Inclusion Decisions Research Articles

A little learning: reflections on 10 years of NICE technology appraisals

Within just a few days of joining NICE, I realised the scale of the task. I thought that grounding in biological science, pharmaceutical R+D and the actual production of submissions to NICE had equipped me with relevant knowledge and skills. How naive; this grounding was merely the starting point of what was needed. The realisation crystallised for me over initial briefings on the ongoing appraisal of drugs for multiple sclerosis. I had joined NICE at the point that it was concluded that the health economic models produced for the appraisal, from pharmaceutical companies and from the academic assessment team, did not help the appraisal committee decision makers reach conclusions on the drugs with sufficient certainty. The decision: NICE would commission the development of another health economic model. The commission went to the School of Health and Related Research in Sheffield UK (ScHARR). The first major task after my appointment was to work with the ScHARR health economists to produce an economic model that would provide robust estimates of the cost-effectiveness of the multiple sclerosis (MS) drugs. That could not be too difficult. This was a world-leading research group who had experience in the therapeutic area. I was wrong. I had forgotten that my new environment was not one where the only people scrutinising the science were a critical bunch of like-minded scientists. I was now in a world of transparent, inclusive and interactive health policy decision making. In its forming principles, NICE committed itself to working in a way that no other NHS health policy organisation before it had worked. The words transparent and inclusive are simple words. Implementing the principle of engagement that lies behind them is not simple at all. I was about to find out how difficult it could get. People wanted to know, in detail, what was wrong with the current models. These stakeholders had submitted the existing models and thought they had produced robust submissions, some with input of leading academic modellers. Why could ScHARR do it any better than they had? How could they interact with the research group? Could they submit data? Could they scrutinise this output? We provided a mechanism for

Natural Resource Dependency and Decentralized Conservation Within Kanchenjunga Conservation Area Project, Nepal

Kanchenjunga Conservation Area Project (KCAP) in Nepal is among the first protected areas in the world to institute a completely decentralized system of conservation and development. Proponents of decentralized conservation claim that it increases management efficiency, enhances the responsiveness to local needs, and promotes greater equity among local residents. This study assessed local equity by evaluating the levels of dependencies on natural resources among households and the factors affecting that dependency. Data were collected via detailed surveys among 205 randomly selected households within the KCAP. Natural resource dependency was evaluated by comparing the ratio of total household income to income derived from access to natural resources. Economic, social, and access-related variables were employed to determine potential significant predictors of dependency. Overall, households were heavily dependent on natural resources for their income, especially households at higher elevations and those with more adult members. The households that received remittances were most able to supplement their income and, therefore, drastically reduced their reliance on the access to natural resources. Socio-economic variables, such as land holdings, education, caste, and ethnicity, failed to predict dependency. Household participation in KCAP-sponsored training programs also failed to affect household dependency; however, fewer than 20% of the households had any form of direct contact with KCAP personnel within the past year. The success of the KCAP as a decentralized conservation program is contingent on project capacity-building via social mobilization, training programs, and participatory inclusion in decision making to help alleviate the dependency on natural resources.

MetaQC: objective quality control and inclusion/exclusion criteria for genomic meta-analysis

Genomic meta-analysis to combine relevant and homogeneous studies has been widely applied, but the quality control (QC) and objective inclusion/exclusion criteria have been largely overlooked. Currently, the inclusion/exclusion criteria mostly depend on ad-hoc expert opinion or naïve threshold by sample size or platform. There are pressing needs to develop a systematic QC methodology as the decision of study inclusion greatly impacts the final meta-analysis outcome. In this article, we propose six quantitative quality control measures, covering internal homogeneity of coexpression structure among studies, external consistency of coexpression pattern with pathway database, and accuracy and consistency of differentially expressed gene detection or enriched pathway identification. Each quality control index is defined as the minus log transformed P values from formal hypothesis testing. Principal component analysis biplots and a standardized mean rank are applied to assist visualization and decision. We applied the proposed method to 4 large-scale examples, combining 7 brain cancer, 9 prostate cancer, 8 idiopathic pulmonary fibrosis and 17 major depressive disorder studies, respectively. The identified problematic studies were further scrutinized for potential technical or biological causes of their lower quality to determine their exclusion from meta-analysis. The application and simulation results concluded a systematic quality assessment framework for genomic meta-analysis.

Influence diagrams as decision‐making tools for pesticide risk management

The pesticide policy arena is filled with discussion of probabilistic approaches to assess ecological risk, however, similar discussions about implementing formal probabilistic methods in pesticide risk decision making are less common. An influence diagram approach is proposed for ecological risk-based decisions about pesticide usage. Aside from technical data, pesticide risk management relies on diverse sources, such as stakeholder opinions, to make decisions about what, how, where, and when to spray. Bayesian influence diagrams allow multiple lines of evidence, including process related information from existing data and expert judgment, in 1 inclusive decision model. In ecological risk assessments, data informally incorporated for pesticide usage decisions, such as field and laboratory effect studies along with chemical monitoring and modeling data, can be formally incorporated and expressed in linked causal diagrams. A case study is presented from the perspective of an environmental manager wishing to efficiently control pests while minimizing risk to local aquatic receptors. Exposure modeling results and toxicity studies were incorporated, and an ecological risk assessment was carried out but combined with hypothetical information on spraying efficacy and valuation of outcomes that would be necessary for making risk management decisions. The variables and their links in the influence diagram are ones that are important to a manager and can be manipulated to optimally control pests while protecting nontarget resources.

A capture-recapture analysis demonstrated that randomized controlled trials evaluating the impact of diagnostic tests on patient outcomes are rare

Objective To estimate the number of randomized controlled trials (RCTs) published annually that evaluate the impact of diagnostic tests on patient outcomes to gauge the extent of available randomized evidence assessing the effectiveness of diagnostic tests. Study Design and Setting Relevant RCTs published in 2004–2007 were identified from electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL). Two search strategies were developed, one using diagnostic methodological terms and one using test names. Potentially relevant RCTs were identified by screening titles and abstracts. Final inclusion decisions were based on full-text review. A random 10% sample of all citations was independently screened by a second reviewer. Capture-recapture methodology was used to estimate the number of relevant RCTs missed by both searches. Results One hundred thirty-five relevant RCTs were identified from the 23,888 records retrieved. Interobserver agreement was substantial. Capture-recapture methodology estimated that 148 (95% confidence interval: 140, 160) relevant RCTs were published in the 4-year period, an average of only 37 publications per year. Conclusion RCTs of diagnostic tests that evaluate patient outcomes are rare. Consequently recommendations on the use of diagnostic tests can rarely be made on the basis of randomized comparisons, lower grade evidence frequently being the best available.

Fathers of children with disabilities: encounters with health professionals in a Chinese context

The aim of this study was to examine the experiences of fathers of developmentally disabled children during interactions with health professionals in Taiwan. The role of Chinese fathers in raising a disabled child has been neglected because most studies on the impact of parenting a child with disabilities in this culture have primarily focused on mothers. A hermeneutic phenomenological approach was undertaken to recover and interpret fathers' experiences. Sixteen fathers living with their disabled child (0-18 years old) were purposively recruited from a teaching hospital in central Taiwan. Data were collected using in-depth interviews and journal notes. All participants were interviewed twice. Interviews lasted from 50-100 minutes, and all were recorded. Three shared meanings were attributed to fathers' interactions with health professionals: (1) experiencing no supportive communication, (2) missing the critical time for disability management and (3) being excluded from medical decision making. Fathers in Taiwan commonly rely on health professionals to solve their child's health problems owing to their perceived power to cure and their professional authority in Chinese society. However, fathers felt powerless and hopeless when they received unclear information and incorrect diagnoses, which delayed appropriate treatment. Expressions of dissatisfaction and possessing a sense of futility were common experiences related to exclusion in a paternalistic healthcare system. Taiwanese clinicians' attitudes and parental-professional relationships challenge an exploration of ethics and standards of medical care shaped by Chinese culture. Ways of promoting parental inclusion in decision making and care, in particular father's inclusion, need to be explored. Recognition of the Chinese mother and father and their differing parental healthcare experiences are important to understand to ensure improvement in encounters with health professionals and the maximisation of positive health outcomes.

Cover Crop, Rootstock, and Root Restriction Regulate Vegetative Growth of Cabernet Sauvignon in a Humid Environment

<h3>Abstract</h3> The psychological impact of the lockdown due to the Covid-19 pandemic are widely documented. In India, a family-centric society with a high population density and extreme social stratification, the impact of the lockdown might vary across diverse social groups. However, the patterning in the psychological impact of the lockdown among sexual minorities and persons known to be at higher risk of contracting Covid-19 is not known in the Indian context. We used mixed methods (online survey, n=282 and in-depth interviews, n=14) to investigate whether the psychological impact of the lockdown was different across these groups of Indian adults. We fitted linear and logistic regression models adjusted for sociodemographic covariates. Thematic analysis helped us identify emergent themes in our qualitative narratives. Anxiety was found to be higher among sexual minorities (β=2.44, CI: 0.58, 4.31), high-risk group (β=2.20, CI:0.36, 4.05), and those with history of depression/loneliness (β=3.89, CI:2.34, 5.44). Addiction to pornography was also found to be higher among sexual minorities (β=2.72, CI: 0.09, 5.36). Qualitative findings suggested that sexual minorities likely used pornography and masturbation to cope with the lockdown, given the limited physical access to sexual partners in a society that stigmatizes homosexuality. Moreover, both qualitative and quantitative study findings suggested that greater frequency of calling family members during lockdown could strengthen social relationships and increase social empathy. The study thereby urgently calls for the attention of policymakers to take sensitive and inclusive health decisions for the marginalized and the vulnerable, both during and after the crisis.

The sustainability of forestry biomass supply for EU bioenergy: A post-normal approach to environmental risk and uncertainty

► The risks of large scale bioenergy and biofuels supply are uncertain and contested. ► This is illustrated with reference to the policy, trends and impacts of European use of solid biomass for bioenergy. ► Post-normal science theory suggests that issues with contested sustainability and risk implications are best resolved or negotiated via inclusive stakeholder fora. ► A novel approach to structuring levels of risk and uncertainty, which acknowledges the post-normal science case, clarifies the different types of risk posed by large scale bioenergy. Most bioenergy supply scenarios suggest that a substantial fraction of future European energy supply could be biomass-based. Yet stakeholder opinion on the risks posed by a high level of bioenergy supply varies and the related science base is relatively undeveloped. Thinking on post-normal science advocates that issues with contested sustainability and risk implications are best resolved or negotiated via inclusive stakeholder fora, in which a variety of values and ways of thinking are respected. As the potential impacts of a large scale supply of forestry biomass for bioenergy have generally received less attention than the potential impacts of first generation biofuels, we use woody biomass risks to illustrate a novel risk perception typology that is consistent with thinking on post normal science. The typology is intended to both strengthen the case for inclusive decision-making in general and to clarify the nature of the risks posed by global solid biomass supply for European bioenergy.

It’s Not Working: Barriers to the Inclusion of Workers with Mental Health Issues

This article examines the judicial treatment of complaints of discrimination from workers with mental health issues. Equality protections promise full inclusion in social, work and community life. The principle of inclusion is understood in three inter-related parts: inclusion in the workforce, inclusion in decision-making and, in the most broad and prospective sense, inclusion in Canadian society. The current framework of equality protections has not effectively addressed these core values of inclusion for workers with mental health issues. The workplace continues to be a site of discrimination and harassment. Barriers prevent workers with mental health issues from getting or keeping employment, discourage their participation in decision-making, and entrench the devaluation, isolation and exclusion of persons with mental health issues. Accommodative measures must be alive to the concrete and attitudinal barriers experienced by workers with mental health issues.Cet article examine l’attitude adoptée par les tribunaux à l’égard des plaintes de discrimination des travailleurs ayant des problèmes de santé mentale. Les protections en matière d’égalité garantissent la pleine inclusion dans la vie sociale et communautaire et dans le marché du travail. Le principe d’inclusion comporte trois volets intimement reliés : l’inclusion dans le marché du travail, l’inclusion dans la prise de décision et, au sens le plus large et prospectif, l’inclusion dans la société canadienne. Le système actuel de protections en matière d’égalité n’a pas convenablement tenu compte de ces valeurs essentielles de l’inclusion des travailleurs ayant des problèmes de santé mentale. La discrimination et le harcèlement sont encore présents sur le marché du travail. Des obstacles empêchent les travailleurs ayant des problèmes de santé mentale d’obtenir un emploi et de le conserver, les dissuadent de participer aux prises de décisions et perpétuent la dévalorisation, l’isolement et l’exclusion des personnes ayant des troubles de santé mentale. Les mesures d’adaptation doivent tenir compte des obstacles concrets et comportementaux que doivent surmonter les travailleurs ayant des problèmes de santé mentale.

South African Mothers' Perceptions and Experiences of an Unplanned Caesarean Section

New motherhood is characterised as a profound change, and research suggests that the psychological effects of childbirth can be significant and far-reaching for some women. This study explored women's perceptions and experiences of childbirth by unplanned Caesarean section. In-depth interviews with 10 Caucasian women (mean age=28; SD=1.97) explored their lived experiences of childbirth. Data were analyzed thematically. Phenomenological theory served as a broad framework for the structuring, organizing and categorizing of data. An unplanned Caesarean section was identified as a potentially traumatic experience. This was in relation to women's contact with medical personnel, as well as the physical, environmental, and emotional aspects of their unplanned Caesarean sections. A sense of loss of control was the most significant contributor to women's negative childbirth experiences. Feelings of failure and disappointment were primarily related to unmet expectations and a lack of preparedness. Negative experiences were mediated by attentive caregiving, inclusion in decision-making, and support from loved ones.

An Examination of the Observed Placebo Effect Associated with the Treatment of Low Back Pain – A Systematic Review

To determine whether the nonspecific effects that occur following the use of sham interventions to treat nonspecific low back pain (LBP) are large enough to be considered clinically meaningful. Electronic databases were searched systematically for randomized placebo-controlled trials of interventions for LBP that used sham ultrasound, sham laser or sham drug therapy as the placebo control. Study selection was accomplished via independent evaluation of scientific admissibility by three reviewers and final decisions of inclusion were based on consensus. None of the studies using sham ultrasound as the placebo control in the treatment of LBP were acceptable for inclusion. Twelve studies were included in the present evaluation of the placebo effect - eight trials that met the strict inclusion criteria for best evidence (three using sham laser placebo and five using sham medication placebo) and four sham medication studies that 'just missed' the inclusion criteria for best evidence. Although the evidence from studies using sham laser was inconclusive, the present review did find a clinically meaningful change in LBP scores following the use of sham oral medications. The present best-evidence review found a clinically meaningful change in pain scores following the use of sham oral medications for the treatment of nonspecific LBP. This finding suggests that further clinical research is warranted to identify which patient subgroups could benefit most from such treatment and to distinguish the true contribution of the placebo effect from other nonspecific effects.

FTA and equity: New approaches to governance

FTA and equity addresses the need for multiple stakeholders’ participation in public policy and corporate decision making thus leading to more democratic societies. The need for more participative and inclusive decision making is due to the move from the technocratic nature of decision making towards more democratic processes, which is a result of the transformation of societies and situations as a result of various factors including globalisation, environmental concerns, more knowledge intensive work and lifestyle. The current paper addresses Future-oriented Technology Analyses (FTA) in the context of a better understanding of issues that ought to be considered by the FTA community so that it can support the quest for new forms of governance. The paper has been structured on the discussion of governance around three pillars: socio-cultural evolution, corporate industrial activity and government. Analysis of the relationship between governance and each of the three pillars poses a number of questions to the FTA community that reflect on the potential impacts of FTA activities in governance. Setting a new landscape for the FTA, the paper concludes with those issues where the FTA community is starting to devote attention, as well as those it still ought to consider.

Justice, community knowledge, and waste facility siting in Taiwan

This article examines justice in the context of a controversial industrial waste facility siting in a Hakka (a minority ethnic group) town in Taiwan. It provides analysis of local perceptions of disproportionate risk, community knowledge claims, and the challenges of citizens to the controversial environmental impact assessment process. It explores knowledge disputes among regulators, developers, and local activists; it considers the struggle of local actors for recognition and inclusion in decision-making; and it argues for the development of institutional procedures that promote dialogue among stakeholders in order to avoid the preemption of debate, the control of the frame by the government and experts, and the centralization of power.

Managing older people's money: assisted and substitute decision making in residential aged-care

ABSTRACTCurrent approaches to the assessment of cognitive capacity in many jurisdictions seek to balance older people's empowerment with their protection. These approaches incorporate a presumption of capacity, a decision-specific rather than global assessment of that capacity, and an obligation to provide the support needed for adults to make or communicate their own decisions. The implication is that older people are assisted to make decisions where possible, rather than using substitute decision makers. For older people, decision making about financial matters is a contentious domain because of competing interests in their assets and concerns about risk, misuse and abuse. In residential-care settings, older people risk being characterised as dependent and vulnerable, especially in relation to decisions about financial assets. This paper reports an Australian study of the factors that facilitate and constrain residents' involvement in financial decision making in residential settings. Case studies of four aged-care facilities explored how staff interpreted the legislative and policy requirements for assisted and substitute decision making, and the factors that facilitated and constrained residents' inclusion in decisions about their finances. The observed practices reveal considerable variation in the ways that current legislation is understood and implemented, that there are limited resources for this area of practice, and that policies and practices prioritise managing risk and protecting assets rather than promoting assisted decision making.

Effects of Reducing or Eliminating Resident Work Shifts over 16 Hours: A Systematic Review

The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours. We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology. Twenty-three studies met inclusion criteria (kappa = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened. In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.

Planning a City through ‘Dialogue’: Deliberative Policy-making in Action in Western Australia

Deliberative policy-making is an alternative method of generating new planning strategies based on the public deliberation of citizens and stakeholders. Four ideals of deliberative policy-making espoused by deliberative democracy theorists are identified. Using this framework the ‘Dialogue with the City’ process undertaken by the Western Australian Government to develop the Network City spatial planning strategy for the Perth metropolitan region is examined. While this process went further than most towards realising the ideals of deliberative policy-making, the Government was not able to fully achieve the ideals of inclusive decision-making, equitable decision-making, deliberation toward the common good and consensus decision-making. It is most likely that the deliberative approach to policy-making does not represent a new model for governing; rather, these participation techniques constitute a more sophisticated model for involving citizens and stakeholders in planning.

WPA Project on Partnerships for Best Practices in Working with Service Users and Carers.

WPA Project on Partnerships for Best Practices in Working with Service Users and Carers.

Young Children’s Decisions to Include Peers With Physical Disabilities in Play

The authors examined factors related to preschool children’s reasoning about including a hypothetical peer with a physical disability in different play activities. They hypothesized that children’s inclusion decisions would be influenced by features of the physical environment, attention to issues of fairness and equity, and individual child characteristics. Participants comprised 72 children enrolled in inclusive preschool classrooms. Children’s ideas about inclusion and their inclusion decisions were gathered in response to vignettes reflecting experiences that children are likely to encounter in preschool. The authors found that children were significantly more likely to say that they would include a child with a physical disability in an activity requiring few motor skills. Children’s inclusion decisions were also significantly associated with their developing theory-of-mind skills and with prompts that encouraged them to consider issues of fairness and equity when making a decision. These results suggest that adaptations of planned activities that promote participation by reducing motor demands for all children, along with attention to issues of fairness and equity of opportunity, may be effective classroomwide interventions to support inclusion of children with disabilities in play activities with peers.

Patient participation in antipsychotic drug choice decisions

Patient inclusion in antipsychotic drug decisions is recommended by international treatment guidelines. For N = 300 in patients with schizophrenia, we analysed patients' preferences for inclusion in decisions and physicians' estimates which patients actually participated in drug choice. Path analysis was used to examine the relationships between patients' preferences/actual participation and clinical variables measured. Forty percent of the patients expressed a wish to participate in clinical decisions. Those patients wishing to participate in medical decisions had less insight into the necessity of treatment. Psychiatrists gave better ratings of the doctor–patient relationship to those patients whom they rated as having participated in their drug choice. These patients had more positive attitudes towards antipsychotic medication. There was no relationship between the desire to participate and actual participation in the drug choice. When working with patients exhibiting poor insight and negative drug attitudes, psychiatrists use authoritative decision-making styles despite the patient's desire to participate.

Efficient protocols for point-convex hull inclusion decision problems

Secure Multi-party Computation (SMC) is dedicated to solve trust problems in cooperative computing with each participant’s private data. Privacy Preserving Computational Geometry (PPCG) is a special area in SMC and being widely researched. In the real world, PPCG theories can be found being used in various occasions such as military cooperation, commercial competitions and so on. Point-convex hull inclusion problem is a practical case in PPCG and has its profound values. This paper firstly investigates the point inclusion problem with static convex hull, and then marches on to the cases of active convex hull, including the parallel moving and rotating ones. To solve the problems above, we propose a secure protocol to determine the relative position of a private point and a private convex hull in the first place. Compared with previous solutions, our protocols perform better in efficiency, especially when the number of the convex hull’s point is large.