Cohort Profile: Healthy Finland Survey

The Healthy Finland Survey was set up to produce reliable and up-to-date information on population health, wellbeing and health, and social services. With a representative and large sample, and comprehensive range of topics, the survey provides unique opportunities for multidisciplinary public health and epidemiological research with continuously up-dated, register-based follow-up. The survey contributes to public health in various ways, including the development of good treatment practices and prevention programmes. Healthy Finland 2022–23 was a nationally representative survey of the adult population aged 20 years and older (28 153 respondents in the questionnaire part, response rate 46%; 5749 participants in the health examination part, participation rate 58%). Data were collected using questionnaires, health examinations, interviews and laboratory analyses, and complemented with extensive individual-level register linkages. The survey covered a wide range of topics such as longstanding illnesses, mental health, quality of life, functioning, work ability, lifestyles, environmental health, and risk factors for major health problems, as well as need and use of health and social services. The data can be used, in collaboration, for research and monitoring. More information: [[email protected]]. Effective health and welfare policy requires up-to-date reliable information on the health and wellbeing of the population and the factors contributing to these. Although Finland has comprehensive administrative and health registers, they do not provide a sufficient basis for generating an overview of population health and wellbeing. Therefore, population-based surveys have been conducted since the 1960s in Finland.1–4 The Healthy Finland Survey is a continuation of the long tradition of population surveys, as it combines the data collection traditions of the earlier questionnaire and health examination surveys and provides information at both national and regional levels. The Healthy Finland Survey was set up to produce reliable, up-to-date and comprehensive information on population health, wellbeing, functioning, need and use of health and social services and their development. The survey covered a wide range of topics such as quality of life, functioning, work ability, lifestyles, chronic diseases, mental health, environmental health and risk factors for major health problems, as well as unmet needs for treatment. The survey enabled comparisons between geographical areas and population groups. Furthermore, the survey aimed to monitor the long-term effects of the coronavirus pandemic on population health and wellbeing, and to provide baseline data for evaluating the wellbeing services counties which were put into operation in January 2023. The survey was carried out in two parts, i.e. the questionnaire and the health examination parts. The Healthy Finland Survey was funded mainly by the Finnish Institute for Health and Welfare (THL). Other funders include the Social Insurance Institution of Finland, the Finnish Institute of Occupational Health, Ministry of Social Affairs and Health, and Ministry of Education and Culture. The clinical oral health examination received funding from the Finnish Dental Foundation, the Finnish Dental Society Apollonia, the Finnish Dental Association, Odontologiska Samfundet and the Finnish Federation of Oral Health Care Professionals and Plandent Oy; and the survey on alcohol use from the state-owned alcohol retail monopoly, Alko Ltd, which reports to the Ministry of Social Affairs and Health. The nationally representative sample of the Healthy Finland Survey consisted of adult population aged 20 years or older residing in mainland Finland. The sampling design was conducted to ensure generalizability of the results throughout Finland and examination of temporal development within population groups. Furthermore, the questionnaire part was designed to produce representative results for each of the 22 wellbeing services counties in Finland. Thus, for the questionnaire part, a stratified random sample including 2000 persons aged 20–74 years and 800 persons aged 75 years or older were derived from each wellbeing service county (n = 61 600). For the health examination part, a sub-sample from the original sample was selected. To provide a reliable picture of changes over time, the 50 health examination sites were in the same localities as the previous health examination survey in 2017, originally selected to form a representative sample of the Finnish population (the FinHealth 2017 Study).4 As the population sizes in some rural localities included in the health examination survey were small, the sample sizes in these localities in the questionnaire sample were likely to be very small. Therefore, an additional sample (n = 1586) was selected in these localities, and the questionnaire sample was augmented with the additional sample to ensure balanced sampling probabilities in the health examination sample. The original sample for the health examination part in total was 9973. The survey sample was drawn from the population register, which includes information on all individuals living in Finland and is maintained by the Digital and Population Data Services Agency. Figure 1 illustrates the sample design and number of individuals in the original sample, as well as in the eligible sample which excluded deceased individuals and those with unknown address. Participation rates were calculated based on the eligible sample, and the rate for the questionnaire part was 46.3% (n = 28 153) and for the health examination part 58.3% (n = 5749) (Table 1). The pattern of participation was rather similar in both the questionnaire and the health examination parts of the survey, with the highest participation rate among those aged 64–74 years. The participation rate was lowest in the youngest age group of 20–39-year-olds. In all age groups, except for those aged 75 years or older, the participation rate was higher among women than men. There were also socioeconomic differences in participation, e.g. the response rates for the questionnaire part increased by level of education (from 40% to 58% between the lowest and highest educational categories). There were no notable differences in response rates between the wellbeing services counties (data not shown). The sample design of the Healthy Finland Survey, and number of individuals in the sample during different phases of the survey Survey sample and participation by sex and age Eligible sample, which excluded deceased individuals and those with unknown address. The data were collected in 2022–23 by using questionnaires and carrying out health examinations, with methods mostly comparable to previous national surveys and health-related data collections at the EU level.5,6 For the questionnaire part, the subjects of the study sample received a postal invitation in September 2022 to fill in a questionnaire focusing on health, wellbeing, and health and social services. Invitees aged 75 years or older received a paper questionnaire, whereas younger people were encouraged to fill in an online questionnaire. For those who had not responded, the recruitment protocol included two text messages (SMS) and three postal reminders, one of which also included a paper questionnaire. Data collection for the questionnaire part ended in March 2023. For the health examination part, the subjects of the study sample were invited to an extensive health examination conducted between January and June 2023. The health examinations were carried out by trained nurses working in six field teams, which visited 50 localities according to a detailed timetable. The postal invitation included a pre-scheduled appointment time for the health examination at a local study site. Participants were requested to confirm (or change and confirm) their appointment time. If an invitee had not responded in time and a phone number was available, the staff from the survey office called or sent SMS reminders to encourage participation. The questionnaire part included a self-administered questionnaire tailored to three different age groups (20–54, 55–74 and 75 years or older) in four languages (Finnish, Swedish, English and Russian). The core questionnaire consisted of approximately 80 questions on health, wellbeing, quality of life, functioning, lifestyle, health and social services, and background information, with a slightly modified content for participants aged 75 years or older (Table 2). The questionnaire for 20–74-year-olds also included a module with questions either on future prospects or working life (Table 2). The questionnaires are available at THL′s web page.7 Topics in the questionnaire (N = 60 869) ADL, activities of daily living; EUROHIS-QOL 8-item index, European Health Interview Survey-Quality of Life; IADL, instrumental activities of daily living; MHI-5, Mental Health Intentory-5. Eligible sample N = 16 992; participation rate 57.0%. Eligible sample N = 14 042; participation rate 39.8%. Eligible sample N = 29 835; participation rate 43.2%. The thorough health examination, lasting for approximately 1.5–2 h, included measurements of height, weight, waist, hip and neck circumferences, blood pressure, functional ability (tests for vision, hearing, memory and attentiveness, joint function, hand grip strength, and chair stand) and pulmonary function (spirometry) (Table 3). A blood sample was taken to assess several biomarkers (see Supplementary Table S1, available as Supplementary data at IJE online), such as markers of lipid and glucose metabolism, liver and kidney function, and levels of vitamin D, thyroid, and testosterone. All participants were asked to collect a stool sample at home, and the participants were given a stool sample kit with sampling instructions and a stamped addressed envelope for the return of the sample. Questionnaires focused on health, lifestyle, functioning and work ability (health questionnaire) and diet (food frequency questionnaire, FFQ), were given to be filled in after the health examination, either online or on paper. Measurements, biological samples and questionnaire topics in the health examination (N = 9862) AUDIT, Alcohol Use Disorders Identification Test; BEWE, Basic Erosive Wear Examination; EQ-5D, 5-dimension health-related quality of life instrument developed by the EuroQol Group; GAD-7, Generalized Anxiety Disorder questionnaire; MDAS, Modified Dental Anxiety Scale; MoCA, Montreal Cognitive Assessment; MPOHL HLS-Q12, Measuring Population and Organizational Health Literacy 12-item Health Literacy Survey; OHIP-14, Oral Health Impact Profile; PHQ-9, Patient Health Questionnaire, depression module; TMD, temporomandibular. Hearing: all aged ≥55 years, eligible sample N = 4571, participation rate 64.9%. Participation rate 98.0% among those who participated in the health examination. Joint function: all aged ≥55 years, eligible sample N = 4571, participation rate 65.9%. Participation rate 99.5% among those who participated in the health examination. Oral health: eligible sample N = 3482, participation rate 51.6%; selected locations, clinical examination carried out at separate visit. Physical activity and sleep: eligible sample N = 1953, participation rate 48.8%. Participation rate 81.7% among those who participated in the health examination. Urine: eligible sample N = 1372, participation rate 31.5%; age 25–74 years; selected locations. Participation rate 53.1% among those who participated in the health examination. Hair: all aged 20–54 years, eligible sample N = 5302, participation rate 29.7%. Participation rate 57.8% among those who participated in the health examination. Alcohol use: eligible sample N = 4578, participation rate 57.7%; age 20–79; carried out as a phone or Teams interview. All subjects were invited to participate in at least one additional sub-study. The topics of the sub-studies were urine sampling, physical activity and sleep, alcohol use (the Drinking Habits Survey), and oral health. At 21 study sites, home collection of urine including both 24-h and a spot urine sample, was organized. Physical activity and sleep were assessed using an accelerometer for 7 consecutive days. Alcohol use was investigated via a phone interview, or a Teams call at a pre-arranged time. The clinical oral examination was conducted by trained dentists and dental nurses at 21 study sites between January and July 2023. Before the oral health examination, participants filled in two questionnaires: one on perceived oral health, self-care habits and service use, and another on temporomandibular symptoms. Digital panoramic radiography was performed for a sub-sample. All the register data are available for all individuals in the original sample (including non-participants). The sample frame, including information on age, gender, marital status, native language, number of people in the household, and place of residence, was derived from the Digital and Population Data Services Agency. These data were linked to the survey data and later to the extensive register-based data (Table 4), individually using personal identity codes to form a single research database. Subjects invited to the survey had been informed of the use of the register data through information given in the invitation letter as well as in the Privacy notice for the Healthy Finland Survey.8 Permissions for register linkage were obtained from relevant data controllers for monitoring and research purposes. Register-based information is used to complement survey data with additional information, e.g. on sociodemographic factors, health status, and health service use. Furthermore, follow-up data from different registers enable up-to-date, individual-level follow-up after the survey data collection. Finally, register data are used to analyse non-response and to calculate inverse probability weights4,9 used in the analyses to adjust for differences in sample selection and participation probabilities, to reduce the bias due to non-participation. Data collected from registers and linked individually with survey data ICD, International Classification of Diseases. Individual linkage between survey and register data allows ongoing, annually updated register-based follow-up for the Healthy Finland cohort. Follow-up will last for decades. Several key outcomes related to population health and wellbeing are covered, such as incident diseases, use of health services and medication, social benefits, pensions and mortality. The quality and coverage of the register information varies between different diagnoses but is generally very high for diseases treated in specialized, tertiary health care.10,11 For example, the coverage of the cancer register is almost complete, and the quality is excellent for solid malignant tumours.12 Table 4 presents the registers and the collected data for the Healthy Finland Survey. Health and wellbeing of the working-age population deteriorated as quality of life declined, and psychological symptoms and suicidal thoughts increased in comparison with the year 2020.13,14 Furthermore, inadequacy of medical services increased in comparison with year 2020, as access to a doctor or a dentist was found increasingly difficult in almost all wellbeing services counties, and high customer fees and long waiting lists were reported to impede access to treatment.13,15 The prevalence of obesity increased; however, the prevalence of diabetes and the estimated risk of having a coronary heart attack or stroke during the following 10 years remained comparable to 2017.15,16 The prevalence of obesity (body mass index ≥30 kg/m2) was 30% in women and 27% in men, and the corresponding prevalence for diabetes was 11% and 14%. The prevalence of having a high risk for coronary heart attack or stroke during the following 10 years was 32% in women and 58% in men, among 50–74-year-olds. There were clearly visible differences by level of education in all domains of functional ability for adults of all ages: the lowest educational group had the highest prevalence of functional limitations and the highest educational group had the lowest prevalence. For example, the prevalence of experiencing major difficulty in walking 0.5 km was 4% in the highly educated and 8% in the lowest educational groups.15,16 Further results on mental health, substance abuse, nutrition, physical activity, risk factors for chronic diseases, diseases, self-assessed health, quality of life, functioning, environmental health, living conditions, loneliness, inclusion, discrimination, social and health services, and sexual and reproductive health by age and educational groups are available at the THL website.16 The Healthy Finland Survey derives from a long history of monitoring health and wellbeing of the population, and it is a continuation to the earlier population surveys in Finland. The sample was randomly drawn, offering a reliable representation of the adult population in Finland. The survey provides accurate information on changes over time as the study protocol, including the questions in the questionnaires as well as the measurements and localities in the health examination, has been kept mostly identical to the previous population surveys. Validated measures and examinations were used throughout the survey. The health examination was conducted by well-trained study nurses according to an exact, standardized protocol, with regular audition visits to assess their performance at study sites. Laboratory analyses were performed in the same accredited laboratory which has been used in previous THL population surveys, allowing reliable monitoring of time trends in the measurements. The measurements included a wide range of topics on health and wellbeing, enabling abundant possibilities for multidisciplinary research, and both self-reported and measured information complementing each other was collected. The participants were systematically contacted and encouraged to participate by the staff of the survey office; this persistent pursuit work was one of the main factors leading to the satisfactory participation rate and success of the survey. We obtained a nearly identical response rate in the questionnaire part of the Healthy Finland Survey (46.3%) as in the previous questionnaire survey in 2020 (the FinSote Survey, 46.4%).2 Furthermore, the participation rate for the health examination part (58.3%) was almost the same as in the previous the health examination survey conducted in 2017 (the FinHealth Study, 58.1%).4 The participation rates of the population surveys have been globally declining over the years, which may weaken the generalizability and comparability of the results, and this is also a limitation in our study. However, in the Healthy Finland Survey, we could use survey weights to attenuate the bias caused by non-participation, as register data (e.g. age, sex, education, socioeconomic position, marital status, and use of health care services) are available for the whole sample (including non-participants). Inverse probability weights were used as a statistical method in the analyses to adjust for differences in selection probability and to reduce the bias due to non-participation. The Healthy Finland data are not publicly available as they include confidential information that could compromise the privacy of the participants. The data can be used for research and monitoring of health, wellbeing, functioning, and use of services of the population at THL, and with collaborators based on collaboration agreement; for more information see [[email protected]]. The data available from the THL Biobank cover those who have participated in the health examination and have given consent to biobanking, and can be applied in accordance with the Biobank Act and THL Biobank research areas [thl.fi/biobank]. The Finnish Social and Health Data Permit Authority, Findata, may grant permits in accordance with the act on the secondary use of social and health data in Finland Further can be to the [[email protected]]. The and in the and research and data such as the of for medical research and the European of for were The research permits were and the was carried For the questionnaire part of the survey, the was conducted by the of in the questionnaire was to For the health examination part of the survey, the survey was by the and on number informed consent was obtained from each in the health examination. The of participation and the to the consent were Participants were also asked to their consent to biobanking, but the consent for the THL Biobank was not a for the participation in the health examination. In both parts of the survey, the questionnaire and the health examination, participants were informed through the invitation information and study including the Privacy for the Healthy Finland Survey. In information was by the trained study nurses at the of the health examination. of the and and and the data All to the or of the survey All the for content and the for were not used in the work related to this Supplementary data are available at IJE The Healthy Finland Survey was funded mainly by Other funders include the Social Insurance Institution of Finland, the Finnish Institute of Occupational Health, Ministry of Social Affairs and Health, and Ministry of Education and Culture. In the clinical oral health examination study received funding from the Finnish Dental Foundation, the Finnish Dental Society Apollonia, the Finnish Dental Association, Odontologiska the Finnish Federation of Oral Health Care and Plandent Oy; and the survey on alcohol use was funded by the state-owned alcohol retail monopoly, Alko Ltd, which reports to the Ministry of Social Affairs and Health. We all the participants of the survey, as well as the at THL and other contributing to the and of the survey.

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