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National Public Health Institute (KTL) Helsinki, Finland
HEALTH 2000
Health and functional capacity of Finns - a national health survey
1. Background
Monitoring and forecasting the population's health and health determinants are prerequisites of knowledge-based health policy, and development of health care and social security both at national, regional and local level.
To obtain the necessary information statistics and registers must be exploited and health surveys need to be carried out at regular intervals.
Available health monitoring information about the ageing Finnish population's health and functional ability is inadequate. The occurrence of many common chronic diseases and functional limitations and consequent need for care, rehabilitation and help are poorly known. For example, information is very limited on musculoskeletal diseases and mental disorders although both are major causes of work disability and functional limitations. There is hardly any information about adult oral health. Prevalence and time trends of functional limitations are poorly known. Also, information on health determinants needs to be gathered simultaneously with information on health and functional capacity. More needs to be known about the effects of these determinants on health and on the age-trends of health and functional capacity.
In Finland, several national research institutes (Social Insurance Institution (SII), National Research and Development Centre for Health and Welfare (Stakes), Statistics Finland and Institute of Occupational Health) have carried out questionnaire and interview surveys with a health component in nationally representative population samples. The National Public Health Institute (KTL) has monitored health behaviour and risk factors by population surveys. However, most of the comprehensive health examination data on the population's health comes from the SII's Mini-Finland Health Survey carried out twenty years ago in 1978 - 1980. One of its findings was that simultaneous use of health interview and health examination methods is a prerequisite of valid information on many common public health problems. A new comprehensive population health survey is needed in order to assess the population's health and functional capacity, their determinants and their time trend in Finland.
2. Aims and significance of the national health survey
The main aim of Health 2000 is to provide an up-to-date comprehensive picture of health and functional ability in the working-aged and aged population by studying the prevalence and determinants of most important health problems and associated need for care, rehabilitation and help.
On one hand the aim is to gather information on individuals' health and functional ability as a whole and on the other detailed information on the most important public health problems and functional limitations as well as on need and use of services. Information will also be produced on health determinants and on health disparities between population groups. In the different study regions further specific studies may be carried out.
Time trends of adult health will be assessed by comparing the findings with earlier data such as those from the Mini-Finland Health Survey, and forecasts will also be prepared. In addition, forecasts and scenarios concerning the future need for health care and social security benefits will use the survey information as a starting point.
Up-to-date information on the whole population's health is essential because valid and comprehensive data have not been collected since the Mini-Finland Health Survey of 1978 - 1980. Lack of information hampers social and health policy planning. Also research on health promotion and disease prevention suffers from this lack of timely data and information on the population's health and health determinants. The information obtained by the Health 2000 -survey is an essential basis for national health policy formulation and health planning. This national survey and associated international cooperation will also demonstrate Finnish health monitoring knowhow, which can be expected to strengthen the role of Finnish researchers and experts in the international community.
3. Study population and targets of the study
A nationally representative sample of 10,000 persons has been drawn of the population aged 18 and over.
Targets of the study are general health, major chronic conditions, functional ability and limitations, determinants of health, diseases, functional ability and limitations, health needs and service needs and their satisfaction.
The data can be grouped as follows: a. Determinants of health and functional ability
b. Health and chronic conditions
c. Functional capacity and limitations
d. Use of services and medicines, their need and adequacy
Of the chronic conditions and public health problems the study will concentrate on
Assessment of functional ability comprises
The questionnaire, interviewing, testing, examination and assessment methods and the data drawn from national registers have been selected on the basis of the project group's extensive experience of population surveys and the broad expertise of the participating researchers and institutions. Comparability of the results with the earlier findings from the Mini-Finland Health Survey has also been an important selection criterion.
4. Implementation of the survey
The target population comprises all persons aged 18 and over and living in Finland. A nationally representative two-stage cluster sample has been drawn, which comprises 10,000 persons and 80 regions (municipalities or groups of municipalities with joint primary care). All 15 bigger cities and towns are included in the sample. Persons aged 30 or over will be interviewed and invited to the health examination and younger adults aged 18-29 will be interviewed only. In addition, one thousand persons who participated in the Mini-Finland Health Survey will be reexamined.
August 15, 2000
1. an interview at home (or institution; one to six weeks prior to the health examination),
2. a health examination in the local health centre or comparable premises,
3. an interview and a health examination of non respondents at home (or institution)
4. a telephone interview and/or a mail questionnaire of remaining non respondents
5. gathering of register information on the whole sample both to complete baseline information and for follow-up purposes.
6. in the second phase of the health examination proper persons aged 45 to 74 years will be invited to university hospitals. In addition, in-depth studies on selected topics will be carried out, e.g. in the SII research centre in Turku and in the UKK-institute in Tampere
Everything possible will be done to keep non response extremely small. Minimal non response is a prerequisite for accurate information about many chronic diseases and functional limitations in the older population. We demonstrated in the Finrisk -97 senior survey that the combination of health centre- based examinations with home visits secures high participation rates of more than 90 per cent.
The field survey will be performed simultaneously by five regional field teams in different parts of the country.
More than 130 persons work in the project organisation. Interviews will be carried out by more than 160 interviewers of Statistics Finland. Each of the health examination field teams comprises 16 persons, together more than 80 persons.
The mean duration of the health interview is 70 to 90 minutes. The health examination comprises 10 measurement and observation stations. It lasts on an average three hours and 30 minutes. The stations are: reception, measurement 1, measurement 2, laboratory, oral and dental examination, break with a snack, tests of functional ability, a doctor's clinical examination, mental health interview and final interview (see Appendix). Since part of the examinations are carried out in parallel together 12 stations are needed. The space requirement is about 12 to 13 rooms plus reception and waiting area.
In August 2000, the second phase of the health examination in university hospitals and specific in-depth studies are still in a planning stage.
5. Partners and organisation
The national project is coordinated by KTL and implemented in collaboration with the Ministry of Social Affairs and Health and the 80 health centre regions. The main partners comprise KTL and the Central Pension Institute, the Social Insurance Institution, the Municipal Pension Institute, Statistics Finland, The National Research and Development Centre for Welfare and Health, the Institute of Occupational Health and the UKK-institute for Health Promotion.
Several other organisations cooperate. These comprise universities, university hospitals, county governments, other pension institutes and patient organisations. Instrumentation and measurement apparatus is delivered by many companies. Transport, data processing equipment and telecommunication services are provided by commercial partners. Implementation of field work calls for cooperation with municipalities and health centres and university hospitals.
A project organisation has been set up to implement the survey. It comprises the following groups: a consultative committee, steering committee, project group and its executive committee, task specific and subject specific working groups (14), and a field work coordinating group. The consultative committee comprises representatives of main partners and important interest groups. The project group comprises chairmen of carious working groups and other experts. Researchers and other experts of the main partners are members of various groups. The consultative committee is chaired by Markku Lehto, chief executive of the Ministry of Social Affairs and Health, the steering committee is chaired by Jussi Huttunen, Director General of KTL and the project group and its executive committee by Arpo Aromaa, Head of the Department of Health and Disability (DHD) of KTL. The field work manager is Sami Heistaro, medical researcher at KTL DHD.
6. A time table
Field work begins in September 2000 and it is estimated to last until February - March 2001. Home visits to non respondents are expected to take some additional time. Health interviews of the younger age group and home examinations of non respondents are expected to be over by the end of May 2001. Examinations in University Hospitals and in-depth examinations are expected to begin by late November 2000 and they are expected to be continued until the end of 2001.
- Preplanning begins
October 15, 1998 - Project organisation is set up and planning begins
March 10, 1999 - 1st pilot study health examination
January 31 to February 4, 2000 - 2nd pilot study health examination
May 2 to 15, 2000 - Training of interviewers begins
August 16, 2000 - Training of field teams
August 21 to September 8, 2000 - The survey proper (interviews begin)
September 1, 2000 - The survey proper (examinations begin)
September 11, 2000 - Examinations in University Hospitals begin
by the end of November 2000 - Data editing, analysis and reporting begins
September 1, 2001
7. Resources
The preliminary budget of the field work proper of the survey is 25 million FIM (3.8 million USD). This estimate excludes the costs of permanently employed researchers and other personnel in different research institutes. The costs of laboratory examinations, storing and handling of samples, storing, updating and editing the data set(s) or analysing the data and publishing reports are also not included. In addition, planning and implementation of the field work requires other major resources both in KTL, which is responsible for overall planning and coordination, and in the other participating organisations. These are needed, e.g. for implementing the field work organisation, planning and administering the subject matter of the survey, for coordinating and administering the work of the project organisation and field work, for editing the data sets, for data processing, for taking care of contacts, coordination and other administration. Further, planning the survey, analysing the results and reporting them all require a large amount of researcher time and other staff time for many years to come.
Field survey stations and personnel: Duration Station
Reception (15 min)
- information and provision of material
- symptom interview
- informed consent
Measurement 1 (15 min)
- ECG
- blood pressure
- other measurements
Measurement 2 (15 min)
- spirometry
- bioimpedance
- heel bone density
Laboratory (15 min)
- drawing blood samples
- handling of samples
Oral and dental examination (15 min)
- clinical examination of mouth and teeth
- orthopantomography
Testing on functional ability (30 min)
- balance and reaction time measurement
- eye examination
- hearing test
- other measurements
Clinical examination (30 min)
- (lääkärin kliininen tutkimus) clinical examination by a physician
Mental health interview (30 min)
- (tutkimushoitajan haastattelu) interview by a nurse
Final interview (15 min)
- checking subject's programme for completeness
- checking questionnaires 1 and 2
- providing questionnaire 3 and dietary questionnaire
- informing about forthcoming examinations
The team manager takes care of the final interview as well as many contacts and everyday matters. In addition to these 14 observers there are two home visitors, who also function as substitutes for other team members. At least one local person is needed to help the team manager, guide and help examinees and take care of various practical matters.
The field team in each of the five regions has 16 members, and a total of 80 persons carry out the health examination. It is foreseen that an additional 2-3 persons will be needed as reserve in head quarters at KTL.