Health Care For Asylum Seekers Research Articles

In their own words: facilitators and barriers to oral health care for asylum seekers and refugees.

In their own words: facilitators and barriers to oral health care for asylum seekers and refugees.

Low access and inadequate treatment in mental health care for asylum seekers and refugees in Germany-A prospective follow-up study over 12 months and a nationwide cross-sectional study.

Refugees experience elevated rates of mental health problems, but little is known about mental health service utilization and quality among asylum seekers and refugees in Europe. In a 12-month follow-up study of newly arrived refugees (N= 166, Mage= 32.38 years, 30.7% female) and a nationwide cross-sectional study (N= 579, Mage= 33.89 years, 36.2% female) of refugees who had been living in Germany for an average of 6 years, we examined objective need for mental health treatment, perceived need, access to treatment services, and adequacy of treatment. We defined minimally adequate mental health treatment according to the WHO World Mental Health Survey as ≥8 sessions of psychotherapy (minimally adequate psychotherapy) or pharmacotherapy plus ≥4 medical visits (minimally adequate pharmacotherapy). In both studies, two in three individuals screened for mental health symptoms and additionally perceived a need for professional treatment. Of those, less than half had contact to any service provider, with only 1 in 14 receiving minimally adequate psychotherapy. Overall, no more than one in seven of refugees in need received minimally adequate treatment. Despite a comprehensive mental health-care system, refugees' access to mental health care and the treatment provided are inadequate. Health policies are urgently needed to provide equitable mental health care for all.

Healthcare for Asylum Seekers and Refugees; A Scoping Review

Abstract The number of asylum seekers and refugees entering the UK is increasing. There is a strong body of evidence considering the health needs and barriers that this group experience. There is far less evidence on the best models for the organisation, delivery and provision of health services for these populations. This scoping review synthesised the published evidence and evaluations on how health care services for asylum seekers and refugees are organised and delivered across the UK. Electronic databases were searched in June 2022 to identify relevant peer reviewed literature from 2002 onwards. Mental and physical health services for adults and children were included. To source grey literature, requests for relevant service evaluations were made through the UK Health Security Agency, the Office for Health Improvement and Disparities Migrant Health Network and the websites of relevant organisations were searched. Six semi structured interviews were carried out with public health practitioners and clinicians working with asylum seekers and refugees. Twenty-one articles were included in the scoping review. Nine (42.8%) were focused on services in London. Seven (33.3%) articles were service evaluations. The majority were descriptive analyses, surveys or reports. Only seven (33.3%) of articles included service users’ views. A thematic analysis grouped the articles and interviews into six themes; accessibility, link worker, training, integrated pathways, GP registration and time. There is a paucity of evidence relating to the delivery and effectiveness of services for asylum seekers and refugees in the UK. The key themes identified were consistent over the 20-year search period. Recommendations for services include routine evaluation of services with dissemination of findings and patient and public involvement. Given the increasing numbers and health needs of this group, the economic evaluation of health care services is essential. Key messages • There is a paucity of evidence on healthcare delivery for asylum seekers and refugees. • Key themes for services are accessibility, link worker, training, integrated pathways, GP registration and time.

'Fragmented care': Asylum seekers' experience of accessing health care in NSW.

Medicare is central to accessing health care in Australia, yet many asylum seekers are ineligible for this scheme. In NSW, Medicare ineligible asylum seekers have some access to public health care under the Medicare Ineligible Asylum Seekers - Provision of Specified Public Health Services policy. This policy was updated in November 2020 to clarify services where a fee waiver applies for asylum seekers without Medicare. We examined the experiences of Medicare ineligible asylum seekers in accessing health care in New South Wales (NSW) in light of the revised policy. Employing qualitative methods, we conducted semi-structured interviews with asylum seekers (n = 7) and service providers (n = 6) in South Western Sydney. The interviews were analysed using thematic analysis and the socio-ecological model was used to interpret the data. Participants identified that chronic and mental health conditions are the main health issues for asylum seekers. Factors across the four levels of the socio-ecological model were identified as influencing the health care of asylum seekers, including a lack of awareness about health care rights at the individual level, support from relatives and friends at the interpersonal level, providers' lack of awareness of fee waivers at the organizational level and limited access to primary health care at the policy level. The results imply that Medicare ineligible asylum seekers in NSW do not have optimal access to health care which may worsen existing health disparities. Educational initiatives that improve service providers' and asylum seekers' awareness of the revised policy are needed to improve asylum seeker health equity in NSW.

The patient journey of newly arrived asylum seekers and responsiveness of care: A qualitative study in Germany.

BackgroundResearch on health and healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness, as non-medical quality of care, in the narratives of ASR patients recently arrived in Germany.Methods31 ASR with existing medical conditions were recruited in six refugee reception centres and three psychosocial centres. Semi-structured, qualitative interviews were conducted which reconstructed their patient journey after arrival in Germany. Interviews were recorded, transcribed verbatim and evaluated using thematic analysis.ResultsThe experiences of participants throughout the patient journey provided a rich and varied description of the responsiveness of health services. Some dimensions of responsiveness, including respectful treatment, clear communication and trust, resurfaced throughout the narratives. These factors were prominent reasons for positive evaluations of the health system, and negative experiences were reported in their absence. Other dimensions, including cleanliness of facilities, autonomy of decision-making and choice of provider were raised seldomly. Positive experiences in Germany were often set in contrast to negative experiences in the participants’ countries of origin or during transit. Furthermore, many participants evaluated their experience with healthcare services in terms of the perceived technical quality of medical care rather than with reference to responsiveness.ConclusionThis qualitative study among ASR analysed patient experiences to better understand responsiveness of care for this population. While our results show high overall satisfaction with health services in Germany, using the lens of responsiveness allowed us to identify particular policy areas where care can be strengthened further. These include in particular the expansion of high-quality interpreting services, provision of professional training to increase the competency of healthcare staff in caring for a diverse patient population, as well as an alignment between healthcare and asylum processes to promote continuity of care.

Factors affecting oral health care for asylum seekers and refugees in England: a qualitative study of key stakeholders' perspectives and experiences.

Aims To investigate factors influencing oral health behaviours and access to dental services for asylum seekers and refugees (ASRs).Methods A qualitative research study using purposeful sampling was undertaken in South West England. Online semi-structured interviews with stakeholders working with or supporting ASRs were analysed through reflexive thematic analysis.Results Twelve participants providing support to ASRs in various capacities participated. Two interviewees had lived experience of forced displacement and the UK asylum process. Key themes into what hinders ASRs' oral health care were: prioritising safety and survival; variations in cultural norms and practice; lack of knowledge about dental care; financial hardship and affordability of care; a gulf of understanding of what dental care would be like and experiences of it; and structures of dental services that leave vulnerable groups behind. Opportunities for improving oral health care were: accessible oral health education; partnership working and creating supportive environments; translation; providing culturally sensitive and person-centred care; and incorporating ASRs' views into service design.Conclusions Several factors affect to what extent ASRs can and are willing to engage with oral health care. Co-developing accessible and relevant prevention programmes and ensuring equitable access to dental services for ASRs is important. Future research should explore ASRs' views and experiences of dental care and explore informed suggestions on how to optimise oral health promotion and provision of care.Supplementary InformationZusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-022-4340-5 für autorisierte Leser zusätzliche Dateien abrufbar.

Health Care for Refugees in Europe: A Scoping Review.

Background: Accessing and using health care in European countries pose major challenges for asylum seekers and refugees due to legal, linguistic, administrative, and knowledge barriers. This scoping review will systematically describe the literature regarding health care for asylum seekers and refugees in high-income European countries, and the experiences that they have in accessing and using health care. Methods: Three databases in the field of public health were systematically searched, from which 1665 studies were selected for title and abstract screening, and 69 full texts were screened for eligibility by the main author. Of these studies, 44 were included in this systematic review. A narrative synthesis was undertaken. Results: Barriers in access to health care are highly prevalent in refugee populations, and can lead to underusage, misuse of health care, and higher costs. The qualitative results suggest that too little attention is paid to the living situations of refugees. This is especially true in access to care, and in the doctor-patient interaction. This can lead to a gap between needs and care. Conclusions: Although the problems refugees and asylum seekers face in accessing health care in high-income European countries have long been documented, little has changed over time. Living conditions are a key determinant for accessing health care.

Sick and Tired-Sociodemographic and Psychosocial Characteristics of Asylum Seekers Awaiting an Appointment for Psychotherapy.

Background: An EU directive holds the EU member states responsible for implementing the provision of health care for asylum seekers. However, current literature indicates insufficient care for asylum seekers in the German health system. This article aims to characterize the situation of the client population on the waiting list of a psychosocial center (PSZ). Methods: We conducted a retrospective observational study based on client files in Halle (Saale), Germany. We included 437 adults who were on the PSZ waiting list between 2016 and 2019. Questionnaires that collected information on the clientele at two different times were analyzed. Results: The average waiting time for psychotherapy was 50 weeks. In total, 85.6% of the 188 respondents reported sleep disorders (n = 161), 65.4% of clients reported pain (n = 123) and 54.8% suicide attempts/suicidal thoughts (n = 54). In the 16-week waiting period in which the clients waited for an initial appointment with a psychologist, the residence status deteriorated in 21.3% (n = 40). Conclusion: Improving asylum seekers’ access to the German health system is urgently needed in order to prevent unnecessary suffering in the future and to comply with EU law.

Improving access to health care for asylum seekers in Belgium: a national stakeholder consultation

Abstract Background All asylum seekers (AS) in Belgium are entitled to health care coverage while awaiting a decision regarding a refugee status. However, in practice, numerous public institutions oversee the governance, the distribution of funding and the practical organisation of health care. As a result, AS have currently no guarantee of receiving the health care they need. Methods In 2017-2019, a 5-step approach was used. Firstly, 3 data sources were combined to identify major problems and possible options to solve it (literature, interviews, and existing databases). Secondly, these options were submitted to a large panel of Belgian experts, field workers and policymakers through an online survey (n = 171). Survey results and non-consensual results were discussed in a 3rd step with 35 field workers, experts, and policymakers. In a 4 step, individual interviews were conducted with stakeholders likely to be affected by the different options. In a final step, all stakeholders attended a final meeting following by an online consultation to validate the final options. Results Stakeholders agreed on 3 basic principles that should sustain a reform of health care for AS: respecting the current legal framework, ensuring equity among all AS and supporting administrative simplification. Three different models of access emerged with 2 options regarding the governance of health care for AS and 3 options for the distribution of the funding. Each model was assessed regarding its impact on the identified problems and the respect of the 3 basic principles. Besides, 8 quick-wins at the system level and 6 at the organisation level were proposed. Conclusions Despite the involvement of the policymakers, no consensus was found at the end of the research. Final decision will then remain in the hands of the policymakers. Key messages In Belgium, access to health care for asylum seekers is impeded by the numerous public institutions involved. Equity between asylum seekers should be guaranteed by an appropriate governance and an adequate distribution of funding.

Trauma, Post-Traumatic Stress Disorder, and Mental Health Care of Asylum Seekers.

Asylum seekers in Israel from East Africa frequently experienced traumatic events along their journey, particularly in the Sinai Peninsula, where they were subjected to trafficking and torture. Exposure to trauma has implications for rights that are contingent on refugee status. This retrospective chart review aimed to characterize the types of traumas experienced by 219 asylum seekers (149 men) from Eritrea and Sudan who sought treatment at a specialized mental health clinic in Israel, and to compare the mental health of trauma victims (n = 168) with that of non-trauma victims (n = 53). About 76.7% of the asylum seekers had experienced at least one traumatic event, of whom 56.5% were diagnosed with post-traumatic stress disorder (PTSD). Most reported traumas were experienced en route in the Sinai, rather than in the country of origin or Israel. Few clinical differences were observed between trauma victims and non-trauma victims, or between trauma victims with and without a PTSD diagnosis. Our findings emphasize the importance of accessibility to mental and other health services for asylum seekers. Governmental policies and international conventions on the definition of human trafficking may need to be revised, as well as asylum seekers’ rights and access to health services related to visa status.

Mental healthcare for asylum-seekers and refugees residing in the United Kingdom: a scoping review of policies, barriers, and enablers

BackgroundSince 2011, a large influx of asylum-seekers and refugees has put pressure on the UK’s under-resourced national health services and mental health services. Asylum-seekers and refugees (ASR) may experience traumatic events pre-departure, life-threating circumstances on their journeys, and difficulties integrating into host countries related to immigration policies, social isolation, poor living conditions, and unemployment, all of which can significantly affect their mental health. This topic is increasingly important due to the numbers of people seeking asylum and growing concern for their mental health on resettlement. This study examined UK-wide policies and guidance, healthcare practices, barriers, and enablers of mental healthcare for ASR residing in the UK.MethodsWe conducted a scoping review using Arksey and O’Malley’s 2005 framework, which included semi-structured interviews with stakeholders from non-governmental organisations, academia, UK National Health Service, and community groups. We synthesised and analysed literature and interview data thematically to examine current barriers and potential enablers of ASR mental health support in the UK.ResultsWe included 39 literature sources, of 1,638 identified, and 10 stakeholder interviews. Sources, most published in 2019 (n = 13), included data from England (n = 13), Scotland (n = 3), Wales (n = 3), and Northern Ireland (n = 2) and covered access to care (n = 16), mental health disorders (n = 7), impacts on health (n = 7), barriers to care (n = 13), policies and plans (n = 4), and clinical recommendations (n = 3). Synthesised themes from literature and interviews included existing barriers (i.e. communication difficulties and lack of funding, resources, and political will) and potential enablers (i.e. proposed provision practices, social needs of ASR, and policy changes).ConclusionsThere is a gap in the literature regarding UK-wide assessment of access and delivery of mental healthcare for ASR in the UK. Time sensitive and culturally appropriate approaches are needed, with greater funding and resource support from the UK Government. This study provides justification for a call to relax hostile environment policies, and for ASR-specific mental health services and support to be considered within the UK. Further research is needed to assess implementation of guidelines across the UK.

Barriers and Potential Improvements in the Diagnosis and Treatment of Asylum Seekers with Tuberculosis in Germany: A Qualitative Study

Since 2014, the number of new cases of tuberculosis (TB) has risen in Germany by about 20%. This coincides with a large number of people applying for asylum in Germany. Some of them are from countries in which TB is much more prevalent than in Germany. The objectives of this contribution are to identify and explain barriers in the diagnosis and treatment of asylum seekers with TB and potential improvements in those fields. Data are derived from 14 problem-centred interviews that were carried out with doctors and staff from public health offices, representing the views of experts in the field of health care. On the one hand, the results suggest that structural factors are responsible for some of the barriers mentioned by the experts. For example, the restricted access to health care for asylum seekers leads to a delayed diagnosis since they visit the doctor too late (if at all). Accordingly, a nationwide implementation of an electronic health card for asylum seekers was proposed. On the other hand, individual and cultural factors play important roles as well. To those belong language barriers: they not only complicate history taking and diagnosis, but also educating patients about their disease and therapy. Moreover, the lack of knowledge concerning the German health care system increases the risk of treatment interruptions. To alleviate those problems, experts propose to carry out train-the-trainer-programmes and to install "guides" who pilot asylum seekers with TB through the German health care system.

Surveillance of health and primary care of asylum seekers in reception centers: concept and results

Abstract Background Reliable data on health and primary care among asylum seekers in reception centers are essential for the planning and provision of medical services, but haphazard care provision and lack of standards for health information systems in these centers preclude routine health monitoring. We aimed to establish a routine surveillance system in reception centers for asylum seekers in Germany, generating multi-center data on key health indicators. Methods To enable routine health surveillance, we established an electronic medical records system (RefCare©), a research network, and an IT-infrastructure for the automated analysis of health data in German reception centers. Within the network, 64 health and health care indicators on morbidity, care processes, quality of care and syndromic surveillance were identified. In November 2018, we analyzed 33 indicators using routine health data from nine centers in three federal states. We calculated single-center prevalence and pooled estimates for selected morbidity indicators stratified by age and sex, and process and quality indicators stratified by center. Results A total of 8,406 patients and 39,449 patient contacts were analyzed, with mean utilization of health services ranging from 2.33 (Standard deviation, SD: 2.0) to 11.49 (SD: 22.82). The morbidities with the highest prevalence were respiratory, digestive and certain infectious diseases, followed by consequences of external causes, musculoskeletal and mental health conditions. Irrational use of antibiotics was below the threshold for primary care settings. Conclusions For the first time in Germany, a harmonized infrastructure for the automated, anonymized surveillance of the health and health care of asylum seekers in reception centers was established in several federal states. The analysis of morbidity indicators shows a primary care-typical disease profile, with special needs regarding mental health and consequences of external causes, such as physical trauma. Key messages Routine health surveillance of asylum seekers in reception centers can be achieved through an innovative harmonized, cross-regional, multi-center, anonymous and automated surveillance system. Health issues of asylum seekers in reception centers in Germany mainly consist of primary care conditions with special vulnerabilities regarding mental health and consequences of external causes.

Health and primary care surveillance among asylum seekers in reception centres in Germany: concept, development, and implementation

Reliable data on health and primary care among asylum seekers in reception centres are not routinely available, but required to plan needs-based healthcare services. To present the concept, development, and implementation of aroutine surveillance system in reception centres for asylum seekers. In the scope of the project PRICARE, medical records in reception centres were standardized and digitized, and continuous surveillance was enabled by means of suitable IT infrastructure. The core elements of the surveillance system were developed in three project phases using an iterative and participative design. Federal Ministry of Health (Grant no. 2516FSB415). Forming the basis for the surveillance, the electronic health record Refugee Care Manager® (RefCare®) was developed and gradually implemented in 13 reception centres in three federal states. For implementing the tool in daily care routines, IT infrastructure was implemented in all sites and alegally required data protection concept was established. An indicator set was developed and agreed upon for the surveillance, comprising atotal of 64indicators in four domains: morbidity, processes of care, quality of care, and syndromic alerts. For the first time in Germany, aharmonized infrastructure spanning federal states was implemented in healthcare settings ensuring medical documentation and surveillance of health and healthcare of asylum seekers in conformity with data protection requirements. The surveillance is feasible; the long-term benefits of routine surveillance and research within the network will be assessed in the future.

Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK.

BackgroundAsylum seekers and refugees (ASR) face difficulty accessing health care in host countries. In 2017, NHS charges for overseas visitors were extended to include some community care for refused asylum seekers. There is growing concern that this will increase access difficulties, but no recent research has documented the lived experiences of ASR accessing UK primary health care.AimTo examine ASR experiences accessing primary health care in the UK in 2018.Design and settingThis was a qualitative community-based study. ASR were recruited by criterion-based sampling through voluntary community organisations.MethodA total of 18 ASR completed face-to-face semi-structured recorded interviews discussing primary care access. Transcripts underwent thematic analysis by three researchers using Penchansky and Thomas’s modified theory of access.ResultsThe qualitative data show that participants found primary care services difficult to navigate and negotiate. Dominant themes included language barriers and inadequate interpretation services; lack of awareness of the structure and function of the NHS; difficulty meeting the costs of dental care, prescription fees, and transport to appointments; and the perception of discrimination relating to race, religion, and immigration status.ConclusionBy centralising the voices of ASR and illustrating the negative consequences of poor healthcare access, this article urges consideration of how access to primary care in the UK can be enhanced for often marginalised individuals with complex needs.

Health Care for Asylum Seekers in Germany according to Asylum Seekers' Benefits Act: Public Perceptions and Preferences

This study analyses public perceptions and preferences regarding scope, access and funding of health care for asylum seekers (AS). Standardized survey addressing the population >18 years, combined quota plan, descriptive and inferential statistics. The sample (n=419) was rather badly informed about this topic. We found heterogeneous preferences. 47.0% preferred to maintain current regulations of the scope of health care, 22.7% wanted an expansion. 56.1% favored a health card. The EU, tax payers, countries of origin and AS were preferred as funders. A consideration of preferences might strengthen the acceptance and legitimation of decisions. Our results indicate that this would lead to moderate changes in health care for AS. Since participants were not well informed subjectively, we suggest qualitative research.

6.1-O6Improving access to appropriate health care for asylum seekers, migrants and refugees in Greece

6.1-O6Improving access to appropriate health care for asylum seekers, migrants and refugees in Greece

Prevalence of acid burns among asylum seekers hosted in an initial reception centre as an example of health assessment in a fragile population

to evaluate the prevalence of acid burns among asylum seekers hosted in an initial reception centre and to evaluate if the prevalence is reduced after the introduction of the European Union (EU) regulation No. 29 (14th September 2016) that indirectly reduced the permanence time of the subjects on board of boats. cross-sectional study. 10,627 asylum seekers hosted in the centre for initial reception of Piedmont and Valle d'Aosta Regions (Northern Italy) between June 2016 and May 2017. frequencies of health problems and prevalence of second and third grade acid burns identified on arrival. among the asylum seekers coming to the centre, about 25% suffered at least from a mild disease, mainly cutaneous, respiratory, or digestive; 69 acid burns were identified (prevalence: 6.7‰, 95%CI 5.2-8.3), mainly located in the lower limbs and in the glutes. Median time between disembarkation and treatment is 2 days. Prevalence is significantly higher in women compared to men and a not-significant 20% reduction was observed comparing the situation before and after the introduction of the EU regulation No. 29. an assessment of the health status of asylum seekers that takes into account more than the identification of the rare life-threatening or infective diseases allows to take prompt action and to invest economical resources in the fields where they are more useful. This would facilitate a good health care for asylum seekers, that is the basis of an efficient functioning of services for integration.

Sleepless Nights because of Ethical Dilemmas in Mental Health Care for Asylum Seekers

The number of asylum requests in the Netherlands in 2015 was relatively high but comparable to 20 years ago. This article compares the social, political and cultural factors in mental health professionals' ethical dilemmas and reflections in both periods. The data consists of papers from an expert meeting in 1995 on Medical Ethical Standards in Mental Health Care for Refugees, and interviews and focus groups with health professionals on ethical dilemmas in mental health care for asylum seekers in 2015. Using a discursive approach to analyse the data, we found that, in 1995, as well as in 2015, the deliberations of mental health professionals reveal medical, social, cultural and judicial paradigms. In 2015, political factors tend to weigh more heavily than in 1995. We conclude that, in both periods, mental health professionals experience conflicts of values but the context of care for asylum seekers changed.

How Do Countries' Health Information Systems Perform in Assessing Asylum Seekers' Health Situation? Developing a Health Information Assessment Tool on Asylum Seekers (HIATUS) and Piloting It in Two European Countries.

Background: Accurate data on the health status, health behaviour and access to health care of asylum seekers is essential, but such data is lacking in many European countries. We hence aimed to: (a) develop and pilot-test an instrument that can be used to compare and benchmark the country health information systems (HIS) with respect to the ability to assess the health status and health care situation of asylum seekers and (b) present the results of that pilot for The Netherlands (NL) and Germany (DE). Materials and Methods: Reviewing and adapting existing tools, we developed a Health Information Assessment Tool on Asylum Seekers (HIATUS) with 50 items to assess HIS performance across three dimensions: (1) availability and detail of data across potential data sources; (2) HIS resources and monitoring capacity; (3) general coverage and timeliness of publications on selected indicators. We piloted HIATUS by applying the tool to the HIS in DE and NL. Two raters per country independently assessed the performance of country HIS and the inter-rater reliability was analysed by Pearson’s rho and the intra-class correlation (ICC). We then applied a consensus-based group rating to obtain the final ratings which were transformed into a weighted summary score (range: 0–97). We assessed HIS performance by calculating total and domain-specific HIATUS scores by country as well as absolute and relative gaps in scores within and between countries. Results: In the independent rating, Pearson’s rho was 0.14 (NL) and 0.30 (DE), the ICC yielded an estimated reliability of 0.29 (NL) and 0.83 (DE) respectively. In the final consensus-based rating, the total HIATUS score was 47 in NL and 15 in DE, translating into a relative gap in HIS capacity of 52% (NL) and 85% (DE) respectively. Shortfalls in HIS capacity in both countries relate to the areas of HIS coordination, planning and policies, and to limited coverage of specific indicators such as self-reported health, mental health, socio-economic status and health behaviour. The relative gap in the HIATUS component “data sources and availability” was much higher in Germany (92%) than in NL (28%). Conclusions: The standardised tool (HIATUS) proved useful for assessment of country HIS performance in two countries by consensus-based rating. HIATUS revealed substantial limitations in HIS capacity to assess the health situation of asylum seekers in both countries. The tool allowed for between-country comparisons, revealing that capacities were lower in DE relative to NL. Monitoring and benchmarking gaps in HIS capacity in further European countries can help to strengthen HIS in the future.