Introduction : Les pressions sont fortes envers les professionnels de la santé pour qu’ils appliquent une pratique factuelle. Toutefois, un écart important demeure entre les résultats des recherches et la réalité clinique. Par son aspect interactif, le Web 2.0 peut contribuer à l’application des données probantes en facilitant l’accès et l’échange de connaissances. Objectif : Ce projet de recherche s’inscrit dans une étude visant à élaborer une plateforme informatisée pour les professionnels travaillant avec la clientèle ayant subi un accident vasculaire cérébral (AVC). L’objectif de la présente étude est de décrire la perception des professionnels de la santé face à l’introduction du Web 2.0 dans leur pratique. Méthode : Un devis de recherche qualitatif avec une approche phénoménologique a été utilisé. Des entrevues individuelles semi-structurées ont été menées auprès de 24 professionnels et gestionnaires. Résultats : Les personnes interviewées étaient toutes des femmes avec un âge moyen de 45 ans (± 18). Le transfert des connaissances est l’utilité du Web 2.0 qui émerge des participants comme étant la plus importante. Les répondants ont également exprimé avoir besoin d'une plateforme conviviale. Les résultats soulignent également un paradoxe lié au temps. En effet, les répondants estiment que le Web 2.0 pourrait leur permettre de sauver du temps, cependant ils affirment qu'ils n'auront pas le temps de l'utiliser. Conclusion : Bien que le Web 2.0 demeure un outil de transfert de connaissances peu intégré dans la pratique, les professionnels travaillant avec la clientèle AVC perçoivent généralement positivement son introduction dans leur pratique. / Introduction: Health professionals are increasingly encouraged to adopt an evidence-based practice. However, gaps continue to be observed between scientific evidence and practice. Through its interactive capabilities, Web 2.0 can contribute to an evidence-based practice by improving exchange of relevant clinical and scientific information’s. Objective: This study is a part of a project that wants to design a Web 2.0 platform for health professionals working with stroke patients. The aim is to gain a better understanding of professionals’ perceptions of Web 2.0 before platform development. Methods: A qualitative study following the phenomenological approach was chosen. We conducted individual semi-structured interviews with 24 clinicians and managers. Results: Interviewed people were all women with a mean age of 45 years (± 18). Knowledge transfer was identified to be the most useful outcome of a Web 2.0 platform. Respondents also expressed their need for a user-friendly platform. Results also highlight a time paradox. Clinicians feel that the Web 2.0 will help them save time while they argue that they will not have time to use it. Conclusion: While Web 2.0 remains a knowledge transfer tool not yet integrated in clinical practice, professionals working with stroke patients generally receive its implementation positively.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Darbo tikslas - ištirti žinių apie šiuolaikinę kontracepciją poreikį slaugytojams ir akušeriams. Tyrimo metu siekta: įvertinti slaugytojų ir akušerių nuomonės apie kontracepciją ir įrodymais pagrįstos medicinos duomenų skirtumus; išsiaiškinti ir palyginti slaugytojų ir akušerių žinių apie šiuolaikinę kontracepciją panaudojimą praktinėje veikloje; išsiaiškinti slaugytojų ir akušerių nuomonę apie jų svarbą, lytinio švietimo ir informavimo kontracepcijos klausimais, veikloje. Tyrimo hipotezė - akušerių žinios apie šiuolaikines kontraceptines priemones yra geresnės negu slaugytojų. Atliktas vienmomentis kiekybinis tyrimas, taikant apklausos metodą, kurio metu naudota autorės sudaryta nestandartizuota anketa. Apklausoje dalyvavo 220 respondentų (107 akušeriai, 111 slaugytojai ir 2 asmenys nurodė kitą profesiją) dirbančių Kauno miesto sveikatos priežiūros įstaigose ir jų skyriuose, kurie dirba su moterimis ir kuriems gali tekti konsultuoti kontracepcijos klausimu. Duomenims analizuoti naudota statistinė analizė. Atliekant statistinę duomenų analizę analizuoti tik slaugytojų ir akušerių duomenys. Tyrimo rezultatai: vertinant teiginius apie kontracepcijos poveikį slaugytojos įvertino teisingai 3 iš aštuonių, o akušerės 5 iš aštuonių teiginių. 76,4 proc. respondentų atsakė, jog domisi naujovėmis apie kontracepciją. 60,5 proc. respondentų jų nuomone žino kas yra įrodymais pagrįsta medicina/praktika. 69,5 proc. apklaustųjų jaučia poreikį įgyti daugiau žinių kontracepcijos tema... [toliau žr. visą tekstą] / Research goal – to analyse the need of information about modern contraceptics for nurses and midwives. Study aims were: assess the differences between the opinions of nurses and midwives and the evidence-based actual data about contraceptics; to find and compare the application of information about contraception by the nurses and midwives in working environment; to gauge the significance placed upon them by the nurses and midwives in sex education concerning contraception. Hypothesis – midwives have a higher knowledge base concerning modern contraception than nurses. Public quantitative research has been conducted using a survey method, in which authors’ non-standardised questionnaire has been used. In total, 220 respondents have participated (107 midwives, 111 nurses and 2 people of other profession) from Kaunas city’s health care establishments and their subsidiaries, in which female patients are present or come to and in which some sort of consultation regarding contraception could be done. The data has been analysed with statistical tools. In the data analysis, only the data concerning nurses and midwives has been analysed. Research results: in the evaluation task of presented statements upon contraception, nurses have answered 3 out of 8 correctly; midwives have answered 5 out of 8 correctly. 76,4 per cent of respondents have stated that they show interest into the new modern contraception methods. 60,5 per cent of respondents claim to know what is evidence-based... [to full text]

Despite decades of research about educational interventions to correct parents' childhood fever management their knowledge remains poor and practices continue to be based on beliefs about harmful outcomes. The purpose of this thesis was to 1) identify Australian parents' fever management knowledge, attitudes, practices and methods of learning to manage fever and 2) undertake a theoretical exploration of the determinants of parents' intentions to reduce fever using the Theory of Planned Behavior (TPB). Two studies were undertaken: a qualitative study with 15 parents; and survey of 401 Queensland parents with a child aged between 6 months and 5 years. Parents determine childhood fever through behavioural changes they have learnt to associate with fever. Few were aware of the immunological beneficial effects associated with fever and most believed fever harmful causing febrile convulsions and brain damage. To prevent harm they monitored temperatures, used antipyretics, dressed children in light clothing and sponged them with tepid, cool or cold water. Despite believing antipyretics harmful most parents reduced temperatures of 38.3 degrees Celsius ± 0.6 degrees Celsius with antipyretics, alternating two antipyretics when fever was not reduced or returned. In addition to temperature reduction antipyretics were used to reduce distress or general unwellness and pain or discomfort. Multiple factors were used to determine antipyretic dosage including temperature, irritability and illness severity. Over one-third of parents had overdosed their child with too frequent antipyretic administration; more frequently with ibuprofen than paracetamol, 12:1. Fever management information was learnt from numerous sources. Doctors were the most frequently reported followed by personal experience. With the variety of information sources nearly half received conflicting information about how to manage fever increasing concerns and creating uncertainty about how to best care for their child. Despite this many believed they knew how to manage fever. Some parents' practices changed over time as a result of either positive or negative experiences with fever indicating more positive or negative attitudes toward fever. Positive experiences reduced antipyretic and medical service use; negative ones had the adverse effect with increase in antipyretic use including alternating antipyretics and double dosing with one antipyretic. Child medication behaviours also influenced attitudes and practice intentions. Parents of children who readily took antipyretics had more negative attitudes and intended to reduce their child's next fever with antipyretics. Negative attitudes were a significant determinant of fever management intentions. Parents' practices were strongly influenced by their perception that doctors and partners expected them to reduce fever. This expectation from partners is understandable; from doctors it is not and indicates doctors' propensity to recommend reducing fever. There is an urgent need to identify doctors' fever management beliefs and rationales for practice recommendations. Parents also learn to manage fever from nurses and pharmacists; their beliefs and management rationales must also be determined and addressed. There is an urgent need to educate parents about evidence-based fever management and reduce their unnecessary antipyretic use. They must be encouraged to delay antipyretic administration using them to reduce pain rather than fever. Findings from this thesis have identified the determinants of parents' intentions to reduce fever; negative attitudes and normative influences and positive child medication behaviours. Future studies should examine the efficiency and cost effectiveness of fever management educational programs for parents using different presentation methods in multiple settings.

Chronic heart failure (CHF) is defined as a complex clinical syndrome that is frequently, but not exclusively, characterised by objective evidence of an underlying structural abnormality or cardiac dysfunction. CHF affects up to 3% of the adult population and this rate is consistent throughout the developed world. In spite of the proven efficacy of treatments, there is a common theme of low implementation rates for recommended therapeutic guidelines. In Australia, where access to specialist CHF management is limited, the burden of care, for the 40% of CHF patients living outside capital cities falls predominantly onto community-based general practitioners (GPs). Unfortunately, there are diminishing numbers of GPs in rural and remote regions and this has created an apparent dual deficit in terms of equitable access to primary and specialist care for the CHF population living in these areas. The purpose of this research was to determine, in a series of themed studies, the population distribution, management and potential information technology solutions for CHF in rural and remote Australia. Appropriate methods were utilised for each study and included epidemiological studies, a quantitative analysis of a large practice audit, geo-mapping, a systematic review, a case study review and a qualitative analysis of participant feedback and clinical notes.

Text in English / The inception of psychology as a practicing profession in 1938 brought with it a continuing scientific struggle geared towards cementing its place as a value-adding health service in the form of psychotherapy. Concepts such as Empirically Supported Treatments (ESTs), Evidence Based Treatments (EBTs) and Evidence Based Practice in Psychology (EBPP) arose out of research attempts to scientifically prove the efficacy of psychological treatment versus psychiatric medications or versus no treatment. This focus on evidence in psychotherapy partly stems from, but also influences public policy in the form of practice and training mandates as well as government and insurance funding policies for psychotherapy. At present ESTs, EBTs and EBPP are the source of polarisation among psychologists who argue for either sides of this controversy, raising questions on a practical/policy level as well as an epistemological level. This thesis differentiates between ESTs, EBTs and EBPP as well as the Common Factors approach and continues to critically investigate the advantages, practical/policy implications and epistemological critiques against these approaches. Some of the identified shortfalls resulting from unwarranted epistemological (empirical) assumptions are addressed by proposing a social constructionist model of therapeutic factors based on social constructionist- and eco-systemic theories. The proposed model allows therapists to employ EBT’s in conjunction with various other (excluded) approaches that are available in their arsenal of treatments. Clinical case studies are used to illustrate the model’s practical operation in therapeutic contexts. / Psychology / Ph.D. (Psychology)

Introdução: Os distúrbios do espectro do autismo são caracterizados como quadros complexos que abrangem dificuldades nas áreas de linguagem, cognição, comportamento e interação social. Diversos autores apontam o comprometimento de linguagem como principal alteração nestes quadros, já que se trata do processo que permite a comunicação intra e interpessoal. A aquisição e o uso da linguagem é foco principal da terapia fonoaudiológica nos distúrbios do espectro do autismo, principalmente no que diz respeito às habilidades pragmáticas. Objetivo: verificar se há correlação entre a frequência nas terapias e a porcentagem de faltas com o processo de evolução terapêutica e se há uma quantidade mínima de frequência em terapia em um semestre para que haja evolução do quadro. Método: Foram analisados os dados de frequência semestral, avaliação pragmática semestral e avaliação sócio-cognitiva semestral dos prontuários de 50 sujeitos com idades entre 2 e 17 anos durante quatro semestres de tratamento de cada um. Resultados: Após a correlação entre todas as variáveis das avaliações pragmática e sócio cognitiva e os grupos de frequências, foi possível observar que é necessário mais do que 60% de frequência nas terapias fonoaudiológicas previstas durante o semestre para que haja evolução terapêutica. Conclusão: O presente estudo é relevante para os serviços que oferecem este tipo de tratamento fonoaudiológico, indicando que há um mínimo de frequência necessária para que haja melhora do quadro, contribuindo para a delimitação de parâmetros mínimos de frequência à terapia / Introduction: The autism spectrum disorders are characterized as a complex condition involving impairments in the areas of language, cognition, behavior and social interaction. Several authors suggest that language impairment is the main disorder in these cases, since it is essential to intra and interpersonal communication. Language acquisition and functional use is the main focus of speech-language therapy in autism spectrum disorders, particularly regarding pragmatic abilities. Objective: Verify if there is a correlation between frequency and percentage of absence in therapy sessions and therapeutic evolution and if there is a minimal amount of frequency in therapy necessary to this evolution. Methods: Data about frequency, pragmatic and social-cognitive assessment regarding four semesters of speech-language of the records of 50 individuals aged 2 to 17 years were analyzed. Results: After the correlation of all variables of pragmatic and socio-cognitive assessments with the frequency in therapy, it was observed that more than 60% of frequency in speech-language therapies during the semester is needed to result in observable therapeutic evolution. Conclusion: The present study is relevant to the services that offer this type of speech therapy, indicating that there is a minimum frequency necessary for there to be improvement, contributing to the definition of minimum parameters of frequency therapy

Tradicionalmente, a escolha pelo tipo de intervenção psicoterápica para diferentes quadros clínicos depende fundamentalmente da experiência profissional do terapeuta e de sua predileção por determinadas estratégias clínicas. Esse cenário, entretanto, tem se modificado no contexto da prática baseada em evidências, definida pela American Psychological Association como o processo individualizado de tomada de decisão clínica que ocorre por meio da integração da melhor evidência disponível com a perícia clínica no contexto das características, cultura e preferências do cliente. O paradigma de prática baseada em evidências está em perfeita harmonia com a ideologia da análise do comportamento aplicada, que, desde a sua origem, apresenta um forte comprometimento com a sustentação empírica de seus procedimentos terapêuticos. Apesar desse comprometimento, é de fundamental importância avaliar em que medida a área está ou não produzindo evidências de eficácia. Em vista disso, o presente trabalho teve por objetivo analisar a produção de evidências empíricas da terapia analítico-comportamental (TAC) e da psicoterapia analítica-funcional (FAP), na literatura nacional e internacional, de modo a complementar as revisões sistemáticas já realizadas sobre outras modalidades de análise do comportamento clínica terapia de aceitação e compromisso (ACT), terapia comportamental dialética (DBT) e ativação comportamental (BA). Para cumprir esse objetivo, foi realizada uma revisão da literatura conduzida de forma a localizar o maior número possível de estudos empíricos sobre TAC e FAP, publicados ou não, que abarcou onze bases de dados globais e três bases de dados específicas da análise do comportamento. A seleção dos estudos obedeceu aos seguintes critérios de inclusão: ser relato de caso, experimento de caso único ou pesquisa de grupo que descreve os resultados obtidos num processo de terapia individual; ter participantes com desenvolvimento típico e idade igual ou superior a 18 anos; ter ocorrido exclusivamente no ambiente de consultório; ser fundamentado no behaviorismo radical e utilizar conceitos da análise do comportamento na descrição do processo terapêutico. No total, foram selecionados 54 trabalhos que apresentaram 72 casos. As informações de cada um dos casos foram organizadas numa planilha do Microsoft Excel e diferentes categorias de análise foram construídas de modo a possibilitar dois tipos de análise. A primeira, descritiva, abarcou a denominação dada à terapia, idade, gênero e diagnóstico dos clientes, método de pesquisa, número de sessões, avaliação da fidelidade ao procedimento, apresentação de análise de contingências, alvos da intervenção, procedimentos utilizados, eficácia, medidas de resultado e follow-up. A segunda análise consistiu em diversos cruzamentos entre esses dados. Os resultados obtidos permitem concluir que a TAC e a FAP carecem de evidências empíricas que comprovem ou rejeitem sua eficácia. À luz desses dados e das revisões sistemáticas sobre ACT, DBT e BA, argumenta-se que terapeutas e pesquisadores brasileiros têm três opções: (1) utilizar apenas os princípios comportamentais básicos, isto é, a teoria, para guiar sua prática clínica, o que é insuficiente para garantir a eficácia da intervenção; (2) adotar um dos modelos internacionais de análise do comportamento clínica; (3) sistematizar a TAC para, posteriormente, pesquisá-la experimentalmente. Espera-se que, além de oferecer o estado da arte da pesquisa clínica sobre TAC e sobre FAP, este trabalho contribua para o desenvolvimento científico das terapias comportamentais e para o fortalecimento da análise do comportamento como ciência e profissão / Traditionally, the choice of the type of psychotherapeutic intervention for various clinical conditions fundamentally depends on the professional experience of the therapist and his/her predilection for certain clinical strategies. However, this scenario has been changing in the context of evidence-based practice, defined by the American Psychological Association as the individualized process of clinical decision-making that takes place through the integration of the best available evidence with clinical expertise in the context of the characteristics, culture and preferences of the client. The paradigm of evidence-based practice is in perfect harmony with the applied behavior analysis ideology, which, since its inception, has a strong commitment to the empirical support of its therapeutic procedures. Despite this commitment, it is of fundamental importance to assess to what extent the area is or is not producing evidence of efficacy. In view of this, this thesis aimed to analyze the production of empirical evidence of behavioral-analytic therapy (TAC) and functional-analytic psychotherapy (FAP), in national and international literature, in order to complement the systematic reviews already conducted on other modalities of clinical behavior analysis acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and behavioral activation (BA). To achieve this goal, a review of the literature was conducted in order to find the largest possible number of empirical studies of TAC and FAP, published or not, which covered eleven global databases and three specific databases of behavior analysis. The selection of studies followed the following inclusion criteria: to be a case report, single-case experiment or group research that describes the results obtained in an individual therapy process; to have participants with typical development and age up to 18 years of age; to have taken place exclusively in the office environment; to be based on radical behaviorism and to use behavior analysis concepts in the description of the therapeutic process. In total, 54 works that presented 72 cases were selected. The information regarding each one of the cases has been organized in a Microsoft Excel worksheet and different analysis categories have been designed so as to enable two kinds of analysis. The first kind was a descriptive one, and embraced the name given to the therapy, age, gender and diagnosis of clients, research method, number of sessions, evaluation of procedure fidelity, description of analysis of contingencies, targets of intervention, procedures used, efficacy, outcome measures and follow-up. The second kind consisted of the analysis of different combinations of these data. The results lead to the conclusion that TAC and FAP lack empirical evidence to support or reject their efficacy. In light of these data and the systematic reviews on ACT, DBT and BA, it is argued that Brazilian therapists and researchers have three options: (1) use only the basic behavioral principles, i.e. the theory, to guide their clinical practice, which is insufficient to ensure the efficacy of the intervention; (2) adopt one of the international models of clinical behavior analysis; (3) systematize TAC so that it can be researched experimentally afterwards. It is expected that, in addition to offering the state of the art of clinical research on TAC and on FAP, this work will contribute to the scientific development of behavioral therapies and to the strengthening of behavior analysis as a science and profession

Conventional hearing aid circuitry is often unable to provide children with hearing loss with sufficient high frequency information in order to develop adequate oral language skills due to the risk of acoustic feedback and the narrower frequency spectrum of conventional amplification. The purpose of this study was to investigate word recognition abilities of children with moderate-to-severe hearing loss using hearing aids with linear frequency transposition. Seven children with moderate-to-severe sensorineural hearing loss between the ages of 5 years 0 months and 7 years 11 months were selected for the participant group. Word recognition assessments were first performed with the participants using their own previous generation digital signal processing hearing aids. Twenty-five-word lists from the Word Intelligibility by Picture Identification (WIPI) test were presented to the participants in three test conditions, namely: at 55 dB HL in quiet, 55 dB HL with a +5 dB signal-to-noise ratio (SNR) and at 35 dB HL. The participants were then fitted with an ISP-based hearing aid without linear frequency transposition, and the word recognition assessments were repeated with different WIPI word lists under the same conditions as the first assessment. Linear frequency transposition was then activated in the ISP-based hearing aid and different WIPI word lists were presented once more under identical conditions as the previous assessments. A 12-day acclimatization period was allowed between assessments, and all fittings were verified according to the DSL v5 fitting algorithm. Results indicated a significant increase of more than 12% in word recognition score for some of the participants when they used the ISP-based hearing aid with linear frequency transposition. A significant decrease was also seen for some of the participants when they used the ISP-based hearing aid with linear frequency transposition, but all participants presented with better word recognition scores when they used the ISP-based hearing aids without linear frequency transposition compared to their previous generation digital signal processing hearing aids. This study has shown that linear frequency transposition may improve the word recognition skills of some children with moderate-to-severe sensorineural hearing loss, and more research is needed to explore the criteria that can be used to determine candidacy for linear frequency transposition. / Dissertation (MCommunication Pathology)--University of Pretoria, 2010. / Speech-Language Pathology and Audiology / Unrestricted

Malgré les avancées considérables pour la prévention et le traitement des troubles du comportement alimentaire (TCA) au courant des dernières années, l’accès à des services de qualité demeure limité pour trois principales raisons : 1) certaines caractéristiques de la population qui présente un TCA peuvent être associées à de la stigmatisation et faire en sorte que des personnes dans le besoin ne reçoivent pas de traitement, 2) la présence d’un écart entre les pratiques fondées sur des données probantes disponibles et les pratiques des intervenants et 3) le format utilisé pour disséminer les pratiques fondées sur des données probantes recommandées (i.e. formation de cliniciens aux études supérieures) limite le nombre d’intervenants formés pour intervenir. Devant ces constats, l’étude du transfert des connaissances (TC) représente un incontournable pour faciliter l’utilisation de pratiques fondées sur des données probantes par les intervenants. La présente thèse vise à mieux comprendre l’écart présent entre la recherche et la pratique dans le domaine des TCA afin de soutenir l’accès à des traitements démontrés efficaces pour la population. Les principaux objectifs de cette thèse consistent à dresser un portrait des effets de stratégies de TC disponibles (ex: matériels éducatifs, guides de pratique, formations, supervisions), de documenter les déterminants influençant l’utilisation de pratiques fondées sur des données probantes par les intervenants et d’identifier des applications potentielles en contexte québécois. La thèse comporte deux articles scientifiques et une discussion critique des résultats issus de ces articles. Le premier article présente une recension systématique des écrits concernant les effets de stratégies de TC existantes et les déterminants influençant l’utilisation par des intervenants et équipes de traitement pour les TCA. Les résultats suggèrent qu’une combinaison de stratégies de TC peut être employée selon les contextes d’intervention pour faciliter l’accès à des services. Peu d’études répertoriées ont identifié des conditions favorables à la prise de décision et au travail interdisciplinaire pour les TCA. L’article propose des pistes de réflexion et d’action pour favoriser l’utilisation par les intervenants tout en tenant compte des défis associés à l’intervention en TCA. Le second article évalue les retombées d’une formation visant l’utilisation de pratiques de dépistage et de référence par des intervenants québécois. Les résultats démontrent une utilisation instrumentale, conceptuelle et persuasive des connaissances par les intervenants et identifie des conditions susceptibles d’influencer cette utilisation. Cette thèse contribue à l’avancement des connaissances en proposant différentes pistes pour faciliter l’utilisation de pratiques fondées sur des données probantes par les cliniciens tout au long du processus de prise de décision clinique. / Despite considerable recent advances in the field of eating disorders (ED) prevention and intervention, access to quality care is limited because: 1) stigma associated with certain ED characteristics can lead to EDs’ going undiagnosed and untreated; 2) healthcare professionals do not always apply available evidence-based practices; and 3) given that knowledge on evidence-based practices is currently disseminated primarily in graduate programs, there are not enough clinicians trained in ED intervention. Thus, the study of knowledge transfer (KT) is vital to facilitate uptake of evidence-based practices by healthcare professionals. The aim of the present thesis is to better understand the research–practice gap in the field of ED with a view to improving access to evidence-based treatment. More specifically, the aim of this thesis is to document outcomes of KT strategies (e.g. educational materials, clinical guidelines, training workshops, supervision) and conditions influencing healthcare professionals’ evidence-based practices. Potential applications for Quebec’s intervention context are also of interest. The thesis consists of two articles and a discussion of main results. The first article documents, in a systematic review, the effects of available KT strategies and conditions influencing evidence-based practices of healthcare professionals and ED treatment teams. The findings suggest a combination of KT strategies might facilitate access to care. Articles reporting conditions that might support decision-making or interdisciplinary work were rare. In light of known challenges in ED intervention and the findings of this review, recommendations are presented to improve evidence uptake. The second article evaluates the impact of a training workshop on ED screening and referral practices by healthcare providers in Quebec’s first-line services. Results indicate that healthcare professionals used evidence- based knowledge in diverse ways (instrumental, conceptual and persuasive use) and under different conditions. This thesis furthers knowledge by identifying relevant strategies for facilitating healthcare professionals’ uptake of evidence-based practices throughout their decision-making processes.