Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Addressing racial/ethnic inequities in vaccine hesitancy and uptake: lessons learned from the California alliance against COVID-19.

Lack of trust in biomedical research, government, and health care systems, especially among racial/ethnic minorities and under-resourced communities, is a longstanding issue rooted in social injustice. The COVID-19 pandemic has further highlighted existing health and socioeconomic inequities and increased the urgency for solutions to provide access to timely, culturally, and linguistically appropriate evidence-based information about COVID-19; and ultimately to promote vaccine uptake. California's statewide alliance STOP COVID-19 CA (comprising eleven sites), leverages long standing community partnerships to better understand concerns, misinformation, and address racial/ethnic inequities in vaccine hesitancy and uptake. Using data from the California CEAL Communication Working Group, we demonstrate the wide range of strategies, communication methods, languages, and trusted messengers that have been effective in reaching diverse communities across the state. We also showcase challenges and lessons learned, such as the importance of including trusted community partners to share information or provide vaccines. These approaches, rooted in community engagement, are crucial for addressing inequities and responding to future public health emergencies.

Moving Towards Equity With Digital Health Innovations for Stroke Care.

Digital health has long been championed as a means to expanding access to health care. Now that the COVID-19 pandemic accelerated many health systems' integration of digital tools for care, digital health may provide a path towards more accessible stroke prevention and treatment, particularly for historically disadvantaged patient populations. Stroke management is composed of multiple time points where digital health innovations have the potential to augment health access and treatment: from primary prevention, to the time-sensitive detection of ischemic stroke, administration of thrombolytic agents and consideration for endovascular interventions, to appropriate post-acute care, rehabilitation, and lifelong secondary stroke prevention-stroke care relies on a multidisciplinary and standardized approach. However, as we discuss pointedly in this Focused Update, underrepresented individuals face multilevel digital health disparities that potentially diminish the benefits of these digital advances. As such, these multilevel needs must be discussed and accounted for as health systems seek to integrate innovative and equitable digital health solutions towards stroke care.

The Impact of Telemedicine on Quality of Care for Patients with Diabetes After March 2020.

BACKGROUND: The impact of telemedicine on ambulatory care quality is a key question for policymakers as they navigate payment reform for remote care. OBJECTIVE: To evaluate whether utilizing telemedicine in the first 9 months of the COVID-19 pandemic impacted performance on a diabetes quality of care measure for patients at a large academic medical center. We hypothesized care quality would reduce less among telemedicine users. DESIGN: Quasi-experimental design using binomial logistic regression. Covariates included age, gender, race, ethnicity, type of insurance, hierarchical condition category score, primary language at the individual level, and zip code-level income. PARTICIPANTS: All adult patients younger than 75 years of age diagnosed with type 2 diabetes mellitus (N = 16,588) as of 3/19/2020 at a single academic health center. INTERVENTIONS: Completion of one or more telemedicine encounters with an institutional primary care physician or endocrinologist between 3/19/2020 and 12/19/2020. MAIN MEASURES: The components met in a five-item composite measure of diabetes quality of care, as of patients' last clinical encounter. Items were (1) systolic blood pressure less than 140 mmHg, (2) hemoglobin A1c less than 8.0%, (3) using a statin and (4) aspirin, and (5) tobacco non-use. KEY RESULTS: From the pre- to post-period, the probability of meeting any given component of the composite measure for patients only utilizing in-person care was 21% lower (OR, 95% CI 0.79; 0.76, 0.81) and for the telemedicine users 2% lower (OR 0.98; 0.85, 1.13). There was an increased likelihood of meeting any given component among telemedicine users compared to in-person care alone (OR 1.25; 1.08, 1.44). CONCLUSIONS: Patients with diabetes utilizing telemedicine performed similarly on a composite measure of diabetes care quality compared to before the pandemic. Those not utilizing telemedicine had reductions. Telemedicine use maintained quality of care for patients with diabetes during the first 9 months of the COVID-19 pandemic.

Effect of Personalized Messages Sent by a Health System's Patient Portal on Influenza Vaccination Rates: a Randomized Clinical Trial.

BACKGROUND: Adult influenza vaccination rates are low. Tailored patient reminders might raise rates. OBJECTIVE: Evaluate impact of a health system's patient portal reminders: (1) tailored to patient characteristics and (2) incorporating behavioral science strategies, on influenza vaccination rates among adults. DESIGN: Pragmatic 6-arm randomized trial across a health system during the 2019-2020 influenza vaccination season. The setting was one large health system-53 adult primary care practices. PARTICIPANTS: All adult patients who used the patient portal within 12 months, stratified by the following: young adults (18-64 years, without diabetes), older adults (≥65 years, without diabetes), and those with diabetes (≥18 years). INTERVENTIONS: Patients were randomized within strata to either (1) pre-commitment reminder alone (1 message, mid-October), (2) pre-commitment + loss frame messages, (3) pre-commitment + gain frame messages, (4) loss frame messages alone, (5) gain frame messages alone, or (6) standard of care control. Patients in the pre-commitment group were sent a message in mid-October, asking if they planned on getting an influenza vaccination. Patients in loss or gain frame groups were sent up to 3 portal reminders (late October, November, and December, if no documented influenza vaccination in the EHR) about importance and safety of influenza vaccine. MAIN MEASURES: Receipt of 1 influenza vaccine from 10/01/2019 to 03/31/2020. KEY RESULTS: 196,486 patients (145,166 young adults, 29,795 older adults, 21,525 adults with diabetes) were randomized. Influenza vaccination rates were as follows: for young adults 36.8%, for older adults 55.6%, and for diabetics 60.6%. On unadjusted and adjusted (for age, gender, insurance, race, ethnicity, and prior influenza vaccine history) analyses, influenza vaccination rates were not statistically different for any study group versus control. CONCLUSIONS: Patient reminders sent by a health system's patient portal that were tailored to patient demographics (young adults, older adults, diabetes) and that incorporated two behavioral economic messaging strategies (pre-commitment and loss/gain framing) were not effective in raising influenza vaccination rates. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT04110314).

Fishing for health: Neighborhood variation in fish intake, fish quality and association with stroke risk among older adults in the Cardiovascular Health Study.

BACKGROUND AND AIMS: Fish consumption has been associated with better health outcomes. Dietary patterns may vary substantially by neighborhood of residence. However, it is unclear if the benefits of a healthy diet are equivalent in different communities. This study examines associations of fish consumption with stroke incidence and stroke risk factors, and whether these differ by neighborhood socioeconomic status (NSES). METHODS AND RESULTS: We studied 4007 participants in the Cardiovascular Health Study who were 65 years or older and recruited between 1989 and 1990 from 4 US communities. Outcomes included fish consumption type (bakes/broiled vs. fried) and frequency, stroke incidence, and stroke risk factors. Multilevel regressions models were used to estimate fish consumption associations with clinical outcomes. Lower NSES was associated with higher consumption of fried fish (aOR = 1.47, 95% CI: 1.10-1.98) and lower consumption of non-fried fish (0.64, 0.47-0.86). Frequent fried fish (11.9 vs. 9.2 person-years for at least once weekly vs. less than once a month, respectively) and less frequent non-fried fish (17.7 vs. 9.6 person-years for less than once a month vs. at least once weekly, respectively) were independently associated with an increased risk of stroke (p-values < 0.05). However, among those with similar levels of healthy fish consumption, residents with low NSES had less benefit on stroke risk reduction, compared with high NSES. CONCLUSION: Fish consumption type and frequency both impact stroke risk. Benefits of healthy fish consumption differ by neighborhood socioeconomic status.

The Association of Broadband Internet Access and Telemedicine Utilization in rural Western Tennessee: an observational study.

BACKGROUND: Broadband access has been highlighted as a national policy priority to improve access to care in rural communities. OBJECTIVE: To determine whether broadband internet availability was associated with telemedicine adoption among a rural patient population in western Tennessee. METHODS: Observational study using electronic medical record data from March 13th, 2019 to March 13th, 2021. Multivariable logistic regression incorporating individual-level characteristics with broadband availability, income, educational attainment, and primary care physician supply at the zip code level, and rural status as determined at the county level. SETTING: Single health system in western Tennessee. PARTICIPANTS: Adult patients with one or more in-person or remote encounter in a health system in western Tennessee and residing in western Tennessee between March 13th, 2019 and March 13th, 2021 (N = 54,688). OUTCOME MEASURES: Completion of one or more video encounters in the year following March 13th, 2020 (N = 3199; 7%). Our primary characteristic of interest was the proportion of residents in each zip code with access to the internet meeting the Federal Communications Commission definition of broadband access, adjusting for age, gender, race, income, educational attainment, insurance type, rural status, and primary care provider supply. RESULTS: Patients in a rural western Tennessee health system were predominantly white (79%), residing in rural zip codes (73%) with median household incomes ($52,085) less than state and national averages. Patients residing in a zip code where there is 80 to 100% broadband access compared to 0 to 20% were more likely in the year following March 13th, 2020 to have completed both telemedicine and in-person visits ([OR; 95% CI] 1.57; 1.29, 1.94), completed only telemedicine visits (2.26; 1.71, 2.97), less likely to have only completed in-person visits (0.81; 0.74, 0.89), but no more or less likely to have accessed no care (1.07; 0.97, 1.18). DISCUSSION: The availability of broadband internet was shown to be one of many factors associated with the utilization of telemedicine for a rural, working-class community after March 13th, 2020. CONCLUSIONS: Access to broadband internet is a determinant of access to telemedicine for patients in rural communities and should be a priority for policymakers interested in improving health and access to care for rural patients.

Portals of Change: How Patient Portals Will Ultimately Work for Safety Net Populations.

Despite the implementation of internet patient portals into the safety net after the introduction of the Affordable Care Act in the United States, little attention has been paid to the process of engaging vulnerable patients into these portals. The portal is a health technology tool that was developed with a mainstream, English-speaking audience in mind. Thus, there are valid concerns that such technologies will actually exacerbate health care disparities, conferring further advantages to the already advantaged. In this paper, we describe a framework for portal engagement (awareness, registration, and use) among safety net patients. We incorporate the experiences in the Los Angeles County Department of Health Services to illustrate important contextual factors for portal outreach in our safety net. Finally, we discuss considerations for moving forward with health technology in the safety net as the next version of patient portals are being developed.

An Untapped Potential in Primary Care: Semi-Structured Interviews with Clinicians on How Patient Portals Will Work for Caregivers in the Safety Net.

BACKGROUND: Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers' use of their patients' portal. OBJECTIVE: Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers' perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers' use of portals in the safety net. METHODS: We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers' experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes. RESULTS: Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers' recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement. CONCLUSIONS: Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers' interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security.

Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions.

Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.

[Measles and chickenpox susceptibility among immigrants]. / Susceptibilité des migrants à la rougeole et à la varicella.

Exposure of immigrants to infectious diseases in their country of origin influences their susceptibility to infections later in life. Susceptibility to certain infections may significantly differs between immigrants depending on their regions of origin. Both measles and chickenpox (varicella) are conditions for which the level of exposure in the country of origin influences the preventive measures that immigrant health providers should propose. Through these two illustrative examples, this article summarizes the practical implications for clinicians who care for immigrants originating from southern countries.

Is the Front Line Prepared for the Changing Faces of Patients? Predictors of Cross-Cultural Preparedness Among Clinical Nurses and Resident Physicians in Lausanne, Switzerland.

UNLABELLED: PHENOMENON: Assuring quality medical care for all persons requires that healthcare providers understand how sociocultural factors affect a patient's health beliefs/behaviors. Switzerland's changing demographics highlight the importance of provider cross-cultural preparedness for all patients-especially those at risk for social/health precarity. We evaluated healthcare provider cross-cultural preparedness for commonly encountered vulnerable patient profiles. APPROACH: A survey on cross-cultural care was mailed to Lausanne University hospital's "front-line healthcare providers": clinical nurses and resident physicians at our institution. Preparedness items asked "How prepared do you feel to care for … ?" (referring to example patient profiles) on an ascending 5-point Likert scale. We examined proportions of "4 - well/5 - very well prepared" and the mean composite score for preparedness. We used linear regression to examine the adjusted effect of demographics, work context, cultural-competence training, and cross-cultural care problem awareness, on preparedness. FINDINGS: Of 885 questionnaires, 368 (41.2%) were returned: 124 (33.6%) physicians and 244 (66.4%) nurses. Mean preparedness composite was 3.30 (SD = 0.70), with the lowest proportion of healthcare providers feeling prepared for patients "whose religious beliefs affect treatment" (22%). After adjustment, working in a sensitized department (ß = 0.21, p = .01), training on the history/culture of a specific group (ß = 0.25, p = .03), and awareness regarding (a) a lack of practical experience caring for diverse populations (ß = 0.25, p = .004) and (b) inadequate cross-cultural training (ß = 0.18, p = .04) were associated with higher preparedness. Speaking French as a dominant language and physician role (vs. nurse) were negatively associated with preparedness (ß = -0.26, p = .01; ß = -0.22, p = .01). INSIGHTS: The state of cross-cultural care preparedness among Lausanne's front-line healthcare providers leaves room for improvement. Our study points toward institutional strategies to improve preparedness: notably, making sure departments are sensitized to cross-cultural care resources and increasing provider diversity to reflect the changing Swiss demographic.

Cultural competency of health-care providers in a Swiss University Hospital: self-assessed cross-cultural skillfulness in a cross-sectional study.

BACKGROUND: As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital. METHODS: A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness. RESULTS: Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (ß = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (ß = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (ß = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (ß = -0.34, p < 0.005) was negatively correlated with skillfulness. CONCLUSIONS: Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.

The Los Angeles County Department of Health Services Health Technology Navigators: A novel health workforce to digitally empower patient communities in safety net systems.

Significant disparities in the uptake of digital health tools have been previously described. Studies have found that low perceived confidence to engage with digital health resources among medically underserved patients partially account for this. To address barriers to digital health engagement (specifically around patient portal enrollment and use), the Los Angeles County Department of Health Services (LAC DHS) introduced the Health Technology Navigators program. To our knowledge, this is the first formal digital health workforce implemented in a safety net system. The objectives of the editorial are to describe the evolution and roles of the health technology navigators and their early effects within LAC DHS, the second largest safety net health system in the United States.

Lessons learned from a multi-site collaborative working toward a digital health use screening tool.

Digital health has the potential to expand health care and improve outcomes for patients-particularly for those with challenges to accessing in-person care. The acceleration of digital health (and particularly telemedicine) prompted by the Coronavirus-19 (COVID-19) pandemic facilitated continuity of care in some settings but left many health systems ill-prepared to address digital uptake among patients from underserved backgrounds, who already experience health disparities. As use of digital health grows and the digital divide threatens to widen, healthcare systems must develop approaches to evaluate patients' needs for digital health inclusion, and consequentially equip patients with the resources needed to access the benefits of digital health. However, this is particularly challenging given the absence of any standardized, validated multilingual screening instrument to assess patients' readiness for digital healthcare that is feasible to administer in already under-resourced health systems. This perspective is structured as follows: (1) the need for digital health exclusion risk screening, (2) our convening as a group of stakeholders, (3) our review of the known digital health screening tools and our assessment, (4) formative work with patients regarding their perceptions on language and concepts in the digital health screening tools, and (5) conclusion with recommendations for digital health advocates generated by this collaborative of digital health researchers and operations leaders. There is a need to develop a brief, effective tool to screen for digital health use that can be widely implemented in diverse populations. We include lessons learned from our experiences in developing and testing risk of digital health exclusion screening questions in our respective health systems (e.g., patient perception of questions and response options). Because we recognize that health systems across the country may be facing similar challenges and questions, this perspective aims to inform ongoing efforts in developing health system digital exclusion screening tools and advocate for their role in advancing digital health equity.

Text vs Patient Portal Messaging to Improve Influenza Vaccination Coverage: A Health System-Wide Randomized Clinical Trial.

Importance: Increasing influenza vaccination rates is a public health priority. One method recommended by the US Centers for Disease Control and Prevention and others is for health systems to send reminders nudging patients to be vaccinated. Objective: To evaluate and compare the effect of electronic health record (EHR)-based patient portal reminders vs text message reminders on influenza vaccination rates across a health system. Design, Setting, and Participants: This 3-arm randomized clinical trial was conducted from September 7, 2022, to April 30, 2023, among primary care patients within the University of California, Los Angeles (UCLA) health system. Interventions: Arm 1 received standard of care. The health system sent monthly reminder messages to patients due for an influenza vaccine by portal (arm 2) or text (arm 3). Arm 2 had a 2 × 2 nested design, with fixed vs responsive monthly reminders and preappointment vs no preappointment reminders. Arm 3 had 1 × 2 design, with preappointment vs no preappointment reminders. Preappointment reminders for eligible patients were sent 24 and 48 hours before scheduled primary care visits. Fixed reminders (in October, November, and December) involved identical messages via portal or text. Responsive portal reminders involved a September message asking patients about their plans for vaccination, with a follow-up reminder if the response was affirmative but the patient was not yet vaccinated. Main Outcomes and Measures: The primary outcome was influenza vaccination by April 30, 2023, obtained from the UCLA EHR, including vaccination from pharmacies and other sources. Results: A total of 262 085 patients (mean [SD] age, 45.1 [20.7] years; 237 404 [90.6%] adults; 24 681 [9.4%] children; 149 349 [57.0%] women) in 79 primary care practices were included (87 257 in arm 1, 87 478 in arm 2, and 87 350 in arm 3). At the entire primary care population level, none of the interventions improved influenza vaccination rates. All groups had rates of approximately 47%. There was no statistical or clinically significant improvement following portal vs text, preappointment reminders vs no preappointment reminders (portal and text reminders combined), or responsive vs fixed monthly portal reminders. Conclusions and Relevance: At the population level, neither portal nor text reminders for influenza vaccination were effective. Given that vaccine hesitancy may be a major reason for the lack of impact of portal or text reminders, more intensive interventions by health systems are needed to raise influenza vaccination coverage levels. Trial Registration: ClinicalTrials.gov Identifier: NCT05525494.

A community-partnered approach for diversity in COVID-19 vaccine clinical trials.

Introduction: Communities of color have faced disproportionate morbidity and mortality from COVID-19, coupled with historical underrepresentation in US clinical trials, creating challenges for equitable participation in developing and testing a safe and effective COVID-19 vaccine. Methods: To increase diversity, including racial and ethnic representation, in local Los Angeles County NIH-sponsored Phase 3 SARS-CoV-2 vaccine clinical trials, we used deliberative community engagement approaches to form a Community Consultant Panel (CCP) that partnered with trial research teams. Thirteen members were recruited, including expertise from essential workers, community-based and faith-based organizations, or leaders from racial and ethnic minority communities. Results: Working closely with local investigators for the vaccine studies, the CCP provided critical insight on best practices for community trust building, clinical trial participation, and reliable information dissemination regarding COVID-19 vaccines. Modifying recruitment, outreach, and trial protocols led to majority-minority participants (55%-78%) in each of the three vaccine clinical trials. CCP's input led to cultural tailoring of recruitment materials, changes in recruitment messaging, and supportive services to improve trial accessibility and acceptability (transportation, protocols for cultural competency, and support linkages to care in case of an adverse event). Barriers to clinical trial participation unable to be resolved included childcare, requests for after-hours appointment availability, and mobile locations for trial visits. Conclusion: Using deliberative community engagement can provide critical and timely insight into the community-centered barriers to COVID-19 vaccine trial participation, including addressing social determinants of health, trust, clinical trial literacy, structural barriers, and identifying trusted messenger and reliable sources of information.