1. Health Promotion and Screening
Winter 2014
Women’s Healthcare: Diagnosis and Management
Molly Altman, MN, CNM, MPH

2. What is Health? Definition:
WHO (1948) – “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”
AMA (2003) – “A state of physical and mental well-being”
Can you think of other definitions of health?
What about health promotion?
Health promotion and disease prevention is now the focus rather than just diagnosis and treatment of disease.
Healthy People 2020 as example for country-wide initiative towards health promotion

3. Prevention as a concept
Primary prevention: services focused on preventing disease in susceptible populations
Examples: health education and counseling, targeted immunizations, lifestyle modification strategies
Secondary prevention: services focused on the early detection and prompt treatment of disease states
Examples: laboratory screening tests, pap smears, screening mammograms
Tertiary prevention: services which limit disability and promote rehabilitation while in disease states
Examples: eye exams for those with diabetes, follow-up exams for recurrence of cancer

4. Counseling and education is KEY!
Some examples:
Dental health
Diet and exercise
Injury prevention (seatbelts, helmets)
Household safety (poisons, guns)
Recreational safety (reflective vests, PFDs)
Fall prevention (railings, fixed carpets)
Sexual behavior
Tobacco use

5. Prevention as a concept
Fits into EVERY patient visit
Applies at all levels
Individual
Family
Community
System

6. Case #1
Marissa, a 19 year old female college student comes to the university health clinic with a complaint of vaginal itching and burning for the past 3 days. As you sit with her getting her history, she admits to having not seen a provider since she was in high school. She has had 3 sexual partners over the past 4 months, and has “tried” to use condoms but admits to sexual encounters in which she “doesn’t remember”. When you ask about birth control methods, she shrugs her shoulders and states that she doesn’t need it.
What other information do you want to obtain from her?

7. Case #1 continued
What are examples of primary prevention you could use in this example?
What are examples of secondary prevention you could use?
If Marissa’s age was 22 instead of 19, would you do anything differently?

8. Case #1 continued Areas for focus and concern:
Immediate problem – vaginal itching and burning
Primary prevention measures – counseling for risky sexual behaviors, safer sex, contraception, personal safety, violence screening, immunizations
Any others?
Secondary prevention measures – screening for STIs, pregnancy, vaginal infections

9. US Preventive Services Task Force
Recommendations for Preventive Screening

10. USPSTF: A & B Recommendations
The Affordable Care Act has mandated that all USPSTF A & B recommendations are covered in full (100%) by every insurance carrier.
Pertains to billable screening and counseling services
Others are often covered, but depends on insurance company
(USPSTF A and B Recommendations. U.S. Preventive Services Task Force.

11. USPSTF: A & B Recommendations Primary Care
The USPSTF recommends for/that:
screening for high blood pressure in adults age 18 years and older.
screening women ages 20 and older for lipid disorders if they are at increased risk for coronary heart disease.
screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.
screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.
USPSTF A and B Recommendations. U.S. Preventive Services Task Force.

12. USPSTF: A & B Recommendations Women’s Health Care
The USPSTF recommends for/that:
primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
screening for chlamydial infection in all sexually active nonpregnant young women age 24 years and younger and for older nonpregnant women who are at increased risk.
clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).
clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.
clinicians screen persons at increased risk for syphilis infection
high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) in all sexually active adolescents and for adults at increased risk for STIs.

13. USPSTF: A & B Recommendations Older Women’s Health Care
The USPSTF recommends for/that:
the use of aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.
screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 40 years and older.
screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.  
screening for osteoporosis in women age 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.
USPSTF A and B Recommendations. U.S. Preventive Services Task Force.

14. Other preventive screening/counseling recommendations
Thyroid screening: insufficient evidence
Skin cancer screening: insufficient evidence
Vitamin D screening: recommendation in progress
Ovarian cancer screening: recommendation against routine screening (D)
Combined or estrogen-only hormone replacement therapy: recommendation against use
Diabetes screening: insufficient evidence for normotensive adults, recommended if co-existing hypertension

15. Case #2
Susan is a 52 year old woman presenting to your clinic for a health maintenance exam. She saw on the TV a recommendation for women her age to get a colonoscopy and wanted to know more about it. She has been married to John for 32 years, monogamous, has two adult children, and she has not had a period for 2 years now. Her last visit to a provider was 6 years ago, when she was told she needed a mammogram and she couldn’t afford the out-of-pocket portion. She was scared to go back because of this.
What other information would you like to know from Susan?

16. Case #2 continued
What primary prevention strategies could you use during this visit?
What secondary prevention strategies would be appropriate?
What could you tell her about her insurance coverage regarding the tests you may be recommending?

17. Case #2 continued Areas for focus and concern:
Immediate problem – lack of preventive screening
Primary prevention measures – diet and exercise counseling, ask about tobacco use, immunizations
Any others?
Secondary prevention measures – screening for hypertension, hyperlipidemia, diabetes (if elevated BP), intimate partner violence, mammogram, colonoscopy or signmoidoscopy, pap?

18. Resources to know… Healthy People 2020
United States Preventive Services Task Force (USPSTF) and the Affordable Care Act
Centers for Disease Control and Prevention (CDC) Recommended Vaccine Schedule
read.pdf
U.S. Dept of Health and Human Services, Office on Women’s Health

19. Questions?