How species richness relates to environmental gradients at large extents is commonly investigated aggregating local site data to coarser grains. However, such relationships often change with the grain of analysis, potentially hiding the local signal. Here we show that a novel network technique, the “method of reflections”, could unveil the relationships between species richness and climate without such drawbacks. We introduced a new index related to potential species richness, which revealed large scale patterns by including at the local community level information about species distribution throughout the dataset . The method effectively removed noise, identifying how far site richness was from potential. When applying it to study woody species richness patterns in Spain, we observed that annual precipitation and mean annual temperature explained large parts of the variance of the newly defined species richness, highlighting that, at the local scale, communities in drier and warmer areas were potentially the species richest. Our method went far beyond what geographical upscaling of the data could unfold, and the insights obtained strongly suggested that it is a powerful instrument to detect key factors underlying species richness patterns, and that it could have numerous applications in ecology and other fields. At large spatial extent, species richness is known to co-vary with climate, typically increasing from the poles towards the tropics1231565Analyses of species richness-climate relationships at large geographical extents often use data at coarse grains (e.g. square cells of 10 × 10 km or larger), obtained from scaling up local site data that are supposed to be too noisy to reveal climatic and environmental signals  in mainland Spain, using data from the Spanish Forest Inventory (SFI), which describes forests at local, site scale (i.e. circular plots of ≤25 m radius). Woody plant species richness in this area has been associated to major climate characteristics, namely mean annual temperature and annual precipitation, in contrasting ways, depending whether the studies use local site dataThe objective of this work is twofold. Firstly, we aim at demonstrating the effectiveness of the method of reflections in removing noise and isolating the signal of potential species richness, calculated at the site level from an ecological presence/absence dataset. Secondly, we apply the method of reflections to investigate how the variations of woody plant species richness across local communities in Spain relate to major climate characteristics. For a comparison, we also explore these relationships with the classical upscaling analysis. As we will show, after removing the noise in our data with the method of reflections, we effectively detect climate relationships with local woody species richness, specifically an increase with mean annual temperature and a decrease with annual precipitation, thus displaying similar relationships to those observed in canonical sites  that characterize the species and the sites, producing a symmetric set of measures. We start from the definition of two widely used ecological quantities, species frequency of occurrence and site species richness:For the species used in the analysis, we introduce the species presence/absence matrix kp,0 is the number of sites where the plant species p is observed (i.e. its frequency of occurrence), and the zeroth order reflection ks,0 represents the number of species per site s (i.e. site species richness). These reflections correspond to the so-called “node degree” of species and sites, respectively  and species  are calculated iteratively as the average value of the previous level properties:The method of reflections introduces a generalization of these two quantities, defining N > 0, thus obtaining a set of reflections  for the plant species and a set  for the sites. For example, the first-order species reflection, kp,1 is defined as:for p was observed. The first site reflection, ks,1 is defined as:and it is thus the average species richness of the sites where a plant species s. These first order reflections have been occasionally used in previous studies29i.e. the average frequency of occurrence of the species growing in a site ks,2 as the weighted average species richness of a site s, where the species assume different weights according to their kp,1, i.e. to the species richness of the sites where they were observed  represent generalized measures of species richness, and are thus related to the site zeroth order reflection ks,0, while odd reflections  are generalized average measures of the frequencies of occurrence of the species present at the site, and thus are related to kp,0 (the zeroth order reflection of the species). For each plant species, even reflections  represent generalized measures of its frequency of occurrence, whereas odd reflections  are related to the species richness of the sites where the species was observed , which represent generalized site species richness. Let us imagine a site that has many species because it is at an early successional stage as a consequence of a “disturbance”, but most of its species tend to live in monospecific stands, or with few other species, in the rest of the dataset. The generalized species richness of this site would then have a relatively low value, because most of its species get low weights. Analogously, if a site is species poor, but its few species generally co-exist with many other species in the rest of the dataset, the site generalized species richness would be high, because the “social” species have large weights. Thus, generalised species richness is an indication of the potential species richness of a site, keeping into account the general properties of the species that compose its local community, as estimated from the whole network (i.e. the dataset). In the following section we illustrate this mathematical property with an example.As an example, we consider high order, even site reflections  in the network. In other words, the method isolates the signal from the noise. It is important to note that the generalized measures are not new estimations of site species richness and species frequency of occurrence, but they rather are new, smoothed indices that contain averaged information about those variables. The iterative procedure used to calculate them stabilizes the averaging effect, and in fact, the reflections tend to converge to similar values when Here we illustrate with an example that the method of reflections can identify the signal of  species richness even when it is hidden behind the randomness of a noisy dataset. We generated two synthetic datasets where the species are stochastically distributed, each according to a known probability of occurrence as a function of the environmental conditions in the sites. In the first dataset (D1), the number of species that could potentially occur in a site changed along the environmental range. In the second dataset (D2), the number of species that could potentially occur did not change along the climatic gradient. We used this dataset to check that the method did not find spurious correlations.−1, and to obtain a uniform distribution of the values across the sites, it was sampled every 25 mm y−1. The probability of occurrence of each species varied with the annual precipitation, and the distributions were normal, truncated between 0 and 1500 mm y−1 (−1 and standard deviation σ = 100 mm y−1), 10 species in the wettest (μ = 1375 mm y−1 and σ = 100 mm y−1), and with the number of species decreasing linearly in between these two extremes. We included also twenty “generalist” species that had a broad probability distribution all over the precipitation range  and standard deviation of 900 mm y−1. For both datasets, the species were then assigned randomly to the different sites, with a probability that was calculated as a function of the site annual precipitation. For each site and species we generated a random number between 0 and 1, and we assigned the species to the site only if the random number obtained was smaller than the probability of occurrence of the species in that site.For both datasets, we generated large matrices of species presence/absence in sites . To keep the example simple, the environment in each site was described by only one variable, namely annual precipitation, which was randomly assigned to the site. The annual precipitation varied between 0 and 1500 mm y0 mm y−1 . In the 2 = 0.06, N = 18, and we plotted the generalised species richness ks,18 as a function of the site annual precipitation . Secondly, we applied the method of reflections to the dataset D2. As expected, no model was supported for the fit of annual precipitation and species richness  was a measure of the potential richness of the site, obtained including information about the species patterns of co-occurrence throughout the dataset at site level. This proof was possible for this dataset, because we could estimate the potential richness from the theoretical probability of occurrence of each species in each site .−1 and 13 °C respectively (2) was very low. At the upscaled grains of analysis, the R2 of species richness were quite low, with temperature explaining a quite small fraction of the variance at all grain sizes, and with precipitation that tended to explain an increasing fraction of the variance when moving from fine to coarse grains . We first analysed the data at site scale (as available from the SFI), and then we processed the site data to generate four new grid-based databases, each consisting of equal sized square cells  for which we computed annual precipitation, mean annual temperature, and the corresponding species richness (i.e. the number of woody plant species present in the sites each cell contains). In mainland Spain, both site and up-scaled species richness values of woody plants varied largely with annual precipitation and mean annual temperature, following highly heteroscedastic patterns with maximums around 700 mm yectively . At the ains see . Models N = 18 , following ref. N ~ 0–12, see N = 18) was high enough. The second aim of the rank analyses was to identify which sites were furthest (or closest) to their potential species richness , and we considered them as “typical” sites, meaning that the behaviour of their species was similar throughout the network, and their species richness was close to the potential species richness, as expected from their species composition. Other sites instead changed a lot in their ranking position, either from very low species richness  to very high generalized species richness (top right corner), or vice versa from high species richness (red lines) to low generalized values (from top left towards bottom right). We defined as “anomalous” those sites whose rank position changed more than 80%: the method corrected their species richness, identifying it as anomalous with respect to what potentially could be expected given their species composition. To illustrate this, we choose two examples of common tree species that occur largely in the “anomalous” sites . Fagus sylvatica tends to live with few other woody species. In our dataset, it occurred with less than 5 species in 67% of its sites. No sites including F. sylvatica increased their rank, while 42% of the sites where this species co-occurs with more than 10 other species decreased in ranking position. Since F. sylvatica behaves as a superior competitor in the study regionF. sylvatica was found with many other species decreased in ranking. Another, opposite example is Pinus halepensis, which tends to co-occur with many shrub species, mainly in calcareous sites  were evenly distributed geographically, while those that decreased in ranking clustered in Northern Spain (a wetter and cooler region with Atlantic macroclimate), and those that increased rank were mostly at the boundary between the semi-arid and arid Mediterranean areas  and the climate site variables. Linear models (selected following the procedure described in the last subsection of this paper) were the best fit for both site annual precipitation and mean annual temperature  was higher in arid (dry and warm) sites (i.e. under characteristic Mediterranean macroclimate conditions). We then focused only on the “typical” sites (i.e. those with less than 1% change in ranking from the lowest to the highest reflection), and we analysed the relationship of their site species richness  with the climate variables. We expected that woody species richness of these sites would follow the same pattern of the generalized species richness of all the sites, because the “typical” sites should not change substantially in their behaviour going from low to high reflection order. We found that the species richness  of the “typical” sites displayed the same general trend as the generalized species richness of all the sites. For the selected sites, species richness decreased as a function of annual precipitation  of the “typical” sites  species richness could be explained with annual precipitation . At the local site scale, the method of reflections showed that woody communities in drier and warmer areas tended to have higher richness of woody plant species, and, remarkably, we observed the same signal in the generalized species richness of all the sites, and in the (non-processed) species richness of a sub-set of sites that we identified as “typical”. Interestingly, these trends largely coincided with those found by Terradas The new index we introduced here, the “generalised species richness”, was closely related to site potential species richness. The index combined information in a novel manner, taking species distribution and the inter-species structure into account. The new definition was based on within-network similarities (i.e. community assembly patterns), including information from sites that had similar species composition, irrespective of their geographical locations. The method actively reduced noise and isolated the signal, including information from the whole dataset at the local (site) scale, and introducing a sort-of weighted averaging technique, in a way reminiscent of e.g. Principal Component Analyses, but with the advantage of not using information from the explanatory variables. Comparing all the communities with similar taxonomic compositions, the method calculated the generalized species richness of a certain site as expected given its current species composition. The method recognized the sites with uncommon richness as outliers with respect to their species composition, reducing the noise they create, and allowing small-scale data to gain greater generality. In this process, the method recognized whether each species in a certain site lived with an anomalous number of other species. However, it did not recognize whether or not these species are always the same throughout the dataset. It is worth remarking that the sites (and their communities) were identified as “anomalous” only because they do not represent the most typical situations, without any implication about their ecological relevance.As in the case of the product exports of countriesF. sylvatica that  appear richer than common F. sylvatica forests, typically poor in woody plants because of the superior competitive abilities of this speciesP. halepensis, at the boundary between the semi-arid and arid areas of Southeast Iberia, or influenced by the Ebro depression. In these sites, the common trend of P. halepensis dominated forests, i.e. exhibiting a rich cohort of shrub species , or to their history of anthropogenic disturbances, which could have lead the local community to be species richer or poorer than potentially expected. Checking the method performance with a few specific examples, we observed that the sites displaying more species than expected often corresponded to sites with These examples, together with the application to synthetic datasets, illustrate that the method identifies the sites that deviate from most common or “potential” assemblages. These deviations could be due to different underlying processes, such as historical legacies (e.g. land use history or forest management), environmental heterogeneity , trophic interactions  or community dynamics . Thus, the method could be used to identify hotspots of species richness , or areas where management could be particularly effective in enhancing species richness (i.e. sites where species richness is currently lower than expected). This information could be usefully applied in community or restoration ecology , our method identifies the local species richness signal, and brings out information about potential species richness, integrating information from the species community composition in the whole dataset, instead of using geographical proximity and calculating species richness at coarser grain. For this reason, in our case study, the method of reflections could identify strong relationships of  species richness with precipitation and temperature , indicating that local woody communities in dryer and warmer areas across Spain, corresponding to the Mediterranean ecosystems, can potentially have higher woody plant species richness.The method of reflections showed a very high performance in catching the main factors of variability underlying the dataset analysed, and allowing an effective integration of ecological variability to obtain indications of potential species richness. Since presence/absence datasets are very common in ecological data collection, the method could be applied to analyse other geographical areas, other trophic levels or species groups at various scales, possibly leading to very interesting ecological insights on the environmental drivers of species distributions and richness, due to a method that elaborates species richness information on the basis of co-occurrence patterns and community structure rather than on geographical or environmental proximity.In the following two subsections, we describe respectively the datasets we used for the analyses of the Spanish woody species, and the use of GLM and the model selection procedures. All the analyses in this work were performed using MATLAB R2013b .2) comprises large altitudinal (max. 3500 m.a.s.l.) and climatic gradients (from Atlantic to Mediterranean climate), and consequently displays a large diversity of habitats and species. We used the third Spanish Forest Inventory (SFI), which was surveyed between 1997 and 2007, distributing a 1-km2 cell grid over SpainIn this paper we analysed data from an extensive dataset describing woody species of continental Spain. This region  being located over mainland Spain; (ii) having at least one adult tree; (iii) showing no evidence of thinning or harvesting; and (iv) not being identified as planted. We obtained the planted character from ref. 47r2 = 0.12), thus minimizing multicollinearity.We considered mean annual temperature and annual precipitation to represent the major climatic conditions of each site in mainland Spain, with climatic variables obtained at 1 × 1 km scale , and the corrected Akaike Information Criterion , we took the following steps .


The Lancet suggested that open health information for all could be achieved by 2015. Unfortunately, this goal has not yet been accomplished. Despite progress in obtaining quality scientific articles in Latin America, it remains difficult to reliably access new and cutting-edge research. As graduating Peruvian medical students, we have confronted many obstacles in obtaining access to quality and up-to-date information and a constant tension between accessing "what is available" rather than "what we need". As we have learned, these limitations affect not only our own education but also the choices we make in the management of our patients. In the following article, we state our point of view regarding limitations in access to scientific articles in Peru and Latin America.In 2004, an influential report in Although this philosophy remains with the scientific community to this day, for-profit publishers continue to charge for access. However, with the development of the internet, a new hope was born for open access2.Since the earliest days of scientific publishing, the dissemination of research has been intended to maximize impact rather than profitet al. proposed inThe Lancet, that we could achieve health information for all by 20153; nevertheless, eleven years later this goal has not yet been fulfilled. Instead, the open medical repository is just a fraction of all the information out there. For example, during 2011, only 17% of the 1.66 million articles published and indexed in Scopus were available through open access4.In 2004, Godlee6. The alternative scenario results in low literacy for medical professionals, affecting the diagnosis and treatment of patients. The scarcity of open literature contributes to an out-of-date medical practice, where health professionals“[believe] that they can go about their job without new information”7. This type of practice is unacceptable and should be changed for the well-being of our patients.Full access to scholarly articles carries several benefits to researchers, healthcare professionals, policymakers and to society in generalMedical school is a key moment to learn how to read critically the current research and to keep up-to-date with it. If we learn it as students, we will carry this practice throughout our career, but if we do not, it will only become harder later. In this context, after having gone through seven years of medical school, we believe it is important to state our point of view, as medical students, regarding the limitation of access to scientific articles in Peru and Latin America.Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), theScientific Electronic Library Online (SciELO), and The RedALyC project 11. LILACS is a database created by Biblioteca Regional de Medicina (BIREME) and the Pan-American Health Organization (PAHO)11. Since 1982, it had become a crucial resource for the identification of Latin America’s peer-reviewed and "grey" literature on medicine, public health and epidemiology11. SciELO was conceived in 1997 as a pilot program to create a virtual library of Brazilian biomedical journals9. This later became an expanding publishing platform for Latin American journals that currently includes 15 countries from Latin America, Europe and Africa9. RedALyC, established in 2003, was born out as a need to cover the social sciences and humanities  that also widened its original focus to all disciplines8. Free-full-text articles in this region have prevailed because most of the journals are not-for-profit enterprises maintained by public academic institutions or scientific societies. In contrast to the usual ‘article publishing charge’ model of open access, Latin American journals follow a ‘fee-less-free’ model providing immediate free access to the electronic edition of the journals without charging the author’s institution for submission, processing or publication of the article on behalf of medical societies or associations12. This enables greater visibility for thousands of articles from Latin America10.Nowadays, without any doubt, the three most visible Latin American efforts to achieve the dream of open access and to catalyze globalized science are the9. This has been reflected in several initiatives such as the Network of Virtual Libraries of the Latin American Council of Social Sciences (CLACSO), the Alliance of Agricultural Information Services (SIDALC), and LATINDEX, all created before the Budapest Open Access Initiative in 200210. Significantly, LATINDEX was one of the first referencing systems for the Ibero-American region, indexing journals related to social and medical sciences9. As Vessuriet al. stated,“[these are clearly great examples] of a region that was already exploring the possibility of building national collections of full-text electronic journals in open access”9. The most recent open access initiative in the region is the Federated Network of Institutional Repositories of Scientific Publications (LA Referencia)10. The aspiration of this regional network is to become the principal gateway through which Latin America expresses its scientific production to the rest of the world13. Since it was established in 2012, this interoperable network of national repository systems  has gathered more than 800,000 full-text documents available for all13.Latin America has long been active in promoting the visibility of its scientific productionuniversal access to essential health-care information”3. In other words, even though information is free in SciELO and RedALyC, most of the journals indexed by these services are outdated. A recent analysis in the field of Dermatology found that 60% of journals in these databases were not recent, had lower impact factors and published fewer issues per year when compared to non-free journals indexed in MEDLINE/Pubmed12.Despite the Latin American contribution towards policies in favor of open access, there is still scarce evidence to guarantee the fulfillment of “Public Library of Science (PLoS),BioMed Central (BMC),PeerJ orF1000Research14 allow scientists to publish their work in a high quality platform that also make their content freely available. Additionally, since 2005, research-funding agencies, such as the Wellcome Trust (UK) and National Institutes of Health (USA), promote a policy that all funded work should be publicly available and provide funds to cover the costs of publishing in open access journals15. These collaborative strategies are increasingly allowing healthcare professionals from developing countries to gain free access to high quality research.Outside of the continent, other international initiatives have also recently been developed. Open science publishing platforms, such as the16, for example, is one of the four programs from Research4Life, a public-private partnership of the World Health Organization, whose main goal is to provide“free or low cost access to academic and professional peer-reviewed content online”17. HINARI has provided access to more than 13,000 journals to developing countries since it was launched in 2002 and has opened the door to a world of relevant and latest medical information17. However, many top-notch journals are not always accessible through HINARI, which in turn creates a major setback for medical students18.Moreover, there are other global alliances that have also aimed to diminish the gap between what exists and what is available. HINARIRevista Peruana de Medicina Experimental y Salud Publica (http://bit.do/rpmesp), and theRevista de Gastroenterología del Perú (http://bit.do/revgastrope). All articles from these journals follow a ‘fee-less-free’ model and are deposited in their respective SciELO library, enabling flow of information and greater visibility19.In Peru, the main sources of scientific information available for students and healthcare professionals are journals indexed in the Latin American databases mentioned above. The access to other international journals, such as those indexed in MEDLINE, is limited by the agreements of each institute. Still, there are two Peruvian journals indexed in MEDLINE and both are characterized by providing articles online free of cost. These journals are theCyberTesis repository. This project was created to allow all theses to stay available online; however, this project is run independently by each school. This is a problem because its not a centralized archive but instead independent local ones. Researchers like to look for information in centralized databases, or at least use a meta-searcher. Local universities should join initiatives to centralize and share their repositories making it easier for researchers to read and cite them. Universities also possess their own independent journals and offer online repositories for the publications found therein. University-run journals can also upload their publications to SciELO repositories, like theRevista Medica Herediana (http://bit.do/revmedhered) from the Universidad Peruana Cayetano Heredia. Finally, as in other parts of the world20, Open Access Week is celebrated locally by some Universities such as Pontificia Universidad Católica del Perú21 and Universidad de Lima22.In addition, Peruvian universities have developed strategies to keep their scientific production visible, available online and free of cost. We will mention three examples of these initiatives. Some universities require students to finish their career with a thesis that is then stored online in the online23. This repository provides access to scientific productions developed in our country  and also grants access to scientific databases such as ScienceDirect, EBSCO and ProQuest through its virtual library (http://proyectos.concytec.gob.pe/access/). However, this initiative is not well known among students and entails several registration requirements that are difficult for students to fulfill.The government of Peru also promotes open access. Under the Peruvian Law N° 30035, there must be a national open-access repository managed by the National Council of Science and Technology and Technological Innovation (CONCYTEC)“up-to-date, easy, fast, reliable, and affordable accesses to scientific information”24.We have completed seven years of medical education in Peru, and as we have passed through each stage of basic science, pre-clinical and clinical work, our need for updated knowledge has increased. This process has a huge impact on our training because medical school is the period during which we are expected to learn to critically read and to keep up-to-date with current clinical research. Our ability to master this skill then reflects on our clinical decision making and ultimately, affects our patients. Therefore, access to information is not only an intellectual exercise, but also an ethical obligation of our profession. If we ever expect to improve the lives of our patients, we needet al. suggested that students in low-income countries have a difficult time maintaining and advancing their knowledge and skills due to the limited access to pay-per-view journals18. This could become a threat to the student’s education since most of these journals require readers to pay a fee at an unattainable cost (USD20–USD45) for the majority of medical students in developing countries18, making access to research a “pay-wall” to overcome20.In 2007, Villafuerte-GálvezRegardless of the efforts aforementioned, we believe that access should have more promotion by local governments and journals. Governments should keep allocating money to help pay open access initiatives and, on the other hand, journals should offer waivers to authors that cannot pay. Some journals already do this, however many do it depending on the country’s income. This becomes a problem when a country changes its classification (eg. from low income country to middle income country), but its researchers are still lacking the resources. This is the case of Peru. Hence, we do not think that waivers should be based solely on the author’s country affiliation, but instead on a case-by-case basis.25 which is much lower than that reported in physicians from USA (81%), Canada (76%) or UK (77%)26. However, we found no data on how many of these queries achieve access to full-text articles. In our experience,“only through removing the barriers to access to global research that health improvements can be accelerated”27. The problem we hope to tackle some day is the one related to the“the ‘last mile’ of the process which actually delivers the document or other source that has been searched for”28.It has been shown that at least one in three (33%) recent Peruvian medical graduates use MEDLINE/PubMed to search for scientific articlesIn order to obtain the best medical knowledge, as medical students from a developing country, we must overcome two main obstacles: access and language. Even if barriers to access can be overcome, the language barrier may remain. English is considered the language of biomedical science. However, not all scientists know it, especially in rural and developing areas. It is a shame when researchers studying the health problems of a rural area only report their findings in English. How will the healthcare personnel from that area learn and apply this knowledge? Some Latin American journals (ie. Medwave) have aimed to lessen this gap by providing the same article, with the same digital object identifier (DOI), in more than one language. This is obviously extra work for both the publisher and the authors, but if the information cannot be understood, then it will not be applied.“Health information for all” should be guided by four principles: access, usability, quality, and cost and sustainability29. First, research should be freely accessible to individuals and organizations all around the globe. As mentioned earlier, the key issue about this criterion is the availability of free full-text, ideally in the native language where the research was done. Second, usability implies being able to access the full range of the latest tools to organize, analyze and manipulate the content relevant to their work. Third, the rigorous peer-review process must be maintained without affecting the previous principles. The openness and transparency of academic publishers (not-for-profit) guarantee the quality and development of publications supported by peer-review. Finally, citing The Finch Report, “the main point of cost and sustainability is that no form of publishing is cost-free, and the key requirement is therefore that publishers, whether commercial or not-for-profit, should be able to generate revenues to meet the cost of services they provide”29.As The Finch Group Report suggests, strategies that aim to achieve the dream ofEleven years have passed and despite some initiatives, the goal of open access has not been achieved. We have not lost hope that universal access to essential health-care information will occur, but maybe it is time to change our individual approach and for governments, universities and academic societies to develop a unified strategy by which open access can be achieved, while still fulfilling the aforementioned four principles.Until then, will we keep dealing with the dilemma of accessing “what is available” rather than “what we need”? I have no further comments to this paper (V2). The authors have fully addressed the comments I made to version one and thoroughly revised the article. It is a very nice paper, that I am sure will create a lot of discussion about access to the best evidence.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is about dreams, and dreams do not always come true, even open access ones.This is an interesting opinion text, and not a researched article. It therefore aims to stimulate discussion about the key issue of open access, particularly in the medical world. It raises the interesting, and often overlooked, issue as to access to research for medical practitioners and not just researchers.There are a number of issues. One is the control of the big publishers who have no intention to release archived texts. Whilst new production may come out as gold open access, there is still a wealth of hidden data. As they say, citing the Finch report, there is a question of cost as publishing one has a cost that the researcher must pay. Another issue is one of language, and that is related to evaluation criteria and indicators. As long as international is seen as a proxy for quality, and as long as the English language will be seen as international, there will be a problem. In years to come, their dream will come increasingly true, but to hasten it a change of mindset on language is vital, especially as Spanish is far from a minority language. The big question will remain archives as the publishers are sitting on a gold mine, and they know it.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a very interesting article facing a challenge for developing countries, costs of publications. Whilst Open Access is excellent in this setting because allows wide access for everybody, also implies costs for authors in most journals, which is also difficult. Particularly this should be considered more in this discussion. Goverments and institutions should be more responsible covering those costs. But also journals should be responsible and consider extreme cases of inability to pay, then offering waivers, and particularly giving different costs for authors from developing countries, regardless of the classification of the World Bank, which is not fair. For example, the HINARI initiative has fallen short for this reason. Many countries there, included Colombia and Peru, were considered according to the WB as countries with an income not classifiable to have access. Then, this is unfair. Anyway, I would like to see more of this discussion in the paper.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. et al. present an interesting opinion paper about the availability of health information for health practitioners in Latin America. The title gains in irony after one reads the article, which concludes that health information for all remains a dream and not an accomplishable goal. The abstract clearly contextualizes the article to the opinions of the authors and adequately encapsulates the depth of the subject matter. The arguments presented in the article are clearly stated as opinions based on personal experiences, and thus are not necessarily substantiated by evidence gathered from relevant literature. I recommend the article be approved as an opinion paper – this is not ground breaking new knowledge - but is a topic that needs discussion as in the end, access to information can affect clinical decisions.Proañominor revisions:I recommend the followingp.3, column 1, line 18-20.  “This project was created to allow all theses to stay available online: however, this project is run independently by each school.”Please include a sentence on why this is problematic – is it a meta-data problem, incompleteness, etc. Do the authors have a solution?et al. p.3, column 2, line 1. “In 2007, Villafuerte-GálvezPlease correct the use of the singular to the plural eg p3. Column 2, line 9-12. “It has been shown that at least one in three recent Peruvian medical graduates use Medline/PubMed….”et al. (ref.#24) 34% of the sample regularly used Medline/PubMed. Other studies, using other countries, for example by Davis , report use of PubMed/MEDLINE to be between 70 and 84%.Is this surprisingly different from any other country? In the referenced article by Mejiahttps://www.researchgate.net/profile/Karen_Davies/publication/49763179_Physicians_and_their_use_of_information_A_survey_comparison_between_the_United_States_Canada_and_the_United_Kingdom/links/004635286b7abf103d000000.pdfp.3, column 2, line 51. “…but maybe is time to change..”Please correct to “…but maybe it is time to change…”p4, column 1, line 2. “ …fulfilling the four principles aforementioned.”Please change to “…fulfilling the aforementioned four principles.”p.4, column 1, line 3-4.  “Will we keep dealing with the dilemma of accessing “what is available” rather than “what we need”?The ending could be stronger. Please consider rewriting this final sentence. Try something like: “Until then, we will keep dealing with the dilemma of accessing “what is available” rather than “what we need”.For my personal interest:p.3, column 2, line 26-28 “Some Latin American journals have aimed to lessen the gap by providing the same article, with the same digital object identifier, in more than one language”This is interesting, I would like to learn more. Is this allowed, ethically? Is this not self-plagiarism? How do you cite such publications and do they count as one or two separate works?I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Thank you very much for your suggestions and for taking the time to review our paper. We look forward to any comments you have on this in the future.p.3, column 1, line 18-20.  “This project was created to allow all theses to stay available online: however, this project is run independently by each school.”Response: “This is a problem because its not a centralized archive but instead independent local ones. Researchers like to look for information in centralized databases, or at least use a meta-searcher. Local universities should join initiatives to centralize and share their repositories making it easier for researchers to read and cite them.”Please include a sentence on why this is problematic – is it a meta-data problem, incompleteness, etc. Do the authors have a solution?et al. p.3, column 2, line 1. “In 2007, Villafuerte-Gálvez Response: Change madePlease correct the use of the singular to the plural eg p3. Column 2, line 9-12. “It has been shown that at least one in three recent Peruvian medical graduates use Medline/PubMed….”et al. (ref.#24) 34% of the sample regularly used Medline/PubMed. Other studies, using other countries, for example by Davis , report use of PubMed/MEDLINE to be between 70 and 84%.Is this surprisingly different from any other country? In the referenced article by Mejia https://www.researchgate.net/profile/Karen_Davies/publication/49763179_Physicians_and_their_use_of_information_A_survey_comparison_between_the_United_States_Canada_and_the_United_Kingdom/links/004635286b7abf103d000000.pdfResponse: We agree with your point of view and think that contrasting Peruvian reality with the one in the UK brings about a good comparison for readers to understand Peru’s reality. Thus, it now reads: “It has been shown that at least one in three (33%) recent Peruvian medical graduates use MEDLINE/PubMed to search for scientific articles 24 which is much lower than that reported in physicians from USA (81%), Canada (76%) or UK (77%) add new citation; however, we found no data on how many of these queries achieve access to full-text articles.”p.3, column 2, line 51. “…but maybe is time to change..”Response: Change madePlease correct to “…but maybe it is time to change…”p4, column 1, line 2. “ …fulfilling the four principles aforementioned.”Response: Change madePlease change to “…fulfilling the aforementioned four principles.”p.4, column 1, line 3-4.  “Will we keep dealing with the dilemma of accessing “what is available” rather than “what we need”?The ending could be stronger. Please consider rewriting this final sentence. Try something like: “Until then, we will keep dealing with the dilemma of accessing “what is available” rather than “what we need”.Response: Change madeFor my personal interest:p.3, column 2, line 26-28 “Some Latin American journals have aimed to lessen the gap by providing the same article, with the same digital object identifier, in more than one language”Response: This is allowed ethically, because it would have the same MEDLINE/PubMed entry. Thus, we do not believe this is self-plagiarism because it does not count as two publications, but just one (same DOI) with two different ways of viewing it. I think this does not pose a big problem, because readers know that it is the same version in different languages. For example, the journal Medwave provides, within the same Pubmed Abstract page two options: English or Spanish such as in this case:https://www.ncbi.nlm.nih.gov/pubmed/26248156This is interesting, I would like to learn more. Is this allowed, ethically? Is this not self-plagiarism? How do you cite such publications and do they count as one or two separate works?Response to specific comments is as follows:


Medical pluralism has flourished throughout the Western world in spite of efforts to legitimize Western biomedical healthcare as “conventional medicine” and thereby relegate all non-physician-related forms of healthcare to an “other” category. These “other” practitioners have been referred to as “unconventional”, “alternative” and “complementary”, among other terms throughout the past half century.This study investigates the discourses surrounding the changes in the terms, and their meanings, used to describe unconventional medicine in North America. Terms identified by the literature as synonymous to unconventional medicine were searched using the Scopus database. A textual analysis following the method described by Kripendorff 2013 was subsequently performed on the five most highly-cited unconventional medicine-related peer-reviewed literature published between 1970 and 2013.not . Authors defined “integrated/integrative” medicine by what it is . Authors who defined terms by “what is not” stressed that the purpose of conducting research in this area was solely to create knowledge. Comparatively, authors who defined terms by “what is” sought to advocate for the evidence-based combination of unconventional and conventional medicines. Both author groups used scientific rhetoric to define unconventional medical practices.Five commonly-used, unconventional medicine-related terms were identified. Authors using “complementary and alternative”, “complementary”, “alternative”, or “unconventional” tended to define them by what they are This emergence of two groups of authors who used two different sets of terms to refer to the concept of “unconventional medicine” may explain why some journals, practitioner associations and research/practice centres may choose to use both “what is not” and “what is” terms in their discourse to attract interest from both groups. Since each of the two groups of terms (and authors who use them) has different meanings and goals, the evolution of this discourse will continue to be an interesting phenomenon to explore in the future. Medical pluralism has flourished despite efforts to legitimize Western biomedical health care as “conventional medicine”, thereby relegating non-physician forms of healing to an “other” category. These “other” practitioners have been labelled as “unorthodox”, “unconventional”, “alternative” and “complementary”, among other terms throughout history , 2. The Numerous terms have emerged to identify the type of medicine practised by physicians including: “orthodox”, “allopathic”, “modern”, “scientific”, “bio-”, “evidence-based”, “Western”, “mainstream”, and “conventional”, each preceding the word “medicine”, and sometimes “therapy” , 4. For We can see that there is great difficulty in defining terms which refer to medical therapies outside the realm of conventional medicine . Over thnot taught extensively at US [and Canadian] medical schools and generally not provided at US [and Canadian] hospitals” Regardless of the terms used to describe unconventional medicine, the challenge of definition still exists , 11, 12.Theories about how groups of health care practitioners form, evolve and interact provide necessary context when aiming to understand the discourses surrounding unconventional medicine. One such theory relevant to this study is that of Thomas Gieryn , who assApplying Gieryn’s perspective served to focus the inquiry on exploring if, and how, conventional practitioners utilize the rhetoric of science to legitimize practices of their own or delegitimize practices of others. We show that conventional practitioners’ use a scientific notion of “effectiveness” to establish the validity of their therapies and research methods, as a rhetorical strategy to establish their authority. Concomitantly, conventional practitioners label unconventional practitioners and their therapies, “unscientific”, which functions to exclude them from conventional medicine and deny them legitimacy and resources.to identify changes in the naming of unconventional medicine over time in the peer-reviewed medical literature and;to conduct a textual analysis to explore how changes in the naming of unconventional medicine occurred and who contributed to them.The overall purpose of this research study was to conduct a textual analysis to identify the shifts in how unconventional systems (and their practitioners) have been described over time in the peer-reviewed literature applicable to Canada and the United States from 1970 to 2013. The specific objectives of this study were two-fold:Textual analysis is a specific study design derived from content analysis. The latter comprises a group of techniques helpful in analysing and understanding samples of text , 17. ConThe goal of conducting a textual analysis is to identify hidden meanings, as well as unquestioned patterns and accentuations of texts, where the intent of the researcher is to acquire a deeper understanding of the context in which the text is written. Hence, textual analysis views a text as a “cultural artifact”, and identifies why written work is produced, in addition to the intended audience of the text being analyzed. Textual analysis focusses on repeated patterns, placing, striking imagery, style, and tone, as examples of items which enable researchers utilizing this study design to elicit “the structures of meanings and the configurations of feelings on which this public rhetoric is based” . This stUnitizing guides the researcher in deciding what type of data should be collected and analyzed. For this study, this was limited to the peer-reviewed literature as these articles serve to communicate discussions and controversies concerning researchers’ and practitioners’ understanding of unconventional medicine.The next step, sampling, involved identifying an appropriate sample of peer-reviewed articles , retrievCoding refers to bridging the gap between texts and the researcher’s reading of them. In this stage, coding categories were developed from the data guided by the theories of professions discussed in the Theoretical Framework section above. According to Krippendorff , “researReducing the data helps researchers to efficiently represent large volumes of data, ultimately reducing the diversity of text to what matters through summarizations . FollowiInferring refers to identifying what unobserved phenomena mean, or refer to, supported by evidence found within the text . This inLastly, narrating makes the researcher’s findings understandable to everyone else. This stage involved describing the practical significance of the results and how the contributions made by our study impacted the existing literature previously published within this subject area .On September 11, 2014, a series of advanced searches of the Scopus database were conducted, encompassing all terms previously identified as being used to represent unconventional medicine synonyms in the literature  interventions/therapies included in the surveys, in order of most common inclusion, were chiropractic care, acupuncture, herbal medicine, hypnosis, massage therapy, relaxation techniques, biofeedback, and homeopathic treatment. CAM interventions/therapies such as chelation therapy, energy therapies, qi gong, tai chi, yoga, high-dose vitamins, and spirituality/prayer for health purposes were less commonly included.” The first sub-theme that emerged was the fact that many authors either defined or used these terms in reference to a list or group of therapies or interventions:While not typically definitions themselves, such lists and/or groups of items often defined the parameters of these therapies in studies. These lists or groups of therapies were often accompanied with a given definition, explaining the reasoning behind what was selected for inclusion in the list.neither taught widely at U.S. medical schools or generally available in US hospitals.” (emphasis added)Medical interventions The second theme related to a major reason as to why these therapies were found on these lists of groups. The best example of this is the definition of the term “unconventional therapies” provided in Eisenberg et al.’s not met by conventional medicine. One good example of this is yet another highly-cited definition  panel members representing a wide range of theories of health and healing were able to communicate easily with one another, s added) The second theme related to the thoughtful combination of conventional and unconventional therapies. Largely, the authors who wrote about “integrated/integrative” medicine believed that numerous and positively-perceived aspects of unconventional medicines could complement conventional ones to form a novel, ameliorated healthcare system. Their language often included a criticism of the reductionist form of conventional medicine-based research, and the need to adopt research strategies that would showcase the optimal therapeutic ability of unconventional therapies. For example:emphasizes wellness and healing of the entire person  as primary goals, drawing on both conventional and CAM approaches in the context of a supportive and effective physician-patient relationship.” (emphasis added) (, Alternative and Integrative Medicine [http://esciencecentral.org/journals/alternative-integrative-medicine.php]), practitioner associations  and research/practice centres , that exist in this field.Stakeholders  interested in attracting authors with an interest in this field appear to have adjusted their language to appeal to both groups. For example, the National Center for Complementary and Alternative Medicine (NCCAM) (formerly named as the Office of Alternative Medicine (OAM)), changed its name to the National Center for Complementary and Integrative Health (NCCIH) in December 2014 . Prior tThe second key finding revolves around scientific rhetoric, which relates to Gieryn’s  scientifAuthors defining terms by “what is” used this rhetoric to describe their integration strategy, which depended upon scientific evidence. Snyderman and Weil explained that the point of integrative medicine is to align medicine so as to allow for it to continue building on its “fundamental platform of science” The primary limitation that should be addressed in this study is with regards to potentially unaccounted for, yet influential, discourses emerging in the most recent years of this study’s timeframe. The nature of the peer-reviewed publication process involves a lag time between authors reading influential work, incorporating it into their studies, and ultimately citing/publishing this work. To combat this limitation, efforts were made to search both the online and grey literature sources to determine whether any discourses surrounding unconventional medicine-related terms appeared to influence the time period corresponding with the years including and directly preceding 2013. No new themes were identified using this strategy.From a theoretical standpoint, our study serves as a compelling example of Gieryn’s perspective on scientific boundary work. We have demonstrated that scientific rhetoric is evident in the discourses of both “what is not” and “what is” author groups, which demarcate their work within a conventional medicine framework from that of work performed by members of unconventional medicine. Through applying Gieryn’s theory, we identify two distinct ways in which conventional practitioners have constructed boundaries to demarcate their work and research.This study provides an analysis of the labelling regarding unconventional medicine-related terms, potentially facilitating more nuanced use of these key terms by the stakeholders invested in the field of unconventional medicine. This study has illuminated a tension in the texts published in the medical literature about unconventional medicine in which two groups of authors leverage scientific rhetoric, but to very different ends. Additionally, our findings can help to explain why academics or practitioners who work in an environment primarily categorized by supporters of “what is not” language but who use “what is” language (or vice-versa) may face criticism from their colleagues, or a lack of traction, with regards to their research or practice goals within the field of unconventional medicine. Lastly, this study suggests that authors looking to continue (or begin) publishing their work in this field, should recognize that these five commonly-used unconventional medicine-related terms are not synonymous in meaning or definition.This study was designed to analyse discourses within the peer-reviewed medical literature, so it was not surprising that the majority of texts were dominated by the voice of conventional medical practitioners and researchers. This was the case in both the “what is not” and “what is” groups of articles. This study was not designed to adequately capture the voices of unconventional medicine members, which were almost completely non-existent in the peer-reviewed literature.Follow-up studies should seek to understand discourses generated by unconventional practitioners and patients. This may involve evaluating other forms of media unconventional medicine practitioners use to produce their discourses. It will be important to explore how unconventional medicine practitioners describe themselves and how patients are interpreting the differing discourses of unconventional medicine.Furthermore, this study focused on the peer-reviewed literature. Future studies should attempt to understand discourses found in forms of media inclusive of the grey literature or the internet to determine whether our results are comparable. By doing this, such information obtained may help to explain whether both “what is not” and “what is” authors engage, if at all, using similar or different discourses outside of the realm of peer-reviewed media. Understanding what and who leads the creation of discourses surrounding the naming of unconventional medicine members found in other forms of media may also help uncover key information associated with the dynamics between and within practitioners and researchers of both conventional and unconventional medical professions.not taught/used in conventional medicine, meet needs not addressed in conventional medicine, and have not been shown to be safe or effective. The second group defined the term “integrated/integrative” medicine as a new model of health and wellness that advocates combination of conventional and evidence-based unconventional therapies, accounts for the whole person and promotes the preventative maintenance of health in both patient and practitioner.This study identified a dichotomy between two groups of conventional medicine practitioners. The first group described the terms “alternative”, “unconventional”, “complementary” and “complementary and alternative” as therapies that are From a practical standpoint, this research has served to crystallize a debate that has been played out in the texts written by both groups of authors. Very different language use between these two author types suggests the possibility of a growing intra-professional split among this group of seemingly homogeneous conventional medicine members. This study will sensitize its audience to a greater awareness of naming surrounding unconventional medicine-related terms and how they may be interpreted by others within their field. This study can help to explain why academics or practitioners who work in an environment primarily consisting of supporters of “what is not” language but who use “what is” language (or vice-versa) may face criticism from their colleagues, or a lack of traction, with regards to their research or practice goals within the field of unconventional medicine. Lastly, this study’s finding of a clear dichotomy in language and meaning associated with “what is not” versus “what is” language provides a service to authors looking to continue (or begin) publishing their work in this field, helping them to identify that these five commonly-used unconventional medicine-related terms are not simply synonymous in meaning or definition.While both groups incorporate scientific rhetoric into their discourses, each seeks to advance their own distinct agenda. The “what is not” group fundamentally attempts to study the field of unconventional medicine as objective, academic researchers. In contrast, the “what is” group are activists with an interest in reforming the present model of conventional healthcare training and delivery. This divide between these two groups of authors within conventional medicine will require ongoing investigation as the discourses change over time.This study involved the peer-reviewed literature only; it did not require ethics approval or consent to participate.All authors consent to this manuscript’s publication.


An additional affiliation of “Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan” was attached for Shih-Chun Yang.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Among staff working in elderly care, a considerable proportion lack formal competence for their work. Lack of formal competence, in turn, has been linked to higher staff ratings of stress symptoms, sleep disturbances and workload. Objectives: 1) To describe the strengths and weaknesses of an e-assessment and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of an e-training program on staff members’ working life  and well-being . The hypothesis was that staff who had completed the e-assessment and the e-training program would rate greater improvements in working life and well-being than would staff who had only participated in the e-assessments.An intervention study with a mixed-methods approach using quantitative (2010–2011) and qualitative data (2011) was conducted in Swedish elderly care. Participants included a total of 41 staff members. To describe the strengths and weaknesses of the e-assessment and the e-training program, qualitative data were gathered using semi-structured interviews together with a study-specific questionnaire. To study the effects of the intervention, quantitative data were collected using questionnaires on: job satisfaction, psychosomatic health, psychological empowerment, structural empowerment and quality of care in an intervention and a comparison group.Staff who completed the e-assessments and the e-training program primarily experienced strengths associated with this approach. The results were also in line with our hypotheses: Staff who completed the e-assessment and the e-training program rated improvements in their working life and well-being.Use of the e-assessments and e-training program employed in the present study could be one way to support elderly care staff who lack formal education by increasing their competence; increased competence, in turn, could improve their self-confidence, working life, and well-being. Today, there is a need for more qualified staff in elderly care -3. In EuIn Sweden in 2011, approximately 213,024 people were working in municipal elderly care and the largest professional group included nursing assistants and licensed practical nurses . SeventyAssessing non-formal and informal learning and providing competence development among staff working in elderly care may be seen as a way of improving lifelong learning. European countries stress the importance of prioritizing lifelong learning in education , where IOne model of healthy workplaces is the Practices for the Achievement of Total Health (PATH) model ,24. The The intervention under study here was designed to assess staff members’ knowledge and abilities, i.e. their established knowledge, skills and abilities learned over years of professional work in elderly care, as well as their needs for competence development. The intervention included both practical and theoretical e-assessments and a subsequent e-training program supported by ICT. Research has found that elderly care staff who lack formal education experience more stress symptoms and sleep disturbances . TherefoThe aim was twofold: 1) to describe the strengths and weaknesses of e-assessments and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of the e-training program on staff members’ working life  and well-being . The hypothesis was that staff who had completed both the e-assessments and the subsequent e-training program would rate greater improvements in their working life and well-being than would staff who had only participated in the e-assessments.An intervention study was conducted using a mixed-methods approach with quantitative (2010–2011) as well as qualitative data (2011) .In central Sweden, one municipality, which provides healthcare and general services in residential homes and in-home care for older people, was involved in the project from 2010 to 2011. In 2009 an inventory of formal education in care was completed by all staff members (n = 887) and became the basis for the e-assessment to 89 staff in relation to their job requirements. Of them 87 underwent both the practical and the theoretical e-assessments. The e-assessments were voluntary and offered by the manager via personal meetings and email. The competence needs  identified at the individual level in the e-assessments were the basis for implementation of a professional e-training program tailored to every individual’s needs. The e-assessments – three practical and eight theoretical e-assessments of staff members’ knowledge, skills and abilities – as well as the completed education were based on the curriculum of the Swedish upper secondary school care program, which includes a total of eight learning objectives .Three practical assessments – morning, lunch and evening – were conducted in a specifically designed apartment with video cameras and ICT technology. They included a total of 5 learning objectives with different grades and were related to everyday work: “Basic health care”, “Communication”, “Rehabilitation”, “Ergonomics, hygiene, esthetics, environment” and “Assistive technology”. The practical skills assessments were carried out by creating everyday situations and took about 40 minutes/person/situation. One test leader was involved, a qualified teacher working in the national care program, who supervised the practical assessments on the computer via video transmission, with both picture and audio transfer. The test leader also judged the staff members based on strict checkpoints and guidelines for the situation. The check points and guidelines were based on the curriculum, goals and grading criteria for the Swedish national care program’s first course “Healthcare and Social Work” and are established by the Swedish National Agency for Education [ducation .The theoretical assessments were performed using a workplace-based ICT tool (computer) that consisted of 8 learning objectives: “Health”, “Communications”, “Oral care”, “Ergonomics, hygiene, esthetic, environmental”, “Rehabilitation”, “Assistive technology”, “Basic health care”, and “Law and organization”. The items were arranged in order, from those expected to be easiest to those expected to be more difficult. The pedagogical aim was to highlight the individual’s strengths and self-esteem. The assessments took about 30 minutes/person/situation.After completion of the e-assessments, staff received a document accredited by the Center for Adult Education in the municipality that was to be used for the individual’s future competence development. The subsequent e-training program was individualized and linked to staff members’ practical and theoretical e-assessment outcomes as well as tailored to suite their learning styles. The e-training program began with the teacher giving an individual follow-up, a debriefing, in relation to the completed e-assessment. After that, the teacher helped the staff member tailor his/her competence development and he/she began studying the areas of deficiency. When the staff member felt he/she was ready to take the practical and/or theoretical test/tests, which were the same as in the e-assessments, he/she was to contact the teacher. The theoretical part was performed through an ICT tool that could be used either at the workplace or at home. This meant that the e-training program could be carried out independent of time and place and be done all at once or divided up. This, of course, depended on how many e-assessments the staff members had failed on. The range of number of failures for the theoretical e-assessments was 2–8, and for the practical e-assessments 1–3. As the e-training program was individualized, it took various lengths of time (1 day to 6 months) for the staff members to complete it. ICT supervision and support were given to the individual by the teacher, whose role was also to serve as a coach when the individual felt the need for guidance and/or support.Of the 87 staff members with no formal education who had completed the e-assessments, 59 remained in 2011 when the e-training program was to be started. During 2010, 28 staff members had dropped out for different reasons . All eligible staff (n = 59) were invited to take part in the e-training program. In 2011, 37 of the 59 staff began the e-training program and, of these, 36 completed it. Twenty-two of the staff members declined to participate in the e-training program. Several of them were not interested, while others felt they were too old. Of the 36 who completed the e-training program, 15 were interviewed. Purposive sampling was used to ensure variation in staff members’ age, gender and e-assessment results. Of the 36 staff who completed the e-training program, 29 had completed both the pre- and post- questionnaires (see data collection) and had responded to the statements about the e-training program. Two staff members only responded to the statements about the e-training program . Those who did not participate in the e-training program, but who completed the questionnaires on both occasions, comprised the comparison group (n = 12) ; the same time interval was used for the comparison group.The Satisfaction with Work Questionnaires (SWQ) [Job satisfaction, quality of care and psychosomatic health were measured using es (SWQ) . The Jobes (SWQ) .The Conditions of Work Effectiveness Questionnaire II (CWEQ II) [Structural empowerment was measured using CWEQ II) , which wCWEQ II) . The insCWEQ II) ,38. ConsCWEQ II) ; this apCWEQ II) .Spreitzer’s Empowerment Scale [nt Scale  has beennt Scale  and is unt Scale . A seconnt Scale .The interview data were analyzed using qualitative content analysis ,34. The The Central Ethical Review Board in Uppsala approved the study (reg. no. 2009/430). The study was also approved by the head of operations for elderly care in the municipality. The study participants received written information about the study, were informed that participation was voluntary and were ensured confidentiality.In total, 41 staff participated in the study, and of them 15  were interviewed. The mean age was 42 years , and number of years working in elderly care ranged from 6 to 28 . In all, 41 staff were included in the quantitative analysis: 29 in the intervention group; 25 women and 4 men ranging in age from 22 to 54 years. Number of years working in elderly care varied between 4 and 32. The comparison group included 12 staff: 11 women and 1 man, ranging in age from 25 to 57 years. Number of years working in elderly care varied between 7 and 34. The intervention and comparison groups’ characteristics are presented in Table Analysis of staff members’ reflections on the e-assessments and subsequent e-training program resulted in two main categories: “Obstacles/Barriers” and “Enablers”, each of which were derived from three sub-categories. Each category and its subcategories are presented separately. Under the respective headings, the content of each category is described and illustrated using staff members’ statements, which are inserted into the text and marked with quotation marks and italics.Obstacles/Barriers consisted of three subcategories representing staff descriptions of Being nervous, Not having confidence in their own abilities, and Internal and external demands. Such descriptions were particularly common in relation to the practical e-assessments carried out in a specifically designed apartment equipped with ICT, including video-recording. However, several of the staff also described being nervous about the subsequent e-training program. No one in the staff passed all of the assessments.The category “Before it I was nervous about being filmed from all angles.... I was actually nervous…” (Informant 4). Others said that it was “… mostly the first morning part… and then once you’re in there and have started ‘yeah, yeah, the cameras’ you thought after a couple minutes, but then you felt like no I’ve forgotten them… I didn’t think about them” (Informant 3). Several of the staff described the morning assessment as “artificial” because they had to work with an adult-sized doll, which was “so different, it was like what should I do what should I say and talking yes it was more difficult to talk in a natural way…” (Informant 5). Lunch and evening assessments were experienced as more real because there they worked with a person posing as an older care recipient. “Couldn’t find things in the apartment but that’s what it’s like when you’re in a client’s home. The actor was true to reality” (Informant 5). These situations were more realistic and “everyday-like”. Concerning the theoretical assessments, none of the staff reported being nervous, though some were concerned that there would be a great deal to read. “It was fun but I was a bit worried there’d be a lot to read” (Informant 2).Before starting the practical e-assessments and the e-training program, most of the staff described being nervous about what was to come and what was expected of them. Concerning the practical e-assessments , some of the staff were nervous about being observed by the cameras set up in every room: “… mostly if I made a mistake and then I thought God if I do something wrong here it means I don’t know my job, that’s how it felt because really I’m supposed to know this” (Informant 2). In the apartment, several of the staff felt they spent a great deal of their energy keeping an extra sharp eye on where things were. “It felt like meeting a new pensioner.... but I know what I know and I know what to do during the morning work” (Informant 6). Regarding the theoretical assessments, some of the staff found them troublesome, because they felt that some of the issues were invented, which made them uncertain about passing the tests. Issues related to oral care and hearing aids were seen as odd, because some of the staff had no knowledge in these areas. Others said that the theoretical assessments were not in concordance with how they worked every day: “I thought the questions on the computer were difficult, well I thought so, you work in a certain way… yeah, it was a bit difficult” (Informant 10).Several of the staff placed high demands on themselves regarding both the practical and theoretical assessments, while some were surprised about not having passed more tests than they did. Concerning the practical assessments, especially the morning assessment, they felt that it was difficult to know what to say or talk about. The situation in itself made it easy to make mistakes, which could be interpreted as them being unable to do their work : “ … can I manage this, I really don’t have a head for studying”, “.... you don’t think you can do things, but that’s how it is, you can do more than you think” (Informant 11). One staff member said she felt her employer made demands on her. She thought it could depend on a previous occasion when she was dismissed due to cutbacks. She was later re-employed and felt motivated to continue the training program though she was not sure she could manage it. “But I feel that the municipality is demanding this of me and I want a job. And I might not end up with a job. I was fired once two years ago. But that wasn’t because I don’t have the right education but because of cutbacks” (Informant 7). Concerning the theoretical assessments, some of the staff experienced pressure because there was a time limit and lack of information and support from the teacher. At the same time, they felt they were motivated to continue the e-training program despite feelings of uncertainty. Regarding the e-training program, some of the staff experienced time pressure and placed great demands on themselves. “Not much gets into my brain, I have so much other crap in there, there’s no room for more and it doesn’t matter how much I read about things they just don’t stick” (Informant 9). Although some of the staff felt these kinds of demands both before and during the e-training program, most of them completed it. As can be seen in Table Prior to the e-assessment and subsequent e-training program, some of the staff experienced negative feelings, such as not being able to cope with the challenge and being afraid of misinterpreting the information: Enablers consists of three subcategories: Having opportunities to develop in a flexible and easily accessible way, Becoming aware and being able to influence and Feeling stronger. The staff described this category in terms of being able to test their skills and knowledge in an easy, flexible and accessible way as well as feeling motivated to receive grades, seeing possibilities and experiencing that their self-confidence increased during the process.The category “Great, they presented it really well, and there were a lot of us who thought finally… because they were anxious for us to do it. That made it more fun too” (Informant 3). Most of the staff were motivated to take part in the assessments and the e-training program as a way to highlight their skills and knowledge using ICT. This was also shown in the study-specific questionnaire (Table “…you got feedback right away so you knew what you’d done wrong” (Informant 1). Concerning the program using ICT, the teacher could give feedback directly and staff could carry out the e-training program (tests) at their own pace. These results corresponded to the study-specific statements, where nearly all agreed that the program was tailored to meet individual needs , that the implementation was good  and that the communication between the teacher and staff had been very good .When staff heard about the e-assessment and the subsequent e-training program, their first thoughts were positive. They saw it as an opportunity to highlight their skills and knowledge in an easy and accessible way, especially when the employer wanted it: re Table  with reg“why they do it and what they do it for”. In their daily work, the new knowledge made them think differently: “I think more now, when I’m working, about what I’m doing” (Informant 5). They were also more aware of how their colleagues worked: “… now I see how my workmates are stuck in their patterns, and so I can, if you have newer information about what you can do at work” (Informant 5). In some cases, staff reported having transferred what they had learned to their workplaces: “good that there were also changes at the workplace” (Informant 3) and that they could now also discuss “this new knowledge” with their workmates. Several of the staff felt it was a great opportunity to test their skills and knowledge, so as to have some influence on their work. If they wanted to advance at work in nursing, they must have some training. However, others said that they had thought about educating themselves, but felt they had too much catching up to do to get a degree. Still, several said they wanted to continue studying to become licensed practical nurses, if they could do it in the same way as in the e-training program “really it makes me want to continue, it does. Well I do hope they do more of this… so that everyone who wants to can keep learning all the licensed practical nurse material this way” (Informant 3). These results corresponded to responses on the study-specific questionnaire, where most of the staff  were willing to continue taking part in the assessments and training program supported by ICT, while only 3 staff members neither agreed nor disagreed . “I’m glad I did it, I’m done, the fact that I could do it at all, what I didn’t think I could” (Informant 10). They said that their independence and self-confidence increased during the process and that they felt stronger: “… I can manage myself to a greater degree, and I mean if you need help there is a back-up” (Informant 3). Results from the interviews are also consistent with responses to the study-specific questionnaire statements: “I feel that the IT-based training program has made me more independent, in that I’ve been able to manage on my own” .In this subcategory, staff described being proud and having trust in their own abilities. Several were happy and proud that they had passed the e-training program: The interviews revealed that the staff felt stronger, and the quantitative data over time support these results. Staff in the intervention group (n = 28) rated their psychosomatic health as better over time  as well as the factor “sleep problems” . For both the factor and total scale, higher scores mean fewer health problems. In the comparison group, staff rated their sleep significantly worse over time . Staff in the intervention group also rated their job satisfaction as better over time for the factors “personal development”  and “position in the group” . Furthermore, they rated quality of care as better over time; total score of quality of care . When differences over time were compared between the groups, there were significant differences for the factor sleep . No other significant differences were found between the groups when comparing differences over time.Staff in the intervention group gave significantly higher scores, over time, for the factor “impact” on the psychological empowerment scale . Furthermore, they rated better structural empowerment over time , as well as for the factors “formal power”  and “informal power” . When differences over time were compared between the groups, there were significant differences for the scale Psychological empowerment  as well as for the factors “self-determination”  and “impact” . Regarding Structural empowerment, no significant differences were found over time between the groups.The present study showed that most of the staff who completed the e-assessments and the subsequent e-training program in elderly care primarily experienced strengths associated with this approach. Several of the staff would also recommend this approach to colleagues. If additional education/training could be performed in this way instead of traditional education, most of the staff would choose it. However, before and during the e-assessments and the e-training program, some of the staff expressed that they were nervous and that they did not have confidence in their own abilities. They also experienced internal demands from themselves and external demands from the employer, workmates and family, which sometimes made it difficult to cope with the challenge. During and after conducting the e-training program, staff talked about how their self-confidence increased. The interviews revealed that staff felt stronger and the quantitative data over time supported these results, which were also in line with our hypotheses, i.e. that staff who had completed the e-training program would rate greater improvement in working life and well-being than would staff who had only participated in the e-assessments.To our knowledge, this is the first study to measure working life and well-being outcomes following e-assessments and an e-training program intervention among elderly care staff lacking in formal education, and where results support the PATH model. The PATH model ,24 indicA review  of whichStudies  have shoIn summary, staff who had completed both the e-assessments and the subsequent e-training program rated greater improvements in their working life and well-being than did staff who had only completed the e-assessments. The results support the PATH model. Assessing and evaluating informal learning, such as knowledge, skills and abilities, and thereafter offering an e-training program based on assessment results, may be a way of improving lifelong learning.The present study has some limitations that need to be considered. Its non-randomized design might have induced selection biases, and the small sample size and high drop-out rate limit generalizability. Another limitation is that a test of inter-rater reliability regarding the e-assessment tool was not performed in this study and that the sample was taken from only one municipality in Sweden. Workplace culture may have played a role in how the individuals felt about the e-training program and may limit generalizability. However, staff members in the intervention group did not differ from those in the comparison group in sociodemographic characteristics and the study variables at baseline. Strengths were the use of a mixed-method design and of validated instruments with satisfactory internal consistency; in the present study, Cranach’s Alpha for all factors and total scores were <0.70. However, to our knowledge, this is the first study to measure working life and well-being outcomes following e-assessments and an e-training program intervention among elderly care staff lacking in formal education. Future studies should test e-assessments and e-training programs using larger samples sizes and in different areas of health care.The present e-assessments and the e-training program could be one way of helping elderly care staff who lack formal education develop their competence, which would, in turn, improve their self-confidence, working life and well-being. Thus, the e-assessments and the e-training program lead, in accordance with the PATH model, to healthy workplaces and organizational improvements. In order to increase quality and security in elderly care, it is important to test different pathways when identifying needs for competence development among staff and to give them opportunities to learn and develop through training.