Boundaries in Action : An Activity-theoretical Study of Development, Learning, and Change in Health Care Organization for Patients with Multiple and Chronic Illnesses

This study examines boundaries in health care organizations. Boundaries are sometimes considered things to be avoided in everyday living. This study suggests that boundaries can be important temporally and spatially emerging locations of development, learning, and change in inter-organizational activity. Boundaries can act as mediators of cultural and social formations and practices. The data of the study was gathered in an intervention project during the years 2000-2002 in Helsinki in which the care of 26 patients with multiple and chronic illnesses was improved. The project used the Change Laboratory method that represents a research assisted method for developing work. The research questions of the study are: (1) What are the boundary dynamics of development, learning, and change in health care for patients with multiple and chronic illnesses? (2) How do individual patients experience boundaries in their health care? (3) How are the boundaries of health care constructed and reconstructed in social interaction? (4) What are the dynamics of boundary crossing in the experimentation with the new tools and new practice? The methodology of the study, the ethnography of the multi-organizational field of activity, draws on cultural-historical activity theory and anthropological methods. The ethnographic fieldwork involves multiple research techniques and a collaborative strategy for raising research data. The data of this study consists of observations, interviews, transcribed intervention sessions, and patients' health documents. According to the findings, the care of patients with multiple and chronic illnesses emerges as fragmented by divisions of a patient and professionals, specialties of medicine and levels of health care organization. These boundaries have a historical origin in the Finnish health care system. As an implication of these boundaries, patients frequently experience uncertainty and neglect in their care. However, the boundaries of a single patient were transformed in the Change Laboratory discussions among patients, professionals and researchers. In these discussions, the questioning of the prevailing boundaries was triggered by the observation of gaps in inter-organizational care. Transformation of the prevailing boundaries was achieved in implementation of the collaborative care agreement tool and the practice of negotiated care. However, the new tool and practice did not expand into general use during the project. The study identifies two complementary models for the development of health care organization in Finland. The 'care package model', which is based on productivity and process models adopted from engineering and the 'model of negotiated care', which is based on co-configuration and the public good.

Lionhearts of the Playworld : An ethnographic case study of the development of agency in play pedagogy

This is an ethnographic case study of the creation and emergence of a playworld – a pedagogical approach aimed at promoting children’s development and learning in early education settings through the use of play and drama. The data was collected in a Finnish experimental mixed-age elementary school classroom in the school year 2003-2004. In the playworld students and teachers explore different social and cultural phenomena through taking on the roles of characters from a story or a piece of literature and acting inside the frames of an improvised plot. The thesis takes under scrutiny the notion of agency in education. It produces theoretically grounded empirical knowledge of the ways in which children struggle to become recognized and agentive actors in early education settings and how their agency develops in their interaction with adults. The study builds on the activity theoretical and sociocultural tradition and develops a methodological framework called video-based narrative interaction analysis for studying student agency as developing over time but manifesting through the situational material and discursive local interactions. The research questions are: 1. What are the children’s ways of enacting their agency in the playworld? 2. How do the children’s agentive actions change and develop over the spring? 3. What are the potentials and challenges of the playworld for promoting student agency? 4. How do the teachers and the children deal with the contradiction between control and agency in the playworld? The study consists of a summary part and four empirical articles which each have a particular viewpoint. Articles I and II deal with individual students’ paths to agency. In Article I the focus is on the role of resistance and questioning in enabling important spaces for agency. Article II takes a critical gender perspective and analyzes how two girls struggled towards recognition in the playworld. It also illuminates the role of imagination in developing a sense of agency. Article III examines how the open-ended and improvisational nature of the playworld interaction provided experiences and a sense of ‘shared agency’ for the students and teachers in the class. Article IV turns the focus on the teachers and analyzes how their role actions in the playworld helped the children to enact agency. It also discusses the challenges that the teachers faced in this work and asks what makes the playworld activity sustainable in the class. The summary part provides a critical literature review on the concept of agency and argues that the inherently contradictory nature of the phenomenon of agency has not been sufficiently theorized. The summary part also locates the playworld intervention in a historical frame by discussing the changing conceptions of adulthood and childhood in the West. By focusing on the changing role of play and art in both adults’ and children’s contemporary lives, the thesis opens up an important but often neglected perspective on the problem of promoting student agency in education. The results illustrate how engaging in a collectively imagined and dramatized pretend play space together with the children enabled the teachers to momentarily put aside their “knower” positions in the classroom. The fictive roles and the narrative plot helped them to create a necessary incompleteness and open-endedness in the activity that stimulated the children’s initiatives. This meant that the children too could momentarily step out of their traditional classroom positions as pupils and initiate action to further the collective play. Engaging in this kind of unconventional activity and taking up and enacting agency was, however, very challenging for the participating children and teachers. It often contradicted the need to sustain control and order in the classroom. The study concludes that play- and drama-based pedagogies offer a unique but undeveloped potential for developing educational spaces that help teachers and children deal with the often contradictory requirements of schooling.

Language in Acquisition : Early Lexical Development and Associations between Lexicon and Grammar Findings from Full-Term and Very-Low-Birth-Weight Finnish Children

The aim was to analyse the growth and compositional development of the receptive and expressive lexicons between the ages 0,9 and 2;0 in the full-term (FT) and the very-low-birth-weight (VLBW) children who are acquiring Finnish. The associations between the expressive lexicon and grammar at 1;6 and 2;0 in the FT children were also studied. In addition, the language skills of the VLBW children at 2;0 were analysed, as well as the predictive value of early lexicon to the later language performance. Four groups took part in the studies: the longitudinal (N = 35) and cross-sectional (N = 146) samples of the FT children, and the longitudinal (N = 32) and cross-sectional (N = 66) samples of VLBW children. The data was gathered by applying of the structured parental rating method (the Finnish version of the Communicative Development Inventory), through analysis of the children´s spontaneous speech and by administering a a formal test (Reynell Developmental Language Scales). The FT children acquired their receptive lexicons earlier, at a faster rate and with larger individual variation than their expressive lexicons. The acquisition rate of the expressive lexicon increased from slow to faster in most children (91%). Highly parallel developmental paths for lexical semantic categories were detected in the receptive and expressive lexicons of the Finnish children when they were analysed in relation to the growth of the lexicon size, as described in the literature for children acquiring other languages. The emergence of grammar was closely associated with expressive lexical growth. The VLBW children acquired their receptive lexicons at a slower rate and had weaker language skills at 2;0 than the full-term children. The compositional development of both lexicons happened at a slower rate in the VLBW children when compared to the FT controls. However, when the compositional development was analysed in relation to the growth of lexicon size, this development occurred qualitatively in a nearly parallel manner in the VLBW children as in the FT children. Early receptive and expressive lexicon sizes were significantly associated with later language skills in both groups. The effect of the background variables (gender, length of the mother s basic education, birth weight) on the language development in the FT and the VLBW children differed. The results provide new information of early language acquisition by the Finnish FT and VLBW children. The results support the view that the early acquisition of the semantic lexical categories is related to lexicon growth. The current findings also propose that the early grammatical acquisition is closely related to the growth of expressive vocabulary size. The language development of the VLBW children should be followed in clinical work.

Widening Perspectives of Teacher Education : Studies on theory-practice relationship, reflection, research and professional development

This dissertation examined the research-based teacher education at the University of Helsinki from different theoretical and practical perspectives. Five studies focused on these perspectives separately as well as overlappingly. Study I focused on the reflection process of graduating teacher students. The data consisted of essays the students wrote as their last assignment before graduating, where their assignment was to examine their development as researchers during their MA thesis research process. The results indicated that the teacher students had analysed their own development thoroughly during the process and that they had reflected on theoretical as well as practical educational matters. The results also pointed out that, in the students’ opinion, personally conducted research is a significant learning process. -- Study II investigated teacher students’ workplace learning and the integration of theory and practice in teacher education. The students’ interviews focused on their learning of teacher’s work prior to education. The interviewees’ responses concerning their ‘surviving’ in teaching prior to teacher education were categorized into three categories: learning through experiences, school as a teacher learning environment, and case-specific learning. The survey part of the study focused on integration of theory and practice within the education process. The results showed that the students who worked while they studied took advantage of the studies and applied them to work. They set more demanding teaching goals and reflected on their work more theoretically. -- Study III examined practical aspects of the teacher students’ MA thesis research as well as the integration of theory and practice in teacher education. The participants were surveyed using a web-based survey which dealt with the participants’ teacher education experiences. According to the results, most of the students had chosen a practical topic for their MA thesis, one arising from their work environment, and most had chosen a research topic that would develop their own teaching. The results showed that the integration of theory and practice had taken place in much of the course work, but most obviously in the practicum periods, and also in the courses concerning the school subjects. The majority felt that the education had in some way been successful with regards to integration. -- Study IV explored the idea of considering teacher students’ MA thesis research as professional development. Twenty-three teachers were interviewed on the subject of their experiences of conducting research about their own work as teachers. The results of the interviews showed that the reasons for choosing the MA thesis research topic were multiple: practical, theoretical, personal, professional reasons, as well as outside effect. The objectives of the MA thesis research, besides graduating, were actual projects, developing the ability to work as teachers, conducting significant research, and sharing knowledge of the topic. The results indicated that an MA thesis can function as a tool for professional development, for example in finding ways for adjusting teaching, increasing interaction skills, gaining knowledge or improving reflection on theory and/or practice, strengthening self-confidence as a teacher, increasing researching skills or academic writing skills, as well as becoming critical and being able to read scientific and academic literature. -- Study V analysed teachers’ views of the impact of practitioner research. According to the results, the interviewees considered the benefits of practitioner research to be many, affecting teachers, pupils, parents, the working community, and the wider society. Most of the teachers indicated that they intended to continue to conduct research in the future. The results also showed that teachers often reflected personally and collectively, and viewed this as important. -- These five studies point out that MA thesis research is and can be a useful tool for increasing reflection doing with personal and professional development, as well as integrating theory and practice. The studies suggest that more advantage could be taken of the MA thesis research project. More integration of working and studying could and should be made possible for teacher students. This could be done in various ways within teacher education, but the MA thesis should be seen as a pedagogical possibility.

The Development of the Concept of Music Education in Estonian Kindergartens, 1905-2008 : a Historical–Critical Overview

The dissertation focuses on the development of music education in Estonian kindergartens and the factors influencing it, analysed in the historical perspective relying on post-positivist paradigm. The study is based on the factors and subjects’ views on kindergarten music education from 1905 to 2008, recorded in written sources or ascertained by means of questionnaire and interview. The dissertation deals with music’s functions, music education in retrospective, factors influencing child’s musical aptitude and development and teacher’s role in it through the prism of history. The formation of Estonian kindergarten music education and the phenomenon of its development have been researched by stages: the first manifestations of music in kindergarten in 1905 - 1940; the formation of the concept of music education in 1941 - 1967 and the application of a unified system in 1968 - 1990. The work also outlines innovative trends in music education at the end of the last millennium and the beginning of this century, in 1991 - 2008. The study relies on a combined design and an analysis of historical archival material and empirical data. The empirical part of the study is based on the questionnaire (n=183) and interviews (n=18) carried out with kindergarten music teachers. The data has been analysed using both qualitative and quantitative methods. The subject of the research is the content and activity types of kindergarten music education and the role of music teacher in their implementation. The study confirmed that fundamental changes took place in Estonian kindergarten music education due to the change in political power in the 1940s. Following the example of the Soviet system of education, music in kindergarten became an independent music educational orientation and the position of a professionally trained music teacher was established (1947). It was also confirmed that in the newly independent Estonian Republic under the influence of innovative trends a new paradigm of music education arose from the traditional singing-centred education towards the more balanced use of music activity types (attaching importance to the child-centred approach, an increase in the number and variety of activity types). The most important conclusions made in the dissertation are that there has been improvement and development deriving from contemporary trends in the clear concept that has evolved in Estonian kindergarten music education over a century; professionally trained music teachers have had a crucial role in shaping it; and kindergarten music education is firmly positioned as a part of preschool education in Estonian system of education. Key words: early childhood music education, history of music education, kindergarten music education, early childhood music teachers

Development of microdevices for proteome research and diagnosis

The basic goal of a proteomic microchip is to achieve efficient and sensitive high throughput protein analyses, automatically carrying out several measurements in parallel. A protein microchip would either detect a single protein or a large set of proteins for diagnostic purposes, basic proteome or functional analysis. Such analyses would include e.g. interactomics, general protein expression studies, detecting structural alterations or secondary modifications. Visualization of the results may occur by simple immunoreactions, general or specific labelling, or mass spectrometry. For this purpose we have manufactured chip-based proteome analysis devices that utilize the classical polymer gel electrophoresis technology to run one and two-dimensional gel electrophoresis separations of proteins in just a smaller size. In total, we manufactured three functional prototypes of which one performed a miniaturized one-dimensional gel electrophoresis (1-DE) separation, the second and third preformed two-dimensional gel electrophoresis (2-DE) separations. These microchips were successfully used to separate and characterize a set of predefined standard proteins, cell and tissue samples. Also, the miniaturized 2-DE (ComPress-2DE) chip presents a novel way of combining the 1st and 2nd dimensional separations, thus avoiding manual handling of the gels, eliminate cross-contamination, and make analyses faster and repeatability better. They all showed the advantages of miniaturization over the commercial devices; such as fast analysis, low sample- and reagent consumption, high sensitivity, high repeatability and inexpensive performance. All these instruments have the potential to be fully automated due to their easy-to-use set-up.

The function of Bmps and Runx2 in normal tooth development and in the pathogenesis of cleidocranial dysplasia

The development of many embryonic organs is regulated by reciprocal and sequential epithelial-mesenchymal interactions. These interactions are mediated by conserved signaling pathways that are reiteratively used. Cleidocranial dysplasia (CCD) is a congenital syndrome where both bone and tooth development is affected. The syndrome is characterized by short stature, abnormal clavicles, general bone dysplasia, and supernumerary teeth. CCD is caused by mutations in RUNX2, a transcription factor that is a key regulator of osteoblast differentiation and bone formation. The first aim of this study was to analyse the expression of a family of key signal molecules, Bone morphogenetic protein (Bmp) at different stages of tooth development. Bmps have a variety of functions and they were originally discovered as signals inducing ectopic bone formation. We performed a comparative in situ hybridisation analysis of the mRNA expression of Bmp2-7 from initiation of tooth development to differentiation of dental hard tissues. The expression patterns indicated that the Bmps signal between the epithelial and mesenchymal tissues during initiation and morphogenesis of tooth development, as well as during the differentiation of odontoblasts and ameloblasts. Furthermore, they are also part of the signalling networks whereby the enamel knot regulates the patterning of tooth cusps. The second aim was to study the role of Runx2 during tooth development and thereby to gain better understanding of the pathogenesis of the tooth phenotype in CCD. We analysed the tooth phenotype of Runx2 knockout mice and examined the patterns and regulation of Runx2 gene expression.. The teeth of wild-type and Runx2 mutant mice were compared by several methods including in situ hybridisation, tissue culture, bead implantation experiments, and epithelial-mesenchymal recombination studies. Phenotypic analysis of Runx2 -/- mutant tooth development showed that teeth failed to advance beyond the bud stage. Runx2 expression was restricted to dental mesenchyme between the bud and early bell stages of tooth development and it was regulated by epithelial signals, in particular Fgfs. We searched for downstream targets of Runx2 by comparative in situ hybridisation analysis. The expression of Fgf3 was downregulated in the mesenchyme of Runx2 -/- teeth. Shh expression was absent from the enamel knot in the lower molars of Runx2 -/- and reduced in the upper molars. In conclusion, these studies showed that Runx2 regulates key epithelial-mesenchymal interactions that control advancing tooth morphogenesis and histodifferentiation of the epithelial enamel organ. In addition, in the upper molars of Runx2 mutants extra buddings occured at the palatal side of the tooth bud. We suggest that Runx2 acts as an inhibitor of successional tooth formation by preventing advancing development of the buds. Accordingly, we propose that RUNX2 haploinsuffiency in humans causes incomplete inhibition of successional tooth formation and as a result supernumerary teeth.

The scientific basis and development of a matrix metalloproteinase (MMP) -8 specific chair-side test for monitoring of periodontal health and disease from gingival crevicular fluid

Matrix metalloproteinase (MMP) -8, collagenase-2, is a key mediator of irreversible tissue destruction in chronic periodontitis and detectable in gingival crevicular fluid (GCF). MMP-8 mostly originates from neutrophil leukocytes, the first line of defence cells which exist abundantly in GCF, especially in inflammation. MMP-8 is capable of degrading almost all extra-cellular matrix and basement membrane components and is especially efficient against type I collagen. Thus the expression of MMP-8 in GCF could be valuable in monitoring the activity of periodontitis and possibly offers a diagnostic means to predict progression of periodontitis. In this study the value of MMP-8 detection from GCF in monitoring of periodontal health and disease was evaluated with special reference to its ability to differentiate periodontal health and different disease states of the periodontium and to recognise the progression of periodontitis, i.e. active sites. For chair-side detection of MMP-8 from the GCF or peri-implant sulcus fluid (PISF) samples, a dip-stick test based on immunochromatography involving two monoclonal antibodies was developed. The immunoassay for the detection of MMP-8 from GCF was found to be more suitable for monitoring of periodontitis than detection of GCF elastase concentration or activity. Periodontally healthy subjects and individuals suffering of gingivitis or of periodontitis could be differentiated by means of GCF MMP-8 levels and dipstick testing when the positive threshold value of the MMP-8 chair-side test was set at 1000 µg/l. MMP-8 dipstick test results from periodontally healthy and from subjects with gingivitis were mainly negative while periodontitis patients sites with deep pockets ( 5 mm) and which were bleeding on probing were most often test positive. Periodontitis patients GCF MMP-8 levels decreased with hygiene phase periodontal treatment (scaling and root planing, SRP) and even reduced during the three month maintenance phase. A decrease in GCF MMP-8 levels could be monitored with the MMP-8 test. Agreement between the test stick and the quantitative assay was very good (κ = 0.81) and the test provided a baseline sensitivity of 0.83 and specificity of 0.96. During the 12-month longitudinal maintenance phase, periodontitis patients progressing sites (sites with an increase in attachment loss ≥ 2 mm during the maintenance phase) had elevated GCF MMP-8 levels compared with stable sites. General mean MMP-8 concentrations in smokers (S) sites were lower than in non-smokers (NS) sites but in progressing S and NS sites concentrations were at an equal level. Sites with exceptionally and repeatedly elevated MMP-8 concentrations during the maintenance phase were clustered in smoking patients with poor response to SRP (refractory patients). These sites especially were identified by the MMP-8 test. Subgingival plaque samples from periodontitis patients deep periodontal pockets were examined by polymerase chain reaction (PCR) to find out if periodontal lesions may serve as a niche for Chlamydia pneumoniae. Findings were compared with the clinical periodontal parameters and GCF MMP-8 levels to determine the correlation with periodontal status. Traces of C. pneumoniae were identified from one periodontitis patient s pooled subgingival plaque sample by means of PCR. After periodontal treatment (SRP) the sample was negative for C. pneumoniae. Clinical parameters or biomarkers (MMP-8) of the patient with the positive C. pneumoniae finding did not differ from other study patients. In this study it was concluded that MMP-8 concentrations in GCF of sites from periodontally healthy individuals, subjects with gingivitis or with periodontitis are at different levels. The cut-off value of the developed MMP-8 test is at an optimal level to differentiate between these conditions and can possibly be utilised in identification of individuals at the risk of the transition of gingivitis to periodontitis. In periodontitis patients, repeatedly elevated GCF MMP-8 concentrations may indicate sites at risk of progression of periodontitis as well as patients with poor response to conventional periodontal treatment (SRP). This can be monitored by MMP-8 testing. Despite the lower mean GCF MMP-8 concentrations in smokers, a fraction of smokers sites expressed very high MMP-8 concentrations together with enhanced periodontal activity and could be identified with MMP-8 specific chair-side test. Deep periodontal lesions may be niches for non-periodontopathogenic micro-organisms with systemic effects like C. pneumoniae and possibly play a role in the transmission from one subject to another.