Being physically active is associated with better health, but rates of physical inactivity are high amongst adults in England. Active travel, defined as making routine journeys in physically active ways, has been identified as a potential solution. There is a lack of research into how modal shift towards active travel can be encouraged in market towns. The aims of the current study are to understand how new cycling and walking infrastructure and community activation projects might support modal shift to active travel amongst commuters and older adults in market towns.This was a qualitative study using focus groups, ‘go-along’ interviews, and in-depth interviews as the main methods of data collection. Thirty-three participants (12 commuters and 21 older adults) took part across six focus groups. Eight of these also completed a go-along interview . Data were analysed using the Framework method of thematic analysis.Market towns have existing advantages for active travel, being relatively compact with most routine destinations within easy reach. The barriers to active travel faced by older adults and commuters in market towns are similar to those in cities; poor infrastructure remains the key barrier. Poorly maintained paths are hazardous for older pedestrians, and low-or-no lighting and lack of well-connected, delineated cycle routes deter both commuters and older adults. One factor which does appear qualitatively different to cities is participants’ perception that the social norms of cycling differ in market towns.Policies to promote active travel in market towns are most likely to be effective when they include measures targeted at both individual behaviour change and population level measures like large-scale infrastructure improvements. Initiatives to change the social norms around cycling may be required to increase active travel rates.The online version contains supplementary material available at 10.1186/s12889-023-15573-3. Physical inactivity has been described as a global pandemic , with a Cycling and walking will be the natural first choice for many journeys with half of all journeys in towns and cities being cycled or walked by 2030”  doing his good deed for the day, or perhaps I should say it is, it’s actually [me] being aware that the people behind me by now are getting frustrated, and that puts me at risk.Older adult (M)Many of the perceived barriers to cycling for older adults were about poor infrastructure. Some reported feeling too unsafe to cycle on roads, but a lack of off-road cycle paths from door to destination meant they would not cycle for routine trips. Cycling on roads presented a number of problems, including being caught up in congested traffic, breathing in fumes, dealing with narrow streets which led to either ‘close passes’ from motorised traffic, or a perception that the cyclist was holding up traffic and frustrating drivers.So I don’t cycle that way. I have to drive to play football now. There's only one person who dares to cycle on that road. The vans are in such a rush delivering their Amazon stuff that they squeeze past you. So I don’t- that’s another reason I don’t cycle.Older adult (M)In one new housing estate in Bicester, traffic calming measures built into the design include high kerbs, narrow carriageways and green barriers between carriageways to deter overtaking. These measures deterred some older adults from cycling because of insufficient opportunity for vehicles to pass cyclists, leading to a perception that they are at increased risk.Dedicated, off-road cycle paths were preferred to using the road network. However where these existed in the market towns they were often poorly lit and maintained; again paths overgrown with vegetation, or too dark in the evenings or in winter, would not be used by most older adults.There’s a section of path if you get into [my estate], after the new crossing, walk in a bit and then you have to go down and then back up. And this sort of down and back up – and everybody knows I’m talking about – it’s not lit. ……it’s trees and it’s dark, so I won't go there. As soon as it’s even dusky, I just feel nervous, and so I won't do it. So then I think well the only alternative is walking all the way round, or I’ll drive.GO8 commuter (F)Participants in the commuting groups reported far less disadvantages about walking than older adults, though female participants shared the concern about poorly lit paths. These were particularly prominent in newer housing estates, and several women who lived in these reported the paths unusable at night, forcing them to drive or walk much longer distances by road to reach their homes.For me, there’s an added thing of if you’re out and about at night, I wouldn't want to cycle on my own. I don’t have somebody at home, so if I’m aware that I’m going to be on my own and coming back late, then I will take the car, which I’m annoyed with. I shouldn't feel like that.Commuter (F)At some point there’s a big queue of traffic. I feel pressure that the cars are thinking, “You’re not a car, get over to the side, I’m going to overtake you even though there is nowhere to overtake.” You’re just going to squish me into a box and I’ll have to…Often I just get off the bike and walk. I think part of it is that I’m a woman as well, I honestly do. A male car driver won’t see that I’m in charge.GO3 commuter (F)Many of the commuters’ concerns about cycling were shared with those of older adults: poor infrastructure and concerns about personal safety. Commuters worried less about hills and weather than older adults but shared many of the same concerns about the dangers of cycling on roads and unlit paths, and poor connectivity of dedicated cycle paths in the towns. Painted advisory cycle lanes on roads were not perceived as helpful, as often the roads were too narrow to allow safe passing distance for vehicles and were often blocked by parked cars Cycle paths shared with pedestrians were perceived as better than road cycling for most respondents, although these are slower for cyclists because of the need to take care around walkers, and the additional road crossings at junctions. Commuters were less likely to use these for work journeys. The additional time required to prepare for cycling  was an additional barrier.Respondents worried about security of bikes and accessories when left outside the home. This was also raised by older adults, but was a particular issue for commuters who may have to leave a bike outside the workplace or at a train or bus station for long periods of time. There was a general perception that bike theft was not prioritised by the police, and a lack of secure, safe locking points around both towns and at public transport hubs. In some cases, concern about bike theft was deterring the purchase of electric bikes, which could help resolve some of the issues around negotiating hills and delaying traffic.Road users hate us, hate cyclists. Two cyclists together is probably enough for some drivers to just think, “What’s this town turned to, a bunch of cyclists.” ……I feel less safe cycling in Witney than I used to in Oxford. That feels a bit weird. It shouldn’t feel that way.Commuter (F)Finally, several respondents noted that cycling was a less common activity in market towns than in larger cities. This meant they believed local drivers were less ‘cyclist-aware’, and fewer cyclists on the road meant there was no safety in numbers. The social norms around cycling were perceived as different between cities and small towns, which made cycling less attractive.Participants were asked during the focus groups about the infrastructure changes and community activation projects implemented by the local authority. There was no discernible difference between the two population groups and as such findings for both groups are combined in this section. Off-road shared paths for cyclists and pedestrians were broadly welcomed, with the proviso mentioned above that cyclists were encouraged to ‘share with care’ to avoid collisions with pedestrians. New signs around both towns with cycling and walking times to popular destinations were perceived as useful way to promote active travel.We’d all like a physical separation between bicycle and motor vehicle. And I also recognise that this is a medieval town, so room is at a premium. Now this particular part of this [painted] cycle lane is better than nothing. Behind where I am there, the cycle lane and the lane for traffic merge, and nobody knows who has got right of way. And that leads to confusion. It certainly leads to confrontation, as well. So in some ways, I wish...where the two lanes merge, it’s almost better not having it. Because I, as a cyclist, am absolutely certain in my mind that I’ve got right of way. But so is that motorist behind me.GO1 (M)Painted cycle paths on roads were less valued, as respondents believed they were often ignored by drivers, frequently parked on, and could cause conflict where lanes merged:End to end cycle paths …… even on my route, I think it’s nice and straightforward, I’ve got a lovely cycle path a lot of the way, but for some of the way there’s just nothing, and it’s forcing you onto the road.Commuter (M)Respondents supported prioritising cyclists and walkers at junctions, either through ‘bike boxes’ at the front of traffic lanes, or ensuring that crossing points did not have too long a wait for walkers (and where applicable cyclists) to cross. Despite efforts to increase cycle routes in both towns, lack of connectivity of paths remains an issue.Reduced speed limits in residential areas were supported by most participants, though many believed that they were not enforced and drivers could speed with impunity. Enforcement of the law emerged as a key concern for many, including of speeding and unsafe driving, and reckless cycling on shared paths with pedestrians.I consider myself a novice rider so I don’t like riding on roads. But I joined the group [Bike User group], and they've given me a biking buddy who's going to teach me, guide me along. We'll go on cycle rides together, and that’s just what I need, just to get used to the roads.Older adult (F)The group health walks I did. They start at one of the practices, the doctor’s practice. They take you different- I didn’t realise there were so many walks you could do round here. I was absolutely flabbergasted. Very good.Older adult (F)I worked at the NHS and during COVID they set up this wonderful scheme, […] Bike Project, which I have had the best experience from, so, so nice. Because I work for the NHS, they said people who work for the NHS during COVID – because we carried on working – were entitled to a free bike, which was amazing. I have Rosie. I’ve named her. She’s red. She’s lovely. A little bit of rust, but it's incredible.Commuter (F)The community activation projects were perceived as helpful and encouraging ways to promote active travel. A small number of both commuters and older adults had participated in these, either through a bike loan, going on a guided walk, or using the cycle training schemes. Where respondents had participated they were very positive about these types of approaches:However, the majority of respondents had not heard of many of these activation projects until they were mentioned during the focus groups. While perceived as useful ideas, respondents would welcome wider promotion and awareness of walking and cycling promotion schemes in both towns.I also think they’ve got to maintain the pavements a lot better, because that’s some of the reason why suddenly as a pedestrian you might suddenly veer. Somebody thinks, "Oh, you're going just a small way where you live," but there's a broken paving slab.Older adult (M)There are tiny little bike signs there, you know, this is still a cycle path as well, but it’s really easy to miss, and so all the pedestrians get really funny with you for cycling on that bit. I’m allowed to. I’m going quite slow now to be polite, but you will get people kind of really trying to block your way.Commuter (F)Both groups of respondents advocated for better maintenance of paths for walking and cycling in both towns, including addressing uneven surfaces, overgrown vegetation, and litter (including broken glass). Adequate lighting is required for these paths to remain accessible for most respondents, but especially females, after dark. Most respondents wanted more, and better, signage to encourage use of the correct side of the path where it was split . For older adults using these paths to walk, this was perceived to reduce the incidence of falls, and collisions with cyclists. This was especially important to older pedestrians who worried about the risks of falls or collisions. Commuters wanted these signs to remind pedestrians that cyclists had a right to use the path.The lack of security puts me off getting an electric bike. I cycle on a really old bike though. I don’t expect it to get nicked, but I am thinking about getting an electric bike. That worries me.Commuter (M)Yes, because I chain both the frame to something structural, you know, like, a cycle pole, and also I chain the back wheel, because that’s where the motor is, so that would be the bit that would be most valuable to steal. So, I am slightly conscious that if I went to the local station...and I would have to leave it all day.Older adult (M)Infrastructure improvements that to date have not been addressed by the local authority include improved bike security and access to bike lockers at key destinations like public transport hubs and town centres. Better provision for bike security was reported as a necessary requirement for some respondents to travel by bike and in some cases, invest in an e-bike.You need people of all different colours, ages, being out there. You need to be seeing people actively travelling, people that look like you so you can relate and think, “Oh actually, I could be doing this.”Older adult (F)More generally, respondents believed that the most useful means to promote active travel was through initiatives that encouraged and rewarded it, rather than punished residents for driving cars. Respondents wanted better awareness of community active travel projects and wider education and promotion of the positive benefits of active travel, including for health, personal finance, and the environment. Role modelling and promotion was thought to be especially important in smaller towns where active travel may be less normalised.Let’s celebrate [cycling], let’s make it obvious. You’re not just saying, “Yes, yes, you’re allowed.” It’s, “You’re welcome. We think you’re doing a good job. Well done for not ruining the planet.”GO3 Commuter (F)Some respondents were keen to see more effort to promote a culture change in market towns, where active travel (in particular cycling) could be more normalised, encouraging a shift from feeling allowed to cycle, to feeling celebrated.Active travel has been identified as a potential solution to high rates of physical inactivity in the UK, which currently contributes to 1 in 6 deaths . The curth century and designed to prioritise the car [Market towns have existing advantages for active travel, being relatively compact with most routine destinations within easy reach. Respondents in our study reported most within-town trips to shops, services and other popular destinations were within a 20-minute walk from home, with the remainder walkable within 30 minutes. This suggests that market towns, at least the two in our study, are already near meeting the criteria for “20-minute neighbourhoods”, a design concept for urban development where daily services can be accessed within a 20-minute walk , 48. Gui the car . Perhaps the car  . Older Older adults reported a range of concerns about walking and cycling in market towns. Hills, poor weather, and self-efficacy were of concern, but the main barriers centred around infrastructure, in particular uneven paths and pavements, overgrown vegetation, and poor or no lighting. The importance of well-maintained footpaths to walking amongst older adults has been reported elsewhere . Poor coCommuters shared the concerns of older adults about poorly lit paths, particularly females. The prominence of dark paths in the newer housing estates surrounding market towns presents a significant barrier to both walking and cycling amongst women who live there. Commuters also shared older adults’ concerns about cycling on roads and potential conflict with motorised traffic – the so-called ‘hostile environments’ reported in other studies . Again, Asked what would encourage more active travel in their towns, respondents were broadly supportive of more and better-connected off-road paths; where these were shared-use they wanted better signage to promote accessibility for both cyclists and pedestrians. Painted cycle paths on roads were not successful in encouraging respondents, who worry about holding up traffic, and conflict and collisions with vehicles when cycling on roads. Reduced traffic speeds may help with this but are not perceived to be enforced strongly enough. However, traffic calming and restrictive measures may be worth pursuing. A recent systematic review and meta-analysis of population-level active travel interventions found that while interventions with positive strategies  were more likely to be evaluated, interventions that include “stick” elements  may be more effective .Maintenance of cycle and footpaths was seen as key, including smoothing out surfaces, cleaning them of litter and glass, and cutting back overgrown vegetation that too often narrowed existing paths. Lighting is also key to path accessibility after dark and during the winter months. Both older adults and commuters wanted more secure cycle parking, including bike lockers, in their towns. These findings are broadly supported by research conducted in UK cities and towns by Sustrans. Improved accessibility for pedestrians is also likely to improve access for ‘wheelers’; those using wheelchairs and/or mobility scooters , 56.The community activation projects such as group walks and cycles, cycle training and buddy scheme implemented by OCC and Active Oxfordshire were welcomed by most respondents as useful ways of encouraging novice cyclists and reluctant pedestrians to try active travel. However, there was a lack of knowledge about these schemes. Better promotion of these types of interventions is necessary if commuters and older adults not already involved in walking and cycling are to engage in them. This matters; a recent systematic review of how policies contribute to increased physical activity concludes that while new infrastructure can be effective, policies are most effective when they are comprehensive and also include educational and promotion activity . While iis safety in numbers; the greater number of cyclists and walkers, the lower rate of collisions involving vehicles [One factor we identified which does appear qualitatively different to cities is participants’ perception of the social norms of cycling. Several reported that cycling was far less common in market towns, leading to the belief that drivers would be less ‘cyclist aware’ as a result, resulting in a greater risk of collisions and conflict. This perception is supported by studies examining the relationship between numbers of walkers and bicyclists, and the incidence of collisions, showing there vehicles , 60. EffThe study is limited by a smaller sample size than we intended. We tried a range of recruitment strategies, and were supported by the Clinical Research Network, however we faced difficulties recruiting respondents currently not interested in walking or cycling to a qualitative study about active travel. We had a limited timescale for this study, and we would recommend any future similar studies plan for a long recruitment period. These difficulties also meant that we had to include some participants who walked or cycled on occasion or more regularly. This may impact on the generalisability of the findings for those older adults and commuters who never, or rarely use active travel modes, although we do note that behaviour change is a process (not an event) and that the findings may be useful to those seeking to encourage infrequent active travellers to do so more often . All of The key strength of this study is the use of focus groups and go-along journeys, combining observation and interview, facilitating rich data grounded to the specific issues supporting or limiting active travel in each market town. We believe this is the first study that has explored attitudes towards active travel held by residents of market towns.Market towns have intrinsic advantages for active travel due to their compact nature but have received little attention in the active travel literature. This matters if the residents of market towns are to gain the significant positive health effects associated with active travel. This study suggests that the barriers faced by older adults and commuters in market towns are mostly no different to those in cities; poor infrastructure remains the key barrier. Poorly maintained paths are particularly hazardous for older pedestrians, and low-or-no lighting and lack of well-connected, delineated cycle routes deter both commuters and older adults. Like cities, policies to promote active travel in market towns are most likely to be effective when they include a suite of comprehensive, integrated and complementary measures targeted at a range of levels from individual behaviour change to population level measures like large-scale infrastructure improvements. Attitudes towards active travel, in particular cycling, may differ in market towns and initiatives to change the social norms around cycling may be required to increase active travel rates.Additional file 1.Additional file 2.Additional file 3.


Piano Nazionale di Ripresa e Resilienza”, PNRR)  . The PNRThose objectives will be achieved through:the creation of Community Health Houses (“Case delle Comunità”) and Community Hospitals  for proximity healthcare;Centrale Operativa Territoriale”, COT) for remote healthcare; andnew Territorial Coordination Centers , the component “Territorial assistance and telemedicine” has the goal of reaching out to at least 10% of the older adult population (over 65 years of age) to tackle the issue of patients with chronic conditions lost to follow-up and who only access the healthcare system when developing acute complications. In order to do so, it is planned to assist through telemedicine at least 200 000 people by the end of 2025. The main objective of the National Portal for Telemedicine is to establish a fundamental level of interoperability that ensures common standards for telemedicine services developed by the regions, enhancing what is already available in the landscape of local contexts while complementing or completing the portfolio of services. In particular, it aims to connect all healthcare providers and patients in Italy, and the dissemination of electronic prescriptions and Electronic Health Records (EHRs)  digital model, as described in the most recently operational manual published by the Ministry of Health. These features will be discussed and analyzed in order to identify strengths, weaknesses, and future implications, as well as to assess how the proposed model fits into the European context, and possibly comparing it to other highly advanced international ones.Agenzia Nazionale per la Sanità Digitale”) is charged with ensuring the provision of telemedicine services through the cloud-based Network Time Protocol. The Network Time Protocol is a national infrastructure which contains the “Enabling Services”  and all the connected regional infrastructures which provide “Basic Telemedicine Services”  , controlled directly by the Ministry of Health will contain data on all telemedicine solutions provided  . Communiprovided .In Similar to many other European countries, Italy is expected a strong decline in population  within the next 10 years . One of Several countries have implemented telemedicine as an effort to improve healthcare for residents of rural or underserved areas, where healthcare facilities and specialists may be hard to reach , 11. Thetelevisita), healthcare professionals' teleconsultation, or similar , and with the unification of health data with the EHR. The possibility of having such uniformity will make both accessibility and decision making easier and faster in the transfer of patients between one structure and another, as well as in acute and chronic management, always in an integrated vision.televisita), or employing a telemonitoring smart bracelet, education and communication is the key to make things run smoothly. Formal programs and updated courses will be needed to embrace the digital illiterate and to prevent the already present gap from expanding further.It is important to address the challenge posed by the “inverse care law”: people who need health assistance the most, will be the ones to have bigger difficulties to access digital healthcare or engage with digital platforms, e.g., disadvantaged groups suffering from poverty, language diversity, or disability. A crucial point is age: some studies found that telemedicine use was decreased as people aged , 34. SinThat said, strengthening communication of the benefits that telemedicine can bring to healthcare will be crucial to avoid frustration and ensure a smooth adoption by end-users . PolicymAlthough various tools and technologies are used for the provision of digitally integrated home care services within the various European countries, it is difficult to identify a nationally approved operational plan which regulates the use of remote home care technologies in a practical and definitive manner, such as the one just published in Italy.One of the countries at a global level that has shown great commitment to the development of a digital ecosystem in the field of home care assistance is Australia. The government has included a specific plan on this area in its national agenda  that implements digitally enabled models of care. The successful implementation of this Strategy is contingent on overcoming challenges related to data security, privacy, interoperability, and the engagement of both healthcare professionals and patients. Nevertheless, it also has the potential to improve the patient care, to enhance efficiency , to guarantee a better access to health records, to increase interoperability of the health system, and to provide telehealth and remote monitoring.FC: Investigation, Supervision, Visualization, Writing—original draft, Writing—review & editing. AG: Investigation, Methodology, Writing—original draft, Writing—review & editing. AM: Investigation, Writing—original draft. FB: Investigation, Writing—original draft. FAC: Methodology, Writing—review & editing. VS: Writing—original draft. SB: Conceptualization, Writing—review & editing. SP: Writing—review & editing. AB: Supervision, Writing—review & editing. MB: Writing—review & editing. EC: Writing—original draft. WR: Visualization, Writing—review & editing.


Hypothetical Inferential Theory, this is explained by a conventional requirement of an inferential connection between conditional clauses. Bayesian theorists have denied the need for such a requirement, appealing instead to a requirement of discourse coherence that extends to all ways of connecting clauses. Our experiment compared conditionals , conjunctions (“A and C”), and bare juxtapositions (“A. C.”). With one systematic exception that is predicted by prior work in coherence theory, the presence or absence of an inferential link affected conditionals and other statement types in the same way. This is as expected according to the Bayesian approach together with a general theory of discourse coherence.Missing-link conditionals like “If bats have wings, Paris is in France” are generally felt to be unacceptable even though both clauses are true. According to the  Hypothetical Inferential Theory (HIT) agree on the importance of uncertainty and subjective degrees of belief in reasoning but reject some aspects of Bayesian orthodoxy   a. If elephants are gray, then 2+2 = 4 Matalon, , p. 82.b. If Napoleon is dead, Oxford is in England  inference. Crucially, this means rejecting Strong Centering, since the truth of “A and C” does not guarantee an inferential connection between them. HIT also rejects Stalnaker's Thesis: one can have high credence in “A and C” and yet be certain that the conditional is false due to lack of an inferential connection.HIT explains the coherence, as already anticipated by Matalon  imagine “A”, and then (b) affirm “C”. A speaker's choice to suppose “A” before affirming “C” suggests that there is some kind of connection between “A” and “C”. Otherwise, we would not be able to rationalize why the speaker would precede the act of affirmation by an act of supposition.In response, strict Bayesians have offered a pragmatic explanation of the relevance effect related to the notion of  Matalon .3 This i Matalon . Accordidiscourse coherence  attempts to account for the way we connect the informational contribution of different clauses in a discourse into a coherent whole  John took the train from Paris to Istanbul. He has family there Kehler, , p. 2.Explanation relation: visiting family is the reason for John's trip.DCT shows that we supply additional information, going beyond the literal content of the text, as a byproduct of an obligatory process of understanding sequences of utterances as coherent texts. We tend to enrich (2) with the information that the clauses are in an cause-effect relations— (a) result, (b) explanation, (c) violated expectation, and (d) denial of preventer —are of particular interest to us in this study.Kehler  describeinferential readings.As Lassiter  discusse(3a) If Lucy is tall enough, she will be able to ride the carousel.(3b) Lucy is tall enough. She will be able to ride the carousel.(4a) If the vase is broken, someone dropped it.(4b) The vase is broken. Someone dropped it.inferential readings match the definition of an inferential link proposed for conditionals by HIT theorists. However, Lassiter argues that the inferential link present in (3a) and (4a) does not come from the semantics of conditionals. Rather, it is explained by DCT, just like in the non-conditional examples (3b) and (4b).These violated expectation and denial of preventer relations indicate a sort of independence: the event in the second clause happened even though the information in the first clause would have led us to expect otherwise, or vice versa. Cruz and Over  If you press the power button, the TV does not turn on.(5b) John pressed the power button. The TV did not turn on.(6a) If Martin arrived on time, his bus still left without him.(6b) Martin arrived on time. His bus still left without him.whether or not the first clause was, and that the resulting lack of connection between clauses is surprising given background knowledge . This is also the case in (5b), suggesting again that conditionals behave similar to other ways of connecting clauses. As a result, these examples do not fit the basic prediction of HIT, which requires that the antecedent's truth should make it possible to infer the truth of the consequent.Both examples convey that the second clause would have been true HIT is limited to making predictions about “standard” conditionals, i.e., those that display an inferential link. This means that we cannot attribute to HIT any direct predictions about non-conditional sentences like (5b) and (6b). However, such parallels between conditional and non-conditional sentences call out for an explanation, and HIT is forced to treat them as an unexplained coincidence, generated by the behavior of “non-standard” conditionals that are put aside as being outside the scope of the theory. Indeed, HIT offers no empirical or theoretical criteria for identifying which examples are “standard” except to inspect them and consider whether they conform to the theory's predictions.As it has been developed, if-sentences should receive a unified semantic-pragmatic explanation. DCT offers such an account, and it provides a set of semantic and pragmatic diagnostics that distinguish inferential and independence conditionals in terms of background assumptions and the availability of various discourse particles . The broad prediction of a parallel between conditional and non-conditional connective devices should hold whether or not there is an inferential link between clauses. If this parallel does hold, it would provide support for DCT and a further explanatory challenge for HIT.Our core hypothesis is that the relevance effect does not depend on the conditional form itself, but rather on our ability to find a coherent reading between utterances. Therefore, we expect conditionals interpreted with an We collected data from 50 participants . Data from one additional participant was discarded because the participant was not a native French native speaker. The average age was 36.2 years . Level of education ranged from no high school degree to postgraduate degree. The participants were recruited via social networks.SoSci Survey website. The material was built in French from 8 pairs of statements with different intended coherence relations: Four that we judged to convey relevance  and four that we judged to convey the absence of a previously expected relevance relation . Those 8 pairs were then crossed with three connective devices  for a total of 24 items (see Our questionnaire was designed on the tems see . We usedpar conséquent (“as a result”) to force an inferential reading. Note that the French phrase is compatible with both a predictive reading (Result relation) and a diagnostic reading (Explanation relation). The second candidate paraphrase added malgré cela (“despite this”) to force an independence reading. The third response option indicated that neither of the paraphrases offered corresponded to the participant's interpretation. The participant pressed the next button to continue to the next item.Each item was presented on a separate page in random order , with onC” from element “A” for each of the eight statements.Following this, eight questions were used to verify that the statements had been understood by the participants as either having the intended inferential link or lack thereof. Participants were asked to rate on a 4-point Likert scale to what extent they would be able to conclude element “Finally, one page was devoted to demographic questions .independence reading. When neither option is plausible, the text should be felt to be incoherent. These options apply in the way to any type of text.Broadly speaking, the strict Bayesian-cum-DCT theory predicts that responses should be sensitive to Relation, but independent of Form. When participants assume the presence of an inferential link, this is attributed to their choice to interpret the text using an inferential coherence relation (result or explanation). When an inferential link is implausible, participants can also assign an Subordinating, including our explanation relation. This point motivates the revised analysis in Section 4.1, which tests the hypothesis that coherence is independent of form for non-subordinating coherence relations.However, the prediction of form-independence holds only if all of the clausal connective devices used are semantically compatible with all of the coherence relations naturally associated with the texts. As we will see below, prior research  readings of conditionals as a default option that is statistically more prominent than Irrelevance readings , followed by model 5 (Relation). Model 7 (Full Relation) fared slightly better than all other models on AIC, which (as noted above) is known to be biased toward complex models  compared to model 7 and anecdotal evidence compared to model 5 (BF65 = 3). A visualization of the data can be seen in A summary of the comparisons done between the models can be found in ls Kuha, . While AW = 30, 433, p < 0.001) between the two types of stimuli.We also verified that our items designed to be interpreted with and without inferential links were perceived as such by participants. We analyzed the responses to the 8 verification items for the presence of an inferential link or not. A paired samples Wilcoxon test  shows a highly significant difference  Resulta. Bill dropped the vase. It broke.b. If Bill dropped the vase, it broke.c. Bill dropped the vase and it broke.(9) Violated Expectationa. Bill dropped the vase. Nothing happened.b. If Bill dropped the vase, nothing happened.c. Bill dropped the vase and nothing happened.(11) Explanationa. The vase broke. Someone dropped it.b. If the vase broke, someone dropped it.c. The vase broke and someone dropped it.and-sentences. Asher and Vieu (Example (11c) is the odd one out: it is not possible to interpret this sentence as indicating that the vase broke because someone dropped it. Since no other connection is plausible, the result is an incoherent text. Txurruka  shows thand Vieu  discuss and to coordinating relations implies that participants should have been inclined to reject the intended interpretation of explanation stimuli that we constructed with “and”. Depending on the example, they might have succeeded in imposing a result interpretation, an irrelevance reading, or simply concluded that none of the available readings was appropriate.For our purposes, the restriction of post hoc analysis would exclude data points that were intended to evoke the problematic explanation relation. With this condition removed, the general predictions described above for DCT and HIT should hold: HIT predicting an interaction between form and relation (as in Model 7), and DCT predicting an effect of relation alone (Model 5).While we did not foresee this issue when constructing our experimental materials, we decided that a reasonable To this effect, we ran the analyses again, but this time without the explanation relation. The models resulting from this analysis can be found in 57 = 1.5e+7). Model 5 was also the best model according to both AIC and BIC . Overall, these results suggest that discourse coherence was the primary determinant of our participants' responses. Setting aside the orthogonal interaction between “and” and explanation relations, the choice of conditional or non-conditional form appears to have played little or no role in participants' interpretations.In terms of Bayes Factors, the revised analysis strongly supported Model 5—with no interaction between intended coherence relation and choice of form —over the HIT-friendly Model 7 (BFresult and explanation) and independence relations . Our initial analysis was inconclusive, because of an unanticipated interaction with a general prohibition on explanation relations with and. However, when the problematic condition was excluded from the analysis, we found that a model of participants' preference for independence or inferential readings that did not include information about the statement's form led overall to a better fit to the data, as predicted by the coherence approach.Our study lends support to an interpretation of the relevance effect in terms of discourse coherence. We compared three ways of combining clauses: conditionals, conjunctions, and juxtapositions. Our prediction was that participants would interpret all three with the same type of reasoning about possible relations of coherence among the constituent clauses, using independently motivated inferential relations  participants were unable to identify a plausible coherence relation between the antecedent and the consequent, or (b) the most plausible coherence relation was one that did not appear among our response options . This result occurred in similar ways in all of our statement types, as expected according to DCT. Our results also confirmed the intuitive claim around (5a) that some missing-link conditionals are acceptable because they can be interpreted with an independence reading.Because of the theoretical flexibility provided by HIT's distinction between “standard” and “non-standard” conditionals, our result does not—and could not—provide a conclusive refutation of this theory. The challenge to HIT is primarily an explanatory one: given that variation in responses was well-explained by a broader theory that is needed in any case to account for coherence effects, it is not clear why HIT would be needed. In addition, as explained in Section 3.3 above, the most plausible reading of HIT as a “default”, together with general principles of discourse coherence, does generate a predicted interaction that was not evidenced in our results. Our experiment thus contributes a major explanatory challenge to HIT. In contrast, the strict Bayesian theory of conditionals, together with DCT, accounts in a single theory for the acceptability of all types of indicative conditionals.Our results are in apparent conflict with the experimental findings of Krzyżanowska et al. , who fouThe relevance effect has been taken in recent research to call into question core principles of the strict Bayesian approach to conditionals, particularly Strong Centering and Stalnaker's Thesis. HIT theorists have argued that the need for an inferential connection is a conventional feature of conditionals. In this study, participants interpreted statements involving two true clauses that varied in the presence or absence of an inferential link. Our results showed little or no evidence that the choice of conditional, conjunction, or juxtaposition interacts with the presence or absence of an inferential link. From the perspective of DCT, it appears that statements of all types were interpreted in the same fashion—with an inferential reading, an independence reading, or neither depending on the content of the clauses, as long as the coherence relation was semantically compatible with the connective device. If this is correct, apparent threats to Strong Centering can be explained by a failure of discourse coherence. This result lends support to the suggestion of Matalon  and Cruzhttps://doi.org/10.17605/OSF.IO/MQKAJ&lt.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The studies involving human participants were reviewed and approved by P-A-R-I-S Association Ethics Committee. The patients/participants provided their written informed consent to participate in this study.MB, DL, and JB: theoretical and conceptual design of the experiment. MB: data collection. BJ: data analysis. MB, BJ, DL, and JB: production of the manuscript. All authors contributed to the article and approved the submitted version.


Self-collection of specimens at home and their return by mail might help reduce some of the barriers to HIV and bacterial sexually transmitted infection (STI) screening encountered by gay, bisexual, and other men who have sex with men (GBMSM). To evaluate the benefits and challenges of bringing this approach to scale, researchers are increasingly requesting GBMSM to return self-collected specimens as part of web-based sexual health studies. Testing self-collected hair samples for preexposure prophylaxis drug levels may also be a viable option to identify GBMSM who face adherence difficulties and offer them support.Project Caboodle! sought to evaluate the acceptability and feasibility of self-collecting at home and returning by mail 5 specimens  among 100 sexually active GBMSM in the United States aged between 18 and 34 years. In this manuscript, we aimed to describe the key lessons learned from our study’s implementation and to present recommendations offered by participants to maximize the rates of self-collected specimen return.Following the specimen self-collection phase, a subset of 25 participants  was selected for in-depth interviews conducted via a videoconferencing platform. During the session, a semistructured interview guide was used to discuss the factors influencing decisions regarding returning self-collected specimens for laboratory processing. The transcripts were analyzed using template analysis.University branding of web-based and physical materials instilled a sense of trust in participants and increased their confidence in the test results. Shipping the specimen self-collection box in plain unmarked packaging promoted discretion during transit and on its receipt. Using different colored bags with matching color-coded instructions to self-collect each type of specimen minimized the potential for confusion. Participants recommended including prerecorded instructional videos to supplement the written instructions, providing information on the importance of triple-site bacterial STI testing, and adding a reminder of the types of testing that would and would not be conducted on hair samples. Participants also suggested tailoring the specimen self-collection box to include only the tests that they might be interested in completing at that time, adding real-time videoconferencing to the beginning of the study to introduce the research team, and sending personalized reminders following the delivery of the specimen self-collection box.Our results offer valuable insights into aspects that facilitated participant engagement in self-collected specimen return, as well as areas for potential improvement to maximize return rates. Our findings can help guide the design of future large-scale studies and public health programs for home-based HIV, bacterial STI, and preexposure prophylaxis adherence testing.RR2-10.2196/13647 Gay, bisexual, and other men who have sex with men (GBMSM) in the United States are heavily affected by HIV and bacterial sexually transmitted infections (STIs) ,2. SexuaIndividual factors , structural factors , socioeconomic factors , and privacy factors  are well-documented barriers to HIV and bacterial STI screening among GBMSM -18. StaySince the 2012 approval of oral preexposure prophylaxis (PrEP) for HIV in the United States, the awareness and use of this prevention tool has steadily increased among GBMSM . PrEP efProject Caboodle! sought to evaluate the acceptability and feasibility of self-collecting at home and returning by mail 5 specimens for HIV, bacterial STI, and potential PrEP drug–level testing among 100 sexually active GBMSM in the United States aged between 18 and 34 years. Complete details pertaining to the study protocol  and a deParticipants were recruited via social media advertising on Facebook and Grindr. Individuals who clicked on the advertisements were directed to the study’s landing page that included a brief overview of the protocol and a link to the informed consent form. Those who consented were asked to complete an eligibility screener. The eligibility criteria included being assigned male sex at birth, reporting a male gender identity, being 18 to 34 years of age, residing in the United States or dependent areas, not known to be living with HIV, having ≥2 male sex partners in the past 3 months, and expressing willingness to receive a specimen self-collection box at home. Those who were eligible were asked to provide their contact information . Those who did not provide informed consent, did not meet the eligibility criteria, or did not provide verifiable contact information were directed to the Centers for Disease Control and Prevention website containing information and resources on HIV and bacterial STIs.In the first phase, 100 participants who completed a web-based survey were shipped a box containing instructions and materials to self-collect and return any of the following: a finger-stick blood sample (for HIV testing), a pharyngeal swab, a rectal swab, a urine specimen (for triple-site gonorrhea and chlamydia testing), and a hair sample . Participants were given a period of 6 weeks from receiving the box to returning self-collected specimens of their choice for laboratory processing by using envelopes affixed with prepaid FedEx shipping labels. No incentive, monetary or otherwise, was provided for completing this step. Test results were delivered back to participants by a counselor via a phone call or an email containing a link to a secure Box folder created specifically for each participant.In the second phase, a subset of 25% (25/100) of participants  was selected for in-depth interviews conducted via BlueJeans (Verizon Communications), a videoconferencing platform that allows compliance with the Health Insurance Portability and Accountability Act. Purposive sampling was used to ensure variations in age, race, and ethnicity. During the session, a semistructured interview guide was used to discuss the participants’ decision-making regarding returning self-collected specimens for laboratory processing. Depending on the number and type of specimens returned by participants, the interviews were tailored to focus on factors that shaped their engagement or lack thereof.The in-depth interviews were transcribed using Scribie, checked for accuracy against the original audio files, and uploaded to Dedoose , a web-based platform for collaborative qualitative data analysis. Transcripts were analyzed using template analysis, a style of thematic analysis that involves developing an initial coding template using a subset of the data, applying it to further data, and refining it using an iterative process . In thisThe study protocol was reviewed and approved by the Institutional Review Board of the University of Michigan in Ann Arbor (HUM00153673). Electronic informed consent was obtained from all individual participants included in the study. Verbal consent for audio recording and transcription was also obtained from all individual participants at the beginning of each in-depth interview. Participants received US $40 for completing a web-based survey in the first phase of the study and US $40 for completing an in-depth interview in the second phase of the study.The age of the participants of in-depth interviews ranged from 20 to 32 years, with the mean and median being 26 (SD 3.49) years. The sample of 25 participants was diverse with respect to race and ethnicity: 5 (20%) participants identified as non-Hispanic White; 4 (16%) as non-Hispanic Black; 7 (28%) identified as Asian; and 9 (36%) identified as Hispanic (irrespective of their race). Most participants had a college degree or a higher educational level , identified as gay , and were single . Regarding their recent sex behaviors, 40% (10/25) of participants engaged in condomless anal sex, and 76% (19/25) of participants engaged in condomless oral sex with ≥2 men in the past 3 months. Most participants  reported testing for HIV and two-thirds  reported testing for bacterial STIs in the past year. Finally, 44% (11/25) of participants indicated that they were using PrEP at the time of the study. This manuscript includes 30 verbatim excerpts from 18 participants (1-3 excerpts per participant).University branding was used throughout the study, including the social media advertisements, the web-based survey, and the specimen self-collection box. Our use of the well-recognized University of Michigan Block “M” logo instilled a sense of trust in the participants whose sentiments are evident in the following excerpts:I think it was an ad, it was on Grindr, and it was just an ad like, “We’ll give you a gift card if you join our study,” and I’m kind of like, “Sounds a little sketchy,” but then I saw it was at University of Michigan, right? I think the university affiliation just makes me feel like a little more confident with it. I have an undergraduate degree. I’m currently going to graduate school. I’m comfortable with the university setting.CAB161, aged 24 years, non-Hispanic White, returned someI see University of Michigan, and I think, ‘Well, there you go. Respected institution.’ I think really pretty much any university that’s not like a private Christian college that was saying that we’re doing a study on this or we’re offering free sexual testing as part of a study I would trust them.CAB002, aged 23 years, non-Hispanic White, returned noneI didn’t see any reason why a university would attempt to do anything out of the ordinary with them given HIPPA and the...What’s it called? When you have to do research and you have to go through the board for them to certify what you’re doing? I forget what that’s called, but I assume you wouldn’t be doing anything out of the ordinary because of that process.CAB069, aged 27 years, Hispanic multiracial, returned someThe institutional review board–approved informed consent form and written instructions indicated that returned specimens would be processed at laboratories in Emory University and the University of California, San Francisco. Several participants noted that this information increased their confidence in the test results:I would assume they would have integrity to give me the correct test results and everything.CAB008, aged 28 years, non-Hispanic Black, returned allI knew that there’s a university behind the study, and so I guess that kind of made me feel like the test was going back to a reputable source, to someone that was trustworthy, because it was for research purposes.CAB012, aged 29 years, non-Hispanic Black, returned allI thought it was reliable ’cause I thought that it was being sent to Emory and plus the study happened at U of M.CAB086, aged 23 years, Hispanic, returned noneDuring the design phase, our research team recognized the importance of discretion while shipping the specimen self-collection box to prevent the inadvertent disclosure of the recipient’s involvement in a study on sexual health for GBMSM. Receiving a plain unmarked package with no reference to the nature of the contents was appreciated by several participants:I did appreciate that because I do live with roommates, so I kind of prefer the discreetness to that. I did appreciate the fact that it was not labeled, and it was discreet and anonymous. So, yeah, I think that was pretty clever... But our neighbor saw it. I know other people saw the box, so it’s like... It was still, again, even though I was the one who picked it up first, I’m sure it was seen by others. So, the discreetness to it was still important.CAB082, aged 32 years, Hispanic American Indian or Alaska Native, returned allThat definitely helped with anonymity, as I don’t live by myself. I don’t like people knowing what I get shipped to me, personally.CAB122, aged 23 years, Asian, returned noneI think that was really great because it was able to just appear like any other package, so if people didn’t want the person delivering the mail or other people in the household to know what they were doing, they were able to have that privacy.CAB120, aged 26 years, non-Hispanic White, returned noneOne participant also appreciated the option of being able to provide a shipping address that differed from their residential address for logistical reasons:I got it sent to my mother’s house. Because I get all my mail at my mother’s house instead of having it shipped to my place... Because sometimes if it’s a box, they’ll leave it on the top of the little mailbox thing because it’s like a little small slot for the mail at my building.CAB091, aged 32 years, non-Hispanic Black, returned allSeveral participants mentioned that upon opening the specimen self-collection box, they found its contents to be neatly organized:It was well-organized, as far as everything was well-labeled and easy to follow.CAB105, aged 29 years, Hispanic American Indian or Alaska Native, returned allIt looks like a very, very well-done prototype to me. I think something more, something that’s launched on a larger scale, you might be able to afford to do some more customized packaging inside of it that means there’s less empty space in it. But apart from that, it was really good, it looked very professionally done.CAB002, aged 23 years, non-Hispanic White, returned noneOthers commented that they appreciated our use of different colored bags with matching color-coded instructions to self-collect each type of specimen, as this helped them readily differentiate between the components inside the specimen self-collection box:I like how it was separated, like each test was separated, and I believe it was color-coded. Like in the bag, that was also cool ’cause it allowed me to easily pin-point which test was for which direction and all that without having to do too much thinking or figuring out on my own.CAB069, aged 27 years, Hispanic multiracial, returned someI liked the colors. It kinda reminded me of Google...It was good. I never had any missing items, everything was pretty clear. The instructions, the layout...You open the box, you have everything in there, you go through the tests one by one. Yeah, so everything was pretty clear.CAB044, aged 28 years, Hispanic multiracial, returned allWhen asked how our specimen self-collection instructions could be enhanced, some participants recommended the inclusion of prerecorded instructional videos in addition to written instructions, especially for the finger-stick blood sample:I think having video instructions where you can actually do the test with someone, that you can just do it while they do it on the video, that’ll be nice... Then you kinda see that in real action versus having to comprehend what’s on paper.CAB014, aged 27 years, Asian, returned noneA video for the blood sample, just to ease anxiety and show people that it’s not what you think it is, like in a doctor’s office, would be helpful. But for something like the rectal swab, a printed thing with a couple of pictures of how far to stick it up your... you know, how far to stick it up is just fine, and you don’t really need a video for that. And let’s say for like the throat, printed text... I think that would be sufficient. But for a blood sample, since that’s a little more invasive, maybe a video would help.CAB086, aged 23 years, Hispanic, returned noneOthers discussed the need to highlight the importance of triple-site bacterial STI testing:I think that information  would have helped me. I don’t know if it would motivate me per se, but I think it would help me understand... “Okay, now I’m doing this for the following purposes” and not so much as “Oh, if I do this and this but that’s retesting the same thing. Why am I doing both?” But if I knew if different things were used for different STIs, then in some ways, I guess I would feel like “Okay, there is a reason for me to be doing all these different tests so that I know my status around all those different STIs.CAB014, aged 27 years, Asian, returned noneSeveral participants did not remember why they were being asked to provide a hair sample by the time they received the specimen self-collection box, suggesting that the inclusion of a reminder on the types of testing that would and would not be performed on hair samples might be helpful:I honestly don’t know what you can get from hair samples other than previous drug testing, so I didn’t know what information you could actually glean from hair sample. But I figured if you asked for it, there must be something.CAB048, aged 22 years, non-Hispanic White, returned someThat one’s different. I didn’t understand that one. I never really did get any samples. The only thing I could think about that one, was more like DNA... I was kind of skeptical of it.CAB033, aged 27 years, non-Hispanic Black, returned noneI did think like, Okay, why are you actually needing to collect hair if it’s an HIV study, or if it’s being marketed as an at-home HIV test?CAB024, aged 26 years, non-Hispanic White, returned noneOne theme that emerged from the participants’ narratives was their desire for a customized specimen self-collection box that only included instructions and materials for those tests that they were interested in completing at that time:I would definitely prefer to do just the four and leave out the blood... Not that I’m opposed to doing it at all, I would just prefer to do it with less frequency than the others.CAB082, aged 32 years, Hispanic American Indian or Alaska Native, returned allIn addition to enhancing the overall experience, a potential benefit of tailoring the specimen self-collection box could be an improved rate of specimen return. Some participants described how they felt overwhelmed at the thought of self-collecting 5 specimens, which prevented them from proceeding any further:I was expecting something smaller, so it was kind of overwhelming and it probably, it kind of influenced my decision about whether to continue on with it or not... Because I thought I had to send all of them together, so I just decided not to send any of it.CAB075, aged 23 years, Hispanic, returned noneI probably wrongly assumed that I should send in all five, and that they were mandatory, but taking two seconds to think about it, I know that it... Yeah, it didn’t really matter, or I could have done some, not all.CAB024, aged 26 years, non-Hispanic White, returned noneParticipants who were using PrEP also discussed that their established routine of clinic-based HIV testing reduced their motivation to undertake home-based HIV testing:Because of PrEP, I’m less inclined to seek out DIY HIV testing at this point...I take PrEP, so I have to go in for quarterly check-ups anyway for that. I had got one (HIV test) done recently when the box arrived and I thought, “I’ll wait until a couple of weeks have passed, so that this is actually useful.”CAB002, aged 23 years, non-Hispanic White, returned noneI get tested for HIV regularly, and I’m on PrEP so I wasn’t dying to know if I had HIV. Does that make sense? Maybe if I didn’t know, I would be much more inclined to go through the pricking. But since I know, I didn’t have the curiosity.CAB051, aged 30 years, Hispanic multiracial, returned someOne participant recommended contacting the participants before shipping them a specimen self-collection box to inquire about which of the 5 tests they desired:I would send them [participants] an email, and then depending on what results, what they send back, I would send them the tests that they wanted to do.CAB044, aged 28 years, Hispanic multiracial, returned allDuring discussions regarding their experiences with receiving communications from the research team at different time points, participants offered suggestions on types of further support that could help improve study engagement.One participant recommended the addition of real-time videoconferencing at the beginning of the study to introduce the research team , as that would allow new participants to ask questions or discuss concerns:If I’m concerned about something I could ask you on the spot, which is different than if you guys just sent me a video. So, it would have made me more comfortable speaking to someone, ’cause if I have a question or something, ask them, where the video doesn’t... Really wouldn’t answer any of those.CAB075, aged 23 years, Hispanic, returned noneSome participants discussed how receiving personalized reminders via their preferred modes of communication  following the receipt of the specimen self-collection box might have increased their likelihood of returning specimens:I would say text reminders would have been fine, maybe emails depending on people’s preferences for contact, and just trying to make sure that regardless of if they were automatic messaging, making it seem as though it’s actually a person would be important so it’s not just a bot.CAB024, aged 26 years, non-Hispanic White, returned noneI think a reminder would have definitely been helpful in terms of just bringing it back in my mind again ‘Oh, I got this thing in my room that I need to do.’ But yes, I mean... I don’t know how it’s actually actualized in a real world setting versus a research setting, where if someone just buys it and no one is reminding them to do it.CAB014, aged 27 years, Asian, returned noneReceiving their test results via multiple communication channels was also valued by participants, as it provided an opportunity to ask questions over the phone immediately and to access a copy of their test results via email later:Okay, I really liked that you emailed the test results. I loved that ’cause you can have it with you and if you have to go get treatment or something, you could just pull it up on your phone. So, I liked that... I would actually prefer both , but just have an email as a backup... Just so I can hear somebody say it and then if I have a question or something I could immediately ask the question.CAB008, aged 28 years, non-Hispanic Black, returned allSeveral aspects of the implementation of Project Caboodle! were appreciated by the participants, as evidenced by their positive feedback during the in-depth interviews. Using the University of Michigan Block “M” logo in all study materials enhanced credibility; shipping the specimen self-collection box in plain unmarked packaging promoted discretion; and using different colored bags with matching color-coded instructions to self-collect each type of specimen minimized the potential for confusion. Participants also offered some constructive commentary, providing important lessons for future refinements to our processes that could help improve the rates of self-collected specimen return in subsequent work with GBMSM. They recommended including prerecorded instructional videos to supplement the written instructions, providing information on the importance of triple-site bacterial STI testing, and adding a reminder of the types of testing that would and would not be conducted on hair samples. They also suggested tailoring the specimen self-collection box based on individual preferences, adding real-time videoconferencing at the beginning of the study to introduce the research team, and sending personalized reminders following the delivery of the specimen self-collection box as practical strategies to bolster the likelihood of specimen return.One feature of our study that contributed to its success was our consistent use of university branding on the social media advertisements, the web-based survey, and the specimen self-collection box. University academic logos are unique visual representations that signal institutional identity and can instill a sense of trust  and percThe participants in our study also appreciated receiving the specimen self-collection box at their residence in plain unmarked packaging. This afforded privacy and prevented an inadvertent disclosure of their involvement in sexual health research to the mail carrier or to someone they lived with such as a roommate or parent. Given the stigma associated with HIV and bacterial STI testing ,59, as wInternal attributes of the specimen self-collection box that were well received by participants included its neat organization and our use of different colored bags with matching color-coded instructions for different types of specimens: red for a finger-stick blood sample, blue for a pharyngeal swab, green for a rectal swab, yellow for a urine specimen, and black for a hair sample. Of note, the bags and instructions were purposefully color-coded to align with the Project Caboodle! study logo . Color cShifting focus to avenues for improvement, some participants recommended the inclusion of prerecorded instructional videos in addition to written instructions, especially for the finger-stick blood sample, to allay their anxiety (by demonstrating how finger-stick blood self-collection differs from phlebotomy conducted in a clinic) and bolster their self-efficacy . We acknowledge that providing access to prerecorded instructional videos is becoming increasingly common in specimen self-collection research -67 and cAnother recommendation put forth by participants was potentially customizing the specimen self-collection box to include only instructions and materials for those tests that they were interested in completing at that time. The prospect of self-collecting 5 specimens was reported to be overwhelming by some participants, and it negatively influenced the likelihood of return despite having a choice to return only those specimens that they felt comfortable returning. Similar results were noted in another recent study with young GBMSM who were offered the option to self-collect and return a finger-stick blood sample for syphilis testing along with pharyngeal, urethral, and rectal swabs for gonorrhea and chlamydia testing . DespiteParticipants in our study also offered recommendations on the addition of communication strategies that could help improve engagement at multiple time points. Connecting with the research team via real-time videoconferencing at the beginning of the study would provide new participants with an opportunity to have their questions or concerns addressed and set the foundation for developing a rapport. Longitudinal studies with GBMSM should consider incorporating onboarding sessions conducted via real-time video conferencing if resources permit. Participants who did not return any specimens mentioned that receiving personalized reminders via their preferred modes of communication  following the receipt of the specimen self-collection box might have prompted them to return the specimens. The reason we did not include reminders (or incentives) was to avoid influencing return rates in our acceptability and feasibility study. However, reminders have been shown to influence behaviors across a spectrum of health care issues and can help promote study engagement ,70. RetuCaution should be exercised in generalizing our findings because our recruitment was restricted to GBMSM who were aged between 18 and 34 years and had accounts on Facebook or Grindr. Their opinions on factors shaping study engagement or lack thereof may differ from users of other social media or dating platforms and from those who do not have a presence on the web. In addition, only 3% (3/100) of the participants in our study resided in areas designated as rural by the Federal Office of Rural Health Policy, and none of them were interviewed. This limitation precludes our understanding of issues unique to rural residents . Our interviews were conducted only in English, which could have posed a language barrier for some participants. Finally, most interviews were completed before the COVID-19–related stay-at-home mandates came into effect, and it is possible that additional themes and subthemes may have emerged had we interacted with the participants during the pandemic.Soliciting self-collected specimens for HIV, triple-site gonorrhea, and chlamydia, and PrEP drug–level testing from GBMSM might hold promise as a remote monitoring strategy for individuals at elevated risk. In-depth interviews with a subset of participants who returned all, some, or none of the specimens in our exploratory study offered valuable insights into aspects that facilitated their engagement as well as areas for potential improvement. Our results have pragmatic implications for the design of subsequent large-scale studies and public health programs for home-based HIV, bacterial STI, and PrEP adherence testing. This comprehensive overview of the key lessons learned from our study’s implementation and recommendations offered by participants could help maximize the rates of self-collected specimen return in future web-based HIV and bacterial STI prevention research and practice.


The review captures primary historical and conceptual references, relevant to the therapeutic-embodied exploratory work. Then, G. Stanghellini’s mental health care model [kinaesthetic intelligence and attunement and to educate healthy persons who can promote edifying social relations and environments.This work begins with a brief review – from the re model  is reviere model  is prese Nature is a principle of motion and change. (…) We must therefore see that we understand what motion is; for if it were unknown, nature too would be unknown’ rue relaxation would mean a complete resignation of the body to the law of gravity, the mind to nature, and the entire energy transferred to a deep dynamic breathing […] To transfer energy by voluntary action and involuntary reaction produces the necessary equilibrium for the renewal of strength (1892: 77–78)”  pain or physical malfunctioning signals our body as warning signs meant to inhibit action. In order to figure out why our body might be malfunctioning; somatic awareness activities allow the individual to access feelings or sensations from the body to develop a sense of personal movement habits and behavior”  is interested in the living body’s subjectively experienced capacity for self-education.”As Michael Murphy states: “, p. 23when and how it is appropriate to modulate the embodied qualitative dynamicsintuitive aspects difficult to formulate into words’  habits are a result of ‘tonus adaptation’ related to certain emotional states” , or readiness to (re)act and be affected in a given way, and probably also to develop certain moods more than others… It is important to notice that all these transformations from affects to moods to character occur pre- reflectively and without a deliberate and thematic involvement of the person in the process, whereas the transformation of a mood into an affect involves reflection , p. 44.Stanghellini refers to the temporal unfolding of affects as part of the dialectical dynamics of personhood by pointing out that top-down emotional constitutive processes (affects → moods) unfold pre-reflexively, but bottom-up processes (moods → affects) unfold reflexively. He writes:Recognition. Stanghellini conceives the latter as a ‘we-experience’ for which reciprocal affective attunement is a necessary condition, discarding understanding as an identification of the other’s mental state and approval/consent as an ethical judgement or stance:Recognition first and foremost presupposes attunement with the Other. It is a mode of being with the Other, a kind of intimacy with the Other, a modulation of the emotional field in- between myself and the Other. In an essay significantly entitled Making music together, Alfred Schutz (1976) explains that the experience of the ‘We’ that is at the foundation of all possible communication is a mutual tuning- in relationship, a sharing of the Other’s flux of experiences similar to that of two co- performers (let us say a soloist accompanied by a keyboard instrument) who have to execute a piece of music , p. 50.A fundamental affective and inter-subjective aspect, where the dialectical dynamic of alterity is instantiated, is the reciprocal one-other’s recognition. There is a teleological agency in inter-corporeality motivated by a basic human desire for (other’s) What do they share in that experience?” – this question is necessary to make sense of the ‘we.’ In agreement with Stanghellini, individuals in a “we-experience” share a common temporal experience or their experience becomes synchronized … This alternative perspective holds that the manifold  phenomena in a syndrome are meaningfully interconnected, that is, they form a structure… To have a phenomenological grasp on these phenomena is to grasp the structural nexus that lends coherence and continuity to them, because each phenomenon in a psychopathological structure carries traces of the underlying formal alterations of subjectivity , p. 118.This model proposed by the author serves as a guideline for the development and application of particular therapeutic methodologies. The model proposes five developing steps: (i) ‘This fragment begins by stating Jasper’s take on the particular ; lived experience being a dynamical, embodied, sense-making, organic structure in continuous flux. The phenomenological work helps to unearth these structures in their constitutive dynamics and in their sense-making or self-constitutive patterns. For example, as an individual’s relation with alterity is altered due to its own fixed interpretation of his experiential changes, if she/he takes into consideration these fixed interpretations and changes,  and the clinician to make sense of the patient’s identity and symptoms through a specific embodied attunement, ‘as-if’ the clinician lived the patient’s experience  79, 36’” , p. 11. e reflex , p. 94, unfolding of the individual’s experience and its constituted sense . Depending on the temporal period or rhythm of anticipation of an individual’s experience, the sense constituted could vary significantly if the other inhibits a response for a temporal period in which the former’s anticipation and corresponding sense-making routines are frequently displayed.There are phylogenetic and ontogenetic conditions defining individual sense-making routines  , p. 8. THence, we can assume that distortions of the lived time are always involved in the core of psychic disturbances and give rise to different symptomatic manifestations”  and even proper elucidation of how time-consciousness is possible lies not in the examination of something external to us, like a melody, but in the very nature of our being the animate organisms we are, that is in the very nature of self-movement” [corporeal dynamics (movement and action) and micro-dynamics , and leads to a synchronic, fine-tuned inter-subjective dynamics, unveiling a shared inner-time consciousness.30Following M. Sheets-Johnstone, “…ovement” , p. 35. Temporal consciousness  and spatial consciousness  [bodily movement , affectivity  and intentionality . The latter variables are to be contrasted with other variables such as the genetic, molecular, cellular, physiological, behavioural, and dialogical-narrative; together, they assemble a mental health matrix for theoretical and/or clinical purposes. This conceptual work is grounded on the latter conceptual and phenomenological Husserlian tools.This paper has looked to contribute a novel framework and approach to mental health, serving the theoretical and clinical realm. As stated above, the present work has argued for the following intuition: that bodily movement and temporality are fundamental psychotherapeutic assets for the development of conceptually guided approaches to mental health applicable for neuroscience, psychiatry and philosophy. Accordingly, the following phenomenological axes were proposed: e space) , bodilyTo conclude, the proposed work is focused on a realm of subjectivity phenomena, which is correlated to the flow of consciousness and the constitutive process stemming from it. These phenomena and processes must be researched and studied to properly account for psychopathological disturbances. Accordingly, the present research offers a methodological challenge to the current conceptual and experimental work of science, which should better synthesize the phenomenological work articulated here with functional connectivity research on large scale brain networks.economic: as the patient grows in self-awareness and kinaesthetic intelligence,therapeutic: the phenomenological approach offers a rich ground from which new therapeutics can merge. As this approach is strongly based on the body, a sense of autonomy is promoted and integrated in the therapeutic approach. And (iii) conceptual: the present phenomenological perspective offers a ground and a solid foundation for mental health research to continue.There are three main advantages of the work proposed: (i) This account aims to promote a holistic conception of health and a positive conception of mental health by working through the continuum between personal development and psychopathological disturbances. Accordingly, this account looks to contribute to preventive work-ethos achievable for the general population through education and self-awareness. This work requires life-long educating on overcoming self-relation issues by enhancing self-awareness, developing skills for inter-corporeal resonance, attunement, and for building healthy strong relations, and finally, educating citizens so as to enable them to govern themselves within relations  in an edifying and effective manner.


Co-produced research is when all stakeholders, including experts by experience and researchers, work together to conceptualise, design, deliver and disseminate research to enhance understanding and knowledge. This type of participatory inquiry is being increasingly used across health research; however, it continues to be a complex area to navigate given existing institutional structures.We collaborated across three independent co-produced research studies to share insights, reflections, and knowledge of our work in the fields of HIV, mental health, and disability research. We co-designed and delivered a three-hour online workshop at a conference to share these reflections using the metaphor of ‘building bridges’ to describe our co-production journey. We generated key principles of co-production from our different experiences working in each individual research project as well as together across the three projects. Our principles are to: (1) be kind, have fun and learn from each other; (2) share power (as much as you can with people); (3) connect with people you know and don’t know; (4) remain connected; and (5) use clear and simple language.We recommend that co-produced research needs additional funding, resource, and flexibility to remain impactful and ethical. Co-produced research teams need to be mindful of traditional power structures and ensure that the process is transparent, fair, and ethical. Addressing equality, diversity, and inclusion of traditionally underrepresented groups in research is essential as are the skills, expertise, and experiences of all members of the co-production team. Co-produced research occurs when a range of people, including researchers and people with lived experience of a topic work together on all stages of a piece of research, from design to publication, to improve understanding of a topic. This methodology has become increasingly popular in the field of health research, however – it can be difficult to undertake because of how health institutions are structured. As a team, we examined three co-produced studies  to share our insights and reflections. We then shared these reflections through a co-designed online workshop at a conference. We used the metaphor of ‘building bridges’ to describe our teamwork. From our experiences on these studies, we came up with five key suggestions for co-production in research: (1) be kind, have fun and learn from each other; (2) share power as much as possible with everyone; (3) connect with people you know and those you don’t; (4) stay connected; (5) use clear and simple language. To achieve ethical and impactful co-produced research, we suggest that it needs more funding, resources, and flexibility. Teams who are conducting co-produced research must be fair and clear about how they do so, and ensure that everyone, especially groups who are often unheard, get a chance to be part of research so that everyone’s skills and experiences are equally considered. Co-produced research is a partnership between academic researchers (academics), and people with lived experience (co-researchers) throughout the research cycle Fig. . SpecifiIn the United Kingdom (UK), the National Institute for Health and Care Research (NIHR) use a broad definition of public involvement of “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them” . TherefoHere, we consolidate our lessons learned in this space using the ‘building bridges’ metaphor to share and reflect on our experiences at Imperial College London across three co-produced projects. Our projects, now complete, consisted of three teams of co-researchers: people living with different health conditions including HIV (in collaboration with peer-led HIV support charity Positively UK) –14, lear.  had been built, then it felt more like my (previous) experiences of doing this type of research  and, looking ahead, it’s like the research I want to continue doing. So, it was going from past research experiences to future research aspirations.” the landscape of the bridge changes. There are multiple bridges and obstacles to overcome. The initial co-produced research bridge changes into a bridge that connects a co-produced research team with new opportunities, places, and communities.With the right infrastructure and support , 27, co-"The reason we are successful is because we know what the problem is" “My experience of being involved in the project has been that the co-researchers bring an insider view/perspective of the research and that can only be a win for any research.” The aim of co-produced research is for co-researchers to build capacity and support the co-researcher’s skill development. Co-researchers have a greater sense of ownership and they independently build further bridges. For example, several co-researchers across our teams are undertaking PhDs, working in the health and care sector, have presented their work at academic conferences  or have Throughout all our projects, we faced similar challenges relating to resources and time, navigating power structures and institutional processes which are often cited in the literature –31. For Increased funder commitment to resources and flexibility in reviewing funding applications .Flexible application and review processes by ethics committees for participatory projects  .A greater emphasis on co-authorship and perspectives of community members by publishers .Increased capacity, training resources and support by professional bodies to conduct co-produced research.Transparency in decision-making, inclusivity and fairness of opportunities is key to ensuring that co-produced research also upholds ethical standards and good practice , 33. TheBuilding on our growing experiences, we aim to champion co-produced research as a method within public health research and ensure that it is understood and valued within academia. Research communities globally are starting to take action to reignite co-produced research and subsequently ensuring equality, diversity, and inclusion are a central focus for all in health, social care and beyond. However, we still have a way to go. For a more creative and engaging explanation of ‘co-produced research’ and how it can be achieved, we invite you to watch two videos produced by our teams , 35.