How researchers can translate health evidence into books for children

The health promotion literature that considers how scientific evidence can be effectively communicated tends to focus on evaluating the effectiveness of communication materials. This has resulted in a knowledge gap regarding effective knowledge translation processes. This study explores the process, reasoning and practices for developing books for children that incorporate evidence-based information to aid understanding of scientific evidence about health and environmental or natural disasters. This study is informed by a systematic review of the literature combined with responses to an email interview with authors of books for children. Nine published studies were included in the systematic review. Twenty-two authors responded to the email survey (25% response rate, following 86 invitations). We report seven key findings to guide the development of health-promoting books for children: (i) understand the needs and expectations of the audience, (ii) articulate the topic and research evidence, (iii) assemble a team with a mix of content knowledge and creative expertise, (iv) format should be chosen to suit the user group and guided by the creative team, (v) early testing with children and their support system is crucial, (vi) develop a dissemination strategy to reach the user group and (vii) engage in reflexivity through evaluation of effectiveness of messaging. The current investigation can guide the process, reasoning and practice of developing books for children that incorporate evidence about health and environmental disasters.

Anticipated and Experienced Stigma After Testing Positive for SARS-CoV-2: A Qualitative Study

INTRODUCTION

Stigma has inhibited public health practitioners' influence during the COVID-19 pandemic. We explore the experienced and anticipated stigma of people affiliated with a large university in the United States, using the Health Stigma and Discrimination Framework.

METHODS

We conducted a qualitative secondary substudy of 20 people who tested SARS-CoV-2 positive and 10 who tested negative in the summer of 2020, selected from a study of 3,324 university students and employees.

FINDINGS

No participants reported anticipated stigmatization prior to testing positive. However, eight of 20 participants recounted stigma marking (being marked by COVID-19 diagnosis or membership in a "high-risk" group) or manifestations of stigma after testing positive, including feelings of guilt or shame, and concerns about being judged as selfish or irresponsible. Three described being denied services or social interactions as a result of having had COVID-19, long after their infectiousness ended. Participants noted that clear public health messaging must be paired with detailed scientific information, rather than leaving people to resort to non-experts to understand the science.

DISCUSSION

Public health messaging designed to mitigate spread of SARS-CoV-2 and protect the community may perpetuate stigma and exacerbate inequities. As a result, people may avoid testing or treatment, mistrust public health messaging, or even use risk-increasing behavior as coping mechanisms.

IMPLICATIONS FOR PRACTICE

Intentional use of language that promotes equity and deters discrimination must be high priority for any COVID-19-related public health messaging. Partnership with community leaders to co-create programs and disseminate messaging is a critical strategy for reducing stigma, especially for historically mistreated groups.

Trust in COVID-19 information sources and vaccination status: Exploring social inequalities and differences within the four United Kingdom nations using a representative survey

OBJECTIVES

To explore how the use of, and trust in, different sources of advice and information on COVID-19 differed across the four UK nations and between different sociodemographic groups and their associations with COVID-19 vaccination status.

METHODS

We used a UK-wide representative survey conducted in July 2021, which included data on uptake of COVID-19 vaccination, trust in information sources, use of sources and geographical and sociodemographic variables. We used multivariate logistic regression to identify factors associated with completed or planned COVID-19 vaccination.

RESULTS

Trust in the NHS, followed by trust in scientists, were the strongest predictors of vaccination intention. NHS websites were the most used (56% across the UK); only the Scottish government website had a higher level of reported use (58%). Using either source was associated with a positive vaccination status as were use of the GP and television as sources of advice. Use of social media, family and friends, and 'none' of the sources enquired about, were all linked to a lower likelihood of being or intending to get vaccinated. Compared to those in England, respondents in other UK nations were less likely to trust the central UK government for advice on COVID-19. There was considerable variation by age in trust and use of some, but not all, sources of advice, with predicted probabilities ranging from 35% among the youngest age group to 62% among those aged 65 years or older. There were also significant differences by annual household income and by occupational class for trust in government, with higher incomes correlating with greater likelihood of trust.

CONCLUSIONS

This study demonstrates high levels of trust in the key sources of public health advice and there was a positive association between using official sources of advice and vaccination intentions, even in the context of overall high vaccination rates. Our findings highlight the need for the UK and devolved governments to value the importance of public trust in the health system and take appropriate measures to avoid undermining such trust.

Trust by Proxy

The coronavirus disease 2019 (COVID-19) pandemic revealed the importance of improving the accessibility of quality public health messaging especially among underserved communities. By establishing a robust communication infrastructure, communities may begin to address the disparities exacerbated by misinformation. In this article, we describe the work done by Worth a Shot, a community-led organization that partnered with trusted, informed county residents; the county residents served as "public health ambassadors" who provided accurate, timely information to their communities in a culturally sensitive approach. This youth-led work may serve as a model for other communities that seek to improve outreach to underserved communities.

Cultural Competence Guides for COVID-19 Messaging in Hispanic Communities

PURPOSE

The Rio Grande Valley in South Texas comprises 5% percent of Texas's population yet 17%of Texas's COVID-19 deaths. We aimed to address underlying mistrust and systemic racism in our Hispanic community that contributes to health inequities by developing a cultural competence guide for public health messaging.

METHODS

We employed a mixed method design (e.g., focus groups, surveys, interviews) to develop and implement a cultural competence guide in an iterative community-informed process. We created a general cultural competence guide, one for the Hispanic community and one for the hard-of-hearing community.

RESULTS

Our cultural competence guides provide an interpretation as to whether the message is culturally competent or requires revisions. The guides have the following five categories: content and clarity, emotions and values, audience and inclusivity, call to action, and gestalt.

CONCLUSIONS

The Hispanic community needs more culturally competent public health messaging to address a key root cause of health inequities surrounding COVID-19. Our novel, concise guides can help organizations and individuals seeking to create culturally sensitive and, therefore, more effective public health messaging for Hispanic or deaf and hard-of-hearing communities.

Ambiguity and unintended inferences about risk messages for COVID-19

The World Health Organization established that the risk of suffering severe symptoms from coronavirus disease (COVID-19) is higher for some groups, but this does not mean their chances of infection are higher. However, public health messages often highlight the "increased risk" for these groups such that the risk could be interpreted as being about contracting an infection rather than suffering severe symptoms from the illness (as intended). Stressing the risk for vulnerable groups may also prompt inferences that individuals not highlighted in the message have lower risk than previously believed. In five studies, we investigated how U.K. residents interpreted such risk messages about COVID-19 (n = 396, n = 399, n = 432, n = 474) and a hypothetical new virus (n = 454). Participants recognized that the risk was about experiencing severe symptoms, but over half also believed that the risk was about infection, and had a corresponding heightened perception that vulnerable people were more likely to be infected. Risk messages that clarified the risk event reduced misinterpretations for a hypothetical new virus, but existing misinterpretations of coronavirus risks were resistant to correction. We discuss the need for greater clarity in public health messaging by distinguishing between the two risk events. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of the "Warning Signs Campaign" on Characteristics of Patients Presenting with Acute Coronary Syndrome (ACS) to Hospitals

OBJECTIVE

The National Heart Foundation's Warning Signs Campaign (2009-2013) aimed to raise awareness amongst the public of Acute Coronary Syndrome (ACS), encouraging people to recognise suggestive symptoms and seek immediate medical attention. This study explores the impact of the campaign on the characteristics of patients presenting to hospitals around Australia with ACS.

DESIGN

Retrospective cohort analysis Setting: 10 Australian Hospitals recruiting for the CONCORDANCE registry continuously throughout the campaign period.

PARTICIPANTS

Patients presenting with ACS to hospitals before, during and after the campaign ran in their jurisdiction.

MAIN OUTCOME MEASURES

Whether an ambulance was called, time between onset of symptoms to first medical contact, as well as time between onset of symptoms to primary percutaneous intervention or lysis.

RESULTS

Time to first medical contact did not improve during or post-campaign for NSTEACS medical hours (IQI) 1.6 (0.5-4.8) pre, 2.2 (0.7-7.6) during, 2 (0.7-6.9) post (p < 0.001) or STEMI, 1.1 (0.4-3.5) pre, 1.6 (0.6-5.1) during, 1.4 (0.5-4.3) post (p = 0.0113). In STEMI, time from symptom onset to pPCI (p = 0.256) and time to lysis (p = 0.387) were also unchanged. The proportion of ambulance arrivals remained stable (pre 55% vs. during 58%, p = 0.493). Patients presenting during the campaign were more likely to be born in Australia 56% pre, 69% during, 68% post (p < 0.001), to report English as a first language 67% pre, 84% during, 79% post (p < 0.001), and had lower likelihood of prior MI or revascularization but greater likelihood of cardiovascular risk factors compared to those presenting prior.

CONCLUSION

Among patients with ACS, we detected no increase in proportion of ambulance presentations nor earlier presentations among NSTEACS or STEMI during the campaign. There was an increase in the proportion of patients for whom English was the first language and those without a prior cardiac history but with cardiovascular risk factors, suggesting that the campaign impacted preferentially on certain strata in the community.

Prosocial nudges and visual indicators increase social distancing, but authoritative nudges do not

Social distancing reduces the transmission of COVID-19 and other airborne diseases. To test different ways to increase social distancing, we conducted a field experiment at a major US airport using a system that presented color-coded visual indicators on crowdedness. We complemented those visual indicators with nudges commonly used to increase COVID-19-preventive behaviors. Analyzing data from 57,146 travelers, we find that visual indicators and nudges significantly affected social distancing. Introducing visual indicators increased the share of travelers practicing social distancing, and this positive effect was enhanced by introducing nudges focused on personal benefits ("protect yourself") and public benefits ("protect others"). Conversely, an authoritative nudge referencing the Centers for Disease Control and Prevention ("don't break CDC COVID-19 guidelines") did not change social distancing behavior. Our results demonstrate that visual indicators and informed nudges can boost social distancing and potentially curb the spread of contagious diseases.

Ensuring Effective Public Health Communication: Insights and Modeling Efforts From Theories of Behavioral Economics, Heuristics, and Behavioral Analysis for Decision Making Under Risk

Public health (PH) messaging can have an enormous impact on shaping how individuals within society behave, and can ensure it is in a safe and responsible way, consistent with up-to-date evidence-based PH guidelines. If done effectively, messaging can save lives and improve the health of those within society. However, unfortunately, those within Government PH bodies typically have little training about how to effectively represent PH messages in a way that is consistent with psychological theories of cognitive bias, in order to avoid cognitively biasing the public through their messages. As a result of this, inadequate representation of PH messages can result, which can often lead to cognitive bias in those from the public who read or listen to the message information. This can lead to poor decision making of the pubic as a whole, which can then further lead to harm and even death of public members as a result of these poor decisions. One way to minimize the problem of bias in decision making is to explore psychology theories that model how bias can occur from PH messaging, and identify ways in which PH agencies can utilize such approaches to improve the effectiveness of their messages. Previous focus has been largely on behavioral economic theories, however, here, other accounts are offered in addition to these. These include theories of heuristics and theories from the behavior analysis domain, which may increase the predictive power of modeling bias, and have applications for how best to represent PH message information which minimize bias.

Impact of COVID-19: A Text Mining Analysis of Twitter Data in Spanish Language

BACKGROUND

Latino communities in the United States and Latin America are disproportionately affected by the COVID-19 pandemic. We analyzed information shared on Twitter in Spanish language for insights into the public's communication and information needs about the COVID-19 pandemic.

METHODS

We performed a mixed-methods analysis using a text mining approach. We used SAS Text Miner, an algorithmic-driven statistical program to capture 10,000 tweets posted between June 3, 2020, and June 10, 2020. We used the following search terms to capture relevant Twitter messages in Spanish language: "coronavirus," "covid-19," "corona," and the hash tags "#COVID19" and "#Coronavirus." Key text topics were identified and categorized into themes using an emergent content analysis.

RESULTS

We identified 12 text topics and six themes: (1) prevention measures, (2) epidemiology/surveillance, (3) economic impact, (4) optimizing nursing workforce, (5) access to reliable information, and (6) call for a response from the local government. Top trending hashtags from our search included #COVID19 (n = 7,098), #Coronavirus (n = 6,394), and #SNTESALUD (n = 2,598).

CONCLUSIONS

Spanish-language Tweets related to the COVID-19 pandemic contained information from health departments and labor unions on the surveillance, prevention, and impact of COVID-19. Public health officials should consider increasing their use of Twitter to ensure a wide dissemination of messages about COVID-19 in Spanish outlets.

Age-Related Differences in Experiences With Social Distancing at the Onset of the COVID-19 Pandemic: A Computational and Content Analytic Investigation of Natural Language From a Social Media Survey

Background

As COVID-19 poses different levels of threat to people of different ages, health communication regarding prevention measures such as social distancing and isolation may be strengthened by understanding the unique experiences of various age groups.

Objective

The aim of this study was to examine how people of different ages (1) experienced the impact of the COVID-19 pandemic and (2) their respective rates and reasons for compliance or noncompliance with social distancing and isolation health guidance.

Methods

We fielded a survey on social media early in the pandemic to examine the emotional impact of COVID-19 and individuals’ rates and reasons for noncompliance with public health guidance, using computational and content analytic methods of linguistic analysis.

Results

A total of 17,287 participants were surveyed. The majority (n=13,183, 76.3%) were from the United States. Younger (18-31 years), middle-aged (32-44 years and 45-64 years), and older (≥65 years) individuals significantly varied in how they described the impact of COVID-19 on their lives, including their emotional experience, self-focused attention, and topical concerns. Younger individuals were more emotionally negative and self-focused, while middle-aged people were other-focused and concerned with family. The oldest and most at-risk group was most concerned with health-related terms but were lower in anxiety (use of fewer anxiety-related terms) and higher in the use of emotionally positive terms than the other less at-risk age groups. While all groups discussed topics such as acquiring essential supplies, they differentially experienced the impact of school closures and limited social interactions. We also found relatively high rates of noncompliance with COVID-19 prevention measures, such as social distancing and self-isolation, with younger people being more likely to be noncompliant than older people (P<.001). Among the 43.1% (n=7456) of respondents who did not fully comply with health orders, people differed substantially in the reasons they gave for noncompliance. The most common reason for noncompliance was not being able to afford to miss work (n=4273, 57.3%). While work obligations proved challenging for participants across ages, younger people struggled more to find adequate space to self-isolate and manage their mental and physical health; middle-aged people had more concerns regarding childcare; and older people perceived themselves as being able to take sufficient precautions.

Conclusions

Analysis of natural language can provide insight into rapidly developing public health challenges like the COVID-19 pandemic, uncovering individual differences in emotional experiences and health-related behaviors. In this case, our analyses revealed significant differences between different age groups in feelings about and responses to public health orders aimed to mitigate the spread of COVID-19. To improve public compliance with health orders as the pandemic continues, health communication strategies could be made more effective by being tailored to these age-related differences.

A Rapid Systematic Review of Public Responses to Health Messages Encouraging Vaccination against Infectious Diseases in a Pandemic or Epidemic

Public health teams need to understand how the public responds to vaccination messages in a pandemic or epidemic to inform successful campaigns encouraging the uptake of new vaccines as they become available. A rapid systematic review was performed by searching PsycINFO, MEDLINE, healthevidence.org, OSF Preprints and PsyArXiv Preprints in May 2020 for studies including at least one health message promoting vaccine uptake of airborne-, droplet- and fomite-spread viruses. Included studies were assessed for quality using the Mixed Methods Appraisal Tool (MMAT) or the Assessment of Multiple Systematic Reviews (AMSTAR), and for patient and public involvement (PPI) in the research. Thirty-five articles were included. Most reported messages for seasonal influenza (n = 11; 31%) or H1N1 (n = 11; 31%). Evidence from moderate to high quality studies for improving vaccine uptake included providing information about virus risks and vaccination safety, as well as addressing vaccine misunderstandings, offering vaccination reminders, including vaccination clinic details, and delivering mixed media campaigns across hospitals or communities. Behavioural influences (beliefs and intentions) were improved when: shorter, risk-reducing or relative risk framing messages were used; the benefits of vaccination to society were emphasised; and beliefs about capability and concerns among target populations (e.g., vaccine safety) were addressed. Clear, credible, messages in a language target groups can understand were associated with higher acceptability. Two studies (6%) described PPI in the research process. Future campaigns should consider the beliefs and information needs of target populations in their design, including ensuring that vaccine eligibility and availability is clear, and messages are accessible. More high quality research is needed to demonstrate the effects of messaging interventions on actual vaccine uptake.

Gambling Self-Control Strategies: A Qualitative Analysis

There is limited research exploring the perceptions of people who gamble on the self-control strategies used to limit their gambling. This qualitative study examines self-control strategies used to limit money spent gambling, frequency of gambling, and time spent gambling. A total of 56 people who gamble (27 males and 29 females) participated in nine focus groups and five individual interviews in Montreal, Calgary, and Toronto (Canada). Self-control strategies used to limit their gambling expenditure were more common than frequency or time limiting strategies. Strategies to limit expenditure included: restricting access to money; keeping track of money allocated to gambling activities; and avoiding certain types of gambling activities. Various contextual factors were identified to influence those strategies, including social influences; winning or losing; using substances. Findings from this study emphasize the importance of communicating clear gambling limits to people who gamble, as well as the value of developing individual self-control strategies to limit frequency, time and money spent gambling.

Who Is Listening? Spokesperson Effect on Communicating Social and Physical Distancing Measures During the COVID-19 Pandemic

Effective communication during a pandemic, such as the current COVID-19 crisis, can save lives. At the present time, social and physical distancing measures are the lead strategy in combating the spread of COVID-19. In this study, a survey was administered to 705 adults from Switzerland about their support and practice of social distancing measures to examine if their responses depended on (1) whether these measures were supported by a government official or an internationally recognized celebrity as a spokesperson, (2) whether this spokesperson was liked, and (3) the respondent's age. We also considered several attitudinal and demographic variables that may influence the degree to which people support and comply with social distancing measures. We found that the government official was more effective in eliciting responses supportive of social distancing, particularly as manifested in the stated current compliance with social distancing measures. The effect was substantially stronger among older respondents, although these respondents expressed a lower risk perception. Although there was a general trend for greater endorsement of the social distancing measures among participants who liked the spokesperson, this was non-significant. In addition, respondents' greater support and compliance was positively associated with (1) higher concern for the current situation, (2) higher concern for the well-being of others, and (3) greater belief that others were practicing social distancing, and negatively with (4) greater self-reported mobility. Current compliance correlated negatively with (5) household size. Since different parts of the population appear to have different perceptions of risk and crisis, our preliminary results suggest that different spokespersons may be needed for different segments of the population, and particularly for younger and older populations. The development of evidence-based knowledge is required to further identify who would be the most effective spokesperson, and in particular to groups with low risk perception and low compliance.

Identifying Community-Informed Language to Promote HIV Pre-exposure Prophylaxis (PrEP) in Black LGBTQ Communities in Baltimore

LGBTQ populations, particularly Black men who have sex with men and transgender women, experience significant HIV disparities; public health messages may inadvertently stigmatize LGBTQ populations. We sought to use qualitative methods to inform a PrEP campaign. Unstructured focus groups were conducted among predominantly Black LGBTQ persons recruited through social media and events. Discussions were audio-recorded, transcribed, and analyzed in NVivo using categorical analysis. Eighty individuals participated in 13 focus groups; 80% (64) identified as sexual or gender minorities. Eighty-eight percent (70) identified as Black/African American. Four themes emerged: (1) culturally competent, community-informed, locally relevant messaging, (2) avoiding stigmatizing language or images, (3) inaccessibility of clinical language, and (4) using identity labels representing local communities and their diversity. Findings suggest PrEP campaigns need to be developed through community-informed processes to engage and avoid stigmatizing priority populations. Ongoing partnerships between public health and LGBTQ communities can facilitate development of campaigns with engaging, acceptable language.

Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk

OBJECTIVES

Reducing access to firearms as a suicide prevention strategy is limited in the US today because of divergent cultural attitudes and political contentiousness surrounding gun restrictions. This research examined the effects of culturally-specific suicide prevention messages on the likelihood of restricting firearm access during periods of suicide risk.

METHODS

Focus groups and key informant interviews were conducted with rural gun owners in order to develop a suicide prevention message that highlighted the importance of restricting access to firearms during periods of risk without threatening second amendment concerns. The effectiveness of this gun culture message, relative to standard suicide prevention messaging and a control condition, was then tested with a national sample of gun owners.

RESULTS

Relative to all other conditions, respondents who received our culturally-specific message in conjunction with standard suicide prevention content reported the greatest likelihood of taking steps to restrict access to firearms. This tendency was enhanced for individuals who were more politically conservative, lived in more rural areas, and supported gun rights to a stronger degree.

CONCLUSIONS

Findings underscore the importance of attending to cultural factors in public health messaging. Messaging that respects the values of gun owners could hold promise in promoting firearm restriction for suicide prevention.

Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk

OBJECTIVES

Reducing access to firearms as a suicide prevention strategy is limited in the US today because of divergent cultural attitudes and political contentiousness surrounding gun restrictions. This research examined the effects of culturally-specific suicide prevention messages on the likelihood of restricting firearm access during periods of suicide risk.

METHODS

Focus groups and key informant interviews were conducted with rural gun owners in order to develop a suicide prevention message that highlighted the importance of restricting access to firearms during periods of risk without threatening second amendment concerns. The effectiveness of this gun culture message, relative to standard suicide prevention messaging and a control condition, was then tested with a national sample of gun owners.

RESULTS

Relative to all other conditions, respondents who received our culturally-specific message in conjunction with standard suicide prevention content reported the greatest likelihood of taking steps to restrict access to firearms. This tendency was enhanced for individuals who were more politically conservative, lived in more rural areas, and supported gun rights to a stronger degree.

CONCLUSIONS

Findings underscore the importance of attending to cultural factors in public health messaging. Messaging that respects the values of gun owners could hold promise in promoting firearm restriction for suicide prevention.

What do we know about health-related knowledge translation in the Circumpolar North? Results from a scoping review

BACKGROUND

Health research knowledge translation (KT) is important to improve population health outcomes. Considering social, geographical and cultural contexts, KT in Inuit communities often requires different methods than those commonly used in non-Inuit populations.

OBJECTIVES

To examine the extent, range and nature of literature about health-related KT in Inuit communities.

DESIGN

A scoping review was conducted. A search string was used to search 2 English aggregator databases, ProQuest and EBSCOhost, on 12 March 2015. Study selection was conducted by 2 independent reviewers using inclusion and exclusion criteria. To be included, studies had to explicitly state that KT approaches were used to share human health research results in Inuit communities in the Circumpolar North. Articles that evaluated or assessed KT approaches were thematically analysed to identify and characterize elements that contributed to KT success or challenges.

RESULTS

From 680 unique records identified in the initial search, 39 met the inclusion criteria and were retained for analysis. Of these 39 articles, 17 evaluated the KT approach used; thematic analysis identified 3 themes within these 17 articles: the value of community stakeholders as active members in the research process; the importance of local context in tailoring KT strategies and messaging; and the challenges with varying and contradictory health messaging in KT. A crosscutting gap in the literature, however, included a lack of critical assessment of community involvement in research. The review also identified a gap in assessments of KT in the literature. Research primarily focused on whether KT methods reflected the local culture and needs of the community. Assessments rarely focused on whether KT had successfully elicited its intended action.

CONCLUSIONS

This review synthesized a small but burgeoning area of research. Community engagement was important for successful KT; however, more discussion and discourse on the tensions, challenges and opportunities for improvement are necessary.

Environmental Justice and Community-Based Research in Texas Borderland Colonias

OBJECTIVE

An innovative academic-community partnership studied daily decisions in communities of mostly Spanish-speaking, low-income residents of colonias in Hidalgo County, TX, about risk of exposure to fish contaminated by PCBs at an Environmental Protection Agency (EPA) Superfund site.

DESIGN AND SAMPLE

The team used focus group interviews with colonia residents and content analysis to assess knowledge of risk related to the Superfund site, the Donna Reservoir and Canal System.

RESULTS

(1) many lacked knowledge of the Superfund site contamination; (2) a few participants fished at the lake, knew people who did so, and consumed the catch, but most participants feared going there; (3) some participants remember receiving messages saying not to fish at the site, although they recalled nothing about contamination, but most participants knew of no such messages; (4) many use cell phones to get local information through personal networks and several Spanish-language news sources, but they have no consistent, culturally tailored local information source.

CONCLUSIONS

The findings indicate the need for further efforts to design culturally tailored means of communication and messages to inform local communities widely about the dangers related to the Superfund site and thus decrease health disparities resulting from consuming fish from the site.