Background, Principles, Implementation, and General Experiences of the North Karelia Project.

The extremely high mortality of cardiovascular diseases in the 1960s in Finland, particularly in the Eastern Province of North Karelia and especially that of coronary heart disease in men, caused great concern among the local population. Action to reduce the problem was demanded in a petition signed in 1971 by the representatives of the population. In response, the North Karelia Project was launched in 1972 to carry out a comprehensive preventive project, first only in North Karelia as a national pilot (1972 to 1977), and thereafter continuing in North Karelia but at the same time transferring the experiences to a national level. The intervention was based on the at-that-time relatively new scientific information on the main causal risk factors. A comprehensive population-based intervention was carried out, aiming especially at the reduction of the high levels of serum cholesterol, blood pressure, and tobacco use, emphasizing general dietary changes and smoking reduction. A comprehensive monitoring and evaluation program was designed and implemented to learn from the experience in preparation for national and international use. Presented here are the background, principles, and general experiences of this project, which has made major contributions both to the contemporary public health work for the prevention and control of heart disease and noncommunicable diseases and for research in the area.

Training practitioners in evidence-based chronic disease prevention for global health.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a "critical mass" of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Rural-urban differences in health and health behaviour: a baseline description of a community health-promotion programme for the elderly.

STUDY OBJECTIVE: To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals. DESIGN: The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments. SETTING: Fourteen municipalities in the Lahti region (Päijät-Häme County) in Finland. PARTICIPANTS: A regionally and locally stratified random sample of men and women born in 1946-50, 1936-40, and 1926-30. A total of 4,272 were invited and 2,815 (66%) participated. MAIN RESULTS: Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43). CONCLUSIONS: The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in Päijät-Häme County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.

Trends and educational disparities in functional capacity among people aged 65-84 years.

BACKGROUND: This study examined 10 year trends in functional capacity by gender, age, and education among elderly Finns aged 65-84 years, focusing on difficulties in basic activities of daily living (BADL). Educational disparities and their trends in the prevalence of these difficulties were also assessed. METHODS: Data were derived from nationally representative monitoring surveys conducted biennially from 1993 to 2003 by the National Public Health Institute (KTL). A total of 5740 men and 5746 women were included in the study (response rate 80%). Activities of daily living (ADL) measures were used to assess levels of functional capacity. Education was divided into two groups: low (0-8 years) and high (9+ years). Age-adjusted trends and logistic regression analyses were computed. RESULTS: A clear downward trend in BADL difficulties was observed in all age groups in both genders. 80-84 year olds had clearly poorer functional ability than 65-69 year olds, even when adjusted for chronic diseases. Despite the overall improvement in functional capacity in both educational groups, low educational status persistently predicted poorer functional capacity. When chronic diseases and survey period were controlled for, the educational disparities attenuated slightly but remained significant. CONCLUSIONS: The number of Finnish elderly with BADL difficulties has declined markedly over the past 10 years. However, persistent educational disparities continue to present a challenge to public health initiatives for reducing inequalities in health.

Twenty-five-year trends in lifestyle and socioeconomic characteristics in Eastern Finland.

AIMS: Little is known about changes in lifestyle and socioeconomic characteristics among physical activity subgroups over time. This study aimed at assessing whether the lifestyle and the socioeconomic profile of people with either low total physical activity (TPA) or high TPA changed during 1972-97. METHODS: Six independent cross-sectional surveys were carried out among a middle-aged population at five-year intervals in Eastern Finland, 1972-97. The participation rates varied from 71% to 95% (n = 33,712). Physical activity during leisure time (LTPA) and occupational physical activity (OPA) were determined by a self-administered questionnaire. TPA was calculated by combining LTPA and OPA. RESULTS: Men with low TPA were older, smoked more, and had a higher BMI than men with high TPA. The increase in BMI was almost fourfold in sedentary men (trend 0.4%/5 years, p = 0.023 for trend) than in highly active men (trend 0.1%/5 years, p = 0.044 for trend). Education no longer accounted for the socioeconomic difference after 1977. Sedentary women had a higher BMI and smoking prevalence than those with high TPA. The difference in age, education, and marital status disappeared between those two groups after 1977. CONCLUSIONS: The lifestyle and the socioeconomic profiles of people with both low TPA and high TPA have changed during 1972-97.

Associations of functional ability with health-related behavior and body mass index among the elderly.

The main purpose of this study was to determine whether functional ability among the elderly associates with body mass index (BMI) and health-related behavior. The secondary aim was to examine whether health behavior and BMI can be seen as mechanisms explaining sociodemographic disparities in functional ability. Cross-sectional biennial surveys from 1985 to 2001 were used to study 11,793 Finnish people aged 65-79 years. Associations of activities of daily living (ADL) with BMI, health behaviors (smoking, alcohol consumption, diet, physical activity), time period, previous occupation, marital status and certain diseases were tested using an ordinal regression model. Current and ex-smoking, heavy and non-alcohol use, unhealthy diet, physical inactivity and obesity were associated with inferior ADL. Alcohol consumption among men showed a U-shaped relation to functional ability. Most of the differences in ADL by occupation and marital status vanished after adjustment of multiple factors. The results showed clear associations of ADL with health-related behaviors and BMI when adjusted for multiple factors. The findings suggesting a U-shaped relation between ADL and alcohol consumption among men and the association between diet and ADL add to our previous knowledge of factors related to functional ability.

Smoking and alcohol consumption among the elderly: trends and associations, 1985-2001.

BACKGROUND: Despite their clear association with health, smoking and alcohol consumption among elderly people have not been extensively researched. This study examined changes in smoking and alcohol consumption and their sociodemographic patterning among the Finnish population aged 65-79 years over the period 1985-2001. METHODS: Population-based monitoring surveys conducted biennially from 1985 to 2001 were pooled into three time periods. Trends in smoking and alcohol consumption and their sociodemographic variations among 5870 men and 5923 women were calculated. Logistic regression was used as the main method of analysis. RESULTS: Smoking declined slightly among men, and consumption of higher levels of alcohol rose in both genders from the mid-1980s to the early 2000s. Smoking among women remained at a very low level throughout the study period. Smoking and higher level of alcohol consumption were more prevalent among the younger elderly and among the men than among their counterparts. Higher alcohol use was more common among retired office workers than other former employees. Smoking was clearly more prevalent among unmarried than married people. CONCLUSIONS: Declining numbers of male smokers and remarkably few female smokers, together with positive changes already noted in diet and functional ability, suggest healthier senior years ahead. On the other hand, the rising trend of alcohol use poses a challenge to future public health.

Health psychological theory in promoting population health in Päijät-Häme, Finland: first steps toward a type 2 diabetes prevention study.

In public health promotion, behavioural science theories and theory-based methods should be translated into practical strategies that fit environmental conditions and are feasible for implementation. In this article, an effort to meet this challenge is presented. As a starting point we describe the conditions for development and success of the previous generation of public health promotion programmes in Finland. However, changes both in the population structure and in the population health bring new demands for programme development. We consider possibilities offered by health psychology and give a practical example of how theories and theory-based methods are applied in a community programme for type 2 diabetes prevention implemented in the Finnish primary health care.

Changes and associations in healthy diet among the Finnish elderly, 1985-2001.

BACKGROUND: diet is related to health and studies of transitions in diet among elderly people are scarce. The aim of this study was to monitor any recent changes in healthy diet among the 65- to 79-year-old population of Finnish citizens. Possible disparities in 5-year age groups, occupation and marital status were examined. METHODS: biennially conducted nationwide monitoring cross-sectional surveys among Finnish elderly people were used to study 11,793 (response rate 82%) men and women from 1985-2001. Data were pooled into three time periods. Analysis of logistic regression was used to compare and test for changes in healthy diet in categories of sociodemographic factors. RESULTS: the diet of the elderly population clearly improved from the mid-1980s to the early 2000s. The change over the monitoring period was slightly steadier among women than men. The youngest respondents, especially women, retired office employees and married persons had the healthiest diet. CONCLUSIONS: continuing improvement in diet might indicate positive health outcomes in the future. Nevertheless, there are still subgroups with unhealthier diets that include persons who are also underprivileged as far as functional ability is concerned.

Anthropometry, bioelectrical impedance and dual-energy X-ray absorptiometry in the assessment of body composition in elderly Finnish women.

In this study, the bioelectrical impedance analysis (BIA), skinfold thickness measurement (STM) and dual-energy X-ray absorptiometry (DXA), as a reference method, were compared with each other in the assessment of body composition in elderly (62-72-year-old) Finnish women (n=93). BIA had better agreement with DXA in the assessment of fat free mass (FFM, R2=0.70, Sres=2.1) and fat mass (FM, R2=0.93, Sres=2.3) than the STM (FFM, R2=0.62, Sres=2.4; FM, R2=0.89,Sres=2.8). There was quite a large variation in the estimates when different BIA prediction equations were used. The equation developed in this study, FFM (kg)=-128.06 + 1.85 x BMI-0.63 x weight + 1.07 x height - 0.03 x resistance +10.0 x waist-hip ratio, yielded a small and unbiased error (0.5 +/- 1.6 kg), with a small residual standard deviation (R2=0.83, Sres=1.6). However, error associated with the estimate of FM was positively related to the degree of FM. BIA(Heitmann) equation yielded unbiased estimates of both FFM and FM (FFM, R2=0.77, Sres=1.8; FM, R2=0.95, Sres=1.9). Both the STM and BIA (manufacturer's equation) resulted in error which was statistically significant and positively correlated with FFM and FM. These results indicate that BIA prediction equations, chosen with care, can improve the performance of equations based upon anthropometric measurements alone in the assessment of body composition in elderly women.