Community health workers (CHWs) can play important roles in primary health care delivery, particularly in settings of health workforce shortages. However, little is known about CHWs’ perceptions of barriers and motivations, as well as those of the beneficiaries of CHWs. In Rwanda, which faces a significant gap in human resources for health, the Ministry of Health expanded its community health programme beginning in 2007, eventually placing 4 trained CHWs in every village in the country by 2009. The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries.As part of a larger report assessing CHWs in Rwanda, a cross-sectional descriptive study was conducted using focus group discussions (FGDs) to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries. A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level . Qualitative and demographic data were analyzed.CHWs were found to be closely involved in the community, and widely respected by the beneficiaries. Rwanda’s community performance-based financing (cPBF) was an important incentive, but CHWs were also strongly motivated by community respect. The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision.This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries, in regards to a nationwide scale-up of CHW interventions in a resource-challenged country. Identifying and understanding these barriers, and addressing them accordingly, particularly within the context of performance-based financing, will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rwanda. Shortages of qualified human resources for health are particularly acute in low-income countries, which face significant burdens of disease and mortality. In 2010, 7.6 million children died before reaching their fifth birthday worldwide, and in Africa, almost three fourths (73.2%) of the under-5 mortalities were due to preventable infectious causes, including pneumonia, diarrhoea, and malaria [CHWs are increasingly being utilized to alleviate the shortage of human resources for health, particularly in the delivery of interventions for maternal and child health . By servEffective CHW case management has been linked to the level of training, transport means, adequate supervision, access to medicines and educational tools, and sufficient incentives –11. BarrRwanda is one of the only countries in the sub-Saharan region on track to achieve the health-related millennium development goals by 2015 . BetweenDespite these impressive health gains, the country still faces significant challenges, including one of the most severe shortages of human resources for health on the continent . Even wibinome) who were responsible for community health, nutrition, and HIV/AIDS prevention, and a maternal health worker (referred to as an Animatrice de Santé Maternelle (ASM)), who managed infant, and pre and postnatal maternity care. In addition, each village had a CHW in charge of social affairs (CHSA) dedicated to addressing the well-being of individuals and the community [Aiming to overcome these health burdens, in 2007 Rwanda initiated a reform of the national community health system, which was initially implemented in 1995. In this system, CHWs are required to have a minimum of 6 years of education, and are elected by their communities. At the time of this study, there were approximately 60,000 CHWs in Rwanda, comprising 3 CHWs per village. Each village had a pair of general CHWs  for both CHWs and their beneficiaries were conducted, which included the collection of demographic data. These data were collected as part of a larger assessment of CHW capacity relating to community-based nutrition (CBN) programmes, as commissioned by the Rwanda Ministry of Health (MoH) with the support from World Bank and UNICEF Rwanda.The study was held from 10 to 20 May 2011, in 3 districts with differing levels of food security, which was selected in accordance with the overall goal of the CHW CBN capacity study. District selection was based on assessment of food consumption levels as reported in the 2009 Rwandan Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey (CFSVA). The CFSVA report divided all districts into three categories of food consumption . One district from each of these categories was purposively selected: Gicumbi with a food consumption score above the national average; Kamonyi with a moderate food consumption score; and Ngororero with a poor food consumption score.binomials, and one focus group of woman beneficiaries of CBN services  was organized. Women are the primary beneficiaries of the CBN services offered by the CHWs, and because vaccination uptake is 98% and antenatal care is sought by over 90% of women [In each of the districts, two administrative sectors were selected via simple random sampling (using the EPIINFO randomization programme). In one sector per district, one focus group composed of twelve of women , this apbinomes, and CHSA) and 36 beneficiaries (12 per district) were included in FGDs. No CHWs or beneficiaries declined to participate in the FGDs.In the other sector selected in the district, a focus group was organized for 12 ASM, and 12 CHSA CHWs. The individual CHWs and beneficiaries were selected randomly, again with simple random sampling, from lists furnished by the local health centres. Thus, in each of the 3 districts, 108 CHWs , and 36 beneficiaries  were interviewed for this study.A total of 108 CHWs  of CHWs was 38 (33 to 45) with 91% being married, 4% single and the remainder either widowed or divorced. Twenty-six percent of the CHWs were male. The median years of experience were 3, although this ranged from 1 to 16. The majority of the CHWs (76%) had only a primary level of education; the average number (±standard deviation (SD)) of children per CHW was 4 (±2.2) children.Targeted beneficiaries of community services were generally younger than CHWs, with a median age of 24 . Thirty-five (96%) of the beneficiaries were farmers, and 80% were married with an average (±SD) of 2 (±1.6) children per woman.CHWs identified five key areas that significantly influenced their effectiveness, including training, the role of community performance-based financing, supervision (cPBF), workload as perceived by CHWs, and motivations. In particular, findings relating to irregular trainings and confusion of the cPBF system were widespread among the FGDs, and constituted key findings of this study.CHWs were generally selected by their communities based on criteria including literacy, past experience, and social acceptance. However, most of the CHWs did not have an education in health, and were not trained prior to beginning their roles as CHWs. Newly-recruited CHWs did not undergo an initial training programme, and only received on-the-job trainings. Although the importance of trainings was well known and widely recognized as key to improving knowledge, training sessions were found to be infrequent and not equitably delivered at the community level for all three types of CHWs.For those who received trainings, the effectiveness of the programmes was highlighted, and CHWs claimed that the trainings helped to improve their knowledge and practices. Most CHWs appreciated the trainings, and felt that the community recognized and appreciated their advanced knowledge. However, trainings were described as inconsistent and insufficient, and some groups of CHWs did not attend any training programmes beyond the basic orientation programme.binomes, as opposed to CHSAs and ASMs, received most of the trainings for nutrition, basic health, preventive, and curative services. One CHW said: 'We were not trained, but we can see what the binomes are doing in terms of benefits of training. We can see how they are taking care of malnourished children, but this does not have to do with our work'. Throughout the FDGs, CHSA and ASM CHWs highlighted this disparity in training, and noted their own lack of access to comprehensive training programmes. In regards to their role in promoting nutrition, many CHWs reported having had some training on nutrition, but the majority expressed the need to understand different components of a balanced diet.The CHWs explained that While the national CHW policy does not intend for ASM CHWs to deliver infants, these CHWs said that they were often confronted with women delivering before arriving at the health centre. The lack of any training on delivery was considerably problematic and viewed as a gap in their knowledge ' … because we all know that the trainings will reinforce our capacity in reducing infant and maternal mortality', said one CHW.The CHWs also explained that they lacked training on communication skills necessary to promote behaviour change in the community. The CHWs noted that their lack of confidence contributed to difficulties in convincing beneficiaries to adopt preferred behaviour such as preparing a balanced diet or practising basic hygiene. The lack of training in communication skills was seen as a complicating factor in facilitating promotion of behaviour change in the community.The Rwanda MoH uses community performance-based financing (cPBF), a remuneration mechanism based on outputs, to create incentives for CHWs. The CHWs are not provided with a monthly salary; however, CHWs are evaluated based on performance indicators and the resulting financial incentive is given to a cooperative of CHWs. Based on the FGD accounts, some CHWs did not clearly understand the concept of cooperatives or cPBF, and they had not received proper training on how to set up the financial mechanisms or manage the cooperatives.According to the CHW respondents in this study, the attempts at including the individual CHWs in the management of cPBF have not been successful. Only one CHW spoke of the benefits of the CHW cooperative system, while some CHWs raised the point that transparency and accountability of cooperative managers contributed to hinder the financial success of their cooperatives. According to the respondents in the study, the workload required of CHWs was high, and for most CHWs, this engagement provided little or no financial gain. Some CHWs were unsure if the cPBF programmes were still ongoing, '… for the last 2 years, I do not know if the cPBF exists or if it was stopped', explained one CHW, and others misunderstood the system, assuming that every CHW would receive a dividend at the end of the year.While national guidelines on CHW supervision existed at the time of this study, there were discrepancies in the frequency and content of supervision. Most CHWs met with their supervisors once a month at the health centre to deliver reports, although there were no standard procedures used for field supervision. Some supervisors accompanied CHWs on home visits occasionally, although this was not consistently a policy. The majority of CHWs recognized the importance of the supervision and noted this in the FGDs, explaining that, on occasion, they learned valuable information from supervision visits. However, CHWs often primarily associated supervision to the handover of the monthly report and not always to obtaining guidance and assistance.In terms of their workload, the CHWs considered their general range of duties to be overwhelming, and subsequently a barrier to the sustainability of the CHW system. The variable hours necessary for their work, and the unexpected crises that arose (such as epidemics), conflicted with CHW family life and their other jobs. The intensity of the work was explained as varied and unpredictable, and detracting from time necessary for families.binomes felt that their range of work was too broad to allow a sufficient and quality provision of care. As a binome CHW explained, 'we have 255 households to follow up each month and each of us takes a quarter of the households to accomplish our work, to help each other'. It was found that as a result of the high workload, the three types of CHWs divided up the houses in the village, travelling only to the houses in their vicinity. This resulted in some households being visited by CHWs who did not have any training in specific areas, such as nutrition management or maternal health.Many Despite an overwhelming workload, the CHWs experienced a sense of pride in their work. Many stated that they felt they were an important part of the whole health system improvement that aimed to reduce the burden of disease in the population. They recognized that under a decentralized system, their roles were increasingly becoming critical in reducing key health indicators, such as the infant and maternal mortality rates. By playing a direct role in improving indicators, CHWs felt valued and respected in their communities.With regard to community recognition, almost all CHWs expressed their feelings about the improving health of the population: '… I feel happy when I see someone who was sick becoming healthy'. Relationships between themselves and their community fostered support and respect, as community members routinely approached the CHWs for advice. The ability to work for oneself, and manage one’s own hours, was also a clear incentive. Beneficiaries’ relatives also recognized the importance of CHWs in the community, as one CHW relayed what a man had said to her: 'without this programme, my wife would have died at home'.A few CHWs also shared that the programme gave them a higher status despite their gender. Some claimed that having this position had given them more authority in the household and more autonomy over household purchases. Many of the ASMs who were trained on family planning had started using family planning methods themselves, and served as role models for the women in the community.For the women who participated in the community beneficiary FGDs, the majority made statements recognizing the benefits of the CHW system and a positive attitude towards the CHWs was generally noted. Multiple women expressed their appreciation for the CHW efforts to care for them and their families. One pregnant woman explained: 'I can see that all CHWs do the best they can … I can see that they are needed in our society', and another woman appreciated how 'they follow and support us on a daily basis'.The beneficiaries described CHWs as their main source of educational messages about topics such as nutrition, malaria, kitchen gardens, family planning, and hygiene. Almost all beneficiaries in the focus groups seemed to know that when a child is malnourished, they should go to the CHW, and if the problem was serious, the CHW would accompany the child to the health centre and follow up on progress afterwards. They added that the CHWs explained the basics of nutrition to the families and made sure that the mothers understood. They further explained that they received frequent visits from CHWs at their houses  to check up on the health of the children and to teach them about healthy meal preparation. Most of them said that they would call the CHW or go to his/her house if they had a problem. Overall, the CHWs were perceived to be very influential in the lives of the women, with the beneficiaries only seeking out further care at the health centre for serious illnesses.CHWs in Rwanda play key roles in linking the country’s primary health care system to the community, and mitigating the country’s health professional shortage by providing basic health care. While these intermediary positions are highly valued by the communities, CHWs experience a range of financial and capacity-building challenges that may limit their effectiveness and hinder integration with the formal health system. This study highlights the perceived benefits of the CHW system such as strong motivation and appreciation, as identified by CHWs themselves as well as their beneficiaries, in addition to the barriers that impede the effectiveness of the programme, including challenges of the cPBF system and irregular trainings.CHWs interviewed in this study expressed a sincere desire to perform well, particularly because they felt valued by their colleagues and their communities, and perceived themselves as key assets to directly improving their communities’ health. While motivated primarily by community recognition and respect, opportunity costs impeded their ability to effectively deliver services, as CHWs performed their duties in addition to income-generating activities.binomes) at the time of the interviews. The need for standardized, comprehensive training systems was noted across all categories of CHWs, as well as the desire for trainings in self-confidence and communication skills in order to appropriately disseminate information.According to this study, the effectiveness of the Rwanda CHW system was hampered by an irregular system of supervision and trainings. At the individual CHW level, there were varying degrees of capacity noted, and many CHWs did not have an educational background in health prior to delivery of health services. On-the-job trainings were done sporadically, and did not necessarily address specific skills gaps or effectively target the three types of CHWs  in Tanzania, and the Health Extension Workers (HEW) in Ethiopia. In Tanzania, the CHAs are formally remunerated, receive 9 months of preservice training, and dually report to health facility staff and village governments . HEWs inPrinciples behind Rwanda’s cPBF system, which was only recently implemented at the time of the study, were not well understood by CHWs. The lack of transparency of the process, and confusion around who should receive payments was noted throughout the FGDs. Since this study, additional efforts have been made to strengthen CHW cooperative financial management and understanding of the programme. In 2014, there were 640 CHW cooperatives which primarily delivery health services and generate income through various farm- and food-related activities. Of the net profit collected by these cooperatives, 50% is managed in a fund at the MoH, and is used for CHW trainings and tools, and additional CHW remuneration. To ensure that these cooperatives are managed appropriately, all cooperatives will be required to hire managers by the end of 2015, and a reporting system called the Community Health Workers Financial Tool will be rolled out in 2015 . FurtherWhile these improvements have helped to institutionalize cPBF-supported CHW cooperatives, other studies have found higher CHW attrition rates in community financing programmes than in salaried programmes , 25. Thebinomes) and one ASM who manage maternal and newborn health. In addition to the strengthening of the cPBF system as mentioned above, comprehensive trainings, focusing on capacity building, have also been conducted for all CHWs throughout the country [Since this study was conducted in 2011, the CHW system has been significantly reorganized and strengthened. In 2012, the MoH and the Ministry of Local Government removed the CHWs in charge of social affairs (CHSA). Each village now has a pair of CHWs ( country .This study has a number of limitations. Methodologically, quantitative data were not available to complement the qualitative analyses. Additionally, data collection occurred in 2011, before significant changes in the Rwanda CHW system were implemented. Furthermore, while our beneficiary FGDs were composed of females as a result of the larger Government of Rwanda capacity assessment goals, future research investigating both male and female beneficiaries’ perceptions would be a useful addition to the literature. Despite these limitations, we believe that this study provides a unique vantage point into an evolving CHW system, and has the potential to inform future policy decisions as the programme continues to improve.While a CHW system can address some of the problems created by a severe human resource shortage, there is a continuous need to harmonize and upgrade the capacity of the CHWs so that they are able to deliver services efficiently and effectively. Both comprehensive and targeted trainings are necessary to fill gaps in knowledge, and must be in conjunction with sufficient follow-up and refresher courses. Targeted trainings based on needs assessments, with proper monitoring, evaluation and supervision, are necessary to maintain the capacities of the CHWs and to scale-up the CHW system. Supervision practices can be maximized, and there is a need to address the issue of institutional incentives that shape the utilization and retention of capacities, which is vital for sustainability. Workloads will continue to be a significant challenge in the underresourced system, and are currently overwhelming to the CHWs. Despite these challenges and clear areas in need of improvement, the CHW system is evolving, and the many CHWs in Rwanda providing vital and necessary services to their communities are remaining motivated by their community recognition and respect.


Previous studies have focused on the differences in the art appreciation process between individuals, and indicated that novice viewers of artworks, in comparison to experts, rarely consider the creation process of the artwork or how this may relate to style. However, behavioral changes in individuals after educational interventions have not been examined. Art education researchers claim that technical knowledge and creation experiences help novice viewers to pay attention to technical features of artwork. Therefore, an artistic photo creation course was designed and conducted to help students acquire techniques and procedural knowledge of photo creation. The present study verified whether students' viewing strategies during appreciation of photographs changed after the course. Twenty-one students participated in two sessions, viewing the same 12 photographs before and after the course. Based on the analysis of recorded eye movements, the results indicated that the students' perceptual exploration became more active with photographs containing recognizable subjects , and their global saccades increased when they viewed classic photography, one of the categories of photography covered in the course. Interview data after the course indicated that students became aware of the technical effects in photographs. These results suggest that students' viewing strategies may change following a course, as assessed by behavioral measures of eye movements. Further examination is needed to validate this approach to educational effect measurement. Does art appreciation change in individuals as a result of educational interventions, and how does it change? This is one of the critical questions in art education. Formal and informal educational institutes, such as schools and museums, provide educational programs and courses, offering laypeople, untrained in art, opportunities to improve their appreciation of it. When evaluating these educational interventions, art educators and researchers have typically focused on subjective, interpretative changes, as described in questionnaires and comment sheets, to analyze them qualitatively  course.If learners acquire procedural and technical knowledge of creation through an art course and their viewing processes change, how can these changes be measured? To date, learners' appreciation has been assessed through verbal protocols in their comments and writing in art appreciation studies. These studies argue that the content of verbal protocols develops with artistic experience Housen, . HoweverIt may be suggested that eye movement is an alternative measure of viewing. Eye movement is recognized as a parameter that reflects visual information processing in the brain .The changes in the appreciation process predicted in Hypothesis 1, above, may depend on the contents of educational interventions. Vogt and Magnussen  proposedTo test these hypotheses, a fine art photography course was conducted for this study. It was designed to help learners acquire procedural knowledge and techniques for art creation, as well as providing declarative information about art history and works of art. Experiments were also conducted before and after the course (pre- and post-tests). In each experiment, the participants studied photographs with recognizable subjects and ones with unrecognizable subjects. Some types of photographs were dealt with in the course, and other types of photographs were not. The present study examined whether the participants' duration of fixation, frequency of global saccades and viewing time of recognizable subjects changed. It also examined whether such changes appeared with photographs containing recognizable subjects or unrecognizable subjects, and with which types of photography . In interviews conducted after the tests, the participants answered questions about whether their appreciation had changed and how. Finally, the interview data was used to discuss whether learners' appreciation changed or not through the educational interventions, and how the interventions affected their appreciation of art.M = 21.33, SD = 1.58). None of them had previously received any professional education in artistic creation, including artistic photo creation. The students borrowed a digital single-lens reflex camera (DSLR) for each class, and some students used the camera outside the class for creation and practice. Five students used their own DSLR's. The students were informed that the course and their homework would be recorded and analyzed for this research.“Artistic Creation,” a fine art photography course for undergraduate students, was held at the University of Tokyo in the spring of 2012. The instructor was a photographer who teaches at a professional school of photography, and holds domestic and international exhibitions. He assisted students in acquiring procedural knowledge and techniques for photo creation. The first and third authors attended the course and provided guidance on academic assessment. The course consisted of 14 classes in total , which is a collection of portrait photographs of people in the early twentieth century. The photograph used in the second session was “Los Angeles, California” by Garry Winogrand (1928–1984), which is a street photograph of people on a city street, and demonstrates the social problems hidden in everyday life. These two classes were designed to give instruction on two types of photographs: classic and street photographs. The instructor explained that the former type consisted of photographs taken using camera techniques in a studio setting, while the latter consisted of photographs of subjects in natural situations, without the use of certain camera techniques.Apart from the technical instruction sessions and the application sessions, the course included classes in freestyle photography, and an exhibition. The students created their photo artwork in the classes on freestyle photography. They also selected five photographs that they had taken during the course as their artwork, showed them to the other students and the instructor, and received comments in the exhibition class. These classes did not support the students' appreciation directly; they were, however, designed to provide the students with opportunities to apply the knowledge and techniques learned in the technical instruction sessions, and the application sessions.The students were given two kinds of homework in order to encourage reflection on their creations after each class. The first involved the task of explaining the photographs they had taken at the classes. The second kind entailed describing what they had considered and noticed about artistic creation each week, both inside and outside of the classes.The present study conducted a quasi-experiment with a three-factorial design. The independent variables were session (pre- and post-test), recognizable subjects in photographs (with recognizable subjects and with unrecognizable subjects), and category of photography . The dependent variables were measures from eye movements: average duration of fixation, frequency of saccades and time viewing the areas including recognizable subjects. All 21 students on the artistic creation course participated in the pre- and post-tests.The 12 photographs that were shown in the experiments were selected according to the hypotheses of this study. They were taken from a photography book Koch,  and diviIn addition, the photographs were selected according to whether they were familiar, attractive, and interesting to viewers or not, because familiarity, liking and interest in pictures are indicated to influence the viewing of art . This consisted of an infrared camera located on a table directly in front of a 24.1-inch monitor showing 12 pictures successively at a screen resolution of 1600 × 1200 pixels. The size of the photographs ranged from 484 to 831 KB, and the width and length of the photographs were 666–1012 pixels, and 648–992 pixels, respectively. The camera recorded the participant's dominant eye and its eye movements. The eye movements were recorded by placing the participant's chin on the chin rest at a distance of 60 cm from the screen with pictures subtending visual angles of 11.7⋅ vertical, 16.1⋅ horizontal. Spatial and temporal resolutions were 0.3⋅ and 60 Hz, respectively.Data was recorded on MiniDV and was analyzed with EMR-dFactory . Data output recorded vertical and horizontal eye movements, fixation, and duration of fixation. Fixation time was set at a minimum of 150 ms in the area within 100 pixels. Saccades were computed from the data files.The participants viewed three sets of four photographs  both before (pre-test) and after (post-test) the course. On entering the laboratory, the experimenter explained the experiment, which was approved by Life Science Ethics and Safety, the Ethics Committee of the University of Tokyo (14–7), and all the participants gave permission for their eye information and interview data to be used in the study. The participants were then seated comfortably in front of a monitor and positioned at a chin rest. A calibration procedure was conducted with a nine-point grid stimulus. Then the participants were instructed to “examine each photograph freely.” They viewed six pictures in each of two sessions, with a few minutes rest between the sessions. Before the second session, the participants were again calibrated, and then instructed to view the other six photographs in the same way as in the first session. The pictures were shown in random order for each participant. The viewing time was 50 s for each picture, with a 20 s interval between each picture, during which the participants could close their eyes in order to minimize eyestrain. After the post-test, the participants were interviewed about the difference in viewing photographs between the beginning and the end of the course. In the interview, they answered the following questions: “Did your way of appreciation change after the course? If it changed, could you tell us about the specific change(s)?” The analysis counted the number of participants who answered “yes”, and then described their specific change or changes.Although, all the students on the course participated in the pre- and post-tests, part of the data was missed in performing the experiments and in the process of data recording. The data of two participants in the post-test could not be recorded to MiniDV due to an operational failure. In addition, part of the eye movement data in some participants could not be detected accurately because of the reflection of some participants' contact lenses, and because of the misdetection of their eyebrows and eyeglasses. These operational failures and accidents in recordings could not be rectified by adding participants because of the limited number of participants on the course. Therefore, the researchers adopted the criterion for the data selection as whether more than 70% of the data pertaining to the participants in each session and for each photograph were recorded successfully or not. As a result, data from 13 of the participants was used for the subsequent analysis.It has previously been shown Antes,  that visThe eye movement measures were operationalized as follows. We computed the average duration of fixation to examine whether students' perceptual exploration changed from being diverse or specific. The frequency of saccades was calculated according to the definition as the movement from one fixation point to another with a velocity greater than 100⋅/s Tursky, . In addiThe interest in the recognizable subjects in each photograph was operationalized as the total duration of fixation time on the area. To assess the interest in recognizable subjects, the area of each photograph was divided into 16 parts by three horizontal lines and three vertical lines. The four central cells were defined as the central area, and the 12 peripheral cells were defined as the peripheral area. The photographs with recognizable subjects had objects and models in the central area of the whole picture. According to Hypothesis 1, if the interest of novices in recognizable subjects in photographs changed, the rate of viewing time on the central areas would be different in the pre- and post-tests.Descriptive statistics of the eye movement measures included in this study are reported in Table F = 9.96, p = 0.01, partial η2 = 0.45]. The main effect was discernable in the two-way interaction between session and recognizable subject . Subsequent analysis showed a simple main effect of session . The average duration of fixation decreased from pre-test to post-test with the photographs with a recognizable subject  = 4.34, p = 0.03, partial η2 = 0.27; Figure F = 3.62, p = 0.08, partial η2 = 0.23]. The results showed that global saccades increased with the classic photography that was covered in the course.Further, the results of global saccades showed a significant interaction between the type of photography across sessions  and type of photography . Specifically, the rate was higher in photographs with a recognizable subject than an unrecognizable one, and the rate with classic photographs was higher than with other types. Additionally, a two-way interaction effect between subject and type was found . The subsequent analysis indicated the simple main effect of a recognizable subject in classic photographs  and street photographs . Specifically, the ratio was higher in photographs with a recognizable subject than without such a subject in both types of photography (Figure However, the interest in recognizable subjects did not change even after the course. The analysis of the ratio of viewing time on the central area showed the main effects of a recognizable subject [hy [F2, 2 = 38.54,The interview data after the experiment confirmed that participants had noticed a change in visual information processing in their own photograph appreciation. Of the 13 participants, 11 answered that their way of appreciating art had changed. Also, nine of them explained that they had started to pay attention to the composition and lighting aspects that they had learned about on the course, as described below.S1: Before the course, I vaguely viewed people's faces in portraits, and objects in still life. After the course, I started to think about where the light came from and what the form of the object was like, and I imagined the way the light would illuminate it.S2: Previously, I observed the models in the photographs, such as people's faces and buildings, but this time I paid attention to the shadows and lights that I had learned about on the course.These interview data indicated that the participants started to appreciate the artistic features by applying the knowledge and techniques they had learned during the course. These verbal protocols provide supporting evidence indicating that the course had helped develop the participants' appreciation process.The purpose of this study was to examine whether learners changed their viewing strategies in art appreciation after an educational course that included appreciation instruction and training in photo creation, and if so, what kind of changes in viewing strategies there were. The results show that the students' mean duration of fixation decreased when viewing photographs with recognizable subjects, whether or not the photo category was covered in the course. In addition, their global saccades also increased after the course when viewing classic photographs, which were covered in the course. Although, there was no change with the street photographs, which were also covered in the course, the results suggest that it was not possible for the viewing strategies to be transferred to the appreciation of street photographs, and that the change in viewing strategies could not be applied to this specific kind of photographs. However, the students' reflections indicate that they utilized their knowledge of composition and lighting acquired on the course.Although, studies of appreciation in art education have focused on changes or differences in viewers' interpretation using analysis of reports and interview data, no studies to date have examined whether educational interventions can improve learners' viewing strategies in art appreciation. The current study has provided new findings about the change in learners' eye movements after educational interventions, which imply the possibility that eye movements may be suitable measures for examining changes in viewing strategies in art appreciation due to educational interventions. They also indicate that perceptual exploration and global saccades can be used as measures. Hence, it may be suggested that researchers could apply these measures for examining the educational effects on art appreciation in the future.Two kinds of educational methods were included in the course. The first method involved technical training in photo creation. The specific knowledge and techniques for photo creation in the course helped the students to visualize the creation process of photos during art appreciation. The second method involved dialogic appreciation and imitation of fine art photography with fellow students and an expert artist. The expert artist provided interpretations of art historical knowledge and techniques used in the artwork. In addition, imitation of artwork provided opportunities for the students to practice creating artwork. These challenges may have helped the students to acquire procedural knowledge and techniques for creation, and they may also have made the knowledge and techniques more applicable, not just to creation but also to appreciation.It is interesting that the change in the students' viewing strategies did not appear with all the types of photography. The educational course in this study, the “Artistic Creation” course, covered classic and street photographs. There was a significant change in viewing photos in a category not covered in the course. Fixation times decreased for photos with recognizable subjects in all categories. By contrast, with the types of photography that had been covered in the course, the change in viewing strategies in photo appreciation was not universal. Appreciation of classic photographs changed after the educational intervention, whereas no changes were found with street photographs. What could be inferred from the results? One possible way to interpret this difference in that the change in viewing strategy relates to the different creation processes between classic and street photographs. The educational intervention that focused on the method of approaching the models as a creation process for street photographs focused on the camera technique for classic photographs. Thus, it could be suggested that the students visualized how to approach the models rather than explore specific camera techniques when viewing street photographs; however, the interpretation process may not be reflected in the eye movements. The results of the interviews provided supporting evidence, indicating that students applied their knowledge of camera techniques, such as composition and lighting, but did not describe their knowledge of how to approach the models.The other possibility relates to the generalizability of knowledge and experience acquired through the educational intervention. If the knowledge was more generally applicable, the change in appreciation might be seen with the other types of artwork. Alternatively, if the students spent more time developing their knowledge, they may have applied it to other types of artwork. If it can be concluded from the results of the interview data that the students utilized the knowledge of composition and lighting, it might be argued that they could have applied the knowledge not only to classic photographs but also to street and control photos, still life and crowds, which also contain composition and lighting components. Why were such results not acquired? We can assume that the students did not apply their knowledge in viewing photographs other than classic ones because their knowledge application was limited to certain kinds of photographs. Future studies are required to examine how knowledge is acquired in educational intervention work in art appreciation.Further examinations are required on the validity and reliability of the individuals' change in eye movement in art appreciation. As a first step, researchers should examine what causes the change. If they suspect that there is an educational effect, they should verify whether there is an educational effect or not by controlling the educational intervention in different aspects. In particular, researchers should study both learners who participate in a course and a control group comprised of individuals who do not participate in a course. Also, it would be meaningful to examine whether the contents of educational interventions are effective or not by designing a variety of interventions. For instance, it would be significant to compare differences in effect between instructions in technical knowledge and art history. Furthermore, researchers should examine how the characteristics of photographs viewed in experiments affect the change in learners' viewing strategies, because it may be inferred that familiarity, liking, and interest influence art viewing (Brieber et al., It is also significant to study how changes in the eye movements of learners affect their interpretation of artworks in art appreciation. For instance, a change in viewing strategies may influence the amount and quality of the information that can be used by viewers in their interpretation. It may therefore be assumed that an educational course can improve the interpretation of artwork, as well.Additionally, it cannot be denied that the participants may have controlled their eye movements after the explanation of the study purpose, even though they were not informed about the hypotheses. To avoid this, researchers might provide other information about the study being conducted in order to divert the participants' attention from their own eye movements, providing both a distraction and a debrief.A reliable method to measure the appreciation process is required for the evaluation of educational effects. As an initial step in this direction, this study examines whether the processes of appreciation in people untrained in art change after educational interventions, and if so, what kinds of changes can be observed. An artistic photo creation course was conducted to provide students with technical and procedural knowledge to promote their art appreciation. Additionally, the students participated in quasi-experiments to measure their eye movements before and after the course. The results suggest that students' viewing strategies changed following the course when viewing classic photos that had been discussed on the course. In addition, the students' feedback after the course demonstrated their improved awareness of technical and procedural knowledge, which they applied in their appreciation.The results of this study suggest the possibility that eye movements may function as measures for examining changes in viewing strategies in art appreciation due to educational interventions. Specifically, the possible measures are perceptual exploration and global saccades. The findings of this study are important for the field of art education, as they suggest that behavioral measures may change in individuals after educational interventions, and that this change is measurable by eye movement.CI, KY, and TO contributed to the conception and design of this study, the analysis and interpretation of data, drafting and revising the study, including the final approval of the version to be published, and accepted the agreement to be accountable for all aspects of this paper. The data collection was made by CI.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.


The distraction osteogenesis (DO) technique has been used worldwide to treat many orthopaedic conditions. Although successful, absent or delayed callus formation in the distraction gap can lead to significant morbidities. An alternate cycle of distraction-compression (accordion maneuver) is one approach to accelerate bone regeneration. The primary aim of our study is to report our experience with the accordion maneuver during DO and to provide a detailed description of this technique, as performed in our center. The secondary aim is to present a review of the literature regarding the use of accordion maneuver. We reviewed the database of all patients undergoing limb lengthening from the year of 1997 to 2012. Four patients (6.15%) out of 65 showed poor bone regenerate in their tibiae and therefore accordion maneuver was applied for a mean of 6.75 weeks. Of these, three patients have had successful outcome with this technique. The literature showed that this technique is successful approach to trigger bone healing. However, details of how and when to apply this combination of distraction-compression forces were lacking. In conclusion, the accordion technique is safe noninvasive approach to promote bone formation, thus avoiding more invasive surgical procedures in cases of poor callus formation in limb lengthening. Thisechnique . Both thAlthough DO is associated with satisfactory outcomes in most cases, absent or delayed callus formation in the distraction gap may occur. This could lead to significant morbidities, as the fixator needs to be kept in place for an extended period of time until the bone is completely consolidated. Consequently, unfavorable psychological impact, increased pin tract infections, persistent pain, and increased risk of osteopenia might be encountered –6. In soThere are several modalities where the use of compressive forces in the context of DO could be used in order to accelerate bone formation in the distracted gap, and these include early and increasing weight bearing on the operated limb, dynamization of the fixator, overdistraction, and then shortening and alternating cycles of distraction and compression –13. ThisThe aim of this study is to report our experience with the accordion maneuver in a small series of cases with absent or delayed bone formation during DO and to provide a detailed description of this technique, as performed in our center. We also present a review of the literature regarding the use of alternating cycles of distraction and compression in cases of DO, nonunions, and fractures in both human and animal studies.After approval from our local institutional review board, we retrospectively reviewed all patients who underwent straight lower limb lengthening at our institution between 1997 and 2012. The medical records of 65 patients  who underwent 72 interventions , in which 72 bone segments were lengthened (44 femora and 28 tibiae), were reviewed. Of these 4 patients underwent the accordion technique. The demographic data, clinical course and imaging information, diagnosis, surgery, lengthening details, and complications were all collected from the medical record system. In all patients, a low energy osteotomy was performed by creating multiple small drill holes at the site of osteotomy followed by completion of the osteotomy with an osteotome. Immediate weight bearing as tolerated was initiated in all patients with intense physiotherapy.The specific indication for using the accordion maneuver was an absent or delayed callus formation in the distraction gap, judged radiographically. The accordion maneuver consisted in alternating distraction with compression as follows: distraction (0.25 mm) in the morning and then compression (0.25 mm) in the afternoon, followed by distraction (0.25 mm) in the evening, resulting in an overall daily lengthening of 0.25 mm.The decision to apply the accordion maneuver was taken during initial distraction when imaging has shown absent or significantly delayed callus formation in the distraction gap. This was the case of tibiae in four patients (6.15%) of the 65 investigated. Their mean age was 16.5 years . After lengthening initiation, their X-rays showed an absent or very timid bone regenerate in the distraction gap . In thesFavorable progression of the bone regenerate was noted after an average of 5.3 weeks  after starting the accordion maneuver in three out of four patients . These pSeveral host related, local, and iatrogenic causes can lead to poor bone regenerate during DO . These iA review of the English literature revealed several clinical studies in humans reporting the use of the accordion technique in cases with poor regenerate bone formation in DO, the majority of them with positive outcome. However, the description of the alternate distraction-compression regimen in these studies is anecdotal and lacks details as of when, how, and for how long this technique is applied  15–17, , 24–28.The accordion maneuver has also been used clinically to stimulate bone formation in the context of fracture healing. Similar to its reported use in DO, most of these studies also reported positive outcome, however still with poor description of the technique  14, 18,–31. InteFrom a mechanistic approach, it would be interesting to understand why the addition of compressive forces to those of distraction in cases of DO (the accordion technique) may lead to successful stimulation of bone formation in the distracted gap. It is well known that the mechanical environment plays a major role in bone formation (osteogenesis and chondrogenesis) and that bones adapt to the mechanical loads they are subjected to in terms of modeling, remodeling, and regeneration (Wolff's law) . InteresIn the context of standard technique of DO, most of the forces generated during the lengthening process are believed to be tensile forces. The addition of outside compressive forces during the lengthening process has been reported to be beneficial for bone formation, whether in the form of weight bearing, compression after overdistraction, or dynamization of the fixator or as mentioned by the accordion maneuver . All theAt the molecular level, numerous studies have analyzed the expression of various cytokines, growth factors, and other molecules in the context of DO , 37–39. All the above-mentioned studies lead us to believe that the addition of compressive forces in the context of DO could have a positive effect in the stimulation of regenerate bone in the distracted gap. However, how frequent these compressive forces should be applied in order to provide optimal results, for how long, and when during the lengthening process remain unanswered questions.Our report has some limitations. This is very small retrospective case series with an absence of a control group. However, delayed or absent bone formation is a rare complication during limb lengthening and it will be difficult to study a large cohort of patients with such complication from a single institution. Additionally, although it appears from the literature review that the effect of compression has a major role for bone formation, we were not able to determine whether the slow speed in the distraction rate or the effect of compression has contributed to successful bone formation in our patients. This can be determined by experimental laboratory studies and/or multi-institutional clinical investigations.In conclusion, we believe that, in our small series, the accordion regimen described in this study may be successful in triggering the osteogenic potential of a poor regenerate, thus avoiding more invasive surgical procedures. The literature showed that the accordion maneuver is a successful approach to trigger bone healing. However, details of how and when to apply this combination of distraction-compression forces were lacking. Further research in the form of multi-institutional clinical as well as experimental studies is needed in order to optimize the use of the accordion technique as a noninvasive and nonpharmaceutical method to stimulate bone formation, not only in the context of DO but also in other bony pathologies with poor bone formation. Finally, our future understanding of mechanotransduction in DO might extend the indications of the accordion maneuver to be used not only in cases of poor regenerate, but also during standard lengthening procedures to accelerate bone regeneration.


Tropical and zoonotic diseases are major problems in developing countries like Ecuador. Poorly designed houses, the high proportion of isolated indigenous population and under developed infrastructure represent a fertile environment for vectors to proliferate. Control campaigns in Ecuador over the years have had varying success, depending on the disease and vectors targeted.In our study we analyse the current situation of some neglected diseases in Ecuador and the efficiency of the control campaigns (by measuring changes in numbers of cases reported) that the Ecuadorian government has been running to limit the spread of these infectious and parasitic diseases.Our study reveals that Brucellosis, Chagas Disease, Rabies and Onchocerciasis have been controlled, but small outbreaks are still detected in endemic areas. Leptospirosis and Echinococcosis have been increasing steadily in recent years in Ecuador since the first records. The same increase has been reported world-wide also. Better diagnosis has resulted in a higher number of cases being identified, particularly with regard to the linking of outdoor activities and contact with farm animals as contributing vectors. Improvements in diagnosis are due to regular professional training, implementation of automatized systems, establishing diagnosis protocols and the creation of an epidemiological vigilance network that acts as soon as a case is reported.Control campaigns performed in Ecuador have been successful in recent years, although natural phenomena limit their efficiency. Leptospirosis and Echinococcosis infections remain a growing problem in Ecuador as it is worldwide. There are several clinically and economically important tropical infectious diseases in Ecuador, six of which have been subject to long-standing control campaigns. These six diseases are reportable in the country and include: Chagas Disease (CD), onchocerciasis, rabies, leptospirosis, cystic echinoccocosis (hydatid disease) and brucellosis. The incidence and prevalence of most of these diseases have declined over the last 20 years, owing mainly to the control and surveillance activities implemented by the government through the Ministry of Health. Yet, factors such as climate change, natural disasters, El Nino and other social behaviours have made difficult to completely eliminate these diseases. These diseases have many economic and patient related consequences. There are many causes, for instance, in urban and suburban areas where sewage systems are inadequate, rain water can overwhelm them causing sewage waste to mix with flood water on the surface, increasing the rate of infections by facilitating the proliferation of pathogens and vectors. Among other major factors are inadequate hygiene practices, difficult environmental conditions, farming practices and human activity.There are several reports regarding the rate and variety of tropical and zoonotic diseases in the most affected South America countries, but few using data from Ecuador and none have been compiled and analysed in such a way as to give a complete overview.In this paper we discussed the seven most common diseases reported in Ecuador. We have excluded Dengue and Malaria which, due to their importance, are the subject of a separate study (manuscript in preparation).Trypanosoma cruzi is endemic in Latin America [Chagas disease (CD) caused by  America . Infecti America  and worl America . In LatiEcuador has been especially vulnerable on both counts due to the way houses are constructed and to the socio-economic situation .T. cruzi worldwide, the main concentrations are in Latin America with an estimated 25 million people living in risk areas, in 2008 alone, 10,000 CD- related deaths were reported.While 7 to 8 million people are estimated to be infected with Onchocerca volvulus. The vector of this disease is the Black fly (Simulium exiguum). The World Health Organization (WHO) estimates that at least 25 million people are infected with O. volvulus worldwide and around 123 million people are at risk of becoming infected with the parasite [Onchocerciasis (River blindness) is caused by the nematode parasite . Ecuadorparasite  but nowaRabies is a viral disease present in most regions of the world but approximately 99% of rabies cases are found in developing countries, 90% of these occurring in Asia. Transmission occurs by contact, often a bite, from an infected animal. The first paper reporting bovine rabies in Ecuador was in 1958  and caniLeptospira spp. in the rivers of the rainforest [Leptospirosis is an increasing worldwide problem; the spirochete is transmitted by contact with water contaminated with urine from infected animals. Precise numbers of cases vary between countries but the WHO estimate rates of around 0,1–1 cases per 100 000 inhabitants in temperate regions and is often over 10 times more in tropical regions. Not a lot of literature is found about Leptospirosis in Ecuador apart from a few clinical cases , a revieinforest , no otheEchinococcosis or Cystic Echinococcosis (CE) are characterized by the formation of cysts on the hosts’ liver or lungs and are caused by tape worm parasites, transmission to humans is normally through ingestion of contaminated meat and water . Around Brucella abourtus) is transmitted by contact with infected faeces, urine and milk from infected animals, but most commonly the infection occurs through poorly prepared and/or preserved food of animal origin. Poor personal hygiene practices also contribute to increase incidence. In endemic areas, the reported incidence from data compiled by WHO quotes ranges from less than 0.01 to more than 200 cases per 100,000 inhabitants [Brucellosis .This retrospective study was based on clinical data, gathered from cases reported by medical doctors directly contacting the Epidemiological Surveillance Department of the Ministry of Public Health of Ecuador . All the data used for this study were approved by the ethical committee of the Ministry of Public Health. A Case was considered, when patients that have been diagnosed and the bacteria, virus or parasite have been isolated and identified. The comparisons made between different areas are based on officially reported cases for each health care district. These data are available on line in the Ministry website .- Prevention treatments; isolation of human or animal carriers, vaccination if applicable, treatments against vectors and other measures to control the spread.For the analysis of the data we follow these steps:(i) Gathering temporal epidemiological data (from website indicated but clarifying the source for data on Chagas and Onchocerciasis); (ii) analysis of the Ministry of Public Health control and surveillance programs; (iii) literature searches from Medline, PubMed and other scientific sources of JCR manuscripts.While Ecuador still suffers from some vector borne and zoonotic diseases , our stuThe control campaigns run by the government of Ecuador have been successful in most cases, taking the numbers reported as an indicator. For all diseases discussed in this manuscript there are standardised protocols for containment and treatment, and are as follows: 1. Passive monitoring that triggers active searches for potential cases, 2. Educational campaigns for dissemination of risk factors and prevention, 3. Isolation of cases, 4. Disinfection of area, 5. Search for the source of infection of index case, 6. Treatment and prophylaxis. However, there are still some zoonotic diseases that continue to be prevalent. Brucellosis is found in low rates in farm animals, usually associated with rural areas. Leptospirosis is increasing in Ecuador . It has been associated to a massive increase in intensive livestock farming with its associated levels of effluent, combined with the poor management of the effluent and increased water related outdoor activities such as canoeing and swimming .In Ecuador, Chagas Disease and Onchocerciasis have all but disappeared. Since 2007 no cases have been reported, except a small outbreak in 2009 where a total of 9 people were diagnosed with Chagas disease, 7 of them in the coast region . The conChagas Disease: In wider Latin America there have been important successes in parasite and vector control since the 1990s in the intergovernmental territories of the Southern Cone, Central American, Andean Pact and Amazonian regions. These multinational initiatives have led to substantial reductions in transmission by vectors. In addition, the risk of transmission by blood transfusion has been substantially reduced by the strict testing of blood donors with ELISA before the extraction, and better control of the storage and use of blood . Other cThe programs for the control of CD in Ecuador started in 2003, now, a decade later, the disease is considered controlled. Our results show that from 2010 no new cases were reported in children less than five years old, indicating that the program of vector vigilance and control of blood transfusion practices are effective in the control of this disease[Onchocera volvulus) Elimination Program of the Americas was established in 1992 in response to a resolution of the Directing Council of the Pan American Health Organization (PAHO) calling for the elimination of Onchocerciasis Ocular Morbidity in the Americas by 2007 [The Onchocerciasis  in the cities; it ran educational campaigns, vaccination campaign for humans in contact with suspicious dogs and other control measures like attempting to isolate affected areas. Massive animal vaccination campaigns that the Government ran effectively controlled rabies transmitted by dogs, but it is more difficult when transmission is caused by other wild animals, particularly bats in the Amazon region. In 2005, in Pastaza (Amazon region), there were 2 cases reported, caused by bites from bats. In 2009, In Esmeraldas , 1 case was reported as being transmitted by a cat that carried the virus. Finally, in 2011, in Morona Santiago (Amazon region), 11 cases were reported, again with bats transmitting the disease through their bites , Fig 1.Rabies Ecuador is part of the “Regional plan of Rabies of Americas” driven by the WHO. In 1996, Ecuador registered one of the biggest outbreaks, with 1700 dogs and 75 humans infected, of which 65 died. Since then, the number of cases reported decreased until 2001, when just one case of human rabies transmitted by a dog was reported and apart from the isolated out breaks of 2005, 2009 and 2011, there have been no reports of human rabies . HoweverIn several parts of the world the control of rabies has been successful. In Romania after the outbreak in 2008 the number of cases of rabies reported has been decreasing, with just 6 cases reported between 2008–2012 . In PolaLeptospira spp.) has been increasing in the last few years. In an outbreak observed in 1998, 398 cases  in 1993 [E. granulosus in 13.53% of pigs slaughtered in the abattoir [Echinococcus spp. was found, but no data on specie was registered [Cystic echinococcosis outbreaks were reported in 1995 and 1996, both in the Pichincha region of Ecuador . Betweencreasing . Cystic  in 1993  but the  in 1993 . When trabattoir , the samabattoir . The samabattoir . In 2010gistered . It is iIn 2012 in Europe most echinococcosis cases were reported in Bulgaria . SwitzerBrucella spp.) infection rates have remained relatively constant and low in Ecuador (Brucellosis ( Ecuador  during m Ecuador . It is eBrucella spp. infections in Latin America, between 1968 and 2006 showing that Ecuador had the third lowest number of isolates after the Dominican Republic and Nicaragua. However, countries like Mexico, Argentina and Peru prove to have among the highest prevalence. That said, the situation in Latin America is not as bad as in other regions, for example Niger, where it is proving to be a serious problem, especially in rural areas like Niamey [Before the government implemented control measures, a study was published  regardine Niamey .Brucella sp. has been found in several wild animals species [In China,  species , whereas species .The Ecuadorian government has been expending increasing amounts of budget in the control of tropical and neglected diseases. The Ecuadorian government has mounted successful control campaigns against most of the tropical and zoonotic diseases described. It was one of the first countries to control Onchocerciasis and Chagas disease, while Rabies has been well controlled except for some small outbreaks caused by wild animals, particularly bats, in the Amazonian region. Brucellosis is well controlled in Ecuador through Governmental initiatives and the number of cases reported continues to be low. Plague is not considered a major issue in Ecuador as all the cases reported are confined to the province of Chimborazo, where the total of 23 cases was in three outbreaks which were successfully treated. No cases have been reported since 2001. This is the reason why we think it is not relevant to highlight as one of the major diseases in Ecuador. Leptospirosis and Echinococcosis are still problems that the government are trying to control through existing initiatives.The strength of these programs relies on multidisciplinary approaches covering education of the population to stop the dissemination of the diseases; training of professionals to improve the diagnosis and control of the diseases; vaccination or personal risk reduction measures; physical cleaning and hygiene and vector or animal control. The figures indicate the efficiency of the Ecuadorian control campaigns and education programs, and the authors suggest that the approaches can be used as a model for other endemic countries that are still suffering these diseases.However, it is crucial these diseases should continue to be monitored as, although this research shows positive results, they are endemic to Ecuador. The starting of “El Nino” with its associated effects on proliferation of vectors and increases in contaminated flood waters, offers an ideal opportunity to stress test these initiatives to ensure the efficiency of these control programs.


An enhancement in recall of simple instructions is found when actions are performed in comparison to when they are verbally presented – the subject-performed task (SPT) effect. This enhancement has also been found with older adults. However, the reason why older adults, known to present a deficit in episodic memory, have a better performance for this type of information remains unclear. In this article, we explored this effect by comparing the performance on the SPT task with the performance on other tasks, in order to understand the underlying mechanisms that may explain this effect.We hypothesized that both young and older adult groups should show higher recall in SPT compared with the verbal learning condition, and that the differences between age groups should be lower in the SPT condition. We aimed to explore the correlations between these tasks and known neuropsychological tests, and we also measured source memory for the encoding condition.A mixed design was used with 30 healthy older adults, comparing their performance with 30 healthy younger adults. Each participant was asked to perform 16 simple instructions (SPT condition) and to only read the other 16 instructions . The test phase included a free recall task. Participants were also tested with a set of neuropsychological measures .The SPT effect was found for both age groups; but even for SPT materials, group differences in recall persisted. Source memory was found to be preserved for the two groups. Simple correlations suggested differences in correlates of SPT performance between the two groups. However, when controlling for age, the SPT and VT tasks correlate with each other, and a measure of episodic memory correlated moderately with both SPT and VT performance.A strong effect of SPT was observed for all but one, which still displayed the expected aging deficit. The correlations and source memory data suggest that the SPT and VT are possibly related in respect to their underlying processes, and SPT, instead of being an isolated process, is in connection with both the episodic memory and executive function processes. Under these circumstances, the SPT seems to contribute to an enhancement of the episodic memory trace, presumably from the multimodality it provides, without involving a separated set of cognitive mechanisms. Future research using more pure measures of other cognitive processes that could be related to SPT is necessary. In the early 1980s, Engelkamp and Krumnacker (1980) and Cohen  introducA critical issue in the SPT effect is automaticity. Cohen  suggesteDefending another perspective, Engelkamp and Krumnaker , EngelkaThe focus of this article is healthy aging, where there is a well-documented deficit in episodic memory, such that older adults show reduced recall and particular difficulty in tasks that require intentional effort  analyzed the memory performance in an action memory task, using a sample of 1,000 subjects aged between 35 and 80 years of age, divided in 10-year age groups. The participants had to study two lists of 16 simple instructions. The results of free recall showed a main effect of age and condition. Additionally, there was a decrease in differences between the age groups in the SPT condition, although a more thorough analysis, suggested that there was a possible floor effect in verbal learning for older age groups, which may explain this pattern of results.put the phone to the ear) and lists with unrelated object – action pairs (e.g. shake the phone). The aim of manipulating the semantic association was to examine whether the associative potential underlying the SPT effect would be independent of the semantic information of items. Their results showed a superiority for SPT encoding compared to verbal encoding, for both groups, with, however, a superior performance for the group of young adults in comparison with the older adults. In the SPT task there were no differences in performance for the lists in any of the groups, which indicates that this type of effect overcomes any semantic contribution. Taken together, these results led the researchers to conclude that the execution of sentences provides a benefit to forming associations, even for a group (the older adults) that usually have difficulties in associating information, even if this effect cannot completely eliminate the performance differences between this group and young adults  and 30 older adults , all of whom had normal or corrected vision and hearing, and were not exhibiting significant depressive symptoms. The older participants also did not show cognitive decline, according to the Addenbrooke's Cognitive Examination-Revised instrument, a 15-min screening test with a range of tasks to detect cognitive deficits . The groups did not differ in terms of gender, education, premorbid IQ and dwelling area  and each sentence was coded the same number of times in both conditions.Symbol Search =41.24, p<.001, η2p=.416] and condition were found . Moreover, with these participants and with this design, an interaction between group and condition was found , where the differences in total recall between groups diminished in the SPT condition  than in the verbal condition . However, when going further into this analysis, a paired samples t-test for each group between the SPT and VT found significant differences . Likewise, we found significant differences when we analyzed the group differences in SPT and VT separately, in an independent sample t-test , thus suggesting that although the SPT increased memory performance in the older adults, significant differences remained between the young and old, which is clear in the large effect sizes of these analyses.The correct recall of the complete sentences (correct action–object pair) was analyzed in both age groups, in the VT and the SPT conditions. A mixed ANOVA with repeated measures for condition (VT versus SPT) was performed to analyze the differences between the two age groups. From this analysis, the expected main effects of group , suggesting that the groups differ less in errors for sentences coded under enactment  than for sentences coded under the verbal condition , although the effect size for this interaction can be considered weak (η2=.135).When looking at the errors (very few as we can see by the recognition scores) committed by participants, we separated the errors committed for sentences coded in the SPT condition and in the VT condition, and we performed a repeated measures ANOVA for these errors within conditions and between age groups. An interaction effect was found between group and the type of error , and also with the Letter–Number Sequencing . Additionally, we found a positive, moderate association between the VT condition and the Symbol Search test . For the SPT condition in the young group, a different pattern of associations was observed; positive, but weak to moderate associations with only two tests of executive function and attention: Visual Patterns Test ; Symbol Search . Analyzing the correlation matrix for the older adults group, we firstly see fewer significant correlations. In the VT condition, we identified positive and weak to moderate associations with the WMS Paired Associates test immediate , and with the Digit Symbol Coding . In the SPT condition, we found no statistically significant associations with any of the neurocognitive tests used.First we present the simple correlations between the two conditions of the Memory for Action task (VT and SPT conditions) and the neurocognitive measures for each group separately see . To contIf there is some pattern in these correlations, it is that the verbal condition of our experimental task seems to show a moderate to strong association with our test of episodic memory, the Paired Associates Test. This pattern is clearer in the immediate test in the younger and older adults. On the other hand, the paired associates’ measure does not correlate significantly with the SPT task in either group.To elucidate further the role of our other cognitive measures on the SPT, we considered an analysis combining the groups but controlling for age with partial correlations. Like this, we aimed to examine if there were any common factors which influenced the SPT. That is, we had group differences in SPT and most of our neuropsychological measures, so it is difficult to know what neuropsychological measures influence directly the SPT and which may just be part of a common aging deficit. In particular we were interested in further examining the above trend that whereas tests of episodic memory (and a few others beside) are associated performance in the verbal condition, there is a different set of correlations for the SPT task – in particular a lack of the relationship with the paired associates task.r=.57, p=.01). Finally, as this pattern in partial correlations was not clear enough to understand the relationship between SPT and the other measures, we decided to analyze the groups as a whole, not controlling for age, and our results were that all complementary neuropsychological measures correlated with both the VT and the SPT, and a stronger correlation between the VT and the SPT . The episodic memory test  correlated more strongly with the VT  than with the SPT  but all correlations were significant. Thus, we might therefore conclude that the SPT task has a relationship with the general episodic memory system, despite it not being entirely driven by it. The two tasks used to measure executive function also correlated positively and strongly with both the VT  and the SPT , indicating again the role of executive functioning in the SPT. Finally, for the attention and speed processing measures, we find the same results, with similar correlations for both VT and SPT with these measures, but these are stronger for the VT task  than for the SPT .In these partial correlations controlling for age see , we obseR2=.76, adjusted R2=.73, F=27.99, p<.001; SPT,=.46, adjusted R2=.40, F=7.61, p<.001] . However, when separating the analysis by age groups, one interesting finding was produced, whereby VT recall and SPT recall are predicted by the combined model of complementary neuropsychological measures only for the younger adults , whereas for the older adults, both VT results and SPT results are not predicted by the model of complementary tests, neither by any of these tests alone . Perhaps the significant differences in most cognitive measures used in this study between older and younger adults justify this pattern, which we will consider in more detail later in the discussion section.Our final analysis considered using a regression to predict the SPT and VT scores. When carrying out the regressions without splitting the age groups, both VT recall and SPT recall are significantly predicted by the combined model of all the other tests together [VT, t-tests showed that significant age differences remained in SPT performance. A similar pattern was obtained by Bäckman & Nilsson . This is also supported by the correlations performed not controlling for age, where the SPT task correlated moderately with the episodic memory measures, thus meaning that there is an involvement of episodic memory in the performance of SPT tasks. Thus we have found that a powerful SPT effect exists in older adults, but not one which reduces age differences to non-significant levels.Based on the original studies of the SPT paradigm with older people, we were interested in the possibility that differences between the two age groups were not eliminated in the SPT condition. Additionally, the fact that the VT and the SPT condition correlated with each other in the correlation matrix suggests that performance in these two tasks is related, so probably activating the same substrate of episodic memory, at least partially , for the group of younger adults, the neuropsychological tests have positive and moderate relationships with the VT and SPT tasks (despite in the SPT task the correlations are only significant for executive function and attention measures). The crucial test was, moreover, the correlations without controlling by age groups, where the SPT showed positive, moderate and significant correlations with all the neuropsychological measures used in this study , which, despite suggesting lower correlation strength compared to the VT task , indicates that the SPT effect is not a separate type of memory. As the correlations are, as mentioned, only moderate in comparison to the control task, we miss some deeper understanding of what more, other than these domains tested, is involved in the SPT effect. It will be important to get a better idea of the domains that can influence the performance of episodic memory for actions, possibly by enlarging the set of neuropsychological tests administered and to use more pure tests that assess a more specific kind of cognitive domains; thus allowing us to understand the more true connections between the action memory processing and the other cognitive processes known to be relatively impaired in aging . This may be related to the visual and sensory component present in the VT condition that is not assessed by the verbal episodic memory test WMS Paired Associates, and that could be some explanation for this finding. A limitation of this set of neuropsychological instruments used in this study is the lack of an episodic visual task, where we could more clearly compare the visual episodic system involved in the Memory for Actions test with another parallel instrument.The results of this investigation, taken together, and although with some equivocal or weak findings, speak to some of the theoretical explanations of the SPT effect. Knowing the difficulty of associating information in a single episode inherent to the cognitive aging process , so perhaps these functions are behind the group differences on the SPT effect too. We stress, however, that the measures used here, as standardized instruments, where not pure measures of any of these domains, thus remaining the need for using more pure tasks of each cognitive domains to understand in deep their connection with the SPT effect.In conclusion, this study finds the standard SPT effect in the context of a memory deficit in older adults. Older adults are able to report the source of items in a subsequent recognition test, showing that they retain episodic information about how they previously encountered the stimuli. Thus, we imagine that the SPT encoding, even if ‘special’ in some way, enters into the episodic system, and is later available for conscious report. This is borne out in our correlations. The general pattern is that people with high VT scores have high SPT scores, and episodic memory measures correlate with SPT scores. Thus, the SPT effect seems to act in concert with, and in line with the episodic system, and not separately from it. We continue to stress the use of this kind of rich multimodal encoding where the episodic memory is particularly impaired (Nadar & McDowd,


This study was conducted to describe the association between central auditory processing mechanism and the cardiac autonomic regulation.It was researched papers on the topic addressed in this study considering the following data bases: Medline, Pubmed, Lilacs, Scopus and Cochrane. The key words were: “auditory stimulation, heart rate, autonomic nervous system and P300”.The findings in the literature demonstrated that auditory stimulation influences the autonomic nervous system and has been used in conjunction with other methods. It is considered a promising step in the investigation of therapeutic procedures for rehabilitation and quality of life of several pathologies.The association between auditory stimulation and the level of the cardiac autonomic nervous system has received significant contributions in relation to musical stimuli. Listen to several auditory stimulation requires the brain articulation of various tasks, it is an act designed to engage perception, cognition, emotion, memory and learning that goes through various stages of processing, causing reactions to reach conscious awareness. Thus, central auditory processing mechanism is a rich and indispensable tool in the investigation of the functioning of the nervous system .In relation to musical auditory stimulation, since ancient time music had its importance to mankind, the Greeks had music as a divine gift, a concept for healing the body and mind in the figurative image of the God of medicine and music, Apollo. However, the song became valued in scientific circles recently, with noticeable benefits to pathological individuals .Several scholars have mentioned the importance of integrating music in the rehabilitation phase, suggesting that this method brings beneficial results in relation to cognitive, emotional and social needs of individuals of all ages, prioritizing the quality of life of these subjects -6.The literature shows the beneficial effects of music both in pre-surgical patients in relieving pain and anxiety , and in It is known that the method used in scientific production in relation to the types of auditory stimulation parameters associating cardiovascular and autonomic nervous system has been the music . On the In this context, an important method used to analysis the central auditory process is the potential long latency auditory, also called as P300 . This meA literature review was conducted between September 2012 and March 2013 and it was divided into two stages: a survey of the material, classification and content analysis.In the first stage the studies were surveyed on the topic addressed in this study, considering the following data bases: Medline, Pubmed, Lilacs, Scopus and Cochrane. Initially a search was made from the title and then collecting their summaries. The key words were: “auditory stimulation, heart rate and P300”. The descriptors used v according to the Medical Subject Headings (MeSH). All references were between 2003 and 2013.The second stage was supervised by two reviewers, an expert in the field of audiology and the other in cardiac autonomic regulation, which included the classification and analysis of the abstracts, according to the focus of the study. We excluded studies which did not cover the thematic objective of the review, published after the deadline, with no scientific content, summaries, the same publication in various media, proceedings of seminars and conferences, thesis and dissertations, and studies that were not part of an indexed journal.After this first analysis, the titles were selected to undergo a new assessment, with more specific criteria considering clinical trials, observational studies, and basic studies investigating cardiovascular parameters and auditory stimulation.The electronic search yielded a total of 1500 references. Reading the titles and abstracts, and after the application of exclusion criteria, 102 articles emained. A complete review of the literature allowed the inclusion and analysis of 19 articles, considered of high scientific impact and according to the theme of the literature. Table In this study review we described previous studies that investigated the influence of auditory stimulation on heart rate variability. According to the findings in the literature auditory stimulation influences the autonomic nervous system and has been used in conjunction with other methods. Regarding the types of auditory stimulation, music was the most used method. The analysis of texts selected for this review indicated that harmonic music is able to improve cardiac autonomic regulation. The literature on the effect of music on the autonomic nervous system activity in healthy subjects is quite large. Conversely, the literature on how musical auditory stimulation affects individuals with cardiovascular dysfunction is less developed.A previous study cited in our review  suggesteTwo studies previously published ,13 aimedIn another study  it was rAlthough exposure to music can lower blood pressure and renal sympathetic nerve activity, it is important to reinforce that not all music styles have this effect, and that the effects of musical stimulation on the cardiovascular system depend on an intact cochlea and proper functioning of histaminergic neurons in the suprachiasmatic nucleus of the hypothalamus . FurtherWithin this context, some authors suggested that music can broaden understanding of neuroplasticity in the long term, and that these findings have implications for policy makers and education for the development of auditory training programs that can generate lasting positive results . In addiExploring the literature we found a study making association between the P300 wave (P300) and musical auditory stimulation in young women in order to avoid habituation . The P30Another study  to test We found in our literature review some studies -32 that Zhao and colleagues investigated the EEG and cardiac autonomic regulation of healthy volunteers during a continuous simulated driving task for 90 minutes . The autOur study presents some points that are worth to be pointed. Although some of the selected studies was performed in animals, the mechanisms observed are currently supported, however, it needs additional clarification for improvement in clinical application. We decided to not select all studies linking auditory stimulation and cardiovascular system in order to focus our objective that was to investigate the relationship between central auditory processing mechanism and autonomic regulation of the heart.This study review indicated that there is a strong association between central auditory processing mechanism and cardiac autonomic regulation, indicating that there is great part of studies focusing on musical auditory stimulation effects on heart rate variability. Nevertheless, it is not fully understood the interaction between auditory evoked potential and cardiac autonomic regulation. Additional studies are necessary to clarify this mechanism.The authors declare that they have no competing interests.All authors participated in the revision of the manuscript. All authors determined the design, interpreted the text and drafted the manuscript. All authors read and gave final approval for the version submitted for publication.