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Finland's Success in NCD Prevention: Lessons from the North Karelia Project

Explore Finland's experience in implementing noncommunicable disease (NCD) prevention through the North Karelia Project. Learn about the challenges, interventions, and outcomes of this community-based program.

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Finland's Success in NCD Prevention: Lessons from the North Karelia Project

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  1. 5th International Seminar on the Public Health Aspects of Noncommunicable Diseases Lausanne, 5-9 September 2011 Finland’s experience in implementing NCD preventionDr. Tiina Laatikainen, DirectorDepartment of Chronic Disease Prevention CVD prevention/ Tiina Laatikainen

  2. Public health development in Finland after the World War II Before the War • Mainly Infectious Diseases Long, heavy war and difficult post war years • The country was very poor In the 1950’s and 60’s • Rapid increase in the CVD and other NCD rates • Public health response mainly building hospitals and health services

  3. In the 1970’s • Statistics showed very bad public health situation • CHD mortality rates among men highest in the world • Short life expectancy • Increasing public discussion • General opinion related CHD to stress, ageing and genetics • It was earlier also referred to as “Disease of the Executives” • Cardiologists were aware that there are numerous “Statistical Associations”

  4. Start of the North Karelia project • North Karelia was part of the Seven Countries Study since 1955 • Public attention to the high CVD mortality and to the statistics showing that the province of North Karelia was in the worst situation • Petition by the representatives of people in North Karelia for national assistance to cope with the problem (January 1971) • Delegation led by the Governor to Helsinki, the petition was handed to the Prime Minister and other decision makers • Involvement of Finnish experts and WHO

  5. 5

  6. North Karelia ProjectPrinciples for Defining the Intermediate Objectives • Due to the chronic nature of CVD, the potential for the control of the problem lies in primary prevention• The risk factors were chosen on the basis ofbest available knowledge: - previous studies - collective international recommendations - epidemiological situation in North Karelia• Chosen risk factors: - smoking - elevated serum cholesterol (diet) - elevated blood pressure

  7. Serum cholesterol distribution in Finland and Japan in 1970’s Frequency % mmol/l

  8. Main Principles of the North Karelia Project • Prevention is the only sustainable public health approach • Risk factors identified by prospective studies, closely linked with certain behaviours - deeply enrooted in the community • Community based preventive programme 1 Target: the community (not individuals) 2 Intervention: through community structures (not external intervention) • Emphasis on community organization, general community changes

  9. CLINICAL INTERVENTION RISK FACTORS PUBLIC HEALTH INTERVENTION

  10. 25 % 5 % 70 % People with average risk factor level People with clinically high risk factor level People with low risk factor level Individual risk of CHD Distribution of people according to risk factor level Theoretical presentation of the difference between individual risk and the proportional attributable risk

  11. Constraints • Suspicions from the scientific community of cardiologists • Medical knowledge on prevention questionable, community prevention new concept • North Karelia socially deprived area, poor and with many social problems (unemployment, migration, shortage of doctors etc) • War and post war years: Great poverty, after that increase in consumption • Dairy farming main agriculture: Butter and animal fat culturally highly valued • Strong commercial pressures (“FAT WAR”), supported by political pressures • Raising the funding (intervention and evaluation research) • To maintain interest and funding over decades

  12. Advantages • Magnitude of problem, concern of people • Relatively homogenous population, traditions of community action • Trust in experts and in public action • Good information system • Good collaboration with people • Good leadership

  13. 69 72 75 78 81 84 87 90 93 96 99 2002 Age-adjusted mortality rates of coronary heart disease in North Kareliaand the whole of Finland among males aged 35-64 years from 1969 to 2002 700 start of the North Karelia Project 600 extension of the Project nationally 500 North Karelia 400 300 - 82 % All Finland Mortality per 100 000 population 200 - 75% 100 Year

  14. North Karelia ProjectPractical intervention • Emphasis on persuasion, practical skills, social & environmental support for change • Research team & local project office with comprehensive community involvement • Main areas: 1. Media activities (materials, mass media, campaigns) 2. Preventive services (primary health care etc.) 3. Training of professional and other workers 4. Environmental changes (smoke-free areas, supermarkets, food industry etc.) 5. Monitoring and feed-back

  15. ANTISMOKING LEGISLATIONIN FINLAND IN 1977: Prohibition of all forms of advertising Restrictions in smoking in public places Health warnings etc. 1/2% level of tobacco tax for antismoking activities Prohibition of sale to under 16 years old ANTISMOKING LEGISLATIONIN FINLAND IN 1995, 2000 AND 2007: Worksite smoking policy Sales to persons under 18 years of age prohibited Restaurant, bar smoking policy

  16. 19-34 35-49 50-64 25-49 25-49 19-34 35-49 50-64 25-49 25-49 Daily smoking • Smoking initiation by birth cohort % % 60 100 90 50 80 Men Men 70 40 60 30 50 40 20 30 Women Women 20 10 10 0 0 1916–20 1921–25 1926–30 1931–35 1936–40 1941–45 1946–50 1951–55 1956–60 1961–65 1966–70 1971–75 1976–80 1960 1970 1997 1999 2001 2003 2005 83-85 78-79 89-90 93-94 Helakorpi S et al. J Epidemiol Community Health 2004

  17. Smokingcontrol programmes • Voluntary restrictions of smoking in public places • Mass media • Voluntary restrictions in advertising • Use of opinion leaders • Training of health care personnel • Cessation services in health centres

  18. Smoking control programmes • Worksite programmes • School programmes • TV programmes • Radio programmes • Quit and Win Competition • Smoke Free Class Competition • Quit and Win - Do Not Start and Win for Young People

  19. A comprehensive television smokingcessation programme in Finland • Voluntary smokers in TV studio tried to stop smoking • 6 sessions + 2 follow-up sessions • Intensified field activity in North Karelia • 250 000 saw at least 4 sessions • 30 000 attempted to quit • 20 000 quitted • 10 000 remained non-smokers

  20. Smoking in men (30–59 y) % North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

  21. NGO’s role • Heart Association • Martta (house wife’s) association

  22. North Karelia ProjectCo-operation with the Martta (housewifes’) organization • Active co-operation since 1972 • Several hundred clubs and many thousand members • Promotion of health cooking = dietary habits • Many special campaigns, notably: - Parties for longlife 1976-77 - Evenings of happy heart 1990-91

  23. Use of lay opinion leaders to promote health innovations in community • Innovation-diffusion theory • Training seminars in municipalities • Discuss health issues in normal life • 805 persons participated • Recruitment by local people and Heart Association • 1975-1982 • Evaluation in 1982: 399 (50%) still active

  24. Discussions with target groups

  25. North Karelia ProjectCholesterol programme • SPECIAL INTENSIFIED PROGRAM • The program was based especially on the following: - New consensus recommendations - New reference values (< 5 mmol = “normal”) - Fingertip determination method - Interest of food industry - Finnish rapeseed oil • MAIN COMPONENTS - Population-wide cholesterol measurements - Dietary counseling - Mass media and many campaigns (incl. Village competition) - Collaboration with industry and supermarkets

  26. Village competition to lower cholesterol • 1991 7 villages, population 105-210 • 1997 16 villages, population 85-420 • Village committees organized • 2 months competition • Baseline and follow-up cholesterol measurement • Best village won 2000 €

  27. Cholesterol changes in 1991 competition

  28. Cholesterol change in 1997 competition

  29. Change (%) in cholesterol by number of dietary changes

  30. Change (%) in cholesterol value by village activity

  31. Fat used for cooking at home in Finland in 1978-2006 Health Behaviour among the Finnish Adult Population 1978–2006

  32. Fat intake Recommendations EN% Year • The FINDIET Study

  33. Serum cholesterol in men aged 30-59 years mmol/L

  34. Cholesterol distribution in North Karelia in 1972 and 2007, men 4 6 8 10 12 mmol/l

  35. North Karelia ProjectBerry project • Aim to increase the consumption of eastern Finnish berries • Rationale: 1) Berries are healthy 2) Enhances switch from dairy farming • First Berry Project 1985-90 • Second Berry Project 1992 - • Methods: various co-operative and innovative interventions

  36. Fruits And Vegetables – Supermarkets

  37. Changes in Finnish food habits Year

  38. Saltintake in Finland 1977-2007 g/day The FINDIET Study

  39. Systolic blood pressure in men (30–59 y) mmHg North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

  40. per 100 000 North Karelia All Finland Decline in CHD mortality in men aged 35-64

  41. Observed and Predicted Decline in CHD mortality 35-64 year old men Vartiainen E et al.

  42. Finland Has Shown • Prevention of major chronic diseases is possible and pays off • Population based prevention is the only cost effective and sustainable public health approach to chronic disease control • Prevention calls for simple changes in some lifestyles (individual, family, community, national and global level action) • Influencing lifestyles is a key issue • Many results of prevention occur surprisingly quickly (CVD, diabetes) and also at relatively late age • Comprehensive action, broad collaboration with dedicated leadership and strong government policy support are crucial

  43. Why success in North Karelia • Appropriate epidemiological and behavioural framework • Restricted, well defined targets • Good monitoring of immediate targets (Behaviours, process) • Flexible intervention • Emphasis in changing environment and social norms • Working closely with the community • Positive feedback, work with media • International collaboration, support from WHO • Close interaction with national health policy, integration with National Public Health Institute • Long term, dedicated leadership

  44. Training seminar on NCD prevention www.thl.fi/ncdseminar Helsinki, Finland and in North Karelia 12-16 March, 2012 11-15 March, 2013

  45. New textbook on North Karelia project Pekka Puska, Erkki Vartiainen, Tiina Laatikainen, Pekka Jousilahti, Meri Paavola (eds.) The North Karelia project: from North Karelia to national action http://www.thl.fi/thl-client/pdfs/731beafd-b544-42b2-b853-baa87db6a046 Also available in Russian

  46. Working intersectorally Work sites Education Food industry Taxation Business Media Agriculture Legislation Third sector Research Health services

  47. POPULATION PUBLIC POLICY PRIVATE SECTOR HEALTH PROGRAMME

  48. Major Elements of Finnish National Action 1. • Research & international research collaboration • Health services (especially primary health care) • North Karelia Project, other demonstration programmes • Health Promotion Programmes (coalitions, NGO’s, collaboration with media etc.) • Schools, educational institutions

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