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Heikkala E, Hagnäs M, Jokelainen J, Karppinen J, Ferreira P, Ferreira ML, Mikkola I. Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients. Prim Care Diabetes 2022; 16:531-536. [PMID: 35523651 DOI: 10.1016/j.pcd.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
AIMS To assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D). METHODS The cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims. RESULTS Overall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01-1.65), but the association was attenuated in the adjusted model. CONCLUSIONS MS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.
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Affiliation(s)
- Eveliina Heikkala
- Rovaniemi Health Center, Rovaniemi, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland.
| | - Maria Hagnäs
- Rovaniemi Health Center, Rovaniemi, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jari Jokelainen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland; Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Paulo Ferreira
- School of Health Sciences, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Kolling Institute, School of Health Sciences, University of Sydney, Sydney, Australia
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Martiskainen TM, Lamidi ML, Venojärvi M, Tikkanen H, Laatikainen T. Effectiveness of physical activity counselling provided for people with type 2 diabetes mellitus in primary healthcare in North Karelia, Finland: a register-based evaluation study. BMJ Open 2022; 12:e058546. [PMID: 35788078 PMCID: PMC9255411 DOI: 10.1136/bmjopen-2021-058546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Physical activity (PA) plays a significant role in the treatment of type two diabetes (T2D). This study evaluated the effectiveness of PA counselling in primary healthcare (PHC) on clinical outcome measures in patients with T2D, comparing them with a registry-based controls. SETTING The study was carried out in North Karelia, Finland, among PHC clients who have been diagnosed with T2D in 2016-2018. PARTICIPANTS The study population consisted of patients aged 19-87 years diagnosed with T2D (n=1803). Altogether 546 patients were referred to the PA educator of whom 521 participated the counselling. In totally 1382 sex, age, time of diagnosis and intervention time-matched controls were used to see the effect of intervention. INTERVENTIONS Patients with T2D followed up in PHC were offered to participate in PA counselling provided by trained PA educators. The number of counselling sessions and their content were tailored according to patients needs and willingness to participate. To assess the effects of PA to management of T2D clinical outcome measures such as weight and Haemoglobin A1c (HbA1c) and lipid levels were assessed using data from electronic patient records. Each patient was followed up from records at least for a year. RESULTS Weight and body mass index (BMI) decreased in both groups and mean yearly changes did not differ between the groups. HbA1c levels declined in the intervention and increased in the control group with statistically significant difference in the mean yearly change between the groups (p=0.001). The low-density lipoprotein declined in both groups. The decline was bigger in the intervention group, but the difference did not quite reach the statistical significance (p=0.096). CONCLUSIONS This study shows that PA counselling in PHC offers significant benefits in the treatment outcomes of T2D although no significant declines were not observed in the weight or BMI.
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Affiliation(s)
- Tuula Marketta Martiskainen
- Joint municipal authority for North Karelia social and health services (Siun sote), Joensuu, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Marja-Leena Lamidi
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Mika Venojärvi
- Institute of Biomedicine/Sports and Exercise Medicine, University of Eastern Finland, Kuopio, Finland
| | - Heikki Tikkanen
- Institute of Biomedicine/Sports and Exercise Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tiina Laatikainen
- Joint municipal authority for North Karelia social and health services (Siun sote), Joensuu, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
- Department of Public Health and Social Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
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Lavikainen P, Aarnio E, Linna M, Jalkanen K, Tirkkonen H, Rautiainen P, Laatikainen T, Martikainen J. Data-driven long-term glycaemic control trajectories and their associated health and economic outcomes in Finnish patients with incident type 2 diabetes. PLoS One 2022; 17:e0269245. [PMID: 35648780 PMCID: PMC9159579 DOI: 10.1371/journal.pone.0269245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022] Open
Abstract
Background Treatments should be customized to patients to improve patients’ health outcomes and maximize the treatment benefits. We aimed to identify meaningful data-driven trajectories of incident type 2 diabetes patients with similarities in glycated haemoglobin (HbA1c) patterns since diagnosis and to examine their clinical and economic relevance. Materials and methods A cohort of 1540 patients diagnosed in 2011–2012 was retrieved from electronic health records covering primary and specialized healthcare in the North Karelia region, Finland. EHRs data were compiled with medication purchase data. Average HbA1c levels, use of medications, and incidence of micro- and macrovascular complications and deaths were measured annually for seven years since T2D diagnosis. Trajectories were identified applying latent class growth models. Differences in 4-year cumulative healthcare costs with 95% confidence intervals (CIs) were estimated with non-parametric bootstrapping. Results Four distinct trajectories of HbA1c development during 7 years after T2D diagnosis were extracted: patients with “Stable, adequate” (66.1%), “Slowly deteriorating” (24.3%), and “Rapidly deteriorating” glycaemic control (6.2%) as well as “Late diagnosed” patients (3.4%). During the same period, 2.2 (95% CI 1.9–2.6) deaths per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 3.2 (2.4–4.0) in the “Slowly deteriorating”, 4.7 (3.1–6.9) in the “Rapidly deteriorating” and 5.2 (2.9–8.7) in the “Late diagnosed” trajectory. Similarly, 3.5 (95% CI 3.0–4.0) micro- and macrovascular complications per 100 person-years occurred in the “Stable, adequate” trajectory increasing to 5.1 (4.1–6.2) in the “Slowly deteriorating”, 5.5 (3.6–8.1) in the “Rapidly deteriorating” and 7.3 (4.3–11.8) in the “Late diagnosed” trajectory. Patients in the “Stable, adequate” trajectory had lower accumulated 4-year medication costs than other patients. Conclusions Data-driven patient trajectories have clinical and economic relevance and could be utilized as a step towards personalized medicine instead of the common “one-fits-for-all” treatment practices.
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Affiliation(s)
- Piia Lavikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- * E-mail:
| | - Emma Aarnio
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Kari Jalkanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Hilkka Tirkkonen
- Siun Sote – Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
| | - Päivi Rautiainen
- Siun Sote – Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
| | - Tiina Laatikainen
- Siun Sote – Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
- Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
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Rossen J, Larsson K, Hagströmer M, Yngve A, Brismar K, Ainsworth B, Åberg L, Johansson UB. Effects of a three-armed randomised controlled trial using self-monitoring of daily steps with and without counselling in prediabetes and type 2 diabetes-the Sophia Step Study. Int J Behav Nutr Phys Act 2021; 18:121. [PMID: 34496859 PMCID: PMC8424865 DOI: 10.1186/s12966-021-01193-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This aimed to evaluate the effects of self-monitoring of daily steps with or without counselling support on HbA1c, other cardiometabolic risk factors and objectively measured physical activity (PA) during a 2-year intervention in a population with prediabetes or type 2 diabetes. METHODS The Sophia Step Study was a three-armed parallel randomised controlled trial. Participants with prediabetes or type 2 diabetes were recruited in a primary care setting. Allocation (1:1:1) was made to a multi-component intervention (self-monitoring of steps with counselling support), a single-component intervention (self-monitoring of steps without counselling support) or standard care. Data were collected for primary outcome HbA1c at baseline and month 6, 12, 18 and 24. Physical activity was assessed as an intermediate outcome by accelerometer (ActiGraph GT1M) for 1 week at baseline and the 6-, 12-, 18- and 24-month follow-up visits. The intervention effects were evaluated by a robust linear mixed model. RESULTS In total, 188 subjects (64, 59, 65 in each group) were included. The mean (SD) age was 64 (7.7) years, BMI was 30.0 (4.4) kg/m2 and HbA1c was 50 (11) mmol/mol, 21% had prediabetes and 40% were female. The dropout rate was 11% at 24 months. Effect size (CI) for the primary outcome (HbA1c) ranged from -1.3 (-4.8 to 2.2) to 1.1 (-2.4 to 4.6) mmol/mol for the multi-component vs control group and from 0.3 (-3.3 to 3.9) to 3.1 (-0.5 to 6.7) mmol/mol for the single-component vs control group. Effect size (CI) for moderate-to-vigorous physical activity ranged from 8.0 (0.4 to 15.7) to 11.1 (3.3 to 19.0) min/day for the multi-component vs control group and from 7.6 (-0.4 to 15.6) to 9.4 (1.4 to 17.4) min/day for the single-component group vs control group. CONCLUSION This 2-year intervention, including self-monitoring of steps with or without counselling, prevented a decrease in PA but did not provide evidence for improved metabolic control and cardiometabolic risk factors in a population with prediabetes or type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov, NCT02374788 . Registered 2 March 2015-Retrospectively registered.
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Affiliation(s)
- Jenny Rossen
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden.
| | - Kristina Larsson
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Maria Hagströmer
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Care Center, Region Stockholm, Stockholm, Sweden
| | - Agneta Yngve
- Department of Nutrition, Dietetics and Food Studies, Uppsala University, Uppsala, Sweden
- School of Health Sciences, Örebro University, Örebro, Sweden
| | - Kerstin Brismar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Barbara Ainsworth
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | | | - Unn-Britt Johansson
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Wikström K, Lamidi ML, Rautiainen P, Tirkkonen H, Kivinen P, Laatikainen T. The effect of the integration of health services on health care usage among patients with type 2 diabetes in North Karelia, Finland. BMC Health Serv Res 2021; 21:65. [PMID: 33441132 PMCID: PMC7805148 DOI: 10.1186/s12913-021-06059-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/02/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The need to improve the care of people with complex care requirements has been driving the reforms integrating care processes. This study examines the effect of the integration of health services on health care usage and the processes and outcomes of care among type 2 diabetes patients. METHODS Data include all type 2 diabetes patients who lived in North Karelia, Finland, between 2014 and 2018. Health care contacts and glycated haemoglobin (HbA1c) measurements were obtained from the electronic health records. Logistic, Poisson and linear models with generalised estimating equations and the Friedman test were used to study the differences between years. RESULTS The health care usage was highest in 2017, the first year of a new organisation, and smallest in the following year. Before the new organisation, the health care usage was lowest in 2014, being slightly higher compared with 2018. Between the last two years, the mean number of contacts per person declined from 3.25 to 2.88 (-0.37, p < 0.001). The decreasing pattern seen in total health care usage was most obvious among contacts with primary health care nurses. The number of contacts increased only among specialised care nurses between the last two years. The number of HbA1c measurements was also in its lowest in 2018 but in its highest in 2015. Between the years 2014 and 2018, the difference in the mean number of contacts was - 0.05 (p = 0.011) for those not measured, -0.02 (p = 0.225) for those measured and within the target level of HbA1c, and 0.12 (p = 0.001) for those measured and not at the target level of HbA1c. CONCLUSIONS Health care integration first increased the health care usage but then brought it to a slightly lower level than before. The changes were most obvious in primary health care nurses' appointments, and no decline was observed in secondary-level care. Even though the numbers of HbA1c measurements and the proportion measured declined, measurements increased among those with poor glycaemic control. The observed changes might reflect the better targeting and more concordant services in different service units.
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Affiliation(s)
- Katja Wikström
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, 70211, Kuopio, Finland. .,Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland.
| | - Marja-Leena Lamidi
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, 70211, Kuopio, Finland
| | - Päivi Rautiainen
- Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
| | - Hilkka Tirkkonen
- Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
| | - Petri Kivinen
- Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, 70211, Kuopio, Finland.,Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland.,Joint Municipal Authority for North Karelia Social and Health Services, Joensuu, Finland
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Lamidi ML, Wikström K, Inglin L, Rautiainen P, Tirkkonen H, Laatikainen T. Trends in the process and outcome indicators of type 2 diabetes care: a cohort study from Eastern Finland, 2012-2017. BMC FAMILY PRACTICE 2020; 21:253. [PMID: 33276719 PMCID: PMC7718663 DOI: 10.1186/s12875-020-01324-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 11/18/2020] [Indexed: 11/16/2022]
Abstract
Background Evidence-based guidelines include concrete treatment targets that can be used as process and outcome indicators in the evaluation of the quality of healthcare services and diabetes care. Quality improvement can be evaluated by monitoring longitudinal trends in the care indicators on the system level. The aim of this study is to describe trends in the processes and outcomes of care among people with type 2 diabetes in North Karelia, Finland. Methods The data consist of all adults with type 2 diabetes (identified from the EHRs using ICD-10 codes) who used primary or specialized care services in North Karelia during 2012–2017. The diabetes care was evaluated using the measurement activity, treatment levels, and the achievement of the treatment targets for HbA1c and LDL as care indicators. Logistic and linear models with generalized estimating equations were used to assess the differences between years, sexes, and age groups. Results The proportion of patients with annual measurement varied between 75.8 and 78.1% for HbA1c and between 67.4 and 69.1% for LDL during a five-year follow-up. The changes in average levels were moderate: a 0.2% (2 mmol/mol) increase for HbA1c and a 0.1 mmol/l decrease for LDL. Anyway, the proportion of patients meeting the treatment target for HbA1c decreased from 72.7 to 67.3% (age-adjusted decrease: 5.7%p, 95% CI: 4.5–6.9) and for LDL it increased from 53.4 to 59.5% (age-adjusted increase: 5.6%p, 95% CI: 4.2–7.0). Women were measured and met the HbA1c target level more often compared with men. Conversely, men met the LDL target level more often than women, and the age-adjusted difference between sexes increased smoothly from 7.9%p to 11.7%p. Conclusions The achievements in relation to type 2 diabetes care in North Karelia are very good, but no major improvement was observed during follow-up. HbA1c levels had a rising tendency and LDL levels declining tendency indicating quality improvement in LDL management, but challenges in further improvement in glucose control.
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Affiliation(s)
- Marja-Leena Lamidi
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.
| | - Katja Wikström
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.,Department of Public Health Solutions, Finnish Institute for Health and Welfare, PO Box 30, FI-00271, Helsinki, Finland
| | - Laura Inglin
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland
| | - Päivi Rautiainen
- Joint Municipal Authority for North Karelia Social and Health Services, Tikkamäentie 16, FI-80210, Joensuu, Finland
| | - Hilkka Tirkkonen
- Joint Municipal Authority for North Karelia Social and Health Services, Tikkamäentie 16, FI-80210, Joensuu, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, PO Box 1627, FI-70211, Kuopio, Finland.,Department of Public Health Solutions, Finnish Institute for Health and Welfare, PO Box 30, FI-00271, Helsinki, Finland.,Joint Municipal Authority for North Karelia Social and Health Services, Tikkamäentie 16, FI-80210, Joensuu, Finland
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Lavikainen P, Aarnio E, Jalkanen K, Tirkkonen H, Rautiainen P, Laatikainen T, Martikainen J. Impact of co-payment level increase of antidiabetic medications on glycaemic control: an interrupted time-series study among Finnish patients with type 2 diabetes. BMC Health Serv Res 2020; 20:1095. [PMID: 33246453 PMCID: PMC7694920 DOI: 10.1186/s12913-020-05952-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022] Open
Abstract
Background A new special reimbursement scheme (SRS) for non-insulin medications used for treatment of hyperglycaemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The new SRS affected all community-dwelling Finnish T2D patients as all community-dwelling residents are eligible for reimbursement for prescription medications. The aim of the study was to evaluate the impact of this co-payment increase on glycaemic control among Finnish T2D patients. Methods Data on glycaemic control were collected with HbA1c measures from electronic health records from primary health care and specialized care in the North Karelia region, Finland, from patients with a confirmed T2D diagnosis in 2012 who were alive on January 1, 2017 (n = 8436). Average HbA1c levels were measured monthly 36 months before and 33 months after the policy change. Consumption of diabetes medications was measured with defined daily doses (DDDs) based on reimbursed medication purchases. Interrupted time series design analysed with segmented regression model was applied to examine the effect of the policy change on average HbA1c levels. Results Eight thousand one hundred forty-three T2D patients had at least one HbA1c measurement within 01/2014–9/2019. Mean age of the patients was 68.1 (SD 11.3) years and 53.0% were women. Average time since T2D diagnosis was 11.5 (SD 6.1) years. An estimated increase of 0.81 (95% confidence interval, CI, 0.04–1.58) mmol/mol in average HbA1c levels was detected at the time of the policy change. In subgroup analyses, strongest effects were detected among patients who used only other diabetes medications than insulin or metformin in 2016 (3.56 mmol/mol, 95% CI 2.50–4.62). Meanwhile, yearly consumption of diabetes medications decreased slightly from 618.9 (SD 487.8) DDDs/patient in 2016 to 602.9 (SD 475.6) DDDs/patient in 2017 (p = 0.048). Conclusions Simultaneously with the increase of the co-payment level, the average HbA1c level increased among T2D patients from the North Karelia region, Finland. This may be explained by the decreased consumption of diabetes medications between 2016 and 2017. Special attention should be allocated to glycaemic control of patients utilizing only other antidiabetic medications than metformin or insulin. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05952-6.
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Affiliation(s)
- Piia Lavikainen
- Faculty of Health Sciences, School of Pharmacy, University of Eastern Finland, P.O.Box. 1627, FI-70211, Kuopio, Finland.
| | - Emma Aarnio
- Faculty of Health Sciences, School of Pharmacy, University of Eastern Finland, P.O.Box. 1627, FI-70211, Kuopio, Finland
| | - Kari Jalkanen
- Faculty of Health Sciences, School of Pharmacy, University of Eastern Finland, P.O.Box. 1627, FI-70211, Kuopio, Finland
| | - Hilkka Tirkkonen
- Joint Municipal Authority for North Karelia Social and Health Services (Siun Sote), Joensuu, Finland
| | - Päivi Rautiainen
- Joint Municipal Authority for North Karelia Social and Health Services (Siun Sote), Joensuu, Finland
| | - Tiina Laatikainen
- Joint Municipal Authority for North Karelia Social and Health Services (Siun Sote), Joensuu, Finland.,Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland.,Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Janne Martikainen
- Faculty of Health Sciences, School of Pharmacy, University of Eastern Finland, P.O.Box. 1627, FI-70211, Kuopio, Finland
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