Kansalaisvaikuttaminen kansalaisraadilla : osallistuminen ja vaikuttaminen kriittisen pedagogiikan näkökulmasta

Kansalaisraati tarkoittaa lähidemokratian työmuotoa, jossa kuntalaiset osallistuvat deliberaatioon. Deliberaatio mahdollistaa kansalaisraatiin osallistuvan henkilön oppimista. Raatien tehtävänä on kouluttaa osallistujia vaikuttamaan yhteisössä käsiteltäviin kysymyksiin. Deliberaatio tarkoittaa keskustelua, joka etenee tietoperusteisen argumentoinnin kautta kohti parempaa ymmärrystä käsiteltävistä kysymyksistä ja kysymyksien ratkaisuesityksistä. Vaikka raadilla on merkitystä lähidemokratian työmuotona ja kansalaisten emansipoitumisen sekä osallisuuden kasvattamisessa, kasvatustieteen piirissä ei ole tutkittu kriittisen pedagogiikan näkökulmasta, miten osallistuminen ja vaikuttaminen kansalaisraadissa toteutuvat. Tutkimuksen tekee yhteiskunnallisesti tarpeelliseksi äänestysaktiivisuuden lasku ja muuttuva kansalaisvaikuttaminen. Kansalaisraati on yksi keskeinen vaikuttamiskanava, jossa käsitellään paikallisella tasolla kehitettäviä asioita eli niitä teemoja, jotka ovat lähellä kuntalaisten arkea. Kansalaisraateja analysoidaan seuraavien tutkimuskysymysten kautta: 1. Millaista osallistumista kansalaisraadeissa toteutetaan? ja 2. Millaisia vaikuttamisen mahdollisuuksia kansalaisraadit tarjoavat? Tutkimus sijoittuu kasvatussosiologian kenttään ja lähestyy osallistumisen ja vaikuttamisen tematiikkaa kriittisen pedagogiikan teoriatiedon avulla. Empiiristä aineistoa tulkitaan Layderin nelitasoisen tutkimuskartan avulla sekä yksilön että yhteiskunnan perspektiivistä. Keskeiset käsitteet ovat kansalaisraadit, osallistuminen ja vaikuttaminen. Metodologisesti tutkimus perustuu grounded-teorian straussilaiseen lähestymistapaan. Aineisto koostuu kuntalaisten (N=9), Kuntapäättäjien (N=5) ja viranhaltijoiden (N=6) haastatteluista ja yhdestä kirjallisesta vastauksesta. Haastattelut kestivät keskimäärin tunnin ja aineistoa on yhteensä 93 litterointisivua fontilla 11 ja rivivälillä 1. Aineisto kuvaa osallistujien kokemuksia suomalaisen voimakkaan teollisen rakennemuutoksen ja muuttotappioista kärsivän, taantuvan paikkakunnan kontekstissa toteutetuista raadeista vuosina 2012–2015. Haastatteluiden pääteemat käsittelivät kansalaisvaikuttamisen osallistumisen ja vaikuttamisen kysymyksiä. Aineisto on koodattu ja analysoitu straussilaisen kolmivaiheisen avoimen, aksiaalisen ja selektiivisen koodauksen mukaisesti. Tulokset osoittavat, että kuntalaisten osallistuminen raadissa ilmenee aktiivisena roolina, jolloin osallistujat tuottavat korkeatasoisia ja toteuttamiskelpoisia parannusesityksiä. Kansalaisraadissa toteutuva deliberaatio lisää raatiin osallistuvien kuntalaisten tietoa käsiteltävästä asiasta ja päätöksenteon taustalla olevista lainsäädännön ja talouden kysymyksistä. Vaikuttaminen osoittautuu heikoksi, sillä kuntalaisten tuottamat parannusesitykset jäävät irrallisiksi päätöksenteossa, eikä raatilaisten tuottamaa lisäarvoa yhteisön kehittämiseksi saada hyödynnettyä tavoitellulla tavalla. Raatilaisten vastavoima päättäjien toimintaan koetaan riittämättömäksi. Osapuolten erilaiset odotukset parannusehdotusten toteuttamisesta ja vaikutuksista yhteisöön aiheuttavat epäjärjestystä. Yhteenvetona voidaan todeta, että vaikuttamistilanteissa kuntalaisten työmuodot ja edustuksellisen demokratian työmuodot eivät kohtaa toisiaan. Tulosten pohjalta esitetään uusi toimenpidemalli kansalaisraatien toteuttamiseen. Johtopäätösten keskeinen ehdotus on kansalaisraatien yhdistäminen osaksi päätöksenteon valmistelua. Raatiin osallistuminen lisää kuntalaisten tietoa, jolla voidaan osallistua vaikuttamaan. Vaikuttamalla tuotetut parannusesitykset voidaan yhdistää päätösten valmisteluprosessiin ja yhteisön kehittämiseen. Tuloksia voidaan hyödyntää kansalaisraatien järjestämisessä. Tuotettu toimenpidemalli avaa uusia näkökulmia jatkotutkimukseen kansalaisraadista osallistumisen ja vaikuttamisen alustana.A citizens’ jury is a form of local democracy where citizens deliberate on public matters. This deliberation enables a participant to engage in learning. The juries train the participants to exert influence on matters discussed in the community. Deliberation refers to discussion that progresses through knowledge-based argumentation toward a better understanding of the matters at hand and solution proposals to them. Although citizens’ juries play a role as a form of local democracy and an enhancer of citizens’ emancipation and participation, educational science has not produced critical pedagogy-based research on how participation and influencing are realised in them. The research bears social importance because of diminishing voter turnouts and a transition taking place in civic participation. Citizens’ juries are a central influencing channel for addressing and improving local matters, that is, themes close to a citizen’s daily life. Citizens’ juries are analysed through the following questions: (1) What type of participation do citizens’ juries entail? and (2) What influencing opportunities do citizens’ juries provide? The research adheres to the field of the sociology of education and approaches the themes of participation and influencing through the theoretical framework of critical pedagogy. The empiric material is interpreted through Layder’s four-level research map from the perspectives of the individual and society. The core concepts are citizens’ juries, participation, and influencing. Methodogically, the study is based on the Straussian approach to grounded theory. The material consists of interviews with municipal residents (N=9), decision makers (N=5), and officials (N=6). In addition, it includes one written reply. The interviews lasted for one hour on average, and the material consists of 93 transcribed pages (font 11, line spacing 1). The material depicts participants’ experiences of juries implemented between 2012 and 2015 in the context of a declining Finnish locality undergoing a strong transition of industrial structure and suffering from migration loss. The main themes of the interviews dealt with civic activism in terms of participation and influencing. The material has been coded and analysed according to the Straussian three stages: open, axial, and selective coding. The results show that when participating in a citizens’ jury, people take on an active role that allows them to produce excellent and implementable improvement proposals. Deliberation in a citizens’ jury increases the participants’ knowledge of the discussed issue and the legal and economical questions behind decision making. However, influencing is ineffective because residents’ improvement proposals remain detached from decision making, and the added value produced by the participants to community development cannot be utilised as intended. Participants feel that their influence on decision-makers’ work is insufficent. The parties have differing expectations regarding the implementation of improvement proposals and exerting influence on the community, which causes confusion. In sum, the work mode of residents and that of representative democracy do not meet in situations of exerting influence. Based on the results, a new operational model for implementing citizens’ juries is introduced. The conclusions centre on a proposal to incorporate citizens’ juries into decision-making preparations. Participation in a jury increases residents’ knowledge, which enables them to engage in exerting influence. Improvement proposals produced through this influencing can be connected to the preparation of decision making and to the development of the community. The results can be used in organising citizens’ juries. This operational model opens up new perspectives for further investigation on citizens’ juries as a platform of participation and influencing

A nationwide real-world study on dynamic ustekinumab dosing and concomitant medication use among Crohn's disease patients in Finland

Background Real-world evidence to support optimal ustekinumab dosing for refractory Crohn's disease (CD) patients remains limited. Data from a retrospective nationwide chart review study was utilized to explore ustekinumab dosing dynamics and optimization, identify possible clinical predictors of dose intensification, and to evaluate ustekinumab trough concentrations (TCs) and concomitant medication use in Finland. Methods Information gathered from17 Finnish hospitals included clinical chart data from 155 adult CD patients who received intravenous ustekinumab induction during 2017-2018. Data on ustekinumab dosing and TCs, concomitant corticosteroid and immunosuppressant use, and antiustekinumab antibodies were analyzed in a two-year follow-up, subject to availability. Results Among 140 patients onustekinumab maintenance therapy, dose optimization was required in 55(39%) of the patients, and 41/47 dose-intensified patients (87%) persisted on ustekinumab. At baseline, dose-intensified patient group had significantly higher C-reactive protein (CRP) levels, and at week 16, significantly lower ustekinumab TCs than in patients without dose intensification. Irrespective of dose optimization, a statistically significant reduction in the use of corticosteroids was observed at both 16 weeks and one year, coupled with an increased proportion of patients on ustekinumab monotherapy. Antiustekinumab antibodies were undetectable in all 28 samples from 25 patients collected throughout the study period. Conclusions Nearly a third of all CD patients on ustekinumab maintenance therapy, with a history of treatment-refractory and long-standing disease, required dose intensification. These patients persisted on ustekinumab and had significant reduction of corticosteroid use. Increased baseline CRP was identified as the sole indicator of dose intensification.Peer reviewe

A nationwide real-world study on dynamic ustekinumab dosing and concomitant medication use among Crohn's disease patients in Finland

Background Real-world evidence to support optimal ustekinumab dosing for refractory Crohn's disease (CD) patients remains limited. Data from a retrospective nationwide chart review study was utilized to explore ustekinumab dosing dynamics and optimization, identify possible clinical predictors of dose intensification, and to evaluate ustekinumab trough concentrations (TCs) and concomitant medication use in Finland.Methods Information gathered from17 Finnish hospitals included clinical chart data from 155 adult CD patients who received intravenous ustekinumab induction during 2017-2018. Data on ustekinumab dosing and TCs, concomitant corticosteroid and immunosuppressant use, and antiustekinumab antibodies were analyzed in a two-year follow-up, subject to availability.Results  Among 140 patients onustekinumab maintenance therapy, dose optimization was required in 55(39%) of the patients, and 41/47 dose-intensified patients (87%) persisted on ustekinumab. At baseline, dose-intensified patient group had significantly higher C-reactive protein (CRP) levels, and at week 16, significantly lower ustekinumab TCs than in patients without dose intensification. Irrespective of dose optimization, a statistically significant reduction in the use of corticosteroids was observed at both 16 weeks and one year, coupled with an increased proportion of patients on ustekinumab monotherapy. Antiustekinumab antibodies were undetectable in all 28 samples from 25 patients collected throughout the study period.Conclusions Nearly a third of all CD patients on ustekinumab maintenance therapy, with a history of treatment-refractory and long-standing disease, required dose intensification. These patients persisted on ustekinumab and had significant reduction of corticosteroid use. Increased baseline CRP was identified as the sole indicator of dose intensification.</div

Ustekinumab for Crohn’s disease: a nationwide real-life cohort study from Finland (FINUSTE)

Background: Ustekinumab (UST), a human anti-IL12/23p40 monoclonal antibody, has been approved for treatment of Crohn?s Disease (CD) since the end of 2016. This nationwide noninterventional, retrospective chart review explored real-life data in patients receiving UST to provide guidance in UST treatment in the era of increasing prevalence of CD.Methods: The study assessed UST treatment patterns such as dosing frequency, concomitant medication and persistence in 48?CD patients commencing UST therapy in 12 Finnish hospitals during 2017. Clinical remission and response rates were explored using a modified Harvey?Bradshaw index (mHBI) and endoscopic response via the simple endoscopic score for Crohn?s disease (SES-CD) as proportions of patients at week 16 and at the end of follow-up.Results: Forty patients (83%) continued UST-treatment at the end of follow-up. At week 16, clinical response and endoscopic healing was observed, where data were available; mHBI decreased from 9 to 3 (p?=?.0001) and SES-CD from 12 to 3 (p?=?.009). Clinical benefit was achieved by 83% (19/23) at week 16 and by 76% (16/21) at the end of follow-up. The proportion of patients using corticosteroids decreased from 48% to 25% at week 16 and to 13% at the end of the follow-up.Conclusion: UST showed to be effective and persistent, inducing short-term clinical benefit and endoscopic response in this real-life nationwide study of CD patients. Significant corticosteroid tapering in patients with highly treatment refractory and long-standing CD was observed.Peer reviewe

Ustekinumab for Crohn's disease: a nationwide real-life cohort study from Finland (FINUSTE)

Background: Ustekinumab (UST), a human anti-IL12/23p40 monoclonal antibody, has been approved for treatment of Crohn's Disease (CD) since the end of 2016. This nationwide noninterventional, retrospective chart review explored real-life data in patients receiving UST to provide guidance in UST treatment in the era of increasing prevalence of CD. Methods: The study assessed UST treatment patterns such as dosing frequency, concomitant medication and persistence in 48 CD patients commencing UST therapy in 12 Finnish hospitals during 2017. Clinical remission and response rates were explored using a modified Harvey-Bradshaw index (mHBI) and endoscopic response via the simple endoscopic score for Crohn's disease (SES-CD) as proportions of patients at week 16 and at the end of follow-up. Results: Forty patients (83%) continued UST-treatment at the end of follow-up. At week 16, clinical response and endoscopic healing was observed, where data were available; mHBI decreased from 9 to 3 (p = .0001) and SES-CD from 12 to 3 (p = .009). Clinical benefit was achieved by 83% (19/23) at week 16 and by 76% (16/21) at the end of follow-up. The proportion of patients using corticosteroids decreased from 48% to 25% at week 16 and to 13% at the end of the follow-up. Conclusion: UST showed to be effective and persistent, inducing short-term clinical benefit and endoscopic response in this real-life nationwide study of CD patients. Significant corticosteroid tapering in patients with highly treatment refractory and long-standing CD was observed

Kirjallisuutta – Litteratur

Ville Kellokumpu: Irti niukkuudesta ja kohti rajatonta yltäkylläisyyttä? (Aaron Bastani: Fully automated luxury communism) Mikko Itälahti: Ymmärryksen rajoja kunnioittaen (Leila Haaparanta: Rajan taju) Matti Seppälä: Taulujen taivaat moniulotteisina (Seija Paasonen: Taiteilijoiden taivaat meteorologin silmin) Hannu Linkola: "Vuoksi isänmaan, eestä ristin tään..." (Arto Jokinen: Isänmaan miehet

Determination of the optimal matching position for setup images and minimal setup margins in adjuvant radiotherapy of breast and lymph nodes treated in voluntary deep inhalation breath-hold

Background Adjuvant radiotherapy (RT) of left-sided breast cancer is increasingly performed in voluntary deep inspiration breath-hold (vDIBH). The aim of this study was to estimate the reproducibility of breath-hold level (BHL) and to find optimal bony landmarks for matching of orthogonal setup images to minimise setup margins. Methods 1067 sets of images with an orthogonal setup and tangential field from 67 patients were retrospectively analysed. Residual position errors were determined in the tangential treatment field images for different matches of the setup images. Variation of patient posture and BHL were analysed for position errors of the vertebrae, clavicula, ribs and sternum in the setup and tangential field images. The BHL was controlled with a Varian RPM® system. Setup margins were calculated using the van Herk’s formula. Patients who underwent lymph node irradiation were also investigated. Results For the breast alone, the midway compromise of the ribs and sternum was the best general choice for matching of the setup images. The required margins were 6.5 mm and 5.3 mm in superior-inferior (SI) and lateral/anterior-posterior (LAT/AP) directions, respectively. With the individually optimised image matching position also including the vertebrae, slightly smaller margins of 6.0 mm and 4.8 mm were achieved, respectively. With the individually optimised match, margins of 7.5 mm and 10.8 mm should be used in LAT and SI directions, respectively, for the lymph node regions. These margins were considered too large. The reproducibility of the BHL was within 5 mm in the AP direction for 75% of patients. Conclusions The smallest setup margins were obtained when the matching position of the setup images was individually optimised for each patient. Optimal match for the breast alone is not optimal for the lymph node region, and, therefore, a threshold of 5 mm was introduced for residual position errors of the sternum, upper vertebrae, clavicula and chest wall to retain minimal setup margins of 5 mm. Because random interfraction variation in patient posture was large, we recommend daily online image guidance. The BHL should be verified with image guidance.BioMed Central open acces

Radiotherapy-induced diffuse myocardial fibrosis in early-stage breast cancer patients - multimodality imaging study with six-year follow-up

BackgroundBreast radiotherapy (RT) induces diffuse myocardial changes, which may increase the incidence of heart failure with preserved ejection fraction. This study aimed to evaluate the early signs of diffuse fibrosis after RT and their evolution during a six-year follow-up.MethodsThirty patients with early-stage left-sided breast cancer were studied with echocardiography and electrocardiography (ECG) at baseline, after RT, and at three-year and six-year follow-up visits. Echocardiography analysis included an off-line analysis of integrated backscatter (IBS). ECG was analysed for fragmented QRS (fQRS). In addition, cardiac magnetic resonance (CMR) imaging was performed at the six-year control. The left ventricle 16-segment model was used in cardiac imaging, and respective local radiation doses were analysed.ResultsRegional myocardial reflectivity in inferoseptal segments increased by 2.02 (4.53) dB (p = 0.026) and the percentage of leads with fQRS increased from 9.2 to 16.4% (p = 0.002) during the follow-up. In CMR imaging, abnormal extracellular volume (ECV) and T1 mapping values were found with anteroseptal and apical localization in a median of 3.5 (1.00-5.75) and 3 (1.25-4.00) segments, respectively. A higher left ventricle radiation dose was associated with an increased likelihood of having changes simultaneously in CMR and echocardiography (OR 1.26, 95% Cl. 1.00-1.59, p = 0.047).ConclusionsAfter radiotherapy, progressive changes in markers of diffuse myocardial fibrosis were observed in a multimodal manner in ECG and echocardiography. Changes in echocardiography and abnormal values in CMR were localized in the septal and apical regions, and multiple changes were associated with higher radiation doses.Peer reviewe