Example 4: The North Karelia Project

Contributed by Samir Kashyp

BACKGROUND

In the late 1960s and into the 1970s, 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 the world's first major community-based intervention in the area of CVD. The intervention involved local consumers, schools, and social and health services and was organized to help raise awareness of the severity of the issue. The initiative began in North Karelia, the area of the country with the lowest socioeconomic status and the region with the prevalent number of cases of CVD. As the project grew, it became known as the North Karelia Project, though it was later expanded to encompass the entire country. The intervention included passing legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in farmers' payment schemes, and incentives for communities achieving the highest reduction in cholesterol levels.  Among the astonishing results, the CVD-related death rates in men have declined by 65% and the life expectancy among men has increased by seven years since the intervention began in the 1970s.

DECIDE WHETHER TO CONDUCT A SOCIAL MARKETING CAMPAIGN

The fact that Finland had the highest incidence of mortality due to cardiovascular disease in the world was reason enough to start an initiative to help curtail the problem. The aim of this initiative was to reach the entire country to significantly decrease the incidence of CVD-related death throughout the nation. Researchers felt it was necessary to combat this problem in several different ways. One of the most effective and efficient ways of doing this was social marketing. The information provided regarding the hazards of smoking and the benefits of eating healthy and living a healthy lifestyle were essential in persuading the community.

COLLECT INFORMATION FROM THOSE WHO WOULD BENEFIT FROM AND CONTRIBUTE TO THE SOCIAL MARKETING CAMPAIGN

The World Report from the World Health Organization (WHO) provided a great deal of information to the primary investigators regarding where the highest incidence of CVD was and who was most at risk. A baseline survey was then conducted in the North Karelia region to further categorize the population. The primary contributors to the social marketing campaign were the local newspaper, the national TV station (Finnish TV2), the health services offices in North Karelia, and various leaders within the community. The expected benefits from the initiative were that the general population would see a decreased incidence of CVD and CVD-related deaths and, more specifically, that this decrease would occur in population aged from 35-54 years old. The cost of mass media efforts was greatly offset by the willingness of Finnish TV2 to allocate its own funds to the "Stop Smoking" TV series. This is particularly important because it demonstrates the station's primary concern as the health and well-being of the citizens of the country.

STATE THE GOALS BEHAVIORAL OBJECTIVES OF THE CAMPAIGN

The overall goal of the North Karelia Project was to reduce the incidence of cardiovascular disease and CVD-related death by 1982 (10 years after the project's initiation). Behavioral objectives of the campaign centered around decreasing the behaviors that put people at greater risk for CVD. There were three primary risk factors identified -- elevated serum cholesterol, elevated blood pressure, and smoking. The behavioral objectives of the campaign addressed these risk factors and included increasing physical activity, reducing the amount of saturated fat consumed, and smoking cessation.

DEFINE THE AUDIENCE OR SPECIFIC PRIORITIZED GROUPS TO BE REACHED. 

The specific group targeted in this initiative was the 35-74 year old age group. This was the population most susceptible to the primary risk factors for CVD and the group most capable of reducing those risk factors.  

More broadly, North Karelia was identified in the planning stages of the project to be the region of Finland most susceptible to CVD risk factors because of its rural setting and its low socioeconomic status. It was found by the Finnish Heart Association that this region of the country had the highest incidence of CVD-related deaths at the time. The behaviors and conditions of the people were well documented in the FHA study and it was the results of this study that sparked people's interest in helping to reduce the prevalence of cardiovascular disease.  

There was a particularly high rate of CVD in this region because of a mixture of factors. Personal factors included the high saturated fat diet that most of the population consumed and the smoking habits that they exhibited. Environmental factors included the hilly terrain and rural landscape that made it inconvenient for the people in the region to travel to a health care facility. Some environmental factors also served as protective factors because the primary health care in the rural region was administered through revenue from municipal and state taxes, meaning that there was access to healthcare for all.

ENGAGE POTENTIAL PARTNERS AND CHANGE AGENTS IN THE CAMPAIGN.

Since this intervention was community-based, it relied on community members to be agents of change for the project. In particular, the North Karelia project engaged lay leaders from the community and local partners from health services, the media, businesses, and the schools to address the issues of CVD and CVD-related mortality.

Within this group of change agents were three distinct categories: connectors, teachers, and persuaders. The connectors in the group were the local schools and businesses that would be promoting the principles of the intervention and bringing the message of the project into the homes of the people. The teachers included the nurses and doctors from the health services organizations who would be instructing citizens on how to improve their health and providing them with the appropriate care and guidance to reduce their risk factors for cardiovascular disease. The persuaders would be primarily the local media. The "Stop Smoking" TV series was particularly effective in its persuasion efforts because it used people from the local community who were making positive changes in their lifestyles and encouraged many people watching at home to engage in the same healthy behaviors.

ANALYZE THE KEY BEHAVIORS AND ENVIRONMENTS RELATED TO THE PROBLEM OR GOAL.

The target behaviors that were being addressed in this initiative were the amount of saturated fat intake in the daily diet, smoking habits, and the amount of physical activity among the people of North Karelia. The intake of a high amount of saturated fat was caused by the traditional diet in the area (i.e. high meat intake, low vegetable intake) and the lack of availability of healthier alternatives. There seemed to be a lack of physical activity because the primary occupation of many in the area was forestry -- the long and tiring hours associated with this occupation were most likely a big contributor to the unwillingness of many to engage in physical activity. The poor diet and lack of physical activity, when paired with smoking, created an unhealthy environment in which the risk factors could not be effectively addressed without significant changes.  

Since this intervention was the first of its kind, implementers did not have any established best practices on which to model their efforts. It instead took very careful planning and integration of medical knowledge to work toward an environment best suited to reducing CVD and CVD-related mortality.

IDENTIFY CORE COMPONENTS OR STRATEGIES OF THE CAMPAING.

The North Karelia Project, in conjunction with the local TV network, developed a Communication-Behavior Change Approach so that it could effectively persuade the local people to change their lifestyles to improve their health. The project communicated memorable messages through its many fliers posted around the community and the programming on television. It was also through television programming that project sought to make the undesirable behaviors (i.e., smoking, unhealthy eating, sedentary lifestyles) seem unattractive. The steps taken in this approach were exposure, attention, comprehension, persuasion, action, and maintenance. These steps were taken while taking into consideration two factors: community and communication. These two factors helped determine what subjects were appropriate for the community and how the message should be communicated to the community. The primary area in which this approach was used was in the TV programming that was implemented. The following model was used to plan and evaluate the content of the programs (Puska et al., 37):

This model illustrated very well the manner in which specific activites were distributed amongst the different components of the social marketing effort. It was also very sequential in the order the different components were implemented. The structure of the model also made it easier for the project to properly tailors its efforts to the proper prioritized groups and subgroups of the North Karelia population.

SELECT AND TAILOR CAMPAIGN COMPONENTS BASED ON THEIR IMPORTANCE, FEASIBILITY, AND FIT WITH DIFFERENT PRIORITIZED GROUPS/ SUBGROUPS.

In this initiative, the prioritized groups were those in the population who were 35-44 years old, 45-54 years old, 55-64 years old, and 65-74 years old. Each of these groups were then divided into subgroups of individuals who either smoked, had an elevated serum cholesterol level, had a high daily intake of saturated fat paired with a low vegetable intake, or all of the above. The biggest channels of influence for this community were the broadcast media, print media, community events, and public and nonprofit organizations (i.e. municipal health centers). The messages of the TV campaigns were tailored to people in the targeted age groups from the actual community, as the "stars" of the shows were community members themselves. The fact that those watching actually knew some of the people on the show and could relate with their problems was seen as an enormous factor in promoting the healthier behaviors.

PRETEST AND REVISE THE CAMPAIGN COMPONENTS BEFORE FULL IMPLEMENTATION

The North Karelia Project actually originated as pilot project attempting to combat the mortality rate from cardiovascular disease for the entire country of Finland, so the project in itself was a pretest before it was fully implemented across the country. At first, baseline surveys were taken to gain a better understanding of the community as a whole, asses its overall health, and determine how to market the media campaign to the targeted population.    

To determine the effectivness of the various campaign components, the investigators of the initiative employed several different tools and agencies in the community. Television programs and advertisements were run to ensure that the message of the campaign was clear. Surveys were mailed to members of the community that were to be filled out prior to coming to receive a health checkup. These surveys evaluated both the effectiveness of the marketing of the campaign and the community's satisfaction with the campaign as well. The 'Quit and Win' competitions conducted in the community also were a good indicator of the community's responsiveness to the media campaign. The intervention underwent constant cost evaluation to see where savings were occurring and where costs were being incurred. There was a great amount of savings in the media campaign, for example, because the television station, whose programming would have incurred significant costs, offered to cover the costs of the 'Stop Smoking' TV ads and programming.     

Once all the components had been implemented for five years, a final survey was conducted to determine the overall effectiveness of the campaign. The surveys determined the changes in the population's overall health, mortality rates, smoking habits, and serum cholesterol levels. Because the initiative was found to be effective in affecting changes in these factors, evaluation was continued after the initial five year period and more components  with more specific foci were added to the project.

IMPLEMENT THE SOCIAL MARKETING CAMPAIGN

The social marketing campaign sought to inform and educate the community on the country's high mortality rate due to CVD. Its goal was to promote awareness of the issue through programs, advertisements run by the local TV station, articles in the local newspaper, flyers posted around the community, pamphlets handed out throughout the community, and through increased visits to the local health center. These actions were carried out by the local media (TV and print), the lay leaders of the community, doctors and nurses, and the members of the community themselves. These action were to occur within weeks of the action plan's implementation and was to be sustained until the the five year evaluation period was reached.   The print and broadcast media made a signifcant contribution to community awareness of CVD and CVD mortality. The following is a more specific breakdown of the media's contributions to the campaign:

• Print Media

• Broadcast Media
   
  • TV Programs
     
    • The North Karelia Project partnered with Finnish TV2, one of the three national TV channels, to air programming that featured "role models" (high risk people who volunteered to be on the show) for the community 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.
  • 'Quit and Win' Campaigns
     
    • 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 to lead healthier lives and quit smoking.

Since this was a community-based intervention, the only difficult need was money. There was also some need for increased staff in the areas of administration and evaluation. The members of the evaluation staff were located at the University of Kuopio. The rest of the staff needed was easily found in the community, but they were worked harder than usual. No new staff was added to the local health centers, but new tasks were added to the normal daily schedule. At these community centers, blood samples were taken, physicals were conducted, and evaluations of the campaign were also conducted. It was expected that the community of North Karelia would, because of this project, eventually understand the risk factors that make them highly susceptible to cardiovascular disease (i.e., smoking, high saturated fat intake, low physical activity) and the preventive measures that they can take to lower their risk.

EVALUATE THE EFFECTS OF THE SOCIAL MARKETING CAMPAIGN

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 the social marketing campaign was successful at reducing rates of CVD and CVD-related deaths. 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. Primary causes of such significant reduction can be attributed to the significant reduction in the risk factors in the population. The significant reduction in risk factors was achieved through the various components of the social marketing campaign- exposure to the issues, attention to the importance of the issues, comprehension of the severity of the issues, persuasion to carry out desired actions, the action itself, and maintaining those actions.

CELEBRATE SUCCESSES AND MAKE ONGOING ADJUSTMENTS  

The North Karelia Project was a pilot project for the entire country of Finland. In response to the results of the study, the social marketing effort expanded into communities all across the country. The primary way in which the community was able to celebrate the campaign was simply by enjoying the fact that they were no longer having to worry about the cardiovascular disease as long as they maintained their health. The television campaigns were also able to broadcast results and give acknowledgments to the success of the community for becoming a healthier place. The 'Stop Smoking' TV series acknowledged those who had achieved significant gains in their health. The 'Quit and Win' campaigns awarded those who were the most successful in quitting smoking. Another aspect of celebration was being able to spend time with family and friends that they never thought they would have been able to spend.   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.

SUSTAIN THE EFFORT LONG ENOUGH TO MAKE A DIFFERENCE

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 intevention 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.