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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
The HUNT Study. www.hunt.ntnu.no
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
Europe.
Norway 4.7 mill inhabitants
The HUNT Study
Norway
(Life expectancy 2004)
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The HUNT Study. www.hunt.ntnu.no
Nord-Trøndelag County, Norway 24 Municipalities, 130.000 inhabitants
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
young-hunt The youth part of
the Health study of Nord-Trøndelag,
Norway
• 13-19 years
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
HUNT1 (1984-86) Invited (aged 20+) 86 404
Participated (89.4%) 77 212
HUNT2 (1995-97) Invited (aged 20+) 93 898
Participated (69.5%) 65 237
HUNT3 (2006-08) Invited (aged 20+) 93 860
Participated (54.1%) 50 807
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
Participants: 47 316
HUNT1 – 2 – 3 cohortb
Participants: 27 992
HUNT2 – 3 cohortc
Participants: 37 071
HUNT1 – 2 – 3 cohort
Participants: 27 992
HUNT1 – 2 – 3 cohort
Participants: 27 992
HUNT2 – 3 cohort
Participants: 37 071
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
HUNT – Research designs
HUNT 1 REGISTERS HUNT 2 HUNT 3 TIME Medial
Birth
Reg.
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
Confidence, our most important
capital enthusiasm
confidence
quality
relevance
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The HUNT Study. www.hunt.ntnu.no
A sustainable population-based
research strategy
Investments
Returns
Altruism
Volunteerism
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
Utilisation
• 80 PhDs – Approx 1 PhD a month
• 600 scinetific international papers – Approx 1 paper a week
• 300 running projects
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
Photo documentation clinical examinations
Heigth Weight
BP. Pulse.
Circumferences.
Biological material.
Screening station in Verdal
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The HUNT Study. www.hunt.ntnu.no
Photo documentation clinical examinations
DTX. DEXA.
Spirometry. Screening station in Verdal
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The HUNT Study. www.hunt.ntnu.no
Photo documentation clinical examinations
Blood vessel function test
Max O2 uptake. Screening station in Verdal
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The HUNT Study. www.hunt.ntnu.no
Adults
Team 1: - 5 Municipalities (towns)
Team 2 (buss team):
- 19 Municipalities
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The HUNT Study. www.hunt.ntnu.no
Cold chain
Blood: 4 deg
Blood: Roomtemp.
Urine: - 18 deg
100.000 km over 2 years
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
Multidisiplinary, - health surveillance
- health services research
- disease cause research
- disease prevention research
- health promotion research
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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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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The HUNT Study. www.hunt.ntnu.no
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)