Community Pharmacies and the Needs of Mobile EU Citizens - A study on Finns living in Spain

Migration within the European Union (EU) has increased since the Union was established. Community pharmacies provide open access to health care services and can be the first, most frequently used or even the only contact with a nation s health care system among mobile community residents. In some of the mass-migration areas in Southern Europe, most of the customers may represent mobile citizens of foreign background. This has not always been taken into consideration in the development of community pharmacy services. Mobile patients have been on the EU's health policy agenda, but they have seldom been mentioned in the context of community pharmacies. In most of the EU member states, governments control the specific legislation concerning community pharmacies and there is no harmonised pharmaceutical policy or consistent minimal standards for community pharmacy services in the EU. The aim of this study was to understand medication use, the role of community pharmacies and the symptom mitigation process of mobile community residents. Finns living in Spain were used as an example to examine how community pharmacies in a EU member state meet the needs of mobile community residents. The data were collected by a survey in 2002 (response rate 53%, n= 533) and by five focus group discussions in 2006 (n=30). A large number (70%) of the respondents had moved to Spain for health reasons and suffered from chronic morbidity. Community pharmacies had an important role in the healthcare of mobile community residents and the respondents were mostly satisfied with these services. However, several medication safety risks related to community pharmacy practices were identified: 1) Availability of prescription medicines without prescription (e.g., antibiotics, sleeping pills, Viagra®, asthma medications, cardiovascular medicines, psoriasis medicines and analgesics); 2) Irrational use of medicines (e.g., 41% of antibiotic users had bought their antibiotics without a prescription, and the most common reasons for antibiotic self-medication were symptomatic common colds and sore throats); 3) Language barriers between patients and pharmacy professionals; 4) Lack of medication counselling; 5) Unqualified pharmacy personnel providing pharmacotherapy. A fifth of the respondents reported experiencing problems during pharmacy visits in Spain, and the lack of a common language was the source of most of these problems. The findings of this study indicate that regulations and their enforcement can play a crucial role in actually assuring the rational and safe use of medicines. These results can be used in the development of pharmaceutical and healthcare policies in the EU. It is important to define consistent minimum standards for community pharmacy services in the EU. Then, the increasing number of mobile community residents could access safe and high quality health care services, including community pharmacy services, in every member state within the EU.

Living arrangements and health

In line with major demographic changes in other Northern European and North American countries and Australia, being nonmarried is becoming increasingly common in Finland, and the proportion of cohabiters and of persons living alone has grown in recent decades. Official marital status no longer reflects an individual s living arrangement, as single, divorced and widowed persons may live alone, with a partner, with children, with parents, with siblings, or with unrelated persons. Thus, more than official marital status, living arrangements may be a stronger discriminator of one s social bonds and health. The general purpose of this study was to deepen our current understanding of the magnitude, trends, and determinants of ill health by living arrangements in the Finnish working-age population. Distinct measures of different dimensions of poor health, as well as an array of associated factors, provided a comprehensive picture of health differences by living arrangements and helped to assess the role of other factors in the interpretation of these differences . Mortality analyses were based on Finnish census records at the end of 1995 linked with cause-of-death registers for 1996 2000. The data included all persons aged 30 and over. Morbidity analyses were based on two comparable cross-sectional studies conducted twenty years apart (the Mini-Finland Survey in 1978 80 and the Health 2000 Survey in 2000 01). Both surveys were based on nationally representative samples of Finns aged 30 and over, and benefited from high participation rates. With the exception of mortality analyses, this study focused on health differences among the working-age population (mortality in age groups 30-64 and 65 and over, self-rated health and mental health in the age group 30-64, and unhealthy alcohol use in the age group 30-54). Compared with all nonmarried groups, married men and women exhibited the best health in terms of mortality, self-rated health, mental health and unhealthy alcohol use. Cohabiters did not differ from married persons in terms of self-rated health or mental health, but did exhibit excess unhealthy alcohol use and high mortality, particularly from alcohol-related causes. Compared with the married, persons living alone or with someone other than a partner exhibited elevated mortality as well as excess poor mental health and unhealthy alcohol use. By all measures of health, men and women living alone tended to be in the worst position. Over the past twenty years, SRH had improved least among single men and women and widowed women, and most among cohabiting women. The association between living arrangements and health has many possible explanations. The health-related selection theory suggests that healthy people are more likely to enter and maintain a marriage or a consensual union than those who are unhealthy (direct selection) or that a variety of health-damaging behavioural and social factors increase the likelihood of ill health and the probability of remaining without a partner or becoming separated from one s partner (indirect selection). According to the social causation theory, marriage or cohabitation has a health-promoting effect, whereas living alone or with others than a partner has a detrimental effect on health. In this study, the role of other factors that are mainly assumed to reflect selection, appeared to be rather modest. Social support, which reflects social causation, contributed only modestly to differences in unhealthy alcohol use by living arrangements, but had a larger effect on differences in poor mental health. Socioeconomic factors and health-related behaviour, which reflect both selection and causation, appeared to play a more important role in the excess poor health of cohabiters and of persons living alone or with someone other than a partner, than of married persons. Living arrangements were strongly connected to various dimensions of ill health. In particular, alcohol consumption appeared to be of great importance in the association between living arrangements and health. To the extent that the proportion of nonmarried persons continues to grow and their health does not improve at the same rate as that of married persons, the challenges that currently nonmarried persons pose to public health will likely increase.

Living on the edge : Population genetics of Finno-Ugric-speaking humans in North Eurasia

The major aim of this thesis was to examine the origins and distribution of uniparental and autosomal genetic variation among the Finno-Ugric-speaking human populations living in Boreal and Arctic regions of North Eurasia. In more detail, I aimed to disentangle the underlying molecular and population genetic factors which have produced the patterns of uniparental and autosomal genetic diversity in these populations. Among Finno-Ugrics the genetic amalgamation and clinal distribution of West and East Eurasian gene pools were observed within uniparental markers. This admixture indicates that North Eurasia was colonized through Central Asia/ South Siberia by human groups already carrying both West and East Eurasian lineages. The complex combination of founder effects, gene flow and genetic drift underlying the genetic diversity of the Finno-Ugric- speaking populations were emphasized by low haplotype diversity within and among uniparental and biparental markers. A high prevalence of lactase persistence allele among the North Eurasian Finno- Ugric agriculturalist populations was also shown indicating a local adaptation to subsistence change with lactose rich diet. Moreover, the haplotype background of lactase persistence allele among the Finno- Ugric-speakers strongly suggested that the lactase persistence T-13910 mutation was introduced independently more than once to the North Eurasian gene pool. A significant difference in genetic diversity, haplotype structure and LD distribution within the cytochrome P450 CYP2C and CYP2D regions revealed the unique gene pool of the Finno-Ugric Saami created mainly by population genetic processes compared to other Europeans and sub-Saharan Mandenka population. From all studied populations the Saami showed also significantly the highest allele frequency of a CYP2C19 gene mutation causing variable drug reactions. The diversity patterns observed within CYP2C and CYP2D regions emphasize the strong effect of demographic history shaping genetic diversity and LD especially among such small and constant size populations as the Finno-Ugric-speaking Saami. Moreover, the increased LD in Saami due to genetic drift and/or admixture was shown to offer an advantage for further attempts to identify alleles associated to common complex pharmacogenetic traits.

Effects of living crown reduction on needle element status of Scots pine

A wide range of biotic and abiotic factors, operating over different time perspectives and intensities, cause defoliation and a rapid decrease in the crown size of trees. Scleroderris canker disease [Gremmeniella abietina (Lagerb.) Morelet] has caused widespread crown reduction and tree mortality in Scots pine (Pinus sylvestris L) in forests in Scandinavia during the last three decades. In the 1980's, attempts were made to show, on the basis of the higher foliar N and S concentrations of affected pines in the diseased area, that sulphur and nitrogen deposition predispose trees to G. abietina. Unfortunately, in many studies on defoliated trees, exceptionally high or low needle mineral nutrient concentrations are still often interpreted as one of the causes of tree injury and not, conversely, as the result. In this thesis, three different field experiments, with foliar analysis as the main study method, were conducted in order to asses the possible long-term effects of living crown reduction on the needle nutrient concentrations of Scots pine trees in southern Finland. The crown ratio and length of the living crown were used to estimate the amount of defoliation in the reduced canopies. The material for the partial studies was collected and a total of 968 foliar samples were analysed individually (15-17 elements/sample) on a total of 488 sample trees (140 diseased, 116 pruned and 232 control trees) during the years 1987-1996 in 13 Scots pine stands. All the three experiments of this thesis provided significant evidence that severe, disease-induced defoliation or artificial pruning of the living branches can induce long-lasting nutritional changes in the foliage of the recovering trees under the typical growing conditions for Scots pine. The foliar concentrations of all the 17 mineral nutrients/elements analysed were affected, to a varying degree, by artificial pruning during the following three years. Although Scots pine, as an evergreen conifer, is considered to have low induced chemical responses to defoliation, this study proved experimentally under natural forest conditions that severe artificial pruning or disease-induced defoliation of Scots pine trees may induce biologically significant changes in the concentrations of most of the important macro- and micronutrients, as well as of carbon, in refoliated needles. Concerning the studies in this thesis, I find the results significant in providing new information about the long-term effects of rapid living crown reduction on the foliar nutrient and element status of Scots pine trees. Key words: Foliar analysis, defoliation, needle loss, pruning, nutrients, Pinus sylvestris, Gremmeniella abietina

Living Poetically in the Modern Age : The Situational Aspects of Kierkegaard's Thought

How did Søren Kierkegaard (1813 1855) situate the human subject into historical and social actuality? How did he take into consideration his own situatedness? As key for understanding these questions the research takes the ideal of living poetically that Kierkegaard outlined in his dissertation. In The Concept of Irony (1841) Kierkegaard took up this ideal of the Romantic ironists and made it into an ethical-religious ideal. For him the ideal of living poetically came to mean 1) becoming brought up by God, while 2) assuming ethical-religiously one s role and place in the historical actuality. Through an exegesis of Kierkegaard s texts from 1843 to 1851 it is shown how this ideal governed Kierkegaard s thought and action throughout his work. The analysis of Kierkegaard s ideal of living poetically not only a) shows how the Kierkegaardian subject is situated in its historical context. It also b) sheds light on Kierkegaard s social and political thought, c) helps to understand Kierkegaard s character as a religious thinker, and d) pits his ethical-religious orientation in life against its scientific and commonsense alternatives. The research evaluates the rationality of the way of life championed by Kierkegaard by comparing it with ways of life dominated by reflection and reasoning. It uses Kierkegaard s ideal of living poetically in trying to understand the tensions between religious and unreligious ways of life.

Living on voles - plastic life of the Ural owl

Individuals face variable environmental conditions during their life. This may be due to migration, dispersion, environmental changes or, for example, annual variation in weather conditions. Genetic adaptation to a novel environment happens through natural selection. Phenotypic plasticity allows, however, a quick individual response to a new environment. Phenotypic plasticity may also be beneficial for individual if the environment is highly variable. For example, eggs are costly to produce. If the food conditions vary significantly between breeding seasons it is useful to be able to adjust the clutch and egg size according to the food abundance. In this thesis I use Ural owl vole system to study phenotypic plasticity and natural selection using a number of reproduction related traits. The Ural owl (Strix uralensis) is a long-lived and sedentary species. The reproduction and survival of the Ural owl, in fact their whole life, is tied to the dramatically fluctuating vole densities. Ural owls do not cause vole cycles but they have to adjust their behaviour to the rather predictable population fluctuations of these small mammals. Earlier work with this system has shown that Ural owl laying date and clutch size are plastic in relation to vole abundance. Further, individual laying date clutch size reaction norms have been shown to vary in the amount of plasticity. My work extends the knowledge of natural selection and phenotypic plasticity in traits related to reproduction. I show that egg size, timing of the onset of incubation and nest defense aggressiveness are plastic traits with fitness consequences for the Ural owl. Although egg size is in general thought to be a fixed characteristic of an individual, this highly heritable trait in the Ural owl is also remarkably plastic in relation to the changes in vole numbers, Ural owls are laying the largest eggs when their prey is most abundant. Timing of the onset of incubation is an individual-specific property and plastic in relation to clutch size. Timing of incubation is an important underlying cause for asynchronous hatching in birds. Asynchronous hatching is beneficial to offspring survival in Ural owl. Hence, timing of the onset of incubation may also be under natural selection. Ural owl females also adjust their nest defense aggressiveness according to the vole dynamics, being most aggressive in years when they produce the largest broods. Individual females show different levels of nest defense aggressiveness. Aggressiveness is positively correlated with the phenotypic plasticity of aggressiveness. As elevated nest defense aggressiveness is selected for, it may promote the plasticity of aggressive nest defense behaviour. All the studied traits are repeatable or heritable on individual level, and their expression is either directly or indirectly sensitive to changes in vole numbers. My work considers a number of important fitness-related traits showing phenotypic plasticity in all of them. Further, in two chapters I show that there is individual variation in the amount of plasticity exhibited. These findings on plasticity in reproduction related traits suggest that variable environments indeed promote plasticity.

Vanhustenhuolto + living lab = mahdollinen yhtälö?

Työ on laajaan dokumenttiaineistoon, haastatteluihin ja havaintoihin perustuva living lab - tyyppisen tuotekehitysprosessin yksityiskohtainen kuvaus. Hankehistoriallisessa tapaustutkimuksessa on käytetty historiantutkimuksen menetelmiä. Vanhustenkeskuksessa toteutetun living lab -hankkeen lopputuloksena syntyi vanhusten liikkeitä monitoroiva hoitotyön apuväline: turvalattia. Living lab -tyyppisessä tuotekehittämisessä on keskeistä teknologian kehittäminen tuotteen todellisessa käyttöympäristössä siten, että käyttäjät osallistuvat aktiivisesti kehitystyön kaikkiin vaiheisiin. Tutkimuksessa hankkeen etenemistä ja turvalattiateknologian rakentumista tarkastellaan toimijaverkostoteorian ja yhteisöllisen oppimisen käsitteen tarjoamista näkökulmista. Tutkimuksessa kiinnitetään erityisesti huomiota siihen, minkälaisia intressejä teknologian kehittämiseen osallistuvilla ryhmillä on ja minkälaisia konflikteja näiden intressien pohjalta syntyy. Lisäksi tarkastelun keskiössä on käyttäjien ja tuotekehittäjien välinen oppiminen, jonka mahdollistaminen ja edistäminen on living lab -kehittämisen päämäärä. Tutkimuksen keskeinen johtopäätös on, että käyttäjiltä saatu palaute on välttämätöntä käyttökelpoisen sosiaali- ja terveydenhuollon alan teknologian aikaansaamiseksi, ja turvalattian tapauksessa käyttäjäpalaute myös uudelleensuuntasi teknologisen järjestelmän innovaatioprosessia. Käyttäjien ja tuotekehittäjien yhteistyön myötä turvalattiaan kehitettiin joukko uusia toiminnallisuuksia ja käsitys tuotteen ydinominaisuuksista sekä hyötylupauksesta muuttuivat. Turvalattian tapaus osoittaa lisäksi yhteisöllisen oppimisen merkityksen innovaatioprosessissa sekä living lab -tyyppisen tuotekehittämisen potentiaalin näiden oppimisprosessien mahdollistajana ja kiihdyttäjänä. Tapaus myös valottaa sitä, kuinka monimutkainen toimintakenttä vanhustenhuolto on teknologian kehittämisen ja sen käyttöönoton näkökulmasta. Näyttäisi kuitenkin siltä, että living lab -metodologian avulla voidaan ylittää joitakin geronteknologian kehittämiseen ja myös käyttöönottoon liittyviä haasteita.

Vanhustenhuolto + living lab = mahdollinen yhtälö? Tutkimus geronteknologisen järjestelmän tuotekehitysprosessista

Työ on laajaan dokumenttiaineistoon, haastatteluihin ja havaintoihin perustuva living lab - tyyppisen tuotekehitysprosessin yksityiskohtainen kuvaus. Hankehistoriallisessa tapaustutkimuksessa on käytetty historiantutkimuksen menetelmiä. Vanhustenkeskuksessa toteutetun living lab -hankkeen lopputuloksena syntyi vanhusten liikkeitä monitoroiva hoitotyön apuväline: turvalattia. Living lab -tyyppisessä tuotekehittämisessä on keskeistä teknologian kehittäminen tuotteen todellisessa käyttöympäristössä siten, että käyttäjät osallistuvat aktiivisesti kehitystyön kaikkiin vaiheisiin. Tutkimuksessa hankkeen etenemistä ja turvalattiateknologian rakentumista tarkastellaan toimijaverkostoteorian ja yhteisöllisen oppimisen käsitteen tarjoamista näkökulmista. Tutkimuksessa kiinnitetään erityisesti huomiota siihen, minkälaisia intressejä teknologian kehittämiseen osallistuvilla ryhmillä on ja minkälaisia konflikteja näiden intressien pohjalta syntyy. Lisäksi tarkastelun keskiössä on käyttäjien ja tuotekehittäjien välinen oppiminen, jonka mahdollistaminen ja edistäminen on living lab -kehittämisen päämäärä. Tutkimuksen keskeinen johtopäätös on, että käyttäjiltä saatu palaute on välttämätöntä käyttökelpoisen sosiaali- ja terveydenhuollon alan teknologian aikaansaamiseksi, ja turvalattian tapauksessa käyttäjäpalaute myös uudelleensuuntasi teknologisen järjestelmän innovaatioprosessia. Käyttäjien ja tuotekehittäjien yhteistyön myötä turvalattiaan kehitettiin joukko uusia toiminnallisuuksia ja käsitys tuotteen ydinominaisuuksista sekä hyötylupauksesta muuttuivat. Turvalattian tapaus osoittaa lisäksi yhteisöllisen oppimisen merkityksen innovaatioprosessissa sekä living lab -tyyppisen tuotekehittämisen potentiaalin näiden oppimisprosessien mahdollistajana ja kiihdyttäjänä. Tapaus myös valottaa sitä, kuinka monimutkainen toimintakenttä vanhustenhuolto on teknologian kehittämisen ja sen käyttöönoton näkökulmasta. Näyttäisi kuitenkin siltä, että living lab -metodologian avulla voidaan ylittää joitakin geronteknologian kehittämiseen ja myös käyttöönottoon liittyviä haasteita.