The Västerbotten Intervention Programme: background, design and implications

Margareta Norberg, Stig Wall, Kurt Boman, Lars Weinehall, Margareta Norberg, Stig Wall, Kurt Boman, Lars Weinehall

Abstract

Background and objective: In Sweden, mortality from cardiovascular diseases (CVD) increased steadily during the 20th century and in the mid-1980s it was highest in the county of Västerbotten. Therefore, a community intervention programme was launched - the Västerbotten Intervention Programme (VIP) - with the aim of reducing morbidity and mortality from CVD and diabetes.

Design: The VIP was first developed in the small municipality of Norsjö in 1985. Subsequently, it was successively implemented across the county and is now integrated into ordinary primary care routines. A population-based strategy directed towards the public is combined with a strategy to reach all middle-aged persons individually at ages 40, 50 and 60 years, by inviting them to participate in systematic risk factor screening and individual counselling about healthy lifestyle habits. Blood samples for research purposes are stored at the Umeå University Medical Biobank.

Results: Overall, 113,203 health examinations have been conducted in the VIP and 6,500-7,000 examinations take place each year. Almost 27,000 subjects have participated twice. Participation rates have ranged between 48 and 67%. A dropout rate analysis in 1998 indicated only a small social selection bias. Cross-sectional, nested case-control studies and prospective studies have been based on the VIP data. Linkages between the VIP and local, regional and national databases provide opportunities for interdisciplinary research, as well as national and international collaborations on a wide range of disease outcomes. A large number of publications are based on data that are collected in the VIP, many of which also use results from analysed stored blood samples. More than 20 PhD theses have been based primarily on the VIP data.

Conclusions: The concept of the VIP, established as a collaboration between politicians and health care providers on the one hand and primary care, functioning as the operating machinery, and the public on the other, forms the basis for effective implementation and endurance over time. After more than 20 years of the VIP, there is a large comprehensive population-based database, a stable organisation to conduct health surveys and collect data, and a solid structure to enable widespread multidisciplinary and scientific collaborations.

Keywords: cardiovascular diseases; community intervention; health promotion; prevention; primary health care; research methodology.

Figures

Fig. 1
Fig. 1
The green keyhole developed from a lattice-work heart pattern. The green keyhole designates a healthy food item.
Fig. 2
Fig. 2
Cumulative number of individuals who participated in the Västerbotten Intervention Programme and the number of health surveys performed during the programme from 1985 to 2007. The start in Norsjö 1985 and subsequent implementation in all municipalities in the county until 1991 is demonstrated.
Fig. 3
Fig. 3
Number of Västerbotten Intervention Programme health examinations of men and women aged 30, 40, 50 and 60 years between 1990 and 2007. Total number: 54,568 men and 58,635 women.
Fig. 4
Fig. 4
The star-profile. Collection of data for blood pressure, body mass index (BMI), plasma glucose, blood lipids, level of physical activity, self-reported health, alcohol consumption (AUDIT) and tobacco habits are marked. Participants estimate their own dietary and eating habits. The example illustrates results at baseline and follow up.
Fig. 5
Fig. 5
Design of the Västerbotten Intervention Programme (VIP) and illustration of different study designs.
Fig. 6
Fig. 6
Potential links between the Västerbotten Intervention Programme database and local, regional and national registers.

References

    1. Weinehall L. The emerging epidemic of cardiovascular disease. Scand J Public Health Suppl. 2003;61:5–8.
    1. Socialstyrelsen. Statistical databases – cause of death statistics [updated 2007] 2007. Available from: [cited 16 October 2007]
    1. Granvik M. Community structure and mortality in the County of Västerbotten (in Swedish); Department of Social Medicine, Umeå University. Report No. 28, Umeå; 1978.
    1. Eriksson CG, Granvik M, Kindblad I, Lindgren G, Nystrom L, Rosen M, et al. Health problems in a Swedish county – what can we learn from official sources? Soc Sci Med [C] 1981;15:143–51.
    1. Wall S, Rosen M, Nystrom L. The Swedish mortality pattern: a basis for health planning? Int J Epidemiol. 1985;14:285–92.
    1. Nystrom L, Rosen M, Wall S. Why are diabetes, stomach cancer and circulatory diseases more common in Northern Sweden? Scand J Prim Health Care. 1986;4:5–12.
    1. Umeå: Västerbotten County Council, Umeå University; 1984. Health problems in Västerbotten – a new agenda for planning? [in Swedish]: Stockholm: Spri; Umeå.
    1. Statistical databases [database on the Internet] Available from: [cited 16 October 2007]
    1. Hälso- och Sjukvårdslag. 1982: 763 [Act on Health Care] 1982.
    1. Västerbottensprojektet 1985–94, en länsaktion för att förebygga hjärt-kärlsjukdom och diabetes. Bilaga till Förvaltningsutskottets protokoll. 1984. Umeå.
    1. Koutis AD, Isacsson A, Lindholm LH, Lionis CD, Svenninger K, Fioretos M. Use of primary health care in Spili, Crete, and in Dalby, Sweden. Scand J Prim Health Care. 1991;9:297–302.
    1. Brannstrom I, Emmelin M, Dahlgren L, Johansson M, Wall S. Co-operation, participation and conflicts faced in public health – lessons learned from a long-term prevention programme in Sweden. Health Educ Res. 1994;9:317–29.
    1. Brännstrom I. PhD thesis, Umeå University. 1993. Community participation and social patterning in cardiovascular disease intervention.
    1. Brannstrom I, Rosen M, Wall S, Weinehall L. Local health planning and intervention – the case of a Swedish municipality. Scand J Prim Health Care Suppl. 1988;1:57–64.
    1. Weinehall L. PhD thesis, Umeå University. 1997. Partnership for health. On the role of primary health care in a community intervention programme.
    1. Weinehall L, Hallgren CG, Westman G, Janlert U, Wall S. Reduction of selection bias in primary prevention of cardiovascular disease through involvement of primary health care. Scand J Prim Health Care. 1998;16:171–6.
    1. WHO. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia. [updated 2006] 2006. Geneva. Available from: [cited 16 October 2007]
    1. Lenner P, Hallmans G, Weinehall L, Stenling R. Population-based biological test bank. New possibilities for epidemiologic cancer research. Lakartidningen. 1991;88:4447–9.
    1. Tibblin G, Tibblin B, Peciva S, Kullman S, Svardsudd K. The Goteborg quality of life instrument' – an assessment of well-being and symptoms among men born 1913 and 1923. Methods and validity. Scand J Prim Health Care Suppl. 1990;1:33–8.
    1. Sullivan M, Karlsson J, Bengtsson C, Furunes B, Lapidus L, Lissner L. The Goteborg quality of life instrument' – a psychometric evaluation of assessments of symptoms and well-being among women in a general population. Scand J Prim Health Care. 1993;11:267–75.
    1. Henderson S, Duncan-Jones P, Byrne DG, Scott R. Measuring social relationships. The interview schedule for social interaction. Psychol Med. 1980;10:723–34.
    1. Unden AL, Orth-Gomer K. Development of a social support instrument for use in population surveys. Soc Sci Med. 1989;29:1387–92.
    1. Karasek R, Theorell T. Healthy work: stress, productivity, and the reconstruction of working life. New York: Basic Books; 1990.
    1. Theorell T, Perski A, Akerstedt T, Sigala F, Ahlberg-Hulten G, Svensson J, et al. Changes in job strain in relation to changes in physiological state. A longitudinal study. Scand J Work Environ Health. 1988;14:189–96.
    1. Aertgeerts B, Buntinx F, Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis. J Clin Epidemiol. 2004;57:30–9.
    1. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. 2nd ed. Geneva: WHO; 2001. AUDIT, the alcohol use disorders identification test: guidelines for use in primary care. Document No WHO/MSD/MSB/01.6a.
    1. Johansson I, Hallmans G, Wikman A, Biessy C, Riboli E, Kaaks R. Validation and calibration of food-frequency questionnaire measurements in the Northern Sweden Health and Disease cohort. Public Health Nutr. 2002;5:487–96.
    1. Miller WR. Motivational interviewing: research, practice, and puzzles. Addict Behav. 1996;21:835–42.
    1. Persson M, Tegman J, Bohlin J. EviBase VHU. 2004. Available from: [cited 12 May 2008]
    1. Umeå: Västerbotten County Council; 2004. Manual 2004, Västerbotten Intervention Program.
    1. Sullivan M, Karlsson J, Ware JE., Jr The Swedish SF-36 Health Survey–I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med. 1995;41:1349–58.
    1. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption – II. Addiction. 1993;88:791–804.
    1. Lindahl B, Weinehall L, Asplund K, Hallmans G. Screening for impaired glucose tolerance. Results from a population-based study in 21,057 individuals. Diabetes Care. 1999;22:1988–92.
    1. Weinehall L, Ohgren B, Persson M, Stegmayr B, Boman K, Hallmans G, et al. High remaining risk in poorly treated hypertension: the ‘rule of halves’ still exists. J Hypertens. 2002;20:2081–8.
    1. Krachler B, Eliasson M, Stenlund H, Johansson I, Hallmans G, Lindahl B. Reported food intake and distribution of body fat: a repeated cross-sectional study. Nutr J. 2006;5:34.
    1. Fharm E, Rolandsson O, Weinehall L. Guidelines improve general trend of lowered cholesterol levels in type 2 diabetes patients in spite of low adherence. Scand J Public Health. 2008;36:69–75.
    1. Soderberg S, Stegmayr B, Stenlund H, Sjostrom LG, Agren A, Johansson L, et al. Leptin, but not adiponectin, predicts stroke in males. J Intern Med. 2004;256:128–36.
    1. Norberg M, Eriksson JW, Lindahl B, Andersson C, Rolandsson O, Stenlund H, et al. A combination of HbA1c, fasting glucose and BMI is effective in screening for individuals at risk of future type 2 diabetes: OGTT is not needed. J Intern Med. 2006;260:263–71.
    1. Norberg M, Stenlund H, Lindahl B, Andersson C, Weinehall L, Hallmans G, et al. Components of metabolic syndrome predicting diabetes: no role of inflammation or dyslipidemia. Obesity (Silver Spring) 2007;15:1875–85.
    1. Nafziger AN, Lindvall K, Norberg M, Stenlund H, Wall S, Jenkins PL, et al. Who is maintaining weight in a middle-aged population in Sweden? A longitudinal analysis over 10 years. BMC Public Health. 2007;7:108.
    1. Emmelin M, Weinehall L, Stenlund H, Wall S, Dahlgren L. To be seen, confirmed and involved – a ten year follow-up of perceived health and cardiovascular risk factors in a Swedish community intervention programme. BMC Public Health. 2007;7:190.
    1. Stattin P, Bjor O, Ferrari P, Lukanova A, Lenner P, Lindahl B, et al. Prospective study of hyperglycemia and cancer risk. Diabetes Care. 2007;30:561–7.
    1. Hallmans G, Agren A, Johansson G, Johansson A, Stegmayr B, Jansson JH, et al. Cardiovascular disease and diabetes in the Northern Sweden Health and Disease Study Cohort – evaluation of risk factors and their interactions. Scand J Public Health Suppl. 2003;61:18–24.
    1. Weinehall L, Janlert U, Asplund K, Wall S. Public health work needs new evaluation models. Primary care projects are more effective than large scale campaigns. Lakartidningen. 1998;95:3812–6.
    1. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007;335:24–27.
    1. The National Survey of Public Health. Swedish National Institute of Public Health [updated 2008] 2008. Available from: [cited 15 April 2009]
    1. Weinehall L, Hellsten G, Boman K, Hallmans G, Asplund K, Wall S. Can a sustainable community intervention reduce the health gap? – 10-year evaluation of a Swedish community intervention program for the prevention of cardiovascular disease. Scand J Public Health Suppl. 2001;56:59–68.
    1. Lingfors H, Lindstrom K, Persson LG, Bengtsson C, Lissner L. Lifestyle changes after a health dialogue. Results from the Live for Life health promotion programme. Scand J Prim Health Care. 2003;21:248–52.
    1. Lauritzen T, Jensen MS, Thomsen JL, Christensen B, Engberg M. Health tests and health consultations reduced cardiovascular risk without psychological strain, increased healthcare utilization or increased costs. An overview of the results from a 5-year randomized trial in primary care. The Ebeltoft Health Promotion Project (EHPP) Scand J Public Health. 2008;36:650–61.
    1. Rasmussen SR, Thomsen JL, Kilsmark J, Hvenegaard A, Engberg M, Lauritzen T, et al. Preventive health screenings and health consultations in primary care increase life expectancy without increasing costs. Scand J Public Health. 2007;35:365–72.
    1. Bach Nielsen KD, Dyhr L, Lauritzen T, Malterud K. Long-term impact of elevated cardiovascular risk detected by screening. A qualitative interview study. Scand J Prim Health Care. 2005;23:233–8.
    1. Lundvall O, Asplund K, Cohen D, Emmelin M, Eriksson C, Janlert U, et al. Stockholm: The Swedish Council on Technology Assessment in Health Care SBU; 1997. Community intervention programs to prevent cardiovascular disease – a systematic review. Report No. 134.
    1. Puska P, Tuomilehto J, Nissinen A, Salonen JT, Vartiainen E, Pietinen P, et al. The North Karelia project: 15 years of community-based prevention of coronary heart disease. Ann Med. 1989;21:169–73.
    1. Fortmann SP, Flora JA, Winkleby MA, Schooler C, Taylor CB, Farquhar JW. Community intervention trials: reflections on the Stanford Five-City Project experience. Am J Epidemiol. 1995;142:576–86.
    1. Luepker RV, Murray DM, Jacobs DR, Jr, Mittelmark MB, Bracht N, Carlaw R, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health. 1994;84:1383–93.
    1. Carleton RA, Lasater TM, Assaf AR, Feldman HA, McKinlay S. The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk. Am J Public Health. 1995;85:777–85.
    1. Mittelmark MB, Hunt MK, Heath GW, Schmid TL. Realistic outcomes: lessons from community-based research and demonstration programs for the prevention of cardiovascular diseases. J Public Health Policy. 1993;14:437–62.
    1. Lindholm L, Rosen M. What is the ‘golden standard’ for assessing population-based interventions? – problems of dilution bias. J Epidemiol Community Health. 2000;54:617–22.
    1. Brannstrom IA, Persson LÅM, Wall SI. Towards a framework for outcome assessment of health intervention. Conceptual and methodological considerations. Eur J Public Health. 1994;4:125–30.
    1. Wall S, Weinehall L. Public health work is improvement without impairment. Lakartidningen. 1998;95:3807–8. 11.
    1. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ. 1996;312:1215–8.
    1. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321:694–6.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ. 2007;334:455–9.
    1. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806–8.
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.
    1. Rosén M. PhD thesis, Umeå University. 1987. Epidemiology and planning for health: with special reference to regional epidemiology and the use of health registers.
    1. Lindholm L. PhD thesis, Umeå University. 1996. Health economic evaluation of community-based cardiovascular disease prevention: some theoretical aspects and empirical results.
    1. Lindahl B. PhD thesis, Umeå University. 1998. Lifestyle and health. On the role of the insulin resistance syndrome in cardiovascular disease and diabetes. The effects of lifestyle intervention.
    1. Söderberg S. PhD thesis, Umeå University. 1999. Leptin – a risk marker for cardiovascular disease.
    1. Rolandsson O. PhD thesis, Umeå University. 2002. Islet beta cell autoimmunity. An epidemiological and experimental study.
    1. Johansson L. PhD thesis, Umeå University. 2002. Hemostatic factors in cardiovascular disease with special reference to stroke.
    1. Persson M. PhD thesis, Umeå University. 2003. Bring hypertension guidelines into play. Guidelinebased decision support system for drug treatment of hypertension and epidemiological aspects of hypertension guidelines.
    1. Emmelin M. PhD thesis, Umeå University. 2004. Self-rated health in public health evaluation.
    1. Karlsson B. PhD thesis, Umeå University. 2004. Metabolic disturbances in shift workers.
    1. Hultdin J. PhD thesis, Umeå University. 2005. Homocysteine in cardiovascular disease with special reference to longitudinal changes.
    1. Thögersen A. PhD thesis, Umeå University. 2005. Risk markers for first myocardial infarction.
    1. Wiklund P. PhD thesis, Umeå University. 2005. Genetic aspects of stroke: association and linkage studies in a northern Swedish population.
    1. Berglin E. PhD thesis, Umeå University. 2006. Predictors of disease onset and progression in early rheumatoid arthritis: a clinical, laboratory and radiological study.
    1. van Guelpen B. PhD thesis, Umeå University. 2006. Folate in cancer and cardiovascular disease: prospective studies from the population-based northern Sweden health and disease study.
    1. Nafziger A. PhD thesis, Umeå University. 2006. A population perspective on obesity prevention: lessons learned from Sweden and the US.
    1. Norberg M. PhD thesis, Umeå University. 2007. Identifying risk of type 2 diabetes: epidemiologic perspectives from biomarkers to lifestyle.
    1. Krachler B. PhD thesis, Umeå University. 2007. Diet and cardiometabolic disease: dietary trends and the impact of diet on diabetes and cardiovascular disease.
    1. Johansson M. PhD thesis, Umeå University. 2008. Prostate cancer aetiology: epidemiological studies of IGF- and one-carbon metabolism pathways.
    1. Wennberg P. PhD thesis, Umeå University. 2009. Beyond the established risk factors of myocardial infarction. Lifestyle factors and novel biomarkers.
    1. Stocks T. PhD thesis, Umeå University. 2009. Metabolic factors and cancer risk: prospective studies on prostate cancer, colorectal cancer, and cancer overall.

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