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The Community-Based Strategy to Prevent Coronary Heart Disease: Conclusions from the Ten Years of the North Karelia Project

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Ann. Rev. Public Health. 1985. 6:147-93
Copyright © 1985 by Annual Reviews Inc. All rights reserved
THE COMMUNITY-BASED
STRATEGY TO PREVENT
CORONARY HEART DISEASE:
Conclusions from the Ten Years of
the North Karelia Project
Pekka Puska, Aulikki Nissinen, and Jaakko Tuomilehto
National Public Health Institute, Department of Epidemiology, Mannerheimintie 166,
00280 Helsinki 28
Jukka T. Salonen
University of Kuopio, Department of Community Health, 70211 Kuopio 21
Kaj Koskela
National Board of Health, Office for Health Education, 00531 Helsinki 53
Alfred McAlister
University of Texas, Health Science Center at Houston, Houston, Texas 77225-0708
Thomas E. Kottke
University of Minnesota, Cardiovascular Division, Department of Medicine, and Divi-
sion of Epidemiology, School of Public Health, Minneapolis, MN 55455
Nathan Maccoby and John W. Farquhar
Stanford University, School of Medicine, Stanford Heart Disease Prevention Program,
Stanford, CA 94305
147
0163-7525/85/0510-0147502.00
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148 PUSKA ET AL
INTRODUCTION
Cardiovascular Disease as a Public Health Problem
Cardiovascular diseases (CVD) are a major cause of mortality in the world,
although great variability exists in the death rates in different regions of the
world. In the developed countries approximately half of the deaths, nearly one
third of the permanent disability, and a high proportion of health service
utilization are due to CVD (65).
During the last hundred years the industrialized countries have shown a
major change in public health: the impact of infectious diseases has been
dramatically reduced owing to general social and hygienic or specific preven-
tive and therapeutic measures. Chronic diseases, especially CVD, have
emerged as the main new public health problem. Analysis of data from several
industrialized countries shows that the greatest potential impact on longevity
among the adult population is from control and prevention of CVD (16). Thus,
new advances in public health are dependent on our achieving control of
cardiovascular and related noncommunicable health problems.
The current high mortality and morbidity from CVD is not only a result of the
aging of the population. In many developed countries, around 40% of all deaths
in the middle-aged population are caused by CVD. About three fourths of these
deaths are due to coronary heart disease (CHD), mainly acute myocardial
infarction (AMI). Since the Second World War the mortality from CHD among
middle-aged people increased considerably, making it one of the worst world-
wide epidemics of all times.
There are considerable differences in CVD and CHD rates, even between the
industrialized countries, as has been shown repeatedly with mortality statistics
(e.g. 37, 38). According to the World Health Organization’s (WHO) statistics
in 1975, Finnish males had the highest CHD mortality rates in the world,
followed by the USA, Australia, England, and Canada (Table 1).
The regional differences in the CVD mortality rates have been confirmed by
the Seven Countries Study (25), which surveyed and followed middle-aged
male population samples in different parts of the world, and by a WHO-
coordinated AMI registration study (67). Both studies found the highest rates
Finland. Already in the 1950s, mortality statistics showed, and later the Seven
Countries Study and the AMI register confirmed, that within Finland the CVD
rates were higher in the east than in the west.
The impact of CVD and other noncommunicable diseases (NCD) in Finland
on premature mortality is further illustrated by the observation that out of ten
deaths in middle-age, about five are due to CVD, two to cancer, one to
non-neoplastic respiratory disease, one to violent causes, and one to all other
causes together. This situation is not very different in many other industrialized
countries. According to the WHO-coordinated register study, in the beginning
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THE NORTH KARELIA PROJECT 149
Table 1 Age-standardized mortality rates from ischaemic heart disease per 100,000 population in
1975 (40-69 year age group)
Males Females
Finland 673 202 UK: Scotland
UK: Scotland 615 193 Israel
UK: Northern Ireland 614 189 UK:Northern Ireland
New Zealand 545 180 Australia
Australia 534 171 United States of America
United States of America 528 168 Ireland
Ireland 508 167 New Zealand
UK: England and Wales 498 143 Canada
Canada 473 142 Finland
Czechoslovakia 410 138 UK: England and Wales
Denmark 400 129 Czechoslovakia
Norway 398 125 Hungary
Israel 370 114 Denmark
Sweden 368 110 Bulgaria
Netherlands 363 102 Sweden
Hungary 328 89 Austria
Federal Rep. of Germany 325 87 Netherlands
Belgium 312 86 Norway
Austria 308 84 Belgium
Bulgaria 237 81 Federal Rep. of Germany
Poland 229 70 Yugoslavia
Italy 226 64 Romania
Switzerland 226 63 Italy
Yugoslavia 180 56 Poland
France 152 50 Switzerland
Romania 146 37 France
Japan 69 29 Japan
of the 1970s the annual incidence rate of AMI (per 1000 population) among the
40- to 59-year-old population was 18 in North Karelia (eastern Finland), 9
Helsinki, 7 in Dublin, 6 in Perth (Australia), 5 in London, 4 in Heidelberg
(West Germany), 3 in Prague, and 2 in Bukarest. Mortality statistics also
showed that the lung cancer rates of Finnish men were high, and within Finland
the rates in eastern Finland were the highest.
History and Organization of the North Karelia Project
These statistics raised the awareness and concern of the Finnish public. The
people of North Karelia in eastern Finland, where the Seven Countries Study
was initiated in the 1950s, were particularly concerned. The statistics showing
the high disease rates confirmed the people’s own observations. In the begin-
ning of the 1970s, among the county’s total population of 180,000, some 1000
myocardial infarctions took place annually, and about half of them were among
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150 PUSKA ET AL
men below 65 years of age. About 40% of these cases were fatal. In 1972,
among people aged 45-59 in North Karelia, 27% were pensioned due to
disability, about one third of those because of CVD (45).
On January 12, 1971, the Governor, all North Karelian members of the
national parliament, and representatives of many official and voluntary orga-
nizations in the area signed a petition for national aid to reduce the cardiovascu-
lar problem in North Karelia. The petition noted the very high frequency of
CVD in the area and proposed that national authorities and organizations
concerned "should urgently undertake efficient action to plan and implement a
program which would reduce this greatest public health problem of the coun-
ty." Simultaneously, related public health questions were discussed nationally.
In 1972, a new Public Health Act reorganized primary health care, and the
University of Kuopio (including a medical school) was started in eastern
Finland.
In response to the North Karelian petition, a panel of Finnish experts,
international experts provided by WHO, Finnish health authorities, and North
Karelian representatives met to outline the scope of the work that was needed
and to recommend further action, including the establishment of the Project
organization.
Based on the recommendations, the North Karelia Project, a major commu-
nity-based preventive cardiovascular study, was formulated and launched.
From the very beginning, the project was to be a planned, action-oriented
program with evaluative and other research. Simultaneously, the project would
work in close collaboration with national health authorities and the WHO as a
major pilot or demonstration project to test the usefulness of this approach for
national and international purposes.
Almost concurrently with the Finnish project, an analogous study, the
Stanford Three Community Study, was planned and launched in the USA (15).
The two projects later developed mutually beneficial scientific exchanges, and
the developments in Finland and in the USA pioneered the work in community-
based prevention of CHD (see below).
After the initial organization of the North Karelia project had been estab-
lished, the intervention program and its evaluation were planned. Since the
importance of the baseline measurements were appreciated and the community
was pressing for action, the initial work of the project team was to establish
proper baseline measurements and disease surveillance methods for the evalua-
tion. In doing so, the project used WHO andother international recommenda-
tions and established contacts with a number of Finnish experts and key North
Karelian representatives.
Once the baseline survey was launched (spring 1972), the project team had
more opportunity to plan the intervention activities. The project field office was
established within the county health department, and local project advisory
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THE NORTH KARELIA PROJECT 151
boards were set up with participation from various community agencies.
Numerous contacts were initiated for community organizing, initial awareness
campaigns were launched, materials and action plans were developed, and
local training activities were started.
North Karelia is the most eastern of the eleven Finnish counties. The area is
18.000 km
2 (nearly 300 km from south to north), with great forests, lakes, hills,
small farms, small towns, and numerous small villages. The population was
180,000 in 1972, and the population density thus relatively low. The area can
further be characterized, relative to other areas of Finland, as having low
socioeconomic status, high unemployment, an income based on farming and
forestry, and scarce medical and other services.
The North Karelia project was thus started in spring 1972 to carry out a
planned, comprehensive community program in all of North Karelia for control
of CVD, especially CHD, in respond to the petition of the population. The
program was aimed at the county’s total population, but with special reference
to middle-aged men, whose disease rates were especially alarming. Evalua-
tions were designed to assess the feasibility, effects, process of change, costs,
and other consequences related to this program. The original project was set up
to carry out this program and to evaluate it for a five-year period from 1972 to
1977. Because this experience was an encouraging one, ’it was decided to
continue the program (45). In spring 1982 a major ten-year survey was carried
out (44).
The aims of this report are (a) to describe the theoretical framework of the
project, its intervention and evaluation; (b) to review and discuss the main
results obtained so far; (c) to relate the North Karelia project to other studies
that have been carried out or are underway in other parts of the world.
THE THEORETICAL FRAMEWORK
General Principles
The historical background of the project in North Karelia led the way to
adoption of the community approach. Also, because CVD was a widespread
health problem and its precursors were present in a major proportion of the
population, a community-wide scale was necessary. Accordingly, the project
principle was to approach these diseases in the entire community in a manner
appropriate to any epidemic.
The community approach assumes that the magnitude and nature of the
problem precludes a simple, externally initiated solution. Instead, the program
has to be integrated with the existing social and health service structure of the
community. Since the problem relates closely lifestyle, the population itself has
to make the decision to organize itself to solve the problem, with the help of the
project experts. A community program for control of CVD (and related noncar-
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152 PUSKA ET AL
diovascular diseases) assumes that existing scientific knowledge can be applied
to serve the population (or that the community can be helped by having better
access to use of the existing knowledge).
Although continuous efforts for new medical and technological advances are
still needed, it is obvious that major control of CVD and related diseases is
possible with existing knowledge if it can be effectively applied in the popula-
tion. Although a full consensus on causal links between health habits and
disease are lacking--as it may always be--we have to act on the best currently
available knowledge. This point is further reinforced by the magnitude of the
problem and the realization that doing nothing is also a decision. A decision to
await "final proof" cannot help the great number of people in our society who
suffer premature death or major disability. In spite of the gaps in our knowl-
edge, we understand few other noncommunicable diseases as well as we do
CHD and stroke.
The history of public health is full of examples of successful actions that are
not based on full knowledge of the pathogenesis and etiology of the disease
concerned. Success has been often based on effective intervention on some
parts of the causal chain that lead to the severe manifestations. Carefully
evaluated community programs form an important link between basic labora-
tory and clinical research and the large-scale application of public health
programs in society. These programs can thus diminish our uncertainty con-
cerning the effectiveness of such action, inform us about effective use of the
existing resources (service and other community resources), and tell us about
other possible consequences associated with such interventions. Therefore,
carrying out a carefully evaluated community program like the North Karelia
Project serves not only its target area, but serves also as a "pilot," "demonstra-
tion," or "model" for testing the approach in wider applications.
The field nature of a community program denies the experimental control of
many variables. The researcher is therefore not able to test specific epidemio-
logical or behavioral hypotheses rigorously. Rather, a community study tests a
complex yet practical program based on pre~;ious theory and of such a nature
that it could be applied elsewhere, if the results demonstrate success. Thus the
limited "internal validity" is compensated by greater "external validity" of the
results, i.e. validity for use in real-life circumstances.
A key feature of the "demonstration" or "pilot" program is that the interven-
tion is well conceived and implemented as a planned, systematic program. The
program contents are determined by existing medical, epidemiological, be-
havioral, and social knowledge applied intelligently and adopted to the local
community setting. Evaluation includes both continuous monitoring and
formative evaluation to guide the program, and comprehensive summative
evaluation to assess the overall results.
Figure 1 describes a model of the precursors and stages in the natural course
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THE NORTH KARELIA PROJECT 153
~’----SOCIOLOGY ANTHROPOLOGY ..... ~EP, D..E_M__~_O_L_O__e_Y_ CL,N~AL MEDICINE
~S~IAL p~ D~IO!-~
COMMUNICATION’ NUTRITION ...............
ENVIRONMENT
- socio
! - physical
EG. ¯ BELIEFS
¯CULTURAL NORMS
¯PI:.ER INFLUENCE
¯MEDIA INFLUENCE
¯SOCIAL NETWORKS
¯OPINION LEADERS
¯CLIMATE
¯DIETARY CUSTOMS
¯~OOD MARKEIING
¯SMOKING POLICY
¯HEALTH SERVICES
Figure 1 Precursors and sequence of factors leading to cardiovascular disease (coronary heart
disease and stroke). The major disciplines needed for effective community-based research in
cardiovascular disease (CVD) are listed above. The traditional scope of each discipline is given
the solid portion of the line. The dotted portion of the line depicts the less common extension of the
particular discipline to broader aspects of the related components.
of developing cardiovascular disease. The disease outcomes are preceded by
their environmental and behavioral origins through biological factors (modified
by individuals’ genetic predisposition) to clinical disease manifestations. A key
feature of the community program is that it simultaneously applies medical and
epidemiological knowledge to identify the health problems and to prioritize in
selecting health objectives, and behavioral and social knowledge to design the
actual program contents and activities. This implies an interdisciplinay
approach both in planning and implementation and in the evaluative research.
The Medical and Epidemiological Framework
The petition and the historical background of the North Karelia Project guided
the adoption of the main objectives. Accordingly, the program’s main target
was the major CVDs responsible for the greatest excess of premature mortality
among that population, especially among men. It was realized that success
would lead to achievement of broader public health aims, since (a) CVD alone
was responsible for nearly two thirds of all deaths among the middle-aged
population, and (b) reductions in the target risk factor would also probably have
beneficial effect for some other NCD and for health in general.
The main medical goal, control of the CVD epidemic, implies all possible
action to reduce the burden of the disease, including primary prevention,
treatment, rehabilitation, and other secondary prevention and related research.
However, major success in controlling a chronic disease can be based only on
primary prevention, since intervention after the clinical stages have been
reached will have only a limited impact. The greatest potential in control of
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154 PUSKA ET AL
CVD thus lies in primary prevention: the "mass epidemic" should be tackled by
"mass prevention."
A great deal was already known about the precursors and risk indicators for
CHD when the North Karelia Project was originally petitioned. Research had
proceeded from desriptive epidemiological studies on populations at high and
low risk and from retrospective studies among CHD patients to prospective
follow-up studies, the first major one being the Framingham study in the USA
(7). A summary of the results of several other prospective studies initiated
the USA in the 1950s and the 1960s was published as the final report of the
Pooling Project (39). Results from a major international prospective study, the
Seven Country Study (25), were available. First results from the Swedish "Men
born in 1913" study became available in the late 1960s (59). All these studies
indicated that a few factors--notably smoking, elevated serum cholesterol, and
elevated blood pressure--predict a major part of subsequent CHD risk, inde-
pendent of other potential factor studied. Results from basic biochemical
studies, as well as results from a few experimental and quasi-experimental
studies on the different risk factors, have also long been available: for smoking
cessation (8), for cholesterol-lowering diets (62), and for blood pressure
treatment (63).
By the beginning of the 1970s these studies had already lead to a number of
excellent reviews (e.g. 3, 11, 56, 57). Several expert groups had published
recommendations for further studies or national applications of preventive
activities. In 1970, a WHO expert group proposed that preventive trials should
concentrate on combined intervention of smoking, hypertension, raised serum
cholesterol level, and physical inactivity (64). In the same year the Report
the Inter-Society Commission for Heart Disease Resources (47) in the USA
recommended that primary preventive efforts should be aimed at elimination of
smoking, change of diet to reduce the serum cholesterol levels, and treatment to
lower high blood pressure, with special emphasis on the combination of these
risk factors.
As the likely major risk factors came to be identified and the multifactorial
origin of the CHD became obvious, several centers started to plan multifacto-
rial trials. A few trials with the classical design of randomizing individuals or
groups to experimental and control groups were initiated in the beginning or
during the 1970s. However, the problems involved with such trials soon
became obvious; namely, the great number of people and many years needed to
test the hypothesis, and the close link between risk factors and the community
lifestyles and environment. An alternative approach, i.e. one involving an
entire community to modify its risk factor profile in a planned and well-
evaluated intervention, had obvious merits and was the choice of the North
Karelia Project.
The choice of the main risk factors to be intervened upon was relatively easy.
The international work had highlighted the obviously important role of smok-
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THE NORTH KARELIA PROJECT 155
ing, serum cholesterol (related to dietary habits), and blood pressure. It was
already well known that the levels of these risk factors were high in the Finnish
and especially in the North Karelian population. Furthermore, some other
possible risk factors, like physical inactivity, obesity, or type A behavior, were
not prevalent in the area.
The validity of the focus of the intervention was further supported by the
results of a separate follow-up study in the North Karelia Project (53).
random population sample of some 3800 men initially aged 30 to 59 years and
free of obvious CVD was followed for seven years. A multiple logistic function
analysis showed that, in addition to age, smoking, serum cholesterol, and
blood pressure were the strongest independent predictors of subsequent AMI.
Out of a number of other variables included, only physical inactivity (negative)
and self-reported alcohol consumption (positive) had some additional indepen-
dent predictive power. It was also found that these factors were also good
predictors of overall mortality.
Once the risk factors have been agreed upon in a program, choices still need
to be made concerning the intervention strategy. The "high risk" (or "clinical"
or "focused") approach attempts to identify those people with high risk factor
levels and to intervene on these. The "community" (or "total population" or
"public health") approach attempts to modify the general risk factor profile of
the whole population.
Although an individual’s risk of CHD increases with increasing risk factor
levels (a fact of obvious relevance for clinical practice), it is critical to realize
Table 2 Standardized coefficients of variables predicting the risk of AMI
and death in multiple logistic analysis and during a seven-year follow-up of
3811 men aged 30-59 years in 1972 and with no AMI, angina pectoris, or
stroke at the outset
Standardized coefficient
Variable AMI Death
Age .68
a.71
a
Serum cholesterol .42
a.22
a
Smoking .35
a.34
a
Diastolic blood pressure .25
a.23
b
Physical inactivity (at work) .19
b.24
b
Alcohol use (self-reported) -. 17
a-.04
Educational level -.06 -.26
a
Familial history of CVD .09 .00
Relative weight (BMI) .07 -.16
Psychosocial stress -.04 -.04
History of diabetes -.03 .03
a= p < .001.
~’= p < .01.
c= p < .05.
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156 PUSKA ET AL
that high risk individuals produce only a small proportion of the disease cases
that occur in the community. Many cases arise among people with only
moderate elevations, but usually in several risk factors. Because the people
with moderate risk outnumber the few really high risk individuals, and because
the simultaneous occurrence of several risk factors has a synergistic impact,
major reduction in the number of disease cases in the community can occur only
if the general risk factor levels can be modified in this great majority--in
practice, the whole population.
The clearly greater potential of the community approach compared with the
high-risk approach in reducing the CHD rates in the community has been
demonstrated by modeling the different approaches and using the data from the
North Karelia Project (27). This point has also been well described by Rose
using the Framingham data (50). The North Karelia Project results also show
that lifestyle changes in the community are not well predicted by people’s
initial risk factor levels, hence further reducing the usefulness of the high-risk
approach (53). Thus, from the epidemiological point of view, major reductions
in the disease rates in the community can be achieved only by widespread
reduction in the levels of the multiple risk factors. This implies community-
NII~ RISK
Risk
toctor
chongo: 0.~chio~:~ Gool
-40-
POPULATION STRA’I~-.I~
,achieved Gocal Ideol
Figure 2 Projected effects of different prevention strategies on reduction of AMI rates in the
community: North Karelia Project data. Achieved and Goal refer to experiences in recent studies
(see Ref. 27).
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THE NORTH KARELIA PROJECT 157
wide effort to promote lifestyles that are likely to reduce the risk of CVD. Such
lifestyle changes are also likely to be beneficial for prevention of several other
NCD, to be safe and to promote health in general.
The Behavioral~Social Framework
Once the aim of the program has been defined to influence lifestyles and risk
factor changes in the whole community, the task enters the realm of the
behavioral and social sciences. Medical practice has long been based on the
assumption that after identification of the behavioral agents leading to diseases,
merely informing the subjects (giving them information) is enough to change
the situation. Numerous studies and everyday practice show that this is seldom
the case. Behavior is embedded in a complex way in the social and physical
environment.
Here we cannot help making reference to the old wisdom of public health:
Consider the totality of host, agent, and environment. Much of the work
concerning prevention of chronic diseases has concentrated on the link between
the agents (risk factors) and the host (man). But actually, many, if not most,
the great achievements in public health have involved major emphasis on the
environment. This linkage to the environment applies to control of CVD and is
a major rationale behind the community approach. The agents (behaviors/risk
factors) of heart disease are largely determined by social forces and other
environmental factors. Any major progress in influencing the disease rates has
to deal with the environmental forces and structures. The natural, most effec-
ENVIRONMENT
EG -~UNI~ WAY ~ L~E
-~NERAL ~LIE~, NO~S AND V~UES
- C~NITY OR~NIZATIONS
-~YSI~L E~RONMENT~0~ ~RK~NO,
~KI~ ~E~ E~.)
M~TM ~RVICES
~4OST
EG: - A~
-SEX
- ~NETIC
-~ITY
Figure 3 Classical epidemiological agent-host-environment model as applied to noncommunica-
ble diseases.
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158 PUSKA ET AL
tive way of changing a population’s risk factor levels is to work through the
community: the community should be the fiaajor target rather than its indi-
viduals.
The task of influencing people’s behaviors and lifestyles is in the domain of
social and behavioral sciences. Still, a major problem has been the lack of a
unifying theory to serve as a guide. Program- and action-oriented people often
feel frustrated by the inability of behavioral and social scientists to tell them
what they should do. In spite of this we feel strongly that there are sound
behavioral and social science principles to guide our way in planning, im-
plementing, and evaluating community-based health programs. We refer to the
old wisdom, "There is nothing so practical as good theory."
In the following we describe briefly four theoretical, somewhat overlapping,
frameworks for behavioral change. Finally we present a model that unifies
these approaches in a community-based health program.
THE BEHAVIOR CHANGE APPROACH This social psychological approach
deals with the determinants of an individual’s behavioral changes, and is based
on B andura’s work on the process of learning. New behaviors tend to originate,
at least on trial bases, from chance exposure to powerful models; external and
self-enforcement and cognitive control are the consequent determinants of
continued new behaviors (2). This approach also includes elements of the
classical field theory of Lewin (29) and the behavioral intention model
Fishbein (17).
In a previous paper we presented a framework compatible with this
approach, using examples from the various activities in North Karelia (32). The
relevance of this approach in different cultural situations gets support from the
recent work of Kar (23), who has shown that in different cultures the main
factors predicting health behavior (e.g. contraceptive use) are intentions, social
support from significant others, and accessibility of knowledge and services.
Our model emphasizes that program planning and evaluation should include
the following key steps to help individuals to modify their behavior:
1. Improved preventive services to help people to identify their risk factors and
to provide appropriate attention and services.
2. Information to educate people about the relationship between behaviors and
their health.
3. Persuasion to motivate people and to promote the intentions to adopt the
healthy action.
4. Training to increase the skills of self-management, environmental control,
and necessary action.
5. Social support to help people to maintain the initial action.
6. Environmental change to create the opportunities for healthy actions and
improve unfavorable conditions.
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THE NORTH KARELIA PROJECT 159
7. Community organization to mobilize the community for broad-ranged
changes (through increased social support and environment modification)
support the adoption of the new lifestyles in the community.
Concerning persuasion, one of the key steps in the model, the North Karelia
Project emphasized the credibility of the message source (WHO, government,
academic expert opinion, health motives etc), various "affective" aspects
(reference to the petition, "county pride," international interest, etc), and
contents of the message that anticipated the counter-arguments and that match-
ed with the local culture. As a whole, the aim was to inspire "community action
for change" in which people would participate not necessarily for their own
sake but for the sake of North Karelia and the Project that had become familiar
and close to the people (thus emphasizing incentives other than those related to
their long-term disease risk). An often used slogan was, "I am in the Project."
As in the Stanford "Three Community Study" (15), the North Karelia project
placed great emphasis on various efforts to teach practical skills for change; for
example, smoking cessation techniques and ways of buying and cooking
healthier foods. In the latter regard, close cooperation with the local house-
wives’ association (MARTTA association) proved most valuable. Various
activities were carried out simultaneously to provide social support, to create
better environmental possibilities (e.g. production and marketing of healthier
foods), and ultimately to organize the community to better meet these needs.
THE COMMUNICATION-BEHAVIOR CHANGE APPROACH The task of intro-
ducing new behaviors in the community is basically achieved by communica-
tion: mass communication and interpersonal communication. A project com-
municates its messages through mass media to the population, in addition to its
direct communication to various community leaders. In addition to Bandura’s
social leaming theory (2), the classical communication-persuasion model
McGuire (33), its modification by Flay et al (18), and the belief-attitude-
intention model of Ajzen & Fishbein (1) provide well-documented theoretical
background for this approach.
The North Karelia Project has developed a model, especially in connection
with the national TV health education programs of the project (42, 46), that
recognizes the various steps of behavioral change, from exposure and attention,
through comprehension and persuasion, to action and maintainance of new
behaviors. Furthermore, the model takes into account the factors that relate to
the communicated message on one hand and to the community-related factors
on the other hand that influence the various steps of behavioral change (see
figure). By carefully observing these aspects in the planning of the message and
by paying attention or even trying to influence these factors in the community
(e.g. increased social interaction) accordingly, the likelihood of positive results
increases.
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160 PUSKA ET AL
~N IC~TtON PROCESS Of" C01~4MUNi’~’
I:’N;’TORS BEH~I/IOR CHANGE F’AC T OP-~
¯ CHANNELIS)~ ATTENTION ~------~./~3DIENC~ TN:~P_.~ETS
¯ EXR73URE ~(~t~)
ethAnE ~ MOTIVATION ~*I~VE~NT
~LEVANCE ~NION
~AT~TU~CHANGE ~-~ ~LEVANT
I~N) ~T~
C~
eTE~HINO H~LTH~TH ~IL~ ~NNG~=~ED
~HAVI~ ~IL~ ~ B~ON FEED-
VIA ~O~TRATION ~J
~I~D ~CE
HEATH SKILLS ~R- *~NIW EVE~
=~ES ~ F~A~E H (T~T DA~ ~TS
~TIVITI~ ~.1
T~NING ~ N~TE~ ~ ~R- ~ACTICAL ~P
~NITY ~ ~TION
~ode] of ~hc communicBdon p~ocess ~n community in~c~cndon ~o induce behavioral
used in [he ~o~h ~el~ P~ojccL
The task of influencing behavior through mass communication is extremely
difficult due to the complex process involved. The danger is that with many,
often conflicting, communication messages, people basically tend to maintain
their well established habits. However, with the several TV programs of the
Noah Karelia project, actual behavioral effects in the population have been
observed. For example, a national survey two to three months after the start of
the 1982 TV series showed that approximately 25% of the population had seen
at least two sessions and that 1-2% of the smokers in the population reported
having stopped smoking with the program and approximately 5% of the
population reported actual dietary changes (42). These rates represent consider-
ably high absolute numbers. Compared with other possible methods, TV
coverage has proven to be a cost-effective and certainly a useful element in the
overall program. Detailed d~scriptions of this type of planned use of the mass
media are published, both in regard to the Finnish TV programs (40, 42, 46)
and the programs of the Stanford Three Community Study (31).
THE INNOVATION-DIFFUSION APPROACH New lifestyles are innovations
that diffuse with time through the natural networks of the community to the
members of the given social system. This diffusion, causing social change,
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THE NORTH KARELIA PROJECT 161
occurs through communication over time. The innovation-diffusion theory
argues that mass media are more effective in creating knowledge of innovations
and are useful for "agenda-setting" purposes, while interpersonal channels are
more effective in actually changing attitudes and behaviors. The innovation
process occurs in four stages (note the similarity to the previous approach): (a)
knowledge, (b) persuasion, (c) decision, and (d) confirmation.
The innovation-diffusion theory classifies people on the basis of their in-
novativeness as innovators, early adopters, early majority, late majority, or
laggards. The social structure has several norms (system effects) that have
strong influence on the rate of diffusion. Early adopters and a greater diffusion
rate are more likely to occur in modern rather than traditional community
norms. The early adopters usually have the greatest social influence in the
community and are thus in key positions to influence a wider adoption of the
innovation. An agent of change is a professional who attempts to influence this
innovation-decision process. Three main types of innovation decisions have
been suggested: (a) optional decisions (made individually), (b) collective
decisions (made by concensus), and (c) authority decisions (made by a super-
ordinate power).
These central principles of innovation-diffusion theory have been developed
mainly by Rogers (48). The theory is well supplemented by the classical idea
the two-step flow of new ideas and attitudes through opinion leaders (24). This
simplified model holds that new ideas, often originating from mass media, are
mediated and modified by certain opinion leaders, and most people are then
influenced mainly by interpersonal contacts with these opinion leaders. Opin-
ion leaders can be identified through their particular expertise or position, or
they can be informal and undistinguishable by formal criteria. Opinion leaders
can either favor or resist the innovation-diffusion process.
The innovation-diffusion principles are of great relevance for many com-
munity programs. A health project is based on certain health innovations that
the project’s change agents try, through communication, to spread through the
social network to the members of the community. The diffusion time is an
essential element of the approach. Diffusion can be facilitated by the skillful
use of theoretical principles of the communication process. The degree of
community resistance (systems effect) also has an obviously important role2.
The central project team of the North Karelia Project tried to observe several
of the well-known principles of being a successful change agent: e.g. under-
stand the needs of the communi~y~ and diagnose the problems, represent a
credible source, establish a close relationship and empathy, create the intent to
change in people and show ways to translate intention into action. From its
inception the Project worked closely with the various formal opinion leaders
(municipal leaders, voluntary organization leaders, health personnel, mass
media and business leaders etc). Later, the Project systematically identified
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162 PUSKA ET AL
informal opinion leaders in order to communicate the innovations through the
county via this network (35, 41).
THE COMMUNITY ORGANIZATION APPROACH Broad-ranged changes in the
community can be achieved ultimately only through the existing community
structures. Every community has a complex network that exercises great
influence over individual behavior and lifestyle. The community organization
approach emphasizes efforts to influence individuals through changing orga-
nizations to meet the desired ends. The concept of community organization
involves both community self-development (the community initially detecting
a problem, and organizing itself to cope with it) and the outside influences
needed to promote the reorganization.
The community petition that initiated the North Karelia Project provided a
favorable subjective climate for community reorganization. However, the
Project team provided the external impetus and resources for change in the
community. In doing so, the principles of persuasion and of the change agent’s
role have been of central importance. The impact depends largely on the degree
to which the existing community organizations find the proposed actions to fit
with their particular needs. It is therefore important for success in community
self-development that the program offer incentives for the proposed collabora-
tion.
The North Karelia Project team tried throughout the program (but with
greatest intensity in the beginning) to have close contact with a great many
representatives of community organizations. The team worked intensively with
the representatives of the mass media (newspapers, radio), with people
health and other services (administrators, doctors, nurses, teachers, social
workers, schools, teachers etc), with business leaders (dairies, sausage facto-
ries, bakeries, groceries, etc), with key persons of voluntary organizations
(heart association, housewives’ organization, labor organizations, sports orga-
nizations, etc), and with local political decision makers (county and municipal
leaders). The team tried to show these organizations practical, feasible ways to
collaborate, while recognizing each organization’s particular needs. The aim
obviously was that the changes so initiated would ultimately influence behavior
in the community.
A UNIFIED MODEL The approaches described above have been unified in
Figure 5 to show the behavioral/s0cial model of community intervention that
we found to be most relevant to the North Karelia Project. The external input
from the project affects the community both through mass media communica-
tion to the population at large (where its effect is mediated through interperson-
al communication) and even more so through formal and informal opinion
leaders acting as change agents to influence various aspects of community
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THE NORTH KARELIA PROJECT 163
organization. This two-pronged emphasis is aimed at increasing knowledge, at
persuasion, at teaching practical skills, and at providing the necessary social
and environmental support for the p~erformance and maintenance of these health
skills in the population. The acquisition and maintenance of new behaviors
ultimately leads to a more favorable risk factor profile, reduced disease rates,
and improved health.
THE MAIN PROJECT COMPONENTS
The practical framework of the North Karelia Project, like any similar project,
consists of three components: (a) planning, (b) intervention program imple-
mentation, and (c) evaluation. Although they usually occur sequentially,
listed, in time, in many cases these elements take place simultaneously as the
project proceeds (Figure 6).
Planning
The major elements in the project planning are (a) definition of objectives, (b)
community analysis, (c) establishment of the project organization, and (d)
preparatory steps.
The main objectives of the program are usually set by the objective and/or
perceived health needs of the community. In North Karelia these were both
met. The intermediate objectives are designed on the basis of the available
medical/epidemiological knowledge concerning how to influence the health
problem(s). The practical objectives and actual intervention measures should
then be based on careful analysis of the community and on understanding of the
strategic determinants of the intermediate objectives (Figure 7).
GOMMUNITY
~NI~’Y "~1~ Opinion leaders
IORGANIZATION - formol
I- mo~s medio ~ - in~l
I~-~t~a~ ~ t..
I// o~ ~i~ ~ I ~na~
/~ -i~. b~ Eady ~o~rs
m~CT -- ~.
IN~
-
O~t
-1-
’qn, "\ IN NEAI_TN
--AND RI~K
"r
T"
Figure 5 Model of community intervention, as used in the North Karelia Project.
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164 PUSKA ET AL
PLANNING ]I~I’INf~.ENENTATION
¯~I~TY
DI~OSIS
¯ DEFINING OF
OBJECTIVES
¯ PROJECT
OI~NIZATION
BUILT
¯PP, E PARATORY
STEPS
Figure 6
{INTERVE]NrnoN F~,06P, AIM)
¯ COIV~ITY- BASED
-TARGET: WHOLE C01~I~JNITY
-C01~UNITY O~ZATION
-CO~IBINATION
OF DIFFEP~
STRATEGIES
-DIFFUSION AND INTEP, ACTION
¯F~,OGP, AM ORC-~NIZATION
-COMMUNITY INVOLVEWE NT
EVALUA~ON
¯ FORMATIVE SIJ~IMATIV~
¯ EVALUATION A~MS
--FEASIBILITY
-EFFECIS F~gK FACTORS
DEEASE
-PROCESS
¯E~LUATION STUOY OES~
-E~ASI EXPERI~IENTAL
-REFERENCE COMMUNITIES
-POPULATION ~
DISEASE MONITORING
¯DIFFEP,ENT RESEARCH
FP.b~4EWOR~S
Model of elements in the community-based project, as used in the North Karelia Project.
To the greatest extent possible, the community analysis ("community di-
agnosis") should provide a comprehensive understanding of the situation at the
start of the program. It should provide the basis for selecting priorities and
appropriate methods for the intervention, and indicate how continuous follow-
up should be carried out to help guide the activities. Background information of
the community was collected in North Karelia along these lines (45, 60).
Already existing data from previous studies, statistics, and expert opinions
were collected and reviewed at the planning seminars. Later on, the results of
the baseline survey were used to complement the picture.
Important information for the community analysis included epidemiological
information from the area: the mortality and morbidity rates of the different
GENERAL BQAL
(IMPROVED HEALTH)
MAIN OBJECTIVES
(DISEASE OUTCOMES)
INTERMEDIATE OBJECTIVES
(risk foctors beh~4ors treatment etc.)
/,’I\\
PRACTICAL OBJECTIVES/INTERVENTION MEA..gJRES
Figure 7
Med’r_~l / Epidemi01~jie:tt
knowledge
,1. Eedier re,seerch
2. Locc,l prevete-~ce
knowledge
1. Theory
2.Community onelysis
Establishment of the hierarchy of objectives in a community-based health program.
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THE NORTH KARELIA PROJECT 165
possible health problems of the total population and various subgroups, the
prevalence rates of the possible factors influencing these diseases in the target
population. Features of the geography, demography, and the socioeconomic
factors of the community were reviewed. Information was obtained about the
various lifestyles related to the risk factors, about the various community
features influencing these behavior complexes, about the community lead-
ership and social interaction/communication channels, and about other factors
relevant to the behavioral/social framework.
Because much of the success of a program depends on the support of the
population, information was obtained on how people and their representatives
saw the problem and how they felt about the possibilities of solving them.
Because the program would depend on the cooperation of the local decision-
makers and the health personnel, these groups were also surveyed at the outset
(43). The community resources and service structure were also considered
before deciding on the actual forms of program implementation.
The historical formation of the project organization and the preparatory steps
for launching the program are described above. The project organization
comprises a principal investigator (project director), co-principal investigators,
a steering committee, and a coordinating center: the Department of Epidemiol-
ogy of the National Public Health Institute (earlier at the University of Kuopio).
This central project organization coordinates the field activities in North
Karelia, the research activities (National Public Health Institute, University of
Kuopio, other), and the national/international activities. The field office of the
project in North Karelia is located at the county department of health (and social
affairs). A local project advisory board serves to enhance the community
participation and feedback.
Implementing the Intervention Program
The goal was systematically to implement the program according to its aims
and principles. Within the overall framework of the program, its actual imple-
mentation was sufficiently flexible to adjust in response to opportunities in the
community. After the needed measures were defined, the formal support was
ensured and community resources were identified to accomplish the tasks.
Integrating the program into the community social organization was neges-
sary because in so doing the participation of the community and the availability
of community resources were ensured. Thus the Project set the objectives and
developed the general framework, while the activities were carried out mainly
by the community. The Project catalyzed this work by providing materials,
training, necessary official support, mass media support, and follow-up.
The program activities were simple and practical in order to facilitate
enactment in the larger community. Instead of highly sophisticated services to a
few people, simple basic services were provided to the largest possible
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166 PUSKA ET AL
population. This eased information dissemination and personnel training. In-
tegration of the comprehensive measures not only saved the project resources,
but avoided duplication and overlapping activities as well, and thus meant
better use of the community .resources.
To identify and mobilize community resources, the Project worked closely
with official agencies and voluntary organizations. As an official pilot pro-
gram, the new health service activities initiated by the Project became part of
formal public health activities in the area. Thus participation in these activities
formed part of the regular work of the health professional, not simply an extra
job or hobby. In this way the Project activities were based on authority
decisions, in addition to training and motivation. Close personal contacts
between the Project team and the local health personnel were emphasized to
help motivation and compliance.
The use of the large network of other organizations and opinion leaders
encouraged population participation. For the most part these organizations
appreciated being able to contribute to the success of an important project.
Numerous personal contacts were made, local problems were discussed, and
possibilities for practical contributions were reviewed. The population’s in-
terest and support generated by the activities and mediated by the mass media
made it easier to establish further intervention activities.
Since the motivation and support of the general population formed a comer-
stone for the project intervention, much of the practical "project work" was
carried out by lay people and voluntary organizations. The well-trained and
motivated public health nurses maintained the systematic basic health center
activities and the necessary administrative framework (e.g. hypertension dis-
pensaries, smoking cessation courses, rehabilitation groups, disease registers
etc). The doctors acted as medical experts within this framework.
The program activities of the North Karelia Project can be divided into the
following groups:
1. media-related and general educational activities,
2. training of local personnel and other active groups,
3. organization of health services (primary health care, other),
4. other community organization activities,
5. project activities for monitoring the development for management and
feedback.
The media activities involved cooperation with the local newspapers and
radio, production of various health education materials, and support to various
community meetings and campaigns. Training extended to doctors, nurses,
social workers, teachers, representatives of voluntary organizations, etc. Later
on in the project informal opinion leaders were identified and trained in a
systematic way (35). Most of training was organized in cooperation with
county administration and/or with other organizations.
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THE NORTH KARELIA PROJECT 167
The necessary reorganization of health services was carried out through
formal decisions, training, demonstrations, provision of guidelines, and mate-
rials. Major activities were the reorganization of hypertension control in the
area (hypertension clinics, and a hypertension register) and organization of the
follow-up and secondary preventive activities for myocardial infarction pa-
tients (36, 45).
Other community organization activities concerned a large number of volun-
tary organizations (heart association, housewives’ association, sports clubs,
etc), the food industry (dairies, sausage factories, bakeries, etc), and grocery
stores. Using and developing various information systems (surveys, registers,
statistics, etc), the project monitored the progress for the continuous manage-
ment and feedback.
A detailed description of the intervention activities can be found in the WHO
monograph on the North Karelia Project from 1972-1977 (45).
Evaluation
PRINCIPLES Evaluation can be divided into internal and formative vs external
and summative evaluation. Internal evaluation is carried out during and within
the program to give rapid feed-back to the program workers and management.
An overlapping concept is formative evaluation, which provides data during
the program about the experience with the various program components and
thus helps further to develop ("formulate") the program. This section concerns
the summative evaluation of the program over a given time that assesses the
overall effects and other results, usually by an expert group in some way
external to the daily community work.
The evaluation aims can be divided into assessment of the program
1. feasibility
2. effects (behaviors, risk factors, disease rates)
3. process
4. costs
5. other consequences.
Feasibility The program feasibility evaluation assessed the extent to which it
was possible to implement the planned activities, i.e. what actually happened
in the community. This concerned the amount of resources that the project had
available, how they were used in the community, and how well the activities
reached the target populations. A feasibility evaluation is especially important
in a large and comprehensive program, like the one in North Karelia, where the
community itself carries out the activities in a large geographical area. Before
the question of effects can be meaningfully addressed, the actual intervention
must be defined. Results of the feasibility assessment in the North Karelia
project were based on survey and other data (project statistics) collected during
and after certain program periods.
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168 PUSKA ET AL
Effect Program effect evaluation was carded out to assess whether and to
what extent the main and intermediate objectives were achieved. Thus indica-
tors of the different objectives were defined and these measured in the com-
munity at the outset and after the given program period. The effect assessment
should especially answer the two questions: 1. Did the program cause changes
in target behaviors and risk factors (and other possible indicators of intermedi-
ate objectives)? And if so, 2. Were these changes associated with changes in
CVD (or other disease) rates?
Since the program target was the whole community, information was col-
lected to represent the whole population. For prevalence data (behaviors, risk
factors), a representative population sample was examined at the outset (the
baseline survey in 1972) and at the main summative evaluation points: after five
years (in 1977) and after ten years (in 1982). Independent, cross-sectional
population samples were used so that the baseline measurements or selective
loss at follow-up would not influence the findings of the subsequent follow-
ups.
The samples were drawn from the national population register. Men and
women were included and a broad age range used to give a comprehensive
picture about the changes. The sample sizes were large to detect changes in risk
factor means that would be small for individuals but meaningful for the
population as a whole. Large sample sizes also enable some interesting sub-
group analyses.
Comparison of baseline and follow-up survey results revealed the changes
that took place in the target community during the program period. However,
the changes during this period of several years could well partly or completely
be due to reasons other than the intervention program. Thus a reference area
was used. A reference area should be as similar to the program area as possible
("matched"), but without the input of the program. In case of the North Karelia
Project, the county of Kuopio, continuous with North Karelia on the west, with
250,000 inhabitants, was chosen. This study design can be called "quasi-
experimental," since it represents the situation in which the study can control
the experimental intervention and the choice of the reference area, but not the
allocation of units to experimental and reference ones.
The baseline and follow-up surveys were carried out simultaneously in the
reference area and in North Karelia with strict adherence to identical methodol-
ogy and sampling procedures. Survey results concerning changes in the refer-
ence area represent changes occurring without the program ("national
changes," "secular trends," "spontaneous changes"). Thus, the program effect
was considered thee observed change in the program area (North Karelia) minus
the observed change in the reference area (the so-called net change).
A problem concerning the reference area is that a major national pilot
program is likely to have an impact also in the reference area. And after the first
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THE NORTH KARELIA PROJECT 169
five-year period the North Karelia project was obliged to help national in-
tervention measures (like the national TV programs). A special feature in the
county of Kuopio was the establishment of a new university (with medical
school) in the same year as the project started. These factors that would tend to
influence health behavior and risk factors in the reference area were not taken
into account in the formal effect evaluation. Thus the given results can be
considered as conservative estimates of the effects.
Mortality rates were collected by disease category and analyzed for North
Karelia and the reference area (and also all other counties of the country). Age-
and sex-specific rates were used. Regression-based trends were calculated to
eliminate the random annual variation. Additional information for the assess-
ment of disease changes concerned hospital discharge data that are available .
from a national register, and data from the national cancer register. Special
AMI and stroke registers were established in North Karelia following WHO
criteria to monitor the respective incidence rates. Since these registers were
thought to be powerful intervention tools and part of the comprehensive
program to be evaluated, no permanent new registers were established in the
reference area. Thus these registers served the process evaluation and valida-
tion of the other mortality and morbidity data.
Process The process evaluation concerned both the change trends with time
during the program and changes in the intervening variables. The former
examined when the changes actually took place during the period. The latter
aspect related to the behavioral/social framework adopted and definition of the
intended intervening (independent) variables. Measurement of these factors
gave a picture of how the change process in the community led or did not lead to
the desired behavioral and risk factor changes.
Cost The cost evaluation assessed the total project resources and how they
were allocated (especially for intervention and evaluation purposes, respective-
ly). In addition, efforts were made to assess the community costs. This
concerned both total community costs, or specifically the extra costs involved
for the community. In addition to the direct community costs, attempts were be
made to estimate the indirect community costs. These costs may also be
negative, i.e. the program may well lead to several types of savings (more
efficient health care, reduced hospital needs, reduced disability payments).
This information for the North Karelia Project was collected using statistical
data sources, project surveys, and other data (45).
Other consequences In a major national pilot program, attempts should be
also made to assess consequences of the program other than those intended. If
the program involves the community deeply and leads to changes in lifestyle, it
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170 PUSKA ET AL
is quite possible that this process may lead to other changes as well. For
example, non-CVD health effects may occur. Positive or negative conse-
quences may take place in people’s symptoms and subjective health. Socioeco-
nomic, social, and emotional consequences, either positive or negative, may
appear. Some of these aspects were assessed in the North Karelia Project, using
especially data from the population surveys.
Figure 8 gives a summary of the main evaluation study design in the North
Karelia Project. A more detailed discussion of the various evaluation principles
and issues can be found in some other publications (5, 12, 68, 70). These issues
concern e.g. the number of communities, the sizes of communities, the length
of the program/observation period, the number and the type of surveys, the
sample sizes, the selections of communities, the time-lag assumptions, and the
methods of analyses, etc.
MATERIALS AND METHODS OF THE MAIN EVALUATION /~ baseline survey
for assessment of the risk factor changes was carried out in spring 1972 in North
Karelia and the reference area. A random 6.6% sample was drawn from the
populations of the two counties by using the national population register. The
sample included men and women aged 25-59 years (born in 1913-47).
1977, exactly five years later, another cross-sectional survey, the five-year
follow-up survey, was carried out in the two areas. The survey methods were
the same as those in the baseline survey. An independent, 6.6% random sample
was used that included both men and women aged 30-64 years (i.e. the same
birth cohort).
In spring 1982, exactly ten years after the start of the program, a third survey.,
the ten-year follow-up survey, was carried out in the two areas. An independent
IVkx-tal~v and I~7~ ~377
inc~enc~ mte~
m~i~ ~ ~.& str~e
r~e ~ a~
c~ ~ion ~ ~ ~j~t~
i"~nt~ J
I
~I ~ *1 I
inter~t~} ~ ~
Figure 8 The main evaluation study design in the Noah K~lia Project. *Refer to Noah K~lia
only (AMI register in the ~ference a~a in 1977 and since 1982).
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THE NORTH KARELIA PROJECT 171
random sample was again drawn. This time the sample was drawn for the age
group 25 to 64 years and stratified so that for each sex and ten-year age-specific
group the sample size would be approximately 500. This procedure was done to
comply with the protocol of the WHO-initiated MONICA project, since this
survey also formed the baseline survey for the Finnish participation in the
international MONICA project (68).
The surveys included a questionnaire answered at home (on general back-
ground, socioeconomic situation, medical history, health behavior, etc) and
examination of height, weight, and blood pressure. A venous blood specimen
was taken for the determination of serum cholesterol. Casual blood pressure
was measured in a sitting position accordingto the standardized technique. The
fifth phase was recorded as the diastolic pressure (44, 45).
Each survey in 1972, in 1977, and in 1982 followed the same methods as
much as possible, and in each survey the two areas were treated in an exactly
similar way, e.g. the blood samples from the two areas were analyzed in mixed
order. Serum cholesterol was determined in 1972 and 1977 from frozen
samples and in 1982 from the fresh serum samples in a central laboratory,
standardized against the international WHO references.
The participation rate in the baseline survey was 94% in North Karelia and
91% in the reference area (from approximately 6% of these subjects, on13(
questionnaire data were available), and in the 1977 survey 89% in North
Karelia and 91% in the reference area, and in the 1982 survey 80% in North
Karelia and 82% in the reference area. For the results reviewed here, the age
range of 30 to 59 years is used for all three surveys samples (Table 3).
For the analysis of the mortality changes, the data on deaths by the disease
category were obtained from the central statistical office of Finland for the
years 1969 to 1979. These were stratified into three age groups (35-44, 45-54,
Table 3 Numbers of men and women studied in the three cross-sectional surveys in North Karelia
and the reference area
North Karelia Reference area
Sex and age
(years) 1972 1977 1982 1972 1977 1982
Men
30-39 588 640 420 891 954 490
40-49 699 607 371 1024 885 364
50-59 547 538 459 750 777 343
Total 1834 1785 1250 2665 2616 1197
Women
30-59 598 595 222 879 928 340
40-49 716 616 423 1003 903 293
50-59 659 634 440 887 925 358
Total 1973 1845 1285 2769 2756 991
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172 PUSKA ET AL
and 55-64) and by sex. The diagnoses on the individual death certificates had
been reviewed according to WHO guidelines. The eighth ICD revision,
adopted in Finland in 1969, was used for the disease classification for the entire
period of study. The population data for 1970 were based on the census, and
those for other years were based on registration of births, deaths, and migra-
tion.
The mid-year populations were used as denominators in computing the
annual mortality. Death rates were standardized for age by the direct method,
using the population distributions of men and women in the whole country in
1969 as the standard. Regression slopes were tested for significance. For
analysis of coronary mortality, the ICD codes from 410 to 414 were used.
The difference in the change in the slope of age-standardized mortality
between North Karelia and the other ten counties of Finland was estimated and
tested for significance with multiple time series regression analysis. The slopes
were compared for the time intervals 1969-1973 and 1974-1979. Because the
program was started in 1972, data for the years 1969 to 1973 were used to
reflect the situation before the program and data for 1974-1979 to reflect the
possible effects (54).
REVIEW OF THE MAIN RESULTS
Main Program Effects
HEALTH BEHAVIOR AND RISK FACTORS In 1972, 52% of the men aged
25-59 years in North Karelia were smokers. This rate reduced to 44% in 1977
and further to 38% in 1982. Among women, changes in smoking rates were
small, with some increase in the 1978-1982 period.
Table 4 shows the amount of reported daily smoking (daily number of
cigarettes, cigars, and pipefuls per subject) in North Karelia and the reference
area, as given by the three major surveys in 1972, 1977, and 1982. Among
men, smoking clearly declined in North Karelia; .among women smoking
increased somewhat. During 1972-1977, a net reduction in North Karelia in
smoking was observed for both men (14% p<0.01) and for women (11%,
n.s.). From 1977 to 1982 a further reduction took place among men, more so
again in North Karelia than in the reference area. Thus the net reduction in
North Karelia for the full ten-year period was 27% (p<0.001). Among women
the net reduction in North Karelia from 1972 to 1982 was 14%.
To validate the self-reported smoking data, thiocyanate was determined in all
serum samples of the I982 survey. The age-adjusted partial correlation be-
tween reported daily amount of smoking and serum thiocyanate among men
was 0.72 in North Karelia and 0.67 in the reference area. Among women it was
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THE NORTH KARELIA PROJECT 173
Table 4 Mean amount of reported daily smoking in North Karelia and the reference area in
independent baseline (1972), 5-year (1977), and 10-year (1982) follow-up surveys
Men Women
North Reference North Reference
Year Karelia area Karelia area
1972 10.0 8.5 1.1 1.2
1977 8.5 8.5 1.1 1.3
1982 6.6 7.8 1.7 1.9
% net change in North Karelia
1972-1977 15
a12
1972-1982 28
b14
~p < 0.01.
~p < o.ool.
0.69 and 0.70, respectively. In 1982 the mean serum thiocyanate of men was
71 mmol/1 in North Karelia and 79 mmol/1 in the reference area (p<.001), and
for women 54 mmol/1 and 57 mmol/l, respectively (p<.01).
Dietary changes were assessed in the surveys by standard questions on
dietary habits. The results showed that there were considerable favorable
self-reported changes in several dietary habits related to the program objectives
in North Karelia. This concerned especially reduction of fat intake. Some
favorable changes were observed also in the reference area, reflecting national
changes, but these were in general smaller than in North Karelia.
During 1972-1977 the program had a highly significant overall effect on
mean serum cholesterol concentrations (p<0.01). Analyzed by sex the effect
was significant among men (4%; p<0.001) but not in the whole age range
women (1%). During 1977-1982 the serum cholesterol concentrations showed
Table 5 Mean serum cholesterol concentrations in North Karelia and the reference area in
independent baseline (1972), 5-year (1977), and 10-year (1982) follow-up surveys
Men Women
North Reference North Reference
Year Karelia area Karelia area
1972 7.1 6.9 7.0 6.8
1977 6.7 6.8 6.6 6.5
1982 6.3 6.3 6.2 6.0
% net change in North Karelia
1972-1977 4
a1
1972-1982 3
a1
ap < 0.001.
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174 PUSKA ET AL
Table tl Mean systolic and diastolic blood pressure levels in North Karelia and the reference area
in independent baseline (1972), 5-year (1977), and I 0-year (1982) follow-up surveys
Year
Men Women
North Reference North Reference
Karelia area Karelia area
SBP DBP SBP DBP SBP DBP SBP DBP
1972 149 92 146 93 153 93 148 92
1977 143 89 146 93 142 87 144 89
1982 145 87 147 89 142 85 144 85
%net change in North Karetia
1972-1977 3
a3
a5
~4
~
1972-1982 3
aI
b5
a2
b
an almost parallel reduction in North Karelia and the reference area, giving for
the full ten-year period 1972-1982 a net reduction of 3% among men
(p<0.001) and 1% among women (n.s.).
The mean systolic and diastolic blood pressures decreased in 1972-1977 in
North Karelia, more so than in the reference area. No further decrease in
systolic blood pressure was observed in either areas in 1977-1982. Thus the net
reductions in systolic blood pressures in men and women remained virtually the
same for 1972-1982 as for 1972-1977 (both sexes p<0.01). For diastolic
blood pressure the means in 1982 were lower than in 1977. The net reduction in
North Karelia became smaller during 1977-1982, but for the whole period
1972-1982 it remained significant for both sexes (p<0.05).
Table 7 summarizes the net reductions in risk factor means in North Karelia.
Table 7 Relative net reductions (--- SD) in North Karelia in risk factor means in men and women
aged 30-59 years in 1972-1977 and 1972-1982. Values are percentages from the baseline value in
North Karelia.
Men Women
1972-1977 1972-1982 1972-1977 1972-1982
Daily s~noking 15(10)
a28(11)
b12(27)
Serum cholesterol 4(1)b 3(2)b 1 (2)
Systolic blood pressure 3(1)
b3(1)
b5(1)
~
Diastolic blood pressure 3(1)~’ 1 ( 1)c 4(l)b
14(38)
1(2)
5(1)
b
2(1)
o
ap < 0.01.
bp < O.OOk
Cp < 0.05.
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THE NORTH KARELIA PROJECT ~ 175
As a whole, the favorable program effect observed during 1972-1977 increased
for smoking and was maintained for serum cholesterol concentrations and
systolic blood pressure during the second five-year period (1977-1982) of the
program.
CORONARY MORTALITY For the assessment of CHD mortality, comparable
data were available from 1969 up to 1979. During the period, CHD mortality
among the middle-aged (35-64 years) male population declined 24% in North
Karelia. Most of the decrease in North Karelia took place after the initiation of
the program. Thus for the 1974-1979 period, the reduction in age-standardized
male CHD mortality was 22% in North Karelia. During this same period the
respective reduction was 12% in the reference area and 11% in all Finland less
North Karelia (/9<0.05) when compared with North Karelia.
CHD mortality also decreased among women in North Karelia, significantly
more than in the rest of the country. Because the absolute number of CHD
deaths was much smaller among women than among men, the decline in actual
number of deaths was much greater among men than among women. For total
and cardiovascular mortality the differences between North Karelia and the rest
of Finland were similar as for_CHD mortality but smaller. A multiple cross-
county time series regression analysis indicated a greater acceleration of the
decline in mortality from CHD (p<.05), CVD (p<.001), and all causes
(p</001) from 1969-1973 to 1974-1979 in North Karelia than in the other
counties of Finland (54).
Process Aspects
CHANGE TIME TRENDS IN NORTH KARELIA For smoking, a sharp reduction
among men took place during the first year. Thereafter, further decline took
place only after 1978, possibly associated with the several antismoking TV
Table $ Average annual regression based decline in age-standardized CHD mortality in 1974-
1979 and 1969-1979 in North Karelia, the reference area, and Finland less North Karelia (--- 95%
confidence intervals) and estimate for 1969 mortality
CHD mortality
rate in 1969
(per 100,000) Annual % decline
Men Women
Area Men Women 1974-1979 1969-1979 1974-1979 1969-1979
North Karelia 663 140 3.7 + 1.5 2.2 -+ 1.1 2.2 -+ 3.4 4.3 --- 1.4
Reference area 606 125 1.9 ± 2.3 1.9 --- 1.3 1.8 ± 1.4 3.1 +-- 1.0
Finland less 501 103 1.7 --- 2.2a 1.1 +- 0.9a 1.2 --- 2.4 2.2 -+ 1.0
a
North Karelia
aDifference from North Karelia in relation to random variation p < 0.05.
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176 PUSKA ET AL
programs produced by the project. For women, changes in smoking rates were
small throughout the period.
The dietary changes took place gradually throughout the project period.
Major changes in government price policy were reflected in these trends. The
serum cholesterol levels in North Karelia fell in a linear way from 1972 to 1977
and to 1982.
T~e frequency of blood pressure measurements increased in the area during
the first couple of years of the intervention. After 1974 some 80% of the
population had their blood pressure measured at least every two years. The
proportion of men under antihypertensive treatment increased from 3% in 1972
to 10% in 1975 and among women from 9% to 14%. These new levels
remained throughout the rest of the period. In the population’s blood pressure
levels, little change took place after 1977.
For other "possible" risk factors, which were not actual targets of the
intervention, like physical activity, relative weight, or perceived social stress,
observed changes were small during the project period.
The AMI register covering whole North Karelia showed a plateau of AMI
incidence rates of men in 1972-1975. Thereafter a gradual decline took place.
The CHD mortality showed an increased decline after 1974. Among women
similar patterns were observed, but because of much smaller absolute numbers,
these changes are less meaningful. Stroke registration in the area showed a
sharp decline in incidence among men around 1974. Among women a more
gradual decline was observed.
CHANGES IN SUBGROUPS Changes in risk factors were generally greater
among men than among women, which was in accordance with project efforts.
A breakdown by age indicated that the observed changes in North Karelia were
usually somewhat greater among older than younger people. Since changes
among the younger people in the reference area compared to those in North
Karelia were smaller for men but rather equal among women, the relative net
changes in North Karelia were greatest among both younger and older men, but
for women among middle or older age groups.
The health behavior and risk factor changes were also analyzed according to
socioeconomic subgroups. The general finding was that the changes did not
markedly concentrate in some subgroups but took place rather generally
throughout the community. Smoking among men dropped somewhat more
among lower educated than higher educated men; this difference was observed
also for the net reduction. Urban-rural differences in smoking changes were
small. Also, dietary changes and serum cholesterol and blood pressure changes
took place rather evenly in the different socioeconomic groups.
Changes in health behavior were analyzed also in relation to the initial
estimated CHD level. The change in the behavior had no consistent relation to
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THE NORTH KARELIA PROJECT 177
the preprogram risk level. It was again concluded that the change in health
behavior in the population was based on common lifestyle changes in the area.
A survey among formal opinion leaders (medical doctors, public health
nurses, and municipal council members) in 1972 and 1977 showed that smok-
ing declined markedly among doctors and public health nurses in North
Karelia, while little change occurred in the reference area. Smoking among
local decision makers changed little during this period in either county.
CHANGES IN INTERVENING VARIABLES The surveys in 1972 and 1977
indicated that knowledge related to the risk factors increased somewhat during
this period, but this increase was only slightly greater in North Karelia than in
the reference area. Various health attitude measures showed no major changes
during the period and little difference between the areas.
During the program, various health education materials were distributed by
the project through health centers and other channels. A survey of the local
newspapers showed that there were three to four times more CVD prevention
and control related articles in North Karelia than in the reference area in
1972-1977. Training of local personnel groups by the project was frequent.
The survey of local health personnel showed that the North Karelian health
personnel was more active in health education measures than their counter-
parts in the reference area. The population surveys showed that there was
little difference between the areas in frequency of health behavior related dis-
cussions at home or at worksite. Somewhat more people in North Karelia
had participated in organized health education meetings. Smokers had re-
ceived advice from doctors to stop smoking equally frequently in the two
areas, but from nurses twice more often in North Karelia than in the refer-
ence area.
The population surveys showed that attempts to stop smoking increased
clearly more in North Karelia than in the reference area from 1972 to 1977.
Evaluation of the TV programs after 1977 indicated that greater attempt rates
lead also to greater success rates. Later on, less difference was found in the
attempt rates but greater difference in maintenance rates in North Karelia.
The doctors and public health nurses had generally been clearly more active
in North Karelia than in the reference area in contacts with various community
organizations concerning health promotion activities. The local decision mak-
ers had received advice from health personnel to stop smoking and to change
dietary habits twice as often in North Karelia as in the reference area. Begin-
ning in 1975 informal lay opinion leaders were identified and trained in a
systematic way in Noah Karelia. Approximately 800 people were trained. A
survey in 1983 showed that about half of them had remained active. This
evaluation indicated that the lay-leader work had obviously been a useful
component of the intervention.
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178 PUSKA ET AL
The increase in blood pressure measurements and antihypertensive treatment
is discussed above. The hypertension care system in North Karelia was reorga-
nized by the project so that patients were registered and followed at special
hypertension dispensaries in a systematic way. The number of hypertensives
registered and followed by the new system reached nearly 17,000 by the end of
1976. Thereafter the number of prevalent cases remained much the same.
Blood pressure measurements, drug treatment, and health personnel contacts
increased somewhat also in the reference area. A more systematic follow-up
and greater compliance obviously contributed to the hypertension control
results in North Karelia.
Patients with acute myocardial infarctions in North Karelia were recruited to
special secondary preventive groups after the attack. Since 1975 more than half
of the AMI survivors participated in this program. Such a rehabilitation and
secondary prevention activity was much less common in the reference area.
AMI patients in North Karelia had after their attack more favorable risk factor
changes than in the reference area.
CHANGES IN CARDIOVASCULAR DISEASE PATTERNS In spite of the decline
in coronary mortality and incidence, no changes were observed by the AMI
register in 28-day case fatality rates in 1972-1977. There was a trend of
reduced mortality one year after the acute myocardial infarction among patients
with recurrent AMI in 1972-1977 in North Karelia. No significant changes
were observed in three-week or one-year fatality rates for stroke cases during
this period. The relative decrease in AMI incidence rates in North Karelia was
greater in the younger than in the older age groups in North Karelia for both
sexes.
The reduction in coronary incidence rates among men was somewhat greater
for recurrent than for the first infarctions. When the cases were classified by
WHO criteria into "definitive" and "possible" myocardial infarctions, the
decline was due to decline in the category "definite" only. The finding that
"possible" AMI cases did not decrease may be a consequence of patients with
less severe symptoms reporting more often to the hospitals because of increas-
ing awareness and increased services in the community.
In the surveys in 1972, 1977, and 1982, people were asked in the self-
administered questionnaires whether they had suffered from angina pectoris
diagnosed and/or treated by a doctor during the year preceding the survey. The
prevalence of angina pectoris among men aged from 50 to 59 years changed in
1972-1982 from 10.4% to 5.6% in North Karelia and from 6.1% to 6.2% in the
reference area.
Other Consequences and Cost Aspects
DISABILITY AND OTHER MORBIDITY Since 1972, both the surveys and the
statistics of the National Social Security Institution showed a more favorable
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THE NORTH KARELIA PROJECT 179
trend in disability pensions in North Karelia compared with the reference area.
According to the surveys the proportion of all disability pensions increased
16% in North Karelia and 25% in the reference area from 1972 to 1977. This
more favorable trend was largely attributable to CHD, but also partly to
respiratory diseases. Age-adjusted prevalence rates since 1968 for CVD-
related disability were calculated from the national disability statistics. From
1971 to 1977 the net reduction in North Karelia was 27% for men and 12% for
women.
According to the surveys in 1972 and 1977 the proportion of people who had
suffered from any chronic disease during the previous year changed in North
Karelia from 51% to 53% and in the reference area from 46% to 51%. The
respective changes for respiratory disease were from 8.8% to 9.4% in North
Karelia and from 7.7% to 10.1% in the reference area. Analyses among
subgroups showed an association between net changes in smoking and in cough
symptoms. Preliminary findings from the national cancer register show a more
favorable lung cancer trend in North Karelia compared with other areas.
The mean self-reported days of illness during the preceding year changed
among .men from 1972 to 1977 in North Karelia from 32 to 25 and in the
reference area from 27 to 24. The respective changes among women were from
17 to 14 and from 14 to 15.
COST ASPECTS The projcc’t budget was used for the extra input to intensify
cardiovascular prevention and care in North Karelia. For the period of 1971 to
1977 (with evaluation up to 1979) the direct project budget was 1.75 million
dollars. Out of this budget 0.73 million dollars went for intervention expendi-
tures and 1.02 million for evaluation costs. It was possible to keep the budget so
modest because many of the actual costs involved were covered by the universi-
ty or other institutions.
The intervention effort was aimed at improved cardiovascular preventive
activity in the area by the existing community resources. The health care and
other community resources naturally increased during the project period in
North Karelia. But this increase was of at least the same magnitude in the
reference area. Furthermore, a new medical school with a university hospital
was established in the reference area in 1972 and has developed gradually since
then.
In North Karelia the primary health care system provided most of the
project-related systematic services. The estimated costs suggested that there
was no major difference in resources devoted to CVD in primary health care
between North Karelia and the reference area. The estimated difference corre-
sponded to a net cost of 2 million US dollars for the program in 1972-1977.
Concerning hypertension care, most of the cost increase was related to an
increase in antihypertensive modification. A more systematic service structure
with the use of nurses resulted in savings.
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180 PUSKA ET AL
Within primary health care about 25%, and for total health service costs
about 20%, could be attributed to CVD-related reasons. The direct Project
costs were only 1% of the total general health service operation costs and 4% of
similar CVD-related costs in North Karelia during the period 1972-1977.
During the same period the reduced numbers of AMI and stroke cases
resulted in a saving of 2 million US dollars. A substantial relative reduction in
CVD disability pension, specific for North Karelia, took place since 1972. The
savings in these pension awards were 4 million dollars during the period
1972-1977.
SUBJECTIVE HEALTH AND PERSONAL EXPERIENCES The survey question-
naires included standard precoded questions that were used to assess psychoso-
cial consequences of the program. In 1972, people in North Karelia reported
themselves to be in poorer health than did the people in the reference area. After
ten years, in 1982, people tended to report their health status more often as
"very good" or"good" than people did in 1972. This improvement in subjective
health status was significantly greater for North Karelia than for the reference
area (p< .005). A similar pattern was present with perceived risk of heart
disease; the decline in North Karelia was again greater than in the reference area
(p < .01).
In addition to these two variables, the survey questions dealt with measures
of psychosocial stress, social interaction, psychosomatic symptoms, somatic
symptoms, subjective fitness, days of illness, etc. Out of 20 variables
(altogether 56 questions) dealing with emotional or psychosocial symptoms
problems, among men 11 showed a net decrease, 3 a net increase and 6 no net
changes during 1972-1977. For females the respective figures were 12, 6, and
2. In a grand score of these complaints, a decrease occurred in both localities.
But the decrease was greater in North Karelia, resulting in a net decrease of 6%
¯ North Karetia
Chanqe
in 1972-82 n Reference Areo
~0
goo
FiB~re 9 ~ba~ses i~ s~bjective health. Differences in ~esponses to the ~estion: "What do ~ou
tbi~ of yo~ present state of health?" in the s~ys in No~b Ka~dia a~d tb~ mfe~ce ~ea betwe~
1972 and 1982. The ~b~Se~ fo~ "ve~ ~ood" or"~ood" were si~i~amly ~r~at~ i~ No~b K~lia:
p < .005.
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THE NORTH KARELIA PROJECT 181
for men (p < .05) and 10% for women (p < .001). A net decrease in
psychosomatic symptoms index was observed also when the analysis was
restricted to people with high risk factor levels in the two surveys.
These findings exclude the possibility of any general unwanted emotional
consequences of the preventive program. They rather suggest a general positive
effect of the intervention in terms of subjective health and quality of life.
The 1977 survey of local doctors, public health nurses, and local decision-
makers asked these people how they felt about various CVD prevention and
control related activities in their own community. For all these activities and all
these groups the degree of satisfaction was clearly greater in North Karelia than
in the reference area. For other types of activities there was little difference
between the areas in the responses. (Table 9). The given results and the
personal experiences of the project team clearly indicate a broad general
satisfaction among the population in North Karelia toward the preventive
program initiated and coordinated by the Project. People participated well in
the activities; cooperation with various community organizations and opinion
leaders was good; and the activities were obviously associated with general
positive consequences, including subjective ones.
DISCUSSION OF THE PROJECT RESULTS
AND EXPERIENCES
General
The North Karelia Project was founded as a response to the burden of heart
disease in North Karelia. Since this problem was not much different in other
parts of Finland and in many other countries, the Project was also to be a "pilot"
or "demonstration" program for wider application. And since the prevention
Table 9 Opinions of health personnel and local decision makers about the sufficiency of the local
CVD control activities in North Karelia (NK) and the reference county (Ref.)
Consider the activity to be sufficient
in the local health center, %
Public Local
health decision
Physicians nurses makers
CVD control activity NK Ref. NK Ref. NK Ref.
CVD control in general 52
Antismoking 45
Nutritional education 35
Hypertension control 79
Heart disease patients’ rehabilitation 52
Health examinations 59
18 49 7 20 7
30 34 19 28 18
13 31 18 24 10
42 90 47 45 31
13 44 9 21 8
35 49 23 28 22
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182 PUSKA ET AL
and control of CVD involved many unsolved scientific questions, careful
evaluative research was linked with the program. Both the background of the
project and the nature of the problem led to adoption of the community
approach as the main strategy.
Public health decisions on risk factor reduction and CHD prevention must be
based on broad information about the overall expected favorable and harmful
consequences of such activity. Community studies investigate several ques-
tions relevant to prevention and community health in a real life situation. Thus,
besides assessing risk factor and disease changes, the North Karelia project has
yielded information about the feasibility of the prevention program and demon-
strated other positive findings, such as reduced disability payments, fewer
reported general health complaints and emotional problems, and popular satis-
faction with the program.
It should be noted that, although the main project features and the evaluation
design were clearly decided upon during the initial planning phase, many of the
theories relating to community intervention were understood and developed
only during the actual work. Thus the theoretical framework was only partly
outlined at the outset. We have aimed here to put the project implementation
into a theoretical perspective to help guide similar activities, and for evaluative
purposes.
The intervention activities of the North Karelia Project have been described
here only to a very limited extent. A complete description of these can be found
in the monograph on the five-year results (45). Most of the results reviewed and
discussed here have been previously published in a number of articles partly
cited here. Because the initial five-year period (1972-1977) has been evaluated
much more thoroughly thus far, many of the process evaluation results men-
tioned here refer to this period. However, the main epidemiological "hard"
effect type of evaluation results include the latest findings of the ten-year
follow-up survey (in 1982) and the continued mortality follow-up.
Program Effects
HEALTH BEHAVIOR AND RISK FACTOR CHANGES The major questions of
the evaluation are naturally whether it is possible to influence the risk factor
levels in the population and, if so, whether such changes lead to respective
changes in CHD rates. A quasi-experimental study design was used to measure
this effect. Changes in the North I(arelian population were compared with
respective changes in a matched reference area to give the net change during the
study period. This estimate of effect is a conservative one, because the project
probably also influenced the reference area. Independent repeated random
sample surveys with standardized and similar questionnaires were used to
assess the risk factor changes in the whole population. The participation rates
were high.
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THE NORTH KARELIA PROJECT 183
Overall, the reductions in risk factor levels observed in North Karelia during
the ten years of the program were substantial: for men, 36% in smoking, 11%
for mean serum cholesterol concentration, and 5% for mean diastolic blood
pressure. The changes in biological risk factors (serum cholesterol and blood
pressure) were much smaller than in smoking, which is to be expected. The
changes of this magnitude in risk factors may be considered small for an
individual, but they represent mean changes for the whole population and
should thus be important for population disease rates. The changes in biological
risk factors among women were similar to those among men, but the results for
smoking differed because of the small initial smoking rates among women.
Risk factor levels also declined somewhat in the reference area, as was
observed already during the first five-year period. During the second five-year
period the net difference in favor of North Karelia further increased for
smoking, remained quite similar for serum cholesterol concentration and sys-
tolic blood pressure, and lessened for diastolic blood pressure. Thus the results
in 1982 were further evidence of the effects of the intervention program in
North Karelia.
Influencing health-related behaviors and risk factors is not an easy task.
Even when the health hazards are well known, many interventions have met
with but limited success. We consider the results and experiences presented
here an encouraging indication that, at least in favorable conditions, a compre-
hensive, determined, and ~,ell-planned activity can indeed lead to substantial
improvements in risk factor patterns.
Similar risk factor changes as reported for ten-year results in North Karelia
occurred within the Stanford Three Community Study reported for two years
and three years (15, 19, 68). Further comments on this study follow in a later
section. Given the analogies in underlying theory and in their application to
total communities as a multifactor CVD risk reduction study, the Finnish North
Karelia Project and the American Stanford Three Community Study can be
seen as replications demonstrating the feasibility and indicating a beginning or
partial generalizability of these types of community studies.
The effects on risk factors in the North Karelia project can be compared with
those observed in some recent major risk factor intervention studies. Compared
with the six-year results of the multicenter MRFIT study in the United States,
the results in North Karelia in the entire population are somewhat greater for
smoking and for serum cholesterol but slightly smaller for diastolic blood
pressure (34). Thus the overall impact of community-based intervention
appeared greater in North Karelia even though the American study was con-
cerned with only some 6500 high risk men who were each intervened upon with
considerable intensity and cost.
The overall results in North Karelia also seem to be considerably better than
the results of the British heart disease prevention project, even when only high
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184 PUSKA ET AL
risk subjects in that multicenter factory study are considered (51). The results
the subsequent Belgian project were also somewhat better than in Britain, but
still smaller than in North Karelia, especially at the six-years point of follow-up
(26). In a smaller scaled clinical trial, the Oslo study, the effect of the
intervention on smoking and serum cholesterol was greater than in North
Karelia (21). In that study, however, the intervention concerned only about 600
men with very high cholesterol values, and the intervention was carried out in
only one center by a few devoted professionals. Special interventions among
restricted groups of the population have also resulted, naturally, in much larger
risk factor changes in North Karelia. For example, in a special dietary interven-
tion study among 30 families, an intensive dietary counselling resulted in 24%
reduction in the average serum cholesterol level of the middle-aged adults of
these families (11). But such costly measures obviously cannot be used for
changing the population’s risk factor levels.
The key question naturally is how CHD-related lifestyles and risk factors can
be permanently achieved and maintained in the entire population in a cost-
effective way. The answer from the NQrth Karelia Project, supported by the
results from the Stanford Study, calls for a broad-ranged and determined
intervention in the whole community. Practical activities integrated with the
existing community organizations should be based on sound theoretical princi-
ples.
It is obviously difficult to know clearly which of many potential determi-
nants from either baseline factors or intervention methods may be responsible
for the favorable risk factor changes and whether further replications elsewhere
can be readily achieved. A community program of this sort ultimately tests
whether a specific program as a whole (which should be designed so that it can
be applied on a larger scale) is feasible and effective under given conditions.
The impact of various community conditions and of different components of
the project on successes and failures can be evaluated only to a limited extent. It
is clear that the great magnitude of the problem in North Karelia (but also in the
reference area), the Finnish health service system, and cultural factors have all
contributed to the achievement in the North Karelia Project. However, great
concern was expressed at the planning stage because of the rural, low socioeco-
nomic nature of the area, with high unemployment, and few medical resources,
and because of the area’s prevalent dairy farming.
The strategy in North Karelia was to introduce a general community action,
using the service structure as a backbone. The role of the Project was to catalyze
and promote activities that would enable people themselves to make the
necessary changes in their habits. The Project team, in close contact with the
community, outlined the different activities and provided materials and train-
ing. It was realized from the very beginning that mere provision of information
would not be enough. Teaching people practical skills was emphasized. Var-
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THE NORTH KARELIA PROJECT 185
ious methods of persuasion were applied; people were asked to comply, not
necessarily to reduce their own disease risk, but as part of a common action and
a county pride. Since influencing lifestyles is ultimately a community problem,
the North Karelia Project involved all segments of the community to achieve
the desired goals.
Results of the process evaluation and the experiences of the Project team
indicated that the success in North Karelia was not primarily based on increase
in health knowledge or changes in health-related attitudes. Instead, broad-
ranged community organization--including provision of primary health care
services and involvement of various other community organizations--were of
central importance. The project was able to disseminate its message through
media and through opinion leaders so that it created a social atmosphere more
favorable to change. The new lifestyles gradually diffused among the popula-
tion. Ten years is sufficiently long to document a permanent change process,
and exclude a temporary campaign effect.
DISEASE CHANGES Given the observed changes in CHD risk factors, the
second evaluation question is whether significant changes occurred in the
disease rates. Earlier evaluation showed that the coronary mortality rates
started to decrease in North Karelia during the first five years, but no clear
differences between the two areas were observed. During the period from 1974
to 1979 (when the impact of risk factor reduction could start to show) the
reduction in age-standardized male CHD mortality was 22% in North Karelia,
12% in the reference area, and l 1% in the whole country, excluding North
Karelia. Thus the reduction in coronary mortality among North Karelian men
has not only been substantial, but actually double that in the reference area and
the rest of the country. This supports the view of some experts that there is delay
between risk factor changes and respective changes in CHD rates (28, 50).
The results from North Karelia show not only that risk factors can be
changed, but that such changes lead to reduced CHD rates. The North Karelia
Project results thus support the findings of the Oslo study and the Belgian study
(21, 26), and are in accordance with the results of the numerous prospective
studies and several single-factorial intervention studies on hypertension and
elevated serum cholesterol levels (22, 30, 58, 63) concerning a causal rela-
tionship between the risk factors and CHD. The negative results from the
British (51) study were probably a consequence of rather small changes in risk
factors. The negative results in the MRFIT study (34) demonstrate the prob-
lems with randomized clinical trials and may be due to several possibilities,
most notably to complications of large-dose diuretic drug therapy.
In addition to the given effects on coronary mortality the results of the project
show a general positive impact on people’s health. The patterns of all CVD and
total mortality follow that of CHD mortality. Favorable effects on other
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186 PUSKA ET AL
noncommunicable diseases were also indicated, notably on respiratory dis-
eases. Evaluation concerning subjective health and emotional consequences
demonstrate improved subjective health, reduced emotional and psychosocial
problems, and general satisfaction with the activities in North Karelia.
National and International Perspectives
FINNISH PERSPECTIVE Before 1977 it was the policy of the Project team not
to promote CVD risk factor changes in the reference area or nationally.
However, already during this period the Project had a great deal of positive
national publicity. After 1977 the project team became involved in national
applications. Governmental health education and hypertension committees
recommended many project experiences for national use and recommended
establishment of a new office for health education in the National Board of
Health. The Project’s health education materials have been distributed nation-
wide in great numbers. A major national activity has been a series of national
health education programs on Finnish television carried out by the project since
1978 (40, 46). Antismoking legislation was introduced in 1977.
The changes observed in the reference area and other available information
show that CVD-related lifestyles have started to change in Finland as a whole.
Associated with these national changes is a favorable change in cardiovascular
disease rates. The coronary heart disease mortality of Finnish men, which used
to be highest in the world, has decreased nationwide and Finland is losing its
position as the country with the highest coronary mortality rates.
The program and the follow-up in North Karelia, as well as the national
applications, continue. This is necessary to fully gauge the impact of the
activity. At the same time, experiences from similar programs in other coun-
tries are needed to confirm the results obtained in North Karelia and to show the
impact of various cultural factors and some different intervention strategies.
Fortunately, several such studies have recently been launched. In addition to
Finland, community-based studies have been launched especially in the USA.
us AND INTERNATIONAL PERSPECTIVE In 1970, a group at Stanford Uni-
versity (California, USA) became convinced that behavioral science must
become aligned with the traditional biomedical sciences in a multidisciplinary
assault to alleviate the human suffering associated with the chronic diseases so
prevalent in the US. Within that context, the Stanford group designed a
community-wide public health education study that included elements from
both the biomedical and social science traditions. The result was the Three
Community Study. Field operations began in 1972, in which educational
programs were introduced to communities at large to modify knowledge,
attitudes, and behaviors associated with cardiovascular disease and to attempt
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THE NORTH KARELIA PROJECT 187
to demonstrate the feasibility of reducing cardiovascular risk for adults in a
community setting.
The strategy was to identify clearly the lifestyle antecedents of cardiovascu-
lar disease that were relevant to adults of varying ethnic and occupational
groups. Appropriate subpopulations then became the "audiences" to be in-
formed and assist in undertaking long-term modification of their risk-taking
behavior. TO do this for large groups of individuals, such as total communities,
the costs of the educational efforts for risk reduction had to be reduced to a
practical level.
The health education strategy selected was to employ a means that could be
widely used in any community. Therefore, two intervention communities were
used in establishing a mass education program for risk reduction. Community
leaders among health providers, and the mass media, were recruited to assist in
the effort.
The study waged extensive mass media campaigns over a two-year period in
two of these communities, and in one of these, face-to-face counseling was also
provided for a small subset of high-risk people. A third community served as a
control. A sample of the population from each community were interviewed
and examined before the campaigns began and one and two years afterwards to
assess knowledge and behavior related to cardiovascular disease (e.g. diet and
smoking) and also to measure physiological indicators of risk (e.g. blood
pressure, relative weight, and plasma cholesterol). In the control community
the risk of cardiovascular disease increased over the two years, but the treat-
ment communities showed a substantial and sustained decrease in risk. In the
community in which there was some face-to-face counseling the initial im-
provement was greater and health education was more successful in reducing
cigarette smoking, but at the end of the second year the decrease in risk was
similar in both treatment communities. These results strongly suggested that
comprehensive educational programs directed at entire communities may be
very effective in reducing the risk of cardiovascular disease (15, 31).
The risk reduction achieved in the test communities exceeded that in the
reference town by margins fairy similar to the ones described for the North
Karelia Project. Among the intensive instruction samples greater changes
occurred, especially in the proportion of smokers who quit smoking by the end
of the second and third years. The study was terminated as planned after three
years, with ihe third year involving a reduced educational program. Effects
were well maintained during this third year (19, 70).
These results encouraged the Stanford Heart Disease Prevention Project
(SHDPP) to initiate a more ambitious study, known as the Five City Project
(FCP) (12, 13). In this investigation, begun in 1978, two larger cities
selected for educational ~i, ntervention, and three were assigned for reference.
Since the total populations of the five cities was approximately 350,000 people~
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188 PUSKA ET AL
with a modest expectation of risk reduction it was anticipated that significant
reduction in morbidity and mortality could also be obtained if the study were to
last nine years. Because a self-sustaining program in the community was
sought, and because of the success of the North Karelia Project in utilizing
community organization in its effort, the aim was to enhance and systematize
the community organization program in the FCP. Preliminary mid-course
results on risk reduction are encouraging and indicate another replication of the
success in community education for risk reduction (14).
Since the completion of the Stanford Three Community Study and the first
five years of the North Karelia Study, several other multi-risk factor studies
have been launched---all with an emphasis on community-wide comprehensive
health educational programs designed to reduce risk and, in some cases,
morbidity and mortality. These studies are on the north coast of New South
Wales in Australia, near Capetown in South Africa, and in Heidelberg in the
Federal Republic of Germany, as well as in Minnesota, Rhode Island, and
Pennsylvania in the US. The studies in Minnesota and Rhode Island are large,
comprehensive, and long-term. The three US studies of Stanford, Minnesota,
and Rhode Island are linked through their common federal funding resources
and through shared methodology for outcome evaluations.
A number of additional studies are being planned or are already under way in
Europe (e.g. Italy, Yugoslavia, GDR, Portugal, USSR, Hungary, Norway)
elsewhere (e.g. Cuba, People’s Republic of China, Israel). Many of these
studies are comparable to the previously mentioned studies, but some of them
lack a formal reference area or concentrate on persons at high risk of disease
rather than on the community as a whole. Some communities are too small to
measure changes in disease rates, hence these studies are concerned with
changes in behavior and risk factors only.
Table 10 lists the some of these projects, best documented internationally,
and indicates the country in which the study has been taking place, the years of
community education, the number of communities involved, and their popula-
tions. Randomization of communities was employed only in the Swiss study
(20). Reductions in cardiovascular risk factors have been observed in several
studies, but so far significant morbidity and mortality changes have been
observed only in the North Karelia Project, which also has the longest follow-
up. During the next few years, many findings as well as new challenges will
emerge from the ongoing studies.
CONCLUSIONS
There has for long been little question about the role of smoking and elevated
blood pressure in the development of CVD. The results of the LRC study have
also fttrnly established the importance of elevated serum cholesterol as a CHD
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THE NORTH KARELIA PROJECT 189
Table 10 Community-based multifactor CVD risk reductiort/CVD risk factor studies
a
Years of
Description Country education Reference
1. North Karelia Project: two Finland 1972-1982 Puska et al
counties, one treatment, 1981, 1983
one reference, n =
433,000.
2. Stanford Three Community USA
Study: three towns, two (California)
treatments, one reference,
n = 45,000.
3. North Coast Project: three Australia
towns, two treatments,
one reference, n =
70,000.
4. Swiss National Research Switzerland
program:
four towns, two treat-
ments, two references,
n = 40,000.
5. Community Health Im-
provement Project: two
counties, one treatment,
one reference, n =
224,000.
6. Eberbach-Wiesloch Project:
three towns, two treat-
ments, one reference,
n = 30,000.
7. South African Study: three
towns, two treatments,
one reference, n =
16,000.
8. Stanford Five City Project: USA
five cities, two treat- (California)
meats, three references,
n = 350,000.
9. Minnesota Heart Health USA
Study: two towns, two (Minnesota)
cities, two suburbs,
paired treatment and ref-
erence, n = 356,000.
10. Pawtucket Heart Health
Study: two cities, one
treatment, one reference,
n = 173,000.
1972-1975 Farquhar et al
1977
1977-1980 Egge~ 1978
1978-1980 Gutzwiller et al
1979
USA 1979-1986 Stolley&Stunkard
(Pennsylvania) 1980
b
Federal Republic 1976-1990 Nussel 1981
b
of Germany
South Africa 1980-1983 Rossouw 1981
USA
(Rhode Island
& Massachusetts)
1980-1986 Farquhar 1978
1982-1989 Blackburn 1980
1982-1986 Carleton 1980
aThis list is necessarily incomplete and represents projects personally known to the authors of studies
based on communities, including at least one reference area, and involving use of comprehensive public
health education and community organization methods.
bPersonal communication.
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190 PUSKA ET AL
risk factor. Now the question is whether such changes should concern only
people with high risk or the entire population, and if the latter, how can such
changes be promoted in the population?
We feel that even if we question some of the given evidence, we have good
reason to promote general risk factor reductions in whole populations. Stopping
smoking has many health benefits; reduction of obesity and increasing vege-
table and fiber consumption are likely to be beneficial; and treatment of
hypertension is warranted. People should be helped to make changes that a
great proportion of them want and that reduce the risk of several chronic
diseases and premature death, and promote health. These factors are common
in the, c.0mmunity and are closely linked with lifestyles. Any intervention
limited to a small group of people at high risk cannot alone have much of a
long-term community impact. In community-based interventions people them-
selves ultimately make the decisions about their health practices and lifestyles.
The proposed changes, recommended for example by a recent WHO expert
group (69) on the prevention of CHD, are moderate and safe, can be enjoyable,
and are likely to reduce the risk of several major noncommunicable diseases
and promote health in general. People have a right to this information and to be
helped to make such changes.
We conclude from our results and experiences in the North Karelia Project
that well-conceived community-based programs can have an important impact
on life styles and risk factor levels in the population. With a sustained program
it is also possible to maintain these more favorable levels over a long period.
These changes result in reduced rates of cardiovascular disease and improved
health and well-being among the entire population. A major community-based
intervention study can also act as a powerful demonstration project to enhance
nationwide reductions in risk factors and control of the cardiovascular disease
epidemic.
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... We identified our initial theory of how, when, and why multiple health behaviour change interventions work by reviewing seven large-scale multi-factorial cardiovascular disease and cancer risk interventions [39][40][41][42][43][44][45]. These studies included the Multiple Risk Factor Intervention Trial (MRFIT) [39], the North Karelia Project [40], the Stanford Five City Project [41], Project PREVENT [43], the Minnesota Heart Health Program [45], the Mediterranean Lifestyle Trial [44], and the BETTER Trial [42], all of which are well-known studies that promoted multiple health behaviour change in large community samples [46]. ...
... We identified our initial theory of how, when, and why multiple health behaviour change interventions work by reviewing seven large-scale multi-factorial cardiovascular disease and cancer risk interventions [39][40][41][42][43][44][45]. These studies included the Multiple Risk Factor Intervention Trial (MRFIT) [39], the North Karelia Project [40], the Stanford Five City Project [41], Project PREVENT [43], the Minnesota Heart Health Program [45], the Mediterranean Lifestyle Trial [44], and the BETTER Trial [42], all of which are well-known studies that promoted multiple health behaviour change in large community samples [46]. As specified in our protocol manuscript [37], our preliminary review of these seven interventions involved having two independent reviewers extract the following information from the studies: ...
... Of these, 10 (83%) interventions reported successful longterm smoking cessation [49,56,61,63,82,83,92,95,96,103]. The majority of interventions that made changes to the physical and/or social environment (8/11; 73%) [40,56,61,71,83,96,103,105] or interventions that improved patient's social support system (10/15; 67%) [51,54,55,65,75,82,96,101,103,105] also reported successful long-term cessation. ...
Article
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Background: Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome. Methods: This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis. Results: Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.'s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant's capability or motivation to make a behaviour change was only successful within certain contexts. Conclusion: In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from 'individualistic epidemiology' and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment). Trial registration: PROSPERO registration number: CRD42017064430.
... Initial theory. We identi ed our initial theory of how, when, and why multiple health behaviour change interventions work by reviewing seven large-scale multi-factorial cardiovascular disease and cancer risk interventions [39][40][41][42][43][44][45]. These studies included the Multiple Risk Factor Intervention Trial (MRFIT) [39], the North Karelia Project [40], the Stanford Five City Project [41], Project PREVENT [43], the Minnesota Heart Health Program [45], the Mediterranean Lifestyle Trial [44], and the BETTER Trial [42], all of which are well-known studies that promoted multiple health behaviour change in large community samples [46]. ...
... We identi ed our initial theory of how, when, and why multiple health behaviour change interventions work by reviewing seven large-scale multi-factorial cardiovascular disease and cancer risk interventions [39][40][41][42][43][44][45]. These studies included the Multiple Risk Factor Intervention Trial (MRFIT) [39], the North Karelia Project [40], the Stanford Five City Project [41], Project PREVENT [43], the Minnesota Heart Health Program [45], the Mediterranean Lifestyle Trial [44], and the BETTER Trial [42], all of which are well-known studies that promoted multiple health behaviour change in large community samples [46]. As speci ed in our protocol manuscript [37], our preliminary review of these seven interventions involved having two independent reviewers extract the following information from the studies: ...
... Supporting evidence. There were 32 interventions [40, that used opportunity as one of the mechanisms for behaviour change with the majority of these interventions (59%) [40,[65][66][67][68][69][70][71][72][73][74][75][76][77][78][81][82][83][84] reporting successful long-term cessation. There were 12 interventions that aimed to increase access to resources as a part of the intervention [ In various settings (e.g. ...
Preprint
Full-text available
Background: Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome. Methods: This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis. Results: Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts. Conclusion: In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment). Study registration: PROSPERO registration number: CRD42017064430
... Much of it came from saturated fat. With the support of the regional administration of the province of North Karelia, the Finnish Ministry of Health and several other organisations our team comprising young medical people Prof. Pekka Puska as the Principal Investigator initiated the study called the North Karelia Project that became the "mother" of community-based cardiovascular (CVD) and non-communicable disease (NCD) prevention actions [5,6]. ...
... [24] Bigger decreases in CHD mortality would be achieved by mandatory reformulation of processed foods and by introducing subsidies for growing healthier foods. [25] As well as making a huge difference to population health, the implementation of population based mandatory standards for lower levels of salt and saturated fats in processed foods is cost effective. [26] The potential of introducing effective food policies is highlighted by recent studies which quantified the number of CVD deaths that could be avoided in NI and Scotland and in ROI by population level changes in diet. ...
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Background: Poland has experienced one of the most dramatic declines in coronary heart disease (CHD) mortality rates in recent decades. This decline reflects the use of evidence based treatments and, crucially, population wide changes in diet. Our aim is to explore the potential for further gains in Poland by achieving population wide reductions in smoking, dietary salt and saturated fat intake and physical inactivity levels. Methods: A validated and updated policy model was used to forecast potential decreases in CHD deaths by 2020 as consequence of lifestyle and dietary changes in the population. Data from the most recent Polish risk factor survey was used for the baseline (2011). We modeled two different policy scenarios regarding possible future changes in risk factors: A) conservative scenario: reduction of smoking prevalence and physically inactivity rates by 5% between 2011 and 2020, and reduction of dietary consumption of energy from saturated fats by 1% and of salt by 10%. B) ideal scenario: reduction of smoking and physically inactivity prevalence by 15%, and dietary reduction of energy from saturated fats by 3% and of salt by 30%. We also conducted extensive sensitivity analysis using different counterfactual scenarios of future mortality trends. Results: Baseline scenarios. By assuming continuing declines in mortality and no future improvements in risk factors the predicted number of CHD deaths in 2020 would be approximately 13,600 (9,838-18,184) while if mortality rates remain stable, the predicted number of deaths would approximate 22,200 (17,792-26,688). Conservative scenario. Assuming continuing declines in mortality, small changes in risk factors could result in approximately 1,500 (688-2,940) fewer deaths. This corresponds to a 11% mortality reduction. Under the ideal scenario, our model predicted some 4,600 (2,048-8,701) fewer deaths (a 34% mortality reduction). Reduction in smoking prevalence by 5% (conservative scenario) or 15% (ideal scenario) could result in mortality reductions of 4.5% and 13.8% respectively. Decreases in salt intake by 10% or 30% might reduce CHD deaths by 3.0% and 8.6% respectively. Replacing 1% or 3% of dietary saturated fats by poly-unsaturates could reduce CHD deaths by 2.6% or 7.7% Lowering the prevalence of physically inactive people by 5%-15% could decrease CHD deaths by 1.2%-3.7%. Conclusion: Small and eminently feasible population reductions in lifestyle related risk factors could substantially decrease future number of CHD deaths in Poland, thus consolidating the earlier gains.
... [24] Bigger decreases in CHD mortality would be achieved by mandatory reformulation of processed foods and by introducing subsidies for growing healthier foods. [25] As well as making a huge difference to population health, the implementation of population based mandatory standards for lower levels of salt and saturated fats in processed foods is cost effective. [26] The potential of introducing effective food policies is highlighted by recent studies which quantified the number of CVD deaths that could be avoided in NI and Scotland and in ROI by population level changes in diet. ...
Research
Full-text available
Objective Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland. Methods CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted. Results Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25-84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8-7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1-3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2-5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8-9.0%. These projections remained stable under a wide range of sensitivity analyses.
... (Puska et al. 1985, 152 (Maschkowski 2019;nach McAlister et al. 1982;Puska et al. 1985). ...
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Die Planetary Health Diet ist mehr als eine neue Ernährungsempfehlung. Sie zeigt Möglichkeiten auf, wie wir unser Ernährungssystem so ändern können, dass wir und unser Planet gesund bleiben. Das ist Herausforderung und Chance zugleich, denn alle Akteure müssen an einem Strang ziehen. Zu den Beispielen, die zeigen, dass ein solch tiefgreifender Wandel möglich ist, gehört die Ernährungsumstellung der gesamten finnischen Bevölkerung. Auch die Foodsharing-Bewegung verdeutlicht, welche Faktoren dazu beitragen, dass Ernährungstransformation gelingt.
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Which are the studies, special reports and commentaries that have been most influential in shaping the health promotion profession? This editorial poses that question to many of America’s most accomplished researchers. Each was asked to name one or two ‘must read’ studies from other scholars as well as to feature one of their own research projects that has had the greatest reach. This review of seminal studies focuses on community health, patient education and behavior change research and a future editorial will focus on workplace based health promotion research. Readers are challenged to review the four decades of research represented by this list and consider whether trends can be identified with respect to the relative attention researchers are giving to individual, interpersonal, community and societal factors influencing health behavior. How clear is the evidence that the choices we make are determined by the choices we have?
Article
Purpose: There has been considerable debate on the extent to which the decline in coronary heart disease (CHD) mortality has been caused by better control of coronary risk factors in the general population or is the result of invasive coronary interventions in symptomatic individuals. Methods Using the Myocardial Infarction Data Acquisition System, a statewide database of all cardiovascular hospital admissions in New Jersey, we examined time trends in incidence of death from CHD in the Years 2000–2014 in persons with a history of hospitalization for CHD in the previous 10 years and those without such a history. Results Over the 10-year study period, there was a marked decline in CHD-related mortality in both persons with a history of CHD and persons without a history of CHD. The decline occurred across all gender, racial, and age groups and was higher in those without a prior history of CHD. Conclusions This adds more evidence that the decline in CHD was not only because of advanced invasive medical and surgical treatments but also equally because of improved lifestyle, pharmacologic treatment of risk factors for CHD, and public health interventions.
Article
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Antecedentes: el sobrepeso y la obesidad son importantes factores de riesgo de hipertensión y diabetes tipo 2. Además, imponen una carga significativa sobre el sistema nacional de salud. Objetivo: evaluar la correlación entre el índice de masa corporal (IMC) y la circunferencia de la cintura (CC) con la glucemia de glucosa en ayunas por presión arterial en residentes de la fracción Norma Luisa del municipio de Minga Guazú, Paraguay en 2013. Métodos: Estudio transversal que incluyó a 280 participantes entre 18 y 64 años, de la comunidad Norma Luisa del municipio de Minga Guazú, Paraguay, entre septiembre de 2012 y mayo de 2013. Resultados: en las cuatro categorías de IMC y WC, las diferencias entre los valores medios para la presión arterial sistólica y diastólica y la glucosa en ayunas fueron estadísticamente significativas (p <0.01). Hubo una correlación estadísticamente significativa entre los indicadores de IMC y WC con la presión arterial sistólica, diastólica y glucosa en ayunas. Además, hubo una correlación significativa entre el IMC y el WC. Conclusiones: Los resultados obtenidos mostraron que el IMC y el WC son predictores de hipertensión y aumento de la glucosa en ayunas. Estos estimadores pueden ayudar a establecer predicciones de morbilidad y mortalidad, tanto con fines clínicos como en el diseño de programas de intervención comunitaria para cambiar los hábitos de estilo de vida en la población local.
Article
The Multiple Risk Factor Intervention Trial was a randomized primary prevention trial to test the effect of a multifactor intervention program on mortality from coronary heart disease (CHD) in 12,866 high-risk men aged 35 to 57 years. Men were randomly assigned either to a special intervention (SI) program consisting of stepped-care treatment for hypertension, counseling for cigarette smoking, and dietary advice for lowering blood cholesterol levels, or to their usual sources of health care in the community (UC). Over an average follow-up period of seven years, risk factor levels declined in both groups, but to a greater degree for the SI men. Mortality from CHD was 17.9 deaths per 1,000 in the SI group and 19.3 per 1,000 in the UC group, a statistically nonsignificant difference of 7.1% (90% confidence interval, —15% to 25%). Total mortality rates were 41.2 per 1,000 (SI) and 40.4 per 1,000 (UC). Three possible explanations for these findings are considered: (1) the overall intervention program, under these circumstances, does not affect CHD mortality; (2) the intervention used does affect CHD mortality, but the benefit was not observed in this trial of seven years’ average duration, with lower-than-expected mortality and with considerable risk factor change in the UC group; and (3) measures to reduce cigarette smoking and to lower blood cholesterol levels may have reduced CHD mortality within subgroups of the SI cohort, with a possibly unfavorable response to antihypertensive drug therapy in certain but not all hypertensive subjects. This last possibility was considered most likely, needs further investigation, and lends support to some preventive measures while requiring reassessment of others.
Article
The Australian therapeutic trial in mild hypertension, which was undertaken to investigate the value of pharmacological treatment, showed significant benefit in treated subjects. The control (placebo) group in this study comprised 1943 persons with mild hypertension who were not given antihypertensive drug treatment. They had regular visits for measurements of blood-pressure and were evaluated at intervals to detect the occurrence of trial end-points (essentially cardiovascular or cerebrovascular events). This paper reports the changes in blood-pressure and occurrence of trial end-points in these untreated subjects who entered the study between June, 1973, and December, 1975; observations were made up to March, 1979. In all subjects of the Australian therapeutic trial in mild hypertension, mean pressures for the two screening visits were within the range 95-109 mm Hg for diastolic blood-pressure phase V (DBP) and <200 mm Hg for systolic blood-pressure (SBP). In the 1943 control (placebo) subjects mean blood-pressures fell from 158/102 mm Hg at the first screening visit to 144/91 mm Hg 3 years later. At that time pressures remained within the mild hypertension range in 32%, had risen above it in 12%, and had fallen below in 48%. Trial end-points (ischaemic heart disease or cerebrovascular accident) occurred in 8%. The outcome was related to the level of initial pressure but not to other characteristics measured at entry. The mean initial pressures of 22 subjects who experienced a cerebrovascular event were higher than those of a matched group with no hypertensive complications, but the 88 subjects who experienced ischaemic-heart-disease events had initial pressures similar to those in a matched control group. The trial end-point was related to the average DBP of subjects throughout the trial in those with average DBP ≥95 mm Hg, and at those levels subjects on active treatment had a higher incidence than subjects of the placebo group with the same DBP level. For those with average DBP below 95 mm Hg the incidence of trial end-points was not related to blood-pressure level or treatment. 16% of placebo subjects in this mild hypertensive population had a mean DBP of less than 95 mm Hg at the first three visits. If this were taken as an indication to withhold drug treatment, 3 years later one-quarter of them (4% of all subjects) would be found to be hypertensive or to have experienced a trial end-point, and thus inappropriately untreated, while the other 12% would have pressures below 95 mm Hg and have had no trial end-point.