1) Sustained changes in population health can only occur through permanent changes in lifestyles and environments, representing a long-term social change process. 2) The changes in smoking and dietary habits in many countries represent complex social change processes involving many sectors of society. 3) The experience in North Karelia, Finland demonstrates that a long-term health program, supported by evidence-based policies, an active private sector, and a complex change process can achieve substantial reductions in cardiovascular mortality rates.

1. SOCIAL CHANGE FOR SUSTAINED
HEALTH OUTCOMES
8GCHP, Helsinki 10. – 14.6.2013
Pekka Puska, MD, MPolSc, PhD
Director General, National Institute for Health and Welfare (THL, Finland)
President, Int. Ass. of National Public Health Institutes (IANPHI)

2. 12.6.2013 Pekka Puska, Director General
Many WHO and other strategies concentrate on
evidence based policy measures but:
- face the implementation gap
- are one time shot
Is it enough to try to convince decision
makers with rational arguments (on cost
effectiveness etc.)?

3. 12.6.2013 Pekka Puska, Director General
Healthy policy decisions are usually result of
complex political power play with conflicting
interests and interest groups
How to support policies and furthermore, a
long term policy process and ultimately long
term healthy changes in the society?

4. Sustained changes in population health
can only take place with permanent
changes in people’s lifestyles and
environments, and represent a long term
social change process!
12.6.2013 Pekka Puska, Director General

5. 12.6.2013 Pekka Puska, Director General

6. Social change and public health
The changes that have taken place in many countries
e.g. in smoking or dietary habits represent a social
change process that concerns many sectors of the
society in a complex way.
• What is the nature of such process?
• What are the drivers of the process?
• How can public health / health promotion promote or
drive a healthy process?
12.6.2013 Pekka Puska, Director General

7. Change in age-adjusted mortality rates
Finland, males aged 35–64 (per 100 000 population)
0
100
200
300
400
500
600
700
69 72 75 78 81 84 87 90 93 96 99 2002 2005Year
extension to national work
start of the North Karelia Project
North Karelia -84%
All Finland -82%
Rate per 100 000
1969-
1971
2006 Change
from 1969-
1971 to
2006
All causes 1328 583 -56%
All
cardiovascular
680 172 -75%
Coronary
heart disease
489 103 -79%
All cancers 262 124 -53%
Coronary heart disease Gain of some 10 healthy years
in Finnish population
12.6.2013 Pekka Puska, Director General

8. North Karelia/Finland experience (1/4)
Population
Health
programme
12.6.2013 Pekka Puska, Director General
1. Health education

9. 2. Important role of policies and private sector
Population
Policies
Private
sector
Health
programme
12.6.2013 Pekka Puska, Director General
North Karelia/Finland experience (2/4)

10. 3. Development of evidence-based policies and methods for the
decisions and actions of policy-makers and the private sector
Population
Policies
Private sector
Health
programme
12.6.2013 Pekka Puska, Director General
North Karelia/Finland experience (3/4)

11. 4. Complex change process with time
Population
Policies
Private sector
Health
programme
12.6.2013 Pekka Puska, Director General
North Karelia/Finland experience (4/4)

12. • We should not blame the patient or blame the
politician!
• Instead we should try to promote a social change
process to the desired direction – and thus promote
conditions for favourable political decisions
• Both policy makers and the private sector are much
influenced by the opinions and intentions of the
people
(Puska. Int. J. Publ. Hlth 2007)
12.6.2013 Pekka Puska, Director General
”Blame the patients or blame the
politicians?”

13. How to influence policies and the private
sector
• Directly through presenting rational arguments for
evidence-based policies and through identifying win-
win situations
• Through populations: Opinions, intentions and
behavior changes of the population ultimately have
a strong influence on politicians (”voters decide”)
and the private sector (”consumer is king”)
• Monitoring and feedback are important instruments
• Use of media for policy change (”behavioral
journalism”)
12.6.2013 Pekka Puska, Director General

14. 12.6.2013 Pekka Puska, Director General

15. Future of the social change with
tobacco?
ENDGAME TOBACCO
• Wide spread implementation of FCTC
• Major new actions: Generic
packaging, restricted sale of tobacco
(pharmacies?), banning the sale of
cigarettes/tobacco?
• How far will the smoke free / tobacco free
innovation go?
• What is the end situation: smoke free /
tobacco free?
12.6.2013 Pekka Puska, Director General

16. 0
2
4
6
8
10
12
Unrecorded
Recorded
New Alcohol Legislation
1968
Price
increases
1975
Alcohol advertising
banned
New Alcohol Act 1994
Excise duty decrease of 33 %
1.3 2004, followed by four
alcohol tax increases
• Alcohol stores allowed
also in rural
municipalities.
• Medium beer to
grocery stores.
• New age limits
(18/20 instead of 21).
• Two
price
increases
• Real
prices up
by 8 %
• Advertising
banned in 1977
• Advertising of
beer and wine
allowed again in
1995
• Comprehensive
monopoly structure
abolished, off-premise
monopoly remained.
• Ban on public drinking
lifted.
• Ciders and longdrinks to
grocery stores.
• 1.1 2008, + 10 - 15 %
• 1.1 2009, + 10 %
• 1.10 2009, + 10 %
• 1.1 2012, + 10 - 15 %
Rapid urbanisation and
changes in occupational
structure.
Emigration to Sweden
Strong
economic
growth
Deep
economic
recession
Economic
recession
Total alcohol consumption in Finland in litres of 100 per cent alcohol per capita

17. Behavioral and social strategies behind
health promotion for social change
Theoretical
frameworks
Practical and
flexible hard work
12.6.2013 Pekka Puska, Director General
Behavioral and
social change
”Nothing is as practical as a good theory”

18. Some classical theories and relevant
disciplines to support social change
process
12.6.2013 Pekka Puska, Director General
Theory Discipline area
Marketing (Social) psychology
Sociology Social policy
Communication
Social marketing Behavior
modification
Communication – Behavior change
Innovation – Diffusion
Community organization

19. Innovation-diffusion theory
• Health promoting lifestyle changes are innovations
that spread in the community following certain
principles
• Change agents: often active professionals
• People can be divided into innovators, early
adopters, early majority, late majority and laggards
• Critical mass is crucial
• Opinion leaders: official / unofficial
• Official regulation / decision can promote or hinder
the change / diffusion process
12.6.2013 Pekka Puska, Director General
(Rogers 1983)

20. Practical use of innovation – diffusion;
opinion leader theory
Use of lay leaders to promote the target life style
changes in North Karelia
• Identification of some 1000 lay leaders all over
North Karelia in the villages
• Recruitment and training
• Provision of materials and regular contacts
• Involvement to support the viewing of the NK
Project TV programmes
• Evaluation conclusion: useful contribution to the
overall results of the project
(Puska, Rogers et al. 1986)
12.6.2013 Pekka Puska, Director General

21. Pekka Puska, Director General12.6.2013
Example of Finland on policy and action
process (”Health in All Policies”) to support
the major nutrition change process &
resulting in changes for example in blood
cholesterol, blood pressure and ultimately in
NCD rates in Finland

22. 1980s
Law on milk fat percentage Fat percentage of low-fat milk reduced from 2.9 % to
1.9 %, new low-fat milk with 1 % fat introduced
Several governmental recommendations Nutrition, worksite lunches, school lunches, CHD
prevention
Law to allow various fat spreads Various fat spreads and low-fat spreads introduced
Law to allow mixture of butter and vegetable
oil
Subsidizing basis changed fat to protein contents
Legislation of special financial support to
butter
Removal of special financial support to butter for
bakeries, etc.; in the army, margarine was allowed in
addition to butter
Legislation on labeling of salt Salt labeling of certain foods
Pekka Puska, Director General12.6.2013
1970s
National public health law Introduction of comprehensive primary health care
(health centers) with great emphasis on prevention
Several governmental recommendations Nutrition, hypertension control, worksite lunches
Law to allow mixture of butter and vegetable
oil
Prior to 1970s a mixture was not allowed in order to
protect butter
Example of Finland on policy and action process (1/3)

23. Example of Finland on policy and action process (2/3)
1990s
Law on milk fat percentage Fat percentage of low-fat milk reduced from 1.9 %
to 1.5 %, and that of consumption milk from 3.9 %
to 3.5 %
Several governmental
recommendations
Nutrition, CVD prevention
EU legislation and policy Finland joined the EU in 1995, which introduced EU
policies into Finnish agricultural and commercial
legislation (e.g., concerning subsidies and customs
policies)
Fat taxation legislation Removal of extra taxation of vegetable oil and
related products (margarine), EU membership
Legislation on salt contents
and labeling
Maximum salt contents of certain foods; obligatory
labeling as heavily salted in certain cases and
labeling of low in salt in certain cases
Pekka Puska, Director General12.6.2013

24. Example of Finland on policy and action process (3/3)
2000s
EU school milk legislation Based primarily on lobbying of Finnish MEPs.
The school milk program was enlarged to
include also low-fat and fat-free milk products
Several governmental policy
programs
Health 2015, health promotion policy
programme, government policy programme on
healthy diet and physical activity
Government budget policies Several decisions to support domestic vegetable
consumption and health-related food innovations
Amendment of salt labeling
decree
To comply with EU regulations, national
regulation for highly salted and reduced salt
The heart symbol – a better
choice
A symbol of certain foods based on fixed expert
criteria, as a healthier choice in their category; a
system operated by Finnish Heart Association
but with endorsements by the national
authorities
Pekka Puska, Director General12.6.2013

25. %
0
20
40
60
80
100
1972 1977 1982 1987 1992 1997 2002
North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province
Pekka Puska, Director General12.6.2013
Use of Butter on Bread (men aged 30–59)

26. Milk Consumption in Finland in 1970
and 2006 (kg per capita)
0
20
40
60
80
100
120
140
kg
1960 1970 1980 1990 2000 2010
Whole milk
Whole form milk
Low fat milk
Skim milk
Pekka Puska, Director General12.6.2013

27. 12.6.2013 Pekka Puska, Director General
The great reduction in butter and milk consumption in Finland has
been a complex process with huge constraints (”fatwar”) in a dairy
farming society. It has concerned many sectors, but the health
argument through people and medical doctors has ultimately
driven the social process for healthier diets.

28. FINRISK Studies 1997 & 2002
mmol/l
5
5,5
6
6,5
7
7,5
1972 1977 1982 1987 1992 1997 2002 2007
North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu
Lapland
Pekka Puska, Director General12.6.2013
Serum Cholesterol (men aged 30–59)

29. Strength of monitoring and feedback
• To support social learning
• To raise public attention and image of change
 “Band wagon” phenomenon
• To convince decision makers
Pekka Puska, Director General12.6.2013

30. Intersectoral work towards prevention
- ”Health in all policies”
• People’s lifestyles are influenced by decisions in
different sectors of society (much of them beyond
the health sector)
• Health in general and NCD prevention in particular
should be taken into account in decisions made by
different sectors (health impact assessment)
• Social change process combining government
policies, expert guidance, broad health promotion
and mobilization of people
Pekka Puska, Director General12.6.2013

31. Examples of intersectoral work (1/3)
Fen:y= -0.16x+ 362
Gen:y= -0.16x+ 358
41
42
42
43
43
44
44
45
45
1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
g/kg
Fen
Gen
12.6.2013 Pekka Puska, Director General
Development of
Finnish Rapeseed oil
Change in fat content of Finnish cow milk

32. Biscuit example
• Leading Finnish biscuit manufacturer (LU Finland Ltd.) has
removed some 80 000 kg of SAFA by changing the fats used
• All trans fats removed and major transfer to rapeseed oil
Meat product example
• HK (Leading Finnish meat company)
• Since 2007 annually:
 40 000 kg less salt
 100 000 kg less saturated
fat in their products 1 9 7 5 1 9 8 0 1 9 8 5 1 9 9 0 1 9 9 5
Y E A R
1 . 6
1 . 8
2 . 0
2 . 2
2 . 4
Saltconcentration(%)
S a l t l e v e l i n F i n n
12.6.2013 Pekka Puska, Director General
Examples of intersectoral work (2/3)

33. Pekka Puska, Director General12.6.2013
Berry project in North Karelia
• To promote berry farming, product development and
consumption
• Dairy farmers could switch over to berry farming
• Financing from Ministries of Agriculture and Commerce
Finnish Heart Symbol
Examples of intersectoral work (3/3)

34. How to promote social change
Comprehensive work
Innovative use of media, including social media
Work with people, ownership, empowerment
Civil society, NGO’s
Bottom up – Top down
Role of change agents
Role of opinion leaders (”gate keepers”): official and unofficial
Importance of critical mass (”low hanging fruits”)
12.6.2013 Pekka Puska, Director General

35. Pekka Puska, Director General12.6.2013
Empower communities and people
”Facilitate social mobilization, engaging and empowering
a broad range of actors, including women as change-
agents in families and communities, to facilitate
dialogue, catalyze societal change and shape a
systematic society-wide national response to address
noncommunicable diseases, their social, enviromental
and economic determinants and health equity (e.g.
through engaging human rights organizations, faith-
based organizations, labour organizations, organizations
focused on
children, adolescents, youth, elderly, women, patients
and people with disabilities, indigenous
peoples, NGOs, civil society, academia, media and the
private sector.”
- WHO NCD Action Plan 2013-20

36. Social change process
People pull policies and
Policies pull people!
12.6.2013 Pekka Puska, Director General

37. Pekka Puska, Director General
Complex Process of Social Change
”Usually, environmental and policy decisions are
key, but such can often be achieved only in health
promotion activities that influence the public agenda
and people’s intentions. At the same time, the
human factor is crucial: persistent and dedicated
work is needed, combining enthusiastic and credible
leadership with also involvement of, and ownership
by, the population.”
Puska 2005. In Coronary Hearth Disease
Epidemiology
(Marmot & Elliott, eds.)
12.6.2013

38. 12.6.2013
Thank you