Principles and Experiences of a Community Control Programme for Hypertension, as Part of the North Karelia Project

P. PUSKA, J . TUOMILEHTO, A. NISSINEN, and J . SALONEN From the Epidemiological Research Unit, Central Public Health Laboratory of Finland, Kuopio, Finland

A programme for community control of cardiovascular diseases (CVD) was estab- lished in 1972 in the county of North Kare- lia, a wide rural area with exceptionally high CVD mortality and morbidity and comprising some 180,000 inhabitants in Eastern Finland (1,4, 5 ) .

In the planning stage it was decided to start a comprehensive community pro- gramme, integrated with the service struc- ture and the social organization of the community. The comprehensive interven- tion was planned to be multifactorial and to consist of both primary and secondary prevention (3).

The main objective of the programme was defined to be a decrease of the CVD morbidity and mortality among the North Karelian population, and especially among the middle-aged and male population. The consideration of available epidemiological information from abroad and from Fin- land, as well as the situation in North Ka- relia, led to :i heavy emphasis on primary prevention of‘ the numerous disease attacks by a general reduction of the risk factors, smoking, serum cholesterol (i.e. change of diet) and high blood pressure among the population (3). The generally high level of these risk factors among the male popula- tion in the area has been shown, for ex- ample, by our studies (6).

Before planning the details of the pro- gramme, background information of the problem in the community was collected - a kind of ”community diagnosis” was made. The community programme was designed to lead to the objectives, and the intervention was gradually implemented in a systematic way. The sub-programmes

were planned to contain the practical objec- tives and measures, as well as the built-in continuous evaluation. For the evaluation and management of the programme an in- formation system was to be established which had to be reliable enough, but at the same time simple enough to be practicable for application in a large community.

In the comprehensive intervention the following methods have been incorporated: 1) increased health information, 2) training of personnel, 3) organization of services, and 4) environmental changes.

One essential sub-programme is the hy- pertension (HT) programme (7). The main objective of the hypertension programme is to lower high blood pressures in the en- tire population, in order to reduce the com- plications, especially cerebral strokes and myocardial infarctions. The objectives cover: detection of hypertension cases, ad- equate diagnosis, treatment, and follow- up of the patients. At the community level this implies blood pressure measurements for the whole population, systematic fol- low-up, and drug treatment of the hyper- tensives. In order to reorganize the services special dispensaries operated by public health nurses were to be established. A special regional hypertension register oper- ating according to the WHO criteria was planned gradually to cover all the hyper- tensives in the community.

The programme is a national pilot pro- gramme of the Finnish health authorities to test the practicability and effect of the CVD community control. The practical programme is implemented as an inte- grated activity within the existing health services of the County, which is reinforced

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by extra persons and resources to organize the activities.

The aim of the evaluation of the entire programme and the hypertension pro- gramme as part of it is to demonstrate the feasibility and the effect of the programme, as well as to estimate the costs and to ob- tain a comprehensive picture of the pro- cess that takes place in the programme community (3).

The methods for the evaluation and the information system for monitoring the changes in the community include, for the main objectives, a myocardial infarction and stroke register and mortality and hos- pital data, and for the intermediate objec- tives random sample surveys covering risk factors and other information. A com- prehensive survey is carried out in the pro- gramme community and in a matched ref- erence community at the beginning and at the end of the five-year programme period (baseline survey 1972, terminal survey 1977). In addition a lot of other informa- tion is collected to follow the changes in the programme area.

The baseline survey and other baseline studies were conducted in the community before starting the intervention. Among the middle-aged population (aged 25-59) the prevalence of HT (160/95) was con- firmed to be high (21%). In the younger age groups the males had a higher preva- lence than females and in the older groups the females had more HT than the males. About half of the hypertensives were not aware about their condition and approxi- mately 10% of the hypertensives were un- der adequate treatment. After the baseline survey, the programme to control HT in the community was es- tablished and integrated with the existing service structure. Blood pressure measure- ments were increased in connection with the usual health services and new screening activities were introduced (6). Everybody with established high blood pressure val- ues (160 and/or 95 in three consecutive measurements) was registered according to the protocol of the WHO HT study (7). The hypertensives were treated and fol-

lowed by the local health centres. The fol- low-up was mostly carried out by trained nurses at the organized hypertension dis- pensaries with systematic health education. The patient was to see the treating physi- cian at least once a year, when the annual follow-up for the register was carried out.

During these years the feasibility of the programme has been good in the area with rather scarce medical resources. The good co-operation of the local population, com- munity leaders and health personnel has been experienced in many ways. For ex- ample, participation rates in the surveys averaged 90 per cent.

Since the beginning of the programme blood pressure measurements gradually in- creased so that they covered practically the whole population. The number of regis- tered hypertensives increased accordingly so that at the end of 1976 nearly 17,000 hypertensives were registered, which ap- proaches 9% of the total population. Out of these subjects more than half became aware of their condition only during the programme. The frequency of control vis- its of those with known hypertension in- creased so that it led within the first years to an adequate situation for practically every known hypertensive.

An interim study showed also that the adherence to the follow-up and to the treat- ment was good. For example during the first year only 1% of the registered hyper- tensives missed their annual follow-up vis- it. The adherence to the treatment was then 94%.

After 4.5 years of the intervention the percentage of the middle-aged population under antihypertensive drug treatment in- creased among the males from 3 to 11 and among the females from 9 to 13 in the whole community. According to the re- gister, the percentage of normotensive subjects in the HT register increased during the first year from 12 to 28, and at the fourth follow-up to 38. The mean change in blood pressure during the first year was a 15 mmHg reduction in the systolic and a 6 mmHg reduction in the diastolic blood pressure for those patients who had had

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this follow-up. It must be noted that 65% References of these hypertensives were already under drug treatment at the time of the registra- tion.

The preliminary information from the stroke register shows that the annual stroke incidence rates were reduced in 1975 to 1.9 for males and 1.8 for females in the 25-74 age group calculated per lo00 inhabitants.

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No age specific trend was noticed in this reduction, which became evident during the third year of the intervention, i.e. 1974. The 3 week case-fatality rates of the re- gistered strokes were reduced from 1972 to 1975 from 23% to 17% among the males and from 27OTo to 10% among the females. During the same period the same system of registration showed no change in the in- cidence rates of acute myocardial infarc- tion (MI). In the total and MI mortality rates of middle-aged males and females during the three first years of the pro- gramme in North Karelia a reduction can be seen compared with the two pre-pro- gramme years.

The presented evaluation of the pro- gramme is preliminary. Only the final eval- uation using different data sources and a matched reference area will reveal the final effect of the programme. It can, however, be already now stated that the feasibility of this community programme has been good and it has needed minimal amount of extra resources. The interim evaluation in- dicates a clear improvement in the blood pressure situation of the population, and it is possible that this is associated with a reduction in the occurrence of cerebral strokes in the community.

Keys, A. (ed.): Coronary heart disease in sev- en countries. Circulation (suppl.) 16: 1, 1970. Puska, P.: SydPn- ja verisuonitautien aiheut- taman kuolleisuuden alueelliset erot 1. Suom. 1tiBk. 1.27: 3071, 1972. Puska, P.: The North Karelia project, a pro- gramme for community control of cardio- vascular diseases. Publication of the Universi- ty of Kuopio, Community Health-series A: 1 / 1974.

4. Puska, P., Aho, K. & Salmi, K.: Sairastuvuus aivohalvauksiin Suomessa. Duodecim 90: 965, 1974.

5. Puska, P. & Mustaniemi, H.: Incidence and presentation of myocardial infarction in North Karelia, Finland. Acta med. scand. 197: 211, 1975.

6. Rimpelti, M., Puska. P., Severs, K., Tuoli- lehto, J., Virtamo, J., Karjalainen, Y. &Prun- nila, T.: The baseline survey of the North Ka- relia project: Study design and prevalence of major CHD risk indicators. Sos. letiket. Aikak. 1.2: 97, 1974.

7. Tuomilehto, J.: Feasibility of a community programme for control of hypertension. A part of the North Karelia project. Publica- tions of the University of Kuopio, Communi- ty Health-series A: 2/1975.

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