The North Karelia Project (1972–1997) and the Origins of the Community Approach to Cardiovascular Disease Prevention

Abstract

Community-based risk factor modification is today an established approach to chronic disease control and public health practice. This article analyzes the shaping of the North Karelia Project (NKP), an early and influential formulation of the community approach that focused on coronary heart disease prevention in Finland. Instead of targeting only high-risk individuals, NKP aimed to change the culture of the local community. On the basis of archival material and interviews, I first trace the multiple origins of the notion of community in NKP, which combined “internal” factors (local risk factor distribution, the role given to the social environment in chronic disease prevention) and “external” influences (regional origin of the initiative, World Health Organization and national policy concepts of community control and primary health care). Second, I describe the shape of the community intervention in NKP. The project foregrounded social relationships as a way to educate the public and influence norms guiding individual behaviors while subordinating environmental changes of a more structural nature.

Coronary heart disease (CHD) emerged as a major public health problem in post–World War II industrialized countries.¹ After two decades of research on the causes of the epidemic, many experts considered the key risk factors for CHD (smoking, hypertension, elevated cholesterol, physical inactivity) sufficiently established and began to explore possibilities to move toward mass prevention in the late 1960s.² Fueling these activities was growing public attention, which created political pressure to tackle the problem.

From the late 1940s onward, World Health Organization (WHO) statistics identified Finland as one of the leading countries in CHD mortality, especially among middle-aged men. The “high premature mortality among a population which earned its living largely from heavy forest and farm work, who might have been expected to enjoy the benefits of a physically active, healthy outdoor life,”³ contradicted the then current belief that CHD struck predominantly wealthy urban sedentary men. Finland became involved in the Seven Countries Study, a large international comparative investigation coordinated by Ancel Keys in Minnesota that tested the cholesterol theory in CHD causation. North Karelia was one of the study areas and had the highest mortality not only in Finland but among all participating countries.

Preliminary information on the 10-year results of the Seven Countries Study published in late 1969 once again highlighted the poor CHD situation in North Karelia.⁴ In early 1971, key members of the local establishment signed a petition demanding that the national authorities “urgently undertake efficient action to plan and implement a programme which would organize and finance general health information to the public, necessary basic research, and individual health education to reduce this greatest public health problem” of North Karelia.⁵

Although the petition surely reflected local sentiments, preparations for the North Karelia Project (NKP) had already started behind the scenes in 1970, involving the National Board of Health, the Office of the North Karelia County Physician, the Finnish Heart Association, North Karelia Central Hospital, and the Martha Organization (a popular association for home economics). The initiator was Martti J. Karvonen, leader of the national arm of the Seven Countries Study and the key personality in Finland’s cardiovascular research field from the 1950s onward.

The result was one of the first community prevention projects that tested concerted methods to reduce cardiovascular problems in a specific area among the entire population instead of only high-risk groups. NKP was located in a socially and economically disadvantaged area of northeastern Finland with a population of 190 000 that suffered exceptionally high CHD morbidity and mortality. Its main objective was to lower CHD incidence by modifying the levels of three key risk factors: smoking, hypertension, and elevated cholesterol.

To facilitate lifestyle change, the project focused on the culture of the local community, introducing changes in the physical and social environment. A massive information and education campaign mobilized various stakeholder groups, civil society actors, and the local populace. In addition, NKP developed methods of early detection, treatment, and rehabilitation of cardiovascular patients in the community. In a population-wide intervention trial design, a neighboring county (Kuopio) with almost equally high CHD mortality served as control, receiving no interventions.

NKP started in 1972. Project evaluation after the initial five-year period showed an overall reduction in risk factors but no effect on CHD mortality relative to the control area.⁶ Determining the project’s impact is complicated by the evaluation design, which relied on cross-sectional surveys for risk factor data along with official morbidity and mortality registers. The great public interest in the project and its principles, as well as a simultaneous secular decline in CHD mortality throughout the country, further complicates impact assessment.⁷ Nevertheless, NKP was deemed a success and continued, with aspects of the project adopted in national public health policies.⁸ A greatly expanded and modified NKP was officially terminated only in 1997.

NKP is regarded an important pilot project both nationally and internationally. Together with the Stanford Three Community Study, led by John Farquhar, NKP was among “the first real community intervention programmes [to] use education or environmental change to promote and facilitate lifestyle and behaviour changes needed to address a particular problem,” such as CHD.⁹ NKP provided a key example when the National Heart, Lung, and Blood Institute in the United States adopted community trials in its research agenda in the early 1980s.¹⁰ Principles formulated by NKP and other similar intervention trials have been applied in subsequent WHO community projects in developing countries.¹¹

Despite the later impact, the community focus initially departed from established expert opinion and WHO guidelines. Although the majority of experts argued for multifactorial mass field trials to provide conclusive proof of the efficacy of modifying the key CHD risk factors, “an active minority among the international [cardiovascular disease] prevention community…were prepared to bypass the complex mass trials [and] move directly into study designs for evaluation of hygienic, safe medical strategies and health promotion in the population.”¹² Karvonen and Farquhar were present at the influential Makarska Conference on Mass Trials in the Prevention of Coronary Heart Disease in Yugoslavia in 1968, where they together with Henry Blackburn advocated this minority position.¹³ After the conference, both Karvonen and Farquhar took steps to establish a community study in their respective home countries.

This article sheds light on the Finnish developments. Why did NKP adopt the novel community approach, and how did project plans and practices formulate that approach? The first section of the article presents the multiple origins of the community approach and the term’s polyvalent nature in NKP. The second section describes NKP’s specific understanding of community as manifested in the project’s plans and activities. The focus is on the preparation and first phase of the project (i.e., 1970–1977).

WHY A COMMUNITY APPROACH?

A number of influences contributed to NKP adopting a community approach and shaped its particular structure.

One motivation for targeting the entire community was the contemporary understanding of risk factors, wherein there was “no natural limit between a normal and an abnormal risk factor level.” Any rise in any risk level thus increased the population risk and rate of coronary events. The effect of the different risk factors was considered “synergistic, not additive”; that is, the estimated disease risk was higher than the sum of the separate risk factors. However, because the number of people with pathologically high risk factor levels was considerably smaller than the number of people with moderate (but important) risk factor–level elevations, the bulk of the disease occurred within the latter group. A large proportion of the population needed to be affected to substantially reduce the disease burden. Because the average level of all risk factors was high in North Karelia, it was important to extend the intervention to all inhabitants of the area.¹⁴

Another influence was the interest in social medicine in Finland in the 1960s.¹⁵ Biomedicine was criticized for a narrow focus on pathological processes in individual bodies and a technological emphasis on treatment. Instead, social medicine promoted prevention and working on the structural causes of ill health. Chronic degenerative conditions such as CHD were thought to result from the interplay of many influences, including the environment and individual behavior; consequently, their prevention and treatment should address the whole community, including both social structure and health services.¹⁶

These ideas had salience among the project developers. Kai Sievers, a professor at the Department of Public Health at the University of Turku assigned with planning NKP, had connections to the Social Insurance Institution in Finland, a key hub of social medicine in the country. His assistant, Matti Rimpelä, and Pekka Puska, the assigned leader of NKP, were both medical students interested in social sciences. Puska even obtained a degree in social policy.¹⁷

The fruitful links between WHO programs and national policy developments were an additional factor shaping the community approach. National planners sought contact at an early stage with WHO, which provided essential advice. Present at NKP’s planning conference in 1971 were, among many national stakeholders, key WHO officials Zdenek Fejfar, Zbynek Pisa, and Peter Rhomberg, as well as two international experts, Jerry Morris and Henry Blackburn.¹⁸ Moreover, the head of WHO Europe, Leo Kaprio, was a Finn, which assured good relations with WHO.

Within WHO, CHD was addressed in the European Program of Cardiovascular Disease Control, established in 1968.¹⁹ Community concepts figured into WHO Europe activities in two ways. First, community-focused preventive trials emerged as a research approach. In the 1960s, the official WHO line was still a cautious one: “no major alterations in living habits can be recommended until preventive trials have been carried out.”²⁰ At this stage, single-factor trials dominated.²¹

Entering the 1970s, one can detect a growing sense of urgency.²² The research focus shifted to multifactorial preventive trials, which promised faster results and corresponded better with real-life situations than single-factor trials, as patients typically had several elevated risk factors simultaneously.²³ Community trials were a further modification. Unlike randomized controlled multifactorial trials, which typically (but not always) focused on high-risk individuals, they targeted entire populations. Community trials were added to the arsenal of available research approaches in WHO documents in the early 1970s, with NKP as the pilot study.²⁴

More influential on NKP was the second WHO context for community concepts, the notion of “community control” that emerged in WHO documents in the late 1960s. It referred to the ensemble of measures to control a specific (chronic) health problem. For example, in WHO’s hypertension control project, community control of hypertension was envisioned as an integrated program that covered all aspects from prevention, detection and diagnosis, treatment and rehabilitation, and follow-up to education, training, and research.²⁵ In practice, much of this comprehensive community work took place in the primary health services.²⁶

The notion of community control resonates with health policy developments in Finland, which culminated in the comprehensive health insurance scheme of 1962 and the Primary Health Care Act of 1972. The reforms purported to conclude a decades-long debate focusing on affordability and availability of services. They were guided by a belief that better benefits and more outpatient services would lead to higher service use and earlier treatment and consequently to less severe illnesses and better health, especially for disadvantaged population groups and areas.²⁷ The Primary Health Care Act introduced universal primary health care, replacing the previous system of municipal officers of health with community health centers.

NKP employed this new service structure but also aimed to develop it further for public health practice at the community level. This reliance on primary health care, as well as the inclusion of secondary prevention and evaluation through research, testifies to NKP’s proximity to the principles of community control as formulated by WHO.²⁸

Finally, the framing of the CHD problem was a crucial element. According to Puska’s retrospective assessment, “the historical background of the Project dictated a community approach.”²⁹ Although high CHD mortality in Finland was not restricted to North Karelia, the 1971 petition framed it as a regional problem for which the local population was seeking help. Hence, it was plausible to direct project activities to the county as a whole.

“Community” thus had multiple references in the discussions surrounding NKP. First, it defined a comprehensive approach that designated an entire population at risk and in need of sociomedical intervention. Second, it signified ambition to extensively target the social environment in addition to individual bodies to prevent illness. Third, it highlighted the need to shift medical activities from hospitals to outpatient services and public health work. Finally, it created a metonymic relationship with the administratively defined geographical area where the political impulse for the project had originated. The path-breaking community approach of NKP emerged as an amalgamation of these influences.³⁰

COMMUNITY APPROACH IN PRACTICE

NKP aimed at a community-based rather than community-placed intervention.³¹ The former involves members of the affected community in the development and implementation of programs, whereas the latter is more expert led, although it can involve measures to garner community support for activities. NKP researchers originated themselves as facilitators stimulating and organizing activities that were then realized by community members. Health service personnel were a key group, especially public health nurses, who carried out many of the practical tasks such as testing, registration, and education. Journalists were another important group. NKP maintained good relationships with various media representatives, who acted as mouthpieces to its message, ensuring good visibility in local media outlets. Later, NKP also involved “lay leaders” who acted as focal points for the project in their home communities, disseminating information and organizing activities on its behalf.³²

However, NKP researchers defined community structure in a hierarchical manner. They first involved key actor groups in the project, which could then reach laypeople via their channels of influence. Accompanying this top-down approach was a massive education campaign that disseminated information on project principles through all possible channels to every member of the local community. Participation was thus distributed according to position in the community; laypeople mostly executed the changes in health behavior stipulated by experts and influencers.

One of the early project plans, formulated by Rimpelä of the University of Turku, explicates the rationale for this approach.³³ According to the plan, three elements regulate individual risk factor levels: genotype, living conditions, and social relationships. The first element is immutable, but the other two can be influenced. Mediating between these elements and risk factor levels (and thus CHD) are aspects of health behavior, including smoking, exercising, eating habits, “psychological stress,” and treatment compliance. These aspects of health behavior were the immediate targets of intervention.

In terms of influencing social relationships, Rimpelä presented a model involving a phased mobilization of actors, beginning with NKP researchers. After identifying and personally adopting mechanisms of risk factor reduction, the researchers educated a first tier of key actors: physicians. They similarly embraced the principles in their work and personal behavior and then began to spread the information to a second tier of key actors, including other health personnel, media representatives, teachers, leaders of public organizations, and administrative officials. Finally, these groups passed on the gospel in their channels to men and women on the street. In this model, schools, public organizations, health services, media, and advertising affected individuals’ social relationships, changing the information they received and the norms guiding their health behavior.³⁴

Altering living conditions focused on “[i]ntroducing environmental changes that would result in behavioural changes.”³⁵ A campaign to prohibit smoking in public facilities and vehicles addressed smoking habits. Dietary change was endorsed by introducing novel types of low-fat milk products and sausages in cooperation with local dairies and a local food company, promoting vegetable growing and use, and raising shopkeepers’ awareness of nutrition campaigns and recommended foods.

These measures, however, left the social determinants of health unaffected and paled in scope to the information and education activities aimed at both various key groups and the public.³⁶ According to the early project plan, “structural changes in society…cannot be an immediate objective of preventive action.”³⁷ The project affected social relationships directly (through the aforementioned mobilization of different actors), whereas its grasp of living conditions was more indirect: changing them was defined as a task of social policy and therefore within the remit of the public administration (i.e., one of the actors to be mobilized).

Thus, the privileged approach in NKP was to educate the public about risk factor modification and to change the normative structure in the community through mass media campaigns and influencer recruitment to facilitate behavior change.³⁸ By comparison, changing living conditions to support healthy lifestyles played a relatively minor role. Community hence became defined as a system of information flows and relationships of persuasion that affect the cognitive and normative basis of individual health behaviors, whereas the social and material conditions of existence were mostly excluded from intervention.³⁹

Moreover, despite NKP’s retrospective public image highlighting primary prevention and a broad community focus, significant portions of its activities were targeted at a specific high-risk group (middle-aged men), of a biomedical nature, and firmly situated within the health services.⁴⁰ This reflected WHO principles of community control and the stated goal of health service development.

CONCLUSION

The community focus in NKP arose from a combination of “internal” factors pertaining to CHD as a public health problem (population risk factor distribution in North Karelia, broad multifactorial concept of chronic disease causation) and “external” influences (the regional origins of the initiative, WHO and national health policy concepts of community control and primary health care). Together they shaped the project into a comprehensive preventive effort that targeted multiple risk factors, defined the entire population of North Karelia at (high) risk, covered the entire area, and strongly relied on the primary health services, which introduced a distinct biomedical aspect.

Regarding the shape of the community intervention, the project foregrounded social relationships as a way to educate the public and influence the norms guiding individual behavior. By comparison, changes in living conditions, especially of a more structural nature, were subordinated. Judging by letters sent to the project office, this approach received criticism from some locals, who connected the CHD epidemic to the effects of ongoing structural changes in Finnish society on local communities. These voices advocated measures against closing farms, unemployment, and migration from the countryside caused by industrialization and urbanization.⁴¹

Such measures were, however, beyond the scope of NKP, which foregrounded individual aspects of lifestyle, quitting smoking, and consuming less (saturated) fat as well as treating hypertension. Despite the project’s intentions and public image, its community commitment was rather narrow. It privileged in a rather hierarchical way community leaders and made no clear effort to address social determinants of health. Community was conceptualized as a supportive structure to facilitate individualized behavioral modification centered on the three key risk factors.