Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Matkalla suomalaiseksi ja hoiva-alan ammattilaiseksi? : Venäläis- ja virolaistaustaisten naisten ja suomalaisuuden kohtaamiset kuulumista rakentamassa

The research examines the process by which a sense of belonging to Finnish society is constructed among women of Russian and Estonian background who are multiply marginalised in Finnish society. It does so by analysing the encounters between their nationality and 'being Finnis'. Attention is focused on the question of what kind of "journey" they take after moving to Finland, how a sense of belonging is constructed especially along the paths followed in education and at work, and what kind of agency is available to them. The thesis is connected with post-colonial research and also draws from studies on citizenship and nationality as well as the social structures of interaction, when analysing careers. As the educational system forms the most central context of the research, the work is also focused on educational sociology. The research methodology includes life history and a narrative approach. The raw data is from thematic interviews concerning the life experiences of women of immigrant backgrounds. They were studying in Finland to be practical nurses or to complete Bachelor of Social Service degree. According to the study, the women had been encountered as alien, strange, and carrying a shade of "otherness". The experience of inclusion in Finnish communities and society turned out to be conditional, an inclusion based on the notion of a citizen worker, which is defined by national needs. The person from abroad is placed in the position of someone who fills gaps in the services of the welfare state. The choice of education in the care sector and the overall necessity of obtaining Finnish education turned out to be socially directed. Gendered structures of education and working life were found to act as a frame in which the decisions of the immigrant women were made. Although national education policy emphasis as an orientation to global labour markets, the immigrant student is placed above all in the position of an object to be made suitable for the Finnish labour market. Citizenship, a goal of education, requires consent to being "socialised" into Finnish society as well as learning to be Finnish. One s only option to negotiate appearing suitable as a member is to construct oneself into someone who adopts Finnish and Western cultural values, values which favour individuality. However, Finnish education is a resource to Finnishness. Finnish education enables a sense of being Finnish, and empowers the job applicant for example, and in addition to providing cultural, human and social capital strengthen inclusion as well. The study confirms the view that the encounter of an immigrant is still characterised by its colonial nature. It shows that encounters with Finns and Finnish society place the person of immigrant background, even one receiving a Finnish education, in the position of "the other". The journey as an immigrant continues. The immigrant has access only to certain predefined subject positions, which limits agency. When categorised as an immigrant, one becomes a per-son who is different and "other", while the sense of belonging as a member of Finnish society without conditions appears to be somewhat unreachable. Yet, new arrivals are capable of acting change. An immigrant woman can challenge the positions offered to her and present herself as strong. Her life story has often included struggle, and she has the fortitude strength to change her circumstances. Key words: life story, post-colonial encounter, nationality, citizenship, the career of immi-grant, position, agency

Stadilaispojat, rikokset ja lastensuojelu : Viisi tapaustutkimusta kuudelta vuosikymmeneltä

Societal reactions to norm breaking behavior of children reveal, how we understand childhood, the relations between generations and communitie's ratio of tolerance. In Finland the children that repeatedly commit crimes receive social service measures that are based on Child Welfare Act. In the city of Helsinki (Stadi in the slang of Helsinki) existed an agency specifically established for ill-behaving children until the 1980's, agter which an unified agency for the maltreated and maladjusted children was founded. Through five boys' welfare cases, this research aims at defining what kind of positions, social relations and structures are constructed in the social dynamics of these children's everyday lives. The cases cover different decades from the 1940s to the present. At the same time the cases reflect the child welfare and societal practices, and reveal how the communities have participated in constructing deviance in different eras. The research is meta-theoretically based on critical realism and specifically on Roy Bhaskar's transformative model of social activity. The cases are analyzed in the framework of Edwin M. Lemert's societal reaction theory. Thus the focus of the study is on the wide structural context of the institutional and societal definitions of deviance. The research is methodologically based on a qualitative multiple case study research. The primary data consist of classified child welfare case files collected from the archives of the city of Helsinki. The data of the institutional level consist of the annual reports from 1943 to 2004 and the ordinances from 1907 onwards, and of various committee documents produced in the law-making process of child welfare, youth and criminal legislation of the 20th century. Empirical finding are interpreted in a dialogue with previous historical and child welfare research, contemporary literature and studies on the urban development. The analysis is based on Derek Layder's model of adaptive theory. The research forms a viewpoint to the historical study of child welfare, in which the historical era, its agents and the dynamics of their mutual relations are studied through an individual level reconstruction based on the societal reaction theory. The case analyses reveal how the positions of the children form differently in the different eras of child welfare practices. In the 1940s the child is positioned as a psychopath and a criminal type. The measures are aimed at protecting the community from the disturbed child, and at adjusting the individual by isolation. From 1960s to 1980s the child is positioned as a child in need of help and support. The child becomes a victim, a subject that occupies rights, and a target of protection. In the turn of the millennium a norm breaking child is positioned as a dangerous individual that, in the name of the community safety, has to be confined. The case analyses also reveal the prevailing academic and practical paradigms of the time. Keywords: childhood, youth, child protection, child welfare, delinquency, crime, deviance, history, critical realism, case study research

Uutta, vanhaa ja lainattua : Tampereen Kaupunkilähetyksen kristillissosiaalisen työn asemoituminen hyvinvointivaltion rakentumisessa vuosina 1939−1973

The main purpose of this study was to provide a full account of the Christian social work carried out at the Tampere City Mission (TCM) as well as the Missions sphere of operations from the Second World War to the early 1970s, comprising a period of significant change. The study consists of charting the processes of change and connections within the activities of the TCM and how examining these were linked to the general tendencies of the period, in lay work, social work, professionalization and the representation of gender. The positioning of the activities is described on the basis of these tendencies. The main sources for the study were the archives of the Mission, for example the minutes of meetings, correspondences as well as annual reports, and the archives of its partners, such as the City of Tampere, the Evangelical Lutheran parishes of Tampere and the State Welfare Administration. The archives of the Helsinki, Turku and Stockholm Missions supplied comparison reference and other material. In particular, social welfare and Christian social work technical journals of were used as printed sources. The principal method used was the genetic method of historiology. The research subject was also evaluated from the point of view of third sector research in addition to that of professionalization studies and gender studies. By the beginning of the research period, the TCM had turned more and more dedicatedly into a multipurpose social service organization maintaining social services such as old people s homes and children´s homes. This development continued, even though new areas of activity emerged and older ones fell into disuse. Social innovations sprang up, marriage counseling being one of them. On the national level, the TCM pioneered the provision of sheltered industrial work for intellectually disabled persons as well as housing services for them. As new activities were initiated, they overlapped with the established ones, and the TCM handed some of its child protection functions over to the municipality, in accordance with the current adaptation theory. The use of its own property to produce ever-changing social services may be the reason why the association s work continued on with vitality. Functional networks and political aid in the field of social services also bolstered the association. As in other Nordic countries, nonprofit organizations served as partners rather than competitors, with the State establishing institutional welfare arrangements. In the 1960s the municipal takeover of social services impacted the TCM activities. Rules for government subsidies and municipal allowances were not well established; hence these funds were not easily available, making improvements difficult. The TCM was a community in which women had a relatively strong position and an opportunity to make a difference. Female staff were reasonably equal to men, and women worked as heads of a several institutions. Care work employed a number of men, which went against the traditional segregation of labour between the sexes. The TCM s operations were from early on very professionalized, and were developed with particular care. Keywords: Christian social work, third sector, professionalization, gender

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.