Trilling race : the political economy of racialised visual-aural encounters

This thesis investigates the matter of race in the context of Finnish language acquisition among adult migrants in Finland. Here matter denotes both the materiality of race and how race comes to matter. Drawing primarily on an auto/ethno/graphic account of learning the Finnish language as a participant in the Finnish for foreigners classes, this thesis problematises the ontology and epistemology of race, i.e., what race is, how it is known, and what an engagement with race entails. Taking cues from the bodily practices of learning the Finnish trill or the rolling r, this study proposes a notion of “trilling race” and argues for an onto-epistemological dis/continuity that marks race’s arrival. The notion of dis/continuity reworks the distinction between continuity and discontinuity, and asks about the how of the arrival of any identity, the where, and the when. In so doing, an analysis of “trilling race” engages with one of the major problematics that has exercised much critical attention, namely: how to read race differently. That is, to rethink the conundrum of the need to counter “representational weight” (Puar 2007, 191) of race on the one hand, and to account for the racialised lived realities on the other. The link between a study of the phenomenon of host country language acquisition and an examination of the question of race is not as obvious as it might seem. For example, what does the argument that the process of language learning is racialised actually imply? Does it mean that race, as a process of racialisation or an ongoing configuration of sets of power relations, exerts force from an outside on the otherwise neutral process of learning the host country language? Or does it mean that race, as an identity category, presents as among the analytical perspectives, along with gender and class for instance, of the phenomenon of host country language acquisition? With these questions in mind, and to foreground the examination of the question of race in the context of Finnish language acquisition among adult migrants, this thesis opens with a discussion of the art installation Finnexia by Lisa Erdman. Finnexia is a fictitious drug said to facilitate Finnish language learning through accelerating the cognitive learning process and reducing the anxiety of speaking the Finnish language. Not only does the Finnexia installation make visible the ways in which the lack of skill in Finnish is fgured as the threshold – a border that separates the inside from the outside – to integration, but also, and importantly, it raises questions about the nature of difference, and the process of differentiation that separates the individual from the social, fact from fiction, nature from culture. These puzzles animate much of the analysis in this dissertation. These concerns continue to be addressed in the rest of part one. Whereas chapter two offers a reconsideration of the ambiguities of ethnisme/ethnicity and race, chapter three dilates on the methodological implications of a conception of the dis/continuity of race. Part two focuses on the matter of race and examines the political economy of visual-aural encounters, whereas part three shifts the focus and rethinks the possibilities and limitations of transforming racialised and normative constraints. Taking up these particular problematics, this thesis as a whole argues that race trills itself: its identity/difference is simultaneously made possible and impossible.

Delivery of European Cross-Border Health Care and the Relevance and Effects of EU Regulations and Judicial Processes with Reference to Delivery of Drugs and Blood Donor Information Material.

Valtion rajat ylittävät terveyspalvelut Euroopan unionissa sekä Euroopan unionin säädösten merkitys ja vaikutus erityisesti lääkejakeluun ja verenluovuttajille jaettavaan tiedotusaineistoon Valtion rajat ylittävä terveydenhuolto on suuren kiinnostuksen kohteena Euroopan unionissa. Resurssien hyödyntäminen parhaalla mahdollisella tavalla ja tiedon keskittäminen ovat tarpeen terveydenhuollon kustannusten alati noustessa. Terveydenhuoltopalvelut kuuluvat Euroopan sisämarkkinoiden vapaan liikkuvuuden piiriin. Euroopan unionilla ei ole kuitenkaan toimivaltaa säädellä terveydenhuoltojärjestelmiä, vaan sen mahdollisuudet ovat enimmäkseen kansanterveyden edistämisessä ja suojelussa, myös muilla toimialueilla kuin terveydenhuollossa. Tutkimuksen tavoitteena oli tutkia Euroopan unionin säädösten vaikutusta terveydenhuoltosektoriin, erityisesti valtion rajat ylittäviin terveydenhuoltopalveluihin. Erityiskohteena olivat lääkemääräyksen toimittaminen toisen Euroopan unionin jäsenmaan apteekista, resepti-lääkkeiden maahantuonti omaan henkilökohtaiseen käyttöön, sähköisen lääkemääräyksen käyttö kansallisesti ja mahdollisuudet sen käyttöön eri jäsenmaiden välillä, online-apteekkien soveltuvuus Euroopan unionin sisämarkkinoille sekä verenluovuttajille jaettavan tiedotusaineiston yhtenäistämistarve Euroopan unionin alueella. Tutkimuksen osa-alueiden aineisto koottiin vuosina 1999–2003, jolloin Euroopan unioniin kuului 15 jäsenmaata. Apteekit toimittivat useimmiten myös ei-kansalliset, toisessa Euroopan unionin jäsenmaassa annetut lääkemääräykset. Kaikki jäsenmaat rajoittivat lääkemääräyksen vaativien lääkkeiden maahantuontia. Rajoituksia oli maahantuontimäärissä ja -tavoissa. Lisäksi sairasvakuutuskorvausten saaminen ulkomailla lunastetuista reseptilääkkeistä oli hankalaa. Sähköiset lääkemääräykset olivat käytössä vain kahdessa maassa, mutta useissa maissa suunniteltiin niiden kokeilua. Standardit ja käyttöjärjestelmät olivat erilaisia eri maissa. Euroopan unionin alueelle on perustettu online-apteekkeja, joiden toiminta on kuitenkin vaatimatonta. Verenluovuttajille annettava tiedotusaineisto ei missään maassa täyttänyt veridirektiivin vaatimuksia. Tutkimuksen tulokset osoittivat kansallisten käytäntöjen eroavaisuuksien rajoittavan valtion rajat ylittäviä terveydenhuoltopalveluita. Vaikka Euroopan unionin tavoitteena ei ole yhtenäistää terveydenhuoltojärjestelmiä, on tarpeen arvioida uudelleen unionin ja jäsenmaiden välistä työnjakoa. Kansalliset terveydenhuoltojärjestelmät eivät ole erillään Euroopan sisämarkkinoista, jotka merkittävästi vaikuttavat terveydenhuoltoon.

IN DUBIO PRO NATURA? A Philosophical Analysis of the Precautionary Principle in Environmental and Health Risk Governance

In this book, I apply a philosophical approach to study the precautionary principle in environmental (and health) risk decision-making. The principle says that unacceptable environmental and health risks should be anticipated, and they ought to be forestalled before the damage comes to fruition even if scientific understanding of the risks is inadequate. The study consists of introductory chapters, summary and seven original publications which aim at explicating the principle, critically analysing the debate on the principle, and constructing a basis for the well-founded use of the principle. Papers I-V present the main thesis of this research. In the two last papers, the discussion is widened to new directions. The starting question is how well the currently embraced precautionary principle stands up to critical philosophical scrutiny. The approach employed is analytical: mainly conceptual, argumentative and ethical. The study draws upon Anglo-American style philosophy on the one hand, and upon sources of law as well as concrete cases and decision-making practices at the European Union level and in its member countries on the other. The framework is environmental (and health) risk governance, including the related law and policy. The main thesis of this study is that the debate on the precautionary principle needs to be shifted from the question of whether the principle (or its weak or strong interpretation) is well-grounded in general to questions about the theoretical plausibility and ethical and socio-political justifiability of specific understandings of the principle. The real picture of the precautionary principle is more complex than that found (i.e. presumed) in much of the current academic, political and public debate surrounding it. While certain presumptions and interpretations of the principle are found to be sound, others are theoretically flawed or include serious practical problems. The analysis discloses conceptual and ethical presumptions and elementary understandings of the precautionary principle, critically assesses current practices invoked in the name of the precautionary principle and public participation, and seeks to build bridges between precaution, engagement and philosophical ethics. Hence, it is intended to provide a sound basis upon which subsequent academic scrutiny can build.

Delivery, Outcome, and Costs of Orthodontic Care in Finnish Health Centres

The goal of the study was to analyse orthodontic care in Finnish health centres with special reference to the delivery, outcome and costs of treatment. Public orthodontic care was studied by two questionnaires sent to the chief dental officers of all health centres (n = 276) and to all specialist orthodontists in Finland (n = 146). The large regional variation was mentioned by the orthodontists as the most important factor requiring improvement. Orthodontic practices and outcome were studied in eight Finnish municipal health centres representing early and late timing of treatment. A random sample of 16- and 18-year-olds (n = 1109) living in these municipalities was examined for acceptability of occlusion with the Occlusal Morphology and Function Index (OMFI). In acceptability of occlusion, only minor differences were found between the two timing groups. The percentage of subjects with acceptable morphology was higher among untreated than among treated adolescents. The costs of orthodontic care were estimated among the adolescents with a treatment history. The mean appliance costs were higher in the late, and the mean visit costs higher in the early timing group. The cost-effectiveness of orthodontic services differed among the health centres, but was almost equal in the two timing groups. National guidelines and delegation of orthodontic tasks were suggested as the tools for reducing the variation among the health centres. In the eight health centres, considerable variation was found in acceptability of occlusion and in cost-effectiveness of services. The cost-effectiveness was not directly connected with the timing of treatment.

Relieved after Doctor's Consultation? Primary Health Care Patients' Complaint-related Worries

Worry is one of the central factors in primary health care patients’ experience with their current complaint. Worry is associated with, e.g., patients’ expectations and the outcomes of doctor’s consultations. The aim of this study was to explore primary health care patients’ complaint-related worry and its changes, as well as contributing factors. Furthermore, the reasons behind patients’ pre-consultation worry and possible relief were examined. The study was conducted in a public primary health care centre in Forssa in Southern Finland. Patients, aged 18–39 years, with a current complaint were interviewed before and after a doctor’s consultation. The patients’ characteristics, perceptions of their complaint and their expectations and experiences concerning the consultation were obtained through interviews. In addition, two questionnaires were administered to measure general tendency to illness worry (IWS) and psychiatric symptoms (SCL-90). The patients’ ratings of the intensity of worry and the severity of their complaint were measured with a visual analogue scale (VAS 0–100). Changes in worry were measured by comparing pre- and post-consultation VAS ratings and asking the patients to compare their worry after the consultation with the worry they felt before it. In connection with these ratings the patients also gave reasons for their experiences in their own words. The patients’ doctors assessed the medical severity of the complaints and whether they had found a medical explanation for the complaints. Many patients were very worried before the consultation (65 % scored over 50 points on the VAS). Worry and severity ratings were associated with the duration and course of the complaint, with a general tendency to illness worry and hostility. On average, the patients were less worried after the consultation than before it. Persistent worry was associated with the patients’ uncertainty about their complaint, their perceiving it as severe, expectations for examinations and reporting symptoms of anxiety. Patients were most often worried about the nature of their complaint (e.g. duration or intensity), not knowing what was wrong, the possible harmful effects of the complaint on body functions, the complaint’s prognosis, e.g. will it get better, and their ability to function. Patients were relieved by getting an explanation or treatment or by having a positive view of the complaint’s prognosis. Patients who reported uncertainty (lack of an explanation, worry about the nature of the complaint) or worry about the complaint’s possible bodily harmfulness were relieved by getting an explanation, often accompanied with getting treatment. On the other hand, worries about the ability to function tended to persist. Doctors should bring up patients’ worries for discussion in order to be able to respond to them appropriately. Because it tends to persist, worry about the ability to function should be addressed. Uncertain patients with concerns about their complaint’s bodily harmfulness or psychological consequences need special attention from their doctor.

Foot Health In Older People - Development of a preventive, evaluative instrument for nurses

Foot health is a part of overall health in every age group and its importance increases during ageing. Health care professionals are in a vital position for preventing foot health problems, and identifying and caring them in older people. Despite the rather high number of studies conducted in the field of foot health in older people, reliable and valid nurse-administered foot health assessment instruments seem to be lacking. By identifying foot health in older people, it is possible to develop nursing interventions to enhance safe, independent living at home. The purpose of this three-phase study was to develop an instrument to assess the level of foot health in older people and evaluate foot care practices from the perspective of older people themselves and nurses in home care. The ultimate goal is to prevent foot health problems by increasing the attention paid to older people’s feet and recognizing those foot health problems which need further care; thus not focus on different foot health problems. The study was conducted in different phases and contexts. In phase 1, a descriptive design with a literature review from the Medline (R) and CINAHL databases to explore foot health in older people and nurses’ role in foot health care and pre-post design intervention study in nursing home with nursing staff (n=16) and older residents (n=43) were conducted. In phase 2, a descriptive and explorative study design was employed to develop an instrument for assessing foot health in older people (N=651, n=309, response rate 47%) and explore the psychometrics of the instrument. The data were collected from sheltered housing and home care settings. Finally, in phase 3, descriptive and explorative as well as cross-sectional correlational survey designs were used to assess foot health and evaluate the foot self-care activities of older people (N=651, n=309, response rate 47%) and to describe foot care knowledge and caring activities of nurses (N=651, n=322, response rate 50%) in home care in Finland. To achieve this, the Foot Health Assessment Instrument (FHAI) developed in phase 2 was used; at the same time, this large sample also was used for the psychometric evaluation of the FHAI. The data analysis methods used in this study were content analysis, descriptive and inferential statistics including factor and multivariate analysis. Many long-term diseases can manifest in feet. Therefore, the FHAI, developed in this study consisted of items relating to skin and nail health, foot structure and foot pain. The FHAI demonstrated acceptable preliminary psychometric properties. A great deal of different foot health problems in older people were found of which edema, dry skin, thickened and discoloured toenails and hallux valgus were the most prevalent foot health problems. Moreover, many older people had difficulties in performing foot self-care. Nurses’ knowledge of foot care was insufficient and revealed a need for more information and continuing education in matters relating to foot care in older people. Instead, nurses’ foot care activities were mainly adequate, though the findings indicate the need for updating foot care activities to correspond with the evidence found in the field of foot care. Practical implications are presented for nursing practice, education and administration. In future, research should focus on developing interventions for older people and nurses to promote foot health in older people and to prevent foot health problems, as well as for further development of the FHAI.

Sick leave prescribing practices in Finland

Background: Sick leave prescribing is a common task of doctors and being on sick leave results in notable economic consequences to society. However, there appears to be limited research into this field and the factors affecting sick leave prescribing practices of doctors. Aims: To examine the prescribing of sick leave by doctors and dentists, the extent of variation in practices, whether clinician-related factors and local structural factors affect variation, and the economic consequences of varying practices. Materials and methods: Questionnaire studies with 19 or 16 hypothetical patient cases were conducted among 165 primary health care (PHC) physicians, 356 occupational health care (OHC) physicians, 338 surgeons and 1132 dentists. Results: The difference between the lowest and the highest number of sick leave days prescribed for the 19 patient cases was almost four-fold in PHC physicians and surgeons and eight-fold in OHC physicians, which represents a societal cost of tens of thousands of euros. Some dentists did not prescribe sick leave to any of the 16 patient cases, and some prescribed nearly a hundred days altogether. The overall number of sick leave days OHC physicians prescribed was smaller than in PHC physicians. More days of sick leave were prescribed by those working in smaller municipalities than larger population centres. Conclusion: There was considerable variation in the sick leave prescribing practices of Finnish health care professionals. This means that patients may not receive equal social benefits. Sick leave carries considerable economic consequences, and unifying prescribing practices could bring significant cost savings to society.

Schools as Oral Health Promoters – Evaluation of National Sweet Selling Recommendation and Oral Health Education Material

The aims were to find out 1) if schools’ oral health practices were associated with pupils’ oral health behaviour and whether 2) the national sweet-selling recommendation and 3) distributing oral health material (OHEM) affected schools as oral health promoters. Three independently collected datasets from Finnish upper comprehensive schools (N=988) were used: longitudinal oral health practices data (n=258) with three-year follow up (2007 n=480, 2008 n=508, 2009 n=593) from principals’ online questionnaires, oral health behaviour data from pupils participating in the national School Health Promotion Study (n=970 schools) and oral health education data from health education teachers’ online questionnaires (2008 n=563, 2009 n=477 teachers). Oral health practices data and oral health behaviour data were combined (n=414) to answer aim 1. For aims 2 and 3, oral health practices data and oral health education data were used independently. School sweet selling and an open campus policy were associated with pupils’ use of sweet products and tobacco products during school time. The National Recommendation was quite an effective way to reduce the number of sweet-selling schools, but there were large regional differences and a lack of a clear oral health policy in the schools. OHEM did not increase the proportion of teachers teaching oral health, but teachers started to cover oral health topics more frequently. Women started to use OHEM more often than men did. Schools’ oral health policy should include prohibiting the selling of sweet products in school by legislative actions, enabling healthy alternatives instead, and setting a closed campus policy to protect pupils from school-time sweet consuming and smoking.

Modularity in Health and Social Services: Perspectives on Organization and Management

Organizations that provide health and social services operate in a complex and constantly changing environment. Changes occur, for example, in ageing, technology and biotechnology, and customers’ expectations, as well as the global economic situation. Organizations typically aim to adapt the changes by introducing new organizational structures and managerial practices, such as process and lean management. Only recently has there been an interest in evaluating whether organizations providing health and social services could apply modularity in order to respond to some of the changes. The concept of modularity originates from manufacturing, but is applied in many other disciplines, such as information technology and logistics. However, thus far, the literature concerning modularity in health and social services is scarce. Therefore the purpose of this thesis is to increase understanding concerning modularity and the possibilities to apply modularity in the health and social services context. In addition, the purpose is to shed light on the viewpoints that are worth taking into account when considering the application of modularity in the health and social services context. The aim of the thesis is to analyze the way in which the modular structures are applied in the health and social services context and to analyze what advantages and possible barriers, as well as managerial concerns, might occur if modularity is applied in the health and social services context. The thesis is conducted by using multiple methods in order to provide a broad aspect to the topic. A systematic literature review provided solid ground for pre-understanding the topic and supported the formulation of the research questions. Theoretical reasoning provided a general overview of the special characteristics of the health and social services context and their effect on application of modularity. Empirical studies concentrated on managerial concerns of modularity particularly from the perspective of health and social services for the elderly. Results of the thesis reveal that structures in products, services, processes, and organizations are rather modular in health and social services. They can be decomposed in small independent units, while the challenges seem to occur especially in the compatibility of the services. It seems that health and social services managers have recognized this problem and they are increasingly paying attention to this challenge in order to enhance the flexible compatibility of services. Advantages and possible barriers of modularity are explored in this thesis, and from the theoretical perspective it could be argued that modularity seems to be beneficial in the context of health and social services. In fact, it has the potential to alleviate several of the challenges that the health and social services context is confronting. For example, modular structures could support organizations in their challenging task to respond to customers’ increasing demand for heterogeneous services. However, special characteristics of the health and social services context create barriers and provide significant challenges in application of modularity. For example, asymmetry of information, negative externalities, uncertainty of demand, and rigid regulation prevent managers from extensively drawing benefits from modularity. Results also reveal that modularity has managerial implications in health and social service. Modularity has the potential to promote and support new service development and outsourcing. Results also provide insights into network management and increases managerial understanding of different network management strategies. Standardization in health and social services is extensive due to legislation and recommendations. Modularity provides alternative paths to take an advantage of standardization while still ensuring the quality of the services. Based on this thesis, it can be concluded, both from a theoretical perspective and from empirical results concerning modularity in health and social services, that modularity might fit well and be beneficial. However, the special characteristics of the health and social services context prevent some of the benefits of modularity and complicate its application. This thesis contributes to the academic literature on the organization and management of health and social services by describing modularity as an alternative way for organizing and managing health and social services. In addition, it contributes to the literature of modularity by exploring the applicability of modularity in the context of health and social services. It also provides practical contribution to health and social services managers by evaluating the pros and cons of modularity when applied to health and social services.