The establishment of the Deputy for Prevention at Iran Health Insurance organization since two years ago has created a golden opportunity for advancing the six types of preventive services in Iran. According to 7th section of Article 73 of the Seventh Development Plan of the Islamic Republic of Iran (2024-2028), basic health insurance organizations have committed to spend at least five percent of their annual approved budgets on preventive services during the implementation of the program. In preventive medicine and public health, preventive services are categorized into six types. In this commentary, each type of the six preventive measures will be briefly defined, and proposed programs will be presented to the Deputy for Prevention at Iran Health Insurance for promoting the quality of each type of preventive service. To successfully implement these programs, it is essential that the Prevention Department designs a comprehensive insurance support system for these six types of preventive services through the Supreme Council of Health Insurance. This system should be developed in collaboration with all insurance organizations, the Deputy for Health, and the Deputy for Treatment of the Ministry of Health, utilizing systems thinking and systems science with the goal of supporting ongoing programs at comprehensive health service centers and health houses. The following sections outline the six types of preventive services and propose actionable recommendations for each:
Primal Prevention: This refers to preventing mental and physical diseases in future generations through preconception care until the child reaches two years of age. For example, efforts by the mother to prevent the fetus from exposure to cigarette smoke during pregnancy. The "Golden Thousand Days" educational programs(1) for parents of children under two years old and pregnant women, presented by Dr. Nozar Nakhaei, a professor of community medicine at Kerman University of Medical Sciences, in collaboration with the Deputy for Prevention at Iran Health Insurance, are examples of primal prevention. However, it should be noted that to effectively prevent the root causes of mental and physical diseases in future generations, improvements in preconception care are essential. Unfortunately, preconception care programs in rural health houses provided by health workers, and in urban comprehensive health service centers, provided by health workers, faces three major issues. First, the coverage of these services is very low, especially in urban areas. Second, these services are not couple-centered as they focus solely on women, while preconception care should involve both the woman and her partner visiting the health house or health service center together for care. Third, Iran's preconception care program pays little attention to the third dimension of health, namely social health, while various aspects of social health, such as food security and social stressors for parents, play a significant role in the health of the fetus and children under two. It is recommended that the Deputy for Prevention at Iran Health Insurance utilize the opportunity of "premarital care" to increase coverage of preconception care. The importance of preconception care can be explained to couples visiting for premarital care, and reminder short text messages can be sent to couples after marriage. Furthermore, it is suggested that in collaboration with the Deputy for Health of the Ministry of Health, the provision of integrated health services be facilitated at rural health houses and urban centers, enabling couple-centered preconception care for couples who cannot attend during the morning hours due to work commitments. Additionally, the social health dimension of pre-pregnancy care should be strengthened with the participation of health charities and philanthropic organizations.
Primordial Prevention: This type of prevention is applied at a stage when risk factors for diseases, such as obesity, have not yet emerged, or when the individual has not been exposed to environmental risk factors. Primordial prevention aims to prevent the emergence of disease risk factors, such as preventing obesity in primary school students. The best time for implementing primordial prevention services is during childhood and adolescence. It is recommended that the Prevention Department of Iran’s Health Insurance Organization, in collaboration with school health services and the Ministry of Education, strengthen primordial prevention within the healthcare programs for students at health houses and urban comprehensive health service centers. Additionally, educational programs in the realm of primordial prevention should be designed for primary and secondary schools.
Primary Prevention: This type of prevention is applied when the risk factors for mental or physical diseases have already appeared in an individual, but have not yet caused disease. The definition of primary prevention is the management of risk factors in individuals to prevent disease onset. Managing disease risk factors in adolescents, such as smoking cessation, is an example of primary prevention. One of the programs offered by Iran’s comprehensive health service centers and health houses is the stroke and heart attack risk assessment program. In this program, an individual's ten-year risk for stroke and heart attack is determined by health workers, and based on this, risk factors are identified and controlled. Unfortunately, people are not sufficiently aware of this program, and the coverage of this service remains low. It is recommended that the Prevention Department of Iran’s Health Insurance Organization provide financial support for this risk assessment program, including motivating both the public and healthcare workers to deliver high-quality and effective risk assessment services.
Secondary Prevention: This type of prevention is applied is implemented when risk factors have already caused mental or physical diseases in an individual, but the symptoms have not yet appeared. The definition of secondary prevention is the early detection and screening of mental and physical diseases, followed by providing treatment services for individuals who test positive during screening. An example is screening for type 2 diabetes in individuals over the age of 30Through the risk assessment program, two major conditions—hypertension and type 2 diabetes—can be identified. Insurance coverage for this program by Iran’s Health Insurance Organization can lead to the early detection and treatment of these two common, high-risk, and potentially fatal conditions. Additionally, supporting mental health screening within the national healthcare system can significantly reduce the incidence of severe mental illnesses, particularly suicide.
Tertiary Prevention: This type of prevention is applied when mental or physical diseases have already manifested in an individual, but complications have not yet developed. Tertiary prevention aims to prevent the complications of mental and physical diseases, such as slowing the progression of type 2 diabetes and preventing diabetic nephropathy. As a pilot study, it is recommended that Iran’s Health Insurance Organization support and evaluate the effectiveness of a monthly care program for diabetic patients, implemented by health workers in rural health houses and by health providers in urban comprehensive health service centers. Furthermore, efforts should be made to engage health philanthropists and non-governmental organizations (NGOs) that support diabetic patients to strengthen the monthly care program for diabetic patients.
Quaternary Prevention: Unlike other types of prevention, quaternary prevention is not aimed at preventing diseases but focuses on protecting patients and healthy individuals from unnecessary diagnostic, therapeutic, and even preventive interventions that lack sufficient scientific evidence of effectiveness. (2) Examples include knee replacement surgery for mild osteoarthritis, the use of MRI for most cases of acute low back pain, and prescribing aspirin to prevent stroke in healthy elderly individuals—all of which are unnecessary and potentially harmful interventions. Fortunately, the Prevention Department of Iran’s Health Insurance Organization has established an independent office dedicated to quaternary prevention. The author of this article has developed the Five Principles of Quaternary Prevention-Based Medical Practice and, after extensive discussions with the esteemed Prevention Department, is working in collaboration with the Quaternary Prevention Office of the Prevention Department and the Iranian Association of Social Medicine to organize continuing education programs for physicians across the country on these principles. The five principles of medical practice based on quaternary prevention are as follow: Principle One: Correctly determining pretest probability before requesting diagnostic tests or screenings (Pretest Probability); Principle Two: Calculating the Unnecessary Overtreatment Index (UOI) based on the results of the latest clinical trials and incorporating it into treatment management; (3) Principle Three: Lifestyle Medicine; (4) Principle Four: Social Prescribing; (5) Principle Five: Participatory Medicine. (6) In conclusion, it is recommended that the Prevention Department of Iran Health Insurance Organization pay special attention to the social approach in primordial, primary, and tertiary prevention, particularly emphasizing Social Prescribing, as the costs and complications of social prevention, social vaccination, and social treatment are significantly lower than those associated with the biomedical approach.