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POPULATION HEALTH: Health determinants, Prevention


Cultural sensitivity ... Risk of Musculoskeletal injuries includes falls & injuries Hypertension/heart diseases Respiratory diseases Dementia Polypharmacy ... beliefs ... – PowerPoint PPT presentation

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Title: POPULATION HEALTH: Health determinants, Prevention

POPULATION HEALTH Health determinants,
Prevention Health promotion
  • Ian McDowell
  • Based on earlier presentations by R.A. Spasoff
    N. Birkett
  • Epidemiology Community Medicine

Other resources SIM web site Toronto Notes
MCC Objectives Population health 78-1 Concepts
of health and its determinants
  • As defined by Health Canada and the World Health
  • discuss alternative definitions of health,
    wellness, illness, disease and sickness
  • describe the determinants of health.
  • explain how the differential distribution of
    health determinants influences health status, and
  • explain the possible mechanisms by which
    determinants influence health status.
  • Discuss the concept of life course, natural
    history of disease, particularly with respect to
    possible public health and clinical
  • Describe the concept of illness behaviour and the
    way this affects access to health care and
    adherence to therapeutic recommendations.
  • Discuss how culture and spirituality influence
    health and health practices, and how they are
    related to other determinants of health.

Objective 1 Definitions of Health
A state characterized by anatomic, physiologic and psychologic integrity ability to perform personally valued family, work and community roles ability to deal with physical, biologic, psychologic and social stress..."  (Stokes J. J Community Health 1982833-41) Medical modelPractical, but often criticized as too narrow
A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO, 1948) Classic concerns over how to measure
The ability to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. (WHO Europe, 1986 Dynamic view a capacity rather than a state
Definitions of Disability, etc
  • WHO (1980) International Classification of
    Impairments, Disabilities Handicaps (ICIDH)
  • Impairment loss or abnormality of
    psychological, physiological, or anatomical
    structure or function (e.g., eye injury)
  • Disability resulting loss of ability to
    function, perform normal activities (cant see)
  • Handicap resulting disadvantage due to
    inability to perform social roles (loses driving
    license, so perhaps job)
  • WHO (2001) Critique of negativity of above leads
    to International Classification of Function
    (ICF). Similar concepts, renamed impairments,
    activities functions. Emphasizes importance of
    environment in which person lives.

  • Discussion over conceptions of what is a disease
  • Pathological process? Abnormal condition?
    Illness causing discomfort?
  • Different nosologies evolve over time
  • Syndrome vs. disease
  • Each civilization defines its own diseases
  • Non-diseases (Richard Smith) burnout,
    senility, baldness, jet lag, etc. Things doctors
    should probably not be treating, but patients
    hope they will

Assembling these concepts
(WHO terms in red)
(disadvantage loss of involvement)
(Sussers terms in green)
(socially defined status of peoplewho are ill)
(restriction in performing a function)
(the patientsexperience of beingunwell)
Level of impact
(something the doctordiagnoses and treats)
(loss or abnormalityof structure or function)
Disease onset
signs symptoms

Time line
Objective 2 Determinants
  • Determinants can be seen as underlying social
    forces that affect large groups of people
  • Causes of the causes of disease
  • E.g. poverty levels policies food prices
    doctor shortage GNP
  • May set the incidence rates of disease in society
  • Risk factors largely operate at individual level
    (age, genetics, health behaviours, etc)
  • Affect whether a person is above or below the
    average risk for their age sex

Health Canadas list of determinants
  • Income and Social Status
  • Social Support Networks
  • Education and Literacy
  • Employment / Working Conditions
  • Social Environments
  • Physical Environments
  • Personal Health Practices and Coping Skills
  • Healthy Child Development
  • Biology and Genetic Endowment
  • Health Services
  • Gender
  • Culture

Note that this list blendsindividual and
societalfactors. But it may be the basis for
the exam!
Objectives 3 4 Differential socioeconomic
impact of health determinants
  • Individual Poverty associated with increased
    incidence of virtually all health problems, often
    working through known risk factors (smoking,
    obesity, etc).
  • On a population level, Income inequality is a
    major factor in richer nations refers to the
    extent of disparities in income in a society (the
    spread, or standard deviation, of incomes).
  • The broader the spread of income (even if the
    overall average is the same), the worse the life
    expectancy other health indicators.
  • Seems to operate through decreased social
    cohesion, community investment, less supportive
    legislation, less caring society, etc. (No

Objective 5 Concept of Life Course
  • Biological programming hypothesis notes long
    term, cumulative health effects of early
    exposures at critical periods (during gestation,
    childhood, adolescence). Alternative to the
    lifestyle explanation of chronic disease.
    Embodiment extrinsic factors inscribed into
    body functions or structures.
  • Life course approach blends these 2 conceptions
    both are important.
  • Descriptive perspective
  • 0 45 age of misadventure (morbidity from
  • 45 75 age of premature degenerative diseases
  • 75 age of senescence
  • Analytic perspective
  • Health is determined by cumulative impact of
    insults at critical developmental times
    lifetime behaviors, exposures compensating
    coping mechanisms (themselves determined by early
    experiences). Accumulation of risk model
  • Child rearing patterning of behaviours that
    become risk factors. Links to SES.
  • Bowlby early child attachment determines
    susceptibility to later psychiatric disorders
  • Eepigenetic influences on neural development that
    establish set points for a range of physiological
  • Barker hypothesis under-nutrition in utero
    programs the structure function of body
    systems and affect later risk of CVD diabetes

Objective 5 Natural history interventions
  • Distinguish between natural history clinical
  • Links to stages of prevention

Pre- and post-disease stages
Clinical Course of a Disease
Etiological Phase
Social EnvironmentalDeterminants
Risk ProtectiveFactors
Preclinical Phase
Clinical Phase
Post-clinical Phase
Longer-termoutcome Impact on
familyworkeconomic impact, etc.
Living environment ? Communitycircumstances(ser
vices available, etc.) ? Conditions in society
(economic stability, etc.)
Personalfactors Lifestyle Genetics Education
Occupation Socialsupports,etc.
Biological onset of disease
Etiological Phase
Social environmentaldeterminants
Risk protectivefactors
Preclinical phase
Clinical phase
Post-clinical phase
Secondaryprevention Detect treat
pathologicalprocessat an earlierstage
whentreatmentcan be moreeffective
Tertiaryprevention Preventrelapses
furtherdeteriorationviafollow-up care
Primordialprevention Alter societalstructures
Primaryprevention Alter exposuresthat leadto
Objective 6 Illness Behavior
  • Utilization of curative services, may seek care
    early or may delay (avoidance, denial)
  • Coping mechanisms, change in daily activities
  • Factors affecting adherence to therapy
  • Describe one or more models of behaviour change,
    including predisposing, enabling and re-enforcing
  • Understand the Health Belief Model
  • Stages of change model (aka trans-theoretical

Modifying Factors
Perceived Susceptibility to Disease
Demographics (age, sex, ethnicity, etc.)
Socio-psychological variables (personality,
social class, peer and reference group
pressures, etc.) Structural variables
(knowledge about the disease, prior
experience of it, etc.)
Perceived Severity of Disease
Perceived benefits of taking action,
minusPerceived barriers to action
Perceived Threat of the Disease
Cues to Action
Raised awareness (e.g., mass media
campaign, newspaper article ) Personal advice
(e.g., reminder from health professional)
Personal symptoms Illness of family member or
Likelihood of TakingRecommended Health Action
Stages of Change Transtheoretical model
Objective 7 Culture Spirituality
  • Culture shared knowledge, beliefs, and values
    that characterize a social group. Learned through
  • Cultural sensitivity understanding the values
    and perceptions of your culture and how this may
    shape your approach to patients from other
  • Cultural competence attitudes, knowledge, and
    skills of practitioners necessary to become
    effective health care providers for patients from
    diverse backgrounds.
  • Cultural safety goes a step beyond accepting
    differences, to appreciating the power imbalances
    and possible discrimination that exist,
    treating people with respect

MCC Objectives Population health 78-3
Interventions at the population level
  • Enabling objectives
  • Define the concept of levels of prevention at
    individual (clinical) and population levels
  • Name and describe the common methods of health
    protection (such as agent-host-environment
    approach for communicable diseases, and
    source-path-receiver approach for
    occupational/environmental health).
  • Apply the principles of screening and be able to
    evaluate the utility of a proposed screening
    intervention, including being able to discuss the
    potential for lead-time bias and
    length-prevalence bias.
  • Understand the importance of disease surveillance
    in maintaining population health and be aware of
    approaches to surveillance.
  • Describe the advantages and disadvantages of
    identifying and treating individuals versus
    implementing population-level approaches to
  • Identify ethical issues with the restricting of
    individual freedoms and rights for the benefit of
    the population as a whole
  • Describe the five strategies of health promotion
    as defined in the Ottawa Charter and apply them
    to relevant situations.
  • Identify the potential community social, physical
    and environmental factors that might promote
    healthy behaviours, as well as ways to assist
    communities in addressing these factors.
  • Be aware of the role of, and work collaboratively
    with, community and social service agencies (e.g.
    schools, municipalities and non-governmental
  • Demonstrate awareness of the contribution of
    allied professionals such as social workers in
    addressing population health issues.
  • Be able to describe the health impact of
    community-level interventions to promote health
    and prevent disease.
  • Describe examples of public policies which have
    had an effect on population health.

Levels of Prevention
  • Categories are not black and white.
  • Primary prevention
  • Strategies applied BEFORE disease starts.
  • E.g. Immunization
  • Secondary prevention
  • Early identification of disease
  • Screening thrombolytic therapy of MI
  • Some people suggest secondary prevention relates
    to reducing the severity of disease.
  • Tertiary prevention
  • Treatment and rehabilitation of disease

The epidemiologic triad of causal factors
(virulence infectivityaddictive
qualitiesfamiliarity of a food, etc.)
(genetic susceptibilityresiliency nutritional
status educationmotivation, etc.)
(public health sanitation social context
availabilityof health care, etc)
(Recall the firemans mantra a fire requires
air, fuel and heat)
Health Protection
  • Wide range of activities undertaken by public
    health departments government agencies, such
    as the Public Health Agency of Canada (PHAC).
  • Includes primordial and primary prevention, such
  • "ensuring safe food and water supplies, providing
    advice to national food and drug safety
    regulators, protecting people from environmental
    threats, and having a regulatory framework for
    controlling infectious diseases in place.
    Ensuring proper food handling in restaurants and
    establishing smoke-free bylaws are examples of
    health protection measures."
  • Public health protection deals with reducing
    threats to the health of the population, such as
    biological, chemical, or physical agents
  • Legislation covers identified threats, which can
    be detected via surveillance systems.
  • Public health policies healthy public policies.

Source-Path-Receiver model for Occupational /
Environmental health protection
Potential approaches to risk control
Modify Redesign Substitute Relocate Enclose
Absorb Block Dilute Ventilate
Enclose Protect Relocate
  • Can either
  • Detect pre-disease states (e.g. dysplasia)
  • Detect the disease at an early stage
  • Criteria for when screening is useful
  • Disease criteria
  • Serious Disease causes significant morbidity,
  • Early detection can alter the course of the
  • Criteria related to the screening test
  • Valid test high sensitivity (and specificity if
  • Safe, rapid, cheap, acceptable
  • Health care System criteria
  • Adequate capacity for follow-up treatment

Evaluating a screening program the hazard of
Lead Time bias
No screening
Screening identifies 2 cases of rapidly
progressive disease and 5 cases of slowly
progressive disease
Note The incidence of rapidly progressive
disease is equal to that of slowly progressive
Strategies for PreventionHigh Risk Approach
  • Identify individuals at high risk and attempt to
    reduce their risk, by changing behaviour, etc.
  • Logical high risk people should be motivated to
  • But it may require testing larger population
    (costs, false positives)
  • Asks targeted people to act differently from
    their peers
  • It may also miss many cases depending on how you
    define high risk. (Mostcases typically occur
    in medium-risk peoplesee next slide)

BMI distribution in the Canadian population (2007)
Population burden new cases of diabetes20072017
Individual risk of diabetes over 10 years

X 32 129,280 cases
12 of total
30 to 34.9
X 21 274,700 cases
25 to 29.9
X 10 418,500 cases
23 to 24.9
X 7 157,800 cases
lt 23
X 3 61,400 cases
6 of total
Data source ICES report, June 2010  How many
Canadians will be diagnosed with diabetes between
2007 and 2017?
Strategies for Prevention Population Approach
  • Attempts to shift distribution of risk factor in
    whole population
  • Gets to root of the problem
  • Shades into health promotion
  • Benefits everyone

Historically, non-specific population approaches
have had major impact
Health Promotion
  • Distinguishable from disease prevention in that
  • Focuses on enhancing health (via resiliency)
    rather than avoiding illness
  • Takes a broad perspective, covering a range of
    issues not a single pathology.
  • Aims to tackle upstream factors, enhancing
    personal resiliency coping skills.
  • Uses a participatory approach active community
    involvement often grass roots groups.
  • Partnerships with NGOs, Non-Profit groups,
    community agencies, social workers, etc.
  • Public health physician roles advocacy, support.

  • Health promotion can be effective in addressing
    physical or social environmental hazards, (e.g.,
    pollution, poverty), usually through community
  • Environmental interventions are usually more
    effective than behavioural ones
  • Emphasis on social environment
  • Theme of multiple interventions. Supportive
    policies community agency individual

HP Goals Squaring the survival curve
Health, Quality of life
Disability-free survival
The red line represents a survival curve for a
population. The blue lines represent varying
levels of disability among survivors. Squaring
the curve implies shifting these lines up and to
the right, towards the green line, which
represents the hypothetical population health
Health Promotion
  • Origins in Health Education limitations of
    giving info
  • Social Marketing approach
  • How to transmit ideas attitudes identify
    needs demonstrate advantages audience
    segmentation select channels, etc.
  • New approaches based on behavior change theories
  • Health Belief model
  • Stages of Change model
  • Early Risk reduction strategies
  • Later Healthy public policy
  • Tax policy to promote healthy behaviour
  • Anti-smoking laws, seatbelt laws
  • Affordable housing
  • Community engagement

Health Promotion
  • Ottawa Charter for Health Promotion (1987)
  • Five key pillars to action
  • Build Healthy Public Policy
  • Create supportive environments
  • Strengthen community action
  • Develop personal skills
  • Re-orient health services
  • Prerequisites for health peace, shelter,
    education, food, income, stable ecosystem,
    sustainable resources.

  • Identify the potential community social,
    physical and environmental factors that might
    promote healthy behaviours, as well as ways to
    assist communities in addressing these factors.
  • Greens model

Planning phase What can be achieved? What needs
to be changed to achieve it?
Identify the administrative financial policies
Identify education, skills ecology required
Identify desirable outcomes Behavioural,
Environmental, Epidemiological, Social
Policies Resources Organisation Service or
programme components
Predisposing factors Enabling factors Reinforcin
g factors
Health status
Quality of life
Implementation What is the programme
intended to be? What is delivered in
reality? What are the gaps between what was
planned and what is occurring?
Process Why are there gaps between what was
planned and what is occurring? What are the
relations between the components of the
Impact What are the programmes intended
and unintended consequences? What are its
positive and negative effects?
Outcome Did the programme achieve its
What can be learned? What can be adjusted?
Evaluation phase
Adapted from Green L. http//www.lgreen.net/prece
Public health ethics
  • Underlying principles of
  • Respect for autonomy (dignity making ones own
  • Beneficence (do good)
  • Non-maleficence (do more good than harm)
  • Justice (distribute benefits fairly
  • Four virtues Prudence, Compassion,
    Trustworthiness, Integrity
  • Conflicts
  • Beneficence for majority may conflict with
    autonomy, e.g. in infectious disease control
  • Justice in funding prevention vs. high-tech cure
  • Between values in different cultures (e.g.

Ethics topics in MCC exam
  • Competency (among elderly, and for adolescents)
  • Who makes decisions proxies, living wills, etc.
  • Consent to treatment
  • informed consent battery
  • need for repeat consent for 2nd surgery, etc
  • Withdrawal of care assisted suicide
  • Disclosure adverse events
  • Justice
  • Legal issues Record keeping

Some ethical principles in Public Health
  • Social beneficence versus individual autonomy
  • Isolation quarantine restrict freedom but are
    acceptable in communicable disease control.
    However, maintain confidentiality avoid stigma.
  • Authority to search for contagious cases is
  • Mass medication (beneficence vs. nonmaleficence)
  • Harm benefit ratios for immunizations have to
    accept some individual harm (should we stop
    immunization against measles after it is
    eradicated, thereby risking returning epidemics?)
    Risks of not immunizing usually greater everyone
    must be informed.
  • Opposition to fluoridation political or
  • Privacy health statistics (individual autonomy
    vs. social beneficence)
  • Surveillance systems can use anonymous, unlinked
    data (e.g. from blood test results)
  • Subsequent analyses of medical records for
    research purposes
  • Computerized record linkage
  • Issue of research discoveries that damage
    commercial interests (e.g. industrial pollution
    cigarette companies lawsuits)
  • Informed consent is required for testing (e.g.
    HIV) (autonomy)
  • Debate, however, over anonymity vs. linking to
    allow for counseling.

(Ethical principles, contd)
  • Occupational health code of ethics guides balance
    between protecting company which employs you and
  • Put the health of the worker first must inform
    workers of health threats
  • MD to remain fully informed of the working
  • Advise management of health threats workers can
    inform unions
  • Apply precautions
  • Must not reveal commercial secrets, but must
    protect workers health
  • Only inform management of workers fitness to
    work, not the diagnosis
  • Crimes against the environment (pollution, etc)
    conflict with economic interests jobs (which
    harm health also)
  • Legally subpoenaing research records in order to
    discredit the data or pursue legal action (e.g.
    toxic shock case breast implant study) not
    allowed, but variations in ruling.

Population health 78-7 Health of Special
  • Enabling objectives
  • Aboriginal health
  • Describe the diversity amongst First Nations,
    Inuit, and/or Métis communities
  • Describe the connection between historical and
    current government practices towards First
    Nations, Inuit, Métis peoples (including, but not
    limited to colonization, residential schools,
    treaties and land claims), and the
    intergenerational health outcomes that have
  • Describe medical, social and spiritual
    determinants of health and well-being for First
    Nations, Inuit, Métis peoples
  • Describe the health care services that are
    delivered to First Nations, Inuit, Métis peoples
  • Global health and immigration.
  • Identify the travel histories and exposures in
    different parts of the world as risk factors for
    illness and disease.
  • Appreciate the challenges faced by new immigrants
    in accessing health and social services in
  • Appreciate the unique cultural perspective of
    immigrants with respect to health and their
    frequent reliance on alternative health
  • Discuss the impact of globalization on health and
    how changes in one part of the world (e.g.
    increased rates of drug-resistant Tuberculosis in
    one country) can affect the provision of health
    services in Canada.

(Objectives, continued)
  • Persons with disabilities..
  • Identify the challenges of persons with
    disabilities in accessing health and social
    services in Canada.
  • Discuss the issues of stigma and social
    challenges of persons with disabilities in
    functioning as members of society (link to mental
  • Discuss the unique health and social services
    available to some persons with disabilities (e.g.
    persons with Downs syndrome) and how these
    supports can work collaboratively with practicing
  • Homeless persons.
  • Identify the challenges of providing preventive
    and curative services to homeless persons.
  • Discuss the major health risks associated with
    homelessness as well as the associated conditions
    such as mental illness.
  • Challenges at the extremes of the age continuum.
  • Identify the challenges of providing preventive
    and curative services to isolated seniors and
    children living in poverty.
  • Discuss the major health risks associated with
    isolated seniors and children living in poverty.
  • Discuss potential solutions to these concerns.

Aboriginal groups
  • Know basic demographics groups age pyramid
  • Elevated rates of
  • Trauma, poisoning, SIDS, ALTE (Apparent Life
    Threatening Event Syndrome)
  • also suicide, substance use
  • Circulatory diseases (incl rheumatic fever)
  • Neoplasms
  • Respiratory diseases
  • Infection (gastroenteritis, otitis media,
    infectious hepatitis)
  • Diabetes
  • Inuit population probably most acutely affected.
  • Questions probably focus on determinants rather
    than statistics list

Special populations Seniors
  • Risk of
  • Musculoskeletal injuries
  • includes falls injuries
  • Hypertension/heart diseases
  • Respiratory diseases
  • Dementia
  • Polypharmacy

Special populations Children in Poverty
  • Note life course approach (above) lasting impact
    of early deficits
  • Low birth weight
  • Trauma/poisoning
  • Oral problems (abnormalities in teeth and jaws)
  • Fever/infectious diseases
  • Psychiatric problems

Special populations People with Disabilities
  • Increased risk of
  • Emotional psychological problems
  • Job insecurity (hence low income poverty)

Some MCQs.
  • 28) In describing the leading causes of death in
    Canada, two very different lists emerge,
    depending on whether proportional mortality rates
    or person-years of life lost (PYLL) are used.
    This is because
  • a) one measure uses a calendar year and the other
    a fiscal year to calculate annual experience
  • b) one measure includes morbidity as well as
    mortality experience
  • c) both rates exclude deaths occurring over the
    age of 70
  • d) different definitions of cause of death are
  • e) one measure gives greater weight to deaths
    occurring in younger age groups

Which of the following statements concerning
cross-cultural care is true? a) It has proven
very hard to change physicians attitudes and
make them more culturally aware. b) There still
is no formal accreditation requirement to train
physicians in cross-cultural skills. c) There is
considerable literature comparing the
effectiveness of different techniques of
cross-cultural communication d) Lower quality
care results when clinicians fail to acknowledge
cultural differences. e) The CMA and Royal
College have collaborated to produce clear
guidelines on developing cultural competency.
  • 26) All of the following statements are true
  • a) one indirect measure of a populations health
    status is the percentage of low birth weight
  • b) accidents are the largest cause of potential
    years of life lost for men in Canada
  • c) the Canadian population is steadily undergoing
    rectangularization of mortality
  • d) morbidity is defined as all health outcomes
    excluding death
  • e) the neonatal mortality rate is the number of
    infant deaths divided by the number of live
    births multiplied by 1000

  • Which of the following statements about oral
    health is true?
  • Children with cleft lip or palate are at
    increased risk of otitis media.
  • Dental caries may affect a childs growthand
  • All of the above

  • 44) Of the five items listed below, the one which
    provides the strongest evidence for causality in
    an observed association between exposure and
    disease is
  • a) a large attributable risk
  • b) a large relative risk
  • c) a small p-value
  • d) a positive result from a cohort study
  • e) a case report

  • Which of the following test characteristics are
    typical of a screening test?
  • A. High sensitivity and high specificity.
  • B. High sensitivity and low specificity.
  • C. Low sensitivity and high specificity.
  • D. Low sensitivity and low specificity.
  • E. Low sensitivity and low accuracy.

  • 23) Which of the following is the most important
    justification for mounting a population screening
    program for a specific disease?
  • a) early detection of the disease of interest is
  • b) the specificity of the screening test is high
  • c) the natural history of the disease is
    favorably altered by early detection
  • d) effective treatment is available
  • e) the screening technology is available

  • 40) The effectiveness of a preventative measure
    is assessed in terms of
  • a) the effect in people to whom the measure is
  • b) the effect in people who comply with the
  • c) availability and the optimal use of resources
  • d) the cost in dollars versus the benefits in
    improved health status
  • e) all of the above

  • 42) Each of the following is an example of
    primary prevention EXCEPT
  • a) genetic counselling of parents with one
    retarded child
  • b) nutritional supplements in pregnancy
  • c) immunization against tetanus
  • d) chemoprophylaxis in a recent tuberculin
  • e) speed limits on highways

  • 12) The following indicate the results of
    screening test Q in screening for disease Z

The specificity of test Q would be a) 40 /
70 b) 120 / 130 c) 40 / 50 d) 120 / 150 e) 40 /
13) The positive predictive value would be a)
40/70 b) 120/130 c) 40/50 d) 120/150 e) 70/200
  • 43) Which of the following describes the factors
    in the classic epidemiological triad of disease
  • a) host, reservoir, environment
  • b) host, vector, environment
  • c) reservoir, agent, vector
  • d) host, agent, environment
  • e) host, age, environment

  • 23) Which of the following is the most important
    justification for population screening programs
    for a specific disease?
  • a) early detection of the disease of interest is
  • b) the specificity of the screening test is high
  • c) the natural history of the disease is
    favourably altered by early detection
  • d) effective treatment is available
  • e) the screening technology is available

  • 42) Each of the following is an example of
    primary prevention EXCEPT
  • a) genetic counselling of parents with one
    retarded child
  • b) nutritional supplements in pregnancy
  • c) immunization against tetanus
  • d) chemoprophylaxis in a recent tuberculin
  • e) speed limits on highways

More MCQs
  • Here are some more questions that students can
    use to test their own knowledge
  • http//www.medicine.uottawa.ca/sim/data/Self-test_
  • (The questions contain comments on the answers,
    to illustrate why a given response is not correct)

Ten leading causes of death, Canada, 2006
(sexes combined, all ages)
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