• Title/Summary/Keyword: Medical Support

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Clinical Investigation about the Result of Surgically Treated Myasthenia Gravis (중증 근무력증의 수술적 치료결과에 대한 임상적 고찰)

  • 김대현;황은구;조규석;김범식;박주철
    • Journal of Chest Surgery
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    • v.36 no.1
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    • pp.15-20
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    • 2003
  • Myasthenia gravis is a rare autoimmune disease involving acetylcholine receptor and its autoantibody on neuromuscular junction. The methods of treatment are medical treatment and surgical thymectomy. In this paper we analyzed the result of thymectomy and the factors affecting the postoperative symptom improvement. Material and method : This study obtained medical records of 37 patients who received the thymectomy for myasthenia gravis from March 1986 to December 1998. Result Out of 37 cases, 21 cases(57%) showed improvement, of which 8 cases (50%) in the group of thymoma(n=16), and 13 cases (62%) in the group of thymic hyperplasia(n=21) showed the improvement of symptoms. Postoperative complications were respiratory insufficiency due to aggravation of symptoms after operation, including tracheal intubation for ventilator support in 9 cases, pneumonia in 3 cases, pneumothorax in 2 cases and left vocal cord palsy in 1 case. There was one postoperative mortality. The relation between postoperative improvement and sex(P=0.3222), age(P=0.7642), thymic pathologic variants,(P=0.4335) and classification of thymoma(P=0.20) showed no statistically significant correlation. However, the lower grade of preoperative symptoms can predict the lower grade of postoperative symptoms significantly(P=0.0032). Follow up study to 36 postoperative survivors was performed in October 2002 based on the out-patient records and call with patients. Out of 36 cases, 33 cases(91.7%) could be investigated and 3 cases could not. Mean follow up period was 83.2 months. Out of 33 cases, 25 cases(75.8%) showed symptomatic improvement, of which 8 cases(53.3%) in the group of thymoma(n=15) and 17 cases(94.4%) in the group of thymic hyperplasia(n=18) showed the improvement of$\boxUl$ symptoms. Conclusion : In myasthenia gravis, thymectomy showed the good improvement, and more important factor affecting the improvement of symptoms was the grdae of preoperative symptoms. Also midterm and long term follow up results showed good symptomatic improvement.

A Survey on Clients' Home Care Satisfaction in Taejon City in Korea (일개 시지역의 가정간호 수혜자들의 만족도 조사)

  • Kim, Sun-Sook;So, Hee-Young;Lee, Tae-Yong
    • Journal of Korean Academic Society of Home Health Care Nursing
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    • v.5
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    • pp.73-83
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    • 1998
  • This study enrolled one thousand five hundred twenty one clients that were receiving home care services at five health centers and a home care services center in the city of Taejon from November 17 through December 7, 1997. The purpose of this study was to analyze satisfaction levels, general characteristics and efficacies, of the client served home care. The main results were as follows; The age group of most of the subjects was 70-79 years: 76.9% of them were female and 87.3% were over 65 years. In education variables, over 90% of the clients were below primary school. In marital status variables, 63.4% of them had no spouse, 57.5% of them were widows and widowers. In living arrangement variables, alone(35.8%) was the most. In insurance status variables, medical aid(69.9%) was the most. In household income variables, below 000 won(72.6%) was the most. In hospitalization variables, 53% of the clients had no hospitalization. The satisfaction level of home care service of male and female was similar. The older the age, the higher the satisfaction level. The satisfaction level of the group having religion was higher than the group having no religion and the Christianity group had the highest satisfaction level(p<0.001). In education variables, the over high school group was the highest satisfaction level(p<0.01). In living arrangement variables, the other (sisters or neighbors etc.) group indicated the highest satisfaction level(p<0.001). In insurance status variables, the other group(except for medical aid) was the highest satisfaction level(p<0.001). In household income variables, below 390,000 won was the highest satisfaction level(p<0.001). In hospitalization variables, 'over 4 times' group indicated the highest satisfaction level (p<0.01). Home care took place more in health centers than in home care services center. In frequency of home care per month three times was the most. In opinion of home care frequency per month 82.8% of the people answered 'proper'. A lot of present illness was neuralgia, arthritis, digestive disease, hypertension & CVA. In contents of home care services variables, education & counselling was the most and medication was second. In duration of illness variables, over 10 years was the most. In place of treatment before home care service variables, hospital(57%) was the most. In illness condition after home care variables, 'moderate' was the most and 'much better'(85.5%) was second. In help of home care variables, 'much help'(71.5%) was the most and 'moderate'(28.1%) was second. In contents of counselling variables, treatment method of illness was the most. Home care services center indicated higher level of satisfaction than health center(p<0.001). In opinion of home care frequency per month variables, 'less' was the highest satisfaction level (p<0.001). In duration of illness variables, below one year was the highest and over 10 years was second(p<0.001). In place of treatment before home care service variables, health center was the highest (p<0.001). In illness condition after home care variables 'much better' was the highest and 'worse' was second (p<0.001). I n help of home care variables, 'much help' was the highest (p<0.001). In contents of counselling variables, cause of illness was the highest(p<0.001). According to the 14 items which consisted of 3 point scales the total level of satisfaction of home care service was very high, with total mean score 36. According to the above results, most clients taking home care services are satisfied. However, organization and a fund are required to support high quality home care services to those who need them. Furthermore, a follow-up survey should be accomplished to evaluate the status of clients.

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Oral Health and Quality of Life of the Orphans in Dong-gu, Daejeon (대전 동구 보육원생의 구강건강 및 구강건강관련 삶의 질)

  • Koong, Hwa-Soo;Song, Eun-Joo;Hwang, Soo-Jeong
    • Journal of dental hygiene science
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    • v.13 no.3
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    • pp.223-229
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    • 2013
  • The aim of this study was to examine the effectiveness of oral health promotion program in a group of 9~18-year-old children and adolescents living in four orphanages in Dong-gu, Daejeon. The program was based on oral disease prevention program including oral health education, fluoride application and scaling every six months. Oral health status of total 109 orphans was examined by one dentists who were trained in 2010 Korean National Oral Health Survey. Dental caries index, community periodontal index and modified patient hygiene performance index (M-PHP) were checked using dental unit chair. Child oral health impact profile (COHIP) and subjective oral health recognition survey were carried out. Compared with data of 2010 national sample, the mean of decayed, missing and filled teeth showed no difference between the subjects and test values, but the means of decayed teeth, decayed surface, toothbrushing frequency of the subjects showed to become worse with advancing years in spite of oral health promotion program. COHIP, subjective oral health status showed lower than test values, too. In M-PHP and Calculus index, the subjects showed better by periodic oral health education and scaling. We suggest that oral health promotion program for orphans include oral disease treatment program as well as preventive program to improve oral health of orphans efficiently. And, oral health promotion program has to be connected with psychological support for improving quality of life of orphans.

Dopamine Transporter Density of the Basal Ganglia in Children with Attention Deficit Hyperactivity Disorder Assessed with I-123 IPT PECT (I-123 IPT SPECT를 이용한 주의력결핍 과잉행동장애 아동에서의 methylphenidate 투여 전후의 기저 신경절 도파민 운반체 밀도 변화 측정)

  • Ryu, Won-Gee;Kim, Tae-Hoon;Ryu, Young-Hoon;Yun, Mi-Jin;Cheon, Keun-Ah;Chi, Dae-Yoon;Kim, Jong-Ho;Choi, Tae-Hyun;Lee, Jong-Doo
    • The Korean Journal of Nuclear Medicine
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    • v.37 no.4
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    • pp.235-244
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    • 2003
  • Purpose: Attention deficit hyperactivity disorder (ADHD) has been known as psychiatric disorder in childhood associated with dopamine dysregulation. In present study, we investigated changes in dopamine transporter (DAT) density of the basal ganglias using I-123 N-(3-iodopropen-2-yl) -2-carbomethoxy-3beta-(4-chlorophenyl) tropane [I-123 IPT] SPECT in children with ADHD before and after methylphenidate treatment. Materials and Method: Nine drug-naive children with ADHD and seven normal children were included in the study. We peformed brain SPECT two hours after the intravenous administration of I-123 IPT and made both quantitative and qualitative analyses using the obtained SPECT data, which were reconstructed for the assessment of soecific/nonspecific DAT binding ratios in the basal ganglia. All children with ADHD reperformed [123I]IPT SPECT after treatment with methylphenidate(0.7mg/kg/d) during about 8 weeks. SPECT data reconstructed for the assessment of specific/nonspecific DAT binding ratio of the basal ganglia were compared between before and after treatment methylphenidate. We investigated correlation between the change of ADHD symptom severity assessed with ADHD rating scale-IV and specific/nonspecific DAT binding ratio of basal ganglia. Results: Children with ADHD had a significantly greater specificinonspecific DAT binding ratio of the basal ganglia comparing to normal children(Right : z = 2.057, p = 0.041 : Left : z : 2.096, p = 0.032). Under treatment with methylphenidate in all children with ADHD, specificinonspecific DAT binding ratio of both basal ganglia decreased significantly greater than before treatment with methylphenidate (Right : t = 3.239, p = 0.018 ; Left : t = 3.133, p = 0.020). However, no significant correlation between the change of ADHD symptom severity scores and specific/nonspecific DAT binding ratio of the basal ganglia were found. Conclusions: These findings support the complex dysregulation of the dopaminergic neurotransmitter system in children with ADHD.

A Study on Improvement of Laws regarding Welfare for the Aged (노인복지 관련법제의 발전방향)

  • Park, Ji-Soon
    • Journal of Legislation Research
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    • no.41
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    • pp.87-123
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    • 2011
  • Korea is expected to become an 'aged society' with more than 14 percent of the public aged 65 years or more by 2018. The rapid aging is giving rise to various problems within the society along with falling birthrate in a short period of time. In this context, the role and function of laws on welfare for the aged must be particularly emphasized. Also the Senior Citizens Welfare Act is of great importance as it provides social welfare service on the basis of functional connection with social insurance and public assistance. First, this paper looks into the history of laws related to welfare for the elderly such as the Senior Welfare Act, the Act on Long-term Care Insurance for Senior Citizens and the Basic Old Age Pension Act as well as the findings of earlier studies. In the second place, it will break down such laws by main components aiming to examine details of the laws and questions raised regarding them and to seek ways to achieve improvement with an emphasis on health care, old age income security, housing welfare(assisted living facilities), job security for the aged. The Senior Welfare Act offers substance of social welfare service for the elderly. Income security, health and medical care, welfare measures through long-term care and assisted living facilities, social participation by working are the key elements and all of them should be closely associated to ensure citizens get sufficient public support in their old age. For this purpose, the Senior Welfare Act is under a normative network with laws such as Act on Long-term Care Insurance for Senior Citizens and Basic Old Age Pension Act. Current laws on welfare for the aged including Senior Welfare Act are not sufficiently responsive to the aged society of the 21st century. Income security combined with decent social participation, health and medical care closely connected with long-term care system, efficient expense sharing between government and local government, enhancement of effectiveness of welfare measures can be considered as means to improve current welfare system so that the elderly can enjoy their old age with dignity and respect.

Shielding Capability Evaluation of Mobile X-ray Generator through the Production assembled Shield (일체형 방어벽 제작을 통한 이동형 엑스선 발생기의 차폐능 평가)

  • Kim, Seung-Uk;Han, Byeoung-Ju
    • Journal of the Korean Society of Radiology
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    • v.12 no.7
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    • pp.895-908
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    • 2018
  • As modern science is developed and advanced, examination and number of times using radiation are increasing daily. General diagnostic X-ray generator is installed on stationary form, But X-ray generator was developed because patient who is in the intensive care unit, operation room, emergency room can not move to general x-ray room. What we examine patient by x-ray generator is certainly necessary, So patient exposure is inevitable. but reducing radiation exposure is highly important matter about radiation technology, guardian, patient in the same hospital room, nurse etc. For this reason, rule regarding safety control of diagnostic x-ray generator revised for radiation worker, patient and protector proclaim that mobile diagnostic x-ray shield must placed in case of examine different location excluding operation room, emergency room, intensive care unit. But, radiogical technologist is having a lot of difficulties to examine with mobile x-ray generator, diagnostic x-ray shield partition, image plate and lead apron. So, when we use x-ray generator, we manufacture shield tools can be attached to the mobile x-ray generator On behalf of x-ray shield partition and conduct analysis and in comparison to part of body and distribution of dose rate and find way to reduce radiation exposure through distribution of dose rate of patient within the radiogical technologist, medical team. Mobile x-ray generator aimed at SHIMADZU inc. R-20, We manufactured equipment for shielding x-ray scattered x-ray by installing shielding wall from side to side based on support beam on the mobile x-ray generator. Shielding wall when moving can be folded and designed to expand when examine. Experiment measured five times in each by an angle for dose rate of eyes, thyroid, breast, abdomen and gonad on exposure condition of upper and lower extremity, chest, abdomen which is examined many times by mobile x-ray generator. We used dosimeter RSM-100 made by IJRAD and measured a horizontal dose rate by body part. The result of an experiment, shielding decreasing rate of the front and the rear showed 77 ~ 98.7%. Therefore using self-production shielding wall reduce scattered x-ray occurrence rate and confirm can decrease exposure dose consequently. Therefore, through this study, reduction result which is used shielding wall of self-production will be a role of shielding optimization and it could be answer about reduction of medical exposure recommended by ICRP 103.

The Influence of Moral Distress and Moral Sensitivity on Moral Courage in Nursing Students (간호대학생의 도덕적 용기에 대한 도덕적 고뇌와 도덕적 민감성의 관계)

  • YUN, Hye-Young;KIM, Sun-Ki;JANG, Hyo-Eun;HWANG, Sin-Woo;KIM, Sang-Hee
    • Korean Journal of Medical Ethics
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    • v.21 no.4
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    • pp.360-376
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    • 2018
  • Nursing students experience ethical conflicts that lead to moral distress and moral sensitivity in clinical practice. Most nursing students have some difficulty in speaking up when faced with morally challenging situations. Hence, increasing moral courage of these students is important to improve the quality of practice, and carry out nursing responsibilities. However, research on the moral distress, moral sensitivity, and moral courage of nursing students has not been reported in South Korea. The purposes of this study were to (a) identify the levels of moral distress, moral sensitivity, and moral courage of nursing students and (b) examine the influence of moral distress and moral sensitivity on moral courage. Data were collected through a survey using self-reported questionnaires sent to senior nursing students at two nursing colleges in Seoul and Gyeonggido. A total of 138 senior nursing students participated in the survey. The data were analyzed using the IBM SPSS Statistics 23 program by Pearson's correlation coefficients and multiple regression analysis. The mean scores of the moral distress thermometer, moral distress, moral sensitivity, and moral courage were $3.53{\pm}2.18$, $57.33{\pm}43.35$, $134.98{\pm}13.98$, and $56.33{\pm}12.75$, respectively. The significant factors influencing moral courage were the moral distress thermometer and patient-centered nursing, which was a subcomponent of moral sensitivity. The explanatory power of the model was 5%. This study confirms that nursing students, like nurses, experience moral distress. It is therefore important to create organizational environments that support the moral courage of nursing students.

Analysis of News Agenda Using Text mining and Semantic Network Analysis: Focused on COVID-19 Emotions (텍스트 마이닝과 의미 네트워크 분석을 활용한 뉴스 의제 분석: 코로나 19 관련 감정을 중심으로)

  • Yoo, So-yeon;Lim, Gyoo-gun
    • Journal of Intelligence and Information Systems
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    • v.27 no.1
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    • pp.47-64
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    • 2021
  • The global spread of COVID-19 around the world has not only affected many parts of our daily life but also has a huge impact on many areas, including the economy and society. As the number of confirmed cases and deaths increases, medical staff and the public are said to be experiencing psychological problems such as anxiety, depression, and stress. The collective tragedy that accompanies the epidemic raises fear and anxiety, which is known to cause enormous disruptions to the behavior and psychological well-being of many. Long-term negative emotions can reduce people's immunity and destroy their physical balance, so it is essential to understand the psychological state of COVID-19. This study suggests a method of monitoring medial news reflecting current days which requires striving not only for physical but also for psychological quarantine in the prolonged COVID-19 situation. Moreover, it is presented how an easier method of analyzing social media networks applies to those cases. The aim of this study is to assist health policymakers in fast and complex decision-making processes. News plays a major role in setting the policy agenda. Among various major media, news headlines are considered important in the field of communication science as a summary of the core content that the media wants to convey to the audiences who read it. News data used in this study was easily collected using "Bigkinds" that is created by integrating big data technology. With the collected news data, keywords were classified through text mining, and the relationship between words was visualized through semantic network analysis between keywords. Using the KrKwic program, a Korean semantic network analysis tool, text mining was performed and the frequency of words was calculated to easily identify keywords. The frequency of words appearing in keywords of articles related to COVID-19 emotions was checked and visualized in word cloud 'China', 'anxiety', 'situation', 'mind', 'social', and 'health' appeared high in relation to the emotions of COVID-19. In addition, UCINET, a specialized social network analysis program, was used to analyze connection centrality and cluster analysis, and a method of visualizing a graph using Net Draw was performed. As a result of analyzing the connection centrality between each data, it was found that the most central keywords in the keyword-centric network were 'psychology', 'COVID-19', 'blue', and 'anxiety'. The network of frequency of co-occurrence among the keywords appearing in the headlines of the news was visualized as a graph. The thickness of the line on the graph is proportional to the frequency of co-occurrence, and if the frequency of two words appearing at the same time is high, it is indicated by a thick line. It can be seen that the 'COVID-blue' pair is displayed in the boldest, and the 'COVID-emotion' and 'COVID-anxiety' pairs are displayed with a relatively thick line. 'Blue' related to COVID-19 is a word that means depression, and it was confirmed that COVID-19 and depression are keywords that should be of interest now. The research methodology used in this study has the convenience of being able to quickly measure social phenomena and changes while reducing costs. In this study, by analyzing news headlines, we were able to identify people's feelings and perceptions on issues related to COVID-19 depression, and identify the main agendas to be analyzed by deriving important keywords. By presenting and visualizing the subject and important keywords related to the COVID-19 emotion at a time, medical policy managers will be able to be provided a variety of perspectives when identifying and researching the regarding phenomenon. It is expected that it can help to use it as basic data for support, treatment and service development for psychological quarantine issues related to COVID-19.

Assessment of Additional MRI-Detected Breast Lesions Using the Quantitative Analysis of Contrast-Enhanced Ultrasound Scans and Its Comparability with Dynamic Contrast-Enhanced MRI Findings of the Breast (유방자기공명영상에서 추가적으로 발견된 유방 병소에 대한 조영증강 초음파의 정량적 분석을 통한 진단 능력 평가와 동적 조영증강 유방 자기공명영상 결과와의 비교)

  • Sei Young Lee;Ok Hee Woo;Hye Seon Shin;Sung Eun Song;Kyu Ran Cho;Bo Kyoung Seo;Soon Young Hwang
    • Journal of the Korean Society of Radiology
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    • v.82 no.4
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    • pp.889-902
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    • 2021
  • Purpose To assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) for additional MR-detected enhancing lesions and to determine whether or not kinetic pattern results comparable to dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of the breast can be obtained using the quantitative analysis of CEUS. Materials and Methods In this single-center prospective study, a total of 71 additional MR-detected breast lesions were included. CEUS examination was performed, and lesions were categorized according to the Breast Imaging-Reporting and Data System (BI-RADS). The sensitivity, specificity, and diagnostic accuracy of CEUS were calculated by comparing the BI-RADS category to the final pathology results. The degree of agreement between CEUS and DCE-MRI kinetic patterns was evaluated using weighted kappa. Results On CEUS, 46 lesions were assigned as BI-RADS category 4B, 4C, or 5, while 25 lesions category 3 or 4A. The diagnostic performance of CEUS for enhancing lesions on DCE-MRI was excellent, with 84.9% sensitivity, 94.4% specificity, and 97.8% positive predictive value. A total of 57/71 (80%) lesions had correlating kinetic patterns and showed good agreement (weighted kappa = 0.66) between CEUS and DCE-MRI. Benign lesions showed excellent agreement (weighted kappa = 0.84), and invasive ductal carcinoma (IDC) showed good agreement (weighted kappa = 0.69). Conclusion The diagnostic performance of CEUS for additional MR-detected breast lesions was excellent. Accurate kinetic pattern assessment, fairly comparable to DCE-MRI, can be obtained for benign and IDC lesions using CEUS.

The Effects of Environmental Dynamism on Supply Chain Commitment in the High-tech Industry: The Roles of Flexibility and Dependence (첨단산업의 환경동태성이 공급체인의 결속에 미치는 영향: 유연성과 의존성의 역할)

  • Kim, Sang-Deok;Ji, Seong-Goo
    • Journal of Global Scholars of Marketing Science
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    • v.17 no.2
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    • pp.31-54
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    • 2007
  • The exchange between buyers and sellers in the industrial market is changing from short-term to long-term relationships. Long-term relationships are governed mainly by formal contracts or informal agreements, but many scholars are now asserting that controlling relationship by using formal contracts under environmental dynamism is inappropriate. In this case, partners will depend on each other's flexibility or interdependence. The former, flexibility, provides a general frame of reference, order, and standards against which to guide and assess appropriate behavior in dynamic and ambiguous situations, thus motivating the value-oriented performance goals shared between partners. It is based on social sacrifices, which can potentially minimize any opportunistic behaviors. The later, interdependence, means that each firm possesses a high level of dependence in an dynamic channel relationship. When interdependence is high in magnitude and symmetric, each firm enjoys a high level of power and the bonds between the firms should be reasonably strong. Strong shared power is likely to promote commitment because of the common interests, attention, and support found in such channel relationships. This study deals with environmental dynamism in high-tech industry. Firms in the high-tech industry regard it as a key success factor to successfully cope with environmental changes. However, due to the lack of studies dealing with environmental dynamism and supply chain commitment in the high-tech industry, it is very difficult to find effective strategies to cope with them. This paper presents the results of an empirical study on the relationship between environmental dynamism and supply chain commitment in the high-tech industry. We examined the effects of consumer, competitor, and technological dynamism on supply chain commitment. Additionally, we examined the moderating effects of flexibility and dependence of supply chains. This study was confined to the type of high-tech industry which has the characteristics of rapid technology change and short product lifecycle. Flexibility among the firms of this industry, having the characteristic of hard and fast growth, is more important here than among any other industry. Thus, a variety of environmental dynamism can affect a supply chain relationship. The industries targeted industries were electronic parts, metal product, computer, electric machine, automobile, and medical precision manufacturing industries. Data was collected as follows. During the survey, the researchers managed to obtain the list of parts suppliers of 2 companies, N and L, with an international competitiveness in the mobile phone manufacturing industry; and of the suppliers in a business relationship with S company, a semiconductor manufacturing company. They were asked to respond to the survey via telephone and e-mail. During the two month period of February-April 2006, we were able to collect data from 44 companies. The respondents were restricted to direct dealing authorities and subcontractor company (the supplier) staff with at least three months of dealing experience with a manufacture (an industrial material buyer). The measurement validation procedures included scale reliability; discriminant and convergent validity were used to validate measures. Also, the reliability measurements traditionally employed, such as the Cronbach's alpha, were used. All the reliabilities were greater than.70. A series of exploratory factor analyses was conducted. We conducted confirmatory factor analyses to assess the validity of our measurements. A series of chi-square difference tests were conducted so that the discriminant validity could be ensured. For each pair, we estimated two models-an unconstrained model and a constrained model-and compared the two model fits. All these tests supported discriminant validity. Also, all items loaded significantly on their respective constructs, providing support for convergent validity. We then examined composite reliability and average variance extracted (AVE). The composite reliability of each construct was greater than.70. The AVE of each construct was greater than.50. According to the multiple regression analysis, customer dynamism had a negative effect and competitor dynamism had a positive effect on a supplier's commitment. In addition, flexibility and dependence had significant moderating effects on customer and competitor dynamism. On the other hand, all hypotheses about technological dynamism had no significant effects on commitment. In other words, technological dynamism had no direct effect on supplier's commitment and was not moderated by the flexibility and dependence of the supply chain. This study makes its contribution in the point of view that this is a rare study on environmental dynamism and supply chain commitment in the field of high-tech industry. Especially, this study verified the effects of three sectors of environmental dynamism on supplier's commitment. Also, it empirically tested how the effects were moderated by flexibility and dependence. The results showed that flexibility and interdependence had a role to strengthen supplier's commitment under environmental dynamism in high-tech industry. Thus relationship managers in high-tech industry should make supply chain relationship flexible and interdependent. The limitations of the study are as follows; First, about the research setting, the study was conducted with high-tech industry, in which the direction of the change in the power balance of supply chain dyads is usually determined by manufacturers. So we have a difficulty with generalization. We need to control the power structure between partners in a future study. Secondly, about flexibility, we treated it throughout the paper as positive, but it can also be negative, i.e. violating an agreement or moving, but in the wrong direction, etc. Therefore we need to investigate the multi-dimensionality of flexibility in future research.

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