If prevention is such a good idea, why aren’t we getting more of it?

That’s the provocative question posed by the Institute of Medicine’s Harvey Fineberg at Preventive Medicine Grand Rounds at Johns Hopkins School of Public Health in early April. Fineberg posed his question after hearing from the audience why prevention is a core tenet of public health. Among the reasons given were that prevention is better than cure, it adds quality of life, is easier to accomplish than cure, and is often cheaper.

Fineberg himself made the case for prevention by noting that life expectancy in the US increased from less than 50 years at the beginning of the previous century to greater than 75 years by the year 2000 because of preventive interventions such as vaccines, sanitation, and safer food and water. These account for two thirds of this increase, and the evidence for the payoff from prevention is overwhelming, he said.

Hard Sell

So, if prevention is so compelling conceptually and empirically, why is implementation such a hard sell?

The obstacles to implementing prevention on a wider scale are not unfamiliar to a public health audience. Fineberg first offered his own list of reasons in a paper in JAMA in July of last year and repeated many of these ideas at the Hopkins Grand Rounds this month. (Fineberg H The Paradox of Prevention  Celebrated in Principle, Resisted in Practice JAMA 2013: 310 (1); 85-90)

Obstacles To Prevention

Key obstacles to practical acceptance of prevention are:

1. Success is invisible, that is, when prevention succeeds it creates an absence of events. We count what occurs, not what does not, said Fineberg.

2. Given this lack of events, there is an absence of drama associated with prevention. Tragedy that is avoided is not considered.

3. Prevention success is about statistics, and statistical lives saved have little emotional effect even though there is a story, or even a tear behind each number, according to Fineberg.

4. The rewards of prevention are delayed and not tangible in the here and now. Most people want quick fixes such as those often associated with surgical interventions.

5. Benefits do not always accrue to the insurer or payor for the prevention activity. The incentives in a system such as ours are to treat people.  They are not aligned with activities designed to eliminate the need for treatment in the first place.

6. Preventive advice changes as we learn more, and this appears inconsistent to the public. Fineberg used the example of mammography screening guidelines for women under 50 to make this point. He said that the guidelines which changed the existing recommendations were not aptly interpreted and proved confusing to the public.

7. Behavior changes tied to prevention often require implementation over long periods, and this is difficult to accomplish. He quoted Mark Twain who said quitting smoking was easy since he had done it hundreds of times.

8. Individuals have a bias against adverse consequences due to action compared to those following natural causes (errors of commission). In clinical medicine, the bias is more against errors of omission.

9. Many accept preventable harm as normal because it exists and may be commonplace. However, what is truly normal or the “right number” of occurrences may be quite different. For example, the right number of murders is zero, said Fineberg.

10. A double standard is used in evaluating prevention compared to treatment. We require that preventive measures be cost saving when in fact we should be prepared to pay for whatever the benefits of prevention are even when above zero cost.

11. Financial conflicts of interest can occur when financial interests are not aligned with prevention activities. In this situation, conflicted persons can fail to perceive the virtues of a preventive approach. Commercial interests can elevate doubt to forestall preventive action, said Fineberg.

12. Conflicts with personal, religious, and cultural beliefs also inhibit the adoption of preventive measures. He gave the example of condoms which can conflict with deep beliefs. Fineberg said success in communicating with the public about prevention should focus not on providing new information but instead on linking prevention activities or concepts to existing interests and values on the part of the public.

Strategies For Enhanced Prevention

Fineberg offered the following strategies to help prevention become more fully integrated into our culture.

1. Pay for prevention. He cited the example of the Affordable Care Act which seeks to put prevention on a par with treatment.

2. Make prevention cheaper than free, that is, give people financial incentives and pay them to take preventive measures.

3. Involve employers to come to understand prevention as a cost-effective investment in the workforce.

4. Reduce the opportunity for people to make decisions by engineering interventions so that they take place automatically such as air bags, and make preventive acts in general less burdensome.

5. Use policy to help people make good choices easier or less voluntary. He cited examples such as eliminating transfats or reducing salt content in food.

6. Use multiple media channels to educate, reframe, and elicit positive change. We need to do a better job of explaining prevention to the population at large and connecting prevention to topics people already value, said Fineberg.

In closing, Fineberg called for the creation of a culture of health by all of the players in the health system. Modeling his idea on the successes in the advertising sector, Fineberg urged uncovering what is already in the mind of the public and tying prevention to these preexisting beliefs and desires. Success would mean that prevention messages become cultural norms and prevention is no longer the same hard sell.  ■

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