Community programme for control of hypertension in North Karelia, Finland

Blood Pressure, Sodium Intake, and Hypertension Control: Lessons From the North Karelia Project

From the very beginning of the North Karelia Project, prevention, detection, and control of hypertension were included as key aims in the project. An intensive hypertension prevention and control program was established in North Karelia in 1972 that included community-based activities to reduce blood pressure levels in the entire population, detect people with hypertension, improve their treatment, establish standard diagnostic and therapeutic methods, and to monitor blood pressure levels, control of hypertension, and the performance of the health care. After the first 5 years of the project, most of these activities were also implemented on the national level. In late 1970s, work to reduce the salt intake was started, and substantial reductions have taken place in salt intake in the Finnish population. Remarkable improvements have been seen both in blood pressure levels and in treatment and control of hypertension in North Karelia and in the whole of Finland. Between 1972 and 2012 in North Karelia, the mean systolic blood pressure among 30- to 59-year-old men has decreased from 149 mm Hg to 135 mm Hg and among women from 153 mm Hg to 129 mm Hg. The decreases in mean diastolic blood pressure have been from 92 mm Hg to 84 mm Hg among men and from 92 mm Hg to 79 mm Hg among women.

Factors associated with changes in serum cholesterol during a community-based hypertension programme

A cohort of 1019 male and 1232 female hypertensives, aged 25-59 years, based on a random population sample, was followed for five years during a community-based cardiovascular prevention programme. A small mean reduction in serum cholesterol level was found. The observed changes in casual serum cholesterol values were partly due to the regression to the mean. The reductions were most marked in elderly people and in those with high baseline serum cholesterol values. The partial regressions of the cholesterol change were computed in subgroups by age, sex and baseline serum cholesterol level. Changes in weight in men and in age in women were the strongest independent predictors of the change in serum cholesterol. Changes in dietary fat intake were also associated with the change in serum cholesterol. Only a small part of the total variation in the change in serum cholesterol was explained by the regression models. The results indicate that reduction of the serum cholesterol level among hypertensive persons, especially men, was caused by changes in their dietary habits.

Is there an association between serum cholesterol and blood pressure changes?

A community-based programme to influence the risk factors of coronary heart disease was carried out in North Karelia, Eastern Finland in 1972-77. The evaluation, based on examination of large cross-sectional random samples at the outset and at the end of the period, showed a greater reduction in both serum cholesterol and blood pressure levels in North Karelia than in a matched reference area. A random cohort of 293 men and 321 women who were studied both in 1972 and in 1977 did not use antihypertensive drugs on either occasion. Among these people the change in blood pressure was positively associated with the change in serum cholesterol even when age, initial blood pressure, changes in body mass and number of blood pressure measurements were allowed for. This finding supports the hypothesis that changes in fat consumption lead to changes in blood pressure, but this hypothesis needs further investigation.

Community control of hypertension— experiences from Finland

The improvement in the hypertension control in Finland started in the 1970s by the activities of the North Karelia Project, a comprehensive programme for the control of cardiovascular diseases. The blood pressure level of the population has had a continuous downward trend according to the population surveys conducted every fifth year since 1972 and the rule of halves has changed to the rule of two-thirds. The serum cholesterol level has decreased among hypertensives, even though it is still higher than among normotensives; the patients with antihypertensive drug treatment smoke less than the rest of the population. However, the situation is far from optimal; BP levels are high and body mass index is continuously increasing among the patients. The need for intensifying both pharmacological and nonpharmacological treatment among the hypertensives on a large scale is obvious.

Trends in blood pressure levels and control of hypertension in Finland from 1982 to 1997

OBJECTIVE

To assess the trends in blood pressure levels and hypertension control in Finland from 1982 to 1997.

DESIGN

Four independent cross-sectional population surveys conducted in 1982, 1987, 1992 and 1997.

SETTING

From 1982 to 1997, the provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in southwestern Finland were surveyed. From 1992 to 1997, the Helsinki-Vantaa region in southern Finland was surveyed.

PARTICIPANTS

Men and women aged 25-64 years were selected randomly from the national population register. The total number of participants was 27 623.

MAIN OUTCOME MEASURES

We assessed mean systolic and diastolic blood pressure, prevalence of hypertension (subjects with systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg or current use of antihypertensive drug treatment) and antihypertensive drug treatment and quality of hypertension care among hypertensive persons.

RESULTS

Mean systolic blood pressure and the prevalence of hypertension decreased significantly in all areas except among men in the Helsinki-Vantaa region. The fall in mean diastolic pressure was significant only in eastern Finland. The proportion of hypertensives who were unaware of their condition fell from 45.5 to 24.1% in men and from 27.2 to 15.7% in women. At the same time, the proportion of hypertensives with adequately controlled blood pressure (systolic pressure < 160 mmHg and diastolic pressure < 95 mmHg) increased from 9.4 to 23.5% in men and from 16.0 to 36.7% in women.

CONCLUSION

Hypertension care in Finland has improved significantly during the last 15 years. However, the situation is still far from optimal. It is obvious that the biggest problem in hypertension care has shifted from detection to adequate treatment of high blood pressure.

Effects of a long-term hypertension control program on stroke incidence and prevalence in a rural community in northeastern Japan

BACKGROUND AND PURPOSE

Although randomized clinical trials have demonstrated the benefit of antihypertensive treatment in preventing stroke, the effectiveness of community-based programs is largely unknown. We investigated long-term community-based prevention activities.

METHODS

In rural northeastern Japan, people aged > or = 30 years numbered 3219 in the full intervention community and 1468 in the minimal intervention community in 1965. Systematic blood pressure screening and health education began in 1963. Stroke was registered through 1987.

RESULTS

More than 80% of people aged 40 to 69 years were screened in both communities in the 1960s. One community charged for screening services after 1968, whereas the other community intensified intervention; subsequently, screening rates and the follow-up of hypertensive individuals declined in the minimal intervention community, especially in men. In men, stroke incidence declined more (P < 0.001) in the full intervention (42% in the period 1970 to 1975, 53% in the period 1976 to 1981, and 75% in the period 1982 to 1987) than in the minimal intervention community (5% increase, 20% decrease, and 29% decrease, respectively); in women, the stroke incidence declined about 45% to 65% in both communities. Changes in stroke prevalence paralleled those in stroke incidence. Trends in systolic blood pressure levels tend to explain the differential stroke rates in men.

CONCLUSIONS

Delivery of hypertension control services through intensive, free, community-wide screening and health education was effective in prevention of stroke for men in a community.

Ultrasonographic manifestations of common carotid atherosclerosis in elderly eastern Finnish men. Prevalence and associations with cardiovascular diseases and risk factors

We investigated the prevalence and associations with cardiovascular symptoms, signs, and risk factors of common carotid atherosclerosis using B-mode ultrasonography in a population sample of 182 eastern Finnish men aged 70 to 89 years. Men were examined in 1989 as a part of the 30-year follow-up examination of the eastern Finnish cohort of the Seven Countries Study. The mean maximal intima-media thickness (IMT) of the right and left common carotid arteries was 1.5 mm (range, 0.7 to 5.3 mm; standard deviation, 0.7 mm). Fifty-one percent of the subjects had nonmineralized atheroma and 91% had single or multiple mineralizations in any of the arterial segments imaged. Both mean maximal IMT and nonmineralized atheromas were associated significantly (P < .05) with the presence of cerebral atherosclerosis, carotid murmur, at least one nonpalpable peripheral arterial pulse, ischemic resting electrocardiographic abnormalities, and history of coronary heart disease but not with intermittent claudication at the 30-year follow-up. No significant associations were found between carotid mineralizations and clinical cardiovascular disease. Long-term elevations of serum cholesterol and long-term smoking, measured as the number of risk factor elevations in the six examinations, were associated with the presence of nonmineralized atheroma in the elderly (in 1989). Smoking and repeatedly detected hypertension, on the other hand, had an association with the presence of mineralizations in 1989.

Adolescents' knowledge and attitudes about and experience with violence

PURPOSE

Educational interventions directed to the prevention of youth inter-personal violence make assumptions about the educational needs of adolescents for violence-prevention despite little available data. This paper provides new information on background levels of adolescents' knowledge of, attitudes about and experience with violence.

METHODS

Over 400 teens across Boston's neighborhoods were surveyed by rando-digit dialed telephone techniques.

RESULTS

Results show that while boys are more often involved in violence, almost one quarter of girls report fighting. Black teens witness more violence and are threatened more often than whites, but they do not fight more. Knowledge scores indicate a need for improvement in adolescents' understanding of risk factors. Attitude scores indicate that adolescents believe fighting can and should be avoided, but they lack knowledge of behavioral options. Regression analyses show a positive relationship between violence experience and knowledge and attitudes.

CONCLUSION

These data suggest that preventive interventions should be directed to both improving adolescents' knowledge and understanding of personal risk and increasing their repertoire of conflict-resolution skills.

Making "time" for preventive services

Although the implementation of clinical preventive services is a high priority on the national agenda and physicians acknowledge the importance of these services, implementation rates remain far below the target years after the recommendations have been released. Physicians repeatedly report that the reason for not providing preventive services is that they do not have "time." In this article, we identify attributes of the health-services system that create this phenomenon. We present evidence that formal delivery systems for preventive services must be developed if the "time" problem is to be solved, and we review why preventive-services systems need to be integrated into the current health-services system. Finally, we list the attributes that we believe a preventive-services system must have if it is to be successful. The success of clinical trials of such systems indicates that our goals of preventive services can be achieved if all persons who have an investment in clinical preventive services commit themselves to developing and supporting these systems.

Hypertension, cigarette smoking, and the decline in stroke incidence in eastern Finland

Finland has high rates of both cardiovascular disease and cardiovascular disease risk factors. We studied random samples of the population 30-59 years of age for risk factors in two provinces of eastern Finland in 1972 and 1977. We then followed both cohorts until 1985 through linkage with national hospital discharge and death certificate registers. The prevalence of hypertension and smoking in both provinces declined between 1972 and 1977, as did the stroke incidence in the 8-year period of follow-up of each cohort. We observed no differences in stroke incidence between the two provinces. The relative risk of stroke in the later period (1977-1985) was 0.71 and 0.58 for men and women, respectively, when compared with the earlier period (1972-1980). Overall, 28% of all stroke events could be attributed to hypertension, 17% to smoking, and 43% to these two factors jointly. The decrease in the prevalence of hypertension and smoking accounted for about 29% of the decline.

Dying is no accident. Adolescents, violence, and intentional injury

Violence and its consequences are a major issue to be addressed by the health care community. The magnitude and characteristics of the problem cry out for new, creative approaches and provide for some insight into the direction that needs to be taken. Some of the components related to violence are societal in scope and will require long-term strategies well beyond the immediate realm of the health care system. Others provide direction that more clearly present a role for health providers and public health planners. Although there will be no easy answers or solutions to this problem, it is essential that support be developed for experimental efforts. The health community cannot ignore this problem and can in fact make a real contribution to its resolution through prevention, treatment, and research.

Sequels to screening for hypertension and diabetes mellitus in Fiji

We evaluated the outcome of a case-finding programme resulting from an epidemiological survey on diabetes and cardiovascular risk factors by re-interviewing 318 persons who had been found to have hypertension and/or diabetes mellitus in a population survey carried out in Fiji 1.5 years earlier in 1980. At re-examination, 34% of the hypertensive patients and 43% of the diabetic patients were not aware of their diagnosis. However, the proportion of treated hypertensive people was tripled and that of diabetic patients doubled. It was not possible to identify the characteristics of the persons who were missed in the follow-up. Many persons who were unaware of their condition regularly used, however, the existing health services available. On the other hand, several initially treated cases had no proper follow-up. More careful planning and development of comprehensive community-based programmes for hypertension and diabetes are needed in Fiji. Simple population screening for hypertension and diabetes may result in an extra work load and limit the available health care resources so that the overall outcome is not satisfactory.

Decline in cardiovascular mortality in North Karelia and other parts of Finland

The trends in mortality from ischaemic heart disease, cerebrovascular stroke, and all cardiovascular diseases were analysed for the province of North Karelia and for the rest of Finland. Linear trends in mortality were computed for the population aged 35 to 64 for the period from 1969 to 1982, and changes in mortality between the three year means of 1969-71 and 1980-2 were calculated. In North Karelia, where a community based preventive programme has been carried out since 1972, the annual decline in mortality from ischaemic heart disease in men was on average 2.9%, whereas in the rest of Finland it was 2.0%. For women the respective average annual declines in mortality were 4.9% and 3.0%. The net decline from 1969-71 to 1980-2 in North Karelia was 100 deaths/100,000 men. The annual mortality from all cardiovascular disease in men decreased by 2.9% in North Karelia and by 2.6% in the rest of Finland; in women the decreases were 6.0% and 5.0% a year, respectively. The net decline in North Karelia was 71 deaths/100,000 men. The decline in mortality from all causes was also appreciable in both sexes in North Karelia, but it did not differ significantly from national trends.

Effectiveness of treatment with antihypertensive drugs and trends in mortality from stroke in the community

A study was made of the changes in the treatment of hypertension, in the effectiveness of that treatment, and in mortality from cerebrovascular stroke in men and women in two counties in Finland. One of these counties was North Karelia, where a comprehensive cardiovascular programme based in the community had been launched in 1972. Cross sectional surveys in large representative samples of the middle aged populations were carried out in 1972, 1977, and 1982. Average annual mortality from stroke adjusted for age was calculated for the two year periods 1971-2, 1977-8, and 1980-1. The proportion of hypertensive men being effectively treated for their hypertension increased in both areas from 1972 to 1977 and further from 1977 to 1982. Mortality from stroke in middle aged men decreased in both areas during both observation periods. The proportion of hypertensive women being effectively treated greatly increased in both areas from 1972 to 1977. This was associated with a large decline in mortality from stroke. In North Karelia the proportion of women being effectively treated was remarkably high but decreased somewhat between 1977 and 1982; this decrease was associated with an increase in mortality from stroke in the women aged 35-64. These results support the idea that effective antihypertensive treatment in the community is a major determinant of mortality from stroke in both men and women.

Alcohol, patient compliance and blood pressure control in hypertensive patients

The association of self-reported use of alcohol with blood pressure and compliance with antihypertensive medication was studied in a randomly selected population sample in eastern Finland. We found a positive correlation between reported use of alcohol and diastolic blood pressure level and a negative correlation with the reduction of diastolic blood pressure during a five-year treatment. These correlations were independent of age, gender, and blood pressure level 5 years earlier. The use of alcohol was associated, especially in men, with poor compliance with antihypertensive medication. In addition to a possible direct contribution to high blood pressure, alcohol intake resulted in an inadequate control of blood pressure in male hypertensive patients by lowering patient compliance.

Message dissemination for a community-based cardiovascular disease prevention programme (the North Karelia Project)

The North Karelia Project was a community-based pilot programme in an Eastern Finnish community of 180,000 adults. During the intervention period from 1972 to 1977, the project successfully demonstrated that changing risk factors at the community level was feasible and could result in a significant reduction in disease rates. The North Karelia Project used mass media for dissemination of the message, but relied on face-to-face contact to persuade people to adopt the new lifestyles. Training seminars for professionals were a key programme component. On average, one seminar was conducted every two and a half weeks. Total project costs were only one per cent of the total health services costs for the county during the project. These findings suggest that community programmes can improve both subjective and objective cardiovascular health, and that the strategy of integrating funding into the project recruitment and commitment process is appropriate and may even be necessary for a successful community based heart disease prevention programme.

Trends in stomach cancer and stroke in Finland. Comparison to northwest Europe and USA

The mortality rates of stomach cancer and stroke were found to decrease in a similar way over a given time in different countries. The same phenomenon can be observed in Finland for both sexes. Salt is suggested to be the linking factor in the stroke-stomach cancer relationship. Recent studies indicate that salt intake in Finland is very high. Actual salt consumption levels are in Finland as high as they were in Belgium 15 years ago. The same observations can be made for cerebrovascular and stomach cancer mortality, making the salt hypothesis plausible. In contrast from 1972-73 on stroke mortality decreases faster than stomach cancer mortality. This could be observed in other western countries: USA, Austria, England and Wales, Belgium, West Germany, etc. The steeper decline may be the consequence of mass drug treatment of hypertension which started in Finland during the early years of 1970's, and also the consequence of changes in dietary habits, especially in fat intake in Finland.

North Karelia (Finland) hypertension detection project. Five-year follow-up of hypertensive cohort

A 5-year follow-up study of a random sample of middle-aged hypertensives indicated that the North Karelia (Finland) Hypertension Detection Project was effective in reducing blood pressure levels. This analysis indicated that the intensification of drug treatment caused marked blood pressure reduction in the community, especially among individuals with previously undetected cases of hypertension. Reduction of blood pressure levels among nontreated persons was observed in this study and may reflect in part the importance of both active case finding and follow-up including health education and preventive services. The community approach used in this study reached and brought under control most of those people who were undetected at the beginning of the study and most of the hypertensives. On the basis of the results, it is concluded that a well-organized hypertension control program can meet the challenge of hypertension care and benefit millions of people throughout the world.

Antihypertensive drug treatment in a middle-aged population

In Finland's North Karelia region a community-based program for control of hypertension was administered for 5 years. Afterward, drug treatment and the impact of such treatment on control of blood pressure were studied in a cross-sectional survey. The study population (n = 10,199) consisted of a 6.6% random sample of people aged 30-64 years in North Karelia (program area) and Kuopio (reference area). Rate of participation was about 90%. The methods included questionnaire, personal interview, and clinical examination. In North Karelia, 24% of the men and 25% of the women were hypertensives (blood pressure greater than or equal to 175 mm Hg systolic and/or 100 mm Hg diastolic, or currently on antihypertensive drug therapy), compared with 33% of the men and 29% of the women in the reference area. In North Karelia, 48% of the male hypertensives and 67% of the female hypertensives were on drug therapy, compared with 32% and 54%, respectively, in the reference area. Of the total population in each area, 14% in North Karelia currently used drugs, compared with 13% in the reference area. Diuretics and beta-blockers were the drugs most commonly prescribed; men used beta-blockers more often than women did. In terms of quantity of medication, type of drugs, and compliance, the differences between the two areas were small. Control of blood pressure, however, was clearly better in North Karelia than in the reference area for hypertensives and drug users and for both men and women. Therefore, compared with the traditional system, organized hypertension care results in more successful treatment.

Combination therapy in hypertension. A population-based study in eastern Finland

In a cross-sectional study, antihypertensive drug treatment was studied in a representative population sample of people aged 30-64 years, using a combination of postal survey, personal interview, clinical assessment and drug prescriptions. 11% of the men and 16% of the women were currently taking antihypertensives; 54% of patients used one, 38% used two, and 8% used three or more preparations. Men used slightly more drugs than women. Diuretics were used by 62% and betablockers by 49% of the sample population. Fixed combinations of thiazides and potassium-sparing agents formed 70% of all diuretic preparations used. Only 12% of the patients used fixed antihypertensive combinations, of which over half were diuretic-reserpine-vasodilator combinations; women and older patients used them most often. The most common freely combined preparations were diuretics and betablockers, which formed almost half of all two-drug combinations, and were also present in 70% of all triple combinations. Adequate control of blood pressure (DBP less than 100 mmHg) was achieved by slightly under 50% of the patients, the BP of women being more adequately controlled than that of men. Differences in BP control were found between the different drugs and combinations. Antihypertensive combination therapy is important in successful treatment, but we still cannot be sure whether fixed combination preparations or, as in this study, free combinations of marketed preparations are better alternatives for treatment.