor Stone has identified as important in any attempt at clarifying values
and in defining the socio-behavioral contexts shaping nascent values, core values or
deeply embedded core values which shape human behaviour in society.
These observations and analyses represent the qualitative contexts of the
practice of the science of Public Health and the evidence is best derived and
informed by the application of the discipline of Qualitative research methods. This
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ibid

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does not negate the importance of the relationship between qualitative and
quantitative analysis and data. Indeed quantitative analysis has its foundation in the
clinical case which is grounded in an evaluation of the health status of an individual.
What is a state of health? What is health in a normative sense? What is the
objective of preventive intervention measures if not to enable the development of a
state of health and wellness? The establishment of the wellness paradigm, and its
relationship to normative health status and behaviour and lifestyles are best
elucidated by the interrelationship of information and data derived from both
qualitative and quantitative research. This data is what ultimately defines the
paradigm of Pre-Primary Prevention and answers the question, what is health? And
therefore what is a healthy lifestyle, within a particular social context, circumstance
and condition?
In the final analysis preprimary prevention is that nascent stage of prevention
which is characterized by an attempt at understanding the dynamic link between
values norms and human behavior traits and characteristics within the target
community or society. These features must be determined within a historical, social,
political, economic, institutional, organizational and structural context. In so doing
we begin to identify both core and non-core values which underpin the process of
adaptation of the individual, the family, the group, and the community to the
environment. This enables the possibility for understanding and defining what is
meant by a healthy lifestyle in a given socio-cultural, political and economic
context.
Pre-primary prevention is thus recognized as a necessary and essential
stage in the prevention process since it creates the basis for clarity and
understanding of the antecedents of primary Prevention. The process of adaptation
is a dynamic one and there is no clear line of demarcation between the
development of the stable healthy state of pre-primary prevention and a state of
risk exposure or contact leading to early disease of injury resulting in changes which
characterize the domain of Primary Prevention.
This demonstrates the principle, embodied in the reality of
prevention being a continuous process across overlapping health care
delivery domains; hence the application of pre-primary measures, means
and methods, e.g. healthy lifestyles, in the domain of primary prevention
is valid and also essential and necessary.
B.
PRIMARY PREVENTION

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This stage of prevention is part of the prevention continuum and is

characterized by introduction of intervention measures and processes applied to
detect, avoid, deter, avert or reverse risk exposures, risk contact, early nondiscernable disease, injury or condition, towards attainment of a state of wellness
and therefore sustainable adaptation.
Risk exposure, risk contact, early non-discernable disease / injury / condition,
early discernable disease / injury or condition, represent the essential domain and
target areas for primary prevention intervention measures and activities. Examples
of primary preventive activities are; avoidance (isolation and quarantine), specific
protection (protective clothing in enterprises, immunization), early diagnosis
through screening, prophylaxis during travel to infected areas; prompt diagnosis
and treatment of new cases essentially but not exclusively restricted to Primary
Prevention. This is so, because the process of prevention is a continuum, and the
domain of treatment and follow-up of old cases which are ambulatory, are best
located in the primary health care domain.
Primary prevention measures are invariably located in a non-institutional or
ambulatory context but are inextricably linked to secondary prevention intervention
measures. Primary prevention invariably prevents new cases from occurring and
therefore invariably addresses the occurrence of the incidence of diseases and
conditions.

C
SECONDARY PREVENTION

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Secondary Prevention is also part of the Prevention continuum and is characterized

by intervention measures which are invariably located within an institutional context
although the interrelationship between primary and secondary prevention is a
dynamic process of continuous interchange. This invariably lends itself to
integration of the intervention measures between primary and secondary
interventions enabling greater and more dynamic efficiencies especially with regard
to early newly discovered cases which lend themselves to ambulatory treatment
measures. Secondary Prevention employs intervention measures such as
emergency care, treatment and disability limitation. It is therefore concerned with
decreasing prevalence rates of diseases and conditions rather than incidence rates
which is the domain of Primary Prevention.
The role of communication and information technology in this prevention paradigm
is critical in determining the presence of absence of an institutional context as the
locus of primary or secondary prevention since 10Anywhere-Care is the new reality
of the 11New Health Economy in the 21st century.
D
TERTIARY PREVENTION

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This term is derived from Professor Winston Davidson's paper on "The New Health
Economy" and is related to the impact of Information and communication Technology on
health care delivery, using remote telemedicine systems
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The New Health Economy presented to a Caribbean EU Forum

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Tertiary prevention occurs after a disease or disability has occurred and the
recovery process has begun; Intent is to halt the disease or injury process and assist
the person in obtaining an optimal health status. Establish a high-level wellness
health development of the individual as far as possible.
Where possible these measures should be aimed at averting further chronicity
instituting measures to enable the earliest recovery by the use of specialized
institutions using the science of rehabilitation.
This science involves the introduction of the following principles:

Enable timely recovery

Re-stabilize
Re-train
Re-motivate
Re-socialize
Re-integrate

Finally, tertiary prevention must advocate for the implementation of the universal
rights of the disabled and should strive for integration of the disabled into the
normal life of the home and community as far as possible rather being confined to
an institutional setting.
PRACTICAL APPLICATION OF THE PREVENTION MODEL FRAMEWORK

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Each stage of prevention is located along the continuum as demonstrated in this

health and disease model. But the model of prevention may be designed for any
condition, as long as the natural history of the condition is known and documented
(see Prevention continuum; pg 4).
In so doing, the outcome of the intervention measure may be precisely defined,
based on the location of the intervention measure within its respective prevention
category (preprimary, primary, secondary, tertiary).
Multiple intervention prevention programs may be introduced simultaneously. They
may also be spread across each prevention category, leading to greater efficiencies
because of the synergistic effect derived from the process of integration of the
respective preventive intervention measures.
The prevention model may therefore be used in program planning, to plan the scope
of work, also to plan the form, content, the appropriate choice and locus of the
intervention programs for best practices. The natural history of the condition will
also give an insight into the relative quantity and quality of the resources needed to
be allocated along the prevention continuum in order to derive best practices in the
allocation of resources.
In the final analysis the effectiveness and efficiency of the program intervention
measures may be measured with a greater degree of accuracy, and the accounting
of the use of resources may be done more accurately, rigorously and clinically.
End
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References to be added:
Copyright: Prof W. G. Mendes Davidson (11th May 2011)

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