In Sweden during the COVID-19 pandemic the Public Health Agency of Sweden assumed the major responsibility for communication and information dissemination about the contagion, and made efforts on preventive work and the risk mitigation. To successfully mitigate the risks it is important for the Public Health Agency to be transparent in their risk communication, in order to gain and strenghten the public’s trust towards their institution, which is a prerequisite for them to be able to work efficiently in changing public behaviour in the population. This study examines what strategies the Public Health Agency of Sweden has used to create transparency within their risk communication, with the theoretical perspective of scholarly communication and information making. The study was conducted by analysing texts in the form of news articles published on the agency’s own website. The study identified eleven different strategies the agency has used in their risk communication, from referring to expert knowledge, to using a language that is accessible to the whole public.

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<p>The purpose of this dissertation was to examine the use of health risk communications as a strategy to change risk perceptions and motivate leisure time physical activity (LTPA) among people with spinal cord injury (SCI). Guided by protection motivation theory (PMT; Rogers, 1983) and the extended parallel processing model (EPPM; Witte, 1992), two strategies were examined as unique approaches to enhancing the effectiveness of health risk information. First, risk information was tailored to individualized, objective data regarding participants’ health risk. Second, risk information was supplemented with framed leisure time physical activity (LTPA) efficacy messages. Gain-framed messages emphasized the benefits of LTPA, whereas loss-framed messages emphasized the risks of inactivity. The relative effectiveness of gain- versus loss-framed messages was considered within the context of the EPPM (Witte, 1992). A secondary purpose of the dissertation was to explore cognitive processing in relation to framed LTPA messages. The attention and elaboration phases of cognitive processing were examined for gain- and loss-framed LTPA messages following exposure to health risk information. Three experiments were conducted to 1) test the effectiveness of individualized health risk information for changing health risk perceptions and LTPA among people with SCI, 2) test the relative effectiveness of gain- and loss-framed LTPA efficacy messages presented following health risk information for changing LTPA response efficacy and LTPA intentions among people with SCI, and, 3) investigate the relative attention given to gain-framed versus loss-framed LTPA response efficacy messages following presentation of health risk information to university students. The theoretical and pragmatic contributions are discussed.</p> / Doctor of Philosophy (PhD)

Pharmakodiagnostische Tests eröffnen die Möglichkeit, Krebstherapien individueller auf den Patienten zugeschnitten zu verschreiben. Die vorliegende Dissertation widmet sich deshalb der Frage, wie diese Gruppen in Deutschland sowie den USA in Bezug auf diese Tests Entscheidungen treffen. Alle im Rahmen dieser Arbeit durchgeführten Studien waren unterteilt in eine Vorstudie und eine Hauptsstudie. Die Ergebnisse der Vorstudie wurden im Rahmen der Hauptstudie zur Entwicklung eines Fall-Vignetten Fragebogens benutzt,um die Verwendung von kompensatorischen und nicht-kompensatorischen Entscheidungsstrategien zu untersuchen. Mit Studie I wurde gezeigt, dass sowohl deutsche als auch amerikanische Onkologen eine hohe Bereitschaft haben, solche Tests anzuwenden. Die entsprechenden Entscheidungen wurden am besten durch ein kompensatorisches Modell (Franklin’s Rule)vorhergesagt. Eine Leitlinien-Empfehlung führte nahezu immer zu einer Test-Entscheidung. Verschiedene Bedingungen machten eine Entscheidung für nicht-empfohlene Tests jedoch wahrscheinlicher. Studie II zeigte, dass Pathologen nur zu einem beschränkten Ausmaß bereit waren, von dem etablierten Test-Standard für neuartige Test-Prozeduren abzuweichen. Die Entscheidungsstrategie beider Gruppen wurde gleich gut durch die jeweiligen kompensatorischen Modelle (Franklin’s und Dawes’ Rule) sowie durch das nicht-kompensatorische Modell (Take The Best) vorhergesagt. Für die mit Studie III untersuchten Krebspatienten zeigte sich, dass ein nicht-kompensatorisches Modell (Matching Heuristic) die besten Entscheidungs-Vorhersagen machte.Während die Entscheidungen der US Patienten jedoch maßgeblich von einer Arzt-Empfehlung geleitet waren, fand sich dies nicht für die deutschen Patienten. Die sich aus den Befunden ergebenden Implikationen für die hier untersuchten Gruppen, für die mit der Leitlinien-Entwicklung beauftragten Autoritäten als auch für das Gesundheitssystem im Allgemeinen wurden abschließend diskutiert. / Upcoming pharmacodiagnostic tests offer the opportunity to better tailor cancer treatment decisions to individual patient needs. However, they put oncologists, pathologists, and cancer patients in the position of having to deal with a new technology, which often comes with its own specific risks. Little is known about how these different groups will handle this situation. This thesis is a first effort to examine, within Germany and the USA, how the respective groups would deal with a decision on applying such a test to a cancer treatment decision. All accomplished studies were divided into an explorative pilot study and a main study. Results of the pilot study were used for the main study to develop a case vignette questionnaire in order to investigate compensatory and noncompensatory decision-making strategies.In Study I, it was found that both, German and US oncologists’ decision-making policies were best described by a compensatory model (Franklin’s rule). A recommendation of a test by guidelines triggered nearly always a choice for having the test, although under different conditions also choices for nonrecommended tests were likely. Study II found that pathologists were, to a rather small extent, prepared to opt for more sophisticated test alternatives, compared to standard procedures. For both samples, decision making was equally well-predicted by two compensatory models (Franklin’s rule and Dawes’ rule), as it was by a noncompensatory model (Take The Best.Study III focused on cancer patients. The German as well as the US patients’ decisions were best predicted by a noncompensatory model (Matching Heuristic), while for the US patients, the most impacting cue was the recommendation by an oncologist, what could not be found for the German sample.Several implications of these findings for the respective groups, for authorities in charge of developing guidelines, as well as for the health systems in general, are discussed.

Diese Dissertation umfasst vier Manuskripte zum Thema Risikokommunikation und medizinischen Entscheidungen. Das erste Manuskript diskutiert Unterschiede, Gemeinsamkeiten und die Anwendbarkeit von drei zentralen Ansätzen, die helfen sollen, bessere Entscheidungen zu treffen (Nudging, Social Marketing, Empowerment). Das zweite Manuskript präsentiert Ergebnisse einer Medienanalyse zur Evaluation von Zeitungs- und Internetberichten in Deutschland und Spanien über die HPV-Impfung. Basierend auf vordefinierten Standards für transparente, vollständige und korrekte Risikokommunikation, deckt die Medienanalyse Schwächen in der Berichterstattung auf. Das dritte Manuskript untersucht wie Laien relative Risikoreduktionen bzw. –erhöhungen, ein Standardformt in der Medizin, verstehen. Beide Formate führen Laien und Experten in die Irre und führen zur Überschätzung der tatsächlichen Effekte. Ein diskutierter Ausweg ist die zusätzliche Kommunikation der Basisrate. Die Ergebnisse zeigen, dass das Verständnis von relativen Risikoreduktionen (-erhöhungen) mit Basisrate von dem Präsentationsformat (Prozent- vs. Häufigkeitsformat) und der individuellen Fähigkeit im Zahlenverständnis abhängt. Teilnehmer mit geringem Zahlenverständnis profitierten von der Darstellung in Häufigkeiten; Teilnehmer mit hohem Zahlenverständnis zeigen ein besseres Verständnis unabhängig des Formats. Dennoch—selbst mit Basisrate—missverstehen viele Teilnehmer die Risikoinformation. Das vierte Manuskript untersucht wie Teilnehmer Behandlungen unter Unsicherheit auswählen. Ein Einwand gegen die Kommunikation von Unsicherheit ist die Behauptung, dass Menschen Unsicherheit in Gewinnsituationen vermeiden, in Verlustsituationen dagegen suchen. Die Ergebnisse dieser Studie in Bezug auf die Auswahl von medizinischen Behandlungen konnten diese Annahmen nicht bestätigen. Darüber hinaus wählte die Mehrheit der Teilnehmer die gleiche Behandlung, wenngleich sich die zugrundeliegende Auswahlstrategie unterschied. / This dissertation comprises four manuscripts focusing on health risk communication and medical decision making. The first manuscript discusses differences, commonalities, and the applicability of three major approaches to help patients make better decisions: nudging, social marketing, and empowerment. The second manuscript presents results of an evaluation of media coverage about the HPV vaccine of newspaper and Internet reports in Germany and Spain. Based on predefined standards for transparent, complete, and correct risk communication, the analysis revealed substantial shortcomings in how the media informed the public. The third manuscript centers on a standard format to communicate treatment benefits and harms: relative risk reductions and increases. Such formats have been found to misinform and mislead patients and health professionals. One suggestion is to always include information about baseline risk to reduce misunderstandings. Results show that even when baseline risk was communicated, it depended on the presentation format (percentage vs. frequency) and people’s numeracy skills whether they correctly interpreted the risk reduction (or increase). Low numerates benefited from a frequency format, whereas high numerates performed better independent of the format. Yet, a substantial proportion of participants still misunderstood the meaning of a relative risk reduction (or increase). The fourth manuscript investigated how laypeople choose between medical treatments when ambiguity is present. One objection against communicating ambiguity is the claim that laypeople are ambiguity averse in the domain of gains and ambiguity seeking in the domain of losses. Results did not find supporting evidence for this claim in medical treatment choice. Moreover, most participants selected the same treatment option, independent of numeracy. However, the underlying choice strategies varied between individuals.

隨著氣候變遷與溫室效應影響日益明顯，台灣近年發生極端強降雨颱風的次數越來越頻繁，更造成流域地區嚴重災情，而從莫拉克風災經驗可體會到家戶風險溝通的重要性，也意識到我國實務與學術上相關研究的缺乏，故本研究探討家戶風險溝通機制中各項重要因素與調適行為間的關係，以及找出影響家戶調適行為決策之關鍵因素，進而提出家戶風險溝通策略之改善建議，以促進家戶採取調適行為。 本研究經由文獻回顧建立家戶調適行為之風險溝通概念架構，依循此架構研擬問卷，以高屏溪流域地區家戶為研究對象進行問卷調查，透過結構方程模式(SEM)驗證風險溝通架構，了解風險溝通機制各項因素與影響調適行為各因素之關係，後以面對災害回應之強烈將調適行為積極程度分為「消極或低度積極」、「中度積極」與「高度積極」，運用多項式羅吉斯迴歸模型建立家戶應變措施決策模型與調適措施決策模型，找出影響家戶調適行為決策之關鍵因素。 研究結果顯示，調適行為受到內在認知的影響，而內在認知同時受風險溝通機制與外在環境之影響，就風險溝通機制而言，親友鄰居、村里長與地方政府等社區網絡為重要管道。影響調適行為之關鍵因素以災害認知為主，其次為調適行為認知，居住村里次之，其中災害認知與調適行為認知越高，越有可能採取較積極之調適行為，此外，由於自然社會環境、風險溝通特性與社會經濟背景等因素交互影響下，各村里在調適行為決策上也有所差異。最後依據實證結果，與水患自主防災社區風險溝通現況，提出改善家戶風險溝通之策略建議，期望增進風險溝通機制的完備與促進家戶採取調適行為，以減緩極端氣候造成的衝擊。 / Along with the intensification of global climate change and greenhouse effect, typhoons with extreme rainfall strike Taiwan more and more frequently, which cause severe disasters in watershed area. From the experience of Typhoon Morakot in 2009, we realized the importance of risk communication with households and also the lack of related academic research. As a result, this study aims to discuss important factors in risk communication mechanism and their relationships with adaptive behaviors. It also find out key factors influencing decision-making of adaptive behaviors. Based on literature review, this study build a conceptual framework of risk communication process to describe how to trigger adaptive behaviors and encourage adaptive behaviors with risk communication. This study send out questionnaires to the households in Kaoping River Watershed and use structural equation modeling(SEM) to verify the conceptual framework. Then according to attitude of positive degree, adaptive behaviors are classified into“passive or low”,“medium” and “high” levels. By multinomial logistic regression, an empirical analysis was performed to analyze the key factors influencing decision-making of adaptive behaviors. The results show that adaptive behaviors are affected by internal cognition and at the same time internal cognition are affected by risk communication mechanism and external environment. As for risk communication mechanism, family, friends, neighbors and local governments are crucial communication channel. Key factors influencing decision-making of adaptive behaviors are cognition of disaster and adaptive behavior. People with higher cognition of disaster and adaptive behavior would more likely to take positive adaptive behaviors. Besides, community they lived in is also a key factor. Because the interaction of environments, risk communication patterns and socioeconomic attributes, people from different communities would take different adaptive behaviors. Based on empirical results, this study propose suggestions of risk communication strategies in order to better the risk communication mechanism and encourage households to take adaptive behaviors.

Suite aux notifications de cas de comportements suicidaires associés aux antidépresseurs (ADs) chez les jeunes, une mise en garde réglementaire a été émise en mai 2004 au Canada, et deux guides de pratique clinique ont été publiés dans la littérature en novembre 2007. L'objectif de ce mémoire fut d'évaluer l’association entre ces interventions de communication et le suivi médical de la population pédiatrique traitée par ADs au Québec. Une étude de cohorte rétrospective (1998-2008) a été menée chez 4 576 enfants (10-14 ans) et 12 419 adolescents (15-19 ans) membres du régime public d’assurance médicaments du Québec, ayant débuté un traitement par AD. Le suivi médical dans les trois premiers mois de traitement a été mesuré par l’occurrence et la fréquence de visites médicales retrouvées dans les banques de données de la RAMQ. Les facteurs associés à un suivi conforme aux recommandations ont été évalués à partir de modèles de régression logistique multivariés. Seuls 20% des enfants ou adolescents ont eu au moins une visite de suivi à chaque mois, en conformité avec les recommandations. La probabilité de recevoir un suivi médical conforme était plus élevée lorsque le prescripteur initial était un psychiatre. L’occurrence et la fréquence des visites n’ont pas changé après la publication de la mise en garde ou des recommandations. De ce mémoire on conclut que d'autres interventions visant à optimiser le suivi médical devraient être envisagées. / Following reports of a potential association between antidepressants (ADs) and suicidal behaviour in youth, a regulatory warning was issued in Canada in May 2004, and clinical practice guidelines on recommended medical follow-up were published in the literature in November 2007. This Master's thesis aimed at assessing the association between these communication interventions and medical follow-up practices. A retrospective cohort study (1998-2008) was conducted among 4,576 children (10-14 years) and 12,419 adolescents (15-19 years) members of the Quebec public drug plan. Medical follow-up was ascertained through patterns of physician billing practices found in the RAMQ medical services databases. Study outcomes consisted of occurrence and frequency of visits in the first three months of AD treatment. Factors associated with follow-up consistent with recommendations were identified through multivariate logistic regression models. The main independent variable was exposure to each of the communication interventions. Covariates included: gender, class of AD, number of concomitant chronic diseases, psychiatric conditions, prescriber’s specialty, and potential exposure to each intervention. Only 20% of children or adolescents received at least one visit each month. The probability of receiving adequate follow-up was greater when treatment was initiated by a psychiatrist. Occurrence and frequency of visits did not change after the warning nor the publication of the recommendations. From this thesis, one may conclude that further interventions to optimize medical follow-up practices should be envisaged.

十八世紀的工業發展富裕了人類的物質生活，生態環境卻也逐遭破壞 ；人們因科技文明引發的現代風險的多樣性、全球性、不易衡量與不易預 測性，遂將傳統注重資源分配的「階級社會」帶領到新的注重風險如何在 社會中平等並合法分配的「風險社會」(Risk society) (Beck,1992)，社 會風險概念乃應運而生。從社會文明演進來看，現代風險與過去風險在本 質上有著極大差異，過去風險多以自然災害的威脅為主，而現代風險則以 科技進步帶來的威亦即公害佔多數，綜言之為風險的不確定性、風險承擔 的不公平性、影響的遲延性與風險產生的社會妥當性。也因如此風險管理 則具相當的「利益衡量」與「政策決擇」色彩，風險溝通遂乃成為有效風 險管理的主要因素，成為綜合其他風險議題如風險認知、風險評估、風險 管理等的橋樑。風險溝通與其他溝通議題的最大差別，前者尤強調人文層 面因素重於科學分析結果。建立一個合理可接受的風險水準與風險認知息 息相關，專家的科學分析結果固然重要，民眾對風險的了解卻多以一般知 識與過去生活經驗認知，再加上現代風險多涉及高度的科技性，專業術語 常令民眾產生距離與不信任感，在公害問題上糾紛多因而產生。風險溝通 除了儘量降低衝突外，更積極地為建立風險的正確認知，加強自我防禦機 能，故公共介入、民眾的參與對於事前與事後溝通的成效，可避免糾紛爭 端的發生。 從７０年代起公害糾紛屢見不鮮，抗議者手段皆多由緩和 後因意見得不到適切回應始引發衝突性高的行動；抗爭者與被抗議者亦多 有組織化趨勢；不管是「事前預防型」或「事後補救型」活動，政府的溝 通方式多仍停留在技術層面單向說服性的宣導亦多為被動；反觀國外對溝 通的努力較為積極，坦誠公開的溝通態度，重視一致、簡明的訊息揭露， 並考慮到居民心理壓力的疏解，強調風險溝通的地方時效性，這是國內糾 紛處理不足之處。由於糾紛事件中多有金錢賠償、健康檢查之訴求，故糾 紛處理與公害賠償制度在事後溝通上就佔極重要角色。日本的公害糾處理 與健康受害補償制度是除了民事訟訴外另闢之行政救濟管道，為衝突解決 與公害損害補償提供了訊速有效的溝通管道。我國有關公害糾紛處理已於 ８２年二月完成立法，至於公害補償卻散見於法令中，盼儘快建立污染者 付費原則、賠償基金的設立及加強公害保險功能，健全風險溝通的角色。