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What is the role of prevention in health policies?

Maria Melchior
Maria Melchior
Epidemiologist specialised in Mental Health at Inserm
Key takeaways
  • Primary prevention is linked to the appearance of health risks due to diet and pollution. Secondary prevention aims to detect diseases that could not be avoided.
  • The VigilanS programme is a good example of primary prevention; it has reduced suicide attempts in the Pas de Calais and Nord regions of France by 10 to 12% in three years.
  • As part of prevention policies, we work with young people on how to deal with emotions but, in order for these programs to be truly effective, teachers also need to be more involved in these subjects.
  • The role of general practitioners is very important in prevention, yet it is often neglected. Moreover, inequalities in access to care, due to medical deserts, reinforce this non-prevention in certain sectors.
  • The private sector could be involved in prevention, but the alcohol and tobacco lobbies are extremely powerful and prevent effective prevention in this sector.

In which area would you say that pre­ven­tion in health poli­cies is most advanced?

Pre­ven­tion is a very broad area. We tend to dis­tin­guish between pri­ma­ry pre­ven­tion, which is relat­ed to the appear­ance of health risks linked to food and pol­lu­tion, and sec­ondary pre­ven­tion, which aims to detect dis­eases that can­not be avoid­ed. Pri­ma­ry pre­ven­tion is com­pli­cat­ed because it is out­side the health sys­tem, but patients can ben­e­fit from it dur­ing their health care. One exam­ple is the suc­cess of the “Vig­i­lanS” pro­gramme, which has been run by psy­chi­a­trists since 2015 and con­sists of call­ing back peo­ple who have been hos­pi­talised after a sui­cide attempt six months lat­er to find out how they are doing.

In 2018, this pro­gramme helped to reduce sui­cide attempts in the Nord and Pas-de-Calais depart­ments by 10 to 12% in three years, which led to it being extend­ed to the whole coun­try. On the oth­er hand, there are still many missed oppor­tu­ni­ties for gen­er­al prac­ti­tion­ers in terms of pri­ma­ry and sec­ondary pre­ven­tion. Although they see many peo­ple who have attempt­ed sui­cide, in prac­tice few doc­tors under­take spe­cif­ic fol­low-up of their patients, which increas­es the prob­a­bil­i­ty of a sec­ond attempt1.

You have worked on addic­tive behav­iour among ado­les­cents. Do pre­ven­tion poli­cies in this area go far enough?

In order to be more effec­tive, the fight against psy­choac­tive sub­stances has been the sub­ject of inter­min­is­te­r­i­al work between jus­tice, health and cus­toms. How­ev­er, the results remain insuf­fi­cient for the time being.  In the frame­work of pre­ven­tion poli­cies, we work with young peo­ple on how to deal with emo­tions. But teach­ers should also be more involved in these sub­jects. In this area, Great Britain, Cana­da, and Aus­tralia have suc­ceed­ed in set­ting up more inte­grat­ed pre­ven­tion pro­grammes. This is prob­a­bly because ded­i­cat­ed experts work direct­ly with the author­i­ties and the ban on the sale of alco­hol to minors is respect­ed. Ice­land has also adopt­ed a fair­ly exem­plary proac­tive pol­i­cy to lim­it the use of psy­choac­tive sub­stances among young peo­ple. The Ice­landic mod­el is based on a num­ber of ele­ments that mod­i­fy the social envi­ron­ment of young peo­ple at school, in the fam­i­ly, in the neigh­bour­hoods where they live – and by strength­en­ing the links between these dif­fer­ent cir­cles to con­crete­ly respect the same rules of non­con­sump­tion in dif­fer­ent spaces, lim­it access to psy­choac­tive sub­stances, and fos­ter com­mu­ni­ca­tion between these dif­fer­ent areas2.

Gen­er­al prac­ti­tion­ers still have an essen­tial role, but do they have the means to car­ry out prevention?

Yes, their role is fun­da­men­tal. Even if it is true that, as they are becom­ing increas­ing­ly spe­cialised, pre­ven­tion is only a minor part of their train­ing. More­over, doc­tors can only spend an aver­age of 10 min­utes with each patient. Although gen­er­al prac­ti­tion­ers can now pre­scribe phys­i­cal activ­i­ty to over­weight dia­bet­ics, there is still no eval­u­a­tion of these pre­scrip­tions. Fur­ther­more, giv­en the med­ical inequal­i­ties in the coun­try, oth­er pro­fes­sion­als will have to broad­en their fields of com­pe­tence. Nurs­es will be able to pre­scribe drugs, mid­wives will have to do more gynae­co­log­i­cal mon­i­tor­ing and pae­di­a­tri­cians will have to train in areas such as addictology.

Can the pri­vate sec­tor be involved in prevention?

It can be, pro­vid­ed that pub­lic poli­cies fol­low. In France, there is an anti-smok­ing pol­i­cy, but fight­ing alco­hol is more com­pli­cat­ed. The gov­ern­ment, which sup­ports the wine indus­try, did not sup­port the “dry Jan­u­ary” cam­paign, which calls for no alco­hol con­sump­tion after the New Year. The indus­try adver­tis­es, includ­ing on social net­works, to young peo­ple, which is pro­hib­it­ed by law. Apart from actions by the asso­ci­a­tion Addic­tions France, few com­plaints are filed. The same applies to the food indus­try, where lob­bies are very pow­er­ful. This is illus­trat­ed by the bat­tle waged by researchers to have labels such as Nutriscore affixed to food in order to increase trans­paren­cy on the com­po­si­tion of food. A label that has come up against the lack of will on the part of industry.

Your work has shown that social inequal­i­ties in health are aggra­vat­ing fac­tors for obe­si­ty and depres­sion. Are these fac­tors being tak­en into account more?

Health also depends on many social and eco­nom­ic deter­mi­nants that lie out­side the health care sys­tem. In this respect, ten years ago, WHO rec­om­mend­ed includ­ing health deter­mi­nants in all poli­cies as indi­ca­tors to be eval­u­at­ed. For exam­ple, in urban plan­ning, in order to mea­sure the impact on the health of the neigh­bour­hood when build­ing a road, or to cal­cu­late the ben­e­fits of poli­cies to extend pater­ni­ty leave. But it is clear that this sys­tem­at­ic inclu­sion has still not been tak­en into account. With the pan­dem­ic, it would be even more nec­es­sary because social inequal­i­ties in men­tal health have increased. So much so that all poli­cies that sta­bilise incomes, pro­mote employ­ment and good work­ing con­di­tions can only be positive.

Interview by Marjorie Cessac
1Younes N, Riv­ière M, Urbain F, Pons R, Hans­lik T, Rossig­nol L, Chan Chee C, Blan­chon T. Man­age­ment in pri­ma­ry care at the time of a sui­cide attempt and its impact on care post-sui­cide attempt: an obser­va­tion­al study in the French GP sen­tinel sur­veil­lance sys­tem. BMC Fam Pract. 2020 Mar 25;21(1):55.
2Krist­jans­son AL, Mann MJ, Sig­fusson J, Tho­ris­dot­tir IE, Alle­grante JP, Sig­fus­dot­tir ID. Devel­op­ment and Guid­ing Prin­ci­ples of the Ice­landic Mod­el for Pre­vent­ing Ado­les­cent Sub­stance Use. Health Pro­mot Pract. 2020 Jan;21(1):62–69.

Contributors

Maria Melchior

Maria Melchior

Epidemiologist specialised in Mental Health at Inserm

Maria Melchior studies life trajectories from childhood to adulthood, and the interactions between social situation, parental characteristics, schooling, and social and professional development. Her work has shown that social inequalities in mental health and addiction emerge from childhood. She is also evaluating interventions to reduce social inequalities in mental health, particularly in relation to the COVID-19 epidemic.