“Well this is it. Just get on with it”: Pain willingness and activity engagement in people with chronic pain

Pain is recognised as a problem of significant concern worldwide and in the latest Global Burden of Disease Study, low back pain was identified as the biggest contributor worldwide to Years Lived with Disability. There is evidence to suggest that people who accept their chronic pain have a higher quality of life, lower levels of disability and distress, and function better emotionally, socially and physically. Findings on the specific pathways linking pain acceptance to quality of life outcomes are less clear. the two widely accepted pain acceptance factors, pain willingness and activity engagement, have not been well explored in qualitative studies on acceptance of chronic pain. To address this deficit in the literature, the current study has two related aims: 1) to explore pain willingness and activity engagement in the lives of people with chronic pain, and ; 2) to find out what people believe helps them to successfully get on with life in spite of chronic pain.

Ruumis ja rauta : esseitä esineiden sosiaalisuudesta

"Body and Iron: Essays on the Socialness of Objects" focuses on the bodily-material interaction of human subjects and technical objects. It poses a question, how is it possible that objects have an impact on their human users and examines the preconditions of active efficacy of objects. In this theoretical task the work relies on various discussions drawing from realistic ontology, phenomenology of body, neurophysiology of Antonio Damasio and psychoanalysis to establish both objects and bodies as material entities related in a causal interaction with each other. Out of material interaction emerge a symbolic field, psyche and culture that produce representations of interactions with material world they remain dependent on and conditioned by. Interaction with objects informs the human body via its somatosensory systems: interoseptive and proprioseptive (or kinesthetic) systems provide information to central nervous system of the internal state of the body and muscle tensions and motor activity of the limbs. Capability to control the movements of one's body by the internal "feel" of being a body turns out to be a precondition to the ability to control artificial extensions of the body. Motor activity of the body is involved in every perception of environment as the feel of one's own body is constitutive of any perception of external objects. Perception of an object cause changes in the internal milieu of the body and these changes in the organism form a bodily representation of an external object. Via these "muscle images" the subject can develop a feel for an instrument. Bodily feel for an object is pre-conceptual, practical knowledge that resists articulation but allows sensing the world through the object. This is what I would call sensual knowledge. Technical objects intervene between body and environment, transforming the relation of perception and motor activity. Once connected to a vehicle, human subject has to calibrate visual information of his or her position and movement in space to the bodily actions controlling the machine. It is the machine that mediates the relation of human actions to the relation of her body to its environment. Learning to use the machine necessarily means adjusting his or her bodily actions to the responses of the machine in relation to environmental changes it causes. Responsiveness of the machine to human touch "teaches" its subject by providing feedback of the "correctitude" of his or her bodily actions. Correct actions form a body technique of handling the object. This is the way of socialness of objects. While responding to human actions they generate their subjects. Learning to handle a machine means accepting the position of the user in the program of action materialized in the construction of the object. Objects mediate, channel and transform the relation of the body to its environment and via environment to the body itself according to their material and technical construction. Objects are sensory media: they channel signals and information from the environment thus constituting a representation of environment, a virtual or artificial reality. They also feed the body directly with their powers equipping their user with means of regulating somatic and psychic states of her self. For these reasons humans look for the company of objects. Keywords: material objects, material culture, sociology of technology, sociology of body, mobility, driving

Food waste, power, and corporate social responsibility in the Australian food supply chain

By examining corporate social responsibility (CSR) and power within the context of the food supply chain, this paper illustrates how food retailers claim to address food waste while simultaneously setting standards that result in the large-scale rejection of edible food on cosmetic grounds. Specifically, this paper considers the powerful role of food retailers and how they may be considered to be legitimately engaging in socially responsible behaviors to lower food waste, yet implement practices that ultimately contribute to higher levels of food waste elsewhere in the supply chain. Through interviews with key actors in the Australian fresh fruit and vegetable supply chain, we highlight the existence of a legitimacy gap in corporate social responsibility whereby undesirable behaviors are pushed elsewhere in the supply chain. It is argued that the structural power held by Australia’s retail duopoly means that supermarkets are able to claim virtuous and responsible behaviors, despite counter claims from within the fresh food industry that the food supermarkets’ private quality standards mean that fresh food is wasted. We argue that the supermarkets claim CSR kudos for reducing food waste at the expense of other supply chain actors who bear both the economic cost and the moral burden of waste, and that this is a consequence of supermarkets’ remarkable market power in Australia.

Yhteinen verkosto? : Tutkimus nuorten syrjäytymistä ehkäisevistä poikkihallinnollisista ryhmistä

Since the 1990s, European policy strategies have stressed the mutual responsibility and joint action of all societal branches in preventing social problems. Network policy is an integral part of the new governance that generates a new kind of dependency between the state and civil society in formulating and adhering to policy goals. Using empirical group interview data collected in Helsinki, the capital of Finland, this case study explores local multi-agency groups and their efforts to prevent the exclusion of children and young people. These groups consist mainly of professionals from the social office, youth clubs and schools. The study shows that these multi-agency groups serve as forums for professional negotiation where the intervention dilemma of liberal society can be addressed: the question of when it is justified and necessary for an authority or network to intervene in the life of children and their families, and how this is to be done. An element of tension in multi-agency prevention is introduced by the fact that its objectives and means are anchored both in the old tradition of the welfare state and in communitarian rhetoric. Thus multi-agency groups mend deficiencies in wellbeing and normalcy while at the same time try to co-ordinate the creation of the new community, which will hopefully reduce the burden on the public sector. Some of the professionals interviewed were keen to see new and even forceful interventions to guide the youth or to compel parents to assume their responsibilities. In group discussions, this approach often met resistance. The deeper the social problems that the professionals worked with, the more solidarity they showed for the families or the young people in need. Nothing seems to assure professionals and to legitimise their professional position better than advocating the under-privileged against the uncertainties of life and the structural inequalities of society. The groups that grappled with the clear, specific needs of certain children and families were the most capable of co-operation. This requires the approval of different powers and the expertise of distinct professions as well as a forum to negotiate case-specific actions in professional confidentiality. The ideals of primary prevention for everyone and value discussions alone fail to inspire sufficient multiagency co-operation. The ideal of a network seems to give word and shape to those societal goals that are difficult or even impossible to reach, but are nevertheless yearned for: mutual understanding of the good life, close social relationships, mutual trust and active agency for all citizens. Individualisation, the multiplicity of life styles and the possibility to choose have come true in such a way that the very idea of a mutual and binding network can be attained only momentarily and between restricted participants. In conclusion, uniting professional networks that negotiate intervention dilemmas with citizen networks based on changing compassions and feelings of moral superiority seems impossible. Rather, one should encourage openness to scrutiny among tangential or contradicting groups, networks and communities. Key words: network policy, prevention of exclusion, multi-agency groups, young people

Genetic Mechanisms Underlying Autism Spectrum Disorders

Autism is a childhood-onset developmental disorder characterized by deficits in reciprocal social interaction, verbal and non-verbal communication, and dependence on routines and rituals. It belongs to a spectrum of disorders (autism spectrum disorders, ASDs) which share core symptoms but show considerable variation in severity. The whole spectrum affects 0.6-0.7% of children worldwide, inducing a substantial public health burden and causing suffering to the affected families. Despite having a very high heritability, ASDs have shown exceptional genetic heterogeneity, which has complicated the identification of risk variants and left the etiology largely unknown. However, recent studies suggest that rare, family-specific factors contribute significantly to the genetic basis of ASDs. In this study, we investigated the role of DISC1 (Disrupted-in-schizophrenia-1) in ASDs, and identified association with markers and haplotypes previously associated with psychiatric phenotypes. We identified four polymorphic micro-RNA target sites in the 3 UTR of DISC1, and showed that hsa-miR-559 regulates DISC1 expression in vitro in an allele-specific manner. We also analyzed an extended autism pedigree with genealogical roots in Central Finland reaching back to the 17th century. To take advantage of the beneficial characteristics of population isolates to gene mapping and reduced genetic heterogeneity observed in distantly related individuals, we performed a microsatellite-based genome-wide screen for linkage and linkage disequilibrium in this pedigree. We identified a putative autism susceptibility locus on chromosome 19p13.3 and obtained further support for previously reported loci at 1q23 and 15q11-q13. To follow-up these findings, we extended our study sample from the same sub-isolate and initiated a genome-wide analysis of homozygosity and allelic sharing using high-density SNP markers. We identified a small number of haplotypes shared by different subsets of the genealogically connected cases, along with convergent biological pathways from SNP and gene expression data, which highlighted axon guidance molecules in the pathogenesis of ASDs. In conclusion, the results obtained in this thesis show that multiple distinct genetic variants are responsible for the ASD phenotype even within single pedigrees from an isolated population. We suggest that targeted resequencing of the shared haplotypes, linkage regions, and other susceptibility loci is essential to identify the causal variants. We also report a possible micro-RNA mediated regulatory mechanism, which might partially explain the wide-range neurobiological effects of the DISC1 gene.

Humanitaarisuuden varjossa : Poliittiset tekijät lastensiirroissa Ruotsiin sotiemme aikana ja niiden jälkeen

The evacuation of Finnish children to Sweden during WW II has often been called a small migration . Historical research on this subject is scarce, considering the great number of children involved. The present research has applied, apart from the traditional archive research, the framework of history-culture developed by Rüsen in order to have an all-inclusive approach to the impact of this historical event. The framework has three dimensions: political, aesthetic and cognitive. The collective memory of war children has also been discussed. The research looks for political factors involved in the evacuations during the Winter War and the Continuation War and the post-war period. The approach is wider than a purely humanitarian one. Political factors have had an impact in both Finland and Sweden, beginning from the decision-making process and ending with the discussion of the unexpected consequences of the evacuations in the Finnish Parliament in 1950. The Winter War (30.11.1939 13.3.1940) witnessed the first child transports. These were also the model for future decision making. The transports were begun on the initiative of Swedes Maja Sandler, the wife of the resigned minister of foreign affairs Rickard Sandler, and Hanna Rydh-Munck af Rosenschöld , but this activity was soon accepted by the Swedish government because the humanitarian help in the form of child transports lightened the political burden of Prime Minister Hansson, who was not willing to help Finland militarily. It was help that Finland never asked for and it was rejected at the beginning. The negative response of Minister Juho Koivisto was not taken very seriously. The political forces in Finland supporting child transports were stronger than those rejecting them. The major politicians in support belonged to Finland´s Swedish minority. In addition, close to 1 000 Finnish children remained in Sweden after the Winter War. No analysis was made of the reasons why these children did not return home. A committee set up to help Finland and Norway was established in Sweden in 1941. Its chairman was Torsten Nothin, an influential Swedish politician. In December 1941 he appealed to the Swedish government to provide help to Finnish children under the authority of The International Red Cross. This plea had no results. The delivery of great amounts of food to Finland, which was now at war with Great Britain, had automatically caused reactions among the allies against the Swedish imports through Gothenburg. This included the import of oil, which was essential for the Swedish navy and air force. Oil was later used successfully to force a reduction in commerce between Sweden and Finland. The contradiction between Sweden´s essential political interests and humanitarian help was solved in a way that did not harm the country´s vital political interests. Instead of delivering help to Finland, Finnish children were transported to Sweden through the organisations that had already been created. At the beginning of the Continuation War (25.6.1941 27.4.1945) negative opinion regarding child transports re-emerged in Finland. Karl-August Fagerholm implemented the transports in September 1941. In 1942, members of the conservative parties in the Finnish Parliament expressed their fear of losing the children to the Swedes. They suggested that Finland should withdraw from the inter-Nordic agreement, according to which the adoptions were approved by the court of the country where the child resided. This initiative failed. Paavo Virkkunen, an influential member of the conservative party Kokoomus in Finland, favoured the so-called good-father system, where help was delivered to Finland in the form of money and goods. Virkkunen was concerned about the consequences of a long stay in a Swedish family. The risk of losing the children was clear. The extreme conservative party (IKL, the Patriotic Movement of the Finnish People) wanted to alienate Finland from Sweden and bring Finland closer to Germany. Von Blücher, the German ambassador to Finland, had in his report to Berlin, mentioned the political consequences of the child transports. Among other things, they would bring Finland and Sweden closer to each other. He had also paid attention to the Nordic political orientation in Finland. He did not question or criticize the child transports. His main interest was to increase German political influence in Finland, and the Nordic political orientation was an obstacle. Fagerholm was politically ill-favoured by the Germans, because he had a strong Nordic political disposition and had criticised Germany´s activities in Norway. The criticism of child transports was at the same time criticism of Fagerholm. The official censorship organ of the Finnish government (VTL) denied the criticism of child transports in January 1942. The reasons were political. Statements made by members of the Finnish Parliament were also censored, because it was thought that they would offend the Swedes. In addition, the censorship organ used child transports as a means of active propaganda aimed at improving the relations between the two countries. The Finnish Parliament was informed in 1948 that about 15 000 Finnish children still remained in Sweden. These children would stay there permanently. In 1950 the members of the Agrarian Party in Finland stated that Finland should actively strive to get the children back. The party on the left (SKDL, the Democratic Movement of Finnish People) also focused on the unexpected consequences of the child transports. The Social Democrats, and largely Fagerholm, had been the main force in Finland behind the child transports. Members of the SKDL, controlled by Finland´s Communist Party, stated that the war time authorities were responsible for this war loss. Many of the Finnish parents could not get their children back despite repeated requests. The discussion of the problem became political, for example von Born, a member of the Swedish minority party RKP, related this problem to foreign policy by stating that the request to repatriate the Finnish children would have negative political consequences for the relations between Finland and Sweden. He emphasized expressing feelings of gratitude to the Swedes. After the war a new foreign policy was established by Prime Minister (1944 1946) and later President (1946 1956) Juho Kusti Paasikivi. The main cornerstone of this policy was to establish good relations with the Soviet Union. The other, often forgotten, cornerstone was to simultaneously establish good relations with other Nordic countries, especially Sweden, as a counterbalance. The unexpected results of the child evacuation, a Swedish initiative, had violated the good relations with Sweden. The motives of the Democratic Movement of Finnish People were much the same as those of the Patriotic Movement of Finnish People. Only the ideology was different. The Nordic political orientation was an obstacle to both parties. The position of the Democratic Movement of Finnish People was much better than that of the Patriotic Movement of Finnish People, because now one could clearly see the unexpected results, which included human tragedy for the many families who could not be re-united with their children despite their repeated requests. The Swedes questioned the figure given to the Finnish Parliament regarding the number of children permanently remaining in Sweden. This research agrees with the Swedes. In a calculation based on Swedish population registers, the number of these children is about 7 100. The reliability of this figure is increased by the fact that the child allowance programme began in Sweden in 1948. The prerequisite to have this allowance was that the child be in the Swedish population register. It was not necessary for the child to have Swedish nationality. The Finnish Parliament had false information about the number of Finnish children who remained in Sweden in 1942 and in 1950. There was no parliamentary control in Finland regarding child transports, because the decision was made by one cabinet member and speeches by MPs in the Finnish Parliament were censored, like all criticism regarding child transports to Sweden. In Great Britain parliamentary control worked better throughout the whole war, because the speeches regarding evacuation were not censored. At the beginning of the war certain members of the British Labour Party and the Welsh Nationalists were particularly outspoken about the scheme. Fagerholm does not discuss to any great extent the child transports in his memoirs. He does not evaluate the process and results as a whole. This research provides some possibilities for an evaluation of this sort. The Swedish medical reports give a clear picture of the physical condition of the Finnish children when arriving in Sweden. The transports actually revealed how bad the situation of the poorest children was. According to Titmuss, similar observations were made in Great Britain during the British evacuations. The child transports saved the lives of approximately 2 900 children. Most of these children were removed to Sweden to receive treatment for illnesses, but many among the healthy children were undernourished and some suffered from the effects of tuberculosis. The medical inspection in Finland was not thorough. If you compare the figure of 2 900 children saved and returned with the figure of about 7 100 children who remained permanently in Sweden, you may draw the conclusion that Finland as a country failed to benefit from the child transports, and that the whole operation was a political mistake with far-reaching consequenses. The basic goal of the operation was to save lives and have all the children return to Finland after the war. The difficulties with the repatriation of the children were mainly psychological. The level of child psychology in Finland at that time was low. One may question the report by Professor Martti Kaila regarding the adaptation of children to their families back in Finland. Anna Freud´s warnings concerning the difficulties that arise when child evacuees return are also valid in Finland. Freud viewed the emotional life of children in a way different from Kaila: the physical survival of a small child forces her to create strong emotional ties to the person who is looking after her. This, a characteristic of all small children, occurred with the Finnish children too, and it was something the political decision makers in Finland could not see during and after the war. It is a characteristic of all little children. Yet, such experiences were already evident during the Winter War. The best possible solution had been to limit the child transports only to children in need of medical treatment. Children from large and poor families had been helped by organising meals and by buying food from Denmark with Swedish money. Assisting Finland by all possible means should have been the basic goal of Fagerholm in September 1941, when the offer of child transports came from Sweden. Fagerholm felt gratitude towards the Swedes. The risks became clear to him only in 1943. The war children are today a rather scattered and diffuse group of people. Emotionally, part of these children remained in Sweden after the war. There is no clear collective memory, only individual memories; the collective memory of the war children has partly been shaped later through the activities of the war child associations. The main difference between the children evacuated in Finland (for example from Karelia to safer areas with their families) and the war children, who were sent abroad, is that the war children lack a shared story and experience with their families. They were outsiders . The whole matter is sensitive to many of such mothers and discussing the subject has often been avoided in families. The war-time censorship has continued in families through silence and avoidance and Finnish politicians and Finnish families had to face each other on this issue after the war. The lack of all-inclusive historical research has also prevented the formation of a collective awareness among war children returned to Finland or those remaining permanently abroad.. Knowledge of historical facts will help war-children by providing an opportunity to create an all-inclusive approach to the past. Personal experiences should be regarded as part of a large historical entity shadowed by war and where many political factors were at work in both Finland and Sweden. This means strengthening of the cognitive dimension discussed in Rüsen´s all-inclusive historical approach.

Tuloverotuksen reaalinen muuttuminen Suomessa : Kuusikymmentä vuotta verojen vuoristorataa

The study seeks to find out whether the real burden of the personal taxation has increased or decreased. In order to determine this, we investigate how the same real income has been taxed in different years. Whenever the taxes for the same real income for a given year are higher than for the base year, the real tax burden has increased. If they are lower, the real tax burden has decreased. The study thus seeks to estimate how changes in the tax regulations affect the real tax burden. It should be kept in mind that the progression in the central government income tax schedule ensures that a real change in income will bring about a change in the tax ration. In case of inflation when the tax schedules are kept nominally the same will also increase the real tax burden. In calculations of the study it is assumed that the real income remains constant, so that we can get an unbiased measure of the effects of governmental actions in real terms. The main factors influencing the amount of income taxes an individual must pay are as follows: - Gross income (income subject to central and local government taxes). - Deductions from gross income and taxes calculated according to tax schedules. - The central government income tax schedule (progressive income taxation). - The rates for the local taxes and for social security payments (proportional taxation). In the study we investigate how much a certain group of taxpayers would have paid in taxes according to the actual tax regulations prevailing indifferent years if the income were kept constant in real terms. Other factors affecting tax liability are kept strictly unchanged (as constants). The resulting taxes, expressed in fixed prices, are then compared to the taxes levied in the base year (hypothetical taxation). The question we are addressing is thus how much taxes a certain group of taxpayers with the same socioeconomic characteristics would have paid on the same real income according to the actual tax regulations prevailing in different years. This has been suggested as the main way to measure real changes in taxation, although there are several alternative measures with essentially the same aim. Next an aggregate indicator of changes in income tax rates is constructed. It is designed to show how much the taxation of income has increased or reduced from one year to next year on average. The main question remains: How aggregation over all income levels should be performed? In order to determine the average real changes in the tax scales the difference functions (difference between actual and hypothetical taxation functions) were aggregated using taxable income as weights. Besides the difference functions, the relative changes in real taxes can be used as indicators of change. In this case the ratio between the taxes computed according to the new and the old situation indicates whether the taxation has become heavier or easier. The relative changes in tax scales can be described in a way similar to that used in describing the cost of living, or by means of price indices. For example, we can use Laspeyres´ price index formula for computing the ratio between taxes determined by the new tax scales and the old tax scales. The formula answers the question: How much more or less will be paid in taxes according to the new tax scales than according to the old ones when the real income situation corresponds to the old situation. In real terms the central government tax burden experienced a steady decline from its high post-war level up until the mid-1950s. The real tax burden then drifted upwards until the mid-1970s. The real level of taxation in 1975 was twice that of 1961. In the 1980s there was a steady phase due to the inflation corrections of tax schedules. In 1989 the tax schedule fell drastically and from the mid-1990s tax schedules have decreased the real tax burden significantly. Local tax rates have risen continuously from 10 percent in 1948 to nearly 19 percent in 2008. Deductions have lowered the real tax burden especially in recent years. Aggregate figures indicate how the tax ratio for the same real income has changed over the years according to the prevailing tax regulations. We call the tax ratio calculated in this manner the real income tax ratio. A change in the real income tax ratio depicts an increase or decrease in the real tax burden. The real income tax ratio declined after the war for some years. In the beginning of the 1960s it nearly doubled to mid-1970. From mid-1990s the real income tax ratio has fallen about 35 %.

Collective Network Capability in International Project Business Networks - A Case Study of the Business Network for the Ashanti Electrification Project in Ghana

Despite thirty years of research in interorganizational networks and project business within the industrial networks approach and relationship marketing, collective capability of networks of business and other interorganizational actors has not been explicitly conceptualized and studied within the above-named approaches. This is despite the fact that the two approaches maintain that networking is one of the core strategies for the long-term survival of market actors. Recently, many scholars within the above-named approaches have emphasized that the survival of market actors is based on the strength of their networks and that inter-firm competition is being replaced by inter-network competition. Furthermore, project business is characterized by the building of goal-oriented, temporary networks whose aims, structures, and procedures are clarified and that are governed by processes of interaction as well as recurrent contracts. This study develops frameworks for studying and analysing collective network capability, i.e. collective capability created for the network of firms. The concept is first justified and positioned within the industrial networks, project business, and relationship marketing schools. An eclectic source of conceptual input is based on four major approaches to interorganizational business relationships. The study uses qualitative research and analysis, and the case report analyses the empirical phenomenon using a large number of qualitative techniques: tables, diagrams, network models, matrices etc. The study shows the high level of uniqueness and complexity of international project business. While perceived psychic distance between the parties may be small due to previous project experiences and the benefit of existing relationships, a varied number of critical events develop due to the economic and local context of the recipient country as well as the coordination demands of the large number of involved actors. The study shows that the successful creation of collective network capability led to the success of the network for the studied project. The processes and structures for creating collective network capability are encapsulated in a model of governance factors for interorganizational networks. The theoretical and management implications are summarized in seven propositions. The core implication is that project business success in unique and complex environments is achieved by accessing the capabilities of a network of actors, and project management in such environments should be built on both contractual and cooperative procedures with local recipient country parties.

Subject Teacher Training and Teaching in English

The purpose of this Master s thesis is on one hand to find out how CLIL (Content and Language Integrated Learning) teachers and English teachers perceive English and its use in teaching, and on the other hand, what they consider important in subject teacher education in English that is being planned and piloted in STEP Project at the University of Helsinki Department of Teacher Education. One research question is also what kind of language requirements teachers think CLIL teachers should have. The research results are viewed in light of previous research and literature on CLIL education. Six teachers participate in this study. Two of them are English teachers in the comprehensive school, two are class teachers in bilingual elementary education, and two are subject teachers in bilingual education, one of whom teaches in a lower secondary school and the other in an upper secondary school. One English teacher and one bilingual class teacher have graduated from a pilot class teacher program in English that started at the University of Helsinki in the middle of the 1990 s. The bilingual subject teachers are not trained in English but they have learned English elsewhere, which is a particular focus of interest in this study because it is expected that a great number of CLIL teachers in Finland do not have actual studies in English philology. The research method is interview and this is a qualitative case study. The interviews are recorded and transcribed for the ease of analysis. The English teachers do not always use English in their lessons and they would not feel confident in teaching another subject completely in English. All of the CLIL teachers trust their English skills in teaching, but the bilingual class teachers also use Finnish during lessons either because some teaching material is in Finnish, or they feel that rules and instructions are understood better in mother tongue or students English skills are not strong enough. One of the bilingual subject teachers is the only one who consciously uses only English in teaching and in discussions with students. Although teachers good English skills are generally considered important, only the teachers who have graduated from the class teacher education in English consider it important that CLIL teachers would have studies in English philology. Regarding the subject teacher education program in English, the respondents hope that its teachers will have strong enough English skills and that it will deliver what it promises. Having student teachers of different subjects studying together is considered beneficial. The results of the study show that acquiring teaching material in English continues to be the teachers own responsibility and a huge burden for the teachers, and there has, in fact, not been much progress in the matter since the beginning of CLIL education. The bilingual subject teachers think, however, that using one s own material can give new inspiration to teaching and enable the use of various pedagogical methods. Although it is questionable if the language competence requirements set for CLIL teachers by the Finnish Ministry of Education are not adhered to, it becomes apparent in the study that studies in English philology do not necessarily guarantee strong enough language skills for CLIL teaching, but teachers own personality and self-confidence have significance. Keywords: CLIL, bilingual education, English, subject teacher training, subject teacher education in English, STEP

Cognitive Functioning in Alcohol and Other Substance Use Disorders in Young Adulthood : A Genetic Epidemiological Study

Alcohol and other substance use disorders (SUDs) result in great costs and suffering for individuals and families and constitute a notable public health burden. A multitude of factors, ranging from biological to societal, are associated with elevated risk of SUDs, but at the level of individuals, one of the best predictors is a family history of SUDs. Genetically informative twin and family studies have consistently indicated this familial risk to be mainly genetic. In addition, behavioral and temperamental factors such as early initiation of substance use and aggressiveness are associated with the development of SUDs. These familial, behavioral and temperamental risk factors often co-occur, but their relative importance is not well known. People with SUDs have also been found to differ from healthy controls in various domains of cognitive functioning, with poorer verbal ability being among the most consistent findings. However, representative population-based samples have rarely been used in neuropsychological studies of SUDs. In addition, both SUDs and cognitive abilities are influenced by genetic factors, but whether the co-variation of these traits might be partly explained by overlapping genetic influences has not been studied. Problematic substance use also often co-occurs with low educational level, but it is not known whether these outcomes share part of their underlying genetic influences. In addition, educational level may moderate the genetic etiology of alcohol problems, but gene-environment interactions between these phenomena have also not been widely studied. The incidence of SUDs peaks in young adulthood rendering epidemiological studies in this age group informative. This thesis investigated cognitive functioning and other correlates of SUDs in young adulthood in two representative population-based samples of young Finnish adults, one of which consisted of monozygotic and dizygotic twin pairs enabling genetically informative analyses. Using data from the population-based Mental Health in Early Adulthood in Finland (MEAF) study (n=605), the lifetime prevalence of DSM-IV any substance dependence or abuse among persons aged 21—35 years was found to be approximately 14%, with a majority of the diagnoses being alcohol use disorders. Several correlates representing the domains of behavioral and affective factors, parental factors, early initiation of substance use, and educational factors were individually associated with SUDs. The associations between behavioral and affective factors (attention or behavior problems at school, aggression, anxiousness) and SUDs were found to be largely independent of factors from other domains, whereas daily smoking and low education were still associated with SUDs after adjustment for behavioral and affective factors. Using a wide array of neuropsychological tests in the MEAF sample and in a subsample (n=602) of the population-based FinnTwin16 (FT16) study, consistent evidence of poorer verbal cognitive ability related to SUDs was found. In addition, participants with SUDs performed worse than those without disorders in a task assessing psychomotor processing speed in the MEAF sample, whereas no evidence of more specific cognitive deficits was found in either sample. Biometrical structural equation models of the twin data suggested that both alcohol problems and verbal ability had moderate heritabilities (0.54—0.72), and that their covariation could be explained by correlated genetic influences (genetic correlations -0.20 to -0.31). The relationship between educational level and alcohol problems, studied in the full epidemiological FT16 sample (n=4,858), was found to reflect both genetic correlation and gene-environment interaction. The co-occurrence of low education and alcohol problems was influenced by overlapping genetic factors. In addition, higher educational level was associated with increased relative importance of genetic influences on alcohol problems, whereas environmental influences played a more important role in young adults with lower education. In conclusion, SUDs, especially alcohol abuse and dependence, are common among young Finnish adults. Behavioral and affective factors are robustly related to SUDs independently of many other factors, and compared to healthy peers, young adults who have had SUDs during their life exhibit significantly poorer verbal cognitive ability, and possibly less efficient psychomotor processing. Genetic differences between individuals explain a notable proportion of individual differences in risk of alcohol dependence, verbal ability, and educational level, and the co-occurrence of alcohol problems with poorer verbal cognition and low education is influenced by shared genetic backgrounds. Finally, various environmental factors related to educational level in young adulthood moderate the relative importance of genetic factors influencing the risk of alcohol problems, possibly reflecting differences in social control mechanisms related to educational level.

Interplay of Virulence Factors in Complement Resistance of Streptococcus pneumoniae

Streptococcus pneumoniae (pneumococcus) is a normal inhabitant of the human nasopharynx. Symptoms occur in only a small proportion of those who become carriers, but the ubiquity of the organism in the human population results in a large burden of disease. S. pneumoniae is the leading bacterial cause of pneumonia, sepsis, and meningitis worldwide, causing the death of a million children each year. Middle-ear infection is the most common clinical manifestation of mucosal pneumococcal infections. In invasive disease, S. pneumoniae gains access to the bloodstream and spreads to normally sterile parts of the body. The progression from asymptomatic colonization to disease depends on factors characteristic of specific pneumococcal strains as well as the status of host defenses. The polysaccharide capsule surrounding the bacterium is considered to be the most important factor affecting the virulence of pneumococci. It protects pneumococci from phagocytosis and also may determine its affinity to the respiratory epithelium. S. pneumoniae as a species comprises more than 90 different capsular serotypes, but not all of them are equally prevalent in human diseases. Invasive serotypes are rarely isolated from healthy carriers, but relatively often cause invasive disease. Serotypes that are carried asymptomatically for a long time behave like opportunistic pathogens, causing disease in patients who have impaired immune defenses. The complement system is a collection of blood and cell surface proteins that act as a major primary defense against invading microbes. Phagocytic cells with receptors for complement proteins can engulf and destroy pneumococcal cells opsonized with these proteins. S. pneumoniae has evolved a number of ways to subvert mechanisms of innate immunity, and this is likely to contribute to its pathogenicity. The capsular serotype, proteins essential for virulence, as well the genotype, may all influence the ability of pneumococcus to resist complement and its potential to cause disease. Immunization with conjugate vaccines produces opsonic antibodies, which enhance complement deposition and clearance of the bacteria. The pneumococcal vaccine included in the Finnish national immunization program in 2010 contains the most common serotypes causing invasive disease. Clinical data suggest that protection from middle-ear infection and possibly also from invasive disease depends largely on the capsular serotype, for reasons hitherto unknown. The general aim of this thesis is to assess the relative roles of the pneumococcal capsule and virulence proteins in complement evasion and subsequent opsonophagocytic killing. The main question is whether differences between serotypes to resist complement explain the different abilities of serotypes to cause disease. The importance of particular virulence factors to the complement resistance of a strain may vary depending on its genotype. Prior studies have evaluated the effect of the capsule and virulence proteins on complement resistance of S. pneumoniae by comparing only a few strains. In this thesis, the role of pneumococcal virulence factors in the complement resistance of the bacterium was studied in several genotypically different strains. The ability of pneumococci to inhibit deposition of the complement protein C3 on the bacterial surface was found to depend on the capsular serotype as well as on other features of the bacteria. The results suggest that pneumococcal histidine triad (Pht) proteins may play a role in complement inhibition, but their contribution depends on the bacterial genotype. The capsular serotype was found to influence complement resistance more than the bacterial genotype. A higher concentration of anticapsular antibodies was required for the opsonophagocytic killing of serotypes resistant to C3 deposition. The invasive serotypes were more resistant to C3 deposition than the opportunistic serotypes, suggesting that the former are better adapted to resist immune mechanisms controlling the development of invasive disease. The different susceptibilities of serotypes to complement deposition, opsonophagocytosis, and resultant antibody-mediated protection should be taken into account when guidelines for serological correlates for vaccine efficacy evaluations are made. The results of this thesis suggest that antibodies in higher quantity or quality are needed for efficient protection against the invasive serotypes.

Hydropower Project Design Incorporating Submergence Costs

Submergence of land is a major impact of large hydropower projects. Such projects are often also dogged by siltation, delays in construction and heavy debt burdens-factors that are not considered in the project planning exercise. A simple constrained optimization model for the benefit~ost analysis of large hydropower projects that considers these features is proposed. The model is then applied to two sites in India. Using the potential productivity of an energy plantation on the submergible land is suggested as a reasonable approach to estimating the opportunity cost of submergence. Optimum project dimensions are calculated for various scenarios. Results indicate that the inclusion of submergence cost may lead to a substanual reduction in net present value and hence in project viability. Parameters such as project lifespan, con$truction time, discount rate and external debt burden are also of significance. The designs proposed by the planners are found to be uneconomic, whIle even the optimal design may not be viable for more typical scenarios. The concept of energy opportunity cost is useful for preliminary screening; some projects may require more detailed calculations. The optimization approach helps identify significant trade-offs between energy generation and land availability.

The Effects of Reduction Mammaplasty

Symptomatic hypertrophic breasts cause a health burden with physical and psychosocial morbidity. The value of reduction mammaplasty in the treatment of symptomatic breast hypertrophy has been consistently reported by patients and has been well recognised by plastic surgeons for a long time. However, the scientific evidence of the effects of reduction mammaplasty has been weak or lacking. During the design of this study most of the previous studies were retrospective and the few prospective studies had methodological limitations. Therefore, an obvious need for prospective randomised studies was present. Nevertheless, practical and ethical considerations seemed to make this study design impossible, because the waiting time for the operation was several years. The legislation and subsequent introduction of the uniform criteria for access to non-emergency treatment in Finland removed these obstacles, as all patients received their treatment within a reasonable time. As a result, a randomised controlled trial with a six-month follow-up time was designed and conducted. In addition, a follow-up study with two to five years follow-up was also carried out later. The effects of reduction mammaplasty on the patients breast-related symptoms, psychological symptoms, pain and quality of life was assessed. In addition, factors affecting the outcome were investigated. This study was carried out in the Hospital District of Helsinki and Uusimaa, Finland. Eighty-two out of the approximately 300 patients on the waiting list in 2004 agreed to participate in the study. Patients were randomised either to be operated (40 patients) on or to be followed up (42 patients). The follow-up time for both groups was six months. The patients were operated on by plastic surgeons or trainees at the Department of Plastic Surgery at Helsinki University Central Hospital or at the Department of Surgery at Hyvinkää Hospital. The patients completed five questionnaires: the SF-36 and the 15D quality of life questionnaires, the Finnish Breast-Associated Symptoms questionnaire (FBAS), a mood questionnaire (Raitasalo s modification of the short form of the Beck Depression Inventory, RBDI), and a pain questionnaire (The Finnish Pain Questionnaire, FPQ). Sixty-two out of the original 82 patients agreed to participate in the prospective follow-up study. In this study, patients completed the 15D quality of life questionnaire, the Finnish Breast-Associated Symptoms questionnaire, and the RBDI mood questionnaire. After six months follow-up, patients who had undergone reduction mammaplasty had a significantly better quality of life, fewer breast-associated symptoms and less pain, and they were less depressed or anxious when compared to patients who had not undergone surgery. The change in quality of life was more than two times the minimal clinically important difference. The patients preoperative quality of life was significantly inferior when compared to the age-standardised general population. This health burden was removed with reduction mammaplasty. The health loss related to symptomatic breast hypertrophy was comparable to that of patients with major joint arthrosis. In terms of change in quality of life, the intervention effect of reduction mammaplasty was comparable to that of hip joint replacement and more pronounced than that of knee joint replacement surgery. The outcome of reduction mammaplasty was affected more by preoperative psychosocial factors than by changes in breast dimensions. The effects of reduction mammaplasty remained stable at two to five years follow-up. In terms of quality of life, symptomatic breast hypertrophy causes a considerable health loss comparable to that of major joint arthrosis. Patients who undergo surgery have fewer breast-associated symptoms and less pain, and they are less depressed or anxious and have an improved quality of life. The intervention effect is comparable to that of major joint replacement surgery, and it remains stable at two to five years follow-up. The outcome of reduction mammaplasty is affected by preoperative psychosocial factors.

The Politics and Policies of Reproductive Agency

This study examines the politics and policies of reproductive agency through a redescription of three Finnish policy documents dealing with the declining birth rate: the Government report on the future 'Finland for people of all ages' (2004), Business and Policy Forum EVA report 'Condemned to Diminish?' (Tuomitut vähenemään?) (2003), and the Family Federation's 'Population Policy Program' (2004). The redescription is done with the help of the notion of reproductive agency, which draws on Drucilla Cornell's concepts of the imaginary domain and bodily integrity. The imaginary domain is the moral and psychic space people need in order to form their personality, which is created in constant identificatory processes. The aim of the processes is imaginary coherence. As the personality is embodied, forming one s imaginary coherence always includes attempts for bodily integrity, also entailing attempts to arrive at an understanding of one's procreative capacities. Besides Cornell, I draw on Judith Butler's thinking and comprehend gender performatively as doing, and in relation to that agency as part of the performative process of one's personality. Reproductive agency is understood in this study as the possibilities to live differently the hegemonic forms of procreative life. I deal with three redescriptive themes: the family, economics and gender. The family is a central element in that it is considered the main location of reproduction. With regard to reproductive agency, the documents include problematic conceptions of the family. It is defined as a heterosexual, monogamous, conjugal relationship, which affects reproductive agency in that these notions do not allow for different modes of family life. The second prominent aspect, economics, features on two levels: the macroeconomic level of GDP, employment and competitiveness, and the level of family policies and concern about family finances. Macroeconomic-level argumentation is problematic in the context of reproductive agency because it implies that procreation is a duty of citizens, and thus has effects on values attached to reproductive potential. On the other hand, family policies may advance reproductive agency in supporting families financially. However, such policies also define how the family is understood, thereby affecting reproductive agency. The third theme, gender, intersects with many issues in the policy documents. All three texts consider the roles of men and women differently: women are primarily responsible for the family, and both men's and women's reproductive agency is affected in that the roles in the procreative process are predefined. EVA and the Family Federation see women as the main target of population policies, and consider it legitimate to try to change women s reproductive decisions. Implicit in the notion of reproductive agency is the idea that it should be possible to overcome and live differently the sex difference, but the three documents do not open up opportunities for that. The notion of reproductive agency makes it also possible to question the legitimacy of population policies in general and offers new perspectives on the vocabularies used in the three policy texts, providing insights into the values and logics that support the concepts.

PERFECT Stroke : PERFormance, Effectiveness, and Costs of treatment episodes in Stroke

Stroke is a major cause of death and disability, incurs significant costs to healthcare systems, and inflicts severe burden to the whole society. Stroke care in Finland has been described in several population-based studies between 1967 and 1998, but not since. In the PERFECT Stroke study presented here, a system for monitoring the Performance, Effectiveness, and Costs of Treatment episodes in Stroke was developed in Finland. Existing nationwide administrative registries were linked at individual patient level with personal identification numbers to depict whole episodes of care, from acute stroke, through rehabilitation, until the patients went home, were admitted to permanent institutional care, or died. For comparisons in time and between providers, patient case-mix was adjusted for. The PERFECT Stroke database includes 104 899 first-ever stroke patients over the years 1999 to 2008, of whom 79% had ischemic stroke (IS), 14% intracerebral hemorrhage (ICH), and 7% subarachnoid hemorrhage (SAH). A 18% decrease in the age and sex adjusted incidence of stroke was observed over the study period, 1.8% improvement annually. All-cause 1-year case-fatality rate improved from 28.6% to 24.6%, or 0.5% annually. The expected median lifetime after stroke increased by 2 years for IS patients, to 7 years and 7 months, and by 1 year for ICH patients, to 4 years 5 months. No change could be seen in median SAH patient survival, >10 years. Stroke prevalence was 82 000, 1.5% of total population of Finland, in 2008. Modern stroke center care was shown to be associated with a decrease in both death and risk of institutional care of stroke patients. Number needed to treat to prevent these poor outcomes at one year from stroke was 32 (95% confidence intervals 26 to 42). Despite improvements over the study period, more than a third of Finnish stroke patients did not have access to stroke center care. The mean first-year healthcare cost of a stroke patient was ~20 000 , and among survivors ~10 000 annually thereafter. Only part of this cost was incurred by stroke, as the same patients cost ~5000 over the year prior to stroke. Total lifetime costs after first-ever stroke were ~85 000 . A total of 1.1 Billion , 7% of all healthcare expenditure, is used in the treatment of stroke patients annually. Despite a rapidly aging population, the number of new stroke patients is decreasing, and the patients are more likely to survive. This is explained in part by stroke center care, which is effective, and should be made available for all stroke patients. It is possible, in a suitable setting with high-quality administrative registries and a common identifier, to avoid the huge workload and associated costs of setting up a conventional stroke registry, and still acquire a fairly comprehensive dataset on stroke care and outcome.