Economic Analysis of the Prevention and Control of Nosocomial Infections: Research Protocol.

Background: Nosocomial infections (NIs) are among the main preventable healthcare adverse events. Like all countries, Canada and its provinces are affected by NIs. In 2004, Ministry of Health and Social Services (MSSS) of Quebec instituted a mandatory surveillance NI program for the prevention and control (NIPC) in the hospitals of the province. One target of the MSSS 2015-2020 action plan is to assess the implementation, costs, effects, and return on investment of NIPC measures. This project goes in the same way and is one of the first major studies in Canada to evaluate the efficiency of the NIPC measures. Three objectives will be pursued: evaluate the cost of implementing clinical best practices (CBPs) for infection control; evaluate the economic burden attributable to NIs; and examine the cost-effectiveness of the NIPC by comparing the costs of CBPs against those of NIs. Methods: This project is based on an infection control intervention framework that includes four CBPs: hand hygiene; hygiene and sanitation; screening; and additional precautions. Four medical and surgical units in two hospitals (nonUniversity, University) in the province of Quebec will be studied. The project has four components. Component 1 will construct and content validate an observation grid for measuring the costs of CBPs. Component 2 will estimate CBP costs via 2-week prospective observations of health workers, conducted every 2 months over a 1-year period. Component 3 will evaluate, through a matched case-control study, the economic burden of the four most monitored NIs in Quebec (C-difficile, MRSA, VRE, and CPGNB). Archival patient data will be collected retrospectively. Component 4 will determine the optimal breakeven point for CBPs associated with NIPC. Discussion: This project will produce evidence of the economic analysis of NIPC and give health stakeholders an overview of NIPC cost-effectiveness. It will meet the objectives of the Canadian Patient Safety Institute and the MSSS action plan to analyze the efficiency of NIPC preventive measures. To our knowledge, this is the first such exercise in Quebec and Canada. It will provide governments with a decision support tool through a major empirical study that could be replicated nationally to capture the financial benefits of NIPC.

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review.

CONTEXT: Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM: To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS: We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS: In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION: These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.

Contribution analysis to analyze the effects of the health impact assessment at the local level: A case of urban revitalization.

The health impact assessment (HIA) is a tool used to estimate the potential impact on health of non-health-related proposals prior to implementation. While it is increasingly used in Quebec, Canada, studies have not analyzed its medium-term impacts and potential long-term impacts. We conducted a contribution analysis using in-depth interviews with key stakeholders, as well as documents, observation and images related to HIA in order to analyze its impacts on the revitalization of road infrastructure, parks and green spaces, and residential housing. Our analysis not only reflects on the decision-making process through the adoption and implementation of HIA recommendations, but also on the link between actions implemented in the field and health outcomes.

Contribution to healthy places: Risks of equity free health impact assessment.

While health equity is central to health impact assessment [HIA], in reality, less is known about potential impacts of equity-free HIA on social inequalities. We assessed equity-free HIA case in a small city east of Montreal, which took place in a context of urban revitalization. We applied a combination of a quantitative review of community characteristics with a qualitative descriptive approach based on in-depth semi-structured interviews and a focus group with multiple stakeholders to shed light on the pitfalls of equity-free HIA. Our results pointed to gentrification process with a gradual relocation of low-income residents in the end. To mitigate mediating circumstances of gentrification and displacement, the municipality should support social housing or at least should ensure rent stabilization ordinance.

Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada.

BACKGROUND: Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. METHODS: A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients' socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. RESULTS: Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. CONCLUSION: Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.

Healthcare reforms, inertia polarization and group influence.

Healthcare systems performance is the focus of intense policy and media attention in most countries. Quebec (Canada) is no exception, where successive governments have struggled for decades with apparently intractable problems in care accessibility overall, poor performance, and rising costs. This article explores the underlying causes of the disconnection between the high salience of healthcare system dysfunctions in both media and policy debates and the lack of policy change likely to remedy those dysfunctions. Academically, public policies' evolution is usually conceptualized as the product of complex, long-term interactions among diverse groups with specific power sources and preferences. In this context, we wanted to examine empirically whether divergences in stakeholders' views concerning various healthcare reform options could explain why certain policy changes are not implemented despite consensus on their programmatic coherence. The research design was an exploratory sequential design. Data were analyzed narratively as well as graphically using a method derived from social network analysis and graph theory. Results showed striking intergroup convergence around a programmatically sound policy package centred on the general objective of strengthening primary care delivery capacities. Those results, interpreted in light of political science elitist perspectives on the policy process, suggest that the incapacity to reform the system might be explained by one or two groups' having a de facto veto in policy-making.

Conceptualizing 20 years of engaged scholarship: A scoping review.

Engaged scholarship, a movement that has been growing steadily since 1995, offers a new way of bridging gaps between the university and civil society. Numerous papers and reports have been published since Boyer's foundational discourse in 1996. Yet, beyond a growing interest in orienting universities' missions, we observed a lack a formal definition and conceptualization of this movement. Based on a scoping review of the literature over the past 20 years, the objective of this article is to propose a conceptualization of engaged scholarship. More specifically, we define its values, principles, and processes. We conclude with a discussion of the implications of this new posture for faculty and students, as well as for the university as an institution.

Assessing the performance of centralized waiting lists for patients without a regular family physician using clinical-administrative data.

BACKGROUND: With 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada. METHODS: We based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014. RESULTS: During the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = -0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators. CONCLUSIONS: Centralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol.

BACKGROUND: Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. METHODS: A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. DISCUSSION: This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.

Investing in a healthy lifestyle strategy: is it worth it?

OBJECTIVES: In Quebec, various actors fund activities aimed at increasing physical activity, improving eating habits and reducing smoking. The objective was to evaluate how effective does the healthy lifestyle habits promotion (HLHP) strategy need to be to make to offset its costs. METHODS: First, we built the logic model of the HLHP strategy. We then assessed the strategy's total cost as well as the direct health care expenditures associated with lifestyle-related risk factors (smoking, physical inactivity, insufficient intake of fruits and vegetables, obesity and overweight). Finally, we estimated the break-even point beyond which the economic benefits of the HLHP strategy would outweigh its costs. RESULTS: The HLHP strategy cost for 2010-2011 was estimated at $110 million. Direct healthcare expenditures associated with lifestyle-related risk factors were estimated at $4.161 billion. We estimated that 47 % of these expenditures were attributable to these risk factors. CONCLUSIONS: We concluded that the HLHP strategy cost corresponded to 5.6 % of the annual healthcare expenditures attributable to these risk factors. This study compared the economic value of HLHP activities against healthcare expenditures associated with targeted risk factors.

Hepatitis C in Intravenous Drug Users: Study of Obstacles and Facilitators to Access to Health Care and Services / Hépatite C chez les usagers de drogues par voie veineuse : exploration des barrières et des facilitants pour l'accès aux soins et services.

Objective: The study was designed to document the experiences of people affected by hepatitis C with respect to prevention, screening and treatment to more clearly understand the determinants of health trajectories and access to the health system.Methods: Based on an evaluative research, we conducted a thematic qualitative analysis of four focus group interviews with people affected by hepatitis C. Two interviews (n = 3) consisted of people at risk of contracting hepatitis C, the third interview (n = 6) concerned people diagnosed HCV positive but not treated and the fourth interview (n = 6) targeted people who had access to treatment (n = 6).Results: We identified the drivers, barriers and facilitating factors, trajectories of health and care of people affected by hepatitis C in two periods of life: from the injection to HCV screening and from HCV diagnosis to treatment. Life trajectories in relation to hepatitis C are the product of many influences: the personal life experience, the attitude of healthcare staff, the organization of the health system and contingent factors.Conclusion: Understanding the life experience of people affected by hepatitis C is essential to identify potential levers of change and new ways to organize the health system in order to more effectively reach these people.

Evaluation of the effects of health impact assessment practice at the local level in Monteregie.

BACKGROUND: In Quebec (Canada), the Monteregie Regional Public Health Department has chosen to use health impact assessment (HIA) to support municipalities through a knowledge exchange and collaborative process in order to positively influence decision-making regarding local policies and projects. The value of HIA is becoming increasingly recognized by municipalities interested in planning and managing their cities with an eco-systemic perspective. However, the knowledge and tools which support the use of the HIA at regional and local levels are still missing. METHODS: The general objective is to evaluate the impact the collaborative HIA process used in Monteregie has had on the formulation, adoption and implementation of policies and projects favourable to health. The methodology is based on Mayne's CA design, which allows the identification of factors which contribute to a change process. It is described as one of the best approaches to reduce uncertainty regarding the observed results and the contribution of a program. All of the HIA processes realised between January 2013 and January 2016 in Monteregie will be studied following a case study strategy. Study populations include regional and local public health professionals, municipal officers and community members implicated in these HIAs. Various qualitative and quantitative methods will be used, including examination of documentation, observations on the city grounds, and individual or group interviews. A model of change will be constructed for each HIA process and will present the logical pathway which leads to the observed results, alternative explanations and hypothesises as to why these results were obtained, and contextual factors that could have influenced them. This model will allow the production of a refined contribution story for each HIA. A convergence and divergence analysis will be completed in order to identify differences or similitudes between the different HIAs studied. DISCUSSION: In addition to contributing to the production of knowledge in relation to the collaborative model of HIA, this research project will allow other regional and local public health actors and municipalities of Quebec or other decision-making and political bodies to understand the usefulness of this approach for the improvement of population health and well-being.

Tool for assessing health and equity impacts of interventions modifying air quality in urban environments.

BACKGROUND: Urban outdoor air pollution (AP) is a major public health concern but the mechanisms by which interventions impact health and social inequities are rarely assessed. Health and equity impacts of policies and interventions are questioned, but managers and policy agents in various institutional contexts have very few practical tools to help them better orient interventions in sectors other than the health sector. Our objective was to create such a tool to facilitate the assessment of health impacts of urban outdoor AP interventions by non-public health experts. METHODS: An iterative process of reviewing the academic literature, brainstorming, and consultation with experts was used to identify the chain of effects of urban outdoor AP and the major modifying factors. To test its applicability, the tool was applied to two interventions, the London Low Emission Zone and the Montréal BIXI public bicycle-sharing program. RESULTS: We identify the chain of effects, six categories of modifying factors: those controlling the source of emissions, the quantity of emissions, concentrations of emitted pollutants, their spatial distribution, personal exposure, and individual vulnerability. Modifiable and non-modifiable factors are also identified. Results are presented in the text but also graphically, as we wanted it to be a practical tool, from pollution sources to emission, exposure, and finally, health effects. CONCLUSION: The tool represents a practical first step to assessing AP-related interventions for health and equity impacts. Understanding how different factors affect health and equity through air pollution can provide insight to city policymakers pursuing Health in All Policies.

Who gets a family physician through centralized waiting lists?

BACKGROUND: North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians' enrolment of orphan patients through centralized waiting lists, the Guichet d'accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians' after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled. METHODS: A longitudinal quantitative analysis spanning a five-year period (2008-2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used. RESULTS: The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level. CONCLUSION: Centralized waiting lists linked to financial incentives increased the number of family physicians' patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.

Evaluation of the implementation of centralized waiting lists for patients without a family physician and their effects across the province of Quebec.

BACKGROUND: Most national and provincial commissions on healthcare services in Canada over the past decade have recommended that primary care services be strengthened in order to guarantee each citizen access to a family physician. Despite these recommendations, finding a family physician continues to be problematic. The issue of enrollment with a family physician is worrying in Canada, where nearly 21% of the country's population reported not having a family physician in the last Commonwealth Fund survey.To respond to this important need, centralized waiting lists have been implemented in four Canadian provinces to help 'orphan,' or unaffiliated, patients find a family physician. These organizational mechanisms are intended to better coordinate the demand for and supply of family physicians. The objectives of this study are: to assess the effects of centralized waiting lists for orphan patients (GACOs) implemented in the province of Quebec and to explain the variation among their effects by analyzing factors influencing implementation process. METHODS: This study is based on two complementary and sequential research strategies. The first (objective 1) is a quantitative longitudinal design to assess the effects of all the GACOs (n = 93) in Quebec using clinical-administrative data. The second (objective 2) involves using four case studies to explain variations in effects through in-depth analysis of the various factors contributing to the observed effects. The primary source of data will be key actors involved in the GACOs. We expect to conduct around 40 semi-structured interviews. DISCUSSION: This will be the first study in Canada to evaluate the implementation of this innovation. It will provide an exhaustive picture of the effects of GACO implementation in Quebec and to assess their potential for generalization elsewhere in Canada. At the theoretical level, this study will produce new knowledge on the factors having the greatest influence on the implementation of primary care innovations in professional environments.

Addressing equity in interventions to reduce air pollution in urban areas: a systematic review.

OBJECTIVES: We did a systematic review to assess quantitative studies investigating the association between interventions aiming to reduce air pollution, health benefits and equity effects. METHODS: Three databases were searched for studies investigating the association between evaluated interventions aiming to reduce air pollution and heath-related benefits. We designed a two-stage selection process to judge how equity was assessed and we systematically determined if there was a heterogeneous effect of the intervention between subgroups or subareas. RESULTS: Of 145 identified articles, 54 were reviewed in-depth with eight satisfying the inclusion criteria. This systematic review showed that interventions aiming to reduce air pollution in urban areas have a positive impact on air quality and on mortality rates, but the documented effect on equity is less straightforward. CONCLUSIONS: Integration of equity in evidence-based public health is a great challenge nowadays. In this review we draw attention to the importance of considering equity in air pollution interventions. We also propose further methodological and theoretical challenges when assessing equity in interventions to reduce air pollution and we present opportunities to develop this research area.

Learning reflexively from a health promotion professional development program in Canada.

In recent decades, reflexivity has received much attention in the professional education and training literature, especially in the public health and health promotion fields. Despite general agreement on the importance of reflexivity, there appears to be no consensus on how to assess reflexivity or to conceptualize the different forms developed among professionals and participants of training programs. This paper presents an analysis of the reflexivity outcomes of the Health Promotion Laboratory, an innovative professional development program aimed at supporting practice changes among health professionals by fostering competency development and reflexivity. More specifically, this paper explores the difference between two levels of reflexivity (formative and critical) and highlights some implications of each for practice. Data were collected through qualitative interviews with participants from two intervention sites. Results showed that involvement in the Health Promotion Laboratory prompted many participants to modify their vision of their practice and professional role, indicating an impact on reflexivity. In many cases, new understandings seem to have played a formative function in enabling participants to improve their practice and their role as health promoters. The reflective process also served a critical function culminating in a social and moral understanding of the impacts on society of the professionals' practices and roles. This type of outcome is greatly desired in health promotion, given the social justice and equity concerns of this field of practice. By redefining the theoretical concept of reflexivity on two levels and discussing their impacts on practice, this study supports the usefulness of both levels of reflexivity.

The economic value of Quebec's water fluoridation program.

AIM: Dental caries is a major public health problem worldwide, with very significant deleterious consequences for many people. The available data are alarming in Canada and the province of Quebec. The water fluoridation program has been shown to be the most effective means of preventing caries and reducing oral health inequalities. This article analyzes the cost-effectiveness of Quebec's water fluoridation program to provide decision-makers with economic information for assessing its usefulness. METHODS: An approach adapted from economic evaluation was used to: (1) build a logic model for Quebec's water fluoridation program; (2) determine its implementation cost; and (3) analyze its cost-effectiveness. Documentary analysis was used to build the logic model. Program cost was calculated using data from 13 municipalities that adopted fluoridation between 2002 and 2010 and two that received only infrastructure grants. Other sources were used to collect demographic data and calculate costs for caries treatment including costs associated with travel and lost productivity. RESULTS: The analyses showed the water fluoridation program was cost-effective even with a conservatively estimated 1 % reduction in dental caries. The benefit-cost ratio indicated that, at an expected average effectiveness of 30 % caries reduction, one dollar invested in the program saved $71.05-$82.83 per Quebec's inhabitant in dental costs (in 2010) or more than $560 million for the State and taxpayers. CONCLUSION: The results showed that the drinking-water fluoridation program produced substantial savings. Public health decision-makers could develop economic arguments to support wide deployment of this population-based intervention whose efficacy and safety have been demonstrated and acknowledged.

Economic evaluation to inform health care decision-making: promise, pitfalls and a proposal for an alternative path.

Health economic evaluation aims at providing information on the efficiency of interventions. Since the 1980s, there have been major developments in the field, especially in terms of methodologies. As the field has expanded and developed, methodologies have become increasingly sophisticated. In parallel, over the past decade, the conduct of economic evaluations has become more and more institutionalized with, among other things, the creation of the National Institute for Health and Clinical Excellence (NICE) in England and Wales and a growing number of health technology assessment (HTA) agencies around the world. Yet the literature has identified important barriers to the use of economic evaluation in decision-making, among them the difficulty of deciphering economic evaluation research. The way the field expanded has thus created a paradox: whereas economic evaluation is seen as an insightful tool for achieving efficiency in health care, its methodological developments have decreased decision-makers' capacity to use it. In this paper, based on a literature survey, we explore this shift by first analyzing how the field of economic evaluation has developed in recent years. Second, we discuss how economic evaluation information is perceived and used in decision-making. Third, we consider a possible direction for reconciling economic evaluation and decision-making. The originality of this article is that it not only highlights the increasing gap between the aim of economic evaluation and its effective use in decision-making but also proposes, based on existing methodologies, a competing approach to the currently dominant paradigm.