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The North Karelia Project in Finland: a societal shift favouring healthy lifestyles

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... One successful example of population-based surveys toward CVDs was the World Health Organization MONICA Project (Monitoring Trends and Determinants in Cardiovascular Disease) that informed governments about various risk factors of CVDs and helped further interventions [34,52]. Another example of community-based programs to stop CVDs was the North Karelia project started in 1972 in Finland in response to high cardiovascular mortality in a region of this country, and aimed to reduce risk factors like HCL by means of population-based prevention strategies like lifestyle and environment changes and could prominently reduce coronary mortality in middle age population by 84% during 42 years of interventions [53,54]. ...
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PurposeCardiovascular diseases (CVDs) are the main cause of deaths among non-communicable diseases. Arguments about the best prevention strategy to control CVDs’ risk factors continue. We evaluated the population attributable fraction (PAF) of CVDs in different levels of plasma cholesterol.Methods Patients’ data were obtained from Iran STEPs 2016 study. In phase 0 we estimated PAF regardless of cholesterol levels and clinical factors. In phase 1 we calculated PAF based on three levels of cholesterol (<200, 200–240, ≥240 mg/dl). In phase 2 we estimated PAF in 3 groups considering lipid-lowering drugs. In phase 3 all treated participants and not treated hypercholesterolemic people were included, to evaluate the impact of treatment. Estimations were done for Ischemic heart disease (IHD) and ischemic stroke (IS), and for two sex.ResultsIn phase 0, the highest PAF for IHD and IS were 0.35 (95% confidence interval 0.29–0.41) and 0.22 (0.18–0.27) for females and 0.27 (0.22–0.32) and 0.18 (0.14–0.22) for males. In phase 1, the highest PAF belonged to population with cholesterol ≥240 mg/dl and IHD, as 0.90 (0.85–0.94) for females, and 0.90 (0.85–0.96) for males. In phase 2, the pre-hypercholesterolemic group had higher PAFs than the hypercholesteremic group in most of the population. Phase 3 showed treatment coverage significantly lowered fractions in all age groups, for both causes.Conclusion An urgent action plan and a change in preventive programs of health guidelines are needed to stop the vast burden of hypercholesterolemia in the pre-hypercholesterolemic population. Population-based prevention strategies need to be more considered to control further CVDs.
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To estimate the extent to which changes in the main coronary risk factors (serum cholesterol concentration, blood pressure, and smoking) explain the decline in mortality from ischaemic heart disease and to evaluate the relative importance of change in each of these risk factors. Predicted changes in ischaemic heart disease mortality were calculated by a logistic regression model using the risk factor levels assessed by cross sectional population surveys, in 1972, 1977, 1982, 1987, and 1992. These predicted changes were compared with observed changes in mortality statistics. North Karelia and Kuopio provinces, Finland. 14,257 men and 14,786 women aged 30-59 randomly selected from the national population register. Levels of the risk factors and predicted and observed changes in mortality from ischaemic heart disease. The observed changes in the risk factors in the population from 1972 to 1992 predicted a decline in mortality from ischaemic heart disease of 44% (95% confidence interval 37% to 50%) in men and 49% (37% to 59%) in women. The observed decline was 55% (51% to 58%) and 68% (61 to 74) respectively. An assessment of the data on the risk factors for ischaemic heart disease and mortality suggests that most of the decline in mortality from ischaemic heart disease can be explained by changes in the three main coronary risk factors.
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The prevalence of coronary heart disease (CHD) risk factors in the population necessitates investment in the design and delivery of effective population-level interventions to prevent and enhance the management of CHD. This review examines the approaches that have been central to the design and delivery of previous, seminal population-level CHD prevention programs; it offers recommendations for the design and evaluation of the next generation of population-level CHD prevention trials. Almost 50% of the decline in the rates of CHD mortality in the developed world can be attributed to population-level declines in CHD risk factors, including cholesterol, hypertension, and smoking. There is evidence that community-based CHD prevention interventions can have a positive impact on these risk factors within a distinct population. More recent community-based CHD trials have focused on discrete populations including the socioeconomically deprived, ethnic minorities, and rural communities. There has been large variability in the success experienced by population-level CHD prevention trials. Best practices have emerged which may be used to inform the design of future trials. These include the need for multisectoral partnerships, coordination of multi-level interventions (programs and policy), and delivering a sufficient intervention dose to targeted populations.
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The North Karelia Project: a programme for community control of cardiovascular diseases. Puska, P., Koskela, K., Pakarinen, H., Puumalainen, P., Soininen, V., and Tuomilehto, J. (Co-ordinating Centre of the North Karelia Project, University of Kuopio, Kuopio, Finland). In this article the background and principles of the intervention and evaluation of the North Karelia Project are presented. The project is a comprehensive community control programme concerning cardiovascular diseases in the province of North Karelia, Eastern Finland. In the baseline survey of the project (1972), 25–59-year-old males had a particularly high of CVD level risk factors: there were 54% current smokers, the mean cholesterol was 269 mg% and the mean casual blood pressure was 147/90 mmHg. According to the myocardial infarction register the incidence rate of acute myocardial infarction was, during the first year of the project (1972), 13.8 per thousand among 30–64-yearold males. During the first 2 1/2 of the intervention the percentage of current smokers decreased among males from 54 to 42. The percentage of males using low-fat milk increased from 17 to 48. The percentage of males who had had their blood pressure measured during the previous half year increased from 28 to 56 and those under antihypertensive drug treatment from 3.1 to 9.1. Local groups for secondary prevention of myocardial infarction were established all over the province. On the basis of the accumulated experience and theoretical considerations, the project plan has further been elaborated.
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The North Karelia Project in Finland illustrates the fundamental goals of health promotion. Specific activities of the project serve as examples of how concepts from the social and behavioral sciences can be applied to achieve estimated reductions in predicted risk of disease. The results in North Karelia are not conclusive, but they are encouraging, and the investigations conducted there is an essential reference for future research in health promotion and disease prevention.
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Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. These primary prevention programs aim to reduce cardiovascular disease incidence by reducing risk factors in whole communities. These risk factors are smoking, high blood cholesterol, diet high in cholesterol and saturated fat, hypertension, sedentary lifestyle, and obesity. This strategy may be contrasted with secondary prevention programs directed at patients who already have symptomatic cardiovascular disease and "high risk" primary prevention programs directed at individuals found through screening to have one or more risk factors. The design of the five major programs is similar in that intervention communities are matched for purposes of evaluation with nearby comparison communities. Underlying these programs are theories of community health education, social learning, communication, social marketing, and community activation, as well as more traditional biomedical and public health disciplines. This is Part I of a two-part article.
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Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. The main hypothesis is that community intervention will reduce the prevalence of cardiovascular disease risk factors and consequently reduce cardiovascular disease incidence, morbidity, and mortality. Intervention strategies include community mobilization, social marketing, school-based health education, worksite health promotion, screening and referral of those at high risk, education of health professionals, direct education of adults, and modification of physical environments. Formative evaluation provides short-term feedback to program managers about immediate effects of intervention strategies. Outcome evaluation examines the effects of intervention on longitudinally sampled cohorts and compares cardiovascular risk status and morbidity and mortality in intervention and comparison communities. Results from North Karelia and the Stanford Three Community Study indicate that this model is efficacious and cost-effective. The National Heart, Lung, and Blood Institute biomedical research spectrum envisions research in knowledge transfer and innovation diffusion as the last link in the causal chain whereby research affects the health of the population, but research in this area remains undeveloped compared to other aspects of cardiovascular disease prevention. This is Part II of a two part article; Part I appeared in Volume 4, Number 3.
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Within the literature on community-based heart health promotion and chronic disease prevention, the North Karelia project is often viewed as a model program for achieving community-wide reductions in risk factors and mortality associated with cardiovascular disease. In the present study, we examine the tendency to attempt replication of elements of the North Karelia project, without due consideration of the unique population and setting being targeted. We analysed a sample of 64 articles reporting on community-based interventions targeting chronic disease, published between 1990 and 2002. Of these 64 articles, 43 (67%) made explicit reference to North Karelia or one of the other early projects (Stanford, Minnesota, Pawtucket). Of these 43 articles, 8 (19%) explicitly acknowledged the unique features of the population/setting in question, and articulated a need to adapt to these unique features, while 10 (23%) provided no acknowledgment of unique population/setting features. The remaining 25 (58%) were 'in between', and examples from each group are discussed. We conclude that for many contemporary community-based interventions, concern with replicating the North Karelia project is accompanied by inadequate consideration or reporting of the details of the unique context (including people, place and time), and this may undermine the success of community-based health promotion.