Cancer prevention research has produced profound scientific knowledge that has led to the development of several evidence‐based prevention strategies. But do these research outcomes lead to preventive action in real life? Many factors contribute to the so‐called 'implementation gap' between prevention recommendations and their application and adherence, including individual actions and behaviour, health service structures and political actions. This article discusses factors underlying the implementation gap in both clinical‐ and population‐based prevention. Understanding how these factors contribute to the implementation gap is important for planning successful cancer prevention strategies, as well as generally achieving disease prevention.
The North Karelia Project was started in 1972 as a response to the high cardiovascular mortality among men in North Karelia, Finland's easternmost province. Prevalent cardiovascular disease risk factors in the province included elevated serum cholesterol, hypertension, and smoking. Through a sociobehavioral framework utilizing community-based interventions and national-level policy changes and legislation, the project targeted lifestyle changes as a means to alleviate cardiovascular disease risk factors. Diet recommendations included minimizing the use of saturated fats and decreasing salt intake. Another target of the project was to reduce the prevalence of smoking. As a result of the lifestyle interventions that continued beyond the initial 5 years of the project and then expanded to all of Finland, there were significant reductions in serum cholesterol levels, hypertension, smoking prevalence, and cardiovascular disease mortality. The North Karelia Project demonstrates that successful population-based lifestyle interventions serve as a sustainable public health solution to the growing chronic disease burden.
This document has been written as a practical tool in the work to strengthen European National Public Health Institutes (NPHIs), their network and collaboration with EU/SANCO. The background text was prepared by Jussi Huttunen and Pekka Puska, with the aid of some IANPHI documents. The text was modified and endorsed by an editorial group of directors of European NPHIs: Reinhard Burger (Germany), Justin McCracken (UK), Jose Pereira Miguel (Portugal), Pekka Puska (Finland), Marija Seljak (Slovenia), Geir Stene-Larsen (Norway), Sarah Wamala (Sweden) and Jane Wilde (Ireland).
BACKGROUND: The WHO Framework Convention on Tobacco Control (WHO FCTC), the first WHO treaty, entered into force in 2005. In April 2015, a seven-member independent expert group (EG) was established by a decision of the FCTC Conference of the Parties to assess the impact of the Treaty in its first decade. One component of the EG's methodology was to gather evidence on WHO FCTC impact from Parties themselves. This paper presents findings from 12 country missions on how the FCTC impacted progress on tobacco control. METHODS: Between November 2015 and May 2016, EG members conducted missions in 12 countries representing each of the six WHO regions and the four World Bank economic development levels. In each country, the EG interviewed a broad range of stakeholders to assess the extent to which the FCTC had contributed to tobacco control. The primary objective was to assess whether tobacco control measures would have been developed or passed, or implemented at all, or as quickly, if there had been no FCTC. Through this counterfactual inquiry, the EG sought to determine the FCTC's causal role. CONCLUSION: The FCTC was reported to have made contributions along the entire policy/regulation process: the development of a measure, building legislative and political support for a measure and its implementation. These stakeholder perspectives support the conclusion that the FCTC has played a pivotal role in accelerating and strengthening the implementation of tobacco control measures, although tobacco industry interference continues to be a significant obstacle to further advancement.
There are few models that describe the experience of implementing multisectoral community-based programs of noncommunicable diseases prevention in developing countries. We describe the barriers and facilitators in implementing the "Isfahan Healthy Heart Program" (IHHP) interventions. The IHHP was conducted from 2000 to 2007 in Iran. The program consisted of 10 multidisciplinary intervention projects using both population and high risk approaches. Multiple organizations contributed to the implementation of the different interventions, including health centers, schools, worksites, food industries, academic institutes, nongovernmental organizations, and the media. To consider how to scale up this project for possible national implementation, we conducted a qualitative study that included interviewing all project managers about the facilitators and barriers they experienced. Factors that facilitated IHHP implementation included ownership and leadership, political will, existing capacity and infrastructure, good managerial relations, dedicated human resources, community empowerment, provider and user acceptance and cooperation, external collaboration, and flexibility of the interventions. Barriers included nonsupportive and unstable policies and environments, absence of universal health insurance coverage for noncommunicable disease primary prevention, "best buys" that were not applicable in different situations or cultures, failure in communication, sociopolitical and economic factors, and lack of connection between researchers and knowledge users. More intersectoral collaboration and adaptation to the continuous dynamic changes and interactions between and among the different components of interventions could overcome some of the barriers experienced. Identifying the barriers and facilitators of implementing community-based program can provide critically important information for large-scale implementation and development of new programs. ; published version ; peerReviewed
After World War II, smoking among men was very common in Finland, and especially in North Karelia, contributing to the high rates of cardiovascular diseases and cancer. Thus, the North Karelia Project, from its very start in 1972, took reduction in smoking as one of its main targets. After 1977, the project actively contributed to national tobacco control work, including comprehensive legislation and many other activities. Smoking in North Karelia declined initially much more than in the rest of Finland, but thereafter there has been a steady national decline, resulting in a prevalence of daily smoking among adults of approximately 15% and contributing to the big reduction in the rates of heart disease and tobacco-related cancers, especially among men.HighlightsThe North Karelia Project reduced smoking first regionally and later in all of Finland.Regional campaigning against tobacco in North Karelia became nationwide.National tobacco control legislation was inspired by the North Karelia Project.Tobacco endgame target is now written in the Finnish Tobacco Act.
During the decades after the start of the North Karelia Project in 1971, cardiovascular diseases and related noncommunicable diseases have emerged as the greatest global public health burden. The prevention and control of these diseases have thus become a major challenge and target for global public health, as emphasized by the Political Declaration of the United Nations (UN) General Assembly in 2011. The experiences and results of the North Karelia Project have accordingly received much international attention and have in many ways contributed to the international work in the area, including the strategies and programs of the World Health Organization. The experience of the Project shows the great potential of population-based prevention of cardiovascular diseases and other noncommunicable diseases and that influencing lifestyles related to heart health with comprehensive health promotion and national policies is the cost-effective and sustainable way to improve contemporary public health.HighlightsThe North Karelia Project has been a powerful demonstration on the potential of CVD prevention.The experience has been widely used as demonstration in international heart health work.The project experience supports and has in many ways contributed to the WHO and other strategies for prevention of CVDs and NCDs.
