Genotype-Phenotype Relationships in Long QT Syndrome: Role of Mental Stress, Adrenergic Activity and a Common KCNH2 Polymorphism

Long QT syndrome is a congenital or acquired arrhythmic disorder which manifests as a prolonged QT-interval on the electrocardiogram and as a tendency to develop ventricular arrhythmias which can lead to sudden death. Arrhythmias often occur during intense exercise and/or emotional stress. The two most common subtypes of LQTS are LQT1, caused by mutations in the KCNQ1 gene and LQT2, caused by mutations in the KCNH2 gene. LQT1 and LQT2 patients exhibit arrhythmias in different types of situations: in LQT1 the trigger is usually vigorous exercise whereas in LQT2 arrhythmia results from the patient being startled from rest. It is not clear why trigger factors and clinical outcome differ from each other in the different LQTS subtypes. It is possible that stress hormones such as catecholamines may show different effects depending on the exact nature of the genetic defect, or sensitivity to catecholamines varies from subject to subject. Furthermore, it is possible that subtle genetic variants of putative modifier genes, including those coding for ion channels and hormone receptors, play a role as determinants of individual sensitivity to life-threatening arrhythmias. The present study was designed to identify some of these risk modifiers. It was found that LQT1 and LQT2 patients show an abnormal QT-adaptation to both mental and physical stress. Furthermore, as studied with epinephrine infusion experiments while the heart was paced and action potentials were measured from the right ventricular septum, LQT1 patients showed repolarization abnormalities which were related to their propensity to develop arrhythmia during intense, prolonged sympathetic tone, such as exercise. In LQT2 patients, this repolarization abnormality was noted already at rest corresponding to their arrhythmic episodes as a result of intense, sudden surges in adrenergic tone, such as fright or rage. A common KCNH2 polymorphism was found to affect KCNH2 channel function as demonstrated by in vitro experiments utilizing mammalian cells transfected with the KCNH2 potassium channel as well as QT-dynamics in vivo. Finally, the present study identified a common β-1-adrenergic receptor genotype that is related a shorter QT-interval in LQT1 patients. Also, it was discovered that compound homozygosity for two common β-adrenergic polymorphisms was related to the occurrence of symptoms in the LQT1 type of long QT syndrome. The studies demonstrate important genotype-phenotype differences between different LQTS subtypes and suggest that common modifier gene polymorphisms may affect cardiac repolarization in LQTS. It will be important in the future to prospectively study whether variant gene polymorphisms will assist in clinical risk profiling of LQTS patients.

Monimuotoisuus ja esteettömyys : Näkövammaisten asiantuntijoiden työelämäkokemuksia

The purpose of this study is to analyse education, employment, and work-life experiences of visually impaired persons in expert jobs. The empirical data consists of 30 thematic interviews (24 visually impaired persons, 1 family-member of a visually impaired person, 5 persons working with diversity issues), of supplementary articles, and of statistics on the socio-economic status of the visually impaired. The interviewees experiences of education and employment have been analysed by a qualitative method. The analysis has been deepened by reflecting it against the recent discussion on the concept of diversity. The author s methodological choice as a disability researcher has been to treat the interviewees as co-researchers rather than objects of research. Accessibility in its different forms is a prerequisite of diversity in the workplace, and this study examines what kind of accessibility is required by visually impaired professionals. Access to working life depends on the attitudes prejudices and expectations that society has towards a minority group. Social accessibility is connected with internal relationships in the workplace, and achieving social accessibility is a bilateral process. Information technology has revolutionised the visually impaired people s possibilities of accessing information and performing expert tasks. Accessible environment, good mobility skills, and transportation services enable visually impaired employees to get to their workplaces and to navigate there with ease. Integration has raised the level of education and widened the selection of career options for the visually impaired. However, even visually impaired people with academic degrees often need employment support services. Visually impaired professionals are mainly employed in the public and third sector. Achieving diversity in the labour market is a multiactor process. Social support services are needed, as well as courage and readiness from employers to hire people with disabilities. The organisations of the visually impaired play an important role in affecting the attitudes and providing peer support. Visually impaired employees need good professional skills, blindness skills, and social courage, and they need to be comfortable with their disability. In the workplace, diversity may actualise as diverse ways of working: the work is done by using technical aids or other means of compensating for the lack of eyesight. When an employee must find compensatory solutions for disability-related limitations at work, this will also develop his/her problem-solving abilities. Key words: visually impaired, diversity, accessibility, working life

The Relational Self, the Social Bond and the Dynamics of Personal Relationships : A Sociological Analysis

This study analyses personal relationships linking research to sociological theory on the questions of the social bond and on the self as social. From the viewpoint of disruptive life events and experiences, such as loss, divorce and illness, it aims at understanding how selves are bound to their significant others as those specific people ‘close or otherwise important’ to them. Who form the configurations of significant others? How do different bonds respond in disruptions and how do relational processes unfold? How is the embeddedness of selves manifested in the processes of bonding, on the one hand, and in the relational formation of the self, on the other? The bonds are analyzed from an anti-categorical viewpoint based on personal citations of significance as opposed to given relationship categories, such as ‘family’ or ‘friendship’ – the two kinds of relationships that in fact are most frequently significant. The study draws from analysis of the personal narratives of 37 Finnish women and men (in all 80 interviews) and their entire configurations of those specific people who they cite as ‘close or otherwise important’. The analysis stresses the subjective experiences, while also investigating the actualized relational processes and configurations of all personal relationships with certain relationship histories embedded in micro-level structures. The research is based on four empirical sub-studies of personal relationships and a summary discussing the questions of the self and social bond. Discussion draws from G. H. Mead, C. Cooley, N. Elias, T. Scheff, G. Simmel and the contributors of ‘relational sociology’. Sub-studies analyse bonds to others from the viewpoint of biographical disruption and re-configuration of significant others, estranged family bonds, peer support and the formation of the most intimate relationships into exclusive and inclusive configurations. All analyses examine the dialectics of the social and the personal, asking how different structuring mechanisms and personal experiences and negotiations together contribute to the unfolding of the bonds. The summary elaborates personal relationships as social bonds embedded in wider webs of interdependent people and social settings that are laden with cultural expectations. Regarding the question of the relational self, the study proposes both bonding and individuality as significant. They are seen as interdependent phases of the relationality of the self. Bonding anchors the self to its significant relationships, in which individuality is manifested, for example, in contrasting and differentiating dynamics, but also in active attempts to connect with others. Individuality is not a fixed quality of the self, but a fluid and interdependent phase of the relational self. More specifically, it appears in three formats in the flux of relational processes: as a sense of unique self (via cultivation of subjective experiences), as agency and as (a search for) relative autonomy. The study includes an epilogue addressing the ambivalence between the social expectation of individuality in society and the bonded reality of selves.

The relationships between work stressors and organizational performance in long-term care for elderly residents

This study investigates the relationships between work stressors and organizational performance in terms of the quality of care provided by the long-term care facilities. Work stressors are first examined in relation to the unit's structural factors, resident characteristics, and to the unit specialization. The study is completed by an investigation into the associations of work stressors such as job demands or time pressure, role ambiguity, resident-related stress, and procedural injustice to organizational performance. Also the moderating effect of job control in the job demands organizational performance relationship is examined. The study was carried out in the National Research and Development Centre for Welfare and Health (STAKES). Survey data were drawn from 1194 nursing employees in 107 residential-home and health-center inpatient units in 1999 and from 977 employees in 91 units in 2002. Information on the unit resident characteristics and the quality of care was provided by the Resident Assessment Instrument (RAI). The results showed that large unit size or lower staffing levels were not consistently related to work stressors, whereas the impairments in residents' physical functioning in particular initiated stressful working conditions for employees. However, unit specialization into dementia and psychiatric residents was found to buffer the effects that the resident characteristics had on employee appraisals of work stressors, in that a high proportion of behavioral problems was related to less time pressure and role conflicts for employees in specialized units. Unit specialization was also related to improved team climates and the organizational commitment of employees. Work stressors associated with problems in care quality. Time pressure explained most of the differences between units in how the employees perceived the quality of physical and psychosocial care they provide for the residents. A high level of job demands in the unit was also found to be related to some increases in all clinical quality problems. High job control buffered the effects of job demands on the quality of care in terms of the use of restraints on elderly residents. Physical restraint and especially antipsychotic drug use were less prevalent in units that combined both high job demands and high control for employees. In contrast, in high strain units where heavy job demands coincided with a lack of control for employees, quality was poor in terms of the frequent use of physical restraints. In addition, procedural injustice was related to the frequent use of antianxiety of hypnotic drugs for elderly residents. The results suggest that both job control and procedural justice may have improved employees' abilities to cope when caring for the elderly residents, resulting in better organizational performance.

Lastensuojelun sosiaalityö asiakirjoina : Dokumentoinnin ja tiedonmuodostuksen dynamiikka

Tutkimuksen keskeinen tehtävä on selvittää, mikä on dokumentoinnin merkitys lastensuojelun sosiaalityön tiedonmuodostuksessa ja ammattikäytännöissä. Asiakirjateksteistä koostuvaa tutkimusaineistoa tarkastellaan kolmesta eri suunnasta kysymällä: 1)Miten asiakirjoja kirjoitetaan? 2) Mitä asiakirjoihin kirjoitetaan? 3) Miksi asiakirjoja kirjoitetaan niin kuin kirjoitetaan? Tutkimusaineisto muodostuu lastensuojelun sosiaalityöntekijöiden laatimista asiakastietojärjestelmään tallennetuista muistiinpanoista ja huostaanottopäätöksistä. Tutkimukseen on valittu 20 huostaanotetun eri-ikäisen lapsen ja heidän perheensä asiakirjat yhteensä 1613 asiakirjatulostussivua. Tekstit ajoittuvat vuodesta 1989 vuoteen 2000. Tutkimusmenetelmä on diskurssianalyyttinen ja tukeutuu Fairclough`n (1997)esittämään kolmiulotteiseen malliin, jossa diskurssi määritellään tekstin, käytäntöjen ja sosiokulttuurisen ympäristön suhteeksi. Diskurssianalyysi on näiden rakenteiden ja niiden välisten suhteiden kuvaamista, tulkintaa ja selittämistä. Fairclough’n mallia mukaillen tutkimuksen analyysi koostuu retoriikan ja tematiikan analyyseistä sekä pragmatiikan näkökulman sisältävästä tarkastelusta. Asiakirjatekstien pilkkominen puhujakategorioihin osoitti tekstien olevan moniäänisiä, useiden henkilöiden näkemyksiä ja mielipiteitä sisältäviä tekstipintoja. Retoriikan analyysi näytti, että lastensuojelun sosiaalityön asiakirjat sisältävät paljon dynaamisia kuvauksia työstä. Asiakirjojen kirjoittaminen moniäänisiksi tuo tekstiin uskottavuutta, ja se on myös yksi retorinen vaikuttamiskeino. Tematiikan tarkastelu osoitti,että asiakirjojen sisällölliset teemat (lapsen hoiva, arjen hallinta, yhteistyö ja päihteiden käyttö) ja kokemukselliset teemat (huoli, vastuu, yhteys ja moraali) toistuvat sisäkkäisinä ja päällekkäisinä säikeinä dynaamisesti vaihdellen. Sosiaalityöntekijät kirjaavat teksteihin monia yhtäaikaisia teemoja, joiden avulla rakentavat ammatillista ymmärrystä kyseessä olevasta tilanteesta. Asiakirjojen tutkiminen pragmatiikan suunnasta toi esiin, kirjoittamisen ja lukemisen kontekstiulottuvuudet sekä tiedonmuodostusprosessin. Asiakirjojen laatiminen on osa sosiaalityön käytäntöjä. Se on myös keskeinen alue ammattikunnan yhteisen ammatillisen ymmärryksen luomisessa ja ylläpitämisessä. Muistiinpanot, huostaanottopäätökset ja lakitekstit ovat intertekstuaalisia. Lastensuojelun sosiaalityön asiakirjojen tutkiminen on avannut uusia mahdollisuuksia ymmärtää sosiaalityön dokumentointiprosessia, merkitystä ja roolia sekä tiedonmuodostuksen dynamiikkaa. Tekstien kirjoittaminen, niiden lukeminen, tietojen siirtäminen ja asiakkaan kuuleminen samoin kuin kuulemisen kirjaaminen ovat sosiaalityön dokumentoinnin keskeisiä haasteita. Tutkimus pyrkii avaamaan ymmärrystä asiakirjatekstien monivivahteiseen ja dynaamiseen maailmaan ja siten myös sosiaalityön dokumentoinnin arkeen. Tarkastelut mahdollistavat työn kehittämisen erityisesti sosiaalityön asiakasvaikuttavuuden mittaamisen ja parantamisen suuntaan. Asiakirjoissa ilmenevä tiedonmuodostuksen dynamiikka syntyy kirjoittamiskäytäntöjen, kirjoittamisen ja lukemisen sekä toimintakäytäntöjen yhteisessä alueessa. Avainsanat: sosiaalityö, lastensuojelu, dokumentointi, asiakirja, diskurssianalyysi, tiedonmuodostus.

Yhteinen verkosto? : Tutkimus nuorten syrjäytymistä ehkäisevistä poikkihallinnollisista ryhmistä

Since the 1990s, European policy strategies have stressed the mutual responsibility and joint action of all societal branches in preventing social problems. Network policy is an integral part of the new governance that generates a new kind of dependency between the state and civil society in formulating and adhering to policy goals. Using empirical group interview data collected in Helsinki, the capital of Finland, this case study explores local multi-agency groups and their efforts to prevent the exclusion of children and young people. These groups consist mainly of professionals from the social office, youth clubs and schools. The study shows that these multi-agency groups serve as forums for professional negotiation where the intervention dilemma of liberal society can be addressed: the question of when it is justified and necessary for an authority or network to intervene in the life of children and their families, and how this is to be done. An element of tension in multi-agency prevention is introduced by the fact that its objectives and means are anchored both in the old tradition of the welfare state and in communitarian rhetoric. Thus multi-agency groups mend deficiencies in wellbeing and normalcy while at the same time try to co-ordinate the creation of the new community, which will hopefully reduce the burden on the public sector. Some of the professionals interviewed were keen to see new and even forceful interventions to guide the youth or to compel parents to assume their responsibilities. In group discussions, this approach often met resistance. The deeper the social problems that the professionals worked with, the more solidarity they showed for the families or the young people in need. Nothing seems to assure professionals and to legitimise their professional position better than advocating the under-privileged against the uncertainties of life and the structural inequalities of society. The groups that grappled with the clear, specific needs of certain children and families were the most capable of co-operation. This requires the approval of different powers and the expertise of distinct professions as well as a forum to negotiate case-specific actions in professional confidentiality. The ideals of primary prevention for everyone and value discussions alone fail to inspire sufficient multiagency co-operation. The ideal of a network seems to give word and shape to those societal goals that are difficult or even impossible to reach, but are nevertheless yearned for: mutual understanding of the good life, close social relationships, mutual trust and active agency for all citizens. Individualisation, the multiplicity of life styles and the possibility to choose have come true in such a way that the very idea of a mutual and binding network can be attained only momentarily and between restricted participants. In conclusion, uniting professional networks that negotiate intervention dilemmas with citizen networks based on changing compassions and feelings of moral superiority seems impossible. Rather, one should encourage openness to scrutiny among tangential or contradicting groups, networks and communities. Key words: network policy, prevention of exclusion, multi-agency groups, young people

Just say no? The influence of personal goals, beliefs, psychosocial adjustment, and parental relationships in drug use by adolescents

The study in its entirety focused on factors related to adolescents decisions concerning drug use. The term drug use is taken here to include the use of tobacco products, alcohol, narcotics, and other addictive substances. First, the reasons given for drug use (attributions) were investigated. Secondly, the influence of personal goals, the beliefs involved in decision making, psychosocial adjustment including body image and involvement with peers, and parental relationships on drug use were studied. Two cohorts participated in the study. In 1984, a questionnaire on reasons for drug use was administered to a sample of adolescents aged 14-16 (N=396). A further questionnaire was administered to another sample of adolescents aged 14-16 (N=488) in 1999. The results for both cohorts were analyzed in Articles I and II. In Articles III and IV further analysis was carried out on the second cohort (N=488). The research report presented here provides a synthesis of all four articles, together with material from a further analysis. In a comparison of the two cohorts it was found that the attributions for drug use had changed considerably over the intervening fifteen-year period. In relation to alcohol and narcotics use an increase was found in reasons involving inner subjective experiences, with mention of the good feeling and fun resulting from alcohol and narcotics use. In addition, the goals of alcohol consumption were increasingly perceived as drinking to get drunk, and for its own sake. The attributions for the adolescents own smoking behavior were quite different from the attributions for smoking by others. The attributions were only weakly influenced by the participants gender or by their smoking habits, either in 1984 or 1999. In relation to participants own smoking, the later questionnaire elicited more mention of inner subjective experiences involving "good feeling. In relation to the perceived reasons for other people s smoking, it elicited more responses connected with the notion of "belonging. In the second sample, the results indicated that the levels of body satisfaction among adolescent girls are lower than those among adolescent boys. Overall, dissatisfaction with one's physical appearance seemed to relate to drug use. Girls were also found to engage in more discussions than boys; this applied to (i) discussion with peers (concerning both intimate and general matters), and (ii) discussion with parents (concerning general matters). However, more than a quarter of the boys (out of the entire population) reported only low intimacy with both parents and peers. If both drinking and smoking were considered, it seemed that girls in particular who reported drinking and smoking also reported high intimacy with parents and peers. Boys who reported drinking and smoking reported only medium intimacy with parents and peers. In addition, having an intimate relationship with one's peers was associated with a greater tendency to drink purely in order to get drunk. Overall, the results seemed to suggest that drug use is connected with a close relationship with peers and (surprisingly) with a close relationship with parents. Nevertheless, there were also indications that to some extent peer relationships can also protect adolescents from smoking and alcohol use. The results, which underline the complexity of adolescent drug use, are taken up in the Discussion section. It may be that body image and/or other identity factors play a more prominent role in all drug use than has previously been acknowledged. It does appear that in the course of planning support campaigns for adolescents at risk of drug use, we should focus more closely on individuals and their inner world. More research on this field is clearly needed, and therefore some ideas for future research are also presented.

Asiakassuunnitelma asiakaslähtöistä auttamista tavoitteellistamassa : Kohteen rakentumisen moniääninen menetelmä

The research focuses on client plan in the field of health care and social work on families with children. The purpose of the plan is to create objectives for helping the client and to assist in coordinating the ever-increasing multi-professional work. In general, the plan is understood in terms of assignments and as a contract specifying what to do in client cases. Taking this into consideration, the plan is outsourced into a written document. Instead of understanding the plan as a tool that stabilizes the objectives of action, documents it and facilitates evaluation, the client plan is conceptualized in this study as a practice. This kind of practice mediates client work as being itself also a process of action that focuses on an object whose gradual emergence and definition is the central question in multi-professional collaboration with a client. The plan is examined empirically in a non-stabilized state which leads to the research methodology being based on the dynamics between stabilization and emerging, non-stabilized entities the co-creation and formulation of practice and context. The theoretical approach of the research is the micro analytic approach of activity theory (Engeström R. 1999b). Grounding on this, the research develops a method of qualitative analysis which follows an emerging object with multiple voices. The research data is composed of the videotaped sessions from client meetings with three families, the interviews with the client and the workers as well as client documents that are used to follow up on client processes for at least one year. The research questions are as follows: 1) How is the client plan constructed between the client and different professional agents? 2) How are meanings constructed in a client-centred plan? 3) What are the elements of client-employee relationships that support the co-configuration necessitated by the changes in the client s everyday life? The study shows that the setting of objectives were limited by the palette of institutional services, which caused that the clients interpretations and acts of giving meaning to the kinds of help that was required were left out of the plan. Conceptually, the distinctions between client-centred and client-specific ways of working as well as an action-based working method are addressed. Central to this action-based approach is construing the everyday life of the client, recognizing different meanings and analyzing them together with the client as well as focusing attention on developing the prerequisites for social agency of the clients. The research portrays the elements for creating an action-based client plan. Key words: client plan, user perspective, multi-voiced meaning, multi-professional social work with children and families, agency

Social Networks and Everyday Practices in Russia

My doctoral dissertation in sociology and Russian studies, Social Networks and Everyday Practices in Russia, employs a "micro" or "grassroots" perspective on the transition. The study is a collection of articles detailing social networks in five different contexts. The first article examines Russian birthdays from a network perspective. The second takes a look at health care to see whether networks have become obsolete in a sector that is still overwhelmingly public, but increasingly being monetarised. The third article investigates neighbourhood relations. The fourth details relationships at work, particularly from the vantage point of internal migration. The fifth explores housing and the role of networks and money both in the Soviet and post-Soviet era. The study is based on qualitative social network and interview data gathered among three groups, teachers, doctors and factory workers, in St. Petersburg during 1993-2000. Methodologically it builds on a qualitative social network approach. The study adds a critical element to the discussion on networks in post-socialism. A considerable consensus exists that social networks were vital in state socialist societies and were used to bypass various difficulties caused by endemic shortages and bureaucratic rigidities, but a more debated issue has been their role in post-socialism. Some scholars have argued that the importance of networks has been dramatically reduced in the new market economy, whereas others have stressed their continuing importance. If a common denominator in both has been a focus on networks in relation to the past, a more overlooked aspect has been the question of inequality. To what extent is access to networks unequally distributed? What are the limits and consequences of networks, for those who have access, those outside networks or society at large? My study provides some evidence about inequalities. It shows that some groups are privileged over others, for instance, middle-class people in informal access to health care. Moreover, analysing the formation of networks sheds additional light on inequalities, as it highlights the importance of migration as a mechanism of inequality, for example. The five articles focus on how networks are actually used in everyday life. The article on health care, for instance, shows that personal connections are still important and popular in post-Soviet Russia, despite the growing importance of money and the emergence of "fee for service" medicine. Fifteen of twenty teachers were involved in informal medical exchange during a two-week study period, so that they used their networks to bypass the formal market mechanisms or official procedures. Medicines were obtained through personal connections because some were unavailable at local pharmacies or because these connections could provide medicines for a cheaper price or even for free. The article on neighbours shows that "mutual help" was the central feature of neighbouring, so that the exchange of goods, services and information covered almost half the contacts with neighbours reported. Neighbours did not provide merely small-scale help but were often exchange partners because they possessed important professional qualities, had access to workplace resources, or knew somebody useful. The article on the Russian work collective details workplace-related relationships in a tractor factory and shows that interaction with and assistance from one's co-workers remains important. The most interesting finding was that co-workers were even more important to those who had migrated to the city than to those who were born there, which is explained by the specifics of Soviet migration. As a result, the workplace heavily influenced or absorbed contexts for the worker migrants to establish relationships whereas many meeting-places commonly available in Western countries were largely absent or at least did not function as trusted public meeting places to initiate relationships. More results are to be found from my dissertation: Anna-Maria Salmi: Social Networks and Everyday Practices in Russia, Kikimora Publications, 2006, see www.kikimora-publications.com.

Exploring primary school sex education in Greece : policies and praxis

This study examines how sex education is currently developed and implemented in Greek primary schools. The four publications that comprise it explore the following themes: (1) the position and visibility of sex education as one of the topics for health education programme development; (2) the inhibiting and enhancing factors in the development and implementation of primary school sex education programmes; (3) how issues of sex, sexuality, the human body and romantic relationships are visually and textually represented in primary school textbooks; (4) the impact of sex education on teachers and pupils; and (5) teachers experiences as practitioners who deal with sexuality- related issues at school. -- The research was based on conducting multiple sub-studies using a mixed-methods approach. Specifically, qualitative and quantitative data were collected and analysed. The initial quantitative data that had been obtained by questionnaire was followed by the collection and analysis of qualitative data. The qualitative data were acquired by way of examining one particular case, various texts, interviews with teachers and self-reflective material. The results of the sub-studies are presented in a more detailed manner in the study s four publications. -- In general, the sub-studies found that sex education as an educational activity occupies a marginal place within the instructional practices of Greek primary school teachers, since the subject is hardly mentioned in classroom material, such as textbooks. However, engaging in the provision of sex education programmes can become a meaningful and rewarding experience for many teachers as well as pupils and their families. Further, teachers classroom experiences pointed to school settings as sexualized environments. These contextual factors and conditions nevertheless affected teachers practices and perceptions on a personal and professional level.Health indicators in Greece provide a picture of a population that faces various sexual health related problems. However, as many studies (including this work) indicate, sex education programmes that meet specific standards can have a positive impact on students overall health and well-being. Sex education teaching has always been a controversial issue. Its successful implementation in Greece demands knowledgeable educators and responsible policy-makers. The findings of this study suggest that the content of Greek primary school textbooks needs to be revised in order to include texts and pictures that deal with the human body and human sexuality, encourage pupils to become involved in designing the content and methods of programmes and give teachers the opportunity to reflect on and discuss their experiences. Keywords: sex education, primary school, Greece