Understanding and Characterizing Shared Decision-Making and Behavioral Intent in Medical Uncertainty

Applying Theoretical Constructs to Address Medical Uncertainty Situations involving medical reasoning usually include some level of medical uncertainty. Despite the identification of shared decision-making (SDM) as an effective technique, it has been observed that the likelihood of physicians and patients engaging in shared decision making is lower in those situations where it is most needed; specifically in circumstances of medical uncertainty. Having identified shared decision making as an effective, yet often a neglected approach to resolving a lack of information exchange in situations involving medical uncertainty, the next step is to determine the way(s) in which SDM can be integrated and the supplemental processes that may facilitate its integration. SDM involves unique types of communication and relationships between patients and physicians. Therefore, it is necessary to further understand and incorporate human behavioral elements - in particular, behavioral intent - in order to successfully identify and realize the potential benefits of SDM. This paper discusses the background and potential interaction between the theories of shared decision-making, medical uncertainty, and behavioral intent. Identifying Shared Decision-Making Elements in Medical Encounters Dealing with Uncertainty A recent summary of the state of medical knowledge in the U.S. reported that nearly half (47%) of all treatments were of unknown effectiveness, and an additional 7% involved an uncertain tradeoff between benefits and harms. Shared decision-making (SDM) was identified as an effective technique for managing uncertainty when two or more parties were involved. In order to understand which of the elements of SDM are used most frequently and effectively, it is necessary to identify these key elements, and understand how these elements related to each other and the SDM process. The elements identified through the course of the present research were selected from basic principles of the SDM model and the “Data, Information, Knowledge, Wisdom” (DIKW) Hierarchy. The goal of this ethnographic research was to identify which common elements of shared decision-making patients are most often observed applying in the medical encounter. The results of the present study facilitated the understanding of which elements patients were more likely to exhibit during a primary care medical encounter, as well as determining variables of interest leading to more successful shared decision-making practices between patients and their physicians. Understanding Behavioral Intent to Participate in Shared Decision-Making in Medically Uncertain Situations Objective: This article describes the process undertaken to identify and validate behavioral and normative beliefs and behavioral intent of men between the ages of 45-70 with regard to participating in shared decision-making in medically uncertain situations. This article also discusses the preliminary results of the aforementioned processes and explores potential future uses of this information which may facilitate greater understanding, efficiency and effectiveness of doctor-patient consultations.Design: Qualitative Study using deductive content analysisSetting: Individual semi-structure patient interviews were conducted until data saturation was reached. Researchers read the transcripts and developed a list of codes.Subjects: 25 subjects drawn from the Philadelphia community.Measurements: Qualitative indicators were developed to measure respondents’ experiences and beliefs related to behavioral intent to participate in shared decision-making during medical uncertainty. Subjects were also asked to complete the Krantz Health Opinion Survey as a method of triangulation.Results: Several factors were repeatedly described by respondents as being essential to participate in shared decision-making in medical uncertainty. These factors included past experience with medical uncertainty, an individual’s personality, and the relationship between the patient and his physician.Conclusions: The findings of this study led to the development of a category framework that helped understand an individual’s needs and motivational factors in their intent to participate in shared decision-making. The three main categories include 1) an individual’s representation of medically uncertainty, 2) how the individual copes with medical uncertainty, and 3) the individual’s behavioral intent to seek information and participate in shared decision-making during times of medically uncertain situations.

End -of -life planning and decision -making: Implications for adults with mental retardation

This research focused on the topic of end-of-life planning and decision-making for adults affected by mental retardation. Adults with mental retardation have unique challenges in this regard, including difficulty communicating their wishes without assistance and diminished decision-making skills. The primary research objective was to identify factors that can affect opportunities for adults with mental retardation in community-based services settings (and their advocates) to be involved in planning and deciding about their own end-of-life experience. ^ A descriptive qualitative inquiry was designed to explore issues related to death and dying, and the notion of end-of-life planning, from the perspective of adults with mental retardation who receive publicly-funded community services ("clients") and family members of individuals who receive such services. Study participants were recruited from a single mental retardation service provider in a large urban setting (the "Agency"). Sixteen clients and 14 families of Agency clients took part. Client data collection was accomplished through face-to-face interviews, focus group meetings, and record reviews; family members were involved in a face-to-face interview only. ^ An initial coding scheme was developed based upon literature and policy reviews, and themes related to the research questions. Analysis involved extracting data from transcripts and records and placing it into appropriate thematic categories, building support for each theme with the accumulated data. Coding themes were modified to accommodate new data when it challenged existing themes. ^ Findings suggest that adults with mental retardation do have the requisite knowledge, interest, and ability to participate in decisions about their end-of-life experience and handling of affairs. Siblings are overwhelmingly the chosen future surrogates and they (or their children) will likely be the end-of-life advocates for their brothers and sisters affected by mental retardation. Findings further point to a need for increased awareness, accurate information, and improved communication about end-of-life issues, both in general and particular to adults affected by mental retardation. Also suggested by the findings is a need to focus on creating accommodations and adaptations that can best uncover a person's authentic views on life and death and related end-of-life preferences. Practical implications and suggestions for further research are also discussed. ^

Chairship system and decision making by consensus in international agreements : the case of ASEAN

How are different positions reconciled under decision making by consensus in international agreements? This article aims to answer this question. Consensus rule provides each participant a veto, which risks resulting in non-agreement. Taking ASEAN as a case study of international organizations that have adopted consensus rule as the main decision-making procedure, this article presents the chairship system as an analytical scheme to examine how different positions are or are not reconciled under consensus rule. The system is based on conventional knowledge regarding the chair in international conference, which can be defined as an institution where the role of the chair is taken by one member state in an international organization and plays a role in agenda-setting. The agenda-setting power given to the chair varies across organizations. This article assumes that the chair in ASEAN is given a relatively strong agenda-setting power to enable the chair to reach agreements and bias such agreements in its own favor.

Participatory modelling to support decision making in water management under uncertainty: Two comparative case studies in the Guadiana river basin, Spain.

A participatory modelling process has been conducted in two areas of the Guadiana river (the upper and the middle sub-basins), in Spain, with the aim of providing support for decision making in the water management field. The area has a semi-arid climate where irrigated agriculture plays a key role in the economic development of the region and accounts for around 90% of water use. Following the guidelines of the European Water Framework Directive, we promote stakeholder involvement in water management with the aim to achieve an improved understanding of the water system and to encourage the exchange of knowledge and views between stakeholders in order to help building a shared vision of the system. At the same time, the resulting models, which integrate the different sectors and views, provide some insight of the impacts that different management options and possible future scenarios could have. The methodology is based on a Bayesian network combined with an economic model and, in the middle Guadiana sub-basin, with a crop model. The resulting integrated modelling framework is used to simulate possible water policy, market and climate scenarios to find out the impacts of those scenarios on farm income and on the environment. At the end of the modelling process, an evaluation questionnaire was filled by participants in both sub-basins. Results show that this type of processes are found very helpful by stakeholders to improve the system understanding, to understand each others views and to reduce conflict when it exists. In addition, they found the model an extremely useful tool to support management. The graphical interface, the quantitative output and the explicit representation of uncertainty helped stakeholders to better understand the implications of the scenario tested. Finally, the combination of different types of models was also found very useful, as it allowed exploring in detail specific aspects of the water management problems.

Drivers in adopting adaptation strategies to face increased water scarcity in agriculture. A case study in Doñana (Spain) and Makueni (Kenya)

La agricultura es uno de los sectores más afectados por el cambio climático. A pesar de haber demostrado a lo largo de la historia una gran capacidad para adaptarse a nuevas situaciones, hoy en día la agricultura se enfrenta a nuevos retos tales como satisfacer un elevado crecimiento en la demanda de alimentos, desarrollar una agricultura sostenible con el medio ambiente y reducir las emisiones de gases de efecto invernadero. El potencial de adaptación debe ser definido en un contexto que incluya el comportamiento humano, ya que éste juega un papel decisivo en la implementación final de las medidas. Por este motivo, y para desarrollar correctamente políticas que busquen influir en el comportamiento de los agricultores para fomentar la adaptación a estas nuevas condiciones, es necesario entender previamente los procesos de toma de decisiones a nivel individual o de explotación, así como los efectos de los factores que determinan las barreras o motivaciones de la implementación de medidas. Esta Tesis doctoral trata de profundizar en el análisis de factores que influyen en la toma de decisiones de los agricultores para adoptar estrategias de adaptación al cambio climático. Este trabajo revisa la literatura actual y desarrolla un marco metodológico a nivel local y regional. Dos casos de estudio a nivel local (Doñana, España y Makueni, Kenia) han sido llevados a cabo con el fin de explorar el comportamiento de los agricultores hacia la adaptación. Estos casos de estudio representan regiones con notables diferencias en climatología, impactos del cambio climático, barreras para la adaptación y niveles de desarrollo e influencia de las instituciones públicas y privadas en la agricultura. Mientras el caso de estudio de Doñana representa un ejemplo de problemas asociados al uso y escasez del agua donde se espera que se agraven en el futuro, el caso de estudio de Makueni ejemplifica una zona fuertemente amenazada por las predicciones de cambio climático, donde adicionalmente la falta de infraestructura y la tecnología juegan un papel crucial para la implementación de la adaptación. El caso de estudio a nivel regional trata de generalizar en África el comportamiento de los agricultores sobre la implementación de medidas. El marco metodológico que se ha seguido en este trabajo abarca una amplia gama de enfoques y métodos para la recolección y análisis de datos. Los métodos utilizados para la toma de datos incluyen la implementación de encuestas, entrevistas, talleres con grupos de interés, grupos focales de discusión, revisión de estudios previos y bases de datos públicas. Los métodos analíticos incluyen métodos estadísticos, análisis multi‐criterio para la toma de decisiones, modelos de optimización de uso del suelo y un índice compuesto calculado a través de indicadores. Los métodos estadísticos se han utilizado con el fin de evaluar la influencia de los factores socio‐económicos y psicológicos sobre la adopción de medidas de adaptación. Dentro de estos métodos se incluyen regresiones logísticas, análisis de componentes principales y modelos de ecuaciones estructurales. Mientras que el análisis multi‐criterio se ha utilizado con el fin de evaluar las opciones de adaptación de acuerdo a las opiniones de las diferentes partes interesadas, el modelo de optimización ha tenido como fin analizar la combinación óptima de medidas de adaptación. El índice compuesto se ha utilizado para evaluar a nivel regional la implementación de medidas de adaptación en África. En general, los resultados del estudio ponen de relieve la gran importancia de considerar diferentes escalas espaciales a la hora de evaluar la implementación de medidas de adaptación al cambio climático. El comportamiento de los agricultores es diferente entre lugares considerados a una escala local relativamente pequeña, por lo que la generalización de los patrones del comportamiento a escalas regionales o globales resulta relativamente compleja. Los resultados obtenidos han permitido identificar factores determinantes tanto socioeconómicos como psicológicos y calcular su efecto sobre la adopción de medidas de adaptación. Además han proporcionado una mejor comprensión del distinto papel que desempeñan los cinco tipos de capital (natural, físico, financiero, social y humano) en la implementación de estrategias de adaptación. Con este trabajo se proporciona información de gran interés en los procesos de desarrollo de políticas destinadas a mejorar el apoyo de la sociedad a tomar medidas contra el cambio climático. Por último, en el análisis a nivel regional se desarrolla un índice compuesto que muestra la probabilidad de adoptar medidas de adaptación en las regiones de África y se analizan las causas que determinan dicha probabilidad de adopción de medidas. ABSTRACT Agriculture is and will continue to be one of the sectors most affected by climate change. Despite having demonstrated throughout history a great ability to adapt, agriculture today faces new challenges such as meeting growing food demands, developing sustainable agriculture and reducing greenhouse gas emissions. Adaptation policies planned on global, regional or local scales are ultimately implemented in decision‐making processes at the farm or individual level so adaptation potentials have to be set within the context of individual behaviour and regional institutions. Policy instruments can play a formative role in the adoption of such policies by addressing incentives/disincentives that influence farmer’s behaviour. Hence understanding farm‐level decision‐making processes and the influence of determinants of adoption is crucial when designing policies aimed at fostering adoption. This thesis seeks to analyse the factors that influence decision‐making by farmers in relation to the uptake of adaptation options. This work reviews the current knowledge and develops a methodological framework at local and regional level. Whilst the case studies at the local level are conducted with the purpose of exploring farmer’s behaviour towards adaptation the case study at the regional level attempts to up‐scale and generalise theory on adoption of farmlevel adaptation options. The two case studies at the local level (Doñana, Spain and Makueni, Kenya) encompass areas with different; climates, impacts of climate change, adaptation constraints and limits, levels of development, institutional support for agriculture and influence from public and private institutions. Whilst the Doñana Case Study represents an area plagued with water‐usage issues, set to be aggravated further by climate change, Makueni Case study exemplifies an area decidedly threatened by climate change where a lack of infrastructure and technology plays a crucial role in the uptake of adaptation options. The proposed framework is based on a wide range of approaches for collecting and analysing data. The approaches used for data collection include the implementation of surveys, interviews, stakeholder workshops, focus group discussions, a review of previous case studies, and public databases. The analytical methods include statistical approaches, multi criteria analysis for decision‐making, land use optimisation models, and a composite index based on public databases. Statistical approaches are used to assess the influence of socio‐economic and psychological factors on the adoption or support for adaptation measures. The statistical approaches used are logistic regressions, principal component analysis and structural equation modelling. Whilst a multi criteria analysis approach is used to evaluate adaptation options according to the different perspectives of stakeholders, the optimisation model analyses the optimal combination of adaptation options. The composite index is developed to assess adoption of adaptation measures in Africa. Overall, the results of the study highlight the importance of considering various scales when assessing adoption of adaptation measures to climate change. As farmer’s behaviour varies at a local scale there is elevated complexity when generalising behavioural patterns for farmers at regional or global scales. The results identify and estimate the effect of most relevant socioeconomic and psychological factors that influence adoption of adaptation measures to climate change. They also provide a better understanding of the role of the five types of capital (natural, physical, financial, social, and human) on the uptake of farm‐level adaptation options. These assessments of determinants help to explain adoption of climate change measures and provide helpful information in order to design polices aimed at enhancing societal support for adaptation policies. Finally the analysis at the regional level develops a composite index which suggests the likelihood of the regions in Africa to adopt farm‐level adaptation measures and analyses the main causes of this likelihood of adoption.

Accessibility instruments for planning practice: bridging the gap between academic research and decision-making.

One of the core objectives of urban planning practice is to provide spatial equity in terms of opportunities and use of public space and facilities. Accessibility is the element that serves this purpose as a concept linking the reciprocal relationship between transport and land use, thus shaping individual potential mobility to reach the desired destinations. Accessibility concepts are increasingly acknowledged as fundamental to understand the functioning of cities and urban regions. Indeed, by introducing them in planning practice, better solutions can be achieved in terms of spatial equity. The COST Action TU1002 "Accessibility instruments for planning practice" was specifically designed to address the gap between scientific research in measuring and modelling accessibility, and the current use of indicators of accessibility in urban planning practice. This paper shows the full process of introducing an easily understandable measure of accessibility to planning practitioners in Madrid, which is one of the case studies of the above-mentioned COST action. Changes in accessibility after the opening of a new metro line using contour measures were analyzed and then presented to a selection of urban planners and practitioners in Madrid as part of a workshop to evaluate the usefulness of this tool for planning practice. Isochrone maps were confirmed as an effective tool, as their utility can be supplemented by other indicators, and being GIS-based, it can be easily computed (when compared with transport models) and integrated with other datasets.

Enrichment of the Phenotypic and Genotypic Data Warehouse analysis using Question Answering systems to facilitate the decision making process in cereal breeding programs

Currently there are an overwhelming number of scientific publications in Life Sciences, especially in Genetics and Biotechnology. This huge amount of information is structured in corporate Data Warehouses (DW) or in Biological Databases (e.g. UniProt, RCSB Protein Data Bank, CEREALAB or GenBank), whose main drawback is its cost of updating that makes it obsolete easily. However, these Databases are the main tool for enterprises when they want to update their internal information, for example when a plant breeder enterprise needs to enrich its genetic information (internal structured Database) with recently discovered genes related to specific phenotypic traits (external unstructured data) in order to choose the desired parentals for breeding programs. In this paper, we propose to complement the internal information with external data from the Web using Question Answering (QA) techniques. We go a step further by providing a complete framework for integrating unstructured and structured information by combining traditional Databases and DW architectures with QA systems. The great advantage of our framework is that decision makers can compare instantaneously internal data with external data from competitors, thereby allowing taking quick strategic decisions based on richer data.

Sport-Specific Practice and the Development of Expert Decision-Making in Team Ball Sports

The role of sport-specific practice in the development of decision-making expertise in the sports of field hockey, netball, and basketball was examined. Fifteen expert decision-makers and 13 experienced non-expert athletes provided detailed information about the quantity and type of sport-specific and other related practice activities they had undertaken throughout their careers. Experts accumulated more hours of sport-specific practice from age 12 years onwards than did non-experts, spending on average some 13 years and 4,000 hours on concentrated sport-specific practice before reaching international standard. A significant negative correlation existed between the number of additional activities undertaken and the hours of sportspecific training required before attaining expertise, suggesting a functional role for activities other than sport-specific training in the development of expert decision-making.

Bridging qualified majority and unanimity decision-making in the EU. IHS Political Science Series No. 132, February 2013

The EU has tried to bridge decision making by qualified majority and unanimity over the years by expanding qualified majorities (consensus) or by making unanimities easier to achieve. I call this decision-making procedure q-“unanimity” and trace its history from the Luxembourg compromise to the Lisbon Treaty, and to more recent agreements. I analyze the most recent and explicit mechanism of this bridging (article 31 (2) of the Lisbon Treaty) and identify one specific means by which the transformation of qualified majorities to unanimities is achieved: the reduction of precision or scope of the decision, so that different behaviors can be covered by it. I provide empirical evidence of such a mechanism by analyzing legislative decisions. Finally, I argue that this bridging is a ubiquitous feature of EU institutions, used in Treaties as well as in legislative decision-making.