Each of these individual-level mechanisms affects an individual's phenotype–environment match, its fitness, and its individualized niche, defined in terms of the environmental conditions under which the individual can survive and reproduce. Our framework identifies how individuals alter the selective regimes that they and other organisms experience. It also places clear emphasis on individual differences and construes niche construction and other processes as evolved mechanisms. The NC3 mechanism framework therefore helps to integrate population-level and individual-level research.Organisms interact with their environments in various ways. We present a conceptual framework that distinguishes three mechanisms of organism–environment interaction. We call these  We focus mostly on animals, but we see our framework as applicable to plants and other taxa, too.By identifying different types of niche-altering mechanisms, we provide a unified framework of organism–environment interactions that integrates individual-level and population-level perspectives. We argue that the different ways organisms alter their niches are evolved causal mechanisms that play a role in evolutionary processes. These insights derive from our work within the interdisciplinary research consortium “A Novel Synthesis of Individualisation across Behaviour, Ecology and Evolution: Niche Choice, Niche Conformance and Niche Construction  vary in their colony-founding behavior, either tolerating other queens or killing them  environment the individual interacts.https://doi.org/10.32942/osf.io/7h5xq; preprint: not peer reviewed], Takola and Schielzeth Hutchinson  focused Individual organisms engage in many sorts of activities altering their individualized niches. Most of the classical examples of niche construction involve organisms actively making changes to their environments, rather than, for instance, changing the environmental conditions they live in by relocation. This makes sense, because we tend to intuitively understand niche construction in analogy to human construction of artifacts such as buildings or roads Archetti .However, many niche construction theorists understand niche construction more broadly. Odling-Smee, Laland, and Feldman  includedniche construction to cover such diverse phenomena is potentially confusing, especially given that paradigmatic examples continue to revolve around making changes to the environment  also includes changes in which an organism is not moving or exerting large amounts of energy, such as resting or going to sleep. Activities can involve one or more entities. These entities can be active, performing the activity, or they can be passive, having the activity done to them  environment with which the focal individual interacts; and in niche conformance, the focal activity is to adjust the phenotype in response to the environment  environmental parameter values under which it survives and reproduces  or even simultaneously. For instance, a bird building a nest is certainly a case of niche construction, but individuals ready to breed often need to relocate to a suitable habitat and choose a tree in which to build their nest, so that niche choice precedes niche construction.The NC3 mechanism definitions in combination with the fact that mechanisms can act in concert means that classification may be ambiguous in some cases. For instance, an organism making changes to the environment (niche construction) typically involves certain behavioral or other phenotypic changes, as occurs in niche conformance. Empirically differentiating niche construction and niche conformance is particularly challenging when it comes to social niches. It is difficult to detect whether a focal individual changes its social behavior first, which then causes a change in the behavior of its conspecifics, or whether it is the other way around. Similarly, choosing a specific social group (niche choice) will also induce changes in the social dynamics of that group, as occurs in niche construction.In addition, the very general nature of the NC3 mechanisms is posed by the cooperatively breeding cichlid Neolamprologus pulcher. In the early postnatal period, individuals already develop integrated behavioral and dispersal phenotypes , dominant females show increased aggression toward pregnant subordinate females, resulting in their temporary eviction from the social group. Being evicted induces severe stress in the subordinates, promoting spontaneous miscarriages. In this way, dominant females shape their social environment, suppressing their competitors’ reproduction, and thereby monopolizing reproduction in the group . Second, the focal individual must have an active role (see above). This excludes changes in the environment in which an individual is only passively involved, such as changes in a nonhuman organism's environment produced by human activities such as farming or anthropogenic climate change. On the other hand, activities such as defecation or trampling may well be considered niche construction, because the focal individual is actively engaging in activities that change its environment, as long as the focal individual's phenotype–environment match and fitness also change as a result. These two conditions are captured in our definition  or making changes to the environment (niche construction).The second NChabitat choice , darker individuals prefer darker underground, whereas individuals with lighter colors prefer lighter underground. Interestingly, manipulation of individuals’ color (with dark or light paint) led to changes in preferences, such that dark-painted individuals preferred darker underground, independent of their original, natural coloration  showed that, following natal dispersal during the first year, most individuals remained in the areas in which they spent their first winter ; individuals have heritable preferences for breeding in smaller or larger groups . Nevertheless, there is a conceptual delineation of the cases; it is then an interesting empirical question whether a particular individual that has maintained the same relationship with its environment has engaged in choice behavior.In most cases of niche choice, the focal individual changes its location, resource use, or interactions with its environment. But what about an individual choosing to not change anything? We think that these cases should qualify as niche choice if the individual was able to explore different options of changing its relationship with the environment. Even if this exploration does not result in a change of the individual–environment relationship, it does involve individuals actively approving their present environments. It might be difficult to discern such cases empirically from cases in which an individual does 3 mechanism is niche conformance, which involves focal individuals changing their phenotypes in response to environmental conditions. Niche conformance involves phenotypic plasticity, the capacity of an organism to develop distinct phenotypes in response to environmental variation  during development in response to anticipated variation in predation risk (Laforsch and Tollrian Parus major); individual females track between-year variation in spring temperatures in order to match supply and demand in nestling food  and can be applied to irreversible developmental changes during an individual's lifetime (nonlabile traits), as well as to reversible changes in response to the current environment (labile traits). An example for a nonlabile, morphological trait is the expression of inducible defenses such as spines and helmets by water fleas . Such measures may serve as fitness proxies, because an improvement of factors such as body condition or effective mimicry will often increase an organism's fitness . It is the specific activity of the focal individual that changes its reproductive success. Changes in absolute fitness will often also affect relative fitness , and relative fitness drives evolutionary change. Whether a particular NC3 mechanisms will tend to increase focal individuals’ (absolute and relative) fitness  and must therefore be maintained by balancing selection favoring alternative phenotypes. Interestingly, some species are able to conform their body color to the background of the habitat . In addition, in the context of the NCSecond, to accommodate changes of niche relations within a lifetime, the quality of match needs to be evaluated with respect to a given situation or short period of time. Realized fitness, being a lifetime outcome, is not the appropriate parameter. Instead, fitness proxies such as individual (ontogenetic) growth rate, territory possession, mating rates and fertilization success can indicate how suitable a combination of niche parameter values is for an individual at a given time.realized individualized niche. We should note, however, that the distinction between fundamental and realized individualized niche does not exactly mirror Hutchinson's concepts. For instance, fundamental individualized niches might include some level of competition between individuals. In contrast, the fundamental population niche excludes competition between populations. Some authors proposed to use the term potential individualized niche instead of fundamental individualized niche to emphasize the difference from Hutchinson's fundamental niche , intraspecific interactions drive dispersal, because subordinate individuals tend to move greater distances in search of resources and less hostile social environments  environment instead of modifying the existing environment figure . IndividNiche conformance changes the individual's phenotype. A different phenotype means that the organism can, for instance, tolerate different conditions or exploit different resources. This, in turn, means that the individual will have changed its fitness value in the absence of any change in the environmental conditions. In this case, the fundamental individualized niche changes because of a change in the shape of the fitness function across the niche dimensions. In addition, the individual may, given its new phenotype, be able to survive and reproduce under new sets of environmental conditions. In this case, the fundamental individualized niche changes because new niche parameter values are included in the niche.Interestingly, a change in the realized individualized niche can eventuate in a change in the fundamental individualized niche. This can happen when niche choice or construction is followed by niche conformance. For example, individual oystercatchers specializing on either soft or hard prey types grow different bill shapes that facilitate efficient processing of their specific prey of choice .Our conception of the NCOur focus on individual activities, individual-level mechanisms and individualized niches extends the initiative from biologists who investigate niche construction in the wide sense. The importance of individual behavior for evolution was even stressed by Mayr , p. 604,Our focus on mechanisms comprised of a focal individual and its focal activity stresses the importance of individuals’ activities  as modulators of the selective regime under which individuals live. When the constructed or chosen environment is inherited, individual activities can also affect the realized individualized niches of future generations, leading to longer-term evolutionary effects (Pontarotti Nevertheless, we do not propose a general answer to the question of whether organisms are evolutionary agents rather than mere objects of evolution. Instead, our framework invites solving this question empirically. This is in contrast to the at times staunchly held positions in the debate about the modern synthesis and extended evolutionary synthesis (Wray et al. 3 mechanisms shows that this empirical study needs to rely on research that acknowledges and investigates individual differences in behavior, physiology, and morphology. In particular, it remains an important challenge to link the results of individual-based research with investigations on the population level, such as the study of population genetics.Scrutinizing the NC3 mechanisms change individuals’ phenotype–environment match and their fitness. Because many examples of NC3 mechanisms have evolved and persisted through natural selection, we expect them to generally improve phenotype–environment match and fitness, as has indeed been shown in several of the examples we have cited.Organisms modify their niches in a number of different ways. We distinguish three different mechanisms by which individuals alter their environments and thereby their niches: niche construction, niche choice, and niche conformance. The three mechanisms are distinguished by the focal activity performed by the focal individual. In niche construction, the individual makes changes to the environment; in niche choice, it selects an environment; and in niche conformance, it adjusts its phenotype in response to the environment. All of the NC3 mechanisms is the way they alter individualized niches, including social niches. Niche construction and niche choice affect the realized niche, altering which options of the fundamental individualized niche are realized in the environment the individual experiences. In contrast, niche conformance affects the fundamental niche, either by affecting the individual's performance in a given range of conditions or by changing the conditions under which the individual can survive and reproduce. Because they are individual-level mechanisms, NC3 mechanisms highlight the potential for individual differences to affect how organisms alter their niches.One interesting feature of NCOur framework recognizes that individuals can be agents of evolution, affecting the selective pressures to which they are exposed and the resources and information available for generating new phenotypic variation. It therefore describes the importance of individualized research in a field that traditionally takes a population perspective. In addition, it provides new material for understanding the evolution of niche-altering individual activities through natural selection.biac023_Supplemental_FileClick here for additional data file.


It is important to understand how to frame the formats for promoting HIV self-testing to increase uptake among young people. In this study, we used a culture-centered model to understand the narratives of HIV self-testing preferences among young people in Nigeria. We conducted a crowdsourcing contest to solicit ideas surrounding HIV self-testing promotion among young people (10–24 years) in Nigeria from October to November 2018 as part of the 2018 World AIDS Day event. We received 903 submissions and employed thematic content analysis to evaluate 769 eligible youth narratives. Thematic content analysis of the statements from the youth narratives was guided by the PEN-3 cultural model to examine the positive, existential, and negative perceptions , enablers (resources), and nurturers (roles of friends and family) of HIV self-testing promotion among young people in Nigeria. Several themes emerged as factors that influence the uptake of HIV self-testing among young people in Nigeria. Specifically, seven themes emerged as perceptions: HIV testing accessibility, stigma reduction, and autonomy (positive); HIV self-testing kit packaging and advertisements ; lack of knowledge and increased stigma (negative). Seven themes emerged as enablers: social media, school, and government promotion (positive); gamification and animation ; high cost and access to linkage to care services (negative); And seven themes emerged as nurturers: peer, families, and faith-based communities (positive); parents and family-centered approach ; and partners and family (negative). Our data suggests that increased awareness around HIV self-testing on current youth-friendly platforms, de-stigmatization of HIV and HIV self-testing, decreased prices for HIV self-testing kits, reliability of testing kits, increased linkage to care services, and promotion of self-testing among family members and the community will be beneficial for HIV self-testing scale-up measures among young people in Nigeria. In 2020, 400,000 young people aged 10 to 24 were newly infected with the human immunodeficiency virus (HIV) . In NigeTo prevent HIV infections among young people globally, the World Health Organization (WHO) recommends HIV self-testing (HIVST) as an additional approach to HIV testing services . HIVST iWhile there is an emerging body of knowledge on barriers and motivators to HIVST among young people, little effort has been made to understand young people’s perspectives on solutions to address these barriers and improve HIVST rates. Traditional methods of data collection such as surveys, focus groups, and interviews lead the process of engaging young people in discussions about their health . Yet, thThe present study sought to combine the creative narratives of young people within a crowdsourcing contest to promote HIVST uptake in Nigeria. Crowdsourcing is ideal for this study as it allows young people the space and agencies to voice their ideas around HIV prevention challenges while also encouraging responses that better contextualize HIVST among young people in Nigeria. In the context of generative ideas, youth narratives are a source of insight into how young people make sense of HIVST and share this understanding with others. We situate our analyses within the PEN-3 cultural model, which centralizes culture in everyday lay meanings of health . We pay The PEN-3 cultural model examines health behavior using a collective approach. The model has been used to assess qualitative data through focus group discussions in studies related to health literacy  and adolWe conducted a crowdsourcing contest as part of the Innovative Tools to Expand Youth-Friendly HIV Self-Testing (I-TEST) study, known locally as 4 Youth by Youth (4YBY), in Lagos, Nigeria . From OcA crowdsourcing contest was coordinated and implemented as part of the youth-centered and youth-led study team “4 Youth by Youth” (4YBY). The 4YBY team includes young people, health professionals, activists, and entrepreneurs from diverse backgrounds that share a passion for advancing Nigerian youth engagement and leadership in creating innovative and sustainable HIV services. The contest was entitled “The 4 Youth by Youth World AIDS Day HIV Self-Testing Contest,” event in Lagos, Nigeria, which marked the annual global World AIDS Day, celebrated on December first each year. The goal of the contest was to solicit ideas and/or concepts in response to the following key question: How might we promote HIVST among young people in Nigeria? The hashtag “HIVSELFTESTINGCONTEST” was generated to identify the campaign on social media platforms. The research team organized a multi-sectoral contest advisory panel to implement the contest, which consisted of youth representatives from diverse backgrounds and cultures to participate and evaluate ideas based on pre-specified criteria. The contest advisory panel also selected the top 30 finalists and invited them to deliver a three-minute pitch of their idea to a panel of judges at the World AIDS Day event and announced finalists and winners at the end of the event. Participants were recruited through open calls disseminated through social media  and in-person announcements and flyer promotions at secondary/high schools, universities, and community centers where young people congregate in Lagos state. In organizing the contest, we used the TDR Practical Guide on Crowdsourcing in Health and Health Research . The guiDe-identified participant entries were transcribed, and thematic data analysis was performed , 38. TheWe received a total of 903 entries over a seven-week period, including 353 entries submitted in-person and 550 online submissions. The research team screened and shortlisted entries based on pre-specified eligibility criteria. Entries were excluded due to incompleteness, plagiarism, and not meeting the age criteria . In total, we found 769 eligible, non-duplicated entries submitted by 769 entrants. Consistent with the application of the PEN-3 cultural model, we generated nine cells by crossing the three domains of Relationships and Expectations with the three domains of Cultural Empowerment see . A totalPerceptions-positive. There were a wide range of positive perceptions of HIVST among young people. The highly convenient and discreet nature of HIVST, as well as reduced potential of experiencing stress due to long travel times, meant that providing HIVST would potentially increase access to HIV testing services among individuals who may have limited access to health facilities, as depicted in the following statement:“The HIVST test kit has the potential to increase access to HIV testing. It gives one convenience and privacy and it’s very easy to use. It can also be beneficial to people who don’t have easy access to healthcare centers…”(#I115)“fear of being perceived as a promiscuous person” (#o28), that are often experienced by young people when accessing HIV testing and/or pre-test information at the health facilities, were frequently cited by the participants, as described below:The possibility of HIVST in reducing HIV-related stigma and discrimination or “The issue of testing and stigmatization is yet a major challenge especially among youth in Nigeria. Young people are often not encouraged to seek information on HIV, especially from an adult who may be judgmental and discriminatory. Worse still, people often misjudge others when they want to go for HIV test when it is not for a job requirement or religious body prerequisite for marriage. Hence, HIV self-testing is a paradigm to overcoming some the drawbacks to gain positive attitudes toward HIV test.”(#o56)“more active role in managing their [youth] health and sexuality” (#I344). A few participants believed that HIVST also creates an opportunity to reach Nigerian youth who may not have otherwise tested for HIV and increase HIV retesting uptake among individuals at higher risk of HIV acquisition.The added autonomy and self-empowerment conferred by HIVST was perceived to be beneficial in creating a Perceptions-existential. The existential perceptions of HIVST among young people centered around HIVST packaging formats, HIV awareness, including HIVST advertisements. Testing kit package instructions, package appeal, and package names were often cited to promote adoption and discretion when testing. In relation to this, a participant mentioned the following:“Test kit can be packaged in a cotton, form, the size be in form of a thermometer like form which comes with a pack or sterilized needle…small innovating book to give them the courage that there is still hope in life.”(#193)Advertisements were mentioned when promoting HIVST and increasing the public’s perception. This can be seen in the following statement:“One of such ways is by placing detailed advertisements on radio programs, television stations, and newspapers; explaining vividly on the importance and benefits of this self-test, as well as how to carry it out.”(#294)Perceptions-negative. The negative perceptions related to HIVST were related to ignorance surrounding HIV and fear when testing. Lack of knowledge or awareness around HIV and HIVST was expressed in the following statement:“Nigeria has lacked behind in the adoption and creation of awareness of HIV self-testing as a testing option to increase access to HIV testing because of constraints and arguments against HIV self-test.”(#057)321). Stigmatization by others when testing for HIV and fear of one’s status being compromised were frequently noted:Contrary to positive perceptions around reducing HIV-related stigma and discrimination when promoting HIVST, some negative perceptions around HIV and HIVST also touched on stigmatization and were often centered around privacy of results and typecasting an individual with HIV as an “outcast” Enablers-positive. Participants identified various mobile health strategies as enablers when promoting HIVST, reaching other young people, and connecting young people to appropriate sexual health services and support systems. Other participants cited governmental, community, and school resources as positive enablers. Due to the extensive use of smartphones and widespread internet access among young people, majority of participants cited the use of social media platforms and mobile apps, like WhatsApp, Facebook, Instagram, and Twitter to increase awareness of HIVST and maintain visibility online, as illustrated below:“We can harness the way social media has linked young people all over the world in discussions about issues that directly affect them. Spurring interest and awareness of HIV self-testing, can lead to conversations about it among young people.”(#o367)Participants also identified certain locations that would be beneficial in making HIVST more accessible to young people in the community. The most frequently cited location for promoting HIVST was in the school setting. One participant suggested introducing HIV prevention in school curriculums and including information on HIVST:“Moreover, adding HIV self-testing into school syllabus will be a great thing because both students in primary and secondary school will be a beneficiary of it. This HIV self-testing should be added to civic education in school because it is a core subjects. This will help the students to know their HIV status and be able to disseminate It to their parent at home, also establishing social clubs known as society or curriculum activity in school, Those social club will serve as counseling link between the doctor and the students through the social club master who will deliver the practical aspect of HIV self-testing after the students had been taught the theory aspect in their various classes. Those club masters will also be a public awarer that will go to various places like markets, universities and colleges of education to teach people the practical aspect of HIV self-testing.”(#184)Other convenient and accessible community venues were also mentioned, such as local government town halls, churches, mosques, youth-friendly centers, concerts, and sports betting centers.Enablers-existential. Like the earlier themes, existential enablers by young people were related to the use of digital technology and advertisements when promoting HIVST. A less common but related theme was incorporating elements of games (gamification) to enhance audience engagement while providing health information and critical measures related to HIVST:It is a story/adventure game in which players would be able to control the actions and choices of characters revolving around real HIV/AIDS issues among youth, suggesting regular self-testing. VIDA will come with an online community where youth from all over the country can discuss issues and questions with the input of professionals.”“(#62)Participants also noted the need to be trained on the product and partnering with trusted companies when promoting the HIVST toolkit, as described below:“Companies producing these drugs can partner with authenticated companies producing such toolkits so that controlled access to the equipment is made possible to prevent inefficient or fake toolkits from reaching the hands of youths to avoid turnout of wrong hiv test result.”(#169)Enablers-negative. There were concerns about decentralizing HIV testing by promoting self-testing beyond facility-based sites. Negative enablers were related to the cost associated with purchasing HIV self-tests and the lack of access to linkage to care services for those who have reactive test results. The first, cost associated with HIVST and facilitating uptake, was described in the below statement:“The cost of an HIV self-test kit is a potential barrier to adoption, willingness to use, purchase, and the uptake of the HIV self-test, particularly among people in poor resource settings… not willing to purchase the self-testing kits as a result of the cost.”(#057)Thus, most participants expressed concerns with those who undergo HIVST having little to no access to pre or post-test counseling support, including linkage to care and treatment services that are typically provided by in-person test counselors:“Crucial that provision of pre- and post-test counseling should be made available in order to avoid misinterpreting the instructions…people might commit suicide if they received positive HIV self-testing results without formal support from a health care provider or counselor… no referral mechanism to link them to a healthy facility after self-testing.”(#057)Nurturers-positive. Participants emphasized the importance of engaging their peers as active change agents in promoting the uptake of HIVST in their communities. They also mentioned educating family members on HIVST to prevent spread to children and utilizing community gatekeepers. A participant mentioned:“…Students are the ones that will still go back to their local area, home, friends, mosque or church and people cherish them as student of knowledge a lot and they influence others a lot…”(#48)A few participants suggested leveraging the influence of faith-based leaders and faith communities in facilitating the uptake of HIVST. A participant stated:“The citizens revere their religious and believe whatever they hear from their religious leaders as being in their best interests. Consequently, the religious gatherings can be used as a means of disseminating information’s on HIV self testing.”(#58)Nurturers-existential. The existential nurturers included parents and the family at large in HIV discussions. One participant noted the lack of such discussion due to traditions and norms:“Our tradition, norms, and values do not promote discussion on sexuality between parents and their children.”(#338)Further, a participant suggested a family-centered approach, in which family members and society work collectively to foster interactions around HIVST, as illustrated:“Teamwork which would involve parents and the society would help in promoting self-testing among youths, encouraging the intervention of the kit.”(#096)Nurturers-negative. The influence partners and family have when learning about HIV and promoting HIVST was highlighted in the narratives:“Unfavorable reaction of partners in relationships and marriages also make people scared of knowing their status especially when the kit can show their path at their comfort zones.”(#058)“HIV destroyed the useful facilities in anyone who is contacted and cannot do anything meaningful… tarnishes the image of the family.”(#135)Furthermore, participants noted the unfavorable reaction of partners when testing for HIV and the impact HIV has on the family’s image.For this study, we used the PEN-3 cultural model to better understand context-specific dynamics around HIVST promotion among Nigerian youth. Findings reveal cultural resources available to young people as they strive to make sense of HIVST and identify context-specific distinctions and nuances necessary for creating demand, improving access, and reaching young Nigerians with HIV who remain undiagnosed. This study enhances the literature by incorporating young people’s voices and narratives to better understand HIV and HIVST uptake in low-and middle-income countries (LMICs) and by broadening the reach of HIVST in this age group.Positive perceptions around HIVST centered around preferences young Nigerians had for the confidential nature of HIVST and the convenience that HIVST provides in permitting testing at home and eliminating travel times for HIV testing in health facilities. This finding is consistent with other studies that have been conducted globally, and in SSA, that have researched HIVST uptake and acceptability , 41. StuExistential perceptions among young people were related to kit packaging and HIVST advertising. Studies have noted that increased anonymity and incorporation of innovative user preferences with packaging will be required when reducing stigma-related barriers and appealing to those of various literacy or education levels , 41. YouOur study also identified positive, existential, and negative enablers for HIVST promotion among young people in Nigeria. A positive enabler included using social media platforms, while an existential enabler included using gamification to promote relatable storytelling and create entertaining and informative ideas to promote HIV and HIVST. The implementation of more media-based interventions for youth-engaged HIV testing is consistent with evidence suggesting a youth-driven approach in designing and implementing a campaign using the media and community outreach for HIV/STI testing . The proAs suggested in our results, incorporating HIVST in places most visited by young people has the power to shift the way young people view HIVST and can help with HIVST acceptability. Results from one study looking at the acceptability of HIVST among students in the Democratic Republic of Congo revealed that unsupervised HIVST was 81% more acceptable among those 24 years and younger and associated with prior knowledge of HIVST . A smallYoung Nigerians expressed concerns relating to high costs for the HIVST toolkits. There have been new pricing deals of HIVST and additional suppliers to make HIVST more accessible through a Unitaid-led pricing agreement . Our finOur study also successfully outlined nurturing factors when promoting HIVST. Positive nurturers included involving Nigerian youth as change agents when promoting HIVST to other young people, promoting HIVST among families and shaping mothers’ awareness of prevention measures, and distributing HIVST information in community settings like faith-based institutions. Utilizing youth as change agents when promoting HIVST will be very important when reaching other young people. In one study, 81% of young women in rural South Africa who used HIVST reported talking to their partner after using HIVST and distributed kits to their female friends and family . This inAdditionally, parents acted as existential enablers in our study. Among adolescents and young adults in Kenya, evidence suggests that peers, partners, and parents can play important roles in testing decisions . This suWhile this study has strengths in applying the domains and constructs from the PEN-3 cultural model, it is not without limitations. For one, the PEN-3 cultural model is a rich model in that it uses different domains to examine culture. By focusing solely on the Relationships and Expectations and the Cultural Empowerment domains for the youth narratives, and not the Cultural Identity domain, this study may lack the ability to explore additional context-specific dynamics from youth narratives. Furthermore, because this study was conducted in Nigeria, much of the youth narratives are specific to young people in Nigeria and may lack generalizability with other young people in SSA and their thoughts around HIVST promotion.The PEN-3 cultural model is useful when exploring cultural context among Nigerian youth narratives and when promoting HIVST. Additional youth-driven interventions, those aware of culture, and those that consider the unique perspectives of youth, will be helpful when reaching more young people and sustaining HIVST practices. It is important that young people in Nigeria are aware of the agency they possess and their ability to promote HIVST in various settings. This not only shapes the way they view their health but is instrumental in the creation of prevention measures for their communities at large. Family, friends, and community organizations can work together with young people and help with promotion activities. Additional strategies when promoting HIVST among young people in Nigeria should consider accessibility, feasibility, desirability, sustainability, and normalization of HIVST activities.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.


South Africa, like other countries around the world, has used a lockdown strategy to address the initial phases of the COVID-19 epidemic. The significant restrictions on population movement have included initially limiting exercise to the home. There is substantial evidence for the many benefits of exercise. This study specifically emphasises the benefits of exercise to the immune system, particularly for those most vulnerable to the effects of the SARS-CoV-2 virus and proposes measures to improve access to exercise in a demographically diverse and economically disparate society. Moreover, South Africa has an HIV prevalence of 20.4% (7.7m people)  and approximately 530 000 tuberculosis cases. Significantly, rates of obesity and metabolic syndrome are also alarmingly high across both cohorts. The country has a demographically heterogeneous population but also a large disparity in resource distribution with a GINI coefficient of 63.,7 Just as intensivists know which pre-existing ailments raise a red flag for the COVID-19 patient, Sport and Exercise Medicine clinicians appreciate how regular exercise is a most effective intervention across the spectrum of these comorbidities.The published data show that pre-existing conditions, such as obesity, diabetes, hypertension and chronic cardiovascular disease, significantly increase mortality in COVID-19 patients. , with a 15% incidence of severe disease and a mortality rate of 2%. A significantly lower disease incidence trajectory was achieved by a 5-week hard lockdown that allowed for only essential services to be open and during which exercise outside of homes was prohibited. Not only did economic productivity inevitably decline but so too did levels of physical activity.Initial predictions indicated a potential positive number of South African COVID-19 cases in excess of 12 million by 10 April 2020 The virtues of regular exercise, namely physical, cognitive, and social, have been validated and extolled repeatedly. Together with sound nutrition, its role in controlling the metabolic syndrome is critical. Less well publicised is the impactful role of exercise on the immune system. Over time, a summation effect occurs resulting in improved immunosurveillance against pathogens and decreased systemic inflammation.  Randomised clinical trials have shown how near-daily moderate activity decreases the incidence of upper respiratory tract infections by 40%–50% surpassing the efficacy of most drugs and supplements. Acute exercise stimulates the interchange of innate immune system cells between lymphoid tissues and the bloodstream.  These include obese, diabetic, hypertensive and cardiac patients. Moreover, regular exercisers have a lower incidence and mortality for influenza and pneumonia. There is also an enhanced response to vaccinations, and immunosenesence (the immune dysregulation associated with aging) is delayed by habitual exercise. Importantly, a recent systematic review of the immunology literature has shown that the most vulnerable patients with an adverse outcome after SARS-CoV-2 infection may benefit most from the immune-regulating effects of regular exercise., 14Exercise needs to be undertaken gradually by those who are unaccustomed to regular exercise and those who have taken a break from training. Changes in training load should be in small increments, with data indicating that weekly increments should be <10%. When introduced responsibly, exercise is an immune booster par excellence with a particularly positive effect in those with comorbidities and in age groups commonly associated with poor outcomes to COVID-19. Exercise should be a key intervention rather than a prohibition in any national pandemic strategy. It is also freely available.South Africa’s initial lockdown directive was to prohibit not only organised sport, but exercise outside of the home, the goal being to prevent the social interaction associated with sport. Those with the self-discipline and the means  to screen athletes for any symptoms of COVID-19 before calculating an individualised safe return to training. But what options exist for those in informal dwellings in an over-populated settlement?WiFi and space) were able to make use of a number of online resources, including personal trainers and ‘Zoom’ classes. A major health insurer (Discovery) introduced the concept of a home workout channel, “Vitality at Home” The first relaxation of lockdown restricted exercise to walking, jogging and cycling for a window of three hours in the early morning within a five km radius of home whilst emphasising physical distancing instructions. This proved difficult as socially-starved active communities often turned out en masse counter to the intention, crowding popular public thoroughfares.If acknowledgement that the immune-boosting benefits of exercise are substantial is given, these authors strongly suggest prioritising the optimisation of immune health during a viral pandemic where the body’s innate and adaptive immune responses are the ultimate defence against the microbe.A more sophisticated strategy is proposed that sees physical activity prioritised at every stage of risk mitigation against the disease. Specifically:Ongoing hygiene measures - handwashing, sanitiser use, respiratory etiquette and increased physical distancing  during exercise remain non-negotiable. The use of masks and buffs when sharing any public space, including during exercise, seems a sensible  interventionAvailing and martialling of public spaces to facilitate exercise with physical distancing under supervised conditionsAllowing more extended periods of exercise outside of the home to diminish the number of people exercising at oncePermitting participation in those sports that easily facilitate physical distancing, such as golf, singles tennis, surfing, swimming in open water or in large, chlorinated pools with lanesProviding specific guidelines to schools to encourage exercise on school grounds with the return to schoolsProceeding with a phased introduction of individual and team sports in controlled environments until herd immunity is achieved or a vaccine becomes available.Physical exercise is accessible across ages, economic strata and social divides. Facilitating outdoor activity in the context of social lockdown may seem counter-intuitive. However, the overwhelming evidence for the benefits of regular physical activity on the human immune system, as well its efficacy as an intervention in those most vulnerable, makes it imperative that exercise is prioritised at every level of lockdown risk stratification. A more nuanced and sophisticated strategy by governments will utilise the current trying global health crisis to highlight exercise as the preventative and interventional medicine that it is.


Aging Research and Practices in Malaysia” has generated a great deal of interest and boasts 22 articles in total. The articles provide a good representation of the types of research ongoing in Malaysia to address the pressing issue of population aging.Malaysia is a rapidly aging upper middle-income nation with the population aged 65 years and over expected to increase 3-fold within the next 20 years. With its universities rapidly ascending international rankings, the research output within this country is also increasing at an unprecedented rate. As a result, our Research Topic on “Murukesu et al.). Mohamad Fuad et al. conducted a controlled study using serial cognitive assessments after stroke confirming the high risk of cognitive decline after stroke. Controversially, Mat et al. found that the presence of OA symptoms was protective against falls after muscle strength is accounted for. The perspectives of older persons with OA toward the Enabling Self-management and Coping with Arthritic Pain using Exercise (ESCAPE-Pain) interventional programme were evaluated with positive responses recorded . Akhtar et al. found that treatment outcome in urinary tract infection is influenced by gender, polypharmacy and comorbidities. The above series of articles demonstrates a wide spectrum of research methods ranging from qualitative to quantitative design, observational to interventional and cross-sectional to prospective now being utilized in clinical studies in older adults.The clinical research areas covered within this Research Topic included cognitive frailty, stroke, osteoarthritis (OA) and infection. Contributors included a team from the Universiti Kebangsaan Malaysia which published their protocol on multimodal intervention for cognitive frailty -WE-RISE , falls risk in older persons , fear of falls (FOF) , falls incidence recording in research  and ankle muscle function in older persons . Generally, the findings showed that there is a lack of research pertaining to home environment risk assessment and intervention in stroke survivors. Factors associated with FOF include limitations in daily functional activities but not home hazards. Instability during turning, visual impairment and back pain were the highlighted falls risk factors in Malaysian older adults. In addition, decreased toe clearance with limited knee flexion and ankle dorsiflexion was established using gait analysis in a simulated study in older persons with falls. In a pilot study testing community-based strengthening exercises for older persons with frailty demonstrated improvement in both upper and lower limb muscles post-intervention . Lastly, one of the novel recommendations from this issue was to consider both retrospective recall and prospective recording of falls incidence using falls calendars in research.Falls related research was heavily represented within this issue. The studies focused on home hazards among stroke survivors . Perception and expectations analysis toward the use of fall detection devices have shown definite interest in using these devices with user friendly, affordable, and accurate features . Research on muscles affecting minimum toe clearance during gait could also reduce risk of falls, as with aging the muscles would weaken and stiffen, coupled with reduced motion join range . The findings of a scoping review concluded that the technological interventions in stroke rehabilitation had a positive impact on stroke rehabilitation .In this Research Topic, how technology could support various health issues related to aging has been covered. Falls are related to instability either permanent or transient and to have a better understanding of physical limitations and visual issues among older persons, research using aging simulation suits could enhance health advocacy among health practitioners (Ng et al. has implemented a Health Care of Elderly course to public university students to look at their attitude, self-perceived competence and interest toward geriatric medicine as a career and found there are positive interests after the course. They also highlighted the importance to increase preparedness in managing frail older adults with multimorbidities. To address issues of limited health screening resources for older persons, Alex et al. has conducted a self-administered online survey in urban community dwelling to screen geriatric syndromes and conclude it is feasible to do it online.The explosion of aging research in Malaysia has been apparent over the past 5 years. This Research Topic showcases the breadth of aging research in Malaysia associated with its rapid population aging that affects individuals, families and society. The published articles also demonstrated extensive inter-disciplinary collaborations within health, economy, social and technology areas. Through this topic, an understanding about aging Malaysia: research and practice has no doubt been enhanced.PT has prepared the initial draft of the Editorial. SA has compiled the article and was reviewed by all authors again, before approving the final version. All authors have made substantial contributions in this writing.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Providing rehabilitation services in primary health care (PHC) is associated with numerous health, social, and economic benefits. Therefore, low and middle-income countries, such as Iran, should benefit from the advantages of integrating rehabilitation services into PHC. We conducted a qualitative study to determine policy solutions that could facilitate the integration of rehabilitation services into Iran’s PHC network.Semi-structured interviews were conducted with 38 participants, including health policymakers, rehabilitation managers, faculty members, and rehabilitation practitioners. Purposive and snowball sampling strategies were adopted to recruit participants. The WHO Health System building blocks framework analysis was applied to analyze the collected data.Participants’ perspectives and experiences outlined potential policy options including: (1) stewardship: increasing political support, strengthening the leadership of the rehabilitation sector, and promoting inter-sectoral collaborations; (2) service delivery: increasing the knowledge of healthcare professionals, using local volunteers, deploying mobile rehabilitation teams, using telerehabilitation, and improving referral pathways; (3) financing: increasing government funding, preparing a package of rehabilitation services, and using appropriate payment mechanisms; (4) human resources: expanding rehabilitation workforce, training rehabilitation assistants, and enhancing employment and social opportunities; (5) information systems: establishing a comprehensive information system and an effective surveillance system; and (6) technologies: facilitating access to a range of rehabilitation equipment and raw materials, especially for prosthetics and orthotics services.Based on the WHO six building blocks framework, this study identified several policy options for integrating rehabilitation services into the Iranian PHC Network. Some of the policy options include increasing political support, promoting inter-sectoral collaborations, increasing the skills and knowledge of healthcare workers, establishing effective referral pathways, strengthening team-working, and increasing government funding. In recent decades, demographic changes and improvements in acute healthcare have led to an increase in long-term conditions , 2. The Rehabilitation services seek to empower people living with disability to participate in their communities by improving functional ability and reducing environmental barriers , 7. RehaPHC services include diagnosing health conditions, recognizing functional problems, and referring patients for secondary and tertiary levels of care . Modern The concept of integration of health services as opposed to fragmented care is not new , and intIran’s Ministry of Health and Medical Education (MOHME) is the main provider and policymaker of health services. More than 90% of Iranians are covered by social insurance organizations for their healthcare, including the Iran Health Insurance Organization, the Social Security Organization, and the Armed Forces Health Insurance Organization . The MOHBehvarz During the interviews, the need to increase political support and strengthen the leadership in the field of rehabilitation in Iran was repeatedly mentioned. One of the participants said:“Various organizations are involved in financing and providing rehabilitation services. The welfare organization itself provides community-based rehabilitation services. However, if there is close co-operation between this institution and the Ministry of Health, these services can be integrated into primary healthcare.“[Faculty member 01]Participants emphasized the promotion of intersectoral collaborations as one of the potential solutions. Participants believed that due to the interdisciplinary nature of rehabilitation, several stakeholders are involved in providing these services, requiring inter-sectoral co-operation.“Interestingly, many health experts are still unaware that these [rehabilitation] services can be preventative and prevent many serious complications in the future. They always think that they should go to rehabilitation if treatment and therapy interventions fail!“[Physiotherapist 03]The level of awareness of policy- and decision-makers about the effects of rehabilitation services, especially their preventive effects, should be increased. Many relevant policymakers view these services as tertiary interventions and a strategy when other options have failed.“What do you expect from a policymaker with very little information about rehabilitation services? In my opinion, rehabilitation specialists should be involved in the care processes of care services to improve their rehabilitation position.“[Faculty member 04]Participation of rehabilitation professionals in the policy-making process can facilitate the strengthening of rehabilitation services, especially in PHC. One participant said:“Adherence to existing upstream laws and documents can be very effective in integrating rehabilitation services. Unfortunately, there is no good adherence to the existing laws.“[Health policymaker 03]Participants believed that national policy documents emphasized the provision of rehabilitation services in healthcare. They suggested that adhering to, and strengthening existing statutes could provide the necessary basis for strengthening rehabilitation services in PHC.“Recipients of rehabilitation services are usually disadvantaged and vulnerable groups and therefore do not have enough power to pressure policymakers. I think their needs can be better shown by holding rehabilitation campaigns and associations.“[Orthotist/Prosthetist 02]Individual service recipients, local community organizations and non-governmental organizations can campaign to improve services:“Scientific associations can provide a list of rehabilitation services that have preventive effects to consider in primary health care.“[Faculty member 05]Rehabilitation associations can also play a crucial role in demonstrating the effectiveness of rehabilitation interventions, and informing relevant policy makers:“We can teach some skills to current staff [Behvarzs] and ask them to provide basic musculoskeletal assessments and some training and exercises.“[Faculty member 02]Some participants proposed increasing the skills and knowledge of current healthcare workers to provide a range of rehabilitation services in PHC. A university professor believed that:“Many volunteers are interested in cooperating, especially in deprived and rural areas. They can be prepared to perform a set of tasks with short training courses.“[Rehabilitation expert 01]Given the current workload of health workers, suitably trained local volunteers could provide a range of rehabilitation services.“Rehabilitation professionals can serve in mobile clinics. For example, one may visit the covered areas every week and provide the necessary services.“[Health policymaker 05]Using mobile rehabilitation teams was mentioned as another solution. Participants believed that mobile rehabilitation teams could provide rehabilitation services, especially in rural and remote areas due to the lack of specialized personnel in non-urban settings.“We now have good Internet throughout the country that we can use to provide telerehabilitation services.“[Rehabilitation expert 04]Telerehabilitation could be used to facilitate the provision of rehabilitation services to remote areas. The development of the Internet across the country could greatly facilitate this approach.“Existence of an effective referral system is a prerequisite for proper integration of rehabilitation services in healthcare, especially primary health care.“[Health policymaker 10]Many participants described how rehabilitation services could be well integrated into PHC if there were effective referral pathways.“There are many professions involved in primary health care, and if there is no team-working, the desired goals will not be achieved!“[Health policymaker 07]As different professions are involved, team working was emphasized as one of the most important strategies for the effective integration of rehabilitation services.“Proper integration of these services in primary health care requires a clear understanding of the role of rehabilitation professions alongside other professions. Also, the knowledge of physicians and other healthcare workers should be enhanced about rehabilitation services to form a good team-working“[Faculty member 06]Nonetheless, clarity on the role of professions involved in PHC, including allied health professionals, and adequate knowledge of physicians and other healthcare workers about rehabilitation professions, can facilitate team working. In this regard, one of the participants said:“If we want to consider rehabilitation services in primary care, we need new financial resources. The government should allocate more resources to this area.“[Health policymaker 03]Integration of rehabilitation services into PHC requires an increase in government funding as a health policymaker said:“Some physiotherapy services can be provided to pregnant mothers during pregnancy. There are also rehabilitation services for infants and children that, if provided timely, can prevent many future problems.“[Physiotherapist 03]An interesting point raised was the need to provide a package of rehabilitation interventions that can be integrated into PHC, such as preventive interventions for pregnant mothers, infants, and children.“How you pay employees is very important to rehabilitation professionals and current primary health care staff. [Payment] Mechanisms should be used to motivate them to perform their tasks.“[Health policymaker 05]Many participants believed that having appropriate and competitive payment mechanisms for the PHC workforce could lead to more effective rehabilitation services provided by PHC staff.“If we want to provide these services well in primary health care, we need to train more rehabilitation professionals in physiotherapy, occupational therapy, and prosthetics/orthotics.“[Faculty member 02]The workforce is one of the most critical challenges addressed in this study. Several solutions were proposed, including increasing the training of the rehabilitation workforce.“Many rehabilitation graduates are not interested in working in primary health care, especially in deprived and remote areas. Rehabilitation assistants can be trained by taking two-year courses.“[Faculty member 04]A curriculum could be developed to train rehabilitation assistants who would be able to work in PHC.“Graduates will no longer be interested in working in the primary healthcare network until we improve the occupational and social status of the workforce in disadvantaged and remote areas.“[Physiotherapist 02]Nonetheless, even if the rehabilitation workforce were increased, there is still a lack of interest amongst rehabilitation professionals in engaging in PHC due to inadequate employment and social opportunities in disadvantaged areas. Therefore, job and social opportunities should be improved for deprived and less privileged areas.“How can we have an effective intervention if we do not have an information system of the needs and records of the patient?“[Faculty member 04]The need for a comprehensive information system was mentioned to facilitate patient follow-up and improve referral pathways in PHC.“There should be a comprehensive system that can well address the rehabilitation needs of the covered population.“[Health policymaker 07]An effective surveillance system that can prepare accurate and timely information on the rehabilitation needs of the population could provide the evidence base for rehabilitation services in PHC.“Some of the required equipment can be provided to employees in remote and rural areas, such as goniometers to measure skeletal deviations and range of motion... Also, some equipment is really expensive and it is better to be in the city or province“[Physiotherapist 03]Providing effective rehabilitation services requires equipment and materials. In this regard, some participants believed that basic equipment and materials could be provided at the rural level and more expensive and sophisticated equipment could be provided at city or provincial levels.Rehabilitation services have been a key but forgotten component of PHC in planning and providing health services. Although these services play an important role in all levels of care, their focus should be close to where people live and work to facilitate their utilization . At presThe first key finding of this study was to design an over-arching concept for integrating rehabilitation services into PHC with respect to legal frameworks, inter-sectoral co-operation, and participation of NGOs and scientific societies. Indeed, effective integration of rehabilitation within the health system depends on the quality of rehabilitation stewardship and governance , 32. AchProposed policy options for providing rehabilitation services at the first level of care include telerehabilitation, mobile rehabilitation teams, and using local capacity to provide rehabilitation services. Previous studies have shown that in health systems where rehabilitation in the primary care infrastructure is very poor, telerehabilitation is a potentially effective way to compensate for this deficiency . CollaboBased on the literature, inadequate financing is one of the most critical challenges of the rehabilitation sector in Iran . The useAn important issue addressed in this study is financing the integration of rehabilitation services into PHC, which means increasing government investment in this area and increasing the utilization of such services by the public. The collaboration of donors and NGOs can be very effective in financing rehabilitation services in PHC in countries like Iran, which face limited financial resources , 33. In Effective integration of rehabilitation services into PHC depends on a trained rehabilitation workforce. However, in addition to the small number of rehabilitation graduates in many countries, especially developing countries , many grThe national health information system often does not include rehabilitation-related information. This hinders rehabilitation policy at all levels and is one of the challenges of strengthening rehabilitation services globally . In IranThe approach to integrating rehabilitation into UHC in each country reflects the characteristics of that country’s health system, its values, the horizontal development of the social welfare system, and the availability of resources and infrastructure . TherefoDespite all the efforts made, the present study has some limitations. Rehabilitation is a broad field consisting of many different professions, of which this study focused on only three: physiotherapy, occupational therapy, and prosthetics/orthotics. In addition, service users were not included in this study, missing important viewpoints.This study has outlined policy options for integrating rehabilitation services into the Iranian PHC network based on the WHO six building blocks framework. In the governance dimension, the leadership of integration, legislation, and participatory decision-making were shown to be the main components of integration policy. Legislation with sufficient executive guarantees is required to put this issue on the policy agenda of the Iranian health system. Considering all policy stakeholders, especially the private sector as the leading actor and provider of secondary and tertiary care rehabilitation services in Iran, the Welfare Organization as the primary steward of disability in the country, and especially the people’s representatives as the users of services and main stakeholders of this policy, can facilitate the integration of rehabilitation services into PHC.


Subliminal stimuli are gaining growing interest due to their capability to induce desensitization to pathologically feared  pictures without inducing exaggerated emotional reactions. However, unresolved methodological issues cast significant doubt on the reliability of these findings and their interpretation. The studies most robustly assessing stimulus detection found that ~30% of the supposed-to-be-subliminal stimuli were, in fact, detected, suggesting that the beneficial effects attributed to subliminal stimuli may result from those actually seen. Nevertheless, a deeper analysis of the data underlying this misinterpretation unveils theoretical and clinical implications. Since the purpose of subliminal stimulation is to reduce the aversiveness of exposure therapies while maintaining their efficacy, researchers should measure the emotional relevance of supposed-to-be-subliminal stimuli that are, in fact, detected. A distinction is needed between perceptually- and emotionally-subliminal stimuli: the former is not consciously detected; the latter just fails to elicit emotional reactions. Emotionally-subliminal stimuli could represent an intermediate step of exposure in addition to those involving perceptually subliminal or supraliminal stimuli. Importantly, emotionally subliminal stimuli could make patients able to sustain a conscious exposure to feared stimuli without exaggeratedly reacting to them: if confirmed by empirical data, this unexpected disconfirmation of patients’ beliefs could pave the way for successful therapy while increasing their self-efficacy and compliance to treatment. Can we reduce fear by merely extinguishing its physiological outputs? Researchers investigating emotions should cautiously infer such an inseparable association between subjective states and their physiological correlates, Taschereau-Dumouchel and colleagues claimed . The autHere, we collect this invitation by introducing an emotion-centered classification of subliminal stimuli to «put the “mental” back» in the scientific debate concerning the therapeutic efficacy of subliminal exposure therapies: in our opinion, the issue raised by Taschereau-Dumouchel and colleagues  cannot lThe debate dates back to the seminal study by Öhman & Soares , demonstCan a phobic stimulus fail to elicit fear thanks to its reduced duration, even if consciously detected? From the systematic review of the studies on subliminal phobic stimulations , it is rThe concerns we have raised do not diminish the relevance of these results: rather, we think that a more rigorous interpretation could increase their impact. Indeed, the same authors also assessed the fear ratings following each block of stimuli: they found no significant increase in fear in phobic participants briefly exposed to phobic stimuli . Given tDespite this evidence, there are currently no terminological differences to distinguish the reasons for which stimuli can fail to elicit the expected emotional response . To avoid further misunderstandings adding to those that already affect this research line ,19, the Rather than perceptually-subliminal stimuli proposed by other authors , we propEven if we hypothesize that exposure therapies based on emotionally-subliminal stimuli are less effective than current ones, their wider acceptability would still result in a higher absolute number of patients successfully treated. As an example, if emotionally-subliminal exposure therapies are proven to reach half the efficacy of current ones, they could overcompensate by reaching more than double the number of patients.However, this is not the only nor the main reason to include emotionally-subliminal stimuli in exposure therapies, as the advantages and disadvantages mentioned so far are partially shared by perceptually-subliminal stimuli. Indeed, perceptually-subliminal stimuli too make exposure therapies more acceptable; they were demonstrated to successfully induce habituation in psychophysiological and behavioral correlates of phobic fear ,22, defiBased on a bifactorial model of fear, we proposed a double-step procedure exposing patients to perceptually subliminal and then to clearly-visible stimuli: this would impact both the cognitive and the defensive survival circuits, finally reducing the conscious feeling of fear and its psychophysiological correlates . The desAn emotionally-subliminal exposure could overcome these limitations by decoupling the perception of a feared stimulus from the expected emotional reaction: this could simultaneously involve both the cognitive and the defensive survival circuits, thus enhancing their connectivity and facilitating a mutual influence. In fact, the everyday-life experience of a phobic patient is that the perception of a phobic stimulus is immediately and inevitably followed by an overwhelming emotional reaction. Conversely, a deeper analysis of experimental methodologies and the related results suggest that perceiving and fearing a stimulus are two distinguishable processes, the effects of which emerge to consciousness at slightly shifted moments. Despite being small in timings, this decoupling could have relevant theoretical and clinical implications.From a theoretical point of view, the existence of such a decoupling—between perceiving a fearful stimulus and being afraid of it—could support theories claiming that emotions arise as cognitive interpretations of physiological reactions, i.e., that the two processes (perception and emotion) are consecutive rather than parallel ,28. SuchFrom a clinical point of view , the data coming from previous studies could represent a first experimental clue in favor of our theory. Future studies referring to—and empirically check-proofing—the conceptual framework proposed in Methodological concerns in the research line investigating the effects of subliminal exposure to phobic clues push for introducing an emotional threshold in stimulus processing. We propose to define a stimulus as emotionally subliminal if it does not induce—even if consciously perceived—the expected emotional reaction. As the observation that even unconscious stimuli induced psychophysiological correlates of fear  gave risIndeed, distinguishing between perceptually- and emotionally subliminal stimuli could significantly improve the understanding of emotions as well as the therapeutic protocols used to treat pathological fear.


In this study, we present a detailed comparison between a conventional supercritical drying process and an evaporative drying technique for hierarchically organized porous silica gel monoliths. These gels are based on a model system synthesized by the aqueous sol–gel processing of an ethylene-glycol-modified silane, resulting in a cellular, macroporous, strut-based network comprising anisotropic, periodically arranged mesopores formed by microporous amorphous silica. The effect of the two drying procedures on the pore properties  and on the shrinkage of the monolith is evaluated through a comprehensive characterization by using nitrogen physisorption, electron microscopy, and small-angle X-ray scattering. It can clearly be demonstrated that for the hierarchically organized porous solids, the evaporative drying procedure can compete without the need for surface modification with the commonly applied supercritical drying in terms of the material and textural properties, such as specific surface area and pore volume. The thus obtained materials deliver a high specific surface area and exhibit overall comparable or even improved pore characteristics to monoliths prepared by supercritical drying. Additionally, the pore properties can be tailored to some extent by adjusting the drying conditions, such as temperature.


Giant cell granulomas (GCG) are uncommon benign tumor-like lesions mostly arising in the oro-facial area. They are more common in women and occur in patients younger than 30 years. Lesions restricted to the bone are referred to as central giant cell granulomas (CGCG), and those developing primarily on soft tissues are termed peripheral giant cell granulomas (PGCG). Both types are histologically identical. The combination of both clinical examination and radiography allows for the differentiation of those two variants. On rare occasions GCG, and especially CGCG, may develop in relation to hypercalcemia linked to hyperparathyroidism (HPT). In those cases, the GCG treatment prognosis is closely linked to the HPT management. Therefore, patients diagnosed with a GCG must be investigated to search for an HPT. Reported herein is a rare clinical case of a mandibular PGCG which led to the diagnosis of primary HPT.


The Black Lives Matter (BLM) protests against racialized police violence represents the most prolific mass social movement in modern times. It has been met by sustained and repressive violence by state authorities and right-wing groups. This review seeks to synthesize existing scholarly, journalistic, case report, and crowd sourced data on violence directed against BLM protestors.Data from various sources suggests that police disproportionately target BLM protests for violent intervention. There is also mounting evidence of organized and vigilante right-wing violence targeting BLM protestors. While police frequently use chemical irritants and projectiles, right-wing protestors often use car ramming to bluntly injure protestors. The true scale and nature of injuries affecting BLM protestors remains unknown though injuries resulting in the need for intensive care, operative intervention, permanent morbidity, and mortality have been reported.State and conservative civilian violence against BLM protestors represents an ongoing threat to the right to organize and publicly dissent. The use of force manifested by police and right-wing groups against BLM protestors resulted in significant injury and mortality. During the summer of 2020, following police killings of Black Americans, the USA saw perhaps the most widespread protest movement in its history . This waIn addition to state violence against BLM protestors, the summer of 2020 and beyond also saw a precipitous rise in violence by right-wing militias and counter-protestors. Similar to police violence reporting, there is no legal obligation for law enforcement to report hate crimes or politically directed violence . The FBIThe purpose of this review is to (a) provide a historical context to state repression of political actors in the USA, (b) review the existing scholarly, journalistic, and civilian-collected data describing state and far-right militia and vigilante violence against BLM organizers and protestors starting in the summer of 2020, and (c) provide a framework for collecting data on state violence against protestors. Importantly, given the existing limitations in data collection described above and the relative opacity of modern municipal police departments, this review combines descriptive analysis with a review of existing, though incomplete, data sources on violence targeting BLM protestors. A primary goal of this review is to capture the scale and nature of state violence and mistreatment of political actors in the USA with a special focus on the events of the summer of 2020.Violence has been central to US state building since its inception and long before the BLM movement. Much historical research has described how the incipient US state explicitly sponsored White vigilante violence to occupy indigenous lands. For example, as White settlers sought to occupy indigenous lands, the US government offered material rewards for the scalps of those it sought to displace . Anti-BlViolence against BLM protestors exists in a long historical arc of state repression of internal political challengers to the US state and capitalism . For exaOn June 4, 2020, Martin Gugino, a 75 year-old peace activist with the Catholic Worker Movement, was in attendance at a nonviolent Black Lives Matter demonstration in Niagara Square Buffalo, New York. During the demonstration he was walking towards approaching police and was first met with a forceful baton to his chest from one officer followed immediately by a push from another officer. Mr. Gugino stumbled backwards, fell and struck his head on the pavement. He lay motionless, bleeding from his ear as several officers walked past. Mr. Gugino suffered a skull fracture and subdural hemorrhage requiring a two-week intensive care unit admission . Gugino is one of the many BLM protestors and organizers who have faced direct physical harm secondary to police action during the summer of 2020. Given the lack of aggregated data collection, the full scale of police-related physical injury of BLM protestors is difficult to capture in its entirety. However, this part of the review will delve into what is known — the nature and recorded scale of police mistreatment of protestors — and its implications for the future of civic action in the USA.In the absence of official state or legal data, the Armed Conflict Location and Event Data project (ACLED) exists as one of the most reliable source of data to track protest-related political violence in the USA during the summer of 2020 [The ACLED collects data by coding over 2800 sources of data including local, state, and national media to identify political violence. In addition to media reports, the ACLED also collects information from data aggregators such as the Crowd Counting Consortium to tabulate political violence . An inheThe ACLED dataset describing political violence during the summer of 2020 — the “US Crisis Monitor” — found that 9% of BLM demonstrations were met by some form of state intervention  compared to 4% of right-wing demonstrations and 3% of all other demonstrations in the same year. This targeting of BLM protestors is despite the fact that 94% of BLM demonstrations were non-violent and non-destructive compared to 86% of right-wing protests. Importantly state intervention at BLM protests was typically more violent than those at right-wing demonstrations. Indeed 51% of BLM protests were met with physical force  compared to 33% of right-wing demonstrations and 26% of other demonstrations . The ACLACLED data also re-affirms the historically consistent reciprocity between the US state and right-wing militia actors. Similar to the collusive episode during the CIvil Rights era, described earlier, between Alabama state authorities and the Ku Klux Klan, there have been important interplays between the US state authorities and White right-wing militia groups like the Proud Boys. Indeed in response to Trump’s command to such extra-legal entities to “stand back, stand by” there were multiple subsequent episodes of Proud Boys initiated street-fighting during demonstrations in North Carolina, New York, California and Washington DC . There aMany of the technologies and vehicles deployed during the mass protests in the summer of 2020 and beyond reflect the growing militarization of United States municipal police . AdditioSome specific examples of police militarization during BLM protests include the use of Mine-Resistant Ambush Protected or MRAP armored vehicles typically designed for military conflict zones. Such vehicles have been deployed around the country both as an intimidation and crowd control technique .Additionally, human rights organizations document that police utilized a basic, recurring set of techniques to escalate protests and make violent confrontation more likely such as “trap and detain” or “kettling” whereby militarized vehicles are employed to encircle protestors. These situations often lead to use of physical force and create pretexts for mass arrests .Importantly, as indicated earlier, in addition to state authorities, far-right civilian militias have engaged in violence directly against BLM protestors and often complement or synergize with police-based tactics to stifle dissent. Indeed the scale of counter-demonstrations to BLM protests has been substantial with the ACLED recording over 750 distinct counter-demonstrations directly in response to BLM demonstrations between January 2020 and April 2021 . Within Individuals ideologically connected to far-right movements in virtual spaces often acted independently to contest various BLM protests. One such example, mentioned earlier was Kyle Rittenhouse’s response to the Kenosha Guard muster call and his subsequent killing of two BLM protestors. In fact armed individuals associated with right-wing movements may see themselves as auxiliary to police or military and respond to their perceived calls. Similar to Rittenhouse, Steven Ray Baca responded to a muster call by the New Mexico Civil Guard. During a symbolic struggle over the statue of Spanish conquistador Juan de Oñate, Baca shot and wounded a BLM protestor. Both Baca and Rittenhouse demonstrated ties to the conservative political establishment. Baca ran for city council as a board member of the Albuquerque Tea Party . In the Far-right militias constitute organized and armed citizens that essentially operate as a paramilitary force . In the Such far-right militias and militant groups have displayed an increasing presence at BLM protests over time. Indeed there have been at least 38 distinctly named far right militia or militant social groups that have directly confronted BLM protests. According to ACLED data the most common organization involved has been the Proud Boys. This group has countered almost 50 demonstrations and in over 36% of these engaged in violence or destructive acts .Importantly, the different far right militias or militant groups are aligned ideologically in their opposition to BLM though they often have different strategies of inciting violence against protestors. For example, the Boogaloo Boys — an extremist far-right group aiming to trigger widespread violence and societal collapse — has located itself in BLM protests as provocateurs, hoping to catalyze large-scale violence. Interestingly, the Boogaloo Boys, distinct from other groups, is not monolithically a White supremacist organization and is knit together by their shared anti-governmental ideology and a desire for the collapse of society . The comA key and common strategic response of these groups has been to establish an armed presence at BLM protests. At least 25 distinctly named groups have brought visibly armed members to BLM protests often in the self-proclaimed role of containing the violent or destructive behaviors of protestors, again indicating their self-perception as an auxiliary to state violence .In addition to the scale of violence against BLM protestors during the summer of 2020, it is important to note the type of injuries sustained. This next section delves deeper into the discrete public health and clinical impact of the violence inflicted by state authorities and right-wing counter-protestors against BLM activists.The racial justice protests of 2020 revealed law enforcement reliance on a particular set of technologies to quell protest. One particularly widespread technology used were chemical irritants, such as tear gas, to disperse gathered crowds. A systematic review of studies on the health impacts of tear gas spanning 29 studies (including 7 from the United States) across 11 countries and 5131 individuals found a total of 9261 injuries and that two people died related to chemical irritant complications and 58 suffered permanent disability . Out of n = 1931), 300 people suffered permanent disability, most commonly vision loss and abdominal injuries requiring splenectomy or colostomies. Two people suffered limb amputation. This study also found that the muzzle velocity of the “less than lethal” projectiles matched that of lethal ammunition [Significantly, the most serious tear gas related injuries stem from the projectile canister rather than the chemical irritant. Indeed state authorities made widespread use of so-called “less than lethal” or “non-lethal” projectiles against BLM protestors that included rubber bullets, pepper balls, beanbag rounds and propelled tear gas canisters. A systematic review spanning 26 articles (including three from the United States) from 1990 to 2017 compiled injury data on 1984 individuals of which 53 died from such projectiles . Half ofmunition .The exact scale of penetrating and chemical irritant related morbidity and mortality secondary to state action during the protests of the summer of 2020 remains unknown. However, case series during the BLM protests give a sense of the type of injuries these police technologies can inflict. One particular report from Austin, Texas following two days of BLM protests describes the impact of beanbag and rubber bullet munitions on 19 patients treated at the local level 1 trauma center.  Eight ofAnother larger sample study of “less than lethal” munitions injuries during the summer of 2020 from Minnesota performed a retrospective review between May 26 and June 15, 2020 of all patients possibly injured during protests . During A final case series of penetrating injury secondary to police projectiles reviewed 14 patients presenting to a level 1 trauma center in Los Angeles over a 48-h period during BLM protests . This seBeyond the documented clinical case series of projectile injuries, blunt injury by car rammings has also been an increasingly prevalent form of violence directed against BLM protestors. Car rammings occurred eight times more frequently at BLM protests compared to other demonstrations and were exclusively initiated by right-wing individuals or groups . There hmore peaceful over time. Between May 25 and June 4, 2020, 89% of protest demonstrations were non-violent while later between June and September 2020 more than 96% of BLM associated protests were non-violent [It is important to note that while the BLM protests generally become more peaceful over time the public perception was that they were becoming more violent. As described earlier, this is in marked contrast to how the public perceived the civil rights movement which gained more public and more White support as televisions streamed the undeniable state violence against peaceful protestors. Such a difference points to the relative importance of curated social media in shaping today’s public views. Indeed according to Pew surveys the BLM protests became -violent . Nonethe-violent .As evidenced by this review the ability to understand the scale and nature of state violence against political actors is limited by the sources of data available. The particular challenge of collecting data on state violence is that the government, which usually has the resources and institutional reach to collect the necessary information for a data set, is also the very entity being interrogated. To come around this problem, researchers and advocates have long proposed alternate methods to improve data collection on officer-involved violence such as equipping trauma centers to gather this information directly from patients. Nonetheless systematic approaches or legal mandates to acquire this information remain notably absent.The current era of public organizing has been accompanied by dramatic episodes of violent repression that highlights the importance of data collection and dissemination. In response, activist individuals and organizations have deployed numerous extra-institutional approaches to data gathering. Considerations for collecting data on political violence against protestors, a review of current data collection efforts and ways to politicize such data are described further.Protestors may be less likely, especially in the era of COVID-19, to present to the formal healthcare system following state-sanctioned injuriesWhile medical professionals and healthcare systems should continue collecting data on state violence as it impacts their patients, episodic violence impacting protestors requires specialized considerations:2.Protestors may be less likely to report state violence to institutional authoritiesData demonstrates a global decrease in utilization of emergency room services since the beginning of the COVID-19 pandemic . This de3.Creating open source data portals allows multiple types of mistreatment to be capturedFor the same reasons listed above, namely general distrust of institutional authority, even those protestors who present to a hospital-based setting may be less likely to report state-sanctioned violence. This distrust is further heightened amongst Black Americans given historical abuse by medical institutions . Indeed Publicly available social media data archiving over a thousand separate instances of state violence and mistreatment against protestors reveals an incredible range of events that may only be partially captured by current dataset, such as ACLED, reliance on media based reports. This includes physical violence as well as verbal abuse and arbitrary arrest. Extra-institutional data collection methodologies should be flexible to capture the entire range of state-based mistreatment of protestors.Linked to the first two reasons described above formal trauma databases, such as the National Trauma Data Bank (NTDB), which collect comprehensive injury related data as reported directly from hospital trauma centers, may only capture a portion of protest injury data . Thus moTwitter archives: Twitter has been a central source of reporting and collecting data on state repression of protests as evidenced by the archive of instances amassed by T. Greg Doucette . VariousThe Witness Archives: An independent initiative to collect and publish incidents of police violence and mistreatment against protestors captured on video by protestors .Geographic Information Systems (GIS) spatial mapping of police brutality: Several independent efforts have sought to synthesize social media derived data into GIS based maps highlighting the regional scale of state violence against protestors .Raheem: Another independent portal to collect data on police brutality. This service mobilizes the narratives of those impacted by the police and translates them into various forms of political engagement including formal complaints and pursuits of justice .Ongoing movements for racial justice as well as the movement to collect data on racialized police brutality are increasingly decentralized. Data for Black Lives is an example of efforts to collect data to bolster the movement with the mission of “using data science to create concrete and measurable change in the lives of Black people” . AnotherIn addition to the efforts listed above, there remains an enormous potential to widen data collection by empowering protestors to directly report state violence and mistreatment in real time. An ultimate, longer-term data goal would be to synthesize the various reporting mechanisms into a central database for research and policymaking purposes. Information about the scale and nature of political violence and mistreatment against protestors can inform policy at local, state and national levels. Specifically this data can be brought to bear on hearings or directly provided to legislators considering the impact of state and right-wing violence on communities.Finally, synthesizing and analyzing such data is particularly important to health professionals caring for trauma patients regardless of one’s political values. As noted above the nature of injuries sustained by BLM protestors, whether due to state or right-wing actors, resulted in significant morbidity and mortality during the 2020 BLM demonstrations. Protestors often required operative intervention and critical care for the treatment of their injuries. Trauma surgeons are often the primary treating clinicians for such injuries and, as such, may be trusted with important information regarding protest related injury. Indeed recent literature has demonstrated the unique trust patients place in their surgeons . This maThis review has sought to provide a quantitative and descriptive sense of violence against BLM protestors in 2020. Importantly this violence exists in historical continuity with other challenges to US state legitimacy including explicit attempts to undermine larger scale political projects for racial justice by groups like the Black Panther Party and myriad others during the civil rights era.The data that currently exists on violence against BLM protestors is incomplete and biased towards media reports on larger scale urban protests. It is apparent, however, that BLM protestors, relative to other demonstrators, have been disproportionately affected by state and right-wing violence. Predominant mechanisms of injury include chemical irritants, projectiles and intentional blunt automobile impact. In reviewing the damage incurred by chemical irritants and “less than lethal” projectiles it is clear these technologies can cause major injuries and even mortality. Additionally, blunt trauma in the form of car rammings, and the legal protections for those who engage in them, represent a highly morbid and often lethal technique used by right-wing actors against BLM protestors. Overall the data reviewed is limited by the inherent biases of media based reports that may be even more pronounced in the case of BLM , 47. HowThere exists growing evidence that the political action of BLM protests has impacted police lethal use of force with a May 2021 study demonstrating a 15–20% decrease in police homicides in census tracts with protests between 2014 and 2019 . This re


Light: Science and Applications, Das et al. have successfully used capping with chiral ligand molecules to obtain chiral carbon dots. The authors provide a theoretical model to describe the origin of chirality in carbon dots as arising due to exciton coupling in a pair of chiral chromophores. Due to non-toxic chemical composition and sizes as small as 2–5 nm, the chiral carbon dots have the potential to outperform other chiral nanostructures in numerous biomedical applications. However, similarly to chiral drugs, their chiral toxicity must be well understood before the carbon dots are brought to living systems.Chirality is a universal property of an endless number of objects in the universe. Nanotechnology is rapidly expanding to find ways to introduce chirality to artificial nanostructures. In a recent publication in  Chirality is a property of symmetry: a chiral object cannot be superimposed on its mirror image by any translations or rotations, thereby chiral objects always have two forms with left and right handedness. Chiral objects exist at pretty much any scale in the physical world, starting from galaxies down to subatomic particles.Light: Science and Applications, Das et al. have successfully used this strategy to obtain chiral carbon dots [Nanotechnology is making rapidly expanding progress in finding ways to induce chirality in artificial materials with nanoscale features. Collective chirality can be introduced by certain spatial arrangements of non-chiral nanostructures . Individbon dots .Das et al. utilize Density Functional Theory (DFT) to investigate the origin of chirality in carbon dots obtained through well-established synthetic protocols. They demonstrate that, similarly to organic molecules, chirality in carbon dots arises due to exciton coupling induced by the interaction between a pair of chiral chromophores. The theoretical modeling reveals that peaks with opposite signs observed by Das et al. in the long-wavelength range of circular dichroism spectra can be attributed to the interactions between one or two chiral ligands and the carbon core constituting a dimer of a polycyclic aromatic hydrocarbon (PAH) centers.Chiral nanostructures can interact selectively with other chiral objects and rotate the plane of polarization of linearly polarized light, giving a rise to optical activity observed in circular dichroism and circularly polarized photoluminescence. These properties open up numerous potential applications, including asymmetric catalysis, enantiomeric separation, chiral sensing, and spintronics . Since mIn living systems, chiral nanoparticles interact with biological enantiomers through the process called enantioselective recognition, which is driven by the difference in the formation energies of the nanoparticle – biotarget complexes with heterogeneous versus homogeneous stereochemistry (e.g., left-right versus right-right complex, Fig. The process of enantioselective recognition can have very important consequences in the biomedical applications of the chiral nanomaterials, as is true for drugs, many of which are chiral with one enantiomer having a therapeutic effect and another one often being toxic or mutagenic. The thalidomide disaster represents an extreme example of chiral drug toxicity. The left-handed enantiomer of thalidomide causes horrific birth defects, while the right-handed enantiomer has a sedative effect . These c