Preventive Dentistry and Dental Education in Iran

The present study investigated the preventive orientation of the dental education system in Iran as reflected in the responses of dental school educators and dental students to a questionnaire survey. Two questionnaires, one for dental school educators and one for senior dental students, were designed and piloted. Of the 15 state dental schools in Iran, 7 were selected using a multi-stage sampling approach, and all the dental school educators and senior dental students in these schools were asked to voluntarily fill in the anonymous questionnaires. Totally, 291 educators (80%) and 270 students (82%) participated in the study. In addition to background information, both questionnaires requested information on knowledge of caries prevention, attitudes towards preventive dentistry and oral health behaviour of the respondents. The students' questionnaire also covered items concerning prevention-oriented practice, study motives, and career preferences. Contrary to knowledge and attitudes of the students, those of the educators' were positively associated with some of their academic and personal background characteristics. Women were more likely to report favourable oral self-care habits than men. The other determinants of oral health behaviour were educators' familiarity with the oral public health field, and students' attitudes towards prevention. A higher score on preventive practice among the students was associated with better oral self-care habits and positive attitudes towards prevention. Characteristics of the profession and social status and security were the top-ranked that motivated students to study dentistry, and students mainly preferred to enter postgraduate courses and private practice after graduation. To increase the orientation of Iran's health care system towards prevention, and to cope with current concepts of prevention, corresponding changes should be made in the dental education system. The results of this study support the revision of the dental curriculum by placing more emphasis on prevention-related topics and by integrating prevention-related concepts into all disciplines. Additionally, practicing dentists and dental educators should be provided with opportunities to attend continuing education courses and to conduct seminars and congresses on various aspects of preventive dentistry at home as well as abroad.

Questions to Artificial Nature: A Philosophical Study of Interdisciplinary Models and their Functions in Scientific Practice

This thesis presents an interdisciplinary analysis of how models and simulations function in the production of scientific knowledge. The work is informed by three scholarly traditions: studies on models and simulations in philosophy of science, so-called micro-sociological laboratory studies within science and technology studies, and cultural-historical activity theory. Methodologically, I adopt a naturalist epistemology and combine philosophical analysis with a qualitative, empirical case study of infectious-disease modelling. This study has a dual perspective throughout the analysis: it specifies the modelling practices and examines the models as objects of research. The research questions addressed in this study are: 1) How are models constructed and what functions do they have in the production of scientific knowledge? 2) What is interdisciplinarity in model construction? 3) How do models become a general research tool and why is this process problematic? The core argument is that the mediating models as investigative instruments (cf. Morgan and Morrison 1999) take questions as a starting point, and hence their construction is intentionally guided. This argument applies the interrogative model of inquiry (e.g., Sintonen 2005; Hintikka 1981), which conceives of all knowledge acquisition as process of seeking answers to questions. The first question addresses simulation models as Artificial Nature, which is manipulated in order to answer questions that initiated the model building. This account develops further the "epistemology of simulation" (cf. Winsberg 2003) by showing the interrelatedness of researchers and their objects in the process of modelling. The second question clarifies why interdisciplinary research collaboration is demanding and difficult to maintain. The nature of the impediments to disciplinary interaction are examined by introducing the idea of object-oriented interdisciplinarity, which provides an analytical framework to study the changes in the degree of interdisciplinarity, the tools and research practices developed to support the collaboration, and the mode of collaboration in relation to the historically mutable object of research. As my interest is in the models as interdisciplinary objects, the third research problem seeks to answer my question of how we might characterise these objects, what is typical for them, and what kind of changes happen in the process of modelling. Here I examine the tension between specified, question-oriented models and more general models, and suggest that the specified models form a group of their own. I call these Tailor-made models, in opposition to the process of building a simulation platform that aims at generalisability and utility for health-policy. This tension also underlines the challenge of applying research results (or methods and tools) to discuss and solve problems in decision-making processes.

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.

Preventive orientation and caries management by Iranian dentists

Ehkäisypainotteisuus karieksen hoidossa: iranilaishammaslääkärien hoitovalinnat Karies aiheuttaa hampaiden kovan pinnan ja hammasluun syöpymistä, joka lopulta näkyy ”reikänä”. Iästä riippumatta kariesvaara vaanii kaikkia hampaiden omistajia, vauvasta vaariin, ja lähes kaikilla aikuisilla on suussaan merkkejä karieksesta. Karies etenee yleensä hitaasti ja antaa siten aikaa ehkäisevälle hoidolle. Tämä etsikkoaika jää usein käyttämättä, ja karieksen hoito painottuu reikien paikkaamiseen. Karies voitaisiin pitää kurissa sen ehkäisyyn kehitetyillä monipuolisilla keinoilla. Hammaslääkärit ovat avainasemassa, sillä he tekevät kauaskantoisia valintoja — hoidetaanko kariesta paikkaamalla vai valitaanko ehkäisevä hoito? Valintojen taustalla ovat hammaslääkärin tietotaso, asenteet ja omat terveystavat sekä potilaiden ja vastaanoton aiheuttamiksi koetut esteet. Tämä kyselytutkimus selvitti karieksen hoitovalintoja ja niiden taustoja Iranissa. Kysymyslomakkeet jaettiin kahdessa hammaslääkärien kongressissa Teheranissa (2004─2005) ja palautettiin nimettöminä. Kysely kartoitti hammaslääkärien tietoja karieksen ehkäisykeinoista ja asenteita ehkäisyä kohtaan sekä koettuja esteitä sen toteuttamisessa. Hoitovalintoja selvitettiin tarkasti kuvattujen esimerkkipotilaiden avulla. Kysely kartoitti myös hammaslääkärien omat terveystavat: suun omahoidon, tupakoinnin ja hammaslääkärissä käynnin. Aineisto käsitti 980 iältään keskimäärin 37-vuotiasta hammaslääkäriä, joista 64 % oli miehiä. Iranilaishammaslääkärien tiedot karieksen ehkäisystä olivat fluorihammastahnan merkitystä lukuun ottamatta hyvät ja heidän asenteensa ehkäisyä kohtaan valtaosin myönteiset. Tästä huolimatta 77 % heistä olisi valinnut suuren kariesvaaran potilaalle hammaskiilteessä olevan reiän hoidoksi paikkauksen. Ehkäisyhoidoksi tarjotuista 8:sta keinosta lähes kaikki hammaslääkärit valitsivat suuren kariesvaaran potilaalle hoidoksi harjausopetuksen ja säännölliset hammastarkastukset, noin 80 % valitsi hampaiden puhdistamisen vastaanotolla ja ravintoneuvonnan, 70 % ohjeet fluorihuuhteluista kotona ja 53 % vastaanotolla tehtävän fluorikäsittelyn. Potilaiden vastustavat mielipiteet arvioitiin suurimmaksi esteeksi ehkäisevän hoidon toteuttamiselle. Hammaslääkäreistä 59 % ilmoitti harjaavansa hampaansa kahdesti päivässä; 76 % ei tupakoinut ja 56 % kertoi aina ehdottavansa tupakoivalle potilaalle tupakoinnin lopettamista. Hammaslääkärien ehkäisypainotteisuus karieshoidossa oli naisilla vahvempi kuin miehillä. Tulosten perusteella voi päätellä, että Iranissa tulisi nykyistä selvemmin suosia ehkäisevää linjaa karieksen hoitovalintoja tehtäessä ja hammaslääkäreitä koulutettaessa. Potilastyössä koettujen ehkäisyhoidon esteiden syvällisempi ymmärtäminen edesauttaisi niiden poistamisessa.

Arresting occlusal enamel caries lesions with pit and fissure sealants

The aim of this study was to evaluate the feasibility of pit and fissure sealants and the effectiveness of the two sealant methods applied in every-day practice in public dental health care in Finland. Two sealant methods were evaluated according to their effectiveness in preventing dentin caries and sealant retention. Application time with these sealant methods was compared. The survival rate of sealed first and second molars was followed for nine and 13 year periods, respectively. Caries risk evaluation and observed increased caries risk were the basis for considering sealant application. A questionnaire, sent to all public dental health centers in Finland, monitored the attitudes of the dental profession towards sealant application and explored the current policies used as well as changes noted in the sealant application protocol. DMFT (Decayed, Missing or Filled Teeth) index values collected from the health centers were evaluated. The difference in caries rate between two methods investigated was highly significant. When compared to the glass ionomer sealant method (GIC), the effectiveness of the resin-based method (RB) in preventing dentin caries was 74% and the rate difference 3%. The relative risk for RB-sealed surfaces vs. GIC-sealed surfaces of having detectable dentin caries was 0.3 (95% CI 0.12, 0.57). The retention rate of sealants was higher with RB than GIC (P<0.001). Application of RB sealant material was less time-consuming than application of GIC sealant. Occlusal dentin caries lesions were found in 4% and proximal caries in less than 2% of sealed teeth. The majority of respondents reported application of sealants on a systematic basis along with caries-risk evaluation. Those health centers sealing over suspected or detected enamel caries had lower average DMFT index values (1.0) when compared to DMFT values (1.2) of health centers applying sealants by alternative criteria. It is concluded that the RB sealant method is more effective than the GIC sealant method in preventing dentin caries. Sealant maintenance may increase the costs of a sealant program. Occlusal caries management may be improved if the applied sealant policies are changed towards an interceptive approach i.e. applying the sealants over detected or suspected enamel caries lesions instead of sealing sound teeth in a preventive manner.

Cone beam computed tomography in oral radiology

In dentistry, basic imaging techniques such as intraoral and panoramic radiography are in most cases the only imaging techniques required for the detection of pathology. Conventional intraoral radiographs provide images with sufficient information for most dental radiographic needs. Panoramic radiography produces a single image of both jaws, giving an excellent overview of oral hard tissues. Regardless of the technique, plain radiography has only a limited capability in the evaluation of three-dimensional (3D) relationships. Technological advances in radiological imaging have moved from two-dimensional (2D) projection radiography towards digital, 3D and interactive imaging applications. This has been achieved first by the use of conventional computed tomography (CT) and more recently by cone beam CT (CBCT). CBCT is a radiographic imaging method that allows accurate 3D imaging of hard tissues. CBCT has been used for dental and maxillofacial imaging for more than ten years and its availability and use are increasing continuously. However, at present, only best practice guidelines are available for its use, and the need for evidence-based guidelines on the use of CBCT in dentistry is widely recognized. We evaluated (i) retrospectively the use of CBCT in a dental practice, (ii) the accuracy and reproducibility of pre-implant linear measurements in CBCT and multislice CT (MSCT) in a cadaver study, (iii) prospectively the clinical reliability of CBCT as a preoperative imaging method for complicated impacted lower third molars, and (iv) the tissue and effective radiation doses and image quality of dental CBCT scanners in comparison with MSCT scanners in a phantom study. Using CBCT, subjective identification of anatomy and pathology relevant in dental practice can be readily achieved, but dental restorations may cause disturbing artefacts. CBCT examination offered additional radiographic information when compared with intraoral and panoramic radiographs. In terms of the accuracy and reliability of linear measurements in the posterior mandible, CBCT is comparable to MSCT. CBCT is a reliable means of determining the location of the inferior alveolar canal and its relationship to the roots of the lower third molar. CBCT scanners provided adequate image quality for dental and maxillofacial imaging while delivering considerably smaller effective doses to the patient than MSCT. The observed variations in patient dose and image quality emphasize the importance of optimizing the imaging parameters in both CBCT and MSCT.

Preadolescents and Their Mothers as Oral Health-Promoting Actors : Non-biologic Determinants of Oral Health among Turkish and Finnish Preadolescents

Is oral health becoming a part of the global health culture? Oral health seems to turn out to be part of the global health culture, according to the findings of a thesis-research, Institute of Dentistry, University of Helsinki. The thesis is entitled as “Preadolescents and Their Mothers as Oral Health-Promoting Actors: Non-biologic Determinants of Oral Health among Turkish and Finnish Preadolescents.” The research was supervised by Prof.Murtomaa and led by Dr.A.Basak Cinar. It was conducted as a cross-sectional study of 611 Turkish and 223 Finnish school preadolescents in Istanbul and Helsinki, from the fourth, fifth, and sixth grades, aged 10 to 12, based on self-administered and pre-tested health behavior questionnaires for them and their mothers as well as the youth’s oral health records. Clinically assessed dental status (DMFT) and self-reported oral health of Turkish preadolescents was significantly poorer than the Finns`. A similar association occurred for well-being measures (height and weight, self-esteem), but not for school performance. Turkish preadolescents were more dentally anxious and reported lower mean values of toothbrushing self-efficacy and dietary self-efficacy than did Finns. The Turks less frequently reported recommended oral health behaviors (twice daily or more toothbrushing, sweet consumption on 2 days or less/week, decreased between-meal sweet consumption) than did the Finns. Turkish mothers reported less frequently dental health as being above average and recommended oral health behaviors as well as regular dental visits. Their mean values for dental anxiety was higher and self-efficacy on implementation of twice-daily toothbrushing were lower than those of the Finnish. Despite these differences between the Turks and Finns, the associations found in common for all preadolescents, regardless of cultural differences and different oral health care systems, assessed for the first time in a holistic framework, were as follows: There seems to be interrelation between oral health and general-well being (body height-weight measures, school performance, and self-esteem) among preadolescents: • The body height was an explanatory factor for dental health, underlining the possible common life-course factors for dental health and general well-being. • Better school performance, high levels of self-esteem and self-efficacy were interrelated and they contributed to good oral health. • Good school performance was a common predictor for twice-daily toothbrushing. Self-efficacy and maternal modelling have significant role for maintenance and improvement of both oral- and general health- related behaviors. In addition, there is need for integration of self-efficacy based approaches to promote better oral health. • All preadolescents with high levels of self-efficacy were more likely to report more frequent twice-daily toothbrushing and less frequent sweet consumption. • All preadolescents were likely to imitate toothbrushing and sweet consumption behaviors of their mothers. • High levels of self-efficacy contributed to low dental anxiety in various patterns in both groups. As a conclusion: • Many health-detrimental behaviors arise from the school age years and are unlikely to change later. Schools have powerful influences on children’s development and well-being. Therefore, oral health promotion in schools should be integrated into general health promotion, school curricula, and other activities. • Health promotion messages should be reinforced in schools, enabling children and their families to develop lifelong sustainable positive health-related skills (self-esteem, self-efficacy) and behaviors. • Placing more emphasis on behavioral sciences, preventive approaches, and community-based education during undergraduate studies should encourage social responsibility and health-promoting roles among dentists. Attempts to increase general well-being and to reduce oral health inequalities among preadolescents will remain unsuccessful if the individual factors, as well as maternal and societal influences, are not considered by psycho-social holistic approaches.

Health-Related Quality of Life, Costs and Treatment of Inflammatory Rheumatic Diseases in Routine Practice : With special emphasis on biological drugs

Rheumatoid arthritis (RA) and other chronic inflammatory joint diseases already begin to affect patients health-related quality of life (HRQoL) in the earliest phases of these diseases. In treatment of inflammatory joint diseases, the last two decades have seen new strategies and treatment options introduced. Treatment is started at an earlier phase; combinations of disease-modifying anti-rheumatic drugs (DMARDs) and corticosteroids are used; and in refractory cases new drugs such as tumour necrosis factor (TNF) inhibitors or other biologicals can be started. In patients with new referrals to the Department of Rheumatology of the Helsinki University Central Hospital, we evaluated the 15D and the Stanford Health Assessment Questionnaire (HAQ) results at baseline and approximately 8 months after their first visit. Altogether the analysis included 295 patients with various rheumatic diseases. The mean baseline 15D score (0.822, SD 0.114) was significantly lower than for the age-matched general population (0.903, SD 0.098). Patients with osteoarthritis (OA) and spondyloarthropathies (SPA) reported the poorest HRQoL. In patients with RA and reactive arthritis (ReA) the HRQoL improved in a statistically significant manner during the 8-month follow-up. In addition, a clinically important change appeared in patients with systemic rheumatic diseases. HAQ score improved significantly in patients with RA, arthralgia and fibromyalgia, and ReA. In a study of 97 RA patients treated either with etanercept or adalimumab, we assessed their HRQoL with the RAND 36-Item Health Survey 1.0 (RAND-36) questionnaire. We also analysed changes in clinical parameters and the HAQ. With etanercept and adalimumab, the values of all domains in the RAND-36 questionnaire increased during the first 3 months. The efficacy of each in improving HRQoL was statistically significant, and the drug effects were comparable. Compared to Finnish age- and sex-matched general population values, the HRQoL of the RA patients was significantly lower at baseline and, despite the improvement, remained lower also at follow-up. Our RA patients had long-standing and severe disease that can explain the low HRQoL also at follow-up. In a pharmacoeconomic study of patients treated with infliximab we evaluated medical and work disability costs for patients with chronic inflammatory joint disease during one year before and one year after institution of infliximab treatment. Clinical and economic data for 96 patients with different arthritis diagnoses showed, in all patients, significantly improved clinical and laboratory variables. However, the medical costs increased significantly during the second period by 12 015 (95% confidence interval, 6 496 to 18 076). Only a minimal decrease in work disability costs occurred mean decrease 130 (-1 268 to 1 072). In a study involving a switch from infliximab to etanercept, we investigated the clinical outcome in 49 patients with RA. Reasons for switching were in 42% failure to respond by American College of Rheumatology (ACR) 50% criteria; in 12% adverse event; and in 46% non-medical reasons although the patients had responded to infliximab. The Disease Activity Score with 28 joints examined (DAS28) allowed us to measure patients disease activity and compare outcome between groups based on the reason for switching. In the patients in whom infliximab was switched to etanercept for nonmedical reasons, etanercept continued to suppress disease activity effectively, and 1-year drug survival for etanercept was 77% (95% CI, 62 to 97). In patients in the infliximab failure and adverse event groups, DAS28 values improved significantly during etanercept therapy. However, the 1-year drug survival of etanercept was only 43% (95% CI, 26 to 70) and 50% (95% CI, 33 to 100), respectively. Although the HRQoL of patients with inflammatory joint diseases is significantly lower than that of the general population, use of early and aggressive treatment strategies including TNF-inhibitors can improve patients HRQoL effectively. Further research is needed in finding new treatment strategies for those patients who fail to respond or lose their response to TNF-inhibitors.

Finnish Dosimetric Practice for Epithermal Neutron Beam Dosimetry in Boron Neutron Capture Therapy

Boron neutron capture therapy (BNCT) is a form of chemically targeted radiotherapy that utilises the high neutron capture cross-section of boron-10 isotope to achieve a preferential dose increase in the tumour. The BNCT dosimetry poses a special challenge as the radiation dose absorbed by the irradiated tissues consists of several dose different components. Dosimetry is important as the effect of the radiation on the tissue is correlated with the radiation dose. Consistent and reliable radiation dose delivery and dosimetry are thus basic requirements for radiotherapy. The international recommendations for are not directly applicable to BNCT dosimetry. The existing dosimetry guidance for BNCT provides recommendations but also calls for investigating for complementary methods for comparison and improved accuracy. In this thesis the quality assurance and stability measurements of the neutron beam monitors used in dose delivery are presented. The beam monitors were found not to be affected by the presence of a phantom in the beam and that the effect of the reactor core power distribution was less than 1%. The weekly stability test with activation detectors has been generally reproducible within the recommended tolerance value of 2%. An established toolkit for epithermal neutron beams for determination of the dose components is presented and applied in an international dosimetric intercomparison. The measured quantities (neutron flux, fast neutron and photon dose) by the groups in the intercomparison were generally in agreement within the stated uncertainties. However, the uncertainties were large, ranging from 3-30% (1 standard deviation), emphasising the importance of dosimetric intercomparisons if clinical data is to be compared between different centers. Measurements with the Exradin type 2M ionisation chamber have been repeated in the epithermal neutron beam in the same measurement configuration over the course of 10 years. The presented results exclude severe sensitivity changes to thermal neutrons that have been reported for this type of chamber. Microdosimetry and polymer gel dosimetry as complementary methods for epithermal neutron beam dosimetry are studied. For microdosimetry the comparison of results with ionisation chambers and computer simulation showed that the photon dose measured with microdosimetry was lower than with the two other methods. The disagreement was within the uncertainties. For neutron dose the simulation and microdosimetry results agreed within 10% while the ionisation chamber technique gave 10-30% lower neutron dose rates than the two other methods. The response of the BANG-3 gel was found to be linear for both photon and epithermal neutron beam irradiation. The dose distribution normalised to dose maximum measured by MAGIC polymer gel was found to agree well with the simulated result near the dose maximum while the spatial difference between measured and simulated 30% isodose line was more than 1 cm. In both the BANG-3 and MAGIC gel studies, the interpretation of the results was complicated by the presence of high-LET radiation.

Balancing Social Citizenship and New Paternalism : Finnish activation policy and street-level practice in a comparative perspective

The study examines the origin and development of the Finnish activation policy since the mid-1990s by using the 2001 activation reform as a benchmark. The notion behind activation is to link work obligations to welfare benefits for the unemployed. The focus of the thesis is policy learning and the impact of ideas on the reform of the welfare state. The broader research interests of the thesis are summarized by two groups of questions. First, how was the Finnish activation policy developed and what specific form did it receive in the 2001 activation reform? Second, how does the Finnish activation policy compare to the welfare reforms in the EU and in the US? What kinds of ideas and instruments informed the Finnish policy? To what extent can we talk about a restructuring or transformation of the Nordic welfare policy? Theoretically, the thesis is embedded in the comparative welfare state research and the concepts used in the contemporary welfare state discourse. Activation policy is analysed against the backdrop of the theories about the welfare state, welfare state governance and citizenship. Activation policies are also analysed in the context of the overall modernization and individualization of lifestyles and its implications for the individual citizen. Further, the different perspectives of the policy analysis are applied to determine the role of implementation and street-level practice within the whole. Empirically, the policy design, its implementation and the experiences of the welfare staff and recipients in Finland are examined. The policy development, goals and instruments of the activation policies have followed astonishingly similar paths in the different welfare states and regimes over the last two decades. In Finland, the policy change has been manifested through several successive reforms that have been introduced since the mid-1990s. The 2001 activation reform the Act on Rehabilitative Work Experience illustrates the broader trend towards stricter work requirements and draws its inspiration from the ideas of new paternalism. The ideas, goals and instruments of the international activation trend are clearly visible in the reform. Similarly, the reform has implications for the traditional Nordic social policies, which incorporate institutionalised social rights and the provision of services.