Social change for sustained health outcomes

SOCIAL CHANGE FOR SUSTAINED HEALTH OUTCOMES

8GCHP, Helsinki 10. – 14.6.2013

Pekka Puska, MD, MPolSc, PhDDirector General, National Institute for Health and Welfare (THL, Finland)President, Int. Ass. of National Public Health Institutes (IANPHI)

12.04.2023 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.)?


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?


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!



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?

Change in age-adjusted mortality rates

Finland, males aged 35–64 (per 100 000 population)

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2000

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2002

2003

2004

2005

2006

0

100

200

300

400

500

600

700

Year

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


North Karelia/Finland experience (1/4)

PopulationHealth

programme


1. Health education

2. Important role of policies and private sector

Population

Policies

Private sector

Health programme



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



4. Complex change process with time

Population

Policies

Private sector

Health programme



• 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)


”Blame the patients or blame the politicians?”

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”)




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?

19581960

19621964

19661968

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19741976

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19821984

19861988

19901992

19941996

19982000

20022004

20062008

20102012

0

2

4

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12

Unrecorded

Recorded

New Alcohol Legislation 1968

Price increases1975

Alcohol advertising banned

New Alcohol Act 1994Excise 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 andchanges in occupational structure.Emigration to Sweden

Strong economic

growth

Deepeconomic recession

Economic recession

Total alcohol consumption in Finland in litres of 100 per cent alcohol per capita

Behavioral and social strategies behind health promotion for social change

Theoretical frameworks

Practical and flexible hard work


Behavioral and social change

”Nothing is as practical as a good theory”


Some classical theories and relevant disciplines to support social change process

Theory Discipline area

Marketing (Social) psychology

Sociology Social policy

Communication

Social marketing Behaviormodification

Communication – Behavior change

Innovation – Diffusion

Community organization


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

(Rogers 1983)


Practical use of innovation – diffusion; opinion leader theoryUse 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)

Pekka Puska, Director General12.04.2023

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

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


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)


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



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


%

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


Use of Butter on Bread (men aged 30–59)

Milk Consumption in Finland in 1970 and 2006 (kg per capita)

0

20

40

60

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100

120

140kg

1960 1970 1980 1990 2000 2010

Whole milk

Whole form milk

Low fat milk

Skim milk



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.

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


Serum Cholesterol (men aged 30–59)

Strength of monitoring and feedback

• To support social learning• To raise public attention and image of change

“Band wagon” phenomenon

• To convince decision makers


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


Examples of intersectoral work (1/3)

Fen: y = -0.16x + 362

Gen: y = -0.16x + 358

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45

1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

g/kg

Fen

Gen


Development ofFinnish Rapeseed oil

Change in fat content of Finnish cow milk

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 1975 1980 1985 1990 1995

YEAR

1. 6

1. 8

2. 0

2. 2

2. 4

Sa

lt c

on

ce

ntra

tio

n (%

)

Sa lt le v e l in Finnis h s a us a ge s




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



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”)


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


Social change process

People pull policies and Policies pull people!

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.)

12.04.2023

12.04.2023

Thank you

Health & Medicine

Social change for sustained health outcomes