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Karam I Turk-Adawi,1 Usra Elshaikh,1 Aashish Contractor,2 Farzana Amir Hashmi,3 Emma Thomas,4 Fabbiha Raidah,5 Sherry L Grace5,6 1Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar; 2Rehabilitation and Sports Medicine, Sir H.N. Reliance Foundation Hospital, Mumbai, India; 3Preventive Cardiology and Rehabilitation, Tabba Heart Institute, Karachi, Pakistan; 4Centre for Online Health, Centre for Health Services Research, the University of Queensland, Brisbane, Queensland, Australia; 5Faculty of Health, York University, Toronto, Ontario, Canada; 6KITE - Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, CanadaCorrespondence: Karam I Turk-Adawi, Department of Public Health, College of Health Sciences, Qatar University, P.O. Box: 2713, Doha, Qatar, Tel +974 4403 7508, Fax +974 4403 4801, Email kadawi@qu.edu.qaBackground: Cardiac rehabilitation (CR) is a proven model of secondary prevention, but new sites, providing quality care, are needed in low-resource settings. This study (1) described the development of International Council of Cardiovascular Prevention and Rehabilitation’s (ICCPR) Program Certification and (2a) tested its implementation, considering (b) appropriateness of quality standards for these settings.Methods: The Steering Committee finalized 13 standards, requiring 70% be met. They are assessed initially through International CR Registry (ICRR) program survey and patient data; if Certification appears possible, a two-hour virtual site assessment is arranged to corroborate. Standard operating procedures for Assessor training were developed. A multi-method pilot study was then undertaken with a quantitative (description of quality indicators) and qualitative (focus groups on MS Teams) component. ICRR sites with post-program data by April 2022 were invited to participate. Two team members independently analyzed focus group transcripts, using a deductive-thematic approach with NVIVO.Results: Five CR programs from the Eastern Mediterranean, South-East Asian and American regions participated. Upon application, with some data cleaning, initially four programs were eligible to proceed to virtual site assessment. Ultimately, all five programs were certified, each meeting a minimum of 12/13 standards (peak MET increase and program completion rate were not met by some centres). Four themes resulted from the two focus groups of 13 site data stewards: motivation and benefits (eg, international recognition, additional program resources), logistics (eg, communication, cost, site visit process), the standards and their assessment (eg, balance of rigor and feasibility), and suggestions for improvement (eg, website).Conclusion: ICCPR’s Program Certification has been demonstrated to be feasible, rigorous, and acceptable Standards are attainable in low-resource settings. Certified programs reap benefits including additional resources. This first international Certification is suitable for low-resource settings, to complete that from the American and European CR Societies.Keywords: quality of care, Certification, cardiac rehabilitation, low- and middle-income countries, registries, cardiovascular diseases

Saba Ali,1 Caroline Chessex,2 Rebecca Bassett-Gunter,1 Sherry L Grace1,2 1School of Kinesiology and Health Science, York University, 2Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada Background: Cardiac rehabilitation (CR) societies recommend assessment of patient satisfaction given its association with health care utilization and outcomes. Recently, the Patient Assessment of Chronic Illness Care (PACIC, Glasgow) was recommended as an appropriate tool for the CR setting. The objectives of this study were to 1) describe patient satisfaction with CR, 2) test the psychometric properties of the PACIC in the CR setting, and 3) assess the association of patient satisfaction with CR utilization and outcomes.Methods: Secondary analysis was conducted on an observational, prospective CR program evaluation cohort. A convenience sample of patients from 1 of 3 CR programs was approached at their first CR visit, and consenting participants completed a survey. Clinical data were extracted from charts pre- and post-program. Participants were e-mailed surveys again 6 months (including the PACIC) and 1 and 2 years later.Results: Of 411 consenting patients, 247 (60.2%) completed CR. The mean PACIC score was 2.8±1.1/5. Internal reliability was α=0.95. The total PACIC score varied significantly by site (F=3.12, P=0.046), indicating discriminant validity. Patient satisfaction was significantly related to greater CR adherence (r=0.22, P

Gabriela Lima de Melo Ghisi,1,2 Rafaella Zulianello dos Santos,3 Eduardo Eugênio Aranha,3 Alessandra Daros Nunes,4 Paul Oh,2 Magnus Benetti,3 Sherry L Grace1,2,5 1Exercise Sciences Department, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada; 2Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; 3Health Sciences and Sports Center, State University of Santa Catarina, Florianopolis, Brazil; 4Luzerne City Hall, Luzerne, Brazil; 5School of Kinesiology and Health Science, York University, Toronto, ON, Canada Abstract: Cardiovascular diseases (CVD) are the leading cause of mortality in middle-income countries, such as Brazil. However, given the diversity in health care systems in Brazil, access to proven services, such as cardiac rehabilitation (CR), varies widely. Purpose: To describe and compare multilevel barriers to CR enrollment and participation in three Brazilian cohorts: (1) cardiac outpatients not attending CR (public or private system); (2) cardiac outpatients paying for CR; and (3) residents at high-risk of CVD with access to a free comprehensive exercise program but not making use of the program. Methods: Brazilian residents from two cities were invited to participate – Florianopolis, an urban center; and Luzerna, a rural center. Respondents completed a survey including the Cardiac Rehabilitation Barriers Scale. Mann–Whitney U tests were used to compare barriers between cohorts cross-sectionally. Results: Six hundred twenty-eight Brazilians consented to participate: 237 (37.7%) from Florianopolis, of which 139 (22.1%) participated in CR; and 391 (62.3%) from Luzerna. The mean total CR barriers for the sample were 1.66 ± 0.6 and differed significantly by cohort (P < 0.001). CR nonattendees from Florianopolis (eg, distance and not knowing about CR) and participants from Luzerna (eg, work and family responsibilities) reported significantly higher barriers than CR attendees from Florianopolis. Conclusion: CR nonattendees reported significantly greater barriers than CR attendees. It is hoped that the provision of CR will increase, and that the development of the programs will be in a manner which mitigates the chief barriers identified herein. Keywords: cardiac rehabilitation, barriers, participation, enrollment, comparison study

Background: Delay in seeking timely medical care by patients with acute coronary syndrome and stroke has been well established in the literature, but less is known about delay in care-seeking behavior by patients with heart failure (HF). The purpose of this narrative review was to synthesize the literature regarding non-symptom-related factors that contribute to delay in seeking medical care for HF symptoms.Methods and Results: A literature search of Scopus, Medline, and Pubmed was conducted for published articles from database inception to July 2009. Available evidence has shown that non-symptom-related factors, such as HF severity, HF history, age, and ethnocultural background, were related to delay in certain studies; however, null results have also been reported. Other non-symptom-related factors, such as male gender, initial contact with a primary care physician, arriving in the emergency department by means other than ambulance, and patient responses such as self-care, low anxiety, and hopelessness, may play a role in longer delay.Conclusions: Although this review identified several non-symptom-related factors that may be implicated in care-seeking delay, health care professionals should be vigilant in identifying all high-risk individuals and educating them about warning signs of HF. Moreover, access to outpatient chronic disease management programs that may have potential to reduce care-seeking delay behavior should be explored. [ABSTRACT FROM AUTHOR]

Both depression and smoking are highly prevalent and related to poorer outcomes in cardiac patients. In this study, the authors examined the association between depressive symptoms and smoking status, described the frequency and type of antidepressant use, and prospectively tested the effects of antidepressant use in smokers on smoking status and psychosocial outcomes. Participants comprised 1,498 coronary artery disease (CAD) outpatients who completed a baseline survey which assessed depressive symptoms, current medications, and smoking status. A second survey was mailed 9 months later that assessed depressive symptoms, anxiety, insomnia and smoking status. Results showed that current and former-smokers had significantly greater depressive symptoms than non-smokers. Ten percent of patients were taking antidepressants, most frequently SSRIs, with significantly more smokers on antidepressants than former and non-smokers. At follow-up, smokers on antidepressants were less likely to have quit, had greater anxiety, depressive symptoms and insomnia than smokers not using antidepressants. This study demonstrated that smokers and quitters with CAD had greater depressive symptoms and use of antidepressants than non-smokers, but that the antidepressants utilized may not be optimizing outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Over one-third of cardiac patients practice Mind-Body Therapy (MBT), particularly women. Considering women are less likely to engage in conventional physical activity, few studies have examined why MBT is well-accepted by women. OBJECTIVES: To qualitatively explore gender differences in the motivations for, and perceived effects of MBT, and the inter-relationships among alternative and conventional physical activities and secondary prevention programs. METHODS: A random subsample of 16 participants (8 female) who reported practicing MBT in a larger study of 661 cardiac patients was interviewed until theme saturation was achieved. Audiotapes were transcribed and coded based on interpretive-descriptive technique within Nvivo-7 software. An audit trail and second coder were utilized to ensure the transparency and validity of results. After main themes emerged, the data were split by gender to identify differences for each theme. RESULTS: Five themes emerged: (1) promotes positive well-being, (2) physical health benefits, (3) intrinsic and extrinsic motivations, (4) proactive health orientation, and (5) MBT as a preferred complementary and/or alternative physical activity. Men more often expressed preference for MBT for increased positive mood and cardiac-specific benefits, whereas women emphasized stress reduction, increasing self-efficacy, and physical activity, and were eager to see MBT offered in cardiac rehabilitation (CR). CONCLUSIONS: Both male and female users perceived substantial psychosocial and physical benefits of MBT practice. MBT addresses some of women's common barriers to CR. Copyright © 2008 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine utilization patterns of diabetes self-management training (DSME) and identify patient factors associated with attrition from these services at an ambulatory diabetes education centre (DEC). METHODS: A retrospective medical chart review of first time visits (536) to the centre between 1 August 2000 and 31 July 2001 was conducted for patients with type 2 diabetes. Descriptive analyses were conducted to examine utilization patterns over a 1-year period. Multivariable logistic regression was used to identify patient factors associated with attrition from DSME and non-use of group education among new patients. RESULTS: Almost 50% of new patients withdrew prematurely from recommended DSME services over the 1-year period, and only 24.8% attended group education. Patient variables such as being older than 65 years of age, primarily speaking English, or working full or part-time were associated with attrition from DSME and non-use of group education when compared with middle aged, non-English-speaking, and non-working patients. CONCLUSIONS: High DSME attrition rates indicate that retention needs to become a focus of programme policy, planning and evaluation to improve programme effectiveness. DSME tailored to the cultural and linguistic characteristics of the community, and convenient and accessible to working and older patients will potentially increase retention in and accessibility to these services. [ABSTRACT FROM AUTHOR]

The authors' objectives of this research were: (1) to assess levels of selfreported antidepressant adherence and reasons for nonadherence and (2) to investigate determinants of nonadherence. A group of general hospital and community psychiatry practice mood disorder outpatients (n=80) took a self-report questionnaire that assessed beliefs about antidepressants, self-efficacy, and reasons for nonadherence. High levels of adherence were reported: 58 patients (73%) indicated they took their medication as directed more than 80% of the time. Practical issues (e.g., simply forgetting or a change in routine) were the most frequently identified reasons for nonadherence. Patients were more likely to report nonadherence if they experienced a sexual side effect, had lower self-efficacy, were female, and had not completed post-secondary education. Clinicians should be cognizant of this complexity and address not only issues related to medication efficacy and tolerability, but also social mediators and health beliefs when prescribing antidepressants. [ABSTRACT FROM AUTHOR]

Background: Literature pertaining to the relationship between workplace factors and depression has been compartmentalized: work conditions, family conditions, and work-family balance have been studied separately as predictors of depressive symptoms but not concurrently.Objective: Work conditions and work-family spillover were considered concurrently as modifiable workplace factors associated with depressive symptomatology, while controlling for confounding socio-economic factors.Methods: This cross-sectional study involved 218 female health care workers who completed a survey assessing work conditions [Effort-Reward Imbalance (ERI) scale and Job Content Questionnaire (JCQ)], work-family balance (work-family spillover scale), sociodemographic information, and depressive symptoms [Center for Epidemiological Studies Depression (CES-D) scale].Results: Path analysis supported the presence of a direct relationship between depressive symptoms and high effort-reward imbalance, high negative work-family spillover, low positive family-to-work spillover, and low education. The indirect effect of low support from work was mediated by negative work-to-family spillover and high effort-reward imbalance. The indirect effect of high effort-reward imbalance was mediated by increased negative work-to-family spillover. The indirect effect of having children 18 years or younger was mediated by decreased positive family-to-work spillover. An indirect effect of low education was mediated by high effort-reward imbalance and high negative work-to-family spillover.Conclusions: The association between work conditions and depressive symptomatology is mediated by increased negative work-to-family spillover. The impact of having young children is mediated by decreased positive family-to-work spillover. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Women's health-promoting behavior changes and their correlates across the transition to motherhood and return to work are insufficiently understood. The purpose of this study was to describe and compare women's health-promoting behaviors, particularly physical activity (PA), across these transitions. A prospective, observational design was employed to assess 243 female healthcare workers from 3 sites with regard to health-promoting behaviors, and their demographic (e.g., age, parity) and psychosocial (i.e., work-family role spillover) correlates. Forty-two participants were recruited while pregnant and re-assessed during maternity leave and upon return to work, and compared to 201 non-pregnant participants. No significant changes in health-promoting behaviors were observed from pregnancy through the postpartum. Pregnant participants reported better nutrition than comparison participants (p=.001), and were more likely to check their pulse when exercising (p=.004). During pregnancy, health-promoting behaviors were related to parental status, with first-time mothers engaging in more positive behaviors. Correlates of PA during maternity leave and return to work included family income and exercise history. Positive family-to-work spillover was significantly greater among pregnant women than among comparison participants (p<.001), and positive work-to-family spillover was related to greater PA upon return to work (p<.01). This study reveals little variability in health-promoting behaviors from the prenatal to the postpartum period. Both demographic and psychosocial factors have effects on health-promoting behaviors, and we must look to these correlates to promote increased PA. [ABSTRACT FROM AUTHOR]

Although several ethnic groups experience a greater burden of diabetes, this has not been examined in first-generation Italians, who compose one of the largest ethnocultural groups in Canada. In this cross-sectional study, the authors examined the relationship among gender and ethnocultural factors, family support, depressive symptomatology, and illness perceptions on diabetes self-management (DSM) in 50 Italian women and men with type 2 diabetes. The authors first conducted a focus group to explore cultural barriers. They then assessed gender, ethnocultural, and psychosocial barriers quantitatively by an interviewer-administered questionnaire. Compared with Italian men, Italian women reported significantly greater depressive symptomatology and perceived disease seriousness. Greater depressive symptomatology was significantly associated with perceived family sabotage and DSM barriers. In univariate analyses, shorter duration of diabetes and greater perceived treatment effectiveness significantly predicted better DSM. In conclusion, certain illness perceptions and culturally relevant gender-specific barriers should be addressed by health care providers to maximize DSM in this population. Index Terms: diabetes, diet, gender, self-management. [ABSTRACT FROM AUTHOR]

Objectives: Cardiac rehabilitation (CR) remains underused and inconsistently accessed, particularly for women and minorities. This study examined the factors associated with CR enrollment within the context of an automatic referral system through a retrospective chart review plus survey. Through the Behavioral Model of Health Services Utilization, it was postulated that enabling and perceived need factors, but not predisposing factors, would significantly predict patient enrollment.Subjects: A random sample of all atherosclerotic heart disease (AHD) patients treated at a tertiary care center (Trillium Health Centre, Ontario, Canada) from April 2001 to May 2002 (n = 501) were mailed a survey using a modified Dillman method (71% response rate).Measures: Predisposing measures consisted of sociodemographics such as age, sex, ethnocultural background, work status, level of education, and income. Enabling factors consisted of barriers and facilitators to CR attendance, exercise benefits and barriers (EBBS), and social support (MOS). Perceived need factors consisted of illness perceptions (IPQ) and body mass index.Results: Of the 272 participants, 199 (73.2%) attended a CR assessment. Lower denial/minimization, fewer logistical barriers to CR (eg, distance, cost), and lower perceptions of AHD as cyclical or episodic reliably predicted CR enrollment among cardiac patients who were automatically referred.Conclusion: Because none of the predisposing factors were significant in the final model, this suggests that factors associated with CR enrollment within the context of an automatic referral model relate to enabling factors and perceived need. A prospective controlled evaluation of automatic referral is warranted. [ABSTRACT FROM AUTHOR]

Visible fingerprints (FPs) play a crucial role in forensic identification, and luminescent carbon nanodots (C-Dots) have shown promise in enhancing their visibility. However, the optimal concentration of C-Dots for effective coating remains largely unexplored. This research aimed to determine the ideal C-Dots concentration for FPs identification. The fingerprint (FP) patterns of two subjects, L and P, were analyzed, revealing intensity peaks in 200 mm - 250 mm and 100 mm - 150 mm, respectively. The FP patterns were observed using a light microscope and Tracker software spectral analysis. The C-Dots samples were produced with variation in concentrations of (%W/V) 40%, 43.4%, and 47.6%. The spectrophotometer ultraviolet-visible (UV-Vis) test of the C-Dots showed absorption peaks at 270 nm and 330 nm wavelengths. The photoluminescence test indicated that the C-Dots have cyan luminescence. The X-ray diffraction (XRD) test showed that the C-Dots were amorphous. The spectrometer Fourier transform infrared (FTIR) test showed the presence of C = C functional groups. The scanning electron microscope (SEM) images with 5000x magnification showed the surface morphology of the C-Dots mimicking crumpled papers. Using Tracker software, FPs were successfully differentiated, with the clearest visual FPs observed when using a C-Dots concentration of 43.4%. Thus, the optimal concentration of C-Dots for FP identification was 43.4%.

Objective: To investigate the degree of CHD awareness as well as symptom, risk factor, and treatment knowledge in a broad sample of cardiac inpatients, and to examine its sociodemographic, clinical and psychosocial correlates.Methods: 1308 CHD inpatients (351 [27.0%] female), recruited from 11 acute care sites in Ontario, participated in this cross-sectional study. Participants were provided with a survey which included a knowledge questionnaire among other measures, and clinical data were extracted from medical charts.Results: 855 (68.8%) respondents cited heart disease as the leading cause of death in men, versus only 458 (37.0%) in women. Participants with less than high school education (p<.001), an annual family income less than $50,000CAD (p=.022), low functional capacity (p=.042), who were currently smoking (p=.022), who had no family history of heart disease (p<.001), and who had a perception of low personal control (p=.033) had significantly lower CHD knowledge.Conclusions: Awareness of CHD is not optimal, especially among women, South Asians, and those of low socioeconomic status. CHD patients have a moderate level of disease knowledge overall, but greater education is needed.Practice Implications: Tailored educational approaches may be necessary for those of low socioeconomic status, particularly with regard to the nature of CHD, tests and treatments. [ABSTRACT FROM AUTHOR]

Competing Interests: Conflict of interest: none declared.