Prof. Mats Brommels
I International comparisons of health care systems
The characteristics of and changes in healthcare systems are studied in a comparative framework with the aim of understanding policy formulation and decision-making as well as their effects in the healthcare arena. Studies are made on both a systemic level and by describing organisational cases. Comparisons are typically “cross-sectional”, but a follow-up of reforms and organisational changes during the 1990's has enabled a developmental analysis as well. Methods used are document analysis, expert interviews and case studies (participant observations).
Activities include the following:
A comparative study of five purchasing health authorities and five provider organisations in Finland, Sweden, Norway, the Netherlands and the United Kingdom during the early years of market-imitating reforms. Despite the policy goals and content of the reforms the same kind of organisational behaviour was observed in all organisations. Differences were possible to elate to the national characteristics of the healthcare systems studied.
The programme co-ordinated the Nordic activities of the EU Clearinghouse on Health Systems Reforms (1994-97), collecting published reports and “grey literature” on reforms in EU countries. A comparative study of the Nordic countries was initiated as a by-product of the Clearinghouse.
Presently the programme takes part in a special study - started in January 1999 - of the role of markets in healthcare, commissioned by the European Union.
Prof. Mats Brommels
II The impact of financial and organisational reforms in Finnish healthcare
The 1993 government subsidy reform coincided with the worst economic recession in Finland since World War II. The extreme circumstances provided a “test laboratory” for organisational behaviour within the Finnish public healthcare system. Two in-depth studies, the first covering six municipalities, and the second eight municipalities, described in detail structural, organisational and service pattern changes, influenced by the reform and the recession. A detailed material was collected, consisting of formal documents, surveys and interviews (with decision-makers, professionals and patients) as well as official statistics. Observations on municipal decision-makers were summarised in a model of strategic behaviour. Strategic choices, organisational changes and changes in service mix were described and related to characteristics of the municipalities, the role of actors and organisational culture within municipalities.
A case study of a hospital closure showed that healthcare professionals involved chose a rational planning approach, and failed to identify potential allies among the decision-makers. Supporters of a competing hospital were better positioned visavis decision-makers and blocked a possible local coalition opposing the closure.
The programme has been engaged to evaluate an organisational experiment, unique in Finland, and with important policy applications. The social services and primary care of a municipality are contracted out in total to a voluntary, private, not-for-profit organisation, basically engaged in health promotion. The organisation intends to include health promotion and active community involvement in the services offered to the population. The decision-making and policy development process will be monitored and activities described. The impact on the behaviour of the population, consumption of services, health status and service production will be evaluated with a before-and-after approach. The study is controlled. The same data collection and analysis will be performed in three similar municipalities that organise their services traditionally.
Prof. Mats Brommels
III Professional practice and educational interventions
The programme has developed special competence in applying adult learning methods in medical education. It participates in the ongoing curriculum development at the Medical School. A recent pilot scheme, utilising a problem-based learning approach, was monitored and evaluated within a quality management framework. The educational outcomes of the scheme were comparable to earlier observations. The pilot was extremely dependent on individual teachers, and the lack of a common vision of the learning model seriously diminished the possibilities to use the experience and transfer insights and skills learned to other programmes.
A consultative evaluation model was developed in a two-stage training project, aiming at influencing the way in which physicians assess work ability. Observations on the educational process, analysis of training programmes and collected participant feedback was presented to project managers and tutors at regular intervals. First order changes were made as result, but no “double loop” learning did occur among tutors. The effects on participants were measured by surveys and interviews. Although intended changes of practice, as reported immediately after the training, did not materialise as surveyed six months later, participants had acquired a deeper understanding of the problems they encounter. Changes in attitudes to networking and consultation - of relevance in assessing work ability - were observed.
The programme is presently evaluating in a similar manner an educational process aimed at changing client service and claims handling within the Social Insurance Institution. The target group is claims adjusters - a semi-professional group with various backgrounds - and observations will be compared to those of the physician study.
Two other projects in progress are:
The evaluation of a group-processed based educational programme with the objective of developing the skills of physicians in communicating with cancer patients uses the same approach as the previous studies.
An assessment of the impact of various continuing medical education initiatives on prescription practices is in a pilot and planning phase. The interventions will utilise local physician networks and physician specific information on prescription patterns.
Prof. Timo Hakulinen
Cancer epidemiology and its methods
The research is conducted as 16 related projects. The main emphasis in methodology is in developing methods for survival analysis and construction of incidence predictions. Also computer software is under development. The applied projects concern, e.g., radiation doses and cancer risks of the Estonian cleanup workers of the Chernobyl accident, drinking water mutagenicity and cancer risk, viral infections and risk of cancer, cancer patient survival in Europe and predicting the occurrence of Cancer in Finland. The projects are funded by cancer foundations in Finland and Sweden, the Nordic Cancer Union, the European Union and the National Cancer Institute.
Prof. Olli P. Heinonen and Jussi Huttunen and Doc. Jarmo Virtamo
Alpha-tocopherol Beta-carotene Cancer Prevention Study
Controlled clinical trials are necessary in order to confirm cause-and-effect relationships between nutritional factors and disease risk. The Alpha-tocopherol, Beta-carotene Cancer Prevention (ATBC) Study, a joint project between KTL and the US National Cancer Institute, was a randomized, double-blind, placebo-controlled trial to examine whether supplementation with alpha-tocopherol (AT) or beta-carotene (BC) or both reduces the incidence of lung cancer and other cancers. The intervention, involving 29,133 smoking males aged 50 to 69 years, was completed in April 1993 and lasted for 5 to 8 years. At the end of the intervention, 20,072 participants were still active in the trial and 88% of the participants had taken more than 90% of the prescribed capsules.
The first results of the ATBC study (2) indicated that supplementation with AT or BC did not reduce the incidence of lung cancer. In fact, a higher incidence of lung cancer was observed among men who had received BC than among those who had not. A possible protecting effect by AT against cancer of the prostate was observed. BC had no significant effect on the incidence of cancer other than lung cancer. AT had no effect on total mortality, although more deaths from haemorrhagic stroke were observed in men who had received AT supplements. Total mortality was increased in men who had received BC supplements, primarily because of the increase in deaths from lung cancer and ischaemic heart disease. The findings of the ATBC study are the first evidence from a randomized trial indicating that AT and BC supplements may have harmful effects in addition to their possible benefits. The study continues exploring the effects AT and BC on other diseases than cancer. Also long-term, post-trial effects on chronic diseases are examined.
Prof. Olli P. Heinonen, and Senior Research Assistant Mikko Paunio
MMR Vaccination Programme in Finland - Programme Performance
Vaccination project against measles, mumps, and rubella (MMR Project) has been the largest single public health programme in Finland during the 1980's; it started in late 1982. Ever since the beginning a multidisciplinary follow team has been evaluating global program performance (compliance, coverage, effectiveness), side effects of the trivalent MMR vaccine (VirivacR), vaccine effectiveness and efficacy, and also economic aspects of vaccination. The programme and its evaluation, has received world-wide recognition, especially when its 12-year-record was published in the New England Journal of Medicine (1994;331:1397-402). Other papers have been published in the Lancet, and American Journal of Epidemiology. By now the three diseases have been eradicated and additional projects and analytic studies of vaccine performance have been undertaken which are about to be published in the following years. One dissertation is under preparation of immunologic aspects of MMR vaccination.
Prof. Marja-Liisa Honkasalo, M.D., D.Med.Sc.
Death, suffering, and meaning-giving
The aim of the project is to understand experience of chronic pain, aging, and dying in the context of suffering. The study is interdisciplinar including approaches in social medicine, medical sociology, comparative religions and sociology of law and justice. The research themes are.
1. Narratives of pain and suffering (Marja-Liisa Honkasalo)
2. How to understand aging - a study of women's own cultural resources in the interpretation of menopause (Ilka Kangas)
3. 'Mater dolorosa', the significative relationships between woman and death (Terhi Utriainen)
4. Widowhood as a cultural construction and individual experience (Auli Suomalainen)
The project is financially supported by Finnish Academy and University of Helsinki.
Prof. Jouni Jaakkola and M.Sc. (Education) Niina Jaakkola
Environmental Epidemiology Unit
This unit co-ordinates and/or participates in a number of national and international studies of the effects of environmental factors on human health. The head of the unit is prof. Jouni Jaakkola, currently working full-time at Johns Hopkins School of Public Health and part time at Harvard School of Public Health.
On-going research projects in Finland:
Children's environment and health
A six-year population-based cohort study in 2,500 children in Espoo
The Finnish prenatal environment and health
A cohort study of 2,800 pregnant women and their children in south-east Finland
Occupational dampness and moldproblems and incidence of asthma
A case-control study in the City of Tampere
Office environment and health
Several datasets from cross-sectional and intervention studies
The Oslo Birth Cohort Study
A cohort study with a nested case-control study and controlled intervention studies in 3,700 Oslo children
A cohort study in Russian pregnant women and their children
A cohort study of 2,000 pregnant women and their children. Data collection will start in 1997.
A cross-sectional study of environment and health in Russian school children
A cross-sectional study in Sverdlovsk Oblast, Russian Federation
Daily mortality and morbidity in relation to levels of air pollution.
Several studies in Russian industrial cities including Cherepovets, Yekaterinburg, and Nizhnij Tagil.
Prof., Doc. Jaakko Kaprio, M.D., D.Med.Sc., and Prof., Doc. Markku Koskenvuo, M.D., D.Med.Sc.
Genetic and environmental factors in complex disease and health-related behaviours: The Finnish Twin Cohort studies.
Background : In a collaborative effort of the Finnish Twin Cohort investigators with investigators at National Public Health Institute and numerous clinical and behavioural scientists from universities in Finland and abroad, we are carrying out a series of studies to identify genetic and environmental determinants of common, complex diseases, and their behavioural risk factors.
1. Like-sexed twin pairs (13,888 pairs of known zygosity) form the older Twin Cohort. They have participated since 1975 in mail surveys, clinical subsample studies and been followed-up for morbidity using national medical registers; the cohort thus forms a phenotypically rich data base of genetically informative family sets. The older Twin Cohort was expanded in 1996 to include opposite-sex pairs born 1938-1957.
2. Two, new longitudinal studies of adolescent twins and their families, with major funding by the National Institutes of Health, USA in 1991 and 1994 respectively form a complementary, ongoing study base. Because of the ages currently studied, the primary focus is on behavioural risk factors at present, and will evolve to disease outcomes on follow-up.
The identification of liability genes is recognized as a key approach to increasing our understanding of diseases mechanisms, opening the door to targeted prevention and new medications. Interaction analyses increase our understanding of the relationship between the action of environmental agents and genetic variability. For disease prevention, knowledge of the dependence of environmental risk factors on genetic risk is scanty. Genetic and environmental effects vary over the life-span, and only longitudinal studies in genetically informative data sets permits the study of such effects.
Prof. Matti Klockars
Sixteen years’ follow-up of aging municipal employees
In collaboration with the Institute of Occupational Health, Helsinki I participate as a co-worker (physician) in the 16-year follow-up study of the Aging worker project (1981-1997). At the start in 1981 the cohort included 6257 municipal workers (aged 44-58 years) and during the follow-up the majority has retired either because of old age or because on working disability. The time and causes of death and disability pension have been recorded. The 1981, 1985 and 1992 questionnaire data, including type of work and work requirements have been analysed to explain certain endpoints. A number of risk profiles have been calculated. A work ability index had been developed. Most recently the importance of subjective experienced health and psychosomatic symptoms in relation to aging and work ability will be analysed. The work ability index (WAI) is used internationally and comparisons will be made between different countries.
Prof. Eero Lahelma
1 Explanations for social variations in health: comparisons and changes over time
The aim of this study is to provide explanations for variations in health between socioeconomic and other population groups, among men and women, in Finland and other European countries, with special reference to changes over time. The substudies included in this project apply medical sociological and social epidemiological approaches and methods. The tasks set for study are anchored in previous research and designed to use appropriate approaches to add and accumulate knowledge on the reasons for social variations in health. The results will add our understanding of the basic scientific questions of medical sociological and public health research concerning the social causes and consequences illhealth. The work is conducted in collaboration with Departments of Sociology and Social Policy, University of Helsinki, University of Surrey and many other British Universities.
Prof. Eero Lahelma
II Social variations in health: Nordic comparisons and changes over time
The aim of this study is to examine trends in variations in health (morbidity) between employment status groups, socioeconomic groups, among men and women in four Nordic countries, Denmark, Finland, Norway and Sweden. The four Nordic welfare states provide good opportunities for focussed comparisons of health variations and their change since these countries show both similar and dissimilar social structural developments. Special attention will be given to the significance of unemployment - a serious social problem in the Nordic countries since the 1970s and 1980s, and an increasing problem in the early 1990s - i.e. processes leading to paid employment and non-employment, and the bearing of illhealth in these processes. A sudden increase of unemployment, such as that in Finland and Sweden, offers challenges for research in a 'natural experimental' setting. The work is conducted in collaboration with other Nordic universities and research institutes
Prof. Eero Lahelma
III Helsinki Health Study: Health and well-being among the staff of the city of Helsinki
The main aim of the Helsinki Health Study is to give a comprehensive picture on health, functional abilities and well-being among the staff of the City of Helsinki. The study is relevant to the scientific community as well as to health promotion, personnel development and employment policies among the staff. In addition to description of the health status a major emphasis is given to determinants and causal factors of illhealth among employees and their subgroups. Particular attention will be devoted to employment, grade, and aging as well as gender difference. The study will be carried out as a collaborative project with the City of Helsinki and The Whitehall Study, University College London.
Prof. Eero Lahelma
IV Monitoring and reporting socioeconomic differences in health indicators in the European Union
The aim of this project is to contribute to the development of a monitoring and reporting system for socioeconomic differences in morbidity and mortality in the European Union. The European Working Group on Socioeconomic Inequalities in Health, directed by prof. JP Mackenbach, Erasmus University Rotterdam, started in 1993 to analyse socioeconomic health differences in European countries. This first phase of research has been accomplished. A second phase will start in 1999. The specific aims of the project are first to develop quidelines for the analysis of trends in socioeconomic differences in health, second to illustrate the quidelines with analyses of changes in socioeconomic differences in health between the 1980s and 1990s; and third to develop a format for regular reporting on socioeconomic differences in health.
Senior Assistant, Doc. Helena Mussalo-Rauhamaa
I Environmental attitudes and knowledge of environmental health hazards among young people in Finland, Russia and Estonia. A cross-national comparison of urban youth.
The aim of this study is to compare environmental attitudes and knowledge of 14-18-year-old students living in urban areas in Finland, Russia and Estonia. The data were collected in schools in Helsinki in the autumn of 1994 (N=1773), in Moscow, Orenburg and Abakan in the spring of 1995 (N=1003), and in Tallinn in the autumn of 1995 (N=1268). The work is conducted in collaboration with the Russian Academy of Science and the University of Tartu, Estonia.
Senior Assistant, Doc. Helena Mussalo-Rauhamaa
II Indoor Air Quality Control
The aim of this study is to establish a causal connection between indoor air quality in a space, perceived comfort and diagnosed health effects, to study the potential of the TVOC-concept, single VOCs and other chemicals emitting from materials to be used as health, irritation and comfort related evaluation criteria in the Finnish classification and their correlation with perceived air quality. In addition, different methods for measuring the impact of emissions on perceived air quality are compared. The work is carried out in collaboration with the State Institute of Technology and University of Kuopio.
Senior Assistant, Doc. Helena Mussalo-Rauhamaa
III Mould and moisture transfer in building structures and buildings with particular regard to prevention on health hazards.
The aim of the research project is to work out mould transfer models by which both the spreading of the metabolic products and the mould spores in the constructions and inside the building can be modelled. To develop a new serum IgG ability test in order to estimate the exposure to moulds in cross-sectional and follow-up studies. The collaborators came from Helsinki University of Technology, University of Kuopio and Helsinki University Central Hospital.
Senior Assistant, D.Med.Sc. Mikko Paunio
Infections disease epidemiology program
Infectious disease epidemiology program at the department of Public Health has - to a large extent - focused its attention in the ongoing measles, mumps, and rubella (MMR) vaccination program, though increasingly assignments through governmental or even legal bodies have become more common tasks. Department of Public Health has been active in the national surveillance group of the MMR vaccination program, and main focus of our department of this multidisciplinary collaboration has been to initiate, execute and consult to studies which try to find out answers to various issues of MMR vaccination. These themes include studies of compliance and vaccination coverage, questions related duration and quality of immunity (a novel approach has been developed) developed by the vaccine, and short-term side effects. Increasingly, because of mounting international pressure, we have focused on long-term side effects or indirect public health effects via our exceptional registries. These issues include questions whether MMR vaccination directly or indirectly increases risk of Crohn's disease, autism or promotes atopy. A major successful effort was made to find source of the first Escherichia coli H7/0157 outbreak in Finland in 1997. Likewise a major industrial cattle feed related epidemic has been under careful investigation by the department.
Prof. Seppo Sarna
Mortality, morbidity and health habits of former elite athletes
The main target of the project is to clarify the long-term effects of physical exercise on health and well-being. The basic data file of the project contains ca. 4500 former Finnish male elite athletes and their referents. So far, by the end of the year 1996, in all 9 original articles in peer reviewed journals has been published and many scientific presentations during the last decade in different congresses has been holed. They have treated life-expectancy occupational disability. Lifestyles, food and exercise habits, knee osteoarthritis, back related symptoms, spine pathology, diabetes, ischemic heart disease, hypertension, asthma, hospital care, etc. More than ten substudies, both clinical and epidemiological, are in progress. The basic study material has been lately expanded by doing a questionnaire study, the aim of which was to clarify the present health status of the persons in the cohort. A lot of substudies are either in planning phase or in progress and many others can be done based on the collected material.
Senior Assistant, Doc. Risto Tuominen
Health Care Marketing Project (HelCaMa) is directed by docent Risto Tuominen. Co-workers are Maj-Britt Hedvall, Doctor in Business Administration, Swedish School of Business Administration, Ari Nyysti, Doctor in Dental Sciences, School of Dentistry, University of Turku and Jaakko Palmujoki, Candidate in Dental Sciences, School of
Dentistry, University of Helsinki.
The aim of the project is to conduct surveys among all eleven professional groups which members are working in private health care provision in Finland. The surveys concentrate on competition within and between professional groups and marketing efforts among them. Adding to these also attitudes towards competition, marketing and colleaques are solicited.
Additionally interview surveys are organized in five biggest cities in Finland where members of the public are evaluating various health related advertisements.
Research is mainly quantitative, but also some elements of qualitative research are included, particularly in Dr. Nyysti's work.
Dr. Nyysti and Cand. Dent. Palmujoki are preparing their Ph.D. works from these data. More researchers are recruited from the Swedish School if Business and from other health related departments of the University of Helsinki.
Data collection started in May 1998 and should be finished by May 1999. Project has been supported by Suomen Kulttuurirahasto - Finnish Cultural Fund.