• Research in Community and Public Health Nursing
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• v.9 no.2
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• pp.502-517
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• 1998

This research intends to survey family environment, health behavior and health status of the students in urban-rural elementary schools and analyze those factors comparatively, and use the result as basic material for school health teacher to teach health education in connection with family and regional areas. It also intends to improve a pupil's self-abilitiy in health care. The subjects involve 2,774 students of urban elementary schools and 583 student in rural ones, who were selected by means of a multi -stage probability sampling. Using the questionnaire and school documents, we collected data on family environment, health behavior and health status for 19 days. Feb. 2nd 1998 through Feb. 20th 1998. The R -form of Family Environment Scale (Moos, 1974) was used in the analysis of family environment(Cronbach's Alpha =0.80). Questionnaires of Health Behavior in School-aged children used by the WHO in Europe(Aaro et al., 1986) and the ones developed by the Health Promotion Committee of the Western Pacific(WHO, 1995)(adapted by long Young-suk and Moon Young-hee(1996)) were used in the analysis of health behavior, as well documents on absences due to sickness, school health room-visits, levels of physical strength, height, weight and degree of obesity were used to determine health status. In next step, We used them with an $X^2$-test, t-test, Odds Ratio, and a 95% Confidence Interval. 1. In two dimensions of three, family-relationship (t=3.41, p=0.001) and system -maintenances(t= 2.41, p=0.0l6) the mean score of urban children were significantly higher than those of rural ones. In the personal development dimension however, there was little significant difference. Assorting family environment into 10 sub-fields and analyzing them, we recognized that urban children were superior to rural children in the sub-fields of expressiveness (t =3.47, p=0.001), conflict (t=0.48, p=0.001), active-recreational orientation (t = 1.97, p=0.049) and organization (t=4.33, p=0.000). 2. Referring to the Odds Ratios of urban-rural children's health behaviors, urban children set up more desirable behavior than rural children wear ing safety belts (Odds Ratio =0.32, p=0.000), washing hands after meals(Odds Ratio = 0.43, p= 0.000), washing hands after excreting (Odds Ratio = 0.39, p=O.OOO), washing hands after coming - home ( Odds Ratio = 0.75, p = 0.003), brushing teeth before sleeping(Odds Ratio =0.45, p=0.000), brushing teeth more than once a day (Odds Ratio =0.73, p=0.0l2), drinking boiled water (Odds Ratio = 0.49, p=0.000), collecting garbage at home(Odds Ratio=0.31, p=0.000) and in the school(Odds Ratio =0. 67, p=0.000). All these led to significant differences. As to taking milk(Odds Ratio = 1.50, p=0.000), taking care of eyesight(Odds Ratio=1.41, p=0.001) and getting physical exercise in(Odds Ratio = 1.33, p=0.0l9) and outside the school(Odds Ratio = 1.32, p=0.005), rural children had more desirable behavior which also revealed a significant difference. There was little significant difference in smoking, but the smoking rate of rural children(5.5%) was larger than that of urban children(3.9%). 3. Health status was analyzed in terms of absences, school health room-visits, levels of physical strength, and the degree of obesity, height and weight. Considering Odds Ratios of the health status of urban-rural children, the health status of rural children was significantly better than that of the urban ones in the level of physical strength(t=1.51, p=0.000) and the degree of obesity(t=1.84, p=0.000). The mean height of urban children ($150.4{\pm}7.5cm$) is taller than that of their counterparts($149.5{\pm}7.9$), which revealed a significant difference (t =2.47, p=0.0l4). The mean weight of urban children($42.9{\pm}8.6kg$) is larger than that of their counterparts($41.8{\pm}9.0kg$), which was also a significant difference(t=2.81, p=0.005). Considering the results above, we can recognize that there are significant differences in family environment, health behavior, and health status in urban-rural children. These results also suggestion ideas for health education. What we would suggest for the health program of elementary schools is that school health teachers should play an active role in promoting the need and importance of health education, develop the appropriate programs which correspond to the regional characteristics, and incorporate them into schools to improve children's ability to manage their own health management.

• Journal of Hospice and Palliative Care
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• v.17 no.2
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• pp.66-74
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• 2014

Purpose: This study is aimed to investigate perceptions of caregivers and medical staff toward do not resuscitate (DNR) and advance directives (AD). Methods: Participants were 141 caregivers and 272 medical staff members from five general hospitals. A questionnaire used for the study consisted of 20 items: 14 about DNR perceptions, three about AD, one each for age, gender and employment. Results: Both medical staff and caregivers strongly recognized the need for DNR and AD, and the level of recognition was higher with medical staff than caregivers (DNR ${\chi}^2=44.56$, P=0.001; AD ${\chi}^2=16.23$, P=0.001). The main reason for the recognition was to alleviate sufferings of patients in the terminal phase. In most cases, DNR and AD were filled out when patients with terminal conditions were admitted, and patients made the decisions by consulting with their guardians. Medical staff better recognized the need and for growing demand for guidelines for the DNR and AD decision making process than caregivers (${\chi}^2=7.41$, P=0.0025). Conclusion: This study showed that patients highly rely on their caregivers when making decisions for DNR and AD. Thus, it is important that patients and caregivers are provided with objective information about the decisions. Since participants' strong support for DNR and AD was mainly aimed at alleviating patients' suffering, further study is needed in the association with hospice care. Medical staff also needs to understand the different views held by caregivers and fully consider the disparity when informing patients/caregivers to make the DNR and AD decisions.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.20 no.3
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• pp.407-416
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• 2019

This study is about a Customized Nursery School where working women can support work - life balance and a reduction in retirement or turnover. The research method is to identify the current status of Customized Nursery services and to recognize the recognition and need of the operation of Customized Nursery School. The importance of securing skilled nurses and preventing them from changing their jobs for the health and safety of people cannot be emphasized enough. A Customized Nursery School must be opened to reduce the retirement or change of jobs of working women nurses and to provide care for continuous work in three shifts from 365days to support the balance between the working mother and family. It is considered that nurses will put their children in relief when using retired nurses who have the ability to work 24hour rotation in a Customized Nursery School and when a Customized Nursery School be ran suited for the condition and demand of working women nurses, it is expected to reduce retirement and the change of jobs, also to give positive effect on marrige and family planning which would make improvement in low birthrate. To activate the Customized Nursery School, Creating a secure learning environment and qualification of educators great effort should be put. A program curriculum based on 'basic life and habits' should be the center of education. Continuous management and effort will need to be placed in continuous development of educators.

• Journal of Korean Academy of Nursing
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• v.25 no.1
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• pp.61-79
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• 1995

When children are admitted to hospital, they have to adapt to new and unfamiliar stimuli. Children may respond with fear to stimuli such as pain or unfamiliar experiences. One goal of nursing is to help hospitalized children to adapt effectively to their hospital experience. Accordingly, nurses need to assess childrens' fears of their hospital experience to contribute to the planning of care to alleviate these fears. The problem addressed by this study was to identify and measure hospital-related fears(hereafter called HRF) in hospitalized school-aged children. The study was conceptualized with Roy's model. A descriptive qualitative approach was used first, followed by a quantitative approach. This study was conducted from November 30, 1989 to January 12, 1991. The sample consisted of 395 hospitalized school-aged children selected through an allocated sampling technique in nine general hospitals. The HRF questionnaire (three point likert scale ) was developed by a delphi technique. The data were analyzed by an SAS program. Factor analysis was used for the examination of component factors. Differences in the HRF related to demographic variables were examined by t-test, analysis of variance and the Scheffe test. The crude scores of the HRF scale were transformed into T- scores to calculate the standard scores. The results included the following : 1. Forty-four items were derived from 188 statements identifying the childrens' hospital-re-lated fears. These items clustered into 14 factors, fear of injections, operations, bodily harm others' pain, medical rounds, physical examinations, medical staff, disease process, blood and X-rays, drugs and cockroaches, tests, harsh discipline from parents or staff, being absent from school, and separation from family. The 14 factors was classified into four categories,'pain','the unfamiliar','the un-known' and 'separation'. 2. The reliability of the HRF instruments was .92(Cronbach's alpha). In the factor analysis, Cronbach's alpha coefficients for the 14 factors ranged from .84 to .86 and Cronbach's alpha coefficients for the four categories ranged from .70 to .84. Pearson correlation coefficient scores for relationships among the 14 factors ranged from ,11 to .50, and among the four categories, from ,44 to ,63, indicating their relative independence. 3. The total group HRF score ranged from 45 to 130 in a possible range of H to 132, with a mean of 74.51. The fears identified by the children were, in order, injections, harsh discipline by parents or staff, bodily harm, operations, medical staff, disease process, and medical rounds ; the least feared was others' pain. The fear item with the highest mean score was surgery and the lowest was examination by a doctor. HRF scores were higher for girls than for boys, and for grade 1 students than for grade 6 students. HRF scores were lower for children whose fathers were over 40 than for those whose fathers were in the 30 to 39 age group, and whose mothers were over 35 than for those whose mothers were in the 20 to 34 age group. HRF scores were lower when the mother rather than any other person stayed with the child. The expressed fear of pain, the unfamiliar, the un-known and of separation directs nurses' concern to the threat felt by hospitalized children to their concept of self. This study contributes to the assessment of fears of hospitalized children and of stimuli impinging on those fears. Accordingly, nursing practice will be directed to the alleviation of pain, pre-admission orientation to the hospital setting and routines, initiation of information about procedures and experiences and arrangments for mothers to stay with their children. Recommendations were made for further research in different settings and for development and testing of the instrument.

• The Korean Nurse
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• v.31 no.2
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• pp.51-69
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• 1992

Grief that is not acknowledged and worked through may manifest itself in some emotional, mental or physical problem. In recent years much has been learned about coping with grief which the hospice program can utilize to help family members cope with their grief. This study was carried out to determine the helpfulness of the bereavement care of Severance Hospice and to learm more about the grief response of the bereaved. The tools used to collect data were an assessment form used in the bereavement program and the Grief Experience Inventory developed by Sanders and revised and translated 'by the researcher. Data was obtained from bereaved family members(54 for the final grief assessment and 39 for the grief response assessment) receiving bereavement follow-up, from July 1989 to March 1991. Results of the study were as follows: 1. Final Grief Assessment Regarding the resolution of their grief the majority of the bereaved accepted the reality of the death of their family member, while slightly more than three-quarters were able to express their feelings toward their loss. A large majority had returned to activities of daily living well or fairly well and had reinvested their energy in a person other than the deceased. In addition, the physical condition of the majority was good or fairly good. A majority of the bereaved considered the bereavement care to be helpful and almost three-quarters were not considered to be in need of more follow-up. 2. Grief Response Assessment Age was found to have a modoerately positive correlation to appetite disturbance(r=.41, P<.Ol) and loss of vigor(r=.37, P<.Ol) A moderately positive correlation was found between the number of contacts and sleep disturbance(r=2.38, P<.01) Significant differences were found between men and women in regard to guilt(t=2.38, P<.05), social isolation(t=2.44, P<.05) and depersonalization(t=2.07, P<.05) with men having the more intense grief. Significant differences were found in the grief responses of somatization(F=5.82, P<.001), physical symptoms(F=5.87, P<.OOl), appetite disturbance(F=4.40, P<.Ol), despair(3.79, P<,Ol), anger(Fp2.83, P<.05), social isolation(F=3.61, P<.05), guilt(F=3.62, P<.05) and depersonalization (F = 2.58, P <.05). In the first six of these grief responses mothers scored highest, followed by husbands and then wives, In the grief response of guilt, daughters scored highest and on the grief response of depersonalization sons scored highest. Only one grief response, that of sleep disturbance(t= -2.19, P<.05) was found to be statistically significant, with those family members who died at home having the higher scores. Based on the results of this study several suggestions are presented as follows: 1. Since unresolived grief can have a detrimental effect on the bereaved person's mental and phys. ical health it would be good for the nurse, to include questions related to death of family members and the bereaved person's response to the grief, in her nursing assessment. And in the case of unresolved grief the nurse should encourage the person to talk with a trusted friend or counselor and express their fellings of grief. 2. A study to determine the degree of resolution of the grief of those in the bereavement program could be carried out by use of the Grief Experience Inventory early in their bereavement and again 13 months after the death of their family member. 3. A comparison of the grief response of the bereaved in the bereavement program and bereaved not in the program could be carried out using the Grief Experience Inventory. 4. After bereavement programs have been started in other hospice programs it would be good to carry out a joint study of bereavement outcomes of those in the bereavement programs.

• Journal of Hospice and Palliative Care
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• v.9 no.1
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• pp.11-16
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• 2006

Purpose: This study is aimed to confirm nurse's attitudes and to investigate the factor analysis on organ donation in brain dead donors. Methods: This survey were collected from 198 nurses in three university hospitals and four general hospitals in B city with questionnaires developed by the author. The consent for this research was obtained from nursing managers, head nurses, and staff nurses after explaining the purpose of this research. Results: In questionnaires, 45 items about attitudes were included and positive and negative attitude were analyzed. The contents of factors are 'legal permission of brain death', 'one's will of organ donation at the brain death', 'need for educational program about brain dead during college curriculum', 'organ donation is good presents for others', 'connection with professional institutes', 'necessity of brain death', 'convenient to control of brain death' and 'the goods for organ transplantation in brain dead donors' as positive attitudes. Meanwhile, 'contrast to certain religion and dignity to life', 'negative dangers on brain dead permission', 'unbelief to the medical teams', 'burdens to ask organ donation to brain deads/families' and 'economical compensation' are factors as negative attitudes about organ donation in brain dead. The total mean point score of positive attitudes about organ donation in brain dead donors was $3.753{\pm}3.398$. The total mean point score of negative attitudes about organ donation in brain dead donors was $2.915{\pm}0.472$. Conclusion: The results of this study may be of help for the nurses who concern organ sharing and make effective interventions and educations to facilitate the decision making process for organ donation in brain dead donors or families.

• Journal of Korean Academy of Nursing
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• v.23 no.3
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• pp.467-486
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• 1993

Today, more chronically ill and handicapped people are being cared for at home by a family member caregiver. The task of caring for a family momber may mean that the caregiver has less time and money and more work which may result in increased fatigue and symptoms of illness. This study was done to examine the well-being of family caregivers. Fifty three family caregivers were interviewed. Concepts were measured using existing tools and included : Burden(25 item 5 point scale), Social sup-port (21 item 7 point scale), Health status defined by a symptom checklist(48 item S point scale), and Well -being defined by a quality of life scale (14 item 7 point scale) and caregiving activities. Data collection was done by interview and Q-sort. Social support and well - being were positively correlated as were symptoms and burden. Symptoms and burden were negatively correlated with social support and well-being. Items on the quality of life scale had a mean score range from 3.09 to 4.96. Quality of life related to income was lowest (3.09) but the desire to use more money for the patient was rated 2.90 on the burden scale where the item means ranged from 0.73 to 3.55. The high mean of 3.55 was for obligation to give care and the low 0.73 was (or not feeling that this was helping the patient. Mean scores for symptoms ranged from 0.26 to 2.15 with the 2.15 being for “worry about all the things that have to be done.” Over half of the patients were dependent for help with some activities of daily living. The caregivers reported doing an average of 3.40 out of five patient care activities including bathing (77.4%), shampooing (67.9%), and washing face and hands (49.1％), and 3.74 out of seven home maintenance activities including laundry (98.1％), cooking (83.0%), and arranging bed-ding(75.5%). The caregivers reported their spouse as one of the main sources of social support, including in times of loneliness and anger The mean score for loneliness as burden was 2.15 and ranked fourth and 31 (58.5％) of the sample reported being lonely recently and not being satisfied with the support received. Similarly anger caused by the patient was given a mean score of 2.13, and anger was reported to have been present recently by 38 (71.7%) of the sample and satis-faction with the support given was low. Having someone to help deal with anger ranked twelfth out of 21 items on the social support scale and had a mean score of 3.98 (range 3.49 to 5.98). Spouses were reported as a major source of social support but the fact that 50% of the caregivers were caring for a spouse, may account for the quality of this source of social support having been affected. These caregivers faced the same problems as others at the same stage of life. but because of the situation, there was a strain on their resources, particularly financial and social. In conclusion it was found that burden is correlated negatively to quality of life and positively to symptoms, but in this sample, symptoms and bur-den were scored relatively low. Does this indicate that the caregivers accept caregiving as part of their destiny and accept the quality of their lives with burden and symptoms just being a part of caregiving\ulcorner Does the correlation between the bur-den and symptoms indicate they are a measure of the same phenomenon or that the sample was of a more mobile, less burdened group of caregivers\ulcorner Quality of life was the one variable that was significant in explaining the varience on burden. Further study is needed to validate the conclusions found in this study but they indicate a need for nurses to ap-proach these caregivers with a plan tailored to each individual situation and to give consideration to interventions directed at improving quality of life and expanding social support networks for those caring for spouses.

• Journal of Korean Academy of Nursing
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• v.20 no.2
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• pp.153-173
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• 1990

One of the important tasks for new parents. especially mothers, is to establish warm, mutually affirming interpersonal relationships with the new baby in the family, with the purpose of promoting the healthy development of the child and the wellbeing of the whole family. Nurses assess the quality of the behavioral characteristics of the maternal-infant interaction. This study examined the relationships between primiparas pereptions of their delivery experience and their maternal infant interaction. It compared to delivery experience of mothers having a normal vaginal delivery with those having a casearean section. The purpose was to explore the relationships between the mother's perceptions of her delivery experience with her maternal infant interaction. The aim was to contribute to the development of theoretical understanding on which to base care toward promoting the quality of maternal-infant interaction. Data were collected directly by the investigator and a trained associate from Dec. 1, 1987 to March 8, 1988. Subjects were 3 random sample of 62 mothers, 32 who had a normal vaginal delivery and 30 who had a non-elective cesarean section (but without other perinatal complications) at three general hospitals in Seoul. Instruments used were the Stainton Parent -infant Interaction Scale(1981) and the Marut and Mercer Perception of Birth Scale(1979). The first observations were made in the delivery room (for vaginally delivered mothers only), followed by day 1, day 2, day 3, and 2 weeks, 4 weeks, 6 weeks and 8 weeks after birth, for a total of 7-8 contacts(Cesarean section mothers were observed on days 4 and 5 but the data not used for analysis). Observations in the hospital were made during the hour prior to scheduled feedings. The infant was placed beside the mother. Later contacts were made at home. Data analysis was done by computer using as SPSS program and indulded X² test, paired t-test, t-test, and Pearson Correlation coefficient ; the results were as follows. 1. Mothers who had a normal vaginal delivery tended to perceive the delivery experience more positively than cesarean section mothers(p＝0.002). The finding supported the hypothesis I that perception of delivery would vary according to the method of delivery. Mothers' perceptions of birth were classified into three dimensions, labor, delivery and the bady. There was a significantly different and positive perception by the vaginally delivered mothers to the delivery experience(p＝0.000) but no differences for labor or the bady according to the delivery method(p＝0.096, p＝0.389), 2. Mothers who had a normal vaginal delivery had higher average maternal-infant interaction scores(p＝0.029) than mothers who had a cesarean section. There were similar higher scores for the 1st day(p＝0.042), 2nd day (p＝0.009), and the 3rd day(p＝0.006) after delivery but not for later times. The findings supported the hypothesis Ⅱ that there would be differences in maternal-infant interaction for mothers having vaginal and cesarean section deliveries. However these differences deccreased section deliveries. However these differences decreased over time . by eight weeks the scores for vaginal delivery mothers averaged 8.1 and for cesarean section mothers, 7.9. 3. The more highly positive the pereption of the delivery experience, the higher the maternal-infant interaction score for all subjects(F＝.3206, p＝.006). The findings supported the hypothesis Ⅲ that there would be correlations between perceptions of delivery and maternal-infant interaction. The maternal infant interaction was highest when the perception of the bady and deliery was positive(r＝.4363, p＝.000, r＝.2881, p＝.012). No correlations between perceptions of labor and maternal-infant interaction were found(p＝0.062). 4. The daily maternal-infant interaction score for the initial contact after birth to 8 weeks postpartum had the lowest average score 5.20 and the highest 7.98(in a range of 0-10). This subjects group of mothers needed nursing intervention to promote their maternal- infant interaction. The daily scores for the maternal-infant over the period of eight weeks. However, there were significantly different increases in maternal-infant interaction only from the first to second day(p＝0.000) and from the fourth to sixth weeks after birth(P＝0.000). 5. When the eight items of maternal-infant interaction were evaluated separately, “Expresses feelings about her role as mother” had the highest average score, 1.64(ina range of 0-3)and “Speaks to baby” the lowest, 0.9. All items, with the possible exception of “Expresses feelings about her role as mother”, suggested the subjects' need of nursing intervention to promote maternal-infant interaction. 6. There were positive correlations between certain general charateristis, namely, both a higher economic status(p＝0.002) and breast feeding(p＝0.202) and maternal - infant interaction. There were positive correlations between a mother's confidence in her role as a mother and the perception of the birth experience(p＝0.004). For mothers who had a cesarean section, a positive perception of the birth experience was related to the duration of her marriage(p＝0.010), a wanted pregnancy (P＝0.030) and her confidence in her role as a mother(p＝0.000). Pereptions of birth for mothers who had a normal vaginal delivery were positive than those for mothers who had a cesarean section. The level of maternalinfant interaction for mothers delivered vaginally was higher than for cesarean section mothers. The relationship between perception of birth and materanalinfant interaction was confirmed. Cesarean section has an impact on the mother's perceived experience of birth which, in turn, is positively related to maternal-infant in turn, is positively related to maternal-infant interaction. Nursing intervention to enhance maternal-infant interaction should begin in prenatal classes with an exploration of the potential impact of cesarean section on the perceptions of the birth experience and continue throughout the perinatal and post-natal periods to promote the mother's ability to control with this crisis experience and to mobilize social support. Nursing should help transform a relatively negatively perceived experience into an accepted, positively perceived and self affirming experience which enhances the maternal-infant relationship.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.18 no.11
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• pp.526-535
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• 2017

This study was conducted to identify the effects of a comprehensive health care program for elderly living alone on blood pressure, fasting glucose, body composition, and depression at a senior welfare center in M city. The study employed a one-group, pre-posttest design. The comprehensive health care program lasted for three months, from March to June in 2015, and consisted of open health education, exercise class, health consulting and personal education, nutritional consultation, and a self-support group. The sample elements of this study were individuals over 65-years-old with hypertension or diabetes mellitus, living near a welfare center in M city. A total of 34 participants were initially selected, but five subjects who were attended less than five times were excluded; therefore, a total of 29 individuals were included. The t-test and Pearson's correlation were used to analyze the data. The characteristics of subjects were 19 male(65.52%) and 10 female(34.48%). The most common age was 70 (16 subjects;55.17%). Additionally, 14 subjects were suffering from hypertension and diabetes mellitus (48.27%), which were occupied in the largest number in this study. The average attendance number of health programs was 10.28 times(${\pm}4.17$). In this study of subjects were significantly lower systolic blood pressure(t=3.275, p=0.004), body weight(t=3.878, p=0.001), depression(t=3.308, p=0.004) compared to pre-test. As the elderly population has increased, the number of individuals living alone has also increased. Accordingly, then need for physical and psycho-social health programs targeting the elderly is greater.

• Journal of Hospice and Palliative Care
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• v.13 no.3
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• pp.153-160
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• 2010

Purpose: The purpose of the present study was to investigate needs and satisfaction on the medical services of cancer patients in Jeju Special Self-Governing Province. Methods: Total 174 cancer patients, who visited at the clinic of Jeju National University Hospital, submitted informed consent and participated in this study from July 13 to July 30, 2009. Self questionnaire was used and data were analyzed with Kolmogorov-Smirnov test, Mann-Whitney U test, ANOVA, and Kruskal-Wallis test. Results: Participants expressed the needs of most economical support (3.38 out of 4), followed by counseling of treatment plan (3.22), information of disease (3.07), and disease management except cancer (2.97). Participants were satisfied most with religious counseling (3.41), followed by nursing service support (3.39), employment counseling (3.26), and counseling for family or interpersonal relationships (3.26). The satisfaction of economical support was the lowest (1.98). Satisfaction of men was higher than women, and needs in patients who were living with children was the highest. Patients who were living alone or with children showed the lowest satisfaction about the medical services. There were no significant differences in the general characteristics, however, participants who were older than 60 years of age or had higher income showed lower needs and higher satisfaction. There were no significant differences in the medical characteristics, however, thyroid cancer patients and patients who were treated with radiation therapy or transarterial embolization showed low satisfaction. Conclusion: Cancer patients seemed to need more economical support, information of treatment or disease, and symptom management. Furthermore, there were various needs about the services, depending on family formation or economical support of patients. Therefore, it is certain that patients who were suffering from other cancers, except the 5 major cancers, needed more services. In conclusion, continuous and systemic policy to consider patient's characteristics and needs are needed in community as well as health care system.