京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第24290号 / 社医博第126号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 今中 雄一, 教授 西浦 博, 教授 寺田 智祐 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

This dissertation presents a body of research consisting of 5 scientific papers with an overarching objective to develop and test interventions that can enhance the dissemination, access and use of current best evidence at the point of care. Questions constantly arise from clinicians’ interactions with their patients, but more than 60% remain unanswered. The first 4 papers therefore focused on evidence dissemination to clinicians and trainees looking for answers and trying to stay alert to new evidence. We used as our “laboratory” an online tool developed at McMaster University’s Health Information Research Unit, the MacPLUS Federated Search (MacPLUS FS), which allows busy clinicians to search multiple top high quality resources simultaneously and display a 1-page output with the most clinically useful results at the top. Guided by effective models for the teaching of clinical skills at the point of care, we designed 3 web-based interventions addressing logistical and educational barriers to increase the quantity and quality of searching for current best evidence. These interventions were: (A) a web-based Clinical Questions Recorder and Reminder; (B) an Evidence Retrieval Coach composed of 8 short videos embedded in MacPLUS; (C) and a Gamified Audit & Feedback based on the allocation of “badges” and “reputation scores” for evidence searching. We tested these interventions in 4 factorial randomized-controlled trials among 1,868 heath care professionals and students currently registered in MacPLUS FS, namely: 477 medical faculty members, 431 postgraduate medical trainees, 725 nursing students and 235 medical students. Results showed that these target populations substantially differed both in their baseline frequency of search and access to alerts, as in their responsiveness to the 3 web-based interventions on evidence utilization. Evidence summaries have traditionally been tailored to meet the educational needs of clinicians, but are seldom provided in a format that supports shared decision-making. Our fifth paper explored a potential solution, which constitutes another route for evidence dissemination and use. In a project called SHARE-IT, we developed a new framework and online prototype for the generic production of decision aids, which allow physicians and patients to discuss the evidence together in the clinical encounter. We present the framework, design methods and early testing of this generic approach, which showed promising results for the translation of evidence summaries into useful tools for shared decision-making. / Thesis / Doctor of Philosophy (PhD)

Background Non-adherence to evidence based secondary prevention medicines (SPM) by coronary heart disease (CHD) patients limits their expected benefits and may result in a lack of improvement or significant deterioration in health. This study explored self-reported non-adherence to SPM, barriers to adherence, and the perception that patients in West Yorkshire have about their medicines in order to inform practice and improve adherence. Methods In this cross-sectional study a specially designed postal survey (The Heart Medicines Survey) assessed medicines-taking behaviour using the Morisky Medicines Adherence 8 items Scale (MMAS-8), a modified version of the Single Question Scale (SQ), the Adherence Estimator (AE), Beliefs about Medicines Questionnaire(BMQ) and additional questions to explore practical barriers to adherence. Patients were also asked to make any additional comments about their medicines-taking experience. A purposive sample of 696 patients with long established CHD and who were on SPM for at least 3 months was surveyed. Ethical approval was granted by the local ethics committee. Results 503 (72%) patients participated in the survey. 52%, 34% and 11% of patients were prescribed at least four, three and two SPMs respectively. The level of non-adherence to collective SPM was 44%. The AE predicted that 39% of those had an element of intentional non-adherence. The contribution of aspirin, statins, clopidogrel, beta blockers, angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) to overall non-adherence as identified by the SQ scale was 62%, 67%, 7%, 30%, 22% and 5%, respectively. A logistic regression model for overall non-adherence revealed that older age and female gender were associated with less non-adherence (OR = 0.96, 95% CI: 0.94, 0.98; OR = 0.56, 95% CI: 0.34, 0.93; respectively). Specific concern about SPM, having issues with repeat prescriptions and aspirin were associated with more non-adherence (OR = 1.12, 95% CI: 1.07, 1.18; OR = 2.48, 95% CI: 1.26, 4.90, OR = 2.22, 95% CI: 1.18, 4.17). Other variables were associated with intentional and non-intentional non-adherence. 221 (44%) patients elaborated on their medicines-taking behaviour by providing additional comments about the need for patient tailored information and better structured medicines reviews. Conclusions The Medicines Heart Survey was successful in revealing the prevalence of self-reported non-adherence and barriers to adherence in our population. Healthcare professionals should examine specific modifiable barriers to adherence in their population before developing interventions to improve adherence. Conducting frequent structured medicines-reviews, which explore and address patients' concerns about their medicines and healthcare services, and enable them to make suggestions, will better inform practice and may improve adherence.

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In the setting of the health care field, multiple decisions must be made on each patient’s care from a variety of viewpoints on the medical team. In these settings, Interprofessional Decision Making is becoming a tool that can incorporate shared decision making with the patients and multiple care team members’ goals in order to optimize and keep an ethical focus on clinical outcomes. By reviewing a patient case below and evaluating the body of literature at the present, it can be determined that a disassembly of the current medical hierarchical structure and the barriers to team based interaction it creates, with a move toward open and ethical interactions, collaborations, and discussions will result in shared consensus on a patients management and care. While this may be difficult to achieve, interventions such as multidisciplinary team building and medical training, prior to matriculation, may provide a foundation for improved Interprofessional Decision Making and overall collaboration. / Urban Bioethics

A main challenge in medicine concerns questions of how to integrate the context and values of patient perspectives with general conceptions of illness and treatment. With medicine increasingly focused on patient-centered and individualized care, approaches to medicine must find ways to gain access to and understand the patient in such a way that recognizes her story as real while at the same time maintaining the value of medicine as an objective practice. Adding to this is the reality that under current models of medicine and decision-making in medicine, healthcare disparities persist for persons belonging to marginalized and vulnerable populations, including racial and ethnic minorities, women, and LGBTQ persons, amongst others. I argue that an approach integrative of shared decision-making built upon a phenomenological framework is a good alternative on which to try and understand questions like these and begin to address disparities in healthcare. / Urban Bioethics

With the advent of the No Child Left Behind legislation and the culture of standards-based education that it brings, it is imperative for educators to focus on the academic growth of students. Indeed, the nation's schools, school districts, and states are being held accountable for student achievement. Administrators in numerous school districts across the United States have implemented a popular reform initiative, Site-Based Management SBM), to improve student achievement. District leaders must examine the efficacy of SBM, where the authority, autonomy, and responsibility for student learning are devolved to the school level, to ensure that SBM is yielding intended results and to ensure fidelity of its implementation. This study examined principal perceptions and implementation of SBM in the Prince William County School District in Virginia after 19 years of implementation. The investigator administered an SBM survey to a population of all 86 principals in the school district. Of those, 78 completed at least part of the survey, for a return rate of 91%. The study focused on the perceptions of principals under SBM and their implementation of SBM as defined by the functions of the School Advisory Council and the shared decision-making processes used at the school level. Variables of the study were principals' years of experience with SBM and the grade level at which they work. Principals reported positive perceptions of SBM, in particular, the perception that SBM contributes to improvements in student achievement and to a climate of enhanced stakeholder satisfaction. A third of the principals indicated that SBM requires principals to spend too much time on administrative tasks. Principals with more than 10 years of experience reported more positive perceptions than principals with zero to three years experience with SBM. Principals reported that School Advisory Councils spend the most time developing, monitoring, and evaluating the school plan. Principals' years of experience with SBM were not related to the functions of their School Advisory Council, but principals with more than ten years of experience with SBM indicated a significantly higher use of consensus as a shared decision-making process. No significant relationship was found between the school level at which principals work and their perceptions of SBM. While not significant, middle school principals rated the School Advisory Council function of aligning the school budget with the school plan slightly higher than principals at other levels. There was no relationship between principals' school level and their use of shared decision-making processes. Principals reported strengths of SBM to be autonomy in making instructional decisions; flexibility with budget; building teacher leaders; and shared decision making. Challenges to the successful implementation of SBM were budget issues; too much time away from instructional focus; and the need for ongoing training. / Ed. D.

Site-based management (SBM) is a strategy that involves the decentralization of authority, and shared decision-making (SDM) among those involved. It is based on the assumption that education will improve when those closest to the situation are included in the decision-making process, and held accountable for their decisions. This study describes the status of SBM/SDM in the public secondary schools of Virginia in regards to teacher and principal participation, size of secondary school, and geographic location. The study collected data from all public secondary school principals in Virginia, and from randomly selected secondary level teachers in order to answer the following six research questions: 1. What kinds of decisions are made at the school level in the areas of personnel, budget, curriculum and instruction, and policy? 2. According to the building administrators, what is the degree of their participation in the decision-making process at the school level? 3. According to the teachers, what is the degree of their participation in the decision-making process at the school level? 4. Is there a difference between the size of the secondary school and the status of site-based management? 5. Is there a difference between the geographic location of the secondary school and the status of site-based management? 6. Is the practice of site-based management in the public secondary schools of Virginia based upon written School Board policy? Major findings revealed that SBM is occurring in the public secondary schools of Virginia. SDM has emerged in the public secondary schools of Virginia, but not to the same extent as SBM, in regards to most decision-making areas. SBM appears to be in existence without the direction of written School Board policy. This study, a collaborative venture between two doctoral students, also discusses the process of collaboration that was utilized in this endeavor. / Ed. D.

Leadership in modern-day schools is changing. School leaders are expected to oversee the physical plant and school finances, as well as to be the instructional leader, personnel officer, public relations specialist, and point person for the accountability efforts at all governmental levels. Principals cannot be experts in every area of school administration; thus, they are more dependent on other members of the educational team. The purpose of this study was to develop and implement a form of shared leadership in an elementary school known as an intelligent hierarchy, to test whether such a model affects the distribution of decision-making, climate, and morale within the school (Leithwood & Mascall, 2008). This was a mixed-methods, action-research project in which the principal of the school served as a participant observer. A leadership team was formed consisting of the principal, teachers, support staff, and parents to aid in the decision-making process. Qualitative data were collected in the form of minutes of leadership team meetings, journal entries by the principal, and minutes of meetings with individual teachers. A modified version of the constant comparative method (Maykut & Morehouse,1994) was used to analyze the qualitative data. Quantitative data were collected with questionnaires administered three times each throughout the course of the study. Data were collected on shared leadership, the distribution of decisions, school climate, and teacher morale. The implementation of the hybrid model of shared leadership led to improvement in the areas of shared leadership, shared decision-making, and employee morale. Improvement was evident in some areas of school climate. The result is a model administrators could implement, either in whole or in part, to track the implementation of shared leadership in their schools. / Ed. D.