IMPLEMENTING BACK PAIN TREATMENT PATHWAYS IN CLINICAL PRACTICE: QUALITATATIVE ANALYSIS OF STAKEHOLDER PERCEPTIONS

Background
Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed.

Aims
The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice.

Methods
A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis.

Results
Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions.

Conclusion
A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice.

Ethical reasoning through simulation: a phenomenological analysis of student experience

Background
Medical students transitioning into professional practice feel underprepared to deal with the emotional complexities of real-life ethical situations. Simulation-based learning (SBL) may provide a safe environment for students to probe the boundaries of ethical encounters. Published studies of ethics simulation have not generated sufficiently deep accounts of student experience to inform pedagogy. The aim of this study was to understand students’ lived experiences as they engaged with the emotional challenges of managing clinical ethical dilemmas within a SBL environment.

Methods
This qualitative study was underpinned by an interpretivist epistemology. Eight senior medical students participated in an interprofessional ward-based SBL activity incorporating a series of ethically challenging encounters. Each student wore digital video glasses to capture point-of-view (PoV) film footage. Students were interviewed immediately after the simulation and the PoV footage played back to them. Interviews were transcribed verbatim. An interpretative phenomenological approach, using an established template analysis approach, was used to iteratively analyse the data.

Results
Four main themes emerged from the analysis: (1) ‘Authentic on all levels?’, (2)‘Letting the emotions flow’, (3) ‘Ethical alarm bells’ and (4) ‘Voices of children and ghosts’. Students recognised many explicit ethical dilemmas during the SBL activity but had difficulty navigating more subtle ethical and professional boundaries. In emotionally complex situations, instances of moral compromise were observed (such as telling an untruth). Some participants felt unable to raise concerns or challenge unethical behaviour within the scenarios due to prior negative undergraduate experiences.

Conclusions
This study provided deep insights into medical students’ immersive and embodied experiences of ethical reasoning during an authentic SBL activity. By layering on the human dimensions of ethical decision-making, students can understand their personal responses to emotion, complexity and interprofessional working. This could assist them in framing and observing appropriate ethical and professional boundaries and help smooth the transition into clinical practice.

A Collaborative Multiagent Framework based on Online Risk-Aware Planning and Decision-Making

Planning is an essential process in teams of multiple agents pursuing a common goal. When the effects of actions undertaken by agents are uncertain, evaluating the potential risk of such actions alongside their utility might lead to more rational decisions upon planning. This challenge has been recently tackled for single agent settings, yet domains with multiple agents that present diverse viewpoints towards risk still necessitate comprehensive decision making mechanisms that balance the utility and risk of actions. In this work, we propose a novel collaborative multi-agent planning framework that integrates (i) a team-level online planner under uncertainty that extends the classical UCT approximate algorithm, and (ii) a preference modeling and multicriteria group decision making approach that allows agents to find accepted and rational solutions for planning problems, predicated on the attitude each agent adopts towards risk. When utilised in risk-pervaded scenarios, the proposed framework can reduce the cost of reaching the common goal sought and increase effectiveness, before making collective decisions by appropriately balancing risk and utility of actions. 

A DST-based Approach for Construction Project Risk Analysis

Despite its huge potential in risk analysis, the Dempster–Shafer Theory of Evidence (DST) has not received enough attention in construction management. This paper presents a DST-based approach for structuring personal experience and professional judgment when assessing construction project risk. DST was innovatively used to tackle the problem of lacking sufficient information through enabling analysts to provide incomplete assessments. Risk cost is used as a common scale for measuring risk impact on the various project objectives, and the Evidential Reasoning algorithm is suggested as a novel alternative for aggregating individual assessments. A spreadsheet-based decision support system (DSS) was devised to facilitate the proposed approach. Four case studies were conducted to examine the approach's viability. Senior managers in four British construction companies tried the DSS and gave very promising feedback. The paper concludes that the proposed methodology may contribute to bridging the gap between theory and practice of construction risk assessment.

The role of muscarinic cholinergic signaling in cost-benefit decision making

Thesis (Ph.D.)--University of Washington, 2016-08

Multiphase flow in porous media: meta-modeling techniques for sensitivity analysis and risk assessment

One of the biggest challenges that contaminant hydrogeology is facing, is how to adequately address the uncertainty associated with model predictions. Uncertainty arise from multiple sources, such as: interpretative error, calibration accuracy, parameter sensitivity and variability. This critical issue needs to be properly addressed in order to support environmental decision-making processes. In this study, we perform Global Sensitivity Analysis (GSA) on a contaminant transport model for the assessment of hydrocarbon concentration in groundwater. We provide a quantification of the environmental impact and, given the incomplete knowledge of hydrogeological parameters, we evaluate which are the most influential, requiring greater accuracy in the calibration process. Parameters are treated as random variables and a variance-based GSA is performed in a optimized numerical Monte Carlo framework. The Sobol indices are adopted as sensitivity measures and they are computed by employing meta-models to characterize the migration process, while reducing the computational cost of the analysis. The proposed methodology allows us to: extend the number of Monte Carlo iterations, identify the influence of uncertain parameters and lead to considerable saving computational time obtaining an acceptable accuracy.

Adapting prospective structural analysis to strengthen sustainable management and capacity building in community-based natural resource management contexts

Local communities collectively managing common pool resources can play an important role in sustainable management, but they often lack the skills and context-specific tools required for such management. The complex dynamics of social-ecological systems (SES), the need for management capacities, and communities’ limited empowerment and participation skills present challenges for community-based natural resource management (CBNRM) strategies. We analyzed the applicability of prospective structural analysis (PSA), a strategic foresight tool, to support decision making and to foster sustainable management and capacity building in CBNRM contexts and the modifications necessary to use the tool in such contexts. By testing PSA in three SES in Colombia, Mexico, and Argentina, we gathered information regarding the potential of this tool and its adaptation requirements. The results suggest that the tool can be adapted to these contexts and contribute to fostering sustainable management and capacity building. It helped identify the systems’ dynamics, thus increasing the communities’ knowledge about their SES and informing the decision-making process. Additionally, it drove a learning process that both fostered empowerment and built participation skills. The process demanded both time and effort, and required external monitoring and facilitation, but community members could be trained to master it. Thus, we suggest that the PSA technique has the potential to strengthen CBNRM and that other initiatives could use it, but they must be aware of these requirements.

Evaluating a School Community Linked Physical Activity Intervention Programme: a Multi-level Analysis.

Previous research has highlighted the importance of positive physical activity (PA) behaviors during childhood to promote sustained active lifestyles throughout the lifespan (Telama et al. 2005; 2014). It is in this context that the role of schools and teachers in facilitating PA education is promoted. Research suggests that teachers play an important role in the attitudes of children towards PA (Figley 1985) and schools may be an efficient vehicle for PA provision and promotion (McGinnis, Kanner and DeGraw, 1991; Wechsler, Deveraux, Davis and Collins, 2000). Yet despite consensus that schools represent an ideal setting from which to ‘reach’ young people (Department of Health and Human Services, UK, 2012) there remains conceptual (e.g. multi-component intervention) and methodological (e.g. duration, intensity, family involvement) ambiguity regarding the mechanisms of change claimed by PA intervention programmes. This may, in part, contribute to research findings that suggest that PA interventions have had limited impact on children’s overall activity levels and thereby limited impact in reducing children’s metabolic health (Metcalf, Henley & Wilkin, 2012). A marked criticism of the health promotion field has been the focus on behavioural change while failing to acknowledge the impact of context in influencing health outcomes (Golden & Earp, 2011). For years, the trans-theoretical model of behaviour change has been ‘the dominant model for health behaviour change’ (Armitage, 2009); this model focusses primarily on the individual and the psychology of the change process. Arguably, this model is limited by the individual’s decision-making ability and degree of self-efficacy in order to achieve sustained behavioural change and does not take account of external factors that may hinder their ability to realise change. Similar to the trans-theoretical model, socio-ecological models identify the individual at the focal point of change but also emphasises the importance of connecting multiple impacting variables, in particular, the connections between the social environment, the physical environment and public policy in facilitating behavioural change (REF). In this research, a social-ecological framework was used to connect the ways a PA intervention programme had an impact (or not) on participants, and to make explicit the foundational features of the programme that facilitated positive change. In this study, we examined the evaluation of a multi-agency approach to a PA intervention programme which aimed to increase physical activity, and awareness of the importance of physical activity to key stage 2 (age 7-12) pupils in three UK primary schools. The agencies involved were the local health authority, a community based charitable organisation, a local health administrative agency, and the city school district. In examining the impact of the intervention, we adopted a process evaluation model in order to better understand the mechanisms and context that facilitated change. Therefore, the aim of this evaluation was to describe the provision, process and impact of the intervention by 1) assessing changes in physical activity levels 2) assessing changes in the student’s attitudes towards physical activity, 3) examining student’s perceptions of the child size fitness equipment in school and their likelihood of using the equipment outside of school and 4) exploring staff perceptions, specifically the challenges and benefits, of facilitating equipment based exercise sessions in the school environment. Methodology, Methods, Research Instruments or Sources Used Evaluation of the intervention was designed as a matched-control study and was undertaken over a seven-month period. The school-based intervention involved 3 intervention schools (n =436; 224 boys) and one control school (n=123; 70 boys) in a low socioeconomic and multicultural urban setting. The PA intervention was separated into two phases: a motivation DVD and 10 days of circuit based exercise sessions (Phase 1) followed by a maintenance phase (Phase 2) that incorporated a PA reward program and the use of specialist kid’s gym equipment located at each school for a period of 4 wk. Outcome measures were measured at baseline (January) and endpoint (July; end of academic school year) using reliable and valid self-report measures. The children’s attitudes towards PA were assessed using the Children’s Attitudes towards Physical Activity (CATPA) questionnaire. The Physical Activity Questionnaire for Children (PAQ-C), a 7-day recall questionnaire, was used to assess PA levels over a school week. A standardised test battery (Fitnessgram®) was used to assess cardiovascular fitness, body composition, muscular strength and endurance, and flexibility. After the 4 wk period, similar kid’s equipment was available for general access at local community facilities. The control school did not receive any of the interventions. All physical fitness tests and PA questionnaires were administered and collected prior to the start of the intervention (January) and following the intervention period (July) by an independent evaluation team. Evaluation testing took place at the individual schools over 2-3 consecutive days (depending on the number of children to be tested at the school). Staff (n=19) and student perceptions (n = 436) of the child sized fitness equipment were assessed via questionnaires post-intervention. Students completed a questionnaire to assess enjoyment, usage, ease of use and equipment assess and usage in the community. A questionnaire assessed staff perceptions on the delivery of the exercise sessions, classroom engagement and student perceptions. Conclusions, Expected Outcomes or Findings Findings showed that both the intervention (16.4%) and control groups increased their PAQ-C score by post-intervention (p < 0.05); with the intervention (17.8%) and control (21.3%) boys showing the greatest increase in physical activity levels. At post-intervention, there was a 5.5% decline in the intervention girls’ attitudes toward PA in the aesthetic subdomains (p = 0.009); whereas the control boys had an increase in positive attitudes in the health domain (p = 0.003). No significant differences in attitudes towards physical activity were observed in any other domain for either group at post-intervention (p > 0.05). The results of the equipment questionnaire, 96% of the children stated they enjoyed using the equipment and would like to use the equipment again in the future; however at post-intervention only 27% reported using the equipment outside of school in the last 7 days. Students identified the ski walker (34%) and cycle (32%) as their favorite pieces of equipment; with the single joint exercises such as leg extension and bicep/tricep machine (<3%) as their least favorite. Key themes from staff were that the equipment sessions were enjoyable, a novel activity, children felt very grown-up, and the activity was linked to a real fitness experience. They also expressed the need for more support to deliver the sessions and more time required for each session. Findings from this study suggest that a more integrated approach within the various agencies is required, particularly more support to increase teachers pedagogical content knowledge in physical activity instruction which is age appropriate. Future recommendations for successful implementation include sufficient time period for all students to access and engage with the equipment; increased access and marketing of facilities to parents within the local community, and professional teacher support strategies to facilitate the exercise sessions.

Decision-making process in Portuguese Erasmus student mobility: case study

With the evolution of nowadays knowledge-based economies, the labour class becomes more competitive. As a way of getting skills that bring benefits to their careers, university students take advantage of the many opportunities available and go abroad to study. This study develops and empirically tests a structural model that examines the antecedents that influence the decision-making process of an Erasmus student under mobility for studies (EMS) in Aveiro, Coimbra and Porto (2014-2015). Reliability analysis, exploratory factor analysis and linear regressions were used to evaluate the model. Based on a survey with a sample of 872 valid responses, this study has demonstrated that EMS students are also influenced by touristic factors, which gives support to what has recently been approached by other authors. Conclusions and suggestions can be applied by other organizations, mainly Higher Education Institutions in order to attract more EMS students.

SCHOOL DISTRICT GOVERNANCE AND KNOWLEDGE-FIT IN DECISION RIGHTS: HOW DISTRICTS RECRUIT AND HIRE SCHOOL LIBRARIANS

This study examines the organizational structures and decision-making processes used by school districts to recruit and hire school librarians. For students to acquire the information and technology literacy education they need, school libraries must be staffed with qualified individuals who can fulfill the librarian’s role as leader, teacher, instructional partner, information specialist, and program administrator. Principals are typically given decision rights for hiring staff, including school librarians. Research shows that principals have limited knowledge of the skills and abilities of the school librarian or the specific needs and functions of the library program. Research also indicates that those with specific knowledge of school library programs, namely school district library supervisors, are only consulted on recruiting and hiring about half the time. School districts entrust library supervisors with responsibilities such as professional development of school librarians only after they are hired. This study uses a theoretical lens from research on IT governance, which focuses on the use of knowledge-fit in applying decision rights in an organization. This framework is appropriate because of its incorporation of a specialist with a specific knowledge set in determining the placement of input and decision rights in the decision-making processes. The method used in this research was a multiple-case study design using five school districts as cases, varying by the involvement of the supervisors and other individuals in the hiring process. The data collected from each school district were interviews about the district’s recruiting and hiring practices with principals, an individual in HR, library supervisors, and recently hired school librarians. Data analysis was conducted through iterative coding from themes in the research questions, with continuous adjustments as new themes developed. Results from the study indicate that governance framework is applicable to evaluating the decision-making processes used in recruiting and hiring school librarians. However, a district’s use of governance did not consistently use knowledge-fit in the determination of input and decision rights. In the hiring process, governance was more likely to be based on placing decision rights at a certain level of the district hierarchy rather than the location of specific knowledge, most often resulting in site-based governance for decision rights at the school-building level. The governance of the recruiting process was most affected by the shortage or surplus of candidates available to the district to fill positions. Districts struggling with a shortage of candidates typically placed governance for the decision-making process on recruiting at the district level, giving the library supervisor more opportunity for input and collaboration with human resources. In districts that use site-based governance and that place all input and decision rights at the building level, some principals use their autonomy to eliminate the school library position in the allotment phase or hire librarians that, while certified through testing, do not have the same level of expertise as those who achieve certification through LIS programs. The principals in districts who use site-based governance for decision rights but call on the library supervisor for advisement stated how valuable they found the supervisor’s expertise in evaluating candidates for hire. In no district was a principal or school required to involve the library supervisor in the hiring of school librarians. With a better understanding of the tasks involved, the effect of district governance on decision-making, and the use of knowledge to assign input and decision rights, it is possible to look at how all of these factors affect the outcome in the quality of the hire. A next step is to look at the hiring process that school librarians went through and connect those with the measurable outcomes of hiring: school librarian success, retention, and attrition; the quality of school library program services, outreach, and involvement in a school; and the perceptions of the success of the school librarian and the library program as seen from students, teachers, administrators, parents, and other community stakeholders.

Decision tools for bacterial blight resistance gene deployment in rice-based agricultural ecosystems

Attempting to achieve long-lasting and stable resistance using uniformly deployed rice varieties is not a sustainable approach. The real situation appears to be much more complex and dynamic, one in which pathogens quickly adapt to resistant varieties. To prevent disease epidemics, deployment should be customized and this decision will require interdisciplinary actions. This perspective article aims to highlight the current progress on disease resistance deployment to control bacterial blight in rice. Although the model system rice-Xanthomonas oryzae pv. oryzae has distinctive features that underpin the need for a case-by-case analysis, strategies to integrate those elements into a unique decision tool could be easily extended to other crops.

Formalizing operator task analysis

Human operators are unique in their decision making capability, judgment and nondeterminism. Their sense of judgment, unpredictable decision procedures, susceptibility to environmental elements can cause them to erroneously execute a given task description to operate a computer system. Usually, a computer system is protected against some erroneous human behaviors by having necessary safeguard mechanisms in place. But some erroneous human operator behaviors can lead to severe or even fatal consequences especially in safety critical systems. A generalized methodology that can allow modeling and analyzing the interactions between computer systems and human operators where the operators are allowed to deviate from their prescribed behaviors will provide a formal understanding of the robustness of a computer system against possible aberrant behaviors by its human operators. We provide several methodology for assisting in modeling and analyzing human behaviors exhibited while operating computer systems. Every human operator is usually given a specific recommended set of guidelines for operating a system. We first present process algebraic methodology for modeling and verifying recommended human task execution behavior. We present how one can perform runtime monitoring of a computer system being operated by a human operator for checking violation of temporal safety properties. We consider the concept of a protection envelope giving a wider class of behaviors than those strictly prescribed by a human task that can be tolerated by a system. We then provide a framework for determining whether a computer system can maintain its guarantees if the human operators operate within their protection envelopes. This framework also helps to determine the robustness of the computer system under weakening of the protection envelopes. In this regard, we present a tool called Tutela that assists in implementing the framework. We then examine the ability of a system to remain safe under broad classes of variations of the prescribed human task. We develop a framework for addressing two issues. The first issue is: given a human task specification and a protection envelope, will the protection envelope properties still hold under standard erroneous executions of that task by the human operators? In other words how robust is the protection envelope? The second issue is: in the absence of a protection envelope, can we approximate a protection envelope encompassing those standard erroneous human behaviors that can be safely endured by the system? We present an extension of Tutela that implements this framework. The two frameworks mentioned above use Concurrent Game Structures (CGS) as models for both computer systems and their human operators. However, there are some shortcomings of this formalism for our uses. We add incomplete information concepts in CGSs to achieve better modularity for the players. We introduce nondeterminism in both the transition system and strategies of players and in the modeling of human operators and computer systems. Nondeterministic action strategies for players in \emph{i}ncomplete information \emph{N}ondeterministic CGS (iNCGS) is a more precise formalism for modeling human behaviors exhibited while operating a computer system. We show how we can reason about a human behavior satisfying a guarantee by providing a semantics of Alternating Time Temporal Logic based on iNCGS player strategies. In a nutshell this dissertation provides formal methodology for modeling and analyzing system robustness against both expected and erroneous human operator behaviors.

Assessing and reducing vulnerability to climate change: Moving from theory to practical decision-support

As climate change continues to impact socio-ecological systems, tools that assist conservation managers to understand vulnerability and target adaptations are essential. Quantitative assessments of vulnerability are rare because available frameworks are complex and lack guidance for dealing with data limitations and integrating across scales and disciplines. This paper describes a semi-quantitative method for assessing vulnerability to climate change that integrates socio-ecological factors to address management objectives and support decision-making. The method applies a framework first adopted by the Intergovernmental Panel on Climate Change and uses a structured 10-step process. The scores for each framework element are normalized and multiplied to produce a vulnerability score and then the assessed components are ranked from high to low vulnerability. Sensitivity analyses determine which indicators most influence the analysis and the resultant decision-making process so data quality for these indicators can be reviewed to increase robustness. Prioritisation of components for conservation considers other economic, social and cultural values with vulnerability rankings to target actions that reduce vulnerability to climate change by decreasing exposure or sensitivity and/or increasing adaptive capacity. This framework provides practical decision-support and has been applied to marine ecosystems and fisheries, with two case applications provided as examples: (1) food security in Pacific Island nations under climate-driven fish declines, and (2) fisheries in the Gulf of Carpentaria, northern Australia. The step-wise process outlined here is broadly applicable and can be undertaken with minimal resources using existing data, thereby having great potential to inform adaptive natural resource management in diverse locations.