Defining Prevention

The Scottish Government Prevention Unit Definition of Prevention

The Scottish Government Prevention Unit definition of prevention includes two components:

• Overarching definition of prevention – to distinguish what activity can be considered preventative as opposed to other types of activity (e.g. responsive activity).
• The “Levels” of prevention – If an activity is preventative, it is assigned a level based on whether it aims to stop a problem (called “primary prevention”), address early emergence of a problem (“secondary”) or stop an existing problem from escalating or recurring (“tertiary”).

The definition has been designed to build on existing definitions used in Scotland and other jurisdictions with a focus on meaningfully categorising different types of prevention activity.^[5]

Overarching Definition of Prevention

The Scottish Government Prevention Unit defines prevention as: activity intended to stop the establishment, escalation or recurrence of problems that lead to negative outcomes for people.

One of the key features of this definition is that it distinguishes between preventative activity (“to stop the establishment, escalation or recurrence of problems”) and responsive activity (immediate response to problems once they occur). Both preventative and responsive activity are crucial in public service delivery, however increasing attention on the former should reduce demand for the latter. Examples of preventative and responsive activities are provided in Figure 1.

Figure 1 – Examples of Preventative Activity vs Responsive Activity

Prevention

Activity that aims to stop the establishment, escalation or recurrence of problems that lead to negative outcomes for people.

• Vaccines
• Prison programmes to prevent reoffending
• Family Nurse Partnership
• Housing support for people at risk of homelessness
• Free school meals for lower income households

Responsive

Activity that aims to respond to immediate problems once they have arisen

• Emergency hospital care
• Police response to emergency incidents
• Emergency response to floods
• Children entering the care system

In addition to defining these two broad areas of spend, it can be useful to define some other categories of spend that are neither preventative nor responsive. For example, the Prevention Unit developed a Preventative Budgeting Tool which includes four categories – preventative, enabling, acute/responsive/treatment and other/ general service.^[6]

We typically don’t define activity as “not preventative” because, even if the main purpose of an activity is not to prevent a problem, it can often still have a role to play in prevention. For example, the main purpose of acute hospital surgery is “responsive” but it does prevent future negative outcomes that would arise without surgery. To help make the distinction, we focus our prevention definition on activity that intends to prevent something as its main purpose. Some other organisations do define “non-preventative” - For example, see definitions used by the Chartered Institute for Public Finance and Accounting (CIPFA) in their report Understanding Preventative Investment.^[7]

Defining Different Levels of Prevention

Below the overarching definition of prevention, the Prevention Unit also defines different “levels” of prevention activity.

The different levels of prevention are intended to reflect where an intervention sits relative to the emergence of problem. Activity that aims to stop a problem happening in the first place is primary prevention, while activity targeted at identifying and responding to early emergence of a problem is secondary prevention, and activity aimed at stopping an existing problem from getting worse or recurring is tertiary prevention. These definitions are commonly used internationally across different jurisdictions and in different sectors. The full definition, including the overarching definition and levels of prevention, is set out in Figure 2.

Figure 2 - Scottish Government Prevention Unit Prevention Definition

Prevention Definition

The Scottish Government Prevention Unit defines prevention as: activity intended to stop the establishment, escalation or recurrence of problems that lead to negative outcomes for people.

Levels of Prevention

Primary Prevention - Population-level action, or action which targets a large subset of the population, to build resilience and stop known risks from developing into problems

Secondary Prevention - Targeted action to identify and respond to early signs of a problem to prevent escalation

Tertiary Prevention - intervention once there is a problem to stop it from getting worse or recurring in future

Figure 3 provides examples of preventative activities at these different stages.

The definitions have been designed to be flexible and usable across all sectors, and can be tweaked to reflect different contexts. For example, the levels definitions are in use in different policy areas from public health^[8] to justice and equalities^[9] and in other jurisdictions^[10]. The Prevention Unit definition is consistent with these definitions used elsewhere.

Note that some organisations tweak this framework to add different categories, or use similar frameworks. For example, the Kings Fund splits out a separate category of prevention from the primary prevention category called “primordial” prevention, which is defined as “action to prevent exposure to risk factors in the first place”.^[11] We opt to merge primordial activity into “primary prevention” for a framework which is simpler to apply. Other frameworks with similar categories are also used: For example, see the homelessness prevention policy briefing by Heriot Watt University which uses a framework of Universal, Targeted, Crisis, Emergency, Recovery.^[12]

Why is Prevention Defined this Way?

Defining prevention clearly within the Scottish policy context offers significant benefits in terms of coherence and alignment. A shared overarching definition, supported by recognised levels of prevention, provides a consistent framework that can be applied across diverse policy areas such as health, social care, education, and economic development. This helps ensure that prevention is not interpreted narrowly or applied inconsistently.

The overarching definition allows a delineation between what is “preventative” vs other types of spend. This helps narrow down the sets of activities that could be focused on when trying to think through prevention in policy and decision making.

The definition of different levels of prevention allows for a distinction to be made between “true prevention” before problems occur (primary prevention) and further downstream forms of prevention such as early intervention (secondary prevention) or tertiary prevention. This categorisation can support, for example, when thinking about the balance of resources and shifting resources “upstream”, which is a stated goal of the Public Service Reform Strategy.^[13] In practice, this can support more strategic, anticipatory decision making and a stronger focus on addressing the root causes of poor outcomes.

Interpreting Preventative Activity

While the definitions provide a systematic way of categorising preventative activities, it is also recognised that there is nuance and subjectivity involved in defining prevention. In particular, it is important to recognise the role played by all types of activity, preventative and other activity, in delivering an effective system of public services. In any prevention analysis, you should consider the role of preventative activity, but also other forms of activity that could potentially impact on prevention indirectly. For example, while acute or responsive service provision may not be considered preventative, the way in which these services are delivered can support prevention.

Furthermore, defining prevention is a first step in understanding the impact of preventative activity. While moving resources upstream is generally important and effective, there are a range of factors which determine the effectiveness of a particular prevention measure, such as where an intervention takes place in the life course (see Box 1). A secondary prevention measure early in life could have significant benefits per person impacted by the policy, whereas a primary prevention later in the life course could have less impact.

This means that these definitions and categorisations of prevention activity have to be supplemented by evidence of the impact of an activity for the population group treated by the measure.

Box 1 – Prevention and the Life Course

There is good evidence that intervening early - particularly investment in

early years childcare, education and family support - is cost-effective. For example the ‘Heckman curve’ visualises that investment in children is most cost-effective when they are young, benefiting growth and reducing inequalities.^[14]

This suggests that in many cases the return on investment of a primary intervention in early years may be higher than a primary intervention later in someone’s life. It could also be the case that a secondary intervention targeting early childhood could have much better returns than a primary intervention later in life.

Related Prevention Terms

Prevention is often confused with other terms, such as “failure demand” or “early intervention”. For clarity, we provide definitions of these concepts to help understand their distinction to prevention. These include:

• “Prevention and early intervention” – Often “prevention and early intervention” is used as a term to describe primary and secondary prevention. “Prevention” in this context is considered “true prevention” or primary prevention (stopping problems from happening in the first place). We typically stick to using the term prevention to cover all three levels of prevention and then specify what level is being referred to (e.g. primary prevention).
• Failure demand – Failure demand refers to demand for services that arises after problems have emerged - often because earlier intervention was absent, insufficient, or ineffective - and therefore reflects avoidable or system-generated need. Failure demand represents the downstream consequences of unmet need or system shortcomings, and typically necessitates reactive, often more costly, responses.
• Preventative spend – Preventative spend is public spending on policies and interventions that aim to either prevent negative outcomes and/or reduce future costs for public services. This is a narrower set of public service activity than prevention, which can include behaviours, legislation, taxes, as well as public spending.

• Upstream and downstream prevention - The upstream–downstream framework and the levels of prevention framework organise interventions in different but similar ways. Upstream and downstream prevention distinguish where action is taken within the wider system of causes - with “upstream” prevention focussing on structural, root drivers of risk (such as income, housing, or environment), while downstream focuses on more immediate risks or emerging problems among individuals. By contrast, the levels of prevention (primary, secondary, tertiary) classify interventions by when they occur in relation to a problem, from preventing its onset, to early detection, to managing established harm.

Further information

More information can be found online at the Scottish Government Prevention Unit. If you have any feedback on the definitions please send to PreventionUnit@gov.scot.

For examples of prevention definitions used in practice, explore the following links:

• Scottish Government Prevention Unit – Piloting an Approach to Preventative Budgeting in the Scottish Budget
• Public Service Reform Strategy
• Population Health Framework
• Learning from 25 years of Preventative Interventions in Scotland