The concept of high risk and population strategies for preventative health was first introduced by Geoffrey Rose in his 1985 paper “Sick Individuals and Sick Populations” (Rose 2001). High risk strategy involves the identification of individuals who are more likely to get a disease and then providing treatment or preventative measures, while population strategies target population risk factors i.e. the primary cause of a disease affecting a population and either removing or preventing exposure (Rose 2001).
Although Rose’s paper was written more than 30 years ago it is still relevant in the 21st century and was republished in 2001. Doyle et al. (2006) conducted an evaluation on the relevance of Rose’s paper and concluded that high risk and population risk strategies strengths and limitations were still the same in 2006 as it was in 1985. Rose (2001) points out the strengths and limitations for high risk and population strategy as follows:
Strengths for Population strategy Radical – targets primary causes of diseases in a population i.e. risk reduction Large potential – has a greater impact i.e. Far-reaching therefore targets a wide range of individuals Behaviourally appropriate – can influence and change individuals way of life Limitations for Population strategy Small benefit to individual – because it focuses on populations some individuals can be overlooked Poor motivation of subject – due to lack of monitoring or follow-up Poor motivation of physician – Does not involve direct contact with doctors Benefit: risk ratio worrisome
Strengths for High Risk strategy Intervention appropriate to individual – because it identifies the risk factors that affect an individual and how to overcome it Subject motivation – due to the subject seeking help Physician motivation – involves direct contact with patients therefore can offer treatment and monitor Cost-effective use of resources – than population since focuses on individuals Benefit: risk ratio favourable Limitations for High risk strategy Difficulties and costs of screening – expensive to screen a wide range of people Palliative and temporary—not radical – i.e. focuses on treatment more than prevention from the risk factors Limited potential for population – interactions difficult to be replicated population-wise Behaviourally inappropriate – difficult to change behaviours and way of life of individuals than population (Rose 2011). This essay will focus on high risk and population strategies for preventive health within the context of 21st century Australia.
This essay will highlight on 3 high risk strategies in Australia; use of Statin to reduce Coronary Heart Diseases (CHD) , use of Metformin for type 2 diabetes and bowel cancer screening in Australia. It will also highlight 2 Population strategies in Australia and 1 in Canada; Tobacco taxation, front-pack food labelling for obesity prevention and Folic acid food fortification in Canada. HIGH RISK STRATEGIES IN AUSTRALIA One of the high risk strategies in Australia is the prescribed use of Statin to lower cholesterol levels which is a risk factor for Coronary Heart Diseases (CHD) (Stocks et al. 2009 and Mant et al. 2007).
The Australian Bureau of Statistics (2013) reported that, in 2011-2012, 5% of the Australian population (1.1 million) had CDH, of this 29.2 % were aged 75 years and over. Due to the high number of CDH cases, Statin use has increased gradually over the years and thus has increased Australian cardiovascular medication budget i.e. Statin took up 16% of the Pharmaceutical Benefits Scheme (PBS) in 2005 (Stocks et al. 2009). However, Stocks et al. (2009) further states that the distribution of Statin use varies in Australia especially in low Social Economic Status (SES) areas where there is limited number of General Practitioners (GP).
Another example of high risk strategy in Australia is, is the use of metformin to treat and manage type 2 diabetes and gestational diabetes mellitus (GDM) (Davoren, 2014 and Moore et al. 2013). Davoren (2014) further states that, metformin has reduced the deaths caused by diabetes in Australia. Metformin works by increasing insulin sensitivity thus increasing peripheral glucose uptake (Davoren, 2014). Moore et al. (2013) state that, metformin can be linked to impaired cognitive performance in diabetes patients using them. The last high risk strategy this essay will look at is bowel cancer screening in Australia.
Cancer Australia (2016) reported that, bowel cancer is the second most diagnosed cancer in Australia and in 2015 there were 17,070 new cases of bowel cancer. The Australian Government initiated the National Bowel Cancer Screening Program (NBCSP) to help in the early detection and treatment of bowel cancer (Pignone et al. 2011). Although this strategy seems like a population strategy it targets risky individuals in the population; the NBCSP involves the home screening of colorectal cancer using immunochemical faecal occult blood test (iFOBT) of people aged 50, 55 and 65 years (Pignone et al. 2011). Pignone et al. (2011) concluded that this strategy if implemented properly, will reduce the bowel cancer mortality and it is cost effective.
POPULATION STRATEGIES IN AUSTRALIA Tobacco control policies were introduced in Australia to reduce prevalence of smoking and tobacco related illness like lung cancer and CHD (Wakefield 2008). These policies include; tobacco taxation which increased the price of tobacco products thus subsequently caused reduction in tobacco products sale, introduction of smoke free public areas i.e. restaurants thus reducing passive smoking and plain packaging of cigarette with smoking related pictures to reduce smoking (Wakefield 2008). The front-of-pack food labelling in Australia is another population strategy that was established to reduce obesity (Magnusson 2010). Australian Bureau of statistics (2016) reported that, 62.8% of Australians 18 years and over were overweight and obese in 2011-12.
Nutrition being a risk factor for overweight and obesity was tackled by the introduction of front-of-pack food labels i.e. the star rating system aiming to improve people’s food choices consequently reducing prevalence of overweight and obesity(Magnusson 2010) The last population strategy is folic acid flour fortification in Canada that was introduced to reduce open neural tube defects (NTD) (Ray 2008). In November 1998 the Canadian Government mandated the fortification of flour with folic acid i.e. 1.5mg of the vitamin was added in 1kg of flour (Ray 2008). This has led to the reduction of NTD by 50% and an increase in folate in both young and older women in Canada (Ray 2008).
CONCLUSION AND RECOMMENDATION Australia uses both high risk and population strategy to promote health. High risk strategies in this essay were mainly clinically based i.e. involved the GP and prescription of medication. To ensure that these clinically based strategies are more effective, the cost of the medication i.e. Metformin and Statin should be made affordable and if possible free to those individuals that are either overweight or obese because overweight and obesity are risk factors for development of CHD and diabetes.
Stocks et al. (2009) mention the decreased use of metformin in rural communities compared to the urban areas due to limited access to GPs and this is the same for statin use and the bowel cancer follow-up. I recommend the increase in GPs in the rural communities and in the case of bowel cancer government should ensure that those that tested positive have access to GP and treatment. Population strategies have a greater impact and outcome as seen by the tobacco taxation strategy. However more needs to be done to ensure public smoking is limited to only designated smoking areas. Also people of low SES need further tobacco cessation programs since majority of smokers are of low SES.
In the case of front-of-the pack labelling the public needs more information on how the labelling system works to guide their food choices and all foods imported or locally made should have the star rating system labelling as is the easiest to interpret. Food fortification should continue as it has reduced the prevalence of food-related deficiency diseases. I recommend the use of population strategy as it is more cost effective i.e. saves the government health care costs in the long run if better health care systems and policies are put forward.