Adverse Childhood Experience, Parental Bonding, and Fatherhood as Parenting Vulnerabilities to Social Anxiety Severity.

Background: The present study aims to elucidate the association between adverse childhood experiences, parental bonding, fatherhood, and social anxiety symptoms among emerging adults within an Iranian context. Methods: This prospective cross-sectional study utilized self-reported assessments to evaluate fatherhood, parental bonding, anxious thoughts, and childhood trauma. The study was administered to 242 university students exhibiting social anxiety symptoms. Among the participants, 181 (74.8%) were boys and 61 (25.2%) were girls between the ages of 18 and 29. In terms of educational background, 64.9% of them held a bachelor's degree, and 35.1% held a master's degree. A majority of them (84.3%) were of middle-class socio-economic status, 6.6% were of low income, and 9.1% were of high income. Results: Analysis via multiple linear regression revealed that individuals with adverse childhood experiences exhibited heightened levels of social anxiety symptoms (R2 = 0.32) compared to their counterparts without such experiences. Furthermore, fatherhood (R2 = 0.28), paternal bonding (R2 = 0.26), and maternal bonding (R2 = 0.26) were all significantly and equally associated with variance in social anxiety symptoms. The findings underscored the substantial correlation between ACEs, fatherhood, and both maternal and paternal bonding with social anxiety symptoms in adulthood. Conclusions: Accordingly, the study emphasizes the importance of thoroughly assessing the multifaceted contributors to social anxiety. Such insights are pivotal for the design and implementation of community-based preventive interventions aimed at reducing the societal burden of social anxiety disorders.

Pathways Linking Parental Care and Control to Loneliness in Breast Cancer Patients with A History of Childhood Maltreatment: Exploring the Mediating Roles of Ambivalence Over Emotional Expression and Self-Discrepancy.

Childhood maltreatment is a risk factor for loneliness and is linked to breast cancer. Parental bonding experienced during one's childhood also plays a significant role in increasing or decreasing the risk of loneliness later in life. Previous research has highlighted the significance of ambivalence over emotional expression (AEE) and self-discrepancy in the psychological adaptation of breast cancer patients, particularly concerning the impact of parental care and control experienced by patients in their relationship with their parents during childhood. Nevertheless, previous studies have not examined the mediating effects of AEE and self-discrepancy on parental care and control, as well as loneliness, in breast cancer patients. This study aimed to investigate whether AEE and self-discrepancy mediate the association of childhood parental care and control with loneliness in breast cancer patients with a history of childhood maltreatment. One hundred and thirty-three breast cancer patients who were receiving chemotherapy within the first 3 months post-diagnosis were recruited from one private and three public hospitals in Tabriz, Iran, to complete questionnaires. Parental bonding, loneliness, AEE, and self-discrepancy were assessed using the Parental Bonding Instrument (PBI), University of California Los Angeles (UCLA) Loneliness Scale, Ambivalence over the Expression of Emotion Questionnaire (AEQ), and Self-Discrepancies Scale (S-DS). Mediation models were tested using structural equation modeling. Effects of parental care (ß = -.17, p < .05) and control (ß = .21, p < .001) on loneliness were significant. Furthermore, both AEE (ß = .19, p < .05) and self-discrepancy (ß = .23, p < .01) significantly predicted loneliness. The pathway between parental care and AEE was significant (ß = -.21, p < .001), as was the direct effect of parental control on self-discrepancy (ß = .19, p < .05). Bootstrapping results showed that AEE significantly mediated the relationship between parental care and loneliness (95% confidence interval [CI] [-0.09, -0.01]). In addition, there was a significant indirect effect from parental control to loneliness via self-discrepancy (95% CI [0.11, 0.01]). These findings suggest that AEE and self-discrepancy could potentially be utilized in preventing or addressing loneliness in breast cancer patients who have a history of childhood maltreatment. Future research could, for example, assess whether integrating psychosocial interventions focusing on these variables as part of medical care can improve the mental health status of this subgroup of breast cancer patients who have experienced childhood maltreatment.

The effects of intensive short-term dynamic psychotherapy on depressive symptoms, negative affect, and emotional repression in single treatment-resistant depression: A randomized controlled trial.

Intensive short-term dynamic psychotherapy (ISTDP) is theorized to reduce negative affect by challenging patients' defense mechanisms so that they can experience and work through attachment-trauma-related emotions. While ISTDP has been shown to decrease depressive symptoms in single treatment-resistant depression (TRD), it has not been established whether negative affect and emotional repression are reduced, as theorized. Next to depressive symptoms, this retrospectively registered (https://osf.io/v46gy) randomized controlled trial, therefore, examined the effects of ISTDP on emotional repression and negative affect in adults with TRD. Eighty-six adults with major depressive disorder, who had not responded to at least one trial of antidepressants were randomized to 20 sessions of ISTDP (N = 43) or a waitlist control condition (N = 43). Mixed-effect models on the intention-to-treat sample showed that compared to the control condition, ISTDP resulted in significantly lower posttreatment levels of depressive symptoms (d = -1.73), emotional repression (d = -1.91), and negative affect (d = -1.45). Similarly, ISTDP resulted in significantly lower levels of depressive symptoms (d = -2.67), emotional repression (d = -2.69), and negative affect (d = -1.85) at the 3-month follow-up. These results support the evidence base of ISTDP by showing that it can decrease depressive symptoms, emotional repression, and negative affect in TRD. Future studies should assess whether these effects are specific to ISTDP. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prioritizing the Psychosocial Support Needs of Mothers with Gestational Diabetes: A Delphi Study.

Background: Gestational diabetes is the most common medical complication in pregnancy, and the psychosocial health of women suffering from this condition affects their adherence to treatment and self-efficacy. However, since it is not possible to design interventions dealing with all of these needs, the aim of this study was to prioritize the psychosocial supportive needs of women with gestational diabetes. Materials and Methods: This was a modified Delphi design study involving 22 experts who were selected using purposive and snowball sampling methods. The study was conducted between April 2021 and June 2021. First, the psychosocial needs of diabetic pregnant women were extracted through a qualitative study involving interviews with multidisciplinary specialists and diabetic pregnant mothers (22 participants) and a systematic review of reputable scientific databases. Throughout the two Delphi stages, the questionnaire was classified, quantified, and analyzed. Results: Based on the results of this study, the following are the top priorities when addressing the psychosocial needs of mothers with gestational diabetes: paying attention to and identifying the mother's worries and anxiety, husband and family support for diabetic pregnant women, the inclusion of specialized nutrition counseling services in mothers' treatment plan, timely education of mothers about diabetes and its complications, and proper nutrition for diabetic mothers. Conclusions: The priorities of the supportive needs obtained in this study can be used to design interventions aimed at promoting psychosocial health, reducing stress and anxiety, and improving medication adherence in women with gestational diabetes.

Loneliness in Breast Cancer Patients with Early Life Adversity: An Investigation of the Effects of Childhood Trauma and Self-Regulation.

Childhood trauma may be prevalent in the general population, and the psychosocial treatment of patients with cancer may require consideration of the effects of such early adversity on the healing and recovery process. In this study, we investigated the long-term effects of childhood trauma in 133 women diagnosed with breast cancer (mean age 51, SD = 9) who had experienced physical, sexual, or emotional abuse or neglect. We examined their experience of loneliness and its associations with the severity of childhood trauma, ambivalence about emotional expression, and changes in self-concept during the cancer experience. In total, 29% reported experiencing physical or sexual abuse, and 86% reported neglect or emotional abuse. In addition, 35% of the sample reported loneliness of moderately high severity. Loneliness was directly influenced by the severity of childhood trauma and was directly and indirectly influenced by discrepancies in self-concept and emotional ambivalence. In conclusion, we found that childhood trauma was common in breast cancer patients, with 42% of female patients reporting childhood trauma, and that these early experiences continued to exert negative effects on social connection during the illness trajectory. Assessment of childhood adversity may be recommended as part of routine oncology care, and trauma-informed treatment approaches may improve the healing process in patients with breast cancer and a history of childhood maltreatment.

Interpersonal Attachment Styles and Body Dysmorphic Symptoms in Adolescent Girls: The Mediating Role of Body Image.

Objective: Body dysmorphic symptoms are one of the most common problems in adolescent girls. The experience of security or insecurity in childhood attachment can be one of the most important fundamental factors affecting the body image and, consequently, body dysmorphic symptoms. However, the mediator role of the body image in the relationship between body dysmorphic and interpersonal attachment styles has not been studied in previous researches. Therefore, the purpose of this study was to investigate the mediating role of body image in the relationship between interpersonal attachment styles and body dysmorphic symptoms. Method: In a cross-sectional research, 250 adolescent girls from Baqer al-Uloom School in Tabriz, were selected by convenient sampling method. Then, The Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), Body Dysmorphic Metacognitive Questionnaire (BDMCQ) and Collins and Reid's Attachment Styles Scale (RAAS) were used to data collection. Results: The findings showed ambivalent attachment style was positively related to body image (ß=-0.91, p<0.01) The direct effect of ambivalent attachment style on body dysmorphic symptom is significant (ß=0.76, p<0.01). The pathway between body image and body dysmorphic symptom is negatively significant (ß= -0.75, p<0.01). Also, the hypothesized model has an acceptable goodness-of-fit. Conclusions: Based on the results, it can be said that in interventions, it is necessary to pay attention to the important role of interpersonal attachment styles and body image in body dysmorphic symptoms.

The Effect of Mindfulness-Based Stress Reduction (MBSR) on Emotional Flexibility and Ambivalence Over Emotional Expression in Divorced Women: A Pilot Randomized Controlled Trial.

ABSTRACT: The present study was developed to evaluate the effects of mindfulness-based stress reduction (MBSR) on the level of emotional flexibility and ambivalence related to emotional expression of divorced women. A general community sample of 30 divorced women was recruited and randomly assigned to experimental and control groups. The experimental group received MBSR for 8 weeks, and the control group was placed on a waiting list. The Emotional Flexibility Questionnaire (EFQ) and the Ambivalence Over the Expression of Emotion Questionnaire (AEQ) were administered to both groups before (pre) and after (post) the treatment. Data were analyzed using two-way mixed repeated-measures analyses of variance. The results showed that women in the treatment group had a significant increase in the total score of the EFQ and its components. In addition, the MBSR group had a significant decrease in the total score of the AEQ and its components. MBSR intervention shows potential for use with divorced women to help with emotion regulation and subsequent better adjustment to separation.

Effect of Group Logotherapy on Anxiety About Death and Existential Loneliness in Patients With Advanced Cancer: A Randomized Controlled Trial.

BACKGROUND: Although logotherapy has been shown to relieve other psychological symptoms of patients with cancer, no studies have specifically investigated the effect of logotherapy on anxiety about death and existential loneliness in these patients. OBJECTIVE: The aim of this study was to determine the effect of group logotherapy on anxiety about death and existential loneliness in patients with advanced cancer. METHODS: Sixty-three patients who were in the advanced stage of cancer were recruited from 2 hospital oncology services and were randomly assigned to either experimental (n = 31) or control group (n = 32). The intervention group received 10 weekly 2-hour group logotherapy. Templer's Death Anxiety Scale and ELQ were completed pre- and posttreatment. RESULTS: A 2 × 2 mixed analysis of variance was used to determine the effect of the treatment on each of the dependent variables. The analyses revealed that patients in the logotherapy group reported a significant decrease in anxiety about death and existential loneliness after (vs before) the treatment. No significant decreases were observed in the waitlist control group. CONCLUSIONS: These results have implications for treating death anxiety and feelings of existential loneliness among patients with advanced cancer. They suggest that group logotherapy is highly effective in reducing these existential concerns. Limitations and avenues for future research are discussed. IMPLICATIONS FOR PRACTICE: The study emphasizes that group logotherapy can be considered in oncology care programs by healthcare professionals and in educational curriculums and is suggested for use among caregivers and patients with advanced cancer.

Pathway linking Emotional Suppression to Depression and Anxiety in Cancer Patients undergoing Chemotherapy: The Mediating Role of Ego-strength.

BACKGROUND: Ego-strength refers to the individual's psychosocial capacity to self-regulate their emotions in the face of stress, developed over the course of the lifespan. Ego-strength may have an important role in understanding psychological adaptation to cancer, especially when considering the effects of emotional suppression in cancer populations. In the present study, we examined the effects of ego-strength and emotional suppression on depression and anxiety in patients coping with cancer. We also tested whether ego-strength may mediate the relationship between emotional suppression and psychological distress in cancer. METHODS: 120 cancer patients were recruited from a private hospital in Tabriz to complete baseline questionnaires. Depression, anxiety, ego-strength and emotional suppression were assessed by BDI-II, BAI, PIES and WAI respectively. Mediation models were tested using structural equation modeling, controlling for age and gender. RESULTS: Emotional suppression was positively associated with depression and anxiety, and negatively associated with ego-strength. Ego-strength was negatively associated with depression and anxiety. Ego-strength partially mediated the relationship between emotional suppression and depression, and fully mediated the relationship between emotional suppression and anxiety. CONCLUSION: Ego-strength may help prevent the onset or unfavorable course of depression and anxiety in cancer patients.

Psychosocial needs of inpatient women with gestational diabetes mellitus: a qualitative study.

BACKGROUND: Gestational diabetes mellitus (GDM) is one of the most common medical complications associated with pregnancy. Its treatment requires multidisciplinary cooperation, and identifying the psychosocial needs of patients is important in the management of their condition. OBJECTIVE: This study investigates the psychosocial needs of inpatient mothers with GDM from the joint perspectives of future mothers and healthcare providers. METHODS: This qualitative study used a content analysis approach. Semi-structured individual interviews focusing on the psychosocial needs of women with GDM were conducted with twelve women suffering from GDM and eight medical staff. Sampling continued until data saturation. RESULTS: According to the findings of this study, the psychosocial needs of these mothers were classified into the following categories: Support for worries related to the consequences of the disease, Interpersonal support, Infrastructural support, educational support. CONCLUSION: The psychosocial needs of inpatient mothers with GDM were identified in this study. Attention to these needs can help enhance the mother's satisfaction and treatment adherence, and reduce worries and anxiety during hospitalisation. ABBREVIATIONS: GDM: Gestational Diabetes Mellitus; hPGH: human placental growth hormone; COREQ: Consolidated criteria for reporting qualitative research; WHO: World Health Organization; HCP: healthcare provider.

Associations of Childhood Maltreatment and Attachment Styles with Romantic Breakup Grief Severity: The Role of Emotional Suppression.

Childhood maltreatment (CM) and insecure attachment styles may partly explain grief severity following romantic breakup. Empirical studies examining the factors that could possibly explain this association, however, remain sparse. The present study tested whether the relations among CM, attachment styles, and romantic breakup grief severity could be explained by emotional suppression in Iranian college students. In a cross-sectional study, 239 Iranian college students (ages 18-45; M = 24.11, SD = 15.29; 50.6% women) with a recent romantic breakup experience were recruited from University of Tabriz. Participants completed a diagnostic interview and self-report battery, including the Persian version of the Child Abuse Self-Reported Scale, Revised Adult Attachment Scale, Romantic Breakup Grief Inventory, and Weinberger Adjustment Inventory. Structural equation modeling was used to empirically explore the relations among variables. Results indicated that those who reported higher levels of CM also reported higher levels of romantic breakup grief. Attachment closeness showed a significant negative and direct effect on romantic breakup grief severity. However, attachment anxiety was positively associated with greater levels of romantic breakup grief. Bootstrapping results showed that CM might affect romantic breakup grief severity via emotional suppression. Furthermore, attachment closeness and attachment anxiety exerted indirect effects on romantic breakup grief severity through emotional suppression. Clinical and empirical implications are discussed.

The psychosocial challenges associated with gestational diabetes mellitus: A systematic review of qualitative studies.

BACKGROUND: Gestational diabetes is a disease with complex management that requires multidisciplinary collaboration. To achieve treatment goals, in addition to using medications and paying attention to exercise and diet, it is also important to take into account the mental health and psychosocial aspects of diabetes management. This study aimed to highlight these challenges associated with gestational diabetes. METHOD: This qualitative systematic review involved a search of the following databases: CINAHL, EMBASE, MEDLINE, and PsycINFO. Title, abstract, and full-text screening was done using Covidence software, and quality assessment of the included papers was conducted using the Critical Appraisal Skills Programme Checklist. Enhancing transparency in reporting the synthesis of the qualitative research statement (ENTREQ) was used in the design of this paper. Data synthesis was done using meta-aggregation method. RESULTS: Out of the 2440 articles searched, 24 were qualitatively analyzed. The CASP score of the included papers was optimal. The 514 findings extracted from the 24 studies were aggregated into five broad conceptual categories: psychological challenges, socio-cultural challenges, information-communication challenges, challenges associated with a lifestyle change, and challenges related to health care. CONCLUSION: Recognizing the psychosocial challenges associated with gestational diabetes and developing support packages tailored to psychosocial needs can help improve the management of these patients.

Associations of Spiritual Well-Being and Hope with Health Anxiety Severity in Patients with Advanced Coronary Artery Disease.

Background and Objectives: Health anxiety is one of the most common problems in patients with coronary artery disease. The present study tested whether health anxiety severity could be predicted by spiritual well-being and hope in patients with advanced coronary artery disease. Materials and Methods: In a cross-sectional study, 100 patients with advanced coronary artery disease were recruited from hospitals and healthcare centers in Iran. Patients completed self-report scales, including the Spiritual Well-Being Scale, Adult Hope Scale, and Short Health Anxiety Inventory. Hierarchical multiple regression analyses were used to empirically explore the relations among variables. Results: Results indicated that patients who reported higher levels of hope (ß = 0.42, p < 0.01) and spiritual well-being (ß = 0.20, p < 0.05) reported lower levels of health anxiety. Agency (ß = 0.58, p < 0.01) scores were a significant negative predictor of health anxiety severity. Additionally, religious spirituality scores (ß = 0.28, p < 0.01) were shown to significantly negatively predict health anxiety level. However, the pathways components of hope and existential spirituality were not significant predictors. Conclusion: The findings of the present study indicate that spiritual well-being and hope could be important factors in determining health anxiety for adults with coronary artery disease, and their role is worthy of further exploration to help improve health anxiety for patients with coronary artery disease.

Pathway Linking Different Types of Childhood Trauma to Somatic Symptoms in a Subclinical Sample of Female College Students: The Mediating Role of Experiential Avoidance.

ABSTRACT: Research has shown that women are more prone to childhood trauma and this state is associated with somatic symptoms. Also, people who have been exposed to traumatic experiences use experiential avoidance to reduce negative emotions. However, the mediating role of experiential avoidance in the relationship between childhood trauma and somatic symptoms is not clear, so, the present study investigated whether the relationships among different types of childhood trauma and somatic symptoms could be explained by experiential avoidance in female college students. In a cross-sectional study, 251 Iranian female college students with somatic symptoms were recruited from the University of Tabriz. Participants completed self-report scales, including the Persian version of Child Abuse Self-Reported Scale, Acceptance and Action Questionnaire-II (AAQ-II), and the Patient-health questionnaire (PHQ-15). A path analysis was used to empirically explore the relationships. Structural equation modeling analyses confirmed a partial mediation model. Study participants who had a higher level of emotional trauma reported higher levels of somatic symptoms. Emotional and neglect trauma showed significant positive relations with experiential avoidance. Bootstrapping results showed that experiential avoidance partially mediated the relationship between emotional trauma and somatic symptoms. Moreover, the association between neglect and somatic symptoms was fully mediated by experiential avoidance. These findings suggest that experiential avoidance might be one mechanism explaining how adverse emotional and neglect experiences influence somatic symptoms. Interventions addressing experiential avoidance through methods such as emotion-focused therapy and mindfulness are discussed as potential future directions for treating somatic symptoms in females who experienced emotional and neglect trauma.

Pathway linking dispositional mindfulness to fatigue in oncology female nurses: Exploring the mediating role of emotional suppression.

PURPOSE: Fatigue is a physical and emotional state associated with certain aspects of nursing practice. The current study aimed to investigate the indirect effect of dispositional mindfulness on fatigue via emotional suppression in oncology female nurses. METHODS: In a cross-sectional study, 137 female oncology nurses were recruited from several hospitals to complete baseline questionnaires. Emotional suppression, dispositional mindfulness and fatigue were assessed with the Weinberger Adjustment Inventory (WAI), Five Facet Mindfulness Questionnaire (FFMQ) and the Multidimensional Fatigue Inventory (MFI) respectively. A Mediation model was tested using structural equation modelling. FINDINGS: Dispositional mindfulness was negatively associated with emotional suppression (ß = -0.69, p = 0.000). In addition, emotional suppression was positively associated with fatigue (ß = 0.32, p = 0.014). The mediation path was significant with emotional suppression fully mediating the relationship between dispositional mindfulness and fatigue (b = -0.20 [CI: -0.01, -0.25]. DISCUSSION: These results support the proposed model, and the assumption that emotional suppression may help facilitate the onset of fatigue or maintain it in female oncology nurses. The findings have implications for the use of brief mindfulness interventions aimed at the effective regulation of emotion in oncology nurses to aid in well-being and optimal nursing practice.

The Big Five Personality Traits and Dispositional Mindfulness as Predictors of Alexithymia in College Students.

OBJECTIVE: The aim of this research was to measure the relationship between the Big Five personality traits, dispositional mindfulness and alexithymia, and to investigate personality traits and dispositional mindfulness as predictors of alexithymia in a group of college students. METHOD: In the present study, 150 college students at Tabriz University, aged between 18 and 26, were selected by convenient sampling method. NEO - Five Factor Inventory (NEO - FFI), Toronto Alexithymia Scale (TAS - 20), and Freiburg Mindfulness Inventory (FMI-SF) were used for data collection. RESULTS: The results showed that alexithymia was positively associated with neuroticism, and negatively associated with conscientiousness and openness to experiences. Neuroticism is the strongest predictor of alexithymia. After controlling for the effects of baseline characteristics and the Big Five personality traits, mindfulness did not remain a significant predictor of alexithymia. CONCLUSIONS: These results suggest that neuroticism, openness to experiences and conscientiousness have an essential role in alexithymia.

Effectiveness of Transactional Analysis Group Therapy on Addiction Intensity of Woman Patients Treated with Methadone.

BACKGROUND: Addiction brings about severe and profound physical, psychological and social damages such as divorce, crime, and unemployment. The present study was to investigate the effectiveness of transactional analysis (TA) therapy on addiction intensity of woman patients treated with methadone. METHODS: The research design was quasi-experimental with a pretest-posttest and a control group. The statistical population consisted of all the addicted women who referred to any drug rehabilitation center of Tehran, Iran, in 2016. They were selected using available sampling. Forty addicted patients were placed randomly in both the experimental and control groups. Addiction severity index (ASI) and demographic questionnaires were used. Group therapy using TA approach was executed on the experimental group for 10 sessions, each session for 2 hours (one session per week). FINDINGS: The results of covariance analysis after controlling pretest showed that the difference between test and control group was significant for three subscales of psychological, drug abuse and alcohol consumption status (P < 0.001). The difference between test and control groups was significant considering the seven-variable centroid (P < 0.001). The difference in dimensions of addiction intensity between the two groups was significant (P < 0.001). Also, analysis of the variables separately showed significant differences in psychiatric condition, drug and alcohol use dimensions (P < 0.001). CONCLUSION: Based on these findings, it seems that group therapy using TA approach is effective in reducing addiction intensity of woman patients treated with methadone. Therefore, it can be concluded that TA group interventions account for 76% of the changes in psychological status, 43% of the changes in drug abuse status, and 49% of the changes in alcohol consumption status in woman patients under methadone treatment.

Functional status, anxiety, cardiac self-efficacy, and health beliefs of patients with coronary heart disease.

BACKGROUND: Beliefs and emotions could effect on functional status, quality of life, and mortality amongst patients who are suffering coronary heart disease (CHD). Current study examined the role of anxiety: trait/ state, self-efficacy, health beliefs, and functional status among patient with history of CHD. METHOD: In this correlational study, 105 hospitalized and outpatients patients suffering CHD in Tehran Heart Center Hospital participated by using convenience sampling method in 2012. Cardiac self-efficacy, Seattle Angina, and research-designed health beliefs questionnaires were used to gather data. RESULTS: The functional status in CHD patients showed significant relationships with gender, job, and type of medical insurance of the participants (All ps<0.05). In addition , perceived vulnerability to face again cardiac attack in the future, per-ceived severity of next cardiac attack, anxiety, state anxiety and trait anxiety (All ps<0.05) had significant and negative relationships with functional status. Con-versely, the cardiac self-efficacy had a positive and significant relationship (P<0.001) with functional status. CONCLUSION: Psychological factors have important role in functional status and quality of life of patients who suffering CHD. Therefore, it is necessary to emphasize on supportive and complementary programs to promote Cardiac Reha-bilita-tion Programs.