Maternal mortality and newborn mortality continue to be major challenges in Nigeria, with the highest levels in the northern part of the country. The objective of this study was to explore the process and sequence of symptom recognition, decision-making, and care-seeking among families experiencing maternal and neonatal illness and deaths in 24 local governmental areas in Jigawa State, Northern Nigeria.This qualitative study included 40 illness narratives , neonatal deaths, and neonatal illness) that collected data on symptom recognition, perceptions of the causes of disease, decision-making processes, the identity of key decision-makers, and care-seeking barriers and enablers. Data were transcribed verbatim, translated to English, then coded and analyzed using Dedoose software and a codebook developed a priori based on the study’s conceptual model.Compared to maternal cases, much less care-seeking was reported for newborns, especially in cases that ended in death. Key decision-makers varied by type of case. Husbands played the lead role in maternal death and neonatal illness cases, while female relatives and traditional birth attendants were more involved in decision-making around perceived PPH, and mothers were the principal decision makers in the neonatal death cases. Demand for health services is high, but supply-side challenges including low quality of care, uncertain availability of health workers, and drug stock-outs are persistent. There is a strong belief that outcomes are controlled by God and frequent use of spiritual care sometimes contributes to delays in seeking facility-based care.These findings suggest key differences in recognition of complications, decision-making processes, and care-seeking patterns between maternal and newborn illness and death cases in Jigawa, Northern Nigeria. Interventions that provide more targeted messaging specific to case and symptom type, are inclusive of family members beyond husbands, and address gaps in quality and availability of care are urgently needed. It may also be important to address the widespread perception that adverse outcomes for mothers and newborns are controlled by fate and cannot be prevented. Maternal mortality and newborn mortality are major challenges in Nigeria. Though home to 2% of the world’s population, Nigeria accounts for more than 10% of the world’s maternal and child deaths .three-delay model, a framework for organizing barriers to recognition and appropriate care-seeking for maternal complications  can’t be there” (PPH-3). However, husbands continued to be key decision-makers in some cases.Across maternal death and PPH cases, symptom recognition was driven by prior experience, knowledge, and perception of normalcy. For example, MD-4’s family member described how cold her body had become as she “had never felt such coldness on someone’s body before.” This signaled how unusual and shocking the symptoms were perceived as, and caused family members to lose hope. One respondent commented that “this had even made her lose hope on her survival.” Another woman described her views on a normal delivery: “Usually when a woman delivers, she smiles and speaks” (MD-2). A deviation from this pattern was seen as the cause for alarm. In another case, perceptions around normal and abnormal deliveries were also important: “…anyone that is going to give birth must discharge blood, even if a person delivers in a hospital” (PPH-5). Perceptions of bleeding as a problematic or non-problematic symptom were often influenced by experiences during past deliveries. For example, one respondent stated “whenever she gives birth, she usually encounters bleeding” (PPH-9).Assessment of symptom severity hinged on sudden, disruptive changes in the woman’s well-being and her ability to undertake her usual activities. One relative stated “the headache was not that serious, since she was talking and drinking water with her family” (MD-1). Another family noted that “it was very serious indeed, at the time we were going to the hospital, she wasn’t able to enter into the car by herself, until she was lifted” (MD-8). Some symptoms such as dafara were ascribed the highest severity level: “…dafara is saliva with bitter taste, if you see it accumulating in a sick person’s mouth, then you should know that he will not survive” (MD-2). Bleeding severity was determined by quantity and flow of blood, with heavy flow considered severe. “I bled so much, almost all the wrappers in my drawer were soaked with blood” (PPH-2). Another family member explained “If the flow of blood is heavy, then it means there is problem, and it can be easily identified” (PPH-8). The presence of additional symptoms beyond bleeding such as shivering, unconsciousness, paleness, and weakness was associated with higher severity. For example, a family member describes the woman’s bleeding as not severe at first, but then “it was [severe] the following day around the late afternoon, when her body became weak” (PPH-6).Medical causes described in maternal death cases include retained placenta, “inadequate blood”—the local phrase for anemia, and eclampsia, while spiritual causes included attack by spirits (one case) or the will of God (four cases). For the most part, medical and spiritual causes were mutually exclusive. Families reported either medical or spiritual causes but not both. In addition, there were a number of cases where family members expressed that they did not know the cause of the symptoms (four cases) but, when pressed, attributed them to God. Headache, the most frequently mentioned symptom in maternal death cases, was seen as a normal sign of impending delivery among families of women who died. In PPH cases, most women attributed bleeding to the delivery process (six cases), one to excess blood sugar, and three to God. Overall, God was mentioned in seven maternal death and five PPH cases as an explanation or contributor to the illness and/or death. God was also described as the ultimate controller of outcomes, highlighting the fatalism and the perceived inability to control final consequences that many respondents expressed. “It is fate. If God gives you safe delivery, you are fortunate enough, and if you didn’t get safe delivery, then the result is just like this one” (MD-2).For maternal death cases, the husband was the key decision-maker with respect to care-seeking. When husbands were absent, relatives including the husband’s brothers, sisters, or mother (two cases) and/or neighbors (two cases) jointly made decisions about how to handle the symptoms, including whether or not to seek care and what type of care to seek and how. In PPH cases, the husband was the decision-maker in four cases but almost always made decisions together with a co-wife. In most of the remaining cases, female relatives made the key decisions. In two cases, TBAs were present and made the decision to seek care at a health facility.In both cases where TBAs were present, they encouraged immediate health facility care and, in one case, strongly discouraged the use of traditional medicine. The evidence suggests TBAs have significant authority within the household, as families trust them and implement their decisions immediately. Families also feel at ease because TBAs are able to navigate the health care system. One TBA stated: “They (the family) are the ones that called me…I am the one that takes pregnant women to the hospital, I am familiar with the health workers, they are my friends” (PPH-4).In addition to the presence of TBAs, decision-making was also enabled by the recognition of the severity of symptoms, an understanding of the causes of symptoms, proximity to a health facility, positive attitudes about care-seeking, and the ability to mobilize resources and transportation. One woman explained that purchasing drugs from a chemist is usually the first line of action, unless the symptoms are considered to be very severe: “whenever any problem of sickness arises, we buy drugs, or we just go to hospital if the case is a major one” (PPH-7). The family of MD-4, who had facial swelling, followed by fever and difficulty breathing, described how the absence of understanding about the cause of the problem was a barrier to decision-making: “Honestly, we did not do anything, because we didn’t know what was wrong with her” (MD-4). However, once symptoms perceived as being very severe such as dafara appeared, the family made the decision to go to the hospital.Other barriers included the absence of health workers, and fear of health workers, or fake drugs. Lack of money or available transportation was the most commonly cited barrier and often contributed to the death. MD-6, who suffered first from headache and swollen face and body while pregnant, was given traditional medicines for these symptoms. However, once her illness progressed and she became unconscious after delivering at home, the family decided to take her to the hospital but was unable to find transportation: “All in all she was not taken away from home, she died while we were trying or in the process of looking for car” (MD-6). In the case of MD-5, who suffered from kidney problems, monetary resources could not be mobilized in time to pay the doctor, despite the family’s best efforts. The deceased’s sister recounts that “It was N37,000 [for her treatment] and altogether N50,000 including bed fees [admission fees], but she died before the time. On hearing this amount of money, we all gave up.”Once the decision was made, families sought care for the illnesses through a variety of channels, including home care via drugs, traditional medicine (such as herbs or plants) or spiritual remedies (such as prayers and recitations), as well as home visits by health care providers and facility-based care. The pattern and sequence of care-seeking for the ten deceased women are illustrated in Fig. As can be seen in Fig. In three cases, spiritual care such as tofi, an act where Koranic verses are recited and air is blown over painful body parts, was sought, often as a first step. All three of these cases were perceived as being very serious, and two cases included symptoms such as paralysis, dafara, and unconsciousness. The two cases that utilized traditional medicines were also described as being very serious and included unconsciousness, and in one case, dafara. All maternal death cases sought some type of care within a day of recognition, and all but one visited a health facility at some point. Once facility-based care was sought, subsequent referrals were common. Three cases  died either en route to or while securing resources to visit a second facility. The sequence of steps involved during care-seeking seemed to depend on the perceived severity and cause as well as the location of the treatment that is perceived to address the problem. One husband explained why family members went to buy drugs from a chemist as the first step in seeking care for his wife who had a fever: “We went there because it was close to us, whenever we got a minor problem like stomach pain or fever we go there, until the problem is beyond there before we go to the hospital” (MD-8). Another respondent felt that “the best advice is to go where one can get remedy, so the best thing is to go to the hospital” (MD-1).In PPH cases Fig. , the firCare-seeking timelines for maternal death and PPH cases are shown in Figs. Among the ten neonatal death cases, paleness of the body and eyes was the most common symptom (six cases). One woman described her newborn’s symptoms: “She was pale and it was as if she had no blood” (ND-3). Another mother stated that her baby “was opening his eyes widely and they had turned greenish, and he also became pale” (ND-1). Other reported symptoms include low body temperature (three cases), difficulty breathing (two cases), excessive crying (two cases), discharging whitish saliva (two cases), inability to cry (one case), weight loss (one case), constipation (one case), bleeding from mouth and nose (one case), convulsion (one case), and fever (one case). In two cases, families stated that the newborns were born early or before it was time. In almost all neonatal death cases, symptoms were first recognized by the mother. The mother’s mother or co-wives were also involved in the recognition process, but husbands were never involved.Excessive crying was reported in six neonatal illness cases and fever in five cases. Other symptoms include rashes (three cases), vomiting (three cases), swollen stomach (two cases), cough (one case), stomach pain (one case), ear ache (one case), and breast pain and swelling (one case). These symptoms spanned longer periods and were often more specific than in newborn death cases. Symptoms were first recognized by the mother, who then called for her husband’s opinion.Perceptions of severity were influenced by previous experience and beliefs about abnormal behavior. For example, one mother described her baby’s abnormal crying: “…I started thinking that maybe she was sick, because I don’t usually see babies crying the way she has been crying” (ND-10). Parents looked for visible signs that were deviations from normality. For example, one mother explained: “This problem is easily identified, because you will see that the child’s stomach will be swelling, especially if he is vomiting” (NI-5). Severity was also judged by symptom magnitude and how widespread they were. For example, one family member said: “Well, it was very serious since the rashes appeared all over her body” (NI-1). A symptom that was short-lived was not considered to be serious: “The cough wasn’t so serious, because it did not last for long” (NI-1). Being born early was considered to be a very severe problem that significantly reduces the chances of survival. One woman stated about a woman who delivered when she was 7 months pregnant: “The reason why I became frightened was because the baby has been delivered before it was time… she [the baby] didn’t survive” (ND-7).yellow fever including body pallor and discharge of saliva: “If you see saliva coming out from a baby’s mouth at the time of delivery, then know that it is ‘ta yara’” (ND-7). Green eyes were described by one family as being caused by an illness they referred to as jaundice and best treated with traditional medicines.Perceived causes in neonatal death cases ranged from illnesses described as yellow fever in three cases, to jaundice, to common cold. Several symptoms were attributed to an illness described as “ta yara” or In newborn illness cases, perceived causes ranged from malaria to common cold to flu. In the case of malaria, the English word “malaria” was used to describe a fever caused by a mosquito bite. In two cases, frequent vomiting and milk regurgitation were considered as normal events. The will of God was mentioned as a contributor to the problem in seven newborn death and four newborn illness cases.In neonatal death cases, decision-making was primarily undertaken by the newborn’s mother or the mother’s mother. In two cases, the decision was made by the husband, while in one case, it was made by a health worker called into the home. In contrast, the baby’s father was a key decision-maker in neonatal illness cases (eight cases).Factors that enabled decision-making, including early symptom recognition, household consensus around appropriate actions, and resource availability, were similar to maternal death and PPH cases. In neonatal death cases, rapid onset of symptoms and progression of the disease were identified several times as a barrier to care-seeking. One mother explained: “We didn’t make any attempt [to seek care], because she died shortly after delivery” (ND-8). A family member of a different newborn who died stated: “As the flow of blood was heavy everyone agreed that nothing should be done to her at home, but should be taken to the hospital, both the paternal and maternal sides agreed upon. But before taking any further step, she died, we were really surprised about her death, it was very fast” (ND-4).Other obstacles included lack of resources and an inability to access care at the point of symptom onset at night, when health facilities are closed or unstaffed. One father explained how perception of severity influenced the decision not to seek care: “Concerning the vomiting, nothing came into my mind, because I did not consider it to be a problem… I did not take it to be an illness, so I was thinking that it will stop.” The mother concurred: “We thought that it wasn’t an illness that was why we did not take him for treatment” (NI-2). Timing of symptom onset was also described as a barrier: “You know it all happened at night, so nothing can possibly be done before morning, since we don’t have a hospital here, had it been there is a hospital here, then she would have been taken to the hospital immediately, because her brother has got a vehicle, so he can convey them. Therefore nothing has been done for the baby” (ND-7). Belief in traditional medicine and perceptions on prematurity also impeded decisions to seek care: “We honestly didn’t think of doing anything because she was a premature baby” (ND-8).Compared to maternal cases, little care was sought for newborn death cases Fig. . In fiveIn two newborn illness cases, no care was sought. In both cases, the decision-maker was the mother and the baby’s main symptom was vomiting which was not believed to be serious Fig. . In eighEnablers of care-seeking at health facilities across all case types included strong belief in and trust of the medical system, proximity to health facilities, readily available transport and funds, and family member support to seek medical care. Many barriers were also identified. Securing resources such as money and transport was a common challenge. In some cases, the nearest medical facility was not open when needed, or no health worker was present. These barriers strongly influenced the decision-making process. For example, in one neonatal death case described above, the symptoms began during the night when the health facility was closed. Despite wanting to seek care immediately, the family decided to wait until the morning when the facility would be open. The baby died before care could be sought.In the maternal death cases, especially, health system challenges were critical in the death. One family described attempts to obtain help at the facility:“We decided to go to Hadejia because the doctor we first met did not do anything since around 7am. We went to pick another doctor whom later we realised that we would not get genuine drugs from him, so we went to the hospital (5:15pm). She was given admission (5:20pm) but nothing was done till the following morning, which they asked us to buy some drugs (5:30am). First, we were asked to buy hand gloves, then some drugs, then second batch of drugs and later asked to buy materials for admission. After buying those things and I sat for a few moments, then I was informed she has passed away” (MD-1).Ultimately, for the maternal death cases, more time was spent waiting at the facilities to receive care than was spent in securing resources or in traveling to the facilities. The third delay in Thaddeus and Maine’s three-delay model seemed to be the most lengthy and critical delay. This contrasts with PPH cases where long delays at health facilities were not experienced. For example, in one PPH case, one respondent explained: “Immediately on reaching the hospital, when they [health workers] heard her problem, they attended to her….they attend to us quickly if it is a case of bleeding, even if it is at night” (PPH-4).The most significant barrier for newborn death cases appeared to be rapid illness progression to death, leaving inadequate time to seek care. Belief in traditional medicines for illnesses such as yellow fever also delayed or prevented care-seeking at a health facility. In one case, the mother explained: “I made the decision to have the rubutu [a traditional medicine] prepared, because I thought she would feel better…In my opinion, it was helpful to her since she stopped crying” (ND-3). However, this perceived improvement prevented any further action, and the baby died.Almost universally, males and females described high risks associated with pregnancy. One woman stated: “Because of its hardship, immediately when you become pregnant, you are being regarded as someone near to death, even you are counting yourself among the dead, until the day you deliver safely” (ND-7). The view that pregnant women are straddling life and death was expressed by several respondents, and in a Hausa proverb: “From the time when a woman becomes pregnant… her life is at risk. According to the Hausa people ‘one leg of a pregnant woman is in the world, while the other one is in the heaven’” (MD-9).Respondents also consistently expressed the belief that pregnancy outcomes are ultimately determined by God. However, despite this belief, many actions were still taken to cure illness. In maternal death cases especially, spiritual care was sought via religious figures or family members. At times, this delayed care-seeking at a facility and contributed to eventual death.The study findings describe patterns of recognition, decision-making, and care-seeking among families of women who died during pregnancy, delivery, or postpartum or who experienced perceived PPH, and newborns who died or experienced an illness during the neonatal period. The findings shed light on the differences and similarities by case type as summarized in Table Key decision-makers varied by case type, with husbands playing the lead role in maternal death and neonatal illness cases, while female relatives and TBAs were more involved in decision-making around perceived PPH, and mothers were the principal decision-makers in the neonatal death cases. This finding was somewhat surprising, as males are often reported as key health decision-makers in Nigeria. For example, in Kaduna, Northern Nigeria, 63% of women required permission from their husbands to visit a hospital . Our resIn cases where there was disagreement about appropriate action to be taken, or uncertainty about the cause, the slower decision-making process led to increases in delay 1. However, these decision-making delays were not particularly linked to a specific case type.Strong trust in the health care system and willingness to seek care were consistent across case types but were impeded by barriers such as cost, distance to health facilities, availability of health workers, and drug stock-outs. These obstacles contribute to both delays 1 and 2 and are consistent with other findings in Northern Nigeria , 10, 11.The largest barrier in the newborn death cases seemed to be rapid progression of symptoms from the moment of recognition to death, leaving no time for care utilization. This was linked to poor timely recognition and influenced by the presence of non-specific symptoms. The third delay in newborn death cases is difficult to assess, as few cases reached a facility prior to the infant’s death. However, of the three newborn death cases that reached a health facility, two faced substantial delays at the facility.Finally, childbearing is seen as a dangerous event by both men and women, but most families believe actions can and should be taken even if outcomes are ultimately controlled by God. These actions include attending antenatal care, seeking care at a health facility when there is a serious complication, or utilizing care at home when the illness is less severe. This belief in God delayed care-seeking at a health facility in several of the maternal death cases when spiritual care was utilized, but was not a major factor in other case types.In Sub-Saharan Africa, several other studies also identified fatalistic views regarding maternal complications –21 and nIn addition, belief in and the use of traditional medicine such as rubutu were also widespread and there was delayed care-seeking at health facilities for both mothers and newborns. This is consistent with other findings in Nigeria which underscore the very high levels of acceptance and the use of traditional medicine among pregnant women , 26 and This study has several strengths. First, it includes a sample drawn from 24 distinct LGAs. The study drew its sample from a large cohort of women being followed prospectively and involved case-finding using real-time surveillance. These elements increase diversity of the sample and ensure the inclusion of perspectives from a wide geographic area. The inclusion of both maternal and newborn cases, as well as cases resulting in death and those where the illness was resolved, allows for novel comparisons. Finally, the creation of detailed timelines allowed systematic comparison of the sequence and timing of care-seeking.Limitations include the use of self-reported data that may be subject to recall bias. To minimize this bias, the majority of cases were visited within weeks of the death or illness. Social desirability bias could have influenced responses, but interviewers were extensively trained in strategies to build trust and rapport with respondents. In addition, as with all qualitative research, external validity is limited. Finally, clinical data to validate reported symptoms was largely absent. While such data would have been useful, the objective was to understand recognition and care-seeking from the perspective of the families.Our findings have implications for future health programming, policy, and research. Interventions developed for Northern Nigeria should carefully tailor educational messaging and other strategies to case type. Interventions targeting maternal care-seeking, for example, require different messages than those focused on newborn care-seeking. While bleeding was generally recognized as an urgent maternal complication, clearer messages on other symptoms as well as where to obtain appropriate care would be helpful, as would the implementation of community-based schemes to ensure transportation and access to financial resources, especially at night. For newborns, messages on danger signs, especially on their non-specificity, and the importance of seeking immediate care are needed as illnesses can progress rapidly to death.Demand for health services is high, but supply-side challenges such as quality of care and availability of health workers and drugs continue to be a problem despite the implementation of the MSS and must be urgently addressed. Maternal and newborn interventions that do not already address the barriers posed by perceived spiritual causes of illness and the importance of spiritual care should also be sought to address this barrier in their programming. Finally, key decision-makers should be targeted, but this must go beyond including husbands and also involve both male and female relatives who are instrumental in decision-making.These findings suggest key differences in recognition of complications, decision-making processes, and care-seeking patterns between maternal and newborn cases in Jigawa, Northern Nigeria. Less care is sought for newborns than for maternal complications often due to symptom non-specificity and rapid progression of illness to death, and the key decision-maker with respect to care-seeking varies depending on the type of case, timing of the symptoms, and perceived severity. Health systems are weak and contribute to poor health outcomes, especially for women with maternal complications. Public health interventions that provide more targeted messaging by case type, are inclusive of family members beyond husbands, and address gaps in quality and availability of care are urgently needed. Fatalistic views related to maternal and newborn outcomes are prevalent and should also be addressed by interventions.


This article examines the construct of disorganized attachment originally proposed by Main and Solomon, developing some new conjectures based on inspiration from a largely unknown source: John Bowlby’s unpublished texts, housed at the Wellcome Trust Library Archive in London (with permission from the Bowlby family). We explore Bowlby’s discussions of disorganized attachment, which he understood from the perspective of ethological theories of conflict behavior. Bowlby’s reflections regarding differences among the behaviors used to code disorganized attachment will be used to explore distinctions that may underlie the structure of the current coding system. The article closes with an emphasis on the importance Bowlby placed on Popper’s distinction between the context of discovery and the context of justification in developmental science. Infant disorganized attachment is a classification for the Ainsworth Strange Situation , used toIn most cases, the behaviors identified by Handbook of Attachment, In the chapter on disorganized attachment in the latest edition of the 1 The article will begin by situating Bowlby’s ideas in their original context of ethological discussions of conflict behavior, and especially the work of Our goal will be to outline a possible architecture of the phenomena of disorganized attachment, drawing distinctions among the behaviors captured by the classification. Simply put, our question is “How are the many different indices used to identify disorganization related to one another?” Naturally, the answer to this question will build on the decades of research and theory regarding the disorganized classification that have taken place since it was first proposed . HoweverIn the Ainsworth Strange Situation, infants are presented with two separations and reunions with their caregiver in a laboratory setting arrayed with interesting toys. Ainsworth, Blehar, Waters, and Wall (1978) reported three patterns of infant response. Most infants displayed distress on the departure of their caregiver, pleasure on reunion, and could be comforted by their attachment figure and returned to play. This was in line with The “disorganized/disoriented” attachment classification was introduced as an additional category for the Ainsworth Strange Situation , 1990. TSequential displays of contradictory behavior,Simultaneous display of contradictory behavior,Undirected, misdirected, or incomplete movements,Stereotypies, mistimed movements, and anomalous postures,Freezing or stilling,Display of apprehension of the caregiver,Overt signs of disorientation.infant approaches with head sharply averted” and “while in apparent good mood, infant strikes, pushes or pulls against the parent’s face of eyes” are both placed in II (Simultaneous display of contradictory behavior). There is no implication that these events necessarily reflect the same qualities in the infant–mother relationship. In addition, no distinction was made among the indices with respect to classification as the special conditions which arise when two or more incompatible innate or learned responses are elicited simultaneously. These are the conditions which have been widely referred to in the research and clinical literature as “conflict.” Under such conditions there may occur disorganisation of normal behaviour and the appearance of apparently non-adjustive responses.Exemplars based on actual observations were listed in each category, resulting in over 50 indices in total. The resulting system amounts to an observationally based catalogue: The distinctions among these different forms of behavior into the I–VII categories were not explicitly based in theory but primarily in differences in how these behaviors looked. For example, gaze avoidance while approaching the caregiver, such as in “But who is speaking here? In fact, the text comes from a discussion between the experimental animal psychologist Roger Russell (Chair of Psychology at University College) and John Bowlby , p. 86 tIn the discussion that took place in 1952, Russell posed four questions to Bowlby about conflict between incompatible motivational responses: (1) “What is the etiology of different disorders of behavior produced by such conflict?” (2) “What factors affect susceptibility to such behavior?” (3) “What factors shape the kind of behavior shown?” and (4) “How is it possible to intervene?” , p. 86. Animal Behaviour, Main and Solomon were explicitly applying the ideas of Robert Hinde from ethology to infant behavior in their introduction of the disorganized attachment classification. Bowlby, too, was deeply influenced by Hinde in thinking about the behavior resulting from incompatible motivational tendencies. In his work, One type of conflict behavior was sequential display of the two tendencies. For example, he describes the conflict a male chaffinch may experience between a sexual tendency and fear of attack by the female; he suggests that this conflict for the male can be managed by inhibition during the act followed by quickly fleeing after copulation—while giving “the same call as that which is given in the presence of a flying predator” , p. 250.Suppose we train a rat to run up an alley for food, and then give it an electric shock at the goal box. When subsequently placed in the alley it may run a little way up . . . [then] hesitate there grooming its fur or cleaning its paws. . The ethological perspective that variations in anomalous or “disorganized” behavior could be interpreted as a meaningful window into experience influenced attachment theory in the years immediately before Main and Solomon e.g. , based iIn May 1963, Bowlby organized a conference funded by the Medical Research Council. The conference, with the ethologists Tinbergen and Hinde as keynote speakers, had two topics. One was how to find lines of determinate difference within the variety of conflict behaviors; the other was to address the issue of “sensitive periods” for the development of behavioral systems. At the conference, Bowlby presented his own initial thinking on the first question, drawing on the observations made by ethologists of different kinds of conflict behavior. In his notes for the paper, Bowlby considered five different behaviors that had been observed by ethologists:Alternation between behavioral tendencies,Simultaneous contradiction between behavioral tendencies,A simultaneous contradiction in which some compromise is reached between the tendencies in behavior that expresses both,The redirection or misdirection of a tendency, and2 or stereotypic behaviors (PP/Bow/D.6/5).DisplacementNot only do these map to several of the Main and Solomon indices. They are even placed in the same order, presumably due to the common debt to Hinde. Whereas Main and Solomon had access to hundreds of recordings of infants displaying these behaviors in the Strange Situation, Bowlby had access primarily to ethological records, his clinical experience, and his own unusual powers of systemization. However, it is equally remarkable that Main was able to sort the behaviors under headings that have held up well over decades, and which would appear to be based to some degree on meaningful distinctions among caregiving histories . In bothIn some cases behaviour deriving from both tendencies is exhibited in such a way that behaviour of one sort alternates with that of the other sort. Although it sounds as though the result would be unfavourable, it is by no means necessarily so. (p. 98)Bowlby argued, at the 1963 conference, that lines of determinate difference among conflict behavior are difficult but not impossible to discern. He would repeat this position across his later writings, both unpublished and published. Even in the context of motivational conflict, “provided observations are skilled and detailed, therefore, a record of the behavior of very young children can be regarded as a useful index of their concurrent mental state” , p. 6. SPatterns of Attachment, Ainsworth pinpointed several conflict behaviors observed in the Strange Situation whose underlying function or cause she wished to be identified, and proposed the use of physiological measures to shed further light on the matter. These included “alternation of behaviors,” “fragmentary behavioral representatives of one or the other system,” and “behavior activated by one stimulus object may be redirected towards another that is not involved in the conflict” . For the sake of scope and coherence within this article, we leave these to the side. Among the behaviors used by Main and Solomon in operationalizing disorganized attachment, Bowlby’s reflections suggest four clusters which summarize his ideas, allowing us to compare these with the ideas of Main and Solomon. We number and place them in this order on the basis of the hierarchy of risk considered by Bowlby—though we would highlight that this is our numbering, not his:Cluster 1. Direct expressions of the fear behavioral system,Cluster 2. Disorientation,Cluster 3. Conflict behaviors without overt fear,Cluster 4. Stereotypies.As we have seen, the latter two clusters were considered already in Bowlby’s 1963 MRC address and in the section “Incompatible behavioural systems: results of simultaneous activation” in Attachment ; the firDue to the common debt to Robert Hinde, the clusters of behavior in Bowlby’s account align closely with distinctions in Main and Solomon, permitting exploration of parallels and correspondences between the two conceptualizations. Cluster 1 parallels “direct indices of apprehension” in Main and Solomon (index category VI). Cluster 2 parallels “direct indices of disorientation” (VII). Cluster 3 parallels “sequential” and “simultaneous” contradiction without overt fear (I and II). Cluster 4 matches with Main and Solomon’s identification of “stereotypies” (IV). Main and Solomon used italicization to indicate those behaviors that most clearly indicated disruption of the attachment system; the frequency of italicizations becomes increasingly sparse as we descend through Clusters 1–4. Likewise, Bowlby discussed behaviors in these clusters as concerning to varying degrees: direct apprehension of the caregiver and disorientation were expected to be associated with greater risk; whereas, in Bowlby’s writings, stereotypies figure as an indicator of stress with numerous possible causes. One point that can be noted in support of such a hierarchy is that in Main and Solomon’s system direct expressions of fear or disorientation (VI and VII) were predominantly, though by no means exclusively, drawn from maltreatment and high-risk samples. This was mentioned in an earlier draft of In We will discuss each of these clusters of behavior in turn, drawing together history, theory, and observation. For each, we will begin by situating Bowlby’s attention to the behaviors, identify the key texts in which Bowlby discusses them, and draw links between Bowlby’s reflections and the kinds of behaviors described by Main and Solomon from observations of the Strange Situation.Bowlby argued that the attachment system is biologically channeled to predispose a child to approach his/her familiar caregiver when alarmed. Building from Bowlby, Main and Hesse (2006) proposed that a child’s experience of frightened, frightening, or dissociative caregiver behavior would be “one highly specific and sufficient, but not necessary, pathway to D attachment status” (pp. 310–311). The reason for this is that such caregivers would themselves become associated with fear for the child, producing a paradox or unresolvable conflict between approach and avoidance of which disorganized behavior could be expected to be the result. The Main and Hesse position, however, has been badly misinterpreted. It was not their intention to suggest that all the different forms of disorganized behavior represent fear in relation to the caregiver in the same way or to the same extent see .The usual practice of including under a single heading, that of behaviour indicative of fear, forms of behaviour that have such different predictable outcomes is of great significance . . . It can very easily make for confusion . . . We are dealing, not with some single comprehensive form of behaviour, but with a heterogeneous collection of interrelated forms, each elicited by a slightly different set of causal conditions and each having a distinctive outcome. Part of the problem is the ambiguity of the word “fear,” which Bowlby reflected upon after reading Only with this qualification firmly in view did Bowlby permit that, in his work, “fear behavior and feeling afraid are used as general-purpose terms, terms that encompass all forms of behavior and, for humans, all shades of feeling also. When greater discrimination is required, the terms used are freezing and withdrawal or escape behavior” , p. 486.to our attachment figures. Yet, Bowlby understood that fear could also present as conflict with respect to the caregiver. He was fascinated by ethological observations that if a male baboon saw a predator slowly approaching, the male may act themselves to scare the juvenile which would then quickly cling to them, despite also showing fear . This would elucidate the otherwise mysterious observation made by aregiver . This isOvertly frightened infant behaviors define Main and Solomon’s VI (direct indices of apprehension). However, as In Fright, it is suggested, is the subjective experience accompanying at least two related instinctual response systems—those leading on the one hand to escape behaviour, and on the other to alert immobility or “freezing.” It is to be noted that as so defined it does not presuppose any conscious awareness of danger. Instead, it is conceived as being the accompaniment of certain instinctual response systems whenever they are activated. (p. 96)The distinction comes into focus if Bowlby’s attention to the freezing response is considered. In his discussion of the products of the fear system, Though both are possible outputs of the fear behavioral system, Bowlby theorized determinate differences between the fleeing and freezing responses. In his notes on “Types of fear response” from 1968 (PP/Bow/H.209) and then in Separation , p. 113,“Highly vigilant posture or appearance when in presence of parent. Movements or posture tense, infant gives the impression of being hyperalert to parent even or especially when parent is positioned behind her” (p. 139). Such observations agree with the characterization by “the holding of movements, gestures, or positions in a posture that involves active resistance to gravity,” for example, “infant sits or stands with arms held out waist high and to sides.” This behavior is probably closest to “tonic immobility,” a phylogenetically more ancient defense strategy that “appears to activate only when newer structures such as the amygdala are deactivated and when freezing and flight or fight are switched off” , evacuated children, and patients in his clinic. Even in the mid-1930s, in the research notes for his MD thesis (PP/Bow/D.2/46), he was offering speculations regarding its cause. Of particular importance for his thinking was the relationship with the caregiver in early childhood. A predisposition to disorientation in response to alarm would be expectable, for Bowlby, if there were obstacles or setbacks in the ability of the caregiver to serve as what he would later call “the psychic organiser” for the child, the one who “orients him in space and time” , p. 53. themselves enact a weakening of integration, in segregating away mental processes that may otherwise result in greater disorganization. Reflecting on the grief response, in which the attachment figure is necessarily gone forever, In the 1960s, Bowlby wrote in detail about dissociative and disoriented responses in unpublished manuscripts such as “Defences that Follow Loss: Causation and Function” (PP/Bow/D.3/78). His attention to such behaviors was provoked by his attempt to develop a general theory of defense mechanisms. He argued that all defenses arise in situations where some “disorganization” of mental processes threatens because of stress placed upon mental processes to the point that homeostatic processes are very costly or impossible (PP/Bow/D.3/78). However, defenses One candidate for dissociated action consists in an episode of distress or angry behavior which appears without explanation or warning . . . in addition, some infants have been observed raising arms to the stranger  with a bright greeting as the parent enters the room. , p. 125Some of the behaviors seen in the Strange Situation distinguish themselves by appearing overtly disoriented, whereas others do not. Main and Solomon set this out explicitly, in justifying why the classification is officially called “disorganized/disoriented.” Behavior directly suggestive of disorientation defines VII in Main and Solomon’s coding system. However, as The Main and Solomon indices began simply as a list of behaviors discrepant with the Ainsworth classifications. They were defined by exclusion. The idea that they represented some disruption of the attachment system solidified only over the course of the 1980s. The Main and Solomon categories were sorted based on what behaviors looked the same: Category I comprised any kind of sequential contradiction that is not visibly fearful (such as strong proximity seeking immediately followed by strong avoidance); II represents any kind of simultaneous contradiction that is not visibly fearful (such as approach of parent with head sharply averted); and III represents miscellaneous other forms of conflict or interference with the attachment response.Conflicts can vary in their intensity, i.e. in the amount of energy spent by conflicting forces, the importance attached by these forces to certain issues, the “cost” of victory or defeat. Conflicts can also vary in their violence of expression, i.e. the militancy of the means chosen for expressing conflict. It is important to distinguish clearly between these two. (PP/Bow/H.67)One of Bowlby’s most characteristic arguments across his career was that emotional conflict can have different kinds and different degrees of intensity, and that this will be substantially shaped by experiences of attachment. For Bowlby, conflict behavior could still be controlled and environmentally responsive so long as the motivational responses in conflict were not too strong, as incompatibility would increase at higher degrees of activation. He reflected in his early notes on Freud and Klein that loss of control could be signaled by behavior that is poorly coordinated and environmentally unresponsive (PP/Bow/D.1/2/11). In an unpublished text circulated to colleagues at the Tavistock in February 1958, Bowlby emphasized thatAinsworth et al. 1978/ and MainYet, Stereotypies and other behavior fragments comprise the last of Bowlby’s clusters, and category IV in Bowlby’s overarching conclusion is that stereotypies may mark tension or stress. He reports a personal communication from Mary Ainsworth that the infants classified as insecure in the Strange Situation, who experienced distress that was either not shown or not comforted by the caregiver, were much more likely than securely attached infants to show stereotypic movements at home in the final quarter of their first year , p. 388.Stereotypies are already recognized by Main and Solomon as ambiguous indices of disorganization. They were included as a disorganization index because they seemed to represent conflict about displaying anger or distress when approaching the parent or when in the parent’s arms. However, none are italicized markers, as it was known that stereotypies can reflect a variety of sources of stress or conflict . Their uTo date, the disorganized attachment classification collects a number of behaviors that look quite different because all, to varying degrees, suggest strong conflict at the level of the attachment system. Exploring the John Bowlby Archive at the Wellcome Trust in London, we were struck by Bowlby’s conviction that meaningful and useful differences could be discerned among conflict behaviors, and by the fact that he even organized a conference with this as one of the two themes. The relentlessly systematic quality of Bowlby’s thinking underpins his continued relevance today in thinking about disorganized attachment, permitting the history of science in this case to operate “as a continuation of science by other means” , p. 249.In his remarks about the behaviors, Bowlby placed stereotypies, conflict without overt fear, dissociation, and direct apprehension of the caregiver along a spectrum of increasing degrees of concern. Frank fear of the caregiver can provoke any of these behaviors . HoweverConjectures and Refutations, In closing, we wish to offer a brief caution regarding the interpretation and direct use of the ideas presented here. In


Recent innovations in gene analysis technology have allowed for rapid and inexpensive sequencing of entire genomes. Thus, both conducting a study using whole genome sequencing (WGS) in a large population and the clinical application of research findings from such studies are currently feasible. However, to promote WGS studies, understanding and voluntary participation by the general public is needed. Therefore, it is essential to investigate the general public’s attitude toward and understanding of WGS studies. The primary goal of our research is to investigate these issues and to discover how they relate to research participation in WGS studies.A survey of awareness regarding WGS and studies using WGS was conducted with a sample of 2000 or more participants using a self-administered questionnaire posted on the Internet between February 20 and 21, 2015. Prior to the survey, we briefly explained WGS and WGS study-related issues to the respondents in order to provide them with the minimum knowledge required to answer the questionnaire. We then conducted an analysis, including cross-classification.For the question regarding interest in WGS, 46.6% of participants responded “Yes.” 70.7% of all respondents said that they were interested in some kinds of findings that could be obtained from WGS studies. Regarding participation in WGS studies, 29.0% were interested in participating. The demographic factors significantly related to attitudes toward research participation were age, level of education, and employment status. The results also suggest that concerns about WGS have a positive effect on people’s willingness to participate. Furthermore, it was shown that for people who were not interested in their gene-related information, concerns about WGS negatively impacted their willingness to participate. However, for people who were interested in their gene-related information, their concerns might not have impacted their willingness to participate.This research has shown several key factors that affect the willingness of the general public for the participation to the WGS studies. One of the unexpected findings is that concerns toward WGS studies generally have positive effect on the peoples’ attitude. It will be interesting to further investigate into the various types of concerns that people in different groups have about WGS. Significant advances in genome analysis have led to increased understanding of diseases related to genome mutation . Such adIn response to this trend, new issues associated with WGS studies have emerged, including the sharing of genome information obtained through WGS (data sharing) and returning personal genetic information to subjects (return of results).In order to conduct future investigations using WGS in a large study population in Japan, and to make effective regulatory policies, we believe that knowledge regarding attitudes toward and understanding of WGS and studies using WGS needs to be obtained. Several reports on WGS awareness surveys conducted in Japan and in other countries have been published , 7, and In this study, after the respondents had received a summary explanation of WGS, we conducted a survey of people’s interest and concerns regarding WGS, their willingness to participate in WGS studies, and background factors correlated with their attitudes, in order to aid in the design of future WGS studies.A survey of awareness around WGS and studies using WGS was conducted using a self-administered questionnaire posted on the Internet. Prior to each section where respondents choose their answers, we briefly explained WGS and WGS study-related issues, including an outline of WGS studies, data sharing, and return of results, to the respondents to provide them with the minimum knowledge required to answer the questionnaire.The survey was conducted with a target number of 2000 or more participants, in accordance with the demographic distribution shown in the Japanese national census between February 20 and 21, 2015. Video Research Ltd. was in charge of the visual layout of the questionnaire and the implementation of the survey.Participants were recruited from the general public who were registered as part-time survey assistants with Video Research Ltd., to which we outsourced part of the survey.The subjects comprised males and females aged 16 years or older with a wide variety of attributes, but who matched with the age distribution of the Japanese population based on the Japanese government’s national population census in 2010. Only the responses from the subjects who completed the entire questionnaire were included, and enrollment was considered to have been completed when the target number of the respondents was reached.We received all the results of the survey from Video Research Ltd. and conducted an analysis, including cross-classification.All data were summarized using medians and interquartile ranges for continuous variables whereas counts and percentages for categorical variables.To identify factors associated with the willingness to participate in WGS studies, a proportional-odds logistic regression model was used with inclusion of age, sex, income, family number, education, employment, and marriage as explanatory variables. Non-linear restricted cubic splines were used to assess non-linearity of all continuous variables. Missing data were imputed using the multiple imputation methods using areg.impute function in rms package of R software .In order to examine the effect of each variable indicating subjects with or without interest in and concerns regarding WGS, as well as those who did or did not wish to get the gene-related information on willingness to participate in WGS studies, similar analyses were performed.To discover whether the effect of concerns about WGS was influenced by whether or not a subject wanted to get gene-related information, the interaction between these two variables was assessed with inclusion of their cross-product terms in the multivariable regression along with the main effect variables.All statistical inferences were made two-sided at the 5% significance level. All statistical analyses were performed with the R software  using the rms package.Institutional review board (IRB) approval was obtained at the Osaka University and Tohoku University prior to implementation of this study.The demographic characteristics of the participants are presented in Table The population comprises 1196 males (49.9%) and 1203 females (50.1%), with a mean age of 44.91 years. While it is difficult to make direct comparisons with the national census data and the results from our study, concerning educational background, we note the following differences: while those who studied until high school make up for 46.5% of people in the 2010 national census , in our After we provided a brief explanation of WGS, the participants answered the questions, including questions regarding their interest in and concerns about WGS, and what type of information they would have interest in if their own sample was to be analyzed using WGS (see Tables n = 1118) “Yes (Very much or Moderate),” 26.1% (n = 625) “Neutral,” and 27.4% (n = 656) “No .” For the question of whether they have concerns regarding the establishment of WGS technology: 28.9% (n = 692) chose “Yes (Very much or Moderate),” 39.5% (n = 947) chose “Neutral,” and 31.7% (n = 760) chose “No .”For the question about interest in WGS, the participants responded as follows: 46.6% (n = 1342),” the second was “information on physical constitution, such as types prone to obesity and inebriety ,” the third most frequent was “information on gene-related drug effectiveness and side effects ,” the fourth was “information on aptitudes and abilities ,” and the fifth was “information on family relations .” Overall, the top 3 were information related to physical conditions. Notably, the answer “there is no gene-related information I wish to know” accounted for a relatively high percentage of answers .For the question, “what type of information would you wish to know if your own sample was analyzed using WGS” (multiple answers), the most frequent answer was “disease-related information  were willing (“Yes—Very much or Moderate),” 33.6% (n = 806) were “Neutral,” and 37.4% (n = 897) were unwilling ” . However, as shown in Fig. p value was marginal (p = 0.062), the curve based on logistic analysis revealed that the people around 40 years of age showed the most positive attitude toward participation in WGS studies, but this attitude became increasingly negative with age after this point.For age see Fig. , willingp < 0.001), high schools (p < 0.001), and professional schools (p < 0.05), but no difference was found for the graduates from technical colleges, junior colleges , and graduate schools. These results suggested that education levels, especially university graduate level or higher, could affect attitudes toward participation in WGS studies.Higher levels of education were associated with positive attitudes toward participation in WGS studies for some comparisons. More specifically, compared with university graduates, significant differences were observed for graduates from junior high schools (p < 0.05).For employment status, compared with permanent employment as a reference, only the student group significantly showed a positive attitude . The people who had concerns about WGS were also more willing to participate in WGS studies (p < 0.001).For the relationship between the general interest in WGS and attitudes toward participation in WGS studies, the n = 1697) showed more positive attitudes toward participation in WGS studies than those who did not have interest in such information  .For the relationship between interest in the information available from WGS and attitudes toward participation in WGS studies, distinct differences were observed between the people who wished to know gene-related information and the people who did not wish to know any gene-related information. The respondents who answered that they were interested in knowing their gene-related information . In contrast, in the group of people not interested in any information from WGS, willingness to participate in WGS studies was significantly lower in the people with concerns about WGS than in those with no such concerns (p = 0.021).Furthermore, analysis of the effect of concerns about WGS on the attitudes toward participation in WGS studies revealed that in the group of people who were interested in their gene-related information, any such concerns were unlikely to significantly influence willingness to participate in WGS studies  showed that men had significantly more positive attitudes toward genomic studies than women . HoweverThe main factor correlated to a respondent’s willingness to participate in WGS studies was whether or not they had interest in gene-related information. The group which expressed interest in gene-related information—compared to the group which did not—was much more likely to have a positive attitude toward participation in WGS research.Additionally, the results suggest that for the group of people who are not interested in their gene-related information, concerns about WGS negatively impact their willingness to participate in WGS studies. However, if people are interested in knowing their gene-related information, their concerns might not impact their willingness to participate in WGS studies, or these concerns might even positively impact their interest in the information to be gained from WGS and their willingness to participate in WGS studies. Therefore, we can safely say that having an interest in gene-related information functions as a very strong and stable factor in whether or not a person is willing to participate in WGS research.Our findings regarding the effect of people’s concerns toward WGS were also of interest. Generally speaking, concerns about WGS would be expected to have a negative effect overall on people’s willingness to participate. However, in our study, these concerns exert different effects depending on whether the person is interested in gene-related information or not. For those who are interested in gene-related information, these concerns do not affect their willingness to participate—in fact, they may positively influence the person’s willingness. For those who are not interested in gene-related information, concerns about WGS seem to exert a negative influence on their willingness to participate. Considering the complexity of these results, it is necessary to understand and analyze the specific kinds of concerns that people have about WGS and whether these concerns are the same among those interested in gene-related information and those who are not.The level of education of the respondents in this study was higher than that shown in the national population census. This might be because the survey was conducted using a self-administered questionnaire posted on the web and because a scientific research topic, WGS, was the subject of the survey. In addition, the unemployment rate referenced in this survey (10.5%) seems much higher than Japan’s actual rate of unemployment (3.4% at the time of writing). We suspect that this number may include some part-time workers. However, we are unable to investigate this statistic further within the scope of this paper.The results suggest, based on the correlation analysis between the background factors and willingness to participate in WGS studies, that if a person has interest in knowing their gene-related information, this could be a major factor in improving their willingness to participate in WGS studies. Additionally, concerns about WGS did not always negatively impact the willingness to participate in WGS studies and thus could be a potential factor in increasing willingness. For these reasons, it is essential that we continue our investigation into the kinds of concerns that people have about WGS, as well as whether these concerns are shared between people who are interested in gene-related information and those who are not.


In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools. Mobile phones offer new opportunities for patients with chronic conditions to engage in self-management activities between clinical visits while also enabling real-time availability of data for health care providers (HCPs) to monitor patients’ status, provide more timely intervention, and coordinate care . A smallHCPs’ attitudes and support for technological innovations in health care are increasingly important given adoption of patient-centered medical home (PCMH) and care coordination models, in which care teams are responsible for managing patients’ comorbidities and related adherence and lifestyle behaviors. HIV care provides a case example with challenging co-morbidities and behavioral factors, and which is being integrated into primary health care in the United States, along with mental health, and drug abuse treatment, as supported by the Affordable Care Act –15. CoinRecent research has identified the potential efficacy of mobile phone self-monitoring and messaging for addressing common behavioral challenges and comorbidities for people living with HIV (PLH) to support self-management of mental health, reduction of substance use, decrease in sexual risk behaviors, and enhanced medication adherence ,19. PrioStudy procedures were approved by the institutional review board (IRB) of University of California, Los Angeles. All members of all five MCC teams in a large HIV-treatment clinic embedded in a social services agency were contacted by the organization’s internal research staff to participate in 45- to 60-minute in-person interviews via announcements at in-service meetings, email, and outreach contacts. The stated purpose of the study was to examine the feasibility, acceptability, and suggestions for the development of mobile phone tools and clinical dashboards to support patient engagement in self-management for adherence, retention in care, and care coordination. Participants provided voluntary informed consent, agreed to have interviews audio-recorded, and were provided $30 remuneration for their time.Participants included members of all five MCC teams, including four team leaders , two nurse case managers  who focus on medication adherence and symptom management, two psychosocial case managers (PCMs) who provide brief behavioral interventions , and two licensed vocational nurses (LVNs) who conduct follow up contacts for adherence and retention. In addition, two staff ancillary to MCC teams also participated; one former PCM (LCSW) who was supervising retention in care program by outreach workers, and a master’s level psychotherapist coach for an intensive evidence-based behavioral intervention (EBI) for PLH disseminated by the CDC.Interviews were guided by a semi-unstructured interview guide that first aimed to assess the roles and functions of the HCPs on the MCC teams. Then, barriers and facilitators to patient adherence, retention, and care coordination were discussed in order to inform feedback on hypothetical mobile phone self-monitoring and messaging tools, and web-based clinical dashboards for medication adherence, physical and mental health symptoms, substance use, and sexual risk behaviors. Interviews then specifically focused on discussion of HCPs’ general interest and perspectives on potential feasibility, acceptability, facilitators, barriers, and suggestions for application functions, priority domains, and priority patient sub-groups.Interviews were transcribed and coded by the authors using a grounded theory approach, which involves working from the data to identify key themes or descriptive codes and subthemes within the data . Coding HCPs discussed themes regarding potential utility and value of mobile phone and web-based dashboard technology tools, with themes broadly focused on both patient-focused and provider-focused domains. Themes related to facilitators and barriers for adoption and use of technology tools were similarly clustered around factors specific to patients and providers, but also included privacy-related barriers for technology-based communications. The following themes were revealed during the in-depth interviews, as highlighted in “I think that, you know, if you’re able to....accomplish....developing the tool, that it will improve the patient’s engagement because if they engage with this, and then we look at it and we address it, then that will be validation for the patient that, ‘Oh, my input is important and they’re trying to do something about it.’ Whether or not you actually fix anything, you know, often times just listening to somebody is enough, so that you can communicate the sense of, you know, ‘We’re trying,’ you know?” .HCPs thought that mobile technologies could be useful to enhance patient engagement, self-management, and satisfaction, as one physician noted:“Tracking is a valuable tool for people who are trying to make behavior change and see progress. You get some sort of immediate feedback and you get a visual feedback, and it helps with mindfulness and awareness.” .One primary function of self-monitoring is to support behavior change through self-awareness and self-tracking, as one psychosocial service provider stated:“I would hope that in this day in HIV [care] that patients want to not have to come into the doctor all the time, and they’d want to be able to manage themselves and stay at home if they’re able to monitor, and take initiative of their own care. That’s something that they can feel good about themselves. I think they would be more apt and inspired to want to use something like that. I think patients, when they feel like they have to come into the office all the time, they do get discouraged.” .HCPs also noted that enhancing patient opportunities for self-management through mobile self-monitoring tools could also enhance patient motivation, as one licensed vocational nurse noted:“You know, the key thing is if you have a patient engaged in care, the way to keep them in care is giving them feedback, ‘You’re doin’ a good job.’ And so, yeah, I’ll give ‘em a call. Free will. I mean, that’s the nurses job, you know, you gotta keep your patients motivated.” .Feedback from providers based on mobile self-monitoring data was suggested as a primary opportunity to enhance patient engagement and motivation, as noted by one LVN:“…for my personal healthcare, I always have access to my labs online, and I think a resource like that, maybe either through the app where they could see their labs or access a website where they could see their labs and they could see a trend, and maybe give them a number of stars or a smiley face or something, I think would be tremendously helpful too. So that patients know that, you know, those taking their medication every day does have some sort of benefit, even if they maybe necessarily don’t feel better. But, just seeing that they’re trending really good and it gives them a score or a grade or something like that, I think would be awesome” .HCPs also noted that feedback could be transmitted by automated and electronic features, for example, by using data on patients’ trends in their progress, and with rewarding and motivating features, as one nurse case manage noted:Overall, HCPs in different roles indicated the potential value of mobile self-monitoring and feedback, but they also suggested that simple reminder functions could also be useful.“I think it’s something good to make someone aware when to take their medications, ‘Oh, I need to take…[medication],’ you know, a reminder.” HCPs identified that the proposed application’s queries would also function simply as a reminder. For example,“I’ve always thought that one great thing would be for us to be able to send them text messages or reminders, especially for lab appointments, appointments with their therapist, appointments with their provider, or just any appointment in general. Even to remind them that they have a financial screening due. There are some patients who hardly ever talk on the phone but they’ll send a text message. So, you know, sometimes if you just need to say, “I’m just reaching out, following up, hope all is well.” I think if they [mHealth applications] are a way to link the application to a website or for us to send them, maybe, just a quick message…” Some HCPs also suggested enhancing simple reminder functions with personalized and automated messaging, such as for appointments, test results, problem solving, rewards and encouragements, and general follow-up. For example, one nurse case manager noted:Overall, HIV HCPs recognized the potential value of mobile phone self-monitoring and feedback tools for patients, as well as for supporting provider-patient counseling.“It probably would be good for me as a tool to see what’s goin’ on like, ‘Why so many variations or variabilities as far as why are you taking it [medication] at this time and not the other time? You know, were you adherent to it?’” The results above highlight insights into the patient-facing aspects of mobile phone support tools. HCPs also recognized how tools could support provider understanding of their patients’ behavioral patterns. For example, one physician noted:“I could see it [mHealth] being a good therapeutic tool to be able to collect that data and have a visual that you could look at with the client in session.” Psychosocial services providers, in particular, recognized the potential of using patient self-monitoring data in their counseling activities, as one psychosocial service provider noted:“Yeah, I could see that […] using it [mHealth technology] as a tool to just reflect on, “What’s going on and how’s it going?” … they like that sort of thing and they enjoy havin’ that kind of interaction, I’d be happy to use that as a tool.” A psychosocial case manager similarly noted:“Visual aids really help to kind of illustrate what you’re trying to explain, or condense, or motivate a patient…we have 40 minutes [sessions]….I think you could set aside a good chunk of time to devote to reviewing that kind of information.” In addition to psychosocial services providers’ roles and expertise related to counseling, their appointment durations also support opportunities to utilize patient monitoring data and visualization dashboards for counseling, as one psychosocial case manager noted:Notably, although this PCM suggested time available to use mobile technology tools, physicians and nurse practitioners reported concerns about lack of time available to counsel patients, which are discussed below in relation to barriers and facilitators to use and adoption.“If an app that the patient can interact act with on their own time that can help to understand that dynamic, and then it can be gotten into the hands of the medical team, like in this huddle, that says, ‘Oh, well….John has never been able to get his viral load under a thousand for the last year and, previously, he used to be really good, and look at the trend in this anxiety or stigma marker that he’s been monitoring for the last several’....well, maybe there’s somethin’ there.” HCPs also suggested how patient mobile self-monitoring data could be used to support care coordination within their MCC teams, as one physician noted:“You know, we work as a team. I would talk to the psychosocial care manager, we also have a person in our clinic who manages the crystal meth recovery services and the other substance abuse recovery system. So if we receive that [mHealth] data, we can always send them a message or an email and say, ‘Hey, you know, this patient that you’re monitoring, you know, stated via the mobile website that he was feeling despondent and depressed, and that he used crystal meth, and there might be a good chance, or this might be a good opportunity just to follow up with him and see how he’s doing and see what’s goin’ on to make sure that he’s okay.’” HCPs also suggested that technology tools could facilitate coordination across other services and also to be able to follow up with patients as suggested by one nurse case manager below:“Yeah, I mean, especially with the ones who are newly diagnosed, that might be good, because there could be a lot goin’ on at the beginning and then as they’re startin’ to get a grasp of what it means for them, what it means with the friends or family they’re talking to or not talking to about, and that just hopefully getting a handle on what it means for them to be HIV positive, that, I see, especially with the newer, the newly diagnosed that that would be useful.” HCPs suggested that intensive self-monitoring would not be useful for all patients, but rather for patients with high self-management needs such as those newly diagnosed with HIV. For example, one psychosocial case manager noted:“If a patient has a moderate acuity, we have to reassess them in six months…Most of my patients that are moderate, initially, will come back self-managed…So, usually, I would say most of ‘em six months, sometimes a year.” Similarly, nurse case managers noted that most newly diagnosed and linked-to-care patients become self-managed  within six-months to one year:Thus, mobile phone support tools may be most useful to help newly diagnosed patients adapt and cope with the transition to managing their HIV infection as a chronic illness.“We have some patients that are co-infected with Hep C, so maybe tracking their Hep C viral load would be great. We have patients that are diabetic, so tracking their AIC or capillary blood glucose would be great. […]For patients that are hypertensive, maybe being able to track, you know, their most recent vital signs, or maybe even having a function where they can check their blood sugar or their blood pressure at home and putting it into the app, and then maybe it could communicate that information back to us. That would probably be great too.” .HCPs also suggested that patients with co-morbidities would be a high priority for self-monitoring and self-management support with mobile technologies. For example, one nurse case manager noted:“I would be pushing it, if something like this were available, I would be pushing it with a bunch of patients…I just wonder whether my patients would even take the time to track stuff. I think most of them wouldn’t be very motivated to do that. But, if they could, it would be very useful in diabetes. They could do food diaries, blood sugar stuff, and medication compliance. They could do that on an app, and [if] they actually did it, it would probably give us some useful information. It would also be useful in people who, for instance, have insomnia, and you want to take a diary about their use of stimulants on a daily basis, their daytime napping, that kind of thing, just to put together a sleep hygiene pattern. People don’t usually remember that stuff, did I take a nap the day I had problems sleeping? So, that’s another scenario where it might be useful.” One physician expressed interest and support for advocating use of mobile technologies with patients with comorbidities but couched in concerns about patient motivations:“If it’s something that maybe if it’s on their cell phone, they’re more apt to do it, you know? People are very electronic driven these days. So….I think it’s a text message generation and applications are like the way to go.” HCPs noted that the primary facilitator to mobile phone self-monitoring and self-management support for patients was perception of nearly universal mobile phone use by patients, as one licensed vocational nurse noted:“I mean, youth these days, especially, it’s all about texting. Hardly anyone calls anybody anymore, you know? So, I could see how, for most people, that would be what they want, you know?” Text messaging was also noted as a common and possibly preferred method for communication for some patients:“Yeah, I feel it would work well. Most people have nowadays, a smartphone, you know, and with the MCC program, ‘cause it’s a program that tries to help them with housing, and from what I understand…homeless patients, you think they, some of them don’t have cell phones, actually most of them do have cell phones anyway. They’re homeless but they have smartphones. So, I think, yeah, it definitely works well.” Smartphone ownership was also noted as being very common, even among homeless patients, as one licensed vocational nurse noted:“… also the instability of people being able to have a phone. I mean, there are a lot of our clients, who if they had the smartphone that would be able to have an app but they may not be able to hang on to it, or people’s phone bills are getting cut off and turned on pretty regularly. And so, it would require a certain…people who have financial stability…I think people do recognize the barriers that not having a phone creates for engaging in medical care. I mean, it’s really huge. We’ll have clients who, their phones are cut off - we have no way of getting in touch with them, you know?” Unstable finances were mentioned as a concern or barrier to mobile phone applications for self-management for some patients, as one EBI Coach noted:“I struggle with this issue a lot, of like the base motivation of folks. I get kind of discouraged and in despair about it a lot of times. I mean, I work a lot in prevention, so it’s like, what? People are still engaging in risk and all that stuff….I have to drag ‘em back into the clinic frequently. I mean, this isn’t everybody, but these are the ones that stick in your mind, you know. They expect another six months of refills without having any kind of lab, monitoring, or interaction with the doctor. And, we don’t think that’s close at all to the standard of care. And, it’s, you know, there’s a certain percentage of patients where, you know, I just have to babysit, kind of to pull them back in the right time and, I don’t know what percentage that is, say 25 percent. The percentage of patients who I think would be really willing and amenable to getting more involved through an app or something is, in my panel, is probably 10 [%].” “I’m skeptical. But, yeah, it’s hard for me to read this younger generation, you know, ‘cause they do seem to be really willing, sometimes, to like do stuff that’s oriented towards their hand-held device. That mystifies me. (laughter)” A primary concern or potential barrier was the lack of motivation among some patients to engage in care and self-management, including the proposed mobile applications, as two physicians noted:“I try to avoid emails at all costs unless someone is really like this is how they prefer to be contacted because things are written down and it’s not - what’s the word for it? It’s not protected over email. You know, it’s not encrypted. It’s not encrypted. It’s not protected. Although, we just learned last Friday, a way that it can be encrypted. But in general, I’d rather just do the best I can for HIPAA compliance to like, to not have anything fall through the cracks in terms of that. So, only if they really want it. So, there’s only a couple people. There’s only like three or four people out of all the people I’ve seen who, here and there, there’s an email correspondence. Yeah, and I do not text. That’s not part of what we can do or are allowed to do.” “I’ve only emailed patients general information. Sometimes they say like, you know, like, ‘You can go ahead and email me the doctor, specialist doctor’s name, phone number, and address.’ I can just do that. It’s not personal information. It’s just a doctor’s, specialist’s name and phone number. But, when, sometimes like I got (inaudible), sometimes we have patients saying like, ‘Oh, I just need my lab work, can you email it to me?’ I can’t do that because I don’t know exactly if the email, I might misspell one letter and it goes to the wrong email and then we get in trouble. “We’ll mail them but that’s not, you know, an email’s not a secure way to communicate with clients, otherwise, we might do it more. We do email some clients if we get their consent.” HCPs noted prior experiences that indicate patients’ desires to receive their health information electronically, such as test results by email, but that under current rules and systems providers can only provide such information in person or by mail, as a psychosocial case manager, licensed vocational nurse, and EBI Coach all noted:“I think maybe part of the only thing, for me, is it would simplify my life a lot if I were to have this data but it were presented very easily for me, just to go ahead [and] access [it], not to have to figure out, ‘Okay, well do I have to fill it out myself?’ As long as it will be self-populated and I wouldn’t have to necessarily do anything extra.” “Depending on how much time it would take to review it, you know what I mean? If it was quick and easy - absolutely. But, if it took me having to, oh my God, I’ve got to log in here, log in there, blah-blah-blah-blah-blah-blah, and then, you know?” Another major concern was ease of access to using the web-based dashboards and reporting, which would be critical to making them useful in health care settings, as one physician and one nurse practitioner noted:“So, we have this EMR, right? But nothing is centralized on that EMR. So, if I have a disability for a patient, I have to go to the disability site, right? It takes forever. Then, I gotta do an e-consult, so I have to check in on e-consult, then I have to go to all these external places. So, if it was one centralized thing, that would be different, but it’s not. So, you have to go out of this program and go into that program[…] and they don’t talk and they don’t communicate, which like our EMR doesn’t communicate with our pharmacy, so it’s like you can’t do one on the same screen, you have to come out of one to go into the other, and so that’s where it becomes really cumbersome…So, then it becomes burnout issues, right, you know? Oh my God, how am I, I don’t have time to do that.” Of the twelve HCPs interviewed eight  talked about feeling overwhelmed by existing electronic medical record (EMR) systems, particularly the poor integration of multiple electronic systems.“Well, stuff is being laid on just endlessly. And, I don’t know why doctors are puttin’ up with this because the length of time, their appointment times are also shrinking, you can’t, it’s like a no win situation. And, so I said, ‘I’m not takin’ anything more on my plate until we get the operational problems fixed.” “So, you know, I think that medical providers, in general, in this day and age of electronic medical records are increasingly frustrated with all of the electronic interface problems to document the medical encounter. And, I know from having read comments from various websites that the problems and complaints are not restricted to just our EMR in this institution. I think it’s across the board, most people who work with electronic medical records have significant levels of frustration. So, what that leads to is a, kind of a constant level of anxiety among the providers as to getting through a medical visit where the provider’s list of things that they want to accomplish during that visit is reasonably accomplished. The patient’s list of items that the patient wants to accomplish is accomplished. And you then have to document things that our funders require. And, all of those tensions and pressures have to be met within a limited period of time, like 20 minutes. That’s a pretty tall order. So, whenever somebody comes and says, ‘I’ve got a new way of helping you get information that’s important to the patient,’ the first thing that’s gonna go down in front of the provider’s eyes is a curtain that says, ‘Oh, great! More stuff that I got to deal with in a limited time.’ However, if there can be a tool that doesn’t require the provider to navigate through various different screens…but that transmits useful information, of course they’re gonna be interested in it.” All of the MDs and the NP also mentioned barriers related to limited time with patients under current reimbursement structures  to counsel patients, and that complicated web-based dashboards would further exacerbate the time concerns:Despite these concerns, HCPs interviewed expressed interest in trying mobile technology tools, and in their care teams, with high-need sub-groups of patients. Again, interests tended to vary by HCPs’ role. The two NCMs (RNs) and two LVNs expressed the most interest in symptom and adherence monitoring, consistent with the scope of their roles on the MCC teams. Behavioral intervention providers  expressed the most interest in using monitoring and dashboard tools, which is likely enabled by 40-minute visit times and their role responsibilities.The results of this study indicates that opportunities for integrating patient mobile monitoring and provider dashboard technologies in patient-centered medical homes, and specifically for HIV care, are feasible and acceptable to HCPs and particularly for patients newly initiating treatment or with co-morbidities. There were notable concerns around patient motivation and technology access, and for provider time burdens and adding another electronic system to workflows. Despite concerns, HCPs were open to trying the technologies if the burdens were allocated acceptably. Specifically, psychosocial or behavioral health services providers were most open to using patient mobile monitoring technologies and would likely drive technology adoption by having primary responsibilities for supporting behavior change and 40-minute visit times with patients typically. Nurses express some support to drive technology adoption, particularly when applied to medication adherence, symptoms, and general health-related behaviors . These results complement results from similar prior studies with other chronic conditions that identify technology barriers such as system readiness and liability concerns, but still finding support from many HCPs ,10.There are several limitations in this study. First, the sample size is small, and so may not have captured the full range of perceived benefits and barriers and qualitative studies in general are not designed to make inferences on the frequency or commonality of themes identified. Inferences suggested by variations in themes by HCP roles are consistent with their roles and expertise, but should be interpreted with caution. Furthermore, since participants were volunteers and represented about half of the HCPs on the care teams, except for MD/NP team leaders, self-selection biases likely result in emphasis of more motivated and optimistic HCPs who might be considered potential early adopters rather than fully representative of their peers. Another limitation is that this preliminary feedback is based on hypothetical discussion of proposed tools (used in prior pilot studies with HIV-positive persons) rather than the HCPs’ actual user experiences. Actual user-experiences are required to make reliable inferences on acceptability, efficacy and potential for scalability.Overall, HCPs interviewed expressed interest in trying mobile technology tools with high-need sub-groups of patients, such as moderate- to high-acuity, newly diagnosed, persistently non-adherent, and dually diagnosed patients, or those receiving behavioral interventions . Mobile phone self-monitoring tools have the potential to support motivation, behaviors, and self-management for people living with HIV, and potentially, to enhance and accelerate treatment and intervention outcomes through integration into treatment settings and HCPs service delivery and care coordination ,19. The