The mother-midwife relationship is a good experience during childbirth, but there is a lack of evidence about the trustful relationship between mothers and healthcare providers during labor and birth in Iran. The current study aimed to discover how a trustful mother-midwife relationship is formed during a vaginal delivery. Findings. The main category of “seeking trust in midwife” and three subcategories of “effective interaction,” “attempt to access to healthcare provider”, and “playing an active role in birth” were extracted from the data.  Twenty-nine women who had a vaginal delivery, midwives, and obstetricians participated in this qualitative research with the grounded theory method. Data were collected using semistructured interviews and observations. Open, axial, and selective coding was used for data analysis.  According to the findings, mothers tried to gain action/interaction strategies and increase healthcare providers' trusts during vaginal delivery. It is essential to consider the factors that improve or disrupt this relationship. Trust is vital in a mother-midwife relationship, without which it is impossible to meet the requests of mothers efficiently and to improve midwifery care –3. A truAs there is regularly a gap between the mothers' prospects and experiences of childbirth, the midwife must provide mothers suitable information on labor development, support her to participate in the childbirth experience actively, and continue the process of delivery for a positive birth experience . MothersDifferent studies mentioned specifically the quality of mother-midwife relationship. Lewis et al. reported that the concept of trust within the mother-midwife relationship was first developed by midwife competency, the kind of communication, the continuity of care, and the mother's ability to make decisions . Boyle eTherefore, while a trustful communication during childbirth is a component of best practice , some miThis qualitative research was done with a grounded theory approach, which looks at qualitative data systematically and aims to generate theory. Categories, codes, and coding are important aspects of the grounded theory approach. The research principle behind the grounded theory method combines both induction and deduction . TherefoThere is no specific rule in qualitative research to estimate the number of participants and sampling continued until data saturation with no new information . In the Before performing the interview, the researcher (FM), the interviewer, and an experienced midwife explained the study objectives. The semistructured in-depth interview was used to collect the data. The interviews began with open-ended questions: “how did you/women experience trust in vaginal delivery? What was the meaning of trust”? Then, the interviewer applied additional questions such as “Would you please tell more about this experience”? All of the interviews were voice recorded using an MP3 recorder (model ICD-PX470) and then were transcribed verbatim. The interviews were recorded and analyzed in the Persian language, and then, the final report was translated into English. Data collection was continued until data saturation. The last four interviews did not add any extra information. Each interview lasted between 45 and 60 minutes. Written narratives were also used, so a notebook was delivered to each of the participants (if they were willing), and they were requested to write their experiences and return the notebook to the researcher. The researcher also wrote field notes and memos throughout and after the interviews, which were used as complementary data.The data analysis was based on the following phases recognized by Strauss and Corbin: (1) open coding, (2) axial coding, (3) selective coding, and (4) development of the theory . ConcurrTrustworthiness, a critical aspect of qualitative research, includes how to judge the similarities and differences among categories. The trustworthiness of the data was tested using Lincoln and Guba's criteria . ReflectThe Ethics Committee of the Kerman University of Medical Science approved this study . Written informed consent was received from all participants before the interviews. The researchers have protected anonymity and confidentiality by assigning numbers to participants and eliminating all possible recognizable data during the transcription of interviews. Similarly, password-protected folders containing anonymized data were available only to the research team. The study purpose was explained, and all participants permitted the author for the audio recording of the interviews. The right to withdraw from the study at any time and ethical commitments were described in all interviews.The age groups of mothers, midwives, and obstetricians were 18–43, 22–53, and 35–52 years, respectively. The work experiences of the midwives and obstetricians also ranged from 1–34 and 1–18 years, respectively .One main category and three subcategories emerged from the data. The main category was “seeking trust in midwife.” The causal, intervening, and contextual conditions shaped this phenomenon. The action/interaction strategies used by mothers resulted in “formation of childbirth experience” as a consequence. From now on, quotes are shown in italics and subjects are identified with Mo, M, and O for mothers, midwives, and obstetricians, respectively.In this study, we achieved a dynamic model for trusting healthcare providers, especially midwives. This model may enable mothers and midwives to form a trusting relationship. “Seeking trust in midwife,” “effective mutual interaction,” “an attempt to access to healthcare providers,” and “playing an active role in birth” are essential components of this model.“I trusted my midwife. When I arrived at the ward, interacted with a midwife, asked her some questions, I did whatever she asked me to make the childbirth easier” .“Trust in doctors and midwives is the cornerstone in vaginal birth and participation in childbirth decision-making is important for women” .“Seeking trust in midwife” was the main category that emerged from the participants' experiences. They behave complexly to achieve this ideal. They manage effective interaction with a healthcare provider, then try to access the healthcare provider, and try to play an active role in birth. The most influential approach expressed by participants was the trust between women and midwives.According to the paradigm model, the category of “the need for taking part in childbirth” was the causal condition for this phenomenon that occurs in the context of labor ward and personality characteristics of mothers and midwives. Participants applied several strategies to organize this phenomenon. This category was supported by three subcategories, including “effective mutual interaction,” “an attempt to access healthcare providers,” and “playing an active role in childbirth.” According to the participants' experiences, these subcategories were the necessary steps in the continuity of trust between mothers and midwives. Eventually, “formation of childbirth experience” was the consequence of the action/interaction strategies.“I should deliver a healthy baby, and then I should help my midwife in the birth process” .“Mothers feel that they should take part in their childbirths” .Participants felt that midwives should help them in their childbirths, so they decided to trust them. Participants also desired to take part in their childbirths “The midwife didn't talk to me and had no relationship with me. She was an introverted person; even she didn't tell me about what I had to do during my childbirth process.” .“Sometimes, the ward is too crowded for us to talk with or to help mothers. Therefore, we can't guide them” .The participants frequently talked about contextual conditions affecting the decisions made. According to participants' experiences, the contextual conditions were “the labor ward atmosphere and personality characteristics of mothers and midwives.” Labor ward atmosphere such as the friendly relationship between mothers and healthcare providers, crowdedness of the ward, the small number of midwives, and their characteristics such as being introverted or extroverted would affect the decisions about birth.Action/interaction strategies are purposeful acts toward a problem to affect the process of trust between mothers and midwives. There were three main subcategories related to action/interaction strategies, including “effective mutual interaction,” “an attempt to access healthcare providers,” and “playing an active role in birth.”I tried to talk to personnel and communicate with them so that they could help me later because no one will help us without communication” .“First, mothers tried to interact with healthcare providers. The communication between midwives and mothers is a key aspect of care. In addition, the use of body language manages the condition through appropriate dialogues between midwives and mothers and makes a meaningful communication.“As a mother respects us, we must respect her, because the first step to help her childbirth is mutual respect and good relationship” .Some participants respected the midwives and obstetricians and needed to be respected by them.“I liked to be under close supervision and control of the healthcare providers. I was worried about problems that might have occurred for my fetus and mine. I tried to seek one who could take care of my fetus and mine” .Mothers tried to access healthcare providers for the childbirth. Participants frequently sought for continual monitoring and tried to keep the healthcare providers close to themselves.“We must pay attention to mothers during childbirth because it shows that we are taking care of them and their fetus. It provides comfort for them, and they feel that somebody is beside them, and they are not alone” .The mothers also tried to attract the healthcare providers, which makes them relaxed and secure.I had an important role in my childbirth. When I arrived at the ward, I interacted with a midwife and asked her some questions; I did whatever she asked me to help my childbirth” . Similarly, “mothers are the cornerstone in normal childbirth and their participation in childbirth is important” .“Finally, the mothers tried to play an active role in childbirth.“It is important for me to help in the childbirth. As a mother, I should contribute to the childbirth, in addition to breeding baby” .It is essential for mothers to play a role in their childbirths. Such a role may empower them in their family lives.“I had a suitable relationship with a midwife, so I trusted her, and consequently, I had a good childbirth. I will select normal vaginal delivery if I become pregnant in future” .Action/interaction strategies taken by the participants resulted in different consequences. The positive experience of childbirth was the prominent consequence of actions/interactions in this study.“A mother's experience of normal vaginal childbirth would depend on our performances and interactions. If we form a positive experience of childbirth in mothers' minds, surely they will select a normal vaginal delivery in future” .According to midwives and obstetricians, their performances can bring mothers a positive or negative experience of childbirth. They believe that mothers would choose a cesarean section in their future pregnancies if they had a negative experience of childbirth.The present study revealed that mothers tried to trust healthcare providers. They applied three strategies of “mutual effective interaction,” “an attempt to access healthcare providers,” and “playing an active role in birth” to achieve this goal. In line with previous studies, our proposed visual model provides a framework for trust within the mother-midwife relationship in childbirth.The mother-midwife relationship is based on mutual trust and assurance. Midwives should prepare the information needed for continuity of care and expand collaboration with mothers. Although such a partnership is essential and principle for mutual working, the role of the parties might not necessarily be equal . Such a According to the participants' experiences, mothers should attempt to access healthcare providers. Stability of care means that mothers and midwives are competent to expand a secure interaction. This interaction is beyond the physical factors . Some stThe midwife's presence in the room with the mother does not necessarily mean that she recognizes maternal feelings and requests . The conFinally, a trustful relationship helps the mother have an active role in childbirth. Edmondson has reported that available facilities will affect the women's decision and plan and form a sense of being supported during normal vaginal childbirth . Rudman This study was conducted in Iran, so the findings might rarely be generalizable, but the results of this study could be generalized to societies with the same cultural backgrounds. Another limitation of this study is lack of interview with women's husbands and their family caregivers who were with mother during childbirth, and it is suggested that they be interviewed in future studies.The present study showed that pregnant women tried to form a trustful relationship with midwives in childbirth by using strategies of “mutual effective interaction,” “an attempt to access healthcare provider,” and “playing an active role in birth”. The formation of trust was visualized in a model to help the healthcare providers in labor wards improve their performances. Such a model can facilitate a tool development to evaluate all midwifery, maternity, and infant care. Further multicenter research with a larger sample size may be necessary to prove these findings.


Although treatment for HIV infection is widely available and well tolerated, less than 30% of adolescents and young adults living with HIV infection achieve stable viral suppression. Mobile technology affords increased opportunities for young people living with HIV to engage with information, health management tools, and social connections that can support adherence to treatment recommendations and medication. Although mobile apps are increasingly prevalent, few are informed by the target population.The objective of this study was to describe the “Positive Peers” app, a mobile app currently being evaluated in a public hospital in the Midwestern United States. Formative development, key development strategies, user recruitment, and lessons learned are discussed in this paper.“Positive Peers” was developed in collaboration with a community advisory board (CAB) comprising in-care young adults living with HIV and a multidisciplinary project team. Mobile app functions and features were developed over iterative collaborative sessions that were tailored to the CAB members. In turn, the CAB built rapport with the project team and revealed unique information that was used in app development.The study was funded on September 1, 2015; approved by the MetroHealth Institutional Review Board on August 31, 2016; and implemented from October 11, 2016, to May 31, 2019. The “Positive Peers” mobile app study has enrolled 128 users who reflect priority disparity population subgroups. The app administrator had frequent contact with users across app administration and study-related activities. Key lessons learned from the study include changing privacy concerns, data tracking reliability, and user barriers. Intermediate and outcome variable evaluation is expected in October 2019.Successful development of the “Positive Peers” mobile app was supported by multidisciplinary expertise, an enthusiastic CAB, and a multifaceted, proactive administrator. By the end of 2016, over 254,000 young people aged between 13 and 34 years were living with HIV in the United States -10. Not Young adults’ high behavioral risk profile is compounded by the stigma associated with HIV and generally low HIV literacy among this group ,14. AlonHIV research reflects a legacy of innovation and commitment to engaging patients in the care cascade. For example, boosting resilience, seek and test strategies, single-tablet treatment regimens, and same-day antiretroviral therapy availability have all been shown to attract hard-to-reach patients to treatment -26. ThisA growing number of mobile apps have been introduced, that offer users a range of functionality -31. MobiAlthough mobile apps that support YPLWH are being implemented with greater frequency ,37-42, mUse of Social Media to Improve Engagement, Retention, and Health Outcomes along the HIV Care Continuum. This is the first report of an ongoing study created to design, implement, and evaluate “Positive Peers.”“Positive Peers” is a Web-based, mobile app that serves as a tool for young adults diagnosed with HIV to manage their health, establish connections with local resources, and engage in a supportive peer community See . Althoug“Positive Peers” is informed by media affordances theory, which specifies that communication qualities of technologies provide opportunities to act in a specific way relative to a user’s needs -51. Althprocess that affords the user opportunities to meet perceived needs, such as HIV-relevant information or supportive companionship. App functions reflect known affordances  and are intended to reflect qualities of social  transactions [The “Positive Peers” app is a social and technological behavioral sactions . As we e“Positive Peers” was prompted by positive experiences with a clinic-sponsored private Facebook page shared by several young adults retained in HIV care. This group comprised 63 in-care patients who consistently attended support groups at the clinic. The age of this group ranged from 13 to 55 years, and 65% (41/63) of them were aged under 35 years. The group included 16 females and 47 males, and 75% (47/63) of them were people of color. As Facebook users thought that a mobile app would be far preferable, the HIV social worker who ran this group met with the users to identify desirable characteristics and potential functions of a HIV-centric mobile app. These specifically included chat, reminder, and resource functions. Consequently, the social worker explored the idea of a locally based mobile app (now named “Positive Peers”) with a hospital physician specializing in HIV.The key members of the “Positive Peers” project team include the clinicians described above; a social scientist with a PhD and training in health communication theory and intervention development for evaluation; and a trained biostatistician to manage, link, and evaluate app data. A local design firm with health care marketing experience was invited to manage the creative activities of the project. The chief executive officer (CEO), a trained graphic designer and creative writer, is the creative director of the project and oversees the development of visual and written material. Finally, a local digital development firm, with significant experience building and maintaining health-related websites and apps, was brought onto the project to create the app architecture from the ground up. The director of app development and the senior developer are both trained in computer science, programming, and coding. They are also responsible for creating tracking tools to reliably record all app activity while it is in the field. The project administrator, selected post funding award, is a community HIV activist trained in public health administration. All activities that followed were conducted under the auspices of the MetroHealth Hospital’s Institutional Review Board.The formative work for “Positive Peers” continued with the creation of a community advisory board (CAB). As user collaboration is key to the development of population-specific health technology -56, we aHIV in the name or function titles and preferred cartoon avatars and made up usernames to selfies and actual names. They also collaboratively imagined app features, including personal stories, a community forum, a resource page, medication, and appointment reminders.To maintain a lively and productive atmosphere, a number of structured techniques were used to collect feedback in the CAB meetings, including card sorting, brainstorming, dyadic and small group idea generation, and traditional focus group methods. The CAB members are sometimes presented with booklets containing illustrated options or screenshots for app functions and features. The CAB first met with team members to view and vote on color schemes and avatar styles and discuss what functions might be most important to them in an HIV-centric app. Their primary concern at this meeting was privacy. They did not want anyone looking over their shoulder to see Following the translation of the CAB’s initial ideas by graphic design and digital team members, a prototype  of the “Positive Peers” app was presented at a joint CAB and project staff meeting. The digital engineers helped the CAB members download and navigate the prototype functions, whereas the design and marketing organization gauged the reaction to the app’s appearance, titling, content, and other design elements. This first meeting provided an opportunity for the nonclinical staff to get to know the CAB members and consider ways to further refine messaging and design. The project staff observed the reactions of the CAB members and noted questions and comments. In general, the CAB members expressed enthusiasm seeing their ideas come to life, which created increased anticipation for a beta version of the app. Subsequent team debriefing concluded that users found the app easy to download and that the app functions were intuitive and potentially useful. Although the CAB recommended against easily identifiable usernames, there were some concerns about users requiring frequent username and password reset.Tales of Triumph), depending on the purpose of that station. In a more private setting, personal stories of living with HIV were recorded by an interviewer, whereas a professional photographer took artistic portraits of the storyteller. Audio and photo consent were collected before this activity. Participants were also given the option to have a photograph that hid their facial features if they wished to maintain anonymity. The team designed colorful game booths and provided inexpensive carnival-type prizes, cotton candy, soda pop, and hot dogs to match the theme.A second CAB event was held a few months later to gain insight on the preferred messaging and content strategies. To attract as many CAB members as possible, this interactive CAB event took on a carnival theme that featured incentivized games designed to collect the CAB members’ needs, perceptions, and concerns about living with HIV as well as inform the tone and appearance of the app. For example, in exchange for a chance to play a game , participants needed to offer a blog topic suggestion, a stigma-inducing or stigma-reducing suggestion, or name a function , Yelp (150 MB), Twitter (110 MB), and some weather apps (120 MB) are much smaller. We aimed to deliver an app comparable in size with those on the lower end. Currently, “Positive Peers” app requires 117 MB of smartphone memory to use. Our next step was to translate our CAB recommendations into a testable digital app with targeted content.At this stage of development, the development team needed to carefully consider the app size. Although we had the plan and expertise to include a wide range of features, we could not deliver an app that was so big that it was quickly deleted by users with budget smartphones. A review of existing popular apps suggested that “Positive Peers” must not exceed 150 MB. For example, popular apps such as Facebook, Instagram, and Twitter. Select “Positive Peers” content is also available on the project website [“Positive Peers” serves as both an information hub for newly diagnosed participants and a recruiting tool for eligible out-of-care community members. Therefore, a broad scope of content is available within the app and via a network of “Positive Peers” branded social media platforms, including  website , althoug“Positive Peers” blog content is researched, written, and presented by the design team. Before content development, a social media posting protocol was developed by the project team in collaboration with MetroHealth. “Positive Peers” text and imagery  are designed to maintain a consistent voice that is proactive, energetic, affirming, contemporary, and accurate. The CAB members asked for information to be realistic and open about the challenges of sex, dating, gender orientation, and LGBTQ issues. Messaging aims toward projecting inclusivity and tolerance while also maintaining a sense of humor and care for people who may follow our messaging. As recommended by the US Department of Health and Human Services, all content is designed not to exceed a seventh-grade reading requirement  and is v’ development phase took 1 year to develop the prototype and an additional 4 months to deliver a beta version.The app development was time and labor intensive. Progress was affected by several unpredictable factors, including CAB availability, organizational constraints , and funder requirements. The app development process benefited from allowing time for key team members to become familiar with each other’s work process, vocabulary, and personalities. The project manager implemented project organization , monitored frequent in-person meetings, and utilized project management tools for electronic to-do lists, group discussion, and document archives. “Positive Peers”The “Positive Peers” app comprises 3 general functions: (1) health management, (2) resources, and (3) social networking. The app affords several features that support these functions.The “Positive Peers” app offers 3 tools for managing HIV-related health needs. These include a reminder tool, lab tracker, and daily inspirational support. Each of these health management tools are described briefly below.This feature allows users to create an appointment or medication reminder that is received directly via push notification on their mobile device. Upon receipt, the user can confirm, snooze, or ignore the reminder directly from the received push notification . As pushCD4 counts and viral load values are the primary indicators of HIV disease progression and response to therapy. “Positive Peers” users have the ability to manually input their CD4 count and viral load values after they receive a lab report. This function is also optional so that the users can choose whether or not to store protected health information in the app.As a means of supporting emotional well-being, the app uses push notifications to deliver daily inspirational messages from the project administrator. These simple, affirming messages  are sent to all registered app users. Brief inspirational messages are drafted by the design team, vetted by the clinical staff, and released on weekdays. These are aimed to (1) normalize fears and uncertainties; (2) create a humorous, positive, and action-oriented tone; and (3) reinforce reaching out for support.Resources tab on the “Positive Peers” app offers 3 features: (1) Tales of Triumph, a collection of CAB-created personal stories; (2) The Blog, a blog feed of culturally affirming content; and (3) Local Resources, a curated list of local organizations and services that may be of interest to young adults living with HIV.The Tales of Triumph is a collection of brief, first-person narratives of personal challenges written by several community members of “Positive Peers”  at their discretion. Chat also provides the project administrator a quick and reliable way to communicate directly with any app user. Importantly, the chat function is stratified by age group. Minor users (<18 years) are segregated from adults to protect them from inappropriate posts or solicitations. The administrator retains the ability to communicate with everyone.The project administrator is a central figure to the “Positive Peers” network and important to the daily functioning of the app. The person in this role manages recruiting, referrals, and onboarding procedures; monitors app-based interaction; responds to users’ questions and password reset requests; coordinates evaluation activities; and generally, serves as the human face of “Positive Peers” in the clinic and the community. This role requires significant flexibility, problem-solving ability, and social skill. Our “Positive Peers” population is generally highly transient and cautious of others. Our administrator is perceived as a group insider and advocate.Updates and bug fixes are a natural part of sustaining a mobile app in the marketplace. Although the app is closely monitored, bugs have been reported by users to the administrator, who works closely with the app design specialist to pinpoint and address the issue. Both planned and unplanned updates are part of regular operating conditions. Planned updates typically reflect expansion, new features, or platform updates. Unplanned updates tend to address bugs, unanticipated platform updates, and other issues that threaten normal operations.“Positive Peers” is designed for use by YPLWH. The design and content of the mobile app are created to be relevant to young people of low socioeconomic status and of racial/minority backgrounds. Although “Positive Peers” was developed for adolescents and young adults, the app could be modified to target any particular user group. The eligibility requirements for “Positive Peers” included (1) being aged between 13 and 34 years, (2) ability to speak English, (3) having a clinical diagnosis of HIV, (4) having either a new diagnosis (within the past year) or being out-of-care for 6 or more months (within the last 2 years) or not virally suppressed , and (5) willingness to receive care at the MetroHealth HIV clinic.Facebook, Instagram, and Twitter) to support recruitment, these methods recruited few eligible users, primarily because of the restriction on where individuals received HIV care. Alternatively, clinic posters, clinician referrals, users’ word of mouth, and team attendance at local events, such as Cleveland’s Pride parade, produced the majority of enrolled participants. The rate of accrual was 6.4 new users a month over a 20-month enrollment period.The most effective form of recruitment for “Positive Peers” was in-person interactions between clinic staff or a current “Positive Peers” app user and an eligible patient. Although “Positive Peers” made use of geographically targeted and carefully targeted social media  and Android platforms. Each enrolled user downloads the app on their own mobile device from the respective app provider for their OS, either Google Play or iTunes. A user’s virtual presence on the app is signified by a colorful contemporary cartoon visage that the user can choose from a large collection created by the design team . The styThe app administrator logs in at least daily for 5 days per week and monitors conversation posts on the community forum. If the participants feel that they are experiencing a mental health crisis, there are in-app directions to text 741741, a national suicide text line. A referral protocol was designed to aid the administrator in addressing or referring users’ concerns. All administrator communications are documented in a secure database and reviewed regularly at team meetings.Daily Inspiration push notifications, the administrator may start or respond to conversation threads on the community forum . After 5 months of weekly monitoring, metadata indicated that several user cases showed no log-in activity at all. This scenario triggered questioning as the user’s enrollment log-in should have been represented as user activity. In response, the digital design specialist and app administrator conducted tests with the archived, raw GA data and discovered that app log-ins that occurred on the hospital campus, or other free Wi-Fi services, were blocked from tracking by GA, our then primary source of user app activity data. Furthermore, GA tended to record additional session time as it did not end a session until the user logged out. GA counted app switching  and smartphone time-outs (without a log out) as time spent in “Positive Peers.” In response, a custom analytic system was created with the Parse open-source platform to collect app activity directly from the “Positive Peers” server.At implementation, all app metadata were hosted on a secure hospital server and tracked by App deletion by the user is a significant and unexpected barrier to using “Positive Peers.” Although users deleting the app to save device space is not unusual, the team was surprised at the regularity of this occurrence. This discovery was first observed during the early examination of the app metadata, which showed a large number of inactive cases. Upon exploration with the CAB and individual users, we discovered that our population not only deleted the app to make room for other apps but also lost, broke, and changed phones often; frequently forgot log-ins; and otherwise just forgot about the app. In response, the administrator monitored weekly activity and contacted those users to troubleshoot problems. Generally, the project team plans updates every 6 months to maintain interest, keep current with the OS changes, and address bugs.Anonymity management was sometimes a barrier to app use for several users. Initially, the CAB requested the use of avatars to provide a layer of anonymity to all users. However, as the number of users grew, so did the demand to provide an option for uploading a profile picture and reveal additional demographic details in users’ profiles. Several users stated that they resisted in-app communications with each other as they were unsure of the identities of potential chat partners or community forum posters. Interpersonal communication theory suggests that this is a typical relational response ,61. InteAnother challenge was jump-starting communication in the community forum. This is a primary app function, but at the outset, users were unsure who was using the app. Consequently, many users lurked instead of risking being the first to send a message. In an effort to increase interpersonal communication on the app, the administrator posted topics several times a week. Although this was successful at generating replies for a short period, the CAB ultimately provided feedback to stop the special posts as they were perceived as “the only posts (users) would ever see when logging in,” thus restricting the open dialog function of the community forum. The CAB further noted that there was a balance needed between the administrator-led conversations and the user-led conversations. After that, the administrator strived to do more replying than posting and limited posting to 1 to 3 posts a month.The immediate next step for “Positive Peers” dissemination and evaluation is the development of a virtual onboarding process that will allow “Positive Peers” to be available throughout the United States. This shift will reduce the responsibility of the app administrator  but enable manageable growth with existing resources. Given the important cohesion that the app administrator generates, we are considering a tiered approach to administration that preserves a local contact but offloads some responsibilities to a central coordinator. Although bimonthly project team meetings continue, CAB meetings now occur on an ad hoc basis when a sufficiently developed agenda emerges from the ongoing activity. We expect that as the density of users increases, the CAB will be invigorated and will assume a more regular schedule. We will be testing long-distance conferencing technology to accomplish this aim.At this writing, the final data collection for this first field experience with “Positive Peers” was near completion. Our evaluation of specific hypotheses and research questions are forthcoming, but given the burgeoning interests in locally designed and implemented health apps, we wished to provide others an overview of our development process and challenges.The “Positive Peers” mobile app aims to provide a secure virtual community tailored to those HIV subgroups most in need of attention and support. The development of “Positive Peers” was strongly collaborative, iterative, and time intensive. Continued development is bolstered by the interpersonal trust and cohesion created between the CAB and development team. The community of “Positive Peers” users made the request for this mobile app, informed its design, and continue to refine its function. Our cross-disciplinary approach provided specific expertise to create, implement, and evaluate this targeted technology.


In total, we analysed responses from 176 children (aged 2–11 years) and 56 adults for ‘how real’ they believed 13 individual figures were . A cluster analysis, based exclusively on children’s ‘realness’ scores, revealed a structure supporting our hypotheses, and multilevel regressions revealed a sensible hierarchy of endorsement with differing developmental trajectories for each category of figures. We advance the argument that cultural rituals are a special form of testimony that influences children’s reality/fantasy distinctions, and that rituals and norms for ‘Cultural Figures’ are a powerful and under-researched factor in generating and sustaining a child’s endorsement for a figure’s reality status. All our data and materials are publically available at https://osf.io/wurxy/.To what extent do children believe in real, unreal, natural and supernatural figures relative to each other, and to what extent are features of culture responsible for belief? Are some figures, like Santa Claus or an alien, perceived as more real than figures like Princess Elsa or a unicorn? We categorized 13 figures into five a priori categories based on 1) whether children receive direct evidence of the figure’s existence, 2) whether children receive indirect evidence of the figure’s existence, 3) whether the figure was associated with culture-specific rituals or norms, and 4) whether the figure was explicitly presented as fictional. We anticipated that the categories would be endorsed in the following order: ‘Real People’ ( By thNot all supernatural figures are created equal. Some are concerned in particular domains of life or behavior, while some are not . Some ac‘engagement in rituals’  Additionally, Goldstein and Woolley  is real?’ as ‘endorsement’ [of reality status], rather than of belief [in reality status] per se . That is, ‘belief’ describes the degree to which a participant authentically holds that a figure is real, while ‘endorsement’ can only be regarded as a self-report measure. We would also stress that this is a study focussed on the cultural processes that sustain endorsement at the level of populations, and not a specific study in individual differences or longitudinal developmental trajectories.Of note, we use the term Here we present ‘The Pantheon’, a list of figures and categories, as well as the associated beliefs and rituals for each figure that are typical in western contexts. In Our study includes two Real Figures —an adult known to the child, but who is not particularly close to the child  and The Wiggles. The Wiggles are an Australian band who perform children’s music on a long-running TV show, and who regularly tour Australia, The US, The UK, and the United Arab Emirates. The Wiggles  are real humans, dressed like humans, and who appear on television as themselves—they are non-animated, and have typical physical and biological limitations. However, The Wiggles also share many qualities associated with animated, absurd, and impossible fictional agents, such as appearing on television, singing and dancing, and having friends who are impossible and who go on fantastic adventures. Given The Wiggle’s extensive touring, children may or may not have had the opportunity to directly interact with these figures—they are, however, extremely popular and widely known in Australia (the population under consideration). We expect by virtue of these figures’ obvious correspondence to human models in the child’s life that children understand that interactions with the Wiggles are in principle real , and that any interactions with The Wiggles will be governed by the same behavioral expectations and norms as any other real person, that they will report that The Wiggles are (highly) real, like a truly real person in their lives. Though it is the case that Wiggles are primarily known to the child via medium of TV, we believe this makes them an appropriate comparison group to the other figures .Cultural figures share many similarities with real figures, despite the fact that they are not, in fact, real. Much like interacting with a human, cultural figures are associated with specific norms and behavioral stipulation. Additionally, from the point of view of the child, cultural figures also provide indirect evidence of their existence in the form of gifts. Moreover, they are broadly endorsed as real by reliable models in the child’s life, and in the media. However, the child does not receive direct evidence of the figure.One notable exception to this statement is Santa. In many parts of the Western world, a typical Christmas time ritual for parents is to take their children to visit a live actor dressed as Santa in a public place, to tell children that this is the real Santa, to take a picture of the child with Santa, and for the child to tell Santa of their desired gifts . ParentsWhile real figures and cultural figures share many similarities the relationship of these two groups to ambiguous figures is of particular interest. By ambiguous, we mean that children are exposed to ideas about these figures, mostly presented either as real (or at least possible), but without ritual or behavioral requirements, nor direct evidence of existence. Dinosaurs and aliens may exist in the world, or may not—but their existence does not impact how the child lives their lives. When children are exposed to these ‘ambiguous’ figures they are forced to make difficult evaluations. Frequently such figures are presented as real in principle, despite the fact that they share many qualities with figures that are real and not real respectively. Dinosaurs are similar to both lizards  and dragons ; while aliens are similar to any novel biological entity  even though the child may never have seen or experienced one first hand. While not perfectly equivalent, in the context of the four factors of testimony  that lead to endorsement, dinosaurs and aliens seem approximately equivalent: Ambiguous figures are endorsed as real by reputable individuals and may be supported by indirect evidence , but–importantly—are bereft of cultural rituals or specific requirements for action. , we have somewhat liberally defined them as ambiguous. Had we not, we may have had particular trouble in accounting for an adult understanding of these figures). A ‘reasonable’ understanding of such an agent would be to admit a degree of ambiguity, without dismissing the possibility of their existence (or non-existence) entirely.Mythical figures are not real, provide no direct or indirect evidence of themselves, and are not associated with any kind of culturally prescriptive actions, but which parents may, or may not, idiosyncratically endorse as real via testimony , and adults (over 18 years) in order to test the hypothesis that such figures feature in a sensible and relative hierarchy of endorsement (where ‘sensible’ is defined relative to adult’s endorsement). We did so using a parent-as-researcher model, which we validated using more traditional methods in study 2. Parents were recruited via online advertisement and mailing lists, and gave consent via survey check-box.The current study expands on previous work by comparing levels of endorsement in different kinds of figures ,30, withThe figures we presented to children were chosen based on whether their exemplar characteristics allowed them to fit clearly in one of our theorised categories see . Both adWe made the following predictions regarding our data:H1: We will observe the expected categorization of figures based on endorsement scores.H2: Children’s endorsement will conform to a hierarchical pattern consistent with the degree to which they are culturally and evidentially supported.H3: Adults’ endorsement of the realness of figures will be high for ‘real figures’, lower for ambiguous figures, and near floor for cultural, mythical, and fictional figures.H4: As age increases, children’s endorsement patterns will become more adult-like.Data collection for this experiment was executed over the course of 12 months in a longitudinal manner, and several additional hypotheses were proposed for this larger within-participants dataset. However, due to attrition we were not able to perform these planned analyses. We have included descriptive, but not inferential, statistics of our longitudinal data in Using our lab databases, as well as our facebook page, we invited Australian parents to enroll their children in a year long study examining their child’s endorsement for various kinds of figures. The first wave of the survey was conducted in July 2015 over a 3 week period. The administration of the study involved an online survey that the parent conducted with their child/children. In order to avoid incomplete responses and to avoid causing offence to parents, we asked parents to indicate which of the figures they were comfortable asking their children about. This was done to ensure that parents could omit any figures they felt were inappropriate . In addition, parents agreed to a set of experimental protocols (common to any lab based study) to minimize bias see .Do you think your child was being truthful with you?), among those that failed to answer the final question, none responded to more than 3 figures. A total of 95 children were included in the final analysis.A total of 154 children provided responses during the first wave of data collection. Surveys that did not include an answer to the final question of the survey were excluded  was recruited from an undergraduate research pool in exchange for course credit. Adults were asked to participate in this study after completing an unrelated study on facial expressions.Children first participated in a number of practice questions in order to become familiar with the 9-point likert scale, which was visually represented as 9 grey stars which turned gold when clicked. These questions related to obviously false things, obviously true things, and confusing things. The goal of this task was to get children using the whole scale . On the more challenging questions of whether ‘Floating Rocks’  were real, it was clear, that the mid-points of the scale were used and understood by the sample, and that skewness and kurtosis were normal. The lowest scores were associated with the obviously false things, such as ‘singing chairs’ ; and ‘Upside down trees’ .Do you think [figure] is real?”, with 1 stars indicating “not at all real” and nine stars indicating “definitely real”. We reduced all values by 1, so that ‘1’ responses—which qualitatively represented ‘not at all real’ were now represented by ‘0’—which we argue is a more interpretable value. During the first wave of data collection we failed to collect data on a real person (who is known to the child). This was an oversight. Data on this target were collected at T2 and have been used during these analyses where appropriate.Children were asked to rate the realness of the 13 target figures (presented in random order) on the 9 star likert scale, by answering the question “https://osf.io/wurxy/, and we invite readers to download it). Sex data was not collected. A total of 57 adults constituted the adult sample. Their mean age was 20.23 years (SD = 5.31). Eighteen of these participants were raised overseas, and all spoke English at a tertiary/university level. A single adult, aged 48, was 5.23 standard deviations above the mean for age, and appeared to influence several regression values—inasmuch as we hope to make age-relevant claims, this outlier is unduly influencing the predictive value of age as a predictor. For this reason, this single individual was removed from regression analyses.A total of 95 children were included in the final analysis. The mean age of these children was 5.12 years (SD = 2.17); the youngest child was 1.97 years, while the oldest was 11.10 years . . First, we produce a correlation matrix . We have termed this the We predicted with Hypothesis 2 that children’s endorsement will conform to a hierarchical pattern consistent with the degree to which agents are culturally and evidentially supported. mice package  attended a Science Museum [details redacted] in a capital city of Australia, in order to collect a corresponding sample of children. The protocol was the same as with study 1, save for the following changes. The RA approached parents in the foyer of the public science museum, and invited them to involve their children in this research project. Parents were then briefed, and gave consent for their child to participate. Parents indicated which figures the child Due to operational and time constraints, we were able to collect responses from 82 children (though one child was excluded for not completing the task). In total, our final dataset included 81 children. The mean age of these children was 6.17 year (SD = 1.79) . The youngest child was 3.44 years [original 1.97 years] while the oldest was 11.67 [original 11.10 years]. As can be seen in Children first participated in a number of practice questions in order to become familiar with the 10-point likert scale, which was visually represented as 10 stars which turned gold when clicked. These questions related to obviously false things, obviously true things, and confusing things. The goal of this task was to get children using the whole scale  on the 10 star likert scale, by answering the question “https://osf.io/wurxy/)All analyses were identical to those of Study 1, and the R code we used to conduct the study is available on open science framework  for children’s endorsement of each figure and each category . Note tha priori analyses, we simply compared the null model to a full model which included freely estimates intercepts and slopes . We identified that a model with a fixed y-intercept (Model I) for all categories was significantly improved by the full model with freely estimated y-intercepts and slopes (Model II), χ2(6) = 224.00, p < .001, The correlation between the category codes and regression intercepts r = -.634, indicating that as age increased endorsement  decreased. This is apparent in Per study 1, we conducted a multilevel model. However, given Study 2 served three purposes: First, to replicate observations made in study 1, second, to determine whether the parent-as-research-assistant model was valid, and third, to collect data with fewer missing values.The present dataset was collected by trained research assistants in a large, metropolitan science museum. Due to time constraints, we were able to collect data from 81 children . While study 2 did not contain individual children as young as those in study 1, we note that only very few children were younger than those in the present dataset. One unintentional difference between study 2 and study 1 was that the children in study 2 were recruited at a Science Museum. One potential implication is that these children may be more science-savvy than the children in Study 1. To what extent this influenced the data, we cannot know, yet we did observe remarkable similar observations, clusters, and model results. The most salient difference in the results of these analyses was the beta value associated with cultural figures. Specifically, in study 1 age only weakly predicts belief, while in study 2 this relationship is considerably stronger. We propose that the nature of this relationship is probably non-linear, where belief declines abruptly , rather than gradually. That said, we are generally confident in our central claim that belief in a range of real and unreal figures conforms to a typology, and we predict that—beyond typical forms of testimony—that rituals and cultural norms associated with cultural figures are a special form of testimony. We hope that it is apparent that this replication, conducted by trained research assistants, has yielded results that should give any reader confidence in the method of parent-collected data and the results of Study 1.To our knowledge this is the first study to examine the relative hierarchy of children’s reality endorsements across a range of figures. We made several predictions. First, that figures would aggregate into a priori categories. Second, that children’s endorsement would conform to a hierarchical pattern consistent with the stated criteria. Third, adults’ endorsement of the realness of figures formed basic categories with less ambiguity. And fourth, age would predict endorsement patterns that converge on sensible ‘adult like’ endorsement. We found broad support for each hypothesis in two separate studies. We are also eager to note that the method by which we collected data—by recruiting parents online, who subsequently acted as research assistants—appears to have yielded results that do not meaningfully or systematically differ from results collected by trained research assistants.Regarding our first hypothesis, we identified that 12 figures aggregated into four clusters which broadly corresponded to our predictions. This pattern we observed is most easily seen in Figs Regarding the interaction between categories of figures and age: The biggest deviation in our results from our hypothesis was that dinosaurs and aliens did not aggregate. But rather, dinosaurs aggregated with The Wiggles in study 1 and that dinosaurs and wiggles did not aggregate in study 2. We termed this cluster ‘virtually real’ as children have had no direct evidence of either figure, and yet both figures are/were real—presumably according to different criteria. Children appear to recognize that the wiggles are extant, and that dinosaurs were once extant. Indeed, in study 1 we observed that the difference in endorsement scores between Dinosaurs (and Aliens) was not significant between children and adults. This suggests that children (as a group) appear to have an already stable and adult-like understanding of Dinosaurs (and Aliens).p = .351; Study 2, p = .066) that dragons did not differ from unicorns  and that unicorns did not differ from ghosts (Study 1: p = .057).  = 2.955, p = .005, such that Unicorns, M = 5.45, were more endorsed than Ghosts, M = 3.406). Rather, unicorns clustered with fictional figures (in study 1), and with dragons, aliens and ghosts (in study 2); while dragons and ghosts clustered with aliens (in both studies). We note that Adults tended to endorse aliens and ghosts at relatively high levels , but did not strongly endorse unicorns. Indeed, we were surprised at the levels adults endorsed ghosts. Children endorse ghosts significantly more than adults, but only by a small margin. And yet, aliens, ghosts, and dragons all provide the same amount of evidence for their own existence, make no demands on believers (inasmuch as behavior is concerned) and are all idiosyncratically presented in media . Any attempted explanation of this would be post hoc speculation, and so we hereby refrain, and look forward to future research efforts. The fictional cluster needs little discussion, except to say that age predicts declining endorsement more strongly for this category than any other.We had hypothesized the existence of a ‘mythical’ cluster—of unicorns, dragons, and ghosts—which did not materialise . An additional point of discussion is that children are likely exposed to more information about Santa than the Tooth Fairy or the Easter Bunny. Though it’s largely an empirical question as to how much exposure children receive for all the figures in studies, we maintain that Cultural Figures are qualitatively different from other figures—particularly their nearest-endorsed-neighbors, aliens and dinosaurs—as they are coupled with rituals and behavioral norms.As predicted, we found that Santa, the Tooth Fairy, and the Easter Bunny aggregated into the The results of our multilevel model expands on existing findings, which has shown that ‘more than half of 8 year olds are still in transition [to disbelief in santa]’  and thatOur hypothesized structure was based primarily on the following features: 1) direct evidence, 2) indirect evidence, 3) ritual and behavioral norms associated with the figure, and 4) explicit presentation as fiction. We tentatively argue that behaviors associated with figures—specifically, cultural rituals and behavioral norms—are a key feature that supports the endorsement of cultural figures at rates approaching that of real figures . Of course, we can only make inferences to this causal factor in the present work, and we have no data to show what kind of behavioral commitments were apparent in the lives of the children we studied. (Though we have work in preparation in which this was the focus).We should note, however, that we are not attempting to dismiss the role that various kinds of testimony play , nor theWe would also like to emphasise the quality of the data collected in Study 1—where parents administered the survey to their children—as evinced by its similarity to the data collection in Study 2. We found no systematic or meaningful differences in our data . We broadly replicated the factor structure, multilevel model, and hierarchy within this data (as well as finding strong age effects for each category in linear regression models). We hope that this replication attempt bolsters support for the present findings, and—more broadly—reveals the value of using parents as research assistants: provided sufficient guidelines and briefing, it appears that parents may be able to efficiently and honestly report the belief, opinions, and preferences of their children, at least to a degree comparable with a research assistant unknown to the child. The extent to which either method (parent vs. RA) introduces idiosyncratic biases is unknown, but the net-results suggest that neither method is empirically inferior to the other in the present context . Largely, we believe that the parent-collection model may be an efficient way to collect data of acceptable quality, even on topics that might be intuitively considered difficult (such as belief in figures like Santa).presence of a hierarchy (rather than a dissection of stated phenomenon), and a sincere advancement of the hypothesis (stated by authors elsewhere) that rituals play an important role in facilitating belief in non-natural figures. We also advance the hypothesis that rituals are a special form of testimony, rather than confidently asserting it is a known and quantified explanation.We believe there are three primary limitations, and some additional, smaller limitations. The first primary limitation, is that children may ‘meet’ some figures in real life, thus having something like direct evidence for the figure; second, the emotional impact and valence of the figures likely plays a role, and this was not accounted for; and third, what exactly does ‘real’ mean in this context. This work should be considered a first attempt at demonstrating the direct evidence of their own existence, but rather that they provide indirect evidence of their existence . We do not at presently know how many children would report having seen the Easter Bunny or the Tooth Fairy, but the extant literature suggests that the Santa data is not surprising. At least in the United States  children often visit a ‘live Santa Claus’ in shopping centres and malls, with many visiting two or more live Santas per year  exists or has existed in some embodied and autonomous way’. That we find middling rates of endorsement for a number of agents  indicates not that something is real and unreal at the same time, but that one has a middling-confidence that a thing is real. One potentially problematic aspect of this can be highlighted by adults’ responses to ‘Dinosaurs’. There was a small number of floor responses for dinosaurs, which may reflect a belief that dinosaurs—though once real—are no longer real. However, some small proportion of those responses may also reflect the beliefs of religious fundamentalists. Largely, however, we think these floor responses—though small in number—are legitimate, and should in aggregate be taken to represent the diversity of respondents understandings of the term ‘real’ . We also note that the measurement we used—particularly for fictional figures—tended to cluster at the floor and the ceiling producing a potentially misleadings ‘mean’ value. While regrettable, we note that the same problem does not occur for the ambiguous and cultural figures, which tend to reveal middling endorsements by individuals .pantheon, united by a coherent structure of underlying qualities, opens the door for higher resolution understanding of how children come to understand what is real and what is not (even when they are wrong), and allow for more nuanced approaches to research when investigating the predictors of belief and endorsement. In addition to testimony, content, and source information, we must pay more attention to the specific role that cultural rituals play in widespread belief of culture-bound supernatural figures.The data we present here suggests that, when children (and even adults) are asked to report their subjective confidence that various kinds of real and non-real figures exists, they are not only able to do so, but do so with nuance, and in a consistent pattern apparent at the population level. We argue that the possibility that cultural rituals and normative requirements on the part of figures like Santa, the Easter Bunny, and the Tooth Fairy may be very powerful cultural tools that lead to children believing such figures are real. And we anticipate—but cannot address directly—that ritual involvement is a key determinant in adult beliefs for more institutional supernatural figures such as the deities of major world religions. We hope that treating the corpus of real, supernatural, and fictional figures as a kind of S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 Fig(TIF)Click here for additional data file.S5 Fig(TIF)Click here for additional data file.S6 Fig(TIF)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S1 Data(DOCX)Click here for additional data file.S2 Data(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file. 25 Feb 2020PONE-D-20-01141The Child’s Pantheon: Children’s Hierarchical Belief Structure in Real and Non-Real FiguresPLOS ONEDear Dr Kapitany,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.There are two main areas of contention:1. The reliability of the method, and especially in the ability of children to understand degrees of probable reality. Speak to the plausibility of the assumption that children understand the question and can use the scale appropriately, either with some validation data, some commentary on your own results, or previous research.2. The interpretation of your findings. Both reviewers took exception to those, and their criticisms should be addressed both in the text and in your cover letter. https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.We would appreciate receiving your revised manuscript by Apr 10 2020 11:59PM. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: [Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: PartlyReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't KnowReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: This is an interesting and thoughtful attempt to examine children's ontological beliefs in a more nuanced fashion than is customary. To simplify somewhat, a great deal of past research has assumed that children classify entities in a dichotomous fashion - as real or unreal. Instead, the authors argue, children have a more differentiated notion of reality with real people at one end, fictional characters at the other, with other categories in between.Despite the strength of the theoretical framing I have several reservations about the data that the authors offer in support of their thesis.1. In both studies, the authors asked a wide age range of children to situate each character on a 9-point star scale using training feedback that included the following: " If you think it's probably real, then choose a big number of stars, if you think it's probably not real you should choose a smaller number of stars". I think the assumption that children, especially preschool children, can understand varying degrees of probability and translate them into a varying number of stars is quite dubious. The fact that similar results were obtained whether or not parents served as the interviewer does not show that children understood the scale. For all we know, children were subject to the same misunderstanding or partial understanding of the response scale no matter who interviewed them.2. Eyeballing the data in Figure 5 (Endorsement for categories), there seems to be little justification for claiming that children differentiate between virtually real characters (e.g. The Wiggles) and cultural figures (e.g. Santa Claus) or between Ambiguous figures (e.g. ghosts) and Fictional Figures (e.g. unicorns). A more cautious and defensible conclusion might be that children make a 3-way split between real figures, less real figures and doubtful figures.3. The authors elaborate on various ways in which different categories of figure might be distinguished (see Table 2 for a listing of these criteria). However, they provide no evidence that these criteria were deployed by children in making their reality judgements. In particular, the authors did not ask children to offer a justification for their judgments even though such justifications might have lent support to the authors' claims. In the absence of such justification data, the authors have to rely on the reality judgment data alone and yet there are all sorts of reasons why children might make different reality judgments for different figures. For example, Figure 3 suggests that children were less confident of the existence of Peter Pan than the Tooth Fairy. This might reflect the fact that children receive indirect evidence for the Tooth Fairy and not for Peter Pan (as implied by the criteria set out in Table 2) but another equally plausible possibility is that children hear more references to the Tooth Fairy (and from more people) as compared to references to Peter Pan.4. I am sympathetic to the authors' proposal that the rituals and norms associated with certain figures might constitute a form of testimony. However, I doubt whether a non-experimental study in which figures that are presumed to be associated with rituals and norms are compared with figures that are presumed to not be so associated are compared can provide strong evidence for their claim. Those two classes of figure will be very likely to vary in other ways (see comment #3 above), weakening any conclusions that can be drawn.Reviewer #2: This paper presents the results of two surveys of children’s and adults’ beliefs about a range of real and fantastical beings. Specifically, the authors presented participants with various beings that they had categorized a priori into 5 groups as a function of a number of characteristics and attributes that they reasoned would affect judgments about reality. Participants were asked to indicate how real they thought the entities were, using a Likert scale. Results indicate that children and adults exhibit different patterns of judgments regarding these entities, and are interpreted as revealing that children’s judgments reflect the predicted characteristics/attributes of the beings, and specifically the important role of participation in the behavioral rituals surrounding the entities.This study is unique in attempting to explore a more nuanced representation of reality than in previous studies of this topic, many of which have simply assessed beliefs about whether something is real or not real. This is a laudable goal. The focus on the role of involvement in behavioral rituals is also novel and important. In general, I really like that the authors are trying to determine how various factors like ritual participants and evidence interact to engender belief.I should note that I reviewed an earlier version of this paper for another journal. I mention this, because I find this version significantly improved over the original version, and that affects my evaluation (in a positive way). Overall, though, I still have some concerns about the paper, and they follow.1. On p. 20, the authors discuss whether endorsement becomes more adult-like with age. The text states that, “it is clear from the data presented in Figure 4 that the negative slopes associated with fictional characters and cultural characters..” From the graph that appears to me to be Figure 4, it doesn’t look like there’s any decline at all in belief in cultural figures—that line looks flat. First, this doesn’t fit with the text, and second, there’s so much research showing that these beliefs decline with age that something must be odd about these data. Can the authors clarify?2. As the authors note, in terms of the hierarchy, for the most part the data from Study 2 replicate Study 1. But I was struck by the differences in the correlations. For the most part, they’re lower in Study 2. Could the authors speculate on why this might be the case?3. Another difference between the two studies is that in Study 2, the slope for Cultural Figures actually does appear to be negative. Why this difference? The authors make much in the General Discussion regarding how the Study 2 results validate the method used in Study 1 but this is a critical difference. Apparently in an attempt to explain it, they state that it is probably due to belief declining abruptly rather than gradually . First, I don’t understand how that explains the difference. Could the authors expand upon their explanation? Second, I only know of one study that looks specifically at Santa disbelief, and that study finds that belief does not decline abruptly: As Anderson & Prentice (1994) state, “the ultimate realization came about through a gradual transition to disbelief rather than at a single point of demarcation” (p. 74).4. On p. 28, the authors state that “endorsement for cultural, ambiguous, and fictional figures declines at differential rates” but it looks to me like in Study 2 , the lines for cultural and ambiguous are parallel. . Could the authors clarify?5. I’m a little confused about the paragraph at the bottom of p. 28 as well. The text states that dinosaurs aggregated with The Wiggles. But on p. 24 they state that Dinosaurs and Wiggles didn’t aggregate (and that in the “primary dataset this cluster had relatively low reliability”). Please clarify.6. On p. 30 the authors state that the “most unbelievable figures” assume the lowest rank in the pantheon. What is meant by “most unbelievable figures”? They also state that ambiguous figures “assume a higher standing than that of cultural figures.” I guess I’d like the language to be more precise in both of these cases. Also, it doesn’t actually seem to be true. In Study 2, it looks like fictitious and ambiguous features are changing their relative standing and in Study 1 there is no change in standing .7. On p. 33 the authors seem to be discussing individual subject patterns but I didn’t see any discussion or analysis of these in the Results sections. The authors should include these data if they want to discuss them.8. There are numerous grammatical errors through the manuscript. I recommend a very close checking before submitting a revision.Some minor points:1. P. 10, states that “endorsement between these figures is not statistically different.” First, the authors needs to specific to which figures they are referring, that is, between Santa and the other two, or between the other two? Second, a citation needs to be provided for this claim.2. P. 10, what is meant by the “four factors of testimony”?3. For Study 1, 59 out of 154 children’s data were dropped. Were these all due to not answering the last question? I’d like a little more information about this and its implications regarding the generalizability of the findings.4. Pp. 14-20, the “hypotheses” in the subheadings aren’t hypotheses. I’d suggest rephrasing.5. P. 20 second paragraph, author should indicate explicitly that these data concern the “Ambiguous” category members.6. None of the (main) figures in my copy are labeled so I had to guess figure numbers.7. What’s wrong with including 3-year-olds (p. 33)? Lots of studies on this topic do so.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  8 Apr 2020Please see attached 'response to reviewers'. The response is far too wordy to include here.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 20 May 2020The Child’s Pantheon: Children’s Hierarchical Belief Structure in Real and Non-Real FiguresPONE-D-20-01141R1Dear Dr. Kapitany,We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. 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For information about this choice, including consent withdrawal, please see our Privacy Policy.Reviewer #2: Yes: Jacqueline D Woolley 26 May 2020PONE-D-20-01141R1 The Child’s Pantheon: Children’s Hierarchical Belief Structure in Real and Non-Real Figures Dear Dr. Kapitány:I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. 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The results showed significant improvement in students’ behaviors and social responsiveness and in teachers’ confidence among those in the IT group; however, those in the DTC group did not show any such improvement. We discuss the program’s feasibility in terms of developing support resources for teachers in Japanese high schools.In the present study, a teacher training program based on behavioral therapy was conducted for high school correspondence course teachers of adolescents aged between 15 and 18 years who showed developmental difficulties. Participating teachers were assigned to either an immediate treatment (IT;  Correspondence high schools have played a key role in offering education to working youths since the end of World War II in Japan, which was their original purpose . HoweverThis system requires remote studying, submitting reports, direct schooling, and taking examinations . StudentAnother change made over time is an increased number of students. Owing to the decreasing birthrate in Japan, the number of full-time and night high school students has been decreasing since 1989; in contrast, the ratio of correspondence high school students to all high school students has been increasing since 2004   = 5.07, p = 0.033, partial η2 = 0.16; and F = 6.55, p = 0.016, partial η2 = 0.20, respectively]  = 11.04,  = 0.29] . On the ctively] .p = 0.050). The subscale of restricted interests and repetitive behavior (RRB), however, showed a significant improvement in the IT group compared to the DTC group   = 5.81, p = 0.023, partial η2 = 0.18, respectively]. Additionally, three other items Q5 “making a space for the student to relax”, Q7 “dealing with the student’s maladaptive behaviors”, and Q12 “reducing troubles at school because of the student’s behaviors” showed more significant improvement in the IT group than in the DTC group   = 7.60, ctively] .The semi-structured post-program interviews of all the participating teachers recorded opinions on their satisfaction with this program and modifications or changes of the target student’s behaviors, as well as to their own cognition and attitude toward the students. Answers from the semi-structured interviews were transcribed by the second author and categorized by two researchers to extract quantitative data using the KJ qualitative analysis method . As TablThe total TRF score of the IT group improved significantly, and the subscales of attention problems, delinquent behaviors, and social problems showed significant improvements in this group . AccordiFirst, TT content on tailored support for students’ pre-academic skills enabled improvements in student’s attention abilities. As shown in In addition, Session 3 of the TT program involved supporting students in developing autonomous management skills, such as document management, which can enable students to improve their self-management sufficiency , a necesSecond, we believe students’ maladaptive behaviors improved due to the modified relationship between the teacher and target student, which resulted from training teachers to show appropriate reactions toward students’ appropriate behaviors, such as by “praising students immediately after an appropriate behavior” . This waThird, the improvement of social problems was promoted within the inclusive environment of X correspondence high school. Lack of assistance from teachers and exclusion from the classroom can aggravate students’ social and academic problems . HoweverFor the SRS−2, an improvement on the subscale for restricted interests and repetitive behavior (RRB) can be attributed to the fact that environmental accommodation depending on each need  created Additionally, as Boulter and colleagues’ anxiety model  shows, sRegarding degrees of teacher confidence, the following five items showed significant improvement: (Q1) “waiting for the student’s growth”, (Q2) “accepting the student’s difficulties”, (Q5) “making a space for the student to relax”, (Q7) “dealing with the student’s maladaptive behaviors”, and (Q12) “reducing troubles at school because of the student’s behaviors”. Compared with previous research results on parent confidence from PT , the impRegarding Q1 “waiting for the student’s growth” and Q2 “accepting the student’s difficulties”, as Regarding Q5 “making a space for the student to relax” having something to do with the improvement of restricted interests and repetitive behavior (RRB) on SRS-2, Session 3 of TT, environmental accommodations  created Regarding Q7 “dealing with the student’s maladaptive behaviors”, previous TT research ,20 reveaLastly, regarding Q12 “reducing troubles at school because of the student’s behaviors”, common discussions on improvements in maladaptive behaviors and social problems of TRF and RRB of SRS-2 mentioned above concern teachers’ increased confidence in reducing students’ troubles at school. With modifications in students’ actions related to maladaptive behaviors, social problems, and RRBs, teachers recovered their confidence in reducing students’ troubles. Although there is a limitation in terms of the lack of correlation analyses reflecting this change, teachers’ comments in the interviews, as shown in These findings highlight the feasibility of introducing TT to teachers of adolescent students who present symptoms of DDs and have difficulties at correspondence high schools in Japan. Correspondence high schools have diverse students, including students with typical developmental needs and students with DD-based support needs. To effectively assist with the needs of adolescent students, supporting teachers’ difficulties are urgently needed. Further, our findings suggest that the TT program enables teachers to learn individually tailored support methods through regular group discussions with other teachers who have similar worries and stressors, even for students with different symptoms. We contend that TT for teachers of adolescents should include a basic behavioral therapy method to cover different types of DDs, so that the facilitators can tailor their advice and support to the participating teachers, depending on their students’ major issues and difficulties.Further, the intervention environment of the current research was a semi-structured school environment, which lacked an environmental structure adjusted for each student’s needs, such as at special support education schools. Regarding support for adolescents, perfect structural adjustments at school are difficult due to the development and complications of interpersonal relationships . The curDespite the study’s contributions to strengthening the teachers’ skills in correspondence high schools in Japan, certain limitations existed with respect to the sample size and generalizability. The teachers who participated in this program were those who were personally motivated to do so; thus, the sample comprised only some teachers working at a private correspondence high school. The target students paired with each teacher were limited to those in the weekday courses because students at correspondence high schools urgently need appropriate daily support from teachers who can spend enough time assisting them Monday through Friday, morning to evening. However, in addition to the weekday courses, correspondence high schools also have students who take weekend and home-study courses, who study at their own pace at home and spend less time at school. Correspondence school students with DDs can have a lot of difficulties, including extending the period of absence from necessary schooling, dropping class credits, or dropping out of school entirely . We wereAnother limitation is that this was not a researcher-blind study. The first author facilitated the program and analyzed the data. Even with data anonymity using IDs and data collection by other researchers who did not facilitate the program, we cannot deny the slight possibility of researcher bias. Moreover, as the questionnaires were completed by the participating teachers, future research should use a more objective means of measuring data. A blind report by other psychological staff, or an evaluation by students—which takes more time to be understood in a school environment, considering the ethical issues related to personal information in Japan—could be undertaken in the future.There are also some limitations pertaining to methodological requirements. The study was conducted during the last two academic trimesters because the teachers would have more accurate student information by the end of the first trimester. Further, the first trimester challenges students with symptoms of DDs due to the new class environment, teachers, and peers. The results of student behavior modification may have been different if the TT program was conducted during this period. We believe a trial performed during the first trimester might be helpful if the research goal were to focus on effective support at the beginning of a new environment. We also understand that it is necessary to conduct more longitudinal research, including a follow-up study, in order to evaluate the persistence of improvements through the duration of this program. Finally, our study design was quasi-experimental; thus, in the future, we would like to conduct a randomized controlled trial.The current research introduced a TT program to high school teachers who are in charge of students with DDs or show DD symptoms at campuses of X correspondence high school. The findings supported the program’s effectiveness, showing improvements in students’ behaviors and social responsiveness and teachers’ confidence in dealing with such students. The difficulties and problems of adolescents with DDs might be considered too complex for their teachers to provide appropriate support because of the secondary disorders often arising from these difficulties. The implementation of TT, however, is imperative to support adolescents with DDs, specifically for teachers to build a positively focused psychological environment. This would reduce the antecedent conditions leading to students experiencing disadvantages in school, and provide a structure to facilitate this change. Currently, in Japan, correspondence high schools have more important roles in supporting students with different DD needs or tendencies in relation to the increasing number of such high school students. Due to this trend, the current study, with certain effective results, reported important indicators for further development of support programs for teachers who are in charge of students with DD-based support needs. Moreover, the support systems and tools for Japanese high school students with DDs are currently in development; thus, the practical feasibility of this program paves the way for further research on different types of educational environments, such as full-time and evening schools, not only correspondence high schools. Moreover, our research could further be extended to countries other than Japan.