Environmental risk factors for respiratory infections

In this study, the authors investigated the possible relationship between environmental-including dietary-factors and respiratory and ear infections in children. A sample of 304 children, aged 4-5 y, in Geneva, Switzerland, was studied. Mothers filled out a questionnaire that the authors provided. The questionnaire included items on food frequency, infections, and background factors (e.g., education, housing conditions, parents' smoking habits). Allergy was a risk factor for all infections, and mother's age was a protective factor. Humid conditions at home was a significant risk factor for cold, sore throat, and otitis (odds ratios = 2.71, 3.03, and 2.77, respectively); mold in the home was a significant risk factor for otitis (odds ratio = 2.80); and attending day-care centers was a significant risk factor for cold and bronchitis (odds ratios = 1.36 and 1.89, respectively). Dietary factors were not related to disease risk nor were environmental tobacco smoke or housing conditions generally related to an increased risk.     

Infections and Atopic Disorders in Childhood and Organochlorine Exposure

The authors investigated whether organochlorine exposure is associated with prevalence of otitis media, pneumonia, pertussis, asthma, and increased immunoglobulin E levels in children. Organochlorine concentrations and histories of infection and atopic manifestation were available for 343 children, and immunoglobulin E levels were available for 340 children. The authors applied logistic and linear regressions and controlled for confounders. In general, the prevalence of infections in children was not related to organochlorine exposure. However, for the combined effect of dichlorodiphenyldichloroethene with polychlorinated biphenyls or hexachlorobenzene, a significantly increased relative risk (odds ratios = 3.70 and 2.38, respectively) was found for otitis media. Exposure to dichlorodiphenyldichloroethene resulted in a significantly higher odds ratio for asthma (odds ratio = 3.71; 95% confidence interval = 1.10, 12.56) and in immunoglobulin E concentrations above 200 kU/l (odds ratio = 2.28; 95% confidence interval = 1.20, 4.31). This is the first study in which dichlorodiphenyldichloroethene has been identified as a substantial risk factor for asthma and for increased immunoglobulin E blood levels.     

Infections and atopic disorders in childhood and organochlorine exposure

The authors investigated whether organochlorine exposure is associated with prevalence of otitis media, pneumonia, pertussis, asthma, and increased immunoglobulin E levels in children. Organochlorine concentrations and histories of infection and atopic manifestation were available for 343 children, and immunoglobulin E levels were available for 340 children. The authors applied logistic and linear regressions and controlled for confounders. In general, the prevalence of infections in children was not related to organochlorine exposure. However, for the combined effect of dichlorodiphenyldichloroethene with polychlorinated biphenyls or hexachlorobenzene, a significantly increased relative risk (odds ratios = 3.70 and 2.38, respectively) was found for otitis media. Exposure to dichlorodiphenyldichloroethene resulted in a significantly higher odds ratio for asthma (odds ratio = 3.71; 95% confidence interval = 1.10, 12.56) and in immunoglobulin E concentrations above 200 kU/l (odds ratio = 2.28; 95% confidence interval = 1.20, 4.31). This is the first study in which dichlorodiphenyldichloroethene has been identified as a substantial risk factor for asthma and for increased immunoglobulin E blood levels.     

Traffic-related air pollution and otitis media

BACKGROUND: Otitis media is one of the most common infections in young children. Although exposure to environmental tobacco smoke is a known risk factor associated with otitis media, little information is available regarding the potential association with air pollution. OBJECTIVE: We set out to study the relationship between exposure to traffic-related air pollution and otitis media in two birth cohorts. METHODS: Individual estimates of outdoor concentrations of traffic-related air pollutants-nitrogen dioxide, fine particles [particulate matter with aerodynamic diameters 相似文献   

A comparison of risk factors for wheeze and recurrent cough in preschool children

In a study of 2,978 Danish children aged 5 years from two suburban counties of Copenhagen, carried out in 1998, the authors compared risk factor profiles for wheeze and recurrent cough without wheeze by using polytomous logistic regression to clarify whether the two conditions are likely to have the same etiology. Data were obtained 1) by a mailed parental questionnaire (International Study of Asthma and Allergies in Childhood questions and supplementary questions on cough, sociodemography, perinatal factors, and environmental exposure); 2) through general practitioners (familial allergic disease); and 3) from the National Medical Birth Register (birth weight). Wheeze (WH) was defined as more than one episode of wheeze within the last 12 months (irrespective of cough status) and recurrent cough without WH (RC) as cough occurring outside colds and usually lasting for periods of more than 1 week in children with no more than one attack of wheeze within the last 12 months. Risk factors for comparison were selected as those that, after repeated stepwise logistic regression, remained significant for children with WH or RC. Significant differences were found for gender (p = 0.003), gestational age (p = 0.0002), maternal history of asthma (p = 0.0008), and standard of housing condition (p = 0.04)-all risk factors for WH but not RC. Results may suggest that the two conditions have different etiologies.     

Housing characteristics, home environmental factors and respiratory health in 3945 pre-school children in China

The objective of the study was to assess the effects of housing characteristics and home environmental factors on respiratory symptoms of Chinese children. A cross-sectional study of 3945 children aged 1-6-years-old was conducted at 24 randomly selected kindergartens in Liaoning province, northeast China during April 2007. Information on respiratory symptoms (persistent cough, persistent phlegm, doctor-diagnosed asthma, current asthma, current wheeze and allergic rhinitis) and exposures to home environmental factors was obtained by a standard questionnaire from the American Thoracic Society. We used Chi-square tests, multivariate logistic regression models and adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) for estimates of the risk of respiratory symptoms. Results suggested that the prevalence of asthma-related symptoms was higher for those who lived along the main stem of traffic, and houses near a pollution source. Lower prevalence rates of respiratory morbidity were associated with households with a larger area of residence and more rooms. Pet keeping was associated with doctor-diagnosed asthma (OR = 1.45; 95% CI, 1.03-2.06). Among boys, home decorations significantly increased the risk of doctor-diagnosed asthma (OR = 1.71; 95% CI, 1.21-2.41), current asthma (OR = 1.80; 95% CI, 1.10-2.94) and current wheeze (OR = 1.81; 95% CI, 1.31-2.50). Environmental tobacco smoke, pests and visible mold on walls were associated with the occurrence of asthma symptoms, especially in boys. Based upon the findings of this study, it is concluded that home environmental factors are particularly important for the development of respiratory morbidity among children. Boys may be more susceptible to home environmental factors than girls.     

环境危险因素暴露对儿童急性淋巴细胞白血病发生风险的影响

目的 探索儿童环境危险因素对儿童急性淋巴细胞白血病（acute lymphoblastic leukemia,ALL）发生风险的影响。方法 采用病例-对照研究的流行病学方法,收集2015年在天津市血液病医院就诊的儿童ALL作为病例组,选取同期同地区的健康儿童作为对照组。通过一对一问卷调查的方式收集研究对象的相关信息。通过单因素χ²检验和多因素非条件Logistic回归模型,分析儿童环境危险因素与ALL发生关联情况,并计算相关危险因素的人群归因危险度百分比（population attributable risk percent,PARP）。结果 单因素分析结果显示,病例组中接触油漆涂料（χ²=7.146,P=0.008）、不爱吃蔬菜和水果（χ²=47.070,P<0.001）以及出生后居室装修（χ²=9.030,P=0.003）的儿童发生ALL的比例均高于对照组。多因素分析结果显示,接触油漆涂料（OR=2.174,95% CI：1.031~4.583）、不爱吃蔬菜和水果（OR=4.990,95% CI：3.017~8.253）和出生后居室装修（OR=2.831,95% CI：1.361~5.889）与儿童ALL的发生相关。上述三种危险因素的PARP分别为11.2%、25.2%和11.7%。结论 油漆涂料接触史、不爱吃蔬菜和水果及出生后居室装修可能是儿童患ALL的危险因素。     

Respiratory illnesses in children younger than 5 years of age in southern Brazil: the influence of the home environment]

OBJECTIVE: To determine the prevalence of acute lower respiratory tract infections and the risk factors associated with living conditions among children up to 5 years of age in the city of Rio Grande, in the state of Rio Grande do Sul, Brazil. METHODS: A population-based cross-sectional study was carried out with 775 children. A standardized questionnaire was administered to the mother or other caregiver at the child's home in order to collect information on housing conditions, socioeconomic status, and smoking in the home. Additional variables examined included nutritional status, duration of breast-feeding, prenatal care, and utilization of health care services. Environmental variables were analyzed individually and were also grouped together in an "environmental score" that encompassed 10 variables: type of house construction, type of floor, home heating system, type of stove, dog in the child's room, dog in the house, cat in the child's room, cat in the house, number of people per room, and maternal smoking. The grouped environmental score ranged from 0 (best) to 10 (worst). The analysis included two stages: a bivariate stage, in which the prevalence ratio was calculated for each risk factor, and a multivariate stage, with logistic regression. RESULTS: The overall prevalence of acute lower respiratory tract infections was 23.9%. The main risk factors identified were: environmental score >/= 3 points, maternal schooling < 5 years, monthly family income < US$ 200, four or more people sharing the child's bedroom, and maternal smoking. Maternal age > or = 30 years was found to protect against the development of respiratory illness. CONCLUSIONS: Specific programs need to be implemented to control acute respiratory illnesses in the population studied. In future studies with this population, the environmental score that we developed could be used in place of the complete set of environmental variables that we tested. This environmental score should be applied in other contexts so as to determine its external validity.     

The Association of Respiratory Symptoms and Indoor Housing Conditions Among Migrant Farmworkers in Eastern North Carolina

Farm labor housing has been described as among the worst in the nation, oftentimes with poor and unsanitary indoor living conditions. The objective of this study was to evaluate the association between indoor environmental risk factors and respiratory health among migrant farmworker occupants (N = 352) living in employer-provided housing. A cross-sectional sample of adult Latino male farm laborers were administered a questionnaire to identify the prevalence of major respiratory symptoms. Self-reported and independent observations were made to evaluate environmental respiratory risk factors and indoor housing conditions, including but not limited to, the presence of cockroaches, rodents, pesticides, and visible signs of mold. Spirometry was performed to evaluate lung function using FEV₁ (forced expiratory volume in 1 second), FVC (forced vital capacity), and FEV₁ /FVC ratio. Bivariate analysis was applied to evaluate associations between respiratory symptoms and selected indoor environmental risk factors. Findings for respiratory health included prevalence of wheeze (11.4%), coughing up phlegm (17.3%), tightness of chest (16.8%), and runny or stuffy nose (34.4%). Respiratory risks identified inside the dwellings included the use of pesticides or bug sprays for cockroaches (31.5%), rat or mouse poison (19.5%), visible signs of water damage in the bathroom (22.5%), and mold in the sleeping room (11.1%). Spirometry values were normal for most occupants, although statistically significant associations were found between mold and coughing up phlegm when not having a cold (P = .0262); presence of mold and asthma (P = .0084); pesticides used in the home and tightness of chest (P = .0001); and use of tobacco and coughing up phlegm (P = .0131). Although causal inference can be difficult to establish from a cross-sectional study, findings from this study represents suggestive evidence that indoor environmental risk factors may be contributory factors for respiratory health problems among this vulnerable workgroup population.     

Housing characteristics, home environmental factors and respiratory health in 14,729 Chinese children

BACKGROUND: Very few studies have assessed the relative impact of housing characteristics and home environmental factors on asthma and asthma-related symptoms in Chinese children who have lower rates of asthma. To our knowledge few studies have assessed respiratory symptoms and allergies in this context. METHODS: To assess the effects of housing characteristics, pet keeping, home decorations and other indoor environmental factors on respiratory health of Chinese children. We studied a population of 14,729 children (1-13 years old) from 12 districts in Liaoning province, Northeast China. Information on respiratory health, housing characteristics, and environmental pollutions were obtained by a standard questionnaire from the American Thoracic Society. RESULTS: Housing conditions, house adjacent to traffic or not, house with or without pollution source nearby, pet keeping, presence of pests and mold/water damage in the home, home decorations and exposure to environmental tobacco smoke (ETS) were associated with doctor-diagnosed asthma and asthma-related symptoms both in boys and girls. The vulnerability towards exposure to housing conditions and environmental factors differed between males and females. Among boys, the risk of respiratory morbidity appeared to be reduced in households with larger surface areas and more rooms; use of a ventilation device was strongly protective against persistent phlegm (OR=0.68; 95%CI: 0.48, 0.96). Asthma-related symptoms were more associated with different pets among girls than among boys. The presence of a cat in the household was associated with doctor-diagnosed asthma (OR=1.89; 95% CI, 1.11-3.20), current wheeze (OR=2.64; 95% CI, 1.52-4.59), persistent cough (OR=1.84; 95% CI, 1.18-2.87) and persistent phlegm (OR=2.17; 95% CI, 1.21-3.87) only among girls. CONCLUSION: Living within the vicinity of a source of pollution, traffic, pet keeping, home decorations, pests, mold and ETS are important determinants of children's respiratory health in China.     

A meta‐analysis of case‐control studies examining sporadic campylobacteriosis in Australia and New Zealand from 1990 to 2016

Objective : We conducted a meta‐analysis of case‐control studies to identify locally relevant risk factors for sporadic campylobacteriosis in Australia and New Zealand. Methods : We searched Medline, Web of Science, ProQuest and Google Scholar using PRISMA guidelines. Reference lists and grey literature were hand‐searched. Meta‐analyses were conducted in the R package ‘metafor’ using published odds ratios and 95% confidence intervals. Results : We identified 325 articles, from which we included 10 that described case‐control studies. Four risk factors were statistically significant in the meta‐analysis: eating undercooked poultry (OR=4.28, 95%CI 3.09–5.93); eating poultry cooked outside the home (OR=2.13, 95%CI 1.66–2.72); having pet chickens (OR=3.29, 95%CI 2.12–5.10); and overseas travel (OR=5.55, 95%CI 3.20–9.63). Among children, having pet dogs showed elevated but not significant risk (OR=1.57, 95%CI 0.99–2.49). Conclusions : We identified consumption of chicken meat and contact with domestic chickens as important risk factors for campylobacteriosis in Australia and New Zealand. Implications for public health : While consumption of chicken meat is a well‐known risk factor for campylobacteriosis, zoonotic transmission is often overlooked. This research indicates a greater need for public health awareness surrounding zoonotic campylobacteriosis, especially for young children.     

Good agreement between parental and self-completed questionnaires about allergic diseases and environmental factors in teenagers

ObjectivesTo study whether the methodological change from parent to index subject as questionnaire respondent affected the prevalence estimates and risk factor patterns for allergic diseases in a longitudinal study.Study Design and SettingA prospective study of asthma and allergic diseases among children was begun in 1996 within the Obstructive Lung Disease in Northern Sweden Study. In 2002, about 3,342 (95% of invited) teenagers (13 to 14 years) completed the annual questionnaire. A random sample of 294 (84% of invited) parents also completed the same extended International Study of Asthma and Allergies in Childhood questionnaire. Skin prick tests were performed in 1996 and 2000.ResultsThere were no significant differences in the prevalence of rhinitis, eczema, or related environmental factors between parental and self-reports, except for the question of having a dog at home. The absolute agreement was high, whereas the kappa values were fair or moderate. Kappa values of questions regarding parental smoking were 0.8–0.9. Allergic sensitization was the major risk factor for both rhinitis and eczema, and the odds ratios were similar regardless of who reported the condition.ConclusionThe agreement between the parental and teenagers' reports was good, and the methodological change did not affect the study results.     

Effects of environmental tobacco smoke on lower respiratory system of children under 5 years of age

OBJECTIVE: To determine the effects of second-hand smoke in the respiratory system of children under 5 years old. METHODS: A cross sectional study of a total of 1,104 children under 5 years old. Information about respiratory symptoms and illness, family history of respiratory diseases, smoking habits of household members and housing conditions were assessed by home interviews with the children's parents. RESULTS: We studied 546 boys and 558 girls. Among 611 children exposed to second-hand smoke, 82% had respiratory problems (odds ratio = 1.64; 95% confidence interval: 1.21-2.20). Children whose parents were smokers at the time of the survey were more likely to experience wheezing than children of nonsmoking parents (odds ratio = 1.66; 95% confidence interval: 1.21-2.27), shortness of breath (odds ratio = 1.91; 95% confidence interval: 1. 36-2.67), morning and day time or night coughs (odds ratio = 1.58; 95% confidence interval: 1.09-2.28). The odds ratio for asthma, bronchitis and pneumonia was greater for children exposed to second-hand smoke (odds ratio = 1.60; 95% confidence interval: 1. 11-2.31). CONCLUSIONS: Maternal smoking, paternal smoking, family history of respiratory diseases, and housing conditions are considered risk factors for respiratory diseases in children.     

Is particle board in the home detrimental to health?

A questionnaire concerning health and living conditions was sent to the parents of 1387 children aged 0-15 years to answer the question if children living in homes built with large amounts of particle board had more headaches and respiratory and skin symptoms than other children. There were 1376 possible respondents, and of those 1036 (75.3)% returned the questionnaire. Of the questionnaires returned, 972 (70.6%) were analyzable. The children lived in homes with much particle board (group A); little particle board, or homes as group A but treated in a special way (group B); and homes with no particle board (group C). For the 0- to 5-year-old children, living in homes with much particle board was a risk factor for developing wheezy bronchitis, eye and nose irritation, and coughing. For the 6- to 15-year-old children, living in a home with much particle board was not a risk factor. Risk factors for headache, irritation of the throat, and need for daily antiasthmatic medication were analyzed for all the children collectively. Living in a home with much particle board was a risk factor for all three conditions.     

Effects of prenatal exposure to dioxin-like compounds on allergies and infections during infancy

Dioxin-like compounds are endocrine disruptors. The effects of prenatal exposure to environmental levels of dioxins on immune function during infancy have not been clarified, although dioxins induce immunosuppression in offspring of animals. Moreover, human studies have not assessed the effects of gender- or congener-specific differences. The purpose of this study was to investigate the association between dioxin levels in maternal blood and the risk of infection and allergies in infancy. We examined 364 mothers and their infants enrolled in a Hokkaido Study on Environment and Children's Health between 2002 and 2005 in Sapporo, Japan. Relevant information was collected from a baseline questionnaire during pregnancy, medical records at delivery, and a follow-up questionnaire when the child was 18 months of age that assessed development of allergies and infections in infancy. Dioxin-like compound levels in maternal blood were measured with high-resolution gas chromatography/high-resolution mass spectrometry. Relatively higher levels of polychlorinated dibenzofuran were associated with a significantly increased risk of otitis media, especially among male infants (odds ratio=2.5, 95% confidence interval=1.1–5.9). Relatively higher levels of 2,3,4,7,8-pentachlorodibenzofuran were also associated with a significantly increased risk of otitis media (odds ratio=5.3, 95% confidence interval=1.5–19). However, we observed a weak association between dioxin-like compound levels and allergic symptoms in infancy. At environmental levels, prenatal exposure to dioxin-like compounds may alter immune function and increase the risk of infections in infancy, especially among males. The compound 2,3,4,7,8-pentachlorodibenzofuran may be responsible for this.     

Epidemiologic evidence of perinatal influence in the etiology of adult cancers

Using data from 5489 cancer patients and 2647 patients without cancer we investigated whether parental age at the birth of the patient or the patient's rank within his sibship was related to the risk of cancer during adulthood. An increase of 10 years in maternal age was associated with an increase of 24% for the incidence of breast cancer (odds ratio = 1.24%; 95% CI = 1.09-1.41); the corresponding increase for paternal age was 19% (odds ratio = 1.19; 95% CI = 1.07-1.33). There was some evidence that the age of each parent may make an independent contribution to the risk of breast cancer. For certain types of genito-urinary cancers, the risk was higher when the parents were relatively young at the birth of the patient. These cancers included tumors arising in the prostate (odds ratios = 0.71 and 0.55 for maternal and paternal ages, respectively), testis (odds ratios = 0.57 and 0.52), penis (odds ratios = 0.37 and 0.45), kidney (odds ratios = 0.66 and 0.60), and bladder (odds ratio = 0.79 and 0.85). The associations for cancer of the prostate and bladder were stronger among patients who were diagnosed at a relatively young age. No statistically significant effects were found for birth order relative to adult cancers. The authors conclude that environmental factors that affect the parents or that operate in the perinatal period may have stronger influences on the incidence of adult cancers than have been previously recognized.     

The family study of otitis media: Design and disease and risk factor profiles

Recurrent acute otitis media (RAOM) and chronic otitis media with effusion (COME) exhibit familial aggregation, but environmental risk factors (day care attendance, cigarette smoke exposure, and bottle feeding) are also important in their development. The Family Study of OM was designed to ascertain the RAOM/COME status of families whose children participated in Otitis Media Research Center studies between 1978 and 1984. Probands were treated with tympanostomy tubes, and had their RAOM/COME status ascertained as criteria for entry into these studies. For the Family Study of OM parents were interviewed about their otitis media and risk factor history; mothers were interviewed about their children's history, and pertinent medical records were obtained. Members of 173 families were examined with otomicroscopy and multifrequency tympanometry; 19% of parents and 32% of siblings were classified as affected, which is substantially higher than RAOM/COME rates from previous reports. Risk factor profiles differed significantly (P < .001) between parents and their children. Younger generation (adjusted odds ratio [OR] = 4.18, 95% confidence interval [Cl], 2.74, 6.36), day care attendance (OR = 1.96, 95% Cl, 1.32, 2.91) and male gender (OR = 1.42, 95% Cl, 1.03, 1.97) were significantly related to RAOM/COME using logistic regression. Analyses confirm (1) higher disease rates in families with an affected member compared to existing studies of the general population, (2) increased risk of RAOM/COME associated with known risk factors, and (3) increased risk for parents irrespective of risk factors. Additional analyses will explore competing models of disease susceptibility using genetic models and known risk factors. © 1996 Wiley-Liss, Inc.     

Risk factors for acute respiratory tract infections in young Greenlandic children

Acute respiratory infections cause considerable morbidity among Inuit children, but there is very little information on the risk factors for these infections in this population. To identify such factors, the authors performed a prospective community-based study of acute respiratory infections in an open cohort of 288 children aged 0-2 years in the town of Sisimiut, Greenland. Between July 1996 and August 1998, children were monitored weekly, and episodes of upper and lower respiratory tract infections were registered. Risk factor analyses were carried out using a multivariate Poisson regression model adjusted for age. Risk factors for upper respiratory tract infections included attending a child-care center (relative risk = 1.7 compared with home care) and sharing a bedroom with adults (relative risk = 2.5 for one adult and 3.1 for two adults). Risk factors for lower respiratory tract infections included being a boy (relative risk = 1.5), attending a child-care center (relative risk = 3.3), exposure to passive smoking (relative risk = 2.1), and sharing a bedroom with children aged 0-5 years (relative risk = 2.0 for two other children). Breastfeeding tended to be protective for lower respiratory tract infections. The population-attributable risk of lower respiratory tract infections associated with passive smoking and child-care centers was 47% and 48%, respectively. The incidence of acute respiratory infections among Inuit children may be reduced substantially through public health measures.     

Health-risk perception in the inner city community of Centro Habana, Cuba

Perceptions of health risks were surveyed in the inner city of Centro Habana, Cuba. A questionnaire developed by community leaders and experts was administered to 348 residents to determine the level of perceived risk for each of 41 risk items. Ecologic-level data on morbidity, mortality, and environmental indicators were also gathered. Using factor analysis to reduce the dimensionality of the data, five factor groupings accounted for 60% of the variance, as follows: social environment (40.8%); infectious agents and other health-risk factors of immediate concern (6.1%); lifestyle risks (4. 9%); environmental sanitation (4.1%); and living conditions (3.3%). A relationship between the perception of risk and the ecologic data was found, with inconsistencies largely attributable to factors known to influence risk perception. The greatest concern identified throughout the municipality was housing conditions, highest in the neighborhood that had already begun to address this problem. The analysis was useful in planning targeted health promotion campaigns and prioritizing further interventions. Repeat evaluation of risk perception will be conducted following the completion of interventions.     

Public Health Interests Override Others

Abstract

Perceptions of health risks were surveyed in the inner city of Centro Habana, Cuba. A questionnaire developed by community leaders and experts was administered to 348 residents to determine the level of perceived risk for each of 41 risk items. Ecologic-level data on morbidity, mortality, and environmental indicators were also gathered. Using factor analysis to reduce the dimensionality of the data, five factor groupings accounted for 60% of the variance, as follows: social environment (40.8%); infectious agents and other health-risk factors of immediate concern (6.1%); lifestyle risks (4.9%); environmental sanitation (4.1%); and living conditions (3.3%). A relationship between the perception of risk and the ecologic data was found, with inconsistencies largely attributable to factors known to influence risk perception. The greatest concern identified through out the municipality was housing conditions, highest in the neighborhood that had already begun to address this problem. The analysis was useful in planning targeted health promotion campaigns and prioritizing further interventions. Repeat evaluation of risk perception will be conducted following the completion of interventions.