Browsing by Subject "EXPERIENCES"

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  • Hartonen, Ville R.; Väisänen, Pertti; Karlsson, Liisa; Pöllänen, Sinikka (2022)
    The asylum regime encloses tens of millions of applicants for international protection in camps and different types of reception centres, to wait even decades for their cases to be resolved. Simultaneously both within and outside the nation state, asylum seekers and refugees occupy a social space outside the natural order of things, a stage of limbo. By incorporating the classical anthropological concepts of limbo and liminality to the methodological possibilities of meta-ethnography, we conducted to our knowledge the first meta-synthesis of 17 scientific peer-reviewed articles with the aims of defining what constitutes the concept of a stage of limbo and investigating refugees' and asylum seekers' agency as they cope when navigating in it. By dissecting detailed descriptions of forced migrants' experiences of liminality, our synthesis identified four key concepts involved in negotiations of agency in a stage of limbo: process of eligibility, spatial-temporal inconsistency, ontological insecurity and actions.
  • Tornivuori, Anna; Tuominen, Outi; Salantera, Sanna; Kosola, Silja (2020)
    Aims To define digital health services that have been studied among chronically ill adolescents and to describe e-health coaching elements that may have an impact on transition outcomes. Design Systematic review without meta-analysis. Data sources MEDLINE (Ovid), Pub Med, Scopus and CINAHL on 28 May 2018. Review methods Peer-reviewed articles published between January 2008-May 2018 were reviewed following the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Results Twelve randomized controlled trials were included. The interventions varied significantly in duration and content. E-coaching that included human and social support showed positive impact on transition outcomes. Digital health services incorporated into usual care provide efficient and accessible care. Conclusion E-coaching elements enable tailoring and personalization and present a tool for supporting and motivating chronically ill adolescents during transition of care. Future research should evaluate the effectiveness of e-coaching elements. Impact Digital services are considered a means for increasing adolescents' motivation for self-care and for increasing their accessibility to health care. The coaching elements in digital services consist of a theoretical basis, human support, interactive means and social support. Included interventions varied in terms of duration, dose, content and design. Our results may serve the development of digital health services for adolescents in transition. E-coaching can be used to engage and motivate chronically ill adolescents to improve health behaviour and self-management during transition of care.
  • Lindgren, Maija; Jonninen, Minna; Jokela, Markus; Therman, Sebastian (2019)
    Background: We investigated whether psychosis risk symptoms predicted psychiatric service use using seven-year register follow-up data. Methods: Our sample included 715 adolescents aged 15-18, referred to psychiatric care for the first time. Psychosis risk symptoms were assessed with the Prodromal Questionnaire (PQ) at the beginning of the treatment. We assessed the power of the overall PQ as well as its positive, negative, general, and disorganized psychosis risk symptom factors in predicting prolonged service use. Baseline psychiatric diagnoses (grouped into 7 categories) were controlled for. Based on both inpatient and outpatient psychiatric treatment after baseline, adolescents were divided into three groups of brief, intermittent, and persistent service use. Results: Stronger symptoms on any PQ factor as well as the presence of a mood disorder predicted prolonged service use. All of the PQ factors remained significant predictors when adjusted for baseline mood disorder and multimorbidity. Conclusions: In a prospective follow-up of a large sample using comprehensive mental health records, our findings indicate that assessing psychosis risk symptoms in clinical adolescent settings at the beginning of treatment could predict long-term need for care beyond diagnostic information. Our findings replicate the previous findings that positive psychosis risk symptoms are unspecific markers of severity of psychopathology. Also psychosis risk symptoms of the negative, disorganization, and general clusters are approximately as strongly associated with prolonged psychiatric service use in the upcoming years.
  • Wu, Anette; Noel, Geoffroy P. J. C.; Wingate, Richard; Kielstein, Heike; Sakurai, Takeshi; Viranta-Kovanen, Suvi; Chien, Chung-Liang; Traxler, Hannes; Waschke, Jens; Vielmuth, Franziska; Sagoo, Mandeep Gill; Kitahara, Shuji; Kato, Yojiro; Keay, Kevin A.; Olsen, Jorgen; Bernd, Paulette (2020)
    Background: At a time of global interconnectedness, the internationalization of medical education has become important. Anatomy as an academic discipline, with its close connections to the basic sciences and to medical education, can easily be connected with global health and internationalization of medical education. Here the authors present an international program based on a partnership between twelve anatomy departments in ten countries, on four continents. Details of a proposed plan for the future direction of the program are also discussed. Objective: The aim is to improve global healthcare by preparing future global healthcare leaders via early international networking, international collaboration and exchange, intercultural experience, and connecting two seemingly distant academic disciplines - anatomy and global health - via internationalization of medical education. Methods: Based in the anatomy course, the program involved early international collaboration between preclinical medical and dental students. The program provided a stepwise progression for learning about healthcare and intercultural topics beyond pure anatomy education - starting with virtual small groups of international students, who subsequently presented their work to a larger international audience during group videoconferences. The above progressed to in-person visits for research internships in the basic sciences within industrialized countries. Findings: Students appreciated the international and intercultural interaction, learned about areas outside the scope of anatomy (e.g., differences in healthcare education and delivery systems, Public and Global Health challenges, health ethics, and cultural enrichment), and valued the exchange travel for basic sciences research internships and cultural experience. Conclusions: This unique collaboration of international anatomy departments can represent a new role for the medical anatomy course beyond pure anatomy teaching - involving areas of global health and internationalization of medical education - and could mark a new era of international collaboration among anatomists.
  • Toivanen, Reetta; Fabritius, Nora (2020)
    This article presents research on contradictory representations of the Arctic and its inhabitants from the point of view of sustainable development. Indigenous peoples are repeatedly presented as connected to nature but outside politics, while business and state stakeholders portray the Arctic as uninhabited and utilizable for extractivism. These depictions diminish the agency of indigenous Sámi in political decision-making, agency that is integral to achieving a sustainable future both for Arctic lands and cultures. Contrary to what older generations fear, research from this decade shows that youth — who are increasingly moving to urban centers — are not necessarily leaving Sámi culture and lands. They are finding new modes of agency by transcending the discursive boundaries of periphery and center, nature and culture.
  • Celikkayalar, Ercan; Airaksinen, Marja; Kivelä, Sirkka-Liisa; Nieminen, Jenni; Kleme, Jenni; Puustinen, Juha (2021)
    Purpose: The use of benzodiazepines and related drugs (BZD) is common among older adults although there is growing evidence of their harmful effects. This study investigated how well older people are aware of the potential risks related to the BZD they are taking and whether the risk awareness has changed in the years between 2004 and 2015. Patients and Methods: The data were collected by interviewing BZD using home-dwelling patients aged >= 65 years with normal cognitive function (MMSE >= 20) who were admitted to the hospital within a 1 month study period in the years 2004 and 2015. Patients were asked whether they were aware of the ten main potential risks related to BZD use. A risk awareness score (range 0-10) was assessed for each patient, each known potential risk yielding one point. Results: The study included 37 patients in 2004 and 31 patients in 2015. In 2004,6/37 patients (16%), while 16/31 patients (52%) in 2015 had risk awareness scores between 6 and 10. Awareness of dependence (p=0.047), interaction with alcohol (p=0.001), dizziness (p=0.002) and developing tolerance (p=0.002) had improved, while awareness of the other potential risks remained unchanged, muscle weakness being the least known (3/37 in 2004 and 4/31 in 2015 were aware of it as a potential risk). Regular BZD use had declined (p=0.043) but pro re nata (PRN; when required) BZD use had increased (p=0.003) between the years 2004 and 2015. Conclusion: Older BZD users' awareness of some potential risks related to BZD use (dependence, interaction with alcohol, dizziness and developing tolerance) had improved between 2004 and 2015, while awareness of other potential risks remained unchanged.
  • Salmela, Jatta Helena; Mauramo, Elina; Lallukka, Tea; Rahkonen, Ossi; Kanerva, Noora (2019)
    Objective: Childhood disadvantage is associated with a higher risk of adult obesity, but little is known about its associations with body mass index (BMI) trajectories during adulthood. This study aimed first to identify adulthood BMI trajectories, and second to investigate how childhood disadvantage is associated with trajectory group membership. Methods: Data from the Helsinki Health Study, a longitudinal cohort study of initially 40- to 60-year-old employees of the City of Helsinki in Finland, were used. The baseline survey was conducted in 2000–2002, and similar follow-up surveys in 2007, 2012, and 2017. Based on self-reported BMI, participants’ (n =5,266; 83% women) BMI trajectories, including their retrospectively reported BMI at the age of 25 years, were examined. Data on childhood disadvantage, including parental education and 7 types of childhood adversity (their own serious illness; parental divorce, death, mental disorder, or alcohol problems; economic difficulties at home; and peer group bullying) before the age of 16 years, were obtained from the baseline survey. Group-based trajectory modeling was used to identify BMI trajectories, and multinomial logistic regression to analyze the odds for trajectory group membership for the disadvantage variables. Results: Four ascending BMI trajectories in women and men were found: persistent normal weight (trajectory 1; women 35% and men 25%), normal weight to overweight (trajectory 2; women 41% and men 48%), normal weight to class I obesity (trajectory 3; women 19% and men 23%) and overweight to class II obesity (trajectory 4; women 5% and men 4%). Compared to trajectory 1, women with multiple adversities and repetitive peer bullying in childhood had greater odds of belonging to trajectories 3 and 4, whereas men with parental alcohol problems had greater odds of belonging to trajectory 4. For women and men, a low level of parental education was associated with a higher-level BMI trajectory. Conclusions: Low parental education for both genders, multiple adversities and repetitive peer bullying in childhood among women, and parental alcohol problems among men increased the odds of developing obesity during adulthood. Further studies are needed to clarify how gender differences modify the effects of childhood disadvantage on adult BMI trajectories.
  • Brown, Edwina A.; Ekstrand, Agneta; Gallieni, Maurizio; Gorrin, Maite Rivera; Gudmundsdottir, Helga; Guedes, Anabela Malho; Heidempergher, Marco; Kitsche, Benno; Lobbedez, Thierry; Lundstrom, Ulrika Hahn; McCarthy, Kate; Mellotte, George J.; Moranne, Olivier; Petras, Dimitrios; Povlsen, Johan; Punzalan, Sally; Wiesholzer, Martin (2022)
    Background Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilized in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. Methods Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow and their top three priorities. Results Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD, with all respondents mentioning the need for nephrology team education and/or patient education and involvement in dialysis modality decision making. Conclusions and call to action Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and in all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policymakers and healthcare providers to develop and support assistance for PD.
  • Kytö, Mikko; Strömberg, Lisbeth; Tuomonen, Heli; Ruonala, Antti; Koivusalo, Saila; Jacucci, Giulio (2022)
    Gestational diabetes mellitus (GDM) has considerable and increasing health effects as it raises both the mother’s and offspring’s risk for short- and long-term health problems. GDM can usually be treated with a healthier lifestyle, such as appropriate dietary modifications and engaging insufficient physical activity. While telemedicine interventions requiring weekly or more frequent feedback from health care professionals have shown the potential to improve glycemic control amongst women with GDM, apps without extensive input from health care professionals are limited and have not shown to be effective. We aimed to improve the efficacy of GDM self-management apps by exploring desirable features in a review. We derived six desirable features from the multidisciplinary literature and we evaluated the state of implementation of these features in existing GDM apps. The results showed that features for increasing competence to manage GDM and for providing social support were largely lacking.
  • Holm, Marja Eliisa; Korhonen, Johan; Laine, Anu; Björn, Piia Maria; Hannula, Markku Sakari (2020)
    This study investigated the big-fish-little-pond effect (BFLPE) on mathematics-related achievement emotions (enjoyment, pride, anger, anxiety, shame, hopelessness, and boredom) among adolescents (N = 1322) using multilevel modeling, controlling for the effects of gender and classroom size. The results indicated that only pride was influenced by the BFLPE. Hence, adolescents reported less pride in mathematically higher-performing classrooms (higher class average). The cross-level interaction effects indicated that the BFLPE varies across mathematics performance levels and gender. In mathematically higher-performing classrooms, adolescents with lower mathematics performance reported less pride and more shame, whereas adolescents with higher mathematics performance reported less enjoyment and more boredom. Additionally, males reported more shame in higher-performing classrooms. We discuss the practical implications of supporting achievement emotions in higher-performing classrooms.
  • Hemminki, Kari; Kanerva, Anna; Försti, Asta; Hemminki, Akseli (2022)
    Background: Incidence of cervical cancer has been reduced by organized screening while for vaginal and vulvar cancers no systematic screening has been implemented. All these cancers are associated with human papilloma virus (HPV) infection. We wanted to analyze incidence trends and relative survival in these cancers with specific questions about the possible covariation of incidence, survival changes coinciding with incidence changes and the role of treatment in survival. We used nationwide cancer registry data for Denmark (DK), Finland (FI), Norway (NO) and Sweden (SE) to address these questions. Methods: We use the NORDCAN database for the analyses: incidence data were available from 1943 in DK, 1953 in FI and NO and 1960 in SE, through 2016. Survival data were available from 1967 through 2016. World standard population was used in age standardization. Results: In each country the incidence of cervical cancer declined subsequent to rolling out of screening activities. The attained plateau incidence was lowest at 4/100,000 in FI and highest at 10/100,000 in DK and NO. The incidence of vaginal and vulvar cancer remained relatively constant at about 2/100,000. Relative 1-year survival in cervical cancer improved in all countries from low 80%s to high 80%s in the 50-year period, and 5-year survival improved also but at 20% units lower level. Survival gains were found only in patients diagnosed before age 60 years. Survival in vaginal and vulvar cancer followed the same patterns but at a few % units lower level. Conclusion: Cervical cancer screening appeared to have reached its limits in the Nordic countries by year 2000. Novel treatments, such as immunotherapy, would be needed to improve survival until HPV vaccination will reach population coverage and boost the global fight against these cancers.
  • Yang, Lei; Hu, Yaoyue; Silventoinen, Karri; Martikainen, Pekka (2020)
    Objectives: A number of studies have established the link between childhood adversity (CA) and depression across the life span. This association can be culturally specific, and it remains unclear whether and how different aspects of CA affect depressive symptoms in later life in non-Western societies. Method: Data were from the China Health and Retirement Longitudinal Study in 2011, 2013, 2014 (Life Event History survey) and 2015 (N = 13,710). Depressive symptoms were measured repeatedly in 2011, 2013, and 2015 using the ten-item Centre for Epidemiologic Studies Depression Scale (CES-D-10). CA was assessed in 2014 by parental physical abuse, maternal emotional neglect, early parental death, parental mental health problems, poor quality of parental relationship, and childhood socioeconomic disadvantage. Multilevel linear models were used to analyse the data. Results: Parental physical abuse was associated with 0.51 (95% confidence interval [CI]: 0.28, 0.74) and 0.59 (95% CI: 0.31, 0.88) higher CES-D-10 scores compared to those without such abuse experience for men and women, respectively. Emotional neglect predicted 0.30 (95% CI: 0.07, 0.51) and 0.33 (95% CI: 0.08, 0.58) higher CES-D-10 scores for men and women. Elevated CES-D-10 scores were also found among men and women whose parents had poor mental health and poor relationship, and those who experienced food inadequacy (men: 0.78, 95% CI: 0.54, 1.01; women: 1.15, 95% CI: 0.90, 1.41). Early parental death nevertheless was not associated with CES-D-10 scores. Conclusion: CA exerts long-term detrimental effects on mental health in mid- and late-life among Chinese adults. The findings are consistent with those from Western societies, except for early parental death.
  • Komulainen, Kaisla; Mittleman, Murray A.; Ruohonen, Saku; Laitinen, Tomi T.; Pahkala, Katja; Elovainio, Marko; Tammelin, Tuija; Kähönen, Mika; Juonala, Markus; Keltikangas-Järvinen, Liisa; Raitakari, Olli; Pulkki-Råback, Laura; Jokela, Markus (2019)
    Introduction: This study used causal mediation analysis to assess the life-course associations of a favorable childhood psychosocial environment with left ventricular mass and diastolic function in adulthood and the extent to which adult health behaviors mediate these associations. Methods: The sample included 880 participants (56% women) from the Young Finns Study with data on the childhood environment from 1980, adult health behaviors (smoking, physical activity, diet, and BMI) from 2001 and an echocardiographic assessment of the left ventricular mass (g/m(2.7)) and diastolic function (E/e' ratio; higher values indicating a lower diastolic function) from 2011. The associations of the childhood environment with the left ventricular mass and E/e' ratio and mediation pathways through health behaviors were assessed using marginal structural models that were controlled for age, sex, and time-dependent confounding by adult socioeconomic position (measured as educational attainment) via inverse probability weighting. The data were analyzed in 2018-2019. Results: The mean age in 2011 was 41 (range 34-49) years. Those above versus below the median childhood score had a 1.28 g/m(2.7) lower left ventricular mass (95% CI = -2.63, 0.07) and a 0.18 lower E/e' ratio (95% CI = -0.39, 0.03). There was no evidence for indirect effects from childhood environments to left ventricular outcomes through adult health behaviors after controlling for time-dependent confounding by the adult socioeconomic position (indirect effect beta = -0.30, 95% CI = -1.22, 0.63 for left ventricular mass; beta = -0.04, 95% CI = -0.18, 0.11 for E/e' ratio). The results after multiple imputation were similar. Conclusions: A favorable childhood environment is associated with more optimal cardiac structure and function in adulthood. After accounting for socioeconomic positions, adult health behaviors explain little of the associations. (C) 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
  • Lahtinen, Hanna-Mari; Laitila, Aarno; Korkman, Julia; Ellonen, Noora (2018)
    Most previous studies on disclosing child sexual abuse (CSA) have either been retrospective or focused on children who already have disclosed. The present study aimed to explore the overall CSA disclosure rate and factors associated with disclosing to adults in a large population-based sample. A representative sample of 11,364 sixth and ninth graders participated in the Finnish Child Victim Survey conceming experiences of violence, including CSA. CSA was defined as having sexual experiences with a person at least five years older at the time of the experience. Within this sample, the CSA prevalence was 2.4%. Children reporting CSA experiences also answered questions regarding disclosure, the disclosure recipient, and potential reasons for not disclosing. The results indicate that most of the children (80%) had disclosed to someone, usually a friend (48%). However, only 26% had disclosed to adults, and even fewer had reported their experiences to authorities (12%). The most common reason for non-disclosing was that the experience was not considered serious enough for reporting (41%), and half of the children having CSA experiences did not self-label their experiences as sexual abuse. Relatively few children reported lacking the courage to disclose (14%). Logistic regression analyses showed that the perpetrator's age, the age of the victim at the time of abuse, and having no experiences of emotional abuse by the mother were associated with disclosing to an adult. The results contribute to understanding the factors underlying children's disclosure patterns in a population-based sample and highlight the need for age-appropriate safety education for children and adolescents.
  • Grano, Niklas; Karjalainen, Marjaana; Ranta, Klaus; Lindgren, Maija; Roine, Mikko; Therman, Sebastian (2016)
    The aim of the present study was to compare change in functioning, affective symptoms and level of psychosis-risk symptoms in symptomatic adolescents who were treated either in an early intervention programme based on a need-adapted Family- and Community-orientated integrative Treatment Model (FCTM) or in standard adolescent psychiatric treatment (Treatment As Usual, TAU). 28 pairs were matched by length of follow-up, gender, age, and baseline functioning. At one year after the start of treatment, the matched groups were.compared on change in functioning (GAF-M), five psychosis-risk dimensions of the Structured Interview for Psychosis-Risk Syndromes (SIPS), and self-reported anxiety, depression, and hopelessness symptoms (BAI, BDI-II, BHS). FCTM was more effective in improving functioning (20% vs. 6% improvement on GAF-M), as well as self-reported depression (53% vs. 14% improvement on BDI-II) and hopelessness (41% vs. 3% improvement on BHS). However, for psychosis-risk symptoms and anxiety symptoms, effectiveness differences between treatment models did not reach statistical significance. To conclude, in the present study, we found greater improvement in functioning and self-reported depression and hopelessness among adolescents who received a need-adapted Family and Community-orientated integrative Treatment than among those who were treated in standard adolescent psychiatry. (C) 2016 Elsevier Ireland Ltd. All rights reserved.
  • Lämsä, Anna-Maija; Mattila, Markku; Lähdesmäki, Merja; Suutari, Timo (2019)
    Purpose In this paper, the following research question is addressed: Why do business organisations recruit employees with a foreign background? This was examined in terms of the values that guide organisations and their management. The paper aims to discuss this issue. Design/methodology/approach The study focused on two businesses in Finland that are pioneers in the recruitment of immigrants. A case study approach was adopted. The research data consist of interviews and documentary data. The data were analysed using content analysis in accordance with grounded theory. Findings Companies can act as an enabling force in the integration of immigrants into the local labour market, especially when the company's value basis extends beyond only economic values. Research limitations/implications - The study was conducted only in two case companies in Finland. Practical implications - Companies have the potential to affect local people's attitudes towards immigrants as workers. This is important because many western societies are likely to face a labour shortage in the future due to the ageing population and low birth rate. Originality/value Prior research has mostly investigated the topic from the viewpoints of the immigrants themselves and of policy makers. The value of this study is that it makes the employers' viewpoint visible. The dominant theories applied in the field of immigrant recruitment are inadequate to explain employers' behaviour because of their underlying assumption of the overwhelming importance of economic values in decision making.
  • Weckström, Elina; Lastikka, Anna-Leena; Havu-Nuutinen, Sari (2022)
    The aim of this research was to explore a socially sustainable culture of participation in which all members of the community can be heard, make initiatives, express their opinions, and alter their practices. We conducted the study by analysing three separate sets of empirical research data in which participation was investigated in an early childhood education and care (ECEC) context and in club activities for children aged 4-12 and the elderly. The data include children's perspectives regarding participation, ECEC practitioners' perspectives on a culture of participation, and children's and ECEC practitioners' shared project-based practices. The results show that children and ECEC practitioners were willing to commit to new practices and construct a collective 'we-narrative'. A we-narrative created a foundation for the conceptual model of a socially sustainable culture of participation, including the prerequisites of participation in adult practices, the goal of participation in children's and adults' shared activities, and a tool for strengthening participation. According to the results, a socially sustainable culture of participation is holistic and dynamic, and children can have an effect on daily activities, including basic care situations, as well as part of the educational activities.
  • Lahti, Henna; Fernström, Päivi (2021)
    Our aim in this article is to introduce the idea of ‘crafticulation’ as a part of scientific method and to present a case study related to it. A novel course, Materializing in Craft Science, was offered in the first year of the craft teacher master’s degree at the University of Helsinki. The aim of the course was to pilot a method of crafticulation by materializing theoretical mind maps. Crafticulation consists of the words, ‘craft’ and ‘articulation’ and further, crafticulation is seen as a part of practice-led research in which craft plays a key role in eliciting a wide spectrum of knowledge. Our research question is how crafticulation emerged in students’ inquiry processes. The research data included twenty individual mind maps, materializations and reflections of the course. Based on theory-driven data analysis, the results indicated that many students used crafticulation for demonstration purposes. For example, they tested the connection between their craft-making process and well-being. Another approach was to convey a certain experience by way of crafticulation. In some cases, crafticulation was linked to analogies and metaphors in learning theoretical concepts. Furthermore, the students found new avenues in which to reflect research topics and to deepen their inquiry processes.
  • Weckström, Elina; Karlsson, Liisa; Pöllänen, Sinikka; Lastikka, Anna-Leena (2021)
    This study reports on critical participatory research in an early childhood education and care centre in Finland. The objective was to study which elements are critical in the development and construction of a culture of participation. The data comprise conversations, team meetings and educators' diaries. Data were analysed using thematic analysis. The results indicated that a culture of participation requires four elements: (a) a shared understanding of the image of the child, (b) a shared understanding of professional development, (c) leadership and (d) a shared we-narrative that enables the comprehensive understanding, promotion and maintenance of a culture of participation.