Applying Cognitive Decision Theory to the Study of Regional Patterns of Illness Treatment Choice

This article argues for the utility of cognitive decision modeling in assessing regional patterns of health behavior and, when combined with the explanatory modeling approach, in describing and analyzing more effectively sources of intracultural variation in choice within a region. A decision model developed in two intensively studied communities in rural Costa Rica was used to predict treatment choice in a third one representative of the rapid social change occurring in the region. A subsequent analysis of the errors made in prediction pinpointed patterns of intracultural variation that were then investigated from the explanatory model perspective. The incorporation of these more qualitative data into the original decision model made it more sensitive to both the complexities of the decision context and the specifics of the individual illness experience while also enabling greater accuracy in the prediction of regional patterns of treatment choice.     

Use of maternal-child health services and contraception in Guatemala and Panama

This paper presents data from 2 recent maternal-child health (MCH) and family planning surveys in Guatemala and Panama and examines the extent to which the use of contraception is influenced by the use of MCH services as compared with the influence of an increase in parity. Fieldwork was initiated in July 1984 but not completed until April 1985. A total of 8240 women aged 15-49 years, of all marital statuses, completed interviews, representing 91% of households with eligible respondents. The findings suggest that utilization of MCH services and parity independently are associated with a woman's decision to use contraception. The study also found 2 groups that appear to be particularly in need of both MCH and family planning services: high parity women and Indians. Nonuse of MCH and family planning services may be due in part to their strong cultural beliefs. In both Guatemala and Panama, improved health care services for these 2 groups should be a priority. Contraceptive use in Panama was over twice as high as in Guatemala. However, method choice and residence-ethnicity patterns of use were similar in each country. In both countries and in all residence-ethnicity groups, female sterilization was the most prevalent method in use, followed by oral contraceptives, except for Panama rural Indians. In Panama, contraceptive use increases up to ages 30-34 and then declines, with a sharp decline for women 40-44. In Guatemala, contraceptive use is generally low for ages 15-24, then increases to a fairly constant level for ages 25-39.     

Beliefs about children's illness.

Beliefs about child illness were investigated using semi-structured interviews with mothers and providers in four rural Guatemalan communities. The two most common forms of child illness in Guatemala--diarrhoea and respiratory disease--were focused upon. These illnesses are particularly difficult to prevent and treat, especially with the rudimentary health services available in rural areas of developing countries. Comparisons with other ethnographic studies in Guatemala suggest that some traditional models of illness causation identified in these earlier investigations are relatively unimportant in the communities studied here. This finding, in conjunction with frequent responses related to hygiene and water, suggests that traditional explanations may be co-existing with biomedical views of illness causation to a greater degree today than in the past.     

Health Care Utilization and Symptom Severity in Ghanaian Children – a Cross-Sectional Study

The aim of this study was to identify factors influencing health care utilization behavior for children with mild or severe disease symptoms in rural Ghana. Between March and September 2008 a cross-sectional health care utilization survey was conducted and 8,715 caregivers were interviewed regarding their intended behavior in case their children had mild or severe fever or diarrhea. To show associations between hospital attendance and further independent factors (e.g. travel distance or socio-economic status) prevalence ratios were calculated for the four disease symptoms. A Poisson regression model was used to control for potential confounding. Frequency of hospital attendance decreased constantly with increasing distance to the health facility. Being enrolled in the national health insurance scheme increased the intention to attend a hospital. The effect of the other factors diminished in the Poisson regression if modeled together with travel distance. The observed associations weakened with increasing severity of symptoms, which indicates that barriers to visit a hospital are less important if children experience a more serious illness. As shown in other studies, travel distance to a health care provider had the strongest effect on health care utilization. Studies to identify local barriers to access health care services are important to inform health policy making as they identify deprived populations with low access to health services and to early treatment.     

Job Preferences of Nurses and Midwives for Taking Up a Rural Job in Peru: A Discrete Choice Experiment

Background

Robust evidence on interventions to improve the shortage of health workers in rural areas is needed. We assessed stated factors that would attract short-term contract nurses and midwives to work in a rural area of Peru.

Methods and Findings

A discrete choice experiment (DCE) was conducted to evaluate the job preferences of nurses and midwives currently working on a short-term contract in the public sector in Ayacucho, Peru. Job attributes, and their levels, were based on literature review, qualitative interviews and focus groups of local health personnel and policy makers. A labelled design with two choices, rural community or Ayacucho city, was used. Job attributes were tailored to these settings. Multiple conditional logistic regressions were used to assess the determinants of job preferences. Then we used the best-fitting estimated model to predict the impact of potential policy incentives on the probability of choosing a rural job or a job in Ayacucho city. We studied 205 nurses and midwives. The odds of choosing an urban post was 14.74 times than that of choosing a rural one. Salary increase, health center-type of facility and scholarship for specialization were preferred attributes for choosing a rural job. Increased number of years before securing a permanent contract acted as a disincentive for both rural and urban jobs. Policy simulations showed that the most effective attraction package to uptake a rural job included a 75% increase in salary plus scholarship for a specialization, which would increase the proportion of health workers taking a rural job from 36.4% up to 60%.

Conclusions

Urban jobs were more strongly preferred than rural ones. However, combined financial and non-financial incentives could almost double rural job uptake by nurses and midwifes. These packages may provide meaningful attraction strategies to rural areas and should be considered by policy makers for implementation.     

Adoption of Liquefied Petroleum Gas Stoves in Guatemala: A Mixed-Methods Study

Household air pollution is the sixth leading risk factor for premature mortality in Guatemala. Households in Guatemala are gradually adopting liquefied petroleum gas (LPG) stoves, but a strong tradition of woodstove use persists. We conducted a mixed-methods study of LPG stove use in peri-urban Guatemala. We used knowledge, attitudes and practices surveys with 187 LPG stove owners who also used woodstoves to identify perceptions of stove and cooking practices. Barriers to sustained use of LPG stoves were evaluated through focus groups, participant observations with stove users, and key informant interviews with community leaders. Seven themes emerged that explain household decisions to use LPG stoves: (1) The “new technology” should be framed in terms of what the “old technology” lacks, (2) income is not a predictor of gas stove acquisition but may predict sustained use, (3) men are key decision-makers but messages about LPG do not target them, (4) when stoves are viewed as “prize possessions” they may not be used, (5) collective fear about gas stoves is not based on personal experience, but on “stories we hear,” (6) sustained LPG use is hampered by two major factors, seasonally available wood and LPG retailers who are perceived as dishonest, and (7) wood fuel collection is a time to enjoy the company of friends and family and is not “drudgery.” National policies should promote the use of clean cookstove technologies in peri-urban and rapidly urbanizing areas in Guatemala where LPG stoves are in use, but used intermittently, instead of the current plan to install 100,000 “improved” woodstoves by 2032. This could be done by improving dependable cylinder distribution services, targeting gas safety and promoting positive health messages that appeal to men, as well as women.     

Utilization of Health Care Services for Childhood Morbidity and Associated Factors in India: A National Cross-Sectional Household Survey

Background

Information about utilization of health services and associated factors are useful for improving service delivery to achieve universal health coverage.

Methods

Data on a sample of ever-married women from India Demographic and Health survey 2005–06 was used. Mothers of children aged 0–59 months were asked about child’s illnesses and type of health facilities where treatment was given during 15 days prior to the survey date. Type of health facilities were grouped as informal provider, public provider and private provider. Factors associated with utilization of health services for diarrhea and fever/cough was assessed according to Andersen’s health behavior model. Multinomial logistic regression analyses were done considering sampling weights for complex sampling design.

Results

A total of 48,679 of ever-married women reported that 9.1% 14.8% and 17.67% of their children had diarrhea, fever and cough respectively. Nearly one-third of the children with diarrhea and fever/cough did not receive any treatment. Two-thirds of children who received treatment were from private health care providers (HCPs). Among predisposing factors, children aged 1–2 years and those born at health facility (public/private) were more likely to be taken to any type of HCP during illness. Among enabling factors, as compared to poorer household, wealthier households were 2.5 times more likely to choose private HCPs for any illness. Children in rural areas were likely to be taken to any type of HCP for diarrhea but rural children were less likely to utilize private HCP for fever/cough. ‘Need’ factors i.e. children having severe symptoms were 2–3 times more likely to be taken to any type of HCP.

Conclusion

Private HCPs were preferred for treatment of childhood illnesses. Involvement of private HCPs may be considered while planning child health programs. Health insurance scheme for childhood illnesses may to protect economically weaker sections from out-of-pocket health expenditure during child illness.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

A prospective study of medical care utilization and morbidity in preschool children belonging to a prepaid group practice: background and methods

The purpose of this paper is to describe the background and methods of a prospective study of medical care utilization and morbidity in a fixed cohort of over 500 preschool children whose families belonged to a prepaid group practice affiliated with Yale University. Following baseline interviews with their mothers, study children were followed for 12 months between 1981 and 1982. Information concerning the subjects' contacts with the health care facility serving members of the group practice was collected from accompanying adults, attending clinicians, and medical records. Using these data, we were able to identify episodes of care, linking all clinical visits and phone calls for single occurrences of an illness or injury. The major aim of the study is to identify psychosocial determinants of pediatric utilization (for both acute and preventive care) and of childhood morbidity. The possible predictors of principal interest are factors associated with the family environment, such as social stress and strain, family structure, and different aspects of the mother's social network. The dual emphasis on both illness and behavior outcomes is based on the important interrelationship between epidemiologic and health services research, especially when examining psychosocial effects.     

Linking Time-Use Data to Explore Health Outcomes: Choosing to Vaccinate Against Influenza

To inform public health and medical decision makers concerning vaccination interventions, a methodology for merging and analyzing detailed activity data and health outcomes is presented. The objective is to investigate relationships between individual’s activity choices and their decision to receive an influenza vaccination. Data from the Behavioral Risk Factor Surveillance System (BRFSS) are used to predict vaccination rates in the American Time Use Survey (ATUS) data between 2003 and 2013 by using combined socioeconomic and demographic characteristics. The correlations between the extensive (do or not do) and intensive (how much) decisions to perform activities and influenza vaccination are further explored. Significant positive and negative correlations were found between several activities and vaccination. For some activities, the sign of the correlation flips when considering either the intensive or the extensive decision. This flip occurs with highly studied activities, like smoking. Correlations between activities and vaccination can provide an additional metric for targeting those least likely to vaccinate. The methodology outlined in this paper can be replicated to explore correlation among actions and other health outcomes.     

Preparation and use of plant medicines for farmers' health in Southwest Nigeria: socio-cultural,magico-religious and economic aspects

Background

Little is known about the use of bush medicine and traditional healing among Aboriginal Australians for their treatment of cancer and the meanings attached to it. A qualitative study that explored Aboriginal Australians' perspectives and experiences of cancer and cancer services in Western Australia provided an opportunity to analyse the contemporary meanings attached and use of bush medicine by Aboriginal people with cancer in Western Australia

Methods

Data collection occurred in Perth, both rural and remote areas and included individual in-depth interviews, observations and field notes. Of the thirty-seven interviews with Aboriginal cancer patients, family members of people who died from cancer and some Aboriginal health care providers, 11 participants whose responses included substantial mention on the issue of bush medicine and traditional healing were selected for the analysis for this paper.

Results

The study findings have shown that as part of their healing some Aboriginal Australians use traditional medicine for treating their cancer. Such healing processes and medicines were preferred by some because it helped reconnect them with their heritage, land, culture and the spirits of their ancestors, bringing peace of mind during their illness. Spiritual beliefs and holistic health approaches and practices play an important role in the treatment choices for some patients.

Conclusions

Service providers need to acknowledge and understand the existence of Aboriginal knowledge (epistemology) and accept that traditional healing can be an important addition to an Aboriginal person's healing complementing Western medical treatment regimes. Allowing and supporting traditional approaches to treatment reflects a commitment by modern medical services to adopting an Aboriginal-friendly approach that is not only culturally appropriate but assists with the cultural security of the service.     

Qualitative study of evidence based leaflets in maternity care

ObjectiveTo examine the use of evidence based leaflets on informed choice in maternity services.DesignNon-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care.SettingWomen''s homes; antenatal and ultrasound clinics in 13 maternity units in Wales.ParticipantsChildbearing women and health professionals who provide antenatal care.InterventionProvision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use.ResultsHealth professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of “right” and “wrong” choices rather than “informed” choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women''s trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced.ConclusionsThe way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

What is already known on this topic

Informed Choice leaflets are widely used in maternity care but little is known about their ability to influence informed choice and decision makingHigh quality information is essential for promoting informed choice but is insufficient by itself

What this study adds

Time constraints and other pressures on health professionals resulted in a lack of discussion of the content of the leafletsFear of litigation, power hierarchies, and the technological imperative in maternity care limited the choices availableHealth professionals promoted normative practices rather than choice, and as women valued their opinions this led to the promotion of informed compliance rather than informed choice     

Food choices and eating difficulty among elderly edentate patients in Greece

Aims: To evaluate food choice and eating difficulty experienced by older Greek edentate patients. Subjects: Three samples of patients seeking provision of replacement dentures were studied. A primary study of urban mainland U1 (n=54) and island rural R1 samples (n=84) was followed by a mainland urban U2 sample (n=119) in the Secondary study. Setting: Greek dental clinics. Intervention: Semi‐structured interviews (SSI) were employed, using both open and closed questions. Design: The primary study used SSI to identify eating difficulty experienced by two culturally different Greek groups. The secondary study established patterns of difficulty for comparisons between an urban Greek population and northern European urban studies. Main Outcome Measures: The prevalence of eating difficulty, the degree of difficulty eating specified foods and the exclusion of foods because difficult. Results: Most patients expressed difficulty eating at least one type of food, a high percentage of these patients were willing to eat foods found difficult, while others use particular methods of food preparation that make food easier to eat. Chicken illustrated the importance of specifying the method of cooking when questioning eating difficulties. Roast meats provided insight into the more difficult end of the food range. Raw vegetables were rated difficult. Apples and oranges were also food of particular interest. Conclusions: The semi‐structured interview method provides a succesful method to identify eating difficulty and food choices by older Greek complete denture wearers. Differences, probably largely cultural, were identified between Greek island rural and mainland urban communities. Greek food choices differed favourably from an English sample, strikingly in that Greek patients report continuing to eat difficult foods despite difficulty eating them. This may be relevant to health data on Greek populations that show better mortality statistics despite adverse factors such as high prevalence of smoking.     

Gaze-dependent evidence accumulation predicts multi-alternative risky choice behaviour

Choices are influenced by gaze allocation during deliberation, so that fixating an alternative longer leads to increased probability of choosing it. Gaze-dependent evidence accumulation provides a parsimonious account of choices, response times and gaze-behaviour in many simple decision scenarios. Here, we test whether this framework can also predict more complex context-dependent patterns of choice in a three-alternative risky choice task, where choices and eye movements were subject to attraction and compromise effects. Choices were best described by a gaze-dependent evidence accumulation model, where subjective values of alternatives are discounted while not fixated. Finally, we performed a systematic search over a large model space, allowing us to evaluate the relative contribution of different forms of gaze-dependence and additional mechanisms previously not considered by gaze-dependent accumulation models. Gaze-dependence remained the most important mechanism, but participants with strong attraction effects employed an additional similarity-dependent inhibition mechanism found in other models of multi-alternative multi-attribute choice.     

互信息理论结合决策树算法的土壤质量预测

在充分利用土壤类型、土地利用方式、岩性类型、地形、道路、工业类型等影响土壤质量主要因素,准确获取区域土壤质量的空间分布特征的基础上,采用互信息理论对13个辅助变量（岩性类型、土地利用方式、土壤类型、到城镇的距离、到道路的距离、到工业用地的距离、到河流的距离、相对高程、坡度、坡向、平向曲率、纵向曲率和切线曲率）进行筛选,然后通过决策树See5.0预测研究区土壤质量.结果表明： 影响研究区土壤质量的主要因素包括土壤类型、土地利用方式、岩性类型、到城镇的距离、到水域的距离、相对高程、到道路的距离和到工业用地的距离;以互信息理论选取的因子为预测变量的决策树模型精度明显优于以全部因子为预测变量的决策树模型,在前者的决策树模型中,无论是决策树还是决策规则,分类预测精度均达到80%以上.互信息理论结合决策树的方法在充分利用连续型和字符型数据的基础上,不仅精简了一般决策树算法的输入参数,而且能有效地预测和评价区域土壤质量等级.     

Choice in multi-alternative environments: A trial-by-trial implementation of the Sequential Choice Model

The sequential choice model (SCM) proposes that latencies to accept options presented alone can be used to predict preferences between these options when they are presented simultaneously. SCM has been proposed and tested in experiments where only two alternatives were present. To further challenge the model, we trained and tested European starlings (Sturnus vulgaris) in an environment with a background of four alternatives differing in delay to reinforcement. Unexpected binary choices between the six possible pairs of alternatives were used to assess preference. The model's predictions of the strength of preference roughly corresponded to the bird's choices for each of the six choice situations. More importantly, a trial-by-trial test of the model correctly predicted 84% of all individual choice trials.     

陕北小流域退耕农户剖面特征的土地利用决策响应

采用基于GIS的空间分析、数理统计(Mathematical Statistics)与Multi-logistic回归模型相结合的方法(GMM),探讨退耕前后陕北燕沟流域土地利用及其关键的社会经济驱动因素的变化,揭示农村劳动力转移在土地利用决策中的重要性,了解农村土地利用变化的驱动机制。结果表明:(1)1990—2013年,流域土地利用变化特征总体上与延安市的土地利用变化趋势一致,即坡耕地减少和林草地增加显著;(2)1990—2001年,农业劳动力转移对农户土地利用决策的影响不明显,农户家庭基本特征与资源禀赋等对农户土地利用决策的影响显著。2001—2013年,劳动力转移和交通条件对农户土地利用决策有显著影响,退耕还林政策对农村劳动力的再分配产生了较大影响。     

Design and Analysis of Simple Choice Surveys for Natural Resource Management

Abstract: We used a simple yet powerful method for judging public support for management actions from randomized surveys. We asked respondents to rank choices (representing management regulations under consideration) according to their preference, and we then used discrete choice models to estimate probability of choosing among options (conditional on the set of options presented to respondents). Because choices may share similar unmodeled characteristics, the multinomial logit model, commonly applied to discrete choice data, may not be appropriate. We introduced the nested logit model, which offers a simple approach for incorporating correlation among choices. This forced choice survey approach provides a useful method of gathering public input; it is relatively easy to apply in practice, and the data are likely to be more informative than asking constituents to rate attractiveness of each option separately.     

Preconception and Prenatal Environmental Factors Associated with Communication Impairments in 9 Year Old Children Using an Exposome-Wide Approach

Although speech and language deficits are common in children and strongly associated with poor educational and social outcomes, little attention has been paid to the antecedents. In this study we used the information from the Avon Longitudinal Study of Parents and Children to examine preconception and prenatal environmental risk factors that were related to communication difficulties in children using the Children’s Communication Checklist (CCC). We used an exposome-wide approach to identify environmental factors univariably associated with the CCC. Taking account of the False Discovery rate, we used a P value of 0.000157 to identify 621 of 3855 items tested. These were then subjected to a series of stepwise linear regression analyses, firstly within 10 domains: personal characteristics, health, development, education, socio-economic variables, lifestyle, home and social environments, life events and chemical and other exposures; and then with the predictive variables from each domain. The final model consisted of 19 variables independently associated with the communication scale. These variables suggested 6 possible mechanisms: stressors primarily associated with socio-economic disadvantage although other lifestyle choices such as a social network of family or friends can ameliorate these effects; indicators of future parenting skills primarily associated with aspects of parental personality; aspects of the home environment; poor maternal health with a novel finding concerning maternal hearing loss; and maternal education which was partially mediated by the child’s IQ. Finally, there may be a mechanism via the maternal diet in pregnancy in particular the consumption of fatty or processed foods. This is the subject of ongoing investigation.     

Inductive learning approaches to rainfall-runoff modelling

Trying to model the rainfall-runoff process is a complex activity as it is influenced by a number of implicit and explicit factors--for example, precipitation distribution, evaporation, transpiration, abstraction, watershed topography, and soil types. However, this kind of forecasting is particularly important as it is used to predict serious flooding, estimate erosion and identify problems associated with low flow. Inductive learning approaches (e.g. decision trees and artificial neural networks) are particularly well suited to problems of this nature as they can often interpret underlying factors (such as seasonal variations) which cannot be modelled by other techniques. In addition, these approaches can easily be trained on the explicit factors (e.g. rainfall) and the inexplicit factors (e.g. abstraction) that affect river flow. Inductive learning approaches can also be extended to account for new factors that emerge over a period of time. This paper evaluates the application of decision trees and two artificial neural network models (the multilayer perceptron and the radial basis function network) to river flow forecasting in two flood prone UK catchments using real hydrometric data. Comparisons are made between the performance of these approaches and conventional flood forecasting systems.