Breast cancer diagnosis and treatment represent stressful events that demand emotional adjustment, thus recruiting coping strategies and defense mechanisms. As parental relations were shown to influence emotion regulation patterns and adaptive processes in adulthood, the present study investigated whether they are specifically associated to coping and defense mechanisms in patients with breast cancer.One hundred and ten women hospitalized for breast cancer surgery were administered questionnaires assessing coping with cancer, defense mechanisms, and memories of parental bonding in childhood.High levels of paternal overprotection were associated with less mature defenses, withdrawal and fantasy and less adaptive coping mechanisms, such as hopelessness/helplessness. Low levels of paternal care were associated with a greater use of repression. No association was found between maternal care, overprotection, coping and defense mechanisms. Immature defenses correlated positively with less adaptive coping styles, while mature defenses were positively associated to a fighting spirit and to fatalism, and inversely related to less adaptive coping styles.These data suggest that paternal relations in childhood are associated with emotional, cognitive, and behavioral regulation in adjusting to cancer immediately after surgery. Early experiences of bonding may constitute a relevant index for adaptation to cancer, indicating which patients are at risk and should be considered for psychological interventions. Breast cancer is not only a cellular disease but also an event which requires adjustments in life-styles, body-image, and in family, couple and social dynamics , 2. WomeAdjustment to the disease, adherence to therapy, and interactions with healthcare professionals do not only depend on the characteristics of the disease but are associated to individual aspects of the patients . Coping When facing the diagnosis of breast cancer, women employ more or less adaptive coping strategies which depend both on the dispositional traits as well as on situational traits such as the phase of the disease. Dysfunctional coping mechanisms are related to less adaptive illness behaviors and psychological distress in cancer patients , 8. For The use of defense mechanisms may be triggered in the attempt to protect the individual from feelings or needs which could expose the individual to excessive affective activation , 11. In However, since coping and defense mechanisms to cancer can be evaluated only at the time of their enactment, it is important to consider factors that may contribute to emotional, cognitive, and behavioral programming and regulation, and may thus provide information on the ability of the individual to adjust to stressful situations. In fact, coping and defense mechanisms are not only related to the characteristics of the event itself, but also depend on patterns acquired through relevant affective relationships, which modulate the subjective perception of an event as stressful and the development of adaptive processes.According to the adult attachment theory, the possibility to receive care and protection when in need during childhood, while allowing for a safe exploration of the environment in other moments  is a preChildren who experienced adequate parental relations are more likely to acquire the ability to master negative emotions independently , 18, andImportantly, early parental relations (including attachment patterns) can influence interactions with healthcare professionals in breast cancer patients –29, thusIn the present exploratory study, we assessed coping styles, defense mechanisms and recollected parental caregiving style in women at their first breast cancer diagnosis in the early post-operative phase (1–7 days after quadrantectomy or mastectomy as a first therapeutic approach). It was hypothesized that the quality of parental relations as recollected would be associated with the adaptiveness of coping strategies and defenses in this phase. To our knowledge, this is the first study investigating the association between the recollection of early parental caregiving and adjustment processes following breast cancer surgery.N = 90) or mastectomy (N = 20) as a first therapeutic approach.Inpatients were recruited between September 2011 and June 2012 during hospitalization in the Breast Cancer Unit of the European Institute on Oncology in Milan, Italy. All women were diagnosed with primary breast cancer and had not received the histopathological results at the time of assessment. Inclusion criteria were: first diagnosis of breast cancer, absence of major psychiatric diseases or severe neurological events that could interfere with test completion. Exclusion criteria were: neo-adjuvant therapy. A total of one hundred fifty-four women were approached. Five women refused to participate due to lack of time, fatigue, or post-surgical pain. Fourty-three women agreed to participate and gave their informed consent but had incomplete assessments or did not return the questionnaires. A total of 110 women participated in the study after written informed consent was obtained  and had complete assessesments. Patients underwent quadrantectomy . The study was approved by the IEO Institutional Review Board.The authors confirm that all procedures contributing to this work comply with the ethical standards of the relevant National and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.Demographic data, clinical data and life-style variables were recorded in a case record form. The characteristics of the sample are shown in Table The Italian version of the PBI was used to evaluate the quality of primary relations as recollected in adulthood . The insThe PBI does not directly measure the state of mind with respect to attachment relations. In fact, being a self-report instrument, it represents the perceived or remembered style of parental caregiving rather than the actual quality of attachment. The PBI showed convergent validity with the Adult Attachment Interview for optimal relations and secure attachment . In thiselplessness/Hopelessness category represents high levels of anxiety and depression, absence of cognitive strategies that may allow acceptance of the diagnosis, use of unaimed behavioral responses. Anxious preoccupation is defined by constant worry about the disease, and feelings of anxiety, fear and apprehension. Fighting spirit is characterized by moderate levels of anxiety and depression, use of confrontation (positive thinking), palliative (reducing the impact of the diagnosis), and behavioral responses. Avoidance reflects the absence of anxiety and depression, and the predominant use of cognitive strategies. Fatalism/Stoic acceptance is characterized by low levels of anxiety and depression, loss of internal control, and fatalistic attitudes. Items assigned to each coping styles are summed to obtain a total score representing the degree of use of each coping style.The Italian version of the Mini-MAC  is a 29 The Italian version of the REM-71  is a selA clinical psychologist approached patients on day 1 or 2 after surgery in the ward. After careful explanation of the study procedures and informed consent procedures, an appointment was scheduled. In the majority of cases, tests were completed during hospitalization. When this was not possible, the appointment was scheduled on the same day of surgical follow-up (within a week from discharge).Descriptive statistics (median and interquartile ranges - IQR) and frequencies were used to describe patients’ socio-demographic features and relevant clinical variables.P-values for the correlation between coping and defenses are presented.Spearman correlations coefficient and Cronbach’s Coefficient Alphas of subscales of the REM-71 were recalculated for the present study.Care and Overprotection dimensions of parental relations were categorized in ‘high’ and ‘low’ considering the cut-off scores of care and overprotection from Parker and collaborators . AssociaP-values from multivariate ANCOVA models, indicating Defense Mechanisms and Coping Styles associated with Care and Overprotection, adjusted for significant confounding factors and other cancer prognostic factors, are presented.Residuals from full model were checked to verify normal distribution.Two-sided P-values were used in the analyses. The criterion for statistical significance was set at 5%. Data were analyzed using the SAS System Software for Windows, release 9.2. .Table Median scores and IQR ranges for parental relations, coping styles and defense mechanisms are shown in Table Median values of Factor 2 (mature) defenses were higher than Factor 1 . Altruism was the most used defense in the sample , followed by idealization , splitting  and withdrawal .ρs = 0.21, p = 0.027; ρs = 0.33, p < 0.001 respectively). Factor2 scores were inversely correlated to the use of helplessness/hopelessness and anxious-preoccupation coping styles , while they were positively correlated to fatalism and fighting spirit . The pattern was maintained when considering only patients who underwent quadrantectomy.In order to explore the relation between defenses and coping strategies, a correlation analysis using Spearman’s coefficient was run . These patients also exhibited higher levels of helplessness/hopelessness coping strategies on the Mini-MAC measure. No significant association was found for other coping strategies. On the contrary, those women who reported high levels of care in the attachment relation with the father also had lower scores on the repression scale (included in Factor1 defenses). No significant association was found for the reported attachment relation with the mother.The results of the present study indicate that recollected characteristics of the relationship with the paternal figure are significantly associated with defense mechanisms and coping strategies. Furthermore, these adaptative mechanisms are related to each other, shortly after the diagnosis of breast cancer, i.e. in the surgical phase of treatment. In particular, elevated overprotection is associated to the reported use of immature defenses and helplessness/hopelessness coping with cancer, while low care was associated to a higher incidence of repressive defenses.These data provide support to the hypothesis that early parental relationships may be related to psychological adjustment in breast cancer. Coherently, insecure attachment  was related to a less flexible use of coping strategies in a group of patients with chronic disease, including a sample of women with breast cancer . PatientDespite research  reportiThe present data pointed to the role of the paternal relationship as an important predictor of adaptive adjustment processes. These evidences are in accordance with experimental, clinical and epidemiological studies that provide evidence of phenotypic and epigenetic effects mediated via the paternal line , 44. It The present study’s results are in line with such evidence, showing that a recollected greater paternal control is associated with the use of a helplessness/hopelessness strategy, which is characterized by a pessimistic and passive attitude . This coThe data of the present study also indicate that high levels of control and low levels of care experienced with fathers led to a greater control on emotional reactions in adulthood, thus recruiting more rigid and controlling defensive styles. In fact, the defenses found associated to paternal styles are characterized by a component of negation and avoidance of reality that, in the case of breast cancer patients, may exclude the cognitive and emotional impact of the disease. In particular, low levels of paternal care were associated with the use of repression as a defense mechanism. In this case, disturbing thoughts, wishes or experiences are expelled from conscious awareness. On the other hand, high levels of overprotection were linked to withdrawal and fantasy as defenses. The former reflects a state of apathy, characterized by emotional indifference, and a reduction of social contacts and activities that leave individuals passive to events and with respect to caregivers. Fantasy refers to daydreaming as a substitute for human relationships, effective actions, or problem solving. Daydreaming and engagement in self-comforting fantasies was previously found to be associated with a negative prognosis in breast cancer patients .High paternal overprotection and insecure attachment are related to the development of psychological disorders such as depression –53. ImmaDefense mechanisms and coping strategies are linked , 56, andIt may be hypothesized that the type of surgery, and in particular its impact on the body image , could play a role in the perceived stressfulness of the event and thus on the type of adaptive processes activated. This factor was not found to be significant in the analysis of confounds, nevertheless the results were corrected for type of surgery since it is possible that the reduced number of patients who underwent mastectomy was not sufficient to guarantee adequate statistical power.From a clinical perspective, our results suggest that recollected significant relationships play a role in the modulation of adult responses to stressful events. In fact, insecure parental relations in childhood are often linked to dysregulation of emotions, and to a reduced ability to express needs and to mobilize internal resources in adulthood. Importantly, these aspects may be reflected in the interactions and levels of cooperation with clinical staff in a potentially stressful situation such as breast cancer treatment , 28, in The limits of the present study lay in its observational nature and in the relatively small sample, which does not allow to draw definitive conclusions on the direction of the associations that were found. For instance, rigid defensive styles and the enactment of dysfunctional coping styles may have influenced the reports of caregiving styles as well as non-optimal parenting may lead to the use of immature defenses and anxious or helpless/hopeless coping styles. This is also connected to the use of self-report measures that, in this case, were chosen for their lower intrusiveness and their easier implementation in the schedules and practices of the hospital setting. Starting from these result, future studies may use a different study design and benefit from the use of different scales that do not implicate self-report, such as the Adult Attachment Interview . Yet, thThe association found between coping styles, defense mechanisms and early parental relations suggests that the evaluation of relational history in the psycho-oncological context may provide an additional prognostic index of adjustment abilities, thus indicating which individuals are at risk and may need support after diagnosis.Previous studies demonstrated that psychological treatment for cancer patients determines an increase of active coping , and decIn this view, psycho-oncological assessments should not overlook the investigation of developmental history, and in particular relations with caregivers, to implement personalized care reflecting the single patients’ characteristics and needs. These evidences support the development of personalized medicine approach , 61 that


Gestural interaction systems are increasingly being used, mainly in games, expanding the idea of entertainment and providing experiences with the purpose of promoting better physical and/or mental health. Therefore, it is necessary to establish mechanisms for evaluating the usability of these interfaces, which make gestures the basis of interaction, to achieve a balance between functionality and ease of use.This study aims to present the results of a systematic review focused on usability evaluation methods for gesture-based games, considering devices with motion-sensing capability. We considered the usability methods used, the common interface issues, and the strategies adopted to build good gesture-based games.The research was centered on four electronic databases: IEEE, Association for Computing Machinery (ACM), Springer, and Science Direct from September 4 to 21, 2015. Within 1427 studies evaluated, 10 matched the eligibility criteria. As a requirement, we considered studies about gesture-based games, Kinect and/or Wii as devices, and the use of a usability method to evaluate the user interface.In the 10 studies found, there was no standardization in the methods because they considered diverse analysis variables. Heterogeneously, authors used different instruments to evaluate gesture-based interfaces and no default approach was proposed. Questionnaires were the most used instruments , followed by interviews , and observation and video recording . Moreover, 60% (6/10) of the studies used gesture-based serious games to evaluate the performance of elderly participants in rehabilitation tasks. This highlights the need for creating an evaluation protocol for older adults to provide a user-friendly interface according to the user’s age and limitations.Through this study, we conclude this field is in need of a usability evaluation method for serious games, especially games for older adults, and that the definition of a methodology and a test protocol may offer the user more comfort, welfare, and confidence. Interactive systems can only be considered useful and practical if they have good usability. According to Karray et al , usabiliResearchers in the area of human-computer interaction have been developing several usability evaluation methods in order to determine whether a system or interactive device is usable or not. According to Cockton , usabiliThe constant development of usability evaluation mechanisms occurs due to the high supply of interactive systems on the market, constantly bringing to the user new ways of interacting. Gestural interactions are among the styles that have evolved in more recent years and used in largely in entertainment applications, such as virtual reality environments and games.According to Morelli and Folmer , gestureGiven the market demand for systems with gestural interaction, it is necessary to establish procedures to evaluate the usability of these interfaces in order to minimize interaction problems. In this perspective, Keskinen et al  proposedDifferent tools are being used now to assist the usability evaluation process: some present qualitative results and others quantitative, some focus on perception or acceptance, some consider physiological measures, and so on. The big gap is the lack of a validated approach that makes it possible to ensure consistent assessment results and increase its credibility. Still, usability patterns could be defined from this approach along time to use as benchmarks in evaluations.In this sense, the aim of this study is to present a systematic review about the usability evaluation methods applied to games with gestural interaction, considering devices with motion-sensing capability. To reach this goal, specific objectives have been set: (1) identify and analyze techniques applied to usability analysis of games interfaces for gesture-based devices, (2) identify common problems found in gesture-based games interfaces, and (3) relate strategies and technologies that have been used to solve user interface problems in gesture-based games.This study is a systematic review, explicit and rigorous research that identifies, critically evaluates, and synthesizes relevant studies about a specific subject .The eligibility criteria to identify studies in the primary phase included were (1) games for gestural interaction devices, (2) Kinect and/or Wii as the gestural interaction device, and (3) description of a usability evaluation technique for analysis of user interfaces.The research was concentrated into four electronic databases: IEEE Xplore Digital Library, Association for Computing Machinery (ACM), Springer International Publisher Science, and Science Direct. This work collected studies published in English between September 4 and 21, 2015, not limited by date, and using the following expression: games AND usability AND evaluation AND (“Kinect” OR “Wii”).Each study will be presented considering the following items:1. Evaluation aim: approach and focus of each study;2. Gesture-based devices used: equipment used during the experiments;3. Evaluator’s profile: professionals and researchers team;4. Profile and number of participants: characterize the sample;5. Evaluation method and its application steps: the author’s methodology and how it was applied;6. User’s tasks: experiment tasks;7. Type of interface (2D or 3D) and software used: the applications used during the experiments;8. Time required for the user experience and evaluation: the period for each user evaluation; and9. Results: the analysis and conclusions of the authors of each study.Komlódi et al  aimed toResearchers from the University of Maryland in the United States and the Budapest University of Technology and Economics in Hungary conducted the evaluation. A group of 14 Hungarian undergraduate students (seven men and seven women) participated in the evaluation; the mean age of participants was 24 years. Half of these users had some experience with computer game simulators. Four had used the Wiimote previously, but none had significant experience.Although this study was not a game, it was included because, in the demographic questionnaire, the authors considered the user’s previous game experience important. According to Bowman et al , this haDuring the pilot test, three participants performed the tasks in a virtual environment and answered questionnaires. The procedure had several changes throughout the testing period: extension of the training period, review of tasks, and changes in the interview questions.The study combined qualitative and quantitative methods to explore the utility of interaction methods in a 3D environment. After a brief training session, 14 participants executed two immersive tasks in three pilot tests. A video camera recorded the entire process and the researchers interviewed participants about their experience immediately after the interaction.After the orientation and training session, participants read instructions for tasks on a poster. This poster displayed the following guidance: (1) walk around the room, find the dominoes, stack the dominoes one on top of another, and dismantle them; and (2) use the KUKA robot to move the gray black balls on the table and, when finished, tell the session coordinator.Participants answered a questionnaire containing 19 questions about their experience using the game. Some questions were issues, such as ease of interaction, first impressions, reactions during use, satisfaction when using, and suggestions for future game improvements. Only two questions used a scale of 0 to 100; the others were dissertated.In addition to this questionnaire, participants were also requested to complete a sociodemographic questionnaire and the Myers-Briggs Type Indicator (MBTI) personality type questionnaire. This questionnaire identifies users’ characteristics of extroversion/introversion, sensing/intuition, thinking/feeling, and judgment/perception. Participants also performed the VZ-2 paper folding test to measure cognitive ability of spatial visualization, which can influence the user’s ability to navigate in 3D space and manipulate objects in space, and the Reading the Mind in the Eyes Test.For effective usability studies, the authors found the need for more training time and practice with games as well as several sessions of interaction involving experts and novices with games and devices. In addition, reducing the memory load for users by including tasks and feedback functions, as well as help in the environment also improves the game usability.Legouverneur et al  aimed toBroca Hospital professionals from Paris, France, conducted the evaluation with two groups of users recruited from a health care center. The first group consisted of elderly people with mild-to-moderate Alzheimer disease as the diagnostic criteria. The second group consisted of elderly people with mild cognitive impairment. A third group consisted of healthy elderly individuals. All users were aged between 75 and 90 years.The test protocol included an introductory session and four test sessions, with mean duration of 1 hour per week. The introductory session included a neuropsychological evaluation. During this session, participants also created their own avatar as a way to learn to use the Wiimote. In the test sessions, the participants interacted with two bowling games and two tennis games alternately. Each test session had two cameras to record the game screen and the player simultaneously.The use of the Wiimote was to mimic the actions of swinging a racket (tennis) or rolling a ball down an alley (bowling). According to the authors, the movement performed by each user was analyzed considering the approach of games .In addition to the game console and cameras, other equipment involved in the experiment was a 46-inch plasma TV and behavioral analysis software. In order to collect performance and behavior data, the authors used the video recordings. A questionnaire using a five-point Likert scale evaluated user preferences. The authors used the questionnaire at the end of the first test session and after session 4 to evaluate whether familiarity with the games influenced user preferences.The results showed that all participants, regardless of their cognitive status, could use the wireless controller and learn to play both games. A positive experiment result, according to the authors, was the improvement of skills with games throughout the sessions on performance measures observed for most participants. The study also confirmed the importance of usability testing with end users before introducing traditional technology to older adults who have cognitive dysfunction. Multiple sessions allowed users with cognitive impairment to be comfortable with technological devices in order to learn how to use them and have a positive experience with them. This experience also confirmed the role of motivation and a socially supportive environment on how a person learns to use new technologies.In the Francese et al study , the aimWith the Wiimote, the gestures were inspired by the motorcycle metaphor: roll/rotation of the Wiimote acts as a motorcycle throttle command connected to navigation forward and backward movements; the turning gestures resemble the turning handlebar of an imaginary motorcycle. With the Nunchuk, the airplane cloche metaphor was used to control altitude: its tilting direction determined the vertical variations of the navigation.Using Kinect, the bird (or airplane) metaphor was used, with natural gestures associated to the various commands. The idea was to mimic the bird’s wing movements, when possible, with arm gestures. For example, the user would move their aligned arms downward to the left as the bird or airplane did onscreen. A virtual paper plane was presented to the user to give a feedback about their movement.The evaluation process involved 24 volunteers (16 men and 8 women), who were staff and students from the University of Salerno in Salerno, Italy. Ages ranged between 18 and 41 years, with a mean of 24 years.Before beginning the experiment, the skills of participants in the games were evaluated. Eight participants mentioned they played at least once a week, three played Wii, and only two played Xbox and Kinect. Each participant answered 12 questions, using a seven-point Likert scale, and three factors were evaluated: involvement, distraction, and control. The study was performed in a research laboratory of the University of Salerno.For the experiment, participants were quickly introduced to gestural interfaces and performed two navigation tasks. After being instructed on how to use both games, Wing and King, users were asked to navigate in two geographical routes involving well-known Italian cities: MAR  and TERRENO (Genoa-Rome-Venice).Both tasks were compatible in terms of distance and difficulty in locating the destination cities. In order to avoid bias in evaluation tasks, the approach defined two user groups in which each member of the same group started the experiment with the same system. After each task, all participants filled-in After-Scenario Questionnaires (ASQ) to evaluate the time spent, the ease of completion, and the adequacy of support information.Authors used the Computer System Usability Questionnaire (CSUQ), consisting of 19 questions, to evaluate user satisfaction with the 3D maps game for four factors: general evaluation, system utility, information quality, and interface quality. According to the authors, evaluation results conducted through questionnaires confirmed that, if the interface is more natural, the user will be as satisfied and engaged in the navigation experience.Norouzi-Gheidari et al  developeThe games’ activities used arm movements  and torso control in the sitting position. For this evaluation, the active range of motion of the arm was only considered within the context of reaching for each patient to determine target placement for the activities.For the experiment, the patients were divided into four groups of six patients based on level of motor ability. Each patient participated in three 20-minute game sessions of over 10 days. During each session, patients should sit in a chair in front of the Kinect camera at a fixed distance of 1.5 meters as per device specifications. The calibration at this distance was important because the active range of arm movement within the game’s reach space determined the target position for the activities.The patient interacted with all five games at least once during the 20-minute session. The doctor defined the level of difficulty of each activity , which could be adjusted during the session.After interacting with each game, the patient had access to a score of correct answers (according to their level of performance) as a way to encourage him/her to continue. At the end of each session, the doctor had access to a global performance report. In the final session, doctors and patients should complete a questionnaire based on the Technology Acceptance Model (TAM) of medical information to assess their opinions about the game system. Additionally, the Fugl-Meier Assessment of sensorimotor recovery after stroke test evaluated the upper limbs. For each patient, session, and activity, they measured the success rate, the performance in tests of success (medium speed and precision), and highest difficulty level reached within the session.However, this article showed only preliminary results, specifically compiling and identifying the advantages and limitations perceived by clinicians and patients with stroke in rehab games. Success rates, performance scores, and difficulty levels have not been studied yet.Liu et al  evaluateThe authors randomly chose six volunteers in a park (two men and four women), who were aged between 50 and 88 years.The players were able to move one of their hands to select any button options to configure the game. During the interaction process, hands were used freely to select the game objects.The evaluation experiment consisted of three stages: a brief introduction to the game, testing activity (use the game), and a follow-up interview to collect their comments. First, the evaluator presented the game and the user could ask questions. After that, the user played the game prototype for 1 minute then answered a list of open questions and provided any suggestions for the game design. The activities performed by the users when using the game consisted of indoor exercises, like jump, hit, and grab onto it.As for results, the authors emphasized some issues. First, the video game presents less danger to the player. Second, it offers more entertainment and, therefore, motivation. The mechanism of obtaining points and prizes by exercising helped the players to increase the amount of exercise unconsciously. The event of winning served as a strong motivator, while also helping to maintain long-term exercise habits for the elderly. Third, through the online gaming platform, players could still have fun together with their friends as if being together somewhere. All current devices work individually and keep the elderly away from their companions, which could have a negative impact on their social life. However, online platforms offer access to players to share their scores and comments with their friends. This not only increased the game’s entertainment, but also added competition among friends, helping with motivation and having a positive effect during the exercises. Although all users showed interest in the game and provided a good evaluation, the evaluation questionnaires showed some directions to consider improving the game. The game should have different difficulty levels and diverse tasks. Game messages should provide clearer instructions and not just information. In addition, it must provide kinds of exercises that can help exercise different body parts, yet must be simple for easy learning and understanding by the elderly.Shin et al  aimed toThe authors evaluated patients’ routine tasks individually and focal group studies were performed once a week for approximately 6 months. The software categorized user feedback during the development process.Regarding gestures and motions, the interventions aimed to stimulate patients through tasks using arm and trunk movements. The motions were intended to promote incremental improvement in range of motion and endurance, strength, and deviation from synergistic motion patterns. RehabMaster provided games to train the patient’s forearm movement and eye-hand coordination; upper extremity control, endurance, speed, accuracy, and range of motion; and to increase the control, speed, and accuracy of extremity control and trunk movements.The same users also participated in the usability study later on. The objective was to evaluate RehabMaster from the perspective of each group. Meetings held with stroke patients took 20 minutes at regular intervals, twice a week for two weeks, under supervision of occupational therapists and physiatrists. Each of the three groups answered a different questionnaire using a five-point Likert scale, so the authors could collect diverse viewpoints. The Fugl-Meyer Assessment and the modified Barthel Index also were used during the evaluation.Patient involvement was a key point of the RehabMaster intervention. With the stroke patients, the authors wanted to evaluate RehabMaster’s ability to provide strong motivation, pleasure, and an optimal flow experience. With the secondary user group , they wanted to assess the usability of RehabMaster for improving upper limb function and the ability to provide adequate challenge levels for all different patients in the stroke group.To diagnose if the game provided stroke patients with a desirable rehabilitation level, the study considered three factors in their game experience: attention maintenance, ability, and motivation. These factors were identified through six questions asked of participants. Generally, it found that participants had serious attention and a pleasant experience (immersion), even considering the users’ motor limitations.Tests showed the viability of using RehabMaster in stroke patients with different levels of severity within a safe virtual environment. However, their results were inconsistent due to the different experimental protocols using different intervention times in both experiments.The authors emphasized the need for a new study. One reason was because cognitive function, motivation, and depression, which are common in stroke patients, were not considered. Another factor was that the usability evaluation did not compare the perspectives of each group.Fang et al  developeThe EFS recognizes body gestures and body motions using Kinect. Gestures were used to select the menu (hand movements), whereas body motions were required as part of the exercises available on the game system. Because the goal was to improve senior’s balance performance, the focus of the exercises was on lower body strength. Tasks developed consisted of specific exercises for balance training and strengthening of the lower limbs. Six exercises designed for improving balance explored knee marching, side hip raise, lunges, partial squats, wide squats, and standing knee flexion.Thirteen participants were involved in the study (2 men and 11 women) aged between 60 and 80 years. The study used six exercises, specifically designed by experts to increase lower body strength in older adults, and integrated the elderly in games. Before the test, users were asked to complete a Physical Activity Enjoyment Scale (PAES) questionnaire to evaluate if they were physically capable of performing the test. After the exercises, participants answered a second questionnaire  that measured the degree of pleasure performing the activity .This study showed that elderly participants approved the exercises based on games, culminating in a positive experience with the EFS. They provided feedback on improving the system design, on the appropriateness of the six exercises, system operation, game design, and demonstrated intention of using the game. It also verified the system should include a navigation requiring less learning, corrective feedback, and warnings while idle.Harrington et al  stated tThe proposed activities were two games that encouraged physical activity: “Body and Brain Connection” and “Your Shape Fitness Evolved.” Both games used body motion, providing different activities as participants used their hands or feet to select objects, used their arms in balance challenges, and did torso exercises. Hand gestures were used to select a particular activity in each game, without any restriction.The evaluation was developed as follows: before participating, each participant completed a health questionnaire, a demographic questionnaire, a technology experience survey, and a game experience questionnaire. Health and demographic questionnaires evaluated the health of the participants and collected basic information, including age, sex, race, education, and limitations . The technology experience questionnaire evaluated the use and familiarity of participants with various technologies. The game experience questionnaire  evaluateAdditional questionnaires were filled out after each individual session to evaluate user satisfaction and performance. A questionnaire with five items measured satisfaction with the motion controls and gestures for navigation. A seven-item questionnaire assessed satisfaction with the activity developed in the program. Both questionnaires used a scale ranging from 1 (strongly disagree) to 7 (strongly agree). The game experience questionnaire was adapted from Boot et al ; informaAfter completing the questionnaires, participants interacted with the Kinect device, including training and definition of the participant’s starting position. Test sessions began with researchers giving details of what would be required from the participant. Researchers informed the participants that they could stop the test at any time if they felt they could not complete an activity. After that, an interview assessed participant behaviors and opinions about the programs and the experience. During the interviews, the participants described what they liked and disliked about each program and their line of thought. In addition, participants also answered if they used some kind of help or additional instruction throughout the program. The purpose of these interviews was to determine what made participants feel more frustrated and what types of assistance would be most beneficial.After completing both exergame programs, each participant completed three questionnaires. The first questionnaire evaluated usability and included the following propositions measured on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree): clear and understandable system interaction, useful system for daily life, daily use of game to make one more physically active, and it improves well-being. The second questionnaire assessed the ease of use including the following items measured on the same Likert scale: easy to use, flexibility to interact, increase of skill, clear tasks, and learn to use. The first and second questionnaires were adapted from Davis et al . The thiThe study showed that older people realize the benefits of exergames, believing it to be a useful means to exercise. Regarding ease of use, the responses were diverse. Most participants in the 60 to 69 year group agreed that the interface was friendly, whereas most in the 70 to 79 year group disagreed with ease of use.Nakai et al  conducteIn this game, the user controls a virtual glider using body motions and rotations, such as front-back movements to change speed and pitch axis, left-right movements to change direction and roll axis, and torso rotations to control yaw axis. A Kinect device was used to capture the movements of users.This approach divided the evaluation into five steps as follows: questionnaire, behavioral observation, speech watching, game testing, and analysis. First, the authors developed a gaming environment, which was tested preliminarily by three participants. There were two game preparation sessions. Then, a pretest questionnaire collected basic information about the topics. After the observations, they used a posttest questionnaire to collect participants’ impressions.During these observations, speech and behavioral data from participants were collected based on the think-aloud method. In this method, players are invited to express aloud what they are thinking, doing, and feeling. Therefore, the researcher must take care to explain the experiment purpose to participants, making it clear that is not to test the player’s playing skills, but the product itself. It is important to clarify the aim so that users know what is being analyzed so the quality of the experiment is guaranteed. Users performed the task and reported their feelings about the product whenever they failed to complete any of the tasks. In addition, users reported their impressions and thoughts; the analysis of these data depended on the task observation, recorded in a time sequence.The results demonstrated that the first four levels had good playability and the necessity for players to receive the largest possible amount of information about the game. Motivation was the key point in the game because while they were motivated the game flow looked promising: the game attracted the players’ attention and players showed eagerness to learn new things.Sheu et al  aimed toThe exercises used gestures for selections .Seven users participated in the experiment (four men and three women), who were aged between 60 and 77 years. The selection criteria for the participants were not detailed. The test had three stages: (1) pretest questionnaires and basic living information for user selection; (2) procedure introduction (game), signing the consent form, and using game for the test procedures (tasks); and (3) posttest questionnaires and interview. Tasks performed consisted of selecting operations in the program interface.Users were able to complete all tasks. On average, users performed the tasks more quickly on the EG II interface, suggesting that EG II was more usable than EG I. Furthermore, the subjective score for EG II was higher than for EG I. For task selection, it was suggested that, in terms of effectiveness and efficiency, vertical selection works better than horizontal selection because moving the right arm to the right to move the cursor to the right and the left arm to the left to move the cursor to the left can be exhausting. If this movement is vertically oriented, the system interaction becomes less tiring.To compile the results from all studies, Of the 10 selected studies, seven used the Kinect device for interaction, two used the Wii device, and one used both devices. From this observation, it is possible to propose a study about the reason for this difference because the interaction device may interfere positively or negatively in a usability evaluation. This research could evaluate, for example, if there is really a usability difference between both devices or if the increased use of Kinect is due to its popularity and its complete controller-free gaming experience.In relation to usability evaluation, nine studies used games in their experiments. Of these, six studies were directed toward the elderly (60%), showing that there are several efforts in serious games for this population. Thus, it is evident there is a need for creating a usability evaluation protocol for serious games for seniors, capable of generating qualitative and quantitative results, because there were no standard serious game evaluation testing protocols found in this research. This trend is supported by the requirements needed to adapt the interface according to age including, for example, the sensitivity of effort and having enough time to do the tasks. In addition, there can be evaluated potential differences in serious game evaluations of 2D or 3D gaming interfaces for the elderly.Of the nine studies that used games to assess usability, eight studies (89%) used games developed by researchers and only one  used a cAccording to Harrington et al , inside On the other hand, the study from Legouverneur et al  showed tNakai et al  determinMost of the studies identified motivation as a major incentive for the elderly to use games to practice physical activities. Zhao et al  confirmeConcerning evaluations, questionnaires were the most used instruments , followed by interviews  and observation and video recording . There was also use of think-aloud methods and the Folding Test, but both were applied only in one study.All studies that used questionnaires were evaluating the interface exclusively. Only two studies used sociodemographic questionnaires ,18. All No author proposed new approaches for evaluation methods. Some authors suggested and used some instruments, such as the CSUQ questionnaire, MBTI questionnaire, Folding Tests, Eyes Test, Fugl-Meyer Assessment, PAES, the think-aloud method, and modified questionnaires from Boot et al  and BrooRegarding usability evaluation methods of this review, we observed a variety of techniques applied by authors in different approaches, with low adherence between selected studies. This heterogeneity shows that researchers are concerned with particularities of their samples and their experiments, avoiding biases. This situation also shows a lack of standardization, at least partially, of a protocol or tools for evaluating games based on gestures and/or movements. This makes the choice of best methods or techniques difficult for a unified approach in future work.The benefits of this diversity are a good number of approaches that used evaluation instruments are well established in the literature. A group of authors, for instance, applied tools to evaluate cognitive, emotional, and motor skills in experiments. Another group applied methods and techniques to evaluate user satisfaction, user perception, and user performance.It is important to keep it in mind during the creation of a standardization process to evaluate usability because there are consolidated techniques and scales for measuring gains according to the specificity of each approach. For example, comparison of games for people with upper limb impairment can use the Fugl-Meyer test as part of the evaluation process. In a rehabilitation context, it can support decisions and appropriately choose and validate a game according to the user’s profile.Considering the evaluation instruments used by selected studies, it is possible to think about advantages and disadvantages to define the basis of a standardized procedure to evaluate usability of gesture-based games regardless of the user experience.In reference to sociodemographic and health questionnaires, it is important to verify the age and previous game experience (software and hardware) of the user. This can help divide the user groups and the test conduction. Preliminarily, physical and cognitive limitations can also be identified to avoid health hazards and contribute to a better gaming experience.Interviews are recommended when the number of participants is small, given that the collection data are qualitative and demands a time-consuming analysis. For example, in preliminary assessments, groups are smaller and interviews are useful to understand the reasoning of the user facing a problem. On the other hand, the subjective nature of the interviews leads to different interpretations by the evaluators in groups with many users.Observations also require time for analysis because of the large amount of data acquired. However, it may provide a different perspective to the evaluator that other techniques do not provide, such as the moment when a problem occurred. Used together with video recording, observations can facilitate the review process of user actions and enrich the usability evaluation.Think-aloud protocols affect user performance because they force the participant to do more than one task at a time, resulting in the loss of focus on game tasks or in unintended actions. Another problem is that motion-based systems use sensors for speech recognition as an interaction technique (because the feature is available on motion-sensing input devices), making it impossible in the use of this protocol. Therefore, we not recommend it in a usability evaluation for motion-based games.User performance reporting is an interesting instrument because the game software can collect the measures during the interaction process and it is useful for collating with other assessment tools. For example, you can make a relationship between time spent executing the task with acceptance of the technology in order to see whether the user liked the game or not. However, if analyzed without comparison with another instrument, it is essential to instruct users in a very specific way about how they should perform the task in order to obtain balanced results. This is important because there is an implicit relationship between task performance metrics, such as speed and accuracy. The participant may be faster, but be less accurate, or the participant can increase accuracy, but decrease the speed .Finally, the use of posttest questionnaires without validation is not a good practice in evaluations because it is not certain that the listed issues are relevant and appropriate inside the application context. Moreover, it is necessary to manage specific questionnaires at the end of experimental session because they can tire the participants leading to them not adequately indicating their impressions about the system. On the other hand, it is important to create specific questionnaires to evaluate the usability of motion-based games. In this case, the questionnaires must be validated in preliminary studies to prove the quality of the results. Preferably, they must be applied with other posttest tools in preliminary assessments in order to define specific time for the experiment.In view of our impressions, a suggested usability evaluation approach for gesture-based and motion-based games can follow some guidelines within the pretest, test, and posttest stages.In the pretest stage, we recommend the use of instruments capable of distinguishing users with previous experience considering the resources under evaluation and capable of indicating user limitations that may interfere during the experiment. We suggest the use of a questionnaire to characterize the sample. This instrument must track cognitive and physical aspects to avoid biases. For example, it can identify a problem that affects the understanding of the game activities during the sessions, or even a limitation that affects the movement required in gestural interaction. Among the instruments listed in the studies included in this systematic review were PARQ and PAES.During the test, we suggest collecting performance and physiological user data using software. User performance reporting is useful if the purpose is to verify the user’s progress during the interaction process, usually from objective measures, such as speed and accuracy. However, it is interesting to use tracker video software to study the evolution of movements. Physiological measures can also be useful to identify emotions that may affect the user’s interaction with the game tasks. Heart rate, for example, can show evidence of stress during the interaction process. Observations can also record the evaluator’s perception during the session. We also recommend testing different versions of the same game to identify relevant issues, such as a version that uses a specific guideline and another without using it.In the posttest stage, one can opt for a qualitative or quantitative analysis, depending on the purpose of the evaluation. If the option is for qualitative results, we recommend an interview to collect the user’s perception of the game. On the other hand, in a quantitative analysis, the use of instruments such as TAM and SUS, for example, may be useful for evaluating user acceptance and user satisfaction. In this case, we recommend scales that allow for statistical analysis, such as a Likert scale.Results show that there is no standardization in evaluation methods because they use different analysis variables. The definition of usability in games, especially in relation to gestural interaction, and of who should be evaluated and how it should be assessed, were not evident in the selected studies. Some studies evaluated users and others experts, using qualitative and/or quantitative methods.We observed that the studies in this systematic review do not use the same methods in the user selection process or similar criteria in pilot tests or protocols for usability evaluations. There was also not similarity between the questionnaires and answer options.We suspect that the lack of studies and methods  that indicate the appropriate interaction techniques for each experience or application is the reason for the lack of standardization.For this reason, the use of a standard usability evaluation process for gesture-based games and definition of criteria to enable a quantitative analysis in evaluations can be significant to this area. Therefore, understanding the different types of goals in usability evaluation and its implementation becomes relevant. Once the different types of goals have been established, it becomes possible, for example, to create a usability evaluation tool for rehabilitation of people with some type of motor or cognitive impairment, or even for unimpaired people with a focus on entertainment or training.An evaluation for gesture-based games may also consider other factors in order to contribute to the usability applications. Physiological metrics, user anxiety levels, and stress issues are measures that could be collected during the evaluation. It is essential to consider these questions to advance the study in this area, defining at least one basic usability method to guide user assessments.With this in mind, it is important to consider the adoption of a standard for usability evaluations for two reasons: to guide the validation of gesture-based and/or motion-based systems in future case studies and to check whether a particular hardware or software is suitable for their intended use. This valuation approach is substantial because the market regularly offers new interaction methods without consideration for how the public will use these solutions. As an example, the elderly, a group that is increasing globally, are using interaction systems more and more every day.Our proposal is to validate the suggested approach in a usability evaluation protocol using, as a case study, two versions of a serious game based on gestures and movements (2D and 3D) for the elderly. We will regard three stages suggested in this study. We believe that this validation can be the basis to consolidate a standardized usability evaluation approach for gesture-based games based on our experiences and the identified studies in this review.The focus for the elderly is justified by the fact that the game industry has been investing in this age group due to the growth of this population and increased life expectancy in most countries. In this systematic review, it was observed that some studies also used this population ,17,18,20Adults today have greater contact with technologies and, therefore, will tend to use them more in the future. Easy access to a larger set of gestural interaction devices and general information systems will also contribute to the use of these technologies by a greater number of users.


Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010–2013 in Nicaragua and Mexico. The Nicaraguan arm of the trial was preceded, from 2004 to 2008, by a feasibility study that provided valuable lessons and trained facilitators for the trial itself. Here, guided by the Template for Intervention Description and Replication (TIDieR), we describe the Camino Verde intervention in Nicaragua, presenting its rationale, its time and location, activities, materials used, the main actors, modes of delivery, how it was tailored to encourage community engagement, modifications made from the feasibility study to the trial itself, and how fidelity to the process originally designed was maintained. We also present information on costs and discuss the place of this study within the literature on implementation science.ISRCTN27581154. Aedes aegypti control indices [The dengue pandemic has continued to grow despite widespread use of temephos, and resistance to this pesticide is well documented. Though several studies have shown an impact of community interventions on vector control, no previous studies had shown an impact on dengue illness or serological evidence of infection. The Camino Verde project was the first to demonstrate, by way of serological evidence, a positive impact of pesticide-free community mobilisation on dengue virus infection in children and reported dengue illness at all ages. It also registered reductions in all  indices .Camino Verde (Green Way) approach to dengue prevention and control with a feasibility study from 2004 to 2008 [In Managua, Nicaragua, CIET initiated the The importance of thorough feasibility studies to explore key issues and test activities before designing and launching a complex intervention is well recognised . The tribrigadistas in the feasibility phase became key personnel during the Nicaraguan arm of the trial, and members of the Nicaraguan team helped to train the field team for the Mexican arm of the trial as well.The feasibility study was the training ground for the two-country cluster randomised trial. People who had served as The results of the Camino Verde trial have been presented elsewhere . Here, g2, and the approximate population at the start of the trial was some 1.25 million, a fourth of the national total. Managua comprises seven administrative-political territories called districts, which cover some 541 low and lower-middle income neighbourhoods, 94 upscale residential enclaves and 21 rural neighbourhoods (comarcas) [. Low and lower-middle income neighbourhoods account for 89% of the city’s residents and comprised the population base for the selection of the 60 clusters that made up the trial’s measurement and intervention framework. The 11% of the population excluded from the trial selection lived in upscale residential neighbourhoods that have enough resources to meet their needs without requiring institutional assistance, and in suburban comarcas with more compromised security conditions.The city of Managua, Nicaragua’s capital, is the centre of the country’s main financial, commercial and service activities. The urban area covers 150 kmManagua’s climate is tropical, warm and wet. The maximum and minimum altitudes are 600 m and 48 m above sea level, respectively. In the trial’s follow-up survey, we found that during the 2013 dry season, 43% of households stored water in barrels and had experienced irregular supply of piped water during the previous week, due to programmed service cuts, to a technical problem in the supply network, or to other operational problems .The feasibility study was carried out between 2004 and 2008. The trial took place from mid-2010 to early 2013. Both phases included baseline and follow-up surveys and in each case, these surveys involved the collection of saliva samples from children between 3 and 9 years of age in two stages, before and after the dengue season, in order to detect recent dengue virus infection. The trial intervention itself occurred between July 2011 and December 2012.During the feasibility study, we conducted four survey cycles with a total of eight measurements among 3200 households from 30 neighbourhoods . During the trial, we carried out two cycles that included three entomological surveys (two in the dry season and one during the rainy season) among 8100 households from 60 neighbourhoods . We assessed dengue virus transmission risk by collecting saliva samples from 2900 children aged 3–9 years during the feasibility study and from 4600 children during the trial.Ae. aegypti specimens at different stages of development. The immunological part consisted of measuring anti-dengue virus antibodies by Enzyme-linked Immunosorbent Assay (ELISA) in paired saliva samples collected before and after the dengue season to detect an increase indicative of dengue virus infection during that period.Both phases of Camino Verde involved close collaboration with the Ministry of Health’s National Diagnostic and Reference Center (CNDR), which directly participated in producing serological and entomological evidence. The entomological portion of these surveys was directed by two supervisors, one of whom either had responsibilities in the vector control programme of the local healthcare system (known according to its Spanish acronym as the SILAIS) or was a CNDR entomologist. The entomological inspection applied the protocol and techniques standardised by the Nicaraguan vector control programme for collecting, transporting, conserving, identifying, counting and classifying immature Aedes aegypti mosquito and the development stages of the aquatic immature forms. The entomological evidence was of two kinds: a) aggregate numbers and percentages of mosquito larvae and pupae derived from systematic inspections of household and community water receptacles and b) visual demonstration of the presence of these larvae and pupae to householders on their own premises. The epidemiological evidence came from the baseline study and concerned risks from failure to protect against dengue and likelihood of protection from various actions that households and communities could take to minimize those risks. The economic evidence was a) cost data on dengue and dengue control gathered in the baseline surveys and b) reflection by each household on the costs they incur from seeking treatment for dengue illness and from purchases of anti-mosquito chemicals and devices.The principal material used in Camino Verde was evidence. The evidence was biological, entomological, epidemiological, and economic. The biological evidence concerned the lifecycle of the Aedes aegypti mosquito with its immature forms made all the difference in people’s understanding of the situation and stimulated decisions about the most convenient way to avoid the mosquito, be it "not providing it with a home" or “preventing it from taking flight,” using the physical evidence found in the households themselves.Among the tools used by brigades during household visits were larval nets, plastic pans, plastic pipettes, magnifying glasses, and flashlights. A particularly important tool was a laminated graphic showing the mosquito vector’s life cycle on one side, with alternative control measures and the advantages and disadvantages of each option on the other. Linking the adult The materials used in collective actions such as clean-up campaigns, parades and festivals were provided by the community members themselves.The intervention was preceded by a baseline survey among 8100 households from 60 neighbourhoods . Paired saliva samples were collected from 4600 children in mid-2010 at the beginning of the dengue season and at the end of it in early 2011, in order to detect recent dengue infection. This process was repeated during the follow-up survey in mid-2012 and early 2013. In January 2011 (and again in 2013) we returned to all households in both intervention and control communities to inform parents of the results from the analysis of the saliva samples for each child who had provided two samples along with recommendations for what action, if any, they should take.The intervention itself was based on a process called Socialisation of Evidence for Participatory Action (SEPA), a communication strategy that bolsters direct community participation by fostering evidence-based dialogue and looking for solutions on the communities’ own terms . In NicaIn May and June of 2011, as a way of gaining access to the neighbourhoods and getting to know the community residents, CIET staff invited community leaders from the 30 intervention neighbourhoods to participate in discussions about the costs incurred by neighbourhood families in relation to dengue as revealed by the baseline survey. The topic of household budget decisions provided a good entry point for researchers to engage with communities, especially when the evidence showed that current expenditures were providing a poor return. People became motivated not only to search for ways to reduce their costs but also to question the current response to the mosquito problem. This in turn helped people create conditions favourable for community mobilisation for change. The results of this activity are reported in a companion article .The dialogue did not attempt to impose externally pre-defined behaviours, which implies a biased relationship of superiority on the part of those who define the behaviour. The informed dialogue was rather conceived as a horizontal relationship where evidence facilitated the conversation about the dengue problem and possible options, and its ultimate effect was motivation for responsible action.brigadistas (See below under Actors).After the focus groups, beginning in June 2011, the community collectives called SEPA brigades took shape. These were conceived as groups of diverse residents who voluntarily organized to prevent dengue in their neighbourhoods. These groups were more than just ad hoc groups created only for the project; rather, they emerged from within the community to address a community problem. They did this by acting as a link between the population and community leaders and by conducting household “accompaniment visits” and collective actions in the neighbourhood. Members of the SEPA brigades were called Aedes aegypti breeding sites on the premises. The dialogue included ways of dealing with the evidence using the household’s own resources, without preconceived recipes or solutions.Household visits were the occasion for informed dialogue with household heads and members. Dialogue was complemented by evidence and emphasized finding solutions suggested by the household members themselves. This implied reviewing what was already being done in the household and, where necessary, looking for alternative solutions based on the evidence from each of the brigadistas had a specific neighbourhood sector or block assigned to it. As time went on and human resources allowed, brigadistas visited additional households in the same residential sector. The trend was to expand the range of visits in order to cover the whole neighbourhood, as the additional households were increasingly considered to be part of the community organization’s everyday efforts. In principle, each household received a weekly visit from the same team, although the regularity depended above all on the household’s entomological condition and vector control capacity. The brigades were soon able to judge from a short visit how well a household was managing its water receptacles, especially households with children who could more easily identify the immature forms of the mosquito. As time went on, brigades were visiting some households more than once a week and others only occasionally.At first, the visits covered only the approximately130 households in each neighbourhood that had been included in the baseline survey. Each team of two brigadistas a commitment not to make public what people considered private when discussed in their households.The moment of knocking on the household door and the initial interaction with residents became a critical point in the relationship between brigades and community members, as it condensed in a single occasion the issues of consent, trust, and confidentiality. Permission to enter the home imposed upon the brigadistas were allowed inside the dwelling, the joint inspection of water receptacles and conversation about new experiences or changes observed since the last visit constituted moments of dialogue in which no one’s knowledge was considered necessarily superior to another’s; participants simply exchanged interpretations and, with the help of some simple educational tools, identified feasible, actionable alternatives. In this manner, the brigade was perceived as a part of the community with recognition of its voluntary character and its service mission.Once Aside from household visits, the purpose of SEPA brigades was to build collective responsibility to tackle common problems beyond the households, whether in the street, the sector or the whole neighbourhood. Their work routine involved participating in community actions jointly with neighbourhood leaders, using evidence whenever possible.Ae. aegypti breeding sites in the household created a risk of dengue for neighbours. This fostered awareness of how each household could affect others, and how other households could affect one’s own. Starting from this awareness, neighbours were stimulated to talk with one another about how to control breeding sites and about mutual responsibility and even solidarity when a household did not have the necessary resources to carry out the appropriate tasks .A first level of collective responsibility focused on making it clear that having More broadly, collective activities included, for example, participating in community clean-up sessions, educational activities during community festivals, and reforestation activities; repairing road infrastructure using old tires and scrap materials, thus converting such materials from potential mosquito breeding sites into useful resources; conducting educational and entomological control activities in schools and workplaces, etc. Communities carried out these dengue prevention activities in coordination with institutions such as the Managua city hall, the Ministry of Health, the Ministry of Education and the Ministry of the Environment and Natural Resources, or used their own resources to meet the neighbourhood’s demands in their streets, parks or schools.http://caminoverde.ciet.org/en/nicaragua/activities/.The progress of the SEPA process allowed for increasingly closer ties between the brigades and community leaders. Thus, just a few months after the start of the project, the SEPA brigades had already become an important part of the community dynamics and structures in several neighbourhoods. Further details, including photographs, of these activities can be found at: brigadistas and health authorities accompanied community residents in entomological inspections of their households, showing them the larvae and pupae they found. The participants also discussed the burden on household economies from the costs of dengue illness or insecticide use.Other events aimed at strengthening relationships between communities and the Ministry of Health around the subject of mosquito prevention. For example, community leaders and SEPA brigades from three neighbourhoods accompanied representatives of Managua’s local health authority in launching the first Day to Combat Dengue in 2012. At this event, Another event that linked the SEPA process with the Ministry of Health took place in the CIET office. The event was a meeting between community leaders from 14 intervention neighbourhoods and staff from the government’s Vector-borne Disease Control Program. The meeting involved an exchange of epidemiological and entomological information, and both Ministry of Health personnel and community leaders showed each other how they visualized their challenges and responsibilities. CIET presented the entomological trends identified by the peer monitoring work (see below), while the government programme director presented the occurrence of registered cases and the results of an entomological survey carried out by the government a few months before the meeting.Aedes aegypti mosquito’s breeding sites that were beyond the households’ control, which were called “critical points”, and included ditches, empty lots, scrapyards, recycling dumps, tire repair shops, workshops, factories, or any other place that was beyond the community’s capacity to control.The exchange of evidence fostered a dialogue aimed at joint actions by the Ministry of Health and the communities in two sensitive areas: information exchange and joint action on the brigadistas. The only requirement for participation was the motivation to prevent dengue and the voluntary decision to devote some time each week to visiting households or carrying out some neighbourhood action. Volunteers were motivated to join the brigades by the desire to participate in the collective experience and to do something for their communities.The brigades were made up of community leaders who had taken part in the focus groups and other community members invited by the leaders. Their members became known as brigadistas worked, they learned and developed an ethic of respect, above all respect for privacy, but also respect for each household’s diversity and self-determination. There was a total of 29 brigades (one per intervention neighbourhood), with members of different ages and genders. By January 2012, there were 474 active brigadistas in 29 collectives, with an average of 16 per brigade and a range of 7–25 members. Thirty-seven percent of brigadistas were children (20% boys and 17% girls); 31% were teenagers ; and 31% were adults (8% men and 24% women). In some brigades, members were predominantly children; in others, they were predominantly teenagers; and in others they were predominantly adult housewives. The rest of the brigades had mixed memberships. The number of brigadistas varied constantly due to the arrival of new members, or the temporary or permanent withdrawal of others.As brigadistas chose a coordinator to serve for a specified period. She or he could be re-elected as many times as the brigade chose, or removed from the post if the brigade so decided. In January 2012, 21 of the coordinators were women and 8 were men, and 16 brigades were directly coordinated by a delegate from the official neighbourhood leadership. The brigades met with varying regularity, usually once a week, in order to discuss their work plans. Decisions were preferably made by consensus. The leadership kept track of these decisions by way of regular meetings with and among the brigades and also through the monthly accounts received from the brigades as discussed below under the heading of Costs. Throughout most of the trial, the brigades trained new members themselves.Within each brigade, In addition to the research team, CIET deployed a group of external community facilitators, whose presence as outsiders to the intervention neighbourhoods was justified insofar as they brought new knowledge into the community and supported the systematization of the communities’ own knowledge and experiences. Brigade members from intervention neighbourhoods in the feasibility phase became facilitators during the trial.Several of the neighbourhood leaders who had begun to “develop the SEPA way” during the feasibility stage continued on as leaders in their own communities, while 19 (17 women and 2 men) joined the project management team of the trial as facilitators, with the aim of having a direct and temporary presence in the intervention neighbourhoods. The facilitators’ first task was to assess the dynamics of their assigned neighbourhoods, their people, and the neighbourhood’s key mosquito-generating points. They later took care of returning baseline results back to the households, coordinating focus groups and, together with community leadership, organizing the brigades and providing the necessary tools and work supplies for household visits. Later elements of their role as facilitators came when they promoted the decentralization of the brigades’ work, accountability, territorial expansion of the work, and neighbourhood peer monitoring.At the beginning of the project, the relationships established between CIET facilitators and communities were slightly hierarchical. But facilitators had learned in the feasibility stage the need for a progressive shift on the part of leaders toward respectful facilitation that stimulated independent development opportunities in a context of shared responsibility. During the trial itself, CIET facilitators progressively withdrew from the communities. The fact that CIET facilitators came from other neighbourhoods to collaborate in endogenous communication processes in a neighbourhood that was not their own was both a challenge and an important point in the development of Camino Verde, specifically in preserving the ethic of respect that had to be present throughout the entire process with regard to local leadership and the brigades’ bond with households and the population.The work of the facilitators was crucial to the SEPA process, including their influence on the brigades, the growing participation of community leaders and ultimately the preparation for their own withdrawal from the neighbourhoods. This exit process was progressive and depended on the brigades acquiring autonomy and self-sufficiency in their organization skills.brigadista and community leadership so that the actions themselves were led by the latter.In the case of the household visits, the mode of delivery was face-to-face with the household head and other household members wherever possible. For collective actions, the initial interface was also face-to-face between brigadistas, residents and leaders could give testimonies of their own experiences, share anecdotes, enjoy photos, access their own data and work tools, monitor the product of their own work, and ask, comment and learn about what was happening in other neighbourhoods. This SEPA blog (http://sepa-nic.blogspot.com) provided "a space that makes visible committed individuals who anonymously offer their solidarity, receiving in exchange their own satisfaction and social recognition" [A few months after the start of the trial, with the aim of creating a space for communication among the intervention neighbourhoods, we launched an electronic platform where community gnition" .brigadistas from 23 neighbourhoods received training on how to use the software. The activity consisted of a demonstration complemented by practical activities with different features of the platform – calendar, image gallery, videos, data, tools – and how to comment. At the brigadistas’ own request, the group was called the “SEPA cybernetic group”. This group was responsible for motivating and facilitating blog access by brigades and community leaders in their neighbourhoods, providing technical support for access, browsing and commenting, and contacting the person charged with the managing the blog at the CIET office. Only ten group members had direct access to the internet in their own homes (10/39), while the others had to visit internet cafés in their neighbourhoods or the home of a relative, friend or neighbour. The group agreed that each SEPA neighbourhood would have its own blog account, for security reasons and to strengthen the neighbourhood’s sense of identity. Each neighbourhood had its own password, as access to the tool was restricted to the intervention neighbourhoods throughout the duration of the trial.A few weeks before the launch of the blog, 39 The Camino Verde intervention was tailored at several levels. At country level, it was tailored to the different political, cultural and socioeconomic conditions of Mexico’s Guerrero state and those of Nicaragua’s capital city, Managua. Appendix 2 to the main report on the trial results presents the main similarities and differences in how the intervention was implemented in the two countries .Within Managua, researchers learned from the feasibility study how different the distinct households, sectors and neighbourhoods were from one another, and, because of this, how different were their interpretations of, and capacities to deal with, the problems they encountered. The dialogue between researcher and communities had to be adapted to the particular circumstances, obliging the former to move beyond academic discourse, preconceived ideas and uniform recipes and, instead of arriving to teach, to approach the neighbourhoods ready to learn.By discussing their own data, brigades systematized their understanding of the different territories in which they worked . In this way, brigade activities were not programmed with a predefined norm, but with recognition of the singularities of each neighbourhood and each block, resulting in household visit plans with specific priorities, contents and frequencies.The intervention, understood as a process rather than as a fixed set of procedures, was not substantially modified from the inception of the feasibility study to the end of the trial, but it was refined and tailored, as mentioned above, during the course of that period.Camino Verde. The two phases developed in markedly different contexts as regards the relation between citizens and state institutions. The feasibility study took place during a political period in Nicaragua when the community voice was not officially promoted, there was minimal community mobilisation, and the presence of government institutions in the neighbourhoods was hardly noticeable. The 2010–2013 trial, on the other hand, took place at a time of major political changes when there was an increased presence of government programmes promoting community organizations, with local political leaders implementing social programmes, and an increased awareness among residents of the government’s vector control programme.An example of how robust the process was can be seen in its application to the feasibility and the trial phases of The different political and institutional contexts in which the feasibility study and the Camino Verde trial were developed in Nicaragua suggests that the Camino Verde protocol could be replicable in dissimilar socio-political contexts, as long as the process focuses on community residents, whose own motivations to participate and mobilise are grounded in their understanding of their own needs. This conclusion is further strengthened by the experience in the Mexican arm of the trial, conducted in the southern state of Guerrero, where community structures and leadership are more heterogeneous.An example of how the process was refined over time can be seen in the evolution of the educational messages. At the beginning of the feasibility phase, we thought that most people were already aware of the connection between the adult mosquito’s existence and its immature forms, but this was not the case. Sharing this knowledge thus became a key element in the communication process.Three types of activity helped to assure fidelity to the intervention, although each of them served other purposes as well.Aedes aegypti prevention, broadened and strengthened the bonds among brigadistas, and created new learning experiences.Aside from the work in their own neighbourhoods, brigades also engaged in formal peer monitoring and evaluation, with a brigade from one neighbourhood monitoring the work of its counterpart in another neighbourhood. In addition to assuring fidelity to the intervention design, these activities helped to strengthen Brigadistas and community leaders from one neighbourhood requested permission from another neighbourhood to be allowed to pay a formal visit and enter that neighbourhood with their work tools, in order to perform measurements and to share the results. The visiting teams usually arrived in the neighbourhood in the morning and inspected households following a protocol that included collecting all the immature forms of Ae. aegypti they found. They also gathered household opinions about the neighbourhood brigade’s work, along with specific recommendations. The visits covered households located within the measurement cluster. The time available to the brigades, the number of visiting brigadistas, and the duration of the visits determined the number of visits.At the end of each neighbourhood peer visit, the visiting team processed the results on site and shared the evidence with the host brigade and community leaders. They submitted collected larvae and pupae in clear plastic bags with labels identifying the source households. They shared the answers to the questionnaire and the visited households’ recommendations, in case there were any questions. Afterwards, the host brigade discussed the visiting brigade’s findings, comparing them with results from previous visits. At a later date, the roles were reversed: the host brigade became the visitor and the visitors, the hosts.There were three cycles of peer monitoring visits between neighbourhoods. The first took place in the last week of November 2011, the second during the first week of January 2012, and the third in May 2012. Each peer monitoring cycle covered between 3500 and 4000 households.brigadistas and community leaders were anxious to receive the entomological results concerning their own areas, giving them an opportunity to validate changes since previous measurements. In some neighbourhoods, larval and pupal positivity decreased. In others, no change was noted, while in others positivity increased. In any of these situations, the new evidence was cause for reflection on factors that could explain the outcomes at the household, neighbourhood and/or sector levels, and efforts to reach a consensus on options to improve the work. Also, neighbourhood peer monitoring broadened the perspectives of the brigades as they recognized that other situations differed from their own, and developed capacities for interpretation and dialogue reaching beyond their own territories.The sense of neighbourhood responsibility for the outcome of the visits stimulated the process. The host piñatas among other entertainment. The host community leadership coordinated the events, with CIET providing some educational materials and lending such items as banners and megaphones. Visits were usually returned at a later date.As part of the intervention, in addition to the peer monitoring activities, brigadistas and community leaders from different neighbourhoods took part in joint activities. Brigadistas and community leaders from one neighbourhood hosted these events, and teams from other neighbourhoods attended. These activities sought to create spaces for bonding and exchanging knowledge and experience among brigades and community leaders. These exchanges centred on household visits that took place in the host neighbourhood, identifying strengths and weaknesses. These gatherings also involved group integration activities, such as sporting events, contests and La Primavera neighbourhood, with some 90 brigadistas visiting from 6 neighbouring barrios. A second encounter took place in Colonia 14 de Septiembre, which was visited by the Villa Libertad and Manuel Fernández brigades. During the 2011 summer holidays, a series of meetings and events provided an opportunity for brigades to share in community activities and entertainment during periods of extreme heat in Managua.The first of these events took place in April 2011 in the During the pilot stage and the trial, we organized four events involving all the intervention neighbourhoods. Three of these took place during the pilot stage and the fourth event took place during the trial. Some 600 delegates from the neighbourhoods, both brigadistas and community leaders, attended the last event, as well as national and international collaborators and funders. The event included presentation of results by the brigades, socio-dramas about the mosquito life-cycle and dengue, music and traditional dances. Overall the delegates and participants demonstrated a sense of pride and ownership of Camino Verde that strengthened participants’ sense of identity and belonging to a social movement with novel proposals to address the dengue problem. The SEPA blog gives details of the event.The Camino Verde intervention in Nicaragua, though animated by volunteer brigades, was not free of costs. Monetary costs included part of the salaries of the research team which, in addition to its measurement activities, devoted a good deal of time to managing the intervention itself. There were payments to facilitators who, although they gradually withdrew from active presence in the communities, were indispensable in launching and guiding the early development of the brigades. And there were logistical and administrative costs as well. These costs will be detailed in an as yet unpublished report on the costs of Camino Verde by a health economist.As for the brigades, individual brigadistas were all volunteers who received no individual payment. There was, however, a monthly fund averaging about US$55 provided to each brigade to cover the costs of supplies, transportation, communication and refreshments for meetings and collective actions. This fund was a contribution to sustain the brigades’ collective effort and to stimulate the development of their capacity for planning based on entomological results. At no point was the fund intended for individual use. In a few cases when this did happen, the brigades themselves determined the means for correcting the situation and sanctioning the person involved. While these resources were initially provided externally, the aim was for communities to progressively mobilise or generate their own resources as they reached greater levels of autonomy and sustainability. From the beginning, the amount provided to each community varied according to its perceived capacity to conduct the intervention using its own resources, and for some brigades the payment was suspended completely three or four months prior to the end of the intervention because they no longer needed it.The brigade coordinator was accountable for the funds, both internally within the brigade and by providing accounting information to the CIET office, where officers registered it in the accounting system. Detailed financial accounting provided evidence of the brigade’s performance and allowed planning of the next work period in a transparent, collective way. The brigade coordinator acted as the link between the CIET office and the accounting system.Implementation Science observed that complex behaviour-change interventions are not well described, making it difficult to replicate them and limiting the possibilities for subsequent interventions to be successful [A July 2009 editorial by four members of the editorial board of the BMC journal ccessful –12. The ccessful .Since 2004, on the other hand, Hawe and colleagues had been arguing that, in complex interventions, the function and process of the intervention should be standardized, rather than the components themselves, thus allowing the form to be tailored to local conditions .The Camino Verde intervention in Nicaragua was designed from the latter perspective. The process standardised throughout the intervention, called SEPA, is the sharing  of evidence with community residents and leaders – largely evidence of the mosquito larvae and pupae growing in their own water receptacles -- in ways that elicit household and community action to prevent the spread of dengue virus (and now chikungunya and Zika virus as well).The experience of both the feasibility study and the intervention convinced the research team that evidence grounded in the specific reality of each household and community has greater potential for mobilisation than any didactic material proposing recipes that are equally applicable for everyone. Researchers also became convinced that evidence-based communication among households, volunteer groups and community leaders helps to increase neighbourhood solidarity and serves as a wellspring of new leadership.We also found that monitoring and evaluation activities carried out by the communities themselves, along with the interpretation of changes brought on by their own efforts, were forces for community empowerment. Evaluations by peer groups and other external agents can complement communities’ own efforts.The quality of external agents can be measured by their ability to shift from a role of leadership to one of respectful facilitation that stimulates opportunities for shared responsibility and autonomous development by the community. NGOs, academic institutions or other external organizations involved in similar interventions might learn from this experience and aim also for progressive withdrawal and eventual exit from the communities.Recent unpublished measurements suggest sustainability of domestic and community knowledge and attitudes two years after the conclusion of the Camino Verde trial. Nevertheless, we need to develop more precise and sensitive sustainability indicators. At the household level, the elimination of breeding sites needs to become part of everyday household cleaning chores, along with the use of sustainable tools and lower dependency on chemical products. Sustainability of collective actions requires identifying community and institutional responsibility for cleaning and controlling breeding sites in communal areas, and continued prioritisation of mosquito control by community leaders and community volunteers.This article is not a manual for step-by-step application in other circumstances. It is a description of how the SEPA process was implemented under the particular conditions of one city in one country during the years 2010–2013. We believe, of course, that its content may be useful to others interested in applying the same process, or a similar one, to their particular circumstances, but only if they strive to adapt the process to those circumstances.