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Community health projects have played a crucial role in improving health issues. Listening to communities' voices and achieving community ownership are essential for conducting effective health projects. However, there are limited studies on the frameworks for collecting, aggregating, and operationalizing community preferences and values. In this study, we selected two cases of community field surveys from Japan and Cambodia to discuss who may represent a community and propose a practical approach to achieving community ownership. Both cases involved various stakeholders. From the insights of these two cases, we suggested the following three key components in the community project: the community representative, the communicator, and the institute outside the community. Notably, the community representative's role as the community's direct voice should be properly recognized and institutionalised to establish community ownership. We proposed the following key terms of the qualifications of community representatives: they should be able to represent voices from the community, should have extensive experience to decide the project direction and manage the project, and should be independent of outside actors. Our theoretical model of the structure of different stakeholder groups in community-based projects will be helpful to accelerate community capacity strengthening; moreover, it can help build the appropriate community institution and process, including multi-stakeholder groups to promote community ownership in health programs.
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Academias e Institutos , Propriedade , Camboja , Instalações de Saúde , Promoção da SaúdeRESUMO
BACKGROUND: Community participation in health programme planning has gained traction in public health in recent decades. When an idea enters the mainstream, it becomes vulnerable to overuse and dilution, and public health professionals claiming "community participation" may intentionally or unintentionally prevent more meaningful participatory action. The principle of community-centred planning is seldom integrated into programme evaluation. We have previously argued that, to prevent ambiguity and abuse, a stronger and more explicit idea of community ownership is useful. Un-like "participation", "ownership" leaves little room for dilution. METHOD: This perspective piece explores a framework to support evaluating community ownership in planning, by emphasising decision-making power in health planning and management as a necessary element for evaluation alongside other outcomes. After defining the concept of community ownership, we identify and discuss challenges and research gaps related to implementing community ownership in health programme planning, management, and evaluation. Such issues include considering which communities have claims to programme ownership, alternative approaches to representation and participation that support ownership, gathering community values and preferences, and incorporating them into ongoing programme planning, management and evaluation. We consider methodological issues likely to arise when transitioning from gathering community voices - which is valuable but incomplete work - towards community decision making power in planning and evaluation. RESULTS: We use cases from recent policy and research in Chile as examples to consider through the lens of this framework. Finally, we discuss some current constraints in implementing community ownership in healthcare planning and evaluation. CONCLUSION: We encourage exploring how to practice evaluation in ways that will further our ability to be helpful professional supporters of community self-determination in finding their paths to health.
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Planejamento em Saúde , Promoção da Saúde , Humanos , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Participação da ComunidadeRESUMO
BACKGROUND: This study aims to assess preferences and values for priority setting in healthcare in Chile through an original and innovative survey method. Based on the answers from a previous survey that look into the barriers the Chilean population face, this study considers the preferences of the communities overcoming those barriers. As a result six programs were identified: (1) new infrastructure, (2) better healthcare coverage, (3) increasing physicians/specialists, (4) new informatics systems, (5) new awareness healthcare programs, and (6) improving availability of drugs. METHODS: We applied an innovative survey method developed for this study to sample subjects to prioritize these programs by their opinion and by allocating resources. The survey also asked people's preferences for a distributive justice principle for healthcare to guide priority setting of services in Chile. The survey was conducted with a sample of 1142 individuals. RESULTS: More than half of the interviewees (56.4%) indicated a single program as their first priority, while 20.1% selected two of them as their first priority. To increase the number of doctors/specialists and improve patient-doctor communication was the program that obtained the highest priority. The second and third priorities correspond to improving and investing in infrastructure and expanding the coverage of healthcare insurances. Additionally, the results showed that equal access for equal healthcare is the principle selected by the majority to guide distributive justice for the Chilean health system. CONCLUSIONS: This study shows how a large population sample can participate in major decision making of national health policies, including making a choice of a distributive justice principle. Despite the complexity of the questions asked, this study demonstrated that with an innovative method and adequate guidance, average population is capable of engaging in expressing their preferences and values. Results of this study provide policy-makers useful community generated information for prioritizing policies to improve healthcare access.
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Prioridades em Saúde , Justiça Social , Chile , Comunicação , Acessibilidade aos Serviços de Saúde , HumanosRESUMO
The authors' purpose in conducting this study was to identify barriers faced by survivors of intimate partner violence (IPV) in accessing services in Gaza. We collected data via in-depth interviews with women (ages 18-49; n = 25). Respondents were recruited through convenience sampling from women's organizations. Interviews were transcribed, translated, and coded using an inductive approach. Results indicate three main factors that influence help-seeking: perceived transgression of traditional gender roles; distrust of women's centers; and contextual acceptance of IPV. An understanding of emic perceptions of IPV can inform the design and delivery of support services and increase access to interventions for women in Gaza.
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Violência por Parceiro Íntimo , Cônjuges , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Narração , Sobreviventes , Adulto JovemRESUMO
Striking changes in the funding and implementation of international health programs in recent decades have stimulated debate about the role of communities in deciding which health programs to implement. An important yet neglected piece of that discussion is the need to change norms in program evaluation so that analysis of community ownership, beyond various degrees of "participation," is seen as central to strong evaluation practices. This article challenges mainstream evaluation practices and proposes a framework of Critical Evaluation with 3 levels: upstream evaluation assessing the "who" and "how" of programming decisions; midstream evaluation focusing on the "who" and "how" of selecting program objectives; and downstream evaluation, the focus of current mainstream evaluation, which assesses whether the program achieved its stated objectives. A vital tenet of our framework is that a community possesses the right to determine the path of its health development. A prerequisite of success, regardless of technical outcomes, is that programs must address communities' high priority concerns. Current participatory methods still seldom practice community ownership of program selection because they are vulnerable to funding agencies' predetermined priorities. In addition to critiquing evaluation practices and proposing an alternative framework, we acknowledge likely challenges and propose directions for future research.
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Saúde Global , Promoção da Saúde , Internacionalidade , Avaliação de Programas e Projetos de Saúde/métodos , Tomada de Decisões , PropriedadeRESUMO
BACKGROUND: The relationship between payments towards healthcare and ability to pay is a measure of financial fairness. Analysis of progressivity is important from an equity perspective as well as for macroeconomic and political analysis of healthcare systems. Bangladesh health systems financing is characterized by high out-of-pocket payments (63.3%), which is increasing. Hence, we aimed to see who pays what part of this high out-of-pocket expenditure. To our knowledge, this was the first progressivity analysis of health systems financing in Bangladesh. METHODS: We used data from Bangladesh Household Income and Expenditure Survey, 2010. This was a cross sectional and nationally representative sample of 12,240 households consisting of 55,580 individuals. For quantification of progressivity, we adopted the 'ability-to-pay' principle developed by O'Donnell, van Doorslaer, Wagstaff, and Lindelow (2008). We used the Kakwani index to measure the magnitude of progressivity. RESULTS: Health systems financing in Bangladesh is regressive. Inequality increases due to healthcare payments. The differences between the Gini coefficient and the Kakwani index for all sources of finance are negative, which indicates regressivity, and that financing is more concentrated among the poor. Income inequality increases due to high out-of-pocket payments. The increase in income inequality caused by out-of-pocket payments is 89% due to negative vertical effect and 11% due to horizontal inequity. CONCLUSIONS: Our findings add substantial evidence of health systems financing impact on inequitable financial burden of healthcare and income. The heavy reliance on out-of-pocket payments may affect household living standards. If the government and people of Bangladesh are concerned about equitable financing burden, our study suggests that Bangladesh needs to reform the health systems financing scheme.
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Atenção à Saúde/economia , Gastos em Saúde/estatística & dados numéricos , Financiamento da Assistência à Saúde , Bangladesh , Estudos Transversais , Características da Família , Equidade em Saúde , Humanos , Renda/estatística & dados numéricos , Fatores Socioeconômicos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Predictors of high out-of-pocket household healthcare expenditure are essential for creating effective health system finance policy. In Bangladesh, 63.3% of health expenditure is out-of-pocket and born by households. It is imperative to know what determines household health expenditure. This study aims to investigate the predicting factors of high out-of-pocket household healthcare expenditure targeting to put forward policy recommendations on equity in financial burden. METHODS: Bangladesh household income and expenditure survey 2010 provides data for this study. Predictors of high out-of-pocket household healthcare expenditure were analyzed using multiple linear regressions. We have modeled non-linear relationship using logarithmic form of linear regression. Heteroscedasticity and multicollinearity were checked using Breusch-Pagan/Cook-Weishberg and VIF tests. Normality of the residuals was checked using Kernel density curve. We applied required adjustment for survey data, so that standard errors and parameters estimation are valid. RESULTS: Presence of chronic disease and household income were found to be the most influential and statistically significant (p < 0.001) predictors of high household healthcare expenditure. Households in rural areas spend 7% less than urban dwellers. The results show that a 100% increase in female members in a family leads to a 2% decrease in household health expenditure. Household income, health shocks in families, and family size are other statistically significant predictors of household healthcare expenditure. Proportion of elderly and under-five members in the family show some positive influence on health expenditure, though statistically nonsignificant. CONCLUSIONS: The findings call for emphasizing prevention of chronic diseases, as it is a strong predictor of household health expenditure. Innovative insurance scheme needs to be devised to prevent household from being impoverished due to health shocks in the family. Policy makers are urged to design an alternative source of healthcare financing in Bangladesh to minimize the burden of high OOP healthcare expenditure.
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Características da Família , Financiamento Pessoal/economia , Gastos em Saúde , Renda , Idoso , Bangladesh , Doença Crônica , Atenção à Saúde/economia , Feminino , Financiamento Pessoal/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Serviços de Saúde , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
Carers were disproportionately harmed in the COVID-19 pandemic. Despite facing an increased risk of contracting the virus, they continued in frontline roles in care services and acted as "shock absorbers" for their families and communities. In this article, we apply an intersectional lens to examine care work and the structural factors disadvantaging carers during COVID-19 through a comparative case study analysis of 16 low-, middle-, and high-income countries. Data on each country was collected through a qualitative framework during 2021-2022. We found that while carers everywhere were predominantly women with low incomes and precarious employment, other factors were at play in shaping their experiences. Moreover, government responses to mitigate the direct impact of the pandemic have created local and global disparities affecting those working in this sector. Our findings reveal how oppressive social structures such as race, class, caste, and migration status converged in contextually specific ways to shape the gendered nature of care within and between different countries. We call for a better understanding of the multiple axes of inequalities experienced by carers to inform crisis mitigations, coupled with long-term strategies to address social inequities in the care economy and to promote gender equality.
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One of the most extensive Chilean health care reforms occurred in July 2005, when the Regime of Explicit Health Guarantees (AUGE) became effective. This reform guarantees coverage for a specific set of health conditions. Thus, the purpose of this study is to provide timely evidence for policy makers to understand the current distribution and equity of health care utilization in Chile.The authors analyzed secondary data from the National Socioeconomic Survey (CASEN) for the years 1992-2009 and the 2006 Satisfaction and Out-of-Pocket Payment Survey to assess equity in health care utilization using two different approaches. First, we used a two-part model to estimate factors associated with the utilization of health care. Second, we decomposed income-related inequalities in medical care use into contributions of need and non-need factors and estimated a horizontal inequity index.Findings of this empirical study include evidence of inequities in the Chilean health care system that are beneficial to the better-off. We also identified some key factors, including education and health care payment, which affect the utilization of health care services. Results of this study could help researchers and policy makers identify targets for improving equity in health care utilization and strengthening availability of health care services accordingly.
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Atenção à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Chile , Estudos Transversais , Atenção à Saúde/organização & administração , Atenção à Saúde/tendências , Pesquisa Empírica , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Modelos Teóricos , Razão de Chances , Satisfação do Paciente , Fatores SocioeconômicosRESUMO
This article aims to explore three main concepts related to the professional development of nursing professionals. This paper first critically reviews and reinterprets scientific evidence on the relationship between nurse staff allocation and healthcare outcomes and then challenges some of the common interpretations of this evidence in the professional literature. Secondly, in the absence of solid empirical evidence provided by sophisticated datasets in this field, we consider how Communitarianism may provide a well-defined, highly appropriate ethical framework for further developing and improving the nursing profession and healthcare outcomes. Thirdly, this article examines the role of Communitarian ethics in setting Taiwan's healthcare priorities and promotion nursing's core professional values. In conclusion, we recommend several conceptual health policy frameworks to ensure patient safety.
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Recursos Humanos de Enfermagem , Segurança do Paciente , Alocação de Recursos , Política de Saúde , Humanos , Responsabilidade Social , TaiwanRESUMO
Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.
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COVID-19 , Humanos , Pandemias/prevenção & controleRESUMO
OBJECTIVE: To examine the relationship between migration and migrant remittances and health care utilization in Ecuador, and to identify any potential equalizing effects. METHODS: Using data from the 2004 National Demographic and Maternal & Child Health Survey (ENDEMAIN), a multilevel multivariate analysis was conducted to assess the relationship of two migrant predictors (households with an international migrant; use of migrant remittances) with use of preventive care, number of curative visits, hospitalization, and use of antiparasitic medicines. Relevant predisposing, enabling, and need factors were included following Andersen's Model of Health Care Utilization Behavior. Interaction terms were included to assess the potential equalizing effects of migration and remittances by ethnicity, area of residence, and economic status. RESULTS: Migrant predictors were strongly associated with use of antiparasitic medicines, and to a lesser extent, with curative visits, even after adjusting for various predisposing, enabling, and need factors. Interaction models showed that having an international migrant increased use of these services among low-income Ecuadorians (quintiles 1 and 2). No significant relationship was found between migrant predictors and use of preventive services. CONCLUSIONS: Migration and remittances seem to have an equalizing effect on access to antiparasitic medicines, and to a lesser extent, curative health care services. Health care reform efforts should take into account the scope of this effect when developing public policy.
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Emigração e Imigração/estatística & dados numéricos , Serviços de Saúde/estatística & dados numéricos , Adulto , Antiparasitários/uso terapêutico , Coleta de Dados , Uso de Medicamentos/estatística & dados numéricos , Economia/estatística & dados numéricos , Equador , Etnicidade , Características da Família , Feminino , Gastos em Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Indicadores Básicos de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza/economia , População Rural , Fatores Socioeconômicos , Adulto JovemRESUMO
All health systems struggle with unlimited needs for healthcare, yet limited resources with which to address them. Under national health insurance systems, policymakers must make explicit and potentially contested decisions around resource allocation. Policymakers have recognized the need to include public values in decisions regarding the distribution of resources across competing health priorities. Given the complex nature of these decisions, however, research into how to effectively measure public preferences is underdeveloped. Measuring community values poses special challenges since they involve normative judgments that can be interpreted differently across individuals and communities. Researchers have previously proposed integrating two methods that are currently used for measuring public preferences around healthcare services: i) an individual survey instrument, the Discrete Choice Experiment (DCE) and ii) a group-based model that incorporates informed opinions and deliberative dialogue, Citizen Juries (CJs). This current paper proposes a framework for implementing that integration and assesses methodological issues in the integration of DCEs and CJs, including issues of generalizability and validity. CJs and DCEs have conflicting epistemological and methodological foundations, which impact how researchers might analyze results of the integrated method. Researchers and policymakers interested in measuring social values should determine the philosophical orientation of their research question prior to study design, which will assist in choosing an appropriate research method. Further research is needed to investigate the empirical validity of the integrated method and how it may be implemented to maximize public acceptance. Advancing these methods can provide an improved instrument for capturing public preferences for policymakers tasked with priority setting in diverse contexts.
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Participação da Comunidade , Atenção à Saúde , Participação da Comunidade/métodos , Instalações de Saúde , Prioridades em Saúde , HumanosRESUMO
Priority setting is a critical process for national healthcare systems that need to allocate limited resources across unlimited healthcare demands. In recent decades, health policymakers have identified the need to combine technical dimensions of priority setting with political dimensions relating to community values. A range of methods for engaging the public in priority setting has been developed, yet there is no consensus around the most effective methodology. A 2014 paper proposed the integration of two methods currently used for soliciting public preferences around health care services: i) an individual survey instrument, Discrete Choice Experiments (DCEs) and ii) Citizen Juries (CJs), a group-based model that incorporates education and deliberative dialogue. This pilot study is among the first to empirically test this integrated method to assess its value across two domains: does the CJ process alter participant preferences and are the consensus values of the CJ captured by the individualistic DCE? The two-part, mixed methods study was administered in Taipei, Taiwan in August of 2016. Twenty-seven participants completed a DCE as a baseline pre-test, ranking a set of attributes in terms of importance for future resource allocation under Taiwan's National Health Insurance System. Twenty of the participants next took part in the integrated CJ-DCE method, which consisted of education and facilitated dialogue through a CJ, followed by retaking the DCE survey. Participant preferences changed after undergoing the CJ process and these new, group-based preferences were reflected in the second DCE, meaning participants did not revert to their original individualistic preferences. The results of this study demonstrate that the integrated CJ-DCE method adds value in allowing an ethically communitarian set of values to be developed and captured via an individualistic methodology. Further testing is needed to investigate the reliability of our findings and how it may be implemented to maximize public acceptance.
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Atenção à Saúde , Instalações de Saúde , Humanos , Taiwan , Projetos Piloto , Reprodutibilidade dos TestesRESUMO
BACKGROUND: There are few studies that have analyzed the context of health care utilization, particularly in Latin America. This study examines the context of utilization of health services in Ecuador; focusing on the relationship between provision of services and use of both preventive and curative services. METHODS: This study is cross-sectional and analyzes data from the 2004 National Demographic and Maternal & Child Health dataset. Provider variables come from the Ecuadorian System of Social Indicators (SIISE). Global Moran's I statistic is used to assess spatial autocorrelation of the provider variables. Multilevel modeling is used for the simultaneous analysis of provision of services at the province-level with use of services at the individual level. RESULTS: Spatial analysis indicates no significant differences in the density of health care providers among Ecuadorian provinces. After adjusting for various predisposing, enabling, need factors and interaction terms, density of public practice health personnel was positively associated with use of preventive care, particularly among rural households. On the other hand, density of private practice physicians was positively associated with use of curative care, particularly among urban households. CONCLUSIONS: There are significant public/private, urban/rural gaps in provision of services in Ecuador; which in turn affect people's use of services. It is necessary to strengthen the public health care delivery system (which includes addressing distribution of health workers) and national health information systems. These efforts could improve access to health care, and inform the civil society and policymakers on the advances of health care reform.
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Acessibilidade aos Serviços de Saúde , Serviços de Saúde/estatística & dados numéricos , Estudos Transversais , Equador , Reforma dos Serviços de Saúde/legislação & jurisprudência , Humanos , Centros de Saúde Materno-Infantil/estatística & dados numéricos , Análise Multinível , Setor Privado/estatística & dados numéricos , Setor Público/estatística & dados numéricos , Análise de Regressão , População Rural , População Urbana , Recursos HumanosRESUMO
OBJECTIVE: To assess the distribution of financial burden in Chile, with a focus on the burden and progressivity of out-of-pocket payment. METHODS: Based on the principle of ability to pay, we explore factors that contribute to inequities in the health system finance and issues about the burden of out-of-pocket payment, as well as the progressivity and redistributive effect of out-of-pocket payment in Chile. Our analysis is based on data from the 2006 National Survey on Satisfaction and Out-of-Pocket Payments. RESULTS: Results from this study indicate evidence of inequity, in spite of the progressivity of the healthcare system. Our analysis also identifies relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. CONCLUSIONS: In order to reduce the detected disparities among income groups, healthcare priorities should target low-income groups. Furthermore, policies should explore changes in the access to education and its impact on equity.
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Atenção à Saúde/economia , Financiamento Pessoal/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Chile , Custo Compartilhado de Seguro , Atenção à Saúde/estatística & dados numéricos , Financiamento Pessoal/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , HumanosRESUMO
The purpose of this study was to examine the relationship between adoption of case payment for laparoscopic cholecystectomy (LC) and the growth rate of LC, outcomes of patients undergoing LC, and total healthcare expenditures on cholecystectomy. We used the claims data from Bureau of National Health Insurance (BNHI) to identify patients who underwent LC and open cholecystectomy (OC). Data were available from January 1996 to October 1997 and from January 1998 to October 1999, enabling use to compare data from before and after the introduction of the new case payment system. Results showed that the volume and the proportion of LCs increased after adoption of the new payment method. We did not find a sharp increase in the cholecystectomy rate during the study period. In terms of outcomes, the admission rate for emergencies decreased; the surgery mortality rate decreased, but the readmission rate increased. The average cost and length of hospital stay for LC subjects decreased; however, the total cost of cholecystectomy increased. The impact on LC of the introduction of a case payment method failed to reduce total health expenditures for cholecystectomy.
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Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/estatística & dados numéricos , Grupos Diagnósticos Relacionados/economia , Programas Nacionais de Saúde/economia , Sistema de Pagamento Prospectivo , Adolescente , Adoção , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Gastos em Saúde/estatística & dados numéricos , Gastos em Saúde/tendências , Pesquisa sobre Serviços de Saúde , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Taiwan , Revisão da Utilização de Recursos de SaúdeRESUMO
OBJECTIVE: The present study was aimed at analysing socioeconomic inequity regarding the use of health services in Ecuador, inequity regarding the geographic distribution of healthcare-related human resources and reflecting on the challenges concerning equity which the Ecuadorian health system is currently facing. METHODS: The Ecuadorian Demographic, Maternal and Infant Health Survey (2004) was used as the main data source, as its sample was representative of the Ecuadorian population. Multilevel multivariate analysis (MLWiN 2.02 statistical software) and spatial data analysis regarding health resources (GeoDa 1.0.1) were used for estimating the effects of using health services. RESULTS: It was found that social, economic and geographic inequity limited access to health services in Ecuador. People living in low economic resource households or indigenous housing and people living in rural areas (many of them having all three characteristics at the same time) had less possibility of using health services. In spite of a marked concentration of health-service providers in urban areas, it was found that the presence of healthcare personnel (excluding doctors) in rural public entities increased the possibility of using preventative and curative services. CONCLUSIONS: Efforts at transforming the Ecuadorian health system must be aimed at reducing social, cultural and financial barriers and inequality regarding the distribution de healthcare-related human resources, particularly in rural areas. Community and family orientation of the services and increasing spaces for citizen participation are necessary for reducing such inequity.