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.

Supporting older people’s independent living at home through social and health care collaboration

Tässä tutkimuksessa tarkasteltiin ikäihmisten kotona asumista sosiaali- ja terveydenhuollon yhteistyön näkökulmasta. Tutkimuksen tarkoituksena oli lisätä ymmärrystä iäkkäiden kotihoidon asiakkaiden voimavaroista arjesta selviytymisen näkökulmasta, ja tutkia miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutuu. Tutkimus oli poikkileikkaustutkimus, jossa sovellettiin kuvailevaa ja vertailevaa tutkimusasetelmaa. Tutkimusaineisto kerättiin yhden länsisuomalaisen kunnan kotihoidon asiakkailta (≥65 v.) ja heitä hoitavilta ammattihenkilöiltä. Kotihoidon 21 iäkästä asiakasta kuvasivat omia voimavarojaan arjesta selviytymisen näkökulmasta sekä kokemuksiaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin avoimella haastattelulla ja analysoitiin sisällön analyysillä. Lisäksi 25 kotihoidon ammattihenkilöä: 13 kotipalvelun työntekijää, 11 kotisairaanhoitajaa ja lääkäri kuvasivat kokemuksiaan iäkkään asiakkaan hoidon toteutumisesta ammattihenkilöiden yhteistyönä. Aineisto kerättiin fokusryhmähaastattelulla ja analysoitiin sisällön analyysillä. Näiden tulosten sekä aikaisemman kirjallisuuden perusteella laadittiin strukturoitu kyselylomake, jolla analysoitiin ja vertailtiin asiakkaiden ja ammattihenkilöiden näkemyksiä siitä, miten asiakkaiden hoito sosiaali- ja terveydenhuollon yhteistyönä toteutui. Esitestausten jälkeen kyselylomake lähetettiin 200 kotihoidon asiakkaalle ja 570 heitä hoitavalle kotihoidon työntekijälle: 485 kotipalvelun työntekijälle, 81 kotisairaanhoitajalle ja 4 lääkärille. Kyselyyn vastasi 120 asiakasta (60 %) ja 370 ammattihenkilöä (65 %). Ryhmien välisten erojen tarkastelussa käytettiin ristiintaulukointia, Pearsonin khin neliötestiä ja Fisherin tarkan todennäköisyyden testiä. Iäkkäiden asiakkaiden kuvauksissa voimavarat muodostuivat elämänhallinnan tunteesta ja toimintatahdon säilymisestä. Asiakkaat ammensivat arkeen voimaa harrastuksista ja sosiaalisesta verkostosta, mutta ulkopuolisten asettamat elämisen ehdot, terveydentilan heikkeneminen sekä yksinäisyys asettivat ikäihmisen ja hänen voimavaransa suurten haasteiden eteen. Tulokset osoittivat, että ammattihenkilöiden toiminta oli osittain ristiriidassa ikäihmisten omien odotusten kanssa, eikä se kaikilta osin tukenut asiakkaiden omia voimavaroja. Ammattihenkilöt tekivät hoitoon liittyviä päätöksiä ja toimintoja asiakkaiden puolesta, vaikka asiakkaille itselleen oli tärkeää elämänhallinnan tunne ja toimintatahdon säilyminen. Asiakkaiden voimavarojen tukemista moniammatillisena yhteistyönä vaikeuttivat ammattihenkilöiden vaikeus tunnistaa asiakkaiden omia voimavaroja sekä niitä uhkaavia tekijöitä, tiedon kulun ongelmat, tavoitteeton ja epäyhtenäinen tapa toimia sekä ammattihenkilöiden vastakkain asettuvat näkemyserot ja toimintatavat. Asiakkaiden ja ammattihenkilöiden näkemykset toteutetusta hoidosta erosivat toisistaan tilastollisesti merkitsevästi (p<0.05). Asiakkaat arvioivat sekä itsenäiseen toimintaan tukemisen että fyysisen, psyykkisen ja sosiaalisen tuen toteutuneen työntekijöitä huonommin. Yhteistyön kehittämishaasteita kotihoidossa ovat asiakkaan oman elämänsä asiantuntijuuden vahvistaminen, toimintakulttuurin muuttaminen asiakaslähtöiseksi tavoitteelliseksi toiminnaksi, ammattihenkilöiden roolien ja vastuun selkiyttäminen sekä tiedon kulun menetelmien kehittäminen. Tutkimus vahvistaa gerontologisen hoitotieteen tietoperustaa ja tuottaa uutta tietoa, jota voidaan soveltaa sosiaali- ja terveysalan koulutuksessa ja johtamisessa

Social capital and health : variations, associations and challenges

Although social capital and health have been extensively studied during the last decade, there are still open issues in current empirical research. These concern for instance the measurement of the concept in different contexts, as well as the association between different types of social capital and different dimensions of health. The present thesis addressed these questions. The general aim was to promote the understanding of social capital and health by investigating the oldest old and the two major language groups in Finland, Swedish- and Finnish-speakers. Another aim was to contribute to the discussion on methodological issues in social capital and health research. The present thesis investigated two empirical data sets, Umeå 85+ and Health 2000. The Umeå 85+ study was a cross-sectional study of 163 individuals aged 85, 90, and 95 or older, living in the municipality of Umeå, Sweden, in the year of 2000. The Health 2000 survey was a national study of 8,028 persons aged 30 or above carried out in Finland in 2000-2001. Different indicators of structural (e.g. social contacts) and cognitive (e.g. trust) social capital, as well as health indicators were used as variables in the analyses. The Umeå 85+ data set was analyzed with factor analysis, as well as univariate and multivariate analysis of variance. The Health 2000 data was analyzed with logistic regression techniques. The results showed that the Swedish-speakers in the Finnish data set Health 2000 had consistently higher prevalence of social capital compared to the Finnish-speakers even after controlling for central sociodemographic variables. The results further showed that even if the language group differences in health were small, the Swedishspeakers experienced in general better self-reported health compared with the Finnish-speakers. Common sociodemographic variables could not explain these observed differences in health. The results imply that social capital is often, but not always, associated with health. This was clearly seen in the Umeå 85+ data set where only one health indicator (depressive symptoms) was associated with structural social capital among the oldest old. The results based on the analysis of the Health 2000 survey demonstrated that the cognitive component of social capital was associated with self-rated health and psychological health rather than with participation in social activities and social contacts. In addition, social capital statistically reduced the health advantage especially for Swedish-speaking men, indicating that high prevalence of social capital may promote health. Finally, the present thesis also discussed the issue of methodological challenges faced with when analyzing social capital and health. It was suggested that certain components of social capital such as bonding and bridging social capital may be more relevant than structural and cognitive components when investigating social capital among the two language groups in Finland. The results concerning the oldest old indicated that the structural aspects of social capital probably reflect current living conditions, whereas cognitive social capital reflects attitudes and traits often acquired decades earlier. This is interpreted as an indication of the fact that structural and cognitive social capital are closely related yet empirically two distinctive concepts. Taken together, some components of social capital may be more relevant to study than others depending on which population group and age group is under study. The results also implied that the choice of cut-off point of dichotomization of selfrated health has an impact on the estimated effects of the explanatory variables. When the whole age interval, 35-64 years, was analyzed with logistic regression techniques the choice of cut-off point did not matter for the estimated effects of marital status and educational level. The results changed, however, when the age interval was divided into three shorter intervals. If self-rated health is explored using wide age intervals that do not account for age-dependent covariates there is a risk of drawing misleading conclusions. In conclusion, the results presented in the thesis suggest that the uneven distribution of social capital observed between the two language groups in Finland are of importance when trying to further understand health inequalities that exist between Swedish- and Finnish-speakers in Finland. Although social capital seemed to be relevant to the understanding of health among the oldest old, the meaning of social capital is probably different compared to a less vulnerable age group. This should be noticed in future empirical research. In the present thesis, it was shown that the relationship between social capital and health is complex and multidimensional. Different aspects of social capital seem to be important for different aspects of health. This reduces the possibility to generalize the results and to recommend general policy implementations in this area. An increased methodological awareness regarding social capital as well as health are called for in order to further understand the cfomplex association between them. However, based on the present data and findings social capital is associated with health. To understand individual health one must also consider social aspects of the individuals’ environment such as social capital.

Sedentary behaviour and health with special reference to obesity and fatty liver in early midlife. The Cardiovascular risk in Young Finns Study

Background: Physical inactivity and positive energy balance pose a risk to health. They increase the risk of obesity and associated non-communicable diseases. Recently, also sedentary behaviour has been associated with obesity and non-communicable diseases. Nevertheless, it has been unclear which type of sedentary behaviour is the most harmful. It is also unknown whether the relationship of sedentary behaviour with obesity is truly independent of other factors, for example physical activity and diet. Longitudinal data are limited, and the direction of causality and the mechanism of action are still unknown. Aims: The aim of this study was 1) to identify the type of sedentary behaviour having the strongest association with obesity, 2) to explore the causal relationship of sedentary behaviour and weight increase, and 3) to additionally, investigate the relationship of sedentary behaviour with fatty liver. These were studied in cross-sectional and/or longitudinal settings using data from the Cardiovascular Risk in Young Finns Study. Special emphasis was put on the evaluation of a wide range of other lifestyle factors and risks for obesity and fatty liver. Subjects: 2,060 subjects (aged 33-50 years in 2011, of which 55 % were female) from the Cardiovascular Risk in Young Finns Study participating in follow-ups in 2001, 2007, and 2011. Measures: Self-reported time spent in various types of sedentary behaviour (I), or TV viewing time (I-III). Measured body weight, height and waist circumference (I-III), and genetic variants for high BMI (I). Fasting plasma concentrations of gamma-glutamyltransferase enzyme and triglyceride, calculated Fatty Liver Index (based on gamma-glutamyltransferase and triglyceride concentration, BMI and waist circumference), and the amount of intrahepatic fat measured with ultrasound (III). Self-reported leisure-time physical activity and active commuting, occupational physical activity, energy intake, diet, alcohol consumption, smoking, socioeconomic status, and sleep duration as possible confounders were considered (I-III). Results: TV viewing is the sedentary behaviour type that has the strongest association with obesity. Sedentary behaviour (TV viewing) precedes weight increase, and not the other way around. Sedentary behaviour (TV viewing) is associated with increased risk of fatty liver. Conclusions: Sedentary behaviour (especially high TV viewing time) is associated with increased risks of obesity and fatty liver. Intervention studies are needed to assess whether reduction of TV time would prevent obesity and fatty liver.