Example 6: The North Karelia Project

BACKGROUND 

In the late 1960s and into the '70s, Finland had the world's highest death rate due to cardiovascular disease (CVD). This was primarily attributed to the prevalence of smoking and a high-fat diet that included a low vegetable intake. In response to this situation, the Finnish government decided to launch what we now recognize as the world's first major community-based intervention in the field of CVD. The intervention involved local consumers, schools, and social and health services and was organized to help raise awareness about the severity of the issue. The initiative originated in North Karelia, the area of the country with the lowest socioeconomic status and the highest prevalence of cases of CVD. As the project grew, it became known as the North Karelia Project. The intervention included passing legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in farmers' harvests (i.e. switching from dairy to berry farming), and incentives for communities achieving the highest reduction in cholesterol. As a result, the death rates have declined by 65% in men and 70% percent in women, and the life expectancy among both has increased by seven years since the intervention began in the 1970s.

IDENTIFY STAKEHOLDERS

The stakeholders in this initiative included the government, North Karelia consumers, schools, social and health services, and those with cardiovascular disease. The University of Kuopio and the National Public Health Institute in Finland were the primary evaluators of this initiative.

DESCRIBE THE PROGRAM OR INITIATIVE'S FRAMEWORK 

The North Karelia Project was a community-based intervention developed in response to reports that Finland had the highest death rates due to cardiovascular disease in the world. In 1970, the death rate was approximately 750 deaths per 100,000 individuals. North Karelia was identified to be the area of lowest socioeconomic status and highest CVD prevalence, so the intervention was begun there. The theory behind starting in the region with the lowest socioeconomic status was that if the intervention is effective in an area of low socioeconomic status, then it will likely be more effective in areas with a higher socioeconomic status. Components of the project included media activities,  preventive services, training of professionals and other workers, environmental changes, and monitoring and feedback. Media activities included the dispersal of health education materials, radio and TV campaigns, and the local press. Preventive services were primarily performed by doctors, nurses, and health professionals. The workers of the North Karelia Project trained and informed health professionals so that they could better inform their patients of the risk factors associated with CVD.   The intervention activities for the project were separated into different categories, as follows, in order to create a better organization for evaluation of the intervention:

• Information for the General Public

  • Mass media

  • Health education materials

  • Campaigns

• Organization of Services

  • Primary health care

  • Other health care

  • Other services (schools, social services)

• Personnel Training Programs

  • Health personnel

  • Other personnel

  • Lay leaders

• Environmental changes

• Information (monitoring) systems

The project's main objectives were to reduce CVD mortality, reduce major chronic mortality, and promote health in the local population. The intermediate objectives of the project were to promote secondary prevention and reduce the main risk factors of smoking, LDL cholesterol, and high blood pressure by promoting a healthier lifestyle. The national objective of the project was to serve as a model for communities and to reduce the CVD mortality rate in all areas of the country.

Primary interventions require that the main risk factors be derived from international literature. In the case of North Karelia, the risk factors were identified easily because of the significant scientific studies that had been done in Finland regarding CVD-related deaths. Risk factors were identified and further categorized within epidemiological/medical and behavioral/social frameworks. The three primary risk factors identified for CVD were elevated serum cholesterol, elevated blood pressure, and smoking. Once these risk factors were identified, a more comprehensive framework was developed that set forth the necessary steps in the intervention. 
    
The epidemiological/medical framework was rather simple for the project because it was a community-based intervention, rather than an intervention directed at only high-risk individuals. The justification for this approach was that most members of the community with CVD have only moderate risk factors, while those with the highest risk factors make up a small proportion of the community. The strategy under this framework was to employ general community activities to inform the entire community about the risk factors for CVD that were common within the community. 
    
The behavioral/social framework provided a structured approach as to how to change the behavior of a population. The behavior change approach developed by this project was broken down into the following elements.

• 1. Improved preventive services to help people identify their risk factors and to provide appropriate attention and services to those at risk.

  2. Information to educate people about the relationship between their behaviours and their health.

  3. Persuasion to motivate people and promote their intentions to adopt healthy actions.

  4. Training to enhance skills of self-management, environmental control, and necessary action.

  5. Social support to help people maintain their initial action.

  6. Environmental change to create the opportunities for healthy actions and improve unfavourable conditions.

  7. Community organization to mobilize the community for broad-ranging changes (through enhanced social support and environment modification) to support the adoption of the new lifestyles in the community.

A unified model that combined these two frameworks was implemented to effectively reduce the risk factors within the community. The activities that followed from this unified model included working with health services, employing mass media, passing legislation, and working with leaders within the community to effectively bring about positive change within the community (e.g. lowered LDL cholesterol in blood serum).

 Focus the evaluation design
The North Karelia Project is particularly known for its comprehensive and ever-expanding evaluation design. A good evaluation technique helps an intervention track its implementation and examine its overall effectiveness. In this project, the following evaluation categories were used:

• Feasibility/performance

  • Feasibility and performance evaluation assessed the extent to which it was possible to implement planned activities while making sure that the necessary resources were available for the project. This type of evaluation is particularly important in projects that extend over a large geographical area or are large and comprehensive in nature.

• Effects

  • Effects evaluation determined whether the main or intermediate objectives of the initiative were fulfilled. After identifying indicators, a baseline was established at the start of the project so that it could be determined whether or not the activities of the intervention were effective in modifying behaviors and risk factors. The sample surveyed both before and after the intervention was intended to be representative of the whole country (the whole area of implementation).

• Process

  • Process evaluation of this project determined how the work of the initiative and the results of the initiative were related. It examined factors stemming from a variety of sources, including exposure to the intervention measures, attitudes and intentions, and changes in health knowledge.

• Costs

  • Cost evaluation examined the various resources of the initiative and how they were used within it.  Cost evaluation, however, does not restrict itself to just the costs incurred by the project due to the implementation of the initiative, but the costs or savings to the community itself as a result of it.

• Other consequences

  • An evaluation of other consequences examined those consequences that were not intended for the population but did occur. This type of evaluation was included in the initiative to examine other possible health changes that may have occurred due to behavioral changes the initiative caused. Unintended consequences could range from health factors, such as a co-occuring loss of weight, to emotional factors, such as increased self-confidence. These additional changes -- positive or negative -- were examined fully to better understand the long term effects of the initiative.

GATHER CREDIBLE EVIDENCE

One of the most celebrated aspects of the evaluation of the North Karelia project was the tools that it used to conduct the evaluation. It was important to be able to examine the population in a variety of ways. The following is a list of tools that were used:

• • Mortality statistics

  • Incidence of major chronic diseases (e.g., heart disease, stroke)

  • Morbidity

    • Disability data

    • Hospital discharge data

    • Population data concerning diagnosed diseases, symptoms

  • Population Surveys

    • Health behavior (e.g., smoking, diet high in saturated fat, lack of physical activity)

    • Quality of life, subjective health

      • Intervention process

  • Risk factor Surveys

Of particular importance in this set of tools were the risk factor surveys. These surveys were performed every 5 years with an independent random sample developed following the WHO MONICA protocol. All individuals submitted to having their serum cholesterol tested, blood pressure measured, and answering a questionnaire regarding their smoking habits. 

The reliability and validity of the results were very high because of the nature of the testing. Everyone who came in for a test at the local health center was examined by a highly trained nurse who checked over each survey that was turned in with every examination. This helped to ensure accuracy of the results and completeness of the surveys. All of the cholesterol tests were performed in a central lab that was standardized against both national and international reference laboratories. This project experienced greater than 90% participation rate, which is very high, and it has only slightly decreased over time. Such a high participation rate may be attributed to the fact that it was conducted through the health services offices alongside regular check-ups.  Results were collected and used to evaluate the different functions of the initiative to improve its effectiveness and reception by the community.

OUTLINE AND IMPLEMENT AN EVALUATION PLAN 

Evaluation of the effectiveness of this project is done every 5 years. Health conditions of a population are not very quick to progress and more frequent evaluation would most likely result in wasted time and effort. The University of Kuopio and the National Public Health Institute in Finland were the primary evaluators of this initiative. Others involved in the evaluation included the government, North Karelia consumers, representatives in schools, workers in social and health services, and those with cardiovascular disease. The steps to implementing evaluation were as follows:

• Mass Media Campaigns

  • Print Media

• The North Karelia Project partnered with Finnish TV2, one of the three national TV channels, to air programming that showed "role models" for the community (high risk people who volunteered to be on the show) trying to make healthy changes to their lifestyles. These shows received high television ratings and were watched by even those in the lowest socioeconomic status. The major benefit for the project was that TV2 covered all the costs for the program.
• While the TV programs were being aired, the project organized 'Quit and Win' contests in the community. These were designed to provide incentive for the community to take action alongside those in the programs to lead healthier lives and quit smoking.

• TV Programs
  • 'Quit and Win' Campaigns
• Health Behavior and Disease Rates
  • All the data was then sent to the University for evaluation and analysis.
  • Highly trained nurses then looked over everything on the questionnaire to make sure that it was completely and correctly filled out.
  • At the local health center, a blood sample was taken to determine cholesterol levels, blood pressure was measured, and patients were given a smoking questionnaire and further categorized into three categories: current smokers, ex-smokers, or never smokers.
  • Prior to an examination at the local health center, a survey was sent out to those in the community to assess overall risk factors, behaviors, medical history, and socioeconomic factors of residents.

MAKE SENSE OF THE DATA AND JUSTIFY CONCLUSIONS 

Very early on in the project, the CVD mortality rates began to decline. There was a significant overall decrease in every part of the country, but there was a more pronounced decrease in North Karelia during the time of the project's initial implementation. As soon as the initial results of the North Karelia project were evaluated, the components of the project were implemented all over the country in an effort to achieve the same results. After the replication of this project across Finland, the mortality rates declined in all of Finland like they did in North Karelia. From the years 1969-71 until the year 2006, both male and female populations achieved significant declines in mortality rates. In men and women aged 35-44 years old, declines of 96% and 40%, respectively, were achieved. In the 45-54 year old age group, men achieved a 91% decrease while women achieved an 89% decrease. In 55-64 year olds, there was an 80% decrease in the mortality of men and a 92% decrease in the mortality of women. Among 65-74 year olds, there was a slightly smaller, but still significant, decline than the other age groups. In men, the mortality rate decreased by 65% and women decreased by 82%. It can be observed that as soon as the North Karelia Project expanded into a national project, the mortality rates throughout the entire country declined sharply from 475 deaths per 100,000 people to below 400 per 100,000 people. This number has since decreased to fewer than 100 deaths per 100,000 people.  

It is clear that this intervention was successful at reducing rates of CVD and CVD-related deaths in Finland. The study results are representative of the population because of the 90% participation rate that was achieved in the surveys that were conducted amongst members of the sample population. The primary causes of such significant reduction in CVD and CVD-related mortality rates is a sharp reduction in the number of risk factors for the disease. This significant reduction in risk factors was achieved through the various components of the intervention -- general public information, organization of services, personnel training programs, environmental changes, and information (monitoring) systems.

USE THE INFORMATION TO CELEBRATE, MAKE ADJUSTMENTS, AND COMMUNICATE LESSONS LEARNEDC  – TAKE STEPS TO ENSURE THAT THE FINDINGS WILL BE USED APPROPRIATELY 

 The North Karelia Project was, in a sense, a pilot project for its own use throughout the entire country of Finland. In response to the results of the study, the intervention was expanded into communities all across the country. The primary way in which the community was able to celebrate the initiative was simply by enjoying the fact that they were no longer having to worry about cardiovascular disease as long as they maintained their health. Being able to spend time with family and friends that they never thought they would have otherwise was celebration enough for the citizens of North Karelia. Soon after the initial findings of success, the project as a whole was divided into many sub-projects targeted at specific issues rather than a breadth of issues, to affect changes in a more focused way. Some of the sub-projects were The North Karelia Cholesterol Project, North Karelia Berry Projects, North Karelia Youth Projects, Stop Smoking, and the Smokefree North Karelia Project.  To this day, the initiatives from this project are being implemented and evaluated in North Karelia. The project still employs individuals to specifically collect and analyze the results that are sent in from around the country. The overwhelming success of this project provided a framework for the world as to how to combat noncommunicable diseases such as cardiovascular disease through community-based interventions. Taking a look back at the initiative, the primary investigators conveyed several lessons that can be learned from this project:

1. A community-based intervention with a solid framework can create significant positive effects on risk factors and lifestyles.
2. Successful community-based efforts combine a solid framework with persistence and hard work and close interaction with the community.
3. An essential component to all community-based interventions is reliable and high-quality evaluation.
4. Much collaboration, strong and dedicated leadership, and support from government policies are essential for the success of an initiative.
5. A major national initiative can be a powerful tool to generate favorable national developments in chronic disease prevention and health promotion.

The overwhelming success of this initiative has translated into its longevity. Overall, North Karelia has served as a model for how different sectors of a community can work together to prevent chronic disease and promote health, and it has also shown how a community-based initiative can create policy changes and even lead to the creation of programs across a country.

RESOURCE

Puska, P., Vartiainen, E., Laatikainen T., Jousilahti, P., Paavola, M. The North Karelia Project: From North Karelia to National Action. Helsinki: Helsinki University Printing House, 2009.