Health dissertation introduction example
1.1 Background to the study
Traditionally, policy interventions especially those meant for health promotion in communities have tended to individualize social problems. From the point of problem identification as a basic tool in constructing the foundation for policy, to policy formulation, application and evaluation, the dominant perspective is linear (Mann 1991), assuming a “rational person” perspective in which individuals are expected to comply to policy prescriptions when provided with relevant information. Following this, knowledge and perspectives of “health experts”, mainly from biomedicine, public health and behavioral sciences are placed at the epicenter of policy setting and application. The call for multi-sectoral intervention as in the case of HIV/AIDS is made for other sectors or professions to pass on the predetermined policy prescriptions, to appeal to people to avoid risk. Social Work and perhaps other professions become more visible as individuals and families, commonly defined as “victims” of the social problem emerge.
In the case of HIV/AIDS in Uganda, for instance, counselling and other psychotherapeutic interventions for persons living with HIV/AIDS, orphans, other vulnerable children, young people in difficult circumstances and other affected categories are reserved for Social Work and related professions to handle. The idea is to help affected individuals and groups to attain satisfying relationships and standards in accordance with their particular capacities and wishes. Little is done to bring community contexts into the definition of the problem and contribute meaningfully to policy interventions. As a result, the social and other conditions that produce and reproduce social problems such as HIV/AIDS in communities remain largely unchallenged.
1.1.2 Uganda and HIV/AIDS: A story of mixed fortunes
Uganda has a history of impressive developments and glaring setbacks in responding to the epidemic. After a decade of increasing numbers of new cases, the spread of the epidemic began to wane. Evidence of a consistent decline in HIV prevalence shows that rates began to decline by 1995 (from over 20-30% in some sites) reaching 8% in the general population at the end of 2000 (UNAIDS 2002; 2004). Throughout the 1990s there was evidence of a consistent decline in HIV prevalence, reaching 8% in the general population at the end of 2000. There was, for instance, a drop in prevalence among pregnant women from as high as 30% in some urban centres to 5-8% by 2000. By 2002, the estimated prevalence rate of HIV among antenatal attendees nationwide was 6.2%. Since 2002, however, the changes in HIV prevalence seem to be occurring very slowly with a current HIV prevalence of 6.4% in the general population (see also Wabwire-Mangen et al 2008; Kirungi et al 2008; UAC 2009; 2010).
Recent trends in HIV prevalence have shown a rise among some populations such as married people, lakeshore communities and other categories. There is also an apparent shift of the peak of the epidemic from young people to adults aged 30-39years. Other data (UNHBS 2005/6 in MoH and ORC Macro 2006) showed a fall in use of condoms among men at the most recent high-risk sexual encounters. Cases of complacency are reportedly more evident among specific categories such as lakeshore people. The national sero-survey (MoH and ORC Macro 2006) also revealed an increase in reported STI symptoms in the year preceding the study. Data available in nearly all official statistics show that Uganda continues to have a generalized and severe HIV epidemic with a prevalence of 6.4% in adults and 0.7% in children despite the effort taken to respond to the HIV&AIDS. Sexual transmission continues to contribute 76% of new HIV infections while mother to child transmission contributes 22%. The authoritative 2010 UNGASS report and Surveillance reports (op.cit.) show that Uganda is still experiencing a high rate of new infections. Currently estimates indicate that over 100,000 new infections occur annually (during 2008, an estimated 110,694 new HIV infections occurred countrywide. Approximately 61,306 people died from AIDS in 2008). Approximately 6.4% of adults or 1.1 million people are HIV-infected. The incidence rate by far outstrips AIDS related mortality and the numbers of clients enrolling into chronic AIDS care. The wave of new as well as old infection has shifted to older age groups and that both HIV incidence and prevalence in Uganda’s mature HIV epidemic stopped declining around 2000, remaining more or less stable,. Whereas the country has not officially declared whether this represents a rise or stagnation in HIV prevalence, it is clear that the less than impressive situation for nearly a decade now is cause to rethink strategies for prevention and learn from omissions and challenges in the national response to the epidemic.
The current argument to rethink practice for addressing HIV/AIDS in Uganda is also strengthened by the wide research in HIV/AIDS prevention globally showing evidence that policy and approaches are not easily implemented in the face of radically different understandings and contexts of different communities and cultures even within the same society (Aggleton and Coates 1995; Parker et al 2000). Indeed the recognition of cultural meanings, identities and community experiences led to a reformulation of HIV/AIDS interventions elsewhere (see Klein et al 2000; Parker and Aggleton 1999) to community-based efforts aimed at transformation of values, norms and the constitution of collective meanings.
The Ugandan situation described above is a sharp contrast from the earlier assessment when, for several years during the late 1990s to about 2003, Uganda was hailed as an example of a country providing a lead in reducing HIV prevalence in the region and beyond, basing on the “impressive decline” recorded between 1995 and 2000. However, the subsequent years to 2008 showed evidence of stagnation and, among some population groups, cases of rising incidence (e.g. Mermin et al 2008; UAC 2008). Since then, policy actors have been struggling to find empirical explanations and ways to address the epidemic better, their dominant option being “to re-launch prevention approaches”.
1.2 Lakeshore communities in the context of this study
For long, HIV/AIDS has been identified as the leading cause of death in adults aged between 15 and 50 in lakeshore areas in Uganda while in Kagara region, Tanzania, fisher folks are said to be five times more likely to die of AIDS-related illnesses than farmers (Ainsworth and Semai, 2000). National seroprevalence rates in the countries bordering Lake Victoria region were already high through the 1990s.
The above trend continued through the 2000s. Sexual behaviour and its relation to high prevalence of HIV (3.2% to 16.1%) was documented among fishermen and other lakeshore groups in Uganda and elsewhere (instance Entz et al 2000; Soskolne 2000; Seeley and Allison 2005; Allison and Seeley 2004; Wiwanitkit and Waenlor 2002). Findings (yet to be published) from a study by Medical Research Council (MRC) which coincided with celebrations to mark World AIDS Day 2010 show that the HIV prevalence rate at Kasenyi landing site in Entebbe is 28.2%, while that of other landing sites in Wakiso and Masaka is at 30%. This prevalence rate at landing sites contrasts sharply with the national rate of 6.4%. All the above fishing sites studied over a period of two years by Dr. Ponsiano Kaleebu, the director of MRC are located on the shores of Lake Victoria. In fact some anecdotal reports show that fishing communities worldwide are up to 10 times more vulnerable to HIV/AIDS than other centres (Cf. BBC 2005). In a broader context, the relative estimates for fishing communities have long been considered devastating. The one minute bulletin (BBC Ibid) for instance quoted University of East Anglia researchers who described fishing villages as the hidden victims of the disease. The communities were particularly vulnerable because the populations were highly mobile, lacked women's rights and had high levels of prostitution (Ibid).
Although the socio-economic effects of HIV/AIDS are now well recognized in other sectors, the implication of HIV/AIDS for the fisheries sector has been much slower in coming to the attention of fishery analysts (Olowosegun et al 2008). There are many glancing references in the media conference abstracts and elsewhere to high rates of HIV infection in fishing communities in East Africa but little reference to policy questions. The same is the case for other areas with the most reliable data on prevalence coming from studies in Thailand and Cambodia (see for instance Entz et al., 2000) where the large populations of the migrant deep sea fisher folks have come to the attention of policy makers, largely through their studies as illegal migrants. In these communities, prevalence rates of 15-20% among fishermen in the region mark them out as a very high risk group, comparable to other sentinel groups such as commercial sex workers, military recruits and long distance truck drivers (ibid).
From overwhelming sources, lakeshore communities are therefore among the highest-risk groups in countries with high overall rates of HIV/AIDS prevalence. Vulnerability to HIV/AIDS stems from complex, interacting causes that may include the mobility of many fisher folk, the time fishermen spend away from home, their access to daily cash income in an overall context of poverty and vulnerability and their demographic profile (see Allison 2003; Allison and Seeley 2oo4-a; 2004-b; Seeley and Allison 2005). The availability of commercial sex in fishing ports and the subcultures of risk taking and hyper-masculinity among some lakeshore people have also been discussed (ibid).
Lakeshore people, mainly those living on fishing and related commercial activities are highly mobile, moving between landing sites. Given their migratory nature, such communities may have limited social cohesion, and socio-cultural norms that regulates behaviour in more stable communities (Bishop-Sambrook and Tanzarn 2004). This reduces opportunities to benefit from traditional social safety nets that exist in more stable rural communities. This may also make generalized policy interventions difficult, as reciprocal networks are noticeably absent in the literature on such communities.
Fishing, the major chore among lakeshore communities is mainly a male dominated activity. The general lack of income generating opportunities for majority of women in such communities, leads to some women engaged in beer brewing and small scale fish-trading often carried out in conjunction with transactional sex amidst a culture of ‘hyper-masculinity’ (Appleton 2000; Allison and Seeley 2oo4-a; 2004-b). The physical demands of offshore fishing and a lack of livelihood options also make the community highly vulnerable to the impact of HIV/AIDS (ibid).
Landing sites are perceived to have a lot of economic potential. Indeed fishermen often carry cash from sales and have plenty of redundant time during day. On the other hand, it is believed that life at the landing sites is anonymous (Bukuluki 2006). As a result, anecdotal reports suggest that some people who have lost their partners due to HIV/AIDS may consider landing sites as refuge from stigmatization, ending into new sexual relationships. Consequently, perception of risk of infection with HIV in the communities is considered to be higher than in other communities. In some of the studies (op.cit) evidence revealed that 40.2% of the respondents considered they were very likely to catch HIV. This is in addition to limited access to health facilities and information, including services for treatment for sexually transmitted diseases.
1.3 Other historical and contextual facts related to the study
Uganda was one of the first countries in sub-Saharan Africa to experience the spread of the HIV epidemic. Since the first AIDS case in Uganda was diagnosed in 1982 in Rakai district, the disease spread to epidemic proportions, reaching all parts of the country. A national sero-survey undertaken in 1987/88 suggested a national infection rate of 6-8 percent. This increased rapidly reaching its peak in the early 1990s. Available data shows that by 1990, HIV prevalence in major urban areas was as high as 31% among pregnant women attending antenatal services. After a decade of increasing numbers of new cases, the spread of the epidemic began to wane in the early 1990s.
In mid-1991, an estimated 9% of the population and 20% of the sexually active age brackets had HIV, the highest being in urban areas where 24-36% of antenatal mothers at main hospitals tested positive (ACP Annual Reports 1987-1993). By 1993, the national estimates of cases of HIV infection had doubled (ACP Ibid). Between 1993 and 2000, there was evidence of a consistent decline in HIV prevalence, reaching 8% in the general population at the end of 2000 (UNAIDS 2000). The estimated prevalence rate of HIV among antenatal attendees nationally was 6.5% in 2000 (MoH 2002), following a history of declining trends from a national average 18.5% in 1995. Available data since 1999-2000 now show a tendency towards stagnation in prevalence between 6.1%, 6.5% and 7% (MoH 2005). Uganda Bureau of Statistics (2003) had earlier showed that the performance of the health sector is still low; the target set in the PEAP of reducing HIV/AIDS prevalence to 5% by 2005 was not unattained.
Since its outbreak, the patterns of transmission of HIV have been evolving over time with trends in HIV prevalence showing three distinct phases between 1989 and 2005. The first is the phase of rapid increase, between 1989 and 1992 with HIV prevalence peaking at an average of 18%; the second is the phase of rapid decline in HIV prevalence between 1992 and 2002; and the third is the phase of stabilization of HIV prevalence between 6.1 and 6.5% (Wabwire-Mangen et al 2008). Data from the two population-based longitudinal cohort studies in Uganda i.e the Medical Research Council (MRC) cohort and the Rakai Health Sciences Project (RHSP) cohort show that HIV prevalence and incidence rates might be rising in some population sub-groups in Masaka and Rakai
Apart from longitudinal studies tracking prevalence (for instance Shafer et al 2008; Lutalo et al 2007 and others); incidence trends have also been examined using laboratory methods including the BED assay (e.g Mermin et al 2008; UAC 2008). All the studies show less than impressive progress in the HIV situation in the country. The key drivers of the HIV epidemic in Uganda that have been identified (see for instance UAC 2007) include socio-cultural factors, poverty and other economic factors, low status of women and girls, human rights challenges, stigma and discrimination as well as issues related to inequity in access to health care (see also Porter 2004). On the other hand, the devastating effects of the epidemic at individual and community level continue to undermine national development efforts into the foreseeable future.
A review of major assessments of the epidemiology of HIV infection in Uganda reveals evidence of the factors associated with increased risk of HIV transmission (UAC 2006; Wabwire-Mangen 2008). Sex with multiple partners, HIV discordance among married and co-habiting couples, unprotected sex, intact foreskin and infection with genital herpes (HSV-2) and other STIs appear to be some of the current key risk factors fuelling the HIV epidemic in Uganda. In addition, vertically acquired HIV infections through mother to child transmission, either through perinatal transmission or post-natally via breastfeeding contribute to transmission of HIV among children. However, the importance of the various factors i.e. their population attributable fraction varies
A secondary analysis of the 2004-05 Uganda HIV Sero-Behavioural Survey (UHSBS) showed that among couples where one is HIV positive, 40% had a HIV negative spouse and only 9% were aware of the HIV status of their spouse (Bunnell et al 2007). In addition, of their last unprotected sexual encounters, 84% were with their spouses and 13% with steady partners (Ibid). While the UHSBS revealed an increase in reported STI symptoms in the past 1 year (MoH and ORC Macro 2006; UAC 2006), other data from MoH showed a fall in use of condoms among men at the most recent high-risk sexual encounters (UAC 2006). This apparent laxity in use of protective measures stems from the assumption that a committed relationship should in itself provide protection for the persons involved.
Since the onset of the epidemic, the country has developed a number of policy frameworks, directives, public statements and guidelines, articulating Uganda’s policy positions on HIV/AIDS. These spell out how explicit government has been on issues of HIV/AIDS (UAC 2002). The Multi-sectoral Approach to the Control of AIDS (MACA) was developed and adopted in 1992 to ensure a concerted effort. The Uganda AIDS Commission (UAC) was established, by Statute of Parliament, in 1992, under the Office of the President, to ensure a focused and harmonized response. This followed the development of the five-year National Operation Plan (NOP), National Strategic Framework (NSF) 1997 and NSF 2000/1-2005/6 to guide the response (UAC 2004).
The Multi-sectoral Approach calls for the involvement of everyone; individually or collectively to fight the epidemic at all levels within their mandates and capacities. The MACA as a framework gives a wide range of actors an opportunity to take part in planning and implementation of HIV/AIDS activities. Within the framework of the MACA, the country has developed a National AIDS Policy, which, is before the Cabinet of Uganda, and hence yet to be passed. There are, however, various inset policies and national guidelines that support the national response. These include the HIV Counseling and Testing (HCT) policy, Anti-Retroviral Therapy (ART), Orphans and Other Vulnerable Children (OVC) and several others such as Universal Primary Education (UPE) and Universal Secondary Education (USE) that directly or indirectly respond to impact created by HIV&AIDS.
At individual level, rigorous information, education and communication (IEC) advocated for a delayed onset of sexual intercourse and abstinence - A -, a marked effort to be faithful once married - B -, as well as the use of condoms particularly in non-marital, non-cohabiting sexual relationships – C (Kyomuhendo and Asingwire 2003). Since about 2000, however, studies reveal challenges to the adoption and consistent use of any of the elements of the famous ‘ABC- model’. Reference has also been made to IEC-fatigue, reluctance to embrace voluntary counselling and testing (VCT) and prevention of mother-to-child transmission (PMTCT), urging for new ways for addressing the social problem, or making existing interventions more appropriate.
Despite the above, Uganda has confirmed itself to Universal Access (UA) to HIV&AIDS preventive, care and treatment in line with WHO/UNAIDS recommendations. In recent years, intensified efforts to re-invigorate HIV prevention have been pronounced and a Road Map towards accelerated HIV prevention developed and adopted, based on analysis of the drivers of the HIV epidemic in the country. Uganda’s new National HIV&AIDS Strategic Plan (NSP) 2007/08-2011/12and the second Health Sector Strategic Plan 2005-2010 (HSSP-11) spell out the country’s priority of comprehensive, evidence-based HIV prevention interventions to be implemented on a scale commensurate with the current HIV transmission dynamics to meet the targets for United Nations General Assembly Special Session (UNGASS) and Universal Access to HIV/AIDS services.
1.4 Statement of the research problem
While much effort is put in asking why communities have not more often followed policy prescriptions and recommendations regarding their health, little is asked whether the policy interventions themselves are often in line with, or responsive to the lived experiences of community people. The later implies a new thinking which requires challenging the dominant paradigm(s) that inform the policies and/or approaches commonly used in addressing social problems. This would call for interrogation of policy content itself and extent of inclusion or exclusion of community contexts and experiences in what is finally laid out as policy intervention for addressing a problem such as HIV/AIDS. Systematic analysis and documentation of this has not been done. Consequently, the content and context of what constitutes effective policy interventions for HIV/AIDS for a specific community remains elusive. Although such investigation may be applied to any communities in Uganda, lakeshore people, commonly described as vulnerable, high-risk, hard-to-reach, transient, and peripheral, provide a good platform for such analysis.
The thesis of this work is that effective policy is one that starts with the community, as agency, as its base and moves to the political arena. This perspective would put more relevance and context to the policy and implementation modalities for addressing social problems. Although this argument has been made before in various degrees (see Osei-Hwedie 1993; 1996; Mupedziswa 1993; Ankrah 1987; Midgley 1996), empirical analysis of how a shift in the paradigms and practices at policy level bring effective practice has not been fully demonstrated.
By shifting the focus to the analysis of vulnerability as understood as socially constructed and conditioned, this rethinking raises the possibility of a transformed policy process in response to social problems such as HIV/AIDS. It implies a shift from the largely technocratic management to one that confronts or takes cognizance of lived experiences of community people and transforms the broader forces structuring vulnerability and enables community people to respond more adequately to policy interventions.
In addition, issues of sexuality, STIs and HIV in particular, are sensitive and private matters commonly considered sacrosanct, and are consequently divorced from everyday discourses. Therefore, an appropriate framework for these matters needs to be carefully investigated to derive relevant interventions that can stem the spread of an epidemic whose major mode of transmission is through sexual relations. For most people, these could be matters that go beyond the realm and choices of sole individuals, unless perhaps, together with significant others or whole communities in the social matrix, the individual is deliberately empowered to be self efficacious.
From a Social Work perspective, this enables practice to emerge from the surroundings and circumstances, or from both the policy and social environments. The argument therefore is that the long standing traditional focus on the individual facing social problems is wrongly placed. Instead, community dynamics should give any policy intervention its meaning, define its process and delineate its practice boundaries.
1.5 Objectives of the study
1.5.1 General purpose of the study
The overall purpose of this study is to investigate the lived experiences of lakeshore communities in relation to HIV/AIDS and relate these to current policy interventions for addressing risk to infection. The broader intent is to use this analysis as a case to reveal challenges and gaps in HIV/AIDS prevention policy interventions when weighed against context, and to provoke another way to think about this debilitating socio-economic and health challenge.
1.5.2 Specific objectives of the study
- Document everyday discourses at a lakeshore related to HIV/AIDS among fishers and off-shore groups
- Assess health and economic vulnerabilities at a lakeshore which could bear on community competence and resilience in the face of the HIV/AIDS epidemic
- Undertake a content analysis of selected policy interventions for HIV/AIDS prevention particularly in relation to the lived experiences of lakeshore people
- Use this analysis to present an argument that would capture people’s lived experiences and make them part and partial of the policy processes for addressing HIV/AIDS
1.6 Research issues/questions guiding the study
The following issues guided the execution of this study:
- What role does HIV/AIDS play in the lived experiences of lakeshore communities? Put differently, what kind of discourse about HIV/AIDS is present at the lakeshore?
- To what extent are the existing policy interventions addressing the concerns and/or needs of target communities at the lakeshore? Which needs are insufficiently addressed?
- How are lakeshore people responding to policy prescriptions for HIV prevention? Do they have any particular ways related to, or simply different from the policy prescriptions? What discrepancies can be discerned?
- What can policy actors in addressing HIV/AIDS learn from lakeshore communities in order to bring more relevance to policy for handling emergent diseases?
- What alternative argument can be developed to capture the lived experiences of communities, and align policies accordingly?
- How in particular can Social Work be useful in this rethinking? Or should we rethink the theory and practice of Social work itself?
1.7 Scope of the study
This is essentially a phenomenological study of lived experiences of lakeshore people in relation to HIV/AIDS, and partly a retrospective investigation of prevention interventions and community responses to these interventions. Focus is placed first on the way different categories among lakeshore people make meaning of their everyday lives, and, later linking this to the kind of policies, guidelines and strategies for prevention and their implementation frameworks. The study describes and assesses the extent of inclusion or exclusion of community contexts and experiences evident in the interventions. For in-depth investigation of how this translates at community levels, one lakeshore community on Lake Victoria was used to study specific aspects of the lived experience and the link (or lack of it) with policy interventions for HIV/AIDS prevention.
The study was limited to a fieldwork period of two years (2008 and 2009) of a structured national response to HIV/AIDS in order to have a more focused analysis. Discourse analysis and in-depth investigation of issues generated were attempted to answer the key research questions. Discourses surrounding the question what has or has not happened with regard to policy interventions were analyzed to delineate the linkages and gaps between policy and lived experiences of lakeshore communities.
Knowledge generation: This study is significant in a number of ways; first it provides a descriptive account of how everyday people live their lives at a lakeshore from a semi-ethnographic lens. The study also generates more knowledge and understanding of the policy intervention processes in order to provide entry points for enhancing policy relevance to people. Through the analysis, it is possible to challenge the ways in which we view, and deal with, social problems.
This study also offers an opportunity to rethink the place of Social Work knowledge, theory and practice and its contribution to macro-level policy articulation. In a sense, the study challenges Social Work in particular to redefine its practice boundaries, broaden its scope beyond remedial practice (dealing with mitigation of problems and emergencies among individuals and groups) and be seen to enter into the political and developmental arena.
Theoretical relevance: The study is designed to benefit from theories and models related to risk assessment and behaviour change and policy implementation. Through this study, theories are examined and aspects of them used in the interrogation. In the end, the utility of some of the theoretical underpinnings are, in a sense, examined against the realities of community people in dealing with a devastating social condition such as HIV/AIDS. Ultimately, this serves to strengthen the theoretical grounding for promoting effective practice in handling social problems
Policy Analysis and Community Practice: The findings of this study are also important in providing a critical analysis regarding developments and gaps in the Uganda’s national policy interventions for HIV/AIDS prevention and to explain how these gaps may be addressed. The wisdom in bringing communities to the epicenter of the problem solving processes as a key tenet in Social Work is particularly articulated, as well as the principle of “starting where clients are”.
Further Research: In using different theoretical and methodological approaches in an eclectic triangulated manner, it is anticipated that this study will stimulate more scholarly, analytical research in the field of Social Work policy and practice for dealing with social problems.
1.9 Organization of the Dissertation
This dissertation is divided into eight major sections or chapters. The first chapter presents the introduction, background and context of the whole study, delineates the problem under investigation as we as the key issues which fall under this interrogation. Chapter two is dedicated to the theories, perspectives and considerations necessary in understanding the linkages between lived experiences, policy interventions, communities and practice in relation to HIV/AIDS while chapter three is reserved for reviewing the literature on the epidemic among lakeshore communities in Uganda and elsewhere. These two chapters are particularly important in as far as they provide a guide and foundation, helping the researcher to delineate scenarios and gaps (theoretical, conceptual, methodological, and interpretive) not sufficiently explained or analyzed and make them the focus of the present study. The first introductory chapters are therefore used herein to shape the fourth chapter, the approach and methodology.
The next three chapters of this dissertation present the three major broad themes of the study, namely;
- Discourses of health and economic vulnerabilities at a lakeshore: The lived experiences of boatmen and off-shore communities
- Agency, Inevitability and victimization: Social identities, partner relations and discourses of risk-taking at a fishing village
- Policy interventions for HIV/AIDS prevention in Uganda in relation to lived experiences at a lakeshore: Analysis of Actors, Processes and Gaps
Finally, but equally important, the dissertation ends with the chapter on synthesis and suggestions for enhancing relevance and appropriateness of HIV/AIDS policy interventions to lakeshore communities. To help in the rethinking, the researcher builds on the earlier argument, namely that effective policy formulation and policy practice is one that starts with the community, as agency, as its base and moves to the political arena. However, beyond the argument, the researcher makes suggestions for an approach by which this can be demonstrated to engender more effective response to pressing social problems such as HIV/AIDS. The lesson in all this is that knowledge and application of community empowerment practice, a core field for Social Work theory and practice, is required for effective intervention to deal with social problems. Social Work in Uganda should therefore broaden its practice boundaries in HIV/AIDS work, and get to the epicenter of policy development and articulation as well.