"There's a little bit of mistrust": Red River Métis experiences of the H1N1 and COVID-19 pandemics.

We examined the perspectives of the Red River Métis citizens in Manitoba, Canada, during the H1N1 and COVID-19 pandemics and how they interpreted the communication of government/health authorities' risk management decisions. For Indigenous populations, pandemic response strategies play out within the context of ongoing colonial relationships with government institutions characterized by significant distrust. A crucial difference between the two pandemics was that the Métis in Manitoba were prioritized for early vaccine access during H1N1 but not for COVID-19. Data collection involved 17 focus groups with Métis citizens following the H1N1 outbreak and 17 focus groups during the COVID-19 pandemic. Métis prioritization during H1N1 was met with some apprehension and fear that Indigenous Peoples were vaccine-safety test subjects before population-wide distribution occurred. By contrast, as one of Canada's three recognized Indigenous nations, the non-prioritization of the Métis during COVID-19 was viewed as an egregious sign of disrespect and indifference. Our research demonstrates that both reactions were situated within claims that the government does not care about the Métis, referencing past and ongoing colonial motivations. Government and health institutions must anticipate this overarching colonial context when making and communicating risk management decisions with Indigenous Peoples. In this vein, government authorities must work toward a praxis of decolonization in these relationships, including, for example, working in partnership with Indigenous nations to engage in collaborative risk mitigation and communication that meets the unique needs of Indigenous populations and limits the potential for less benign-though understandable-interpretations.

Newcomer knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination.

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually transmitted infection in Canada and around the world. Vaccination is an effective prevention strategy, but uptake is low, especially among newcomers to Canada. We sought to understand newcomers' knowledge, attitudes, and beliefs (KAB) on HPV and HPV vaccination and their role in HPV vaccine acceptance. METHODS: Newcomers were defined as individuals born outside Canada, (i.e., individuals born in a different country, the majority of whom are immigrants or refugees, but also includes students and undocumented migrants). Eligible participants were newcomers, aged 16 or older and who could read or write in English, French or Arabic. Surveys were administered in two community health centres in Ottawa, Canada that primarily engage with newcomer populations. Follow-up interviews were conducted either at the community health centre or over the phone, depending on participants' preferences. RESULTS: Fifty participants completed the survey, the majority of whom were women (74%) and spoke Arabic as their first language (54%). Seven participants completed supplemental interviews to complement their survey responses. The majority (70%) of participants had not previously heard of HPV. Less than half (46%) knew that the vaccine is effective in preventing certain types of cancer; nearly 40% incorrectly believed the vaccine could cure HPV. Qualitative interviews supported the survey findings. CONCLUSIONS: Despite a lack of HPV knowledge due to cultural and language barriers, there is still a strong desire among newcomers to receive the vaccine, especially when accompanied by a physician recommendation. Cultural and language-appropriate resources are needed to help newcomers make informed vaccination decisions and promote HPV vaccine uptake.

Factors influencing H1N1 vaccine behavior among Manitoba Metis in Canada: a qualitative study.

BACKGROUND: During the first wave of the H1N1 influenza pandemic in 2009, Aboriginal populations in Canada experienced disproportionate rates of infection, particularly in the province of Manitoba. To protect those thought to be most at-risk, health authorities in Manitoba listed all Aboriginal people, including Metis, among those able to receive priority access to the novel vaccine when it first became available. Currently, no studies exist that have investigated the attitudes, influences, and vaccine behaviors among Aboriginal communities in Canada. This paper is the first to systematically connect vaccine behavior with the attitudes and beliefs that influenced Metis study participants' H1N1 vaccine decision-making. METHODS: Researchers held focus groups (n = 17) with Metis participants in urban, rural, and remote locations of Manitoba following the conclusion of the H1N1 pandemic. Participants were asked about their vaccination decisions and about the factors that influenced their decisions. Following data collection, responses were coded into the broad categories of a social-ecological model, nuanced by categories stemming from earlier research. Responses were then quantified to show the most influential factors in positively or negatively affecting the vaccine decision. RESULTS: Media reporting, the influence of peer groups, and prioritization all had positive and negative influential effects on decision making. Whether vaccinated or not, the most negatively influential factors cited by participants were a lack of knowledge about the vaccine and the pandemic as well as concerns about vaccine safety. Risk of contracting H1N1 influenza was the biggest factor in positively influencing a vaccine decision, which in many cases trumped any co-existing negative influencers. CONCLUSIONS: Metis experiences of colonialism in Canada deeply affected their perceptions of the vaccine and pandemic, a context that health systems need to take into account when planning response activities in the future. Participants felt under-informed about most aspects of the vaccine and the pandemic, and many vaccine related misconceptions and fears existed. Recommendations include leveraging doctor-patient interactions as a site for sharing vaccine-related knowledge, as well as targeted, culturally-appropriate, and empowering public information strategies to supply reliable vaccine and pandemic information to potentially at-risk Aboriginal populations.

"I won't be a guinea pig": Rethinking public health communication and vaccine hesitancy in the context of COVID-19.

At the beginning of 2021, when Canada started distribution of COVID-19 vaccines, the unprecedented scope and severity of the pandemic led to very high levels of public awareness and attention, with Canadians actively seeking information. We argue that while there was continuous public health communication about COVID-19 and the newly available vaccines, these messages did not address the specific anxieties elicited by the novel vaccines, even as vaccination guidelines changed. Instead, public health messages about COVID-19 vaccines resembled those aimed at reducing vaccine hesitancy for routine immunization and did not sufficiently address the constant changes to COVID-19 vaccine recommendations. In a context of heightened public concern and significant public attention, it is crucial for communicators to acknowledge that hesitancy is vaccine-specific, and that novel diseases and new vaccines produce specific concerns. Long-term strategies should address the novelty of the technology and of the risk, thoroughly explain the reasons for shifting vaccination guidelines, and leverage trusted sources, such as community leaders. Further, as COVID-19 vaccines become less effective against some of the more recent variants of the virus, vaccine messaging needs to be tailored to evolve with shifting realities to not lose productive gains in the COVID-19 vaccination campaign to date.

Risk communication and perceptions about lead ammunition and Inuit health in Nunavik, Canada.

Lead ammunition is commonly used to hunt waterfowl and other wildlife in the Arctic. Hunting with lead is problematic because the toxicant can be transferred to the consumer. Therefore, it is critical to evaluate perceptions and awareness of the risks associated with using lead ammunition among Arctic populations. Results of the Nunavik Child Development Study (a longitudinal health study gathering information on health and well-being among Inuit in Nunavik, Canada) included advice to eliminate the use of lead ammunition in hunting practices. We surveyed 112 Nunavik residents (93 women; 18 men) about their awareness of lead related messages, use of lead ammunition and risk perceptions about contaminants. Sixty-seven participants (59.8%) reported there was an active hunter in their household. We found that only 27% of participants had heard or seen the messages about reducing lead ammunition. After participants viewed the Nunavik Child Development Study messages about lead, 44% stated they would stop using lead ammunition. However, 28% indicated that they would continue using lead ammunition. We conclude that, while messages had an overall positive effect, further study is required to understand why people continue to use lead ammunition.

When good messages go wrong: Perspectives on COVID-19 vaccines and vaccine communication from generally vaccine accepting individuals in Canada.

Vaccines are one of the most important and successful public health interventions to reduce the spread of infectious diseases. However, unlike childhood diseases and routine vaccines, COVID-19 is a novel threat, and COVID-19 vaccines may elicit specific anxieties. Through focus groups, we examine the concerns and attitudes toward the COVID-19 vaccine expressed by individuals who accept routine vaccinations in Canada. We also conducted a pre-focus group survey to document participant attitudes towards vaccines in general. While most participants had received at least one dose of the COVID-19 vaccine or had the intention to get it, many had concerns. First, participants felt anxious about the quick development and approval of the vaccines, even if they recognized that the vaccines have undergone clinical trials. Second, participants felt confused about shifting public health guidelines regarding vaccine safety, changing the interval between doses, and mixing different vaccine brands. Finally, participants said they felt abandoned when deciding whether to get vaccinated or not. People who generally accept vaccines expressed concerns about COVID-19 vaccines, mostly related to the inevitable uncertainties of a new vaccine (i.e. novelty, safety, mandates, etc.). COVID-19 vaccine hesitancy, understood as concerns about the novelty of a vaccine and the rapid implementation of it, could be useful for understanding questioning attitudes towards COVID-19 vaccines from people who accept routine vaccinations. Understanding COVID-19 vaccine hesitancy can also provide valuable insights as booster doses are periodically needed and people may not be as accepting of these additional doses.

"They're trying to bribe you and taking away your freedoms": COVID-19 vaccine hesitancy in communities with traditionally low vaccination rates.

Vaccination is an essential public health intervention to control the COVID-19 pandemic. A minority of Canadians, however, remain hesitant about COVID-19 vaccines, while others outright refuse them. We conducted focus groups to gauge perceptions and attitudes towards COVID-19 vaccines in people who live in a region with historically low rates of childhood vaccination. Participants discussed their perception of COVID-19 vaccines and their intention to get vaccinated, and the low rate of COVID-19 vaccine uptake in Manitoba's Southern Health Region compared to other regions in Canada. We identified three drivers of vaccine hesitancy: (1) risk perceptions about COVID-19 and the vaccines developed to protect against it, (2) religious and conservative views; and (3) distrust in government and science. Participant proposed recommendations for improving communication and uptake of the COVID-19 vaccines included: public health messages emphasising the benefits of vaccination; addressing the community's specific concerns and dispelling misinformation; highlighting vaccine safety; and emphasising vaccination as a desirable behaviour from a religious perspective. Understanding the specific anxieties elicited by COVID-19 vaccines in areas with low childhood immunization rates can inform risk communication strategies tailored to increase vaccination in these specific regions. This study adds important information on potential reasons for vaccine hesitancy in areas with historically low rates of childhood vaccination, and provides important lessons learned for future emergencies in terms of vaccine hesitancy drivers and effective risk communication to increase vaccine uptake.

Risk ranking: investigating expert and public differences in evaluating food safety hazards.

The allocation of resources with respect to food safety issues requires that decision makers prioritize these issues, which may conflict with the public's opinions on these matters. The purpose of this study was to compare how Canadian expert and lay respondents rank different food hazards, with a view to better understanding their underlying rationales for making decisions on food safety. A Carnegie Mellon risk ranking model was adapted for use by individuals with different backgrounds to rank six food safety issues: bovine spongiform encephalopathy (BSE), Escherichia coli O157:H7, Salmonella, botulism, paralytic shellfish poisoning (PSP), and acrylamide. Focus groups were conducted using public (n=29) and expert (n=21) participants. Key themes were identified from the focus groups as reasons why issues were rated high or low. The most common themes for high rankings were prevalence (of an agent) and/or severity (of a disease) and knowledge and control of a food safety issue. For the lowest rankings, common themes included low prevalence and severity and personal control over an issue. Explanations for why choices were made included availability, affect, numeracy, and optimistic bias. The majority of the rationales used by all participants were similar with the exception of the high ranking given to acrylamide by the public participants. The effect of attribute framing seemed to be the most influential in a participant's choices. Understanding that comparable reasoning is used in food safety decisions by both experts and the public has important implications for developing productive risk communication dialogues about issues and priorities.

Healthcare provider perspectives on the uptake of the human papillomavirus vaccine among newcomers to Canada: a qualitative study.

Human papillomavirus is among the most common sexually transmitted infections in the world. Newcomers, defined in Canada as foreign-born individuals who are either immigrants or refugees, but may also include students and undocumented migrants, face numerous barriers to HPV vaccination. This study sought to understand, from the perspective of healthcare providers, barriers and facilitators to HPV vaccination, and recommendations to improve HPV vaccine uptake among newcomers. Semi-structured interviews were conducted with 10 healthcare providers between March and April 2018. Data were analyzed at the manifest level using a Qualitative Content Analysis approach. Categories of barriers to vaccination included: access, communication, knowledge, culture, and provider-related factors. Facilitators included targeted health promotion; understanding the relevance of HPV vaccination; trusting the healthcare system; and cultural sensitivity. Two overarching recommendations were to publicly fund the HPV vaccine, and enhance language- and culturally-appropriate health promotion activities. Further research should explore informational desires and needs from the perspective of newcomers to inform strategies to promote equitable HPV vaccine coverage.

Barriers to immunization among newcomers: A systematic review.

INTRODUCTION: Currently, there is a lack of comprehensive evidence exploring vaccine decision-making among newcomers. We conducted a systematic review of qualitative studies aimed at identifying factors that influence newcomers' decision-making with regards to vaccination. METHODS: We conducted a search of MEDLINE, EMBASE, CINAHL and Cochrane Central. To be included, studies needed to employ a qualitative methodology and address newcomer attitudes, beliefs, and/or perceptions regarding vaccination. Two independent reviewers screened the articles for relevant information and applied a content analysis methodology to code the identified barriers. RESULTS: Twenty-one studies were included in this review, and four types of barriers were identified: cultural factors, knowledge barriers, insufficient access to healthcare, and vaccine hesitancy. Insufficient knowledge about vaccination and the virus being prevented and concerns about safety were the most commonly reported barriers. A sub-analysis of barriers specific to HPV indicated that cultural beliefs about sexuality and incomplete knowledge about the role of HPV in the development of cervical cancer are major barriers to vaccine uptake. CONCLUSION: Strategies to improve vaccination uptake in newcomers should consider focusing on the barriers identified in this review while taking into account the unique opportunities for promoting uptake within newcomer populations.

Partnering with Indigenous student co-researchers: improving research processes and outcomes.

OBJECTIVE: To examine the contribution of student co-researchers to a community-based participatory Photovoice investigation of Indigenous children's food-related lived experience. We examine co-researchers' contributions to the research process, their role in knowledge co-generation and dissemination, and factors that fostered research partnership with the teenage co-researchers. METHODS: High school students attending a First Nation community school in Canada were trained as research partners. They contributed to aspects of research design, conducted interviews with grades 3 and 4 Photovoice participants, and participated in data analysis and the development of a culturally relevant photobook. The study was initiated by the community's research committee. It is informed by critical consciousness theory and the positive youth development framework. RESULTS: Student co-researchers incorporated culturally appropriate strategies as they interviewed participants. Co-researchers adopted conversational approaches, built rapport by articulating personal and cultural connections, and engaged in mentoring and health promotion as they interviewed participants. They made critical contributions to dissemination by developing photobook content that promoted the importance of traditional foods and the vital role of family and community in healthy eating practices. Relationships and "dialogic" space were important to building partnership with and promoting capacity development among youth co-researchers. CONCLUSIONS: Partnership between university researchers and Indigenous student co-researchers holds great promise for health promotion in communities. Co-researchers developed research and leadership skills, gained understanding of health challenges facing their community, and initiated health and cultural promotion through the project's Photobook. This investigation supports the powerful potential of student co-researchers to meaningfully contribute to research processes and to build knowledge that is relevant and credible both within and outside of their communities. Findings have implications for youth, communities and researchers.

When pictures waste a thousand words: analysis of the 2009 H1N1 pandemic on television news.

OBJECTIVES: Effective communication by public health agencies during a pandemic promotes the adoption of recommended health behaviours. However, more information is not always the solution. Rather, attention must be paid to how information is communicated. Our study examines the television news, which combines video and audio content. We analyse (1) the content of television news about the H1N1 pandemic and vaccination campaign in Alberta, Canada; (2) the extent to which television news content conveyed key public health agency messages; (3) the extent of discrepancies in audio versus visual content. METHODS: We searched for "swine flu" and "H1N1" in local English news broadcasts from the CTV online video archive. We coded the audio and visual content of 47 news clips during the peak period of coverage from April to November 2009 and identified discrepancies between audio and visual content. RESULTS: The dominant themes on CTV news were the vaccination rollout, vaccine shortages, long line-ups (queues) at vaccination clinics and defensive responses by public health officials. There were discrepancies in the priority groups identified by the provincial health agency (Alberta Health and Wellness) and television news coverage as well as discrepancies between audio and visual content of news clips. Public health officials were presented in official settings rather than as public health practitioners. CONCLUSION: The news footage did not match the main public health messages about risk levels and priority groups. Public health agencies lost control of their message as the media focused on failures in the rollout of the vaccination campaign. Spokespeople can enhance their local credibility by emphasizing their role as public health practitioners. Public health agencies need to learn from the H1N1 pandemic so that future television communications do not add to public confusion, demonstrate bureaucratic ineffectiveness and contribute to low vaccination rates.

Understanding the interplay of factors informing vaccination behavior in three Canadian provinces.

Arguably, the two most critical components in any response to a pandemic are effective risk communication and the rapid development of a vaccine. Despite the roll-out of a publicly-funded H1N1 vaccine program across the country, less than half of all Canadians were vaccinated during the 2009-10 pandemic. Using focus group data, this study examined vaccinating behaviors, the impact of public health messaging, and the public's attitudes toward H1N1 and the H1N1 vaccine in three Canadian provinces. Drawing on vaccine risk communication literature, a framework was devised to identify and analyze the factors related to vaccine uptake and vaccine refusal. The most predictive factor for H1N1 vaccine uptake was a prior history of vaccinating against seasonal influenza. Other important factors included barriers to immunizing (access issues) and an individual's perception of serious risk from contracting H1N1. Although critical gaps in the public's understanding of influenza infections were identified, together with misinformation about vaccination effectiveness and safety, these factors were less frequently reported to be the core factors influencing an individual's decision to vaccinate.

Communicating risk to aboriginal peoples: first nations and Metis responses to H1N1 risk messages.

Developing appropriate risk messages during challenging situations like public health outbreaks is complicated. The focus of this paper is on how First Nations and Metis people in Manitoba, Canada, responded to the public health management of pandemic H1N1, using a focus group methodology (n = 23 focus groups). Focus group conversations explored participant reactions to messaging regarding the identification of H1N1 virus risk groups, the H1N1 vaccine and how priority groups to receive the vaccine were established. To better contextualize the intentions of public health professionals, key informant interviews (n = 20) were conducted with different health decision makers (e.g., public health officials, people responsible for communications, representatives from some First Nations and Metis self-governing organizations). While risk communication practice has improved, 'one size' messaging campaigns do not work effectively, particularly when communicating about who is most 'at-risk'. Public health agencies need to pay more attention to the specific socio-economic, historical and cultural contexts of First Nations and Metis citizens when planning for, communicating and managing responses associated with pandemic outbreaks to better tailor both the messages and delivery. More attention is needed to directly engage First Nations and Metis communities in the development and dissemination of risk messaging.

Risk management frameworks for human health and environmental risks.

A comprehensive analytical review of the risk assessment, risk management, and risk communication approaches currently being undertaken by key national, provincial/state, territorial, and international agencies was conducted. The information acquired for review was used to identify the differences, commonalities, strengths, and weaknesses among the various approaches, and to identify elements that should be included in an effective, current, and comprehensive approach applicable to environmental, human health and occupational health risks. More than 80 agencies, organizations, and advisory councils, encompassing more than 100 risk documents, were examined during the period from February 2000 until November 2002. An overview was made of the most important general frameworks for risk assessment, risk management, and risk communication for human health and ecological risk, and for occupational health risk. In addition, frameworks for specific applications were reviewed and summarized, including those for (1)contaminated sites; (2) northern contaminants; (3) priority substances; (4) standards development; (5) food safety; (6) medical devices; (7) prescription drug use; (8) emergency response; (9) transportation; (10) risk communication. Twelve frameworks were selected for more extensive review on the basis of representation of the areas of human health, ecological, and occupational health risk; relevance to Canadian risk management needs; representation of comprehensive and well-defined approaches; generalizability with their risk areas; representation of "state of the art" in Canada, the United States, and/or internationally; and extent of usage of potential usage within Canada. These 12 frameworks were: 1. Framework for Environmental Health Risk Management (US Presidential/Congressional Commission on Risk Assessment and Risk Management, 1997). 2. Health Risk Determination: The Challenge of Health Protection (Health and Welfare Canada, 1990). 3. Health Canada Decision-Making Framework for Identifying, Assessing and Managing Health Risks (Health Canada, 2000). 4. Canadian Environmental Protection Act: Human Health Risk Assessment of Priority Substances(Health Canada, 1994). 5. CSA-Q8550 Risk Management: Guidelines for Decision-Makers (Canada Standards Association, 1997). 6. Risk Assessment in the Federal Government: Managing the Process (US National Research Council, 1983). 7. Understanding Risk: Informing Decisions in a Democratic Society (US National Research Council, 1996). 8. Environmental Health Risk Assessment (enHealth Council of Australia, 2002). 9. A Framework for Ecological Risk Assessment (CCME, 1996). 10. Ecological Risk Assessments of Priority Substances Under the Canadian Environmental Protection Act (Environment Canada, 1996).11. Guidelines for Ecological Risk Assessment (US EPA, 1998b). 12. Proposed Model for Occupational Health Risk Assessment and Management (Rampal & Sadhra, 1999). Based on the extensive review of these frameworks, seven key elements that should be included in a comprehensive framework for human health, ecological, and occupational risk assessment and management were identified: 1. Problem formulation stage. 2. Stakeholder involvement. 3. Communication. 4. Quantitative risk assessment components. 5. Iteration and evaluation. 6. Informed decision making. 7. Flexibility. On the basis of this overarching approach to risk management, the following "checklist" to ensure a good risk management decision is proposed: - Make sure you're solving the right problem. - Consider the problem and the risk within the full context of the situation, using a broad perspective. - Acknowledge, incorporate, and balance the multiple dimensions of risk. - Ensure the highest degree of reliability for all components of the risk management process. - Involve interested and effected parties from the outset of the process. - Commit to honest and open communication between all parties. - Employ continuous evaluation throughout the process (formative, process, and outcome evaluation), and be prepared to change the decision if new information becomes available. Comprehensive and sound principles are critical to providing structure and integrity to risk management frameworks. Guiding principles are intended to provide an ethical grounding for considering the many factors involved in risk management decision making. Ten principles are proposed to guide risk management decision making. The first four principles were adapted and modified from Hattis (1996) along with the addition of two more principles by Hrudey (2000). These have been supplemented by another four principles to make the 10 presented. The principles are based in fundamental ethical principles and values. These principles are intended to be aspirational rather than prescriptive--their application requires flexibility and practical judgement. Risk management is inherently a process in search of balance among competing interests and concerns. Each risk management decision will be "balancing act" of competing priorities, and trade-offs may sometimes have to be made between seemingly conflicting principles. The 10 decision-making principles, with the corresponding ethical principle in italics are: 1. Do more good than harm (beneficence, nonmalificence).- The ultimate goal of good risk management is to prevent or minimize risk, or to "do good" as much as possible. 2. Fair process of decision making (fairness, natural justice). - Risk management must be just, equitable, impartial, unbiased, dispassionate, and objective as far as possible given the circumstances of each situation. 3. Ensure an equitable distribution of risk (equity). - An equitable process of risk management would ensure fair outcomes and equal treatment of all concerned through an equal distribution of benefits and burdens (includes the concept of distributive justice, i.e., equal opportunities for all individuals). 4. Seek optimal use of limited risk management resources (utility). - Optimal risk management demands using limited resources where they will achieve the most risk reduction of overall benefit. 5. Promise no more risk management that can be delivered (honesty).- Unrealistic expectations of risk management can be avoided with honest and candid public accounting of what we know and don't know, and what we can and can't do using risk assessment and risk management. 6. Impose no more risk that you would tolerate yourself (the Golden Rule). - The Golden Rule is important in risk management because it forces decision makers to abandon complete detachment from their decisions so they may understand the perspectives of those affected. 7. Be cautious in the face of uncertainty ("better safe than sorry"). - Risk management must adopt a cautious approach when faced with a potentially serous risk, even if the evidence is uncertain. 8. Foster informed risk decision making for all stakeholders (autonomy). - Fostering autonomous decision making involves both providing people with the opportunity to participate, and full and honest disclosure of all the information required for informed decisions. 9. Risk management processes must be flexible and evolutionary to be open to new knowledge and understanding (evolution, evaluation, iterative process). - The incorporation of new evidence requires that risk management be a flexible, evolutionary, and iterative process, and that evaluation is employed at the beginning and througthout the process. 10. the complete elimination fo risk is not possible (life is not risk free).- Risk is pervasive in our society, and cannot be totally eliminated despite an oft-expressed public desire for "zero risk". However, the level of risk that may ve tolerable by any individual is dependent on values of beliefs, as well as scientific information. Each agency must continue to employ a process that meets the needs of their specific application of risk management. A single approach cannot satisfy the diverse areas to which risk decisions are being applied. However, with increasing experience in the application of the approaches, we are evolving to a common understanding of the essential elements and principles required for successful risk assessment, risk management, and risk communication. Risk management will continue to be a balancing act of competing priorities and needs. Flexibility and good judgement are ultimately the key to successfully making appropriate risk decisions.