Treatment fidelity remains underreported in health intervention research, particularly among Indigenous communities. One explanation for this gap is the lack of culturally consonant strategies listed in the National Institutes of Health (NIH) Behavior Change Consortium (BCC) treatment fidelity framework, the gold standard for understanding and measuring fidelity. This paper focuses on the development and implementation of a culturally consonant treatment fidelity support plan across two of the five BCC fidelity areas, provider training and treatment delivery, within a chronic illness self-management program for the Apsáalooke (Crow) Nation. Our team selected and adapted strategies from, and added strategies to, the BCC framework, that centered on relational accountability and the Apsáalooke culture. To be culturally consonant, we approached treatment fidelity as supporting Aakbaabaaniilea  rather than monitoring them. This resulted in the development of a fifth treatment fidelity area: building and fostering relationships. We propose that fidelity to relational accountability is the foundation of successful programs in Indigenous communities. This suggests an important shift from tracking what was conducted in an intervention to prioritizing how things were conducted. We encourage others to view the BCC framework as a starting point in developing fidelity strategies that are consonant with local cultures. In the Apsáalooke (Crow) language, Bílaxpaake báaxiakuleetak means people are aware of each other and there is nothing hidden 3]. The BDespite literature supporting the importance of establishing and maintaining fidelity standards, treatment fidelity remains underreported in health intervention research. In a review of health intervention research articles published between 1990 and 2000, Borrelli et al.  found reTreatment fidelity is also underreported in health intervention research with Indigenous communities. Part of the underreporting is likely due to the lack of culturally consonant fidelity strategies in the BCC framework since the strategies were derived from intervention research with non-Indigenous communities. Despite authors calling for the “flexible adaptation [of BCC strategies] according to setting, provider, and patient”  (p. S52)The purpose of this paper is to describe how our community-based participatory research (CBPR) partnership selected and adapted strategies from, and added strategies to, the BCC framework that centered on relational accountability and the Apsáalooke culture in two fidelity areas: (1) provider training and (2) treatment delivery. The strategies informed our treatment fidelity support plan which was implemented in the Báa nnilah  Program—a health intervention designed to improve self-management of chronic illnesses (CIs) within the Apsáalooke Nation. Our treatment fidelity support plan was intended to support Aakbaabaaniilea (ones who give good advice), or Apsáalooke program facilitators, in leading the Báa nnilah Program.The Apsáalooke or “children of the large-beaked bird” are “exactly in the right place” as stated by Chief Eelápuash (Sore Belly)  (p. 118)Although more fortunate than many tribes, since the Apsáalooke are located on land that is sacred to them, the destructive impacts of colonization continue today in the form of many inequities, including health outcomes. This aligns with data showing that in Montana, American Indians/Alaska Natives with heart disease, diabetes, and cerebrovascular disease die 14, 11, and 10 years earlier than Whites, respectively . EncompaSince 1996, Apsáalooke community members and Montana State University faculty and students have partnered to develop, implement, and evaluate health programs based on community interests and strengths. In 2013, the partnership’s Community Advisory Board (CAB) identified support for community members with CIs as the next area of focus. To meet this need, our partnership developed, implemented, and evaluated the Báa nnilah Program. We evaluated the program using a randomized waitlist-controlled trial in which each of the two arms consisted of 10 groups of 11 Apsáalooke community members—one Aakbaabaaniilea and 10 participants—who were at least 25 years old and interested in improving their CI self-management. Aakbaabaaniilea were members of or had family in the district where they led their meetings (referred to as gatherings) and were seen as role models in their community for being engaged in their health. They led seven gatherings that covered topics including CI self-management, physical activity and healthy eating, historical and current trauma and resilience, patient–provider relationships, and healthy communication. From their personal experiences and community ties, they shared words of advice with and provided support to program participants. To start in a good way, Aakbaabaaniilea opened each gathering with a prayer and a healthy meal. This provided a strong foundation for the rest of the gathering which included an Apsáalooke story related to the topic of the gathering, a lesson, a sharing circle, and an activity completed in supportive partnerships. For more information about the Báa nnilah Program development, implementation, and evaluation, please see Iitáa Dáakuash et al. , and HalOur team’s positionality contributed to how we engaged with the Apsáalooke community throughout the development and implementation of the Báa nnilah Program. Shannen Keene identifies as a first-generation biracial Filipino American woman who grew up in southern Indiana. Grounded in Filipino cultural values of kapwa (inner connectedness) and bayanihan (solidarity), she actively works to uplift the community’s voices and strengths. Sarah Allen is an Associate Professor and Department Chair of Family Life and Human Development at Southern Utah University. She is a white, female, colonial settler from Canada. Her research, teaching, and service have informed her approach to strength-based programs that build individual, family, and community health and well-being in culturally consonant ways. Alma Knows His Gun McCormick is a member of the Apsáalooke Nation and the Executive Director of Messengers for Health, an Apsáalooke non-profit organization. She is a passionate leader and a community activist who desires to see improved health and wellness among her people. Coleen Trottier is a member of the Blackfeet Nation and is also Turtle Mountain Chippewa. She completed her Bachelor of Science at Montana State University in Psychology and is currently on a path toward attending medical school. She works as a student researcher to help in the advancement of ways to improve health so that the approach to better health best serves the community in which it is carried out. Brianna Bull Shows is an Apsáalooke and Pikuni (Blackfeet) tribal member who grew up on the Apsáalooke reservation in Pryor, Montana. She identifies as a kaalishbaapite (grandmother’s grandchild). The knowledge that has been passed down through generations shaped her understanding of treatment fidelity. John Hallett is a community physician who is white and was raised in Wisconsin. He practices trauma-informed primary care with underserved communities in Northern California. He does this work because he believes that relationships and personal stories are central to health. Rae Deernose, Iitáa Dáakuash (Always Has a Good Place to Be), is a member of the Crow Nation and grew up in a five generation family in Benteen, Montana on the Crow Reservation. She received her bachelor’s and master’s degrees in Community Health from Montana State University. During graduate school, she joined Messengers for Health and focused her research on IRM. She also worked to further ignite an Apsáalooke methodology, Walk Story, in Crow Agency, Montana to incorporate methodologies such as making relatives, storytelling, humor, ceremony, language, and physical activity. Suzanne Held is a Professor at Montana State University. She has worked since 1996 as a non-Indigenous partner with the Messengers for Health program. Her interests are to work in partnerships to establish trust, share power, foster co-learning, and address community-identified health issues using strengths- and community-based approaches.Our research approach is led by Apsáalooke cultural values and IRM. This approach resulted in conceptualizing fidelity as modeling Bílaxpaaktialeek because Aakbaabaaniilea are recognized and honored for their good character within the community. This meant doing what we said we would do within our partnership of Indigenous and non-Indigenous scholars as well as within our partnerships among the Aakbaabaaniilea, the Báa nnilah participants, and the Apsáalooke community. Leading with Apsáalooke values also aligns with IRM principles of relevance, reciprocity, respect, relationality, responsibility, and redistribution ,23,24,25We referred to our treatment fidelity support plan as the Aakbaabaaniilea support plan and believed that supporting Aakbaabaaniilea would allow them to follow through with supporting program participants, which would allow the participants to follow through with actions to support their health. Aakbaabaaniilea were lay community health workers with varying levels of comfort and experience in leading groups. They also served many roles in their community and families, while still managing their CIs. Consequently, we wanted to be mindful of additional responsibilities required by the program and be intentional in how we provided one-on-one support to each Aakbaabaaniilea to lessen or alleviate the stress that the role placed on them. We did this to show respect for their time, knowledge, willingness to share with others, and trusted relationships within the community.To develop the Aakbaabaaniilea support plan, team members discussed each of the five BCC areas and strategies and their consonance with the Apsáalooke culture over multiple team meetings. Through discussion and discernment, we determined which strategies to select, adapt, and add. Treatment fidelity strategies used in a tobacco cessation intervention for Alaska Native women also informed our work . Below wAccording to Bellg et al. , this fiThis goal intends to ensure that the research team provides training similarly across providers . The majWe also selected and adapted various other BCC strategies to standardize training. We used a training manual—developed by our CBPR team—that included program gathering summaries and addressed topics such as how to support participants, be mindful of cultural communication patterns, maintain confidentiality, facilitate sessions, and prepare for gatherings. In other words, the “training [took] into account the different experience levels” of Aakbaabaaniilea. We also “design[ed] training to allow for diverse implementation styles” by encouraging them to show their personalities, use their own words, speak the Apsáalooke language (if applicable), and use humor. The final strategy that we utilized was to “ensure that providers meet a priori performance criteria”. To be culturally consonant, the performance criteria were based on lived experience, character, integrity, and respect in the community as positive role models. This has been referred to as reservation credibility—or rez cred. This is different from Western views of leadership, which emphasize education and professional experience, though some Aakbaabaaniilea had backgrounds in relevant fields including community health, social work, and nursing in addition to reservation credibility. This BCC goal involves researchers “train[ing] providers to well-defined performance criteria”  (p. 447)By optimizing this goal, researchers support providers in maintaining their skills across time . In the This goal ensures that researchers adequately train providers with varying levels of skills and backgrounds . While “We viewed the unique backgrounds and experiences of our Aakbaabaaniilea as a strength of our program. As such, we encouraged Aakbaabaaniilea throughout the training to use their own words, experiences, and stories to convey the meaning, intent, and content when delivering the gathering rather than reading from a script. This approach is congruent with the Apsáalooke cultural value of speaking good words from the heart that connects with the needs of the participants. This helped personalize the program delivery approach to reflect their personalities and best meet their participants’ needs.Two additional ways provider differences were accommodated in culturally consonant ways were using the Apsáalooke language and the way feedback was provided to the Aakbaabaaniilea. The Executive Director, a fluent Apsáalooke speaker, worked one-on-one at trainings with an Aakbaabaaniilea who felt more comfortable leading the gatherings in the Apsáalooke language. This accommodation allowed him to understand his role more clearly. She also provided feedback to Aakbaabaaniilea by honoring their unique strengths at monthly meetings, while also addressing areas for growth with the entire group. As mentioned above, it is culturally appropriate to provide constructive feedback to a group versus to an individual to avoid shaming (“have inexperienced providers add to training by attending workshops or training programs”). We highlighted strengths such as expressing genuine concern for participants, communicating in the Apsáalooke language, and using humor to break the ice. Our CBPR team did not approach this fidelity area with the intention to “supervise” Aakbaabaaniilea as stated in BCC strategies. Instead, we supported their growth, encouraged them, and uplifted their inherent strengths.By implementing strategies related to treatment delivery, researchers can ensure that providers deliver the intervention as intended based on the protocol . Goals iThis goal involves selecting providers based on specific characteristics and assessing participants’ perceptions of the providers’ non-specific treatment effects  . As discThis goal serves to “ensure that providers in the same condition are delivering the same intervention”  (p. 448)Often thought of as the heart of fidelity , this goThe third author, the Messengers for Health Executive Director, conducted an in-person evaluation of a 10% random sample of the gatherings as an additional way to evaluate adherence. The gatherings were not video recorded as our CAB and community member staff felt that doing so would take away from the safe and confidential space that was created. The evaluation included identifying the extent to which each gathering component was implemented as intended  and other factors that may have influenced the gathering . She approached the evaluation as an active participant in the gathering, further honoring the relationship she had with Aakbaabaaniilea and the participants. If Aakbaabaaniilea felt unsure during the gathering, they felt comfortable openly asking for her advice and input. Aakbaabaaniilea modeled respecting that advice as their participants did for them. These activities were our culturally consonant adaptation of the BCC’s strategy to “randomly monitor [intervention sessions] for both protocol adherence and non-specific treatment effects”. We also added two new strategies to support treatment protocol adherence. First, the first author called and/or texted Aakbaabaaniilea before each gathering to check in and remind them of materials to bring to the gathering. This is another example of relational accountability. Second, we developed “how to prepare for each gathering” information sheets to meet the request from Aakbaabaaniilea for more organizational tools. These handouts included actions to take before, during, and after the gathering. According to Bellg et al. , this goOur results reaffirmed the cultural value of relationality in that we found a high rate of sharing program content between the intervention and waitlist control groups as well as with the community at large. Eighty percent of waitlist control participants responded “yes” to the question of taking action to improve their health based on something they learned . AlthougWe added a new area to the BCC framework that reflects our CBPR team’s goals of building and fostering relationships that are grounded in trust, integrity, and genuine care and concern. With these intentions, researchers can work towards the following goals: (1) identify and act on support needs, (2) promote relational accountability across the research team, (3) support provider communication with participants, and (4) promote a culture of care. By working towards this goal, researchers can ensure that they are meeting the evolving needs of providers. In the Báa nnilah Program, this occurred through routine in-person and telephone check-ins with Aakbaabaaniilea and by careful observation of Aakbaabaaniilea. Upon learning about or noticing support needs, we followed through. For example, when we learned that an Aakbaabaaniilea needed support with transportation, program staff gave them a ride to the grocery store to pick up food for the opening meal and to their gathering. Also, we noticed that one of the Aakbaabaaniilea was holding the program manual close to their face, making it more difficult to facilitate the gatherings, and inferred that they were having difficulty reading the small print. We followed up one-on-one and after asking if a larger font size would help, printed and provided a new version of the manual. By creating a safe place and facilitating open dialogue for providers to share their unique needs, research teams can address needs and foster trust within their partnership. The purpose of this goal is to foster the research team’s active responsibility to support providers, understanding that every team member contributes to the program’s success. The Messengers for Health Executive Director attended many gatherings to show genuine care, answer questions, and help in whatever way Aakbaabaaniilea needed. For example, she brought more food to a gathering when an Aakbaabaaniilea realized they did not have enough food. This was especially important because they had invited the family members of a participant who had passed on. Montana State University staff, students, and program volunteers also attended gatherings. Some Aakbaabaaniilea also attended others’ gatherings to provide peer support, serving as a backup and complementing the efforts of the Aakbaabaaniilea leading. As a result, at least one team member supported each Aakbaabaaniilea in person at most of their seven gatherings. Indeed, post-program interviews with Aakbaabaaniilea revealed perceptions of timely and accessible support from the CBPR team, resulting in feeling secure, at ease, and not alone.This goal serves to ensure that the research team supports providers in communicating key program information to participants in a culturally consonant and respectful way. After learning that some participants were not attending gatherings and that this impacted the comfort and confidence of Aakbaabaaniilea leading gatherings, research team members connected with Aakbaabaaniilea to support them by providing texts or making phone calls to their participants to remind them of gathering dates, times, and locations. One Aakbaabaaniilea preferred to text their participants. If we were unable to reach participants, we identified additional contacts who could share the information with them. We also communicated with participants when we modified gathering dates to reduce conflict with community events , inclement weather, and deaths in the community. This reflects ongoing team support for flexible timelines as well as respect for the community and the Apsáalooke values. This goal intends to prioritize the providers’ well-being throughout intervention planning, implementation, and evaluation. Our CAB and Aakbaabaaniilea emphasized the importance of well-being based on their belief that we must first take care of ourselves to fully show up for others. Throughout the program, we sent supportive text messages to Aakbaabaaniilea expressing encouragement and gratitude. For example, we texted Aakbaabaaniilea: “As you end your week, remember to be gentle with yourself. You are doing the best you can. Please let me know if I can help you in any way”. Additionally, we integrated mindfulness activities into monthly meetings, encouraged self-care plans, and provided healthy recipe booklets based on Aakbaabaaniilea feedback. This care also extended to their family members when the team expressed care and concern for those who were sick or injured. Similarly, Aakbaabaaniilea reciprocated this care for the CBPR team by offering prayers for their well-being and safe travel through the often dangerous nighttime driving in rural Montana. This support within our partnership was congruent with the Apsáalooke cultural values of Diichikaatah (taking good care of yourself) and Báachiikitáalah (taking care of one another). Similarly, one Aakbaabaaniilea spoke of self-care as an integral part of “practic[ing] what you preach” because “being a mentor is being a role model and being able to give advice to others”, as shared by another Aakbaabaaniilea . They believed that by taking care of themselves and each other, they could “fully get the program out the way we want it to”. This approach was fundamental to fostering trusting relationships and implementing the support plan in a good way.There is consonance between the Apsáalooke concept of Bílaxpaaktialeek, those that align words with actions, and the Western research concept of treatment fidelity. Grounding our treatment fidelity approach in the Apsáalooke culture and relational accountability  led us tOur treatment fidelity approach is consistent with the Apsáalooke culture and IRM, as we prioritized building respectful and reciprocal relationships. We believe this was foundational to the program’s success in health promotion ,23. We aThe BCC strategies selected for our support plan were consistent with those used in health interventions among Indigenous communities. For example, many studies used standardized training materials and role-playing in training sessions ,32,33,34Centering Indigenous values and following Indigenous protocols does not necessarily mean the rejection of all Western methods and theories. Instead, it means that the community leads the determination of what should be selected, adapted, and added to be appropriate and beneficial ,40. OtheWe experienced challenges during the implementation of the support plan. First, some Aakbaabaaniilea forgot to complete sections of the behavioral checklist used to track adherence to the gathering protocol, and two lost their checklist packet. This resulted in missing data, a common issue in fidelity research . To miniOur development and implementation process can inform how future practitioners and researchers approach treatment fidelity in health promotion interventions within Indigenous communities. First, we recommend that communities lead the conversation in selecting, adapting, or adding fidelity strategies that are relational to their culture. Next, we recommend that practitioners and researchers actively engage providers/facilitators to personalize how they would like to receive support. Implementing these strategies in a way that upholds relational accountability and fosters respect, reciprocity, and responsibility is vital. Given the power of sharing in many Indigenous communities, it is also important to assess whether the treatment fidelity goal of “minimizing contamination” is appropriate within specific community contexts. We discussed the Western bias embedded within the construct of contamination elsewhere  and beliIn this paper, we described how our CBPR partnership developed and implemented a culturally consonant Aakbaabaaniilea support plan for the Báa nnilah Program, a chronic illness self-management program for the Apsáalooke Nation. Throughout the process, we were grounded in relational accountability—our CBPR team and Aakbaabaaniilea actively followed through with what we asked of each other. We worked to uphold our relational accountability by reconceptualizing treatment fidelity as providing ongoing, tailored support that centered on Apsáalooke values. In this way, we used the BCC framework as a tool we could select from, adapt, and add to in order to better meet the Aakbaabaaniilea and community’s needs. We hope our approach supports other communities in tailoring treatment fidelity to their local cultures.


Nigeria is estimated to have the largest number of children worldwide, living with chronic hepatitis B virus (HBV) infection, the leading cause of liver cancer. Up to 90% of children infected at birth develop chronic HBV infection. A birth dose of the hepatitis B vaccine (HepB-BD) followed by at least two additional vaccine doses is recommended for prevention. This study assessed barriers and facilitators of HepB-BD administration and uptake, using structured interviews with healthcare providers and pregnant women in Adamawa and Enugu States, Nigeria. The Consolidated Framework for Implementation Sciences Research (CFIR) guided data collection and analysis. We interviewed 87 key informants  and created a codebook for data analysis. Codes were developed by reviewing the literature and reading a subsample of queries line-by-line. The overarching themes identified as barriers among healthcare providers were: the lack of hepatitis B knowledge, limited availability of HepB-BD to vaccination days only, misconceptions about HepB-BD vaccination, challenges in health facility staffing capacity, costs associated with vaccine transportation, and concerns related to vaccine wastage. Facilitators of timely HepB-BD vaccination included: vaccine availability, storage, and hospital births occurring during immunization days. Overarching themes identified as barriers among pregnant women were lack of hepatitis B knowledge, limited understanding of HepB-BD importance, and limited access to vaccines for births occurring outside of a health facility. Facilitators were high vaccine acceptance and willingness for their infants to receive HepB-BD if recommended by providers. Findings indicate the need for enhanced HepB-BD vaccination training for HCWs, educating pregnant women on HBV and the importance of timely HepB-BD, updating policies to enable HepB-BD administration within 24 hours of birth, expanding HepB-BD availability in public and private hospital maternity wards for all facility births, and outreach activities to reach home births. Chronic hepatitis B virus (HBV) infection is a major cause of liver cancer, with 296 million individuals affected worldwide . HBV is Haemophilus influenzae type b-hepatitis B pentavalent combination vaccination) given at six, ten, and 14 weeks of age. However, as of 2021 only 14 (28%) of 47 WHO AFRO member countries have introduced HepB-BD  and Enugu [MH/MSD/REC21/184] States. We obtained verbal informed consent before all discussions to ensure each participant was informed of the risks, benefits, and purpose of their participation. We did not collect identifiable nor sensitive information from participants.Each study population  had a unique but complementary interview guide for discussion . The ConInterviews took place within the HCWs respective primary care government run facilities at the selected study sites and the designation of each HCW was noted. Interviews were audio recorded and transcribed verbatim. More than half of the interviews  were conducted in English, while 18 (38%) interviews with pregnant women were conducted in the local language (Hausa or Igbo). The use of a translator required back translation to ensure translation accuracy. Participants did not review transcripts after interviews were transcribed and translated.a priori) and through the line-by-line reading of a subsample of queries  comprising 7 Doctors, 3 community health extension workers, 7 routine immunization focal persons, 7 officers in charge (HCW in charge of the facility), 8 midwives, and 8 CHVs were interviewed, with equal numbers from each state. The majority of officers in charge, community health extension workers, community volunteers, and midwives were female (73%) and all doctors interviewed were male. All HCWs interviewed were between the ages of 23 to 57 years with an average age of 36 years. The remaining 47 informants were pregnant women attending antenatal care at select health facilities in each state. Findings demonstrate barriers and facilitators to timely HepB-BD and were thematically defined, using quotes describing the overarching themes organized by healthcare providers and pregnant women. The codebook used to organize thematic findings with the corresponding frequencies See .The analysis of our qualitative interviews with HCWs and CHVs revealed that the overarching themes related to barriers were the lack of HBV-specific knowledge in the community, limited staffing within the health facility, unavailability of a specific budget for vaccine transportation to the health facility, limited availability of HepB-BD outside of immunization days, the lack of outreach to provide timely HepB-BD to children born outside of health facilities or outside of fixed immunization days, and misconceptions on HepB-BD timeliness and contraindications. Facilitators were the lack of vaccine stock-outs as a result of solar-powered refrigerators, the community’s trust in HCWs, and awareness among HCWs about the need for expanded sensitization and knowledge on HBV and HepB-BD. Constructs identified from findings were outlined by the CFIR .virus that normally affects the liver. Once you receive the vaccine, it will produce antibody against the virus and protect the child from contracting that virus.” However, misconceptions emerged during interviews with several healthcare providers regarding the transmission of HBV. One nurse described, “they usually like to hold the baby, and some of them might be infected with Hepatitis B without having any symptoms. Hence, when they hold the baby, they may infect it.”The range of knowledge about HBV was highly variable among the HCWs interviewed. Doctors knew significantly more about HBV than other health professionals interviewed ; however, doctors were less familiar with routine immunization logistics for hepatitis B, specifically who administered timely immunization and where immunization occurred. Most HCWs knew hepatitis B was a “if the person that have the disease touch the baby or even the baby inhales it from the carrier, the baby may contract the disease, so you have to protect the baby before going to the village.” A nurse midwife in Adamawa shared misconceptions related to the transmission of hepatitis B as “people can also get it from sweats from a patient link in a vehicle.” A health facility nurse-in-charge in Enugu described, “Hep B is a viral infection. Mosquito can transfer it from person to person.” Other misconceptions emerged regarding hepatitis B being curable. One doctor shared, “hepatitis B is not a death sentence, and it is curable, and equipment for the test should be made available in the health facilities.” Overwhelmingly, health professionals agreed that there is a strong need for hepatitis B education at the community level. The majority of HCWs and CHVs interviewed acknowledged that the most significant barrier to HBV prevention and control is the lack of knowledge associated with the disease.Similarly, a CV shared, “most people having hepatitis B, they are not aware that they have it.” One chief medical officer noted treatment being a significant burden for HBV, describing, “Yes, treatment of hepatitis B infection is not as available, because the medication for it is not as usually accessible, [it’s] very costly… some prefer carrying their infection and wait for the consequences.” Similarly, a doctor shared, “The challenge we have here is that if we test a person and we found out that he has hepatitis, we usually advise or refer. So, the challenge here is that some of them, usually don’t go for their drugs. And after giving their drugs, the fact that the treatment take[s] longer time. Because of poverty, some of them, they will decide to drop the treatment halfway. And as a result, some will lead to dead.” Related to challenges accessing care for hepatitis B, a doctor described challenges with referrals, “Whenever we send them over to go to the state capital to go and get adequate care most of them turn it down due to distance, financial constraint.”A nurse noted symptoms of hepatitis B impacting those living with the disease, “Hepatitis B is a killer disease. Whenever someone is affected, the person will be frequently ill, sometime[s] they present with oedema, abdominal swelling, and sometime[s] they will be irritable.” The lack of resources and infrastructure to manage those living with hepatitis B was further described as “Then you do the fibroid scan which I doubt if there is any place in Adamawa state that has the fibroid scanning machine. Maybe Adamawa German hospital. So, it is actually very cumbersome.”Health professionals noted the following challenges associated with the lack of knowledge on hepatitis B: a) costly medication and treatment were unaffordable for many people, b) isolation due to the illness, c) referrals causing people to drop out of care, and d) overwhelming general lack of resources and hospitals that accommodate people living with HBV. The majority of health professionals interviewed noted the lack of knowledge in the community regarding the diagnosis of HBV, “The need is to create awareness at their settlement, at their villages, the mode of transmission, then the basic symptoms and if they have those symptoms, they should present to the hospital as early as possible instead of using local medication, herbs.” Similarly, another doctor spoke about the lack of awareness of their diagnosis among those living with hepatitis B and described, “I have seen a quite a lot of patients with hep-B and to my surprise, most of them are not even aware they have the infection. So, I think there is lack of awareness.” A chief medical officer in Enugu described, “you know the infection is something they don’t know they have, sometimes they might be thinking they’re charmed, sometimes they might be thinking they are charmed by witchcraft in the society.” A nurse discussed the importance of prevention, “We also need to educate people about the importance of the vaccine and how to live in a health[y] way to avoid getting infected. It is good to start since birth, so that we get optimal protection.”Health professionals spoke of the need for increased awareness and sensitization regarding HBV within communities, the need for infrastructure and resources to manage people living with HBV, and the need to spread the word about the importance of immunization. A unique finding identified the lack of a word for hepatitis B within local languages in Adamawa and Enugu, adding to HBV being described by symptoms and causing confusion within the community. One described, “It’s always available, we have solar fridge here. So, the vaccine is always there in the fridge, and somebody is always there.” Similarly, another mentioned, “because the solar is here, at the beginning of the month, we do bring all the vaccines we need for the month. So most often we do not run out of stock.” While most HCWs noted that stockouts of the hepatitis B vaccine have not happened in some time thanks to the solar refrigerators, a few did mention a few occurrences. One described, “The challenge is when the vaccine is out of stock. That is the only challenge.”All health professionals mentioned that the hepatitis B vaccine was easily available and maintaining the cold chain worked well; many noted that solar refrigerators were very helpful. One physician from Enugu mentioned, “the only thing, we transport. They don’t give us money for collection of vaccine or anything. Challenges is that maybe their facility is far from the health local government where they do get the vaccine.” HCWs in both Adamawa and Enugu also shared that staffing is a significant challenge, a nurse midwife in Enugu explained, “we don’t have enough workers here, we are understaffed.” Another nurse echoed “we do not have enough staff so that we will be going to outreach to far place from this health center and tell them the importance of that Hep B.”Challenges associated with access to HepB-BD for HCW were the costs of transportation and health facility staffing. Similarly, a nurse responsible for immunization services shared, “Some areas in the urban slums people who patronize the birth attendants, after delivery they don’t get the Hepatitis B [birth dose] because they don’t have it there. So, the attendant nurses who have the knowledge will always refer them to [health] centres where they can receive [it] but sometimes, those women don’t access the vaccine.”The main challenges affecting timely HepB-BD vaccination (within 24 hours of birth) were births outside of public health facilities, misconceptions among HCWs about the timeliness of HepB-BD administration, and the lack of vaccine administration outside of regularly scheduled immunization days. A medical officer in Enugu shared the challenges associated with home births: "some [pregnant women] end up in the private sector, some end up in the TBAs area, some don’t even go, they delivery at home. So for those ones that do not have access to government establishment, most don’t hear it.” A nurse responsible for immunization in Adamawa described, “the challenges is like the way I said it before if the women did not deliver at the hospital or they are too far from the hospital and during raining season that time and then they doesn’t know about it.” A CHV in Adamawa shared, “In our Clinic as of now, we are giving hepatitis B within 14 days but if the woman delivered at antenatal health care at immunization date, we give the injection at birth.” Similarly, a nurse mentioned the role of immunization days and stated, “if you don’t deliver at the hospital on that day, please bring in your child during the week for the immunization day and even if she delivers at the hospital and is not the day of immunization, we tell her to come back.” Other HCWs echoed similar sentiments relating to the roles of immunization days. Similarly, a doctor from Adamawa shared, “women who come around to deliver on Wednesdays, Tuesdays, Fridays, Saturdays and the rest of them? So usually what you expect that these ones are not, they may not really get within the first 24 hours.” Another nurse midwife in Adamawa stated that “Women are coming for the vaccine though most come late at 2 weeks, but we emphasize for women to have it at the clinic after birth.”A medical doctor from Enugu emphasized the importance of TBAs and shared, “We keep encouraging [because] prevention is far better than cure so it is better prevented than waiting for when it comes down with the infection at that time the cost will be high.” A nurse mentioned confusion around birth dose and described, “It is important, like [the oral polio vaccine] zero dose, it has no function, but after that zero dose and Hepatitis B one, then, the immunity will now activate and work very well.” Another mentioned avoiding immunization of HepB-BD if there are contraindications, a common misconception about HepB-BD, and shared, “If we notice the baby has no jaundice we give immediately.” Another misconception about HepB-BD administration was described by a community volunteer who shared, “in order to avoid vaccine wastage we normally ask patients to come back on that immunization days… I want them to come together so that they will receive it like at a larger number.”HCWs agreed that HepB-BD vaccination was important. All of them described that hepatitis B vaccine administration within two weeks of birth is critical, while some noted the importance of administrating HepB-BD within 24 hours of birth. These findings demonstrate a need to expand knowledge about the importance of HepB-BD timeliness. HCWs agreed that there is some knowledge of hepatitis B at the community level, but overall knowledge is limited. Most described the need for improved education, particularly to encourage health facility deliveries rather than home births so HepB-BD can be administered on time. A HCW mentioned, “What I will suggest is that hepatitis B vaccine should be available in all the health facilities, that is, even in the labour room so that as the child is being delivered, you give the hepatitis B, in that way they will not be missing the birth dose, even the private hospital.” Another individual stated, “The awareness should be there, create more awareness, that’s number one. Then number two, empower the health workers on the need for them to reach out to their clients. For instance, series of training, training resource persons on the need for this.” Others suggested broader outreach, “Outreaches, that’s always done in churches and schools, maybe girls’ schools, boys’ schools, and then in the marketplaces then awareness, then you increase the rate at which we advertise in the radio.”We asked healthcare providers to provide recommendations on strategies to improve timely HepB-BD uptake in their facilities. Many suggested logistical strategies, such as ensuring HepB-BD is available within maternity wards. One HCW stated, “educating people by way of maybe, you can come and do some dramas for us or training the community, educating the community. so that they will know or even if you have posters.” One nurse noted the importance of including TBAs in the education about HepB-BD and shared, “A lot of pregnant women go for antenatal but not all of them. Secondly, not all of them go to government centers where those things are supposed to be available, some end up in the private sector, some end up in the Traditional Birth Attendants area, some, they deliver at home. So, what I have come to say the organization need to extend their hands not to restrict the training or awareness to those working in the government establishment, if it can be extended to non-governmental areas like private clinics, TBAs, give them their training.” Another suggested financial resources would be valuable by stating, “please employ workers and give us transport.” Another suggested going to homes to encourage delivering in a health facility and emphasize the importance of coming to the facility for HepB-BD administration.Another individual similarly stated, “We identified the lack of knowledge about HBV, limited understanding of the importance of timely HepB-BD, and access to the vaccine as overarching themes for barriers among pregnant women. The main facilitator to getting a HepB-BD was the high acceptability of HepB-BD if it is offered by HCWs. Women also suggested that HCWs conduct outreach activities to improve HepB-BD uptake and increase HBV awareness within the community, incorporate education about HepB-BD during antenatal care, and provide education about HBV and HepB-BD in the media. Below are some examples of each overarching theme from the interviews and by using the CFIR as outlined in From the little I know is that they say that it’s a deadly disease and it’s contacted by through sexual intercourse and also breastfeeding of baby.” A few women did know that hepatitis B “is a disease of the liver,” and others shared that there is “an immunization given to kids. It’s for health purpose.” Others also had misconceptions about HBV and one shared, “I don’t know much, I know it’s a disease of newborn babies that affect them when they are born,” while another stated, “the little knowledge I know about it is that it is a disease that normally treated in pregnant woman during about 3 to 6 months of pregnancy to avoid some sicknesses after childbirth.” Others mentioned they had heard of HBV but described, “it is not in my lineage” or shared, “the little I know about it, is a disease that kills but for now there is no remedy for it.” Overall, there was limited knowledge about HBV and misconceptions about disease transmission existed within the community.Many women reported not knowing much about HBV. However, some had heard of it but remembered a few details about the virus. An individual shared, “I just told the midwife that she should attend to me that the way that my baby will be okay, that will not have issue on my baby, that anything that you know as you are a mother before me that you can take care of my child, as in I give everything to you.” Interestingly even though women did not know much about HBV, they would still take it “to protect my baby against hepatitis B.” When asked, all women interviewed felt the birth dose was essential and said they would request it from their HCWs after delivery.When asked about the HepB-BD, many women mentioned they did not know much about it other than the fact that it is given to children. All women interviewed shared that they would ensure their child would get HepB-BD if their HCWs recommended it. Overall, the women expressed significant trust in their HCWs. One individual shared, “some people if the[y] give birth at home they don’t use to bring their child for vaccination, so the suggestion I will make here is that if it will be possible it is good for health workers like you to go into the community make awareness tell them the danger that is involved if your child doesn’t have the vaccine.” Similarly, another woman expressed the importance of rural outreach. She shared, “Some people we come but when you have time to come to village square and make the village come out, that some people are coming to address you people on hepatitis B. If it’s the village square everybody will come and hear what you are saying.”Women described the importance of messaging to increase awareness and access to HepB-BD, especially in rural areas or those delivering at home. A woman described the importance of reaching all women, “Antenatal day, so that’s the best way I suggest that you should come and lecture them about it.” Others suggested using mass media as a strategy to reach a broader audience. Another said, “I suggest that the government should try to give all information on hepatitis B on radio and television, even on, maybe in churches and schools, we announce to them about it.” Others suggested incentives to increase women’s attendance in educational events. A prospective mother shared, “Some will give bag, some will give tissue, and some will give soap. If you give anything that will, even those that will collect bag. Whenever they hear that they will get them something, [they] will want to come out.”The pregnant women interviewed overwhelmingly suggested that providing education during antenatal care through health talks could be most effective in improving HepB-BD awareness among women. Many women described how antenatal care was a helpful tool in education and described receiving information on giving birth, baby positioning, signs the body is ready to deliver, and immunizations. A woman said, ““that one is included because during that time of education all this flyers now they use to give us example show us all this flyer and also pictures.” A couple of women emphasized the importance of social media and mass media messaging. A woman explained, “I advise that you put it on social media… like on Facebook, and then Instagram. You should make sure they always advertise … all these a radio station, television station for them for people, because, not everybody that go online or have phone to browse, to go on Facebook, and most people even in these rural area, they’d have television, and when they start seeing this hepatitis B vaccine.” Others also suggested expanding awareness at various places where people go, stating that “Yes, they should create awareness at the markets, mosques, and churches.”Another woman suggested having print materials at the time of education and added that visuals would help with learning, This qualitative study among HCWs, CHVs, and pregnant women in two Nigerian states demonstrated that healthcare providers in Adamawa and Enugu experienced barriers regarding the accessibility of HepB-BD, including transportation costs for accessing vaccination, staffing shortages within health facilities, and births taking place outside public health facilities . In addition, gaps in knowledge among HCWs regarding HBV transmission, misconceptions about the timeliness of HepB-BD, and concerns about vaccination wastage. Facilitators included the cold chain availability in most cases, low stockout of the vaccine, the acknowledgment of the importance of HepB-BD among providers, and high acceptability of HepB-BD among pregnant women. Healthcare providers and pregnant women noted a significant need for enhanced training, sensitization, and awareness on HBV and the importance of timely HepB-BD. While we expected to see significant differences in barriers and facilitators to HepB-BD administration between the two states, findings identified similarities among both states rather than differences.Pregnant women interviewed were receptive to all services offered and recommended by healthcare providers. Acceptance of HepB-BD if offered by HCWs indicate that vaccine acceptability is high among pregnant women but vaccine access is limited due to the restriction of HepB-BD vaccination to immunization days in most public facilities, the lack of HepB-BD at private health facilities, and the lack of outreach sessions to vaccinate children born at home. Findings also suggest low vaccine stocks due to solar refrigerators. With these findings, HCWs involved in labor and delivery and routine immunization should work collaboratively to ensure HepB-BD is administered on time. HepB-BD should be accessible within delivery wards and beyond regularly scheduled immunization days, not only in public facilities but also in private facilities and among TBAs.Successful strategies in improving timely HepB-BD vaccination among health facility births include integration of HepB-BD vaccination with essential newborn care, assigning the responsibility of HepB-BD vaccination to the person who delivers the baby, and storing HepB-BD near the delivery ward to reach children at all times and not only during immunization days , 24. In Pregnant women and healthcare providers interviewed were not widely aware of HBV, and several misconceptions about its transmission, symptoms, and consequences emerged. This finding is consistent with other studies within the African region, highlighting the low knowledge and awareness related to HBV –29, and Healthcare providers and pregnant women expressed the need for education and awareness on HBV, emphasizing the importance of timely HepB-BD. Healthcare providers and pregnant women discussed the significance of providing education throughout the community, both within antenatal care through health talks and beyond through multi-media platforms, such as radio, social media, and community religious leaders. Future efforts should educate and train healthcare providers on hepatitis B disease and the importance of administering timely HepB-BD. Emphasis should be placed on addressing any misconceptions about transmission and contraindications associated with vaccine administration. Several pregnant women recommended incorporating education on hepatitis B and the importance of HepB-BD vaccination during antenatal care visits. Literature has demonstrated that patients with more antenatal care visits have lower maternal, fetal, and neonatal morbidity and mortality than those with fewer visits . AdditioWhile this study provides valuable insight into HepB-BD barriers, facilitators, knowledge, and practices related to hepatitis B virus infection and management, limitations should be noted. While qualitative data collection methods provide rich, in-depth, experiential information, data are limited in external validity  and cannot be representative of all experiences related to the HBV knowledge, administration, and uptake of HepB-BD within Nigeria. Additionally, some bias may be present in the selection of respondents as some respondents may have been different than those who did not volunteer to participate. However, the number of respondents approached to participate was large in order to capture a more broad and representative cross section of the population and diversify responses for better generalizability. Additionally, saturation of data was reached for both healthcare workers and pregnant women in this study to mitigate this limitation.Nigeria has one of the highest burdens of hepatitis B virus infections globally and the highest burden among children under five years of age . To reacS1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S1 Data(PDF)Click here for additional data file.


This article reviews historically significant phenomenological studies of visual mental imagery (VMI), starting with Fechner in 1860 and continuing to the present. This synthesis of diverse VMI phenomenological studies in healthy adults serves as a unique resource for investigators of individual differences, cognitive development and clinical and neurological conditions. The review focuses on two kinds of VMI, “memory imagery” and “eidetic imagery”. Ten primary studies are drawn from three periods of the scholarly literature: early (1860–1929), middle (1930–1999) and recent (2000–2023). It is concluded that memory and eidetic imagery are two forms of constructive imagery, varying along a continuum of intensity or vividness. Vividness is a combination of clarity, colourfulness and liveliness, where clarity is defined by brightness and sharpness, colourfulness by image saturation and liveliness by vivacity, animation, feeling, solidity, projection and metamorphosis. The findings are integrated in a template that specifies, as a tree-like structure, the 16 properties of VMI vividness in healthy adult humans. The template takes into account the weight of evidence drawn from the accounts and reveals an extraordinary degree of consistency in reported VMI characteristics, revealed by specialized studies of healthy adult humans across time, space and culture. Any stable environment of familiar objects evokes sensations, images and feelings that vary by degree across individuals. Accordingly, it is surprising that any pair of individuals is able to reach agreement about what they are perceiving and feeling based on the two sets of fallible conscious experiences. While everyone may have their own unique perspective, there must also exist rules that create consistency. Anyone can experience the “redness” of an apple, the “pointedness” of a stick or “the warm feeling” of a campfire because there is, one must believe, something that it is like to have these experiences. There are particular phenomenological qualities or “qualia” that each of us has with these experiences . The redAlmost every reviewer of mental imagery research starts with Aristotle 384–322 B.C.E.), who stated that “Images belong to the rational soul in the manner of perceptions, and whenever it affirms or denies that something is good or bad, it pursues or avoids. Consequently, the soul never thinks without an image” .KAMBA WOMAN: I see some people and motor cars, one man on top, with goods on top. (What is the color of the bus?) Looks like red and green [brownish and white]. (What else do you see?) Many people.(Do you see any trees?) Yes. (Where?) [Points correctly]. (Do you see anything else?) I see nothing more. (Can you see the license plates on the cars?) No.MASAI HERDER: (Can you see their trousers?) No, I can’t see them. (What do you see on the screen now?) I still can see that person, but it is not now very clear.SWAHILI CULTIVATOR: I see some numbers, an elephant, a man. (Do you see them clearly?) I see them. (Can you see the numbers?) I see the numbers clearly. (Can you read them?) I can read them.  0 [pause of 7 s] 2 [5 s] 2 [4 s] 1 [5 s] 7 [6 s] 0 again [actually: 0714653282760].The incidence of eidetic imagery is not significantly higher or lower in African societies than in European or US samples;(ii)A high degree of variability was evident within each sample and “the attributes and characteristics of eidetic imagery when they do appear do not vary from society to society and, in fact, are no different from those found in Europe and America” ;(iii)As was the case in the Western laboratory studies, the differences within groups appeared much greater than those between groups.Doob reported: “Almost without exception those with eidetic imagery…stated that they had been amazed to see the images on the screen, that this was an experience they had never or seldom previously had ”. However, this latter finding was most likely a consequence of the participants’ unfamiliarity with being tested by looking at pictures on easels because the majority claimed they customarily were used to “seeing pictures in front of my eyes” (projected imagery) . There was no statistically significant relationship between the presence of eidetic imagery and of projected imagery in any of the groups. Likewise, many informants stated that often they have “pictures in my head,” or pictorial images when recalling events or people from the past . Pictorial images were occasionally reported by Somalis to be “in my heart” and by the Swahili to be “in my mind”. No association existed between eidetic imagery and pictorial imagery, nor between eidetic imagery and projected imagery. During or after the tests for eidetic imagery, the accuracy of recall was also found to be unrelated to claims of projected imagery or pictorial imagery for the pictures that had been exposed. A Somali stated that he could see “the bus” in his head but, when asked to describe what he saw on top of the bus, he incorrectly replied that “nothing” was there. From the standpoint of most informants questioned, there was a difference between remembering with eidetic, projected or pictorial imagery on the one hand, and what is ordinarily called “simple memory” or recall on the other . Doob’s  observatImagination and Thinking [https://cir.nii.ac.jp/all?q=Tohoku%20psychologica%20folia. Until now, they have not been widely disseminated and they warrant closer attention. The original purpose was to determine, through the use of VMI, whether Y.K. could fill a empty circle on a small, neutral card spontaneously with mentally imaged colour. The author used what later became known as the “Open Circle Test”, which is described as follows:With the exception of the above-mentioned studies on eidetic imagery, the absence of any new phenomenological studies for almost half a century left a vacuum that remained unfilled until the 1960s and 1970s, when an “explosion” of mental imagery studies occurred. The 1957 book by Peter McKellar, Thinking , presageThinking ,43 publiOne of the twenty subjects, YK, could see inside of the circle vivid images of concrete shape and colour, not mere colour image, at any time when a certain colour name was given to her. She gave a signal by tapping the desk with her right-hand forefinger, every time such an eidetic image appeared or it changed in its figure. She could also scan the images as if she were looking at paintings or photographs.The investigator used a white card (12.5 cm by 20 cm) and a grey card (10 cm by 15 cm). A circle of 5 cm in diameter was drawn in the centre of the white card, and one of 2 cm on the grey one. The investigator asked the participant to imagine a blue colour inside the circle, and then red, yellow and green. With the white card first and then the grey card, 3 min were assigned to each of the four colours . After each occasion, Y.K. was required to state whether a colour image appeared, and if it did, what it looked like. They were requested to draw an image if they saw one, on a sheet of paper with a pencil.tapped the desk with her forefinger to indicate that an image had begun to appear inside the circle or if it transformed its shape. Y.K. produced drawings afterwards, and her responses to nine of the twenty-four tests are reproduced in Two months after the first laboratory visit, Y.K. came to two more sessions using the same methods. Twenty-four tests were carried out. The findings showed that, at each test, Y.K. could project images associated with the appointed colour names; the VMI content changed over the 3 min of the test. Y.K. Hatakeyama’s conclusion was that eidetic imagery is a constructive process similar to those of the other VMI kinds of memory and imagination imagery. Hatakeyama (1975)  stated tVarious experimental evidences given by a twenty-year-old female of extremely high eidetic ability shows that eidetic imagery is possessed of the constructive character. The word “constructive” means not only the fact that different features from the original stimulus appear in the image, but also, more positively speaking, that eidetic imagery has an aspect of being constructed like any other ordinary memory imagery. In this regard, it deserves emphasis that an eidetic image belongs to “imagery” and that it should not be construed merely as a photographic image, that is, an accurate copy of the original stimulus, or as a photographic memory, that is, an accurate retention of the original stimulus in visual memory.Thus, eidetic imagery appears to be a highly flexible and fluid form of VMI that does not necessarily require an evoking stimulus. Hatakeyama ,43 dividAs noted, Y.K. visualized vivid eidetic images inside the circle at any time colour names were given to her. There were some cases when the content of a produced image could not be identified, or when part of the image was discrepant with the original object that had been indicated . When Y.(i)Gradual Development and Fading;(ii)Attentional Effort;(iii)Supplementation: “new features, which the stimulus pictures did not contain, were added to the images”;(iv)Grounding: “where images lacked a particular part, such part was not left entirely blank but suffused as some kind of ground in the image”;(v)Metamorphosis: dramatic and sudden changes in eidetic imagery content;(vi)Re-emergence;(vii)Replication: e.g., “an orange square was presented and the same colour image appeared”;(viii)Figure–Ground Colour Reversal.Observations in  show higEidetic images reproduced after a lapse of time revealed an “exceedingly constructive character”. It took time before the eidetic images were produced. These images tended to appear “little by little”. Details of the image were often initially indistinct and became more distinct. There were instances where motion or activity appeared in the image, e.g., “in the image of one silhouette picture evoked on the following day, a flag on the top of the building in the original picture, was seen fluttering”. When the picture of the “Sparrows’ School” was evoked on the following day, “the sparrows were moving about inside the nest, bobbing their heads; at the same time S sensed them peeping”. There were some cases of divergence between the eidetic image and the memory contents of the original stimulus picture.When the projection cards presented complex designs, such as patterns of chiyogami (rice-paper with coloured figures) or a black-and-white striped pattern, eidetic images were constructed to assimilate elements of the projection surface.Tests with complex, abstract stimuli of Chinese characters used complicated numeral patterns . The eidetic imagery here were far from complete reproductions of the original stimuli, with “extremely constructive features”, which lacked unity with other parts. The “entire image did not appear at the same time, but a restricted part, to which YK directed her eyes on the projection surface, was visualized and, as she shifted her eyes, the missing part appeared”.(i)EI is a constructive process of agency involving the participant’s attentional efforts, force of will and intentions. This point is reminiscent of Fechner’s and Galton’s findings;(ii)EI is a flexible and fluid process with gradual development and fading, attentional effort, supplementation, grounding, metamorphosis and figure–ground colour reversal;(iii)As suggested by Fechner, there is a dynamic interaction between the after-image and the eidetic image.Hatakeyama’s research ,43 led tThis study with a young woman of high eidetic imagery ability indicates the pinnacle of eidetic imagery achievement. Further studies by Hatakeyama  in diffeTwo replication studies of Hatakeyama’s findings were conducted by the author and Peter McKellar at the University of Otago, New Zealand . InitialNext, we presented the Open Circle Test to randomly selected samples from the student population. Thirty of forty-four (68.2%) unselected students gave positive eidetic imagery reports in response to specific colour names . Using l(i)Eidetic imagery is a vivid, fluid and flexible process;(ii)Eidetic imagery is a constructive process, not a reproductive or “photographic” one;(iii)Eidetic imagery can be voluntarily controlled by the participant’s focus of attention;(iv)Like all other kinds of VMI, there are wide individual differences;(v)In its weakest, spontaneous form, eidetic imagery is available to the entire population.Studies of eidetic imagery using unselected student samples suggest these conclusions:There are only a few studies of mental imagery in people with intellectual disabilities. In the recent period, there have been efforts to fill this gap. Brown and Bullitis  exploredVividness of Visual Imagery Questionnaire [Another new dataset has been provided by Hewitt et al. , who useionnaire  was presionnaire . The res(i)People with ID experience and engage with mental imagery across different sensory modalities;(ii)The clarity, detail and richness of the images is notable. As well as creating mental images, participants described changing and manipulating these images with VMI metamorphosis as observed by previous investigators described above;(iii)Images could be “surprising, extraordinary and humorous”;(iv)Almost all participants described feelings associated with mental imagery, which “could be strong and powerful and encompassed a wide range of different emotions, such as surprise, delight, disgust and fear”;(v)There is a continuum of “mastery over mental imagery”, with wide individual differences, as observed in all of the VMI studies reviewed here.Hewitt et al.’s study suggests the following conclusions:Another recent study  found noThis review summarizes the findings of a specialized array of phenomenological investigations of VMI covering the entire history of mental imagery research. The review has collated, into a single analysis, a unique database that is drawn from a rich diversity of participants, beginning with Gustav Fechner (1860); then Galton’s (1880) 100 distinguished “men of science’; samples of US university students; German, Japanese and New Zealand eidetic imagers; Africans in five countries on that continent; and groups of contemporary Britons with intellectual disabilities. In each and every group, there existed a widespread variability in the nature and vividness of VMI, but there is no obvious distinction in overall VMI abilities and characteristics between the different participant groups. The reviewed findings indicate an extraordinarily high level of consistency, replicability and coherence in phenomena that were written off for half a century by the behavioural school of psychology as “unscientific”.The purpose remains to synthesize the present findings in the form of a template that specifies the properties of VMI in healthy adult humans. The findings have comprised quantitative and qualitative data of a verbal and graphic nature on VMI phenomenology. This synthesis is inductive in nature, while taking into account the frequency of each of a complex of 16 characteristics across the ten datasets. The entire corpus of findings is synthesized in It can be seen that the template of VMI characteristics ranges from the most general at the top of the hierarchy (“Vividness”) to the most specific at the bottom of the hierarchy . To guide the construction of the template, it was necessary to weigh the relative importance of any descriptive term employed in the VMI phenomenological accounts using the frequency of each term as a proxy measure of a term’s relevance and prominence.The most frequently mentioned attribute of vivid VMI in the research participants’ descriptions across the ten reviewed studies has been “colour”, and the term “Colourfulness” is therefore included in the second tier of the template hierarchy, together with “Clarity” and “Liveliness”.The taxonomic rank at each level has been applied to the phenomenological descriptors of VMI vividness, according to their frequencies in the datasets in combination with their conceptual similarities and differences. The taxonomy started by establishing the taxonomic ranks in broad categories like “Low Vividness,” “Moderate Vividness,” and “High Vividness”, and then proceeded with defining a second tier of specificity: “Clarity”, “Colourfulness” and “Liveliness”, and then a third and a fourth tier in a hierarchy.Next, the content of the data from the reviewed studies suggested many other characteristics for classification that distinguish one level of vividness from another, including “Brightness”, “Sharpness”, “Saturation”, “Vivacity”, “Projected” and “Solidity”. As noted, the categories are arranged hierarchically, with the most general one at the top (“Vividness”) and more specific subcategories below . The fourth row indicates the most specific level of VMI characteristics: “Outline”, “Detail”, “Animation”, “Feeling” and “Metamorphosis”.The present review examines, collates and synthesizes historical and contemporary datasets on the phenomenology of VMI. As suggested in the Introduction, the process of discovering the nature of VMI is reminiscent of the parable of the blind monks inspecting the different part of an elephant . The curThe Vividness of Visual Imagery Questionnaire (VVIQ), refers to colour in eight of its sixteen items [Until now, our understanding of VMI has been fragmentary and piecemeal. The VMI template is a step towards describing the VMI “elephant” in its entirety for the first time. In light of this synthesis, it is possible to provide as comprehensive a specification of VMI vividness as possible using extant data. Previous definitions of VMI vividness had included clarity and liveliness, but not colourfulness ,52. Hoween items .consists of a highly constructive and dynamic process that is both enactive and affective, having its own momentum, and often leading to unpredictable outcomes that can include the metamorphosis of the initial image content. Thus, the present findings on VMI phenomenology are consistent with an enactive approach to perception and mental imagery, such as one proposed by this author [The historical knowledge vacuum left by the neglect of VMI phenomenology led to a variety of incomplete or erroneous theoretical speculations and inadequate clinical applications. To give an example, the “Imagery Debate” ,9 embracs author ,52.Another example of a mismatch between assumptions and practice occurs in research attempting to link VMI content with the clinical condition of depression. Emily A. Holmes et al.  suggest The template of By applying the taxonomic rank to the 16 criteria of phenomenological experiences of mental image vividness, future investigators will be able to create a structured framework that enhances our understanding of mental imagery experiences and contributes to the broader fields of cognitive science, vision science and psychology more generally.The main strengths of this review are: (i) that it integrates for the first time findings from a set of nine largely neglected studies together with a widely-cited, but misinterpreted, study by Galton; (ii) that the selected studies represent highly diverse samples from five continents and 163 years of controlled investigation; and (iii) the impressive degree of consistency between these ten sets of findings. The main limitations are: (i) the relative lack of studies using non-verbal measures of VMI and (ii) the omission of publications in languages other than English, German and French.This review and synthesis of diverse VMI phenomenological studies in healthy adults serves as a unique resource for investigators of individual differences, cognitive development and clinical and neurological conditions. The review has revealed an extraordinary degree of consistency and replicability of VMI characteristics across time, space and culture. VMI is a constructive process, with a continuum of intensity or vividness as its most prominent and frequently reported feature. The discovered template specifies the properties of VMI in healthy adult humans, taking into account the weight of evidence drawn from ten primary studies. Vividness is defined as a combination of clarity, colourfulness and liveliness, where clarity consists of brightness and sharpness, colourfulness consists of saturation, and liveliness consists of vivacity, animation, feeling, solidity, projection in three-dimensional space and metamorphosis. The template provides a schema for further research on the phenomenological properties of VMI. The taxonomic template for the phenomenological experience of mental image vividness enhances our understanding of VMI experience and contributes to the broader fields of cognitive science, vision science and psychology more generally.