Barriers of evidence based policy making in iran's health system

La formation des sociétés fondées sur la connaissance, le progrès de la technologie de communications et un meilleur échange d'informations au niveau mondial permet une meilleure utilisation des connaissances produites lors des décisions prises dans le système de santé. Dans des pays en voie de développement, quelques études sont menées sur des obstacles qui empêchent la prise des décisions fondées sur des preuves (PDFDP) alors que des études similaires dans le monde développé sont vraiment rares. L'Iran est le pays qui a connu la plus forte croissance dans les publications scientifiques au cours de ces dernières années, mais la question qui se pose est la suivante : quels sont les obstacles qui empêchent l'utilisation de ces connaissances de même que celle des données mondiales? Cette étude embrasse trois articles consécutifs. Le but du premier article a été de trouver un modèle pour évaluer l'état de l'utilisation des connaissances dans ces circonstances en Iran à l’aide d'un examen vaste et systématique des sources suivie par une étude qualitative basée sur la méthode de la Grounded Theory. Ensuite au cours du deuxième et troisième article, les obstacles aux décisions fondées sur des preuves en Iran, sont étudiés en interrogeant les directeurs, les décideurs du secteur de la santé et les chercheurs qui travaillent à produire des preuves scientifiques pour la PDFDP en Iran. Après avoir examiné les modèles disponibles existants et la réalisation d'une étude qualitative, le premier article est sorti sous le titre de «Conception d'un modèle d'application des connaissances». Ce premier article sert de cadre pour les deux autres articles qui évaluent les obstacles à «pull» et «push» pour des PDFDP dans le pays. En Iran, en tant que pays en développement, les problèmes se situent dans toutes les étapes du processus de production, de partage et d’utilisation de la preuve dans la prise de décision du système de santé. Les obstacles qui existent à la prise de décision fondée sur des preuves sont divers et cela aux différents niveaux; les solutions multi-dimensionnelles sont nécessaires pour renforcer l'impact de preuves scientifiques sur les prises de décision. Ces solutions devraient entraîner des changements dans la culture et le milieu de la prise de décision afin de valoriser la prise de décisions fondées sur des preuves. Les critères de sélection des gestionnaires et leur nomination inappropriée ainsi que leurs remplaçants rapides et les différences de paiement dans les secteurs public et privé peuvent affaiblir la PDFDP de deux façons : d’une part en influant sur la motivation des décideurs et d'autre part en détruisant la continuité du programme. De même, tandis que la sélection et le remplacement des chercheurs n'est pas comme ceux des gestionnaires, il n'y a aucun critère pour encourager ces deux groupes à soutenir le processus décisionnel fondés sur des preuves dans le secteur de la santé et les changements ultérieurs. La sélection et la promotion des décideurs politiques devraient être basées sur leur performance en matière de la PDFDP et les efforts des universitaires doivent être comptés lors de leurs promotions personnelles et celles du rang de leur institution. Les attitudes et les capacités des décideurs et des chercheurs devraient être encouragés en leur donnant assez de pouvoir et d’habiliter dans les différentes étapes du cycle de décision. Cette étude a révélé que les gestionnaires n'ont pas suffisamment accès à la fois aux preuves nationales et internationales. Réduire l’écart qui sépare les chercheurs des décideurs est une étape cruciale qui doit être réalisée en favorisant la communication réciproque. Cette question est très importante étant donné que l'utilisation des connaissances ne peut être renforcée que par l'étroite collaboration entre les décideurs politiques et le secteur de la recherche. Dans ce but des programmes à long terme doivent être conçus ; la création des réseaux de chercheurs et de décideurs pour le choix du sujet de recherche, le classement des priorités, et le fait de renforcer la confiance réciproque entre les chercheurs et les décideurs politiques semblent être efficace.

Knowledge transfer intervention theory : a model grounded in the strategies used by intermediate agents in the context of education

La présente thèse se base sur les principes de la théorisation ancrée (Strauss & Corbin, 1998) afin de répondre au manque de documentation concernant les stratégies adoptées par des « agents intermédiaires » pour promouvoir l’utilisation des connaissances issues de la recherche auprès des intervenants en éducation. Le terme « agent intermédiaire » réfère aux personnes qui sont positionnées à l’interface entre les producteurs et les utilisateurs des connaissances scientifiques et qui encouragent et soutiennent les intervenants scolaires dans l’application des connaissances scientifiques dans leur pratique. L’étude s’inscrit dans le cadre d’un projet du ministère de l’Éducation, du Loisir et du Sport du Québec visant à améliorer la réussite scolaire des élèves du secondaire provenant de milieux défavorisés. Des agents intermédiaires de différents niveaux du système éducatif ayant obtenu le mandat de transférer des connaissances issues de la recherche auprès des intervenants scolaires dans les écoles visées par le projet ont été sollicités pour participer à l’étude. Une stratégie d’échantillonnage de type « boule-de-neige » (Biernacki & Waldorf, 1981; Patton, 1990) a été employée afin d’identifier les personnes reconnues par leurs pairs pour la qualité du soutien offert aux intervenants scolaires quant à l’utilisation de la recherche dans leur pratique. Seize entrevues semi-structurées ont été réalisées. L’analyse des données permet de proposer un modèle d’intervention en transfert de connaissances composé de 32 stratégies d’influence, regroupées en 6 composantes d’intervention, soit : relationnelle, cognitive, politique, facilitatrice, évaluative, de même que de soutien et de suivi continu. Les résultats suggèrent que les stratégies d’ordre relationnelle, cognitive et politique sont interdépendantes et permettent d’établir un climat favorable dans lequel les agents peuvent exercer une plus grande influence sur l’appropriation du processus de l’utilisation des connaissances des intervenants scolaire. Ils montrent en outre que la composante de soutien et de suivi continu est importante pour maintenir les changements quant à l’utilisation de la recherche dans la pratique chez les intervenants scolaires. Les implications théoriques qui découlent du modèle, ainsi que les explications des mécanismes impliqués dans les différentes composantes, sont mises en perspective tant avec la documentation scientifique en transfert de connaissances dans les secteurs de la santé et de l’éducation, qu’avec les travaux provenant de disciplines connexes (notamment la psychologie). Enfin, des pistes d’action pour la pratique sont proposées.

Le programme cognitif-comportemental au CJM-IU : l'effet du degré d'exposition au programme sur l'ampleur des troubles de comportement des adolescentes six mois après leur admission au CJM-IU

L’implantation de programmes probants dans les milieux d’intervention peut comporter son lot de difficultés pour les gestionnaires ainsi que les intervenants en contexte de réadaptation pour adolescents. En effet, les contraintes auxquelles peuvent être confrontés les milieux de pratique mènent parfois à la modification des programmes, ceci en vue de faciliter leur implantation. Il devient alors important de documenter ainsi qu’identifier l’effet des éléments associés à la fidélité d’implantation lorsque les programmes d’intervention sont évalués. En plus d’évaluer l’effet du degré d’exposition au programme cognitif-comportemental implanté dans les unités d’hébergement du Centre jeunesse de Montréal – Institut universitaire (CJM-IU) sur l’ampleur des troubles de comportement des adolescentes, ce mémoire propose une nouvelle piste de recherche. Puisque la recherche empirique ne permet pas encore d’identifier les conditions selon lesquelles il serait possible de modifier les programmes d’intervention qui sont adoptés dans le contexte de la pratique, cette étude propose d’élaborer une logique d’exposition au programme qui s’inspire des principes d’intervention efficace élaborés par Andrews et ses collègues (1990). Cette approche permettrait d’adapter le niveau d’intervention aux caractéristiques de la clientèle, et ce, tout en s’assurant de l’efficacité du programme cognitif-comportemental. L’échantillon de cette étude est donc constitué de 74 adolescentes hébergées au CJM-IU pour une durée de six mois. Les résultats indiquent d’abord que les activités du programme cognitif-comportemental ont été appliquées de façon plutôt irrégulière et bien en deçà de la fréquence initialement prévue, ce qui rend bien compte des difficultés à implanter des programmes en contexte de pratique. Les résultats suggèrent aussi une diminution de l’ampleur des troubles de comportement six mois après l’admission au CJM-IU pour les adolescentes qui étaient caractérisées par une ampleur des troubles de comportement plus marquée au moment de leur admission et qui ont complété un plus grand nombre d’auto-observations durant leur placement.

Favoriser le développement du rôle des infirmières chefs afin d'accroître les pratiques basées sur des résultats probants en centre hospitalier

Travail dirigé présenté à la Faculté des sciences infirmières en vue de l'obtention du grade de maître ès Sciences (M.Sc.)

Knowledge Building in Landscape Architecture

The objective of this study was to develop an internet-based seminar framework applicable for landscape architecture education. This process was accompanied by various aims. The basic expectation was to keep the main characteristics of landscape architecture education also in the online format. On top of that, four further objectives were anticipated: (1) training of competences for virtual team work, (2) fostering intercultural competence, (3) creation of equal opportunities for education through internet-based open access and (4) synergy effects and learning processes across institutional boundaries. This work started with the hypothesis that these four expected advantages would compensate for additional organisational efforts caused by the online delivery of the seminars and thus lead to a sustainable integration of this new learning mode into landscape architecture curricula. This rationale was followed by a presentation of four areas of knowledge to which the seminar development was directly related (1) landscape architecture as a subject and its pedagogy, (2) general learning theories, (3) developments in the ICT sector and (4) wider societal driving forces such as global citizenship and the increase of open educational resources. The research design took the shape of a pedagogical action research cycle. This approach was constructive: The author herself is teaching international landscape architecture students so that the model could directly be applied in practice. Seven online seminars were implemented in the period from 2008 to 2013 and this experience represents the core of this study. The seminars were conducted with varying themes while its pedagogy, organisation and the technological tools remained widely identical. The research design is further based on three levels of observation: (1) the seminar design on the basis of theory and methods from the learning sciences, in particular educational constructivism, (2) the seminar evaluation and (3) the evaluation of the seminars’ long term impact. The seminar model itself basically consists of four elements: (1) the taxonomy of learning objectives, (2) ICT tools and their application and pedagogy, (3) process models and (4) the case study framework. The seminar framework was followed by the presentation of the evaluation findings. The major findings of this study can be summed up as follows: Implementing online seminars across educational and national boundaries was possible both in term of organisation and technology. In particular, a high level of cultural diversity among the seminar participants has definitively been achieved. However, there were also obvious obstacles. These were primarily competing study commitments and incompatible schedules among the students attending from different academic programmes, partly even in different time zones. Both factors had negative impact on the individual and working group performances. With respect to the technical framework it can be concluded that the majority of the participants were able to use the tools either directly without any problem or after overcoming some smaller problems. Also the seminar wiki was intensively used for completing the seminar assignments. However, too less truly collaborative text production was observed which could be improved by changing the requirements for the collaborative task. Two different process models have been applied for guiding the collaboration of the small groups and both were in general successful. However, it needs to be said that even if the students were able to follow the collaborative task and to co-construct and compare case studies, most of them were not able to synthesize the knowledge they had compiled. This means that the area of consideration often remained on the level of the case and further reflections, generalisations and critique were largely missing. This shows that the seminar model needs to find better ways for triggering knowledge building and critical reflection. It was also suggested to have a more differentiated group building strategy in future seminars. A comparison of pre- and post seminar concept maps showed that an increase of factual and conceptual knowledge on the individual level was widely recognizable. Also the evaluation of the case studies (the major seminar output) revealed that the students have undergone developments of both the factual and the conceptual knowledge domain. Also their self-assessment with respect to individual learning development showed that the highest consensus was achieved in the field of subject-specific knowledge. The participants were much more doubtful with regard to the progress of generic competences such as analysis, communication and organisation. However, 50% of the participants confirmed that they perceived individual development on all competence areas the survey had asked for. Have the additional four targets been met? Concerning the competences for working in a virtual team it can be concluded that the vast majority was able to use the internet-based tools and to work with them in a target-oriented way. However, there were obvious differences regarding the intensity and activity of participation, both because of external and personal factors. A very positive aspect is the achievement of a high cultural diversity supporting the participants’ intercultural competence. Learning from group members was obviously a success factor for the working groups. Regarding the possibilities for better accessibility of educational opportunities it became clear that a significant number of participants were not able to go abroad during their studies because of financial or personal reasons. They confirmed that the online seminar was to some extent a compensation for not having been abroad for studying. Inter-institutional learning and synergy was achieved in so far that many teachers from different countries contributed with individual lectures. However, those teachers hardly ever followed more than one session. Therefore, the learning effect remained largely within the seminar learning group. Looking back at the research design it can be said that the pedagogical action research cycle was an appropriate and valuable approach allowing for strong interaction between theory and practice. However, some more external evaluation from peers in particular regarding the participants’ products would have been valuable.

Búsqueda sistemática de guías de práctica clínica en cuidados paliativos pediátricos

Actualmente se estima que más de 160.000 niños en todo el mundo son diagnosticados de cáncer cada año y esta cifra podría ser considerablemente superior debido que los datos en su mayoría son imprecisos (1), hay un gran número de niños que junto con sus familias deben hacer frente a las implicaciones del diagnóstico de cáncer o enfermedad terminal, del tratamiento y el pronóstico. En Colombia se viene practicando en los servicios de pediatría, sin embargo no se realiza bajo un protocolo establecido El objetivo de este trabajo fue realizar una búsqueda sistemática de Guías de Práctica Clínica en Cuidados Paliativos Pediátricos basadas en la evidencia en el mundo y evaluarlas mediante preguntas clínicas preestablecidas, y bajo la metodología GLIA indicada por el ministerio de protección social, teniendo en cuenta la realidad colombiana y los principios de accesibilidad, calidad y eficiencia consagrados en el Sistema General de Seguridad Social de Salud de Colombia, con el fin de identificar la mejor Guía de Práctica Clínica (GPC) para la población de la Fundación Cardioinfantil de Bogotá – Colombia. Como resultado de la búsqueda se obtuvieron 32 GPC en Cuidados Paliativos de los cuales 8 guías se relacionaban con la población objeto y solo 5 de las guías respondían a las preguntas clínicas. El informe se elaboró según la metodología PRISMA con el fin constituir una base de datos para posteriores estudios, realización de guías o la adaptación de guías basadas en la evidencia.

Percepción de residentes de medicina de urgencias en Colombia del ambiente educativo en los servicios de urgencias

Introducción: La atención de calidad en urgencias sólo es posible si los médicos han recibido una enseñanza de alta calidad. La escala PHEEM (Postgraduate Hospital Educational Environment Measure) es un instrumento válido y fiable, utilizado internacionalmente para medir el entorno educativo, en la formación médica de posgrado. Materiales y métodos: Estudio de corte trasversal que utilizó la escala PHEEM versión en español para conocer el entorno educativo de los programas de urgencias. El coeficiente alfa de Cronbach se calculó para determinar la consistencia interna. Se aplicó estadística descriptiva a nivel global, por categorías e ítems de la escala PHEEM y se compararon resultados por sexo, año de residencia y programa. Resultados: 94 (94%) residentes llenaron el cuestionario. La puntuación media de la escala PHEEM fue 93,91 ± 23,71 (58,1% de la puntuación máxima) que se considera un ambiente educativo más positivo que negativo, pero con margen de mejora. Hubo una diferencia estadísticamente significativa en la percepción del ambiente educativo entre los programas de residencia (p =0,01). El instrumento es altamente confiable (alfa de Cronbach = 0,952). La barrera más frecuente en la enseñanza fue el hacinamiento y la evaluación fue percibida con el propósito de cumplir normas. Discusión: Los resultados de este estudio aportaron evidencia sobre la validez interna de la escala PHEEM en el contexto colombiano. Este estudio demostró cómo la medición del ambiente educativo en una especialidad médico-quirúrgica, con el uso de una herramienta cuantitativa, puede proporcionar información en relación a las fortalezas y debilidades de los programas.

Parametric pension reform and the intensive margin of labor supply, evidence from Colombia

We analyze the effect of a parametric reform of the fully-funded pension regime in Colombia on the intensive margin of the labor supply. We take advantage of a threshold defined by law in order to identify the causal effect using a regression discontinuity design. We find that a pension system that increases retirement age and the minimum weeks during which workers must contribute to claim pension benefits causes an increase of around 2 hours on the number of weekly worked hours; this corresponds to 4% of the average number of weekly worked hours or around 14% of a standard deviation of weekly worked hours. The effect is robust to different specifications, polynomial orders and sample sizes.

Hydrological controls on soil redox dynamics in a peat-based, restored wetland

Increasing areas of altered wetland are being restored by re-flooding the soil. Evidence in the literature indicates that this practice can induce the redox-mediated release of soil nutrients, thereby increasing the risk of diffuse water pollution. However, for the sake of improving wedand management decisions, there is a need for more detailed studies of the underlying relationship between the hydrological and redox dynamics that explain this risk; this is particularly the case in agricultural peatlands that are commonly targeted for the creation of lowland wet grassland. A 12-month field study was conducted to evaluate the relationship between hydrological fluctuations and soil redox potential (Eh) in a nutrient-rich peat field (32 g N kg(-1) and 1100 mg P kg(-1) in the surface 0-30 cm soil) that had been restored as lowland wet grassland from intensive arable production. Field tensiometers were installed at the 30-, 60- and 90-cm soil depths, and Pt electrodes at the 10-, 30-, 60- and 90-cm depths, for daily logging of soil water tension and Eh, respectively. The values for soil water tension displayed a strong negative relationship (P < 0.001) with monthly dip well observations of water table height. Calculations of soil water potential from the logged tension values were used, therefore, to provide a detailed profile of field water level and, together with precipitation data, explained some of the variation in Eh. For example, during the summer, alternating periods of aerobism (Eh > 330 mV) in the surface, 0-10 cm layer of peat coincided with intense precipitation events. Redox potential throughout the 30-100 cm profile also fluctuated seasonally; indeed, at all depths Eh displayed a strong, negative relationship (P < 0.001) with water table height over the 12-month study period. However, Eh throughout the 30-100 cm profile remained relatively low (< 230 mV), indicating permanently reduced conditions that are associated with denitrification and reductive dissolution of Fe-bound P. The implications of these processes in the N- and P-rich peat for wetland plant diversity and water quality are discussed. (c) 2006 Elsevier B.V. All rights reserved.

Quality of medicines stored together in multi-compartment compliance aids

Background and Objective: Dispensing medicines into compliance aids is a common practice in pharmacy contrary to manufacturers’ advice and studies have shown the appearance of light-sensitive tablets is compromised by such storage; we previously found evidence of reduced bioavailability at elevated temperature and humidity. Our objective was to examine the physicochemical stability of two generic atenolol tablets in different compliance aids and with aspirin co-storage at room temperature and at 40 °C/75% relative humidity. Methods: The physicochemical stability of atenolol tablets was evaluated after 28 days of storage and compared with controls by examining visual appearance, weight, disintegration, dissolution, friability and hardness to accepted standards and using a previously validated HPLC method for chemical assay. Results and Discussion: The response to storage was brand-dependent and not straightforward. With one make of atenolol (Alpharma), storage in compliance aids even at room temperature impacted on physical stability, reducing tablet hardness, with storage in Dosett® exerting a greater impact than storage in Medidos® (t-test P < 0·001). Co-storage at elevated temperature and humidity also impacted on the appearance of non-coated aspirin tablets (Angette™). The chemical stability of atenolol was not affected and we did not find evidence of changes to bioavailability with either make. Certainly data for one atenolol make (CP Pharmaceuticals) co-stored with aspirin (Angette™ and Nu-Seals) in both compliance aids at room temperature provided evidence of short-term stability. But medicines are dispensed into compliance aids in multi-factorial ways so our study highlights not only the lack of evidence but also a realization that evidence to support real practice may not be accomplished through research. Conclusion: Reassuring practitioners of the continued stability of medicines in compliance aids under the countless condition in which they are dispensed in practice may requires a different approach involving medical device regulators and more definitive professional guidance.

Subcontract and supply enquiries in the tender process of contractors

In the tender process, contractors often rely on subcontract and supply enquiries to calculate their bid prices. However, this integral part of the bidding process is not empirically articulated in the literature. Over 30 published materials on the tendering process of contractors that talk about enquiries were reviewed and found to be based mainly on experiential knowledge rather than systematic evidence. The empirical research here helps to describe the process of enquiries precisely, improve it in practice, and have some basis to support it in theory. Using a live participant observation case study approach, the whole tender process was shadowed in the offices of two of the top 20 UK civil engineering construction firms. This helped to investigate 15 research questions on how contractors enquire and obtain prices from subcontractors and suppliers. Forty-three subcontract enquiries and 18 supply enquiries were made across two different projects with average value of 7m. An average of 15 subcontract packages and seven supply packages was involved. Thus, two or three subcontractors or suppliers were invited to bid in each package. All enquiries were formulated by the estimator, with occasional involvement of three other personnel. Most subcontract prices were received in an average of 14 working days; and supply prices took five days. The findings show 10 main activities involved in processing enquiries and their durations, as well as wasteful practices associated with enquiries. Contractors should limit their enquiry invitations to a maximum of three per package, and optimize the waiting time for quotations in order to improve cost efficiency.

Commercial reviews in the tender process of contractors

Purpose – The purpose of this paper is to show the extent to which clients amend standard form contracts in practice, the locus of the amendments, and how contractors respond to the amendments when putting together a bid. Design/methodology/approach – Four live observational case studies were carried out in two of the top 20 UK construction firms. The whole process used to review the proposed terms and conditions of the contract was shadowed using participant observation, interview and documentary analysis. Findings – All four cases showed strong evidence of amendments relating mostly to payment and contractual aspects: 83 amendments in Case Study 1 (CS1), 80 in CS2, 15 in CS3 and 29 in CS4. This comprised clauses that were modified (37 per cent), substituted (23 per cent), deleted (7 per cent) and new additions (33 per cent). Risks inherent in the amendments were mostly addressed through contractual rather than price mechanisms, to reflect commercial imperatives. “Qualifications” and “clarifications” were included in the tender submissions for post-tender negotiations. Thus, the amendments did not necessarily influence price. There was no evidence of a “standard-form contract“ being used as such, although clients may draw on published “standard-form contracts” to derive the forms of contract actually used in practice. Practical implications – Contractors should pay attention to clauses relating to contractual and financial aspects when reviewing tender documents. Clients should draft equitable payment and contractual terms and conditions to reduce risk of dispute. Indeed, it is prudent for clients not to pass on inestimable risks. Originality/value – A better understanding of the extent and locus of amendments in standard form contracts, and how contractors respond, is provided.

Communities of practice in construction case study organisations: questions and insights

Purpose – At the heart of knowledge management (KM) are the people – an organisation's important knowledge asset. Although this is widely acknowledged, businesses seldom understand this axiom in terms of the communities through which individuals develop and share the capacity to create and use knowledge. It is the collective learning that takes place within the social systems, i.e. communities of practice (CoP) that are of particular significance to an organisation from a KM perspective. This paper aims to review, critique, and raise some pertinent questions on the role of CoPs; and with the help of case studies shed light on the “goings-on” in construction practices. Design/methodology/approach – After critically reviewing the literature on CoPs and querying some underlying assertions, this research investigates how these issues are addressed in practice. A case study approach is adopted. Three organisations operating in the construction sector are interviewed for the purpose of this paper. Findings – Case study findings highlight the potential challenges and benefits of CoPs to a construction organisation, the role they play in generating and delivering value to the organisation and their contribution towards the collective organisational intelligence. From the findings, it is clear that the question is not whether communities exist within organisations, but how they deliver value to the organisation. From an organisational perspective, the key challenge is to provide an environment that is conducive to developing and nurturing such communities as opposed to merely creating them. Practical implications – Challenges and benefits demonstrated through the case studies should be taken in context. The findings are not intended to be prescriptive in nature, but are intentionally descriptive to provide contextual data that allow readers to draw their own inferences in the context of their organisations. They should be applied taking into account an organisation's unique characteristics and differentiators, the dynamics of the environment in which it operates and the culture it harbours within. Originality/value – Investigating the role of CoPs in the context of case study construction organisations forms the prime focus of this paper.

Planning the sustainable eco-city in Taipei: The implementation of green design and green building schemes

Taipei City has put a significant effort toward the implementation of green design and green building schemes towards a sustainable eco-city. Although some of the environmental indicators have not indicated significant progress in environmental improvement, implementing the two schemes has obtained considerable results; therefore, the two schemes are on the right path towards promoting a sustainable eco-city. However, it has to be admitted that the two schemes are a rather “technocratic” set of solutions and eco-centric approach. It is suggested that not only the public sector but also the private sector need to put more effort toward implement the schemes, and the government needs to encourage the private sector to adopt the schemes in practice.