1. CVD prevention/ Tiina Laatikainen
5th International Seminar on the Public Health Aspects of Noncommunicable Diseases
Lausanne, 5-9 September 2011
Finland’s experience in implementing NCD prevention Dr. Tiina Laatikainen, Director Department of Chronic Disease Prevention
13/10/2017
CVD prevention/ Tiina Laatikainen

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

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

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

6. 5

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

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

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

10. CLINICAL INTERVENTION
RISK
FACTORS
PUBLIC
HEALTH
INTERVENTION

11. 25 % 5 % 70 % Theoretical presentation of the difference between
People with
low risk
factor level
People with average risk factor level
People with clinically high risk factor level
Individual
risk of CHD
Distribution of people
according to risk factor level
Theoretical presentation of the difference between
individual risk and the proportional attributable risk

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

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

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

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

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

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

19. Smoking control programmes
Voluntary restrictions of smoking in public places
Mass media
Voluntary restrictions in advertising
Use of opinion leaders
Training of health care personnel
Cessation services in health centres

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

21. A comprehensive television smoking cessation programme in Finland
Voluntary smokers in TV studio tried to stop smoking
6 sessions + 2 follow-up sessions
Intensified field activity in North Karelia
saw at least 4 sessions
attempted to quit
quitted
remained non-smokers

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

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

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

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

26. Discussions with target groups
Very often (%)
Occasionally(%)
Family 43 41
Neighbors 18 60
Work 16 31
Relatives 20 48
Friends 46
NGO meetings 13 28
Shopkeepers 8 27
Media 15

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

28. Village competition to lower cholesterol
villages, population
villages, population
Village committees organized
2 months competition
Baseline and follow-up cholesterol measurement
Best village won 2000 €

29. Cholesterol changes in 1991 competition
Village
Baseline
% Change 1
5.9
-10.8 2
5.8
-9.2 3
-8.9 4
-6.8 5
6.0
-4.0 6
5.7
-2.3 7
+1.4
Mean

30. Cholesterol change in 1997 competition
Baseline
End
Change
Change% N
6.19
5.59
-0.60
-9.0 16

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

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

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

34. Fat intake
Recommendations
EN%
Year
The FINDIET Study

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

36. Cholesterol distribution in North Karelia in 1972 and 2007, men4 6 8 10 12
mmol/l

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

38. Fruits And Vegetables – Supermarkets

39. Changes in Finnish food habits
Year

40. Salt intake in Finland 1977-2007
g/day
The FINDIET Study

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

42. Decline in CHD mortality in men aged 35-64
North Karelia
All Finland
per

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

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

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

46. Training seminar on NCD prevention
Helsinki, Finland and
in North Karelia
12-16 March, 2012
11-15 March, 2013

47. New textbook on North Karelia project
Pekka Puska, Erkki Vartiainen, Tiina Laatikainen, Pekka Jousilahti, Meri Paavola (eds.)
The North Karelia project: from North Karelia to national action
Also available in Russian

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

49. POPULATION
PUBLIC
POLICY
PRIVATE
SECTOR
HEALTH PROGRAMME

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

51. Major Elements of Finnish National Action 2.
Industry, business - collaboration
Policy decisions, intersectoral collaboration, legislation
Monitoring system: health behaviours, risk factors, nutrition
International collaboration

52. Prevention and management of cardiovascular disease
Action Plan for Promoting Finnish Heart Health

53. DPS-F study
Diabetes by treatment group during the total follow-up period 50
Log-rank test: p=0.0001
Intervention ceased
Control
Hazard ratio=0.57 (95% CI ) 40 30
Cumulative incidence of T2D, % 20
Intervention 10 1 2 3 4 5 6 7 8
Follow-up time, years
Lindström et. al. Lancet 2006:368;

54. } 15.7% } 11.2% Total*: 41.8% 33.2% Background
Disturbances in glucose metabolism in Finns aged y.
FIN-D2D survey 2004 (n=2896)
Men Women
Diagnosed type diabetes 7.4% 4.3%
Screen-detected type 2 diabetes 8.3% 6.9%
Impaired glucose tolerance % %
Impaired fasting glucose 9.3% 4.8%
} 15.7%
Total*: % 33.2%
} 11.2%
* Age-adjusted
Suom Lääkäril 2006;61:

55. Development Programme for the Prevention and Care of Diabetes in Finland: DEHKO 2000-2010
Finnish Diabetes Association as initiator and coordinator
Preparation of the programme:
Approval at a large concensus meeting January 2000
Implementation:
First official assessment March 2003

56. Development Programme for the Prevention and Care of Diabetes in Finland: DEHKO 2000-2010
3) Support for Selfcare
Education and counselling
Rehabilitation
Self Support groups
Co-operation of associations and professionals
Influence at community level
1) Prevention of Type 2 Diabetes
The Programme for the prevention of type 2 diabetes in Finland,
The Implementation of the prevention programme: Dehko 2D Project (FIN-D2D)
2) Improving the Quality of Diabetes Care
The care organization
The care chains
Quality criteria and the follow-up system of patients
Basic and higher education of personnel
Non-medical and medical treatment

57. Early diagnosis and treatment strategy
Programme for the Prevention of Type 2 Diabetes in Finland
Three strategies:
Population strategy
High risk strategy
Early diagnosis and treatment strategy
Population-based strategy / health promotion and more effective lifestyle counselling, prevention of overweight and obesity
High risk strategy /prevention or postponing diabetes in those at risk
Early diagnosis and treatment strategy / prevention of complications in those diagnosed having diabetes

58. Asthma Programme
Focus: (1) inflammation, (2) early intervention, (3) guided self-management, and (4) networking
Haahtela T, et al. Thorax 2006
National Allergy Programme – time to act and change the course
Finn Med J 2008,Suppl 14:1-22; Allergy 2008;63: ; Allergy 2008;63: , Editorial;
Allergy 2009;64:
In association with the WHO GARD Programme = Global Alliance against Respiratory Diseases
Focus: (1) children, young people, (2) from treatment to prevention, (3) tolerance, (4) diagnostic quality, and (5) early intervention to control severe allergies
Ministry of Health; National Public Health Institute; NGOs: Allergy & Asthma Federation, Finnish Lung Health Association, Finnish Pulmonary Association HELI 58

59. Key messages of the Allergy Programme
► Endorse health, not allergy
► Strenghten tolerance
► Adopt a new attitude to allergy. Avoid allergens only if mandatory
► Recognize and treat severe allergies early. Prevent exacerbations
► Improve indoor air quality. Stop smoking
■ Haahtela T, von Hertzen L, Mäkelä M, Hannuksela M, The Allergy Programme Group. Finnish
Allergy Programme – time to act and change the course. Allergy 2008
■ Bousquet J, et al. In Allergy, ”A new day has begun”. Allergy 2008, Editorial 59

60. Allergy Programme Goals 2008-2018
► Prevent allergies. – Prevalences of asthma, allergic rhinitis and atopic
dermatitis reduce by 20 %.
► Increase tolerance to allergens in the population. –
Avoidance diets to foods decrease by 50 %.
► Improve allergy diagnostics. – All patients are tested in a quality
certified allergy-testing centre.
► Reduce work related allergies. – Their numbers reduce by 50 %.
► Use resources to treat severe allergies and reduce
exacerbations. – ”Good Allergy Care” is employed in the whole country and
asthma exacerbations are reduced by 40 %.
► Reduce costs caused by allergies. – Costs reduce by 20 %.
■ Haahtela T, von Hertzen L, Mäkelä M, Hannuksela M, The Allergy Programme Group. Finnish
Allergy Programme – time to act and change the course. Allergy 2008
■ Bousquet J, et al. In Allergy, ”A new day has begun”. Allergy 2008, Editorial 60

61. Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability OBJECTIVE:
To reduce cognitive impairment in an at risk population through a 2-year multi-domain life-style intervention including:
Nutritional guidance
Strength training and aerobic exercise
Cognitive training, increased social activity
Intensive monitoring and management of metabolic and vascular risk factors: hypertension, dyslipidemia, obesity, impaired glucose tolerance
13/10/2017

62. Thank you!

63. Health in All Policies – The Finnish Initiative

64. What is Health in All Policies (HiAP) approach?
Horizontal, complementary policy related strategy
The core of HiAP is to examine determinants of health -> are mainly controlled by policies of sectors other than health
Addresses policies in the context of policy-making at all levels of governance (global, European, national, regional and local levels)
The ultimate aim of HiAP is to improve evidence informed policy-making
Health in all policies is closely related to other terms with similar agenda, such as healthy public policies and intersectoral action for health
Ståhl et al. (eds). Health in All Policies – Prospects and potentials, 2006

65. Focusing on policies Key concern: policies
The broad economic, social, environmental and cultural health determinants are the bridge between policies and health outcomes
For example, alcohol policy (tax) influences the price of alcohol that has an effect on alcohol consumption that (alcohol abuse) in turn has an effect on harms, both health and social
Less concerned with single programmes and projects
alcohol policy tax on alcohol alcohol consumption health and social harms

66. Broad determinants of health
Social, economic, structural, environmental, cultural
Present everywhere in the society
Often beyond the control of individuals
Same determinants are linked with many major public health problems (nutrition, physical activity, tobacco, alcohol, psychosocial situation, stress)
Mostly a responsibility of other government sectors
Impossible to target effectively through sectorial health policies alone

67. Intersectoral mechanisms/tools for implementing HiAP
Formal consultations on e.g. legislation
Horizontal public health committees
Ad hoc committees on specific initiatives
Cross-sectorial programmes
Public health reporting (with co-operation of other sectors)
Formal communication between sectors (e.g. bilateral meetings of Permanent Secretaries)
Informal contacts at desk level
EU co-ordination
Health impact assessment
Stahl T (2009) Is health recognized in the EU's policy process? An analysis of the European Commission's impact assessments. The European Journal of Public Health 2009; doi: /eurpub/ckp082