Development and evaluation of the psychometric properties of a new measure of athlete insomnia: Insomnia in Response to Sports-related Stress Test questionnaire.

To develop and validate the Insomnia in Response to Sports-related Stress Test (IRSST) questionnaire, a new specific instrument with the goal of sensitively measuring vulnerability to sport-specific stressful situations among elite athletes. Five hundred and thirty-one competitive elite athletes (mean age = 17.6 ± 4.4 years) completed the Ford Insomnia Response to Stress Test (FIRST) questionnaire and the IRSST, a six-item questionnaire developed to assess the level of sleep disturbance in response to the commonly experienced sport-specific stressful situations. A development and validation process including substantive, structural, and external stages was used in the present study. One eigenvalue of the exploratory factor analyses was greater than 1.0 (i.e., 2.91, 48.52% of explained variance) whereas the scree test provided evidence for a one-factor solution, with all the six items achieving a loading of 0.40 or higher on the factor. Cronbach alpha was 0.77 and provided evidence for the reliability of the IRSST score. The correlation between IRSST and FIRST scores was 0.47 (p < 0.001, moderate effect size). These results provide strong evidence for construct validity, indicating that the IRSST is a promising scale for assessing the likelihood of sleep disruption due to sports-related stressful situations. The results of reliability and correlational analyses provided further evidence of the promising psychometric properties of the IRSST. We believe that the IRSST could provide to the sport and sleep science communities a sleep screening tool for use in this unique population.

The relationship between motivation profiles for health-oriented physical activity, basic psychological needs and emotional regulation.

The study of motivation toward health-oriented physical activity helps to know the reasons that guide people to practice physical activity. Moreover, different types and levels of motivation may coexist. As such, this paper aimed to analyze the combination of motivation for health-oriented physical activity profiles and examine whether profiles differed in emotional regulation and basic psychological needs. A sample of 808 Spanish adults between 18 and 65 years old (Mage = 33.90; Standard Deviation = 12.91; 366 men) participated in a cross-sectional study. Results revealed the existence of three different motivational profiles: (a) Low scores in self-determined motivation and average-high scores in non-self-determined motivation; (b) Average scores in self-determined and non-self-determined motivation; (c) High scores in self-determined motivation and average-high in non-self-determined motivation. Furthermore, participants differed in the satisfaction of basic psychological needs and cognitive-emotional regulation strategies depending on the profiles combination that they perceive. In conclusion, practitioners need to enhance an optimal combination of motivation profiles to satisfy better basic psychological needs and the use of functional cognitive-emotional regulation strategies since this could help improve psychological and emotional health in adults.

Psychophysiological Effects of Slow-Paced Breathing on Adolescent Swimmers' Subjective Performance, Recovery States, and Control Perception.

This study examined the effect of a Slow-Paced Breath (i.e., 6 breaths per minute) without Biofeedback (SPB-NoHRVB) protocol on semi-elite adolescent swimmers' psychological and physiological states during a seven-week ecological training period. A linear mixed-effects multilevel regression analysis approach was used with 13 adolescent national-level swimmers. Athletes were randomly assigned to an intervention group (n = 7) and a control group (n = 6). Seven waves of assessments were completed weekly during a seven-week training preparation in ecological conditions. During the protocol, swimmers completed subjective quantitative measures (RESTQ-36-R-Sport; cognitive perceived stress and control states about the training process, training subjective performance, and subjective internal training load) and physiological heart rate (HR) (HR of exercise, absolute and normalized HR recovery during the first 60 s of recovery; HRR60 and nHRR60) and heart rate variability (HRV) (MeanRR, RMSSD, LFnu and HFnu, LF/HF ration) tests (through a submaximal heart rate (5'-5' test) once a week. Results revealed that the SPB-NoHRVB protocol significantly predicts biopsychosocial recovery states, cognitive perception of control, and training subjective performance (i.e., a significant effect of the SPB-NoHRVB protocol with the dependent variables simple time trajectories). However, no significant effects were found for biopsychosocial stress scales, cognitively perceived stress, HR, or HRV markers. Our results suggest that SPB-NoHRVB induces simple evolutions over time for crucial variables in athletes' adaptation to the training process (i.e., cognitive appraisals and biopsychosocial states). In contrast, it highlights that SPB-NoHRVB does not induce better stress states. This specific effect on the resource component is an exciting result that will be discussed in the manuscript.

Visual Search Strategies of Elite Fencers: An Exploratory Study in Ecological Competitive Situation.

This study investigates the visual activity of fencers in conditions resembling official competitions. Previous research in experimental conditions has shown that experts focus on specific areas of the torso and the armed arm to control movement initiation. Eight right-handed fencers (epee: two males, one female; foil: one male; sabre: two males, two females) participated in a simulated competition, wearing an eye tracker during one bout. The findings showed that the main fixation in foil and sabre is the upper torso, while in epee, it is the lower torso. In epee and sabre, the upper torso is viewed about 50% of the time, with three other areas also observed, while in foil, the fixation is totally directed to the upper torso. Additionally, two new areas of interest were identified: the score machine and an area involving fixations other than the opponent. The study found no direct link between visual activity and performance. The visual search strategy varies among weapons, with foil using a gaze anchor or foveal spot and epee and sabre utilizing a visual pivot due to the discipline's inherent rules. The study also emphasizes that competition-like conditions can disrupt visual activity with external stimuli, possibly affecting performance.

Fatigue in elite fencing: Effects of a simulated competition.

The fatigue induced by fencing remains scarcely investigated. We aimed to investigate both objective (neuromuscular performance fatigability) and subjective (perceived fatigue, effort, and workload) manifestations of fatigue in elite fencers following a five-bout simulated competition. Changes in countermovement jump height, knee extensors maximal isometric torque, rate of torque development, voluntary activation, and contractile response to muscular electrical stimulation were measured in 29 elite fencers [12 epee (6 women), 11 saber (5 women), and 6 foil]. Perceived fatigue and effort were evaluated with visual analog scales, and the perceived workload with the NASA Task Load Index scale. During the competition, maximal torque and rate of torque development decreased by 1.6% (p = 0.017) and 2.4% (p < 0.001) per bout, respectively. Perceived fatigue before each bout increased (12% per bout), with similar values observed at the end of all bouts (bout × period interaction: p < 0.001). Perceived effort increased during the bouts (10% per period, p < 0.001) and during the competition (3% per bout, p = 0.011). Perceived mental demand increased during the competition (2% per bout, p = 0.024). These results suggest that elite fencers needed to increase the allocation of mental rather than physical resources to the task to counterbalance the deleterious effect of fatigue on performance.

Obesity in Childhood and Adolescence: The Role of Motivation for Physical Activity, Self-Esteem, Implicit and Explicit Attitudes toward Obesity and Physical Activity.

The purpose of the present study was to compare attitudes toward body weight and physical activity in both regular-weight and overweight/obese children and adolescents, and assessing relations between attitudes and self-esteem, motivation for physical activity, life satisfaction and level of physical activity. A total of 126 children (Mage = 12.2, SD = 3.4), divided into two subsamples (i.e., overweight/obese, N = 44, and regular-weight), voluntarily participated in the study. A series of univariate analyses of variance was conducted to examine the differences in the study variables across the subsamples. Correlational analyses were conducted to examine the relationships among the variables. The results indicated that obese/overweight participants expressed a more positive implicit attitude toward the thin category than regular-weight participants. Furthermore, among overweight/obese participants, implicit attitude toward physical activity was significantly negatively correlated with explicit attitude toward physical activity and general self-esteem. Significant differences between obese/overweight and regular-weight participants indicated that the status in terms of weight played a key role in attitudes toward the explored constructs.

Asynchronous Heart Rate Variability Biofeedback Protocol Effects on Adolescent Athletes' Cognitive Appraisals and Recovery-Stress States.

This study examined the effect of an asynchronous heart rate variability biofeedback (HRV-BFBasync) protocol on national-level adolescent swimmers' cognitive appraisals and recovery-stress states during a six-week ecological training period. A polynomial mixed-effects multilevel regression analysis approach was used with 27 adolescent national-level swimmers randomly assigned to an intervention group (n = 14) and a control group (n = 13). Six waves of assessments of cognitive appraisals and recovery-stress states were completed during six weeks of training preparation in ecological conditions. The results revealed that the HRV-BFBasync protocol significantly predicts lower levels of biopsychosocial stress states and cognitive stress. However, no significant effects were found for biopsychosocial recovery scales and cognitive perceived control. The results suggested that total stress states, sport-specific stress, and cognitive perceived stress evolutions are a function of polynomial time third-degree interactions with HRV-BFB protocol. Overall, this study suggested that the HRV-BFBasync protocol leads adolescent athletes to experience lower biopsychosocial and cognitive stress levels during training periodization. Our results also suggest that HRV-BFB induces complex evolutions over time for stress and recovery states but does not have a predictive function for the recovery states and perceived control.

Longitudinal relationships between mental toughness, resilience, cognitive appraisals and perceived performance in competitive soccer goalkeepers.

The purpose of this study was twofold: (1) to examine the influence of the mental toughness (MT) trait on resilience, cognitive appraisals and perceived performance states and (2) to explore dynamic relationships between these states among soccer goalkeepers during a competitive season. Thirty-six soccer goalkeepers from regional to professional levels first voluntarily completed a questionnaire measuring their mental toughness. Subsequently, a single-item approach was used to assess resilience, cognitive appraisals (threat, loss, challenge and benefit) and subjective performance every 2 weeks for 4 months. Results of multilevel analyses showed that mental toughness significantly and positively predicted resilience, which significantly and positively predicted benefit appraisal and negatively predicted threat appraisal. Moreover, subjective performance was significantly and positively predicted by benefit appraisal. Our results also revealed the mediating role of resilience in the relationship between mental toughness and appraisals (threat and benefit) as well as the mediating role of benefit appraisal in the relationship between resilience and subjective performance. Practical applications are proposed to optimize the daily experiences of goalkeepers, such as creating a supportive climate.

The impact of stress, recovery and coping on burnout symptoms of young elite table-tennis players: A prospective multilevel study.

Objective: The aim of the present study was to explore the role of stress, recovery, and coping on table-tennis athlete burnout symptoms in considering both the roles of individual and contextual (training center) factors. Methods: One hundred and fifty-nine youth elite table-tennis players (Mage = 14.07, SD = 2.13) involved in 15 intensive training centers completed self-report questionnaires and socio-demographic data. Results: When time 1 (T1) levels 1 (individual) and 2 (training group, contextual factor) stress, recovery, and coping were simultaneously entered as predictors of each of the three burnout symptoms (physical and emotional exhaustion, sport devaluation, reduced accomplishment) at T2 (controlling for levels 1 and 2 burnout at T1), the results of multilevel analyses revealed that: (a) T1 level 1 recovery significantly negatively predicted T2 reduced accomplishment (ß = -0.23, p = 0.03); (b) T1 level 2 disengagement-oriented coping significantly negatively predicted T2 reduced accomplishment (ß = -0.71, p = 0.03); and (c) T1 level 2 task-oriented coping marginally significantly positively predicted T2 physical and emotional exhaustion (ß = 0.99, p = 0.06). Conclusion: Results of the present study provided evidence for the usefulness to disentangle the variances attributable to the individual (level 1) and contextual (level 2; training group) levels of the predictors (recovery, stress and coping) of athlete burnout. Moreover, rather than examining the antecedent role of stress on athlete burnout, it could be particularly fruitful to explore theoretical constructs able to annihilate the maladaptive effects of chronic stress such as coping and recovery.

Validation of the motivation scale towards Health-Oriented physical activity (EMAPS) in Spanish Population.

The aim of the present study was to examine the psychometric properties of the motivation scale towards health-oriented physical activity (EMAPS) in the Spanish Population. A sample of 808 participants (Mage = 33.90; SD = 12.91; 366 men and 440 women), participated to ensure the structural, methodological, and external correlates of EMAPS scale validation. Results of the structural stage of analyses confirmed 6 dimensions of EMAPS (i.e., intrinsic motivation, integrated regulation, identified regulation, introjected regulation, external regulation and amotivation). In conclusion, results provided evidence for the reliability and validity of the Spanish version of the EMAPS scores. Thus, this instrument may serve to provide a measure of the motivation towards health-oriented physical activity purposes in the Spanish population.

Emotional Intelligence in Ultra-Marathon Runners: Implications for Recovery Strategy and Stress Responses during an Ultra-Endurance Race.

The aim of this research was to investigate the role of trait emotional intelligence (EI) in recovery stress states in a mountain ultra-marathon (MUM) race. Recovery stress states of 13 finishers were assessed before, during, and immediately after the end of an extreme MUM, whereas emotional intelligence was assessed 2 days before the MUM race. Temporal evolutions of recovery stress states were examined. Stress states increased after the race whereas recovery states decreased in all participants. In addition, recovery states were influenced by the trait EI level assessed before the competition. Results supported the hypothesis that trait EI tends to have a positive effect by boosting recovery strategies. In this perspective, trait EI could have a protective role against stress and improve pre-competition mental preparation. High scores of trait EI (in comparison to low scores of trait EI) could have helped athletes to increase recovery states in order to improve their psychological adaptation to one of the most difficult races in the world.

Development and validation of a quality of life measurement scale specific to hereditary hemorrhagic telangiectasia: the QoL-HHT.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) disease is a rare genetic disorder with symptoms and complications that can significantly affect patients' daily lives. To date, no scale has been validated to assess the specific symptoms of this disease on the quality of life (QOL) of HHT patients. This makes it difficult for clinicians to accurately measure the quality of life of patients with HHT. The present study aims to develop and validate a QOL measurement tool specific to HHT disease: the QOL questionnaire in HHT (QoL-HHT). METHODS: A quantitative, non-interventional, multi-center study involving HHT patients in twenty French HHT expert centers was conducted. A calibration sample of 415 HHT patients and a validation sample of 228 HHT patients voluntarily participated in the study. Data were analyzed using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), Exploratory Structural Equation Modeling (ESEM) analyses, reliability analyses, and correlational analyses. RESULTS: The EFA, CFA and ESEM results allowed us to provide evidence of the factorial structure of a questionnaire composed of 24 items measuring 6 domains of QOL: Physical limitations, social relationships, concern about bleeding, relationship with the medical profession, experience of symptoms, and concern about the evolution of the disease. Cronbach's alpha coefficients (> 0.70) demonstrated reliable internal consistency of all the QoL-HHT scores (dimensions). The results of the test-retest provided further evidence of the reliability of the QOL-HHT scores over time. Correlational analyses provided evidence for the convergent validity of the QoL-HHT scores. CONCLUSIONS: We developed a simple and quick self-assessment tool to measure quality of life specific to HHT disease. This study demonstrated reliability and validity of our QoL-HHT scores. It is a very promising tool to evaluate the impact of HHT disease on all aspects of the quality of life of HHT patients in order to offer them individualized medico-psycho-social support. TRIAL REGISTRATION: ClinicalTrials, NCT03695874. Registered 04 October 2018, https://www. CLINICALTRIALS: gov/ct2/show/NCT03695874.

The Predictive Role of Perceived Support from Principals and Professional Identity on Teachers' Motivation and Well-Being: A Longitudinal Study.

The aim of this study was to estimate the influence of perceived support from principals and teacher professional identity (TPI) on teacher's motivation, vigour and burnout using a longitudinal design during a school year. A sample of 544 secondary teachers reported their perceived support from principals and TPI at the beginning of the year (T1) and their self-determined motivation, vigour, and burnout both at the beginning (T1) and at the end of the year (T2). Structural equation modelling (SEM) revealed that the support from principals was associated with T1 TPI. T1 TPI only partially predicted T2 self-determined motivation (controlling T1 scores), and T2 self-determined motivation was associated with T2 burnout and vigour (controlling T1 scores). The SEM revealed a positive process involving perceived support from principals, pedagogical expertise, autonomous motivation, and well-being indicators. In summary, the present study extends the knowledge about the teacher well-being process and the role of contextual and individual antecedents. In an applied perspective, to prevent burnout, teachers need efficient initial and continuing pedagogical education to be armed in front of the students and need the support of their principals during the school year.

A Temporal Study on Coach Behavior Profiles: Relationships With Athletes Coping and Affects Within Sport Competition.

The study aimed to identify coach behavior profiles and explore whether athletes from distinct profiles significantly differed on coping and affects experienced within 2 hr before the competition and during the competition (measuring them 2 hr after the competition). A sample of 306 French athletes (Mage = 22.24; SD = 4.91; 194 men and 112 women) participated in the study. The results revealed the emergence of two profiles: (a) a coaching engaged profile that stands out for moderate physical training and planning, technical skills, mental preparation, goal setting, competition strategies, personal rapport, and moderate negative personal rapport; and (b) a less engaged coaching profile with low physical training and planning, technical skills, mental preparation, goal setting, competition strategies, personal rapport, and moderate negative personal rapport. Memberships of coach behavior profiles were not confounded by athletes' practice experience, athlete's gender, and coach experience. Results of latent profile analyses with Bose-Chaudhuri-Hocquenghem method (BCH) method revealed that coping and affective states significantly differed across the coach behavior profiles. As a whole, the less engaged coaching profile engenders the worst outcomes in competition. In conclusion, the detection of less adaptive coaching profiles would be crucial to prevent negative outcomes in athletes during the competition. This might be using intervention programs adapted to the peculiarities of athletes from a particular coach behavior profiles.

Dealing with elite sport competition demands: an exploration of the dynamic relationships between stress appraisal, coping, emotion, and performance during fencing matches.

The present research aimed to provide a more holistic analysis of stressful experiences in sport by examining how stress appraisal, coping and emotion are dynamically inter-related constructs and the extent to which their dynamic relationship is associated with objective performance. Based on process-oriented methods, two studies were conducted with elite athletes in order to investigate the dynamic relationship between these constructs and performance in highly demanding sport situations (Study 1: simulated competitive fencing matches during a training session; Study 2: real-life competitive fencing matches during an international competition). The results of the random coefficient regression models emphasise the dynamic nature of the relationship between stress appraisal, coping behaviour, emotion and objective performance over the course of fencing matches. They allowed identification of additional mediating effects of coping and emotion within dynamic relationships between stress appraisal and performance. These studies contribute to a deeper understanding of psychological adaptation in performance environments. The implications of the findings are discussed in relation to the design of effective coping interventions to support the learning of performance-related coping skills and the attainment of performance goals among individuals in highly demanding environments.

Acceptability of technology-based physical activity intervention profiles and their motivational factors in obesity care: a latent profile transition analysis.

OBJECTIVES: This study aimed to: (a) identify the acceptability profiles for three technology-based physical activity interventions (TbPAI) in obesity treatment (active video games, mobile applications, telehealth), (b) examine the issues of consistency or change in these profiles for the same individual across technologies, and (c) determine whether acceptability profiles are related to motivational factors. METHODS: Three hundred and twelve women (Mage = 30.7, SD = 7.1 years; MBMI = 34.5, SD = 7.8 kg/m²) using obesity services were recruited for this cross-sectional survey. They completed an online survey including sociodemographic data and measures related to physical activity: level, stage of change, motivation, and general causality orientations. The women read descriptions of the three technologies and rated their acceptability. We used a latent profile transition analysis (LPTA) approach. RESULTS: A 2-class model (high and low acceptability) best described the profiles for each technology. Intra-individual analysis revealed that the profiles exhibited both changes and stability across TbPAI. Women with high scores on impersonal orientation were more likely to be in the high acceptability telehealth profile, whereas those reporting high scores on control orientation were more likely to be in the high acceptability active video games profile. Women with high scores on control orientation and low scores on impersonal orientation were more likely to be in the high acceptability mobile applications profile. CONCLUSIONS: Results showed that the causality orientations were factors related to the TbPAI acceptability profiles, suggesting that clinicians should consider these psychological characteristics in TbPAI counseling.

Need frustration and depressive symptoms in French older people: using a self-determination approach.

OBJECTIVES: To provide evidence of the relationship between basic psychological need frustration (BPNF) for autonomy, competence and relatedness, and depressive symptoms in French older people, and to explore the potential moderator effects of place of residence (home vs nursing home) on this relationship. METHODS: Partial least squares path modeling (PLS-PM) was used. A total of 410 French older people (212 women, 198 men, Mage = 77.13 years, SD = 9.19, age range: 60-98 years) voluntarily participated in the study and completed the measures of BPNF and depressive symptoms. Sociodemographic data were collected. RESULTS: Findings showed that for all the participants, competence and relatedness need frustration positively predicted depressive symptoms. More particularly, BPNF for relatedness significantly predicted depressive symptoms for older people living at home (ß = .18, p < .05), whereas BPNF for competence significantly predicted depressive symptoms for both participants living at home (ß = .25, p < .05) and in nursing homes (ß = .34, p < .05). Among participants living at home, results showed that BPNF for competence significantly predicted depressive symptoms (ß = .28, p < .05) across married participants, while BPNF for relatedness significantly predicted depressive symptoms (ß = .27, p < .05) across participants living alone. CONCLUSION: By focusing on BPNF and its relationship to depressive symptoms, this study suggests the importance of investigating further this concept, and alerts to the long-term consequences of frustration of competence and relatedness needs in older people.

The role of dispositional emotion regulation strategies on the longitudinal emotional process and subjective performance during a competitive season.

The purpose of this study was to shed light on the associations between emotion regulation (ER) strategies used, their emotional processes (including cognitive appraisals and discrete emotions), and subjective performance across a competitive season. A sample of fifteen national-level rink hockey players completed ER questionnaire at the beginning of the season (T0) and reported their experiences of everyday appraisal, emotions, and subjective performance every week. A series of hierarchical linear modelling analyses (HLM) were performed to investigate the associations between the variables. Sobel tests were computed to identify the mediating effects of emotions and appraisals on these relationships. HLM results revealed that (a) T0 adaptive ER strategies were positively related to adaptive appraisals; (b) adaptive appraisals were positively related to pleasant emotions and negatively with unpleasant emotions and opposite relationships emerged for maladaptive appraisals; (c) happiness was positively associated with subjective performance. Sobel tests provided evidence of mediating effects of (a) appraisals in the relationships between T0 adaptive ER and pleasant emotions; and (b) happiness in the relationships between appraisals and subjective performance. The results highlighted the positive relationships between the adaptive dispositional ER strategies at the beginning of the season and the emotional experiences. Moreover, the analyses revealed relationships between appraisals, emotions, and subjective performance of athletes. In sum, this study provided additional knowledge about the capture of the emotional process during a competitive season highlighting the associations between a variety of emotions and selected key variables in a competitive context (i.e. ER strategies, appraisal, subjective performance).

Relationships between perceived coach leadership and athletes' affective states experienced during competition.

We examined whether coach leadership behaviours predicted the intensity and direction of positive and negative affects experiencing during competition controlling for affects experienced within two hours before competition. A total of 296 athletes (33% female and 67% male; Mage = 21.61; SD = 6.32) voluntarily participated in the study. A partial least square path modelling (PLS-PM) approach was used to examine the relationships between the study variables. The results showed that coach social support significantly positively predicted the direction of negative affects during competition controlling for pre-competitive negative affect direction. Besides, results revealed that coach democratic behaviour marginally and negatively predicted Negative Affects direction during competition whereas coach autocratic behaviour marginally and negatively predicted Positive Affects intensity. Thus, coach social support emerged as an adaptive coaching behaviour. The usefulness of a longitudinal approach might reveal the multivariate experience of affects states and the manner to handle them from a coach leadership perspective.

Personality traits, stress appraisals and sleep in young elite athletes: A profile approach.

The aim of this study was to identify young elite athletes' personality profiles using a person-centred approach and to investigate whether the profiles significantly differ in stress and sleep. 260 athletes from a variety of sports completed a questionnaire package to assess neuroticism and conscientiousness traits, stress appraisals (i.e. intensity and directional interpretation of stress, challenge and threat appraisals), and various indicators of sleep (i.e. sleep quality, social jet lag, Ford insomnia response to stress test (FIRST)). A latent profile analysis (LPA) approach was used to identify personality profiles based on the scores of neuroticism and conscientiousness. A multivariate analysis of variance was performed to examine if the athletes belonging to different personality profiles differ on stress appraisals and indicators of sleep. Three profiles emerged: Maladaptive profile (high levels of conscientiousness and neuroticism); Highly adaptive profile (moderate level of conscientiousness and low level of neuroticism); Adaptive profile (high level of conscientiousness and moderate level of neuroticism). Results showed that athletes from the adaptive profile reported significantly lower scores of stress intensity and threat appraisal than those from other profiles. Athletes from the maladaptive profile reported significantly higher levels of FIRST than those from other profiles as well as worse sleep quality and lower levels of challenge appraisal than the athletes from the highly adaptive profile. These results suggest that investigating personality profile may be useful in identifying athletes at higher risk of stress sensitivity and worsening sleep that are likely to benefit from preventive actions (e.g. cognitive behavioural therapy interventions).