International Network on Research in Inequalities in Child Health: 2nd workshop, November 6-7th, 2009Friday November 6th 2009The following members were present:Nick SpencerLouise SeguinAnders HjernClare BlackburnTom BoyceRona CampbellJailson CorreiaDave GordonJody HeymannPatricia LucasJennifer McGrathKate PickettHein RaatLuis RajmilHelen RobertsIngrid SchoonElspeth WebbRussel WilkinsPaul WiseBeatrice NikiemaMai Thanh TuKristen McNeillParama SigurdsenLucie LevesqueJas BainJanet Reid, and Ling Wu and Lina Shaheen (2 graduate students) joined as well. 9:00 The 2nd INRICH workshop is opened: Welcoming address from Nick Spencer and Clare BlackburnThe Network is pleased to have people from around the world attending this 2nd INRICH workshop and would like to welcome them at University of Warwick. We are expanding in members and we hope for a productive and useful meeting. The Objectives of this Network are to share ideas and information regarding child health inequalities, to generate collaborative projects across countries and to tackle various issues related to child health inequalities on the international level. During this workshop, we will be looking at various aspects of child health inequalities through 4 sessions in the programme. In particular, we will discuss policies and how research can reinforce them in helping children in need. Local graduate students have been invited to join this workshop to discuss specific issues they are facing in their projects. The Network now has more than 60 members, and is open to suggestions for new members. Membership is based on interest in Child Health Inequalities research. Since the last workshop in Montreal, in November 2008, there are a number of appointments made within INRICH that should be mentioned, which allowed the development of a website, setting up e-learning tool (Wiziq), organizing a phone virtual conference last June and this meeting. Soura Biesse and Lucie Levesque are mostly responsible for this work and we have to mention the help of Isabelle Therien, who is dealing with financial matters at the Centre Léa Roback, in Montreal. With the progress made in the Network, we are now aiming to have collaboration work, rather than just emails to build on. To maintain the Network, we should think about funding opportunities, and we are sending a call for help from every member. The Canadian Institutes of Health Research (CIHR) funds received last year was only a one-time funding opportunity. If we have a few collaborative projects, it will help to get funding as there is very little money available for infrastructure projects. For this particular workshop, we have to acknowledge the support received by Université de Montréal, La Direction des Relations Internationales, Centre Léa-Roback, Foundation for the Sociology of Health and Illness, Child Care Health and Development Trust, The University of Warwick, Health at Warwick. Introduction of attending membersAll members present at this workshop introduced themselves and provided a brief presentation of their current research interests and projects. A summary of the profile of each member is available here. Suggestions for future initiativesIt was suggested to build a potential branch of INRICH for developing countries. There could be possible groups for collaborative work to discuss later on during the workshop. Groups can perhaps discuss data issues, birth cohorts, health and social policy, health and evidence-based, child life course, child rights, methodology issues. These topics derived from natural clusters of research interests among the Network members attending this workshop. For e.g. UK, Sweden, NL and Canada have similar cohort studies and can perhaps work together to address similar questions. Within each group, we can have people interested in both individual mechanisms (e.g. stress pathways) and global aspects of child health (policies).10:25-10:45 Coffee break10:45 Nick Spencer: Systematic review on poverty/low SES during early childhood (slides for this presentation are available here)This presentation was followed by a period of questions and discussion where these points were raised. Studies published in grey literature, such as a PhD thesis, and some articles “in press” were included in this review, but we will need to be more systematic in our research of the grey literature.How do we distinguish between acute and cumulative exposure to poverty when the child is aged 0 to 2 years? Most studies have adjusted for current poverty level to better examine the cumulative aspect.Can we use maternal and paternal education level to define SES? Maternal education is more stable and more available, especially in single parent households. However, it is important to use income as an indicator of poverty, because otherwise, one may believe that we can simply educate a poor mother to better balance her budget.Adjusting for different variables is a good way to outline the effects of the variables of interest, but what about the mediators? It’s a correction for the role of mediators or confounders. By looking at each study, basic models can first be assessed with confounders, then, mediators can be added. It was suggested to look at which variables were added in the adjusted odd ratios. It was agreed that there is a need to think about pathways, to examine the underlying child health inequalities and this approach could help. This might be important for the conclusion in the systematic review. Among children from the Generation R cohort, there were differences in language skills during assessments due to ethnic background, which can also be a problem as there is a cultural difference in many health behaviours (e.g. smoking). Furthermore, genetic differences could play a role, e.g. height of parents influence on height of children. There are different approaches to address this issue: to analyze all data as one group and to correct for ethnicity/immigration status, or to have subgroups of SES, then look at ethnicity/immigration status within each subgroup or to do a separate analysis according to ethnicity/immigration status. Similar problems are also seen in the Quebec ELDEQ cohort. Children of poor immigrant mothers present often better health than poor children from Canadian-born parents. The narrative account of the review should include previous work in this field that did not specifically meet inclusion criteria, so that we do not undermine their importance to the field. One has to be cautious that no reports of an association in paper might reflect a non-significant association observed. We can perhaps cite structural studies focusing on what causes poverty, even though they did not look at the root of poverty. We will then avoid misinterpretation by policy makers that a lack of evidence about early life poverty and child health problems means an absence of association. Researchers understand this distinction better. We have to be aware of what the requirements and taxonomy of policies are to adjust the presentation of research results for policy makers. 12:00 Lunch13:25 Thomas Boyce: Early adversity and future health (slides for this presentation are available here)This presentation was followed by a period of questions and discussion where these points were raised. What is the gender distribution in the gradient? When boys and girls are observed together as a quartet (4 at a time), the data becomes incoherent. In a quartet of boys, there will be a lot of pushing each other for access to the target toy, while the quartet of girls will discuss for a combined strategy to reach the goal. How stable are these behaviors through preschool and kindergarten or puberty? Work is in progress to examine this question. What we know is that when there is a new child coming in the daycare, there is swapping of role, but if conditions remained similar, the roles are maintained. Are there any known differences across countries in the expression of these behaviors in children? The data do not allow addressing this question yet. What we know is that the teacher plays a fundamental role in moderating the amplitude of the slopes of differences between schools. Some teachers use the hierarchy to control their class, so they contribute to the hierarchy, other teachers made what they could to flatten the slope e.g. by enhancing a skill of the subordinate. Therefore, there are differences in the climate of each school (unpublished data), which could perhaps translate into regional differences as well. Altruism, pro-social or poor social skills, can that explain some of these behaviors?Girls are very different from boys, consistent observation within the 29 schools. Whether these differences remain once they reach puberty is not known yet. Work is in progress to examine these issues. The 4 types of behaviors are labeled that way, but they could be labeled otherwise, it’s a matter of interpretation.It is important to mention that in real life, each individual displays a blend of different behaviors, not just one single type presented here. Could the dominant or displacement behavior be another dimension of poor social skills?14:30 Nick Spencer: Intergenerational pathways to child health inequalities: what do we know and what do we need to find out? (slides for this presentation are available here)15:00-15:30 Coffee break15:30 Clare Blackburn: Poverty and childhood disability: cause or consequences?(slides for this presentation are available here)This presentation was followed by a period of questions and discussion where these points were raised. It is important to define disability, the age range of interest. WHO defines disability based on function, it could be physical or mental and visual disability is included in this definition It is dangerous to use a broad measure such as disability and address economic impact.There is a difference between countries in indicators of disability, treatments and occupational resources, e.g. wheelchair and local transport policiesThere is a lot of heterogeneity in disability, for instance, in children with ADHD, while a proportion have true ADHD, the other part may just have phenotypic ADHD due to violence at home 3 levels of difference in disability could be applied: does the child have disability or long lasting illnesses? Does the child have activity limiting due to long lasting illnesses? Does the limiting activity change when medications are used?16:00 – 17:30 Small group of discussions with a focus on informing future collaborative work18:30 DinnerSaturday, November 7th, 20098:45 StartNew members joined the 2nd day of the workshop, including Elizabeth Waters, Laurence Moore and Bolanle Ola, a PhD student. Reports from small group discussionCollaborative project on birth outcomes (Nicholas Spencer, Louise Seguin, Hein Raat, Beatrice Nikiema, Luis Rajmil, Russel Wilkins, Ingrid Schoon) This project focuses on birth outcomes and infant mortality by SES across countries. The problem is to make it comparable by using the same definitions. We could consider singleton births with more than 28 weeks of gestation, look at infant mortality together, live births, small, appropriate or large for gestational weights, preterm birth, mean birthweight, still births, neonatal and postnatal death. SES measures will include maternal education when possible, neighbourhood-based proxy income or deprivation index if the income not available. We could look at absolute rate rather than relative, in cohorts based in the UK, Canada, the Netherlands, Sweden, Spain, and the US. We can consider as associate factors parity, maternal age, marital status, smoking and cohabitation, look at the slope of gradient, and ratios. We can also examine these issues in a cohort in Burkina Faso, where larger polygamous families are common (at times, with up to 17 children per household). Russell Wilkins will undertake initial drafting of a proposal that will then be modified by other group members.Collaborative project on child life course (Jailson Correia, Jennifer McGrath, Kate Pickett, Tom Boyce, Mai Thanh Tu, Ling, Kristen McNeil) Following our discussion, we were thinking of developing optimal ways to study child life course studies. The next best thing to writing a grant for new projects could be how to conceptualize and standardize measures to assess health and SES in children. SES and health have already been addressed in the McArthur studies, but this time, we can adapt it for families and children. The methodological aspects can be posted online. Then, we can use what current cohorts with nested designs, already have measured, and eventually, adding measures to cohorts currently underway, but using a more uniformed method. The conception of SES, based on Nancy Adler’s ladder, could include available resources which might explain inequalities in underdeveloped countries, such as access to water and electricity, compared to industrialized countries where education, income and occupation are indicative of SES level. Collaborative project on child rights (Elspeth Webb, Lina Shaheen)Our discussion, with a very small number of discussants (2) talked about applying the children’s right perspective in a group of children with poor language skills, those who didn’t speak the main official language, and therefore, who failed to develop (local) language skills. This can cause identity problems as those with poor English language skills are still more accepted by their peers when their mother tongue is one of the languages of European Union countries than when they only speak dialects of foreign languages. Potential collaborations with NGO are to be kept in minds. Collaborative project on child policy (Jody Heymann, Clare Blackburn, Janet Reid, Patricia Lucas, David Gordon, Paul Wise, Parama Sigurdsen, Anders Hjern, Helen Roberts) Discussion within this group was focused on bringing in resources for research training and advocacy. There should be a focus on the child in policies to reduce inequalities, between countries or within country, comparable across countries. Individuals can collaborate within countries, but the strength of this project relies on between countries. We can look cross-nationally on what would not just improve, but also reduce health inequalities. We could apply for a grant to get data from household survey across 40-50 countries. The data is already available, so this appears feasible. We could write systematic reviews, critical reviews, think of what data exist or not exist. On the training side: what would work across fields? By using a multidisciplinary approach, the training aspects could help NGO have more rigorous research.9:25 Kate Pickett: Child health and well being in rich nations: the role of income inequality(slides for this presentation are available here)This presentation was followed by a period of questions and discussion during which these issues were raised: Information about violence is missing from this presentation and from all other data cohort, but it seems related to all the problems listed here. Bullying has different meanings across culture and country, but this is feasible to addressChildren are more sensitive, they will rapidly notice type of clothes, toys and other materiel differences 10:15-10:30 Coffee break10:35 Jody Heymann: Social policies and the health of children (slides for this presentation are available upon request to Dr. Heymann). Below is a summary of the presentation: In this presentation, Dr. Jody Heymann presented work in progress on social policies that can have an impact on children’s health involving 192 countries and is welcoming feedback from members, especially regarding measures that they wished they knew and could be collected, and what they think might be less important to children’s inequalities, The focus is on measures that could be available in many countries, rather than measures that are available in depth, but in only a restricted number of countries. What do we know about social policies affecting children? The World Legal Rights Data (WoRLD) Centre, led by Dr. Heymann, is an initiative to help improve knowledge and comparative data for global policymakers, NGOs and researchers on a number of social policies. Policy areas captured are education policy, child labour, poverty policies, adult labour conditions, discrimination and equity and social and economic rights. Education: Education policies include access and affordability to public education at the primary, secondary and tertiary levels and whether it is compulsory or not. Related information are also available regarding teachers’ training qualifications and possibility for specialized education.Labour:Adult labour condition is the most efficient way to lift children from poverty as it shapes parents’ availability to care for their children. Examples of information gathered by the WoRLD are a maximum number of working hours, overtime work restrictions, night work restrictions, weekly day rest from work, annual leave. Large proportions of low income families going for night work. Interestingly, 61 countries have guaranteed wage premium for night work. However, one has to keep in mind that the rate of drop out of school is higher if parents work night. Among universal measures that may influence children’s health, 65 nations provide work leave to attend to children’s health needs, education and development, but this leave is paid in only 48 nations, which include most north countries such as Canada, Europe, Russia and Australia provide paid leave. The United States provide unpaid leave, while Africa and Asia do not give any leave to care for children’s needs. Child labour: Policies regarding child labour are also important, with minimum wages, maximum working hours, with a minimum of 12h nightly rest. There are penal sanctions for people violating child labour such as exposure to hazardous environment, child sex workers, or child slavery. Poverty policies: Policies related to poverty included family cash benefits, and other aspects such as unemployment benefits, number and age of children, which contribute in avoiding having children working. Parental leave: 177 nations provide paid leave for new mothers, excluding the US and Australia. However, Australia is introducing this measure next year. Only 74 nations provide paid leave for fathers with Russia offering many weeks, compared to South America, Canada, Malaysia and a few African countries. Discrimination and equity: social policies regarding discrimination and equity will allow the parents to provide a better environment to care for their children’s. It will shape the children’s own expectation for their future. Through these measures, the WoRLD captures legal guarantees of equal rights, regardless of sex, gender, race or religion.This presentation was followed by a period of questions and discussion where these points were raised. What social policies matter to children? What data missing that could be collected? This is a call for input.Information about the curriculum could be interesting, whether the pre-primary education is play-based or more formal, as poorer children may not benefit from itAccess to learning material could be another aspect of education to examine Regarding adult labour policies, is it possible to look at union rights? Is there a health person available in preschool and school? Answer is that the data is available for 95 countries for preschool, but the information is not clear. Health and nutrition in school is not known, but there is information about whether it is provided and whether it is free. Problem is that children caring for children might not go to school. Any information about water and sanitation? The information about minimum wage and purchasing power have to be converted into something that is comparable across countries. Whether work is domestic or not is important as well, because of significant gender disparities Information about criminal justice system Rich nations have building regulation so that poor families don’t spend a too large amount of their income for housing and basic needs. However, this information is rather difficult to gather for a large number of countries. 11:25 Liz Waters and Helen Roberts: What works in reducing child health inequalities?Slides for these presentations are available here and here.Summary:Since 2008, Sir Michael Marmot is leading a major review of health inequalities in England to propose evidence-base strategies to reduce health inequalities from 2010. We have to use what we already know to achieve it. Initiatives aiming to end child poverty can be achieved by adressing workforce issues and cost effectiveness of non clinical interventions, and paying attention to Nordic countries and other countries with good trials, transport, housing and green spaces as major routes to better child health. There is a need to identify where disinvestment might take place. Various methods that address effectiveness can be used including effectiveness of service delivery, safety, cost effectiveness, acceptability, appropriateness, quality and salience. We should focus on the user’s perspectives, those on the receiving end of services. They need to be part of the dialogue and integral rather than an add-on. As part of various initiatives to reduce child health inequalities, The Cochrane Public Health Review Grouphttp://www.ph.cochrane.org aims to produce and publish reviews on public health interventions at the level of the population. Topic categories include income distribution, education, public safety, housing and built environment, employment and work environment, social networks, food supply and access, transport, natural environment, health and related systems. There are a number of published protocols and titles under development. For instance, published protocols include collaboration between local health and local government agencies for health improvement. Other protocols are registered and are now under development such as flexible working condition and effects on employee’s health and wellbeing, a review on food security in developed countries, workplace-based health promotion interventions, increasing physical activities through community wide activities, wheat flour fortification, access to fruits and veggies in children and adolescence. Titles under development include school time scheduling, community-building interventions to improve physical, mental and social health, oral health promotion, and slum upgrading strategies. A more extensive list of titles currently registered and titles currently under development can be found at http://www.ph.cochrane.org/en/scope.htmlThe goal is to bring together people to strengthen these areas. Reviews have about 3-4 people working together, sometimes more. Everyone can access to the protocol while it is being applied, information about these protocols are available and open for further suggestions. This presentation was followed by a period of questions and discussion during which these issues were raised:We know what works and what doesn’t work, but we don’t know how to change and achieve them. Studies should publish SES information so that they can be included in those studies. List what SES variables were collected in table and people will know they can go back and run more analyses. Collected but never analyzed will provide information. We want to see a country-wide scale. We still have problems to apply interventions from 10 000 people to 100 million or more. How do we scale up?, e.g. education not same interventions as vaccination because of different training. At a time of urgency, e.g. early 40’s, with the financial crisis, interventions were just carried on faster, without thinking of pilot testing. There is a constant fear of doing things only perfectly, there is a lot of caution to not go forward on policy. Collaboration opportunities include: shared long-term vision on cohort birth to 15 years old. We could have the IRCHI subdivision of INRICH: International Reduction in Children Health Inequalities. 12:30-13:30 Lunch13:40 Discussion with a focus on links with policy makersWhat does it mean to make links with policy makers? We should make ourselves clearer, say it more loudly, policy makers might not come to research meetings. We should find ways to reach policy makers. We have resources here to translate good research into a format that can be heard. Within INRICH, we can help each other. One of the prob is how to start? We are addressing research in many countries, so how do we proceed from here on?A range of different activities to outline evidence to actions should be taken.In UK, the problem is that you need to change policy makers’ mind, but need also to take the message from research to practice. Once you got a policy, there is a pathway of taking it into practice. We can research why policy is not enacted, but we need to get the ear of policy makers, as an organization, creating policy partnership. Proximity to government, in Wales and in Australia is good, relative to UK. There is study that was just completed in the UK, where we had to have an advisory committee involving NGO representatives and policy makers. Suggestions for 3 ways: 1st way is informal who has links with government or IGO. 2nd way: the group has a single topic. 3rd way: skill building across context. Upscaling research capacities. The government asks for evidence, more evidence, across countries, to strengthen the point, not just in one country. We are just beginning to do collective work, we are starting, but can we have one message that collectively we agree on, that we can transfer? In our next meeting, we could open a few sessions to the public, not all, to make sure to maintain depth in discussion.It is difficult to provide the time for face-to-face interactions with policy makers, but we can put together a publication to release to the press.We have to adapt to priorities of politicians, so we need to think about what information to get during data collection, to make a stronger case. One way is to target the media. Focus the message and send to pressure group and advocacy. We need to see who wants to do what and to send a clear single message to the politician. We need to describe what is achievable and what isn’t, this will be more specific and we will be able to work more quickly. With good communication, there will be best to ensure that this group is coherent (not unified), in the approach and that the address to social policy is comprehensive. In the US, many findings presented during this workshop will go against actions. E.g. they will interprete a trend to devaluate clinical care. We want to focus our activities on our own. Many of the findings shown can cause more mischief on public health in US. We have to ensure that methods are constructive. On the practical level, let people know that this 2nd workshop was ongoing, with the publicity and central theme of CHI.We should create partnerships with policy makers, to form a trusted relationship. How to maximize and include them in building projects. When you work that closely, you are more aware of what is coming up in the agenda. It will open window not present in regular relationship.Within the umbrella of this Network, if there are members working on policy, they are welcome to feed in, working with NGOs, advocacy organizations who are set up to advocate on particular issues. E.g. in UK, the anti-poverty coalition. We can use the Network to bounce off ideas. 14:15 Discussion of collaborative projectsThere were 2 collaborative projects we could work on.Collaborative work on perinatal outcomesThe systematic review will be put out for further discussion. We will try to nuance the points in the presentation of the systematic review on paper, addressing the issues on limitations of evidence. Are we looking from the right lens, equity? Is it appropriate for childhood?Looking at progress and produce recommendations from studies already done, look for the best measures to use, we could inform on what the measures differ, or adapt to adolescent. We could look at parenting interventionsWe can make intervention and policy research attractiveDo similar work to Kate Pickett’s, but on the 26 states of Brazil, known to have many disparities. We have gone straight down to the data, but we need to get our head together for one collaborative project.The fundamental challenge that we face in the US is the need to ensure that communication on key issues is very central. Take advantages of communication, blogs, to engage on regular basis to maintain momentum, instead of a few times per year, by email, to have a collaboration that will be more constructive. We have created a type of forum and we need to stabilize it. Small groups can take over specific projects together. This is a transdisciplinary group, which has a richer role in the INRICH workshops, with more constructive dialogues, greater analytical coherence, to make it strong enough to be heard The UNICEF meeting is coming up soon: we can come up with a collaborative project to develop more real time impact on global recession and child’s well-being. UNICEF is mounting a rapid survey and could be complementary with this group. The reason to monitor and do surveillance is to better understand and take better actions. E.g. neonatal mortality. 15:25 Discussion about administrative aspects of INRICH Future programmeJailson Correia suggests holding next year’s workshop in Recife in Brazil. The Institute where he works celebrates its 50th anniversary and there are many activities on the schedule. He was given the task to organize an international meeting on research, with issues to be tackled such as Inequalities and translation. The first option is to have INRICH help with identify the right people to talk, while the 2nd option is to host the 3rd INRICH workshop. To justify local involvement, we could have a day or half-day organized as open activities to the general public and the rest for more internal work. However, the implications include allowing more latin American or developing countries to participate, while remaining within the missions of the INRICH. An email survey to consult other members of this Network will be sent. As the initial idea was to alternate between America and Europe as location of INRICH workshop, Brazil would fit this alternate location. This is a good way to start involving low income country such as Brazil. Funding could be a little issue, but this could be dealt with. VISAs are needed to travel to Brazil for some members from the US, Canada and Australia, but not from Europe. The timing aimed at is April as there are days opened for this event, however, this can be changed to late September or early October. Mid-October and November should be avoided as elections are planned for this period. Location for the 2010 INRICH workshop should finalize by early 2010, to allow sufficient time for planning the event.On the programme for the next workshop, a few sessions should be devoted to address a natural research tensions or questions. Here are 3 examples of issues:Relationship between medical care and social determinantsAbout the impact of gradient, how much is due income, hierarchical gradient (ex race, ethnicity), which portion is poverty or mat deprivation?We can also discuss the dominance hierarchy compared to pro-social behaviorsFurthermore, local students will be welcome to attend each workshop meeting. This also applies if the meeting is held in Brazil. For upcoming workshops, Rotterdam was suggested as the venue for the 2011 Workshop (hosted by Hein Raat), while California (Stanford) was suggested as the venue for the 2012 Workshop (hosted by Paul Wise). FundingA Canadian funding agency is offering grant opportunities for networking, for which INRICH meet the requirements. This could span up to 5 years. The deadline for submitting a letter of intent is January 1st 2010. This opportunity has to be checked out further.(note: we are not eligible to that source of funding) It is very important to get a large grant to keep on developing and expanding the Network. Other than this possibility, we have to consider approaching other funding sources and everyone is asked to look for any opportunity in their own country. We are now preparing a proposal to the Ford foundation, which appears more flexible for its objective, compared to other foundations suggested during last workshop. Most are funding only specific projects. Many funding agencies would fund interventions projects but not research. An application to the Ford Foundation would require to have a US sponsor for the grant. Another source of funding could also be to charge a small fee to run the meeting, to cover the expenses. This should be discussed with other members who did not attend the 2nd workshop. It was also suggested to charge a small fee to attend the section of the workshop that will be open for the public. WebsiteShould we make the website public or private? It was suggested that the website could have both public and private sections that would be would be password-protected and restricted to members only. Virtual conferenceAs mentioned during last summer’s phone conference, virtual conferences are planned to take place between annual workshops, using Wiziq. This tool is currently being set up and should be ready for use shortly. This will help both members and students to communicate with other members and to arrange international visits for short duration. Students might communicate with a few members to arrange visiting international students for short visits. Local students are welcome at each workshop meeting. To facilitate student exchanges we will need to know who is ready to receive students and with what sort of facilities. This will be an objective for next year.Jailson Correia announced that his Institute will be happy to host a few students to carry comparative studies. Also, there is a Journal on Child Health in Brazil, indexed in a database that also hosts WHO publications. It is not yet in Medline, but this is in progress. Currently, this Journal is becoming one of the preferred journals for Latin American on child and family health. Publications can be in English, Spanish or Portuguese, abstract has to be in original language and in Portuguese. This report could be part of the proceedings. Concluding remarks by Nick SpencerThis 2nd workshop has been an interesting and useful meeting. Our colleagues’ discussion on policy was very valuable. We have the potential to continue our mandate and are moving forward, not just surviving from year to year, but are gaining momentum by adding new members to our list and by starting collaborative projects.