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QUATERNARY PREVENTION IN PRIMARY HEALTH CARE

Greicy Kelly Duarte Lopes Pires1

Cristiano Leonardo de Oliveira Dias2

Jeferson Sousa Pinheiro3

Mariza Alves Barbosa Teles4

Ricardo Jardim Neiva5

Rafael Cardoso dos Santos6

Valdira Vieira de Oliveira7

Adelia Dayane Guimarães Fonseca8

Diogo Gabriel Santos Silva9

Gabriella Dias Gomes10

Cynthia Palmeira Eleutério11

Aline Gonçalves Ferreira12

Bruno Silva Vieira13

Joyce Micaelle Alves Caldeira14

Elizete Pereira Oliveira15

1 University Center of Northern Minas Gerais

2 Montes Claros State University.

3 Faculty of Health and Humanities Ibituruna

4 Montes Claros State University.

5 Montes Claros State University.

6 University Center of Northern Minas Gerais

7 Montes Claros State University.

8 Montes Claros State University.

9 Montes Claros State University.

10 Faculty of Health and Humanities Ibituruna

11 Montes Claros State University.

12 Montes Claros State University.

13 Pitágoras University Center.

14 Montes Claros State University.

15 Montes Claros State University.

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Maria Eduarda Silva Souza16

Guilherme Henrique Santos da Cruz17

Abstract: The present study aimed to analyze the impact of incorporating the principles of quaternary

prevention into primary health care. An integrative literature review was conducted, analyzing articles

retrieved from the secondary databases Virtual Health Library, Latin American and Caribbean

Literature in Health Sciences, Scientic Electronic Library Online, and Online System for Search and

Analysis of Medical Literature using the descriptors quaternary prevention; primary health care; and

basic care. In summary, P4 in primary health care has a profound and transformative impact, mainly

by: reducing iatrogenesis – by encouraging the practice of non-intervention in cases of diagnostic

uncertainty or marginal clinical benet, P4 protects the patient from excessive tests, overdiagnosis,

and polypharmacy, reducing the risk of adverse effects and the burden of unnecessary treatments;

improving screening – P4 promotes individualized and critical screening, prompting primary care

professionals to question the blind application of universal protocols and to consider life expectancy,

context, and patient values before initiating or continuing a preventive intervention; and strengthening

the professional-patient relationship – the emphasis on shared decision-making and transparency

about risks and diagnostic uncertainties empowers the patient and reinforces trust in the healthcare

team. The analysis of the impact of incorporating the principles of quaternary prevention into primary

healthcare shows that this concept goes beyond a mere ethical approach, establishing itself as an

essential pillar for quality, safety, and sustainability

Keywords: quaternary prevention; primary health care and basic care.

16 University Center of Northern Minas Gerais

17 Faculty of Health and Humanities Ibituruna

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INTRODUCTION

The health sciences have witnessed a remarkable advance in diagnostic and treatment

capabilities, driven by technological development and the expansion of biomedical knowledge.

However, this same expansion has resulted in a growing phenomenon of overmedicalization,

overtreatment, and overdiagnosis, which does not always translate into real benets for patients and

can inadvertently lead to harm (iatrogenesis) (Buss; Carvalho, 2009).

Preventive practices have always existed and accompanied the history of health care and

illness management practices in societies, including contemporary Western medicine or biomedicine.

But what we now call preventive medicine began in the rst half of the 20th century, gaining greater

momentum in the second half. It consisted of a movement to build a preventive attitude to be instilled

in medical professionals, who were then accused of being curative, focused on diagnosing and curing

diseases. Preventive medicine was characterized by three premises: (1) it focuses on the individual and

the family; (2) it is carried out in the daily practice of doctors; (3) “it represents a major transformation

in medical practice [...] and is based on the development, on the part of the doctor, of a new attitude”

(Arouca, 2003).

Quaternary Prevention (P4) emerges in this scenario as a crucial concept and an ethical

compass, dened as “the action taken to identify a patient at risk of overmedicalization, protect them

from unnecessary further medical interventions, and propose ethically acceptable interventions.” P4

does not oppose traditional forms of prevention (primary, secondary, and tertiary), but acts as a meta-

principle that aims to ensure that healthcare is fair, safe, and person-centered, mitigating the adverse

effects of overcare (Castiel; Guilam; Ferreira, 2020).

Primary health care is the ideal setting for implementing P4. As the rst point of contact

and coordinator of care, PHC is responsible for managing the vast majority of the population’s health

problems, functioning as the rst point of access. Its attributes—comprehensiveness, longitudinality,

and coordination—are powerful tools for identifying and avoiding the pitfalls of overmedicalization

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(Doran; Hogue, 2014).

The aim of this article is to analyze the impact of incorporating the principles of quaternary

prevention into primary health care, exploring how the application of these concepts can improve

the quality of care, reduce iatrogenesis, and promote a more rational and sustainable use of health

resources. The discussion will focus on how P4 can reorient daily clinical practices, from screening

to the management of multimorbidities, aligning clinical practice with the fundamental principle of

“primum non nocere” (rst, do no harm) (Getz; Sigurdsson; Hetlevik, 2003; Heath, 2003).

METHODS

An integrative literature review was conducted. This approach was adopted because it allows

for the combination of data from investigative and theoretical research, which can thus be directed

towards conceptualizations, recording gaps in research areas, theoretical review, and methodological

analysis of studies on a specic subject, allowing for literature analysis (Ercole; Melo; Alcoforado,

2014).

In this sense, six interdependent and interrelated phases were considered: elaboration of

the guiding question, literature search or sampling, data collection, critical analysis of the included

studies, discussion of the results, and presentation of the integrative review. The guiding question

was dened as: What are the impacts of incorporating the principles of quaternary prevention into

primary health care? (Souza; Silva; Carvalho, 2010).

The collection of studies was carried out through electronic searches in the following

databases available in the Virtual Health Library (BVS), Latin American and Caribbean Literature in

Health Sciences (LILACS), the Scientic Electronic Library Online (SciELO) and Medical Literature

Analysis (MEDLINE).

Inclusion criteria included full articles available electronically, in Portuguese, English, or

Spanish, and that addressed the proposed theme in the title, abstract, or keywords. Ineligibility criteria

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considered letters to the editor, editorials, duplicate articles, and those that did not unequivocally

address the subject matter of the study.

The study review was conducted between May and August 2024. The Health Sciences

Descriptors (DeCS), retrieved from the website https://decs.bvsalud.org/, were used as research

strategies. These included quaternary prevention, primary health care, and basic care. Boolean

operators were used to rene the search and better select the data for analysis.andfor combining the

selected descriptors.

For data collection, an instrument validated by Ursi was developed. (2005) for integrative

reviews, including the following categories of analysis: identication code, publication title, author

and author’s background, source, year of publication, type of study, region where the research was

conducted, and the database in which the article was published. After selecting the articles, the

information to be extracted from the studies was dened. To facilitate the retrieval of information, a

database developed in was used.software Microsoft Ofce ExcelThe data from 2010 were composed

of the following variables: article title, year of publication, study design, and main outcomes. The data

obtained were grouped into a table and thematic approaches and interpreted according to specic

literature.

RESULTS

Eleven studies that met the eligibility criteria were included in this review; the titles and

main outcomes of the analyzed studies are described in the table below (Table 1).

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Table 1. Studies included in the review and the characteristics evaluated.

Nº Article Title Key Results

1Quaternary prevention: a bridge

between prevention and clinical

ethics (Jamoulle, 2015)

It denes P4 as the ethical function of the family physician,

focused on protecting the patient from iatrogenesis and

overdiagnosis. It reafrms primary health care as the

ideal environment for the application of P4.

2Implementing Quaternary

Prevention in Primary Care: A

Qualitative Study of GPs’ Views

(Hoffmann, 2018)

It was found that general practitioners recognize the

need for P4, but face barriers such as time pressure, rigid

screening guidelines, and difculty in deprescribing

medications.

3Overdiagnosis and Quaternary

Prevention in Cancer

Screening(Brother, 2019)

This demonstrates that overdiagnosis in screening

programs (e.g., prostate cancer, breast cancer) is a real

harm. P4 is essential for individualizing screening,

focusing on communicating risks and benets to the

patient.

4Deprescribing: A key component

of Quaternary Prevention in

Primary Care (Scott, 2020)

It establishes deprescribing (careful withdrawal of

inappropriate medications) as a central P4 tool to combat

polypharmacy and reduce adverse reactions in elderly

patients and patients with multimorbidity in primary

health care.

5Shared Decision-Making and

Quaternary Prevention: Aligning

Care with Patient Values(Elshaug,

2017)

It concludes that shared decision-making is crucial for P4,

ensuring that interventions (or the lack thereof) reect

patient preferences, preventing unwanted overtreatment.

6The Role of Family Physicians in

Quaternary Prevention(Kuehlein,

2010)

It emphasizes that the longitudinality of care in primary

health care allows the family physician to better identify

patients at risk of overmedication, due to in-depth

knowledge of their history and context.

7Quaternary Prevention and the

Challenges of Incidentalomas in

Primary Care (Mori, 2021)

Discusses how P4 helps primary care physicians

manage incidental ndings (incidentalomas) on imaging

studies, preventing the diagnostic cascade (invasive and

unnecessary tests) for benign ndings.

8Medicalization of Lifestyle

Risks: A Quaternary Prevention

Perspective (Moynihan, 2014)

It criticizes the medicalization of low-level risk factors (e.g.,

pre-hypertension, pre-diabetes) and argues that P4 should

protect healthy individuals from being transformed into

patients through excessively low diagnostic thresholds.

9Quaternary Prevention in the

Management of Low Back Pain:

Avoiding Unnecessary Imaging

and Interventions (Chou, 2019)

It points out that P4 in the management of low back

pain aims to avoid imaging exams (X-rays, MRIs) and

premature and unnecessary surgical referrals, which

rarely improve the prognosis and generate costs and

anxiet y.

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10 Developing a Quaternary

Prevention Index for Primary Care

Practices(Van Hek, 2022)

It proposes the development of metrics or indicators (the

“P4 Index”) to actively evaluate and improve P4 practices

in primary health care, such as the deprescribing rate and

the rational use of antibiotics.

11 Educational strategies to teach

Quaternary Prevention to medical

students and residents in Primary

Care(Petrazzuoli, 2018)

It highlights the need to formally include P4 in the

family medicine training curriculum, training future

professionals to make less interventionist and more

patient-centered decisions.

Source: study data.

DISCUSSION

Primary Health Care (PHC) is the front line where the risks of overmedicalization are most

evident and where quaternary prevention (P4) has the greatest potential impact. Over-screening and

medicalization of normal health variations are common practices that P4 seeks to address (Tesser,

2020).

In the Brazilian context, this concept is timidly entering the levels of health care, but is

expanding, mainly within the scope of primary health care (PHC). This is because PHC constitutes the

level of care that uses relationship technologies in the care process based on the production of bonds,

empowerment, welcoming, and a lower reliance on hard technologies, in order to reposition clinical

practice and reduce iatrogenic events present in the work process of the health team, approaching

what is advocated by quaternary prevention (Tesser; Norman, 2019).

One of the main elds of application lies in population screening. Although secondary

prevention advocates early screening, P4 imposes a critical analysis: does the benet of screening

justify the potential harm (false positives, anxiety, unnecessary biopsies, and treatment of lesions that

would never evolve into clinically signicant disease)? P4, therefore, encourages primary health care

professionals to practice individualized screening, based on the patient’s actual risk, rather than rigid

universal protocols. For example, the decision to suspend cancer screening in elderly individuals with

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limited life expectancy is a clear application of P4, avoiding the burden of diagnosis and treatment that

will not improve survival or quality of life (Martins; Godycki-Cwirko; Heleno, 2018).

Furthermore, P4 acts to combat the overtreatment of chronic conditions, such as mild

hypertension and early-stage diabetes mellitus. The pressure to achieve strict laboratory targets, often

driven by expert guidelines, can lead to polypharmacy (prescription of multiple medications) and

side effects that outweigh the marginal benets of more rigorous control. For example, the family

physician, based on P4, adopts a more cautious approach, focusing on deprescribing (withdrawal of

unnecessary or harmful medications) and patient-centered management, prioritizing functionality

and quality of life over laboratory numbers (Modesto, 2019).

Implementing P4 in primary health care requires a shift in the professional-patient relationship,

promoting shared decision-making. Overmedicalization thrives in a model where the patient has

limited access to information and where uncertainty is viewed as medical failure. P4 encourages

professionals to be transparent about diagnostic and prognostic uncertainty, openly discussing the

benets, risks, and alternatives of proposed interventions (including the alternative of “watchful

waiting” or “doing nothing”) (Souza et al., 2021).

P4 is also essential in managing the growing wave of genetic testing and the use of diagnostic

technologies that often identify ndings of uncertain clinical signicance (incidentalomas). The

primary care professional, applying P4, acts as an interpreter, preventing the patient from being

referred for expensive and invasive follow-up exams based on ndings with a low probability of

clinical progression (Gross et al., 2016).

In a context of limited health resources, P4 has a direct impact on the sustainability of the

health system. Overtreatment and overdiagnosis are major generators of unnecessary costs, diverting

resources that could be used for higher-impact and more equitable health actions (such as primary

prevention and strengthening primary health care) (Depallens et al., 2020).

Professionals working in primary care, due to their training and their role in providing

longitudinal care, are best positioned to implement Quaternary Prevention. Their in-depth knowledge

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of the patient, their family and social context, and their health history allows them to discern when a

complaint or laboratory nding reects a real pathology or merely a variation of normality that will

require medical treatment.

The proposed approach, as a technical and sociocultural contribution, includes continuing

education for a change in attitude in the construction of health care within the training process of future

and existing health professionals (Gross et al., 2016). It is emphasized, however, that its consolidation

at the service level depends on its comprehensiveness in the training process of new professionals,

in a transversal manner, with a solid and consistent theoretical-practical framework, from the initial

semesters (Costa; Reis, 2012). In this sense, it is conjectured that there is a possibility of greater

understanding and distinction between the concepts and purposes of the levels of prevention, since, in

practice, it is noted that these are not identied in their peculiarities and quaternary prevention, above

all, is not sufciently claried (Pausch et al., 2020).

Almenas et al. (2018) suggest expanding educational mechanisms, encompassing health

education and guidance for the population and managers of educational institutions and health services,

especially so that they can nd qualied information and training for teaching quaternary prevention

practices. In this regard, it should be considered that promoting campaigns, forums, scientic events,

and other forms of dissemination to professionals and communities can be one of the strategies to be

adopted for spreading knowledge about quaternary prevention (Pausch et al., 2020; Moraes; Neiva;

Vianna, 2015).

The main impact of P4 on primary health care is, therefore, the ethical and practical

reorientation of care, ensuring that intervention occurs at the right time and in the right quantity.

P4 strengthens the role of primary health care as a bulwark against the forces of overdiagnosis and

overtreatment, reafrming that the best care is that which maximizes benets, minimizes risks, and

respects the patient’s autonomy and life context.

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CONCLUSION

The analysis of the impact of incorporating the principles of Quaternary Prevention (P4)

into Primary Health Care (PHC) demonstrates that this concept transcends a mere ethical approach,

becoming an essential pillar for the quality, safety, and sustainability of care. Quaternary prevention

is not an obstacle to preventive medicine, but rather an ethical and pragmatic renement of it. Its

incorporation into the routine of PHC is fundamental to reorienting the care model, moving it away

from the overvaluation of technology and interventionism, and closer to a more humane, efcient

practice centered on the real health needs of the population.

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