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Improving early recognition and management of child maltreatment at the emergency department
No full textChild maltreatment is a large public health problem, with long-lasting effects on both the individual and future generations because of intergenerational trauma effects, and society. It is therefore of the utmost importance to increase early recognition and adequate management of (possible) child maltreatment. Studies have shown systematic screening for child maltreatment at the emergency department is effective in improving its detection rate. A multidisciplinary approach including physical, psychological and forensic assessment is specifically necessary in the evaluation of child sexual abuse.The overall objective of this thesis is to improve the early recognition and management of child maltreatment at emergency departments (EDs) in Europe, by exploring areas of improvement, developing and validating a screening instrument, establishing a comprehensive approach for implementation, and evaluating existing procedures of a multidisciplinary and specialized child sexual abuse team.<br/
Exploring the borders:Diagnosis and surgical treatment of lentigo maligna
No full textEXPLORING THE BORDERS – Diagnosis and surgical treatment of lentigo malignaThis thesis demonstrates the increasing incidence of cutaneous melanomas in the Netherlands. The largest proportion of the cutaneous melanomas are in situ or thin melanomas. Possible explanations of this increase include a true increase, in conjunction with ‘overdiagnosis’ caused by increased awareness, early detection and diagnostic drift. Lentigo maligna (LM) is the most common in situ melanoma subtype and accounts for three quarters of all in situ melanomas. Retrospective, prospective, and national data show that upstaging to LMM occurs in approximately one of ten patients after surgery. This should be taken into account when making therapeutic decisions, especially when non-surgical treatments are being considered. Evaluating LM on frozen sections with additional staining is possible and should be further explored in the future to incorporate in daily practice and improve the tolerability of the surgical treatment of LM. Treating LM remains a therapeutic challenge due to its predominance in the face and in elderly patients. Surgical treatment is generally recommended, though striving for clear margins may not always be necessary, and a ‘wait and see’ approach should be considered in some cases. Future research should consider integrating frailty screening and focus on developing tools to support shared decision-making prior to treatment. In conclusion, the treatment of LM is challenging and there is no one-size-fits-all solution.<br/
Screening for colorectal cancer screening tests
Full text linkIn this thesis we aimed to evaluate the performance of fecal immunochemical test (FIT) in comparison with already established colorectal cancer (CRC) screening tests and potential new screening tests to improve CRC screening (part II). In addition, we aimed to provide insights on how to reduce PCCRC risk and therefore improve colonoscopy quality within the screening program (part III).Part II of this thesis results in three main conclusions. The first conclusion (Chapter 2) is that FIT outperforms guaiac-based fecal occult blood tests (g-FOBTs). The second conclusion (Chapter 3, 4 and 5) is that the multitarget FIT (mtFIT) outperforms FIT in the detection of advanced neoplasia by increased detection of advanced adenomas. The third conclusion (Chapter 6) is that tests that measure circulation tumor DNA (ctDNA) could potentially be used for CRC screening and have complementary value to FIT.Part III of this thesis results in four additional main conclusions. The fourth conclusion (Chapter 7) is that the number of post colonoscopy colorectal cancers (PCCRCs) in the Dutch CRC screening program is low, which reflects high quality colonoscopy by accredited and audited endoscopists. The fifth conclusion (Chapter 8) is that adenoma detection rates (ADRs) are substantially higher for colonoscopies after positive FIT compared to colonoscopies performed for other indications. The sixth conclusion (Chapter 8) is that endoscopists their ADRs are inversely associated with the interval PCCRC risk of the screenees that undergo colonoscopy after positive FIT by these endoscopists. The seventh conclusion (Chapter 9) is that CRC risk, 2.5 years after a negative colonoscopy (after positive FIT), is equal to the CRC risk 2 years after a negative FIT.<br/
Queering courts:Analysing equal marriage rights cases before the European Court of Human Rights, the Court of Justice of the European Union and the United States Supreme Court
Full text linkAlmost forty countries around the world currently allow same-sex couples to marry. While most of these decisions were made through legislative action, petitioners have increasingly also turned to courts to obtain marriage equality or enjoy ‘equal marriage rights,’ i.e. the numerous rights and benefits connected to marriage and/or the legal recognition of same-sex relationships. With the use of queer legal theory, this dissertation researches how courts such as the European Court of Human Rights (ECtHR), the Court of Justice of the European Union (CJEU), and the United States Supreme Court (US Supreme Court) interpret and apply the notions of ‘sex,’ ‘gender,’ ‘sexuality’ and ‘sexual orientation’ in their equal marriage rights case law. The research reveals that courts interpret the notions as binary constructs with the dominance in one part commonly anchored on certain heteronormative beliefs. This results in the discrimination, non-inclusivity and ‘othering’ of all that do not fall within the dominant part of the hierarchies, making them thus ineligible to enjoy ‘full’ or ‘equal’ marriage rights. While the decision-making of the courts is influenced by factors such as history, culture, religion, politics, etc., judicial self-restraint is oftentimes exercised for credibility, legitimacy, and authority reasons.The research suggests that courts queer their approaches, for instance by considering the notions more as spectra instead of fixed binary constructs, focusing more on the ‘dignity’ of the petitioners involved, the Yogyakarta Principles or on creating an ‘equal level playing field,’ and focusing less on applying heteronormative tools and methods, such as looking for ‘consensus.’ Queering their approaches might lead the courts to more inclusive, diverse and universal adjudication. Until then, the enjoyment of full equal marriage rights is only for the heterosexually privileged. <br/
Digital health in cardiovascular disease:The current status of remote monitoring in heart failure and the potential future development
No full textThe thesis explores the role of digital health technologies in managing heart failure (HF) and out-of-hospital cardiac arrest (OHCA). It evaluates the effectiveness of remote monitoring (RM) in HF care, focusing on its potential to reduce mortality and hospitalizations, while addressing the need for greater standardization and personalized approaches.Wearable technologies for HF monitoring are examined, with an emphasis on their promise and the challenges in achieving broad clinical implementation. The integration of AI with these technologies is discussed as a pathway for more personalized and responsive care.The thesis also investigates the use of wrist-based photoplethysmography (PPG) for OHCA detection, presenting promising results from clinical studies. It highlights how AI algorithms can enhance early intervention and improve survival rates.<br/
Imagining China:The discursive construction and circulation of the nation in Chinese cyberspace
No full textPersonalized music in healthcare
No full textPersonalized music has the most significant effect on pain relief. While previous studies have shown that music can positively influence pain, anxiety, stress, sleep, and delirium in hospitalized patients, it was unclear which type of music worked best for which patient and context. Many of these studies lacked diversity in their participant groups, prompting this thesis to investigate the impact of music on pain across individuals from varied socio-cultural backgrounds. It also includes a comparative study of five music genres – urban, electronic, classical, rock, and pop. Both studies found that preferred music, regardless of music genre or socio-cultural background, consistently reduced pain more effectively than non-preferred music. A global survey across 20 countries with over 33,000 participants revealed that almost 90% of people would like to listen to music when in pain. The thesis further explores how music is implemented in healthcare from the patient’s perspective, showing that many patients are unaware of the option, and even when they are, they often feel uncomfortable and/or awkward requesting it, or fear judgment from medical staff regarding their musical taste
‘We gave them the glass, now it’s up to them to pour the tea’:Exploring farmers’ appropriation of water user associations in rural Morocco
No full textIn the early 1990s, Morocco adopted participatory irrigation management (PIM) and irrigation management transfer (IMT) as key policy frameworks in irrigation management following international donors’ agendas. As part of this framework, Water User Associations (WUAs) were implemented to decentralize resource management, promote farmers’ participation, and reduce irrigation system maintenance costs. By the early 2000s, evaluations reported mixed results and challenges in promoting active participation and securing financial support. Factors explaining these outcomes include insufficient training and capacity building, unequal power relations and elite capture, and the unclear definition of WUA roles. More broadly, disappointing performances are often attributed to the mismatch between donor-driven, state-imposed bureaucratic WUA frameworks and the complex socio-cultural and political context in which they were implemented. Externally imposed frameworks often fail to account for long-established, embedded institutions and traditional practices shaping irrigation management, contributing to weak institutional embeddedness, reduced management efficiency, and low local ownership of imposed models.Research examining WUAs globally has analysed factors contributing to these outcomes from different angles and regional perspectives. Despite contextual differences, common challenges have emerged across studies. A subset has examined the interaction between WUAs and pre-existing traditional forms of irrigation management, exploring the capacity of local communities to transform, reject, and reconfigure bureaucratic institutions, shedding light on local-level dynamics driving institutional transformation and adaptation processes. Research in rural Morocco shows that WUAs, depending on context and actors, may become innovative arenas serving socially valued purposes through locally driven reconfiguration processes.This thesis contributes to this body of research by examining how local farmers appropriate or reject WUAs and how communities reshape and repurpose WUAs through micro-level institutional bricolage processes. The study situates this analysis within the structure-agency interplay, examining how local actors navigate political and socio-cultural dynamics, as well as the role of state public policy, agrarian transformation, and the impact of climate change on water resources.An original analytical framework is developed, combining the notion of appropriation of space adapted from Henri Lefebvre with institutional bricolage theory as conceptualized by Frances Cleaver. The framework focuses on the transformative potential of place politics, examining how WUAs are locally reshaped or rejected. It explores how communities selectively draw on bureaucratic and customary practices, as well as their own experiences, to integrate different institutional logics in local irrigation governance. The framework was refined through iterative engagement between theoretical reflections and empirical observations, grounded in local perspectives. This approach provides insight into institutional change dynamics in response to evolving socio-political and ecological conditions, and policy implementation, revealing how these factors redefine local irrigation governance.Empirically, the thesis is based on qualitative, participatory, and exploratory research in two municipalities on the Moroccan Atlas. A comparative case study of 12 WUAs in small-scale irrigation systems in Ain Leuh (Ifrane Province) and the Zat Valley (Al Haouz Province) identifies common patterns and divergent trajectories. Comparative analysis allows a nuanced understanding of how community-endogenous factors and external pressures shape irrigation management. Ethnographic approaches combined with participatory methods enable deep contextual understanding and incorporation of local perspectives, complementing the qualitative inquiry.A key finding is that WUAs initially functioned mainly as ‘contractual’ entities, adopted primarily to access state funding for infrastructural development. Following this phase, most returned to customary management, highlighting limits of externally imposed models. Over time, communities engaged with WUAs through three distinct processes of institutional appropriation, each contributing to reconfiguration through institutional bricolage, involving selective borrowing, adaptation, and recombination of bureaucratic and customary systems. Civic-driven appropriation involves new forms of rural leadership integrating local practices within bureaucratic institutions. Partial appropriation refers to coexistence and interaction of customary and bureaucratic logics, resulting in hybrid modes. Cultural non-appropriation describes cases in which WUAs are primarily contractual for infrastructure, while customary institutions retain water management control. Together, these processes illustrate the plurality of local responses and highlight the role of bricolage in generating adaptive, contextually grounded, and socially legitimate water management institutions.The thesis is structured around eight chapters. Following the introduction of the research design and problem framing, the methodological approach is described. The theoretical and analytical framework is then presented. Historical, socio-cultural, and political dimensions of irrigation management in Morocco are examined to understand the interplay between legacies, state-driven policies, socio-political changes, and climate dynamics influencing local irrigation management. This contextual analysis informs empirical findings, discussed for Ain Leuh and the Zat Valley. Comparative analysis shows that WUA reconfiguration is a dynamic process evolving over time, with varying engagement and approaches depending on local socio-cultural factors, intra-community politics, and external factors such as climate change and development policy. Communities borrow and selectively recombine elements from customary and bureaucratic domains, producing diverse locally elaborated water management institutions. Some WUAs are repurposed to address locally identified needs and functions.The thesis offers theoretical, empirical, and methodological contributions. Empirically, it sheds light on the interplay between externally introduced bureaucratic practices and socio-culturally embedded institutions. By combining institutional bricolage with appropriation of space, the thesis offers a lens for understanding locally-led institutional adaptation and the emergence of novel governance arrangements. Methodologically, it demonstrates the value of community-based, comparative, participatory, and ethnographic research in capturing micro-level institutional transformations from farmers’ perspectives. Theoretically, it links appropriation of space with institutional bricolage, revealing local dynamics and the ways actors transform imposed models. It highlights how communities rework, hybridize, or reject WUAs to produce governance arrangements reflecting local norms and needs.The thesis suggests future research should investigate how WUAs are reshaped to become embedded in rural settings and repurposed to serve community-based functions. When locally legitimized, WUAs may support adaptation practices, infrastructural co-design, local agricultural development, and act as innovation platforms. Comparative and participatory research can reveal historical, socio-cultural, political, and external drivers shaping institutional reconfiguration. Policy implications emphasize reconsidering the WUA model, adopting a flexible, context-sensitive framework accommodating locally elaborated functions and management options, integrating locally produced practices to better serve and empower communities.<br/