• Title/Summary/Keyword: Patterns of Care Study

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The Comparative Study on Health Promoting Behaviors by Shift Pattern of Duties of Women Workers in workplace (산업장 여성근로자의 근무형태에 따른 건강증진행위 비교)

  • Jang, Hee Jung;Park, Kyung Min
    • Korean Journal of Occupational Health Nursing
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    • v.8 no.1
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    • pp.22-41
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    • 1999
  • This study intended to analyze the health promoting behaviors, compare their factors according to the shift pattern of duties of women workers who were working in the industrial workplace and present basic data in planning systematic and effective programs of health promotion for three-shift system and day-duty. Using Quota Sampling, 219 women workers were selected as subjects from 5 workshops which had 50 settled workers up to 300 and 10 factories which had more than 300 located in Taegu and Kyung-Book Province. Data were collected by means of questionnaire from September 12 to September 30, 1998. As the instruments of the study were used Health Promotion Lifestyle Profile(HPLP) which was adapted and adjusted by Seo, Y. O. for health promoting behavior, the one developed by Moon, J. S. (1990) for health-belief, the one developed by Sherer et al.(1982) and then adapted by Oh, H. S. for self-efficacy, and the one developed by Park, J. W. (1985) for social support. The analysis of data were performed with Cronbach's ${\chi}^2$-test, t-test, ANCOVA, Kendal tau, Pearson correlation, Stepwise Multiple Regression test using SPSS program. The results of the study are as follows : 1. There was a significant difference in age(${\chi}^2=32.46$, p=0.000), career (${\chi}^2=18.47$, p=0.000), working day(t=-3.18, p=0.000) by the shift pattern of duties in terms of socio-demographic characteristics. 2. There was a statistically significant difference between the two groups on the health promoting behaviors (t=2,52, p=0.012). The score of three-shift group on health promoting behaviors was 2.27, showing that it was lower by .13 than that of day-duty group(2.40). 3. ANCOVA involving age, career and working day as covariables, which had revealed significant difference before, showed that health promoting behaviors by the shift patterns of duties was significantly different(F=4.88, p=0.028). 4. In consideration of variables that have an influence on health promoting behavior by the shift pattern of duties, social support occupied 19.4% of health promoting behavior in the three-shift group and 22.5% including the sense of self-efficacy. In the day-duty group, social support occupied 34.4% of health promoting behavior. 5. The score of three-shift group(2.94) was significantly lower than that of day-duty group(3.12) in the perceived benefit of health-belief(t= -3.29, p=0.001), while the score of three-shift group (2.48) was significantly higher than that of day-duty group(2.24) in the perceived barrier (t=4.22, p=0.000). In the sense of self-efficacy(t=-4.20, p=0.000), the score of three-shift group(3.24) was significantly lower than that of day-duty group(3.53) while in social support(t=-4.56, p=0.000) the one of three-shift group(2.64) was significantly lower than that of day-duty group(2.88). The suggestions are as follows on the basis of the results of this study : 1. It is required to develop health promoting program that takes the shift pattern of duties of women workers into consideration. In addition, there are special demands on developing nursing strategies for health promoting behavior of three-shift workers. 2. It is required to develop specific strategies for social support which is the most significant factor to the health promoting behavior for women workers. 3. It is necessary to develop some programs for improving the sense of self-efficacy, social support, and health-belief of three-shift workers. To achieve these tasks, industrial nurses should play an active role and improve the ability of self-health care of women workers.

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An Analytical Study of the Quality of Life in Dental Hygienists in Seoul (서울지역 치과위생사의 삶의질(Quality of Life)에 관한 분석 연구)

  • Kim, Yeun-Sun
    • Journal of dental hygiene science
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    • v.5 no.1
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    • pp.39-43
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    • 2005
  • This study was carried out to provide fundamental data for an examination of a health promotion program by determining the influence of the Health Promoting Lifestyle Profile on the quality of life of female dental hygienists. The sample was selected from the population of 1,148 who were registered in the Association of Seoul Dental Hygienists. 800 subjects were randomly selected from 25 districts in Seoul. The data was collected by calling the dental hygienists to, explaining the contents and objective of our study, and sending them a questionnaire by post. The questionnaire consists of the total number of 97 questions: 62 questions on the Health Promoting Lifestyle Profile, 26 questions on the quality of life and 9 general characteristics questions. The data was collected from August 16 to October 15, 2004. Out of 800 subjects, 481(60.1%) completed the questionnaires. For statistical analysis, the frequency, percentage, arithmetic mean, ANOVA, and multiple regression analysis, were analyzed using the SAS 8.1 Analysis program. The significance level was set to 0.05. The results of this study were as follows: First, The average score of the subjects' quality of life was 3.1. For the sub-categories, it was shown that the degree of satisfaction on the condition of society was the highest at 3.2, and the degree of satisfaction on the condition of the individuals was the lowest at 3.1. The average score of the Health Promoting Lifestyle Profile variable was 2.5. For the sub-categories, it was shown that the degree of sanitary life was at 3.2, and degree of the professional health maintenance was the lowest at 1.7. Second, There were significant differences in the Quality of Life benefits of action with the general characteristics. There were significant differences in age, educational level, income, marital status, career, and Perceived Health Status. There were significant difference in Health Promoting Lifestyle Profile benefits of action with the general characteristics. There were significant differences in terms of age, educational level, income, marital status, career, and the Perceived Health Status. Finally, The stepwise multiple regression analysis revealed that the powerful predictors were Health Promoting Lifestyle Profile, income and the Perceived Health Status. These factors accounted for 37.6% of the variance in the Quality of Life patterns. As the subjects were limited to dental hygienists in Seoul, care should be taken when applying these results to all dental hygienists in Korea. In order to generalize the study, a large number of subjects selected from all regions in Korea will be needed.

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Utility and Care Patterns of Lotus Shown in Classic Poetries and Proses, Painting (고전 시문과 회화를 통해 본 연(Nelumbonucifera)의 활용과 애호 행태)

  • Kim, Myung-Hee;Hong, Hyoung-Soon
    • Journal of the Korean Institute of Traditional Landscape Architecture
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    • v.29 no.4
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    • pp.1-13
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    • 2011
  • The purpose of this study is to consider practical examples of the method of utilizing plant material 'lotus' used by the ancients, and the value and meaning they wanted to get from it. The method of this study to do this is descriptive study to consider and interpret poem and painting reflecting impression and concept world of lotus. Summary of this study is as follows. First, ornamental value of lotus could be divided in effect of group plant and detail value held by the flower, the leaves and the stem. Especially, group plant lotus in large site provides unique landscape differentiated form other flowering plants. As well, another feature of lotus is its high ornamental value spread in detail elements including the flower, the leaves, the stem and the lotus seed. Second, fragrance expressed 'Hyang-won-ik-cheong(香遠益淸)' is an important charm of lotus. Lotus was utilized as olfactory element providing fragrance. The ancients considered lotus fragrance not only for enjoy but as symbolic object comparing noble man's dignity so that they expressed it in poem and painting. Third, lotus was utilized as acoustical element. That is, the sound of raindrops harmonizing the surface of water and wide lotus leaves was called 'hearing lotus fond and rain', enjoying it as classic grace. Fourth, summer play lotus sightseeing was called mind wash up meaning 'washing the mind polluted by the mundane world'. Such poetic taste was widely enjoyed by various classes from general public to royal family. Besides, poetic taste related with lotus is the method of drinking alcohol using the feature of big lotus leave and vacant stem, called 'Beog-tong-ju(碧筒酒)'. And in the Joseon dynasty period, when the distinction between the man and the woman influenced by Confucian, lotus seed and 'lotus collecting song' was important sign to express romance between man and woman. Lotus has been enamored by wide classes transcending cultural background as thought and religion since ancient times. Due to such reasons, various symbolic meaning of lotus and planting examples related to religious facilities as temples could not be considered in various manner is limitation of this study, and which is research project for the future.

Plant Species Utilization and Care Patterns Using Potted Plants in the Traditional Gardening (전통조경에서 분(盆)을 이용한 식물의 활용과 애호 행태)

  • Kim, Myung-Hee
    • Journal of the Korean Institute of Traditional Landscape Architecture
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    • v.31 no.3
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    • pp.61-74
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    • 2013
  • This study examined and analyzed ancient writing and poetry regarding cases of appreciating plants by using pots in a garden of a palace or private houses by ancestors, and examined shape and planting method of plant species and potted plants, arrangement and preference of potted plants. As for the method of the study, description research method which examines and interprets poem and painting based on potted plants. The results of this study is summarized like the following. First, the plants which were favorably used for potted plants include 19 kinds such as Prunus mume, Pinus densiflora, Pinus pumila, Phyllostachys spp., Camellia japonica, Punica granatum, and Gardenia jasminoidesa, and as for herbs, 12 kinds such as Chrysanthemum monifolium and Nelumbo nusifera . Second, the species which were specially arranged into artificial shapes include Prunus mume and Pinus densiflora. The two plants made the shape of severe curves of stems such as Wangpi. Gyuban, and Bangan, and there are Pinus densiflora dwarfed potted plant whose roots are stretched on Prunus mume grafted into a strange stump and an oddly shaped stone. For the beauty of the dwarfed tree shape, pine cones are added to an old Pinus densiflora or Parthenocissus tricuspidata is planted to stems, and additional method of making moss on the soil, which is called 'Jongbunchuigyeong'. As for planting method, water culture, planting on a stone, planting on a charcoal, and assembled planting are expressed in poetry. Third, as for external space for potted plants, a place where a king stays, a bed room for a king, surrounding areas and gardens of private houses, and step stones were used as a space which adds artistic effects. Potted plants are placed on a table in a library, on a desk, on a drawer, and near a pillow as a small items in a room, and scholars enjoyed original characteristics and symbolism of the potted plants. Fourth, at the time of flowering of Prunus mume, poetry event was held to enjoy the tree and writing poetry begun. And at the time of flowering of Chrysanthemum monifolium, the flowers were floated in a liquor glass or shadow play was enjoyed. Fifth, potted plants played the role of garden ornaments in elegant events of a palace, the gentry, wedding ceremony, and sacrificial rites. Sixth, potted plants were used as tributes between countries, donation to a king, or a gift of a king. In addition, there were many cases where scholars exchanged potted plants and there is the first record of giving a potted plant in 'Mokeunsigo' by Mokeun Isaek, scholar in the late era of Goryeo. Seventh, at the time of flowering Prunus mume, Chrysanthemum monifolium, Gardenia jasminoides, Nelumbo nusifera, and Narcissustazetta var. chinensis, they enjoyed the particular fragrance and express it into poetry. Eighth, plant species from southern parts such as Camellia japonica, Daphne odora, Gardenia jasminoides, Citrus unshiu, Phyllostachys spp., Punica granatum, Rosa rugosa, and Musa basjoo, or foreign plant species, and species weak against the cold were utilized as pot plants for enjoying green trees indoors in northern central province in harshly cold winter.

Spatial Distribution of Macrobenthic Communities on the Rocky Intertidal Zone of Specified Islands, Southern Coast of Korea (남해안 특정도서 암반조간대의 대형저서동물 군집의 공간분포)

  • Yang, Sehee;Yang, Hyosik;Lee, Changil;Seo, Chonghyun
    • Journal of the Korean Society of Marine Environment & Safety
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    • v.28 no.6
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    • pp.853-865
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    • 2022
  • In this study, from August to October 2019, we conducted a survey of the spatial distribution and dominant species of macrobenthos on the rocky intertidal zones of 38 specified islands distributed along the southern coast of Korea. On the basis of observation made using 50 × 50 cm quadrats, we identified a total of 80 species, among which, Mollusca were the most abundant fauna, with 54 species that accounted for 67.4% of the total, followed by Crustacea with 15 species (18.7%). The recorded numbers of Cnidaria, Porifera, and Echinodermata species ranged from 1 to 6. In terms of the regional patterns of species richness, specified islands in Yeosu were found to be the most species rich, supporting 61 species, whereas islands in Hadong, Namhae, and Chujado were found to have a similar level of species richness, ranging from 42 to 46 species. Islands in Boseong and Goheung were home to the fewest species, with only 29 species being recorded. At the sampling station scale, we noted a considerable difference in faunal richness, ranging from 6 (St. 6) to 33 (St. 20) species. Among the recorded species, Echinolittorina radiata was identified as the dominant species on 15 specified islands, with the next most abundant species being Tetraclita japonica, considered an indicator species of climate change, which was recorded on 11 islands. In terms of frequency, E. radiata, found on 36 islands, was identified as the most frequently occurring species, followed by Reishia clavigera (30 islands), Mytilisepta virgata (29), Nerita japonica (28), Ligia. exotica (27), and Littorina brevicula (26). Of the 80 species identified, 9, 4, and 2 species of Mollusca, Crustacea, and Cnidaria, respectively, are classified as Marine fauna of accepted foreign export, whereas 50 are Red List species, 44 are species of Least Concern, 3 are Data Deficient species, and 1 species was not evaluated. However, during the survey, we found no Near Threatened or Not Applicable species. On the basis of the findings of this survey, it would appear that the abundance and richness of macrobenthic fauna inhabiting the rocky intertidal zones of specified islands along the southern coast of Korea differ according to different habitat conditions, particularly with respect to the duration of exposure and the extent and properties of the substrata. The findings of this study will provide baseline data for future monitoring and management of specified islands in Korea.

Comparison of the Therapeutic Effects of $Curosurf^{(R)}$ and $Newfactan^{(R)}$ in Respiratory Distress Syndrome (신생아 호흡 곤란 증후군에서 $Curosurf^{(R)}$$Newfactan^{(R)}$의 치료 효과 비교)

  • Hong, Suk-Woo;Lee, Eun-Ho;Kim, Seung-Yeon;Park, Ho-Jin
    • Neonatal Medicine
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    • v.15 no.2
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    • pp.142-151
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    • 2008
  • Purpose : The aim of this study was to compare the clinical effects of modified porcine (Curosurf$^{(R)}$) and bovine (Newfactan$^{(R)}$) surfactants in the treatment of neonatal respiratory distress syndrome. Methods : Between April 2004 and December 2006, 65 neonates (birth weight ${\leq}$2,500 g and gestational age ${\leq}$35 weeks) with neonatal respiratory distress syndrome were treated in our neonatal intensive care unit with surfactant. Thirty-one neonates received Curosurf$^{(R)}$ and 34 neonates received Newfactan$^{(R)}$. The neonates were not enrolled if they had major congenital anomalies or meconium aspiration syndrome. We compared the changes in respiratory parameters after surfactant instillation, the incidences of acute and chronic complications, and the mortality between the two treatment groups. Results : Neonatal and maternal demographic characteristics were not different between the groups. The patterns of change in the respiratory parameters after surfactant instillation were not statistically different between the groups. The incidences of surfactant reinstillation and acute complications, such as pneumothorax, patent ductus arteriosus, pulmonary hemorrhage, and grade 3-4 intraventricular hemorrhage, were not different between the neonates who received Curosurf$^{(R)}$ and the neonates who received Newfactan$^{(R)}$. There were no statistically significant differences in the duration of mechanical ventilation, oxygen therapy, hospitalization, prevalence of bronchopulmonary dysplasia, periventricular leukomalacia, retinopathy of prematurity, necrotizing enterocolitis, and mortality between the groups. Conclusion : In the present comparative study, no significant differences in the clinical effects of Curosurf$^{(R)}$ and Newfactan$^{(R)}$ were observed.

Retrospective Analysis of Clinical Patterns and Antibiotic Utilization in Pediatric Patients Hospitalized with Respiratory Syncytial Virus Pneumonia at a Recently Established General Hospital (신생 대학병원에서 호흡기세포융합바이러스 폐렴으로 입원한 건강한 소아청소년환자에서의 임상 양상 및 항생제 사용에 대한 후향적 분석)

  • Hyejin So;Kyung Min Kim;Eun Young Cho
    • Pediatric Infection and Vaccine
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    • v.31 no.1
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    • pp.75-82
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    • 2024
  • Purpose: As the coronavirus disease 2019 (COVID-19) pandemic ended, the number of patients with respiratory syncytial virus (RSV) pneumonia increased during the spring/summer of 2022. This study aimed to analyze the clinical features and antibiotic usage of children hospitalized for RSV pneumonia in a recently established general hospital in Sejong city. Methods: In this retrospective review, we included inpatients of the Pediatric Department of Chungnam National University Sejong Hospital diagnosed with RSV pneumonia between March 2022 and April 2023. Patients were divided into 2 groups: with and without antibiotic treatment. Demographic data, initial presentations, and clinical courses were reviewed. Results: A total of 116 patients with RSV pneumonia were hospitalized during this period, of which 102 were analyzed, excluding 14 with underlying diseases or who did not fall within the definition of pneumonia. The median age was 17 months. Diagnoses of bacterial infections (acute otitis media and sinusitis) were documented in 9.8% of cases. Intravenous (IV) antibiotics were administered in 46% of cases. The group receiving IV antibiotics showed higher inflammatory levels (C-reactive protein; CRP), more infiltration on initial chest X-rays, and longer fever duration. There was no difference in the length of hospitalization between the groups with and without IV antibiotics. Conclusions: This study showed a tendency for the attending physician to prescribe IV antibiotics to patients with longer fever duration, pulmonary infiltrations on the initial chest X-ray, and higher CRP levels. However, given the high rate of IV antibiotic usage compared to previous studies, care should be taken in antibiotic use.

The Experience of the Family Whose Child Has Died of Cancer (암으로 자녀를 잃은 가족의 경험에 대한 질적연구)

  • 이정섭;김수지
    • Journal of Korean Academy of Nursing
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    • v.24 no.3
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    • pp.413-431
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    • 1994
  • The purpose of this study was to build a substantive theory about the experience of the family whose child has died of cancer The qualitative re-search method used was grounded theory. The interviewees were 17 mothers who had cared for a child who had died of cancer Traditionally in Korea, mothers are the care givers in the family and are considered sensitive to the family's thoughts, feelings. The data were collected through in-depth interviews by the investigator over a period of nine months. The data were analyzed simultaniously by a constant comparative method in which new data are continuously coded into categories and properties according to Strauss and Corbin's methodology. The 16 concepts which were found as a result of analyzing the grounded data were, -left over time, the empty place, meaninglessness, inner sadness, situational sadness, heartache, physical pain, guilt, resentment, regret, support / stigmatization, finding meaning in the death, changing attitudes about life and living, changing attitudes about health, changing religious practice and changing family relations. Five categories emerged from the analysis. They were emptiness, consisting of left over time, the empty place and meaninglessness ; sadness, consisting of inner sadness and situational sadness ; pain, consisting of heartache and physical pain ; bitterness, consisting of guilt, resentment, regret, sup-port / stigmatization and finding meaning in the death : and transition, consisiting of changing attitudes about life and living, changing attitudes about health, changing religious practice and changing family relations. These categories were synthesized into the core concept, -the process of filling the empty space. The core phenomenon was emptiness. Emptiness varied with the passing of time, was perceived differently according to support / stigmatization and finding meaning in the death, was followed by sad-ness, pain, and bitterness, and finally resulted in changes in attitudes about life and living and about health, and in changes in religious practice and family relations. The process of filling the empty space proceeded by ① accepting realty, ② searching for the reason for the child's death, ③ controlling the bitter feelings, ④ reconstructing the relationships ameng death, illness and health and ⑤ filling the emptiness by resolving causes of child's death, adopting, having another child or with work. Six hypotheses were derived from the analysis. ① The longer the bereavement, the mere the empty space becomes filled. ② The longer the hospitalization, the more sup-port the family needs. ③ The more the sadness, pain and bitterness are expressed, the mere positive changes emerge. ④ Family support faciliates the process of filling the empty space. ⑤ Higher family cohesiveness faciliates the process of filling the empty space. ⑥ The greater the variety of reasons attributed to the child's death, the greater the variety of patterns of change. Four propositions related to emptiness and bitter-ness were developed. ① When the sense of emptiness is great and bitterness is manifested by severe feelings of guilt and resentment, the longer the process of fill-ing the empty space. ② When the sense of emptiness is great and the family is highly motivated to get rid of the bitterness, the shorter the process of filling the empty space. ③ When the sense of emptiness is less and bitter-ness is manifested by severe feelings of guilt and resentment, the process of filling the empty space is delayed. ④ When the sense of emptiness is less and the family is highly motivated to get rid of the bitterness, the process of filling the empty space goes on to completion. Through this substantive theory, nurses under-stand the importance of emptiness and bitterness in helping the family that has lost a child through cancer fill the empty space. Further research to build substantive theories to explain other losses may con-tribute to a formal theory of how family health is restored after human tragedies are experienced.

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Measurement of Radiation Using Tissue Equivalent Phantom in ICR Treatment (자궁강내 근접방사선조사시 인체조직등가 팬톰을 이용한 방사선량 측정)

  • Jang, Hong-Seok;Suh, Tae-Suk;Yoon, Sei-Chul;Ryu, Mi-Ryeong;Bahk, Yong-Whee;Shinn, Kyung-Sub
    • Journal of Radiation Protection and Research
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    • v.20 no.1
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    • pp.45-52
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    • 1995
  • This study is to compare A point doses in human pelvic phantom by film dosimetry, computer planning and manual calculation by using of along-away table. We developed tissue equivalent human pelvic phantom composed of four pieces of cylindrical acryl tubes with water, to simulate intracavitary radiation (ICR) in patients with cervix cancer. When the phantom assembled from 4 pieces, it has a small space for inserting Fletcher-Suit-Delclos applicator like a human vagina. Fletcher-Suit-Delclos applicator inserted into the space was packed tightly with furacin gauzes, and three $^{137}Cs$ sources with radioactivity of $15.7mg\;Ra-eq$ were inserted into the tandem. For the film dosimetry, two pieces of X-OMAT V film (Kodak Co.) of which planes include point A, were arranged orthogonally in the slits between phantoms. A point dose and iso-dose curves were measured by means of optical densitometer. A point doses by film dosimetry, RTP system and manual calculation by using of along-away table were compared, and iso-dose curves by film dosimetry and computer planning were also compared. The dose of A point was 51.2cGy/hr by film dosimetry, 46.7cGy/hr by RTP system and 47.9 cGy/hr by along-away table. A point dose by computer planning was similar to the dose by calculation using of along-away table with acceptable accuracy $({\pm}3%)$, however, the dose by film dosimetry was different from two others with about 10% error. Since most clinical beams contains a scatter component of low energy photons, the correlation between optical density and dose becomes tenuous. In addition, film suffers from several potential errors such as changes in processing conditions, interfilm emulsion differences, and artifacts caused by air pockets adjacent to the film. For these reasons, absolute dosimetry with film is impractical, however, it is very useful for checking qualitative patterns of a radiation distribution. In future, solid state dosimeter such as TLD must be used for the dosimetry of ionizing radiation. When considerable care is used, precision of approximately 3% may be obtained using TLD.

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Associated-Genes and Virulence Factors of Staphylococcus aureus Isolated from Nasal Cavity of Neonates (신생아 비강에서 분리된 황색포도구균의 병원성 인자와 관련 유전자)

  • Kim, Yung Bu;Moon, Ji Young;Park, Jae Hong
    • Clinical and Experimental Pediatrics
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    • v.46 no.1
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    • pp.24-32
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    • 2003
  • Purpose : Nosocomial infection with Staphylococcus aureus, especially methicillin resistant S. aureus, has become a serious concern in the neonatal intensive care unit. The aim of this study is to investigate the virulence factors, and the relationship between the antibiotic resistance and the associated genes of Staphylococcus aureus isolated from nasal cavity of neonates. Methods : Fifty one isolates of S. aureus were obtained from nasal swab taken in 28 neonates in the NICU and nursery of Pusan National University Hospital between February and May, 2001. They were tested in regard to antibiotic susceptibility, coagulase test and typing, plasmid DNA profile, as well as reactivity to enterotoxin A-E(sea, seb, sec, sed, see) genes and toxic shock syndrome toxin-1(tst) gene by polymerase chain reaction(PCR). Associated genes such as mecA, mecR1, mecI, and femA were also determined by PCR. The origin of MRSA strains was assessed using DNA fingerprinting by arbitrarily-primed polymerase chain reaction(AP-PCR). Results : Twenty three(45.1%) and six(11.8%) isolates were resistant to oxacillin and vancomycin respectively. Multidrug resistance to three or more of the antibiotics tested was observed in 51.0% of the isolates. Forty two isolates were coagulase positive and twenty two isolates had mecA gene. Sixteen isolates had both mecA and femA genes and had type I-III plasmids. 64.7% of isolates carried sec gene, and 80.4% carried tst gene. DNA fingerprinting by AP-PCR for 12 MRSA strains showed 10 distinct patterns, suggesting different origins. Conclusion : We confirmed that the prevalence of nasal carriage of S. aureus and the incidence of antimicrobial-resistant S. aureus, especially vancomycin resistance, is very high in neonates who were admitted in NICU and nursery. It is possible that these pathogens are responsible for serious nosocomial infections in neonates. The need for improved surveillance and continuous control of pathogens is emphasized.