a large epidemiological study as basis for health

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The HUNT Study. www.hunt.ntnu.no

A large epidemiological study as basis

for health promotion in municipalities

HUNT Research Centre, Norway Steinar Krokstad, Director, MD PhD


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My position

• Medical doctor – General practice 7 yrs

– Psychiatry 13 yrs

• PhD in Social Epidemiology – Studying social and economic factors effect on health and disability

• PI of the HUNT3 Survey 2006-08

• Head of the HUNT Research Centre (pt on sabbattical)

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No data – no problem

No problem – no action

No data – no visible gains

No visible gains – no action

Prevention

Promotion

Our motivation

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Teenagers: Start smoking

22 %

40 %

30 %

24 %

26-28 %

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The HUNT strategy Ten «Commandments» to achieve good results

1. Volum, age range and generalisability

2. Longitudinal design, follow-up

3. PIN and data linkage

4. Pro et contra

5. Reseach ethics and openness

6. Confidence

7. Availability and utilisation

8. Quality

9. Multi-disciplinary, health promotion research

10. Health promotion in public health

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Volum, age range and

generalizability

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Europe.

Norway 4.7 mill inhabitants

The HUNT Study

Norway

(Life expectancy 2004)

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Nord-Trøndelag County, Norway 24 Municipalities, 130.000 inhabitants

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The HUNT Study Survey Material Invited Part. rate

Total population

HUNT 1 (1984-86) > 20 years 85,000 90 %

HUNT 2 (1995-97) >13 years 104,000 70 %

HUNT 3 (2006-08) >13 years 105,000 60 %

HUNT Research Centre, Norway Steinar Krokstad, Director, MD PhD

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young-hunt The youth part of

the Health study of Nord-Trøndelag,

Norway

• 13-19 years

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0

10

20

30

40

50

60

70

80

90

%

13-15 16-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89

HUNT 3

Gender

Attendance by age and sex

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Kilde: Statistisk

Sentralbyrå

Dødelighet per 100 000 menn

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

An

tall

dø

de

pe

r 1

00

00

0

0

100

200

300

400

500

600

700

Hjerte - karsykdommer, Nord - Trøndelag

Hjerte - karsykdommer, Norge

Kreft, Nord - Trøndelag

Kreft, Hele Norge

Lungesykdommer, Nord - Trøndelag

Lungesykdommer, Hele Norge

Hjerte- og karsykdommer

Kreft

Lungesykdommer

HUNT – generalizability to Norway

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HUNT –

generalizability to

Norway

Work related

disability

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Longitudinal design,

follow-up

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HUNT1 (1984-86) Invited (aged 20+) 86 404

Participated (89.4%) 77 212





Flow chart showing the number of invited and the number of participants in the

differende cohorts in the HUNT Study. The total county population 20+ years in

Nord-Trøndelag County Norway have been invited to all the surveys. Krokstad et al. The HUNT Study, Norway. Int J Epidemiol 2012, in press.

Dead, emigrated, disappeared: 8545

Moved to other county: 4357

Dead, emigrated, disappeared or

moved to other county: 17 389

HUNT1 – 2 cohorta

Participants: 47 316

HUNT1 – 2 cohort


HUNT1 – 2 – 3 cohortb


HUNT2 – 3 cohortc


HUNT1 – 2 – 3 cohort


HUNT1 – 2 – 3 cohort


HUNT2 – 3 cohort


Registers

Participants can be

followed up in local

or national end-point

register, or censored

due to available

information about

death, emigration or

disappearance.

Important in observational studies: Follow-up!

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PIN and data linkage

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Population registers • National total population registers

– Family (biology/household)

– Mortality (total/cause spesific)

– Cancer

– National insurance

– Birth register (all births from 1967)

– Education

– Income

• Local hospital registers – Levanger and Namsos local hospitals

• Cardiovascular diseases (stroke, MI)

• Fractures (hip, forearm)

• Psychiatric diseases (dementia, schizofrenia, bipolar disorders)

– University hospital (St. Olavs, Trondheim) • Meningitis

• SAH

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HUNT – Research designs

HUNT 1 REGISTERS HUNT 2 HUNT 3 TIME Medial

Birth

Reg.

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young-HUNT 95/97 (13-19 yrs, n=9131)

+

young-HUNT2000/01 (17-19 yrs, n=2700)

+

Norwegian Birth Register

+

HUNT I and HUNT II (adult-HUNT)

(parents, siblings, grandparents)

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Pro et contra

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Risk factor detection

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Critical to risk factor clinical practice

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Reseach ethics

and openness

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Steinsbekk KS, Ursin LO, Skolbekken JA, Solberg B

We`re not in it for the money-lay people`s moral intuitions on commercial use

of "their" biobank

Med Health Care Philos. 2011 Oct 26

Skolbekken JA, Ursin LO, Solberg B, Christensen E, Ytterhus B

Not worth the paper it's written on? Informed consent and biobank research

in a Norwegian context.

Critical Public Health 2005;15:335-47

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Active information policy

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All projects listed on web

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Confidence

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Confidence, our most important

capital enthusiasm

confidence

quality

relevance

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A sustainable population-based

research strategy

Investments

Returns

Altruism

Volunteerism

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Availability and

utilisation

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Data access See www.hunt.ntnu.no

• Data are available for all serious researchers

• Access is based on

• Protocols

–Access restricted to a specific publication

plan and for a limited time

• Anonymous data files

• No individual results, - no intervention

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Utilisation

• 80 PhDs – Approx 1 PhD a month

• 600 scinetific international papers – Approx 1 paper a week

• 300 running projects

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Quality

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Data collection

• Questionnaires

• Clinical measurements

• Biological material, biobanking

• Linkage to national total population registers (projects) – The unike 11 digit personal identification number

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Invitation, Q1 Pamphlet

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Q2

Handed over at the screening

Q3 Questionnaires

HUNT 3

Q1 mailed Men

Women

Q3 Cardiovaskular Diabetes Brestcanster

Q3 Canser prostate and colon Health services

Q3 Psoriasis Hand eczema CAM

Q3 Carnivores

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Photo documentation clinical examinations

Heigth Weight

BP. Pulse.

Circumferences.

Biological material.

Screening station in Verdal

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DTX. DEXA.

Spirometry. Screening station in Verdal

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Blood vessel function test

Max O2 uptake. Screening station in Verdal

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Adults

Team 1: - 5 Municipalities (towns)

Team 2 (buss team):

- 19 Municipalities

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Cold chain

Blood: 4 deg

Blood: Roomtemp.

Urine: - 18 deg

100.000 km over 2 years

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EDTA plasma 1

Serum (SST)

ACD blod for celle immortalisering

Buffy coats

Biochem. Liq. N2 -80ºC

EDTA plasma 2

Na-Heparin

HUNT 3, strict biological sample protocol

• Rapid cooling to + 40C, transport at + 40C, temp. log and history of every singel tube,

fractionation and alikvotation, in 36 hours

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50


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Fully automated sample handling, fractionation and distribution at 40 C

Cold room at 40 C

Automated distribution from vacutainer tubes to cryo tubes

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Multidisiplinary, - health surveillance

- health services research

- disease cause research

- disease prevention research

- health promotion research

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Helsetjeneste

forskning

Revma

Osteoporose

Kvinne/barn

Eldre. Smerte

Farmakologi

Psykiatri

Mental helse

Kreft

Nevro-

vitenskap

Samfunns-

vitenskap

Hjerte/kar

Nyrer

Diabetes

Endokrinologi

Gastro

Urogenital

Luftveier

Allergi

Hud

Gruops Leader

HUNT / NTNU

HUNT3

18 research groups

Cooperation

Medical Fac., all Dept.

SVT fac.

HF fac.

IME fac.

NT fac.

HMN, HNT, St. Olav

HINT, HIST

115 research proposals

R Wiseth, ISB

K Ringdal, ISS, SVT

A Langhammer, ISM

K Hagen, INM

K Midhjell, ISM

P Romundstad, ISM

TP Flaten, IKJ, NT

K Hveem, ISM

E Stordal, INM

O Dale, ISB

S Forsmo, ISM

JF Skomsvoll, St. Olav

R Johnsen, ISM

Miljø

Groups Leader

Teknologi-

vurdering

Odontologi

JA Skolbekken, ISH, SVT

D Holst, ISO, UiO

TL Holmen, ISM

AG Berg, HINT

T Sørensen, MF

Ungdom

Folk og dyr

Religion og

helse

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Multidisiplinary utilisation

0

10

20

30

40

50

60

70

80

90

100

ISMDMF

INMDMF

ISBDMF

IKMDMF

LBKDMF

SVT NT St.OlavHMN

HNTHMN

Andre

300 running projects

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Health

promotion

research

and

action

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Physical being Physical health, mobility, nutrition, fitness, appearance

Psychological being Independence, autonomy, self-acceptance, freedom from stress

Spiritual being Values and standards, spiritual beliefs

Physical belonging Physical aspects of the immediate environment

Social belonging Relationships with family, friends and acquaintances

Community belonging Availability of societal resources and services

Practical becoming Home, school and work activities

Leisure becoming Indoor and outdoor activities, recreational resources

Growth becoming Learning, improving skills and relationships, adapting

Table 1. Quality of life domains (2010)

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Examples

• Quality of life data in HUNT1 (1984-86), (Moum et al., 1990)

• Comparing in-patients quality of life with the HUNT-population,

utilizing HUNT as a reference normal population sample.

(Helvik, Engedal, Krokstad, & Selbæk, 2011)

• Gender differences in subjective well-being, self-esteem and

psychosocial functioning in adolescents with symptoms of

anxiety and depression. (Derdikman-Eiron et al., 2011)

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Culture participation and health

• From a public health point of view, the motivation has been

– the marked geographical and socioeconomic inequalities in health

– constraints seen in traditional methods in health care and in public

health efforts to influence health-related behaviour. (Illich, 1975; Rose,

2001)

• The scientific basis for utilizing culture participation in public health is

still scarce. (Cuypers et al., 2011)

• Inclusion of questions on active and passive cultural participation in the

questionnaires in the HUNT3 Survey (2006-08).

• The first international scientific paper based on these data was

published in 2011, (Cuypers et al., JECH, 2011)

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HUNT3

segment of

questionnaire

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Religous attendance research

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Culture and Health in Public Health strategies in a

Norwegian County – Nord-Trøndelag County

• The FOLK Project – North-Trøndelag County Council

– Nord-Trøndelag University College

– HUNT Research Center-NTNU

– County Governor of Nord-Trøndelag

– Several municipalities

• Promoting greater cultural participation and the use

of arts and culture in public health, care and

nurturing.

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Culture and Health integrated in Public Health

strategies in the Nord-Trøndelag County

• Through cooperation with several municipalities in

the county and regional and international actors,

methods, theory and new knowledge in the field have

been developed and have contributed to increased

participation, a change of regional political priorities

and international attention

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Health promoting policy by Nord-

Trøndelag County Council

• The Public Health Strategy in Nord-Trøndelag County

is being based on data from HUNT

• One aim has been to exploit the possible effects of

stimulating cultural participation in public health, not

at least among vulnerable groups. (Knudtsen, Holmen, &

Håpnes, 2005; Knudtsen, Holmen, & Hapnes, 2005)

• Behaviour regarding cultural attendance in the

population based on HUNT3 data has been mapped

geographically, and has been used in the culture

strategic work in the county. (2011)

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Mapping health and disease

factors stimulate action

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No data – no problem

No problem – no action

No data – no visible gains

No visible gains – no action

Prevention

Promotion

Our motivation

a large epidemiological study as basis for health

Documents