Elämää syövän kanssa : Narratiivinen tutkimus henkisen ja hengellisen tuen merkityksestä syöpää sairastavalle

Cancer diseases are considered to be relatively common among the Finnish population, every fourth Finn has been affected by cancer in their lifetime. Around 24,000 new cases of cancer are diagnosed each year in Finland. According to the estimations, about half of all diseased will recover. This research examines cancer patients experiences and needs for mental and spiritual support. This paper answers questions what kind of support cancer patients were given after the diagnosis and how did they felt about it. My research was conducted by thematic interviews (N=7) with cancer patients and letters (N=13). To analyze I used narrative holistic-content analysis and holistic analysis of form. Narrative holistic-content analysis consists of reading the material and writing down common points, themes and deflections. By using holistic analysis of form, I observed changes and turning points in one s story of life. Then I could graphically show the emotional changes in the cancer patients life. By rereading the material, examining and comparing it, I was able to build different categories. After defining these categories (Longing, Supported, Individualists, Believers) I reread the interviews in terms of which category it belonged to. I chose one story from each category to represent the whole group. This so-called central story was complemented by other stories from the same group. Analysis enables to define a type story from each group, they were examples of the various ways of reacting about support that they were giving or not having the support that were needed. The stories reflect the participants feelings about support they were given but some cases feeling rejected.

Asunnoton yhteiskunnan jäsenenä : Sosiaalisesti syrjäytyneen osallistumismahdollisuudet ja deliberatiivinen demokratia

Tutkielmassani selvitän, millä tavalla sosiaalisesti syrjäytyneen, kuten asunnottoman, on mahdollista osallistua yhteiskunnan toimintaan ja itseään koskevaan päätöksentekoon. Tutkimuskysymykseni ovat: Toteutuvatko perustuslain 14 § ja 19 §:ssä säädetyt oikeudet, ja ovatko viranomaisten toimet riittäviä edistämään syrjäytyneiden asunnottomien itsenäistä asumista sekä lisäämään vaikutusmahdollisuuksia itseään koskevassa päätöksenteossa. Voisiko deliberatiivisen demokratiamallin avulla vahvistaa syrjäytyneiden yhteiskunnallista osallistumista, ja siten helpottaa asunnottomuusongelmaa. Asunnottomia oli vuonna 2006 noin 7 400 henkilöä. Syitä joutua asunnottomaksi on useita. Valtaosalla ongelmat ovat kasautuneet, minkä jälkeen itsenäinen selviäminen on hankaloitunut. Asunnottomilla on usein monia eri ongelmia kuten pitkäaikaissairauksia, työttömyyttä ja päihteiden väärinkäyttöä. Avioero on yksi keskeisistä yksittäisistä syistä etenkin miehille päätyä asunnottomaksi. Maahanmuuttajien asunnottomuus voi olla seurausta pyrkimyksestä integroitua yhteiskuntaan: Muuttaessa sijoituspaikkakunnalta esimerkiksi ystävien, työn tai opiskelun vuoksi kasvukeskukseen, maahanmuuttajan voi olla vaikeaa saada asuntoa. Näin työn tai koulutuspaikan vastaanottaminen voi pakottaa maahanmuuttajan ottamaan riskin menettää asunto. Sosiaalisesti syrjäytyneeksi voidaan määritellä ihminen, joka ei kykene tai halua sopeutua normaalina pidettyyn elämään yhteiskunnassa. Tämä tutkimuksissa käytetty normaalin elämän määritelmä muotoutuu yhteiskunnan arvojen ja käytäntöjen pohjalta. Syrjäytyminen voi tarkoittaa myös sitä, että ihminen kokee itsensä ulkopuoliseksi yhteiskunnasta. Syrjäytymistä aiheuttavatkin siten toistuvat syrjinnän ja voimattomuuden kokemukset sekä hankaluus vaikuttaa itseään koskevaan päätöksentekoon. Asunnottomien yö –tapahtumassa syksyllä 2007 vapaaehtoiset haastattelivat asunnottomuutta kokeneita. Haastattelut on julkaistu internetissä ja ne ovat vapaasti tutkijoiden, toimittajien ja poliitikkojen käytettävissä. Useissa haastatteluissa asunnottomat kertovat, että he eivät koe olevansa täysivaltaisia yhteiskunnan jäseniä. Haastatteluissa kritisoidaan sitä, että poliitikot ja sosiaalityöntekijät päättävät asunnottomuuden hoidosta sekä asunnottomia koskevista asioista ilman, että asunnottomilla on mahdollisuutta vaikuttaa päätöksentekoon. Turhautumisen tunne paistoi läpi useissa haastatteluissa. Useissa vastauksissa asunnottomat vaativat poliitikkoja ja sosiaalityöntekijöitä perehtymään asunnottomien arjen elämään. Deliberatiivisessa demokratiassa yksi keskeisistä ajatuksista on, että vain sellaiset päätökset, jotka on tehty kaikille avoimen keskustelun ja vapaan tahdonmuodostuksen pohjalta voivat saada hyväksynnän ja luottamuksen kansalta sekä muodostua sitoviksi. Deliberatiivisessa demokratiakäsityksessä on kyse siitä, että asioista päätetään yhdessä, julkisen ja tasa-arvoisen keskustelun sekä harkinnan pohjalta. Keskeistä on myös, että kaikkien, joita päätökset koskettavat, täytyy voida osallistua päätöksiä edeltävään keskusteluun. Erityisesti Young ja Bohman korostavat, että myös sosiaalisesti syrjäytyneellä tulee olla mahdollisuus osallistua poliittiseen keskusteluun ja itseään koskevaan päätöksentekoon. Muun muassa koulutuksen kautta opitaan rauhallinen, asiallinen ja kielellisesti oikea argumentaatiotapa. Ihmisten erilaisuus ja kouluttamattomuus eivät Youngin mukaan saa estää mahdollisuutta osallistua yhteiskunnassa käytävään poliittiseen keskusteluun. Tutkimuskysymykseeni, lisäävätkö viranomaiset toiminnallaan yksilön mahdollisuutta vaikuttaa itseään koskevaan päätöksentekoon ja edistävätkö he yksilön mahdollisuuksia osallistua yhteiskunnalliseen toimintaan, vastaan eivät. Kuitenkin viranomaisten mahdollisuudet edistää perustuslaissa säädettyjä velvollisuuksia ovat poliittisten päättäjien budjetoinnin vuoksi rajoitettuja. Helsingin sosiaaliasiamiehet pitivät huolestuttavana sitä, että sosiaalityöntekijät pakotetaan toimimaan sekä lainsäädännön että ammattietiikkansa vastaisesti. Sosiaaliasiamiesten raportin perusteella voisi päätellä, että ainakin Helsingissä viranomaisilla olisi tahtoa toimia lain velvoittamalla tavalla. Asunnottomista suurin osa asuu Helsingissä ja Pääkaupunkiseudulla, joten tämän perusteella tutkimuskysymykseeni voi vastata yleistäen Helsingin esimerkin pohjalta. Syrjäytymistutkijoiden tulkinnan mukaan syrjäytyminen ja siitä pahimmillaan seuraava asunnottomuus johtuvat osittain ihmisten kokemien vaikutusmahdollisuuksien puutteesta. Deliberatiivisen demokratian tavoitteena on luoda sellainen demokraattinen malli, jossa poliittinen keskustelu ja vaikutusmahdollisuudet olisivat kaikkien yhteiskunnan jäsenten saavutettavissa. Syrjäytymistutkimuksen valossa deliberatiivinen demokratia voisi olla malli, jonka avulla vahvistettaisiin sosiaalisesti syrjäytyneiden kuten asunnottomien vaikutusmahdollisuuksia. Myös asunnottomien haastatteluissa nousi esille toive tulla kuulluksi. Moni kommentoi, että asunnottomuuden hoidosta ja heidän asioistaan päättävät sellaiset ihmiset, joilla ei ole todellista tietoa asunnottomien arjesta ja toiveista. Deliberatiivisen demokratian malli voisi näiden tutkimusten valossa olla keino lisätä osallistumismahdollisuuksia ja vähentää sitä kautta myös syrjäytymistä ja asunnottomuutta.

Kummisetien katolinen kirkko : Kummisetä-trilogian ja Sopranos-televisiosarjan välittämä kuva roomalaiskatolisesta kirkosta

Tässä tutkielmassa tutkin millaisen kuvan Francis Ford Coppolan ohjaamat kolme Kummisetä-elokuvaa ja David Chasen luoman Sopranos-televisiosarjan kaksi ensimmäistä tuotantokautta antavat roomalaiskatolisesta kirkosta ja erityisesti Amerikassa toimivasta roomalaiskatolisesta kirkosta. Kummisetä-elokuvat valmistuivat vuosina 1972, 1974 ja 1990, Sopranos-sarjan kaksi ensimmäistä tuotantokautta taas esitettiin HBO-kanavalla ensimmäisen kerran vuosina 1999 ja 2000. Lähteet kattavat Amerikan katolisen kirkon historian 1900-luvun alusta aina 2000-luvun alkuun asti. Pyrin vastaamaan tutkielmassani siihen, millaisena lähteet kuvaavat katolisen ja onko kuvaukselle löydettävissä jotain syitä. Kummisetä-elokuvien kohdalla on paradoksaalista se, että ne kaikki kuvaavat menneisyyden eivätkä tekohetkensä tapahtumia, mikä mahdollisesti näkyy myös niiden tavassa kuvata katolista kirkkoa. Vaikuttaisi siltä, että varsinkin kahden ensimmäisen Kummisetä-elokuvan tapa kuvata Amerikan katolista kirkkoa pohjautuu pitkälti elokuvan tekohetken tunnelmiin. Elokuvien ohjaaja Francis Ford Coppola on myöntänyt käyttäneensä Kummisetä-elokuvien päähenkilöinä olevaa Corleone-perhettä Amerikan vertauskuvana. Elokuvien yksi kattava teema on eräänlainen maallistumiskehitys, jossa vanhan polven edustajan, don Vito Corleonen, arvot syrjäytyvät ja tilalle nousee uusi johtajapolvi Viton nuorimman pojan don Michael Corleonen hahmossa. Michael Corleone edustaa huomattavasti armottomampaa polvea kuin Vito eikä uskonto ja katolinen kirkko näy hänen elämässään juuri lainkaan. Michaelin kyyninen ja kylmäkin hahmo on mitä todennäköisemmin vertauskuva elokuvien tekohetken yleisistä tunnelmia, jolloin Watergate-skandaali kansallisella tasolla ja Vatikaanin II konsiili ja paavin kiertokirje Humanae Vitae muokkasivat rajusti perinteisen katolisuuden ja amerikkalaisuuden identiteettiä. Kolmas Kummisetä-elokuva käsittelee lähes kokonaan paavi Johannes Paavali I:n lyhyeksi jäänyttä paaviuskautta vuodelta 1978 osittain fiktioin keinoin. Elokuvan yhtäläisyydet rikoskirjailija David Yallopin menestyskirjaan In Gods Name. An Investigation into the Murder of Pope John Paul I, jossa kirjailija esittää paavin tulleen kuurian virkamiesten ja mafiosoiden murhaamaksi, ovat selkeät. Kirkosta luodaan kuva toisaalta armottomona valtakoneistona, mutta toisaalta myös hengellisenä yhteisönä, josta katuvan ihmisen on mahdollisuus löytää apua. Sopranos-televisiosarja jatkaa kahdella ensimmäisellä tuotantokaudellaan saman maallistumiskehityksen kulkua kuin kaksi ensimmäistä Kummisetä-elokuvaakin. Päähenkilö Tony Soprano perheineen on lähes täysin irrallaan katolisesta perinteestä eivätkä he enää tunne sen oppejakaan kunnolla. Silti he mieltävät itsensä katolilaisiksi. Tämä vastaa joiltain osin tutkimustuloksia todellisista amerikkalaisista katolilaisista. Kaiken kaikkiaan Kummisetä-elokuvatrilogia ja Sopranos-televisiosarja antavat katolisesta kirkosta hyvin monipuolisen ja joissain asioissa totuudenmukaisenkin kuvan, joskin tekijöiden oma henkilöhistoria ja ajan skandaalit ovat väistämättä värittäneet kirkkokuvausta. Siten ne muodostavat värikkään läpileikkauksen Amerikan katolisen kirkon kehityksestä amerikanitalialaisessa yhteisössä 1900-luvun alusta 2000-luvun alkuun.

Efraim Syyrialaisen luostari: Tapausesimerkkejä munkkien luostariin vetäytymisen syistä

Tutkielma on kaksivaiheinen. Ensin esittelen apostolisen, Syyrialaisortodoksisen kirkon historiaa ja luostariperinnettä. Toisen osan tarkoitus on selvittää, liittyykö Pyhän Efraim Syyrialaisen luostarin munkkien luostariinjäämispäätökseen yhteiskunnallisia syitä ja mitä muita mahdollisia syitä voidaan löytää. Vertailen lopuksi varhaisia, 400-luvulla eläneiden kilvoittelijoiden Pyhän Efraim Syyrialaisen, Antonius Suuren ja Simeon Pylväspyhimyksen motiiveita nykykilvoittelijoiden motiiveihin, sikäli kuin se on mahdollista. Selvitän myös, onko Efraim Syyrialaisen esimerkillä ollut merkitystä nykykilvoittelijoille. Empiirinen aineisto kerättiin kahtena vuotena v. 2002 ja 2003. Tutkielmaa varten haastattelin kolmea Efraim Syyrialaisen luostarin munkkia. Pääinformanttini oli ko. luostarin seminaarin teologiopiskelija. Heidän kotitaustansa on syyrialaisortodoksinen, voimakkaasti uskonnollinen. Spiritualiteettia harjoitettiin jo lapsuudessa sekä kotona että kirkossa. Tutkielmani näkökulma on uskontohistoriallinen ja uskontososiologinen. Tutkin miten varhaiset- sekä nykypäivän kilvoittelijat ovat suhtautuneet yhteiskuntaan ja miten he ovat integroituneet luostariinsa. Kysymyksessä on nykypäivän osalta laadullinen tapaustutkimus, jonka metodeina ovat teemahaastattelu, jonka yhtenä osana olivat argumentit ja osallistruva havainnointi. Analysoin vastaukset sisällön analyysiä käyttäen. Haastatellut munkit korostivat syyrian kielen ja tradition opiskelun ja sen siirtämisen tärkeyttä seminaariin opiskelemaan hakeutumisensa, ja sen jälkeen munkiksi jäämisensä perusteluna. Pyhän Efraim Syyrialaisen esimerkin munkit kokivat olevan heille hyvin tärkeän tradition siirtäjän. Opiskelemisen ja matkustamisen mahdollisuus munkkina koettiin myös tärkeänä ja siitä syystä luostariin jäätiin, eli yhteiskunnallinen syy löytyi. Sisällön analyysissä ilmeni, että alkujaan koti edusti munkille primaarista tekijää. Sekundääristä tekijää edustivat kirkkoon kuuluva ryhmä, munkit ja luostari. Kodin ja kirkossa käynnin seurauksena tradition ja syyrian kielen oppimisen halu korostui ja niitä haluttiin lähteä opiskelemaan. Positiiviseksi viiteryhmäksi tällöin muodostuivat seminaariopiskelun aikana munkit ja muut luostarin asukkaat. Luostariin jäämisensä jälkeen primaarin tekijän voidaan huomata vaihtuneen luostariksi ja kodin asema on jäänyt sekundaariseksi. Yhteys luostarin ja ympäröivän yhteiskunnan kanssa tapahtui varhaisena aikana pääasiallisesti siten, että ihmiset tulivat kilvoittelijan luokse. Nykymunkit puolestaan käyvät niiden seurakuntalaisten kotona, jotka eivät pääse yhteisiin jumalanpalveluksiin ja auttavat heitä sielunhoidollisesti ja tarvittaessa taloudellisesti. Kirkon patriarkka Mar Ignatios Zakka I Iwasilla ja metropoliitta Eusthatios Matta Rohamilla on paljon yhteyksiä myös islaminuskoiseen väestönosaa Syyriassa. Ekumeenisia yhteyksiä on munkeillakin runsaasti. Ne mahdollistuvat erilaisissa kirkon kokouksissa ja konferensseissa sekä opiskelupaikkakunnalla Kreikassa.

Puukaupan säännöt : Yksityismetsänomistajien ja metsäteollisuuden puukauppa Itä-Suomessa 1919 - 1939

The Finnish forest industry bought more than half of the timber used in factories and sawmills in the 1930s from non-industrial private forests (NIPF). This research investigates the rules conformed to this timber trade. The main research questions are: what were the rules that influenced the timber trade; and by whom they were set up? Attention is also paid to the factors which advanced the forest owners’ negotiation possibilities. A variety of sources were used: legal and company statutes, timber trade contracts, archives of the forest companies and organisations. Moreover, the written reminiscences collected by the Finnish Literature Society in the early 1970s were used to analyse the views of individual sellers and buyers. An institutional economics approach was applied as the theoretical framework of this study. In the timber trade the seller (forest owner) and the buyer (the employee of the forest company) agreed to the rules of the timber trade. They agreed about the amount and the price of the timber on sale, but also rules concerning, e.g., timber marking and harvesting. The forest companies had a strong control over the written contracts. Neither the private forest owners nor the forest organisations had much influence over these contracts. However, they managed to influence the rules which could not be found in the contracts. These written and unwritten rules regulated, for instance, the timber marking and measurement. The forest organisations such as Central Forestry Board Tapio (Keskusmetsäseura Tapio) and associations of forest owners (metsänhoitoyhdistykset) helped private forest owners in gaining more control over the timber marking. In timber marking, the forest owner selected trees to be included in the timber trade and gained more information, which he could use in the negotiations. The other rule, which was changed despite forest companies’ resistance, was the timber measurement. The Central Union of Agricultural Producers (MTK) negotiated with the Central Association of Finnish Woodworking Industries (SPKL) about changing the rules of the measurement practices. Even though SPKL did not support any changes, the new timber measurement law was accepted in the year 1938. The new law also created a supervisory authority to solve possible disagreements. Despite this the forest companies were still in charge of the measurement process in most cases. The private forest owners attained changes in the rules of the timber trade mainly during the 1930s. Earlier the relative weakness of the private forest organisations had diminished their negotiation positions. This changed in the 1930s as the private forest owners and their organisations became more active. At the same time the forest industry experienced a shortage of timber, especially pulp wood, and this provided the private forest owners with more leverage. Full-text (in Finnish) available at http://helda.helsinki.fi/handle/10224/4081

Empirical Analysis of Competition in Procurement Auctions

A vast amount of public services and goods are contracted through procurement auctions. Therefore it is very important to design these auctions in an optimal way. Typically, we are interested in two different objectives. The first objective is efficiency. Efficiency means that the contract is awarded to the bidder that values it the most, which in the procurement setting means the bidder that has the lowest cost of providing a service with a given quality. The second objective is to maximize public revenue. Maximizing public revenue means minimizing the costs of procurement. Both of these goals are important from the welfare point of view. In this thesis, I analyze field data from procurement auctions and show how empirical analysis can be used to help design the auctions to maximize public revenue. In particular, I concentrate on how competition, which means the number of bidders, should be taken into account in the design of auctions. In the first chapter, the main policy question is whether the auctioneer should spend resources to induce more competition. The information paradigm is essential in analyzing the effects of competition. We talk of a private values information paradigm when the bidders know their valuations exactly. In a common value information paradigm, the information about the value of the object is dispersed among the bidders. With private values more competition always increases the public revenue but with common values the effect of competition is uncertain. I study the effects of competition in the City of Helsinki bus transit market by conducting tests for common values. I also extend an existing test by allowing bidder asymmetry. The information paradigm seems to be that of common values. The bus companies that have garages close to the contracted routes are influenced more by the common value elements than those whose garages are further away. Therefore, attracting more bidders does not necessarily lower procurement costs, and thus the City should not implement costly policies to induce more competition. In the second chapter, I ask how the auctioneer can increase its revenue by changing contract characteristics like contract sizes and durations. I find that the City of Helsinki should shorten the contract duration in the bus transit auctions because that would decrease the importance of common value components and cheaply increase entry which now would have a more beneficial impact on the public revenue. Typically, cartels decrease the public revenue in a significant way. In the third chapter, I propose a new statistical method for detecting collusion and compare it with an existing test. I argue that my test is robust to unobserved heterogeneity unlike the existing test. I apply both methods to procurement auctions that contract snow removal in schools of Helsinki. According to these tests, the bidding behavior of two of the bidders seems consistent with a contract allocation scheme.

Functional and work disability and treatment received by patients with major depressive disorder

This study is one part of a collaborative depression research project, the Vantaa Depression Study (VDS), involving the Department of Mental and Alcohol Research of the National Public Health Institute, Helsinki, and the Department of Psychiatry of the Peijas Medical Care District (PMCD), Vantaa, Finland. The VDS includes two parts, a record-based study consisting of 803 patients, and a prospective, naturalistic cohort study of 269 patients. Both studies include secondary-level care psychiatric out- and inpatients with a new episode of major depressive disorder (MDD). Data for the record-based part of the study came from a computerised patient database incorporating all outpatient visits as well as treatment periods at the inpatient unit. We included all patients aged 20 to 59 years old who had been assigned a clinical diagnosis of depressive episode or recurrent depressive disorder according to the International Classification of Diseases, 10th edition (ICD-10) criteria and who had at least one outpatient visit or day as an inpatient in the PMCD during the study period January 1, 1996, to December 31, 1996. All those with an earlier diagnosis of schizophrenia, other non-affective psychosis, or bipolar disorder were excluded. Patients treated in the somatic departments of Peijas Hospital and those who had consulted but not received treatment from the psychiatric consultation services were excluded. The study sample comprised 290 male and 513 female patients. All their psychiatric records were reviewed and each patient completed a structured form with 57 items. The treatment provided was reviewed up to the end of the depression episode or to the end of 1997. Most (84%) of the patients received antidepressants, including a minority (11%) on treatment with clearly subtherapeutic low doses. During the treatment period the depressed patients investigated averaged only a few visits to psychiatrists (median two visits), but more to other health professionals (median seven). One-fifth of both genders were inpatients, with a mean of nearly two inpatient treatment periods during the overall treatment period investigated. The median length of a hospital stay was 2 weeks. Use of antidepressants was quite conservative: The first antidepressant had been switched to another compound in only about one-fifth (22%) of patients, and only two patients had received up to five antidepressant trials. Only 7% of those prescribed any antidepressant received two antidepressants simultaneously. None of the patients was prescribed any other augmentation medication. Refusing antidepressant treatment was the most common explanation for receiving no antidepressants. During the treatment period, 19% of those not already receiving a disability pension were granted one due to psychiatric illness. These patients were nearly nine years older than those not pensioned. They were also more severely ill, made significantly more visits to professionals and received significantly more concomitant medications (hypnotics, anxiolytics, and neuroleptics) than did those receiving no pension. In the prospective part of the VDS, 806 adult patients were screened (aged 20-59 years) in the PMCD for a possible new episode of DSM-IV MDD. Of these, 542 patients were interviewed face-to-face with the WHO Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Version 2.0. Exclusion criteria were the same as in the record-based part of the VDS. Of these, 542 269 patients fulfiled the criteria of DSM-IV MDE. This study investigated factors associated with patients' functional disability, social adjustment, and work disability (being on sick-leave or being granted a disability pension). In the beginning of the treatment the most important single factor associated with overall social and functional disability was found to be severity of depression, but older age and personality disorders also significantly contributed. Total duration and severity of depression, phobic disorders, alcoholism, and personality disorders all independently contributed to poor social adjustment. Of those who were employed, almost half (43%) were on sick-leave. Besides severity and number of episodes of depression, female gender and age over 50 years strongly and independently predicted being on sick-leave. Factors influencing social and occupational disability and social adjustment among patients with MDD were studied prospectively during an 18-month follow-up period. Patients' functional disability and social adjustment were alleviated during the follow-up concurrently with recovery from depression. The current level of functioning and social adjustment of a patient with depression was predicted by severity of depression, recurrence before baseline and during follow-up, lack of full remission, and time spent depressed. Comorbid psychiatric disorders, personality traits (neuroticism), and perceived social support also had a significant influence. During the 18-month follow-up period, of the 269, 13 (5%) patients switched to bipolar disorder, and 58 (20%) dropped out. Of the 198, 186 (94%) patients were at baseline not pensioned, and they were investigated. Of them, 21 were granted a disability pension during the follow-up. Those who received a pension were significantly older, more seldom had vocational education, and were more often on sick-leave than those not pensioned, but did not differ with regard to any other sociodemographic or clinical factors. Patients with MDD received mostly adequate antidepressant treatment, but problems existed in treatment intensity and monitoring. It is challenging to find those at greatest risk for disability and to provide them adequate and efficacious treatment. This includes great challenges to the whole society to provide sufficient resources.

Men´s health behaviour, health beliefs and need for health counselling : A study amongst 40-year-old males from one Helsinki City region

Tavoitteena oli tutkia 40-vuotiaiden miesten terveyskäyttäytymistä, terveysuskomuksia ja miesten saamaa terveysneuvontaa Helsingissä. 273 miestä vastasi kyselyyn ja osallistui terveystutkimuksiin. Terveydentilan perusteella miehet arvioitiin matalan (n=145) ja korkean (n=128) riskin ryhmiin. Khin neliö-testillä tutkittiin elämäntapa- ja riskitekijöitä koetun terveyden (hyvä, keskinkertainen/huono) luokissa ja verrattiin matalan ja korkean riskin ryhmiä em. tekijöiden osalta. Askeltavalla logistisella regressiomallilla analysoitiin tulosmuuttujia taustatekijöiden, terveyskäyttäytymisen, terveysuskomusten ja kliinisten riskitekijöiden avulla sekä arvioitiin oireiden ja vaivojen suhdetta koettuun terveydentilaan. Korkeassa riskissä olevien terveyttä seurattiin vuosina 2001–2004 analysoimalla mini-intervention vaikutusta terveysriskeihin ja elintapoihin varianssianalyysin avulla (ANOVA) (n=46). Matalasta vastausprosentista johtuen (39.6%), ei-vastanneiden aineistoa kerättiin käyttämällä syvähaastattelua (n=28) sekä puhelinkyselyä (n=40). Lopullinen aineisto koostui 341 miehestä. Tulokset osoittivat, että miehillä oli sydän- ja verisuonitautiriskejä. Kaksi kolmesta osallistuneista oli ylipainoisia tai lihavia, yli kolmanneksella vyötärönympärys oli ≥100 cm, ja yli 40%:llä oli diastolinen verenpaine ≥90 mmHg. Yli puolet tupakoi päivittäin ja 40% käytti alkoholia runsaasti. Ristiriitaisuutta ilmensi se, että huolimatta riskitekijöistä noin puolet miehistä koki terveydentilansa hyväksi. Sairauden tai vamman puute, hyvä suun terveydentila ja normaali vyötärönympärys olivat yhteydessä hyväksi koettuun terveydentilaan. Suora yhteys voitiin havaita omaisten tarjoaman neuvonnan ja vähäisen alkoholin käytön välillä. Masennus ja unettomuus olivat voimakkaasti yhteydessä loppuun palamiseen. Miehillä oli erilaisia fyysisiä ja psyykkisiä oireita, jotka korreloivat voimakkaasti masennuksen kanssa. Pieni määrä miehistä koki saaneensa terveysneuvontaa hoitohenkilökunnalta verrattuna perheenjäseniltä saatuun ohjaukseen. Korkeariskisten miesten (n=46) arvot parantuivat merkitsevästi lyhyellä aikavälillä. Kolesteroliarvoja lukuunottamatta ne palautuivat kolmen vuoden kuluttua alkumittausarvoja kohti. Laadullinen tutkimus osoitti, että “ei-vastanneet“ eivät osallistuneet projektiin, sillä he olivat oireettomia tai kiireisiä. Heillä todettiin samoja terveysriskejä kuin projektiin osallistuneilla. Syvähaastattelussa miehet toivat esille kokemuksiaan huolista, vihan tunteista, peloista ja yksinäisyydestä. Hoidonantajien on tärkeää ymmärtää ristiriidat miesten subjektiivisen ja objektiivisen terveydentilan välillä, mikä auttaa havaitsemaan esteitä terveyskäyttäytymiselle. Yhä enemmän tarvitaan yhteistyötä yksityisen ja julkisen terveydenhuollon välillä varmistamaan terveystottumusten jatkuminen miesten keskuudessa.

Depressive Disorders in Primary Health Care

The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study concerning primary care patients with depressive disorders. It forms a collaborative research project between the Department of Mental and Alcohol Research of the National Public Health Institute, and the Primary Health Care Organization of the City of Vantaa. The aim is to obtain a comprehensive view on clinically significant depression in primary care, and to compare depressive patients in primary care and in secondary level psychiatric care in terms of clinical characteristics. Consecutive patients (N=1111) in three primary care health centres were screened for depression with the PRIME-MD, and positive cases interviewed by telephone. Cases with current depressive symptoms were diagnosed face-to-face with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P). A cohort of 137 patients with unipolar depressive disorders, comprising all patients with at least two depressive symptoms and clinically significant distress or disability, was recruited. The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), medical records, rating scales, interview and a retrospective life-chart were used to obtain comprehensive cross-sectional and retrospective longitudinal information. For investigation of suicidal behaviour the Scale for Suicidal Ideation (SSI), patient records and the interview were used. The methodology was designed to be comparable to The Vantaa Depression Study (VDS) conducted in secondary level psychiatric care. Comparison of major depressive disorder (MDD) patients aged 20-59 from primary care in PC-VDS (N=79) was conducted with new psychiatric outpatients (N =223) and inpatients (N =46) in VDS. The PC-VDS cohort was prospectively followed up at 3, 6 and 18 months. Altogether 123 patients (90%) completed the follow-up. Duration of the index episode and the timing of relapses or recurrences were examined using a life-chart. The retrospective investigation revealed current MDD in most (66%), and lifetime MDD in nearly all (90%) cases of clinically significant depressive syndromes. Two thirds of the “subsyndromal” cases had a history of major depressive episode (MDE), although they were currently either in partial remission or a potential prodromal phase. Recurrences and chronicity were common. The picture of depression was complicated by Axis I co-morbidity in 59%, Axis II in 52% and chronic Axis III disorders in 47%; only 12% had no co-morbidity. Within their lifetimes, one third (37%) had seriously considered suicide, and one sixth (17%) had attempted it. Suicidal behaviour clustered in patients with moderate to severe MDD, co-morbidity with personality disorders, and a history of treatment in psychiatric care. The majority had received treatment for depression, but suicidal ideation had mostly remained unrecognised. The comparison of patients with MDD in primary care to those in psychiatric care revealed that the majority of suicidal or psychotic patients were receiving psychiatric treatment, and the patients with the most severe symptoms and functional limitations were hospitalized. In other clinical aspects, patients with MDD in primary care were surprisingly similar to psychiatric outpatients. Mental health contacts earlier in the current MDE were common among primary care patients. The 18-month prospective investigation with a life-chart methodology verified the chronic and recurrent nature of depression in primary care. Only one-quarter of patients with MDD achieved and maintained full remission during the follow-up, while another quarter failed to remit at all. The remaining patients suffered either from residual symptoms or recurrences. While severity of depression was the strongest predictor of recovery, presence of co-morbid substance use disorders, chronic medical illness and cluster C personality disorders all contributed to an adverse outcome. In clinical decision making, beside severity of depression and co-morbidity, history of previous MDD should not be ignored by primary care doctors while depression there is usually severe enough to indicate at least follow-up, and concerning those with residual symptoms, evaluation of their current treatment. Moreover, recognition of suicidal behaviour among depressed patients should also be improved. In order to improve outcome of depression in primary care, the often chronic and recurrent nature of depression should be taken into account in organizing the care. According to literature management programs of a chronic disease, with enhancement of the role of case managers and greater integration of primary and specialist care, have been successful. Optimum ways of allocating resources between treatment providers as well as within health centres should be found.

Irritable bowel syndrome in the general population : epidemiology, comorbidity and societal costs

Background: Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder characterised by abdominal pain and abnormal bowel function. It is associated with a high rate of healthcare consumption and significant health care costs. The prevalence and economic burden of IBS in Finland has not been studied before. The aims of this study were to assess the prevalence of IBS according to various diagnostic criteria and to study the rates of psychiatric and somatic comorbidity in IBS. In addition, health care consumption and societal costs of IBS were to be evaluated. Methods: The study was a two-phase postal survey. Questionnaire I identifying IBS by Manning 2 (at least two of the six Manning symptoms), Manning 3 (at least three Manning symptoms), Rome I, and Rome II criteria, was mailed to a random sample of 5 000 working age subjects. It also covered extra-GI symptoms such as headache, back pain, and depression. Questionnaire II, covering rates of physician visits, and use of GI medication, was sent to subjects fulfilling Manning 2 or Rome II IBS criteria in Questionnaire I. Results: The response rate was 73% and 86% for questionnaires I and II. The prevalence of IBS was 15.9%, 9.6%, 5.6%, and 5.1% according to Manning 2, Manning 3, Rome I, and Rome II criteria. Of those meeting Rome II criteria, 97% also met Manning 2 criteria. Presence of severe abdominal pain was more often reported by subjects meeting either of the Rome criteria than those meeting either of the Manning criteria. Presence of depression, anxiety, and several somatic symptoms was more common among subjects meeting any IBS criterion than by controls. Of subjects with depressive symptoms, 11.6% met Rome II IBS criteria compared to 3.7% of those with no depressiveness. Subjects meeting any IBS criteria made more physician visits than controls. Intensity of GI symptoms and presence of dyspeptic symptoms were the strongest predictors of GI consultations. Presence of dyspeptic symptoms and a history of abdominal pain in childhood also predicted non-GI visits. Annual GI related individual costs were higher in the Rome II group (497 ) than in the Manning 2 group (295 ). Direct expenses of GI symptoms and non GI physician visits ranged between 98M for Rome II and 230M for Manning 2 criteria. Conclusions: The prevalence of IBS varies substantially depending on the criteria applied. Rome II criteria are more restrictive than Manning 2, and they identify an IBS population with more severe GI symptoms, more frequent health care use, and higher individual health care costs. Subjects with IBS demonstrate high rates of psychiatric and somatic comorbidity regardless of health care seeking status. Perceived symptom severity rather than psychiatric comorbidity predicts health care seeking for GI symptoms. IBS incurs considerable medical costs. The direct GI and non-GI costs are equivalent to up to 5% of outpatient health care and medicine costs in Finland. A more integral approach to IBS by physicians, accounting also for comorbid conditions, may produce a more favourable course in IBS patients and reduce health care expenditures.

Topical tacrolimus in atopic dermatitis : Effects of long-term treatment on skin and respiratory symptoms

Objective: Patients with atopic dermatitis often have a poor long-term response to conventional topical or systemic treatments. Staphylococcal superinfections, skin atrophy due to corticosteroid use, and asthma and allergic rhinitis are common. Only a few, usually short-term, studies have addressed the effects of different treatments on these problems. Tacrolimus ointment is the first topical compound suitable for long-term treatment. The aim of this thesis was to evaluate the effects of long-term topical tacrolimus treatment on cutaneous staphylococcal colonization, collagen synthesis, and symptoms and signs of asthma and allergic rhinitis. Methods: Patients with moderate-to-severe atopic dermatitis were treated with intermittent 0.1% tacrolimus ointment in prospective, open studies lasting for 6 to 48 months. In Study I, cutaneous staphylococcal colonization was followed for 6 to 12 months. In Study II, skin thickness and collagen synthesis were followed by skin ultrasound and procollagen I and III propeptide concentrations of suction blister fluid samples for 12 to 24 months and compared with a group of corticosteroid-treated atopic dermatitis patients and with a group of healthy subjects. Study III was a cross-sectional study of the occurrence of respiratory symptoms, bronchial hyper-responsiveness, and sputum eosinophilia in atopic dermatitis patients and healthy controls. In Study V, the same parameters as in Study III were assessed in atopic dermatitis patients before and after 12 to 48 months of topical tacrolimus treatment. Study IV was a retrospective follow-up of the effect of tacrolimus 0.03% ointment on severe atopic blepharoconjunctivitis and conjunctival cytology. Results: The clinical response to topical tacrolimus was very good in all studies (p≤0.008). Staphylococcal colonization decreased significantly, and the effect was sustained throughout the study (p=0.01). Skin thickness (p<0.001) and markers of collagen synthesis (p<0.001) increased in the tacrolimus-treated patients significantly, whereas they decreased or remained unchanged in the corticosteroid-treated controls. Symptoms of asthma and allergic rhinitis (p<0.0001), bronchial hyper-responsiveness (p<0.0001), and sputum eosinophilia (p<0.0001) were significantly more common in patients with atopic dermatitis than in healthy controls, especially in subjects with positive skin prick tests or elevated serum immunoglobulin E. During topical tacrolimus treatment the asthma and rhinitis (p=0.005 and p=0.002) symptoms and bronchial hyper-responsiveness (p=0.02) decreased significantly, and serum immunoglobulin E and sputum eosinophils showed a decreasing trend in patients with the best treatment response. Treatment of atopic blepharoconjunctivitis resulted in a marked clinical response and a significant decrease in eosinophils, lymphocytes, and neutrophils in the conjunctival cytology samples. No significant adverse effects or increase in skin infections occurred in any study. Conclusions: The studies included in this thesis, except the study showing an increase in skin collagen synthesis in tacrolimus-treated patients, were uncontrolled, warranting certain reservations. The results suggest, however, that tacrolimus ointment has several beneficial effects in the long-term intermittent treatment of atopic dermatitis. Tacrolimus ointment efficiently suppresses the T cell-induced inflammation of atopic dermatitis. It has a normalizing effect on the function of the skin measured by the decrease in staphylococcal colonization. It does not cause skin atrophy as do corticosteroids but restores the skin collagen synthesis in patients who have used corticosteroids. Tacrolimus ointment has no marked systemic effect, as the absorption of the drug is minimal and decreases along with skin improvement. The effects on the airway: decrease in bronchial hyper-responsiveness and respiratory symptoms, can be speculated to be caused by the decrease in T cell trafficking from the skin to the respiratory tissues as the skin inflammation resolves, as well as inhibition of epicutaneous invasion of various antigens causing systemic sensitization when the skin barrier is disrupted as in atopic dermatitis. Patients with moderate-to-severe atopic dermatitis seem to benefit from efficient long-term treatment with topical tacrolimus.

The Effect of Intrauterine Growth Restriction on Long-Term Outcome in Very or Extremely Low Birth Weight Infants

The project consisted of two long-term follow-up studies of preterm children addressing the question whether intrauterine growth restriction affects the outcome. Assessment at 5 years of age of 203 children with a birth weight less than 1000 g born in Finland in 1996-1997 showed that 9% of the children had cognitive impairment, 14% cerebral palsy, and 4% needed a hearing aid. The intelligence quotient was lower (p<0.05) than the reference value. Thus, 20% exhibited major, 19% minor disabilities, and 61% had no functional abnormalities. Being small for gestational age (SGA) was associated with sub-optimal growth later. In children born before 27 gestational weeks, the SGA had more neuropsychological disabilities than those appropriate for gestational age (AGA). In another cohort with birth weight less than 1500 g assessed at 5 years of age, echocardiography showed a thickened interventricular septum and a decreased left ventricular end-diastolic diameter in both SGA and AGA born children. They also had a higher systolic blood pressure than the reference. Laser-Doppler flowmetry showed different endothelium-dependent and -independent vasodilation responses in the AGA children compared to those of the controls. SGA was not associated with cardio-vascular abnormalities. Auditory event-related potentials (AERPs) were recorded using an oddball paradigm with frequency deviants (standard tone 500 Hz and deviant 750-Hz with 10% probability). At term, the P350 was smaller in SGA and AGA infants than in controls. At 12 months, the automatic change detection peak (mismatch negativity, MMN) was observed in the controls. However, the pre-term infants had a difference positivity that correlated with their neurodevelopment scores. At 5 years of age, the P1-deflection, which reflects primary auditory processing, was smaller, and the MMN larger in the preterm than in the control children. Even with a challenging paradigm or a distraction paradigm, P1 was smaller in the preterm than in the control children. The SGA and AGA children showed similar AERP responses. Prematurity is a major risk factor for abnormal brain development. Preterm children showed signs of cardiovascular abnormality suggesting that prematurity per se may carry a risk for later morbidity. The small positive amplitudes in AERPs suggest persisting altered auditory processing in the preterm in-fants.

Long-term results of obstetric brachial plexus surgery

Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams.