Does disruption of prefrontal cortical activity using transcranial magnetic stimulation (TMS) impair visual metacognition? An initial study supporting this idea  motivated an attempted replication and extension . Bor et al. failed to replicate the initial study, concluding that there was not good evidence that TMS to dorsolateral prefrontal cortex impairs visual metacognition. This failed replication has recently been critiqued by some of the authors of the initial study . Here we argue that these criticisms are misplaced. In our response, we encounter some more general issues concerning good practice in replication of cognitive neuroscience studies, and in setting criteria for excluding data when employing statistical analyses like signal detection theory. We look forward to further studies investigating the role of prefrontal cortex in metacognition, with increasingly refined methodologies, motivated by the discussions in this series of papers. Rounis et al. found that tbTMS to dorsolateral PFC (DLPFC) selectively reduced visual metacognition, while first-order perceptual accuracy remained unchanged by design. This finding, if it stands up, provides strong evidence supporting a causal role for DLPFC in visual metacognition, which in turn support , a causHowever, attempted replications by our laboratory failed to find any reliable effect of tbTMS to DLPFC on visual metacognition , conclud2not exclude subjects, they argue that we unnecessarily lowered our chances of finding a true effect (of TMS on metacognition) when we did apply our rigorous exclusion criteria. Ruby et al. then present a Bayesian analysis purporting to show that the data from Bor et al., support, rather than conflict with, Rounis et al.In this spirit of open and constructive debate, the remainder of this paper describes our opinion on We disagree with this claim, as we will explain.Ruby et al. also selectively criticize some of the methodological changes we made, raising important issues about what constitutes an adequate replication. We take the opportunity here to revisit the reasons for these design decisions in the context of this broader concern. Finally, Ruby et al. appeal to evidence from a diverse range of alternative studies when discussing the overall question of the role of PFC in metacognition and consciousness. We do not think this appeal is relevant to the specific discussion about methods and analyses. Instead, it leads to further confusion since we do not claim our analyses undermine any of these alternative studies.2.1Ruby et al. motivate their simulations by saying that our main reason for subject exclusion was to avoid a high FP rate. Ruby et al. claim that excluding the subjects as we did in We in fact performed these exclusions based on well-established theoretical arguments, elaborated in not near 0 or 1, there is a roughly linear relationship between changes in HRs or FARs and meta d’. Such smooth, approximately linear relationships are good indicators of a reliable measure . However, when HRs or FARs become too big or too small (i.e. close to 0 or 1), a small change to them causes a big change in meta-d’. In other words, at these  extreme values, the relationship between changes in HRs or FARs changes from smooth and linear to non-smooth and non-linear, and the meta d’ measure is no longer reliable. This is clearly illustrated in As this is such a critical point, let us rephrase it here: When hit rates or false alarm rates (HR/FARs) are Although the above figure was for simulated data, this is an empirical problem too. To put it even more bluntly, such subjects with extreme SDT values will have a meta-d’ measure that will not reflect their metacognitive performance, since the measure is effectively breaking down due to the extreme HR or FAR. These extreme meta d’ values can have an influential effect at the population level, depending on what statistical tests are used.Ruby et al. take the view that all that matters is whether subject exclusion will affect FP (or FN) values, e.g. “we emphasize that in classical hypothesis testing there are two main types of error: Type I and Type II. Within this standard framework, any statistical decision or justification of a choice of procedure is meaningful only with respect to its impact on these two kinds of error” (p. 39). Our view instead is that the proper application of statistical techniques requires confidence that measured variables, on which inference is performed, reflect the property of interest. If it’s clear that some portion of data, due to mismeasurement  do not reflect the property of interest, then they should be excluded for this reason, regardless of statistical concerns  rates may well be reduced). From this perspective, the main purpose of the Ruby et al. paper, namely to use simulations to demonstrate that FP rates are unaffected by subject exclusions, becomes irrelevant.It is worth noting that these principled reasons apparently motivated the authors of the original Rounis study to mitigate these problems in their original design, by instructing subjects to keep their type II responses as even as possible, thus avoiding the extreme HR/FAR values. Having taken such clear methodological steps to reduce extreme values, it would then seem reasonable for Rounis et al. to have excluded their remaining subjects that included extreme HR/FAR values, as we did ours. However, we also note that had they done this, as Ruby et al. report, they would have reduced their n from 20 to 7. In other words, their attempt to avoid the extreme HR/FAR values by this design failed.2.2A second point of disagreement has to do with the relative value of empirical data compared to simulations. In both the Rounis et al. and Bor et al. studies, including unreliable meta d’ measures, based on extreme HR/FAR data leads to a significant result , while excluding these results leads to a null. This is entirely consistent with the notion that including unreliable meta d’ scores increases one’s chances of a false positive, which to our minds provides the most parsimonious explanation of both these results. The Ruby et al. simulations may even lend credence to this interpretation, given that they show  that power should have increased in our between subjects design (where there was a positive result on one measure without excluding subjects) after exclusion.Principled analysis of actual empirical data is preferable to claims based on computer simulation of empirical data that are then used to reinterpret that data. Simulations necessarily have a range of parameters, some of which are inevitably set with somewhat arbitrary values, as compared to rigorous theoretical and analytical approaches applied to empirical data. In addition, simulations often embed assumptions about the nature of the data generating process which are by construction in line with the analysis methods, meaning that they will tend to overestimate the sensitivity and validity of the corresponding analyses.Furthermore, the simulation parameters used by Ruby et al. to model our (2017) data are drawn from the original Rounis et al. study empirical data, not from the empirical data in Bor et al. As Ruby et al. themselves emphasise, the two studies are not identical . In which case, it would seem more appropriate to use the parameters from our own empirical data, which are bound to differ somewhat from their dataset.In addition, the analysis of 2.3Ruby et al. claim that DLPFC tbTMS in the Bor et al. study actually caused a metacognitive deficit, on the basis of a Bayesian analysis, using a prior of 0.5, partially based on the Rounis et al. data. We are not compelled by this logic since we have argued that the results found in Rounis et al. are based on invalid data . It therefore seems arbitrary and unjustified to assign any Bayesian prior  to the probability that the effect found in that study is true. Indeed, the primary contribution of our study was to examine what happens when only valid data are included in the analysis.enhanced perceptual metacognition. Ruby and colleagues conclude that these results “suggest that different parts of DLPFC perform different [metacognitive] functions.” However, given that tbTMS to both an anterior and dorsolateral region of the prefrontal cortex enhanced perceptual metacognition compared to a control site, the results of this new study are evidently relevant to any putative Bayesian prior, making a metacognitive impairment due to DLPFC TMS even less likely. If two null results and an opposite effect are input into a Bayesian prior, we assume the value would be very different to 0.5 and consequently the conclusions of the Ruby et al. paper about the likelihood of our results actually reflecting a DLPFC-induced metacognitive impairment would be very different as well.If a prior is anyway to be selected, what should that prior be? Based on only valid data, both the Rounis and Bor et al. studies found a null result. In addition, the Ruby et al. paper cites a relevant recent TMS prefrontal cortex metacognition paper by Rahnev and colleagues , where T2.4t-test, without multiple comparisons on non-parametric data we found a significant difference between the DLPFC and control (vertex) group (p = 0.03). We included this invalid statistical test (a parametric test on non-parametric data) explicitly to make a point: “We should emphasise, however, that this significant result, aside from being uncorrected for multiple comparisons [we had 4 experimental groups and three metacognitive measures], is not to be trusted as it includes data that invalidates the (parametric) assumptions underlying the analysis. We merely include this analysis to demonstrate how the inclusion of unstable [unreliable] values could potentially generate spurious significant results.” (p. 12).Ruby et al do not merely disagree with our conclusions in Bor et al. They in fact say, “We therefore find it striking that t-test was appropriate here, given any prior expectation to replicate the Rounis et al. result was potentially nullified by other more recent studies showing the opposite results, such as t-test, this single significant result would not have been significant. Similarly, had we corrected either for the number of experimental group or number of metacognitive measures, the result would not have been significant either.It is unclear whether a one-tailed Our suspicion was that the main parametric result from Rounis et al. was based on non-normal data, as was our significant result above. Had we carried out the more appropriate non-parametric equivalent test, this result would not have approached significance . Ruby et al. confirm the non-normality of their original data in the last paragraph of their supplementary materials document, and claim that the critical non-parametric equivalent interaction test was still significant, though unfortunately without providing any details on p-values or related quantities.Moreover, in the Bor et al. case the effect (if any) seems to be driven by an unpredicted boost to metacognition in the control group, rather than a reduction in metacognitive performance in the experimental (DLPFC) group, as interpreted by Rounis et al. This solitary statistical effect therefore does not seem to replicate Rounis et al., contrary to Ruby et al.’s claim.In addition, when we used the main alternative version kindly supplied by Rounis and colleagues , or a new Bayesian method by Stephen FlemingFurthermore, in Experiment 2 within the Bor et al. paper, we were even less successful in attempting to replicate the Rounis et al. findings. We designed our Experiment 2 as an adaptation of a within-subject design, and was therefore in this way a closer replication of Rounis et al. Our double-within-subjects protocol  was in fact designed to be sensitive to the presence of even just a single subject  who would follow the pattern of the Rounis et al. study. Had we found just one subject who replicated the Rounis et al. results over the 4 sessions of session 2, we may have been able to describe this experiment as providing a partial replication. This was indeed our intention, contrary to Ruby et al. in their abstract claiming that we “adopted an experimental design that reduced their chance of obtaining positive findings.”enhancement of metacognition for this single subject following DLPFC cTBS, as opposed to the impairment found in the Rounis study.”  equivalent to the Rounis et al. study. Our original wording from Bor et al. makes clear the nature of our non-replication: “Of the remaining 7 participants, 3 showed the expected impairment, while 4 showed a clear metacognitive enhancement following DLPFC cTBS. 6 of these 7 participants also showed a clear metacognitive change for the vertex control session, and thus were not asked to return for the 3rd session (2nd DLPFC). Only 1 participant that showed a clear DLPFC cTBS metacognitive change in the first session also showed no change for the 2nd vertex cTBS session, and thus was brought back for the 3rd session (2nd DLPFC). This session, unfortunately, included unstable SDT values [here meaning extreme HR/FAR values close to 0 or 1], and thus the participant was not asked to return for a 4th session. If these instabilities [unreliable measures] are ignored, though, the metacognitive change for the 3rd session was very similar to the 1st session. Both sessions, however, showed a robust  study.” .no metacognitive effect when tbTMS is applied to the control site (vertex).A comprehensive appreciation of our Experiment 2 therefore reveals that not even a single participant replicated the results in Rounis et al. Even when just considering the first two sessions, which would make our Experiment 2 even more closely resemble the original Rounis et al. study with its two sessions, not a single participant (out of 27) showed both a DLPFC tbTMS metacognitive impairment, as well as In terms of statistical power, which Ruby et al. critique for our Experiment 2, we note that their reported power for our Experiment 2 after excluding subjects was 0.308, which was almost identical to the Rounis et al. study (without subject exclusions) of 0.311.  Thus, on the basis of power calculations, it remains difficult to explain why our experiments failed to find a positive result, while the Rounis et al. study did find such a result. However, we emphasise that modelling of power and false positive rates are a poor alternative to rigorous analysis of the empirical data itself, as our Experiment 2, in particular, demonstrates.Finally, even if discounting all the arguments we make above, relying on outliers for a positive result – as in the original Rounis et al. study – suggests, at best, only a small effect size.2.5In their manuscript, Ruby et al. also criticise the fact that we modified the experimental design of Rounis et al. in various ways. For example, they say “[Bor et al.] made several changes to the original study design, some of which are known to undermine the chance of finding meaningful results from the outset”.Indeed, we did make small changes to the Rounis et al. design. As we made clear in Bor et al., in each case the changes were made to improve the design with respect to its suitability to address the underlying experimental question. Some of these changes should be entirely uncontroversial; for instance, in removing some minor software ‘bugs’ in the experimental scripts which Rounis and colleagues kindly shared with us, and in ensuring consistency in behavioural responses, and so on .One notable change was that we used a between-subjects design rather than  a within-subjects design for our Experiment 1. This was mandated by our original aim to replicate and extend Rounis et al. by exploring the potential causal contribution of other regions within the frontoparietal network to metacognition. Our Experiment 2, however, utilised a double-repeat within-subject design and still failed to find any effect of cTBS on metacognition. This double-repeat design exemplifies that the changes we made were employed to maximize the chance of finding a true effect should one exist.The other design changes in We also used an active TMS control (vertex) rather than sham TMS, to provide a closer match between experimental and control conditions. Part of our justification for this change was to address demand characteristics, with sham TMS versus real TMS potentially causing subjects to demonstrate a stronger impairment for that condition (DLPFC) for which they perceive is the real condition. However, although we continue to believe that a real TMS site is preferable to sham as a control, we also acknowledge that the choice of vertex itself is not perfect. First, a vertex control would not have induced as many peripheral nerve issues  as the DLPFC stimulation in a subset of subjects . Second, the vertex control meant that the same region was stimulated twice, unlike any of the experimental conditions. It is difficult to know how such a difference would affect participants both psychologically and neurophysiologically.Interestingly, at one point, Ruby et al. (p. 15) criticise that we used only two levels of confidence judgements, suggesting that using more than two would have allowed more sensitive estimation of meta-d’. However, although we agree that more than two levels would have been beneficial,we used two levels because Rounis et al. also used two levels (in their case of visibility ratings rather than confidence). Had we used more than two levels, this would have changed the design considerably, and any subsequent null result might have been attributed to such a clear departure from the original protocol.2.6These points speak to a broader discussion of what counts as an adequate replication in cognitive neuroscience . Our viA related point is that, as Ruby and colleagues admit, both the original Rounis et al. and the Bor et al. studies were relatively underpowered. We attempted to include a high n and sufficient power in our studies, but the extent of subject exclusions due to extreme HR/FAR values was substantial, which weakened power, even when the data were cleaner. Our view is that the best way forward is to collect more empirical data, rather than run simulations. We freely admit limitations in both the Rounis and Bor et al. studies, and that a new experiment with more robust power could address these limitations. A new design could also improve on both studies by having MRI-guided TMS, using a continuous confidence or visibility judgement (or at least including many more options than the binary options we both used), with a sufficiently large n, and multiple controls . To our minds, such a study could definitively answer the question of whether tbTMS to DLPFC can impair visual metacognition, and would be far beneficial to any simulation or to debates about the perceived differences between two experiments.In general, lack of power is a persistent problem in cognitive neuroscience studies , and if 2.7Ruby et al. imply that we argue against any role for PFC in metacognition or conscious perception. For instance, in the introduction they write that following our null result, “they… suggest that DLPFC might not be ‘critical for generating conscious contents’.” This quoted phrase is a misrepresentation of our position, and we urge readers to read the entire discussion from Bor et al. to retrieve the full context. There we raised the possibility that our findings in Bor et al. are consistent with so-called ‘no report’ paradigms which have independently cast doubt on the role of the DLPFC in generating conscious contents e.g. , but alsIndeed, we completely agree with Ruby et al. when the say “Ultimately, whether theta-burst TMS to DLPFC can robustly impair visual awareness concerns the specific method and details. More important is the general question regarding the role of the prefrontal cortex in metacognition and conscious perception”. Absolutely. But the only points of debate between Ruby et al. and Bor et al. concern the specific details and methods. Simply citing evidence from other studies relating to PFC and consciousness does not contribute to the present discussion; instead it falsely suggests that one should believe Rounis et al. simply because it may possibly fit better with some other independent experiments. However, Ruby et al. agree with us that establishing the role of PFC in awareness is a very important, interesting, and open question .3In summary, we continue to think the evidence so far, across studies, does not (so far) demonstrate that theta-burst TMS to prefrontal cortex can disrupt visual metacognition. Moreover, the findings from each study depend on the fine details of methods and analyses. Further investigations would be helped by open access provision of data , and simulation code  – so that interested researchers can draw their own conclusions in addition to the opinions presented in this series of papers. We also look forward to further studies with increasingly refined methodologies, motivated by the discussions here.


Viruses, I dared not expect that ‘Mycoviruses’ would include such a large number of manuscripts. Therefore, it is with great delight that I can count today a total of twenty-three, high-quality publications and I would like to take this opportunity to thank deeply all the contributing authors who chose ‘Mycoviruses’ as a vehicle for sharing their fascinating work with the mycovirology community.Approximately a year ago, when I accepted the offer to act as a Guest Editor for the Special Issue ‘Mycoviruses’ organised by the MDPI journal Chrysoviridae, Endornaviridae, Hypoviridae, Mymonaviridae, Narnaviridae, Partitiviridae, Totiviridae, Quadriviridae, and others [‘Mycoviruses’ consists of three timely reviews on virus structure  and virud others ,14,15,16d others ,18 and td others ,20. Of pd others ,21,22,23d others ,15,16. FCryphonectria parasitica hypoviruses to control chestnut blight in Europe during the last century and today the major interest stems from the potential of mycoviruses as biological control agents in the context of integrative pest management programs. Based on this observation, a way forward would be to genetically engineer mycovirus-mediated hypovirulence or hypervirulence instead of merely hoping for a fortunate discovery. To this end, both the understanding of the molecular mechanisms underpinning these phenotypes and the development of reverse genetics systems for mycoviruses is an essential prerequisite.As a relatively young mycovirologist with hopefully many active years to look forward to and a scientist with some first-hand knowledge in animal and plant virology, I frequently question how our work on mycoviruses conforms with the rapidly developing research in other fields and which future directions will lead to mycovirology being rightfully accepted as a mainstream research area and not merely esoteric, as it is often regarded. Mycovirology is not as advanced as human, animal, or even plant virology; overall our understanding of mycoviruses is not as detailed and in depth while the methodology we use to study them is not at the cutting edge. Since mycoviruses are not causative agents of significant diseases, they receive much less attention than, for instance, life-threatening human pathogens. Their ‘moment of glory’ was the use of


Lifestyle modifications represent the first line of treatment in obesity management; however, many adolescents with obesity do not meet lifestyle recommendations. Given that adolescents are rarely consulted during health policy development and in the design of lifestyle interventions, their first-hand experiences, preferences, and priorities may not be represented. Accordingly, our purpose was to explore adolescents’ lifestyle treatment recommendations to inform policy and program decisions.NVivo 11, and analyzed using quantitative and qualitative content analysis by two independent researchers.Conducted from July 2017 to January 2018, this study adhered to a qualitative, crosslanguage, patient-oriented design. We recruited 19 13–17-year-old adolescents (body mass index [BMI] ≥85th percentile) seeking multidisciplinary treatment for obesity in geographically and culturally diverse regions of Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews were audio-recorded, transcribed verbatim, managed using (i) establish parental support within limits, (ii) improve accessibility and availability of ‘healthy foods’, (iii) limit deceptive practices in food marketing, (iv) improve accessibility and availability of varied physical activity opportunities, and (v) delay school start times. Respect for individual autonomy and decision-making capacity were identified as particularly important, however these were confronted with adolescents’ partial knowledge on nutrition and food literacy.Adolescents’ recommendations were organized into five categories, each of which denotes health as a collective responsibility: Adolescents’ recommendations highlighted multi-level, multi-component factors that influenced their ability to lead healthy lifestyles. Uptake of these recommendations by policy-makers and program developers may be of added value for lifestyle treatment targeting adolescents with obesity. Pediatric obesity is recognized as a public health priority and is often accompanied by physical, physiological, and psychosocial health risks , 2. EffoGiven that noncommunicable diseases such as obesity, including determinants and consequences, strongly impact adult health, a life-course perspective is gaining attention to nurture current and adult health status , 6. For Adolescence, therefore, becomes an important period for health promotion, prevention, and intervention for obesity since it is a time of much experimentation in light of behavioral, cognitive, physiological, and psychosocial growth. In a series of studies we conducted on the adoption of healthy lifestyle habits, we targeted the first-hand perspectives and experiences of adolescents with obesity, many of whom identified a number of challenges that prevented them from achieving a healthy lifestyle such as the convenience of unhealthy foods, negative experiences in physical education classes in school, sleep difficulties, and mental health issues . Growing, low recruitment and initiation, high attrition)  don't really exercise a lot with me. So, I feel like I don't have enough motivation and they're saying, oh yeah walking the dog isn't enough and stuff, so I guess that doesn’t really help with kind of getting along. My Mom’s trying to lose weight, but my Dad’s not, so it’s like, it's not an entire family sort of thing household and my brother that's still living at home, he's kind of really slacking off somewhere, not doing much or always out, so that doesn't help either.”“Well, they are already making some changes anyways, so... but my dad is not really involved, because in my case, my parents are separated. So, I don’t talk to my dad, so he can’t realize what is changing in my life. My mom helps me, my step-dad also helps me, he is super cool.”Many adolescents, including Chloe, described parents shifting the blame on their sons and daughters, and vice versa, which is a scenario that tends to be observed in practice to a similar extent. For example, adolescents commented on lack of active involvement by their parents in making changes and associated impact on personal motivation levels. Respectively, Chole and Mona shared their experiences: “I am starting to do things on my own, but not in relation to health or politics, I prefer they [parents] come with to advise me, but I am starting to realize that I like social situations where I come alone, I prefer doing things alone, but I am happy that they’re here to support me in things like health care.”To resolve these issues, but still maintain a degree of independence in light of increasing developing autonomy and identity, adolescents recommended parents to practice role modelling and actively support their attempts, within limits, at a healthier lifestyle. Nicholas stated:, preparing healthy leftovers and pre-packaged meals), physical  and sedentary  activities, and sleep habits . For example, Daniel explained, “I need an internet connection and a phone because then I can watch YouTube while I’m walking [basement treadmill].” and recommended his parents facilitate and support this combined activity. These examples showcased adolescents’ desire for achieving optimal balance in parents’ involvement in their lives, and can be of great importance to inform the conceptualization of lifestyle treatment interventions.Other adolescents echoed Nicholas’ preference for parental involvement in health-related decisions, and provided recommendations particularly for nutrition  that emphasize healthy, budgetfriendly foods. Courtney supported her recommendation with an anecdote:“More programs telling families like here are some recipe ideas that are healthy, but like really cheap or even a Facebook page or something because it’s really hard planning a meal that’s different every night that’s healthy, but isn’t like extremely expensive to plan. Right now, we’re trying to keep our grocery bill to like a hundred and forty every Sunday, but it has to feed four people and that also has to include buying animal food when we need it because we have six pets. My cousin [...] they actually have a book that they distributed at schools that was like a little recipe book, an idea book and stuff. So that was really useful.”Despite having access to a dietitian as part of multidisciplinary clinical care for pediatric weight management, one adolescent made a distinct recommendation to facilitate access to healthy foods, namely enhancing resources  as roadblocks to a healthy diet and recommended healthier alternatives. It is worth noting that the recounted imbalance of healthy foods in favour of unhealthy foods in school cafeterias may explain why most adolescents’ recommendations were to limit unhealthy foods rather than increase availability of healthy foods; the impact of this imbalance on adolescent food choices is a subject of speculation. Consider the examples Nicholas provides below:“I don’t think it’s unhealthy, so...” (Abdi). This raises the question of how and why adolescents attribute particular indicators and dimensions to healthy and unhealthy foods. Others, such as Dominic, speculated about the practicability of any changes:“My cafeteria has changed so often. When I started in 9thgrade, way before it was all poutines, pizza, fatty things. After, it changed to be healthy, salad, chicken, things like that. After, it changed again and they re-added the things [unhealthy foods] to make money, because everyone was buying that. But now, they put a mix of both. I mean it’s good for health, there’s other things [than unhealthy foods], but it’s hard to change things at school [for the better]. There’s still vending machines, there’s still things like that, but to change things at school [for the better], they try each year and it doesn’t work.”Unlike most affirmations for change, one adolescent did not perceive cafeteria food, except for fries, as being unhealthy, and shared no recommendations for change in this environment: , home economics) focused on healthy eating would be helpful to build practical knowledge, skills, and culinary techniques. However, enrolling in nutrition education classes at school was not without challenges; some adolescents expressed difficulties due to the popularity of these classes among students and limited available spaces, which is contrasted with vanishing home economics classes in many jurisdictions. Eliza notes:“My high school had foods class, and it’s almost like you don’t have a chance to take it. As soon as it opens, you’re placed on a waiting list to enroll in the class [...] maybe they should have had a second class.”A few adolescents shared that classes at school . Adolescents’ recommendations included airing more commercials of healthy foods and banning commercials of unhealthy foods. As stated by Amber, “Always, when they show the commercial, usually every single commercial is about junk food. And then you’ll see the one or two like special like good foods for you. That’s pretty much it. They should fix that.” Nixy provided support for these recommendations by commenting on the impact of food advertisement on her appetite:“Commercials for junk food make me hungry then I want food and then I go try to find food and I can’t find food so then I just drink chocolate milk. It’s repetitive. I just want commercials to stop, they’re annoying.”.Adolescents commented on the extent to which digital and commercial culture saturated their lives and highlighted the need to change the digital and commercial food environment to facilitate dietary changes. As Michel stated: “They always want to increase their revenue, they want to show how food is. It’s not always like in the picture. They show you a picture, it’s not really that, I mean…”Adolescents described other tactics used in food advertising, including the digital editing of fast food advertisements to make them look more appealing. As Dominic noted: “I watched a video with Photoshop, where they took a picture of a slice of pizza and made a perfect girl. It looks like a girl, but when they undid the picture and all the Photoshop, it was a slice of pizza [...] so, why do you need a model that has 6 feet of legs and the size of a twig or tooth pick when you can make a girl out of pizza. I saw this and I assure you I was mind blown.”Eliza described an exaggerated example of digital editing of food that is consistent with societal expectations surrounding women’s bodies:“fruits, and other foods that are like the best for you, there isn’t a lot of packaging. It’s just fruit. Then if it’s processed, it’s like super [colourful], it’s really in your face.”She continued, Here, I am thinking not only for the health of people, but also about the health of the planet. When you put all this candy near the cash register or when passing by checkout, you’re promoting more processed things that take time to produce, that need more resources I should say, natural resources and so they are less expensive. I would change these promotions to advertise items on sale that are healthy for the environment and us as well.”“Another element of food marketing that adolescents commented on was in relation to advertising manipulation in the commercial environment, which incited adolescents to make recommendations for environmental restructuring. Several adolescents noted promotion of junk foods in numerous aisles or in attractive places like near cash registers in supermarkets, and how they perceived this to be done strategically. As Nicholas stated:“With diet, probably make it so that there’s no pop vending machines at the pool because it’s easy for me to just get like two dollars and twenty-five cents and just go there and buy a pop and not actually go swimming.”Similarly, a few adolescents remarked the use of vending machines as a manipulative sales platform, particularly for sugar-sweetened beverages, and how these interfered with other planned activities; whether this trigger is equally observable among adolescents without obesity and how it influences their subsequent behaviors is unknown. For example, Daniel suggested to remove vending machines from his local swimming pool:It [sugar content] depends on the fruit. Vegetables aren’t as bad, they have more nutritional value than fruits.” (Mona). Dominic expanded on other likely drivers of this misclassification, “A lot of people have complained that fruits aren’t natural, they add chemicals to them, which means less fruits and vegetables were being purchased, which means less uptake in supermarkets.”Of note, the complexity of digital and commercial environments calls for more robust media and food literacy education as these too, may have influenced adolescents’ understanding of nutrition and lifestyle, and subsequently their recommendations. For example, while most adolescents correctly labelled fast foods as unhealthy and fruits and vegetables as healthy, a few adolescents incorrectly placed bagels and other cafeteria food in the healthy category and fruits in the unhealthy category due to their sugar content. Lack of knowledge on the digestive physiology of dietary fiber found in fruits and postprandial glycemic responses to sugar in fruits compared with other sources of sugar was alluded to by an adolescent who compared the sugar content of fruits and vegetables, and stated that “Collectively, adolescents’ discussions of food marketing revealed vulnerabilities to marketing which should be taken into account when considering regulations for digital and commercial environmental restructuring. Of note, while adolescents argued that marketing was often misleading, they did not comment on their logic behind supporting food regulation as a solution.And so, I would add more physical activity programs that are not only accessible for the community, and kids, but also teens. Because right now, it’s programs that are for kids.” (Nicholas).“Although some adolescents reported being aware of available physical activity opportunities at school and in their communities, others lacked information and recommended that opportunities be better disseminated to reach more adolescents. Those who were aware of opportunities commented on limited choices and variety of physical activity and recommended having physical activity opportunities tailored to different ages, religions, and interests. In support of this recommendation, adolescents discussed how the currently available physical activity programs were mostly designed for younger boys and girls:“Um, it would be cool if there were some more like uh teen programs that weren’t religion-based.” (Courtney).Another adolescent recounted a time when her parents did not allow her to join organized physical activities with religious components:“It had to be volunteering for ten hours and it had to be supporting physical activity, and so the main areas where they needed volunteers were like for when marathons were being run, but that’s only two hours at the most, so then it’s like great – now I need five more marathons somehow. So that made it really challenging. I checked with my high school and then checked with my sister’s junior high, and mostly just looking in the newspaper and Saint Albert’s has a website where you can see where they need help volunteer-wise, and they just didn’t really have anything. Yeah, so that was like a challenge with that so I just dropped the course because it was too stressful.”These issues are reminiscent of a dominant parenting style and likely hindered finding proper physical activities to partake in to fulfill physical activity requirements for one of her school classes:“For activity, it’d be nice if they had, I don’t know, just like a class where kids come in and kind of go in and do whatever they wanted activity-wise because they [school] have like a really big gym, so if there’s like a set time in the schedule for that to happen, but it wasn’t like gym class where they were telling you what to do kind of, you know? Like that would be really helpful.”Adolescents, including Courtney, also desired more flexibility in exercising at school, such as allowing flexibility in access to facilities during non-supervised times and limiting the degree of monitoring being done by authority figures during supervised times. Of note, some adolescents described a benefit to coaching by a fitness instructor, however preferred to not be monitored by their parents in after-school activities, which highlighted the narrow window of adolescents’ desire for receiving parental support and gaining individual autonomy. Courtney’s recommendation was as follows:, volleyball) over physical education  classes. Dominic and several other adolescents recommended merging the two classes:“I went for the other one [Sport Performance], but the only thing to change is to just put the two together. Do both, workout [Physical Education] and gym [Sport Performance] together, you don’t always have to play a sport, you can do both. This is what I would change.”For classes that did include supervision, adolescents described a preference for sports . They reported that distance would deter them from being physically active, even if they had a way to travel there, which is reminiscent of the earlier observed scenario on consumption of healthy foods being counteracted by efforts and time required for preparation: “It’s a drive [gym], I could bike there if I wanted to, but it’s a no.” (Chloe).Adolescents also recommended physical activity opportunities be made more accessible, citing issues related to cost and distance. Adolescents shared strong feelings about improving affordability of physical activity programs, recreation centres, and exercise equipment. As Abdi mentioned, “In sum, adolescents articulated a number of recommendations to improve physical activity provision, uptake, and sustainability, which was indicative of a disconnect between what is accessible and available for adolescents and their own agendas. That is, local, low-cost, enjoyable, and tailored opportunities to be active., skipping breakfast) and physical activity  choices due to feeling fatigued as a result of waking up early for school. When discussing sleep, adolescents described favouring later school start times to better match their sleep schedules. As such, adolescents made specific recommendations to delay school start times by approximately 1 hour. Courtney exclaimed:“I'd probably change so that I didn't start until like nine in the morning kind of thing, like kind of have a spare first thing because then I wouldn't have to get up until seven thirty whereas right now I'm getting up at like six thirty and this is only my fourth day of school, but I'll need to start getting up sooner so I can like do everything.”Adolescents commented on the complex interrelationship between lack of sleep and their other lifestyle habits. In particular, adolescents described impact on their dietary  [The experiences of adolescents in our study add to our understanding of the inherent challenges that they encounter within an environment most familiar to them – the home. Adolescents’ recommendations emphasized a supportive home environment with less parental conflict. Previous studies and reviews have shown links between youth weight and household organization, including sleep, screen time, and family meal routines , 23, hig Theory)  and are  Theory) . Authors Theory) . It is p Theory) , 26. The Theory) . WhetherSchools are a natural setting for effective nutrition and physical activity policies since it is where adolescents spend the majority of their day. Although many adolescents may bring food from home, up to 40% of adolescents’ calories are consumed at school, so the quality of foods and beverages available in this setting is crucial in promoting nutrition standards . As note, better understanding of ethical considerations and economic consequences of the interventions) and stakeholders involved  [School environments can also promote or limit healthy physical activity for adolescents. Interventions have shown increased physical activity levels in adolescents in schools once barriers were minimized or removed , but as faction) , 39. Stafaction) , and regadolescents in Canada remain exposed to junk food advertisements while awaiting amendments and approval of a Health Canada legislation to prohibit marketing of unhealthy food to children in other provinces and adolescents under the age of 17 [Adolescents made several recommendations for policymakers regarding food marketing, which is a powerful factor in the health of young people. The potency of our external environment that is in part responsible for the increased food intake observed today has been influenced dramatically by food advertisements . This isge of 17 . A similge of 17 . Failed ge of 17  and rapige of 17  cannot b, sleep) that dictate chronic disease risk, including obesity. The implications of our findings should be considered alongside our study limitations. Arguably of highest importance, our study relied on reported effectiveness, and future research investigating measured effectiveness is essential to complement identified recommendations as trusted strategies. Next, most participating adolescents were of Caucasian origin, and adolescent experiences and recommendations may be varied sociodemographically. To increase transferability of our findings, we included both Anglophone and Francophone participants from two geographically diverse provinces in Canada, thereby strengthening implications on a national level. Lastly, adolescents may have been limited in their ability to articulate some of their experiences and formulate recommendations due to challenges in delving into macro-level factors. To minimize these possibilities, the interviewer provided adolescents with numerous probes and opportunities to refine or expand on their answers at multiple time points during the interview.Overall, our findings suggest the need to broaden the framing of obesity-related policy to go beyond nutrition and physical activity and target other modifiable lifestyle areas . Reporting checklist for qualitative research.


Cigarette smoking is highly prevalent among persons living with the human immunodeficiency virus (HIV) (PLWH), with rates as high 50% as compared to 14% in the general U.S. population. Tobacco use causes morbidity and mortality in PLWH, and tobacco-related harm is substantially higher in PLWH than smokers in the general population, providing the scientific premise for developing effective tobacco cessation interventions in this population. To better address this issue, we conducted six focus group sessions with 45 African American smokers who are living with HIV to understand the barriers to smoking cessation and the strategies that would be helpful to overcome these barriers. We organized our findings by the Phase-Based Model of Smoking Treatment to understand the intervention components that are needed at each phase to help PLWH successfully quit smoking. Participants in our focus group sessions articulated key components for incorporation into tobacco cessation intervention for PLWH: a personalized plan for quitting, reminders about that plan, and a support system. Participants thought that their HIV and tobacco use were disassociated. Participants described barriers to the use of pharmacotherapy, including adverse side effects of the gum and patch and concerns about the negative health effects of some oral medications. Substance use was identified as a commonly co-occurring condition as well as a barrier to successfully ceasing to smoke tobacco products. In summary, these findings offer information on the components of a tobacco cessation intervention for PLWH, namely reminders, a support system, substance use treatment, and monitoring to prevent relapse. Cigarette smoking is highly prevalent among persons living with the human immunodeficiency virus (HIV) (PLWH). The prevalence of smoking in the general U.S. population has gradually declined to 14% in 2017; the lowest rate ever recorded ,4. In ouTobacco use causes morbidity and mortality in PLWH, and tobacco-related harm is substantially higher in PLWH than smokers in the general population. The high rates of smoking present grave health implications for PLWH, placing them at increased risk for: bacterial pneumonias , acute bEvidence-based interventions for tobacco cessation exist, but there are hurdles to their effective use by PLWH. Research shows that, in addition to accelerating the development of adverse health consequences of tobacco use, intervening to improve the rate of smoking cessation has the potential to significantly improve the health and longevity of HIV-positive smokers. Many innovative and effective smoking-cessation treatments, both behavioral and pharmacologic, have been developed over the past several decades , but theGuided by the Phase-Based Model (PBM) of Smoking Treatment , we sougAll study activities were approved by the Columbia University Medical Center Institutional Review Board (IRB). Participants were recruited from our study registry of research participants who agreed to be contacted for future use and through study flyers posted at the Columbia-University-affiliated HIV clinic. Inclusion criteria were: PLWH aged 18 and older, able to read and write in English, current smoker, smoked at least 100 cigarettes in their lifetime, seeking cessation treatment, and self-identified as Black/African American. We conducted six focus group sessions with 45 PLWH. Prior to the start of the focus group session, participants completed a demographic survey administered via Qualtrics Software and then watched the Pathways to Freedom: Leading the Way to a Smoke-Free Community© (PTF) video . PTF wasWe audio-recorded and transcribed verbatim all focus group discussions, and analyzed them using a thematic approach. Data were organized by the Phase-Based Model (PBM) of Smoking Treatment . This MoThe first author  reviewed all transcripts and organized them according to the Phases of the Phase-Based Model of Smoking Treatment , and theForty-five PLWH self-identifying as Black/African-American participated in the smoking cessation focus group sessions and completed the Qualtrics survey. Participants’ ages ranged from 28 to 63 years with a mean age of 52 years (SD 7.78). Twenty-four (53.3%) of the participants were female and 19 (42.2%) were male. Forty-three (95.5%) of the participants self-identified as non-Hispanic and 2 (4.4%) self-identified as Hispanic/Latino. Thirty-one (68.8%) members of the study sample reported their most recent viral load as undetectable (<200 copies/mL). Further details on the sample demographics can be found in Findings from the focus group session are organized by each of the phases of the model. The definition for each phase as well as a sample quote are illustrated in Motivation phase comprises smokers unwilling to make a quit attempt. Despite our inclusion criterion of people who want to quit smoking, we had one participant who was adamant during the focus group session that she was not interested in quitting smoking. She explained, “I was diagnosed with HIV in 2011. Now for me, it didn’t affect nothing. I go to the doctor. My health is A-1. My doctor is telling me; hey baby, what you doing? Are you still smoking cigarettes? Yeah. I think you need to quit, but I ain’t going to tell you not to. My job, my drug test is cool. I do what I do. But as far as my health, it don’t affect me.” Another woman confided in the group and said, “To be honest with you, I don’t want to quit, even though all of the negative sides there are. I just don’t want to quit. I love that jack pull. I mean I love it and I crave it”.The On the other hand, there were many participants who appreciated the health effects of smoking. One participant said, “So, it’s affecting our immune system, which means we’re more susceptible to things. And under the hood, it’s killing me. I hate stairs and I hate hills.” Another participant agreed and said, “I can’t do steps, either.” Another participant described, “Cigarettes are not good for my skin. It breaks me out every time.” Participants acknowledged that some of their health conditions were directly attributable to their tobacco use. For example, one participant said, “I have COPD [chronic obstructive pulmonary disorder] now. I’m just upscaled from being asthmatic to COPD, and I know I have problems breathing. And, when I don’t have cigarettes, it seems like I breathe better.”Participants highlighted the exacerbation of negative health effects of smoking for PLWH. One person explained that the video needed to emphasize the urgency of quitting smoking for PLWH. He said, “Well maybe what might be missing…it may be the urgency that people with HIV have, when quitting. Only because the HIV complicates what you’re going to get from smoking anyway. So if you’re likely to get lung cancer, an HIV-infected person is like double.” Participants acknowledged that smoking exacerbated their health conditions, stating, “With HIV and smoking cigarettes, it makes it ten times worse. You can’t have surgeries because you don’t heal properly when you are smoking cigarettes.” Finally, a participant attributed the extent of his pain to smoking and explained, “That pain probably would be more suppressed had I wouldn’t have been smoking cigarettes.”Preparation phase. In this phase, the smoker is willing to make a quit attempt, but the patient will likely need to use some form of pharmacotherapy to be able to achieve a successful quit attempt. Participants in the focus groups provided suggestions for their peers on pharmacotherapy-based treatment that they heard had worked or they had tried and had been helpful. Participants’ discussion of their use of pharmacotherapy was mostly focused on the Preparation Phase since most of our study participants had not quit smoking and were focused on how to use the pharmacotherapy in the future when they decided to stop smoking .”Maintenance phase follows the establishment of initial abstinence in the Cessation phase and is of indeterminate length. The chief goal is the preservation or restoration of abstinence, while representative challenges include flagging motivation, poor adherence to interventions, and the transition of lapses to relapse. A number of participants had previously quit smoking for greater than the immediate post-quit period and described the challenges and encounters that they faced in maintaining tobacco cessation. One man explained, “The most I went was six months. And I walked in the store. And I just said; let me get a pack of Newport. I just walked in the store, six months, just let me get a pack of Newport. The six months that I stopped was the most. And that was in the 80s.” Another participant described that the craving overtook her even after she finally quit and described, “I did so many smoking things and I quit it, then one day I was like, just any little thing, the craving was so strong that I walked to the store and I don’t buy one cigarette, got to buy the whole pack because I’m already messed up.” Stressful life events also make maintenance very challenging as one participant said, “I stopped one time for three years. And you know. So, as soon as one of my siblings passed away, you know, I was at the wake, and had depression, and I picked up a cigarette and smoked.” Finally, one participant who was receiving treatment for a brain tumor did not smoke for 6 months while hospitalized and then when he was discharged “they gave me the cigarettes back. And the lighter. As soon as I came out of the hospital, I lit a cigarette, after not having a cigarette for like six months.”The Participants thought it would be important to have tools to maintain their tobacco cessation. For instance, one participant said that he wanted a sensor to stop him from smoking. He described, “So when you do decide to smoke a cigarette, it says; you need to put this cigarette down.” Related to this suggestion a woman in a different focus group said, “It (the smart watch) needs to have a voice on it so when you do decide to smoke…It can tell you; you need to stop.” Another participant wanted a support system and suggested, “How about a hotline number to call somebody?”Our focus group findings were organized by the Phase-Based Model to better inform the components of an intervention that would be appropriate for PLWH who self-identify as African American tobacco smokers. Given that smokers typically undergo numerous stages through the process of tobacco cessation ,42, bettMany innovative and effective smoking-cessation treatments, both behavioral and pharmacologic, have been developed for tobacco cessation . HoweverParticipants in our focus group sessions articulated key components for incorporation into a tobacco-cessation intervention for PLWH. First, participants stressed the need for a personalized plan for quitting, reminders about that plan, and to stop smoking when someone is about to light-up. Participants thought that their HIV and tobacco use were disassociated and therefore a tobacco-cessation intervention may focus on stress and depression associated with living with HIV, but these may not need to be disease specific to HIV and may relate to any chronic illness. Finally, participants described the need for a support system and how useful it would be to talk to someone who can talk them out of lighting up.Although there is strong evidence for the effectiveness of pharmacotherapy in supporting tobacco cessation ,44,45,46Importantly, there is strong evidence that tobacco use commonly co-occurs with other substance use. Alcohol use is highly correlated with nicotine dependence in PLWH . AdditioTaken together, these findings offer useful information on the components of a tobacco cessation intervention for African American PLWH who are tobacco smokers, namely reminders, a support system, and monitoring to prevent relapse. Future work should explore the practicality of pharmacotherapy for PLWH who self-identify as African American tobacco smokers given the extensive barriers that were identified in our focus group sessions. Finally, future interventions for tobacco cessation in PLWH will likely need to incorporate substance use treatment as this was identified as a commonly co-occurring condition as well as a barrier to successfully ceasing to smoke tobacco products.


Mahouts, often known as elephant handlers, or by other terms, such as oozie in Myanmar, work closely with captive Asian elephants in elephant range countries. This work usually involves taking responsibility for just one elephant. The daily tasks of mahouts can include feeding, cleaning or bathing elephants, treating minor medical conditions, participating in training, and riding elephants in order for them to achieve specific tasks, such as transportation of materials, religious functions, or tourism activities. Because of their close interactions with elephants, mahouts have knowledge of elephants that stretches from the cultural to the behavioral and ecological. In this study, I interviewed mahouts in their own languages with a translator, using a mix of short and open-ended questions. The second kind of questions allowed mahouts to elaborate in as much detail as they wanted on their experience. The methods allowed me to collect perspectives on welfare and the associations with elephants in Nepal. I also asked questions about how long they had worked with elephants and how many elephants they worked with. The mahouts were not a uniform group, with differences in age, experience, and perspectives. The mahouts gave their most extensive comments when discussing elephant welfare, particularly on the use of fenced enclosures versus chains, elephant diet, and interactions with domestic animals. The input of mahouts could be useful for proposing and implementing plans for elephant welfare in range countries.The skills, knowledge, and expertise of mahouts have been recognized by organizations and individual managers who are responsible for captive elephants and by academics, where they have been a source of studies from the ethnographic to animal behavior research. In this study, I used semi-structured interviews in local languages to explore individual experiences of mahouts in Nepal. I also investigated perspectives on elephant welfare, including the use of corral (fenced) enclosures. I undertook a further key informant interview in English to gain more discursive perspectives on the topics. Our results revealed that mahouts at the study site are unlikely to come from multi-generational families of mahouts. All mahouts referenced the religious significance of elephants in their country when describing broader local perspectives. Many mahouts explained both positive and negative implications for differing strategies in housing captive elephants, often balanced the competing interests of elephant welfare with their own need for elephants to follow verbal communication, and their responsibility for the safety of the elephants, other staff, and tourists. The fine-balancing perspectives of mahouts, taking both humans and elephants into account, underlines their role as an important source of knowledge of captive Asian elephants in range countries, and their potential role as co-producers of research linked to welfare. This approach could also be of relevance to the welfare of ex-situ Asian elephants. Elephas maximus) in captivity can live in a wide range of different settings. These include, but are not limited to zoos and safari parks [Asian elephants , but within visual, auditory, and olfactory contact of another elephant or elephants, or in a shared corral with one other elephant (n = 6). In total, the corrals cover 15 acres. All elephants overnight in the corrals. They also feed in their corrals.This study was conducted at the Tiger Tops Tharu Lodge (27°34′10.5″ N 84°06′06.9″ E), located just outside of Chitwan National Park, Nepal in January 2019 over 10 days. The Lodge’s primary function is for-profit wildlife tourism. It also engages in philanthropy as part of its wider activities. The mahouts at the lodge are from the local Tharu communities. Their working conditions and economical security may be higher than that of mahouts at other camps because of the “high-end” nature of their workplace. Ten female Asian elephants were housed by the Lodge, each in a fenced enclosure known as a corral. They were in the corral alone  also prepared food including bundling grasses into bales, making kuchis or “elephant sandwiches”, a mix of chickpeas, molasses, and rock salt wrapped with paddy. These wraps are given to elephants as a supplement to their primary diet. The second and first mahouts also clean the corral areas and remove dung to be utilized as fertilizer. The elephants might be engaged in tourism-related activities for up to two blocks of 2–3 h per day.The corral system was introduced in 2016, after the elephants were moved from being kept in the National Park to just outside of it. Before the move, they were kept on a chain (1.5 m long) overnight. It was attached to one leg and the elephants were provided with a cover over this area to protect them from dew and rain. They spent time foraging in the surrounding forest areas in the day. They were involved in the same suite of tourism-related activities, which then also included tourist riding. The change to the system of corral living, made as a welfare decision to improve the living conditions of the elephants, marks a significant transition in the lives of the elephants and the working lives of the mahouts.Interview tools are often used in cases in which answers to open-ended questions are solicited. They are increasingly used in ecological and environmental sciences in order to obtain information about attitudes, behaviors, and preferences, amongst others . First, The purpose of the interviews was to determine the information that mahouts were willing and did share in such a context, because if decisions about welfare and management are made, the mahout perspectives are solicited in such a way. Whilst the mahouts might not feel comfortable to share all their views in their workplace and with the knowledge that they are being recorded, it is the views they are willing to share in those circumstances that are most salient for contributions that can be made to welfare.In addition to the mahout interviews, I conducted one more discursive key-informant interview with a previous head mahout and current naturalist, also employed at the site. Mahouts frame and share their knowledge and experience not in the structured interview framework, but in stories like these. That is how knowledge about being a “good mahout” is transferred. If researchers want to understand how the mahouts conceptualize mahout-elephant relationships, these stories may communicate a lot of information in a format that mahouts develop and are comfortable with themselves, rather than one formed and chosen by the researcher. The interview was conducted in English and was 1 h 35 min long. This interview also followed a protocol, but the interviewee chose to raise several points and experiences, which led to further questions in addition to the original protocol. The interview was audio-recorded and transcribed in full verbatim. All interviewees provided informed consent and were afforded the opportunity to withdraw consent at any time in line with the ethical approval for this project by the University of Hong Kong.Summary statistics, including mean and range, were calculated for the following numeric variables: time worked with the current elephant (years) and time worked with elephants in total (years). For the “yes or no” or either/or questions, the number of mahouts was totaled. These questions were: “Has your elephant had any health problems?”, “Have they had a baby ?”, “Where is the elephant (elephant name) happier: in the corral or on the chain?”, and “is the elephant (elephant name) happier here (in the buffer zone) or in the jungle ?” The questions were framed to avoid neutral responses. For the remaining questions, the text was analyzed to extract themes and the most common responses. These questions were: “What activities do you do with your elephant?”, “What is the personality of your elephant, what are her characteristics?”, “How does she interact with other humans?”, “How well do mahouts understand elephants?”, and “Why?” follow-ups to the questions on the elephant’s happiness in different keeping situations.Rather than a priori making any assumptions about the responses or creating categories, the entire interview texts (English translation) were transcribed. This allowed a search for positive, such as “good”, “well”, and negative descriptors, such as “bad” and “rude”, in the text, and these were highlighted in the analysis. Searches for words associated with comparison were also used, such as “but”, “same” and so on, to analyze the balancing of responses by the mahouts. If concepts such as “respect” or “freedom” were raised in responses, they were presented. To avoid the researcher misclassifying the responses, the translation of the mahouts’ words are used and reported here as quotes, to allow the reader to consider the responses themselves.For the more extended naturalist interview, key themes were extracted by the author from the transcribed interview in English that indicated mahout perspectives, since the interviewee had been a mahout, and his perspectives gained from training and managing mahouts. In particular, the meaning of his lived experience as he reflected on it and the descriptors he chose for mahouts and elephants were used in this analysis. In the case of “traditional knowledge” it is often through such stories and experiences that perspectives are developed, imagined, and reimagined.All 10 mahouts and one naturalist interviewed were male and all currently worked with female elephants. The mahouts reported years of experience with their current elephant as ranging from 6 months to 30 years  10.5) see . Their yn = 2) and Sitamali (n = 5). These purchases took place around 30 years ago.The elephants themselves ranged in age from 13 to 58 years  see . ExcludiThe mahouts reported the following activities as part of their routines: cleaning the enclosure, feeding the elephant, cutting grass, bathing the elephant, taking the elephant to water, trekking with the elephant in the forest, walking with their elephant in the camp, making “elephant sandwiches” , feeding the elephant by hand, and checking the elephants when they were sleeping. They described interacting throughout the day, with one mahout emphasizing that he thought of his elephant throughout the day, and even at night.The questions on elephant personality and interactions generated overlapping responses. Although the mahouts were not asked to frame their responses in terms of positives and negatives, eight of the 10 mahouts referred to “good” or “nice” or “bad” behavior. Examples of the positives include responsiveness to mahout directions: “She understand my verbal command, accept any verbal command…talk with her, very good understand”. Another such characteristic was not reacting to other animals: “She behave very nice. Not any dangerous animals, if any new people go in front, not dog, cow, buffalo, and she like it.” In terms of “bad” behavior, not responding to verbal cues was categories as “bad”, another example given of “bad” behavior was: “Every evening she makes a loud sound.” Behaviors associated with vocalizing to obtain food and reacting with aggression to other mahouts, visiting humans, and wild or domestic animals were viewed as negative. The questions linked to personality were mainly discussed through these specific behaviors. Many of the mahouts framed their answers as “she is good, but one thing she does is bad”, and listing those things. This suggests that the mahout position comes with an expectation of elephants following verbal signals, not reacting to other elephants, other animals, and humans, and not vocalizing to obtain food. Four of the mahouts did not give any negative examples of their elephant’s behavior. One of the mahouts characterized his elephant as “hard” to work with, but did not use any negative terms in describing her behavior. Instead, he spoke of the importance of how mahouts behave around this elephant: “The elephant give little bit sign to the mahout. At that time the mahout must be polite”. One mahout spoke about his relationship with his elephant and how that related to her behavior: “If we love each other feeding time, grass cutting time, she enjoys that.”When discussing the interactions of the elephants with humans, the mahouts were primarily concerned with safety of tourists and also the ability of other mahouts to interact with their elephant. Two of the mahouts stated their elephants did not react to other humans: “Nothing any happens.” Two of the mahouts mentioned that the mahout should be present when their elephant is interacting with tourists, without being prompted to discuss safety: “Don’t do the dangerous behavior”. Three of the mahouts mentioned that new humans could arouse expectations of food provisioning, for example: “Any guest, Nepali or foreigner, and they have food, she makes a whooshing sound with the trunk. That means begging, that means, come to me, give grass, sugar cane, apple.” Six of the elephants mentioned interactions between their elephant and other mahouts. Four of these highlighted that the old mahout must be present if a new mahout is taking over: “If the new driver doesn’t understand, old driver can teach him.” Three of the mahouts mentioned that their elephant reacts negatively to other mahouts: “She becomes rude”, “she doesn’t accept”, “if goes away from mahout…If you would like to feed, only put on ground, not in mouth. From far distance.” One of the mahouts gave his answer from the elephant perspective, highlighting that the interaction was two-way: “Elephants feel this is a nice person come to my corral, give to me some food and grass.”When discussing the understanding between mahouts and elephants, all of the mahouts expressed there was a level of understanding between elephants and mahouts. Four of the 10 mahouts expressly referred to verbal communication: “My verbal command very well understand because (I) gives love to the elephant, elephant don’t accept any command without love.” One mahout also discussed the role of “respect” in the understanding between him and his elephant. Another referred to nuance in his relationship: “They understand but sometimes is not agree.” In the context of broader perceptions of elephants in Nepal, all of the mahouts referred to the religious significance of elephants in Nepal: “Nepali people everybody say they are god.” Or: “The Nepali people say the elephant is goddess or god most have the respect this is god.” Four of the mahouts referred to specific practices that people engage in: “Most people if going to the countryside, if coming to the elephant, they pray. They say this elephant is god. If they pray, my life is getting bit longer. If I pray, I am feeling more healthy. They believe.” Or: “Sometimes try to make the red mark on the head. (Some) give to the money, food, and praying.”The mahouts were also able to discuss a specific change that had affected their camp: the elephants had moved from the national park to the community area outside and also, they had new enclosures, fenced corrals, rather than being on chains. Nine of the 10 mahouts said their elephant was “happier” in the corral . Six of In comparing the elephants living inside to outside of the national park, the mahouts also weighed positive and negative aspects of both. Eight of the 10 mahouts specified that their elephant was happier in the jungle  as opposed to the current location (buffer zone) . Five ofIn addition to the semi-structured interviews, a discursive interview was undertaken with one individual who had been a mahout since 1988 and now worked as a naturalist since 2004. As with mahout interviews, he highlighted the importance of understanding between mahouts and elephants, respecting the autonomy of elephants, and that within a mahout and elephant relationship, complex interactions may take place. He did this primarily with two stories. In the first story, he spoke of being a new mahout. He had not gone with the elephant he was working with into the forest as he was a junior mahout, and his main tasks were cleaning and food preparation. The elephant was also new to the camp and had not been around wild animals before: “Ram Kali (the elephant) before I think never see rhino. Never see tiger.”A fellow mahout decided it was time for the young mahout and Ram Kali to have their first trip into the forest. It was not long before they encountered a rhino. He describes a tense encounter: “And elephant does not understand, what is these animals? … afraided rhino also.” He noticed the fear of the elephant, whilst he and his friend sat on the elephant’s neck and back. Suddenly, the elephant reacted in response to the rhino and ran away. The more experienced mahout was thrown from her back, and to the ground, his sickle cutting through the younger mahout’s clothes. The younger mahout attempted to stay on the elephant’s neck, but he could not grip well. His only attachment was to the rope around her neck. Gradually, he slipped, until he was hanging upside down between her front legs from the rope. The elephant continued to run. “I am a hanging here… and I’m saying stop, stop.” He feared he would soon fall and die: “This is the last day.” However, the elephant used her trunk to cradle him and picked up her pace. When she slowed, he was able to free himself, but the elephant disappeared into the long grass. The young mahout was alone. He did not know whether his friend had survived the fall, particularly being so close to the rhino. However, he decided to find his elephant and search for his friend: “I’ll walking, walking and calling to my friend and we had a very far away, about five six kilometer distance, left my friend and me. And my friend walking, walking.” But the two mahouts eventually found each other, celebrating their survival: “We laughing and then we say, ok, well tonight we do need a big party plan because we have new life.” Bringing back the elephant proved to be more difficult. The elephant’s fear was palpable and she ran away every time they got close. They worked together to rejoin with the elephant: “I talking to her very polite…Elephant has the feel, my driver speak very polite.” They decided one would hold her tail and the other hold her ear and gain a foothold so he could climb up again. After several failed attempts, they succeeded. All three returned back to the camp, exhausted, but before nightfall. That night, they celebrated their safe return. He reflected on what he had learned from the experience: “Elephant and driver is very good relationship, if driver have got any problem, (the elephant) can help.”In the second story, he describes returning from the thick forest with his elephant when the night was falling. “From the place to the tented camp one and a half hours and very dense and very dangerous place. There find wild elephant, rhino, tiger, sloth bear, leopard, very small track.” They come across a rhino and startle it: “I’m pulling the rope (tied to the elephant) and rope sound “quarrrrrrrr” and rhino is afraid they heard, my sound and go “tuh-tuh-tuh-tuh-tuh” and elephant down.” He describes falling in the commotion and injuring himself: “My nose is broken…my shirt is all tear.” He lay unconscious on the ground, “elephant feel I am not wake up and the elephant come here.” The elephant stood over him, attempting from time to time to move his body with her trunk. “I’m middle of two legs front, two legs back and I’m middle. And about my one hour after I wake up and I’m looking, plenty dark.” When he finally woke up, he was surprised and relieved to see the elephant had stayed with him as he lay bleeding and unconscious. “Really this elephant is god. Real friend, better than human. And I’m climb up, touch here, from here to here all of the blood.” He describes seeing his injuries when he returned to camp and feeling grateful to the elephant for standing by him: “Two time, I’m saying, thank God, thank elephant.”He then explains, given his experience, what he thinks makes a good mahout. Of primary importance is a genuine interest in elephants and welfare: “Who is very interested elephant and very loving to elephant, that kind of person and he keep everything every time you have.” He said that such mahouts should be rewarded and promoted, “need a behavior very nice, very nice behave, we have him to give nice salary.” He noted that the ease with which mahouts could communicate to elephants and the responsiveness of the elephants were things he looked for when determining whether a mahout was effective. He mentioned that some mahouts might use their whole leg when riding an elephant, but a skilled mahout only needed to use the lower part. His view is that mahouts should be judged on their “nice” behavior around elephants, dovetailing with the “good” and “bad” behavior discussion that the mahouts themselves engage in regarding elephant personality.The study results showed some differences in the composition of the mahout community in comparison to other studies. At this site, the mahouts were not from families of mahouts. However, they did have relatively long associations with their elephants and also had extensive experience with other elephants at the site. This pattern is suggestive of a specialized group who are retained by an employer. The recent shorter relationships between elephants and younger mahouts were not observed as in Myanmar . HoweverMahouts have been a source of information on elephant behavior and personality in a number of studies. Whilst I do not question their ability to contribute to studies, researchers should also be aware of their questions. I found that when mahouts are directly asked about their elephant’s personality and characteristics, the responses followed a specific format: the assumption was that all the elephants would exhibit “good” behavior, associated with compliance and responsiveness to mahout communication. Mahouts highlighted “bad” behaviors, usually linked to aggression directed at humans or conspecifics, fear of wild animals, or behavior associated with acquiring food. This pattern underlined the expectations of mahouts in terms of elephant behavior and their standards. Beyond that, it emphasizes the importance of safety and that mahouts set great store in their ability to direct and communicate with elephants. In systems where there are no physical barriers between elephants and their handlers, it is entirely understandable that this should be a priority, and has been highlighted in other studies . More peSince mahouts occupy a unique and multi-dimensional position in terms of human-elephant relationships, it is not surprising that their answers were revealing concerning human-elephant interactions. One striking feature was the seeming division of the “sacred” and “every day” elements of the interaction. When mahouts described their relationship with elephants, they focused on their mahout role, the tasks they undertake as part of it, and contrasted their relationship with the elephant with that of the elephant with other mahouts. When they discussed how Nepali people perceive elephants, the sacred was central. It was one of the points on which the mahouts achieved a consensus. This could be because the mahouts were participating in the interviews at their place of work, and assumed that the interviewer was interested in their work. However, it still shows that the mahouts have important relationships with elephants in addition to those they perceive in Nepali people who have less contact with elephants. The only other example of mahouts having such a view came in the stories of the former mahout when he referred to the elephant saving his life. In the same story, he elevated the relationship, stating that elephants were better than humans.The stories and reflections of the experienced mahout and naturalist spoke to these themes. They also revealed the singularity of mahout experiences and relationships. The sample size of this study was small in terms of mahout numbers, but also covered mahouts working with all elephants at the site. Moreover, the key-informant interview approach taken with one allowed more depth and expression of his personal experience in his own words, unlimited by an interview structure presented by a researcher. If researchers aim to study how concepts such as “traditional knowledge” intersect with their study systems, more open approaches should be taken to sources of such knowledge, including through stories . If an iBecause the elephants are managed in such an individual way, these specific associations matter as well as broad patterns and trends among mahouts. Elephants do not experience the average. Rather, they experience their specific mahouts. That the mahout and naturalist wanted to highlight formative stories and the trust he had in elephants is reflective of his mahout experience. Risks exist, but he worked with the elephant through them, and the stories had happy endings, with the mutualism between human and elephant enabling it. What is important in the stories might not be the content itself, instead how the mahout chose to present his extensive experience: in terms of cooperation, thankfulness, learning, and positivity. That as an ideal of the mahout-elephant relationship is a topic that should be the subject of further research.Discussing the understanding between mahouts and elephants gave the mahouts some space to describe complex concepts such as “love” and “respect” and their role in the relationship. This discussion illustrated the layers of interaction between mahout and elephants that they can express in their own terms. The mahout interviews give the opportunity not just to extract quantitative information, but also allow space for reflection and consideration of the complexity on the part of the mahout. The mahouts never explicitly humanize the elephants in question, but implicitly discuss that the elephants can share love and trust with them. They show that those concepts are not limited to humans in the mahout experience. The answer from one mahout to the question “Do mahouts and elephants understand each other?” was illustrative of this, and the humor with which mahouts can express it: “They understand, but not always agree.”The discussion about enclosures was extremely revealing of the balancing that is part of mahout life. The consensus was that elephants were happier in corral enclosures, because of the “freedom” it gave elephants. However, the mahouts expressed they had concerns about whether elephants still followed their verbal signals with the same adherence. This presents not just a push and pull between control and freedom and how that operates for captive elephants; it also shows that mahouts do not always prefer the strategy that is easiest for them. Instead they are considering safety and welfare for all the humans and animals in the free contact system. They were in favor of enclosures that maximize an elephant’s ability to make choices for itself, as long as it still responds to the mahout. This theme is relevant to a range of captive species and methods that are used to ensure that captive animals respond to human communication within their enclosures could be relevant to mahouts, such as the target training methods often used in protected contact conditions .Bubalus bubalis), dogs (Canis familiaris), and other domestic species shows nuance in the perception of the mahouts’ views of what wildness is. Although elephants are captive, their residence should be in the “wild” area with other wild animals. This perception of the best place for elephants being in the wild was also presented in an earlier study in Nepal [The discussion of being in the national park versus the human-occupied zone was also a space that allowed mahouts to explore concepts of freedom and choice. In particular, food choice and variety were raised. Food is a crucial point in any captive elephant site because of the quantities required . The mahin Nepal . The graThis study highlights the delicate balancing involved in mahout perspectives and the multiple roles they take in their relationship with elephants, as nurturer and feeder, protector, dependent, teacher, cooperator, and others. Mahouts have long been a source of information for a range of fields ,6,10, whMahouts and others working with elephants, such as the naturalist with decades of mahout experience who gave a key informant interview, represent an opportunity for the co-production of knowledge and co-production of solutions for captive elephants. Co-production can be defined as “the collaborative process of bringing a plurality of knowledge sources and types together to address a defined problem and build an integrated or systems-oriented understanding of that problem” . It is oFurthermore, the complexity of mahout answers speaks to their empathy and their continual balancing of their roles and responsibilities. Their inclusive approach to welfare, covering diffuse concepts such as “freedom” and concrete concerns such as food variety, can be used to inform our definitions and approaches to those concepts. Stakeholder participation and co-production with stakeholders are increasingly prominent topics in conservation ,35,36, b


Gestalt for psychiatric disorders and guided clinical as well as scientific progress in modern psychiatry. In the wake of the immense technical advances, however, psychopathology has been increasingly marginalized by neurobiological, genetic, and neuropsychological research. This ongoing erosion of psychiatric phenomenology is further fostered by clinical casualness as well as pressured health care and research systems. The skill to precisely and carefully assess psychopathology in a qualified manner used to be a core attribute of mental health professionals, but today's curricula pay increasingly less attention to its training, thus blurring the border between pathology and variants of the “normal” further. Despite all prophecies that psychopathology was doomed, and with neurobiological parameters having yet to show their differential-diagnostic superiority and value for differential indication, psychiatric diagnosis continues to rely exclusively on psychopathology in DSM-5 and ICD-11. Their categorical systematic, however, is equally challenged, and, supported by advances in machine learning, a personalized symptom-based approach to precision psychiatry is increasingly advocated. The current paper reviews the objectives of psychopathology and the recent debate on the role of psychopathology in future precision psychiatry—from guiding neurobiological research by relating neurobiological changes to patients' experiences to giving a framework to the psychiatric encounter. It concludes that contemporary research and clinic in psychiatry do not need less but rather more differentiated psychopathologic approaches in order to develop approaches that integrate professional knowledge and patients' experience.Psychopathology is the scientific exploration of abnormal mental states that, for more than a century, has provided a  The term “psychopathology,” from the Greek ψυχminghaus , Englishminghaus –10. To Jminghaus , 6, 11. minghaus . In the In line with Jaspers' general definition, psychopathology is currently broadly defined, e.g., as “the scientific exploration of abnormal mental states” “We need to make a serious investment in training a new generation of real experts in the science and art of psychopathology. Otherwise, we high-tech scientists may wake up in 10 years  and discover that we face a silent spring. Applying technology without the companionship of wise clinicians with specific expertise in psychopathology will be a lonely, sterile, and perhaps fruitless enterprise.”FS-L was responsible for the conception of the work and drafted the first version of this work. SS and AT revised it critically for important intellectual contents. All authors provided approval for publication of the content.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.