Health Promotion Project Research Articles

Evaluating the Healthy Futures Nearby Program: Protocol for Unraveling Mechanisms in Health-Related Behavior Change and Improving Perceived Health Among Socially Vulnerable Families in the Netherlands.

BackgroundThe persistence of health inequalities within high-income societies such as the Netherlands indicates the importance of researching effective ways to reduce those inequalities. Multiple strategies for reducing health inequalities have been identified. Specifically targeting health-related behaviors among lower socioeconomic status groups is one of those strategies. All in all, it seems relatively clear what types of approaches in general lead to health-related behavior change. However, it is still unclear how these approaches, in interaction with context, trigger a specific desired change. In the Netherlands, the private funding organization, Fonds NutsOhra, funded 46 small-scale projects under the umbrella of the Healthy Futures Nearby program. The projects aim to reduce vulnerable families’ health deprivation by triggering lifestyle changes.ObjectiveThis study aimed to outline and justify the protocol for the overall evaluation of the program. The evaluation aimed to find out to what extent and how the small-scale projects and approaches within the program affect (or not) health-related behaviors and improve perceived health.MethodsThe approach to the overall evaluation of the 46 projects builds on a combination of 3 frequently used evaluation models; it is theory-based, realist informed, and uses a mixed methodology design. Methods include analysis of quantitative project data, document analysis, focus groups, and interviews. A study design has been drawn up that values and uses the multifaceted development of the projects and the influence this might have on implementation and project outcomes. Also, it respects the complex nature of the projects and is suited to studying health promotion mechanisms in depth. Finally, it optimizes the usage of all—quantitative and qualitative—project evaluation data available.ResultsThis study protocol included the design of at least 4 different studies. The results will hence provide information on (1) building and defining theories of change in health promotion practice, (2) mechanisms at work in promotion of healthy behavior among vulnerable families, (3) what works and what does not in professionals’ practices in health promotion among those vulnerable groups, and (4) what works and what does not in health promotion projects with a participatory approach. In addition, data will be collected on the overall effectiveness of the 46 initiatives. Data collection started in 2016. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.ConclusionsThis overall evaluation provides a unique opportunity. The diversity of projects allows for a study protocol that answers in greater depth questions of how specific health promotion approaches work while also elucidating their effectiveness in a more traditional way. Using a theory-based complexity-sensitive approach that is mainly realist informed, this study also provides an opportunity to see whether combining assumptions from different evaluation perspectives yields relevant information.International Registered Report Identifier (IRRID)DERR1-10.2196/11305

Challenging Diversity: Steering Effects of Buzzwords in Projectified Health Care

This article discusses the effects of two trends in contemporary biomedicine that have so far been largely addressed separately: the steering of fields through programmatic “buzzwords” and the projectified nature of contemporary health research, care, and promotion. Drawing on a case study of an Austrian diversity-sensitive health promotion project related to obesity prevention, we show how the articulation of these trends—governance by buzzwords and projectification—often leads to not unproblematic and often paradoxical outcomes. Buzzwords such as “diversity” become especially important in an innovation-driven environment encouraging a promissory rhetoric. At the same time, the project form shapes and restricts how buzzwords (as typically vague terms that need to be fleshed out) are articulated and translated into a specific project design. In our case study of an obesity prevention program, the need to translate diversity into a “doable” project encouraged the identification of seemingly clearly delineated target groups and thus promoted a rather narrow understanding of diversity, which stands in tension with much more fluid and context-sensitive ways of performing “diversity.” We show how actors grapple with these paradoxes. This restricts the full power a buzzword such as diversity could achieve in terms of social justice.

A Move-A-Thon Event: A Workplace Demonstration of a Proposed Alternative Strategy to Incentivize Workers to Engage in Physical Activity.

Motivating employees to increase their physical activity is a health promotion challenge. A Move-A-Thon (MAT) event approach was implemented as an alternative incentive to help workers to optimize their physical activity levels. We implemented a demonstration project in which workers were incentivized for their participation through monetized donations to charity. Their steps were monitored over the 2-week demonstration period. The MAT goal was for participants to achieve a minimum of 3,000 daily steps for 2 weeks, for which they could earn a total donation of up to US$20. Participants walking at least once with up to five different "exercise buddies" could earn up to US$2 more per buddy for donation. Of 10 workers invited, nine enrolled and eight completed participation by logging their monitored steps across an average of 13.75 full MAT participation days. Participants averaged 9,330.8 steps per day-more than triple the lower threshold required for a maximum US$20 charitable donation. The eight participants walked with a total of 21 "exercise buddies." They were receptive to future MAT events of longer duration. In total, the monetized donation to charity made by those eight participants was US$202. The MAT event participants were successful at promoting physical activity among a small group of workers for 2 weeks. Future worksite health promotion projects with this type of incentive strategy are indicated.

A Nationally Coordinated Health Promotion Program for the Elderly in a Federal State, Switzerland

In a federal state like Switzerland, where health policies are the responsibility of local, regional and federal authorities, implementing a nationally coordinated health promotion program is a political and logistic challenge. The VIA project, presented hereafter, is one of the rare health promotion projects to be coordinated at the national level in Switzerland. Its aim is to promote the health of older people, a population which is heavily affected by chronic diseases. Indeed, in the group aged 65–79 years living at home, 28.8% suffer from one and 25.2% from several chronic diseases; in the over-80 age group, the proportions are 29.6% and 41.3%. The VIA project, a multi-year project, tackles specific issues known to affect the health of the elderly, such as fall prevention, promotion of physical activity and healthy eating as well as social integration through supporting local stakeholders with theoretical knowledge, practical know-how and facilitating networking among various stakeholders. The coordination work was considered useful by most local program-managers: especially considered as useful were network encounters and exchange of experiences among professionals.

Atividades físicas no contexto urbano saudável: a experiência de Conchal [SP

Na Carta Magna do Brasil, a Constituição Brasileira (1988) traz premissas para o desenvolvimento urbano através da função social da cidade proporcionado assim, uma vida saudável e digna de ser vivida. Relatar a implantação de um Projeto de Atividades Físicas em um município de pequeno porte pertencente a Rede de Municípios Potencialmente Saudáveis (RMPS para promover o urbano saudável. A metodologia é descritiva, sendo um estudo de caso a partir de iniciativas da Política Nacional da Promoção da Saúde (PNaPS) do Brasil de 2014 com a coleta dos resultados nos anos de 2010 a 2018 no Departamento Municipal de Saúde do município de Conchal [SP, Brasil]. A implantação de projetos de Atividades Físicas foi realizada através da criação de um Comitê Local, baseado na metodologia da RMPS, que proporcionou o mapeamento das ações desenvolvidas no território desse município e a gestão saudável do repasse federal do Ministério da Saúde (MS) desde 2010 destinado para implantação e implementação de projetos de promoção da saúde no combate ao sedentarismo. O projeto proporcionou o envolvimento, participação e comprometimento dos gestores locais e o empoderamento da comunidade, através das políticas de Promoção da Saúde vigentes com enfoque no urbanismo saudável. A participação do município na RMPS contribui no que diz respeito à promoção de saúde e trocas de experiências com outros municípios.

Participatory action research, mixed methods, and research teams: learning from philosophically juxtaposed methodologies for optimal research outcomes

BackgroundWorkplace health interventions incorporating qualitative and quantitative components (mixed methods) within a Participatory Action Research approach can increase understanding of contextual issues ensuring realistic interventions which influence health behaviour. Mixed methods research teams, however, face a variety of challenges at the methodological and expertise levels when designing actions and interventions. Addressing these challenges can improve the team’s functionality and lead to higher quality health outcomes. In this paper we reflect on the data collection, implementation and data analysis phases of a mixed methods workplace health promotion project and discuss the challenges which arose within our multidisciplinary team.MethodsThis project used mixed methods within a Participatory Action Research approach to address workers’ sun safety behaviours in 14 outdoor workplaces in Queensland, Australia, and elucidate why certain measures succeeded (or failed) at the worker and management level. The project integrated qualitative methods such as policy analysis and interviews, with a range of quantitative methods – including worker surveys, ultraviolet radiation (UVR) exposure measurement, and implementation cost analyses.ResultsThe research team found the integration of qualitative and quantitative analyses within the Participatory Action Research process to be challenging and a cause of tensions. This had a negative impact on the data analysis process and reporting of results, and the complexity of qualitative analysis was not truly understood by the quantitative team. Once all researchers recognised qualitative and quantitative data would be equally beneficial to the Participatory Action Research process, methodological bias was overcome to a degree to which the team could work cooperatively.ConclusionsMixed methods within a Participatory Action Research approach may allow a research team to discuss, reflect and learn from each other, resulting in broadened perspectives beyond the scope of any single research methodology. However, cohesive and supportive teams take constant work and adjustment under this approach, as knowledge and understanding is gained and shared. It is important researchers are cognisant of, and learn from, potential tensions within research teams due to juxtaposed philosophies, methodologies and experiences, if the team is to function efficiently and positive outcomes are to be achieved.

Staff Self-Efficacy and Staff Outcome Expectations for Function-Focused Care: Rasch Testing.

The purpose of this study was to test the reliability and validity for two new scales. We used baseline data from a worksite health promotion project with 98 long-term care staff and Pearson correlations and Rasch analysis testing. For Staff Self-Efficacy for Function Focused Care and Staff Outcome Expectations for Function Focused Care item, reliability was .80 and .83, respectively. All items except one had acceptable INFIT and OUTFIT mean square statistics. Both new scales were significantly correlated (r = .342, p = .007), but neither of the scales were correlated with participants' baseline exercise levels (r = .014, p = .918; r = .092, p = .454, respectively). There was some evidence of validity and internal consistency for both scales. Suggestions are provided to improve the measures for future use.

Whole-Volume ADC Histogram Analysis of Parotid Glands to Identify Patients With Sjögren's Syndrome

Background: There was no functional MR sequences have been reported in identifying Sjogren’s syndrome in patients suspected of the disease. Methods: The 2002 AECG classification criteria were used to diagnose Sjogren's syndrome. A total of 52 patients with Sjogren’s syndrome and 24 patients suspected of having the disease prospectively underwent 3.0 T magnetic resonance (MR) scanning including diffusion weighted (DW) imaging (b = 0, 1000 s/mm2). Whole-volume ADC histogram analysis generated ADCmean, skewness, kurtosis and entropy values of bilateral parotid glands. Continuous variables were compared with two independent samples t-test and categorical variables were compared with Fisher’s test between the two groups. The diagnostic performance of the indexes was evaluated with receiver operating characteristic (ROC) analysis. Findings: Fisher’s tests showed that some clinical indexes and MR morphology grade differed significantly between Sjogren’s syndrome and suspected patients (all p ≤ 0.001). The parotid entropy value of patients with Sjogren’s syndrome was significantly higher than that of patients suspected of the disease (p < 0.001). Among MR parameters, entropy combined with kurtosis performed best in differentiating patients with Sjogren’s syndrome from those suspected of having Sjogren’s syndrome (AUC= 0.955). Interpretation: Whole-volume ADC histogram analysis could provide a series of parameters reflecting tissue characteristics, proved useful in the diagnosis of Sjogren’s syndrome. Funding Statement: The study design was supported by the National Natural Science Foundation of China (ID: 81371516, 81501441). The collection, analysis and interpretation of data was supported by the Foundation of National Health and Family Planning Commission of China (ID: W201306), the Social Development Foundation of Jiangsu Province (ID: BE2015605) and the Key Project and Outstanding Youth supported by Medical Science and Technology Development Foundation Nanjing Department of Health (ID: YKK15067). The writing of the report was supported by the Jiangsu province key medical young talents, 13th Five-Year health promotion project of Jiangsu province (ID: JH.2016-2020). The decision to submit the paper for publication was supported by the Natural Science Foundation of Jiangsu Province (ID: BK20171118). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The ethics committee of Nanjing Drum Tower Hospital approved this study. Written informed consent was obtained from all subjects.

The Health of Older People in Switzerland

Over the past century, the proportion of Swiss residents aged 65 or older rose from 5.8% to 17.8%; during the same period, the proportion aged over 80 rose from 0.5% to 5.0%. Although the majority of older people in Switzerland enjoy good health, disease prevalence rises with age. Almost half (49%) of people over 65 living at home report at least one chronic illness. Among the 65- to 79-year-olds living at home, 25.2% suffer from several chronic diseases; among people in the 80s, this figure reaches 41.3%. People aged over 80 are also particularly at risk for falls (30%). In addition, between 15% and 25% of the elderly suffer from at least one mental illness. Close to 30% of healthcare costs are attributable to people over the age of 75, who make up only 8% of the total population. Given the public health importance of the issue a health promotion project targeting the elderly – the VIA Project -, based on successful local programs, is being implemented throughout the country. The overall goal of the VIA project is to promote the health of older people and to strengthen their self-determination and independence.

Relationship between oxidative stress and lower urinary tract symptoms: results from a community health survey in Japan.

To investigate the relationship between oxidative stress and lower urinary tract symptoms (LUTS) in a community-dwelling population. The cross-sectional study included 1113 people who participated in the Iwaki Health Promotion Project of 2015 in Hirosaki, Japan. LUTS were assessed using structured questionnaires, including the International Prostate Symptom Score (IPSS) and the Overactive Bladder Symptom Score (OABSS). IPSS > 7, OABSS > 5, nocturia score > 1, or urge incontinence score > 1 were defined as moderate to severe symptoms. 8-Hydroxy-2'-deoxyguanosine (8-OHdG) and advanced glycation end products (AGEs) were measured by urine analysis and skin autofluorescence, respectively. The relationship between oxidative stress and LUTS was investigated using logistic regression analyses. This study included 431 men and 682 women. AGEs and 8-OHdG levels were significantly higher in severe forms of LUTS. Multivariate logistic regression analyses showed that AGE levels were significantly associated with a higher frequency of nocturia but were not associated with IPSS, OABSS or urge incontinence. No significant association was observed between LUTS and 8-OHdG levels. We observed a significant association between AGE levels and nocturia score > 1. Further research is necessary to clarify a possible causal relationship between oxidative stress and nocturia.

Higher plasma leptin and lower C-peptide levels are associated with depression: A cross-sectional study

BackgroundDepression is a seriously disabling public health problem with very high world-wide prevalence. This study examined cross-sectional association between depression and both inflammatory markers and laboratory data involved in metabolic disturbance among Japanese subjects. MethodsThis cross-sectional study is a secondly analysis for the data of the Iwaki Health Promotion Project 2014 (1167 subjects). Plasma inflammatory markers and laboratory metabolic data involved were used. Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess the prevalence and severity of depressive symptoms. Participants with CES-D scores ≥ 16 were assigned to the ‘Depression’ group (Group D). Differences between group Non-depression (ND) and D were estimated using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Mann-Whitney test for continuous variables. Multivariate logistic regression analysis was also used to identify characteristics, co-morbidities, conditions and laboratory data associated with depression after adjusting for possible confounding factors. ResultsThere were significant differences in sex, age, blood pressure, interleukin (IL)-6, fasting blood sugar (FBS), hemoglobin A1c (HbA1c), and cortisol level using univariate analysis between the two groups. However, multivariate logistic regression analysis indicated that lower age, lower C-peptide, and higher leptin were associated with the depression. ConclusionThis study showed that higher plasma leptin and lower C-peptide levels were significantly associated with depressive symptoms. No significant association was found between plasma inflammatory markers and depressive symptoms after adjusting for possible confounding factors.

Aging and APOE-ε4 are determinative factors of plasma Aβ42 levels.

ObjectiveThe aim of this study was to confirm determinative factors for plasma Aβ and its association with cognitive function.MethodsFasting plasma Aβ40 and Aβ42 levels were measured by ELISA in 1019 participants in the Iwaki Health Promotion Project. The relationships between plasma Aβ and health‐related items, including physical characteristics, cognitive function tests, blood chemistry, and APOE‐ε4 genotype were analyzed.ResultsThe plasma levels of Aβ40 and Aβ42, and Aβ40/42 ratio were found to significantly increase with aging. The age‐dependent increase in Aβ42 level was significantly suppressed by APOE‐ε4. Renal function was an associated factor for the plasma Aβ40 level. The plasma Aβ42 level and Aβ40/42 ratio correlated with cognitive function.InterpretationAge and APOE‐ε4 are major determinative factors of plasma levels of Aβ42 and the Aβ40/42 ratio. These factors are critical adjustment factors for the usage of plasma Aβ as a biomarker of central nervous system amyloidosis.

Reduction of health inequalities: Lor’IS, a tool for health promotion field workers

Health inequalities is a complex issue and may appear to be unrelated to the reality of field workers. This article describes Lor'IS, a support grid for project leaders designed to enable them to review their actions based on criteria contributing to reduction of social and geographical inequalities in health. This tool was based on a review of the literature and assessment of the needs of field workers. It was created by a multidisciplinary working party and was tested and improved by the future users. Lor'IS justifies the role of all institutional or associative field workers to fight against inequalities in health. This readily accessible tool is designed to facilitate the setting-up of health promotion projects, that are known to contribute to reduction of these inequalities, based on a set of 51 items. This approach must be extended to professionals in the fields of health care, housing, employment, rural environment, who constitute essential links in reduction of inequalities, but who are currently not involved in this challenge. Lastly, advocacy actions must be conducted to ensure that health inequality issues are integrated into all public policies.

Theory-Based Behavioral Intervention Increases Mother–Son Communication About Sexual Risk Reduction Among Inner-City African-Americans

PurposeAfrican-American adolescent males are at increased risk for HIV, yet there are few sexual risk-reduction interventions targeting this population. Interventions that include mothers can influence parentingbehaviors and in turn, reduce risky behaviors in adolescents. This study tests the efficacy of the Mother–Son Health Promotion Project at increasing mother–son communication about sexual risk reduction. MethodsAfrican-American mothers with their sons (ages 10–15 years) residing in public housing in Philadelphia, Pennsylvania were randomized into a HIV/sexually transmitted infections risk-reduction intervention consisting of 16 1-hour modules or an attention-matched health-promotion control intervention.Mothers and sons completed surveys pre-intervention, immediately postintervention, and at 3-, 6-, 12-, 18- and 24-months postintervention. ResultsOf 525 mother–son dyads, 366 (69.7%) completed the 24-months postintervention follow-up survey. Generalized-estimating-equations models using both mothers’ and sons’ reports revealed that over 24 months, mothers and sons in the HIV/sexually transmitted infections risk-reduction intervention were more likely to communicate about sexual health, including sexual intercourse, birth control, HIV/AIDS prevention, and condoms. Intervention efficacy was found to weaken over time. ConclusionsThis culturally grounded, theory-based intervention was efficacious in increasing mother–son communication about sexual risk reduction. The work highlights the value of the intervention toincrease parental protective factors, including communication by mothers, to decrease HIV risk behaviors of African-American adolescent males.

Children as visionary change agents in Danish school health promotion.

This paper describes children's perceptions and visions for a healthier social and physical environment in the setting of a primary school on the Danish island of Bornholm. Guided by an everyday-life perspective and applying participatory action research methods including social imagination and visual techniques within the framework of future creating workshops, the study engaged 50 children aged 6-9 years in creative processes of identifying health-related problem areas and solutions in their school setting. The study observed that the children were very capable of articulating their thoughts, ideas and visions for a better and healthier school environment. Identified problem areas and solutions differed widely and represented a broad perspective of health including social, physical, environmental and emotional aspects. The paper discusses advantages and challenges of involving children in decision-making processes and concludes that children are visionary and creative agents of change in health promotion projects provided that applied participatory methods are appealing to the children.

Impact of oral health promotion project on periodontal condition and life quality of the elderly in long-term care institutions

To assess the impact of oral health promotion project on periodontal condition and life quality of the elderly in long-term care institutions. Elder people from 5 nursing homes in Wuhan city were selected and assigned to either the experimental group or the control group by random cluster grouping method. A six-month oral health promotion project was provided to the experimental group. The changes of geriatric oral health assessment index (GOHAI), oral hygiene index-simplified (OHI-S), gingival index (GI), bleeding on probing (BOP) and probing depth (PD) were compared with student's t test and repetitive measure analysis of variance using SPSS21.0 software package. A total of 322 subjects completed the study for 6 months, with 144 from the experimental group and 178 from the control group. No significant difference was observed between the two groups in social demographic characteristics, GOHAI scores, OHI-S, GI, BOP and PD at baseline(P>0.05). Greater improvements were observed in GOHAI scores, OHI-S, GI and BOP in the experimental group than the control group after interventions (P<0.05). Oral health promotion project can improve the elderly's oral health-related quality of life and periodontal condition.

Collaborating With Youth in School Health Promotion Initiatives With Photovoice.

Photovoice, a community-based approach that is being embraced in school settings, can help to nurture collaborations with youth, particularly adolescents, and engage them in the development of social policy and health promotion projects. Photovoice is an approach that positions school nurses to inspire youth to take ownership of health promotion issues that directly affect them in the school and in their communities. Engaging youth in Photovoice not only allows advocates to directly work with youth but also promotes critical thinking and the exploration of topics that may not otherwise be considered. Photovoice raises awareness about issues through critical dialogue and is well suited to engage youth and provide a channel for youth to assert their voices.

Physical exercise health promotion in the workplace: participative experimentation in a private company

The objective of this study was to identify collaborative processes involved in a physical activity health promotion project in companies, conducted through a participatory approach in a cross-sectoral partnership, and to estimate the preliminary effects in terms of employee health. Action research was conducted in an industrial company comprising 240 employees over a 2-year period. This research was based on 4 criteria: description of the actors' network, the opportunities and constraints of the project, the implementation of physical activities, the participation of employees in the various activities, the impacts observed (after 3 months of activities) on physical parameters and quality of life. Six work groups selected two activities : muscle-development exercise and Taïchi. We evaluated muscle strengthening activity. The participation rate in the activity was 16%. A higher age, female gender and being a manager or employee rather than a worker were significantly associated with participation. A tendency towards increased physical and mental scores of SF12 was observed. We identified two major barriers: logistic and communicational. The participatory approach, based on a cross-sectoral partnership, is the determining element of the project's success in a context of local opportunities. Two factors were identified to perpetuate this dynamic and improve the system: rationalization of the structuring of the service and greater resources, particularly financial resources.

Integrating community service learning in undergraduate dental education: A controlled trial in a residential facility for people with intellectual disabilities.

The present report describes an oral health promotion project in a residential facility for people with intellectual disabilities as a strategy to implement community service learning in undergraduate dental education. Two undergraduate students developed a project aimed to improve the oral health in residents with intellectual disabilities by educating caregivers. The impact was investigated by a pretest-posttest design, evaluating residents' plaque and gingival indexes and caregivers' knowledge, behavior, attitude, and self-efficacy. Findings demonstrated that within a semester, it was possible for students to obtain a limited but positive impact on the local community. Based on the experiences at Ghent University, the following guidelines were suggested to implement service learning in a dental curriculum that renders both a positive impact on student learning and the local community : (1) integrate community service learning in multiple years in the curriculum; (2) use a stepwise approach from theory to exercises to extramural experiences; (3) create a partnership with a local organization; (4) organize long-term projects and annual follow-up to increase the impact; (5) involve supervisors from both the university and the local organization; and (6) establish an evidence based approach to benefit the quality of projects and to facilitate students to develop research competences.

Relationship Between Serum Eicosapentaenoic Acid Levels and J-Waves in a General Population in Japan.

We previously showed that J-waves were found more frequently in patients with low levels of serum eicosapentaenoic acid (EPA) in the acute phase of myocardial infarction, and were associated with the incidence of ischemia-related ventricular arrhythmias. However, the relationship between J-waves and serum EPA levels in a general population remains to be elucidated.The Iwaki Health Promotion Project is an ongoing community-based health promotion study in Iwaki, Hirosaki, which is in northern Japan. A total of 1,052 residents (mean age, 53.9 ± 15.4 years; 390 men) who participated in this project in 2014 were studied. A standard 12-lead electrocardiogram (ECG) was recorded and serum EPA levels were measured to evaluate the relationship between J-waves and serum EPA levels. J-waves were found in 52 (5%) subjects and were observed more frequently in male than female subjects (44 [11%] versus 8 [1%], P < 0.0001). More than half of the J-waves were the notched type (60%), and J-waves were detected most frequently in inferior leads on ECG (52%). The RR interval was longer and QTc duration shorter in subjects with J-waves than those without. No significant difference was found in serum EPA levels between subjects with and without J-waves (70 [49-116] versus 65 [41-106] μg/mL, P = 0.40). In multivariate analysis, male gender and RR interval were independent factors associated with the presence of J-waves.There was no significant relationship between J-waves and serum EPA levels in this general population in Japan. Various mechanisms for manifestation of the J-waves are suggested.