As a reading comprehension strategy, mind mapping has a positive influence on the development of students’ reading ability. However, how mind mapping affects reading ability has not been well documented. In this study, we used eye tracking sensors to explore mind mapping’s effects on reading ability. The participants were foreign language learning university students in Dalian city, China. One group received foreign language reading teaching integrated with mind mapping training , and the other group received regular foreign language reading teaching (control group). We analyzed eye movement indicators, including fixation-related indicators , regression count, saccade amplitude, and pupil diameter. In addition, the analysis of heat maps and fixation trajectory maps, which are specific tool for visualization of eye movement data and intuitive analysis of reading process, were explained. The results show that the number of fixations, fixation frequency, mean fixation duration, and regression count in the experimental group were all lower than in the control group, and the pupil diameter was larger than in the control group. The heat map and fixation trajectory map show convergence, mostly focusing on the position of keywords and key sentences, with relatively large saccade amplitude and more information obtained by one gaze. Moreover, they had a higher skipping reading rate, which enhanced reading speed to obtain information accurately and quickly. These empirical results indicate that mind mapping training was an effective method for improving students’ reading ability. Reading ability is significant in foreign language learning . ApplyinLinguistic psychology demonstrates that reading refers to the process of extracting information from the word system and then understanding the article through brain coding processing . Nerves The mind mapping training reading teaching strategy proposed in this study requires students to consciously find keywords and key sentences from the article and draft the structural framework of the whole article, which allows them to fully grasp the main content of the reading article and therefore realize the goal of quickly understanding the general idea of the article and therefore improve reading efficiency. Mind mapping is a cognitive process, thus it is of great practical significance to study how mind mapping training affects students’ reading process. In this study, the eye tracking research method was used to investigate eye movement characteristics of students in the process of reading; both students who accept mind mapping training as well as those who do not accept mind mapping training were included. The results show that there are differences in the eye movement indicators for the two groups. Participants of different reading levels have different cognitive processing levels during the reading processing, and the eye movement indicators can be used as a means of detection . Data anEye movement indicators can reflect cognitive process in the reading process, and this is an important research area of psycholinguistics and reading psychology . Eye traThe reading process is the course of cognitive processing of visual information, and eye tracking is the most effective method of studying cognitive processing of visual information . There iThe participants consisted of 40 university students from the school of Japanese studies at a university in Dalian city, China. All participants gave their informed consent for inclusion before they participated in the study. The experimental group  and the control group  had similar Japanese-language expertise skills. Both groups received a practical 8-week Japanese reading course. The experimental group’s reading teaching was integrated with mind mapping training. Students mainly learned to take a hierarchical or tree branch format to express the main idea of the article and keywords and key sentences of each paragraph. This reading comprehension strategy focuses on activating students’ divergent thinking to form an article structure frame, which clearly show the composition of the article and the specific details of each part. On the other hand, the control group was taught with a regular curriculum and the students learned in the traditional way. Both groups’ teaching was carried out by their current Japanese teachers with the same teaching materials.t-test results in t = −2.12, p < 0.01). To the analyze the significant difference in reading ability improvement between the experimental group and the control group, an eye tracking experiment was conducted for comparing the eye movement characteristics of the two groups during their reading process.To assess the reading ability improvement for the two groups, we first administered a reading comprehension test before and after the intervention. The reading comprehension test was created based on previous reading comprehension assessment instruments used in Japanese reading courses, which contained 46 test items with a full mark of 100. The difficulty levels of the pre-test and post-test were similar but not identical. The The experiment used the Tobii T120 eye tracker, which is produced by Tobii in Stockholm, Sweden, with a sampling frequency of 1000 Hz and a resolution of the test machine display of 1024 × 768 pixels. The data of eye movement indicators were imported into Tobii Studio software. The reading materials were the Japanese International Proficiency Test N2 exam reading comprehension simulation test materials. The number of words in each article is approximately 500, and the basic frame is 16 lines × 30 characters. The reading article contains Kanji, Hiragana, and Katakana, ensuring a comprehensive examination of Japanese reading ability.Give instructions to the participants about how to do the experiment.Ask the participants to read four Japanese articles that are displayed randomly on a PC screen, one after another. The time given for reading is unlimited.Record eye tracking data during reading.Follow each article with two reading comprehension multiple-choice questions and a requirement to write down the keywords and key sentences to measure their reading comprehension rate and reading efficiency, which participants must do immediately after reading.Analyze the obtained eye tracking data and other data (reading comprehension data).The procedures for obtaining eye movement indicators consist of the five steps as follows:Among all kinds of eye movement indicators, fixation-related indicators, regression count, saccade amplitude, and pupil diameter are the most reported data in eye-tracking studies and recognized as primary indicators playing critical roles in identifying students’ reading abilities ,25. In aFixation indicates the position where eye remains still for a certain period of time ,38, whicRegression refers to the reading process that move in the opposite direction to the reading materials ,38. The Saccade is the rapid movement between fixations ,38. SaccPupil diameter is an eye movement indicator used to infer the size of “cognitive processing” and “cognitive load”, which is often used in the field of education (unit: mm) . The sizHeat map representing fixation duration and fixation location have been shown to be a better representation of visual processing . It is aTo measure reading comprehension rate and reading efficiency, each article was followed by questions that participants needed to answer after eye tracking. Reading comprehension indicators were used for analysis, which are divided into four aspects: reading time, reading speed, reading comprehension rate, and reading efficiency ,48. Readt-test was conducted . In terms of the saccade amplitude, the experimental group was significantly higher than the control group . The pupil diameter in the experimental group was larger than that in the control group, although there were no significant differences .Based on the statistical comparison in onducted . The resThese eye movement indicators can reflect the understanding and information processing of the article when reading. From the perspective of fixation, a high number of fixations and fixation frequency indicate the difficulty in interpreting the fixated information , and shoThe number of fixations and fixation frequency were lower in the experimental group than in the control group. The number of fixations and fixation frequency can reflect the comprehension and information processing of the subjects, which indicates that the experimental group can understand the reading materials easily.The mean fixed duration in the experimental group was shorter than the control group. The length of the mean fixed duration is related to the semantic extraction of the observed words. The mean fixed duration of the experimental group was 0.20 s, which can show that the main content of the reading materials can be extracted in a short time and the reading speed can be improved.The regression count of the experimental group was significantly less than of the control group. Generally, regression is produced when there are difficulties and errors in understanding the reading content. The regression count of the control group was 90 times/s, which could infer that there were some difficulties in extracting and processing the information of reading materials, which requires repeated processing to achieve the goal of understanding the content of reading materials.Saccade amplitude can reflect reading efficiency and processing difficulty. The saccade amplitude of the experimental group was significantly larger than that of the control group, which indicates that the experimental group could obtain a larger amount of information from the reading material and had a higher level of reading efficiency, while the saccade amplitude of the control group was small, indicating difficulty in processing reading materials.The pupil diameter of the experimental group was larger than that of the control group. This indicates that the experimental group paid more attention to the information processing when reading materials, and their effort of cognitive processing was higher than that of the control group. In addition, it is possible that, after mind mapping training, the experimental group was more confident in their reading comprehension and had positive emotions regarding the completion of the reading task. The difference between the two groups did not reach a significant level, which may be due to the fact that the reading materials were not difficult and did not cause excessive psychological load on either group.The reason the two groups have the above differences in these eye movement indicators is that the cognitive processing level of students with different reading ability will be different during the reading process. Mind mapping training can effectively improve the reading comprehension rate, while reducing the total reading time, the number of fixations, fixation frequency, mean fixation duration, and regression count and increase the saccade amplitude and pupil diameter, which can help the students to complete reading comprehension more quickly and accurately.The visual focused areas were compared by detecting the mean fixation duration and fixation location in heat maps. As presented in t = 6.543, p < 0.001). On the other hand, there were no significant differences in the control group’s mean fixation duration on Text Areas 1 and 2 of four Japanese reading articles .The results are shown in The experimental group’s most focused areas were the keywords and the key sentences, and the control group’s reading process was fragmented. The results show that different reading teaching methods had different reading effects, and they affected the students’ most focused areas on the reading materials. Through mind mapping, the students could create associations on keywords and key sentences, establish memory links, and use relevant hierarchical diagrams to integrate the language knowledge in the reading materials ,7. The sNumber of fixations and saccade amplitude results for the two groups are shown in t-test of t = 13.375, p < 0.001). In terms of the saccade amplitude, the experimental group was significantly higher than the control group . The results show that the experimental group’s reading process was relatively smooth, and the overall grasp of the article was good, which could save reading time and improve reading speed. On the other hand, the control group had some difficulty in reading the article, which would lead to increasing reading time and decreasing reading speed.As mentioned in the During the reading process, people obtain information through fixations and transferred the fixations through saccades. The saccade amplitude changed due to the difficulty of reading materials. Saccade amplitude in fixation trajectory map indicates the skipping phenomenon. The greater is the saccade amplitude, the more words are skipped . During t-test results show that there were significant differences in the reading comprehension indicators between the two groups. By comparing with the control group, in the experimental group, the reading time was significantly shorter ; the reading speed was significantly faster ; and the reading comprehension rate and reading efficiency were significantly higher .To further investigate the reading ability of the two groups, reading comprehension indicators analysis was conducted. As presented in The results further confirm the considerable reading effect of mind map training, which can save reading time, improve reading speed, enhance reading comprehension rate and reading efficiency, and thus promote students’ reading ability to a certain extent. Mind mapping training can activate students’ reading skills to form a clear article structure frame in head. It can clearly show the structure of articles, so that students can more clearly understand and grasp the specific details of each paragraph and analyze the structure and content of the article in detail. Through mind mapping, students will have a clear grasp of the overall structural context and layout of the article, as well as deepen their understanding of the content of the article and obtain detailed information efficiently. It can improve their ability to analyze micro-details of the article.By eye tracking analysis, the reading process can be inspected in-depth. In this study, we used eye tracking sensors to record eye movement indicators in real time, which provides a quantitative assessment and data evidence of mind mapping’s effectiveness on reading ability. The results suggest that there are significant differences between the experimental group and control group’s eye movement indicators during the reading processes. Their different eye movement indicators reflect their different states as parts of the process of information input and information extraction. Students in the experimental group were found to understand the reading materials more promptly, showing fewer fixations, fewer regressions, longer saccades, and larger pupil diameter. Previous studies on mind mapping training effectiveness mainly focused on the traditional assessment of reading comprehension testing methods. This study applied eye movement indicators to investigate cognitive comprehension process, so as to measure and evaluate mind mapping training effectiveness on reading ability more comprehensively. However, certain limitations should be noted. First, although the sample size was sufficient to clarify the effectiveness of mind mapping training to improve students’ reading ability, it is still a small number and low gender balance for the generalization of eye tracking results. In the future, it is necessary to conduct an experiment with larger number and higher gender balance of participants and to analyze the results further. Second, this study only applied six eye movement indicators to describe and explain the reading process. It may give limited implication to the correlation between the improvement of reading ability and the eye movement indicators. More eye movement indicators could be considered for further investigation and verification, such as refixation rate, landing position, and first fixation duration. Third, in future work, we look forward to recognizing students’ cognitive and emotional status according to their eye movement indicators in order to have a more comprehensive and in-depth understanding of the cognitive process of reading.


To the best of our knowledge, no previous studies on carotid webs with atherosclerosis plaque have been conducted. Thus, both radiologists and clinicians have insufficient knowledge of this disease, which could lead to misdiagnosis and missed diagnosis. An accurate diagnosis is beneficial to clinical management and prevention of stroke. Here, we present a case of a carotid web with an atherosclerotic plaque, which was confirmed by histopathology and was treated at the Department of Neurosurgery, Beijing Tiantan Hospital.We report a rare case of a carotid web with an atherosclerotic plaque in a 61-year-old Han man. He presented to our hospital with history of intermittent dizziness and slurred speech for 1.5 years and numbness of both upper limbs for 4 months. A computed tomography angiography examination indicated severe stenosis at the beginning of the left internal carotid artery with plaque surface ulceration. Doppler ultrasound examination showed a carotid web with a thin isoechoic plaque and a membrane-like structure protruding into the lumen from the lateral posterior wall at the beginning of the left internal carotid artery. The thin isoechoic plaque could be seen at the base of the membrane-like structure. Carotid endarterectomy was performed to alleviate symptoms. A carotid web with atherosclerosis was diagnosed intraoperatively, and postoperative pathology confirmed extensive intima fibroid hyperplasia accompanied with myxoid degeneration. The base of the carotid web was attached to the thin atherosclerosis plaque, and between the web and the plaque, a cavity was observed. In this case report, we aim to discuss the diagnosis of carotid web with atherosclerosis, its physiopathology and management, and the possible reasons for missed diagnosis or misdiagnosis.Carotid webs with atherosclerosis have no known etiological factors and are rarely reported. Thus, carotid webs could be easily confused with ulcerations on the surface of the atherosclerosis plaque. The diagnosis could be difficult and effective management remains indeterminate. Moreover, prompt recognition of this disease is key to correct treatment and management. Hence, this case report and the relevant data in the literature could contribute to the improvement of the diagnosis and treatment of this disease. Carotid webs with atherosclerotic plaques are one cause of stroke; however, misdiagnosis and missed diagnosis of this disease are frequent. Its diagnosis is a challenge for radiologists and sonographers because it is rare and relevant reports are scarce, which in turn affects the treatment and management of the disease. Although previous reports of carotid web exist –18, caroA 61-year-old Han man presented to our hospital with intermittent dizziness and slurred speech for 1.5 years and numbness of both upper limbs for 4 months. After resting, he showed improvement and had intermittent attacks without any treatment. A computed tomography angiography (CTA) examination indicated stenosis at the beginning of the left internal carotid artery. Because of recurrent symptoms, he sought admission to our hospital for further treatment. Moreover, he had diabetes for 17 years and was treated with an orally administered antidiabetic medication. He also had hypertension for 10 months (blood pressure up to 220/120 mmHg) and was treated with an orally administered antihypertensive drug. He had 20-pack years of smoking history.Routine examination with CTA and DUS before surgery was performed. CTA indicated a small niche shadow in the left internal carotid artery on sagittal view Fig. , and no To relieve the symptoms of our patient, CEA was performed. The diagnosis of a carotid web with an atherosclerotic plaque by DUS was confirmed by the postoperative specimen Fig. ; both thet al. [To understand carotid webs with plaque formation, we should first fully understand a carotid web. The term “web” was first used to describe this disease by Momose and New in 1973 at the Massachusetts General Hospital , which set al.  describeet al. . While aet al. . Thus, DMoreover, DUS could show the carotid web and the plaque clearly, that is, the structural and positional relationships between the carotid web and plaque could be clearly displayed on ultrasound. However, slight adjustment of the probe direction is needed to trace the direction and angle change of the membrane structure, and careful observation on multiple angles is necessary. Moreover, high suspicion of the disease may be helpful for the diagnosis. In our case, a minor niche shadow on the lateral wall at the beginning of the internal carotid artery was identified with CTA Fig.  and the Clinicians, including radiologists and sonographers, should be aware that carotid webs with atherosclerotic plaques could occur not only in young patients with stroke but also in elderly patients with stroke. Because the pathogenesis of carotid webs alone versus carotid webs with atherosclerotic plaques are similar, accurately distinguishing the two diseases presents a diagnostic and therapeutic challenge. Thus, careful examination of the diseases is vital to decrease missed diagnosis and misdiagnosis. A previous study reported that early and correct diagnosis of carotid webs is crucial not only to establish the probable cause of stroke but also to prevent the risk of recurrence ; thus, aHowever, currently, carotid webs are challenging because of their small and thin characteristics. The low detection rate may be due to a lack of experience, insufficient scanning skills, and limited understanding of the image characteristics. To reduce the rate of missed diagnosis and misdiagnosis, both radiologists and sonographers should increase their familiarization of the image features of the disease. Moreover, acoustic beam direction should be traced along the direction of the carotid web, the whole length evaluated, and the basilar part of the carotid web carefully observed to detect whether the base is attached to the plaque or has thrombus formation. Lastly, high suspicion of the disease could aid in the diagnosis.In conclusion, DUS could show the morphology of the carotid web with or without plaques; however, improvement in scanning skills is vital. CTA was considered the gold standard for the diagnosis of this disease; however, without adequate knowledge, it could lead to misdiagnosis and missed diagnosis. Early diagnosis of the disease could guide the clinical management of the disease, thereby reducing the incidence and recurrence of stroke.


New printed evidence reignited the controversy over the EXCEL affair, exposing more important flaws, both in the trial’s statistical analysis and the revelation that the previously concealed myocardial infarction data has now been made available., the June edition of the Journal of American Medical Association (JAMA) Internal Medicine revealed and highlighted that the formal hypothesis testing, which in the EXCEL trial was prespecified as a demonstration of noninferiority at 3 years, was without discussion or explanation switched to a superiority test in the 5-year analysis. If as prespecified, the same noninferiority analysis had been conducted at 5 years it would not have met the criteria for statistical significance, and the printed conclusion would not have been possible. This is a classic case of interpretation bias, otherwise known as spin.Further to the extensive disclosure of flagrant bias introduced into the design, analysis, and publication of the 5-year follow-up of the EXCEL trial.The newly identified violation follows in the wake of the controversy over data manipulation in the EXCEL trial. The article authored by Professor James M. Brophy, who is a professor of Medicine, Epidemiology, and Biostatistics at McGill University in Montreal, Canada, re-examines the design and results of the EXCEL trial and other recent randomized clinical trials related to the left main coronary artery disease (LMCAD) using Bayesian methodsThe article shows furtive aspects and details of the statistical analysis, not previously acknowledged, that in effect concealed and circumvented the real results of the EXCEL trial to attain the desired conclusion. The method of statistical analysis used to interpret the 5-year data was different from that used in the 3-year publication, and in direct contrast to the original protocol, without explanation or justification. If EXCEL’s 5-year results had been interpreted in alignment with its original primary non-inferiority design of a pre-specified 4.2% primary result margin, a different conclusion would have been reached, even within the context of a standard analysis. Instead, the EXCEL authors construed the 5-year results as a superiority analysis, in which the null hypothesis did not consist of any differences so that the observed data was not extreme enough to reject that null hypothesis. The Bayesian analysis of the EXCEL primary outcome estimated with 95% probability that the 5-year primary outcome difference was increased with PCI compared with CABG and 87% probability that this difference was greater than one extra event per 100 patients treated. Given that in EXCEL these were relatively young patients with a mean age of 66 years  and that the statistically significant observed increase in mortality of 38% was actively accelerating raises real clinical concern. For the secondary composite endpoint, which also included repeated revascularizations, there were estimated probabilities of 98% for at least 4 extra events and of 90% for at least 5 extra events per 100 patients treated with PCI. Therefore, PCI was associated with less favorable results for all events, including mortality, compared to CABG in patients with LMCAD..Professor Brophy, although recognizing that these analysis failures by the authors of the EXCEL trial may have occurred due to carelessness and/or incompetence of the authors, questions if sponsorship by the company that produced the stent used in the study led to more favorable results and conclusions. He reinforces that fourteen of 34 EXCEL trial authors, including the first and last authors, had a relationship with the study sponsor (the stent maker), and that 8 authors listed an affiliation with the Cardiovascular Research Foundation (CRF) which oversaw the study. CRF received a donation of US$ 937,000 from the sponsor during the study and Professor Brophy infers that these factors may have contributed to the entirely speculative hypothesis that these conflicts of interests contributed to the biased interpretation of EXCEL. The reason for this change is not justified or even explained in the final EXCEL trial manuscript. However, it emphasizes that, if the authors had maintained the non-inferiority analysis that was performed in 3 years (with a pre-specified upper margin of 4.2%), it would not meet those existing criteria at 5 years because the upper limit of the 95% difference at 6.5%, now exceeds that non-inferiority margin. He reiterates that the conclusion of EXCEL that PCI and CABG were similar, despite a 3.1% difference in mortality that favors CABG, is a classic example of interpretation bias, also known as spin. Spin is recognized to occur frequently when associated with commercial study sponsorship,4.In the same issue of JAMA Internal Medicine, a commentary by Professor Sanjay Kaul  raises the same concerns about the inappropriateness of changing the protocol specified statistical analysis from non-inferiority at 3 years to superiority at 5 years,5.The disclosure of alteration in the statistical methodology in the 5-year EXCEL analysis, making possible the printed conclusion, is very worrisome in view of its potentially adverse implications for patient safety. Likewise, the earlier claim from the EXCEL trial authors that the per-protocol Universal Definition of Myocardial Infarction data analysis, which was prespecified as a secondary endpoint, had been deemed ‘impossible’ because troponin was not properly collected, was overly refuted by the unveiling of the definition of the Third Universal Definition of Myocardial Infarction, which clearly states that if a cTn assay is not available, the best alternative for analysis is CKMB (measured by mass assay).Despite the prior assertions of the EXCEL authors that no such data was available, in a new publication from the EXCEL trial authors, compulsorily replying to letters to New England Journal of Medicine (NEJM), now reported the protocol specified analysis of Third Universal Definition of Myocardial Infarction, based on CKMB data. This revealed a stark difference from the original paper, by now demonstrating the higher rate of periprocedural myocardial infarction related to PCI. And therefore, nullifying the original conclusion published in the NEJM. Mounting evidence implicates inflammation as a key player in many, if not all, diseases of the human body. The presence of a metallic intracoronary stent, acting as a foreign body inducing formation of a cardiac granuloma, elicits a local and systemic chronic inflammatory reaction, leading to a perennial low-grade inflammation with persistently higher blood TNF-alpha and interleukin-6 expression-10. Inflammation has long been recognized as a key component of carcinogenesis and chronic low-grade inflammation, characterized by elevated concentrations of IL-6, TNF-α, and C-reactive protein, increase susceptibility to cancers and infections-14. Additionally, drug-eluting stents actively releasing antiproliferative drugs promote chronic inflammation and determine a greater endothelial dysfunction and neoatherosclerosis, which is associated with an long-term increased risk of solid-tumor cancer.The authors claim that the difference in all-cause death was driven by an increase in non-cardiovascular death, due to late malignancies and sepsis, and in the absence of any obvious biologic plausibility is therefore likely due to chance. However, this denotes unfamiliarity with the basic principles of pathophysiology of coronary artery disease and the repercussion of distinctive revascularization therapiesAs external and independent denouncements of the conduct and interpretation of the EXCEL trial are escalating, why do the EXCEL authors, of whom many are distinguished doctors, still remain silent over these crucial facts and the implication of potential real harm to patients? And what about the implications for guidelines that may have been or could in the future be based on such a flawed trial and conclusion?Furthermore, the EXCEL trial has generated dozens of offspring manuscripts. Can we now trust these manuscripts if the primary manuscript was so severely flawed? And what about the patients enrolled in the EXCEL trial, who committed their trust and safety, to participate in a trial professedly created to help save lives? And how they might be now frustrated and even feeling betrayed by outcomes skewed for not confessed reasons?Until these issues are addressed the EXCEL trial has the potential to become a deplorable example of distrust as a distorted form of science, leaving both the public and the medical profession to question how this happened and how to ensure that it cannot happen again.While it would be hoped that the serious flaws of the EXCEL trial occurred through ignorance and/or incompetence it still raises the question of whether the EXCEL affair may have been driven by other conflicts both by the investigators and the company. The data generated by the EXCEL trial, the largest ever trial on this subject, is crucial for science and medical practice to understand the impact of the competing therapies of PCI and CABG in this deadly condition. Accordingly, and to restore trust both for patients and the medical profession the EXCEL data must be made open for unbiased and truthful thorough scrutiny, managed by independent reviewers. In the meantime, and given these very serious flaws the NEJM should issue a temporary retraction to prevent patients from being submitted to serious potential harm.


Background: Across the globe, managing chronic diseases has been recognized as a challenge for patients and healthcare providers. The state of the art in managing chronic conditions requires not only responding to the clinical needs of the patient, but also guaranteeing a comfortable state of wellbeing for them, despite living with the disease. This demands mutual effort between the patient and the physician in constantly collecting data, monitoring, and understanding the disease. The advent of artificial intelligence has made this process easier. However, studies have rarely attempted to analyze how the different artificial intelligence based health coaching systems are used to manage different types of chronic conditions. Objective: Throughout this grounded theory literature review, we aim to provide an overview for the features that characterize artificial intelligence based health coaching systems used by patients with chronic diseases. Methods: During our search and paper selection process process, we use three bibliographic libraries . Using the grounded theory, we extract overarching themes for the artificial intelligence based health coaching systems. These systems are then classified according to their role, platform, type of interaction with the patient, as well as targeted chronic conditions. Of 869 citations retrieved, 31 unique studies are included in this review. Results: The included studies assess 14 different chronic conditions. Common roles for AI-based health coaching systems are: developing adherence, informing, motivating, reminding, preventing, building a care network, and entertaining. Health coaching systems combine the aforementioned roles to cater to the needs of the patients. The combinations of these roles differ between multilateral, unilateral, opposing bilateral, complementing bilateral, one-role-missing, and the blurred role combinations. Conclusion: Clinical solutions and research related to artificial intelligence based health coaching systems are very limited. Clear guidelines to help develop artificial intelligence-based health coaching systems are still blurred. This grounded theory literature review attempted to shed the light on the research and development requirements for an effective health coaching system intended for patients with chronic conditions. Researchers are recommended to use this review to identify the most suitable role combination for an effective health coaching system development. Chronic diseases are considered among the most widespread and cost exhaustive health conditions around the world . The WorThe transition from a patriarchic to a collaborative way of managing the disease: The classic standard of care relies on a model where the physician has full authority and power over the treatment of the patient. Hence, the patients do not participate in curating the parameters of their treatment at all. The new operational shift provides more control and personalization for patients in terms of the way they manage their condition.The transition from an episodic to a continuous monitoring cycle for the patients’ health indicators. This aspect refers to the number of times a follow-up with the physician is held. Unlike for acute diseases, where follow-ups are rarely held, chronic conditions require a continuous monitoring process. Thanks to the advent of artificial intelligence and thanks to the affordability of sensors, patients’ indicators are measured around the clock for an efficient health and wellbeing management.The transition from prioritizing volume to prioritizing value for the healthcare provided: The focus for healthcare management has shifted from treating acute illnesses in a massive way, to more time allocated to understanding the patient. Value is added to the patients’ experience of managing their chronic disease through the use of connected health, tele-medicine, and tele-presence robotics ,12,13,14Healthcare systems around the world have adapted their modes of operation to suit the needs of patients coping with those diseases in order to effectively manage these growing conditions ,9. ThereThese three shifts in the healthcare system’s mode of operation have profound implications on how artificial intelligence-based health coaching systems are designed .In this work, we perform a literature review using the Grounded Theory in Literature Review (GTLR) methodology . We aim What is the influence of different types of chronic diseases on the design choices for AI-based health coaching systems for patients?The use of e-health technologies in managing chronic diseases has increased. Moreover, healthcare providers understand the essential role of the patient’s feedback  methodology in order to reach the aforementioned aim . A GTLR The studies in the literature review are collected over the first half of the month of June 2020 from the following three electronic libraries: Pubmed, IEEE Xplore, and ACM Digital Library. Numerous papers from key academic venues according to the Scopus index for academic journals and conferences are included. Reference lists of the selected publications are checked for additional studies that are relevant to the topic (Backward reference list checking). Moreover, additional relevant studies are checked using the “Cited by” functionality available in the above-mentioned databases (Forward reference list checking).Search terms used in the current review are curated by taking into consideration three essential elements: target population , healthcare intervention , and technological solution . The search terms are derived from the few studies that are available in the literature. These studies address e-health systems as a solution for self managing chronic conditions ,18. The In order for studies to satisfy the eligibility criteria, they need to convey primary research findings regarding artificial intelligence-based health coaching systems for a specific chronic condition. The review also includes articles that describe rule-based intelligent systems under one condition due to the novelty of the field, and due to the limited number of research articles pertaining to this area of research. The condition is that the system’s main goal it to serve for health coaching patients manage their chronic condition. Therefore, this review focuses on AI-based systems that coach patients to be more independent in managing their chronic condition. These systems may work on the following platforms: stand-alone software, web browser, specialized hardware dedicated for a specific chronic condition , serious games, SMS based systems, and mobile applications. The review also includes studies containing health coaching systems that are designed to be used by both the patients and the coaches . Studies about AI-based health coaching systems whose main target audience is not coping with a chronic condition or chronic disease are excluded. The review includes peer-reviewed articles, dissertations, conference proceedings, and reports. However, it excludes reviews, conference abstracts, proposals, and editorials. Included articles need to be published starting from the year 2012. They also need to be written in the English language to be considered for selection in the literature review. No restrictions are imposed with regards to the type of the chronic condition, input and output modality, study design, study setting, measured outcome, or country of publication.This review follows two major steps in selecting the studies. During the first step, two reviewers independently screen the titles as well as the abstracts of all initially retrieved studies. In the second step, the same reviewers study individually the full texts of the articles included from the first step. Any dis-accord between both reviewers is resolved through a discussion involving both reviewers about the concerned research paper. Inter-coder agreement between both reviewers is assessed while using Cohen’s kappa . The ratIn order to perform a systematic and precise data extraction, the reviewers developed a data extraction spreadsheet and tested it with few studies before using it. The data extraction step follows a similar process to the study selection one. In this step, the two reviewers independently perform the data extraction. Once disagreement occurs, it is collaboratively resolved and ultimately agreed upon. Inter-coder agreement between the reviewers was good (Cohen’s kappa = 0.85).Grounded theory based literature reviews differ from systematic reviews. The difference lies in reviewing wider topics and including studies with varying study designs . Thus, gWe refer to a narrative approach in the data synthesis stage. We classify the health coaching systems according to the chronic condition addressed, the patient profiles, and the technical solutions. We also identify the duration of the study and the number of participants involved. Accordingly, we adopt the appropriate taxonomy published in the literature by Nunes et al. Characteristics of the studies and the population are summarised in n = 311, IEEE Xplore n = 185, ACM Digital Library n = 373). After removing 376 duplicates, 493 unique citations remain. After reviewing their titles and abstracts, 419 citations are excluded . By entirely reading the full text of the 74 remaining publications, 46 publications are excluded , n = 13 are purely medical articles, and n = 5 articles compare public health systems between countries). 28 articles are therefore included. The included articles satisfy the study eligibility criteria detailed in Three bibliographic databases are searched to result in a total of 869 citations . Although studies are authored in 11 different countries, more than one-third of the studies, about 38%, are authored in the USA (n = 12). About half of the studies are published between 2019 and 2018 . The sample size is less than 50 participants in 19 studies and between 50 and 375 participants in 12 studies. The mean sample size is 54.17. The sample size ranges between 5 and 375 participants per study. The age of participants is only reported in 12 studies, whereby the mean age is 34.6 years. In the included studies, the recruited participants are either from a clinical setting (n = 9), a community setting (n = 17), or an academic setting (n = 5). Throughout the experiments conducted, the studies attempt to measure or quantify four types of outcomes. The effectiveness (n = 17), the usability (n = 5), the acceptability (n = 5) and the adoption (n = 4) of the artificial intelligence based health coaching system.The process of performing axial coding on the included studies enables a detailed analysis of the different AI-based HCS types along with their roles. n = 19, 62%) prefer to develop the health coaching system on a stand-alone application while the remaining third uses a web-based platform to develop the health coaching system. The interaction between the health coaching systems and the patients is nuanced between the use of an expert system or involves machine learning into the interaction. The included studies cover a range of 14 different chronic condition. Almost two-thirds of these studies , as they have been captured and prioritized by the product designers. Thus, these roles enable the identification of the important features impacting the end product (AI-based HCS). These features are influenced by the context of the disease, intervening and causal conditions of the patient, as well as the chronic disease itself (phenomena), as depicted in The Full Multilateral HCS combination category: is characterized by the combination of all the HCS roles in the same system. The HCSs for cardio-vascular diseases, chronic obstructive pulmonary disease, and multiple sclerosis all fall under this category.The Unilateral HCS category: is a configuration focused on a system implementing only one role. Chronic musculo-skeletal pain, Parkinson, and rare chronic diseases fall under this category.The Opposing Bilateral HCS combination category: refers to different HCS roles, if combined together might undo the progress that each role has contributed to. An example of that would be the inform and entertain functionality. In the majority of cases, developing digital games is mainly intended for entertainment. Therefore, it is rare to find a video game with the intention to inform and educate. However, combining these two functionalities is possible, as it is the case for the diabetes HCSs for adolescents ,38.The complementing Bilateral HCS combination category: complementing bilateral HCS roles refer to the roles that complement each other. The way these roles complement one another is by one role contributing to the development of the other. The end goal is to achieve better chronic disease management. Examples of this configuration is the “remind” and “prevent”. The roles in the HCS that remind patients with chronic migraine to take medications also contribute in preventing a migraine crisis from happening ,41. AnotThe one-role-missing combination category: is characterized by a HCS incorporating all the roles except one. The case of arthritis and obesity falls under this category.The blurred roles combination category: is characterized by some roles not being incorporated fully or accurately. The case of serious mental illness falls under this category.The nature of the chronic disease has a direct influence on the design of health coaching systems (HCSs). We discuss how the combination of these roles mentioned in the previous section form the end design of AI-based HCSs of different chronic conditions. We identify six common combination categories applying a coding scheme on the 28 HCSs.We elaborate, in details, on the resulting role combinations for the HCSs. We use the included 31 studies as an illustration to the different combinations.We use the case studies of both cardiovascular diseases and multiple sclerosis shown in The difference in the number of participants for cardiovascular diseases’ studies as compared to the other chronic conditions is noticeable. While the majority of the experiments recruit participants in the range of five to 50 participants. The cardiovascular diseases studies recruited 210 participants in total. This is due to the quantitative nature of the experiment. Sideris et al. attribute this abundance in terms of participants to the fact that cardiovascular diseases are the first cause of death in the US.In the three selected studies VeraMunoz et al., Sideris et al., Ayobi et al., the authors emphasize the importance of the process of self care and wellbeing management in addition to the clinician’s follow up. The authors argue that clinicians face a lack of control and uncertainty in managing the chronic disease when patients are not involved in the process of self-care. The authors ,22,42 arWhen patients are selfly willing to be involved in a self-care process, they creatively find effective self-tracking tools, even when HCSs are not accessible for them . This obThe authors, prior to the development of a HCS, gathered the different types of engagements for the patients with both the HCS as well as the clinician recommendations. These gathered elements incentivized the design of an all inclusive multilateral system design. This design is reflected on the HCSs, as it is observed in both cardiovascular diseases and multiple sclerosis systems.We use the case studies of both Parkinson , as wellNunes and Fitzpatrick explain how living with parkinson disease dictates a complicated life and one full of “mundane challenges” . These cA similar effect is observed by MacLeod et al., MacLeod et al. in both of their studies about rare chronic diseases . One of Although there exists a difference in the nature of the chronic diseases investigated by MacLeod et al. , MacLeodWe use the case of two diabetes studies performed by denAkker et al. and Harris et al. shown in Both of the studies design HCSs for diabetic adolescents. They suggest that clinicians and health coaches fail in motivating and engaging adolescents in their chronic disease care program, especially when an overwhelming amount of information is communicated to the adolescents. Harris et al. observe that teenagers, in general, and the ones with diabetes have a rebellious persona towards receiving information with regards to their chronic disease. Adolescent patients see this amount of information as “overwhelming” requiring them to adhere at an early age to a rigorous care program. Therefore, the authors  realizedWe use the case studies of two migraine experiments performed by Park and Chen and Schroeder et al. shown in the Schroeder et al. in their study explain that chronic migraine is a chronic disease unlike other chronic diseases. It “is characterized by unpredictable, intermittent, and poorly understood symptoms”. Therefore, the health coaching care program varies widely from person to another, and from clinician to another. This entails that each patient might track a wide array of different symptoms that relate to their unique chronic migraine case. For those reasons, Schroeder et al. conclude that, in order to contribute to reducing the frequency and intensity of the symptoms, there needs to be a deep investigation about how people with migraine track and use the data related to their disease. Therefore, the study that the authors conduct involves 279 different participants. The investigations use in depth interviews to understand the different ways that patients feel and deal with chronic migraine. The investigation also consists of patients self documenting the tools, as well as the techniques they use to deal with the disease. Schroeder et al. conclude that the best HCS to enhance patients with chronic migraine’s lives is a self-tracking system that helps identify personal triggers to causing intense headaches. Therefore, Schroeder et al. designed a system that was powered by machine learning where self-tracked migraine data are used to enable prediction, communication ahead of time, and prevention for the symptoms that might cause an eventual migraine crisis. In this complementing bilateral category, each of the two role functionalities complement one another. The two roles here are the prevent and remind.We use the case studies of arthritis and obesity performed by Gupta et al. and Barnett et al., as shown in When it comes to the one role missing category, it is important to understand why among all available seven roles, one is not considered. In the studies included for the analysis, both the arthritis study done by Gupta et al. and the obesity study conducted by Barnett et al., discarded one role in the development of their HCSs. The obesity study discarded the prevention role, while the arthritis study discarded the entertainment role. For obesity, and according to Barnett et al., it is one of the chronic diseases that has a methodical care program, where the results are to be calculated and predicted. Therefore, unexpected results or symptoms rarely occur. The feature set for the HCS remains effective and sufficient, even without a prevention role. With regards to the arthritis study, the same rationale is behind, but, for this case, the HCS not involving the entertainment aspect instead of the prevention aspect. The reason for this decision, according to Gupta et al., is that the system focuses on involving vizualization heavily, since the physiotherapist coach needs to monitor several parameters at a time to design the most effective coaching program in real time. Gupta et al. see that the system is able to skip presenting the information in a fun entertaining way due to the fact that the system is directed to the therapist coach in the first place.We use the study of serious mental illness performed by Aschbrenner et al., as shown in In our analysis, the blurred roles category is represented by the serious mental illness study that was conducted by Aschbrenner et al. As the study involved clinical research, there is an observation that patients with serious mental illness, such as schizophrenia and bipolar disorder, have a higher risk of early death due to cardiovascular diseases and other preventable chronic illnesses. Aschbrenner et al. pointed that young adulthood is an important opportunity for the development of health coaching lifestyle interventions to improve the long-term health and quality of life in this fragile population. The authors also mention that serious mental illnesses cause other chronic diseases if not addressed as early as possible. When different chronic diseases get discordantly involved in a patient, treatments become challenging. One treatment for a specific chronic disease can awake symptoms of another chronic disease. Therefore, Aschbrenner et al.’s study compared two HCSs that were targeted to different treatments: the peerFit and BEAT interventions. The first is targeted in order to develop adherence to treat the cardiovascular disease which is a consequence of the serious mental illness repercussions. The second is meant to develop a care network through the HCS to help patients with serious mental illnesses to develop a social circle. Managing two chronic diseases in parallel creates a dispersion of focus in the overall design of the HCSs, and thus the blurred roles reflected in these studies.The study measured outcome: Sample of participants. The sample size across the primary studies ranged between five up to 375 participants ,35. ThisSetting of the study. The setting where the study is conducted may also be a factor in hindering an objective measurement for the effectiveness of the health coaching system. Across the primary studies, the authors of the selected articles proposed numerous health coaching systems. These systems vary in terms of the roles they play in order to support the patient through the self-management of the disease. Across the subset of the analyzed studies, there were no common efficiency metrics in use to measure the effectiveness of the HCSs. Hence, the diversity of the roles and their combinations that these systems play. This is observed first-hand across the primary studies, as each study attempted to measure the outcome of its system differently. Moreover, the nuanced study designs across the primary studies adds to the complexity of proposing a unifying effectiveness metrics. However, this does not prohibit drawing conclusions at the study characteristics level instead of a unifying global level. The following paragraphs elucidate the main findings and the conclusions drawn at the characteristic level.The three points mentioned above do not enclose the totality of the factors involved in the success or failure of a health coaching system. However, these points are the remarks that the authors find noteworthy to mention before initiating the design and implementation of a study involving a health coaching system.The authors of the primary studies revealed some limitations that their conducted studies suffer from. Most of the noted limitations correlate with the observations made in the concluding remarks. We discuss two types of limitations. Limitations at the level of the primary studies’ design and limitations at the level of the conducted literature review. The below two sub-sections expand and discuss these two types.The limitations at the level of the conducted primary studies cover the study design, the number of recruited participants, and the duration of the study. The authors of the primary studies acknowledge that designing and conducting a feasible study is a trade-off between these three parameters mentioned  against In contrast with Fadhilet al.’s study, Mateevitsi et al. chose a different approach as the number of participants is significantly lower (five instead of 375). This smaller sample size has its advantages in terms of: following up with the participants, allowing a more comfortable home setting instead of a clinical or academic setting, and in terms of the choice and control of the evaluation metrics. Moreover, the smaller number of participants allowed for a follow-up period of six months past the end date of the study. However, the limitation that the smaller number of participants brings is the lack of objectivity in evaluating the health coaching system. Claiming that five out of five participants adopted the use of the system does not translate into claiming the adoption of the system by a larger population size with different backgrounds and chronic condition needs. Therefore, a small number of participants is a limitation that may discredit the significance of the results obtained after experimentation.Lastly, the final element that may hinder the significance of the results and cause bias for the conducted study is its duration. The duration of the primary studies ranged between one week up to 40 weeks ,43. The The methodology followed to perform the literature review: the authors follow a grounded theory literature review methodology. This methodology is more common in the social sciences compared to computer sciences . This isThe search and selection process: while there exists some commonalities among the search and selection strategies of both the systematic review and the GTLR methodologies. These commonalities are summarized in a systematic approach to searching, analysing, and reporting a set of literature  . The sysWe list the limitations that this work suffers from at the literature review level. We also explain the trade-off accepted by the authors that justify these limitations.The conclusions from the analysis, discussion, and conclusion sections will be carried out to design a study that uses an AI-based HCS dedicated for supporting patients with cardiovascular diseases independently interpret their electrocardiograms (ECGs). With the advent of wearable technologies that are capable of measuring patients’ ECGs, supporting patients understand and properly read their electrocardiogram is of paramount importance ,8. Howev


Recent success stories in automated object or face recognition, partly fuelled by deep learning artificial neural network (ANN) architectures, have led to the advancement of biometric research platforms and, to some extent, the resurrection of Artificial Intelligence (AI). In line with this general trend, inter-disciplinary approaches have been taken to automate the recognition of emotions in adults or children for the benefit of various applications, such as identification of children's emotions prior to a clinical investigation. Within this context, it turns out that automating emotion recognition is far from being straightforward, with several challenges arising for both science  and technology . In this paper, we present a methodology and experiment and some interesting findings, which raise the following research questions for the recognition of emotions and attention in humans: (a) the adequacy of well-established techniques such as the International Affective Picture System (IAPS), (b) the adequacy of state-of-the-art biometric research platforms, (c) the extent to which emotional responses may be different in children and adults. Our findings and first attempts to answer some of these research questions are based on a mixed sample of adults and children who took part in the experiment, resulting in a statistical analysis of numerous variables. These are related to both automatically and interactively captured responses of participants to a sample of IAPS pictures. Emotions are the essence of what makes us human. Emotional response can be measured by at least three different systems: affective reports, physiological reactivity, and overt behavioral acts Lang, . One of Prominent position in these studies was taken by the International Affective Picture System (IAPS)  algorithms  Given this context, this paper contributes to the lively debate and criticism surrounding the effectiveness of automated emotion recognition approaches. In particular, it presents the results and interesting findings from a study and experiment that set out to determine how children and adults may respond to emotional stimuli and whether such emotions can be adequately captured and analyzed by state-of-the-art biometric research platforms. The study has the potential to advance our ability to identify children in a hospital environment who are very anxious, scared, or upset.This paper, however, focuses on the observed discrepancies, under specific circumstances, in expected  and observed  emotional responses, which may further help in identifying the root for the emergence of such a criticism against automated emotion recognition approaches, in general, and those based on facial recognition, in particular. Hence, the rest of the paper is structured as follows. The state of the art is reviewed in section 2. Section 3 presents our methodology and experimental setup, where materials are thoroughly explained by giving an overview and then focusing on each piece of the system. Then, the first statistical results are presented in sections 4.1 (adults) and 4.2 (children). Finally, we conclude by also considering the outlook for the future.This section provides a brief overview of the literature on the attempts to classify emotions and of the development of affective computer systems in relation to facial expression recognition and other computer-based systems developed to recognize human emotions.Emotion refers to a shaking of the organism as a response to a particular stimulus , which is generalized and occupies the person as a whole. Usually, it is very brief in duration, which makes it different than Mood. Mood is a feeling that tends to be less intense than emotion and often lacks a contextual stimulus  discrete categories, and (2) emotions grouped on a dimensional basis. In the first category, all humans are believed to have an essential set of basic emotions that are distinguishable by an individual's facial expression and biological processes -based brain-computer interface systems (BCI) are also providing interesting results, and there is promise for use in a number of real-world applications. Huang et al.  showed pAll of the above models of emotions are very important when designing and informing the development of affective systems. Dimensional models have been used by various researchers, mainly because they provide a way of describing a wide range of emotional states that occur in real life. “Basic” emotional models were very influential in early human-computer interaction studies. When all these emotional models are put into a computational framework where programmers and developers map aspects of emotion to aspects of the system, different models have different pros and cons  . The positive subset were selected as positively valenced on the criterion of being equal to or greater than 5 . As we were particularly interested in negative emotions, the images selected were based on emotions that may be experienced in a hospital waiting room, such as fear and sadness. Images of a sexual nature or ones that evoked disgust were not relevant to the current study.Normative ratings are available for the pictures based on a nine-point scale. Mikels et al.  selectedThe affective digital slider is a tool that provides a self-assessment scale for the measurement of human emotions that does not require written instructions. There are two sliders, one measuring arousal, ranging from calm to excited, and one measuring affective valence, ranging from pleasant to unpleasant see . Each slIn addition to providing dimensional data using the digital slider, participants were asked to select from a list the word that best described the predominant emotion that they felt after viewing each picture. The list included the words happy, sad, fear, neutral, and disgust; there was also an option for the participants to select ‘other' and write their own description. For data analysis purposes, these subjective ratings were then coded as negative, neutral, or positive .Galvanic Skin Response (GSR) and facial expressions were measured using the iMotions Biometric Research Platform 6.0, iMotions A/S, Copenhagen, Denmark, 2016. An Application Programming Interface (API) module was used together with the iMotions platform and the Galvanic sensor to monitor and control in real time the connections with the biometric sensors through TCP ports, and the data flow of the experiment, with time, sequence number, and stimulus name and type assigned to variables see . Facial iMotions can detect changes in key face features such as brows, eyes, and lips and analyze the basic emotions of the recorded face. Researchers can choose between two different algorithms to classify emotions from facial expressions in iMotions's platform: the FACET module, based on the FACET algorithm  electrodes placed in reusable snap-on Velcro straps. For each participant, the GSR recorded in microvolts (μV) was segmented into 8-s intervals for each picture, and the mean of each participant's 2-min baseline measure was subtracted from the peak of each segment.Galvanic skin response was measured from the phalanx of the index and middle finger of the nondominant hand using 1 The API module was designed to receive the biometric sensor data, analyse it, and control the delivery of the presented materials. The Unified Modeling Language (UML) interaction overview diagram see  shows hoParticipants were seated comfortably in front of a computer screen. They were advised that their facial expressions in response to each photograph would be recorded via a webcam and recorded with iMotions facial expression analysis software. Participants were recorded individually in a quiet laboratory at the university and were asked to rate a set of 80 photographs selected from IAPS. The order of the photographs was pseudo-random such that each emotive photograph was preceded by a neutral photograph. Each photograph was presented on a computer screen for 8 s. Participants were instructed to maintain their attention on the screen for the whole time that the image was present. Galvanic skin response was recorded from each participant at baseline for 2 min, during which time the participants were asked to relax and close their eyes. GSR was then recorded throughout the study. Standardized instructions were read to each participant based on the Self-Assessment Manikin instructions  were selected from IAPS for the study with children based on those used in a study by McManis et al. , where tThe following section provides details of the treatment of results from both experiments. The participant's valence, arousal, and GSR scores are subjected to Analysis of Variance (ANOVA), whilst participants' subjective ratings and iMotions classification are subjected to analysis using Chi-square.V) are shown in Participants' responses on the digital slider scales for valence and arousal were recorded for each picture, as was GSR response. Mean scores and standard deviations (SD) of participants' ratings  for each of the IAPS negative, neutral, and positive pictures and their GSR response recorded in microvolts  indicate negative valence and low arousal, scores around 5 indicate neutral valence and little or no reported arousal, and higher scores  indicate positive valence and high arousal. The descriptive statistics reported in V) indicate that positive pictures and negative images elicited a greater GSR response than neutral pictures, with positive pictures eliciting the greatest GSR.In terms of arousal, it was expected that both positive and negative images would have a higher mean arousal rating than neutral images. However, the descriptive statistics suggest that negative images elicited a higher mean arousal rating, while the ratings for neutral and positive images were similar. In addition, mean GSR scores  = 39.989, p < 0.01]. Bonferroni-corrected simple effects reveal that, using the digital slider, positive images were rated as significantly more positive than both neutral and negative images  and negative images were rated as significantly more negative than neutral images .In order to establish whether any of these differences were significant, repeated-measures one-way ANOVA was conducted. The within-subjects factor, the type of IAPS image, had three levels: negative, neutral, and positive. There was a significant effect of the type of IAPS image on the valence score . Bonferroni-corrected simple effects reveal that, using the digital slider, negative images were rated as significantly more arousing than positive images  but not significantly more arousing than neutral images , and there was not a significant difference in arousal rating between neutral and positive images .There was a significant effect of the type of IAPS image on the arousal score . Bonferroni simple effects reveal that positive images provoked a significantly higher GSR than neutral or negative images ; there was no significant difference in GSR between neutral and negative images . These findings suggest that, when using the digital sliders, participants generally showed agreement with the IAPS classification of the images in terms of their valence rating and that negative images were more arousing when rated using the digital slider but that positive images elicited the greatest GSR.There was a statistically significant effect of the type of IAPS image on the GSR score . This indicates that the pictures did not evoke reported emotional responses in the children. There was a significant effect of the type of IAPS image on the arousal score . Bonferroni-corrected simple effects (p should be ≤0.0016 to reach significance), however, did not reach significance when comparing negative with neutral images  and positive with neutral images .The within-subjects factor, the type of IAPS image, had three levels, negative, neutral and positive. There was no significant effect of the type of IAPS image on the valence score . Bonferroni-corrected simple effects reveal that positive images had a significantly higher GSR than negative images , but there was no significant difference in GSR between neutral and negative images  or between neutral and positive images; . These findings suggest that, when using the digital sliders, participants did not report either negative or positive responses or higher arousal to negative and positive images, as would be expected. GSR, however, was higher in response to positive images.There was a statistically significant effect of the type of IAPS image on the GSR score [X2 = 0.006, df = 1, p = 1). Participants rated negative pictures as negative in 50% of cases and rated positive pictures as positive in 49.4% of cases  and subjective rating of participants, who selected a word that best described how each picture made them feel (negative or positive). The results show no association between IAPS picture type and subjective ratings . The iMotions software identified negative facial expressions in participants viewing negative images in 71.4% of cases where a negative picture was shown and identified positive facial expressions in participants viewing positive images in 46.7% of cases , who also found that standardized sets of stimuli, such as IAPS, may not be as effective as they once were at evoking emotions, due to our exposure to highly arousing stimuli in the media and general desensitization. In addition, the respective associations of subjective ratings and iMotions classification of facial expressions with picture category suggest that, for adults, subjective rating is better at identifying emotions than biometric software. It is unsurprising that participants show higher reliability than iMotions in classifying positive and negative images, given the importance of facial expression to human communication. In children, subjective ratings and the iMotions identification of expressions were at the level of chance. An additional factor that must be considered is that researchers in both studies noted little change in the facial expression of participants as they observed the IAPS images, once again suggesting that the stimuli may not have sufficiently evoked the emotions of the participants.Other explanations for the difference in findings between children and adults could be due to the IAPS pictures selected and the environment in which the studies took place. Children were shown different and fewer images to ensure that the images were age-appropriate and that the task was not too onerous. The adult experiments took place in a laboratory at the University, whilst the children performed the task in their home environment. In the home environment, conditions such as lighting could not be controlled in the same way as in the laboratory, and this may have led to the biometric platform not detecting all facial movements. One of the difficulties with evoking and categorizing emotions in a laboratory scenario and not only through the use of pictures is establishing how each picture will actually make the individual feel—this will vary between participants. What may evoke fear in one participant may evoke anger, or indeed a mixture of more than one emotion, in another. In future studies, it is important to use more provocative stimuli  to ensure that emotions are sufficiently elicited and a larger sample and to ensure maximal environmental conditions for the use of the biometric platform.While the biometrics facial recognition industry has grown, facial movements and expressions may not always be a reliable indication of how someone is feeling. Studies have shown that humans make assessments about other people's emotions based on factors including body language and tone of voice. As such, many emotion detection algorithms that have been developed in the last two decades are still facing problems with accuracy, complexity, and real-world implementation due to the irregularities in the complexity of models and unpredictability between expression categories. These approaches should thus always be used responsibly, especially when used in crime-detection applications.In this paper, we contributed to the lively debate about and criticism of the effectiveness of automated emotion recognition approaches by attempting to question the following aspects: (a) the adequacy of well-established techniques such as the International Affective Picture System (IAPS), (b) the adequacy of state-of-the-art biometric research platforms, (c) the extent to which emotional responses may be different between children or adults. Our initial statistical analysis and results indicate that although there is, in general, an alignment between expected (IAPS) and observed (iMotions) responses for negative images, there is an interesting discrepancy in the expected and observed responses for positive images. This may be for many reasons ranging from incorrect classification of images in IAPS to incorrect classifications of responses by the biometric research system, iMotions, to significant changes in the emotional responses of the human population. In the future, we plan to dig deeper into the correlations among all of the significant variables by addressing all aspects of the experiment: facial recognition, subjective classification of responses, collection of images (IAPS), and different groups, i.e., adults and children. This multi-dimensional, multi-variate analysis will help shed more light on the real causes of such problems with automated emotion recognition, as well as into the limitations of current state-of-the-art approaches and technologies.The datasets generated for this study are available on request to the corresponding author.This study was approved by the Psychology Ethics Committee at the University of Westminster. The participants provided their written informed consent to participate in this study. For those under the age of 16, written informed parental consent and verbal child consent was obtained. Written informed consent was obtained from the individual(s) AND/OR minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.All authors contributed equally for the experimental analysis and preparation of the manuscript.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.


In this article we aim to briefly describe how Puerto Rico’s living conditions influence adverse health outcomes at an individual, community and population level using the National Institute of Minority Health and Health Disparities (NIMHD) Research Framework that considers multiple factors and their intersecting influence. People living in Puerto Rico face significant levels of poverty, a deficient infrastructure, a fragile healthcare system and the continuing dismantling of the public education system as well as hazardous environmental exposures. The treatment of Puerto Ricans as second-class citizens due to the federal policies of the U.S. government and also the mismanagement of funds from local authorities impacts the prevalence of chronic health conditions and vulnerability to disasters such as hurricanes, earthquakes and pandemics. Puerto Rico’s health disparities are rooted in historical, cultural, political and economic factors that have an impact on biology, interpersonal and environmental aspects. In order to significantly reduce health disparities, systemic change is needed at a local, national and federal level. Interventions must consider how social determinants impact the quality of life and seek to impact the intersections of different contexts that have an effect at an individual, interpersonal, communal and societal level. This can be achieved through evidence-based, culturally appropriate and community based as well as translational research approaches that seek to impact behavior and social economic factors. Puerto Rico is an archipelago composed of Isla Grande, Vieques, Culebra and other smaller islands located in the Caribbean with a population of 3.2 million people . Puerto These living conditions have led to adverse health outcomes that impact individuals and their families as well as the general population. In general, Puerto Rico has several health disparities in relation to several chronic conditions such as diabetes, asthma, cancer, HIV and cardiovascular diseases . When coDuring the mid-20th century, the economic development plan popularly known as Operation Bootstrap helped to transform the local economy from an agrarian society to an industrialized one at an accelerated rate. The plan relied on incentives such as federal tax exemptions and low labor costs to attract U.S. companies to the archipelago . It alsoDuring the last decade there have been significant incremental budget cuts in education, health, culture and environmental protections. Puerto Rico is presently undergoing a socio-economic crisis because of an enormous government debt that has led to the institution of a Fiscal Oversight and Management Board appointed by the Federal Government, which has led to severe austerity measures and emigration . It is wCurrently, 43.1% of the population lives under poverty conditions and in 2017 57.8% of children lived in poverty . In FebrInfrastructure is central to the quality of life, productivity and economic development of individuals and communities. However, Puerto Rico relies on a deficient infrastructure that negatively impacts the daily life of residents and also hinders social and economic development. According to the American Society of Civil Engineers’ 2019 Report Card, the island has an overall grade of D. This is because we lack programmed funding to invest in the comprehensive maintenance of the existing infrastructure as well as exploring modern and more sustainable options . CurrentThere are several structural challenges regarding the how the healthcare system operates and its capacity to address the population’s health needs. In the Puerto Rico Health Care Infrastructure Assessment: Site Visit Report from 2017 four main challenges were identified: (1) the privatization of the public health care system and the rise of managed care, (2) the aging of the Puerto Rican population combined with high rates of poverty and some chronic health conditions, (3) the economic instability and low private sector tax base of the commonwealth and (4) the high cost of living in Puerto Rico, poorly coordinated care, difficulty receiving referrals and long wait times  (p. 3). In addition, according to this Report, which was based on the experts that were interviewed, the current structure of the health care system has made it difficult to have high-quality medical services. Most Puerto Ricans depend on public health insurance such as Medicaid and Medicare; commercial insurance or employer-provided insurance sectors are significantly smaller. The payment rates of Medicaid managed care and Medicare Advantage in Puerto Rico are less than 40% of the average rates for both programs in the U.S. . In the last ten years, 5000 doctors have left Puerto Rico and have gone to work in the United States for economic reasons. The decline in the population of doctors is 36% compared with the decline of the general population, which is 9% . This meAccording to Onieva López , the mai“The inconsistency in implementing the educational plans of the different governments; the existence of an obsolete curriculum that has failed to implement new technological resources in classrooms; that teachers are overloaded, poorly prepared, unmotivated, and poorly resourced; blaming teachers for the ills of the country’s education; school absenteeism; violence in classrooms; poor infrastructure of schools and their poor maintenance; fast schools; and the continuous attack on the public school and its devaluation, while important areas of the educational system are privatized”  Research Framework provides an insight into the multiple intersections that influence health outcomes in minority populations. According to Alvidrez and collaborators , the NIMWe also consider that this framework is related to the concept of Social Determinants of Health, which focuses on how the conditions in which people are born, live, work, learn and age impact their quality of life . This reHealth disparities do not occur in a vacuum, which is why the concept of Social Determinants of Health (SDH) along with the previously mentioned Socio-Ecological Framework provide a holistic and integrative approach where socio-economic policies and also cultural patterns are taken into consideration when studying differential health outcomes in minority populations. In considering how living conditions impact health outcomes, we can infer that adverse experiences have a negative impact on the wellbeing of communities as well as individuals. There is growing evidence that an exposure to adverse living conditions can have a negative impact on childhood development, which can lead to disease later in life . We must-The Jones–Shafroth Act (1917): through this, Puerto Ricans were granted full U.S. citizenship and it established an elected  legislature on the island; however, this did not mean that they could vote in presidential elections or have voting representatives in Congress. The case Balzac v. Porto Rico (1922) established: “the granting of citizenship to Puerto Ricans did not mean that Congress had expressed an intention of eventually incorporating Puerto Rico as a state...the Act merely allowed the residents of Puerto Rico free entry into the United States, where they could exercise full rights at citizens.” Balzac v. Porto Rico firmly cemented Puerto Ricans’ status as second-class citizens and served to keep the political status of the island in limbo indefinitely by assuring that no promises regarding statehood and equality were made  (p. 3).-“basic shipments of goods from the island to the US mainland, and vice versa, must be conducted via expensive protected ships rather than exposing them to global competition. That makes everything Puerto Ricans buy unnecessarily expensive relative to goods purchased on either the US mainland or other Caribbean islands, and drives up the cost of living on the island overall .” This increase in prices, along with a minimum wage of USD 7.25 and an increase in part time jobs without marginal benefits, had an impact in access to health services and medications, nutritious food, secure housing and educational opportunities.The Jones Act : this legislation was related to protecting U.S. interests in relation to national shipping and interstate commerce. After World War II, it established cabotage regulations that required that only U.S. ships could transport materials and supplies from one domestic port to another . This me-The Puerto Rico Oversight, Management, and Economic Stability Act : this law was created to supervise the government efforts to manage the payment of bonds related to the accumulated debt. This legislation has contributed to refute the discourse that Puerto Rico is a self-governing territory . The HarHere are a few federal policies that have impacted the quality of life for Puerto Ricans:Another legal aspect that impacts the quality of life of Puerto Ricans is federal transfer payments. These are divided into two categories, earned benefits such as Medicaid, Social Security and veterans’ pensions and direct aid such as nutritional assistance and grants . In 2019Puerto Ricans are being treated as second-class citizens due to the unequal treatment of the U.S. government through federal regulations, which are implemented arbitrarily without any consultation or participation from Puerto Ricans. These federal regulations influence the living conditions of Puerto Ricans at individual, interpersonal, community and societal levels see . This haThe NIMHD Research Framework see  serves tPuerto Rico’s health disparities are rooted in historical, cultural, political and economic factors that have an impact on biology, interpersonal and environmental aspects. The NIMHD Research Framework helps illustrate the complex relationship between the environment and the individual and how health disparities may originate. This analytical instrument can serve to visualize the multitude of factors that impact on the health outcomes of populations living in poverty. With almost half the population living in poverty, significant budgets cuts in education and healthcare, a deficient infrastructure, an economic crisis and a very limited political autonomy, Puerto Rico is very vulnerable to significant health disparities with regard to chronic health conditions and disasters such as hurricanes, earthquakes and pandemics. Being resilient is not enough to significantly reduce these health disparities and a systemic change at a local and federal level is needed. In order to mitigate health disparities and adverse health outcomes, we must implement evidence-based strategies, multilevel interventions, participate in public policy development and implementation and promote community engagement in translational research processes.