Functional outcome and health-related quality of life after traumatic brain injury in the framework of the International Classification of Functioning, Disability and Health (ICF)

Traumatic brain injury (TBI) affects people of all ages and is a cause of long-term disability. In recent years, the epidemiological patterns of TBI have been changing. TBI is a heterogeneous disorder with different forms of presentation and highly individual outcome regarding functioning and health-related quality of life (HRQoL). The meaning of disability differs from person to person based on the individual s personality, value system, past experience, and the purpose he or she sees in life. Understanding of all these viewpoints is needed in comprehensive rehabilitation. This study examines the epidemiology of TBI in Finland as well as functioning and HRQoL after TBI, and compares the subjective and objective assessments of outcome. The frame of reference is the International Classification of Functioning, Disability and Health (ICF). The subjects of Study I represent the population of Finnish TBI patients who experienced their first TBI between 1991 and 2005. The 55 Finnish subjects of Studies II and IV participated in the first wave of the international Quality of life after brain injury (QOLIBRI) validation study. The 795 subjects from six language areas of Study III formed the second wave of the QOLIBRI validation study. The average annual incidence of Finnish hospitalised TBI patients during the years 1991-2005 was 101:100 000 in patients who had TBI as the primary diagnosis and did not have a previous TBI in their medical history. Males (59.2%) were at considerably higher risk of getting a TBI than females. The most common external cause of the injury was falls in all age groups. The number of TBI patients ≥ 70 years of age increased by 59.4% while the number of inhabitants older than 70 years increased by 30.3% in the population of Finland during the same time period. The functioning of a sample of 55 persons with TBI was assessed by extracting information from the patients medical documents using the ICF checklist. The most common problems were found in the ICF components of Body Functions (b) and Activities and Participation (d). HRQoL was assessed with the QOLIBRI which showed the highest level of satisfaction on the Emotions, Physical Problems and Daily Life and Autonomy scales. The highest scores were obtained by the youngest participants and participants living independently without the help of other people, and by people who were working. The relationship between the functional outcome and HRQoL was not straightforward. The procedure of linking the QOLIBRI and the GOSE to the ICF showed that these two outcome measures cover the relevant domains of TBI patients functioning. The QOLIBRI provides the patients subjective view, while the GOSE summarises the objective elements of functioning. Our study indicates that there are certain domains of functioning that are not traditionally sufficiently documented but are important for the HRQoL of persons with TBI. This was the finding especially in the domains of interpersonal relationships, social and leisure activities, self, and the environment. Rehabilitation aims to optimize functioning and to minimize the experience of disability among people with health conditions, and it needs to be based on a comprehensive understanding of human functioning. As an integrative model, the ICF may serve as a frame of reference in achieving such an understanding.

Early Growth and Later Health, Focus on Metabolic Syndrome, Obesity and Physical Activity

The Developmental Origins of Health and Disease Hypothesis proposes that adverse health outcomes in adult life are in part programmed during fetal life and infancy. This means that e.g. restricted nutrition during pregnancy programmes the offspring to store fat more effectively, to develop faster and to reach puberty earlier. These adaptations are beneficial in terms of short term survival. However, in developed countries these adaptations often lead to an increased risk of obesity and metabolic disturbances in later life, due to a mismatch between the prenatal and postnatal environment. This thesis aimed to study the role of early growth in people who are obese as adults, but metabolically healthy as well as in those who are normal in weight but metabolically obese. Other study aims were to assess whether physical activity and cardiorespiratory fitness are programmed early in life. The role of socioeconomic status in the development of obesity from a life course setting was also studied. These studies included 2003 men and women born in Helsinki between 1934 and 1944 with detailed information of their prenatal and childhood growth as well as living conditions. They participated in the detailed clinical examination during the years 2001-2004. A sub-group of the subjects participated in the UKK Institute 2-kilometre walk test. Metabolic syndrome was defined according to the 2005 criteria of the International Diabetes Federation. Among the obese men and women 20 % were metabolically healthy. Those with metabolic syndrome did not differ in birth size compared to the healthy ones, but by two years of age, they were lighter and thinner, and remained so up to 11 years. The period when changes in BMIs were predictive of the metabolic syndrome was from birth to 7 years. Of the normal weight individuals 17 % were metabolically obese. Again, there were no differences in birth size. However, by the age 7 years, those men who later developed metabolic syndrome were thinner. Gains in BMI during the first two years of life were protective of the syndrome. Children who were heavier, and especially taller, were more physically active, exercised with higher intensity and had higher cardiorespiratory fitness in their adult life than those who were shorter and thinner as children. Lower educational attainment and lower adult social class were associated with obesity in both men and women. Childhood social class was inversely associated with body mass index only in men while lower household income was associated with higher BMI in women. These results support the role of early life factors in the development of metabolic syndrome and adult life style. Early detection of risk factors predisposing to these conditions is highly relevant from a public health point of view.

Housing the skilled migrants in the Helsinki Metropolitan Area : International attractiveness of housing, neighbourhoods and the city region

The aim of this thesis is to examine the skilled migrants’ satisfaction with the Helsinki Metropolitan Area. The examination is executed on three scales: housing, neighbourhoods and the city region. Specific focus is on the built environment and how it meets the needs of the migrants. The empirical data is formed of 25 semi-structured interviews with skilled migrants and additionally 5 expert interviews. Skilled and educated workforce is an increasingly important resource in the new economy, and cities are competing globally for talented workers. With aging population and a need to develop its innovational structure, the Helsinki Metropolitan Area needs migrant workforce. It has been stated that quality of place is a central factor for skilled migrants when choosing where to settle, and from this perspective their satisfaction with the region is significant. In housing, the skilled migrants found the price-quality ratio and the general sizes of apartments inadequate. The housing market is difficult for the migrants to approach, since they often do not speak Finnish and there are prejudices towards foreigners. The general quality of housing was rated well. On the neighbourhood level, the skilled migrants had settled in residential areas which are also preferred by the Finnish skilled workers. While the migrants showed suburban orientation in their settlement patterns, they were not concentrated in the suburban areas which host large shares of traditional immigrant groups. Migrants were usually satisfied with their neighbourhoods; however, part of the suburban dwellers were unsatisfied with the services and social life in their neighbourhoods. Considering the level of the city region, the most challenging feature for the skilled migrants was the social life. The migrants felt that the social environment is homogeneous and difficult to approach. The physical environment was generally rated well, the most appreciated features being public transportation, human scale of the Metropolitan Helsinki, cleanliness, and the urban nature. Urban culture and services were seen good for the city region’s size, but lacking in international comparison.

Water Management in Cambodia Resources and Relations

In Cambodia, water has a special purpose as a source of life and livelihoods. Along with agriculture, fishing and forest use, industry, hydropower, navigation and tourism compete for the water resources. When rights and responsibilities related to essential and movable water are unclear, conflicts emerge easily. Therefore, water management is needed in order to plan and control the use of water resources. The international context is characterized by the Mekong River that flows through six countries. All of the countries by the river have very different roles and interests already depending on their geographical location. At the same time, water is also a tool for cooperation and peace. Locally, the water resources and related livelihoods create base for well-being, for economical and human resources in particular. They in turn are essential for the local people to participate and defend their rights to water use. They also help to construct the resource base of the state administration. Cambodia is highly dependent on the Mekong River. However, Cambodia has a volatile history whose effects can be seen for example in population structure, once suspended public institutions and weakened trust in the society. Relatively stable conditions came to the country as late as in the 1990s, therefore Cambodia for example has a weak status within the Mekong countries. This Master s thesis forms international, national and local interest groups of water use and analyzes their power relations and resources to affect water management. The state is seen as the salient actor as it has the formal responsibility of the water resources and of the coordination between the actions of different levels. In terms of water use this study focuses on production, in management on planning and in power relations on the resources. Water resources of Cambodia are seen consisting of the Mekong River and Tonle Sap Lake and the time span of the study is between the years 1991 and 2006. The material consists of semi-structured interviews collected during summer 2006 in Finland and in Cambodia as well as of literature and earlier studies. The results of the study show that the central state has difficulties to coordinate the actions of different actors because of its resource deficit and internal conflicts. The lessons of history and the vested interests of the actors of the state make it difficult to plan and to strengthen legislation. It seems that the most needed resources at the central state level are intangible as at the village level instead, the tangible resources (fulfilling the basic needs) are primarily important. The local decision-making bodies, NGOs and private sector mainly require legislation and legitimacy to support their role. However, the civil society and the international supporters are active and there are possibilities for new cooperation networks. Keywords: Water management, resources, participation, Cambodia, Mekong