Overdue choices : how information and role in decision-making influence women's preferences for induction for prolonged pregnancy

Background: Enabling women to make informed decisions is a crucial component of consumer-focused maternity care. Current evidence suggests that health care practitioners’ communication of care options may not facilitate patient involvement in decision-making. The aim of this study was to investigate the effect of specific variations in health caregiver communication on women’s preferences for induction of labor for prolonged pregnancy. Methods: A convenience sample of 595 female participants read a hypothetical scenario in which an obstetrician discusses induction of labor with a pregnant woman. Information provided on induction and the degree of encouragement for the woman’s involvement in decision-making was manipulated to create four experimental conditions. Participants indicated preference with respect to induction, their perceptions of the quality of information received, and other potential moderating factors. Results: Participants who received information that was directive in favor of medical intervention were significantly more likely to prefer induction than those given nondirective information. No effect of level of involvement in decision-making was found. Participants’ general trust in doctors moderated the relationship between health caregiver communication and preferences for induction, such that the influence of information provided on preferences for induction differed across levels of involvement in decision-making for women with a low trust in doctors, but not for those with high trust. Many women were not aware of the level of information required to make an informed decision. Conclusions: Our findings highlight the potential value of strategies such as patient decision aids and health care professional education to improve the quality of information available to women and their capacity for informed decision-making during pregnancy and birth. (BIRTH 39:3 September 2012)

A new approach for power system black-start decision-making with vague set theory

Power system restoration after a large area outage involves many factors, and the procedure is usually very complicated. A decision-making support system could then be developed so as to find the optimal black-start strategy. In order to evaluate candidate black-start strategies, some indices, usually both qualitative and quantitative, are employed. However, it may not be possible to directly synthesize these indices, and different extents of interactions may exist among these indices. In the existing black-start decision-making methods, qualitative and quantitative indices cannot be well synthesized, and the interactions among different indices are not taken into account. The vague set, an extended version of the well-developed fuzzy set, could be employed to deal with decision-making problems with interacting attributes. Given this background, the vague set is first employed in this work to represent the indices for facilitating the comparisons among them. Then, a concept of the vague-valued fuzzy measure is presented, and on that basis a mathematical model for black-start decision-making developed. Compared with the existing methods, the proposed method could deal with the interactions among indices and more reasonably represent the fuzzy information. Finally, an actual power system is served for demonstrating the basic features of the developed model and method.

An entry mode decision-making model for the international expansion of construction enterprises

Purpose – The purpose of this paper is to provide a new type of entry mode decision-making model for construction enterprises involved in international business. Design/methodology/approach – A hybrid method combining analytic hierarchy process (AHP) with preference ranking organization method for enrichment evaluations (PROMETHEE) is used to aid entry mode decisions. The AHP is used to decompose the entry mode problem into several dimensions and determine the weight of each criterion. In addition, PROMETHEE method is used to rank candidate entry modes and carry out sensitivity analyses. Findings – The proposed decision-making method is demonstrated to be a suitable approach to resolve the entry mode selection decision problem. Practical implications – The research provides practitioners with a more systematic decision framework and a more precise decision method. Originality/value – The paper sheds light on the further development of entry strategies for international construction markets. It not only introduces a new decision-making model for entry mode decision making, but also provides a conceptual framework with five determinants for a construction company entry mode selection based on the unique properties of the construction industry.

Application of multi-criteria decision making methods to compression ignition engine efficiency and gaseous, particulate and greenhouse gas emissions

Compression ignition (CI) engine design is subject to many constraints which presents a multi-criteria optimisation problem that the engine researcher must solve. In particular, the modern CI engine must not only be efficient, but must also deliver low gaseous, particulate and life cycle greenhouse gas emissions so that its impact on urban air quality, human health, and global warming are minimised. Consequently, this study undertakes a multi-criteria analysis which seeks to identify alternative fuels, injection technologies and combustion strategies that could potentially satisfy these CI engine design constraints. Three datasets are analysed with the Preference Ranking Organization Method for Enrichment Evaluations and Geometrical Analysis for Interactive Aid (PROMETHEE-GAIA) algorithm to explore the impact of 1): an ethanol fumigation system, 2): alternative fuels (20 % biodiesel and synthetic diesel) and alternative injection technologies (mechanical direct injection and common rail injection), and 3): various biodiesel fuels made from 3 feedstocks (i.e. soy, tallow, and canola) tested at several blend percentages (20-100 %) on the resulting emissions and efficiency profile of the various test engines. The results show that moderate ethanol substitutions (~20 % by energy) at moderate load, high percentage soy blends (60-100 %), and alternative fuels (biodiesel and synthetic diesel) provide an efficiency and emissions profile that yields the most “preferred” solutions to this multi-criteria engine design problem. Further research is, however, required to reduce Reactive Oxygen Species (ROS) emissions with alternative fuels, and to deliver technologies that do not significantly reduce the median diameter of particle emissions.

Decision and reasons for calling an ambulance : patients’ perspective

Background: Demand for pre-hospital emergency care is increasing in Australia as in many other countries. Using posthoc criteria such as triage, diagnosis and admission status, some authors view a considerable number of these as "inappropriate". Yet, calling an ambulance at the time of emergency is rarely studied from the patients’ or their carers’ perspective. This study interviewed patients about the decision, circumstances surrounding and reasons for calling an ambulance in Queensland, Australia. Methods: A cross-sectional survey of patients attending a sample of eight public hospital emergency departments in Queensland was undertaken between March and May 2011. In total, 911 questionnaires were collected (response rate: 67%), of whom 226 (24.8%) had arrived by ambulance. Results: In 35.6% of ambulance arrivals, the decision to request an ambulance was made by the patient; 25% by a doctor; 20% by a family member, friend or carer. Other callers included nurse, people at work or school, and passers-by. Reasons to request an ambulance included urgency (87%) and severity (84%) of the condition. Other reasons included requiring special care (76%), getting higher priority at the emergency department (34%), not having a car (34%), and financial concerns (17%). Decision to request an ambulance varied significantly according to the time of illness onset (e.g. on the day, week before), and location (e.g. home, outside). Conclusion: The decision to call an ambulance is made mostly by non-medical professionals in a perceived emergency situation. They call the ambulance for different reasons but mainly take into account the patient’s welfare and safety. Better understanding of these reasons will affect the direction and effectiveness of demand management strategies.

Workplace information literacy : cultivation strategies for 'working smarter' in 21st century libraries

This paper presents a hybrid framework of Swedish cultural practices and Australian grounded theory for organizational development and suggests practical strategies for 'working smarter' in 21st Century libraries. Toward that end, reflective evidence-based practices are offered to incrementally build organizational capacity for asking good questions, selecting authoritative sources, evaluating multiple perspectives, organizing emerging insights, and communicating them to inform, educate, and influence. In addition, to ensure the robust information exchange necessary to collective workplace learning, leadership traits are proposed for ensuring inclusive communication, decision making, and planning processes. These findings emerge from action research projects conducted from 2003 to 2008 in two North American libraries.

A systematic approach for selecting lean strategies and assessing leanness in manufacturing organizations

Lean strategies have been developed to eliminate or reduce manufacturing waste and thus improve operational efficiency in manufacturing processes. However, implementing lean strategies requires a large amount of resources and, in practice, manufacturers encounter difficulties in selecting appropriate lean strategies within their resource constraints. There is currently no systematic methodology available for selecting appropriate lean strategies within a manufacturer's resource constraints. In the lean transformation process, it is also critical to measure the current and desired leanness levels in order to clearly evaluate lean implementation efforts. Despite the fact that many lean strategies are utilized to reduce or eliminate manufacturing waste, little effort has been directed towards properly assessing the leanness of manufacturing organizations. In practice, a single or specific group of metrics (either qualitative or quantitative) will only partially measure the overall leanness. Existing leanness assessment methodologies do not offer a comprehensive evaluation method, integrating both quantitative and qualitative lean measures into a single quantitative value for measuring the overall leanness of an organization. This research aims to develop mathematical models and a systematic methodology for selecting appropriate lean strategies and evaluating the leanness levels in manufacturing organizations. Mathematical models were formulated and a methodology was developed for selecting appropriate lean strategies within manufacturers' limited amount of available resources to reduce their identified wastes. A leanness assessment model was developed by using the fuzzy concept to assess the leanness level and to recommend an optimum leanness value for a manufacturing organization. In the proposed leanness assessment model, both quantitative and qualitative input factors have been taken into account. Based on program developed in MATLAB and C#, a decision support tool (DST) was developed for decision makers to select lean strategies and evaluate the leanness value based on the proposed models and methodology hence sustain the lean implementation efforts. A case study was conducted to demonstrate the effectiveness of these proposed models and methodology. Case study results suggested that out of 10 wastes identified, the case organization (ABC Limited) is able to improve a maximum of six wastes from the selected workstation within their resource limitations. The selected wastes are: unnecessary motion, setup time, unnecessary transportation, inappropriate processing, work in process and raw material inventory and suggested lean strategies are: 5S, Just-In-Time, Kanban System, the Visual Management System (VMS), Cellular Manufacturing, Standard Work Process using method-time measurement (MTM), and Single Minute Exchange of Die (SMED). From the suggested lean strategies, the impact of 5S was demonstrated by measuring the leanness level of two different situations in ABC. After that, MTM was suggested as a standard work process for further improvement of the current leanness value. The initial status of the organization showed a leanness value of 0.12. By applying 5S, the leanness level significantly improved to reach 0.19 and the simulation of MTM as a standard work method shows the leanness value could be improved to 0.31. The optimum leanness value of ABC was calculated to be 0.64. These leanness values provided a quantitative indication of the impacts of improvement initiatives in terms of the overall leanness level to the case organization. Sensitivity analsysis and a t-test were also performed to validate the model proposed. This research advances the current knowledge base by developing mathematical models and methodologies to overcome lean strategy selection and leanness assessment problems. By selecting appropriate lean strategies, a manufacturer can better prioritize implementation efforts and resources to maximize the benefits of implementing lean strategies in their organization. The leanness index is used to evaluate an organization's current (before lean implementation) leanness state against the state after lean implementation and to establish benchmarking (the optimum leanness state). Hence, this research provides a continuous improvement tool for a lean manufacturing organization.

Decision making guidelines for sustainable construction of industrialised building systems

The construction industry has an obligation to respond to sustainability expectations of our society. Solutions that integrate innovative, intelligent and sustainability deliverables are vital for us to meet new and emerging challenges. Industrialised Building Systems (IBS), or known otherwise as prefabrication, employs a combination of ready-made components in the construction of buildings. They promote quality of production, enhance simplification of construction processes and minimise waste. The unique characteristics of this construction method respond well to sustainability. Despite the promises however, IBS has yet to be effectively implemented in Malaysia. There are often misconceptions among key stakeholders about IBS applications. The existing rating schemes fail to assess IBS against sustainability measures. To ensure the capture of full sustainability potential in buildings developed, the critical factors and action plans agreeable to all participants in the development processes need to be identified. Through questionnaire survey, eighteen critical factors relevant to IBS sustainability were identified and encapsulated into a conceptual framework to coordinate a systematic IBS decision making approach. Five categories were used to separate the critical factors into: ecological performance; economic value; social equity and culture; technical quality; and implementation and enforcement. This categorisation extends the "Triple Bottom Lines" to include social, economic, environmental and institutional dimensions. Semi-structured interviews help identify strategies of actions and solutions of potential problems through a SWOT analysis framework. These tools help the decision-makers maximise the opportunities by using available strengths, avoid weaknesses, and diagnose possible threats in the examined issues. The recommendations formed an integrated action plan to present information on what and how to improve sustainability through tackling each critical factor during IBS development. It can be used as part of the project briefing documents for IBS designers. For validation and finalisation the research deliverables, three case studies were conducted. The research fills a current gap by responding to IBS project scenarios in developing countries. It also provides a balanced view for designers to better understand sustainability potential and prioritize attentions to manage sustainability issues in IBS applications.

Factors influencing the impact of primary and secondary prevention strategies for cervical cancer among Queensland women

Since the introduction of the National Human Papillomavirus Vaccine Program (NHPVP) in 2007, few studies have assessed women's knowledge, beliefs and attitudes towards cervical screening and human papillomavirus (HPV) vaccination in Australia. It is imperative to ascertain this, as substantial changes are anticipated to the National Cervical Screening Program (NCSP) through a process called 'the Renewal', to ensure any changes that are introduced will be acceptable and well understood by women. The objectives of this study were to describe Queensland women's current knowledge of cervical cancer/screening and HPV, their beliefs and attitudes towards Pap smears and the HPV vaccine and seek their advice on effective methods for communicating changes to the NCSP in their communities. This research was a descriptive-exploratory study that incorporated a combination of qualitative and quantitative methods within the context of the Health Belief Model (HBM). A computer-assisted telephone interview (CATI) survey of 1002 Queensland women was conducted in Phase 1 of the study. During Phase 2 of the study, 23 focus groups were conducted throughout Queensland to gather in-depth information about women's knowledge, awareness and acceptance about cervical cancer prevention strategies. This study found high levels of awareness of HPV (over 60%) and the HPV vaccine (over 86%) amongst Queensland women. However, it also identified considerable uncertainty amongst participants about perceived susceptibility to cervical cancer, especially, the link between cervical cancer, HPV and sexual activity. Women also had limited understanding of the benefit of the Pap smear as a preventative strategy, with many women thinking the main purpose of the Pap smear was for the early detection of cancer. Despite high awareness of HPV, women participating in this study also had significant knowledge deficits about their susceptibility to HPV and the severity of HPV infection. Queensland women had high levels of awareness of the HPV vaccine, which was most commonly via the media. High acceptance of the HPV vaccine was found amongst participants although awareness of the full benefits of vaccination was not evident with little acknowledgement that the quadrivalent vaccine used in the NHPVP would also prevent genital warts. Extensive barriers to having Pap smears, including physical and psychological discomfort, were identified and the most common barriers to vaccination were concerns about side effects and a lack of information upon which to make a decision about consent. Women described enablers for screening participation, such as reminder systems and practitioner characteristics, and expressed positive views towards self collected testing as an enabler, particularly for women who did not attend screening. As this study was conducted with Queensland women it may therefore not be representative of women from other parts of Australia and as participants were more likely to report they were regular screeners than Queensland women overall, these results may not be representative of women least likely to participate in cervical screening. The use of self-reported cervical screening history may also have led to over-reporting of screening status and previous abnormalities by participants. This study reveals significant gaps in Queensland women's knowledge that require effective communication strategies to address. Recommendations from this study highlight the need for increased community education to raise awareness about primary and secondary cervical cancer prevention strategies, training of cervical screening providers in sensitive examination techniques, a reduction in costs associated with screening, the exploration of alternative service models and communication plans that incorporate methods women trust and recommend for disseminating information about changes to the NCSP. This study is the first large study to explore women's perceptions of the Pap smear and barriers to screening, their knowledge about HPV and their attitudes towards the HPV vaccine in Queensland, since the introduction of the NHPVP. It highlights considerable uncertainty about many aspects of cervical cancer and primary and secondary prevention strategies available in Australia and identified many barriers to cervical screening and concerns about HPV vaccination. These knowledge gaps and barriers need to be taken into account and addressed within the context of anticipated changes to the NCSP to ensure benefits are maximised for women in future primary and secondary cervical cancer prevention strategies in the Australian context.

The health effects of temperature : current estimates, future projections, and adaptation strategies

Climate change is expected to be one of the biggest global health threats in the 21st century. In response to changes in climate and associated extreme events, public health adaptation has become imperative. This thesis examined several key issues in this emerging research field. The thesis aimed to identify the climate-health (particularly temperature-health) relationships, then develop quantitative models that can be used to project future health impacts of climate change, and therefore help formulate adaptation strategies for dealing with climate-related health risks and reducing vulnerability. The research questions addressed by this thesis were: (1) What are the barriers to public health adaptation to climate change? What are the research priorities in this emerging field? (2) What models and frameworks can be used to project future temperature-related mortality under different climate change scenarios? (3) What is the actual burden of temperature-related mortality? What are the impacts of climate change on future burden of disease? and (4) Can we develop public health adaptation strategies to manage the health effects of temperature in response to climate change? Using a literature review, I discussed how public health organisations should implement and manage the process of planned adaptation. This review showed that public health adaptation can operate at two levels: building adaptive capacity and implementing adaptation actions. However, there are constraints and barriers to adaptation arising from uncertainty, cost, technologic limits, institutional arrangements, deficits of social capital, and individual perception of risks. The opportunities for planning and implementing public health adaptation are reliant on effective strategies to overcome likely barriers. I proposed that high priorities should be given to multidisciplinary research on the assessment of potential health effects of climate change, projections of future health impacts under different climate and socio-economic scenarios, identification of health cobenefits of climate change policies, and evaluation of cost-effective public health adaptation options. Heat-related mortality is the most direct and highly-significant potential climate change impact on human health. I thus conducted a systematic review of research and methods for projecting future heat-related mortality under different climate change scenarios. The review showed that climate change is likely to result in a substantial increase in heatrelated mortality. Projecting heat-related mortality requires understanding of historical temperature-mortality relationships, and consideration of future changes in climate, population and acclimatisation. Further research is needed to provide a stronger theoretical framework for mortality projections, including a better understanding of socioeconomic development, adaptation strategies, land-use patterns, air pollution and mortality displacement. Most previous studies were designed to examine temperature-related excess deaths or mortality risks. However, if most temperature-related deaths occur in the very elderly who had only a short life expectancy, then the burden of temperature on mortality would have less public health importance. To guide policy decisions and resource allocation, it is desirable to know the actual burden of temperature-related mortality. To achieve this, I used years of life lost to provide a new measure of health effects of temperature. I conducted a time-series analysis to estimate years of life lost associated with changes in season and temperature in Brisbane, Australia. I also projected the future temperaturerelated years of life lost attributable to climate change. This study showed that the association between temperature and years of life lost was U-shaped, with increased years of life lost on cold and hot days. The temperature-related years of life lost will worsen greatly if future climate change goes beyond a 2 °C increase and without any adaptation to higher temperatures. The excess mortality during prolonged extreme temperatures is often greater than the predicted using smoothed temperature-mortality association. This is because sustained period of extreme temperatures produce an extra effect beyond that predicted by daily temperatures. To better estimate the burden of extreme temperatures, I estimated their effects on years of life lost due to cardiovascular disease using data from Brisbane, Australia. The results showed that the association between daily mean temperature and years of life lost due to cardiovascular disease was U-shaped, with the lowest years of life lost at 24 °C (the 75th percentile of daily mean temperature in Brisbane), rising progressively as temperatures become hotter or colder. There were significant added effects of heat waves, but no added effects of cold spells. Finally, public health adaptation to hot weather is necessary and pressing. I discussed how to manage the health effects of temperature, especially with the context of climate change. Strategies to minimise the health effects of high temperatures and climate change can fall into two categories: reducing the heat exposure and managing the health effects of high temperatures. However, policy decisions need information on specific adaptations, together with their expected costs and benefits. Therefore, more research is needed to evaluate cost-effective adaptation options. In summary, this thesis adds to the large body of literature on the impacts of temperature and climate change on human health. It improves our understanding of the temperaturehealth relationship, and how this relationship will change as temperatures increase. Although the research is limited to one city, which restricts the generalisability of the findings, the methods and approaches developed in this thesis will be useful to other researchers studying temperature-health relationships and climate change impacts. The results may be helpful for decision-makers who develop public health adaptation strategies to minimise the health effects of extreme temperatures and climate change.

Monitoring policy and actions on food environments : rationale and outline of the INFORMAS policy engagement and communication strategies

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific sub-regions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

The importance of importance : its impact on decision-making in mall retail categories during an economic downturn

The study examines how, during an economic downturn, the perceived importance of the value offering of retail store categories, as identified by a major international mall operator based in Australia, influences the relationship between consumers’ shopping attitudes and likelihood of purchasing in those categories. The findings show variance in the importance pertaining to retail store categories between those that have and those that have not altered their shopping behaviour. Different mediating effects were found in the major, mini-major, leisure, apparel, and mobile phone categories, suggestive of each group having differing levels of self-interest in the value offerings of each category, thus, symptomatic of dissimilar decision-making strategies for each group. Contributions to theory and practice are discussed.

Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum : an Australian observational study

Background Breastfeeding self-efficacy (BFSE) supports breastfeeding initiation and duration. Challenges to breastfeeding may undermine BFSE, but second-line strategies including nipple shields, syringe, cup, supply line and bottle feeding may support breastfeeding until challenges are resolved. The primary aim of this study was to examine BFSE in a sample of women using second-line strategies for feeding healthy term infants in the first week postpartum. Methods A retrospective self-report study was conducted using the Breastfeeding Self-Efficacy Scale - Short Form (BSES-SF), demographic and infant feeding questionnaires. Breastfeeding women who gave birth to a singleton healthy term infant at one private metropolitan birthing facility in Australia from November 2008 to February 2009 returned anonymous questionnaires by mail. Results A total of 128 (73 multiparous, 55 primiparous) women participated in the study. The mean BSES-SF score was 51.18 (Standard deviation, SD: 12.48). The median BSES-SF score was 53. Of women using a second-line strategy, 16 exceeded the median, and 42 were below. Analyses using Kruskal-Wallis tests confirmed this difference was statistically significant (H = 21.569, p = 0.001). The rate of second-line strategy use was 48%. The four most commonly used second-line strategies were: bottles with regular teats (77%); syringe feeding (44%); bottles with wide teats (34%); and nipple shields (27%). Seven key challenges were identified that contributed to the decision to use second-line strategies, including: nipple pain (40%); unsettled infant (40%); insufficient milk supply (37%); fatigue (37%); night nursery care (25%); infant weight loss > 10% (24%); and maternal birth associated pain (20%). Skin-to-skin contact at birth was commonly reported (93%). At seven days postpartum 124 women (97%) were continuing to breastfeed. Conclusions The high rate of use of second-line strategies identified in this study and high rate of breastfeeding at day seven despite lower BFSE indicate that such practices should not be overlooked by health professionals. The design of this study does not enable determination of cause-effect relationships to identify factors which contribute to use of second-line strategies. Nevertheless, the significantly lower BSES-SF score of women using a second-line strategy highlights this group of women have particular needs that require attention.

Megaprojects, Affected communities and sustainability decision making

Increasing scrutiny from the wider community is contributing to a shift towards the delivery and operation of major projects that meets and maintains the sustainability priorities of the community. This is especially significant for large economic projects which have a global track record of social benefit shortfalls, cost overruns, and underestimation of risks. Major industrial and infrastructure projects that cost more than US$1 billion are typically called mega-projects. Globally, investment in mega-projects has exceeded $10 trillion in the last ten years. With so many projects in the pipeline -and many taking place in emerging economies – the effectiveness of the sustainability decision making process is particularly important. The purpose of this paper is to examine how the existing sustainability decision making processes and strategies address the potential challenges facing communities affected by mega-projects. It highlights issues with current operational level approaches to social sustainability assessment at the project level, and argues that to improve accountability and transparency of project outcomes, positive externalities that flow from goods and services provided by the social and cultural systems of the community must be incorporated into decision making.