Evidence based decision making to strenghten local governance : nutritional health interventions

Since 2001, district governments have had the main responsibility for providing public health care in Indonesia. One of the main public health challenges facing many district governments is improving nutritional standards, particularly among poorer segments of the population. Developing effective policies and strategies for improving nutrition requires a multi-sectoral approach encompassing agricultural development policy, access to markets, food security (storage) programs, provision of public health facilities, and promotion of public awareness of nutritional health. This implies a strong need for a coordinated approach involving multiple government agencies at the district level. Due to diverse economic, agricultural,and infrastructure conditions across the country, district governments’ ought to be better placed than central government both to identify areas of greatest need for public nutrition interventions, and devise policies that reflect local characteristics. However, in the two districts observed in this study—Bantul and Gunungkidul—it was clear that local government capacity to generate, obtain and integrate evidence about local conditions into the policy-making process was still limited. In both districts, decision-makers tended to rely more on intuition,anecdote, and precedent in formulating policy. The potential for evidence-based decision making was also severely constrained by a lack of coordination and communication between agencies, and current arrangements related to central government fiscal transfers, which compel local governments to allocate funding to centrally determined programs and priorities.

Augmenting competitiveness of cities through tourism planning : the role of collaborative decision support systems

Many cities around the globe are now considering tourism facilities and their remarkable revenues in order to become competitive in the global economy. In many of these cities a great emphasis is given to the cultural tourism as it plays an important role in the establishment of creative and knowledge-base of cities. The literature points out the importance of local community support in cultural tourism. In such context, the use of new approach and technologies in tourism planning in order to increase the community participation and competitiveness of cities’ cultural assets gains a great significance. This paper advocates a new planning approach for tourism planning, particularly for cultural tourism, to increase the competitiveness of cities. As part of this new approach, the paper introduces the joined up planning approach integrated with a collaborative decision support system: ‘the community-oriented decision support system’. This collaborative planning support system is an effective and efficient tool for cultural tourism planning, which provides a platform for local communities’ participation in the development decision process.

Determining the psychosocial predictors of living, living-related, and posthumous organ donation

The worldwide organ shortage occurs despite people’s positive organ donation attitudes. The discrepancy between attitudes and behaviour is evident in Australia particularly, with widespread public support for organ donation but low donation and communication rates. This problem is compounded further by the paucity of theoretically based research to improve our understanding of people’s organ donation decisions. This program of research contributes to our knowledge of individual decision making processes for three aspects of organ donation: (1) posthumous (upon death) donation, (2) living donation (to a known and unknown recipient), and (3) providing consent for donation by communicating donation wishes on an organ donor consent register (registering) and discussing the donation decision with significant others (discussing). The research program used extended versions of the Theory of Planned Behaviour (TPB) and the Prototype/Willingness Model (PWM), incorporating additional influences (moral norm, self-identity, organ recipient prototypes), to explicate the relationship between people’s positive attitudes and low rates of organ donation behaviours. Adopting the TPB and PWM (and their extensions) as a theoretical basis overcomes several key limitations of the extant organ donation literature including the often atheoretical nature of organ donation research, thefocus on individual difference factors to construct organ donor profiles and the omission of important psychosocial influences (e.g., control perceptions, moral values) that may impact on people’s decision-making in this context. In addition, the use of the TPB and PWM adds further to our understanding of the decision making process for communicating organ donation wishes. Specifically, the extent to which people’s registering and discussing decisions may be explained by a reasoned and/or a reactive decision making pathway is examined (Stage 3) with the novel application of the TPB augmented with the social reaction pathway in the PWM. This program of research was conducted in three discrete stages: a qualitative stage (Stage 1), a quantitative stage with extended models (Stage 2), and a quantitative stage with augmented models (Stage 3). The findings of the research program are reported in nine papers which are presented according to the three aspects of organ donation examined (posthumous donation, living donation, and providing consent for donation by registering or discussing the donation preference). Stage One of the research program comprised qualitative focus groups/interviews with university students and community members (N = 54) (Papers 1 and 2). Drawing broadly on the TPB framework (Paper 1), content analysed responses revealed people’s commonly held beliefs about the advantages and disadvantages (e.g., prolonging/saving life), important people or groups (e.g., family), and barriers and motivators (e.g., a family’s objection to donation), related to living and posthumous organ donation. Guided by a PWM perspective, Paper Two identified people’s commonly held perceptions of organ donors (e.g., altruistic and giving), non-donors (e.g., self-absorbed and unaware), and transplant recipients (e.g., unfortunate, and in some cases responsible/blameworthy for their predicament). Stage Two encompassed quantitative examinations of people’s decision makingfor living (Papers 3 and 4) and posthumous (Paper 5) organ donation, and for registering and discussing donation wishes (Papers 6 to 8) to test extensions to both the TPB and PWM. Comparisons of health students’ (N = 487) motivations and willingness for living related and anonymous donation (Paper 3) revealed that a person’s donor identity, attitude, past blood donation, and knowing a posthumous donor were four common determinants of willingness, with the results highlighting students’ identification as a living donor as an important motive. An extended PWM is presented in Papers Four and Five. University students’ (N = 284) willingness for living related and anonymous donation was tested in Paper Four with attitude, subjective norm, donor prototype similarity, and moral norm (but not donor prototype favourability) predicting students’ willingness to donate organs in both living situations. Students’ and community members’ (N = 471) posthumous organ donation willingness was assessed in Paper Five with attitude, subjective norm, past behaviour, moral norm, self-identity, and prior blood donation all significantly directly predicting posthumous donation willingness, with only an indirect role for organ donor prototype evaluations. The results of two studies examining people’s decisions to register and/or discuss their organ donation wishes are reported in Paper Six. People’s (N = 24) commonly held beliefs about communicating their organ donation wishes were explored initially in a TPB based qualitative elicitation study. The TPB belief determinants of intentions to register and discuss the donation preference were then assessed for people who had not previously communicated their donation wishes (N = 123). Behavioural and normative beliefs were important determinants of registering and discussing intentions; however, control beliefs influenced people’s registering intentions only. Paper Seven represented the first empirical test of the role of organ transplant recipient prototypes (i.e., perceptions of organ transplant recipients) in people’s (N = 465) decisions to register consent for organ donation. Two factors, Substance Use and Responsibility, were identified and Responsibility predicted people’s organ donor registration status. Results demonstrated that unregistered respondents were the most likely to evaluate transplant recipients negatively. Paper Eight established the role of organ donor prototype evaluations, within an extended TPB model, in predicting students’ and community members’ registering (n = 359) and discussing (n = 282) decisions. Results supported the utility of an extended TPB and suggested a role for donor prototype evaluations in predicting people’s discussing intentions only. Strong intentions to discuss donation wishes increased the likelihood that respondents reported discussing their decision 1-month later. Stage Three of the research program comprised an examination of augmented models (Paper 9). A test of the TPB augmented with elements from the social reaction pathway in the PWM, and extensions to these models was conducted to explore whether people’s registering (N = 339) and discussing (N = 315) decisions are explained via a reasoned (intention) and/or social reaction (willingness) pathway. Results suggested that people’s decisions to communicate their organ donation wishes may be better explained via the reasoned pathway, particularly for registering consent; however, discussing also involves reactive elements. Overall, the current research program represents an important step toward clarifying the relationship between people’s positive organ donation attitudes but low rates of organ donation and communication behaviours. Support has been demonstrated for the use of extensions to two complementary theories, the TPB and PWM, which can inform future research aiming to explicate further the organ donation attitude-behaviour relationship. The focus on a range of organ donation behaviours enables the identification of key targets for future interventions encouraging people’s posthumous and living donation decisions, and communication of their organ donation preference.

Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Defining the public interests in airport development decision-making

Residents, businesses, local, state and national government stakeholders all want to have their say when airports expand or develop. While stakeholder engagement is increasingly a strategy employed for managing the tensions attracted to airport development, different stakeholders have different expectations and demands of airports. This requires different approaches to stakeholder engagement. Identifying the public interests that are at stake in developing airports provides an initial step towards building a platform for selecting and applying stakeholder engagement strategies in airport and more general infrastructure contexts. This paper uses the existing literature of public interests and values to build a general typology of public values for the stakeholders of airport development. A range of semi-privatised and state owned airport case studies from Europe have been used to demonstrate the universal nature of the identified values. The result is a framework that identifies both the substantive and procedural values, separated into local, state/regional and national levels of interest. The typology provides a generalised view of public interests in airport development; however, the public interests identified may be limited to more western oriented societies due to the skew of airport cases reviewed. Contributions are made to the literature with a typology of public values derived from existing knowledge and explored using empirical case examples. The provided typology enables research of airport development decision-making to delineate public interests both within and between stakeholder groups, and helps to explain the different perspectives that stakeholders have towards airport development. Future research may focus on refining the typology for different types of airport governance structures, such as differences between public values in state and market-led airport development; include more airport cases from eastern societies to draw parallels or differences between western and eastern societies; or utilise the typology as a framework for analysing changes in public interests of airports over time.

Sustainable housing implementation through mutual benefits to stakeholders : a decision making approach

Improved public awareness and strong sentiments towards environmental issues will continue to create increasing demand for sustainable housing (SH) in the coming years. Despite this potential, the up-take rate of sustainable housing in new build and through home renovation is not as high as expected within the housing industry. This is in contrast to the influx of emerging building technologies, new materials and innovative designs seen in exemplar homes built worldwide. How we should use the increasing awareness of SH and emerging technologies as an impetus to change the un-sustainable designs and practices of the building industry is high on the agenda of the government and majority of the stakeholders involved. This warrants the study of multifaceted strategies that meet the needs of multiple stakeholders and integrated seamlessly into housing development processes. Specifically, the different perceptions, roles and incentives of stakeholders, who inevitably need to ensure their benefits and commercial returns, should be highlighted and acted upon. ----- This paper discusses the preliminary findings of a research project that aims to promote SH implementation by identifying and materializing the mutual benefits among key stakeholders. The aim is to be achieved through questionnaire surveys, structural equation modelling, interviews and case studies with seven major stakeholders within the Australian housing industry. This research identifies the influence and relationship of relevant factors, investigates preferences, similarities and differences between stakeholders on perceived benefits and in turn explores the mutual-benefit strategy package that facilitates decision making towards sustainable housing development.

Evaluation of community participation for the development of culture-based fisheries in village reservoirs of Sri Lanka

In this paper an attempt is made to identify the socioeconomic characteristics of a community that influences the development and management of culture-based fisheries in village reservoirs of Sri Lanka. Socioeconomic data were collected from 46 agricultural farming communities associated with 47 village reservoirs in Sri Lanka. Principal component analysis indicated that scores of the first principal component were positively influenced by socioeconomic characteristics that are favorable for making collective decisions. These included leadership of the officers, age of the group, percentage of active members of the group, percentage of kinship of the group, percentage of common interest of the group, and percentage of participation of the group. The size of the group had negative effect on the first principal component. The principal component scores of communication were positively related to willingness to pay (P< 0.001). The communities with socioeconomic characteristics favouring collective decision making were in favor of culture-based fisheries. Homogeneity of group characteristics facilitated successful development of culture-based fisheries.

Defining the public values in airport development decision-making

Residents, businesses, local, state and national government stakeholders all want to have their say when airports expand or develop. While stakeholder engagement is increasingly a strategy employed for managing the tensions attracted to airport development, different stakeholders have different expectations and demands of airports. This requires different approaches to stakeholder engagement. Identifying the public values that are at stake in developing airports provides an initial step towards building a platform for selecting and applying stakeholder engagement strategies in airport and more general infrastructure contexts. -------- This paper uses the existing literature of public values to build a general typology of public values for the stakeholders of airport development. A range of semi-privatised and state owned airport case studies from Europe have been used to demonstrate the universal nature of the identified values. The result is a framework that identifies both the substantive and procedural values, separated into local, state/regional and national levels of interest. The typology provides a generalised view of public values in airport development; however, the public values identified may be limited to more western oriented societies due to the skew of airport cases reviewed. --------- Contributions are made to the literature with a typology of public values derived from existing knowledge and explored using empirical case examples. The provided typology enables research of airport development decision-making to delineate public values both within and between stakeholder groups, and helps to explain the different perspectives that stakeholders have towards airport development. Future research may focus on refining the typology for different types of airport governance structures, such as differences between public values in state and market-led airport development; include more airport cases from eastern societies to draw parallels or differences between western and eastern societies; or utilise the typology as a framework for analysing changes in public values of airports over time.

Driver behaviour and decision making at railway level crossings : An exploratory on-road case study

Crashes at rail level crossings represent a significant problem, both in Australia and worldwide. Advances in driving assessment methods, such as the provision of on-road instrumented test vehicles, now provide researchers with the opportunity to further understand driver behaviour at rail level crossings in ways not previously possible. This paper gives an overview of a recent on-road pilot study of driver behaviour at rail level crossings in which 25 participants drove a pre-determined route, incorporating 4 rail level crossings, using MUARC's instrumented On-Road Test Vehicle (ORTeV). Drivers provided verbal commentary whilst driving the route, and a range of other data were collected, including eye fixations, forward, cockpit and driver video, and vehicle data (speed, braking, steering wheel angle, lane tracking etc). Participants also completed a post trial cognitive task analysis interview. Extracts from the wider analyses are used to examine in depth driver behaviour at one of the rail level crossings encountered during the study. The analysis presented, along with the overall analysis undertaken, gives insight into the driver and wider systems factors that shape behaviour at rail level crossings, and highlights the utility of using a multi-method, instrumented vehicle approach for gathering data regarding driver behaviour in different contexts.

Adults who lack capacity : substitute decision-making

• Mechanisms to facilitate consent to healthcare for adults who lack capacity are necessary to ensure that these adults can lawfully receive appropriate medical treatment when needed. • In Australia, the common law plays only a limited role in this context, through its recognition of advance directives and through the parens patriae jurisdiction of superior courts. • Substitute decision-making for adults who lack capacity is facilitated primarily by guardianship and other related legislation. This legislation, which has been enacted in all Australian States and Territories, permits a range of decision-makers to make different types of healthcare decisions. • Substitute decision-makers can be appointed by the adult or by a guardianship or other tribunal. Where there is no appointed decision-maker, legislation generally empowers those close to the adult to make the relevant decision. Most Australian jurisdictions have also provided for statutory advance directives. • For the most serious of decisions, such as non-therapeutic sterilisations, consent can only be provided by a Tribunal. Other decisions can generally be made by a range of substitute decision-makers. Some treatment, such as very minor treatment or that which is needed in an emergency, can be provided without consent. • Guardianship legislation generally establishes a set of principles and/or other criteria to guide healthcare decisions. Mechanisms to resolve disputes as to who is the appropriate decision-maker and how a decision should be made have also been established.

Best practices in prediction for decision-making : lessons from the atmospheric and earth sciences

Predictions that result from scientific research hold great appeal for decision-makers who are grappling with complex and controversial environmental issues, by promising to enhance their ability to determine a need for and outcomes of alternative decisions. A problem exists in that decision-makers and scientists in the public and private sectors solicit, produce, and use such predictions with little understanding of their accuracy or utility, and often without systematic evaluation or mechanisms of accountability. In order to contribute to a more effective role for ecological science in support of decision-making, this paper discusses three ``best practices'' for quantitative ecosystem modeling and prediction gleaned from research on modeling, prediction, and decision-making in the atmospheric and earth sciences. The lessons are distilled from a series of case studies and placed into the specific context of examples from ecological science.

Poisson, Poisson-gamma and zero-inflated regression models of motor vehicle crashes: balancing statistical fit and theory

There has been considerable research conducted over the last 20 years focused on predicting motor vehicle crashes on transportation facilities. The range of statistical models commonly applied includes binomial, Poisson, Poisson-gamma (or negative binomial), zero-inflated Poisson and negative binomial models (ZIP and ZINB), and multinomial probability models. Given the range of possible modeling approaches and the host of assumptions with each modeling approach, making an intelligent choice for modeling motor vehicle crash data is difficult. There is little discussion in the literature comparing different statistical modeling approaches, identifying which statistical models are most appropriate for modeling crash data, and providing a strong justification from basic crash principles. In the recent literature, it has been suggested that the motor vehicle crash process can successfully be modeled by assuming a dual-state data-generating process, which implies that entities (e.g., intersections, road segments, pedestrian crossings, etc.) exist in one of two states—perfectly safe and unsafe. As a result, the ZIP and ZINB are two models that have been applied to account for the preponderance of “excess” zeros frequently observed in crash count data. The objective of this study is to provide defensible guidance on how to appropriate model crash data. We first examine the motor vehicle crash process using theoretical principles and a basic understanding of the crash process. It is shown that the fundamental crash process follows a Bernoulli trial with unequal probability of independent events, also known as Poisson trials. We examine the evolution of statistical models as they apply to the motor vehicle crash process, and indicate how well they statistically approximate the crash process. We also present the theory behind dual-state process count models, and note why they have become popular for modeling crash data. A simulation experiment is then conducted to demonstrate how crash data give rise to “excess” zeros frequently observed in crash data. It is shown that the Poisson and other mixed probabilistic structures are approximations assumed for modeling the motor vehicle crash process. Furthermore, it is demonstrated that under certain (fairly common) circumstances excess zeros are observed—and that these circumstances arise from low exposure and/or inappropriate selection of time/space scales and not an underlying dual state process. In conclusion, carefully selecting the time/space scales for analysis, including an improved set of explanatory variables and/or unobserved heterogeneity effects in count regression models, or applying small-area statistical methods (observations with low exposure) represent the most defensible modeling approaches for datasets with a preponderance of zeros