Afghanistan has struggled with several decades of well-documented conflict, increasing the importance of providing emergency services to its citizens. However, little is known about the country’s capacity to provide such care.Three native-speaking Afghan-American physicians performed an assessment of emergency care via combined quantitative and qualitative survey tools. Hospitals in Kabul, Afghanistan were selected based on probability proportional to size methodology, in which size was derived from prior work in the country and permission granted by the administering agency and the Ministry of Health. A written survey was given to physicians and nurses, followed by structured focus groups, and multiple days of observation per facility. A descriptive analysis was performed and data analyzed through a combination of variables in eight overarching categories relevant to emergency care.p = .001), confidence in the system , assault , and feeling safe in the emergency departments . Confidence negatively correlated to frequency of assaults  but positively correlated with feeling safe  and reliability of equipment . The only correlation for access to services was prehospital care .One hundred twenty-five surveys were completed from 9 hospitals. One third of respondents (32.8 %) worked full time in the emergency departments, with another 28.8 % working there at least three quarters of the time. Over 63 % of providers believed that the greatest delay for care in emergencies was in the prehospital setting. Differences were noted among the various types of facilities when looking at specific components of emergency care such as skill level of workers, frequencies of assaults in the hospitals, and other domains of service provision. Sum of squares between the different facility types were highest for areas of skill  contains supplementary material, which is available to authorized users. In early 2002, the Ministry of Public Health (MoPH) of Afghanistan and the major donor organizations for the country, including the World Bank, the United States Agency for International Development, and the European Commission, created a Basic Package of Health Services (BPHS) for Afghanistan . The BPHThe World Bank has advocated for designing essential packages of health services based on country-specific burden of disease for some time . AfghaniHowever, despite improvements in general and preventive health outcomes , 11, terAfghanistan’s general health structure since the implementation of the BPHS/EPHS contains little recommendations regarding the establishment of emergency and acute care for the country . This isWe chose a convenience sampling of hospital physicians, nurses and medical residents in training to survey in Kabul, Afghanistan. All hospitals were either public, private, or run by the Afghan military. Approval was granted from the McLaren IRB/Ethics Review Board for exemption status and the Ministry of Health of Afghanistan. For each chosen hospital, we provided a written survey to providers that were on duty on sequential days. Provider inclusion criteria were physicians, residents, or nurses trained in Afghanistan, employed by the institutions and willing to answer our written survey.The written survey was an 87-item questionnaire in Likert-scale focusing on personnel background and training, hospital background, emergency room services, emergency personnel, transportation, and prehospital questions  for data analysis.After collection, the data was coded and entered into SPSS software. Quality checks were performed on every tenth entry. We used PASW 18 Statistical Package  from government hospitals, 42 (33.6 %) from military hospitals, 17 (13.6 %) from NGO hospitals, and 4 (3.2%) not specified  and some of our measures were significant at the .01 to .05 level.Skill level was significantly correlated to the type of hospital, confidence in the benefit of emergency care, feeling safe while practicing, and having sufficient supplies Tables  and 6.TaConfidence in the particular health system was negatively correlated to frequency of assaults, and positively correlated with feeling safe in that particular system and in the adequacy of supplies/equipment, the amount of hospital staffing and in the skill level of the workers Table .Time to the ED/prehospital time was heavily correlated to the levels of access in each facility.The type of hospital was significantly correlated to the number of assaults experienced by respondents and negatively correlated to confidence in the system, feeling safe, adequacy of staffing, and supplies.From our observations, medical training and adequate equipment was a large barrier in providing services. Many public facilities were often so crowded that we could not safely get in through the hospital doors and we met many patients waiting hours for basic life support mechanisms such as oxygen tanks or an EKG. Physicians were very eager to learn, and requested support for medical education and greater training. User fees were collected at one of the NGO sites, whereas all other facilities collected intermittently for medical supplies, blood products, and other equipment that were not immediately available within the facility itself.The Afghan health care system is limited in its capacity to provide in-and-out-of-hospital emergency care. Our data and analysis shows wide variation in emergency services provided in Kabul, with much of the variability dependent on the type of hospital facility.We found that medical training at the military hospital had some, although limited focus on emergency medical training, but this was not persistent in the public sector system. Resident physicians often noted that they were left to deal with emergencies that came to the hospital, regardless of whether they had prior training in certain clinical scenarios. During focus groups and in our observations, limitations highlighted were not always due to resources constraints but also to a lack of organizational structure and processes in place to prioritize and triage cases.Although the public hospitals see a disproportionately large number of patients, they trended toward having less capacity, supply, and resources. These issues were highlighted in their level of confidence, skill and staffing issues corroborated by our quantitative analyses. They were also more subject to frequent assaults and disaster scenarios, further creating barriers to consistent staffing of the emergency departments. From our own observations, their medical and equipment supply, including items as simple as oxygen supplementation, did not meet the demands of the volume of patients treated daily.From our observations, the military hospitals were not open for civilian care unless injuries were the direct result of combat. Our focus groups highlighted that most patients, despite being from remote areas of the provinces, knew of the existence of public facilities and were either referred to or directly came to public facilities much more readily than the NGO hospitals or other private facilities. There was also a sense that public sector hospitals were always free, whereas NGO facilities would charge a fee, even though only one of the NGO facilities we visited had begun a process of user fee collection on a very limited basis.From our summary measures and correlations data, we found that NGO’s consistently had the better trained staff compared to the public and military hospital. We found that confidence in emergency medicine skills, such as intubation were much better in NGO and military hospitals as compared to the Public system. Even when we split the data based on occupation (nurse or physician), we found that differences among the facilities persisted in their level of skill.Skill was also an outstanding variable that was positively correlated to the type of hospital , confidence in the emergency care system, feeling safe while practicing, and having sufficient supplies. It is a possibility that the skilled workforce migrates to higher paying, better supplied, and safer working conditions.Our assessment demonstrated that there is a high need for ongoing investment in the skills based training of physicians, nurses, residents, and other emergency personnel especially in the public sector hospitals.Tables As part of the current debate on a national salary policy, adequate compensation, and incentives for health workers should be addressed to maintain adequate staffing for the care of emergency patients in light of such safety issues. Its also noteworthy that the reality of Kabul still purports a more secure work environment in comparison to other provinces and in particular rural areas where corruption will more likely be a contributing factor given fewer civil services and the paucity of security forces.Time to the ED and prehospital time was heavily correlated to the levels of access in each facility. Whether this implied that more efficient prehospital care, as provided for example in places like the military, also allows for quicker and more effective initial entry and triage via the ambulance system cannot be determined by our quantitative data alone, but this was corroborated repeatedly by our focus group discussions and our qualitative analyses. Our own observations of seeing patients brought in by local taxis to the public hospitals also begged the question of whether more focus on the development of the prehospital system is a key to increasing access for all citizens. Time to ED undoubtedly differs in urban centers like Kabul, versus rural Afghanistan, but we cannot make any specific conclusions at this time.Since most admitted knowing colleagues who were assaulted or having been assaulted themselves during the highly emotional moments that medical emergencies provoke, the addition of further security measures for workers in the hospitals, especially within the public sector hospitals, would allow physicians to feel safer committing more time to emergency sections, such as taking night shifts. Studies in Iraq have found that within the Emergency Department alone, over 80 % of physicians were victims of assault at least once . CorrelaIt is also worthwhile to discuss our two summary measures that were consistently not significantly different among facility type; access and prehospital care. Neither of these components proved to be different among the various facility types throughout our analyses. This may be indicative of the fact that most respondents were in agreement regarding the landscape of prehospital care and access issues. Therefore, when we tried to decipher if respondents felt differently about these particular issues based on their facility type, our conclusions were never statistically different.The challenges of providing care in Afghanistan combine those of a developing nation, an intra-conflict nation and a combat zone . Our conOur survey combined with the focus group conclusions and our own first hand witness of the emergency system in Kabul, Afghanistan reveals critical lack of resources, capacity, and safety while providing initial care. Additionally, there is a widely accepted opinion that although an emergency call number exists, there is no consistent and reliable predhospital system.There are frequent shortages of lifesaving medications, a lack of functioning medical equipment, and a paucity of opportunity for continuing training and medical education.There are also few incentives for clinicians to provide emergency care. Neither the national health service primary package, the BPHS, or the hospital wide quality initiatives of the EPHS focus much detail on initial point of care guidelines or resources , 22. At In a country plagued by decades of war and unrest, a comprehensive and effective prehospital and emergency care system is paramount to saving lives, meeting critical health care needs, and providing a reliable safety net for the population.Despite documented success in indicators as maternal mortality rates and infant mortality rates , much moThe major limitation in this study is that although the hospitals were randomly sampled, we used a convenience sampling of health workers present in the hospitals during our data collection period. The experience and opinions of the health workers present may not reflect those of their hospital overall throughout the full year.Additionally, our study was limited to Kabul. Although a majority of resources are concentrated in Kabul, it is unclear if this survey is generalizable to other urban centers and the more remote areas of Afghanistan. As of 2012, there are still only 26 hospitals in the entire country that implement the quality initiatives and standards of the EPHS, therefore data on the capacity of emergency care in all hospitals as a whole may not be fully reflected at our chosen sites [It is possible that our survey was influenced by cultural bias, since many health workers may fear job loss in an ongoing insecure labor market, due to retribution if respondents were honest about the shortcomings of the system. We maintained that all surveys were completely confidential, but this limitation is still a possibility. Also, though we did not ask directly about corruption and theft as a factor during open-ended focus groups, it is likely that out of fear of retribution or cultural nuances, these issues were not discussed.In our focus groups, we avoided asking direct response questions and instead opted for more open-ended questions. However, it is a well-known limitation of focus groups that surveyors asking questions may indirectly elucidate responses already programmed through a society’s own belief system and systems of hierarchy (Maxwell) . Focus g


We are facing a global epidemic of non-communicable disease (NCDs), which has been linked with four risky lifestyle behaviours. It is recommended that primary care providers (PCPs) provide individual brief behaviour change counselling (BBCC) as part of everyday primary care, however currently training is required to build capacity. Local training programmes are not sufficient to achieve competence.This study aimed to redesign the current training for PCPs in South Africa, around a new model for BBCC that would offer a standardised approach to addressing patients’ risky lifestyle behaviours.The study population included clinical nurse practitioners and primary care doctors in the Western Cape Province.The analyse, design, develop, implement and evaluate (ADDIE) model provided a systematic approach to the analysis of learning needs, the design and development of the training programme, its implementation and initial evaluation.This study designed a new training programme for PCPs in BBCC, which was based on a conceptual model that combined the 5As  with a guiding style derived from motivational interviewing. The programme was developed as an eight-hour training programme that combined theory, modelling and simulated practice with feedback, for either clinical nurse practitioners or primary care doctors.This was the first attempt at developing and implementing a best practice BBCC training programme in our context, targeting a variety of PCPs, and addressing different risk factors. These NCDs have been linked to underlying risky lifestyle behaviours such as tobacco smoking, unhealthy diet, alcohol abuse and physical inactivity.5 Training can enhance PCPs efficiency and capacity to provide this counselling, provided adequate resources and support are available in the workplace.7 Most of the research that explores training interventions for PCPs to deliver this counselling is from developed countries, such as the USA, Australia and Canada.9 The few studies that have been undertaken locally suggest that such training is currently inadequate.12It is feasible for BBCC to be effectively delivered by PCPs, who have both the opportunity and credibility to do so.11PCPs face a difficult task in helping patients to change their risky lifestyle behaviours. In South Africa the experience of counselling in practice tends to be discouraging, because of the poor response of patients, and challenging because of numerous barriers. These include language barriers, lack of time, poor knowledge of lifestyle modification, inadequate counselling skills, lack of self-efficacy, and poor continuity of care. PCPs reported lack of confidence in their ability to help patients change and their scepticism about the effectiveness of lifestyle counselling may partly be a reflection of inadequate training in this area.11 Training programmes were mostly theoretical and without the opportunity to practise key skills, and receive constructive feedback on performance. PCPs therefore were not confident to perform BBCC. Due to time constraints, training was not integrated throughout the curriculum and there was no reinforcement afterwards. The training outcomes were not assessed, and even lecturers were unaware of the evidence in support of BBCC and had low confidence in the effectiveness of their training.11 Therefore trainers, and not just students, needed training in BBCC.Recent situational analyses in the Western Cape showed that current training programmes on behaviour change counselling for PCPs are not sufficient to achieve competence in clinical practice.13 Changing the PCPs current style of communication could be challenging, and we realised that the training should focus not only on teaching PCPs a structure for BBCC and evidence-based knowledge of lifestyle modification, but also to transform their style of communication.Traditionally PCPs rely mostly on the directive style when counselling patients on behaviour change, resulting in resistance from the patient, and frustration for the PCPs.14 This study aimed to address this need by redesigning the current training around a new model for BBCC that would offer a standardised approach to addressing different NCD risk behaviours, be realistic in terms of training time and resources, be feasible to perform in clinical practice, as well as evidence-based and effective.Capacitating PCPs to deliver BBCC in a skilful way that is integrated within the consultation is essential.The aim of this study was to develop a training programme for PCPs that delivered a best practice BBCC method for patients with risky lifestyle behaviours and evidence-based information on NCDs. This paper focuses on the development of the training intervention; the evaluation of it in clinical practice will be reported on at a later date. Specific objectives were to:Design a best practice BBCC training programme to meet the needs of PCPs.Develop the structure and content of the training intervention, as well as the skills and resources needed to deliver this programme.Implement the training programme.Evaluate and revise the training programme.15 The ADDIE model may be particularly useful if the main focus of the new training programme is changing the behaviour of participants.15 The objectives above were based on the ADDIE model, which is also shown in 15 The ADDIE process had also been previously used in local educational research and development of training programmes.17 The methods used to complete each step of the model are described below.Most approaches to instructional systems design reflect the ADDIE  model, which uses a systemic problem solving approach to develop new training programmes.18 The majority of patients are seen by clinical nurse practitioners in either small clinics or larger health centres. Clinical nurse practitioners only receive an additional one year of training to cope with the wide range of problems seen in primary care. Clinical nurse practitioners are supported by primary care doctors, who usually have no additional postgraduate training. Therefore, the PCPs targeted by this training programme were clinical nurse practitioners and primary care doctors.Eighty percent of the South African population make use of public sector health care facilities, particularly those with NCDs, which are amongst the commonest conditions seen in primary care.The training programme was developed with the intention of initially implementing and evaluating it as part of the one-year Diploma course  at Stellenbosch University, which focused on training clinical nurse practitioners, and the four-year postgraduate training programme in family medicine, which was aimed at doctors, at both the University of Cape Town and Stellenbosch.1722An educational team was created to collaborate on the ADDIE process and consisted of the three authors. The team combined expertise in motivational interviewing, adult education, NCDs, primary care research and brief behaviour change counselling (BBCC).11 This article reports on the remaining ADDIE process.The situational analysis of current training and clinical practice for the target audience has been summarised in the introduction and published elsewhere.In the design stage the educational team developed a conceptual model and learning outcomes that were derived from the findings of the situational analysis and a literature review. The literature review searched PubMed, Google Scholar and local African journals for evidence on effective models of BBCC, as well as approaches to the design and implementation of training programmes.The educational team then developed the structure and content of the training programme, learning activities and strategies, as well as the educational resources required. Care was taken to ensure that all of these elements were aligned with the design of the learning outcomes and conceptual model.The educational team then prepared the actual content, for instance power point slides, instructions for role plays and practical exercises, by drawing on existing materials and previous experiences in training motivational interviewing. This process also helped the team to determine which resources were available and which needed to be developed, or obtained.The training programme that emerged from the design and development phases was presented to a group of programme managers, clinicians and trainers of family medicine and primary care at Stellenbosch University to obtain further input from experts in primary health care.During 2012–2013 three groups of nurses and three groups of primary care doctors completed the training programme at Stellenbosch University.Feedback forms from the training courses during 2012–2013 were used to obtain the participants’ opinions on how to improve the model, content or approach to teaching. The trainers analysed the information, and used it to revise the training programme accordingly. Revisions were also made based on the reflections of the educational team on their training experience.This study was approved by the Health Research Ethics Committees (HREC) at Stellenbosch University (Reference number: N11/11/321), on 27 February 2012.8 The 5A construct consists of five steps: ask, advise, assess, assist and arrange. It provides PCPs with a broad framework for BBCC, which is simple to understand, applicable to different settings, and can be used by PCPs from different disciplines and levels of expertise.The Canadian Task Force on Preventative Health, the Royal Australian College of General Practitioners, the National Health Service in the UK, the Department of Health and Aging in the Australian government and the Kinect consortium, all recommend the use of the 5 A construct in BBCC and promote its integration into primary care.23MI provides an alternative approach to the usual more authoritarian approaches and outperforms traditional advice-giving in 80% of studies.22 PCPs, who have little time with patients, can expect a 10% – 15% improvement in patients changing their risky lifestyle behaviours after counselling based on motivational interviewing (MI).23 At the core of MI lies the guiding style, which promotes collaboration, empathy, evocation, respect for choice and control, and a clear focus.Motivational interviewing (MI) is a flexible, evidence-based, clinical skill that can be used when talking to patients about how and why they might change their behaviour.A guiding style communicates an approach of ‘I can help you solve this for yourself’ as opposed to ‘This is what you must do’. To accomplish this, PCPs need to be able to switch from their traditional role as directive, expert advice givers, to guides that can skilfully assist the patient to make difficult decisions about change.24The decision was taken therefore to rather focus on the characteristics of a guiding style derived from MI and the essential underlying communication skills.25 The recommended approaches to completing each of the steps in the 5A model were rewritten to adopt this guiding style. The title of the second step, which was ‘advise’ in the original model, was changed to ‘alert’ as unsolicited advice-giving is seen as incongruent with a guiding style. The concept of alerting someone to a potential risk and evoking their response was, however, seen as more congruent with a guiding style.Training practitioners to be competent in MI is not easy, and in our context unlikely to be achievable with the majority of PCPs in a short training course.22 Core key communication skills that support the guiding style were defined as asking open-ended questions, reflective listening, affirmations and summaries (OARS).13 Reflective listening and summarisation are perhaps the most crucial skills, which demonstrate empathy and encourage the patients to elaborate, whilst the use of open-ended questions invites patients to consider how and why they might change. Offering affirmations helps the patient to recognise their own strengths.The underlying spirit of the guiding style was based on three elements, which were collaboration vs. confrontation between the provider and the patient, evoking or drawing out the patient's ideas about change rather than imposing ideas, and emphasising the patient's autonomy versus being authoritative.20Therefore, in our model of BBCC the key principles of a guiding style were integrated into each step of the 5As structure as shown in Based on this conceptual model, the results of the situational analysis and learning outcomes identified from the literature, as well as the educational team's own expertise in MI, the following learning outcomes were developed. At the end of the training programme participants would be able to:Use a guiding style of counselling.Practice reflective listening.Recognise, elicit, and respond to change talk.Exchange information.Assess readiness to change.Use the 5A steps .Counsel patients regarding the four key risk factors.A key principle of this stage was to develop an educational process that itself resonated with the guiding style. In essence we recognised that we were asking PCPs to change their own behaviour regarding how they counselled other people about behaviour change. Therefore, the principles being recommended for BBCC should also be embodied in the course itself regarding its structure and process.26These principles needed not only to be embodied in the structure and process of the course, but also modelled by the trainers themselves. In other words, the trainer's style of training needed to be congruent with the style of counselling being taught.27 This approach recognises three key areas: namely, that the desired behaviour is the clear focus of the learning, that participants can practice the behaviour in a controlled and safe environment and that the training reinforces the behaviour by providing feedback on performance. Typically, the teacher demonstrates the specific behaviours, whilst participants observe, and then they practice and receive feedback on their own performance under controlled circumstances.27Behaviourist learning theory is particularly useful when a change in behaviour is the desired outcome of a training intervention.26 Group discussions provide an essential component of training, and to ensure participation from every participant, group size should be limited to 20 or less. For this training programme, a ratio of one trainer to 12 students was thought to be possible, but ideally one trainer to eight participants was seen as the ideal.The training was designed to give participants time to create a safe, supportive and reflective group environment.26 Although the training included some brief sharing of theory using didactic methods, these were combined with other approaches, such as the jig-saw method, in which members of a small group collectively master a piece of the whole theory and then share this piece with others in a new small group that includes peer-experts in all the other pieces. After information was given in a didactic manner the participants were also encouraged to reflect as a group, or individually, and consider their response to the theory or ideas presented.26 The programme included information on the specific risk factors, as this improves participant content knowledge and confidence in delivering effective interventions.26,28Traditional didactic teaching methods were not considered effective in changing behaviour.29Based on best evidence from the literature review, the following principles were used in the development of the training course:Provide evidence of the current deficiencies in counselling, the reasons for them, and the consequences for patients and doctors.Offer an evidence base for the skills needed to overcome these deficiencies.Demonstrate the skills to be learned.Provide the opportunity to practice these skills.Give constructive feedback on performance.Based on the time that could reasonably be made available for the training within the selected curricula for nurses and doctors, the training was designed as an eight-hour workshop, with four two-hour sessions. The final training programme that was developed is summarised in A checklist of all the educational resources required was developed. This included the PowerPoint slides needed for the talks, the DVD material, the instructions for the small group exercises, the course manual with information on risk factors, and the equipment needed. From this list the team decided which resources could be accessed from already available materials, and which resources needed to be developed.30 This website has a manual containing a menu of exercises that MINT trainers use for various skills training. Practical exercises were chosen from the MINT manual, adapted for our setting, and used as practical exercises after a skill had been modelled.30The international Motivational Interviewing Network of Trainers (MINT) operates a website with extensive information about the clinical method and training of MI.A training manual that summarised the model of BBCC and the underlying evidence, as well as applying the model practically to each risk factor, was printed for each participant. In addition each participant received, on each risk factor, patient educational material that was designed to dovetail with the approach to BBCC. All of these printed materials can be accessed via the web at www.ichange4health.co.za.30 This experience was useful to improve their embodiment of the guiding style in the teaching approach, to update the practical exercises, and to incorporate the latest theory of MI.13Both the researcher and Dr Katherine Everett-Murphy were trained internationally as MI trainers during the development of the course and became members of MINT.Twelve family medicine registrars, two general practitioners in private practice, and four family physicians were trained. Twenty three nurses on the one year Diploma course  at the University of Stellenbosch were trained.Overall feedback on the conceptual model and content was positive. Doctors reported that the 5As framework was a useful structure, and that the patient information materials could help them save time during counselling. Nurses felt that reflective listening skills could help them feel less frustrated when counselling patients, as they conceptualised their potential roles as expert guides, rather than expert advice givers. Nurses found the course materials useful, not only as a source of information on NCDs, but also as resource when arranging for referral. Whilst participants found the interactive sessions  to be valuable in practicing new skills, they also identified the need for clearer instructions from trainers before exercises. Participants valued feedback from trainers during practical sessions, as they felt this improved their confidence in trying out new skills.The training programme was adapted by the team using the participant's feedback, as well as their individual experiences during training. The team realised that, ideally, two trainers were needed during clinical skills training sessions to ensure individual feedback from a trainer. The need to encourage and strengthen the value of peer reviews was identified, therefore trainers purposefully selected group members to combine stronger and weaker members. To improve individual participation and save time, trainers provided clearer instructions before practical exercises.This study has led to the design, development and implementation of a training programme for BBCC aimed at primary care providers (PCPs) in the South African context. The training programme incorporated best practice from both international and local studies and was tailored to the needs of local PCPs and their context. To our knowledge, this training programme is the first attempt at developing and implementing best practice BBCC training in our context, targeting a variety of PCPs, and addressing all four NCD risk factors.32 Although approaches to training elsewhere include combinations of e-learning, with face-to-face training as well as ongoing support and feedback, they all aim to teach the underlying spirit of the guiding style of MI.32 Training as part of continuing professional development through GP networks showed incomplete uptake, which could imply the need to integrate BBCC training into undergraduate and postgraduate programmes.25 One training programme which measured patient level outcomes was found ineffective, and interestingly did not train clinicians in listening skills, but focused more on the value of the guiding style, rather than achieving clinical competence.32The adaptation of the 5 A approach with a guiding style derived from MI was an innovation in the African context, and there are only a few other published examples internationally.33 In an attempt to address this a review of BBCC and training resulted in a best practice checklist for training programmes.28 In line with the checklist our programme includes: clear information about the evidence base and theoretical underpinning of the model, tools for assessing readiness to change, reflective listening skills, provides tailored made information for patients, and topic specific training, whilst focussing on the development of essential communication skills by providing time for demonstrations, practice of skills and feedback. Our programme, however, does not include training on tailoring information specifically for different patient groups, such as the young, those with cultural differences, or minority ethnic groups.Training interventions for BBCC are not always clearly described and the terminology used is inconsistent.28 However, ongoing support and feedback was not provided. Booster sessions to provide feedback and continuous support is regarded as important to maintain and develop skills over time.34 On-line support and feedback with the use of formative assessment of audiotapes is currently being developed to supplement this course.The best practice checklist suggests that the individual context of participants, the trainer's attributes, as well as the process of delivery influence effectiveness. In our programme the participants were from a variety of linguistic, cultural, and professional contexts. In order to improve the trainer's understanding of their context, the programme always started with a session to elicit participant's prior experience, attitudes and expectations. Our trainers had completed training both in MI and in how to train MI, which enabled them to embody and evoke the guiding style during the training. We believe that trainers should have this level of proficiency, which may limit the immediate scaling up of training. If trainers with less proficiency are used then this may reduce the effectiveness of the training. Regarding the process of delivery, the workshop style used is supported by the checklist.35 This article is consistent with the WIDER recommendations in giving a detailed description of the intervention, which includes the characteristics of the trainers, the recipients, the setting, the mode of delivery, the intensity and duration of delivery, and a detailed description of the content. Likewise, the findings have described how the intervention was designed and developed, the techniques used to elicit change and the underlying conceptual model. A detailed manual has also been made available as a supplementary file. As this is not yet being assessed as part of a clinical trial the characteristics of a control group are not relevant here and the fidelity of the trainers to the design was not formally assessed.The WIDER recommendations were developed to improve reporting of behaviour change interventions in clinical trials.A possible limitation of the ADDIE process is that there was less engagement with nurses, compared to doctors, in the design and development stages. For example, the design was presented mainly to expert doctors in primary care, and the educational team consisted of two family physicians and a social scientist. Nevertheless we did consult extensively with nurses during the situational analysis. During the implementation phase, the training was offered as an optional extra to nurses on the diploma programme as the time required was too much for the formal curriculum, and this could have selected a more motivated group. The majority of doctors were registrars in family medicine and their motivation and experience could also be different from other primary care doctors working in the public and private sector.The study was conducted in the Western Cape, where the health system and human resources for health are generally better developed than elsewhere in the country. Additional contextual challenges might have been encountered if the programme had been developed in another province.28 Exploring the application of this programme to other PCPs, such as community health workers and lay counsellors, is also recommended for future research. Ultimately evaluation should measure the effect on patient behaviour and risk factors.Evaluating the effect of training is good practice, and future research is focussing on evaluating the effectiveness of this training programme. The results of this evaluation will be published elsewhere. Evaluation should make it possible to determine the impact on clinical practice amongst the target groups, measure the degree to which the learning outcomes were met, and might also indicate which PCPs are best to train.Although the training programme has not yet been fully evaluated, the need for it in our context has been immediately recognised and embraced. The Chronic Diseases Initiative for Africa, through a programme entitled ichange4health, helped to further develop the materials and train trainers from Departments of Family Medicine and Primary Care throughout South Africa. These trainers are now training medical students, general practitioners and other family physicians in their respective areas. A strength of this training intervention is its feasibility to train PCPs to train others in BBCC, and future research could evaluate the effectiveness of training the trainers. The authors have also presented the training programme in other countries such as Botswana and Namibia.This study designed a new approach to BBCC, which was based on a conceptual model that combined the 5As  with a guiding style derived from MI. The study then developed an eight-hour training programme that combined theory, modelling and simulated practice with feedback, delivered also in a guiding style, for either clinical nurse practitioners or primary care doctors in South Africa. The programme was implemented and revised based on initial feedback. The programme has already been widely adopted, but also requires further evaluation in our context.


While regional mortality inequalities in Germany tend to be relatively stable in the short run, over the course of the past century marked changes have occurred in the country’s regional mortality patterns. These changes include not only the re-emergence of stark differences between eastern and western Germany after 1970, which have almost disappeared again in the decades after the reunification of Germany in 1990; but also substantial changes in the disparities between northern and southern Germany. At the beginning of the twentieth century, the northern regions in Germany had the highest life expectancy levels, while the southern regions had the lowest. Today, this mortality pattern is reversed. In this paper, we study these long-term trends in spatial mortality disparities in Germany since 1910, and link them with theoretical considerations and existing research on the possible determinants of these patterns. Our findings support the view that the factors which contributed to shape spatial mortality variation have changed substantially over time, and suggest that the link between regional socioeconomic conditions and recorded mortality levels strengthened over the last 100 years. Since 1910, German society has undergone a number of fundamental developmental processes which have led to substantial improvements in the survival chances of its individual members. This rapid rise in life expectancy has been achieved by many societies across the globe, and is sometimes referred to as the longevity revolution. At the beginning of the twentieth century, large parts of German society could still be characterised as agrarian. However, rapid industrialisation in the second half of the nineteenth century had already spurred urban growth. Particularly in big cities, governments struggled to alleviate the poor hygienic conditions which contributed to an urban penalty in survival chances Woods . InfectiThese shifts have also contributed to a growing gap in the survival chances of people based on their social status  play a role in organising the health care infrastructure and in formulating regional education and economic development policies. There is also substantial variation in socioeconomic conditions across the German federal states.The degree to which the administrative territorial divisions we refer to in studying variation in life expectancies are relevant for understanding the macro-level determinants also depends on the social relevance of these divisions. While Germany was divided, the border between eastern and western Germany was of considerable relevance, as it separated the country into two states with little social interaction and with very different political and economic systems. But also the administrative division of the country in 1910 was mainly based on previously long-standing borders between independent German states. The social, economic, and political characteristics of these states varied substantially. Even today, Germany has a decentralised political structure in which the federal states Contextual macro-level factors include variation in socioeconomic and ecological conditions and  policies, and spatial variation in access to infrastructure such as housing and health and emergency care ; to the third stage of degenerative, stress, and man-made diseases ; and finally to the fourth stage of declining cardiovascular mortality, ageing, lifestyle modification, and emerging and resurgent diseases. The fourth stage started with the cardiovascular revolution in the 1970s . Based on these data, we calculated regional life expectancies at birth.We present data on regional mortality variation for the following periods: 1910, 1970, and 1995–2011. These time periods were selected based on theoretical and data availability considerations. The year 1910 marks the end of the rather peaceful period following the unification of the German Empire in 1871. During these decades, the country underwent rapid economic development, and a national welfare system emerged. For the 1910 observation period we obtained age-group specific mortality rates for the states and territories of the German Empire covering the years 1908–1913. These data also allowed us to subdivide the biggest German state, Prussia, into its provinces; and the second-biggest state, Bavaria, into parts east and west of the Rhine  for the period 1970–1972 were obtained from regional life tables calculated by the Federal Statistical Office  in 1968–1971 were derived from regional life tables calculated by the Statistical Office of the GDR  for the period 1995–2011. As the colour categorisation schemes in the maps can be affected by changes in the number of districts, we created a dataset of regional units with time-constant boundaries for this period by combining all of the districts which exchanged territories as a result of reforms in district-level borders (N = 396). Life expectancy was calculated from the age-specific population and death counts . This investigation demonstrates that around 1910, (north-)western German regions such as Hanover and Hesse-Nassau still had much lower infant mortality rates than Bavaria in southern Germany and eastern German regions such as Mecklenburg-Schwerin and the Prussian province of Saxony . However, the infant mortality rates of these regions rapidly converged in the 1920s and 1930s. Remarkably, the biggest improvements appear to have occurred in 1918–1930, a post-war period which was characterised by very unfavourable economic conditions, including hyperinflation in 1923 and the onset of a world economic crisis.After World War II and the subsequent division of Germany into the capitalist West Germany  and the communist East Germany , both states initially reported very similar mortality improvements Table . Among oThe national averages for West Germany are, however, misleading, as the trends varied substantially at the subnational level. According to the Federal Statistical Office, between 1960–1962 and 1970–1972 the registered increase in life expectancy in the southern states of Baden-Württemberg and Bavaria and in the centrally located state of North Rhine-Westphalia was about 1 year among males and between 1.5 and 2 years among females. The situation was very different in the three northern states of Hamburg, Bremen, and Lower Saxony (no data are provided for the northern German state of Schleswig-Holstein in 1960–1962). Male life expectancy at birth was decreasing in these three states, and the declines were particularly large in Bremen and Lower Saxony. While women in the north of West Germany also experienced a rise in life expectancy of around 1 year, this increase was far lower than the increase recorded in southern Germany (Statistisches Bundesamt (Bundesländer) of West Germany (the FRG) and at the level of the regions (Bezirke) of East Germany (the GDR). This period approximately marks the beginning of the onset of the cardiovascular revolution in western Europe  in the GDR in 1966 concluded that the differences in infant mortality rates were related to the quality of the paediatric care   are supposed to be distributed equally across the regions (Ozegowski and Sundmacher Several studies have attempted to explore whether regional variation in environmental pollution is important for understanding regional mortality disparities, but the results have been inconclusive for the most recent decades and at the regional level (Maier et al. In this paper we took a long-term perspective to study regional mortality disparities in Germany, and followed these differences over the course of a full century. Our empirical analysis focused on spatial and temporal variation in life expectancy at birth as an indicator of population health and survival conditions. We were able to identify both continuities and discontinuities in the spatial patterns. A major discontinuity is that northern Germany, and particularly the north-western part of the country, was at the forefront of the German longevity revolution at the beginning of the twentieth century, but had forfeited this position to southern Germany by the end or our study period. Southern Germany, on the other hand, went from being one of the most disadvantaged areas in terms of mortality levels to being the region with the highest life expectancies in Germany. This trend generally appears to correspond with long-term shifts in regional variation in economic conditions. A continuity, at least among women, seems to be that eastern Germany tends to lag behind western Germany; although the southern part of eastern Germany, and particularly Saxony, represents an exception to this general pattern, both in 1970 and in recent years.The existing research on determinants which might explain regional mortality variation within Germany in different time periods in the twentieth century suggests that over time, there were substantial changes in the factors which contributed to spatial life expectancy disparities. This aspect is in line with the theoretical considerations of Omran . The resOur study has some limitations. First, the descriptive aggregate-level analysis was complicated by changes in the administrative division of Germany over the last 100 years, including the loss of the territories east of the Oder-Neisse line. Thus, for many parts of Germany it was not possible to conduct the analysis based on time-constant areas, which would have allowed us to study regional trend data. In addition, the level of spatial detail at which data could be obtained varied over time, as small-area mortality data were readily available for the most recent decades only. Moreover, as we were working with aggregate-level information, we were not able to look into the role of compositional and contextual effects and the potential influences of selective migration on the observed pattern. Selective migration can reinforce regional mortality patterns by attracting migrants to prosperous regions which already have lower mortality, as migrants are usually healthier Boyle .There are a number of potential avenues for future research which would further improve our understanding of long-term regional mortality trends in Germany. As Germany is situated at the centre of Europe, it would be interesting to consider in an extended analysis regional mortality trends in neighbouring countries as well (cf. Shaw et al.


The ANN method has been applied by means of multilayered feedforward neural networks (MLFNs) by using different macroeconomic variables such as the exchange rate of USD/TRY, gold prices, and the Borsa Istanbul (BIST) 100 index based on monthly data over the period of January 2000 and September 2014 for Turkey. Vector autoregressive (VAR) method has also been applied with the same variables for the same period of time. In this study, different from other studies conducted up to the present, ENCOG machine learning framework has been used along with JAVA programming language in order to constitute the ANN. The training of network has been done by resilient propagation method. The ex post and ex ante estimates obtained by the ANN method have been compared with the results obtained by the econometric forecasting method of VAR. Strikingly, our findings based on the ANN method reveal that there is a possibility of financial distress or a financial crisis in Turkey starting from October 2017. The results which were obtained with the method of VAR also support the results of ANN method. Additionally, our results indicate that the ANN approach has more superior prediction performance than the VAR method. From the Great Depression in 1929 until the recent financial crisis of 2008, the world economy has experienced several financial crises that had grievous impacts on both industrialized and developing countries such as the Tequila crisis in 1994 in Mexico, the 1984 savings and loans (S&L) crisis in the US [As Berg and Pattilo  point ouWith the emergence of the 2008 global financial crisis, researchers accelerated their empirical works on prediction of financial crises and developing early warning systems. Due to the systemic risk and the contagious effect of the recent crisis, economists and policymakers realized how financial shocks can cause devastating consequences on the real economy. Small investors suffered a significant decline in the value of their stocks, which had serial negative impacts on such economic variables as household consumption spending, business investment spending, total demand, and employment rate . In thisIf the crisis had been predicted, economists and policymakers would have provided an opportunity to reduce the negative impacts of the crisis or even totally avoid them . HoweverTo identify (if any) the causal relationship between macroeconomic variables such as gold prices, the exchange rate of USD/TRY, and the BIST 100 index.To predict a potential stock market crash or a financial crisis by using different variables in the future in order to minimize their costs to the economy.The major purpose of this study is to predict stock market crash and financial distress before financial crisis by using different macroeconomic variables such as the exchange rate of USD/TRY (USD), gold prices (GOLDPRICE), and the Borsa Istanbul 100 index (BIST). Our specific objectives in this study can be listed as follows:This paper provides a highly expandable approach to neural networks and examines the connection between classical econometric techniques. An extensive review of the literature indicates that ANNs are generally more suitable than linear models for forecasting macroeconomics and financial variables. Although this method has several weak aspects, ANNs exhibit excellent results in many fields. In contrast to many researchers in the field, who tend to adopt an all-or-nothing approach to this issue, we argue that neural networks should be considered as the most powerful processor as compared to classical econometric methods. The full potential of neural networks can be exploited by using them in conjunction with linear regression models. Hence, as Gonzalez  states, This paper is composed of four sections including introduction. The second section examines the main empirical literature which employs either the ANN method or the VAR method to test the relationships between different variables to predict financial distress or stock market crashes before the financial crises. The third section explains the empirical methodology used in the study and presents a detailed explanation of the empirical findings with their interpretations. The fourth section is the conclusion part.In the last few decades, ANNs have been frequently used to solve complicated problems and to test the relationship between different variables. Empirical researches clearly indicate that they can be used as efficient tools to analyze critical issues in business decisions. In this context, ANNs have many advantages which may help to solve problems in finance as well as in other fields with poorly defined models. As Tu and Oztemel , 7 set fMany researchers prefer to utilize ANN to conduct their studies in different fields. However, only a limited number of researchers prefer to use ANN in their empirical researches to identify financial distress, to develop early warning systems, or to predict financial crisis. In one of these studies, Nag and Mitra  utilizedFranck and Schmied  used theOzkan-Gunay and Ozkan  used ANNFioramanti  tried toBan and Mazibas  developeSeveral other researchers choose to employ VAR model to determine the relationships between different variables which might be used to predict stock market crashes or financial crises. As Shinkai and Kohsaka  state, eDhakal et al.  are amonSengonul et al.  utilizedBayraci et al.  construcKoc and Akgul  aimed toZhou and Zhang , in theiyt1, and yt2,, where t = 1,…, T. The development of the series should be explained by the common past of these variables. That means the explanatory variables in the simplest model are yt−11, and yt−12,. The VAR(1) model with lagged values for every variable is determined byεit ~ i.i.d are assumed to be white noise processes, which may be contemporaneously correlated, but are uncorrelated with any past or future disturbances [VAR model is an easy to use model for the analysis of multivariate time series. It has been proven to be especially useful for describing the dynamic behavior of economic and financial time series and for forecasting. With VAR models, it is possible to approximate the actual process by arbitrarily choosing lagged variables. Thereby, one can form economic variables into a time series model without an explicit theoretical idea of dynamic relations. The easiest multivariate time series model is the bivariate VAR model with two dependent variables, urbances .VAR analysis assumes that all the stochastic processes in the autoregressive system are variance-covariance stationary. If this condition is not met, little confidence can be placed in the VAR regression results. Since most if not all of the data here are highly autocorrelated and tend to drift over time, some form of detrending is obviously required before the models can be estimated. Our choice was influenced in part by the recent work of Dickey and Fuller . The AugΩ when the lag order used in estimation is j. T shows the sample size. An alternative information criterion suggested by Hatemi-J [However, some situations exist when SBC has the highest rate of picking the right lag order compared to HCQ and there are also situations when HCQ outperforms SBC. Nevertheless, compared to Monte Carlo simulation studies, the true model is not known in empirical research. Thus, when these two information criteria are selected according to the two different lag orders, it is quite difficult to determine which criterion one should rely on. Some researchers suggest linking these two criteria to obtain the performance of the above information criterion based on Monte Carlo simulation experiments for choosing the optimal lag order in stable and unstable VAR models :2)HJC=lHatemi-J  is(3)HQCnd Quinn  suggesteHJC=lHateI(1).The impulse response analysis quantifies the reaction of every single variable on an exogenous shock to our model. The impulse response function of VAR is to analyze dynamic effects of the system when the model receives the impulse. Impulse response analysis based on vector autoregressions (VARs) has an important place in modern empirical macroeconomics  and the website of the World Bank, were used. In the empirical analysis part, three different variables, which are USD/TRY exchange rates (USD), gold prices (GP), Borsa Istanbul (BIST) 100 index, were used. In the prediction of the next 36 months of crisis indicator data in Turkey, we preferred to use feed-forward, backpropagation, multilayered ANN. It consists of an input layer, two hidden layers, and an output layer as shown in ∗12 = 36 inputs, 3 outputs, and 2 hidden layers in which 25 neurons are included in each layer. In the layers of the network, the sigmoid activation function has been used. In addition to this, the resilient propagation learning algorithm has been used for the learning of the network. In this learning process, the error value of 0.1% has been determined as a target value, which provides a limit between the desired values. In the structure of a multilayered ANN, there are mainly three layers. The first layer is an input layer with artificial neural cells, which are connected to each other in different ways. The second one is the hidden (intermediate) layer. Finally, the third one is the output layer. In ∗12) data sets, is the first layer and it is responsible for transmitting incoming data in the ANN. It also serves to distribute the incoming data to the hidden (intermediate) layer. The neurons in the hidden layer, which process the information, do not have any links with the external environment. The output layer, which is composed of 3 data sets, processes the information coming from the intermediate layer. It also generates the outputs which are constituted for the input data presented by the input layer.In this study, in terms of applied method, a feed-forward and multilayered ANN has been used which is composed of 3As seen in Because of easiness in its utilization, time series, which take part in ENCOG framework, have been given preference in the Temporal Neural Dataset class of software that are constituted for the data sets. Additionally, we benefited from several strategies in order to assist coding in the framework such as “if certain number of iterations have been passed in the training of the network, restart to learning” or “if the error value does not progress a significant proportion, restart to learning.”In this study, the normalization and the denormalization of data have been done with the help of built-in functions found in framework. While the network is being trained, the twelve-month lagged values of data were given as prologue and we demanded the forecasting of the 37th month. In the same manner, we tried to estimate results starting from the 37th month of 176 months that are in the data set. For each month to be predicted, ANN has been trained iteratively with its previous three-year data. For the 178th and the following months, again its previous three-year data has been given to the ANN as training set, and the missing months have been filled by the prediction values obtained in previous iterations. In other words, different networks have been used in our analysis in the calculation of each prediction value as compared to other studies which use a single network.Turkish economy also experienced the major crises of 1994 and 2001 until 2008. During both crises, large amounts of capital entered and left Turkey, leading to instability in the exchange rate regimes. In the aftermath of the 1994 crisis, the Turkish economy contracted by 6% and the Turkish Lira was devalued by more than 50% against the US Dollar. The second crisis erupted in the midst of an exchange rate based stabilization program. In February of 2001, the fixed exchange rate system was collapsed and Turkey began to implement the floating exchange rate system. Instability in the financial markets and lack of confidence together with optimism in expectations all created speculative attacks. As a result of both of these crises, the trust to the Turkish Lira was shaken, the reserves of the Central Bank of Turkey decreased significantly, and inflation rate skyrocketed. The period of 2002 and 2007 was a stability period thanks to structural reforms applied in Turkish economy and the financial system and the positive course of events in the global economy. However, this stability period has come to an end with the 2008 financial crisis.The 2008 financial crisis, the first global financial crisis of the world, has had a deep negative effect initially on developed countries and later on emerging countries. Turkey is one of these developing countries which have been affected negatively from this crisis. As it can be seen from The current financial crisis, the dynamism of financial markets, and the globalization process have accelerated the obsolescence of financial crisis prediction models and emphasized the need to reformulate these models. Neural networks arise as a powerful tool to enhance modeling flexibility and dynamism and to identify the most outstanding properties to predict financial crisis originated in some financial variables such as gold prices, stock exchanges, and exchange rates.In this study, the causal relationship between macroeconomic variables such as gold prices, the exchange rate of USD/TRY, and the BIST 100 index has been investigated. Additionally by using these variables, we aimed to predict potential stock market crashes or financial crises in order to minimize their costs to the economy. We used two different methods of Artificial Neural Networks (ANNs) and the Vector Autoregressive (VAR) method to conduct this study. According to the findings of the ANN method, there is a possibility of significant fluctuations for the USD/TRY exchange rate and the BIST 100 index between 2015 and 2017 except for gold prices. Strikingly, our findings based on the ANN method reveal that there is a possibility of a financial crisis starting from October 2017.Our results that we obtained with the VAR method is different from our results that we obtained with the ANN method. According to the results of VAR method, all of these three variables will fluctuate significantly between 2015 and 2017. However, very sharp fluctuations can be observed in the fourth quarter of 2015 and the third quarters of 2016 and 2017 for all of the variables. Based on our findings with the VAR method, we interpret that there is a possibility of a potential crisis in one of these dates.Our study indicates that predictions of VAR method do not correspond to the ANN results. In this regard, it can be said that ANN method has a better estimation capability and we obtain more accurate results as compared to the VAR method. We come to this conclusion by analyzing the real values obtained in the past for both the methods of VAR and the ANN. Some of the major literatures, which support our perspective, include Nag and Mitra , Franck The literature on building economic models and early warning systems for the prediction of financial crisis is promising but still new. The main difficulty in studying macroeconomic problems is how to model people's expectations when the economic environment is volatile mainly in developing countries. Small changes in expectations can often lead to large changes in people's behavior and, thus, in the behavior of macroeconomic variables such as GOLDPRICE, foreign exchange rates, and stock market exchanges.As a suggestion for further research, researchers can obtain more accurate results and make more precise predictions by using more macroeconomic variables. This study can also be extended to a larger time period covering the major crises experienced in 1990s to see the prediction capabilities of different methods such as VAR, ANN, or other alternative methods. By extending this study with more variables and more countries covering a larger time interval, a potential global crisis can even be predicted prior to its occurence. Consequently, long-term forecasting will contribute positively to the global economy as a first step of providing stability which is needed in the international business and economic environment.


Conceptual distinctions between perception, action, and cognition are convoluted in real world proceedings, as we meander through life, tied to past thoughts and actions, oriented toward future goals, guided by current perceptions. The research topic “Perception, Action, and Cognition” aimed to go beyond the already established perception-action links to study the role of cognitive mechanisms in this triad.Hommel develops an efficient way to conceptualize embodied cognition using the Theory of Event Coding (TEC) framework. Arguing against the anti-cognitivist stance of many embodiment theorists, he firmly puts cognition back in the perception-action link, by maintaining the importance and involvement of internal representations in the production of actions. Vernon et al. propose that perception-action coupling is not only manifest in the behavioral arena, but also shows up in the internal processes of the agents, particularly those related to the self. The self-organizing, self-producing, and self-maintaining processes explain the reciprocity of perception and action. The sense of presence, which is the focus of the article by Triberti and Riva actually implies the presence of the “self” in the environment where perception-action coupling is manifest. Brizio and Tirassa go a step further to expound on how the mind is rooted in the self, particularly the biological self. They offer a taxonomy of control systems based on whether they are intentional, non-intentional, or meta-intentional, drawing on arguments from diverse disciplines ranging from psychology to biology to philosophy to artificial intelligence. The next two articles provide evidence for embodied cognition from clinical samples. Dreyer et al. report evidence from two patients with focal lesions, regarding sensorimotor systems in the cortex being crucial for the processing of semantic concepts, suggesting that without intact perceptual-motor systems, meaningful cognition is all but impossible. Wolpe et al. show that Parkinsons' Disease (PD) patients with higher levodopa dose equivalent show an abnormally high awareness of their actions and their positive outcomes, providing evidence for intact action systems feeding perceptual awareness. Finally, evidence regarding action being important for cognition also comes from a cross cultural study by Wang et al. who studied children's use of imitation in learning how to categorize objects. They propose that imitation of an action leads to direct experience, which in turn stimulates rule learning/categorization. This process is the same across the two cultures studied—Chinese and US.A popular way of conceptualizing the triad of perception, action, and cognition is the idea of embodied cognition. The first section entitled “Embodied cognition” presents seven articles related to this concept. In the leading article, Volta et al. report an fMRI study that showed similar brain areas to be activated whether participants were actually walking or merely observing someone else walking, thus supporting the idea of mirror mechanisms for walking. However, differences in brain areas activated were evident between two conditions—one in which a video of open countryside was played and the other in which the closed space of a corridor was depicted, indicating the strong influence of external context on brain processing. Desanghere and Marotta show that the physical shape of an object and its center of mass, are distinct influences, in how we look at it, and grasp it. This study independently manipulated physical shape and center of mass of an object, and thus used irregularly shaped objects to study the effect of these physical features on gaze and grasp. This study is a good illustration of how the same percept may lead to different reactions in different parts of the body perhaps because the relevance of the percept to the body part is different. In another study demonstrating the effect of perceptual cues on Simon task performance, Umemura demonstrates that stimulus locations in 2D and in 3D space give independent cues for task performance to the participants. This seems understandable; for pictorial cues are sufficient for 2D locations, but 3D locations can be precisely pinpointed only by the convergence of the eyes. Studying an important variable in our social interactions, Kuraguchi and Ashida focus on detection of beauty and cuteness. They found that whilst beauty can be equally discerned in central as well as peripheral vision, the detection of cuteness declines in peripheral vision as compared to central vision, especially in males. In another study of face processing, it becomes clear why autism is associated with difficulties in the socio-emotional sphere. Ujiie et al. found that university students scoring high on Autism Spectrum Quotient, a measure of autistic traits, show abnormal audio-visual speech integration, probably because they do not show adequate processing of global facial configurations. All these studies show how changes in the external environment result in behavioral/ motor changes.The rest of the articles are ingenious forays into the socio-cultural realm. The second section of the research topic is, therefore, titled “The external world and inner reality.” We begin the section with mirror mechanisms in the brain, the biological underpinnings of social perception and interactions. Sun et al. compared decision times on a simple task presented on the winners' or the losers' side of the screen. Results showed an attention bias in the onlookers for the losers' side of the screen. Could this be the basis of empathy/sympathy in social situations? Using a Rapid Serial Visual Presentation paradigm, Kihara et al. demonstrate that when participants were asked to change a digit stream to a letter stream by pressing a button and identify four successive targets, successful target identification was linked to pupil dilation . Thus, voluntary action initiated this neural substrate of transient visual attention.In turn, the influence of actions or their outcomes on socio-cognitive processing is clear from the next two studies. Spape et al. present a new paradigm utilizing “avatars” or representations of the self in virtual reality, which can be used by researchers in cognition, social psychology, and human computer interaction. The study also augments our conceptualization of executive control, by showing how changes in the gender of the “avatars” can disrupt conflict adaptation in the virtual reality version of the Simon task. Zhang et al. use the virtual hand illusion to demonstrate that the bodily self is not a definite exact entity, rather, body representations are dynamic and are constantly updated by current inputs from the context. Imbir demonstrates the effect of subjective significance on the rational mind, and arousal on the experiential mind, using the emotional stroop task. The control of “reason,” therefore, is dependent on whether we perceive a situation to be of significant or not. Finally, the review by Kavanagh and Winkielman suggests mimicry as an implicit but adaptive mechanism that underlies affiliation between the model and the mimic, and also signals affiliation with the group.The “self” emerges as a strong player in this section as well. All these articles are heartening examples of work that goes much beyond establishing the perception-action link. Most contributions specify the mechanisms for this link, or the antecedent or consequent conditions of the link. For example, the articles in the first section propose the self as the unifying entity for perception and action. In the second, whereas some articles study the effect of perceptual factors on behavior, others specify how action influences attention/perception, and still others focus on the mediator. i.e., person involved. A perusal of all articles in this research topic reveals that perception, action, and cognition, are an unbreakable triad. Many manifest links have been established, and many other latent ones need to be explored in future research.The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.