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.

Behavioral decision making and the levels of change: An application of the transtheoretical model to prenatal smoking in low -income women

Despite continued research and public health efforts to reduce smoking during pregnancy, prenatal cessation rates in the United States have decreased and the incidence of low birth weight has increased from 1985 to 1991. Lower socioeconomic status women who are at increased risk for poor pregnancy outcomes may be resistant to current intervention efforts during pregnancy. The purpose of this dissertation was to investigate the determinants of continued smoking and quitting among low-income pregnant women.^ Using data from cross-sectional surveys of 323 low-income pregnant smokers, the first study developed and tested measures of the pros and cons of smoking during pregnancy. The original decisional balance measure for smoking was compared with a new measure that added items thought to be more salient to the target population. Confirmatory factor analysis using structural equation modeling showed neither the original nor new measure fit the data adequately. Using behavioral science theory, content from interviews with the population, and statistical evidence, two 7-item scales representing the pros and cons were developed from a portion (n = 215) of the sample and successfully cross-validated on the remainder of the sample (n = 108). Logistic regression found only pros were significantly associated with continued smoking. In a discriminant function analysis, stage of change was significantly associated with pros and cons of smoking.^ The second study examined the structural relationships between psychosocial constructs representing some of the levels of and the pros and cons of smoking. The cross-sectional design mandates that statements made regarding prediction do not prove causation or directionality from the data or methods analysis. Structural equation modeling found the following: more stressors and family criticism were significantly more predictive of negative affect than social support; a bi-directional relationship was found between negative affect and current nicotine addiction; and negative affect, addiction, stressors, and family criticism were significant predictors of pros of smoking.^ The findings imply reversing the trend of decreasing smoking cessation during pregnancy may require supplementing current interventions for this population of pregnant smokers with programs addressing nicotine addiction, negative affect, and other psychosocial factors such as family functioning and stressors. ^

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.

State-business relations in the smaller gulf monarchies -- the role of business actors in the decision-making process

The Arab monarchies of the Gulf have been undergoing striking socio-economic changes caused by the ending of the rent-based welfare state model on which they had largely relied since the 1950s. In this perspective, this paper aims at examining the comparative role of local business communities in affecting the orientations and the outcomes of the policies implemented during the period of high oil prices in the 2000s. This paper pays a special attention to the impact of the Arab Spring on the state-business relations in two of the smaller Gulf monarchies (Bahrain and Oman).

Participatory modelling to support decision making in water management. A case study in the middle Guadiana basin, Spain.

The objective of this research was the implementation of a participatory process for the development of a tool to support decision making in water management. The process carried out aims at attaining an improved understanding of the water system and an encouragement of the exchange of knowledge and views between stakeholders to build a shared vision of the system. In addition, the process intends to identify impacts of possible solutions to given problems, which will help to take decisions.

Effect of positioning on the accuracy of decision making of association football top-class referees and assistant referees during competitive matches

The aim of this study was to examine the effect of positioning on the correctness of decision making of top-class referees and assistant referees during international games. Match analyses were carried out during the Fe´de´ration Internationale de Football Association (FIFA) Confederations Cup 2009 and 380 foul play incidents and 165 offside situations were examined. The error percentage for the referees when indicating the incidents averaged 14%. The lowest error percentage occurred in the central area of the field, where the collaboration of the assistant referee is limited, and was achieved when indicating the incidents from a distance of 11–15 m, whereas this percentage peaked (23%) in the last 15-min match period. The error rate for the assistant referees was 13%. Distance of the assistant referee to the offside line did not have an impact on the quality of the offside decision. The risk of making incorrect decisions was reduced when the assistant referees viewed the offside situations from an angle between 46 and 608. Incorrect offside decisions occurred twice as often in the second as in the first half of the games. Perceptual-cognitive training sessions specific to the requirements of the game should be implemented in the weekly schedule of football officials to reduce the overall error rate.

The Learning of the Mathematical Models to Aid Decision Making in the High Level Engineering Schools?

At present, in the University curricula in most countries, the decision theory and the mathematical models to aid decision making is not included, as in the graduate program like in Doctored and Master´s programs. In the Technical School of High Level Agronomic Engineers of the Technical University of Madrid (ETSIA-UPM), the need to offer to the future engineers training in a subject that could help them to take decisions in their profession was felt. Along the life, they will have to take a lot of decisions. Ones, will be important and others no. In the personal level, they will have to take several very important decisions, like the election of a career, professional work, or a couple, but in the professional field, the decision making is the main role of the Managers, Politicians and Leaders. They should be decision makers and will be paid for it. Therefore, nobody can understand that such a professional that is called to practice management responsibilities in the companies, does not take training in such an important matter. For it, in the year 2000, it was requested to the University Board to introduce in the curricula an optional qualified subject of the second cycle with 4,5 credits titled " Mathematical Methods for Making Decisions ". A program was elaborated, the didactic material prepared and programs as Maple, Lingo, Math Cad, etc. installed in several IT classrooms, where the course will be taught. In the course 2000-2001 this subject was offered with a great acceptance that exceeded the forecasts of capacity and had to be prepared more classrooms. This course in graduate program took place in the Department of Applied Mathematics to the Agronomic Engineering, as an extension of the credits dedicated to Mathematics in the career of Engineering.

MOIRA-PLUS use in decision making on the long-term management of contaminated freshwater bodies and catchments

In the mid-long-term after a nuclear accident, the contamination of drinking water sources, fish and other aquatic foodstuffs, irrigation supplies and people?s exposure during recreational activities may create considerable public concern, even though dose assessment may in certain situations indicate lesser importance than for other sources, as clearly experienced in the aftermath of past accidents. In such circumstances there are a number of available countermeasure options, ranging from specific chemical treatment of lakes to bans on fish ingestion or on the use of water for crop irrigation. The potential actions can be broadly grouped into four main categories, chemical, biological, physical and social. In some cases a combination of actions may be the optimal strategy and a decision support system (DSS) like MOIRA-PLUS can be of great help to optimise a decision. A further option is of course not to take any remedial actions, although this may also have significant socio-economic repercussions which should be adequately evaluated. MOIRA-PLUS is designed to allow for a reliable assessment of the long-term evolution of the radiological situation and of feasible alternative rehabilitation strategies, including an objective evaluation of their social, economic and ecological impacts in a rational and comprehensive manner. MOIRA-PLUS also features a decision analysis methodology, making use of multi-attribute analysis, which can take into account the preferences and needs of different types of stakeholders. The main functions and elements of the system are described summarily. Also the conclusions from end-user?s experiences with the system are discussed, including exercises involving the organizations responsible for emergency management and the affected services, as well as different local and regional stakeholders. MOIRAPLUS has proven to be a mature system, user friendly and relatively easy to set up. It can help to better decisionmaking by enabling a realistic evaluation of the complete impacts of possible recovery strategies. Also, the interaction with stakeholders has allowed identifying improvements of the system that have been recently implemented.

Systematic Approach for the selection of monitoring technologies in CO2 geological storage projects. Application of multicriteria decision making

Geologic storage of carbon dioxide (CO2) has been proposed as a viable means for reducing anthropogenic CO2 emissions. Once injection begins, a program for measurement, monitoring, and verification (MMV) of CO2 distribution is required in order to: a) research key features, effects and processes needed for risk assessment; b) manage the injection process; c) delineate and identify leakage risk and surface escape; d) provide early warnings of failure near the reservoir; and f) verify storage for accounting and crediting. The selection of the methodology of monitoring (characterization of site and control and verification in the post-injection phase) is influenced by economic and technological variables. Multiple Criteria Decision Making (MCDM) refers to a methodology developed for making decisions in the presence of multiple criteria. MCDM as a discipline has only a relatively short history of 40 years, and it has been closely related to advancements on computer technology. Evaluation methods and multicriteria decisions include the selection of a set of feasible alternatives, the simultaneous optimization of several objective functions, and a decision-making process and evaluation procedures that must be rational and consistent. The application of a mathematical model of decision-making will help to find the best solution, establishing the mechanisms to facilitate the management of information generated by number of disciplines of knowledge. Those problems in which decision alternatives are finite are called Discrete Multicriteria Decision problems. Such problems are most common in reality and this case scenario will be applied in solving the problem of site selection for storing CO2. Discrete MCDM is used to assess and decide on issues that by nature or design support a finite number of alternative solutions. Recently, Multicriteria Decision Analysis has been applied to hierarchy policy incentives for CCS, to assess the role of CCS, and to select potential areas which could be suitable to store. For those reasons, MCDM have been considered in the monitoring phase of CO2 storage, in order to select suitable technologies which could be techno-economical viable. In this paper, we identify techniques of gas measurements in subsurface which are currently applying in the phase of characterization (pre-injection); MCDM will help decision-makers to hierarchy the most suitable technique which fit the purpose to monitor the specific physic-chemical parameter.

The analytic hierarchy process to support decision-making processes in infrastructure projects with social impact

There is an increasing awareness among all kinds of organisations (in business,government and civil society) about the benefits of jointly working with stakeholders to satisfy both their goals and the social demands placed upon them. This is particularly the case within corporate social responsibility (CSR) frameworks. In this regard, multi-criteria tools for decision-making like the analytic hierarchy process (AHP) described in the paper can be useful for the building relationships with stakeholders. Since these tools can reveal decision-maker’s preferences, the integration of opinions from various stakeholders in the decision-making process may result in better and more innovative solutions with significant shared value. This paper is based on ongoing research to assess the feasibility of an AHP-based model to support CSR decisions in large infrastructure projects carried out by Red Electrica de España, the sole transmission agent and operator of the Spanishelectricity system.

A multi-criteria optimization and decision-making approach for improvement of food engineering processes.

The objective of this study was to propose a multi-criteria optimization and decision-making technique to solve food engineering problems. This technique was demostrated using experimental data obtained on osmotic dehydratation of carrot cubes in a sodium chloride solution. The Aggregating Functions Approach, the Adaptive Random Search Algorithm, and the Penalty Functions Approach were used in this study to compute the initial set of non-dominated or Pareto-optimal solutions. Multiple non-linear regression analysis was performed on a set of experimental data in order to obtain particular multi-objective functions (responses), namely water loss, solute gain, rehydration ratio, three different colour criteria of rehydrated product, and sensory evaluation (organoleptic quality). Two multi-criteria decision-making approaches, the Analytic Hierarchy Process (AHP) and the Tabular Method (TM), were used simultaneously to choose the best alternative among the set of non-dominated solutions. The multi-criteria optimization and decision-making technique proposed in this study can facilitate the assessment of criteria weights, giving rise to a fairer, more consistent, and adequate final compromised solution or food process. This technique can be useful to food scientists in research and education, as well as to engineers involved in the improvement of a variety of food engineering processes.

Supporting decision making under uncertainty: Development of a participatory integrated model for water management in the middle Guadiana river basin.

Following the Integrated Water Resources Management approach, the European Water Framework Directive demands Member States to develop water management plans at the catchment level. Those plans have to integrate the different interests and must be developed with stakeholder participation. To face these requirements, managers need tools to assess the impacts of possible management alternatives on natural and socio-economic systems. These tools should ideally be able to address the complexity and uncertainties of the water system, while serving as a platform for stakeholder participation. The objective of our research was to develop a participatory integrated assessment model, based on the combination of a crop model, an economic model and a participatory Bayesian network, with an application in the middle Guadiana sub-basin, in Spain. The methodology is intended to capture the complexity of water management problems, incorporating the relevant sectors, as well as the relevant scales involved in water management decision making. The integrated model has allowed us testing different management, market and climate change scenarios and assessing the impacts of such scenarios on the natural system (crops), on the socio-economic system (farms) and on the environment (water resources). Finally, this integrated assessment modelling process has allowed stakeholder participation, complying with the main requirements of current European water laws.

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.

Decision-Making Mechanism to Organize the Agenda of a Guide-Robot

One of the major challenges in evolutionary robotics is constituted by the need of the robot being able to make decisions on its own, in accordance with the multiple tasks programmed, optimizing its timings and power. In this paper, we present a new automatic decision making mechanism for a robot guide that allows the robot to make the best choice in order to reach its aims, performing its tasks in an optimal way. The election of which is the best alternative is based on a series of criteria and restrictions of the tasks to perform. The software developed in the project has been verified on the tour-guide robot Urbano. The most important aspect of this proposal is that the design uses learning as the means to optimize the quality in the decision making. The modeling of the quality index of the best choice to perform is made using fuzzy logic and it represents the beliefs of the robot, which continue to evolve in order to match the "external reality”. This fuzzy system is used to select the most appropriate set of tasks to perform during the day. With this tool, the tour guide-robot prepares its agenda daily, which satisfies the objectives and restrictions, and it identifies the best task to perform at each moment. This work is part of the ARABOT project of the Intelligent Control Research Group at the Universidad Politécnica de Madrid to create "awareness" in a robot guide.