A comparison of rural Australian First Nations and Non-First Nations survey responses to COVID-19 risks and impacts: implications for health communications.

INTRODUCTION: This study investigated differences between rural Australian First Nations and non-First Nations survey respondents' perceptions of COVID-19-related risks and analysed other variables that could predict an exacerbation of anxiety related to COVID-19 harms. METHODS: A cross-sectional online and paper survey of rural residents from the western regions of NSW, Australia, was conducted. Descriptive and multivariate statistical analyses were used to assess links between First Nations status and demographic measures including postcode, age, gender, education, rural or town/village location, proximity to medical services and living situation. The analysis included five items related to perceptions about COVID-19: perceived likelihood of contracting COVID-19 in the next 12 months, perceived harmfulness of the virus, how often people felt afraid, perception about respondents' ability to do something about the virus and perceived economic impacts of the pandemic. RESULTS: There were significant differences between First Nations (n=60) and non-First Nations (n= 639) respondents across all sociodemographic categories. The results reflect a significantly higher level of anxiety among the First Nations Australians in the sample: they felt afraid more often, felt it was highly likely they would catch the virus and if they did catch the virus perceived that it would be very harmful. Living with children under eighteen years of age and in small rural towns were key factors linked to feeling afraid of COVID-19 and First Nations status. CONCLUSION: Health risk communication in pandemic response should include an equitable focus on rural areas, recognising that First Nations Australians are a significant proportion of the rural population with different risk factors and concerns than those of non-First Nations Australians. This principle of First Nations-led design is critical to all health policy and planning. The Australian Government should include rural areas in planning pandemic responses, recognising that First Nations populations are a significant proportion of the rural population creating syndemic conditions.

Private Well Testing in Peri-Urban African-American Communities Lacking Access to Regulated Municipal Drinking Water: A Mental Models Approach to Risk Communication.

Majority African-American neighborhoods on the edges of North Carolina municipalities are less likely than white peri-urban neighborhoods to be served by a community system regulated under the Safe Drinking Water Act. These households rely on unregulated private wells, which are at much higher risk of contamination than neighboring community water supplies. Yet, risk awareness of consuming well water is low, and no prior research has tested risk communication interventions for these communities. We present a randomized-controlled trial of an oversized postcard to promote water testing among this audience. The postcard design followed the mental models approach to risk communication. To our knowledge, this is the first U.S. randomized-controlled trial of a mailed communication to promote water testing in any audience and one of few trials of the mental models approach. We evaluated the postcard's effects on self-reported water testing with and without a free water test offer (vs. no-intervention control) via a survey mailed one month after the interventions. The combined communication and free test doubled the odds of self-reported water testing, compared to the control group (p = 0.046). It increased the odds of testing by 65%, compared to the free test alone. Recall of receiving a postcard about water testing increased the odds of self-reported testing twelve-fold (p < 0.001). Although these results suggest that targeted risk information delivered by mail can promote water testing when paired with a free test, the mechanism remains unclear. Additional research on beliefs influencing perceptions about well water may yield interventions that are even more effective.

Contested solidarity and vulnerability in social media-based public responses to COVID-19 policies of mobility restrictions in Singapore: a qualitative analysis of temporal evolution.

BACKGROUND: Mobility restriction is the most effective measure to control the spread of infectious disease at its early stage, especially if a cure and vaccine are not available. When control of the coronavirus disease 2019 (COVID-19) required strong precautionary measures, lockdowns were necessarily implemented in countries around the globe. Public health risk communication about the justification and scope of a lockdown was challenging as it involved a conflict between solidarity and individual liberty and a trade-off between various values across groups with different socioeconomic statuses. In the study, we examined public responses to the government-announced "circuit breaker" (a local term for lockdown) at four-time points in Singapore: (1) entry, (2) extension, (3) exit of lockdown 'phase 1' and (4) entry of lockdown 'phase 2'. METHODS: We randomly collected 100 comments from the relevant articles on new organisations' Facebook and Instagram pages and conducted preliminary coding. Later, additional random 20 comments were collected to check the data saturation. Content analysis was focused on identifying themes that emerged from the responses across the four-time points. RESULTS: At the entry, public support for the lockdown was prevalent; yet most responses were abstract with uncertainty. At six weeks of lockdown, initial public responses with uncertainty turned into salient narratives of their lived experiences and hardship with lockdown and unmasking of societal weaknesses caused by COVID-19. At the entry to phase 2, responses were centred on social-economic impact, disparity, and lockdown burnout with the contested notion of continuing solidarity. A temporal pattern was seen in the rationalisation of the lockdown experience from trust, anxiety, attribution of pandemic and lockdown, blaming of non-compliant behaviours, and confusion. CONCLUSIONS: The findings indicated a temporal evolution of public responses from solidarity, attribution of the sustained pandemic, increasing ambiguity towards strong precautionary measures, concerns about economic hardship and mental well-being to worsened social vulnerability, where the government's restrictive policies were questioned with anxiety and confusion. Public health risk communication in response to COVID-19 should be transparent and address health equity and social justice to enhance individual and collective responsibility in protecting the public from the pandemic.

Developing oral health risk assessment as routine practice during early stages of clinical careers: A cross-sectional study of dental students using the NoMAD questionnaire.

BACKGROUND: Effective implementation of healthcare initiatives is of key importance for ensuring high-quality clinical and health outcomes. Using Normalization Process Theory, this study investigates the implementation behaviour of dental students in relation to a novel oral health risk assessment tool. It considers the impact of advancing learning on normalisation of innovative healthcare practice. METHODS: Students completed the NoMAD (normalisation of complex interventions-measure development) questionnaire and an additional scale to assess perceived value of the oral health risk assessment tool, after having used the tool for nearly one academic year. The sample comprised third- (n = 75), fourth- (n = 77) and fifth-year (n = 37) students. Differences between groups in relation to the four generative processes of normalisation were analysed using ANOVA. Cohen's d effect sizes were calculated between groups. Multiple linear regression was undertaken to investigate the impact of normalisation level on value/utility judgements. RESULTS: There were significant group differences for three of the four generative processes of normalisation (coherence, cognitive participation and reflexive monitoring). Third- and fourth-year students were highly similar but these groups showed lower normalisation compared to fifth years. Normalisation assessment predicted perceived value and utility of the oral health risk assessment tool. CONCLUSIONS: The findings suggest that dental students show lower normalisation of novel tools at earlier stages in their course, possibly due to increased cognitive load, and that perceived value and utility of a novel tool is related to increased normalisation.

Collaborative accountability for sustainable public health: A Korean perspective on the effective use of ICT-based health risk communication.

The sustainability of public health practices requires collaboration between the government and its citizens. On the government's side, social media can provide a conduit for communicating health risk information in an effective and timely fashion, while also engaging citizens in informed decision-making. On the citizen's side, information communication technology (ICT)-based practices cannot function unless citizens recognize and act on their responsibility to actively engage with government social media platforms. Despite an increasing interest in understanding the adoption of ICT practices and e-government services for health risk communication, there remains a crucial need for a comprehensive framework to explain which factors determine citizen use of digital government resources. The purpose of this study is to investigate how to increase government accountability for motivating citizens to engage in ICT-based health risk communication, thereby attaining sustainable public health practices through collaborative governance. By integrating trust and health risk information into the e-government adoption model (GAM), this research examines factors that influence citizens' likelihood of using government social media resources. Survey data from 700 Korean citizens were analyzed using structural equation modeling. The results indicated that individuals with higher social media competency are more likely to (a) seek risk information through social media and (b) perceive the government's social media sites as easy to use. Consistent with the GAM, intentions to use the government's social media sites for information and interactions appear to increase as citizens perceive more value in using them regarding information quality, ease of use, functional benefit, and security. Furthermore, perceived trust in the government's social media resources appears to function as a mediator of this process. Initial trust in the government is an important determinant of perceptions of its digital resources. Citizens who trust the government tend to evaluate new initiatives positively and are more likely to accept and make use of them. The results of this study can inform policy design and implementation by elucidating the mechanisms that determine citizens' adoption and usage of digital government services. Theoretically, this work expands the GAM to include health risk communication and adds empirical evidence to the small yet growing body of knowledge of e-government initiatives. These findings also highlight the importance of public trust in the government, as this encourages citizens to seek health risk information and assistance from the government. Overall, the data and model generated in this investigation represent an important step toward the successful and sustainable modernization of public services.

Why COVID-19 Symptomatic Patients Did Not Seek Healthcare Service at the Early Phase of the Pandemic in Bangladesh: Evidence From a Cross-Sectional Study.

Objective The health-seeking behavior (HSB) of patients during an outbreak is crucial in mitigating the spread of disease. Poor HSB can increase mortality and make contact tracing more difficult. In this study, we aimed to examine the status of HSB among Bangladeshi educated individuals during the early phase of the COVID-19 pandemic when infection was spreading quickly, and social distancing measures were tightened across the country. Methods We conducted a cross-sectional survey online among Bangladeshi individuals using a virtual snowball sampling method to capture suspected COVID-19 patients who did not undergo COVID-19 diagnostic testing. Descriptive and inferential analyses were performed with statistical significance defined as p<0.05. Results The study consisted of 390 participants with 44.9% having a bachelor's degree, followed by 25.9% with a master's or PhD degree. Commonly reported symptoms among the participants included fever (77.7%), cough (50.5%), headache (46.2%), body pain (36.4%), sore throat (35.6%), anosmia (31.3%), anorexia (13.8%), diarrhea (11.4%), and dyspnea (11.3%). The most common reasons for not taking the COVID-19 test were limited testing facilities (48%), the risk of infection from the test center (46%), fear of social stigma (19%), considering COVID-19 infection as innocuous (18%), and fear of forced quarantine (5%). In regression analysis, participants who lived in rural areas were found to be 2.5 times more likely to buy medications from nearby pharmacies. Males were more likely to self-medicate, with male participants being 3.2 times more likely than female participants to consider COVID-19 infection as harmless (AOR: 3.2, CI: 1.28-7.98). Smokers were more likely to seek help from government hotlines and to use drugs at home. Respondents with higher monthly income were less likely to fear forced quarantine (AOR: 0.27, CI: 0.4-2.02) but more likely to consider the risk of infection at the test center (AOR: 1.75, CI: 0.88-3.49). Conclusion Our study highlights that non-compliance with public health guidelines by educated people during an epidemic indicates a general lack of health literacy and distrust in the healthcare system. Along with improved infrastructure, efforts to enhance public health risk communication and health literacy are necessary to rebuild public trust in the healthcare service.

Developing and validating intracity spatiotemporal air quality health index in eastern China.

BACKGROUND: Recently pilot published city-level air quality health index (AQHI) provides a useful tool for communicating short-term health risks of ambient air pollution, but fails to account for intracity spatial heterogeneity in exposure and associated population health impacts. This study aims to develop the intracity spatiotemporal AQHI (ST-AQHI) via refined air pollution-related health risk assessments. METHODS: A three-stage analysis was conducted through integrating province-wide death surveillance data and high-resolution gridded estimates of air pollution and climate factors spanning 2016-2019 in Jiangsu Province, eastern China. First, an individual-level case-crossover design was employed to quantify the short-term risk of nonaccidental mortality associated with residential exposure to individual pollutant (i.e., PM2.5, NO2, O3, and SO2). Second, we accumulated and scaled the excess risks arising from multiple pollutants to formulate daily gridded ST-AQHI estimates at 0.1° × 0.1°, dividing exposure-related risks into low (0-3), moderate (4-6), high (7-9), and extreme high (10+) levels. Finally, the effectiveness of ST-AQHI as composite risk communication was validated through checking the dose-response associations of individual ST-AQHI exposure with deaths from nonaccidental and major cardiopulmonary causes via repeating case-crossover analyses. RESULTS: We analyzed a total of 1,905,209 nonaccidental death cases, comprising 785,567 from circulatory diseases and 247,336 from respiratory diseases. In the first-stage analysis, for each 10-µg/m3 rise in PM2.5, NO2, O3, and SO2 exposure at lag-01 day, population risk of nonaccidental death was increased by 0.8% (95% confidence interval: 0.7%, 0.9%), 1.9% (1.7%, 2.0%), 0.4% (0.3%, 0.5%), and 4.1% (3.7%, 4.5%), respectively. Spatiotemporal distribution of ST-AQHI exhibited a consistent declining trend throughout the study period (2016-2019), with annual average ST-AQHI decreasing from 5.2 ± 1.3 to 4.0 ± 1.0 and high-risk days dropping from 15.8% (58 days) to 1.6% (6 days). Exposure associated health risks showed great intracity- and between-city heterogeneities. In the validation analysis, ST-AQHI demonstrated approximately linear, threshold-free associations with multiple death events from nonaccidental and major cardiopulmonary causes, suggesting excellent performance in predicting exposure-related health risks. Specifically, each 1-unit rise in ST-AQHI was significantly associated with an excess risk of 2.0% (1.8%, 2.1%) for nonaccidental mortality, 2.3% (2.1%, 2.6%) for overall circulatory mortality, and 2.7% (2.3%, 3.1%) for overall respiratory mortality, as well as 1.7%-3.0% for major cardiopulmonary sub-causes. CONCLUSIONS: ST-AQHI developed in this study performed well in predicting intracity spatiotemporal heterogeneity of death risks related to multiple air pollutants, and may hold significant practical importance in communicating air pollution-related health risks to the public at the community scales.

Adoption intention of e-government application for public health risk communication: Risk information, social media competence and trust in the government.

Backgrounds: Effective risk communication depends on the government's ability to deploy the latest communication technologies to promptly educate its citizens of new hazards and assist them in making informed decisions. This study investigates the influence of risk information seeking, social media competency and trust in the government on the intention to adopt e-government apps for communicating public health risks. Design and methods: To achieve the study's objective, a convenience sample of 149 Malaysian residents residing in Shah Alam was obtained via a structured questionnaire and subsequently analyzed using the Partial Least Squares-Structural Equation Method. The validity and reliability of the study were evaluated through the outer loadings, Average Variance Extracted (AVE), and Composite Reliability (CR). The influence of underlying factors on the outcome was evaluated by examining path coefficients, standard errors, and t-values. Results: The measurement model suggested to use three items to measure the risk information seeking and five to measure trust in the government information and social competence. Loadings ranged from 0.681 to 0.972. The three factors explained the 43.2% of the outcome variability, and all had a positive effect on the intention to adopt information from the e-government application with coefficients estimates ranging from 0.133 to 0.541. The model showed an adequate predictive relevance with Q2 = 0.381. Conclusion: Public health risk communication via e-government applications rely on the active and accountable engagement of the citizens. To stimulate higher acceptance and utilization of government digital services for sustainable health risk communication and management, the government must raise the public's level of digital literacy and proficiency. By offering training programs and demonstrations, the government may also need to think about making investments in education about digital and technological skill levels.

REACH Worker Exposure Assessments: Ensuring Meaningful Health Risk Communication.

OBJECTIVES: Within the chemical legislation, REACH was implemented in order to improve safe working conditions with hazardous substances. Literature and real-life experiences by those concerned have shown that there are still gaps with a need for improved risk communication. This study elaborated on how information provided by REACH is understood and acted on by down- and upstream users, and how it can be further improved. METHODS: An extensive literature study including 21 studies and 13 tools was carried out. The outcomes were discussed and further supplemented by means of 18 interviews concerning 37 internal safety and REACH documents to build six different use cases representing different Dutch downstream companies. For the upstream perspective also 2 sector organizations and 2 registrants were interviewed. Three online workshops were organized in order to share insights and gather input on international recognition, potential suggestions and further recommendations with 30 participants from nine different EU countries. RESULTS: Although the methods to collect the data differed between the different stages of the study, the general results from all three stages elucidated similar themes in the data and each of the stages used the results from the previous stage as a starting point. Recurring themes concerned the (i) complexity of documents, (ii) deficiencies as experienced by SMEs in REACH, (iii) feedback and responsibilities in the supply chain, and (iv) the cooperation between REACH and OSH. DISCUSSION: The study at hand revealed that even though there are currently several activities to improve communication on safe-use of chemicals, communication on safe-use in the scope of REACH should be improved. This includes e.g. the future involvement of actual end-users in activities and development related to communication of safe-use information in the scope of REACH including feedback, less complicated and complex documents and clear communication concerning legislations and updates of documents. Furthermore, the issues recognized in the Netherlands are mostly also recognized by international workshop participants, thereby indicating international benefits in various areas by means of improved communication. CONCLUSIONS: The study confirmed that many of our generic conclusions were already part of the shared knowledge in the REACH community, but that it is very valuable that this knowledge has been explicated, validated and reported in a structured way in the present project. Besides uncovering some crucial aspects that offer potential improvements regarding risk communication, this study offers possible solutions and next steps to be taken.

Initial Stage of the COVID-19 Pandemic: A Perspective on Health Risk Communications in the Restaurant Industry.

Restaurant online review websites have made changes to adapt to customers' shifting needs during the COVID-19 crisis. Based on information behavior theory and social penetration theory, the present study investigated the changes in customers' emotions and how the volume of online reviews as an indication of sales is impacted by the instructional (i.e., with quantitative variables) and emotional (i.e., with qualitative variables) information on review websites. By comparing the same month (January-April) during 2017-2020, positive sentiment experienced a plunge, while negative sentiment showed an upsurge in April 2020. The volume of reviews was impacted by five quantitative variables (i.e., confirmed COVID-19 case number, food delivery option, takeout option, delivery fee, and delivery time) and seven qualitative variables (i.e., anticipation, fear, trust, anger, disgust, joy, and sadness). This study provides new insight into understanding information content on review websites during the crisis (e.g., pandemic) from the perspective of health risk communication.

FishChoice 2.0: Information on health benefits / risks and sustainability for seafood consumers.

Since seafood is a significant source of nutrients with known health benefits, its consumption is promoted as a healthy food choice. However, seafood can also contain potentially hazardous environmental pollutants. In the context of the ECsafeSEAFOOD FP7 project, FishChoice (www.fishchoice.eu) was developed as a communication tool to help to the consumers to take the most appropriate decisions on their seafood consumption habits. FishChoice relies on scientific information that allows calculating, on an individual basis, intakes of nutrients and pollutants derived from seafood consumption. In the framework of the EU-H2020 funded SEAFOODTOMORROW project, an optimized version of the online tool has been released. FishChoice is available in 25 EU languages with a customized list of seafood species per EU country, considering specific (national) consumption habits. The list of nutrients has been extended according to the latest EFSA recommendations, while pollutants data incorporate results from recent studies. The sustainability of seafood consumption has been also implemented, providing recommendations to help preserve the marine environment. Finally, FishChoice is suitable not only for consumers, but also health professionals, schools and academia, as well as the industrial sector and public health providers.

"I Just Want Some Clear Answers": Challenges and Tactics Adopted by Migrants in Denmark When Accessing Health Risk Information about COVID-19.

Health risk communication plays a crucial role in preventing the spread of infectious disease outbreaks such as the current coronavirus (SARS-CoV-2). Yet, migrants are far too often forgotten in health risk communication responses. We investigate the challenges and efforts made by migrants in Denmark-in the initial months of the pandemic-to access information about COVID-19. We draw on 18 semi-structured interviews conducted in May and June 2020. All interviews are thematically coded and analyzed. Our analysis reveals that many of the migrants faced several challenges, including accessing information in a language understandable to them and navigating constant streams of official news flows issuing instructions about which actions to take. However, we also note that the participating migrants found numerous creative ways to address some of these challenges, often aided by digital tools, helping them access crucial health and risk information. This paper highlights that migrants constitute an underserved group in times of crises. They are vulnerable to getting left behind in pandemic communication responses. However, we also identify key protective factors, social resources, and agentic capabilities, which help them cope with health and risk information deficits. National governments need to take heed of these findings to inform future pandemic responses.

Communicating radiation risks to the residents of the Chernobyl-affected areas in Russia: key lessons learned.

This paper does not necessarily reflect the views of the International Commission on Radiological Protection.This article analyses the communication experiences of radiation protection experts at federal/regional and local level. Efforts to justify protective measures were more successful at federal level, while the task of adjusting risk perception among local residents remains unresolved. At the recovery stage (15 years after the accident at Chernobyl nuclear power plant), the main difficulties were associated with the fact that expert knowledge was in conflict with public perception of the risk of low doses and legislative approaches. In these situations, communication success depends directly on an expert's personality. When large areas are affected, the efforts of a few dedicated experts are clearly not sufficient. More systematic approaches (training of doctors, teachers, etc.) require governmental support and experienced personnel. Federal authorities had changed their attitudes by the 15th anniversary of the accident. However, at regional level, this process stretched out for another 15 years. Public perception of large-scale health consequences still persists. Examples and survey results are presented in this article.

A deep learning approach to identify smoke plumes in satellite imagery in near-real time for health risk communication.

BACKGROUND: Wildland fire (wildfire; bushfire) pollution contributes to poor air quality, a risk factor for premature death. The frequency and intensity of wildfires are expected to increase; improved tools for estimating exposure to fire smoke are vital. New-generation satellite-based sensors produce high-resolution spectral images, providing real-time information of surface features during wildfire episodes. Because of the vast size of such data, new automated methods for processing information are required. OBJECTIVE: We present a deep fully convolutional neural network (FCN) for predicting fire smoke in satellite imagery in near-real time (NRT). METHODS: The FCN identifies fire smoke using output from operational smoke identification methods as training data, leveraging validated smoke products in a framework that can be operationalized in NRT. We demonstrate this for a fire episode in Australia; the algorithm is applicable to any geographic region. RESULTS: The algorithm has high classification accuracy (99.5% of pixels correctly classified on average) and precision (average intersection over union = 57.6%). SIGNIFICANCE: The FCN algorithm has high potential as an exposure-assessment tool, capable of providing critical information to fire managers, health and environmental agencies, and the general public to prevent the health risks associated with exposure to hazardous smoke from wildland fires in NRT.

An Analysis of Government Communication in the United States During the COVID-19 Pandemic: Recommendations for Effective Government Health Risk Communication.

Governments throughout the world can learn many critical lessons from examining instances of ineffective communication with the public during the global coronavirus disease (COVID-19) pandemic. Ineffective government communication has resulted in a great deal of public confusion and misunderstanding, as well as serious errors in responding to this evolving health threat, leading to disastrous health and social outcomes for the public and prolonging the pandemic, especially within the United States. This article uses systems theory as a template for analyzing government communication in the United States during the COVID-19 pandemic, providing governments with recommendations for establishing effective health risk communication strategies for use with the public. The communication strategies offered here promote the delivery of relevant, accurate, and sensitive information to key public groups, minimizing communication noise to guide desirable coordinated actions. These communication strategies can be applied locally, nationally, and internationally.

Consumers' acceptance of an online tool with personalized health risk-benefit communication about seafood consumption.

The importance of seafood for a healthy diet is widely recognized but concerns are raised over the risks associated with contaminants, causing a communication dilemma concerning this nutritional-toxicological conflict. Although health benefits outweigh the risks for the general population, caution is needed for vulnerable groups. Increased use of the internet for health and nutrition information grants new opportunities for online tools with tailored information. The interactive FishChoice tool, developed within EU-funded ECsafeSEAFOOD project, informs consumers on the health benefits and risks linked to their seafood consumption pattern. This study assesses the acceptance of the FishChoice tool through an online survey in five European countries, namely Belgium, Norway, Spain, Portugal and Ireland (n = 703). About two thirds of consumers agreed they would use the provided information when choosing seafood species, portion size or frequency of consumption. Heavy users of seafood had a higher intention to reuse the tool. This study provides preliminary evidence that for risk-benefit communication about seafood, online tailored tools such as FishChoice are evaluated as user-friendly and useful. Similar tools can be used in situations where no general recommendations can be made. Further research should determine the long term impact of these communication messages and tools on consumers' behavior.

Improving Heart Disease Risk Through Quality-Focused Diet Logging: Pre-Post Study of a Diet Quality Tracking App.

BACKGROUND: Diet-tracking mobile apps have gained increased interest from both academic and clinical fields. However, quantity-focused diet tracking (eg, calorie counting) can be time-consuming and tedious, leading to unsustained adoption. Diet quality-focusing on high-quality dietary patterns rather than quantifying diet into calories-has shown effectiveness in improving heart disease risk. The Healthy Heart Score (HHS) predicts 20-year cardiovascular risks based on the consumption of foods from quality-focused food categories, rather than detailed serving sizes. No studies have examined how mobile health (mHealth) apps focusing on diet quality can bring promising results in health outcomes and ease of adoption. OBJECTIVE: This study aims to design a mobile app to support the HHS-informed quality-focused dietary approach by enabling users to log simplified diet quality and view its real-time impact on future heart disease risks. Users were asked to log food categories that are the main predictors of the HHS. We measured the app's feasibility and efficacy in improving individuals' clinical and behavioral factors that affect future heart disease risks and app use. METHODS: We recruited 38 participants who were overweight or obese with high heart disease risk and who used the app for 5 weeks and measured weight, blood sugar, blood pressure, HHS, and diet score (DS)-the measurement for diet quality-at baseline and week 5 of the intervention. RESULTS: Most participants (30/38, 79%) used the app every week and showed significant improvements in DS (baseline: mean 1.31, SD 1.14; week 5: mean 2.36, SD 2.48; 2-tailed t test t29=-2.85; P=.008) and HHS (baseline: mean 22.94, SD 18.86; week 4: mean 22.15, SD 18.58; t29=2.41; P=.02) at week 5, although only 10 participants (10/38, 26%) checked their HHS risk scores more than once. Other outcomes, including weight, blood sugar, and blood pressure, did not show significant changes. CONCLUSIONS: Our study showed that our logging tool significantly improved dietary choices. Participants were not interested in seeing the HHS and perceived logging diet categories irrelevant to improving the HHS as important. We discuss the complexities of addressing health risks and quantity- versus quality-based health monitoring and incorporating secondary behavior change goals that matter to users when designing mHealth apps.

Unresolved issues in risk communication research: the case of the H1N1 pandemic (2009-2011).

The 2009 H1N1 pandemic had considerable impact on risk perceptions, vaccination campaigns, and global health governance. In this context, risk communication issues have been probably the most puzzling and the least understood in retrospect. This article reviews the current knowledge on the following issues: risk and pandemic perceptions; vaccination perceptions and practices; rumors and rumor propagation; and health risk communication. It also highlights the research gaps in these areas that remain to be further explored in the future.