Delphi Investigation Research Articles

Perceived factors and barriers affecting physiotherapists’ decision to use spinal manipulation and mobilisation among infants, children, and adolescents: an international survey

ABSTRACT Objective To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. Methods Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. Results Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist’s knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. Conclusion This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.

Adalimumab in the management of psoriasis and psoriatic arthritis: Results from a Delphi investigation.

Psoriasis (PsO) and psoriatic arthritis (PsA) are often undertreated and require a multidisciplinary approach. In recent years, patent expiration has allowed the introduction of tumor necrosis factor inhibitor (anti-TNF) biosimilars, which have stimulated a significant increase in the use of biological therapies. This article reports the findings of a multidisciplinary approach to achieve a consensus on the use of adalimumab in patients with PsO or PsA. A voting panel of 36 Italian dermatologists and rheumatologists were chosen by eight Italian clinicians (the Board), to provide a consensus on the real-world management of PsO and PsA with adalimumab using the Delphi Method, comprising three survey rounds. Twelve statements were defined by the Board and submitted to the panel (rating scale 1-7). Clinicians reached a wide consensus on the effectiveness (score 6-7: 67%) and long-term efficacy (6-7: 100%) of adalimumab in all clinical forms of PsO and PsA, including pediatric patients (6-7: 85%). Considering cost-effectiveness and safety, adalimumab is suggested as a first-line treatment in patients with enthesitis, predominant peripheral arthritis, axial involvement or associated inflammatory bowel disease (IBD) or uveitis. Adalimumab can be also considered after failure of etanercept (6-7: 94%). Results from this Delphi study clearly show an overall consensus on the use of adalimumab in the management of PsO and PsA, particularly as first-choice for specific subpopulations (uveitis, IBD, hidradenitis suppurativa). Considering the cost-effectiveness of biosimilars within Italy, adalimumab may represent an effective and safe first-line treatment for patients with moderate-to-severe PsO or PsA, and a valid choice for switching after failure.

The development of fear of missing out scale for early childhood teachers’ work information and the influencing factors of fear of missing out

More and more people over-rely on social software, which causes anxiety due to their failure to check work information in time. However, this type of scale has not been developed yet. The objective of this study was to develop a measurement tool for early childhood teachers’ fear of missing out on work information and verify its reliability and validity. Based on the Fear of Missing Out Scale developed by Przybylski et al. this paper with the methods of interview and Delphi investigation, re-developed the Fear of Missing Out Scale for early childhood teachers’ work information. The exploratory factor analysis showed that the scale was divided into two dimensions, and the confirmatory factor analysis data showed that the scale had good convergent validity. The retest results of the scale showed that the scale had high stability. The reliability and validity of the questionnaire were in line with the requirements of measurement, and it was an effective measurement tool for evaluating early childhood teachers’ fear of missing out on work information. Taking 270 early childhood teachers in Guangzhou as the subjects, the data showed that the fear of missing out on work information of early childhood teachers in Guangzhou was at a moderate level. The teacher’s teaching grade had no significant impact on the early childhood teachers’ fear of missing out on work information, but teaching experience had a significant negative impact on the fear of missing out on work information.

Delphi-Based Expert Consensus Statements for the Management of Percutaneous Radiofrequency Neurotomy in the Treatment of Lumbar Facet Joint Syndrome.

A modified Delphi strategy was implemented for obtaining recommendations that could be useful in the management of percutaneous radiofrequency treatment of lumbar facet joint syndrome, as the literature on the argument was poor in quality. An Italian research team conducted a comprehensive literature search, defined the investigation topics (diagnosis, treatment, and outcome evaluation), and developed an explorative semi-structured questionnaire. They also selected the members of the panel. After an online meeting with the participants, the board developed a structured questionnaire of 15 closed statements (round 1). A five-point Likert scale was used and the cut-off for consensus was established at a minimum of 70% of the number of respondents (level of agreement ≥ 4, agree or strongly agree). The statements without consensus were rephrased (round 2). Forty-one clinicians were included in the panel and responded in both rounds. After the first round, consensus (≥ 70%) was obtained in 9 out of 15 statements. In the second round, only one out of six statements reached the threshold. The lack of consensus was observed for statements concerning the use of imaging for a diagnosis [54%, median 4, interquartile range (IQR) 3-5], number of diagnostic blocks (37%, median 4, IQR 2-4), bilateral denervation (59%, median 4, IQR 2-4), technique and number of lesions (66%, median 4, IQR 3-5), and strategy after denervation failure (68%, median 4, IQR 3-4). Results of the Delphi investigations suggest that there is a need to define standardized protocols to address this clinical problem. This step is essential for designing high-quality studies and filling current gaps in scientific evidence.

Integration of twin cities: A Delphi investigation of the urban areas on both sides of the Strait of Messina

ABSTRACT There are several cases of twin cities worldwide. In Europe, most of them came to attention after the fall of the Berlin Wall, when divided twin cities were still located on opposite sides of the Iron Curtain. Since then, many cases have been investigated, especially focusing on their functional and institutional integration, which turns out to be fundamental for their development. In this paper we deal with the case of Reggio Calabria and Messina, two large cities which face each other on the two banks of the Strait of Messina. Despite their proximity, they are poorly connected: socioeconomic interactions (e.g., commuting flows) are limited, and institutional coordination is lacking. However, they have a remarkable integrative potential, based on their complementary characteristics. By conducting a Delphi investigation, a technique which to date has never been used in this field, we analyze the potential, the scenarios, and the strategies to achieve the integration of these twin cities. Our findings show that integration may give back centrality to these two urban areas. This is a feasible scenario, which can be expected to materialize in a relatively short time even without full institutional coordination, focusing on transport services rather than on other infrastructural options (e.g., the Messina Bridge project).

Author Response to Shear et al.

We thank the colleagues who provided meaningful comments to our manuscript.1 A Delphi investigation aims to gather expert opinions, frame future studies, and guide clinical practice in research areas where there is sparse quality literature available.2 Because children can present with orthopedic/musculoskeletal and/or neurological impairments, physical therapists credentialed in those treatment skill sets would be most capable of identifying effective treatment techniques. Therefore, we recruited physical therapists who were board-certified clinical specialists in pediatric physical therapy, were certified in neuro-developmental treatment (C/NDT), or had manual therapy credentials (Fellow of the American Academy of Orthopaedic Manual Physical Therapists [FAAOMPT]) to participate in our Delphi study. Although these credentials are not specific to craniosacral therapy (CST) and visceral manipulation, the Round 1 respondents identified CST and visceral manipulation as manual techniques that could be utilized to treat children. Although we cannot ascertain that the respondents in Rounds 2 and 3 had advanced training (continuing education) in CST or visceral manipulation, no respondent indicated being certified in those specific techniques.

다문화사회 통합을 위한 여가스포츠 활동요인 순위결정

The purpose of this study is to determine and present the Priority Order of leisure sports activity factors for Multicultural Society Integration using Delphi. To achieve the purpose of this study, we will conduct a third Delphi questionnaire for 21 experts including experts of multicultural centers in the Metropolitan City · Province(4 place). And semi-structured open survey of the Delphi investigation was prepared through a pre-examination on the leisure sports policy professors(2) and in-depth interviews with multicultural centers policy expert(1), Metropolitan City · Province center executives(8), and Immigrant Womens(10). The data resulting from the investigation was revised, and opinions were collected using five-point (re-cut) scale. In conclusion, The results of the investigation recommend five policies and twenty pertinent specifics on priority order of leisure sports activity factors for Multicultural Society Integration as described below: First, the current Multicultural leisure sports activity factors is divided into five classes(poicy system, institution discontinuity, social culture, economic, leisure participation leaning), the first importance of the institution discontinuity factor has been recognized.<BR> Second, the first priority order of leisure sports active factor is incentive grant of Multicultural leisure partaker, and time deficit of leisure activity with a member of society is the lowest appeared.

Delphi Investigation of Administrative Security to Prevent Industrial Spy Crimes - Focusing on Small and Medium sized Enterprises -

Delphi Investigation of Administrative Security to Prevent Industrial Spy Crimes - Focusing on Small and Medium sized Enterprises -

Delphi Studies: The Value of Expert Opinion Bridging the Gap - Data to Knowledge

This paper reports an as yet unfinished Delphi investigation of information management futures. Too often the personal aspect of information provision is overlooked in the light of the dramatic development of technology. However, behind every technological advance there is a provider whose role it is to source, organise and disseminate the information gleaned via that technology. To investigate what is at heart a very subjective situation—an individual’s reaction to a changing work place—the Delphi approach seemed most appropriate. Designed to collect expert opinions as independent, considered views on a commonly debated topic, this method offered structure and validity without a framework too formal to allow for personal, subjective considerations. A Delphi approach provides a unique methodology for studying the trend of future developments. In this particular study it demonstrated a clear perception by senior members of the profession as to the future.

피지컬 컴퓨팅 게임 개발을 위한 환경적 요소에 관한 연구

본 연구는 가상세계에서 물리적 성질을 부여해 인터렉션하는 피지컬 컴퓨팅의 개념을 게임 개발에 적용함에 있어 중요한 환경적 요소에 관한 것이다. 이를 위해 피지컬 컴퓨팅 환경과 기존의 피지컬 컴퓨팅게임, 디지털 아트와 정보교육 분야의 연구 사례 분석을 통해 환경적 요소를 선별했다. 도출된 요소들은 델파이 조사방법으로 합의를 검증했다. 개발 환경 측면, 관련 사례 측면, 개발 서비스 측면으로 구분하여 27개의 요소를 선정했으며 피지컬 컴퓨팅의 환경 측면의 중요도가 가장 높게 나타났다. 세부 영역별로는 가상세계의 물리적 성질부여, 구현 기술의 적합성, 현실의 플레이이어와 가상의 플레이어와의 일치성 순으로 나타났다. In this study, we derive the important environmental elements for developing physical computing game. Environmental elements are selected based on the analysis of the physical computing environment in the area including physical computing itself, existing physical computing games, digital art, and information education. The derived elements are verified by Delphi's investigation methodology. The 27 factors are chosen in terms of development environment, development case, and development service. Among them the environmental aspects of physical computing are ranked as the highest importance.

Manual Therapy in Preadolescent Children: A Delphi Investigation of Physical Therapists in the United States.

Limited research has investigated the use of manual therapy to treat the preadolescent (0-12years of age) population with musculoskeletal and neurological impairments. The purpose of this study was to identify the following among physical therapists holding advanced credentials in pediatrics, neurodevelopmental treatment, or manual therapy: (1) consensus regarding effective techniques in the preadolescent population, (2) differences in opinion, and (3) perceived decision-making barriers and factors regarding use of manual therapy techniques. Credentialed physical therapists in the United States were recruited for a 3-round Delphi investigation. An electronic survey in Round 1 identified musculoskeletal and neurological impairments and the manual techniques considered effective to treat such conditions, in addition to factors and barriers. Responses were used to create the second round, during which a 4-point Likert scale was used to score each survey item. A third round of scoring established consensus. Descriptive statistics and composite scores were calculated for each manual technique by impairment. Between-group differences were calculated using the Mann-Whitney U test with Bonferroni correction. Consensus was determined for several concepts. First, neuromuscular techniques were considered effective across all impairments, and joint mobilizations (grades I-IV) were believed to be effective to treat joint and muscle and myofascial impairments. Second, visceral manipulation and craniosacral therapy were considered ineffective in treating most impairments. There was lack of consensus and clear differences of opinion regarding the use of grade V mobilizations and dry needling. Significant barriers to use of manual therapy were: lack of knowledge, lack of evidence, and fear of litigation and harming patients. This study is an initial step for developing manual therapy guidelines, research, and educational opportunities regarding manual therapy in pediatric physical therapy.

Moxibustion therapy on myofascial pain syndrome: An evidence-based clinical practice guideline.

Background:Myofascial pain syndrome (MPS) is a chronic systemic pain disorder. Among the common treatments, moxibustion has an irreplaceable therapeutic effect and is an effective Traditional Chinese Medicine therapy for MPS. However, the lack of clinical practice guidelines (CPGs) has prompted the publication of guidelines on the use of moxibustion in the treatment of MPS.Methods:The clinical practice guideline will base on the Institute of Medicine, the World Health Organization guideline handbook, the Grade of Recommendations Assessment, Development, and Evaluation the Appraisal of Guidelines for Research & Evaluation II, Reporting Items for practice, Guideline in Healthcare and recommendations thereof will be made on the basis of systematic reviews. We will establish a guidelines development team that will draft clinical questions in the form of population, intervention, comparison, results and conduct a literature search and quality of evidence assessment. The experts will make recommendations after 2 or 3 rounds of Delphi investigations. We will carefully consider the patient's values and preferences and conduct a peer review.Ethics and dissemination:The guidelines will not contain any personal data and will not prejudice individual rights, so no ethical approval will be required. The guidelines will be subject to rigorous peer review and may be published in a journal or circulated at relevant conferences.Results:The guidelines will be published in relevant peer-reviewed journals.Conclusion:This guideline will make it easier for clinicians to treat MPs in the clinical setting and improve the effectiveness of treatment for MPS.Study registration:The study is registered with the International Practice Guideline Registry Platform (IPGRP): IPGRP-2020CN030

First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation

ABSTRACT Background First rib dysfunction is a possible cause of symptoms in patients with neck and/or shoulder pain. Objectives To explore therapists’ perceptions of useful diagnostic criteria to identify first rib dysfunction. Methods A Delphi survey over four rounds involving international manual therapy experts who were asked to agree on which items were most useful in identifying first rib dysfunction. Results Consensus (>70% agreement) was reached on key aspects of first rib dysfunction being first rib mobility restriction, upper limb symptom distribution, and a subclassification into two subgroups was suggested. The main clinical findings suggested were: painful and restricted neck movements and shoulder girdle loading activities; positive Upper Limb Neural Test 1; direct palpation of first rib, neural structures, and scalene muscles; pain and hypomobility of first rib accessory movements with improvement after mobilization. The cervical rotation lateral-flexion test was considered a useful, although not widely used test among the experts. Its diagnostic accuracy and interpretation in isolation was questioned. Conclusions This Delphi study produced a cluster of clinical tests aimed to identify first rib dysfunction in patients with neck and/or shoulder conditions. However, these need to be tested out in further research to establish reliability and validity.

In-depth Approach to Korean Medical Institutions’ Overseas Expansion: Focusing on the Current Status of Medical Institutions’ Overseas Expansion and Expert Delphi Analysis

Purpose The purpose of this study is to find out which factors are necessary that Korean medical institutions find a larger market abroad. Design/Methodology/Approach This study conducted a Delphi survey with 15 experts including 11 hospital directors and related institution experts, who promoted overseas advancement of medical institutions. Also, this research confirmed the content validity ratio (CVR), convergence, and stability of variables, which were selected through previous related studies. Then, Delphi investigation was conducted. Findings Excluding 4 of the 29 variables selected through previous studies, the panel of experts agreed on 25 variables as a factor, which is necessary that Korean medical institutions find a larger market abroad. Research Implications There is insufficient research on Korea’s medical institution overseas expansion. With regarding the situation, this study presented current status data related to overseas entry into Korean medical institutions, and conducted research using Delphi method for experts.

의료관광 활성화 요인 도출을 위한 전문가 대상 델파이 분석

Purpose - Medical tourism refers to an industry in which medical services and tourism services are converged, and medical tourists visiting other countries to receive high-quality medical services are continuously increasing. Therefore, this study aims to derive medical tourism activities through Delphi techniques in terms of selection factors and customer satisfaction. Design, Data, and Methodology - For the Delphi survey, a panel of 15 experts, including the head of a medical institution (11 people) and a researcher from an institution in charge of medical tourism (4 people), were selected. First, six variables were selected through prior research, and four variables were additionally selected by collecting opinions from expert panelists. However, the study was conducted with a total of 9 variables, excluding one variable that experts determined was not suitable. Results - As a result of the Delphi survey, a total of 9 variables were used in this study, and content validity for the 1st and 2nd Delphi investigations was found to be no problem. Also, it was confirmed that there was no problem in the convergence and stability of expert opinion on variables. This means that the opinions of experts agree on the factors that promote medical tourism. Conclusions - The panel of 15 experts on the 9 variables suggested for facilitating medical tourism was generally agreed. Therefore, it is judged that these variables can be used as an important factor in promoting various projects for actual medical tourism.

A Data Management Model for Proactive Risk Management in Healthcare

The Delphi investigation made possible to create and present a model of data flows and expertise for decision - making in healthcare. The model structures and visualizes data flows including population health risks assessment and healthcare interventions value. Most elements of this model are used in practice and are regulated by international or local documents. The investigation also indicates the need for the creation and utilization of additional level of expertise including integrated analysis and modeling of the results of management decisions. Structuring of data management in accordance with this model provides an opportunity to implement proactive risk management in healthcare there to increase healthcare effectiveness significantly.

Delphi investigation of strategies to develop cultural competence in physical education teacher education

ABSTRACT Background: The shifting demographics of the United States population remains a central challenge for the education sector. A pressing concern rests with the continued cultural gap that exists between a largely homogenous teacher labor force and an increasingly heterogeneous student population. Provided the longstanding existence of a cultural gap, there have been calls for scholars to identify strategies that could help current and future teachers bridge this gap in their classrooms. Purpose: The purpose of this study was to generate consensus regarding the strategies physical education teacher education (PETE) programs can adopt to develop cultural competence among physical education teacher candidates. Method: The study employed a three-round Delphi process involving the repeated circulation of a survey to panel members (N = 12) with a record of pedagogic and/or scholarly engagement with cultural competence. In Round-I, participants were provided an open-ended question that prompted them to list up to ten strategies a PETE program could use to promote cultural competence in teacher candidates. During Round-II, participants were then asked to rate the list of strategies regarding the impact and contextual feasibility within a PETE program. In Round-III, participants again rated the same list of strategies with the considerations of other panelists’ ratings. Results: The Delphi panel created an initial list of 37 strategies that could be used to develop cultural competence in teacher candidates. Round-II and Round-III data were analyzed using descriptive statistics to calculate group means. Expert consensus determined eight cultural competence strategies as the most impactful and feasible for PETE programs. The eight strategies illustrated how cultural knowledge, critical awareness, skill development, and environmental supports all need to be addressed. Faculty buy-in and departmental leadership were also identified as critical to executing those strategies. Discussion/Conclusion: The list of strategies is not intended to be exhaustive; however, it does provide a guide for PETE faculty to start the process of promoting cultural competence. In light of the growing societal emphasis on issues pertinent to the cultural gap in teaching, the authors encourage further investigation of the actual impact and feasibility of these strategies.

Developing sustainable national infrastructure supporting high-impact research to improve the care of older adults with cancer: A Delphi investigation of geriatric oncology experts

Developing sustainable national infrastructure supporting high-impact research to improve the care of older adults with cancer: A Delphi investigation of geriatric oncology experts

Logic Model Development of Vocational Training Teacher Certification Course

이 연구에서는 직업능력개발훈련교사 신규 양성과정인 교직훈련과정을 대상으로, 훈련과정에 내재되어 있는 구성 요소를 찾아내고 그 요소들 간의 관계를 규명하여 도식화함으로써, 정부 등 이해당사자들의 기대를 효과적으로 달성 할 수 있는 운영 매뉴얼 및 평가도구 개발을 위한 기본 모형을 제시하고자 하였다. 이러한 목적을 달성하기 위하여 선행연구 및 정책자료 등의 조사를 통하여 직업훈련 정책 및 직업훈련교사 현황을 분석하고, FGI를 통한 요구조사를 실시하여 교직훈련과정의 ‘상황-투입-활동-산출-단기성과-중장기성과-성과영향요인’의 7개 구성요소별 44개 하위요소를 발굴하였다. 발굴된 하위요소를 기반으로 2차례의 델파이조사를 진행하였으며, 1차 델파이조사에서는 하위요소에 대한 타당성 검증과 의견수렴을 통한 수정·보완을 실시하여 7개 구성요소 39개 하위요소로 수정·보완하였다. 개발된 하위요소를 기반으로 하위요소의 내용을 정립하고자, 하위요소의 개념 및 인과관계를 발굴하고 논리모형도를 도출하였다. 그리고 2차 델파이조사를 통하여 도출된 하위요소의 개념 및 인과관계와 논리모형도를 검증하고 수정·보완하여, 7개 구성요소에 40개 하위요소로 수정·보완하여 논리모형도를 구성하고 영향관계를 표시하여 도식화하였다. 이 연구에서 제안된 교직훈련과정의 논리모형도는 예산·인력·시설장비·정보시스템 등 인적·물적 자원을 투입하여 훈련프로그램 개발, 훈련과정 운영·평가 등의 활동을 통하여 교육훈련생의 역량강화 및 직업능력개발훈련교사 자격 취득의 성과를 기하며, 직업능력개발훈련교사 자격을 취득한 자에 대한 사후관리 활동을 통하여 훈련교사를 직업훈련현장에 배치하고, 배치된 훈련교사의 전문화 지원을 통하여 소속 직업훈련기관의 성과창출 및 훈련교사의 처우개선, 경력만족의 성과를 기하여 결국에는 직업훈련 품질 개선의 효과를 기대한다는 것이다.This study aims to present a basic model for the development of operational manuals and evaluation tools that can effectively reflect the expectations of the government and other stakeholder by identifying components inherent in the training courses for the vocational training teacher certification. It has developed the 44 sub-elements, the “Circumstances - Input - Operation - Output - Performance(short term, mid and long term)” respectively under the 7 stages in the vocational training teacher certification course by conducting the current trend analysis of TVET policies and vocational training teacher and FGI surveys based on the study of preceding research and policy materials. With the developed sub-elements, 2 different Delphi investigations have been made. The first Delphi investigation has been focused on the supplementation and revision by the verification of sub-elements and opinion investigation, which led to the decreased number of 39 sub-elements under 7 stages. The definition and correlation along with the diagram of logically systematic model has been designed in the developed sub-elements. In the following second Delphi investigation, the definition, corelation and the diagram have been re-verified and supplemented, which led to the decreased number of 40 sub-elements under 7 stages with the systematization of logical diagram and correlation. The logic model of vocational training teacher course presented at this study is expected to improve the quality of TVET, including with the mid and long term task of the specialization of vocational training teachers. To achieve the desired result of this study, it’s important for us to invest a lot of resources and carry out the related effective follow-up programs.

A new understanding of health related empowerment in the context of an active and healthy ageing

BackgroundRecently, several initiatives have focused on how to create true person-centred health services. This calls for a new understanding of health-related empowerment in relation to people living with one or more chronic conditions.We report on a Delphi investigation among participants in the European Innovation Partnership on Active and Healthy Ageing that has led to a new understanding of health-related empowerment.MethodsThe Delphi process was conducted in three sequential rounds. In the first round, we presented a suggested first version for a definition of “health-related empowerment” divided into nine statements. One hundred and twenty-two experts were then asked if they agreed or not with each individual statement, and in the case they disagreed, to state the reasons for their disagreement.After revisions, the experts who had replied to the first version were asked again, if they agreed or not with each individual statement of the second version and to elaborate on disagreements.Finally, in the third round the experts were asked to provide comments to the final proposed definition in general and not by each statement.ResultsA total of 33 experts responded to the first version. The following revision included a merging of two statements, and the addition of health literacy as part of the understanding. The second version was sent out to the 33 experts and a total of 19 experts commented with moderate consensus. Changes included removal of “self-esteem” and change of “self-confidence” to confidence.Third version was sent out to all 122 experts with 16 respondents. Strong consensus was obtained for this third version, and is with one minor change presented as the final version.ConclusionWe propose a new understanding of the concept health-related empowerment, by focusing on the individual as a co-manager with freedom to choose and focus on their own well-being.