N = 115) interacted with a cinematic avatar that displayed different facial expressions. Their task was to regulate the avatar’s expression to a specified level. Unbeknownst to them, an equation mediated the relationship between their responses and the avatar’s expressions. Learning occurred in the task, as participants gradually increased their ability to bring the avatar in the target state. Subjective measures of awareness revealed that participants acquired both implicit and explicit knowledge from the task. This is the first study to show that IL operates in interactive situations upon socially relevant surface stimuli, facilitating future investigations of the role that IL plays in (a)typical social functioning.Implicit learning (IL) deals with the non-conscious acquisition of structural regularities from the environment. IL is often deemed essential for acquiring regularities followed by social stimuli , hence is hypothesized to play a role in typical social functioning. However, our understanding of how this process might operate in social contexts is limited for two main reasons. First, while IL is highly sensitive to the characteristics of the surface stimuli upon which it operates, most IL studies have used surface stimuli with limited social validity . Second, while the social environment is dynamic , the bulk of IL research employed noninteractive paradigms. Using a novel task, we examine whether IL is involved in the acquisition of regularities from a dynamic interaction with a realistic real-life-like agent. Participants (The online version contains supplementary material available at 10.1007/s00426-022-01709-4. One of the biggest contributors to the evolution of humankind is our ability to swiftly function as part of complex social systems. Recent perspectives suggest that humans acquire the necessary skills and knowledge to effectively interact within such systems through unconscious learning processes  and personality features , and that the judgement of new avatars is influenced by the learned covariation , but not when it is instantiated by evolutionary irrelevant stimuli (buildings)  to which the participant typically reacts again, thereby perpetuating a loop of informational exchange.However, the loops through which information is exchanged in most IL tasks are fundamentally different from those in which information is exchanged in social environments. Specifically, in the real-world environment, if an individual behaves in different manners, s/he should expect different responses—i.e., information is being exchanged via feedback-driven interactive loops  the artificial nature of the surface stimuli  and (b) the static nature of the paradigms themselves, which seldom, if ever, afford the kinds of interactive contexts that nevertheless constitute the core feature of social life.To overcome these limitations, we developed a novel task consisting of a learning phase and of an awareness test phase. In the learning phase, based on the classic DSC task, participants responded to the cinematic facial expressions of a realistic avatar, with the aim of bringing its facial expression in a predefined state. Unbeknownst to the participants, their responses were related to the avatar’s expressions via a complex equation modeled after Berry and Broadbent : the equThe awareness test phase measured to what extent participants were aware of the information required to regulate the avatar’s state. As the issue of measuring awareness remains highly controversial, we discuss our choices in the following subsection.immediacy criterion of Newell & Shanks, First, we used a subjective measure of awareness. Considering that any awareness measure requires a subjacent theory of consciousness, using a subjective measure is informed by two of the most validated empirical theories of consciousness: the global workspace theory and the higher-order theories. In brief, global workspace theories show that the information one is aware of, is globally available for the cognitive subsystems, including those responsible for verbal reporting of the information. Hence, information one is aware of should be verbally reportable , while asking them to report on their subjective, conscious, access to this knowledge.Second, a proper measure of awareness needs to precisely specify what content it attempts to capture  and modes of interaction with the task . As discussed in the previous sections, the nature of the surface stimuli and the mode of interaction with those stimuli has been shown to influence the nature and the extent of learning  participated in this research. All participants had normal or corrected-to-normal vision, enrolled voluntarily, gave written informed consent, and were told that they could withdraw from the experiment at any time, without any negative consequences. Participants consented to have their anonymized data being made publicly available. This study respected the regulations of the Babeș-Bolyai University’s Research committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.We determined our sample size considering the statistical power needed to test H3, because it has a smaller expected effect size than that of H1 and H2. We expected a small to medium effect size for the unconscious learning effect stipulated by H3, based on previous studies that used similar methods to measure conscious and unconscious knowledge ; the JavaScript experiment was coded in PsychoPy/PsychoJs  were linear and respected the guidelines provided by the Facial Action Coding System  saw a facial expression of the avatar and (2) had to respond by selecting an expression, so that the avatar’s expression would change to neutral in the next trial .Participants were informed that they will interact with a fictional character from an unknown culture who is able to display only a limited number of facial expressions and is unable to regulate his facial expressions. They were further instructed that the avatar attends an important task in which he must not express intense facial expressions—neither positive nor negative—and that their task is to assist him in regulating his emotions, aiming to get him into the Neutral state as many times as possible. Then, participants were instructed on how they could interact with the avatar. Specifically, they were told that the avatar will display a facial expression and they will have to show him a picture of himself that they think will bring him in the Neutral emotional state. For instance, if the avatar displays Intense anger, they will have to show him a picture of himself that they think can calm him down to the Neutral state. All trials in which participants succeeded to regulate the avatar in the target  state were classified as Crucially, undisclosed to participants, in the first milliseconds of each trial, the program determined the facial expression that the avatar will morph into by computing a rule that took into account both the avatar’s expression in the previous trial and the participant’s response in the previous trial. We detail the contents of this rule in the subsection below.To describe our implementation of the equation, it is first necessary to present the fact that each of the avatar’s 7 possible facial expressions, as well as each of the participants’ seven possible response options were assigned a constant position within a looped numerical sequence; for a graphical representation, see Fig. .t), the task was programmed to compute the equation “Av. Exp.t = 0 + [Av. Exp.t−1 + (Av. Exp.t−1 − P. Resp.t−1)]” where, “Av. Exp.t” denotes the Avatar’s expression in the current trial; “0” represents the starting point of the stimulus set ; “Av. Exp.t−1” represents the Avatar’s expression in the previous trial and “P. Resp.t−1” represents the Participant’s response in the previous trial.To determine the avatar’s facial expression on any given trial ]} or, alternatively, it is possible that they eventually learned to respond adequately in several specific interaction instances . Note that, according to the equation, after the avatar reached the Neutral state, it could be maintained in this state indefinitely simply by repeatedly choosing the Neutral response option. However, to prevent participants from obtaining a high performance in the learning phase based on this instance-specific rule, they were not allowed to repeat the same response in two consecutive trials. In this case if the avatar reached the Neutral state, participants could maintain its expression Neutral for just another trial . If they attempted to repeat their response, a feedback message was displayed on the screen and participants were asked to select a different response.Noteworthy, our task has no specific input—specific output mapping; therefore, task habituation cannot explain performance improvements. Instead, participants could become proficient in controlling the system by engaging in an abstract learning process or, alternatively, by engaging in an instance-specific learning process. To better exemplify, it is possible that participants acquired the abstract equation from the task {i.e., Av.Exp.Participants interacted with the avatar dynamically. Specifically, given the same facial expression of the avatar, two different responses from the participants would produce different responses from the avatar in the next trial .On-target trial). In other words, an On-target trial was achieved when the result of the equation indicated the facial expression that will be displayed by the avatar is the Neutral state . Evidence of learning was considered if the number of On-target trials increased with practice . In the next section, we present a specific account of the events that occurred during a typical trial.Task performance was indexed by the number of trials in which participants regulated the avatar to the Neutral facial expression  and consisted of 300 trials divided to ten equal blocks, with 30 s rest breaks between each of them.knowledge attribution . To this end, we employed an extensively used subjective measure of awareness, called The PDP assesses participants’ ability to flexibly operate with their acquired knowledge. The procedure consists of two tasks: inclusion and exclusion. As applied here, in each trial of both tasks, participants were presented with an image depicting one of the previously encountered facial expressions of the avatar. They were then asked to respond  to either bring the avatar in the target state (in the inclusion task) or to bring the avatar in any other state but the target state (in the exclusion task). The avatar’s seven facial expressions were randomly presented twice in each task. The task order effect was controlled by a counterbalanced design, 64 participants started the test phase by completing the inclusion task, and the other 51 participants started the test phase by completing the exclusion task. To prevent learning during the test phase, the experiment proceeded without feedback as soon as a response has been given. If participants regulated the avatar to the target state on significantly more trials in inclusion vs. exclusion, we would conclude that they had acquired accurate judgement knowledge. Crucially, however, accurate judgement knowledge can be based on unconscious structural knowledge . Indeed, this is what was found by most—if not all—IL studies that used a PDP in conjunction with subjective measures: participants are able to control their knowledge even when they are subjectively unaware of the learned structures  with Guess, Intuition, Rules and Memory as response options. The Guess and Intuition response options denote that participants attribute their answer to unconscious structural knowledge (hereinafter implicit attributions) whereas the Rules and Memory response options denote that participants attribute their answer to conscious structural knowledge . Participants were presented with explanations of these response options after each trial of the PDP  reflects conscious knowledge of the Guess and Intuition), they are able to accurately use their judgement knowledge . Before initiating the experimental trials of the learning phase, we verified that participants knew how to interact with the avatar by asking them to perform 10 practice trials. Here, the avatar reacted randomly to participants’ inputs and these trials were dropped from the analyses.After they completed the learning phase, participants were given the written instructions for the awareness test phase. Participants were informed that they would be presented with a facial expression of the avatar and they would have to choose the response they thought would bring the avatar in the target state (for the inclusion task) or in any other state but the target (for the exclusion task). They were further instructed to indicate the subjective basis of their response by choosing one of the four possible response options . After participants indicated that they understood their task, we presented them with one practice trial . The practice trial was also discarded from the analyses. After completing the practice trial, participants started the awareness test phase. The definition of the response options appeared on the screen after each trial of the PDP.After the awareness test phase was completed, participants were thanked for their involvement in this research and were given the contact information of the principal investigator in order to address their potential questions.In the following, we will first analyze whether participants acquired knowledge of the regularity. Then, we analyze whether they possess accurate judgement knowledge. Last, we assess whether their accurate judgement knowledge is based both on unconscious structural knowledge and on conscious structural knowledge.On-target trials as the task progressed. A one-way repeated measures ANOVA revealed a significant effect of Block  on the number of On-target trials, F = 38.33, p < 0.001, η2p = 0.252. A follow up repeated measures t test indicated that participants generated significantly more On-target trials in the 10th acquisition block  than in the 1st acquisition block , t(114) = − 9.05, p < 0.001, Cohen’s d = 0.84. Altogether, these results clearly show that learning had occurred during the task . If participants acquired knowledge from the task, we would expect an increase of the number of s, F9, 11 = 38.33,On-target trials from the inclusion task with those from the exclusion task.Participants’ ability to flexibly conform to the opposing requirements of the inclusion and of the exclusion tasks would be enabled by their possession of accurate judgement knowledge. To determine whether they possessed this accurate judgement knowledge, we compared the number of Instruction (within-subjects: inclusion vs. exclusion) and task order (between-subjects: inclusion–exclusion vs. exclusion–inclusion) on the number of On-target trials generated in the test phase. We found a significant Instruction effect, F = 107.01, p < 0.001, η2p = 0.486, indicating that participants generated significantly more On-target trials in the inclusion  than the exclusion  task. We failed to detect either a significant Task order effect, F = 0.61, p = 0.435, η2p = 0.005, or a significant Instruction by Task order interaction effect F = 0.07, p = 0.794, η2p = 0.005. These results suggest that participants acquired accurate judgement knowledge from the task. For a graphical representation and analysis of participants’ accuracy in the PDP against the chance level, consult Supplementary material E.A mixed ANOVA assessed the effects of After having established that participants possessed accurate judgement knowledge, we now analyze to what extent it is based on unconscious and/or on conscious structural knowledge.Implicit attributions scores, and the Rules and Memory attributions to create the Explicit attributions scores. Roughly half of the total responses were based on Implicit attributions  and the other half were based on Explicit attributions . For a detailed perspective on the distribution for each of the four response bases  across the inclusion and the exclusion tasks of the PDP, see the Table Following established analytical strategies in IL research  on at least one trial in both the inclusion and the exclusion tasks. For responses based on Explicit attributions, a paired sample t test indicated that participants generated significantly more On-target trials in the inclusion  than the exclusion task , t(96) = 13.02, p < 0.001, d = 1.32. In a more granular perspective, for responses based on Rules, a paired sample t test indicated that participants generated significantly more On-target trials in the inclusion  than the exclusion task , t(62) = 9.38, p < 0.001, d = 1.18. The same pattern of results was observed for the responses based on Memory—participants generated significantly more On-target trials in the inclusion  than in the exclusion task , t(53) = 10.09, p < 0.001, d = 1.37. Collectively, the analyses above indicate that participants had accurate judgement knowledge on trials where they reported relying on conscious structural knowledge.We then analyzed the accuracy of participants’ judgement knowledge depending on the conscious/unconscious status of their structural knowledge. First, we assessed whether participants had accurate judgement knowledge when they reported that their responses were based on explicit structural knowledge. Note that the overall analysis only included the 96 (out of 115) participants, who reported relying on an Implicit attributions, a paired sample t test indicated that participants generated significantly more On-target trials in the inclusion  than the exclusion task , t(87) = 2.88, p = 0.006, dz = 0.31. In a more granular perspective, for responses based on Intuition, a paired sample t test indicated that participants generated significantly more On-target trials in the inclusion  than the exclusion task , t(73) = 1.67, p = 0.05, d = 0.19. Furthermore, even for responses that were attributed to Guess, the inclusion —exclusion  difference on the number of On-target trials that were generated by the participants remained statistically significant, t(61) = 1.76, p = 0.041, d = 0.224.We then assessed whether participants had accurate judgement knowledge when they reported that their responses were based on unconscious structural knowledge. Note that the overall analysis only included the 87 (out of 115) participants who reported relying on an implicit attribution  in at least one trial in both the inclusion task and the exclusion tasks. For responses based on t test indicated that even when indicating guessing as a response attribution, participants generated significantly more On-target trials  than what would be expected at the chance level , t(88) = 2.26, p = 0.0013, Cohen’s d = 0.239.In the following, we employed an alternative method to verify if IL occurred in the task: the guessing criterion  reported that their decisions were based on implicit decision strategies, indicating that they did not feel that they were aware of the structure that guided their responses in the PDP. We note that initial IL studies operated on the assumption that an accurate PDP performance indicates conscious knowledge of the learned structure; that is, participants would be able to respond according to the learned structure in inclusion, or avoid responding according to it in exclusion, only if they were aware of the structure  and partly explicit .Second, as in most other IL tasks, our results do not provide a clear answer regarding the exact nature of the acquired knowledge. For instance, as discussed in the introduction, in the AGL task, participants could learn both specific combinations of letters that make a string grammatical or not, but could also learn more abstract types of knowledge pertaining to the structure of the grammar  or verbal report. To the best of our knowledge, this is the first DSC study to employ trial by trial subjective measures of awareness ; thereby, offering a more precise perspective on the way in which explicit knowledge, as well as implicit knowledge, contribute to task performance.First, the test phase consisted of precisely the same interaction instances encountered in the acquisition phase. Therefore, on the grounds of this method, we cannot infer transfer of the learned information to novel situations. Future research could use different avatars across the acquisition blocks while maintaining the same rule that structures the interactions to assess the transference of the learned content to novel situations. At this stage, our task cannot provide a definitive answer to whether participants learned the abstract mathematical equation or they learned specific interaction sequences , our DSC task indeed produces implicit knowledge, along with a significant amount of explicit knowledge.”Supplementary file1 (DOCX 182 KB)Below is the link to the electronic supplementary material.


HIV epidemics in Western and Central Africa (WCA) remain concentrated among key populations, who are often unaware of their status. HIV self-testing (HIVST) and its secondary distribution among key populations, and their partners and relatives, could reduce gaps in diagnosis coverage.We aimed to document and understand secondary HIVST distribution practices by men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD); and the use of HIVST by their networks in Côte d’Ivoire, Mali, and Senegal.A qualitative study was conducted in 2021 involving (a) face-to-face interviews with MSM, FSW, and PWUD who received HIVST kits from peer educators (primary users) and (b) telephone interviews with people who received kits from primary contacts (secondary users). These individual interviews were audio-recorded, transcribed, and coded using Dedoose software. Thematic analysis was performed.A total of 89 participants, including 65 primary users and 24 secondary users were interviewed. Results showed that HIVST were effectively redistributed through peers and key populations networks. The main reported motivations for HIVST distribution included allowing others to access testing and protecting oneself by verifying the status of partners/clients. The main barrier to distribution was the fear of sexual partners’ reactions. Findings suggest that members of key populations raised awareness of HIVST and referred those in need of HIVST to peer educators. One FSW reported physical abuse.Secondary users generally completed HIVST within two days of receiving the kit. The test was used half the times in the physical presence of another person, partly for psychological support need. Users who reported a reactive test sought confirmatory testing and were linked to care. Some participants mentioned difficulties in collecting the biological sample (2 participants) and interpreting the result (4 participants).The redistribution of HIVST was common among key populations, with minor negative attitudes. Users encountered few difficulties using the kits. Reactive test cases were generally confirmed. These secondary distribution practices support the deployment of HIVST to key populations, their partners, and other relatives. In similar WCA countries, members of key populations can assist in the distribution of HIVST, contributing to closing HIV diagnosis gaps. West and Central Africa (WCA) has the third highest burden of people living with HIV in the world. In this region, key populations and their sexual partners accounted for 74% of new HIV infections in 2021 . Less HIHIVST can be provided through a variety of strategies. Primary HIVST distribution refers to the direct provision of HIVST to users. Social-network strategies to deliver HIVST can be developed through secondary distribution, where primary contacts are invited to redistribute HIVST kits to their peers, partners, clients, and relatives. HIVST allows the user to perform the test with full confidentiality , 6. It aThe HIVST strategy has been more commonly employed in Eastern and Southern Africa, than in WCA. Studies have found that HIVST is accepted by MSM and FSW, who are able to use and interpret the oral HIVST results correctly –12. It aHowever, in WCA, secondary distribution practices have not been studied in depth. Most studies so far have used quantitative approaches and have lacked the qualitative nuances required to understand particular contexts where HIV is less prevalent and stigma levels are higher. Also, in WCA, qualitative studies examined attitudes to and perceptions on HIVST secondary distribution, and not on their actual practices. Specifically, there is little data available on distribution of HIVST within key populations’ networks with otherwise difficult access to facility-based HIV testing. For example, what are the motivations and barriers to secondary distribution? What are the strategies used by key populations for distribution to partners, peers, clients and other relatives? What are the HIVST practices after receiving the kit? Some studies examining perception related to the introduction of HIVST among stakeholders in Africa generally casts doubt on the effective use of the distributed kits, the capacity of key populations to use HIVST and correctly interpret the results , 19–22, Using qualitative methods, the objective of this paper is to analyse secondary HIVST distribution practices by MSM, FSW and PWUD, as well as the use of HIVST by their partners, peers and social contacts who received the kits through secondary distribution in Côte d’Ivoire, Mali, and Senegal.This analysis was undertaken within the ATLAS project which the research protocol is published elsewhere . Funded primary users”.ATLAS delivery of HIVST to members of key populations starts at fixed or outreach sites. HIVST kits are provided by trained health providers and mostly by peer educators (85% of distribution). The peer educators explain to members of key populations who wish to use HIVST how to use the kits, how to interpret the results, and the requirement to seek confirmatory testing if the result is reactive. Peer educators further refer users to the materials included in the HIVST kit: the manufacturer’s instructions and a complementary explanatory brochure, produced by the project. Peer educators have access to videos in French and various national languages that contain the same information, which they can share with other persons as needed. A free hotline number is provided to support HIVST users and/or for referral in case of reactive tests. Users also have the option of being assisted in-person by peer educators in performing HIVST; alternatively, they can do so on their own at a time and place of their choice. There is no obligation to share the results with the peer educators who facilitate HIVST. In this article, users at this first level are referred as “secondary users”. In turn, these users may provide kits to others, referred to as “tertiary users”. Secondary or tertiary users may not be members of key populations. More than 30% of the kits were distributed by primary contacts to their peers, partners, and clients.Peer educators provide kits to primary users that can be shared with members of their social network , after assessing their needs and providing brief training concerning how to distribute HIVST. It was recommended that a maximum of 1 to 5 kits be distributed per primary user. The exact number of kits was determined by the peer educators who identified with the primary users the people eligible for HIVST in his/her social network. In this article, people to whom primary users provide HIVST kits are referred to as “Further details on the ATLAS project can be found in the research protocol . Furthersecondary recipients” as well as the ability of those recipients to perform self-testing and to seek confirmation and care services in case of a reactive result.This article is based on data taken from two qualitative studies and focuses on secondary HIVST distribution among MSM, FSW, PWUD, and their respective social networks . The studies conducted consisted of (i) individual face-to-face interviews to analyse the use and secondary distribution of HIVST by MSM, FSW, and PWUD who received the kits from peer educators and (ii) phone interviews to analyse the practices involved in HIVST kits distribution from the perspective of “The face-to-face interviews with primary users were conducted between January-April of 2021. The phone interviews with secondary or tertiary users were conducted between June–August of that same year. The interviews lasted between 40 min (phone interviews) to one hour (face-to-face interviews). Before the beginning of the interviews, basic data concerning the sociodemographic profile of participants were collected. The interviews were conducted in French and/or in national languages  according to the preferences of the participants. All participants in Côte d’Ivoire preferred to be interviewed in French. The same researchers conducted the face-to-face and phone interviews . Interviewers had a minimum of a master’s degree in social sciences or public health and they were originally from the same country and racial group as interviewees; they were experienced in data collection with vulnerable key populations and were familiar with the groups and organizations or clinics where the interviews were conducted. The study design is presented in Fig. Interviews were conducted in urban and semiurban settings in which HIVST were distributed using both fixed and outreach strategies: Abidjan and San Pedro in Côte d’Ivoire, Bamako and Kati in Mali, and Dakar and Mbour in Senegal. Peer educators invited MSM, FSW, and PWUD to whom they had provided HIVST kits to take part in the study, regardless of the period of the kits’ receipt, the distribution to their network or the test’s result. A semistructured interview guide was used during the interviews, which addressed five topics: i) the motivations and circumstances for HIVST use, ii) first experiences with HIVST, iii) social experiences of HIVST use , iv) confirmation and management pathways, and v) participants’ suggestions.Phone interviews were conducted with two types of users. Those who i) had received their HIVST kits from MSM or FSW who were not peer educators and those who ii) declared that their HIVST result was reactive. Participants were recruited from a related quantitative study (phone survey) conducted between March-June 2021. For this phone survey, a flyer was distributed with the HIVST kits that invited individuals to call an anonymous toll-free number to participate in a short survey. A unique participation number on each flyer identified the original distribution channel of the HIVST kits . From this phone surveys, participants were further recruited for this qualitative study. They were selected based on the following criteria: i) having completed the quantitative survey; ii) having consented during the quantitative survey to be contacted again for a complementary qualitative component; iii) having provided a telephone number to be called back; and iv) having been recruited via the FSW or MSM channels and/or having declared that their HIVST result was reactive. The dates and times of the interviews were determined in advance in collaboration with participants. The phone interview guide focused on 5 topics: i) the modalities of access to HIVST via secondary distribution, ii) first experiences of HIVST, iii) participants’ opinions of HIVST, iv) experiences of tertiary HIVST distribution, and V) the healthcare trajectories of people who declared a reactive test result.The interviews were audio-recorded with the consent of the participants. During transcription, the interviews were translated to French when necessary by one of the researchers from each country. The study’s field coordinator (the first author) proofread the transcripts. The content of the edited versions was pseudonymized by removing the names of people and places mentioned by the participants. From the interview guide topics and the content of the interviews, codes and subcodes were first identified by the field coordinator. A coding base was created using Dedoose® software. A pretest was conducted by two researchers (KZO and CSC) and an independent consultant (Barro Saran). They first coded the same interviews separately, compared results, and discussed the similarities and differences to reach a consensus. The coding tree was corrected before the data was coded by the same researchers. The coding report was then exported into Word by code/subcode, and by key population profile. Data memos were written first for each code in turn, and a thematic analysis was performed. The themes were deductively informed from the interview guide, while additional themes were identified from interview content. Emerging themes were compared between FSW, MSM and PWUD.For this article, we analysed the themes that emerged from data i) the social experience of HIVST distribution among primary users who were interviewed face-to-face and ii) the modalities of access to self-testing, the experiences of first-time HIVST users, and the tertiary HIVST distribution experiences of secondary users who were interviewed by phone. The care itineraries were analysed for primary and secondary users who declared a reactive test.The research protocol and the various tools used were approved by the ethics committees of the study countries and the WHO: the WHO Ethical Research Committee ; the National Ethics Committee for Life Sciences and Health of Côte d’Ivoire ; the Ethics Committee of the Faculty of Medicine and Pharmacy of the University of Bamako, Mali ; and the National Ethics Committee for Health Research of Senegal . Before each interview, an information sheet was read to participants and translated into a national language when necessary. All participants in the face-to-face interviews signed a consent form regarding their participation in the study and the recording of the interviews, while participants in the telephone study provided verbal consent. The completed forms and audio recordings of the interviews will be destroyed at the end of the project. The face-to-face interviews were conducted in private spaces located within NGO structures. No names were recorded, as each participant was assigned a participation number. The phone interviews were conducted at a time chosen by the participant, which we assume corresponded to a time when they could be surrounded by the secure conditions required for participation in the study. When participants were contacted again regarding the qualitative component, verbal consent was once again collected. For reasons of confidentiality, information concerning the geographic location of participants was not collected during the interviews.The two studies involved a total of 89 people: 65 participants (73%) in the face-to-face interviews and 24 participants (27%) in the phone interviews.Individual face-to-face interviews were conducted with 21 MSM (32%), 24 FSW (37%), and 20 PWUD (31%). The sociodemographic characteristics of the participants are presented in Table Of the 24 participants in the phone study, 16 received HIVST kits through the MSM-based channel and 8 through the FSW-based (Table The majority of participants in the face-to-face interviews (primary users) reported having distributed at least one HIVST kit to a third party (45/56). Secondary distribution was often to partners (40/45) and peers (20/45). FSW reported distribution to their clients (6/24). Secondary distribution was also provided to others, such as friends, peers, and coworkers, who may not be part of the key population communities. Unlike MSM and PWUD, FSW also distributed HIVST kits to family members Table .Table 3PBecause he said [to give it to] my partners and their partners, because as it is, in the community, I may know someone who also knows someone, and so the distribution is done. So, I take it and I give it to my partners who will give it to their partners, and so on. Male, 28 years old, phone interview, MSM-based channel, Mali.Distribution continues beyond the secondary users to whom HIVST kits were initially given according to a strategy adopted by some participants.One-third of secondary users reported tertiary distribution experiences (8/24), reflecting the penetration of HIVST among certain networks of key populations.Five main interrelated motivations for secondary HIVST distribution emerged from the interviews. Motivations for secondary HIVST distribution by members of key populations appeared to vary according to their profile and that of the secondary user.You can’t do these things [have multiple sexual partners] and be in a relationship with someone without offering it to them [HIVST]. Female, 45 years old, face-to-face interview, FSW, Senegal.First, with respect to participants’ main partners, the motivations reflect a certain degree of altruism, namely, through a feeling of moral obligation to protect partners by ensuring that they know their HIV status and are able to access care. This desire seemed to motivate FSW and PWUD in particular.I don’t know his status. I don’t want him to give me the virus, so I asked him to get tested before we had sex. Male, 24 years old, face-to-face interview, MSM, Côte d’Ivoire.Second, this apparent altruism appears motivated by a desire to protect themselves because condoms are rarely used with these main partners or with partners with whom participants have sex regularly. With these partners, reasons related to the need to know one’s status as a precondition of unprotected sex were also reported by MSM.In the maquis , everyone uses condoms there. But if I go to the other client’s house, because he’s in an apartment, he doesn’t use a condom… Every time he needs me, he does the test; and if he needs an HIVST kit too [for other users], he calls me to tell me. Female, 27 years old, face-to-face interview, FSW, Mali.Third, secondary distribution to FSW’s casual clients seems to be more closely targeted at those who refuse condoms before sex than at clients who practise safe sex. Such distribution is also targeted at regular partners with whom FSW have unprotected sex, as reported by an FSW in Mali.Yeah, it’s three people, they don’t like to hear about that at all [using a condom]; it’s easy to say, “Hey, I did my HIV test last week”, or “I did it the day before yesterday”. So, every time they say that, and finally they get mad at me, because I say, “If you did it, show me the result”. Male, 21 years old, face-to-face interview, MSM, MaliThe fourth reason is simple. HIVST could serve as a means of verifying the alleged negative HIV status of a partner or client.Many were afraid of the needle, and I preferred to give this to someone so that they too would know if they were sick or not, so that I too would take precautions, so that I would not be infected with this disease too [during the use of shared injection materials]. That’s it, since we’re always together. So, I wanted to take precautions too. Male, 44 years old, face-to-face interview, PWUD, Côte d’Ivoire.Finally, secondary distribution to peers seems “natural” because primary users are convinced that all of them are exposed to the same degree of risk. Among peers, distribution is mostly to those who are reluctant to be tested or who are assumed to be at greater risk.Between the delivery of HIVST to primary users by peer educators to its use by secondary users, some attrition occurs. However, every key population member who has used HIVST contributed to its promotion to some degree. In situations in which members of key populations perceive that they might face difficulties when offering the kits to partners or peers, they generally opted to take another approach, namely, to raise awareness among those around them and to refer anyone wishing to use HIVST to distribution sites or to peer educators. This strategy is also used when members of key populations did not have kits to distribute. In summary, challenges can arise at two levels: the peer educator level and the primary user level.To ensure secondary distribution, kits must be available. Of the 65 primary users in the face-to-face interviews, seven said they did not have kits for secondary distribution: two MSM and five PWUD. Two primary users (1 MSM and 1 PWUD) reported refusing to take the kits for secondary distribution in anticipation of possible negative reactions from secondary users.One thing that is absolutely sure: she gave [the HIVST] to me and she [the peer educator] said go and do it. She did not tell me to share. Female, 29 years old, face-to-face interview, FSW, Côte d’Ivoire.Among the 56 other members of key populations who received kits to distribute within their social network, 11 did not complete the distribution. Lack of communication between peer educators and primary users limited secondary distribution by some users, who said they did not understand that the additional kits were intended for members of their social network and therefore kept them for their own use.Finally, situations have occurred in which the number of HIVST kits allocated to the primary user for secondary distribution was inadequate, and in these cases, distribution to the main partner was privileged.Secondary distribution and the related challenges appear to differ across key populations as well as according to the relationship between the primary user and the potential secondary users.When I saw my result [nonreactive], I took the second one [HIVST] there. I called my friend, who is a little bit frivolous too—he doesn’t stay quiet like me—I told him that he only has to do his test because he doesn’t like to use a condom. I know he does his own stupid things; I do my own stupid things, so I prefer to be protected. Female, 32 years old, face-to-face interview, FSW, Côte d’Ivoire.Among FSW, perceptions of partners’ sexual behaviours appeared to influence the prioritization of partners to whom HIVST kits are offered. FSW are more likely to offer the kits to partners with whom they do not use condoms and partners whom they assumed engaged in relationships with other women.Because I don’t know how she’s going to take it, I don’t know how she’s going to take it, so I never offered it to her. Male, 35 years old, face-to-face interview, PWUD, Côte d’Ivoire.Among PWUD, the main reason that some participants did not distribute HIVST kits to their partners was because they were afraid of those partners’ reactions.Misinformation seemed to contribute to this fear. Indeed, according to one of the PWUD users who did not distribute an HIVST kit to his partner, only people who engage in risky behaviours should be tested for HIV, which would not be the case for his wife.These are our partners who do not identify as MSM, so we are wary of giving the kits to these people because they might expose the secret [identity as an MSM] to the grins . Male, 28 years old, face-to-face interview, MSM, MaliAmong MSM, the anticipation of a possible negative reaction from the partner seemed to be a difficulty experienced by some. Two MSM who did not distribute kits to their partners motivated that decision based on their partners’ older age or because they did not identify as MSM.Two MSM noted that they were concerned about the voluntary and confidential nature of HIVST. They opted to make a passive offer by talking to partners, displaying the kits, and waiting for them to express a desire to use them before offering them.MSM, FSW, and PWUD reported experiences with secondary distribution to peers Table , with thIn fact, I protect myself, and when the person protects himself, he is not at risk, unless the client breaks the condom. Female, 32 years old, face-to-face interview, FSW, Senegal.FSW were less likely to offer the kits to clients with whom they did not experience fear of HIV infection given their consistent condom use. This rationale was expressed by a FSW, who said she never offered HIVST to her clients.But the client, to explain it to him, it will take an hour of time, and during that time I lose other clients; he too may have other activities to do. Female, 32 years old, face-to-face interview, FSW, Senegal.Condomless sex usually entails that clients pay a premium and FSW were more likely to offer HIVST kits to clients who request condomless sex. If clients have a reactive result, FSW can refuse to have sex without a condom. However, there are some barriers to distribution. For one FSW, the time that she has to spend with the client is too short to talk to him about HIV and testing; she also fears losing other clients if she spends sufficient time with each one to engage in HIVST distribution.Well, I didn’t tell her directly that it’s for AIDS testing, but I told her it’s a test for malaria and stuff, and she took it. So, when she got one line, I told her that she doesn’t have malaria, so that’s how I did it with her. Male, 28 years old, face-to-face interview, MSM, Mali.Finally, secondary distribution appears to be difficult for individuals with reactive tests because of the issues of disclosing their HIV status. One FSW who determined her status through HIVST use reported sharing her result with her partner but failing to ensure that he was tested. One MSM with a reactive HIVST provided a kit to his partner but did not inform her of the nature of the test.Well, at first she doubted a little bit. She said, “But how can we be sure that her status can be known with this?”... I told her you’ll see. When you do, you will come and congratulate me. And then it was really the case. When she came, she thanked me. Male, 44 years old, face-to-face interview, PWUD, Côte d’Ivoire.According to the experiences of primary users, the people to whom they offered the HIVST kits frequently accepted them. Some primary users reported that when they offered an HIVST to secondary users who were not familiar with or never head of HIVST, these secondary users were often, at start, surprised and curious, or reluctant and hesitant. But after explanation, they usually expressed enthusiasm for this new tool.There was one person who was sick, and it was not easy for him to get there. He was a bit old, and he said it had been a long time since he had been tested. So, I said “Wait, I have the HIVST for you”. I explained it to him, I played the video, I explained it to him, and he did it, so when he did it, he told me the result because he is a long-time friend. Male, 35 years old, face-to-face interview, MSM, Mali.This enthusiasm is justified as HIVST meets the needs of people who want to know their HIV status but are reluctant go to HIV testing facilities.The “branchés” [a term used in Côte d’Ivoire to refer to MSM]… they didn’t like the injection either. They didn’t like it at all. That’s why they had already stopped doing their tests for a while, even completely. Even if you come and say that you are going to prick them, they tell you “never”. So, when they saw the HIVST, they were really happy. They were really happy to do that. Male, 21 years old, face-to-face interview, MSM, Côte d’Ivoire.Additionally, individuals with a fear of needles, especially in the MSM and PWUD communities, have found an alternative with the oral HIVST.He knows very well that I wanted him to do it. So, he asked me if this is what I really want, and I said yes, so he did it. Male, 30 years old, face-to-face interview, MSM, Mali.Trusting or influential relationships between partners are factors affecting the acceptance of HIVST through secondary distribution.However, some refusals of HIVST kits were reported . Fear of the testing result seemed to be the main reason for refusal.I told my husband about the HIVST. He asked me what the advantage of it is, and I told him that it is advantageous because when you do it and you see your result yourself, that is one of the advantages, but he never asked me to give him a kit. Female, 20 years old, face-to-face interview, FSW, Mali.When peers and partners refused to use the HIVST, it took the form of passive indifference.They don’t want you [the FSW] to know their results. Maybe they are people who are already infected and they don’t want us to know”. Female, 27 years old, face-to-face interview, FSW, Mali.“With FSW’s clients, refusals could lead to an immediate break-up of the relationship initiated by either clients or FSW, as reported by three FSW. Verbal abuse by clients was reported by three FSW. Only one instance of physical abuse perpetrated by a client who had a reactive test was reported by a FSW.My girlfriend told me that she prefers the evening, and that, when I come by, we’ll do it together. So, when I arrived, we did it together. She did not trust my test result, so I also did it again. I took the HIVST out, and we both did it. Male, 39 years old, face-to-face interview, PWUD, Côte d’Ivoire.In the aim of avoiding secondary users' negative reactions to offers of HIVST kits, some primary users developed strategies beforehand. The first strategy was to do an HIVST themself (and therefore knowing their own HIV status), before offering HIVST kits to others, so they could explain how to use it to others. Additionally, this allows them to know their current HIV status, and they could be tested again either “as a couple” or alongside the recipient without having doubts about their result, especially in the context of reluctant or hesitant partners or clients.They [clients] would tell me that they are not sick, so I would tell them that nobody is sick. You just get tested to find out your status... But sometimes clients would get into conversations about AIDS with me, and I’d take the opportunity to tell them about the HIVST, until I could convince them to take it and do it at home. Female, 35 years old, face-to-face interview, FSW, Senegal.Raising HIV/AIDS awareness, prior to initiating discussion of HIVST, is also a relatively common step among all three key populations.When I gave him the HIVST, he said that I don’t trust him...I joked with him, “Baby, that’s not it. You know, the life we lead here, really, it’s not that I don’t trust you, but you have to do it to see. That way, you are free, you at least know your status, you at least know that you are really healthy because first you have to know yourself, whether you are healthy or not. I spoke to him gently with soft, soft words. Female, 24 years old, face-to-face interview, FSW, Côte d’IvoireFinally, some key populations-specific techniques have been developed. For example, FSW often reported using certain methods to cajole their partners and clients.So, I told him, “If you don’t do [the HIVST test], we don’t have sex. Well, I convinced him, but he didn’t want to, so I came back home. That’s how he called me to tell me to come, that he was going to do [the test]. So, when he did the test, it came out negative. Male, 24 years old, face-to-face, MSM, Côte d’Ivoire.With their clients, some FSW reported requiring HIVST as a condition for sex without condoms. Conditioning condomless sex on the partner performing the HIVST was also reported by some MSM, although not by PWUD.In situations in which communications about HIV with partners was difficult, passive distribution remained the preferred option for MSM.Data from the phone interviews enabled us to examine HIVST practices by secondary users who had received HIVST kits through the MSM or FSW distribution channels.You don’t know what the result will be; it can make you hesitate... when he came back, he encouraged me and we did it... you know what this test is! No one, not even doctors, does this test without being afraid in advance. Male, 43 years old, phone interview, MSM-based channel, Mali.The majority of secondary users performed the HIVST within two days of receiving the kit, with some conducting it immediately upon receipt. Some of those waiting beyond that time period justified that delay by the innovative nature of the tool, which they did not fully trust. However, the most common reason for delaying the test was fear of the results, as noted by the following participant, who used his HIVST kit five days after receiving it.The longest delay observed was one month, as reported by a man who had received the HIVST kit from a colleague.Approximately half of secondary users performed their test alone, without physical assistance (42%). Other secondary users required in-person assistance, which they usually sought from the primary user. Assistance could be requested for the purposes of psychological support or technical assistance.My concern was the interpretation of the lines. Then, he came to my house; he’s my cousin, we share the same life [they are both part of the MSM community] so we don’t hide anything from each other. I trust him completely. Male, 30 years old, phone interview, MSM-based channel, Senegal.From a technical point of view, requests for assistance were aimed at understanding the process of performing the test, assisting with the sample collection and/or interpreting the results. A few times, this assistance could either be total, with the primary user acting as a provider of HIV testing and conducting the whole process from beginning to the end, even announcing the result, or partial, as a means of meeting a specific need on the part of the secondary user. The latter was the case for the following participant, who required support from his partner with respect to interpretation of his HIVST test results.Question: And after you took the test, did you need to talk to anyone or get any specific information?Answer: Well, when I finished taking the test, I needed an explanation of one part.Question: What did you need to talk about?Answer: It was part of the result display that I didn’t understand.Male, 25 years old, phone interview, MSM-based channel, Mali, reactive test result. The majority of secondary users who performed HIVST reported no particular difficulties (75%). The challenges mentioned by the other six participants were related to the process of collecting the buccal swab sample (2 participants) or interpreting the results (4 participants).I saw my result, I filed on the table, as I did not control that too much; I was not too happy I looked. I couldn’t laugh [rejoice], I couldn’t say a word; here I am. I thought, I’m going to call my guy [his friend who gave him the HIVST kits] so he can tell me if it’s good or not [reactive or not reactive]. As Mrs. [his wife] dropped off her kit next to me, when we saw the same things, she said here it is... here is the same line that is there. I said ok, let’s not rush, my guy will come and explain this. Male, 45 years old, phone interview, FSW-based channel, Côte d’Ivoire.With respect to the psychological aspect, the purpose of receiving assistance was to be provided with a reassuring presence. Indeed, few people sought support from the primary user simply because they needed encouragement to perform HIVST or because they had doubts regarding their ability to perform and interpret the results correctly. This was the case for one couple who received non-reactive results and the husband related the following during the telephone interview:Question: How easy or difficult do you think it is to do HIVST on your own?Answer: It’s easy.Question: What makes it easy?Answer: When it’s explained to you properly, it’s easy.Question: But why didn’t you do it by yourself after he explained it to you?Answer: Because I was afraid.Female, 25 years old, phone interview, FSW channel, Mali.Occasionally, fear of the test results motivated secondary users to request the primary user’s physical presence when performing HIVST. Such was the case for the following woman, who received her HIVST kit from her partner who had already used it.Support tools such as the video, the free hotline and the written materials (the information leaflet and supplementary brochure) were very useful for secondary users. Indeed, whether participants used HIVST alone or with the assistance of others, the majority referenced the support materials. Written materials were used more often than the hotlines and the video. According to participants, these written materials were those most often adopted by primary users during distribution. The video was rarely used. For two participants, the primary user’s explanations were sufficiently clear, and they did not need to use any tools. Two internet searches were conducted on the internet by two MSM-channel users to complement these explanations.Since I had the phone number of the one who gave me the test, I told him that after doing the test, the two lines are red. He told me that means I have an infection, to go [to the health facilities] and take some medicine... I went, and they gave me some tablets. Male, 24 years old, phone interview, MSM-based channel, Mali.Regardless of the result, users generally communicated it to the person who gave them the HIVST kit, whether or not they requested such communication. The majority of users expressed a feeling of accountability to the person who gave them HIVST kits, whether that individual was a peer educator or a primary user. This communication has the advantage of facilitating access to confirmation services in case of a reactive result.However, two secondary users who received a reactive result reported that they did not share their result with the primary user to maintain the confidentiality of their HIV status. One of these users used the hotline for referral, and the other went to a key population-friendly clinic.Not more than three days [time taken before confirmation] because I couldn’t be quiet. I remembered it every moment. Male, 28 years old, phone interview, MSM-based channel, Mali.Most frequently, the need to be informed of their “true” HIV status and to end their anxiety led members of key populations who had a reactive test result to seek confirmation within a short time period, either the same day or within three days of using the HIVST.No. I haven’t left yet anyway. But there are others who went to get a needle and got the same result [confirmation of HIV positive], so I said to myself that the [HIVST] test doesn’t lie, everything they put on it is true... they went to get a needle and they came back with the same result. I don’t like to be pricked, so I can’t go. Male, 36 years old, phone interview, MSM-based channel, Côte d’Ivoire.One person who received a test through the MSM-based channel reported waiting a month to confirm his results. Almost all participants who had a reactive test result had their result confirmed (7/8). Only one person reported not confirming his result because of his fear of having a blood sample drawn. He preferred to consider himself to be HIV-positive, irrespective of the confirmatory result.This reasoning contrasted to that of one MSM who was interviewed face-to-face. He had never been tested for HIV due to a fear of needles. However, he was able to overcome his fear and use the confirmatory facilities when his HIVST result was reactive, and he received care.All the individuals who confirmed their HIVST result had access to antiretroviral treatment.This study documented the motivations, experiences, and challenges of MSM, FSW and PWUD who were provided HIVST kits for secondary distribution as well as the experiences of secondary users. We found that secondary distribution through key population can increase access to HIV testing for their partners, peers, and other relatives. Their motivation is to protect both others and themselves from HIV. Refusals to use HIVST was rare/not common and various reasons were provided for it. Secondary users often maintain contact with primary users and are able to complete HIVST with their help and/or the help of written materials, the video, or the hotline. Those with reactive results use confirmation and care services, with or without the help of those who provided them with the HIVST kit. The negative consequences of HIVST use are minimal.Effective HIV secondary distribution to partners, peers, and other relatives was achieved by the majority of primary users. This result confirms the feasibility of secondary distribution by MSM, FSW, and PWUD . The lowSecondary distribution is not always easy to perform and requires some degree of effort from primary users. They occasionally used clever strategies to convince others to use HIVST. In the case of regular partners, the classic couple testing strategy of first finding out one’s own status and then retesting together is often used by primary users who receive nonreactive results to overcome various kinds of resistance, or when such resistance is suspected . This teTesting for HIV before sex to prove negative status, particularly when negotiating condom use, is potentially a risk compensation strategy. This practice is not completely safe, but in a context where negotiating a protected relationship is difficult it was the best one that some participants found to protect themselves. Even if some uses of HIVST are not "officially" recommended, people can adopt their own practices and do their own benefit/risk analysis. It is interesting to note that those who feel unable or unwilling to distribute HIVST kits contribute to the promotion of HIVST by raising awareness and providing referrals to HIVST supplies, thereby facilitating access to HIV testing. Fear of secondary users’ reactions was a common barrier faced by all three key populations but appeared to be more pronounced among PWUD concerning their life partners. Barriers to secondary distribution were most notable among PWUD and FSW, as no MSM mentioned a total refusal by a secondary user. Do MSM have other ways of selecting the members of their networks to whom they offer HIVST or more appropriate strategies for such proposals? Further studies are needed to explore this issue. As observed in other studies, responses to HIVST offers were generally positive . Most stCertain opportunities for HIVST distribution were missed. Some members of key populations did not have sufficient HIVST kits to ensure full secondary distribution to all members of their sexual networks; this scarcity was especially salient among FSW who have both partners and clients. In such situations, FSW prioritize their own sexual networks. While the emotions and the types of relationship with the secondary user  influence distribution decisions, the systematic use of condoms with the person in question is another. FSW prioritize the distribution of HIVST to people with whom condom use is inconsistent or absent. With FSW’s clients, the choice of “HIVST or condom” is pervasive and needs to be explored further. Indeed, the practice of testing clients who refuse condoms or are willing to pay a premium to engage in condomless sex appears to be adopted by some FSW. This practice has also been described elsewhere as a strategy to increase fees for sexual services . The samHIVST utilization by secondary users is effective. The results show that some of the initial concerns raised by stakeholders in these three countries at the beginning of the project were unfounded . Data taReactive HIVST results are also confirmed. According to almost all interviewees with a reactive self-test, they have linked to confirmatory HIV testing (7/8), which often took place within a relatively brief period of time. Studies of secondary distribution among MSM have shown that they used care services , 23. ThiOur results should be interpreted in light of the study’s limitations. First, the analyses were based on participants’ self-reports. Given the sensitivity of the topic , the nature of the respondents (populations who are at risk of HIV), and especially their double stigma of HIV and membership in a key population, some participants’ response could have been affected by social desirability bias. Few secondary users were interviewed, especially those from FSW channel and their statements in the telephone study may also have been influenced. Indeed, establishing a relationship of trust with a “stranger” over a short period of time is challenging. In the absence of such bond, it may have been difficult for participants to express themselves without reservations. Nevertheless, the preservation of anonymity may have encouraged disclosure. Additionally, not all participants received HIVST kits for secondary distribution or personal use at the same time, and the information collected is likely to change. For example, over time, some participants were able to overcome barriers to secondary HIVST distribution. Only three female PWUD were interviewed as primary users, and a gendered approach was not used for data analysis. Nonetheless, these analyses, which are among the first pertaining to secondary distribution of HIVST in West Africa, demonstrate its feasibility and acceptance by members of key populations in these countries. The results are specific to those key populations and their particular community-based setting. They could be different from health facilities where people are seeking care; health providers have less time to support them and incentivize their relatives to use HIVST.Strengths of this study include use of standardized methodology across key populations and countries, as well as the consistency of our finding across settings, where there was little difference between participants’ point of view. Second, in settings of high HIV burden where key populations face considerable stigma, HIVST users including PLHIV accepted to share their experiences with a research team. Finally, it is notoriously difficult to survey secondary users. Through the broad range of research undertaken by the ATLAS project, including the current study, we were able to reach secondary users through the telephone contacts they left during the quantitative study.HIVST kits redistribution is common in MSM, FSW and PWUD communities. Secondary distribution is more likely to occur among sexual partners with whom condoms are not used and to peers of individuals belonging to key population. When such kits are not available, key populations are promoting HIVST and referring potential users to people or places where they can receive kits. The reactions of secondary users to HIVST proposals are generally positive, with very few adverse reactions . People who receive HIVST via secondary distribution do the test relatively quickly after having it (2 days). In-person assistance is sometimes requested, for psychological support reason. These results support the deployment of HIVST to key populations, their partners and other relatives. In Central and West Africa countries with the same context, HIVST should be more widely and systematically accessible by FSWs, MSM and PWUD.


Although caesarean section (CS) rates have increased rapidly in Thailand, the upward trend is not supported by significant maternal or perinatal health benefits. The appropriate use of CS through QUALIty DECision-making by women and providers (QUALI-DEC project) aims to design and implement a strategy to optimize the use of CS through non-clinical interventions. This study aimed to explore the factors influencing women’s and health professionals’ preferences for CS delivery in Thailand.We conducted a formative qualitative study by using semi-structured in-depth interviews with pregnant and postpartum women, and healthcare staff. Purposive sampling was used to recruit participants from eight hospitals across four regions of Thailand. Content analysis was used to develop the main themes.There were 78 participants, including 27 pregnant and 25 postpartum women, 8 administrators, 13 obstetricians, and 5 interns. We identified three main themes and seven sub-themes of women and healthcare providers’ perceptions on CS: (1) avoiding the negative experiences from vaginal birth ; (2) CS is a safer mode of birth ; and (3) CS facilitates time management .Women mentioned negative experiences and beliefs about vaginal delivery, labor pain, and uncertain delivery outcomes as important factors influencing CS preferences. On the other hand, CS is safer for babies and facilitates multiple tasks in women’s lives. From health professionals’ perspectives, CS is the easier and safer method for patients and them. Interventions to reduce unnecessary CS, including QUALI-DEC, should be designed and implemented, taking into consideration the perceptions of both women and healthcare providers.The online version contains supplementary material available at 10.1186/s12884-023-05576-8. Caesarean section (CS) can be life-saving obstetrical surgical procedure in high-risk pregnancies . HoweverCS is associated with an increased risk of adverse outcomes in women and babies , 11. PreBoth medical and non-medical factors affect women’s mode of birth. Non-medical factors include both the woman and her family’s beliefs and preferences, as well as the woman’s care environment and healthcare providers during pregnancy . GloballThe views of healthcare providers, particularly obstetricians, significantly impact women’s mode of birth . While sThe QUALI-DEC project aims to design and implement a multifaceted strategy that is locally relevant, culturally accepted by women and providers, and can be implemented effectively to reduce unnecessary CS. In the first phase of the project, a formative study using a descriptive qualitative approach was conducted to elicit factors influencing preferences for CS in both women and health professionals , 25. SemThe study was conducted in eight health facilities with CS rates ranging from 34.3 to 56.9% where the QUALI-DEC interventions will be implemented. The eight participating facilities were selected purposely according to the programmatic activities and priorities of the country and geographical representation of regions and facilities in Thailand with three hospitals in central Thailand, three in northeastern Thailand, one in northern Thailand, and one in eastern Thailand. All hospitals are public, with one secondary and seven tertiary hospitals.We identified three groups of participants: (1) pregnant women; (2) postpartum women; and (3) healthcare providers. The stratified sampling in this study recruited from eight hospitals consisted of 27 pregnant women, 25 postpartum women, 18 obstetric doctors, and 8 administrative doctors. The sample size was aligned with data saturation to ensure adequate data for drawing phenomenon conclusions , I think CS seems like a better way because it doesn’t make you suffer, right?” A negative experience of pain from vaginal birth led the women to think about the advantages of a CS for future births:Among these women, CS was viewed as a way to circumvent the pain of labor and vaginal birth. While they understood that post-CS healing could also be painful, CS could help them avoid pain during a longer labor.“Unfortunately, my sister-in-law had some problems during childbirth and finally changed to a CS. I’m afraid I’ll have a similar problem if I choose to give birth vaginally. I will be in pain for 3–4 hours and again from the CS. Thus, I would definitely like to get a CS for sure. Women and doctors agreed that vaginal delivery was perceived as an uncertain and unpredictable method for childbirth in terms of labor duration, process, and outcome. While CS could provide a certain process of childbirth. Seventeen women agreed that CS helped them avoid uncertainty during delivery regarding the progress of labor, severity of pain, and “double suffering” from emergency CS. For example, one pregnant woman was afraid of getting double pain from both a failed vaginal birth and an emergency CS. The uncertain outcomes of vaginal birth may affect maternal perception of the mode of birth.“…I’m still afraid of labor pain. For my last child 5 years ago, I felt pain from 6 pm until 10 pm. That was a long-suffering time…if you have a CS, you will know the exact time and the duration will be reduced.” In addition, the women compared the unpredictable nature of labor duration to the shorter period of CS management.“Without a doubt, I would prefer a CS. Attending during the labor period is difficult because we can’t predict the exact time and may encounter fetal distress.” Similarly, doctors disclosed that CS decisions in cases where there is an ambiguous indication for CS, such as cephalopelvic disproportion and a large infant, to avoid negative outcomes, vaginal delivery does not guarantee good fetal outcomes.Both women and doctors agreed that CS was a safer mode of birth. In the case of pregnant and postpartum women, they expressed that CS is safer for their babies, while doctors agreed that it could guarantee the babies’ safety. Furthermore, the safe method for babies may shield doctors from patient dissatisfaction. Two subthemes were presented, as follows:“Right now, the health of my child is the most important aspect of my pregnancy. I didn’t give any consideration to myself because I believe I can handle it. But not my child, and I just want him to be safe.” Twelve women believed that the outcome of a CS is more certain about the child’s safety than vaginal birth. Infant safety was the most important aspect of CS preference revealed by beliefs and modern-era perspectives. CS was perceived as a quick method performed by highly-skilled physicians. Even though the women were aware of some risks of CS such as incision pain and the lengthy recovery period, they still felt that CS has fewer risks than vaginal delivery, which includes baby distress and trauma. For example, a pregnant woman said that her baby’s health was the most important consideration, emphasizing how delicate her baby was, as she said:“CS is sure for the baby’s health. I saw some women on social media who were depressed because of fetal distress caused by vaginal birth… for CS, I am sure the doctor’s skills can help my baby safely.” Furthermore, the doctor’s competence in performing CS was an important factor related to women’s trust.“…my friend attended to a shoulder dystocia case and, unfortunately, the baby died. He quit his job to work only on medical record, not clinical practices anymore.” Many doctors were also concerned about the risks of vaginal birth during the intrapartum period, particularly the risk of infant complications, which could lead to blame, lawsuits, and stigma. The CS would be a safer method of childbirth than vaginal birth, requiring fewer skills and greater precision. Three administrators, five doctors, and one intern believed that vaginal birth was difficult to manage due to the unpredictable length of time it takes for the baby to be born. In addition, there may be complications in the birthing process, such as labor obstruction, severe perineal laceration, hemorrhage, the baby’s head trauma, or any danger from birth. A doctor talks about his friend facing a negative consequence of vaginal birth, and reflected the opposite side of the risk of vaginal birth.“There will be problems such as some cases...there is a chance of causing hematoma or tearing down to the anal sphincter as well. There might be some things beyond our control. If we make a mistake in the assessment, that is the disadvantage.” A vaginal birth safely includes the need for precise skills in labor progress assessment, timely assessment of complications, and effective management.Therefore, some healthcare providers perceived CS as a safer mode of birth compared to vaginal birth. In some cases CS may reduce the incidence of injury to the baby. Finally, women could avoid labor pain, resulting in more satisfaction than vaginal birth.“If fetal distress is detected only partially, we may decide to perform a CS right away out of concern for negative outcomes in later shifts, which could lead to legal issues.” The CS protected the physician, implying that CS delivery may be appropriate care for meeting the needs of patients and families, as well as a reasonable procedure in high-risk situations. Similarly, CS can protect the clinician against dissatisfied patients. Along with advancing medical technology, CS is viewed by some doctors as a straightforward and convenient mode of birth. When there are complications with vaginal birth, healthcare providers, particularly obstetricians, were reportedly quick to perform a CS, as they believed it to be safer and easier than instrumental birth using vacuum or forceps. Furthermore, thirteen healthcare staff members believed that CS met the requirements of women and their families while preventing litigation in the event of negative birth outcomes. One doctor mentioned;“We work on women and their families’ expectations, right? If there is a little obstruction to vaginal birth, we rapidly do something for a solution, such as intrapartum CS. For assisted procedures such as vacuum extraction, it is more difficult” Moreover, it is easy to perform CS, while using other modes of instrumental birth such as vacuums or forceps may require expertise and high-level skills. Thus, CS is the best solution to prevent adverse outcomes.CS was perceived as a mode of childbirth that facilitated time management in various key aspects of life for both women and doctors. Pregnant and postpartum women expressed their perceptions and experiences in terms of how CS facilitated planning an exact date and time to balance their maternal role and work, as well as cultural beliefs. For healthcare providers, CS could provide the precise schedules they need and allow them to manage their many duties in the workplace. There were three subthemes, as follows:“In my mind, I prefer CS since I can schedule the good and ready days in advance. It will help me feel less anxious. I have the ability to choose my own day and time.” The auspicious time was a critical point of view linked with cultural beliefs predicting the destiny of an infant. The birth date would represent the best start to the baby’s life and meet the family’s expectations, which could be facilitated by CS delivery. Eleven women who preferred CS believed that it could allow them to schedule the birth for an auspicious time. They could choose the best birth times to predict that the baby’s life will be good in the future. For example,“Now, there are many media on the internet. So, many people view that CS is normal. From my friend’s perspective, most of them choose CS because they could control their baby’s destiny, deciding on an auspicious time for CS.” Furthermore, the influence of social media and the significant other’s experiences may influence women’s preference for CS.“I may not know how to go to the hospital, who will care for me while I’m there, or what vital items I’ll need because I don’t know the exact time for birthing. I also have to handle my son’s daily routine when he goes to school... I can’t tell when labor pain will start.” CS aids family management, demonstrating interpersonal influence on the mother’s mode of delivery decision. Women with CS can plan and manage their schedules with their families, relieving stress and organizing comprehensive postpartum preparation. From a logistical perspective, CS is perceived as a convenient and controllable birth mode for women and their families. In this study, ten women and their families had positive perspectives about CS, believing that CS best met women’s and families’ needs as a solution to reconcile life and maternal demands. For example, a woman spoke about the need to consider practical aspects such as the necessity of time management in preparing materials, caregiver, and maternal responsibilities for child care. Thus, CS makes her plan easier.“I had already planned an auspicious time for my maternal leave and managed my work.” CS has significant professional and social meaning. In their daily lives, women have to manage multiple tasks. The organizational factor influences CS delivery preference, which facilitates work responsibility and the maternal role. Three women described how CS could help them manage their full-time working in urban areas. For example, a woman may be concerned about her work responsibilities as she attempts to manage and balance both her maternal and societal roles.Actually, my boss allowed me to stop working and take maternity leave. But I worry about my work…CS can help me have certainty in my schedule.” “The CS was able to assist women in balancing their lives and social and professional relationships.“CS is better and faster…vaginal birth is more likely to increase the risk if the mother has pushed for a long time. The child who has been stuck for a long time will have more hypoxia because of lack of oxygen and caput succedaneum than CS.” Regarding healthcare providers’ viewpoints, CS can help them manage their clinical and academic work and personal time. Clinical time management allowed to figure out an organization’s influence and work system in hospitals. Busy schedules and many duties in the workplace could affect the quality of life of health professionals. Seven administrators, seven obstetricians, and four interns indicated that CS allowed them more precision to determine the time for birth, manage time for other clinical work, and balance their personal lives. The time management concern is connected to staff shortages, large numbers of patients, multiple jobs, and staff health. For example, a doctor believed that the advantage of CS was that it is better and faster:“You must comprehend the setting of our facility. We receive 500–600 cases per month, despite having only six obstetricians. We put up so much effort! It’s easy to make decisions on unclear indication of CS such as cephalopelvic disproportion. After a job is done, we can take a rest.” Furthermore, the effectiveness of time management was influenced by the organizational system. The barriers were frequently discovered to be a result of a staff shortage. As a result, CS could be handled quickly.This qualitative study deepens our understanding of women’s and healthcare providers perceptions of the benefits of CS compared to vaginal birth in Thailand. These benefits vary between women and healthcare providers, but are typically centered on the convenience of CS to schedule birth, avoid labor pain, and ensure safe childbirth. In addition, these results allow us to better understand some of the most important values in Thai society likely driving increasing rates of CS in this country, particularly in relation to CS on maternal request.Most women in this study shared their concerns about fear of labor pain and uncertainty during vaginal birth, which resulted in preferring CS as a way to avoid both. Women’s negative experiences with these reasons have been represented in stories aired in the mass media and within communities. Storytelling about childbirth experiences from mother-to-mother providing not only information, but also a means for empathy and understanding . SeveralIn previous studies, there were a few discussions about CS and women’s social roles and responsibilities. This study found that the reality of women’s social and professional roles was challenging and complex, particularly for working women. Women’s scheduling a CS allows them to better organize and plan other responsibilities. In Thai culture, most women have to balance many tasks and live in an unequal power relationship between genders. As the head of the family, men are not responsible for the household duties, and women have to manage the household, childcare, and outside work . MoreoveMoreover, several women and healthcare providers in this study perceived positive viewpoints on CS as the childbirth method to give safe birth to babies. According to previous studies, CS is safer for baby and/or mother, which is a key factor influencing the preference for CS , 49. WomFrom obstetricians’ viewpoints, CS is perceived as a positive and necessary management for high-risk cases to ensure the safety of infants during an emergency and prevent patient dissatisfaction. However, the medical indications and clinical practice guidelines for necessary CS should be declared and discussed. According to a study in China, health professionals believed CS to be safe due to its availability and accessibility , 55. In Our results will be used to develop and tailor effective interventions to reduce unnecessary CS by addressing the negative perceptions of vaginal birth among both women and doctors in Thailand. Moreover, we identified limitations in knowledge about benefits and risks of different modes of birth among women. These results support and guide antenatal intervention with a data analysis tool (DAT) providing comprehensive childbirth information and a draft on how to use DAT with counseling skills and preparing pain management for optimal outcomes. For obstetricians, the training system on necessary childbirth skills may increase practical confidence and create a support system to help them balance their work and lifestyles.From both women’s and doctors’ viewpoints, CS is seen as a safer mode of birth for the baby and facilitate time management compared to vaginal birth. In the case of women, CS was primarily perceived as having the potential to help them avoid labor pain and uncertainty during labor. Moreover, CS allows women to manage their time for family management and balance their work, as well as adhere to cultural beliefs. Furthermore, obstetricians’ perspectives of CS were that it was simple to manage clinical time. The intervention to reduce unnecessary CS should be designed and implemented by concerning both women’s and doctors’ perceptions.Below is the link to the electronic supplementary material.Additional file 1