X Close

Linking Our Lives

Home

Menu

Does social position affect our chances of contracting bowel cancer?

By Chris A Garrington, on 13 July 2022

We know cancer incidence is linked to socio-economic status, but that this differs according to types of cancer. In the second of three blogs on research using the ONS-LS to explore cancer and social status, Charlotte Sturley has examined diagnoses of bowel cancer, and found some clear evidence of a social effect.

Bowel cancer – also known as colorectal cancer – is the fourth most common cancer in the UK. Over 42,000 people are diagnosed with it in the UK each year so it is a major public health problem. 

Cancer incidence varies between different groups of people, and differences have been found based on gender, age, ethnicity and where people live.   

In England, for most cancer types, incidence is higher in the most deprived areas compared with the least deprived. The deprivation gap is largest for lung cancer, reflecting the fact that more deprived groups are more likely to smoke. Conversely some cancer types, such as breast cancer in females and prostate cancer in males, are more common in the least deprived areas.

The association between colorectal cancer and deprivation is less clear, and findings from previous studies have been inconsistent. In the 1980s, affluence was associated with an increased risk of colon and rectal cancer in Europe. But more recently, evidence has emerged of links between this type of cancer and living in a deprived area.  

Understanding the causes

Given this apparent shift in the relationship between socio-economic deprivation and colorectal cancer, it is important for researchers to monitor recent data to see if the patterns are changing. We also need to understand the extent to which inequalities are associated with both individual and area-level factors to better target their underlying causes.

Most research on inequalities in cancer incidence has focussed on indicators of deprivation at area level, largely because cancer registries do not collect data on indicators of socio-economic position, such as the patient’s level of education or occupation.

Using Census Data to dig deeper

The Office for National Statistics Longitudinal Study (ONS LS) offers the opportunity to investigate variations in cancer incidence using information gathered in the census on individuals’ socioeconomic positions. My study used measures of educational attainment, occupational social class and housing tenure, along with an area-based measure of deprivation called the Townsend deprivation score. 

My sample were LS members who were present at the 2001 Census and were aged 50 years or over, as incidence of colorectal cancer is very low among people aged under 50. 

Among the study sample of 178,116 individuals present at the 2001 census, there were 4,418 cases of colorectal cancer recorded by the end of 2015. Because the ONS LS links census responses to cancer diagnoses, we could measure the average length of time between the 2001 census and the diagnosis.

Results

The study found evidence of socio-economic inequalities in colorectal cancer incidence and that these differences varied by indicator of socio-economic position. LS members with a degree were less likely to have a colorectal cancer diagnoses compared to those without a degree, after accounting for differences by age, sex, ethnicity and area deprivation. A statistically significant association was also observed between housing tenure and colorectal cancer incidence, but only for those in social rented housing, who were at an increased risk of colorectal cancer compared to owner-occupiers.

Those employed in manual occupations were more likely to have a colorectal cancer diagnosis, compared to those in non-manual occupations – however this association was not statistically significant when adjusted for other variables. There was no statistically significant difference in colorectal cancer risk among study members in private rented accommodation compared to those in owner-occupied housing. No significant variation in colorectal cancer incidence was found by the level of area deprivation.

So, we can say individual measures of socio-economic position based on educational attainment and housing tenure are associated with colorectal cancer. My finding that there is not a link with area-level deprivation differs from other recent research which reported an emerging association between this type of cancer and deprivation, measured at the area-level. But these other studies used a different measure of deprivation which means comparisons are more difficult. The longitudinal nature of the LS data and the long-follow up period enabled time-to-event analysis to be employed in my study, whereas previous studies have tended to be more of a snapshot.

Not all individuals living in deprived areas will experience the same level of deprivation, and that could explain why I did not find area effects even though I did find individual ones.

Risk factors

One explanation for an association between colorectal incidence and socio-economic position could be different levels of exposure to risk factors such as poor diet or smoking. There is strong evidence to link socio-economic disadvantage with such behaviours.

My study highlights the complexity of the relationship between socio-economic circumstances and health outcomes and the need to investigate socio-economic inequalities by a range of different indicators in order to implement targeted policy interventions to reduce cancer incidence.

Future work

An interesting next step using the LS would be to investigate if and how change in individual socio-economic position and area deprivation over a person’s lifetime might influence their risk of having a colorectal cancer diagnosis. Linking the LS to data from the bowel cancer screening programme to investigate the impact of screening on colorectal cancer incidence and socioeconomic inequalities would also provide valuable insight.

Further information

Charlotte Sturley, who carried out this study as part of her PhD research, presented the work at the 19th International Medical Geography Symposium 2022, which is being held at the Royal College of Surgeons of Edinburgh from 19th-24th June

Her presentation is available here: (PDF) Contrasting socio-economic influences on colorectal cancer incidence and survival (researchgate.net)

Read the full paper

 

ONS research plays key role in children’s social care review

By Chris A Garrington, on 25 May 2022

by Fran Abrams

Three pieces of research using the ONS Longitudinal Study were cited in the recent report of the Independent Review of Children’s Social Care. The findings from the Looked After Children Grown Up project played a key part in providing evidence to the review – and were reflected in its report and the Government’s response.

The government’s 2019 Manifesto included a commitment to a review of the care system, and in March 2021 the independent review of children’s social care, led by Josh MacAlister, was given a year to produce a report.

The Looked After Children Grown Up project, which was funded by the Nuffield Foundation and led by Professor Amanda Sacker with colleagues at the UCL Institute of Epidemiology and Health Care and Kings College London, had already begun in February 2018 and was able to provide important evidence to the review.

The adverse consequences of being looked after as a child were already well recognised, but this research project was set up to address a lack of evidence on what happened to looked-after children later in life. Studies tended to follow them into early adulthood and no further, but using census data from the ONS Longitudinal Study the researchers were able to explore outcomes for those who experienced care from the 1970s onwards, up to the age of 50.

The study allowed researchers to track those who were children at the time of each census, and to identify whether they were living in residential care,  as an unrelated member of an individual household, as a biological or adopted child in a parental household or as a child in a relative’s household.

By tracking care-experienced children into mid-life, the project was able to look at their later outcomes from a variety of different angles: it was able, for instance, to look at their likelihood of long-term illness, their employment, their education, their housing tenure, the type of family relationships they had and even whether they were at greater risk of dying early.

A fuller picture

The research, which was shared with Josh MacAlister at an event last July, was also able to drill deeper into the later experiences of children who experienced different types of care: it compared the outcomes of those who experienced residential and foster care with those who remained living with relatives, both parental and other.

Findings from the project were shared in an earlier Linking our Lives blog, and were welcomed by Josh MacAlister at the event last Summer.

In his report he focused on many aspects of the research, both citing it explicitly and reflecting its findings in his narrative.

The review

In particular, he focused on a 2021 report from the study which showed lower rates of long term illness and higher rates of employment for adults with a history of kinship care compared to those that grew up in foster or residential care.

He also highlighted  a second report from the team which showed that care leavers who were in residential care had the highest prevalence of limiting long term illnesses (around 32 per cent on average), followed by adults who lived in foster care (around 16 per cent on average) and adults who lived in kinship care (12 per cent on average). This was significantly higher than the average prevalence of limiting long term illnesses amongst individuals who had not been in care (7 per cent) , he said.

The review report also focused on mortality rates among care leavers from different types of care, and cited a 2020 report which used the ONS Longitudinal Study to link childhood out-of-home care status with all-cause mortality up to 42-years later.

It highlighted findings which showed adults who spent time in care between 1971-2001 were 70 per cent more likely to die prematurely than those who did not, and were also more likely to experience an unnatural death through self-harm, accident, mental or behavioural causes.

The review report made a number of recommendations which chimed with the research findings, including:

  • Support for families to cut down referrals and help to keep children in their family homes or with relatives – £2 billion over five years.
  • Unlocking wider family support networks including payments for relatives to act as foster carers.
  • Support for a ‘new deal’ with foster carers to help larger numbers of children to be cared for in families rather than in residential care – 9000 new carers over three years.

The response

In his response for the Government, the Education Secretary Nadim Zahawi promised more support for family hubs which offer early help and intervention. This would add seven new areas to an existing network of centres in 75 areas that receive a £302 million pot of funding for family hubs. A further 5 areas would receive part of a £12 million investment to deliver on a manifesto commitment to a network of family hubs around the country, he said.

Addressing concerns about the educational outcomes of children who had been in care – the research found those in parental care had a 28 per cent chance of achieving an NVQ level 3 qualification compared with just 11 per cent for those in residential care – Mr Zahawi promised funding for local authorities to help them keep vulnerable children in education.

Funding would be provided to local authorities for continued delivery of the Social Workers in Schools and designated safeguarding lead supervision programmes, which launched in September 2020, he added.

An evidence-based approach

In both the review report and in the Government’s response, there was a strong focus on the need for reforms to be underpinned by evidence.

The review suggested the Office for National Statistics should collect and report data on the mortality rate of care leavers and care leaver health outcomes, and that the Government should also launch a new cohort study which tracks the health outcomes of care experienced people and helps to gather other missing data on housing, education and employment outcomes.

In his response, Mr Zahawi promised support to help the most at-risk families to stay safely together, and a focus on early help, preventing them from reaching crisis point.

As part of this, he said, the government would set up a new National Implementation Board of sector experts and people with experience of leading transformational change and the care system. This would boost efforts to recruit more foster carers, increase support for social workers including on leadership, recruitment and retention, improve data sharing, and implement a new evidence-based framework for all the professionals working in children’s social care.

“Everything we do to raise the outcomes for children and families must be backed by evidence,” he said. “This report will be central in taking forward our ambition to ensure every child has a loving and stable home and we will continue working with experts and people who have experienced care to deliver change on the ground.”

The Looked After Children project involved Professor Amanda Sacker, Dr Emily Murray, Professor Barbara Maughan and Dr Rebeccca Lacey. 

Can housing policies affect assimilation of the children of migrants?

By Chris A Garrington, on 17 February 2022

by Fran Abrams

Immigrant families often choose to live in neighbourhoods where there are others from similar backgrounds. But does this affect their children’s prospects? New research using the ONS- LS suggests policies aimed at desegregating neighbourhoods could make a difference. 

Many immigrant children grow up in segregated ethnic enclaves, which raises a question: Does this have an impact on their cultural assimilation, and if so, how? 

There is a difficulty in answering this question. New migrant parents who choose to live outside of such enclaves may be different from those who choose to live in ethnic areas. They may be better educated and may have a wider variety of different contacts. Maybe their language skills are better and that might open up a range of opportunities for them. But we don’t know which of those who do live in ethnic enclaves also have these skills.

Hard to unpick

So it’s hard to unpick what comes from children’s environment, rather than directly from their parents. It’s a complex picture. 

But using data from the Census for England and Wales alongside information from the Fourth National Survey of Ethnic Minorities, which tells us about first-generation immigrants’ cultural preferences and their neighbourhood choices, new research has come up with some answers.

The researcher, Yujung Hwang, used information on families with South Asian origins living in England and Wales, and asked if the area where they grew up made a difference to their children’s prospects later on. She was able to produce a picture of the outcomes of offspring from Indian, Pakistani, and Bangladeshi families in Census 2011.

She asked if living in an ethnic enclave influenced whether these second generation migrants remained in a similar area, whether they kept the South Asian religion of their parents and whether they married someone from the same religion or ethnicity. For women, she looked at whether neighbourhood was linked to success in education and in work.

While some of those factors did not seem to be affected, she found, some of were significantly altered by neighbourhood effects.

Overall, the outcomes which showed the strongest effect were the likelihood of continuing to live in an ethnic enclave: those who grew up in such an area were 44 percentage points  more likely to continue living in one as adults.  Women who grew up in those areas were also less likely to graduate from college and less likely to go to work. 

Cohort differences

There were differences between the two age cohorts, though. Those born in the 1970s were 22 percentage points more likely to live in an ethnic enclave if they grew up in one. For women in that age group growing up in an enclave meant a 25 percentage point lower employment rate and a 29 percentage point lower rate of college graduation.

For those born in the 1980s, the only significant neighbourhood effect was on residency – the likelihood of staying in such an area was 55 percentage points higher for this group, though that could be at least partly because they were still unmarried and living with parents in 2011.

Once parental characteristics such as education, ethnicity, religion, employment status during childhood, and years since arrival were taken into account, there was no significant neighbourhood effect on the intergenerational transmission of religion or marriage preference.

This, the author suggested, could be explained by the fact that second-generation migrants were highly likely to remain and to marry within their parents’ religion and ethnic group, regardless of where they lived: there was no neighbourhood effect because both groups tended to conform to the ethnic and religious norm.

The results of the study point to possible policy implications: measures which support the ethnic desegregation of neighbourhoods could lead to the wider cultural assimilation of immigrant groups.

For instance, building social housing in diverse neighbourhoods could support the children of migrants in their educational and employment journeys.

Neighbourhood Effects on Intergenerational Cultural Transmission is a working paper by Yujung Hwang.

What can the Census tell us about extended working lives?

By Chris A Garrington, on 19 October 2021

by Fran Abrams

Across the developed world, populations are ageing and policy makers are wondering how to keep people in work for longer. But at the same time, greater numbers of older people are claiming sickness benefits. So what can the Census tell us about the true picture, and about the types of policy interventions that might help? 

Heated debate has raged for years around the issue of disability and sickness benefits. More people are claiming them – and a key response from the UK Government has been the use of ‘Nudge’ techniques to encourage the reluctant to return to work.

But a range of studies which use data from the ONS Longitudinal Study suggest popular assumptions on the topic may be flawed.

One such study challenges the assumption that the number of people claiming sickness benefits is growing because they are becoming available to people whose conditions are less serious: that claiming has become easier and that those with milder illnesses are doing so.

Bola Akinwale from Public Health England and colleagues from the ESRC International Centre for Lifecourse Studies at University College London compared Census data from 1971 to 2001. 

There had been big changes in the labour market positions of 60-64 year-old men, they found:

  • Working – 78.4 percent v 47.5 percent
  • Retired – 7.2 percent v 24.7 percent
  • Permanently sick – 9 percent v 19.7 percent

The proportion of permanently sick men had doubled in 30 years, but the trend was even more striking among women:  12.4 percent of 55-59 year-old women described themselves as permanently sick in 2001 compared with 3.4 percent in 1971.

And yet in the last 30 years of the 20th century, life expectancy for those aged 65 increased more than it did in the previous 70 years, and the risk of dying just before State Pension Age decreased substantially – by more than 60 percent for men and by more than 50 percent for women. This increase in life expectancy benefited the permanently sick as much as those in work, with both  living longer than their counterparts 30 years previously.

Are sick people less sick nowadays?

 But the researchers found that statistic did not tell the whole story: yes, people were living longer and healthier lives by the turn of the century. But if the ‘permanently sick’ were in fact less sick than in the previous generation, the gap between their chances of dying prematurely and that of someone in work would have got smaller over the 30-year period. It didn’t.

Permanently sick men aged 65-69 were three times more likely to die prematurely than their working peers in 2001 – an increase on the 1971 figure. For women, the figure was between four and five times higher.

The  life expectancy of the permanently sick increased in line with others’ as medical and social advances were made. But their likelihood of dying when compared to working people if anything, increased slightly.

So, Census data confirms the United Kingdom has an ageing population that contains more people with long-term and life-limiting illnesses. It also gives us a richer picture of who those people are, and where they live.

Dr Emily Murray and colleagues* used census data to look at who lives longest after leaving work, and they found wide disparities in health and life expectancy between different social classes. 

They compared data on people who were aged 50-75 at the time of the 2001 census and who had stopped work by 2011 – the average age of stopping was 58 for women and 60.2 for men. 

The study showed those in professional occupations could expect to live and enjoy good health for longer than those in manual jobs: the average 50 year-old man in a professional job could expect 25 years of good health, while a man in a manual occupation could expect only 18: a seven-year difference. And that explains why lower social class groups are more likely to find themselves on disability benefit.

Among the sample group of 50-75 year-olds from 2001,  14.6 per cent of the women and 25.1 per cent of the men died within 10 years. For both genders, those in lower social classes tended to die younger – professional women lived two years longer than unskilled women, and professional men three years longer than unskilled men.

But despite these longevity gaps, those from lower social groups faced more years between leaving work and being able to draw their state pensions – because they left work earlier.

The researchers estimated that if two women were 65 in 2001, the woman who had worked in an unskilled occupation would live five years longer after leaving work than the professional woman with good health – because the unskilled woman would have left at a younger age. Two men in the same circumstances would live on average 25.0 and 19.5 years from stopping work to death.

Poor health

The most likely explanation, they said, is that poor health has a greater impact on the ability of manual workers to continue working than it does on non-manual workers.

There is a clear message for policymakers: a uniform state pension age disproportionately affects the poorest because they must wait longer between stopping work and qualifying for their state pension, at a time when they are likely to be in poor health: over half of women and two-fifths of men  fall out of the labour market before state pension age.

A two-year earlier pension age may be more appropriate for individuals who work in manual occupations, the researchers say, in order to improve the financial security and health of the most vulnerable in society. Such occupation-specific pensions already exist in some other countries, along with pensions based on duration of employment – people in manual occupations generally start work earlier so they work more years if they retire at same time. The issue was raised in the Cridland review on the state pension age.

A third paper addresses Government responses to these issues, which have tended to focus on behavioural techniques for encouraging older people to stay in work. It asks whether official publications, which have suggested there may be resistance to continuing in work among some groups, are correct in their assumptions.

Census data

Nicola Shelton and colleagues* used census data to look at what happened in 2011 to adults aged between 40 and 49 in 2001 and found significant regional differences: men in the North East were significantly less likely to extend their working lives than others, for instance, while women in all regions apart from London and Wales were significantly more likely to stay in work than those in the North East.

But further analysis showed that for men at least, other social factors could explain these differences. Put bluntly, men in the North East leave work earlier because they tend to have fewer qualifications and less favourable employment status – both of which are associated with shortened working lives.

For women, some additional factors affected the likelihood of staying in work. Those in lower-skilled jobs were less likely still to be in work by 2011, but those working for larger employers, for long hours or away from home were also more likely to have left.

Working conditions

So, what can governments do? Given a good work environment, choosing to remain in work may have positive benefits such as maintaining good health and functioning and providing a sense of purpose- so working conditions are important, the researchers suggest.

The biggest single factor in determining whether workers stay on for longer is prior employment – and that is not likely to be changed by behavioural approaches such as the ‘nudge’ theory of behavioural economics, which is popular with policy makers, they say.

Policies that do not address issues such as low levels of education and high levels of unskilled employment can only be partially successful in enabling people to work for longer. Indeed, some groups who may have the most financial need to remain in work are most likely to leave earlier. This is particularly an issue for women.

Policies that increase skills and education in later life, rather than simply targeting those ‘receptive’ to extended working, will be more likely to make a difference, they conclude.

Shedding new light on the adult outcomes of people who were in care as children

By Chris A Garrington, on 20 July 2021

by Fran Abrams

Census data from the ONS-LS has helped shed new light on outcomes for children who have been in care in a major research project led by the UCL Institute of Epidemiology and Healthcare. The study uses Census data to push forward the boundaries of knowledge by looking at what happens in mid-life to those who have been in care as children. It finds disturbing disparities – with some groups faring much worse than others. 

Care-leavers have long been known to suffer worse outcomes than their peers. Now a programme of research funded by the Nuffield Foundation has highlighted the ways in which these issues continue throughout the lives of those affected. At an event to share the project’s findings with those interested in improving the lives of children who cannot live with their parents, Josh MacAlister, who is leading an independent review of children’s social care, said the research had already had a major impact on its work. 

It is actually breaking new ground in our understanding of where care-experienced people end up in later life,” MacAlister told an audience of more than 200 practitioners, policymakers and academics.

“One of the questions we pose is: ‘How many parents don’t know where their own child is at 30, 40 or 50?’ It’s a common refrain that the state is the corporate parent, and actually not knowing really basic things about destination and outcomes for care-experienced people later on into life has been a huge blind spot. So this study is very significant in that respect,” he said.

Raising the bar

The Government review led by MacAlister was launched earlier this year with the aim of ‘raising the bar for vulnerable young people across England.

The UK’s National Statistician, Sir Ian Diamond, who chaired the event, told the audience the care research was an exemplary use of data from the ONS-LS dataset.

Sir Ian highlighted a key issue for those studying children’s social care: the evidence shows those who have been in care suffer worse outcomes than their peers – for example higher than average levels of unemployment, lower levels of educational qualification and early pregnancy. But that research tends to focus on recent care-leavers while this project follows them into mid-life.

The project, led by a team of researchers at University College London, used Census data from the ONS-LS to explore outcomes for those who experienced care from the 1970s onwards, up to the age of 50.

Census data

The ONS-LS has gathered information on approximately a million people, and from this the researchers were able to look at a sample of just under 500,000 children. Of those, around 3,500 were looked after by family members other than their parents, 2200 were in formal foster care and 900 in residential care. Over time, residential care had become less common and family or kinship care more so.

There were four main aims of the research:

  • To determine whether children who had experienced care had worse health and social experiences from 10 to 40 years later, compared to others.
  • To explore whether children in residential care did better or worse than children in foster or kinship care.
  • To look at care differences related to gender, ethnicity or migration status.
  • To investigate trends and look at whether longer-term outcomes had improved over time.

Amanda Sacker, Professor of Lifecourse Studies, Epidemiology and Public Health at UCL, who led the study, told the launch one of its strongest findings was that inequalities within the cared-for population were as great as inequalities between that group and those in parental care.

Impacts of a childhood in care

The research found the impact of being in care on health, socio-economic circumstances, family life and living arrangements varied according to the type of care experienced – those who were cared for by relatives had the best outcomes and those who had been in residential care the worst, with foster care sitting between the two. 

This did not necessarily mean the type of care had led to better or worse outcomes, Professor Sacker explained at the event – those who were most vulnerable or damaged by early experiences might be more likely to go into residential care rather than family care or a foster home.

In relation to employment there was some evidence these inequalities between care groups reduced with age, though adults in their 20s were twice as likely to be employed if they had been in their parental home rather than in residential care.

Social inequalities between care groups also extended to the age of death: while those brought up by parents had become less likely to die prematurely in the past 30 years, this was not true for those in non-parental care. Those in care in 1971 were 30 per cent more likely than average to die but by 2001, this ratio had grown to more than 300 per cent, most commonly from preventable causes such as car accidents, alcoholism and assault.

When the researchers looked at education, they found a similar picture: those in parental care had a 28 per cent chance of achieving an NVQ level 3 qualification compared with just 11 per cent for those in residential care. There was some good news, though – the care groups were more likely to be in education later in life, and this helped them to catch up with their peers.

The project’s findings on ethnicity were more mixed. White and south Asian groups were found to have worse outcomes if they had been in care, but for black children the study found having been in care did not seem to be associated with any additional detrimental effect over and above the inequalities seen for all black children. The researchers said more investigation was needed into this complex picture.

Caregivers’ children

The final key findings of the study were on the children of those who give care. They too, it found, were affected by their experiences – there had been reports that the children of foster parents or of kinship carers had felt disadvantaged.

The research looked at five ‘transition milestones into adulthood: leaving education, leaving home, starting work, forming a relationship and becoming a parent. It found children of care-givers were less likely to have higher qualifications, more likely to be unemployed, more likely to be married early and less likely to own their own home than others. If they were female, they were likely to be younger when they had their first child.

“Our work in the field of life course social epidemiology has highlighted that inequalities in health cannot be reduced without tackling social inequalities too,” Professor Sacker said.  “By shining a light on the life courses of children who have had to be placed in care, our aim is to get it right for care leavers.”

Further work

Sir Ian Diamond said the Office for National Statistics was keen to make more use of longitudinal data such as the ONS-LS to help inform policy on issues such as this one.

“Among the most disadvantaged in society are clearly those young people and children who have experienced care, and care  leavers, we know empirically, have not had great outcomes.  It’s always seemed to me that we needed better longitudinal data to understand the pathways that would help us to inform policy, which could improve the outcomes for people who are under-achieving because they have been let down early in their lives for all kinds of reasons.  So it seems to me there’s an enormous need for this work,” he said.

Tim Gardam, Chief Executive of the Nuffield Foundation, said the research fitted very well with its aim of viewing social wellbeing primarily through the lens of the experiences of the most disadvantaged and vulnerable.

“What we find here is the ONS-LS using Census data from five decades, painting a vivid and complex picture of vulnerable people’s lives and their health and social outcomes that in places brings the reader, quite frankly, up short in shock. 

“We have known for a long time that being in care as a child is associated with poorer outcomes in adulthood. But most research has previously ended with young adulthood and been based on small population samples. This research documents people’s lives in their 40s and enables us to understand the longer-term effects,” he said.

The lifelong health and wellbeing trajectories of people who have been in care: Findings from the Looked-after Children Grown up Project, is by Amanda Sacker with Emily Murray, Rebecca Lacey and Barbara Maughan. It is published by the Nuffield Foundation.