The Effects of Endocrine Disrupters on Fetal Male Rat Testicular and Adrenal Development

Many of the reproductive disorders that emerge in adulthood have their origin during fetal development. Numerous studies have demonstrated that exposure to endocrine disrupting chemicals can permanently affect the reproductive health of experimental animals. In mammals, male sexual differentiation and development are androgen-dependent processes. In rat, the critical programming window for masculinization occurs between embryonic days (EDs) 15.5 and 19.5. Disorders in sex steroid balance during fetal life can disturb the development of the male reproductive tract. In addition to the fetal testis, the adrenal cortex starts to produce steroid hormones before birth. Glucocorticoids produced by the adrenal cortex are essential for preparing the fetus for birth. In the present study, the effects of exposure to endocrine disrupters on fetal male rat testicular and adrenal development were investigated. To differentiate the systemic and direct testicular effects of endocrine disrupters, both in vivo and in vitro experiments were performed. The present study also clarified the role of desert hedgehog signalling (Dhh) in the development of the testis. The results indicate that endocrine disrupters, diethylstilbestrol (DES) and flutamide, are able to induce rapid steroidogenic changes in fetal rat testis under in vitro conditions. Although in utero exposure to these chemicals did not show overt effects in fetal testis, they can induce permanent changes in the developing testis and accessory sex organs later in life. We also reported that exposure to antiandrogens can interfere with testicular Dhh signalling and result in impaired differentiation of the fetal Leydig cells and subsequently lead to abnormal testicular development and sexual differentiation. In utero exposure to tetrachlorodibenzo-p-dioxin (TCDD) caused direct testicular and pituitary effects on the fetal male rat but with different dose responses. In a study in which the effects of developmental exposure to environmental antiandrogens, di-isononylphthalate and 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (p,p^’-DDE), on fetal male rat steroidogenesis were investigated, chemicals did not down-regulate testicular or adrenal steroid hormone synthesis or production in 19.5-day-old fetal rats. However, p,p^’-DDE-treatment caused clear histological and ultrastructural changes in the prenatal testis and adrenal gland. These structural alterations can disturb the development and function of fetal testis and adrenal gland that may become evident later in life. Exposure to endocrine disrupters during fetal life can cause morphological abnormalities and alter steroid hormone production by fetal rat Leydig cells and adrenocortical cells. These changes may contribute to the maldevelopment of the testis and the adrenal gland. The present study highlights the importance of the fetal period as a sensitive window for endocrine disruption.

Mental Health of Expatriates in Finnish Enterprises in Brazil

Expatriation has become increasingly common due to the global trade expansion. Many large companies base their production facilities in far-flung countries, where experts are sent from their own countries to launch the operations. Working in a foreign environment demands from so-called expatriates considerable adaptability. This study aimed to investigate if following expatriation mental health difficulties were experienced by the employees themselves or their family members. This study investigated by a questionnaire and interviews how expatriate employees in Finnish companies operating in different regions of Brazil and their families adjusted. Investigated employees were required to be at least 6 months in expatriation. Data were collected in Brazil during their stay at least 3 months after the arrival. The survey covered 121 expatriate employees, that operated in 17 different companies, from which 71 employees from 10 different companies responded to the questionnaire. All the employees from the two largest enterprises and their spouses were invited to focus groups; in total 43 persons (22 employees and 21 employees’ spouses) participated in a group or individual interviews. No significant mental health difficulties were found among the expatriate employees. Only a tenth of the expatriate employees reported strain. The experience of strain symptoms was found to be related to long working days, intense working rhythm and lack of friends. Work satisfaction seemed to be an important mediator in the coping process. While abroad, the expatriate employees were highly recognized for their work. Due to the immature organization of work they could often use their creative capacities to improve the work flow. The opportunity to see the effects of their own contribution with their own eyes to the development of the enterprise made them feel good. The association between the expatriate employees’ adjustment and that of their spouses’ was evident. The spouses’ situation was markedly different than that of the expatriate employees’ themselves. Expatriation changed the family members’ previous division of tasks considerably. The expatriate spouses had to change their roles more than the expatriate employees themselves; since most of them were highly educated women, who were leaded through an identity crisis due to at least temporary renunciation of own work and career.

Synnytyksen ponnistusvaiheen hoidon käytännöt. Yhteys ensisynnyttäjän välilihan kuntoon synnytyksen jälkeen, synnytyskokemukseen, kipuun ja seksuaaliterveyteen

Hyvän syntymän hoidon tavoitteena on turvata synnyttäjän paras mahdollinen terveys, vähentää tarpeetonta puuttumista synnytyksen kulkuun ja mahdollistaa voimaannuttava synnytyskokemus perheelle. Hyvä syntymän hoito ja siihen liittyvä kätilöiden kliinisen hoitotyön osaaminen ei voi kehittyä, ellei hoitotyön käytäntöjä tutkita. Suomalaista hoitotieteellistä syntymän hoitoon liittyvää tutkimusta on vähän. Tämän tutkimuksen tarkoituksena oli kuvata synnytyksen ponnistusvaiheen hoidon käytäntöjä Suomen synnytyssairaaloissa. Lisäksi seurantatutkimuksen avulla selvitettiin, miten ensisynnyttäjät kokivat synnytyksen ponnistusvaiheen, sen aikana saamansa hoidon, ensisynnyttäjien synnytyskokemusta, kivun kokemista, vointia kolmena päivänä synnytyksen jälkeen sekä heidän seksuaaliterveyttään ensimmäisen vuoden aikana synnytyksen jälkeen. Tutkimuksen tavoitteena oli tuottaa tietoa, jonka avulla voidaan kehittää synnytyksen ponnistusvaiheen hoitoa ja lisätä tietoa synnyttäneiden naisten voinnista ja seksuaaliterveydestä. Tutkimuksen ensimmäinen osio toteutettiin poikkileikkaustutkimuksena (2009), johon osallistui Suomen synnytyssairaaloiden synnytysosastoilla työskentelevät kätilöt (N = 662). Tutkimuksen toinen osio toteutettiin seurantatutkimuksena (2009−2011), jossa oli neljä mittausajankohtaa: kolmantena päivänä synnytyksestä sekä kolmen, kuuden ja kahdentoista kuukauden kuluttua synnytyksestä. Tähän osioon osallistui spontaanisti alateitse yhden elävän lapsen (pää tarjoutuvana) synnyttäneet ensisynnyttäjät (N = 453) ja sikiön perätilan vuoksi suunnitellusti keisarileikatut ensisynnyttäjät (N = 84). Aineisto analysoitiin tilastollisin menetelmin. Tutkimustulosten mukaan osa kätilöiden käyttämistä synnytyksen ponnistusvaiheen hoitokäytännöistä ei ole näyttöön perustuvia. Synnytyssairaalan synnytyksen hoidon kulttuuri näyttää siirtyvän mallioppimisen kautta. Ensisynnyttäjät kokivat synnytyksen ponnistusvaiheen hoidon pääsääntöisesti myönteisenä. Alateitse synnyttäneillä ensisynnyttäjillä oli myönteisempi synnytyskokemus ja vähemmän kipua heti synnytyksen jälkeen ja kolmena synnytyksen jälkeisenä päivänä verrattuna keisarileikkauksella synnyttäneisiin ensisynnyttäjiin. Alateitse synnyttäneillä ensisynnyttäjillä kipu ja ompeleet eivät vaikuttaneet haitallisesti vastasyntyneen hoitoon tai imetykseen niin paljon kuin keisarileikkauksella synnyttäneillä ensisynnyttäjillä. Välilihan leikkaus-, repeämä- tai keisarileikkaushaavat olivat täysin parantuneet suurimmalla osalla naisista kolmen kuukauden kuluttua synnytyksestä. Yleisimpiä naisten kokemia oireita ensimmäisen vuoden aikana synnytyksestä olivat emättimen kostumisen vaikeus, yhdyntäkivut, peräpukamat sekä arpikudoksen kipu ja kiristys. Sukupuolinen halukkuus ja tyytyväisyys seksielämään olivat huonompaa ensimmäisen vuoden aikana synnytyksestä verrattuna aikaan ennen raskautta ja synnytystä. Synnytyksen aikaisella hoitotyöllä ja näyttöön perustuvalla synnytyksen ponnistusvaiheen hoidolla on suuri merkitys naisen synnytyskokemukseen, synnytyksen jälkeiseen vointiin ja seksuaaliterveyteen.

Family rivalry in the testis: Retinoblastoma protein and E2F transcription factors in testicular development and adult spermatogenesis

Disorders of male reproductive health are becoming increasingly prevalent globally. These defects, ranging from decreasing sperm counts to an increasing rate of infertility and testicular cancer, have a common origin in the early phases of testicular development, but the exact mechanisms that cause them remain unknown. Testicular development and adult spermatogenesis are complex processes in which different cell types undergo mitosis, meiosis, differentiation and apoptosis. The retinoblastoma protein family and its associated E2F transcription factors are key regulators of these cellular events. In the present study, the functions of these factors in postnatal testicular development and adult spermatogenesis were explored using different animal models. In addition, a new application of flow cytometry to study testicular cell dynamics was developed. An ablation of retinoblastoma protein in mouse Sertoli cells resulted in their cell cycle re-entry in adult testes, dedifferentiation and a severe spermatogenic defect. We showed that deregulated E2F3 contributed to these changes. Our results indicated that the E2F1 transcription factor is critical for the control of apoptosis in the developing postnatal testis. In the adult testis, E2F1 controls the maintenance of the spermatogonial stem cell pool, in addition to inhibiting apoptosis of spermatocytes. In summary, this study elucidated the complex interdependencies of the RB and E2F transcription factor families in the control of postnatal testicular development and adult spermatogenesis. Furthermore, this study provided a new methodology for the analysis of testicular cells.

Expertise and decision making among clinicians in investigations of alleged child sexual abuse

The purpose of the present thesis was to explore different aspects of decision making and expertise in investigations of child sexual abuse (CSA) and subsequently shed some light on the reasons for shortcomings in the investigation processes. Clinicians’ subjective attitudes as well as scientifically based knowledge concerning CSA, CSA investigation and interviewing were explored. Furthermore the clinicians’ own view on their expertise and what enhances this expertise was investigated. Also, the effects of scientific knowledge, experience and attitudes on the decision making in a case of CSA were explored. Finally, the effects of different kinds of feedback as well as experience on the ability to evaluate CSA in the light of children’s behavior and base rates were investigated. Both explorative and experimental methods were used. The purpose of Study I was to investigate whether clinicians investigating child sexual abuse (CSA) rely more on scientific knowledge or on clinical experience when evaluating their own expertise. Another goal was to check what kind of beliefs the clinicians held. The connections between these different factors were investigated. A questionnaire covering items concerning demographic data, experience, knowledge about CSA, selfevaluated expertise and beliefs about CSA was given to social workers, child psychiatrists and psychologists working with children. The results showed that the clinicians relied more on their clinical experience than on scientific knowledge when evaluating their expertise as investigators of CSA. Furthermore, social workers possessed stronger attitudes in favor of children than the other groups, while child psychiatrists had more negative attitudes towards the criminal justice system. Male participants held less strong beliefs than female participants. The findings indicate that the education of CSA investigators should focus more on theoretical knowledge and decision making processes as well as the role of beliefs In Study II school and family counseling psychologists completed a Child Sexual Abuse Attitude and Belief Scale. Four CSA related attitude and belief subscales were identified: 1. The Disclosure subscale reflecting favoring a disclosure at any cost, 2. The Pro-Child subscale reflecting unconditional belief in children's reports, 3. The Intuition subscale reflecting favoring an intuitive approach to CSA investigations, and 4. The Anti Criminal Justice System subscale reflecting negative attitudes towards the legal system. Beliefs that were erroneous according to empirical research were analyzed separately. The results suggest that some psychologists hold extreme attitudes and many erroneous beliefs related to CSA. Some misconceptions are common. Female participants tended to hold stronger attitudes than male participants. The more training in interviewing children the participants have, the more erroneous beliefs and stronger attitudes they hold. Experience did not affect attitudes and beliefs. In Study III mental health professionals’ sensitivity to suggestive interviewing in CSA cases was explored. Furthermore, the effects of attitudes and beliefs related to CSA and experience with CSA investigations on the sensitivity to suggestive influences in the interview were investigated. Also, the effect of base rate estimates of CSA on decisions was examined. A questionnaire covering items concerning demographic data, different aspects of clinical experience, self-evaluated expertise, beliefs and knowledge about CSA and a set of ambiguous material based on real trial documents concerning an alleged CSA case was given to child mental health professionals. The experiment was based on a 2 x 2 x 2 x 2 (leading questions: yes vs no) x (stereotype induction: yes vs no) x (emotional tone: pressure to respond vs no pressure to respond) x (threats and rewards: yes vs no) between-subjects factorial design, in which the suggestiveness of the methods with which the responses of the child were obtained were varied. There was an additional condition in which the material did not contain any interview transcripts. The results showed that clinicians are sensitive only to the presence of leading questions but not to the presence of other suggestive techniques. Furthermore, the clinicians were not sensitive to the possibility that suggestive techniques could have been used when no interview transcripts had been included in the trial material. Experience had an effect on the sensitivity of the clinicians only regarding leading questions. Strong beliefs related to CSA lessened the sensitivity to leading questions. Those showing strong beliefs on the belief scales used in this study were even more prone to prosecute than other participants when other suggestive influences than leading questions were present. Controversy exists regarding effects of experience and feedback on clinical decision making. In Study IV the impact of the number of handled cases and of feedback on the decisions in cases of alleged CSA was investigated. One-hundred vignettes describing cases of suspected CSA were given to students with no experience with investigating CSA. The vignettes were based on statistical data about symptoms and prevalence of CSA. According to the theoretical likelihood of CSA the children described were categorized as abused or not abused. The participants were asked to decide whether abuse had occurred. They were divided into 4 groups: one received feedback on whether their decision was right or wrong, one received information about cognitive processes involved in decision making, one received both, and one did not receive feedback at all. The results showed that participants who received feedback on their performance made more correct positive decisions and participants who got information about decision making processes made more correct negative decisions. Feedback and information combined decreased the number of correct positive decisions but increased the number of correct negative decisions. The number of read cases had in itself a positive effect on correct positive decision.

How (not) to interview children : interviews with young children in sexual abuse investigations in Finland

The present thesis had two main objectives: The first was to assess how child sexual abuse (CSA) interviews in Finland are conducted through analysing the interviewing techniques applied and the language used by the interviewers, as well as to suggest ways to improve interviews if they were found to have deficiencies. The second main aim was to contribute to the growing research corpus concerning CSA interviews, in particular, by addressing how interviewers follow up information provided by the child, by analysing whether child health care professionals would use childadapted language, and by studying the kind of modifications in the verbal behaviour of interviewers and children that were associated with a) repeated interviews, b) a support person’s presence at the interview, and c) the use of anatomically detailed dolls. Two complementary samples of CSA interviews were analysed. The first one was composed of child interviews with 3-12-year-old children (N = 27) that had been considered problematic by lawyers or other involved professionals (Studies I and IV). The second sample consisted of unselected interviews (N = 43) with children aged 3 to 8 years conducted in a number of hospitals in different parts of the country (Studies II and III). Study I: The verbal interaction between interviewer and child was analysed in a sample of interviews that had been considered to be problematic by involved professionals. Results showed that interviewers used inappropriate questioning techniques, relying on option-posing, specific suggestive and unspecific suggestive questions to a significant extent, these comprising around 50% of all interviewer utterances. The proportion of invitations, which the research community recommends interviewers to rely on, was strikingly low. Invitations and directive utterances were associated with an increase in informative responses by the child in terms of response type, number of new details reported, as well as length of response. The opposite was true for option-posing and suggestive utterances. Longer questions by the interviewer (in number of words) often rendered no reply from the child, whereas shorter questions were followed by descriptive answers. Even after the child had provided an informative answer, interviewers failed to follow up the information in an adequate way and instead continued to rely on focused and leading questions. Study II: Due to the possible bias of the sample analysed in Study I, the most important analyses were rerun with the unselected sample and reported separately. Results were quite similar between the two studies, indicating that the problems observed in Study I, with interviewers relying on option-posing and suggestive questions to a significant extent, are likely to be general and not specific for those interviews. Even if suggestive questions were slightly less and invitations slightly more common in this sample than in the previous study, almost half of the interviewer questions were still optionposing or suggestive, and also in this sample, interviewers failed to follow up information by the child in a facilitating manner. Differentiating between judicial and contextual details showed that while facilitators, invitations, and directive utterances elicited more contextual than judicial details, the opposite was true for specific suggestive utterances. These results might be explained by the reluctance of children to describe sexual details related to the abuse events. Alternatively, they may also be due to children describing incorrect sexual details as a result of suggestive interviewing techniques. Study III: This study examined features of the language used by the interviewers. Interviewer utterances included multiple questions, long statements, complicated grammar and concepts, as well as unclear references to persons and situations. More than a fifth of the interviewer utterances were coded as belonging to at least one of these categories. The results suggest that even professionals who are experienced in interacting with children may have difficulties in using a child-sensitive language, adding to the pool of studies showing similar problems to occur in legal hearings with children conducted by lawyers. As children rarely comment on, or even recognise, their lack of comprehension, the use of a language that is too complex can have detrimental consequences for the outcomes of investigative interviews. Interviewers used different approaches to introduce the topic of abuse. While 15% of the children spontaneously addressed the topic of abuse, probably indicating that they felt confident with the interviewer and the situation, in almost 50% of the cases, the interviewer introduced the topic of abuse in a way that can be considered leading. Interviews were characterised by a lack of structure, apparent in frequent rapid switches of topic by the interviewer. This manner was associated with a decrease in the number of new details provided by the children. Study IV: This study analysed possible changes in the interview dynamics associated with repeated interviewing, the presence of a support person (related to the child), and the use of anatomically detailed (AD) dolls. Repeated interviewing, in combination with suggestive questions, has previously been found to seriously contaminate children’s accounts. In the present material, interviewers used significantly more suggestive utterances in the repeated condition, thus endangering the reliability of the children’s reports. Few studies have investigated the effects of a support person’s presence at the interview. The results of the present study showed that interviewers talked more and children provided less information when a support person was present. Supporting some earlier findings regarding the use of AD dolls, the present results showed that using AD dolls was associated with longer interviewer utterances and shorter, less responsive, and less detailed child responses. Interviewers used up to five times more unspecific suggestive utterances when dolls were used, for instance through repeatedly asking the child to show “what really happened” with the dolls. Conclusion: The results indicate that CSA interviews in Finland are not conducted in a manner that follows best practice as defined by the research community and as stated in a number of guidelines. When comparing these questioning strategies with the recommendations, which have been predominant in the field for more than ten years now, it can be concluded that the interviews analysed were conducted in a manner that undermines the possibility to elicit an uncontaminated and accurate narrative from the children. A particularly worrying finding was the fact that interviewers did not follow up relevant information by the children in an adequate way. A number of clinical implications can be drawn from the results, particularly concerning the need for improvement in the quality of CSA interviews. There is convincing research regarding how to improve CSA interviews, notably through training forensic child interviewers to use a structured interviewing protocol, and providing them with continuous supervision and feedback. Allocating appropriate resources to improve the quality of forensic child interviews is a matter of protecting the rights of all persons involved in CSA investigations, in particular those of the children.

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

Classification, comorbidity, heredity, and risk factors of female sexual dysfunctions

Female sexual dysfunctions, including desire, arousal, orgasm and pain problems, have been shown to be highly prevalent among women around the world. The etiology of these dysfunctions is unclear but associations with health, age, psychological problems, and relationship factors have been identified. Genetic effects explain individual variation in orgasm function to some extent but until now quantitative behavior genetic analyses have not been applied to other sexual functions. In addition, behavior genetics can be applied to exploring the cause of any observed comorbidity between the dysfunctions. Discovering more about the etiology of the dysfunctions may further improve the classification systems which are currently under intense debate. The aims of the present thesis were to evaluate the psychometric properties of a Finnish-language version of a commonly used questionnaire for measuring female sexual function, the Female Sexual Function Index (FSFI), in order to investigate prevalence, comorbidity, and classification, and to explore the balance of genetic and environmental factors in the etiology as well as the associations of a number of biopsychosocial factors with female sexual functions. Female sexual functions were studied through survey methods in a population based sample of Finnish twins and their female siblings. There were two waves of data collection. The first data collection targeted 5,000 female twins aged 33–43 years and the second 7,680 female twins aged 18–33 and their over 18–year-old female siblings (n = 3,983). There was no overlap between the data collections. The combined overall response rate for both data collections was 53% (n = 8,868), with a better response rate in the second (57%) compared to the first (45%). In order to measure female sexual function, the FSFI was used. It includes 19 items which measure female sexual function during the previous four weeks in six subdomains; desire, subjective arousal, lubrication, orgasm, sexual satisfaction, and pain. In line with earlier research in clinical populations, a six factor solution of the Finnish-language version of the FSFI received supported. The internal consistencies of the scales were good to excellent. Some questions about how to avoid overestimating the prevalence of extreme dysfunctions due to women being allocated the score of zero if they had had no sexual activity during the preceding four weeks were raised. The prevalence of female sexual dysfunctions per se ranged from 11% for lubrication dysfunction to 55% for desire dysfunction. The prevalence rates for sexual dysfunction with concomitant sexual distress, in other words, sexual disorders were notably lower ranging from 7% for lubrication disorder to 23% for desire disorder. The comorbidity between the dysfunctions was substantial most notably between arousal and lubrication dysfunction even if these two dysfunctions showed distinct patterns of associations with the other dysfunctions. Genetic influences on individual variation in the six subdomains of FSFI were modest but significant ranging from 3–11% for additive genetic effects and 5–18% for nonadditive genetic effects. The rest of the variation in sexual functions was explained by nonshared environmental influences. A correlated factor model, including additive and nonadditive genetic effects and nonshared environmental effects had the best fit. All in all, every correlation between the genetic factors was significant except between lubrication and pain. All correlations between the nonshared environment factors were significant showing that there is a substantial overlap in genetic and nonshared environmental influences between the dysfunctions. In general, psychological problems, poor satisfaction with the relationship, sexual distress, and poor partner compatibility were associated with more sexual dysfunctions. Age was confounded with relationship length but had over and above relationship length a negative effect on desire and sexual satisfaction and a positive effect on orgasm and pain functions. Alcohol consumption in general was associated with better desire, arousal, lubrication, and orgasm function. Women pregnant with their first child had fewer pain problems than nulliparous nonpregnant women. Multiparous pregnant women had more orgasm problems compared to multiparous nonpregnant women. Having children was associated with less orgasm and pain problems. The conclusions were that desire, subjective arousal, lubrication, orgasm, sexual satisfaction, and pain are separate entities that have distinct associations with a number of different biopsychosocial factors. However, there is also considerable comorbidity between the dysfunctions which are explained by overlap in additive genetic, nonadditive genetic and nonshared environmental influences. Sexual dysfunctions are highly prevalent and are not always associated with sexual distress and this relationship might be moderated by a good relationship and compatibility with partner. Regarding classification, the results supports separate diagnoses for subjective arousal and genital arousal as well as the inclusion of pain under sexual dysfunctions.

Late effects of cancer at a young age: Registry-based studies of the health of cancer patients and their off-spring

Modern cancer therapy has resulted in increased survival among patients diagnosed with cancer at a young age. These improvements have led to the investigation of late morbidity and mortality associated with cancer and its treatments. The aim of this study was to evaluate late effects of cancer treated at a young age on the health of patients and their offspring. Utilising the nationwide population-based registries in Finland, we evaluated the risk of hypothyroidism and the probability of parenthood in cancer survivors as well as preterm birth, neonatal outcomes, and the risk of cancer among offspring of patients. The survivor cohort, identified from the Finnish Cancer Registry, consisted of 25,784 cancer patients diag-nosed between ages 0 and 34 in 1953–2004. By linkage to the population register, siblings of these patients were identified for comparison. The prevalence of hypothyroidism was higher among former childhood cancer (aged 0–16) patients than in the general population. The probability of parenthood following early onset cancer was overall significantly reduced compared to siblings. Offspring of female cancer survivors were at an increased risk of preterm birth, this risk being highest among patients diagnosed in childhood and early adulthood (aged 20–34 years). The offspring were not, however, at a significantly increased risk of neonatal death or stillbirth, though they were more likely to need monitoring or intensive care in the neonatal period. The risk of sporadic cancer among offspring of male and female cancer survivors was not elevated in comparison to the general population. The study showed that former cancer patients are at risk of certain adverse endocrine and reproductive health outcomes and should be followed for timely intervention. The offspring of cancer survivors do not appear to be at risk for adverse health outcomes.

Venäläistä rulettia – Nuorten perhesuunnittelun esteet ja tarpeet Pietarissa ja Riiassa

Latviassa ja Venäjällä heikko demografinen tilanne on lisännyt keskustelua seksuaali- ja kansalaisoikeuksista sekä valtion merkityksestä niiden toteuttamisessa. Väestöpolitiikassa näkyy yhteiskunnallinen tilanne sekä sen kyky ja mahdollisuudet huomioida nuorten perhesuunnitteluun liittyviä tarpeita. Huomion kohteena on myös palvelujärjestelmä ja siinä toteutuva yksilöllinen taso. Tutkin perhesuunnittelua kokonaisvaltaisesti, mikä ilmenee erilaisten polkuriippuvuuksien tarkasteluina. Mielenkiintoiseksi kohteen tekee entisten sosialististen valtioiden erityislaatuisen murroksen läpikäyminen. Perhesuunnittelu on osa seksuaali- ja ihmisoikeuksia. Siihen kuuluu seksuaaliterveydestä tiedottaminen ja ohjaus sekä siihen liittyvät toimenpiteet. Perhesuunnittelu sisältää niin sosiaaliset, kasvatukselliset kuin lääketieteellisetkin näkökulmat. Siihen liitetään myös moraalisia ja taloudellisia näkemyksiä, sekä politiikkaa ja henkilökohtaisuutta. Tutkimustehtäväni on nuorten perhesuunnittelun esteet ja tarpeet Riiassa ja Pietarissa. Sovellan metodologisena lähestymistapana sosiaalihistoriallista ja etnografista tutkimusotetta, jolloin perinteen vaikutusten, kulttuuristen rakenteiden ja yksilöllisten toimintatapojen ymmärtäminen mahdollistuu. Aineisto koostuu viranomaishaastatteluista sosialismin kaudella toteutuneesta sekä nykyisestä perhesuunnittelusta ja nuorten haastatteluista Pietarissa ja Riiassa. Perehdyn myös lisääntymisterveyteen liittyviin sanomalehtiartikkeleihin sekä Latviassa että Venäjällä. Lisäksi havainnoin seksuaalineuvontatilanteita Pietarissa. Sekä sosialismin aikana että nykyään painottuvat väestönkasvun odotukset, joita tuetaan sukupuoli- ja moraalikasvatuksen avulla. Perhesuunnittelun esteiden analyysin tuloksissa on nähtävissä sosiaalisten olosuhteiden ja rakenteiden merkitys. Jälkisosialistisesta riskiyhteiskunnasta puuttuvat yhteiskuntaan integroitumisen mahdollistavat instituutiot. Tämä ilmenee yhteiskunnallisena vastuuttomuutena. Universaalit palvelut ovat suurelta osin peräisin sosialismin ajalta. Kaupalliset yritykset tekevät lähinnä teknisiä, yksittäisiä ehkäisyvälineisiin liittyviä interventioita nuorten elämään. Teini-ikäiset jätetään oman harkintansa varaan. Latviassa perhesuunnitteluun liittyvä ennalta ehkäisevä toiminta on huomioitu uudessa lisääntymisterveyslaissa, mutta sen heikko toteutus tuo sen lähelle neuvostoaikaista kulttuurikonventiota, jossa määrällisillä suoritteilla ja sekundaaripreventiolla on arvoa. Venäjällä voimavarat kohdentuvat jälkihuollon palveluihin. Foucaultin valta-analyysi kertoo strategiasta, jossa ihminen sisäistää vallankäytön osaksi omaa ajatteluaan ja toimintaansa. Tässä näkökulmassa yksilöllinen, yhteiskunnallinen ja historiallinen ulottuvuus limittyvät toisiinsa. Vallan muodot ovat yhteiskunnan rakenteissa. Väestöpolitiikan avulla tuotetaan tietoa ja muovataan hallitsemisen kohteita. Osa haastatelluista nuorista omaksui yhteiskunnan passiivisuuden osaksi omaa toimintaansa. He eivät tiedostaneet palvelujärjestelmän puutteita eivätkä kyseenalaistaneet sen oikeutusta. Myös lehtiartikkelit ja viranomaishaastattelut tukivat osittain seksuaalikasvatuksen sivuuttamista. Silloin hyväksyttävänä totuutena pidettiin väestöpolitiikkaa, jossa on annettu tilaa populistisille suuntauksille. Sekä Latviassa että Venäjällä ilmaistiin tavoitteita väestön kasvusta. Kansainvälisten seksuaalioikeuksien maihinnousu ei ole poistanut ääri uskonnollisten ja osittain kansalaisjärjestöjen puitteissa tapahtuvaa perhesuunnittelun vastustusta. Näissä suuntauksissa vaikutetaan ihmisten moraaliin ja vastustetaan yhteiskunnan interventioita kieltämällä seksuaalikasvatus. Sosialismin aikana sosiaali- ja terveydenhuoltoa toteutettiin totalitaristisessa, suljetussa yhteiskunnassa tiukasti rajatuilla voimavaroilla. Tuolta ajalta peräisin oleva viranomaisten yleinen medikalisoitunut ja tekninen lähestymistapa estää osittain nuoren valtaistumista. Vieläkin heikko tiedottaminen ja puutteellinen koulutus vaikuttavat ammattilaisten keskuudessa. Yksi haitallisista perhesuunnitteluun kuuluvista uskomuksista oli hormonaalisen ehkäisyn aiheuttamat ongelmat. Lisäksi pelättiin heikkotasoisesti tehtyjen aborttien aiheuttavan hedelmättömyyttä. Uskomukset ovat eläneet vieläkin, kun osa asiantuntijoista kannusti ensimmäisen raskauden päättymistä synnytykseen. Näillä käsityksillä on ollut taipumus siirtyä sukupolvelta toiselle myös kansalaisten keskuudessa. Sukuyhteisöjen ja verkostojen oleellinen merkitys teini-ikäisen arjessa ja selviytymisessä painotti perinteistä sosialisaatiota. Uskomusten lisäksi nuorten heikko taloudellinen tilanne on ohjannut heitä ehkäisyssä luonnonmenetelmien käyttöön. Neuvostoaikainen seksuaalikielteisyyden perinne on vaikuttanut myös sukupolvien kyvyttömyyteen keskustella aiheesta. Yleisen ennaltaehkäisevän neuvonnan puuttuminen on suunnannut suurta osaa nuoria mallioppimiseen, jossa esimerkit ovat nousseet satunnaisista löydöistä. Toisaalta työntekijöiden neuvokkuus ja aloitteellisuus erilaisissa ohjaamistilanteissa, toimintatavoissa ja instituutioiden perustamisissa kuvaavat eettistä vastuunottoa ja paneutumista nuorten perhesuunnittelun toteutumiseen sekä sen mahdollisuuksiin. Perhesuunnitteluun liittyvän tiedonsaannin parantamiseksi viranomaiset ovat aloittaneet nuorten vertaisryhmiä. Lisäksi yhtenä uutena virallisena lähestymistapana oli neuvostoaikana kielletty psykoterapeuttisen suuntauksen avoin käyttöönotto. Myös nuorille suunnattuja palveluja niin lainsäädännön kuin instituutioiden tasolla on saatu aikaan. Nämä myönteiset tapaukset jäivät kuitenkin yksittäisiksi, osittain joidenkin työntekijöiden omakohtaisen sitoutumisen varaan toimiviksi. Tutkimuksessa nousee esiin yhteiskunnan vastuu erityisesti haavoittuvien ryhmien kohdalla. Nuoret ovat tiedoiltaan ja kokemuksiltaan heikossa asemassa. Sosiaalipoliittisesta näkökulmasta julkisilla ja ennaltaehkäisevillä palveluilla on keskeinen merkitys etenkin niiden kohdalla, jotka tarvitsevat runsaasti palveluja. Usein tähän ryhmään kuuluvat ovat passiivisia tiedon hakijoita. Tutkimus tuo esille perhesuunnittelun palvelujärjestelmään ja sen kohderyhmään kuuluvan moniulotteisuuden, jossa toisiinsa nivoutuvat kulttuuriset myytit, uskomukset, tabut, toimintatavat ja tietämys. Näiden polkujen avaaminen tässä tutkimuksessa edistää perhesuunnittelun esteiden tunnistamista ja niihin soveltuvien ratkaisukeinojen löytymistä.

Health Related Quality of Life after Childhood Cancer - A Finnish Nationwide survey

The purpose of this Finnish epidemiological nationwide cross-sectional study was to evaluate the Health Related Quality of Life (HRQL) of young people that have survived childhood cancer at least four years after cancer diagnosis. The study aims were (1) to increase knowledge and understanding about the relationship between childhood cancer and its treatment and HRQL of childhood cancer survivors and (2) to identify survivors who need and could benefit from ongoing long-term follow-up, as well as (3) to identify what kind of aftercare the childhood cancer survivors will possibly need. HRQL and fatigue of currently still young survivors of extracranial childhood malignancies were evaluated with self-reports and parent proxy reports. HRQL was measured with age-appropriate generic instruments: PedsQL™, SF-36, 15D, 16D and 17D. Fatigue for children and adolescents aged below 18 years was measured with the PedsQL™ Multidimensional Fatigue Scale Finnish version. PedsQL™ parent-proxy and the PedsQL™ Multidimensional Fatigue Scale Parentproxy instruments were used to assess the perception of the parents on HRQL and fatigue of their children and adolescents. Postal-survey questionnaires were mailed to 852 childhood cancer survivors aged 11-27 years and their randomly selected gender-, age and living-place matched controls, as well as under 18-year-old children´s parents. A total of 474 survivors, 595 controls, 209 survivor’s parent and 253 control’s parent replied. The mean age of survivors at the time of the study was 18.4 years. The mean length of survival was 12.3 years, and the mean age at diagnosis 5.5 years. The most of the Finnish childhood cancer survivors evaluated that their HRQL as good. Survivors rated their HRQL equal or higher than their controls. The only dimension where the survivors scored poorer than the controls was the 15D mobility dimension. Survivors of childhood cancer did not suffer from significant fatigue. There were subgroups of childhood cancer survivors who had poorer level of HRQL, and suffered from fatigue more than the reference group. The demographic factors that associated with poorer HRQL were female gender, greater weight, living alone, need of remedial education, an additional non-cancer diagnosis, survivors with siblings, and self-reported unhappiness. Disease-related factors that associated with poorer HRQL were higher age at the time of diagnosis, the diagnosis of Wilms tumor, neuroblastoma, or osteosarcoma, and treatment with stem cell transplantation. The factors associated with more fatigue in survivors were male gender, older age at evaluation, the need of remedial education at school, lower overall average grade in the latest school marks report, length of survival more than 10 years, lower HRQL-scores, and a sarcoma diagnosis. However, all the used demographic and disease related factors explained only about one third of the variation in the HRQL scores. In open questions, the survivors were most worried about their physical health, but were also worried about their mental health, cancer inheritance, late-effects, and fertility and relapse issues. It seems that there are subgroups of survivors who need and could benefit from ongoing long-term follow-up. In the future, the survivors of childhood cancer need more information about their physical and mental health, as well as on their cancer inheritance, possible late-effects including fertility issues, and on the risk of relapse.

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.

Pain symptoms and sleep problems among school-aged children. Long-term prevalence changes, and pain symptoms as predictors of later mental health

Children’s pain symptoms and sleep problems are among the most common health complaints. They distract children from activities, decrease the quality of life, contribute to a significant economic burden, and have shown continuity into adulthood. The main aims of this thesis were to investigate long-term changes in the prevalence of pain symptoms and sleep problems among Finnish school-aged children, and the later mental health of those who in childhood experience pain. Prevalence, co-occurrence, and associated psychosocial factors of pain symptoms and sleep problems were also assessed. In study I, prevalence changes in eight-year-old children’s pain symptoms and sleep problems were investigated in three cross-sectional population-based samples (years 1989: n=1038, 1999: n=1035, and 2005: n=1030). In study II, cross-sectional associations between pain symptoms, sleep problems, and psychosocial factors were assessed among 13-18-year-old adolescents (n=2476). In studies III and IV, associations between pain symptoms at age eight (n=6017), and register-based data on antidepressant use and severe suicidality by age 24, were examined in a nationwide birth cohort. Pain symptoms and sleep problems were common and often co-occurred. A considerable number of children’s pain symptoms remained unrecognized by the parents. The prevalence of pain symptoms, sleep problems, and multiple concurrent symptoms approximately doubled from 1989 to 2005. Psychiatric difficulties or demographic factors did not explain the increase. Psychosocial factors that were associated with pain, sleep problems, and a higher number of symptoms, were female sex, psychological difficulties, emotional symptoms, smoking, victimization, and feeling not cared about by teachers. In longitudinal analyses, the child’s own report of headache, and to a smaller degree the parental report of the child’s abdominal pain predicted later antidepressant use. Parental report of the child’s abdominal pain predicted severe suicidality among males. If one of the symptoms is present, health care professionals should inquire about other symptoms as well. Questions should be directed to the children, not only to their parents. Inquiring about psychiatric difficulties, substance use, victimization, and relations with teachers should be included as a part of the assessment. Further studies are needed to clarify the reasons that underlie the increased prevalence rates, and the factors that may increase or decrease the risk for later mental health problems among pain-suffering children.