Social Inequalities In Access Research Articles

Scaling the value of multilingualism: ‘Common-sense’ narratives of growth and inequality in an expert report to the U.S. Congress

I examine the powerful institutional scaling project of the 2017 American Academy of Arts & Sciences report, America’s Languages: Investing in Language Education for the 21st Century. I analyze the scalar configurations emerging in the report’s narrative argumentation with the goal of denaturalizing its scale-making narratives in the production of a ‘common-sense’ regimentation of the value of language learning and multilingualism in the United States. These configurations show how social inequalities in access to language learning are reinforced through the ideologically mapped categorizations of language to sociocultural domains and kinds of speakers. Nomically- and reportively-calibrated, future-oriented narratives present figurations of growth and progress that mix nationalist ideologies of US expansionism, neoliberal and raciolinguistic logics, and even utopian visions. By focusing on scale, and in particular on interscalar processes of comparison, the resonances across these sometimes contradictory ideological frames are brought into focus.

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review.

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients. A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients. Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities. This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

Social Inequities in Access to Dental Care in Australian Adults over Time.

Social inequities in dental caries are reflected by both inequities in the social structures that contribute to disease severity and inequities in the provision of dental care. This study aimed to describe social differentials in the dental caries experience among Australian adults across a 13-y period and to examine if the highest magnitude of oral health inequities persisted across dental caries prevalence (decayed teeth [DT]) or its management (missing teeth [MT], filled teeth [FT]). Data were from 2 population-based cross-sectional surveys of Australian adult oral health conducted in 2004-2006 (National Survey of Adult Oral Health-1 [NSAOH-1], n = 5,505) and 2017-2018 (NSAOH-2, n = 5,022). In each survey, representative samples of adults were obtained through a 3-stage, stratified sample design within metropolitan and regional areas in each state/territory. Clinical outcomes included the prevalence and mean of DT, MT, FT, and DMFT. Equivalized household income was grouped into approximately quartiles from low to high. Across all income quartiles, the mean DT and % DT >0 was higher in NSAOH-2 than in NSAOH-1. The increase in prevalence was highest in the third highest income group (prevalence difference [PD] = 8.4, from 24.1 to 32.5). Similarly, % MT >0 was lower in NSAOH-2 than in NSAOH-1 across all income groups, with the decrease most marked for the lowest income group (PD = -6.5, from 74.1 to 67.8). Across all income quartiles, % FT >0 was lower in NSAOH-2 than in NSAOH-1. The decrease was the most marked for the lowest income group (PD = -8.9, from 81.1 to 72.2). The findings confirm that although oral health inequities decreased for the most extreme management outcome of dental caries (MT), inequities increased for experience of that disease (DT) and the more conservative management of dental caries (FT). For all D, M, and F components (DMFT), inequities between the lowest and highest household income groups increased from 2004-2006 to 2017-2018. This study found that social inequities in oral health (experience of untreated dental caries and missing teeth) increased between the most socially advantaged and disadvantaged groups between 2004-2006 and 2017-2018. This suggests that models of dental service provision in Australia are increasingly benefitting those who can afford and access the care and who arguably need the services less than their less socially advantaged counterparts do.

Weaknesses of the existing organization of emergency medical care in European countries

The importance of an emergency medical care system for ensuring affordable and quality healthcare in any country is indisputable. Studying and analyzing existing problems in organizing this system is the first step to solving them. The present study aimed to investigate and outline the possible scope of the problems of emergency medical care, their recurrence, and similarity in 17 European countries. Content analysis of documents was used. The most characteristic organizational problems in providing emergency medical care for each of the countries are identified and grouped into five categories: Direct patient access to hospital emergency departments; Overloading of emergency departments by non-urgent, self-referral patients; Telephone triage by dispatchers - nurses or assistants; Existing and/or impending shortage of doctors in Emergency Medical Services (EMS); Regional and social inequalities in access to emergency medical care. A quantitative measurement of the categories and their relative weight were reported. Based on the analysis, the conclusions of the study were drawn. The identified problems, grouped into categories of weaknesses of the existing emergency medical care organization in European countries, may serve as a basis for undertaking health care reforms.

Social inequality in skills: Exploring the moderating role of extracurricular activities related to socio‐economic differences in non‐cognitive and cognitive outcomes

AbstractEngaging in extracurricular activities is known to affect both cognitive and non‐cognitive outcomes, but there is social inequality in access to these activities. In this study, we examine the role of extracurricular activities in moderating the relationships between secondary school students' social background and their cognitive and non‐cognitive outcomes. Secondly, we examine variations in these relationships among three European cities that represent different educational systems in managing student heterogeneity. Based on the study findings, the effects of extracurricular activities on academic outcomes varied with regard to measured skills and the city of study. Extracurricular activities were related to enhanced interpersonal skills in all cities studied. However, in Turku and Ghent, extracurricular activities buffered the socio‐economic gradient in interpersonal skills, whereas in Barcelona, such activities increased it. Rather surprisingly, in all cities, engaging in extracurricular activities magnified the effect of socio‐economic status on cognitive skills.

Land system governance shapes tick-related public and animal health risks

ABSTRACT Land cover and land use have established effects on hazard and exposure to vector-borne diseases. While our understanding of the proximate and distant causes and consequences of land use decisions has evolved, the focus on the proximate effects of landscape on disease ecology remains dominant. We argue that land use governance, viewed through a land system lens, affects tick-borne disease risk. Governance affects land use trajectories and potentially shapes landscapes favourable to ticks or increases contact with ticks by structuring human-land interactions. We illustrate the role of land use legacies, trade-offs in land-use decisions, and social inequities in access to land resources, information and decision-making, with three cases: Kyasanur Forest disease in India, Lyme disease in the Outer Hebrides (Scotland), and tick acaricide resistance in cattle in Ecuador. Land use governance is key to managing the risk of tick-borne diseases, by affecting the hazard and exposure. We propose that land use governance should consider unintended consequences on infectious disease risk.

The views of family physicians on National Health Insurance in Gauteng Province, South Africa.

Universal health coverage (UHC) improves national health outcomes while addressing social inequalities in access to quality healthcare services. The district health system (DHS) is critical to the success of UHC in South Africa through the National Health Insurance (NHI) scheme. Family physicians (FPs), as champions of primary care, are central to the DHS operation and implementation of NHI. This was a qualitative exploratory study that used semi-structured interviews to explore FPs views and engagement on NHI policy and implementation in their districts. Ten FPs were included through purposive sampling. Most of the FPs interviewed were not engaged in either policy formulation or strategic planning. The NHI bill was seen as a theoretical ideology that lacked any clear plan. Family physicians expressed several concerns around corruption in governmental structures that could play out in NHI implementation. Family physicians felt unsupported within their district structures and disempowered to engage in rollout strategies. The FPs were able to provide useful solutions to health system challenges because of the design of their training programmes, as well as their experience at the primary care level. Healthcare governance in South Africa remains located in national and provincial structures. Devolution of governance to the DHS is required if NHI implementation is to succeed. The FPs need to be engaged in NHI strategies, to translate plans into actionable objectives at the primary care level.Contribution:This study highlights the need to involve FPs as key actors in implementing NHI strategies at a decentralised DHS governance level.

When social, relational and sexual vulnerabilities increase vulnerability to HIV/AIDS: the case of migrants living in Switzerland

ABSTRACT There is emerging evidence that a significant proportion of migrants acquire HIV after arrival in Europe. Thus, to strengthen prevention efforts, it is crucial to understand migrants’ vulnerability to HIV/AIDS. This article contributes to this understanding by analysing the perspectives of prevention actors and migrants. Data were collected through a qualitative and participative research study conducted in Switzerland. Twenty prevention actors and 28 migrants participated in in-depth interviews. Results show that migrants’ difficulties in accessing and adopting measures to prevent HIV are related to three types of situational vulnerability that increase their vulnerability to HIV/AIDS: social vulnerability, which refers to social inequalities in access to care; relational vulnerability, which refers to unequal distribution of power within intimate relationships; and sexual vulnerability, which refers to stigmatization of sexualities that some people may consider as socially nonconforming. For HIV/AIDS prevention to be successful among migrants, power structures such as sexism, heterosexism, cisgenderism, ethnocentrism, and racism need to be addressed. Reducing stigma related to HIV among migrants requires a struggle against these power structures as well as health inequities.

Access to oral care in the «100% Santé» reform: Context and perspectives

The “100% Santé” (100% Health) reform was intended to address the major problem of social inequalities in access to dental care in France. We explain the reform as well as the numerous challenges that come with its application. The difficulties encountered in accessing dental care were associated with particularly high out-of-pocket expenses for users. The main objectives of the dental component of the “100% Santé” reform are to improve access to dental care and to strengthen preventive health policy. The main tool of this reform is a cap on the price of certain treatments. This makes it possible for health insurance organizations to be responsible for the total financing of such care. There are now three baskets of care, each with a different pricing and financing structure. The first basket proposes capped fees with no payment for users. This reform constitutes a significant change in the regulation of dental care, which could have very different consequences depending on the region and the number of dentists operating in it. The effectiveness of the reform on the evolution of health care consumption and on reducing inequalities of access must be monitored.

‘This is how the game works’: navigating access and choice in transnational higher education fields

ABSTRACT Drawing on Bourdieu’s field theory the study describes access to transnational mobility as a contextual process to which transnational and location-specific capitals make joint contributions. In doing so, the paper responds to calls against methodological nationalism, i.e. confining research to national boundaries, which is becoming increasingly inadequate in a global world where capital may be produced and subsequently utilised in different countries (Weiss [2021]. “Re-thinking society: How can sociological theories help us understand global and crossborder social contexts?” Current Sociology 69 (3): 333–351.). Using in-depth interviews with international students the paper illustrates the complexities of ‘choice’ and the intricacies of ‘playing the game’ in transnational spaces while exposing how nations structure and (re)produce social inequality in access to educational opportunities.

A critical review of the use of cognitive ability testing for selection into graduate and higher professional occupations

AbstractThis article presents a critical review of the use of cognitive ability testing for access to graduate and higher professional occupations to promote further debate and reflection in both the academic and practitioner community. The main contentions are that the practice of applying cognitive ability testing in these contexts has strong potential to both maintain and exacerbate social inequality in access to higher occupations and professions, and that validity evidence does not justify this to the extent that has previously been presumed. Five critical observations are examined, namely (1) evidence of adverse impact in test outcomes; (2) the tendency to position cognitive ability testing early in selection processes in high‐volume recruitment; (3) recent evidence challenging the meta‐analytic validity of cognitive ability tests; (4) weaknesses in historical primary validity studies; (5) conceptually flawed examination of differential validity evidence in the literature. Implications for practice are discussed, contrasting strategies that involve modifying selection systems that include cognitive testing, versus removing and replacing cognitive tests.

What is known about what works in community-involved decision-making relating to urban green and blue spaces? A realist review protocol

BackgroundThere is now a relatively well-established evidence base suggesting that greener living environments and time spent in urban green and blue spaces (UGBS) can be beneficial for human health and wellbeing. However, benefits are not universal and there remain widespread social inequalities in access to such resources and experiences, particularly along axes of class, race, ethnicity, age and disability, and in relation to efforts to increase the availability and accessibility of such spaces. These injustices often relate to distributive, procedural and recognition-based processes. There is growing interest in how to ensure that efforts to increase access to or use of UGBS (whether through infrastructural or social programmes) result in equitable outcomes whilst minimising potential for exacerbating existing inequalities and injustices. Community engagement is considered an important step towards more inclusive UGBS decision-making, from planning and design to management and maintenance processes. It is thought to contribute to better and more widely trusted decisions, enhanced democracy, community satisfaction, civic interest and feelings of green space ownership, and greater longevity of UGBS projects. However, uneven representation and barriers to participation can create imbalances and undermine these benefits.MethodsAn iterative, multi-stage realist-inspired review will be conducted to ask what works, in what context and in what ways relating to the meaningful involvement of communities in UGBS decision-making, focusing on the skills, capacities and capabilities of different stakeholders and the role of contexts and processes. ‘Effectiveness’ (or what works) will be understood as a multifaceted outcome, encompassing both the processes and results of community engagement efforts.Following a scoping stage to identify initial programme theory, inclusion/exclusion criteria and derive search terms, relevant databases and grey literature will be searched to identify interdisciplinary literature in two phases. The first phase will be used to further develop programme theories, which will be articulated as ‘if then’ statements. The second phase searches will be used to identify sources to further explore and evidence the programme and formal theory. We will assess all includable evidence for conceptual richness, prioritising more conceptually rich sources if needed.DiscussionThe realist synthesis will explore the key context, mechanism and outcome configurations that appear to explain if and how different approaches to community-involved UGBS decision-making are or are not effective. We will consider factors such as different conceptualisations of community, and if and how they have been involved in UGBS decision-making; the types of tools and approaches used; and the socio-cultural and political or governance structures within which decision-making takes place.

Social inequality in navigating the healthcare maze: Care trajectories from hospital to home via intermediate care for older people in Norway

Although health inequality is a growing concern, striking differences in health and life expectancy still exist across and within OECD countries. In Oslo, the largest city in Norway, life expectancy differs by up to 7 years between districts. Equal access to healthcare can help reduce social differences in health. However, research indicates that older people at the lower level of the social gradient have more difficulty accessing health services. Older people experience early hospital discharge and several transitions between and across care levels. In this study, using Bourdieu's theory of practice as a theoretical lens, we explore social inequality in access to universal healthcare within care trajectories for older people in Oslo. Through observation of family meetings in intermediate care (N = 14) and semi-structured interviews with older patients (N = 15), informal caregivers (N = 12) and healthcare professionals (N = 18), the study identifies 15 unique care trajectories from hospital to home via intermediate care. Informed by a critical realist perspective and moving from west to east via the urban areas, there is a prominent finding of climbing down the social gradient and, subsequently, reduced access to healthcare. An overarching theme, ‘Navigating the healthcare maze’, was identified along with two subthemes: ‘Individuality meets system’ and ‘Having a feel for the game’. Navigating the healthcare maze depends on where you live, your level of education and health literacy and the ability to mobilize social networks. Furthermore, it is an advantage to fit into the professional habitus of the ‘active patient’ discourse. The findings will be relevant for politicians, managers, healthcare professionals and other stakeholders working in the field and in the development of services adapted to the needs of various socioeconomic groups.

Urban COVID-19 endemism in Petrópolis: detection of an endemic focus by spatial analysis.

Motivation for the study. During the COVID-19 pandemic, spatial analysis methodologies were used to identify the territorial determinants of its distribution and social inequalities in access to medical care. Main findings. We found a concentration of cases in a specific location of the municipality, which remained constant throughout the study period, with sporadic outbreaks in other areas. Implications. It is necessary to pay attention to possible endemic foci of viral diseases in urban settings and to take measures to eliminate them as well as to prevent their spread within and outside the area.

Issue highlights

Hans Asperger is best known for Asperger syndrome, but has been accused of knowingly referring patients to a Viennese children's home notorious for murdering disabled children during the Nazi occupation. Two of the 13 children he referred there died. Tatzer et al.1 assessed original documents and found no evidence that Asperger was aware of the ‘euthanasia’ programme when he referred them. Czech strongly criticises the paper and says Asperger must have known about the ‘euthanasia’ programme early on, because he worked with the doctor responsible for the murders.2 Gillberg shares his thoughts on Asperger and meeting his daughter.3 A review by de Boer et al.4 looks at parents' perspectives about making prenatal decisions regarding treatment for babies born at the limit of viability. It is accompanied by a perspective, where the parents of an infant born at 24 weeks of gestation share their experiences5 after an unexpected pregnancy was discovered at 18 weeks. They faced the risk of an extremely premature birth at 22 weeks and agreed with the physicians to initiate intensive care treatment if their infant was born in the grey zone. Poor sleep has been associated with poor physical and mental health, including increased risks of heart disease and type 2 diabetes and higher levels of symptoms of depression and anxiety. Balfour et al.6 looked at the parent-reported sleep trajectories of 1192 young Australians from 5 to 17 years of age and the subject's self-reported sleep problems. They found no relationships between these sleep-related reports and measures of epigenetic age acceleration at 17 years of age, after adjusting for depressive symptoms. Størksen et al.7 reviewed the literature on Internet-based interventions that aim to support the parents of young children aged 0–5 years. They found that more interventions focused on mental health than somatic health, with developmental disorders and obesity being the most frequently studied conditions in those respective categories. Several gaps were identified, such as the need for more research outside English-speaking countries. The authors suggest that program developers should consider using more audio-visual technology to avoid reinforcing social inequalities in access to healthcare. Holter comments on the findings.8 Researchers in many medical fields are increasingly reporting outcomes that are important to patients who have shared their lived experiences with their illnesses. Thivierge et al.9 explored the pulmonary outcomes that were important to parents after extremely preterm birth and created a list that could be considered by future respiratory outcome studies. These reflected outcomes during the infants' neonatal intensive care hospitalisation and after discharge. The 285 parents described numerous important pulmonary events, but the authors were interested to note that bronchopulmonary dysplasia was not on the list, despite being the main respiratory outcome investigated in neonatology. Figure 1: Alamy, Figure 2-5: Istockphoto

Individual and environmental determinants associated with longer times to access pediatric rheumatology centers for patients with juvenile idiopathic arthritis, a JIR cohort study

BackgroundDespite guidelines, poor access to appropriate care for juvenile idiopathic arthritis (JIA) patients remains a global issue. Prompt referral to a pediatric rheumatology (PR) center and effective care is known to be critical for changing the natural history of the disease and improving long-term prognosis. This project assesses socio-economic factors of delayed referral to a pediatric rheumatologist (PRst) for JIA patients in France and Switzerland within the Juvenile Inflammatory Rheumatism (JIR) Cohort.MethodsAll patients diagnosed with JIA, presenting at one center of the JIRcohort in France or Switzerland with additional data on referral pathway were included. Patient characteristics at first visit to the PR center, dates of visits to healthcare providers during referral, and parent characteristics were extracted from the JIRcohort database.ResultsTwo hundred fifty children were included. The overall median time to first PR assessment was 2.4 months [1.3; 6.9] and ranged widely across the JIA subtypes, from 1.4 months [0.6; 3.8] for children with systemic juvenile idiopathic arthritis (sJIA) to 5.3 months [2.0; 19.1] for children with enthesitis-related arthritis (ERA). A diagnosis of ERA and an appointment with an orthopedist during the referral pathway were significantly associated with a longer time before the first PR visit (hazard ratio HR 0.50 [95% CI: 0.29; 0.84]) and HR 0.68 [95% CI: 0.49; 0.93], respectively) in multivariable analysis. Having a mother with a post-graduate educational attainment level was tendentially associated with a shorter time before the first PR visit, (HR 1.32 [95% CI: 0.99; 1.78]).ConclusionsTime to first PRst visit was most often short compared to other studies and close to the British recommendations. However, this time remained too long for many patients. We observed no social inequities in access to a PRst, but we show the need to improve effective pathway and access to a PR center for JIA patients.

Problems of human capital development in the context of digital transformations

Introduction. The article examines the issues of human capital development in the context of digital transformations. This topic is relevant and important for understanding the challenges and opportunities that arise in modern digital society, and it contributes to the development of strategies to enhance human capital development in this context. The purpose of the article is to identify and analyze the challenges faced by society and businesses in the rapid technological development and digital transformation. Methodology. The research methodology is based on a systematic analysis of scientific sources, statistical data, and expert assessments. A comprehensive approach is applied to study the problem, incorporating knowledge from economics, sociology, and management. Results. Key problems related to human capital development in the context of digital transformations have been identified. Specifically, challenges related to inadequate preparation and adaptation of employees to new digital technologies, changing skill and competency requirements, as well as risks of social inequality in access to digital opportunities and issues of government investment in human capital development. The obtained results provide a basis for the development of strategies and policies aimed at enhancing the level of human capital development in the context of digital transformations. It is established that only the collaboration of society, businesses, and government will be effective in ensuring sustainable human capital development and minimizing the negative consequences of digital transformations.

Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil

ObjectiveThis study monitors trends in access to cancer screening, focusing on mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA), assessing the magnitude of inequality in the city of São Paulo from 2003 to 2015 according to education level. MethodThis is a cross-sectional population-based study conducted with data from the 2003, 2008, and 2015 editions of the Health Survey of the City of São Paulo (ISA-Capital). Outcome variables were the proportion of mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA) tests according to the protocols. Inequality was measured by education level according to years of study. For static analysis, Poisson regression was used to estimate proportion ratios. ResultsThe proportion of Pap smears remained stationary at a high level (>89%) throughout the study period, while access to mammography and PSA tests significantly increased in the 2003‒2015 period. The present results indicate inequalities in access to cancer screening due to education, and being more expressive for mammography and PSA tests. However, this inequality significantly decreased over the period analyzed comparing the most educated individuals with those with the lowest educational level. In addition, an increase in the proportion of tests performed in the Brazilian Unified Health System was identified, especially for mammography and PSA tests, in the period 2003‒2015. ConclusionsThe inequalities observed in the access to preventive exams were influenced by the level of education. The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Internet-based interventions for parents with children 0-5 years: A scoping review.

This study aims to review the existing literature on Internet-based health interventions directed to support parents of children aged 0-5 years. We systematically searched electronic databases between January 2000 and 2018. The search consisted of terms describing eHealth, intervention and families and/or children. Internet-based parent support interventions were most often directed at rehabilitation and selective prevention, and we identified more studies on mental health (57%) than somatic health (41%). Developmental disorders were the most frequently studied mental health condition (n=33), while interventions for obesity (15%) were the most studied somatic health condition. Forty-four percent of mental health studies were RCTs and 65% of interventions were theory driven. Interventions most often used a behavioural approach, included guidance and delivered content via text-based information. Several significant gaps were identified such as the need for more research outside of English-speaking countries, more systematic reviews and effect studies. This review also elucidates the need for researchers to improve reporting on the theoretical approaches employed in interventions, and to focus on determining the importance of guidance. Finally, program developers should consider using more audio-visual technology to avoid reinforcing social inequalities in access to healthcare.

Ways of development of theory and practice of social work in the conditions of globalization

The article is devoted to the results of research of the directions of development of theoretical knowledge and practice of social work as an independent branch in the conditions of growth of globalization influences on the social sphere. It is established that globalization has contributed to the focus of representatives of the international professional communities of social workers on the issues of mission, purpose of social work. In particular, the recognition of professional activity of social workers as one that contributes to social change, development, social cohesion, strengthening people's ability to function independently, freeing them from the negative, dangerous influences of the environment and the environment. Particular emphasis in the practice of social work - on the observance of the principles and values of the profession, such as social justice, respect for human rights, respect for diversity.
 Representatives of international professional organizations of social workers - the International Federation of Social Workers (IFAS), the International Association of Schools of Social Work (ISAF) and the International Council for Social Welfare - are leading the way in shaping the development of the theory and practice of social work. Thanks to the joint efforts of active representatives of these global professional communities in the field of social work, a number of studies have been conducted with the involvement of professionals from all levels of social work practice - from micro to macro and including social policy. This made it possible to find that in the context of ongoing and growing globalization changes in the world there is a growing social inequality in access to basic resources. Inequality in access to health services is particularly illustrative, prompting social workers to recognize this area of the social sphere as one of the most threatening in terms of social justice and human rights. One of the urgent ways to solve this problem is to promote social development, which is realized through the formation of strong and stable communities. Achieving this will be facilitated by the stable well-being and strengthening of the role of social work practitioners in improving and strengthening communities.