KB Collaboratory

A Protocol for a Facebook Intervention for Young Melanoma Survivors and Their Families

February 1, 2023 Klein Buendel

Individuals diagnosed with melanoma before the age of 40 (young-onset melanoma survivors) and their first-degree relatives (FDRs) are a growing population at risk for developing recurrent melanoma or new melanomas. Regular surveillance using clinical skin examination (CSE) and skin self-examination (SSE), and engagement in preventive behaviors including sun protection are recommended. Given the growing population of young melanoma survivors and their families who are at increased risk, it is surprising that no behavioral interventions have been developed and evaluated to improve risk-reduction behaviors.

In response, 16 researchers from ten institutions and organizations have developed an intervention and published its protocol in JMIR Research Protocols. Ultimately, the intervention is designed to improve skin cancer prevention and screening for young-onset melanoma survivors and their families. The authors believe the intervention’s delivery via Facebook will increase its impact because of the dissemination potential.

The randomized controlled trial will evaluate the efficacy of a Facebook intervention providing information, goal setting, and peer support to increase CSE, SSE, and sun protection for young-onset melanoma survivors and their FDRs. A sample of over 500 melanoma survivors and their FDRs will be randomly assigned to either the Young Melanoma Family Facebook Group or another Facebook group control condition. Before and after the intervention, study participants will complete measures of CSE, SSE, sun protection, attitudes, and beliefs. An additional objective is to evaluate the efficacy of the Facebook interventions on perceived stress, physical activity, and healthy eating behaviors.

The authors plan to complete study enrollment by late 2023. Data analysis will employ multilevel modeling with family as the upper-level sampling unit and individual as the lower-level sampling unit. According to the authors, “Fixed effect predictors in these models will include condition, role, sex, all 2- and 3-way interactions, and covariates.” If effective, the Young Melanoma Family Facebook program could be disseminated by dermatology practices, public health and nonprofit melanoma organizations, and existing melanoma and skin cancer Facebook groups, expanding its reach.

Paper Authors and Affiliations

Dr. Sharon Manne, Dr. Carolyn Heckman, Sara Frederick, Mara Domider, and Marissa Grosso: Behavioral Sciences, Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, New Jersey

Dr. Sherry Pagoto: Department of Allied Health Sciences, College of Agriculture, Health and Natural Resources, University of Connecticut, Storrs, Connecticutt

Dr. Susan Peterson: Department of Behavioral Science, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, The University of Texas, San Antonio, Texas

Dr. Deborah Kashy: College of Social Science, Department of Psychology, Michigan State University, East Lansing, Michigan

Dr. Adam Berger: Division of Surgical Oncology, Department of Surgery, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, New Jersey

Dr. Christina Studts: Pediatrics – General Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado

Dr. Rosalyn Negron: College of Liberal Arts, University of Massachusetts Boston, Boston, Massachusetts

Dr. David Buller: Klein Buendel, Inc, Golden, Colorado

Dr. Lisa Paddock and Alexandria Kulik: Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey

Joseph Gallo: Hackensack Meridian Jersey Shore Medical Center, Hackensack Meridian Health, Neptune City, New Jersey

Morgan Pesanelli: School of Public Health, Rutgers, The State University of New Jersey, New Brunswick, New Jersey

This project was supported by a grant from the National Cancer Institute to Rutgers University (CA221854; Dr. Sharon Manne, Principal Investigator). Dr. David Buller, Klein Buendel Director of Research, is a Co-Investigator on the project.

Collaborator Spotlight:
Dr. Wendy Hadley

January 3, 2023 Klein Buendel

Wendy Hadley, PhD, is an Associate Professor in the Department of Counseling Psychology and Human Services in the College of Education at the University of Oregon. She is also the Julie and Keith Thomson Faculty Chair and HEDCO Clinic Director at the University of Oregon.

Dr. Hadley received her doctoral degree in clinical child psychology and behavioral medicine from the University of Memphis in 2003. She went on to complete a postdoctoral fellowship with the Brown University Clinical Consortium. Dr. Hadley has worked with many pediatric patients and their families, including those affected by cancer, HIV, feeding disorders, cardiac issues, and obesity.

In addition to her clinical work, Dr Hadley conducts research on adolescent health issues such as obesity, substance use, and risky sexual behaviors. Her recent work has focused on the development and evaluation of interventions focusing on parent-child communication, parental monitoring, and adolescent emotion regulation skills. Some of her work uses web-based technology to deliver and enhance the interventions.

Dr. Hadley is currently working as a Co-Investigator on a collaborative web-based project with Dr. Christopher Houck (Principal Investigator) from Rhode Island Hospital and its parent organization Lifespan Health Systems. The program is called iTRAC, which stands for “Talking about Risk and Adolescent Choices.” The research is funded by an STTR Fast-Track grant to Klein Buendel from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Dr. Christopher Houck, Principal Investigator; HD110333). The goal of the project is to convert the previously existing TRAC program to a web app format while integrating emotional regulation and sexual health education. The program targets young adolescents (ages 12-14 years) at a crucial time of development in order to provide them with evidence-based approaches to manage emotional situations and risky behavior. Additional Co-Investigators include Dr. David Barker from Rhode Island Hospital and Ms. Julia Berteletti from Klein Buendel.

2022 Research Highlights

December 30, 2022 Klein Buendel

Klein Buendel celebrated its 20^th Anniversary in 2022! Our scientists and staff continued to pursue rigorous behavioral science research with numerous national and international collaborators. Our creative team designed and engineered multiple web-based programs to positively impact the health and safety of people’s everyday lives.

In 2022, we launched four new prime research projects and started two new subaward collaborations with Emory University and Harvard University. We published (or e-published ahead of print) ten research papers in peer-reviewed journals and presented research analyses and outcomes at eight regional, national or international conferences.

In February, a targeted version of our WayToServe responsible alcohol server training program was launched for the state of California by our licensee, Wedge Communications. WayToServe is now sold in Colorado, California, New Mexico, Oregon, and Washington.

In September, we welcomed a new Scientist, Dr. Kayla Nuss, to Klein Buendel. Dr. Nuss’ research interests center on motivation for physical activity, how wearable technology supports or thwarts motivation in various populations, and how to optimize wearable technology to support the development and maintenance of engagement in physical activity. Dr. Nuss graduated with a Ph.D. in Bioenergetics from Colorado State University in 2021.

In October, Dr. David Buller, Director of Research, participated in a discussion on responsible vendor practices for alcohol and cannabis sponsored by the New Jersey Prevention Network.

In December, Dr. Barbara Walkosz, Senior Scientist, gave a presentation for NATO and the Center for Media Literacy. The webinar was about the pandemic, the dangers of misinformation, health communication, and media literacy.

Prime Projects Launched in 2022

“Computer-based Learning to Enhance ADRD Care in Prison: Just Care for Dementia.” Phase I STTR grant to Klein Buendel from the National Institute on Aging (AG078103; Dr. Susan Loeb from Penn State University, Principal Investigator).

“Translation of an In-Person Brief, Bystander Bullying Intervention (STAC) into a Technology-Based Program.” Phase II STTR grant to Klein Buendel from the National Institute on Minority Health and Health Disparities (MD014943; Dr. Aida Midgett from Boise State University, Principal Investigator).

“#4Corners 4Health: A Social Media Cancer Prevention Program for Rural emerging Adults.” R01 grant to Klein Buendel from the National Cancer Institute (CA268037; Dr. David Buller from Klein Buendel and Dr. Andrew Sussman from the University of New Mexico, Multiple Principal Investigators).

“An Interactive Education Program to Reduce High Risk Behavior in Adolescents.” Fast Track STTR grant to Klein Buendel from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (HD110333; Dr. Christopher Houck from Lifespan Health Systems and Rhode Island Hospital, Principal Investigator).

For these new prime projects and two new subaward projects, we are collaborating with primary investigators from the following universities and organizations:

Boise State University
Colorado State University
Emory University
Georgetown University
Harvard University
Penn State University
Rhode Island Hospital/Lifespan Health Systems
University of Arizona
University of Colorado
University of New Mexico
University of Oregon
University of Utah

2022 Publications*

Buller DB, Pagoto S, Henry KL, Baker K, Walkosz BJ, Hillhouse J, Berteletti J, Bibeau J, Kinsey A. Persisting effects of a social media campaign to prevent indoor tanning: a randomized trial. Cancer Epidemiol Biomarkers Prev. 2022; 31(4):885-892.

Wallace GT, Buller DB, Pagoto S, Berteletti J, Baker KE, Mathis S, Henry KL. Nonmedical prescription drug use among female adolescents: the relative influence of maternal factors, social norms, and perceptions of risk and availability. Drugs (Abingdon, England). 2022. Published online ahead of print. doi: 10.1080/09687637.2022.2028727

Myers VH, Loeb S, Kitt-Lewis E, Jerrod T. Large-scale evaluation of a computer-based learning program to increase prison staff knowledge on geriatric and end-of-life care. Int J Prison Health. 2022. Published online ahead of print. doi: 10.1108/IJPH-08-2021-0078.

Greene MM, Schoeny ME, Berteletti J, Keim SA, Neel ML, Patra K, Smokse S, Breitenstein S. ezPreemie study protocol: a randomized controlled factorial trial testing web-based parent training and coaching with parents of children born very preterm. BMJ Open. 2022;12: e063706. doi: 10.1136/bmjopen-2022-063706.

Midgett A, Doumas DM, Buller MK. Posttraining outcomes, acceptability, and technology-based delivery of the STAC Bystander Bullying Intervention teacher module: mixed methods study. JMIR Form Res. 2022 Aug;6(8):e40022. doi: 10.2196/40022.

Buller DB, Pagoto S, Henry KL, Baker K, Walkosz BJ, Hillhouse J, Berteletti J, Bibeau J. Effects of engagement with a social media campaign for mothers to prevent indoor tanning by teens in a randomized trial. J Health Commun. 2022 Jun 3;27(6):394-406.

Buller D, Walkosz B, Henry K, Woodall WG, Pagoto S, Berteletti J, Kinsey A, DiVito J, Baker K, Hillhouse J. Promoting social distancing and COVID-19 vaccine intentions to mothers: randomized comparison of information sources in social media messages. JMIR Infodemiol. 2022 Jul-Dec;2(2):e36210. doi: 10.2196/36210.

Dobbinson SJ, Buller DB, Chamberlain JA, Simmons J, Buller MK. Solar UV measured under built-shade in public parks: findings from a randomized trial in Denver and Melbourne. Int J Environ Res Public Health. 2022 Aug 25:19(17):10583. doi: 10.3390/ijerph191710583.

Buller DB, Pagoto S, Walkosz BJ, Woodall WG, Berteletti J, Kinsey A, Henry K, DiVito J. The process of responding to COVID-19 misinformation in a social media feed. J Public Health Manag Pract. 2022. Published online ahead of print. doi: 10.1097/PHH.0000000000001679.

Houck C, Modrowski CA, Hadley W, Barker D, Myers V, Bala K, Wickham B, Jerrod T. A pilot study of a tablet-based emotion regulation intervention for early adolescents. J Dev Behav Pediatr. 2022 Oct/Nov;43(8):e505-e514(10). doi: 10.1097/DBP.0000000000001094.

*KB investigators and staff (current or at the time of the project) are indicated in bold type

2022 Conference Presentations

Research analyses and outcomes were presented and disseminated by KB scientists, staff, and their collaborators at the following national and international conferences in 2022:

34^th Annual Scientific Sessions of the Eastern Nursing Research Society (March/April)
43^rd Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine (April)
72^nd Annual Conference of the International Communication Association (May)
47^th Annual Meeting of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol (May/June)
45^th Annual Scientific Meeting of the Research Society on Alcoholism (June)
National Association of Media Literacy Education Conference (July)
State of the Science Congress on Nursing Research (September)
Mountain West CTR-IN Annual Meeting (November)

Addressing COVID-19 Misinformation

December 12, 2022 Klein Buendel

Misinformation online can confuse consumers and influence people to dismiss vital public health advice. Health Chat team members from Klein Buendel, the University of Connecticut, and Colorado State University have published analyses of misinformation from a social media study in the Journal of Public Health Management and Practice. The purpose of the study was to examine how an epidemiological procedure for monitoring, diagnosing, and responding quickly to misinformation among members of a Facebook group may have affected debate and dropout among group members.

Facebook group participants were 303 mothers of adolescent daughters. The Facebook group was administered by a community manager. The social media feed varied the source of information in posts on four topics: social distancing, COVID-19 vaccines, digital and media literacy, and family communication about COVID-19. Mothers received one social media post each weekday in three randomly assigned Facebook private groups, covering all four topics plus one additional post on a positive non-pandemic topic to promote broad engagement. Posts in the three groups had the same messages but differed by links to information from government agencies, near-peer parents, or news media sources in the post.

The community manager identified misinformation in mothers’ comments. Misinformation was defined as COVID-19 information in opposition to recommendations from the Centers for Disease Control and Prevention, National Institutes of Health, and/or World Health Organization. Misinformation took several forms. In some comments, mothers directly presented false information or expressed their own negative opinions or opposition toward COVID-19 prevention. In other comments, mothers presented misinformation indirectly.

Research methods and analyses are detailed in the Journal of Public Health Management and Practice paper. Most misinformation comments were in response to posts about vaccination, followed by non-pharmaceutical interventions, digital and media literacy, and family communication. The responsive epidemiological protocol exposed the mothers to credible information and appeared to prevent debate and dropout of Facebook group members.

This research was funded by a grant and supplement from the National Cancer Institute (CA192652). Dr. David Buller from Klein Buendel and Dr. Sherry Pagoto from the University of Connecticut were the project’s Multiple Principal Investigators. Additional authors on this publication include Joseph Divito from the University of Connecticut; Dr. Kim Henry from Colorado State University; and Dr. Barbara Walkosz, Dr. Gill Woodall, Julia Berteletti, and Alishia Kinsey from Klein Buendel.

STAC Parent Module Pilot Study

November 28, 2022 Klein Buendel

Klein Buendel collaborator, Dr. Aida Midgett from Boise State University, presented formative research findings from her CTR-IN Pilot Grant at the Mountain West CTR-IN Annual Meeting in Las Vegas, Nevada, November 17-18, 2022. Mountain West CTR-IN connects research investigators to mentors, collaborators, and funding opportunities to improve the health and lives of people in mountain west communities, including through research projects funded by the National Institutes of Health. Ms. Mary Buller, President of Klein Buendel, is Dr. Aida’s mentor for the CTR-IN Pilot Grant.

Dr. Midgett presented on the “Development, Acceptability, and Short-Term Outcomes of a Parent Module for Brief, Bullying Bystander Intervention for Middle School Students in Rural, Low-Income Communities.” Her co-author was Dr. Diana Doumas from Boise State University. The project statistician was Ms. Laura Bond from Boise State University. The pilot study used a mixed-methods design to develop a 30-minute pre-recorded Parent Module as a companion training to a brief bullying prevention program for middle schools, called STAC. The study assessed the need, feasibility, acceptability, delivery format preference and immediate outcomes (e.g., knowledge, attitudes, self-efficacy, and behavioral intentions) of the Parent Module.

As background, the STAC bystander intervention is a 75-minute training that includes didactic and experiential components. It teaches middle school students to act as “defenders” on behalf of targets of bullying through utilizing four intervention strategies: (1) “Stealing the Show” – using humor or distraction to interrupt a bullying situation and remove the attention away from the target; (2) “Turning it Over” – identifying a trusted adult at school, reporting, and asking for help during a bullying incident; (3) “Accompanying Others” – befriending and/or providing support to a peer who was a target of bullying; and (4) “Coaching Compassion” – gently confronting the perpetrator and increasing empathy for the target.

Dr. Midgett reported that preliminary data with 23 parents in the pilot study demonstrated acceptability, relevance, and need and increases in immediate post-training outcomes including knowledge, confidence, self-efficacy, responsibility, and anti-bullying attitudes, as well as parents’ behavioral intentions to support their adolescents to utilize the STAC strategies.

Another aim of Dr. Midgett’s CTR-IN pilot grant is to provide data to support a STTR Fast Track proposal to develop and evaluate a web-based version of the Parent Module as a STAC companion training. The proposal will be submitted through Klein Buendel and the research plan will include a multi-site randomized trial in rural schools. Klein Buendel’s Creative Team will program the web-based Parent Module.

iTRAC Pilot Study

November 16, 2022 Klein Buendel

A research team led by Dr. Christopher Houck from Lifespan and the Rhode Island Hospital has published a paper in the Journal of Developmental & Behavioral Pediatrics on the feasibility and acceptability of an initial digital iTRAC (Talking About Risk and Adolescent Choices) intervention. Collaborators included colleagues from the Rhode Island Hospital, the University of Oregon, Brown University, Penn State University, and Klein Buendel. iTRAC is a tablet-based intervention to promote emotion regulation skills among middle schoolers as a strategy for reducing risky behavior.

For the pilot study, adolescents aged 12–14 years were recruited from three urban schools for advisory groups (n=15), acceptability testing (n=11), and pilot testing (n=85). Youth advisory boards and expert panels tailored content, resulting in an animated intervention of instructional videos, games, and activities designed to teach emotion regulation strategies to young adolescents. Eighty-five adolescents were randomized to the 4-module digital iTRAC intervention or a wait-list control group. Adolescents and one parent completed baseline and 3-month follow-up questionnaires examining emotion regulation attitudes and behaviors. The adolescent participants also completed behavioral tasks related to distress tolerance.

Eighty-eight percent of those randomized to iTRAC completed all modules. Moderate effect sizes were found from baseline to follow-up on adolescents’ beliefs in the controllability of emotions, awareness of emotions, self-efficacy for managing emotions, perceived access to emotion regulation strategies, and use of emotion regulation strategies. Parent measures of adolescent regulation showed mixed results.

A tablet-based intervention to enhance emotion skills for youth in early adolescence was deemed feasible and demonstrated promising indicators of impact on emotional competence. Increasing adolescents’ awareness of and access to emotion regulation strategies may reduce decisions driven by transient emotions, which in turn may reduce engagement in risky behavior and resultant negative health outcomes. The authors conclude that the brief iTRAC intervention may be used to increase emotional competency among middle schoolers.

Dr. Valerie Myers and Ms. Tiffany Jerrod, both formerly from Klein Buendel, were co-authors on this publication. Research on the full production and evaluation of iTRAC is continuing with an STTR Fast Track grant to Klein Buendel from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Dr. Christopher Houck, Principal Investigator from Lifespan; HD110333). Collaborators on the current study include Dr. Wendy Hadley from the University of Oregon; Dr. David Barker from Rhode Island Hospital; and Ms. Julia Berteletti from Klein Buendel. The iTRAC modules will be programmed by Klein Buendel’s Creative Team.

Welcome Dr. Kayla Nuss!

November 9, 2022 Klein Buendel

Dr. Kayla Nuss

Kayla Nuss, Ph.D., is Klein Buendel’s newest Scientist and Principal Investigator. Dr. Nuss comes to Klein Buendel from a post-doctoral fellowship with the Digital Health Lab at the University of Victoria in Canada, where she analyzed de-identified data for a comprehensive digital diabetes intervention program in India.

In 2021, Dr. Nuss earned her Ph.D. in Bioenergetics from Colorado State University (CSU). Her dissertation was titled “Wearable Fitness Trackers in Physical Activity Research: Accuracy and Effects on Motivation and Engagement.” She also has two Master’s Degrees: one in Health and Exercise Science from CSU and a second in Student Development in Post-Secondary Education from the University of Iowa. She has a Bachelor’s Degree in Psychology and Spanish from Cornell College in Iowa. And she graduated from our local Golden High School!

Dr. Nuss’ research interests center on motivation for physical activity, how wearable technology supports or thwarts motivation in various populations, and how to optimize wearable technology to support the development and maintenance of engagement in physical activity.

At Klein Buendel, she is currently collaborating with Dr. Robert Newton from the Pennington Biomedical Research Center in Louisiana, Dr. Derek Griffith from Georgetown University, and Dr. David Buller from Klein Buendel on a research study to address physical activity maintenance in African American men with smartphone technology (MD014947; Dr. Robert Newton and Dr. Kayla Nuss, Multiple Principal Investigators).

Dr. Nuss is also a Co-Investigator on a collaborative team of highly-experienced cancer prevention and control investigators from the Four Corners Cancer Centers Collaborative (University of Arizona, University of Colorado, University of New Mexico, and University of Utah), Colorado State University, and Klein Buendel (CA268037; Dr. David Buller and Dr. Andrew Sussman from the University of New Mexico, Multiple Principal Investigators). This team is launching a 5-year research study focusing on decreasing cancer risk factors among emerging adults (ages 18-26) living in rural counties in the “Four Corners” states (Arizona, Colorado, New Mexico, and Utah) using a social media campaign. Dr. Nuss will lend her expertise in the area of motivation for physical activity.

iTRAC Fast Track Project

October 12, 2022 Klein Buendel

A collaborative research team from the University of Oregon, Rhode Island Hospital and its parent organization Lifespan Health Systems, and Klein Buendel has launched a new research project to develop and evaluate the impact of an emotion regulation program for adolescents. iTRAC will be a web-based program for “Talking about Risk and Adolescent Choices” to prevent risky sexual behavior and negative sexual health outcomes through emotion regulation strategies. The original TRAC program was developed and evaluated in multiple previous studies (MH078750, NR011906, and HD089979) by Dr. Christopher Houck from Lifespan and his team.

In the new study, the original TRAC will be enhanced for emotion regulation, programmed as a web-based app (iTRAC) and assessed for acceptability by adolescents ages 12 to 14. The investigators will then conduct a randomized controlled trial examining the efficacy of the completed iTRAC intervention relative to a waitlist control among 120 adolescents. The study will examine the efficacy of iTRAC relative to a waitlist control in enhancing theoretically important emotional competencies, such as emotion regulation, emotion recognition, and distress tolerance that mediate risk as measured by self-report, performance measures, and parent report.

The investigators hypothesize that: (1) iTRAC will receive positive adolescent ratings during acceptability testing for ease of use, enjoyment, and usefulness of content; (2) participants in iTRAC will report greater self-efficacy for sexual risk prevention skills over 6-month follow-up than comparison participants; and (3) youth in iTRAC will exhibit improved emotional competencies relative to the comparison group.

The iTRAC project is funded by an STTR Fast Track grant to Klein Buendel from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Dr. Christopher Houck, Principal Investigator from Lifespan; HD110333). Collaborators include Dr. Wendy Hadley from the University of Oregon; Dr. David Barker from Rhode Island Hospital; and Ms. Julia Berteletti from Klein Buendel. The iTRAC modules will be programmed by Klein Buendel’s Creative Team.

Collaborator Spotlight:
Dr. Alexandra Morshed

October 3, 2022 Klein Buendel

Alexandra Morshed, Ph.D., is a Research Assistant Professor in the Department of Behavioral, Social and Health Education Services at Emory University. She is also a Co-Investigator with the Emory Prevention Research Center. Dr. Morshed received her Master of Science degree from Wageningen University in the Netherlands and her Ph.D. from Washington University in St. Louis.

Dr. Morshed is an implementation scientist with more than ten years of experience in public health research and practice. Her primary areas of interest include implementing interventions in vulnerable populations, chronic disease prevention, public health nutrition, and capacity building and knowledge expansion in dissemination and implementation science.

Dr. Morshed is currently collaborating with Dr. David Buller from Klein Buendel on a research study titled “Go Sun Smart at Work: A Sun Safety Program for Underserved Outdoor Workers” (Dr. Morshed and Dr. Buller, Multiple Principal Investigators). This CDC-funded study builds upon Klein Buendel’s evidence-based comprehensive occupational skin cancer prevention intervention, Go Sun Smart at Work, and aims to reduce UV exposure and prevent skin cancer among underserved outdoor workers in Georgia. Hispanic and African American adults have been overlooked in skin cancer prevention efforts, due to their lower incidence of skin cancer. However, among Hispanic and African Americans, skin cancer is diagnosed at more advanced stages, leading to higher mortality rates than non-Hispanic whites. The Emory University study aims to develop an intervention and implementation strategies to increase policies and practices to support sun safety among outdoor workers in Georgia.