Adherence to care and antiretroviral therapy is challenging, especially for people living with HIV (PLWH) with additional co-occurring risk factors. Case management interventions, including motivational interviewing (MI), show promise to improve HIV treatment adherence, but few studies have examined how such interventions are delivered to or experienced by PLWH who have been reengaged in care. We conducted qualitative interviews with six case managers and 110 PLWH exiting from a randomized study (HPTN 078) who received a MI-based case management intervention in addition to standard patient-navigation services, or standard services only. Our study provided greater insight into the main findings from HPTN 078, including an in-depth description of the multiple barriers to adherence faced by this largely “out-of-care” population, as well as a more nuanced understanding of the benefits and challenges of implementing MI. A blend of MI plus more intensive interventions may be needed for PLWH facing multiple structural barriers.The online version contains supplementary material available at 10.1007/s10461-022-03644-2. For people living with HIV (PLWH), achieving and maintaining viral suppression (VS) is critically important to managing their own health and reducing the risk of transmitting HIV to others. Despite a growing armamentarium of antiretroviral therapies (ART) that promote viral suppression, an estimated 47% of PLWH struggle with HIV medication adherence . Among PBarriers to medical care visits and medication adherence are numerous and include individual risk factors such as mental health and substance use problems , 4, inteVarious strategies have been evaluated to address these individual, social, and structural barriers to adherence. Several studies have examined the effect of provider relationships on patients’ medication adherence. In a study of 2765 PLWH on ART living in four major U.S. cities, respondents who indicated more frequent interactions with providers who provided positive support  had higher scores on medication self-efficacy, leading to higher medication adherence . CultivaThis study provides an in-depth examination of participants’ experiences with case management in the context of an intervention trial titled “Enhancing Recruitment, Linkage to Care and Treatment among HIV-Infected Men Who Have Sex With Men in the United States”.HIV Prevention Trials Network (HPTN) 078 was a randomized trial to compare the effectiveness of a case management intervention versus standard of care (SOC) on viral suppression (VS) among gay and bisexual men with unsuppressed HIV. The study was conducted through four HPTN trial sites including University of Alabama-Birmingham; Fenway Clinic in Boston, Massachusetts; Johns Hopkins University, Baltimore, Maryland; and Ponce de Leon Clinic in Atlanta, Georgia. It employed respondent driven sampling, supplemented by direct recruitment, to recruit participants who had been disengaged from or had never linked to care. Participants randomized to the intervention arm were assigned to a study-specific case manager (SCM) who had been trained in MI techniques and provided tailored support for ART adherence. Participants in the SCM arm could also elect to receive automated or personally recorded motivational messages, visit and medication reminders via text, email or phone, choosing the frequency and content of provider sessions and automated/personalized content . Over thThe study screened over 1300 individuals, of whom 902 were living with HIV; the study enrolled 144 of the 154 individuals who were virally unsuppressed. After one year, 91% of participants were still in follow-up and almost half of all participants (48%) had achieved viral suppression. Viral suppression did not differ by study arm . QualitaThe local institutional review board for each study site approved the protocol prior to study implementation. Participants provided written informed consent prior to any study procedures. HPTN 078 is registered on ClinicalTrials.gov (NCT02663219).Between March 2018 and January 2019, we conducted phone-based semi-structured interviews with a total of 111 participants who had participated in HPTN 078 through one of the four sites. The time between the qualitative interview and the month 12 visit  varied widely (-1 month to + 10 months). The interviews were conducted by a team of five interviewers, generally one interviewer per site with a back-up interviewer, who had received training in qualitative interviewing. Although contact with participants was facilitated by each site, qualitative interviewers were not associated with the clinic. The topic guide explored participants’ experience with HIV care as part of the study and more generally, challenges and facilitators of medication and care adherence, and perspectives on overall and sexual health. As part of the main protocol, participants provided written consent to be contacted at exit for the qualitative interview. Prior to beginning an interview, the former HPTN 078 participant reconfirmed verbal (audio-recorded) informed consent. In addition, telephone interviews were conducted with six SCMs to explore their own experiences, including their perspectives on the use of motivational interviewing and major barriers and facilitators of adherence encountered by study participants.All interviews were audio-recorded, transcribed verbatim and typed into word documents. An initial team of seven coders used a team-based coding approach to first apply structural coding  and then develop and apply a thematic codebook to transcripts in NVivo 12, a qualitative software program used to manage analysis of textual (and other) data. Thematic codes included current clinic support, study SCM interactions, non-Study CM interactions, housing, finances, transportation, substance abuse, mental health and HIV medication and care adherence. Team members could apply multiple codes to the same excerpt. Team members coded the first several transcripts independently and met to discuss and reconcile differences in how they applied the coding scheme. Subsequently, each team member was assigned a set of transcripts to complete with periodic coding of a shared transcript to check that coders were still applying the codebook in a similar manner. Over the course of six months, the team held three structural inter-rater coding reliability (ICR) meetings, one content focused ICR and one final structural + content ICR meeting.Working with the previously coded data, this subsequent analysis was conducted by two team members to explore whether and/or how the support delivered by the SCMs and experienced by participants in the SCM arm differed from those in the SOC arm. Analyst 1 read coding reports related to CM interactions and developed memos by arm and VS status. Both analysts explored and completed a matrix, organized by arm and VS status, summarizing participant reports of secondary codes that emerged from initial investigations. These included specific experiences related to housing, mental health issues, religion and other personal or contextual information. Analyst 2 reviewed and developed memos related to the SCM interviews. The team specifically examined how study CMs and participants described their case management experiences and assessed whether and/or how the content and strategies used by study and non-study CMs differed. We also examined whether or how services desired and/or provided by case managers varied by VS status and study arm.Sociodemographic characteristics Most participants (88%) in the qualitative sub-study were Black or African American men between the ages of 22–50. Most (79%) self-identified as gay or homosexual.As shown in Table Despite similar proportions of participants by arm who were and were not virally unsuppressed at exit, our qualitative analysis identified important differences in how participants experienced interactions with their case managers, as well as the kinds of support that were needed and provided by study arm and by viral suppression status. In the remainder of this section, we describe these differences in greater detail, highlighting both participant and SCM perspectives. Additional illustrative quotes are presented in Table 2 (supplement), organized by study arm, general theme, and viral suppression status.virally suppressed participants in the SCM arm (n = 12 of 27) described their SCM in very positive terms, often emphasizing the relational aspects of his/her support. Some participants used the phrase “like I was talking to a friend,” while others compared their relationship to that of a family member. They described discussions with the SCM as being two-way, non-judgmental.Almost half of Well, when they talked to me, they made it so like that I was talking to a friend and someone that I can trust. So, they made it easier to open up and just relax and be able to put everything on the table, without worrying that I was being judged or anything… Because I ended up meeting, I met someone and started a new relationship. And then, for them just to inquire about it and I was filling them in, and they could see the happiness in my face, and they kept encouraging me, knowing that it was going to be okay. That impressed me also. She would talk to me like she was my mom. She gave me straight talk. She didn’t take no shit. You know? (60 year-old Black participant at the Birmingham site.)already in care, and therefore did not take much advantage of the program. A few such participants suggested they enjoyed interacting with the SCM despite having no direct need for assistance. Others implied that they did not have much contact with the SCM, while adding that there was “nothing to improve” or clarifying that the study intervention was unnecessary for them personally, because they already had the disease under control.Most other virally suppressed participants in the intervention arm (11 of 27) said that they were I mean in the past we haven’t had conversations like that. But ah, like I said, it’s always been, for me, it’s been my self-motivation that keeps me focused and, and, and has um kept me doing, what I had to do as far as taking medication to keep my health um in check. Um, as far as him helping me, not that much. And that’s not a, not a bad thing. I mean, […] If you’re saying if I benefitted from his help, then, no. But not in a bad way. (28 year-old Black participant at the Atlanta site)50/50” and not really coming through with his need for an apartment. The other implied that the “one-on-one” nature of SCM counseling sessions felt “harsh” and “very serious”.Only two of the virally suppressed participants in the SCM arm shared any concerns about their interactions with the SCM, both from the same clinic. One person described the SCM as being “I think that more people will feel more comfortable with a group instead of it being more one-on-one. Because when it’s one-on-one, it’s - it’s very serious. I’m not saying that, you know, HIV medication and discussions aren’t - shouldn’t be taken seriously, but it should be - it shouldn’t be so harsh on people because some people might have, um, a harder time coming to terms of what they - what - what they’re doing. (23 year-old Black participant at the Atlanta site.)Unsuppressed intervention participants were even more likely than those who were suppressed to describe SCMs in positive terms (n = 22 of 29). Like those who were virally suppressed, they used familiar terms “like a friend” or “like a brother”. Similarly, they emphasized the non-judgmental, caring relationships provided by SCMs - someone who really cared for them and who was rooting for their success. Indeed, several virally unsuppressed participants in the intervention arm regretted that they would no longer be seeing their SCM given the end of the study. For some, having developed a relationship over the course of the study, it was as if they were losing a friend or a family member.I’m ending the study, but you know, I was saying to [SCM1 name] the other day, it’s been so nice dealing with both of you and [SCM2 name]’s mother that passed away. I wrote him a card and got him a little gift, because I’ve got a friend who is an artist, and he does glasswork. So, … you know, kind of, we’ve developed some bonds in the time I’ve been in the study. Both gentlemen are so nice, [names of SCM1 and 2]. So, like I said, it’s bittersweet um you know, I didn’t want to participate at first, you know, it got kind of cumbersome keeping up with the appointments and the interviews. But then, I began to enjoy it. (55 year-old Black participant at the Boston site.)The remainder of these participants (n = 7) were somewhat more neutral about their SCMs, although none expressed any direct criticisms. They acknowledged some functional support provided by the SCM but did not indicate a more personal connection with their assigned SCM.virally suppressed participants in the SOC arm described their CCM in overtly positive terms. Some, for example, described their CCM as someone who truly loved his/her work and went beyond expectations, while others described their relationships with CCMs in more professional terms, identifying the CCM’s provision of specific services as well as the emotional support and non-judgmental approach that their CCM provided. None of the SOC arm participants, however, used terms like “friend” or “family”.Like those in the intervention arm, half (n = 17 of 32) of He’s just an amazing guy. He’s just, the way he, he – you could tell that he really has a passion for it, he’s not here just because of his paycheck… (He) is the reason why I come there, come here. Uh he actually was but they, they switched, like they got – he actually uh, got promoted here, actually, but they – yeah, they kind of switched different social workers sometimes… Oh, the past year, it’s over the past year, yeah, that’s my, my new case worker. And she’s like, she has um, a passion for it as well. (29 year-old Black participant at the Birmingham site)“the case manager has changed quite a bit,” “my case manager has changed three or four times” or “they switch your social worker around without you knowing”.About a third of virally suppressed participants in the SOC arm (n = 10) did not appear to have relationship with a case manager or patient navigator. Some directly denied they were ever assigned a CCM (n = 4). Others recollected having met with a CCM on occasion but noted that such people often turned over (n = 6). Typical responses included that “forever to respond back to emails or phone calls.”A small number of virally suppressed participants described their non-study CCM encounters in negative terms (n = 4). Mostly, these few participants suggested that their CCMs did not proactively check in with them, were not responsive to their needs, and that it might take them And she doesn’t seem like she’s personable. She’s like, you know, I mean, come on. Like, I’m gay and usually females are always like, “Hey,” well it’s like a good time. But with her, …it’s like we don’t click at all. And my lover has a social worker that’s on her job, does her thing, if she can’t get in contact with him on the phone, she sends an e-mail and lets him know. I mean, like she cares, and mine just don’t do that. So, I deal with her as little as possible. (33 year-old Black participant at the Birmingham site)unsuppressed participants in the SOC arm (n = 6 of 22) developed a strong personal bond with their CCM. While some CCMs were described as “very helpful,” “comfortable” or even as “going above and beyond,” more unsuppressed SOC participants were either neutral (n = 11) or critical in their descriptions of CMs (n = 4). For example, some participants depicted the CCM as “very casual” or “very tolerated” but also stated s/he was just “doing her job.” Several emphasized the transience of staff, and at times, the poor treatment they had received from CCMs.In contrast, far fewer I could tell, she was of no help to me at all. There were other case managers there that I would see in the hallway, and I would ask them the questions, and then of course they would refer me back to my case manager, who wouldn’t keep appointments, so on and so forth. (49 year-old White participant at the Atlanta site)moved on,” “might not remember their name,” or were not responsive to calls and emails.Half of participants in the intervention arm (n = 28 of 56) also had concurrent interactions with non-study CCMs. Whether virally suppressed or not, their experiences with these staff were reflective of participants in the SOC arm. For example, more than half of intervention arm participants (18 of 28) also described their non-study CCMs in very positive terms, portraying these staff as respectful, caring, and dedicated professionals who provided valuable services. Like some in the SOC arm, however, others noted that caseworkers frequently “VS intervention participants, the SCM’s role appeared to focus on addressing participant questions about medical issues, assisting them to make and keep their clinic visits and to stay on track with their medications and with other life goals. Some participants highlighted the important role that the SCM played in helping them confront emotional challenges and dealing with mental health issues. The non-judgmental approach was like being in a therapy session.Among …as far as like the um the study that I was going through with [de-identified], those, the case workers there, they allowed me to actually talk and open up and they listened to where I was able to, you know, express myself and get some stressful things off my chest. They were very helpful… they helped me get into contact with the people at [de-identified] that I needed to get in touch with, and as I started going through some of the clinics and they started seeing if I needed to see any other ones like mental health and all, others started opening up doors for other appointments for me.  - SCM arm.“A lot of sessions became counseling sessions. Some serious drug use and mental health issues came up. Everything came out.”SCMs validated this idea. As one SCM (#2) emphasized, many of the participants were dealing with complex life issues. VS participants in the SOC arm (n = 16 of 32) were more likely to describe getting support for insurance and/or keeping their appointments than they were to receive emotional support. Non-study CCMs helped participants fill out insurance claims, apply for Medicaid or the Ryan White program, process disability claims. Like their SOC counterparts, about a third of virally suppressed participants in the intervention arm also attributed support with appointment reminders and insurance to non-study CMs.In contrast, Some virally suppressed participants in both arms described having needs outside of the HIV services. These included requiring assistance with housing (8 in the SOC and 9 in SCM arms), linkages to mental health services (2 in SOC and 3 in SCM arms), access to food pantries or fitness programs (3 in SOC and 3 in CM arms), and transportation services (4 in SOC and 3 in SCM arms). Although SCMs provided these linkages at times, they were more often provided by non-study CCMs or other groups. In general, at the time of the exit interview, VS participants in both arms indicated that these non-HIV needs had been or were in the process of being met.Um, I have a great relationship with my care manager, because she helps me get a lot of things done in case I need um, if I have problems with housing, she gets me connected with the right person in housing. Um, she also helps me with getting co-pays and um anything I have to deal with my disability, trying to file for disability, that’s who I go to get the help that I need. So, she’s pretty much a handy person when it comes to me needing things.  – SCM arm.Getting out of drugs. Okay. And how did she help with that? She stayed on my ass and got me a self-program… It’s something that we were working on now. Just sort of working on it, but I don’t know (how to) tie this one to that. But I’m – in my opinion, I think it’s working out great. (37 year-old Black participant at the Birmingham site) - SOC arm.major motivator. Others draw on their faith in God or their own internal strength and experience to stay healthy and adherent. One participant, who described himself as living to serve others, both professionally as someone engaged in customer service and outside of work as a praise and worship minister at a church, explained his commitment to keeping his appointments like this:Virally suppressed participants often expressed, however, that they also relied on other sources of support. Some point to their mothers or their children as their This is imperative with me. This is almost like a lifeline with me. Okay? It’s almost – needed. It’s just as imperative to me as eating, resting, driving, working… because first of all, I love my life. I love living. I love living wholesome, as opposed to partial. I’m not seeking for any type of breakdown during this entire journey. (53 year-old Black participant at the Birmingham site.) – SCM arm.Another, who was diagnosed with HIV in 1996 while in prison, struggled with active addiction and feelings of depression before accepting the help of various case managers and peer support groups to first accept his situation and then apply himself to improving it. He now looks towards using his inner strength to help others:According to what they told me, my viral load is 100 or less, which is good. Meaning that I’ve come a long, long way, thank God! And, if I keep taking my medicine, that I could be undetectable. That’s what I’m striving for, to be a peer support, um, coordinator. But, you have to be undetectable, so that’s something else. […] (My intentions are) Continue taking my medicine and just allowing God to strengthen me where I may be weak.  - SOC arm.gently admonish, encourage or get them to commit to their medication adherence. In general, participants perceived these efforts as showing how much the SCM cared about them as a person, not just a patient. At the same time, several participants acknowledged that “you can’t twist a grown man’s hand.” An Atlanta participant who suffered a relapse during the study described the following encounter when he came in for his next blood draw:Half of unsuppressed participants in the intervention arm (14 of 29) described the SCMs’ efforts to follow up on missed visits, keep them informed about test results, and to He (SCM) said, “What’s going on?” And I broke down and he told me, he’s like, “You’ve got to change. You cannot stay out there on drugs. you’ve got to like commit.” You know he gave me the encouragement and the uh -- the showing that he really, really -- that someone cares about me --to get my life back together. He -- you know he -- it wasn’t fake. […] He wasn’t rushing to do the blood draw and things like that. He was really not rushing -- he wasn’t rushing. He wanted to hear what my pain and my problems were, and some people really don’t you know -- they’re all about just business […] I just, I let him know what -- that I had relapsed you know. His main issue was trying to get me back on my meds. That was his main issue coz that’s the only issue I let him really know that I needed. Everything else – I kept that hidden. (51 year-old Black participant at the Atlanta site) - SCM arm.Indeed, more than half of unsuppressed participants, regardless of study arm, described dealing with on-going non-HIV related challenges – issues that were not always addressed by a case manager. These larger life problems, including a lack of housing, drug and alcohol dependencies, feelings of stigma and shame, and serious physical disabilities, seemed to get in the way of focusing on medication adherence per se.“where I would be sleeping” when the next visit was scheduled. An Atlanta participant described his situation:Although many study participants identified having struggled to obtain stable housing at some point since being diagnosed with HIV, more virally unsuppressed than suppressed participants (10 versus 4) continued to face housing problems even at the end of the study. They described having to keep their medications in a backpack or at a friend’s house when they were living in a shelter or on the street. It was sometimes challenging to make or keep clinic appointments when unsure about I was looking for housing some time ago and I wasn’t assisted with that, so I’m living, I always say communal living … it’s a single home, but there’s … actually ten different people living in the house. They’ve broken it up into little rooms. Um, the living conditions are extremely poor. There is one refrigerator for ten people to use, the refrigerator does not work. My food that I do have is being stolen all the time. … Um, they’re playing loud music. They’re smoking all kinds of drugs that I can, seeps through the door, I have to put stuff down at the bottom of my door, so I don’t smell them. … I’m not tending to myself in a way that it should be done. It’s one community bathroom. The one woman that uses the bathroom, um I’m gonna try to be as polite as possible, when it is her time of the month, it ends up on the toilet seat and she doesn’t clean it up. … It’s a very, it’s a disgusting, poor living condition, and I can’t take care of myself at all. So, on top of your depression, you go for your food and it’s not there. I’m not eating. So that all leads up to poor health. (49 year-old White participant at the Atlanta site) - SOC arm.While some unsuppressed participants had been linked to mental health services before or during the study, about a third of virally unsuppressed intervention and SOC participants (n = 16) described on-going, unresolved struggles with mental health issues, social stigma and substance use that interfered with healthy living and with medication adherence. Some unsuppressed participants struggled with anxiety or depression because of their HIV diagnosis, sorting through issues of disclosure to sexual partners and family, and/or accepting the need to take medications for a lifetime. For others, such mental health issues were precipitated by other life events – the loss of a family member or having to manage other serious health problems. For many, these issues were exacerbated by food, employment, and housing insecurities. Resorting to drugs or alcohol to alleviate the stress also contributed to missed appointments or pills.I don’t know if it’s ever easy, you know when you live with this uh, it kind of overshadows, basically your life experience. […] Sometimes, it’s just a little depressing, you’re reminded each day, you know, each day you take the meds, you’re reminded of your condition, or my condition… I don’t think anybody really likes meds, but they’re essential to our well-being, you know. I guess I’m grateful that they do have all these different meds today that can help with different conditions. You know, and I’ve got other medical conditions also, so it’s not just the HIV that I’m dealing with, so. (55 year-old Black participant at the Boston site) - SCM arm.“in God’s hands.” As one participant explained who was diagnosed in 1998 but hadn’t taken HIV drugs since 2011:Challenges accepting the disease, the need to take HIV medications or deal with their side effects led three participants to discontinue their medications and to leave their fate Well, um, it was a choice that I made um, when I was... and they had put me on medication, and it made me real sick. And when I stopped taking the medication, I was – I got back to feeling fine, so you know, I’m kind of superstitious. I prayed about it and put it in the hands of God and […] I guess you can say I’m not, I, I don’t, um. How can I say it? I don’t claim it. I don’t claim the um, disease and I just live day-by-day. And I’ve been alright. I haven’t been sick. I haven’t, have not ever been hospitalized. And I really haven’t had no problems as far as the HIV is concerned, since I stopped taking the medicine. You know, I’ve just been, honky dory so far. (50 year-old Black participant at the Atlanta site) – SOC arm.“lifts” for unsuppressed patients to get to their clinic visits. However, neither group of counselors was always oriented towards assisting with the root problems that virally unsuppressed participants faced. This seemed especially the case for CMs in the SOC arm. Only eight of 22 virally unsuppressed SOC participants described receiving any kind of support, and this was generally described as cursory. Several participants in this group described knowing more  than their case worker did.In general, both SCMs and CCMs helped people obtain Social Security disability, deal with lost IDs or other issues. They provided tokens, bus passes and sometime actual The one  that I had before, they don’t do nothing. I don’t know about the one now because I’m gonna start new with him today. But uh, the ones that I have, and they supposed to help with housing and with other things. They never, they never help me with, with nothing. And the, and the time that she see me, it’s because the doctor push her to see me… Yeah, uh, housing, but they don’t, they don’t, but seriously, they can’t help me with my health. Why would they help me with my housing problem? (44 year-old Puerto Rican participant at the Boston site) – SOC arm.From the SCMs’ perspectives one of the main benefits of the intervention was the more personalized care and attention they could provide to patients. One SCM (#1) explained that clinic-based social workers might have 500–600 other patients. Because the SCMs were not employed through the clinics, they could offer their “undivided attention,” more flexible scheduling, and no time limit during their sessions. Using a MI approach, SCMs would try “tapping into what they (patients) thought was important to them, whether that’s their family, or they want to go to school, or just whatever it is to stay healthy.” By providing a sympathetic and non-judgmental ear, the intervention works to “build an extra layer of trust.” (SCM #3).I found what seemed to be most helpful to clients is to have a sympathetic, nonjudgmental ear, aside from their medical team to help them, you know, just put a handle on what was going on with regard to --… Medication adherence and what have you and sometimes that seemed to make a difference, that really you know playing the role of you know um a nonmedical provider, you know I was more uh perceived I think as an ally by them in their efforts to become adherent. (SCM #4)Most SCMs acknowledged, however, that the intervention only appeared to work if participants put in effort to engage with it. Echoing statements by a few participants in the SCM arm, several SCMs acknowledged that some participants already had a good support system in place and did not need the additional services, and occasionally a participant might just want to work the system, only making visits that would be reimbursed by the study.“life circumstances”  that prevented them from engaging in care. Helping participants navigate these structural barriers required having good working relationships and networks with other providers for services outside of a SCM’s job scope (SCM #1). Linkage to additional services was difficult in at least one study location, because “things here are very scattered.” A patient might have to go to multiple places across town to access different services (SCM #2). As SCM #3 noted, a person could be on a housing list for 12 months before lodging became available.SCMs concurred with the mental health and structural challenges described by participants. They acknowledged that the biggest barriers to medication adherence were often “get off the fence,” they also concluded that to be successful MI requires “a revolution in your thought processes” (SCM #4) – and not just the participant’s thinking, but also the counselor’s. In different ways, SCMs questioned how well a participant who was resistant, in denial or facing major life challenges could generate his own plan of action. If MI were to work under these circumstances, they suggested that the intervention dose should be larger – for example, having weekly or at least monthly visits for a longer duration. Although SCMs joined the study with different levels of experience using MI techniques, most suggested that MI was “a really hard skillset to learn” (SCM #6), particularly when working with clients in such challenging situations and over such a short period of time. They concluded that the two-day MI training they received at study initiation was not adequate to ensure SCMs possessed the correct mind and skillsets at the beginning of the intervention, rather than building them along the way. Recommendations included conducting a two-week intensive training followed by weekly coaching sessions.SCMs had mixed views on MI. Although most identified MI techniques as especially suitable to help participants get in touch with their intrinsic desires to better manage their disease and Our qualitative exit-interview study provided greater insight into the main findings from HPTN 078, including an in-depth description of the multiple barriers to adherence faced by this largely “out-of-care” population, as well as a more nuanced understanding of the benefits and challenges of implementing MI.First, despite SCMs’ questions about how well they were able to implement the MI approach, it was clear that the study CM created a relationship that was different from patients’ experiences in routine clinical care. This emotional bond was noticed, strongly appreciated – and in a few circumstances, its absence after the study closure was regretted. Although SCMs linked people with other services, they did not provide the services themselves, focusing more on the motivational aspects of care and medication adherence. Regardless of viral suppression status, participants in the SCM arm felt acknowledged and supported. On the other hand, peoples’ experiences with CCMs were more variable. Some CCMs were able to create a bond, focusing not just on helping to fill paperwork or schedule appointments, but also showing personal interest and support. Frequently, however, patients experienced gaps in services, including high turnover in staffing, apathetic and sometimes judgmental treatment from support staff.Although not directly expressed, participants may have valued the SCM relationship (and MI’s client-centered approach) because it contrasted with stigmatizing interactions often experienced or anticipated, particularly by PLWH of color. Indeed, some have suggested that the patient-centered nature of MI may help to reduce the imbalance of power between providers and patients of color, restoring the psychological power of those traditionally disenfranchised .Nevertheless, despite the perceived high quality of the intervention, the main study found no differences in VS. One explanation is that, especially for this hard-to-reach population, it takes time to get to viral suppression, perhaps because they had to sort out so many of the other  deterrents to care and medication adherence. Overall, only 48% of study participants were virally suppressed at the end of the study . Participants who were suppressed, whether in the CM or SOC arm, appeared to have fewer intractable barriers to their care. While they might need assistance with insurance, fewer needed support from their CMs to address issues of housing or food insecurity. In some cases, they had already developed the personal skills and/or access to networks to take care of these needs. Nonetheless, many virally suppressed participants described having struggled with such issues in the past. Many virally unsuppressed participants attributed their challenges with visit and medication adherence to homelessness, housing or food insecurity, mental health and/or substance use problems, other chronic health issues, including blindness, or underlying job and financial security. In some cases, CMs were working with them to resolve these issues; in other cases, the system seemed ill-equipped to address them. A synthesis of qualitative studies exploring underlying reasons for poor treatment outcomes among Black and Latino PLWH identified similar phenomena in which participants’ cyclic and/or long terms experiences of material, social and emotional challenges wore down their sense of self-worth and their ability or resolve to remain engaged in care .Some researchers have found that, while MI leads to subjective improvements in quality of life and reduction in some risk behaviors, this has not necessarily translated into changes in objective measures of adherence or VS –28. Furtbefore the outset of study and supported with fidelity monitoring and coaching throughout the study to sustain fidelity and allow an accurate assessment of the efficacy of MI (The challenges encountered by our SCMs to learn and deliver MI impeded our ability to accurately assess its efficacy in improving HIV outcomes among HIV virally unsuppressed patients, many of whom had been out-of-care. Nonetheless, the established efficacy of MI to improve HIV, mental health and substance use outcomes in other studies –17 suggecy of MI .Several limitations should be kept in mind when considering our findings. The study aimed to identify the “hard-to-reach” PLWH; those who had been out of care. Due to challenges with slow recruitment, strategies shifted away from deep-chain, respondent-driven sampling towards a wider range of recruitment strategies, including direct recruitment through clinic advertisements . ThroughThis qualitative exit study was conducted among a sample of mostly Black or African American MSM living with HIV, most of whom were out-of-care and all of whom were virally unsuppressed when initially enrolled in a randomized trial to assess the effect of an enhanced case management intervention on viral suppression. Our findings reinforce the literature suggesting the benefits of an MI approach to support PLWH intrinsic motivation for medication adherence, provide social support and counter stigma. However, they also provide a more in-depth picture of the multiple systemic challenges, including housing and job insecurity, mental health, substance use and other chronic health issues – barriers that may not be easily resolved through MI alone. Our findings suggest that an enhanced case management approach, one that includes the rapport-building qualities of MI, can have very positive effects on PLWH attitudes towards medication adherence, but that more intensive and coordinated support to address the broader structural barriers is required for some, not all, of those who have fallen out of care or remain virally unsuppressed. A differentiated care model that provides a more intensive MI plus structural intervention approach for patients facing multiple systemic challenges warrants further evaluation.Below is the link to the electronic supplementary material.Supplementary Material 1


Informed by the principles of grounded theory, the inductive analysis identified five processes in which migration and violence shaped meanings of motherhood: risking everything, embodying separation, braving reunification, mothering others, and experiencing motherhood due to sexual violence. The findings contribute knowledge of how violence shapes and informs women’s migrations and decision-making, and the consequences women endure in taking action to mitigate threats of violence in their own and their children’s lives. The analysis furthermore highlights the specific and profound effects of family separation on mothers. The voices, perspectives, and experiences of migrating mothers and the ways in which migration and violence shapes notions and lived experiences of motherhood are imperative to research, practice, and advocacy to change oppressive immigration policies.In the recent Central American migrations spurred by violence, political instability, and economic insecurity, women grapple with whether and when to bring their children with them in pursuit of safety in another country, and with fulfilling their roles as mothers from afar. Drawing from the transnational motherhood literature and critical feminist theories, this interpretive qualitative study examined transnational motherhood grounded in the lived experiences of Central American women ( Against the backdrop of contemporary Central American migrations spurred by violence, political instability, and economic insecurity, mothers contend with leaving children behind in pursuit of safety in another country. Mothers migrate expecting to settle in the United States (US) and send for their children in hopes of securing their collective safety over the long-term. Immigration policies, including those that separate families and limit avenues for asylum, influence and restrict decisions, actions, and opportunities available to migrating mothers. In the midst of complex structural and interpersonal dynamics, lived experiences of family and motherhood are altered and reshaped. This study offers a nuanced examination of transnational motherhood, grounded in the lived experiences of Central American women in the shadows of violence and migration to the US.Transnational motherhood acknowledges the ways in which people are anchored to multiple spaces and processes of mothering span geopolitical boundaries. Mothering across borders involves ongoing emotional care of, provision of financial support to, and communication with children from afar . The ideRecent studies have investigated how family is reorganized through separation, fears of separation, and upon reunification ,9. TransWomen and girls in Central America are exposed to a constellation of violence, including from gendered impacts of criminal gang activity, to intimate partner violence (IPV), sexual violence, exploitation, and high rates of femicide ,18. PoveThe sensitive interplay between violence, migration, and motherhood represents an emerging and needed area of continued inquiry. This study draws from transnational feminisms, which recognize migration as a process involving complex, unsettled, and fluid senses of place, belonging, identity, and responsibility ,26,27. FThemes of motherhood presented in this articled emerged inductively from a study conducted in 2014, which examined violence against women and processes of migration among Central American women in the US ,33.Based on a purposive sampling approach, researchers recruited women based on inclusion criteria: (1) 18 years of age and over; (2) migration to the US within the past 15 years; and (3) Central American country of origin: El Salvador, Guatemala, or Honduras. These criteria reflect the original study’s focus on contemporary patterns of migration from Central America to the US among adult women and women with children . In recrn = 19) women participated in the study, eight of whom originated from Honduras, six from El Salvador, and five from Guatemala. The average age of participants was 35 years (range: 25 to 53 years). Their average length of time in the US was 5.4 years (range: 2 months to 15 years). All participants identified as mothers, and on average women had 3.26 children (range: 1 to 7). Seventeen participants experienced one or more forms of intimate partner violence, sexual violence, and/or human trafficking.Nineteen . In an effort to build rapport and develop trust, the lead researcher reminded potential participants that their legal immigration status was not a topic of inquiry and that researchers would not report immigration status to any governmental or other entity . All parInformed by grounded theory analytical approaches , data anMotherhood was a salient and ever-present factor throughout women’s migrations from Central America to the US. The analysis identified five processes related to transnational motherhood at the intersection of migration and violence: risking everything, embodying separation, navigating reunification, mothering others, and experiencing motherhood due to sexual violence. All names are pseudonyms.“They have a right to live a future without violence, without problems, without death threats.”) Isabel also described her efforts to break the cycle of violence she had experienced, “no quería que mi historia se repitiera en mis hijos y por eso yo he sido bien luchadora.” (“I didn’t my kids to repeat my history and that’s why I’ve been a fighter.”) Sierra was in an untenable position as a mother trying secure safety for herself and her two young children in the context of regional gang violence in Honduras. She had only enough money to pay for herself and one child to travel to the US. On the one hand, she was concerned about the gangs that controlled her community targeting her son; on the other hand, she had to consider the likelihood that her daughter would be at risk of sexual assault and exploitation if she remained in Honduras. Sierra weighed the risks and ultimately decided to bring her daughter to protect her from sexual violence, leaving her son in Honduras. María first migrated from Guatemala to the US without her children. She then returned to Guatemala, hoping to remain there with her family. However, her life was again threatened and she decided to make the journey again, this time with her children, which she and her mother both perceived as a decision to risk everything. With great emotion María shared,Women’s efforts and risk-taking to protect and provide their children a life free from violence directly influenced their meaning making of motherhood. While some women migrated with one or more children, most women left their children in their home country when they migrated to the US. Women talked about fearing for their children’s safety back home and feeling guilt for having left them. María stated her hopes for her children: “tienen derecho a vivir un futuro sin violencia, sin problemas, sin amenazas de muerte.”  Le dije, no me importa, lo único que me importa es tratar de hacer algo por ellos, que no un día me voy a arrepentir y dije lo pude hacer y no lo hice. Y quería escapar, de ese infierno.I grabbed a backpack and filled it as much as I could with my children’s clothes and another bag I filled with food. [My mother told me], “No, you’re crazy, you’re going to get your children killed. You’re a murderer.” I said, “No, I’m not going to do that, and if that does happen I would rather we all die.” (crying) I said, “I don’t care, the only thing that matters is that I try to do something for them, I don’t want to one day regret being able to do something and not doing anything. I want to escape from that hell.“I just want your blessing, that’s all I’m asking of you.”) Part of “risking everything” included the possibility that the decision to migrate could damage relationships with family at a time when they needed their loved one’s blessings and emotional support to undertake a dangerous trip. The decision to migrate put the support and trust from their families and their most important relationships at risk.For María, taking leave from her mother in Guatemala also included a desire for her mother’s permission and blessing, and she told her mother, “yo solo quiero su bendición es todo lo que le pido.”  After talking with her children during her travels through Mexico, Clara said, “ponía a llorar después de oír a mi hijo. Y decía, ojalá que esto valga la pena.”  Beatriz referred to these worries as, “las madres rompen la cabeza pensando.” (“mothers worry themselves sick.”) In addition to fear and concern, women felt a tremendous sense of guilt in having migrated and the resulting separation from their children. Beatriz, for example, returned to Guatemala after four years in the US, fulfilling a promise she had made to her children. When she arrived back in Guatemala, they passed by her in the airport without recognizing her. She said,When separated, mothers constantly thought about their children and worried about their safety, well-being, and schooling. Mothers spoke at length about the stress and sense of guilt related to arranging care across borders. They expressed concerns about how to send money, and whether it would arrive and adequately cover their children’s needs. Despite feeling some satisfaction with being able to provide for their children’s education or health needs, women felt distress at not being physically present to keep their kids safe from gang violence. Women experienced the separation from their children in terms of acute suffering and fear. Sierra recalled leaving her son in Honduras, “mi corazón se partió en dos, dejar la mitad allá y traerme mi otra mitad para aquí.”  Women drew strength from having migrated for their children and felt supported by their children’s love and encouragement from afar. Facing inconsistency of support systems over time and space, women described ongoing processes of losing support, building support, and re-building supportive relationships with their children and others.Women shared painful examples of how motherhood plays out in separation from home and children throughout migratory processes. While Celia migrated to the US with one child at great emotional and physical cost, she continued to grieve the death of her son, who had died before she left Honduras. Her physical distance from Honduras played a significant role in her grief. She was plagued with not being in Honduras to provide him a proper burial. She was no longer in contact with anyone who had known him and felt that she, alone, carried his memory. Furthermore, she carried the burden of her abusive husband blaming her for the boy’s death. Hortensia shared another painful example of embodying separation during migration. While being held against her will in a drop house and having been sexually assaulted by smugglers, Hortensia learned that gang members had murdered her oldest daughter on the street in Guatemala. Hortensia was later able to bring two of her four surviving children to the US, though she remained physically separated from her two children in Guatemala and permanently separated from her deceased daughter. In spite of the separation, however, women described their children and motherhood as a source of strength. María, for example, shared “por mis hijos, no me da miedo nada.”  The US border patrol finally located them and sent them to the hielera [“freezer” or “ice box” in reference to the temporary detention facility] where they spent three days. From there, US immigration officials sent them to a center for minors where Isabel went to get them. Karla had two children in Honduras and gave birth to a third child in the US. She and her husband worked hard to save money to bring the older children to the US. They twice collected the required money, only to have it stolen. The third time they paid $20,000, with the intention of bringing both boys safely, avoiding the danger and suffering they had experienced. Yet, despite promises of better conditions, the boys ultimately travelled for one month by train, slept outside, and went without food. After six years of separation, Karla described their reunification: “Estaban enojados con nosotros, porque dijeron cómo era posible que nosotros habíamos mandado traerles así. (“They were angry. They said how was it possible that we would send for them to be brought like that?”) Some women reported that they would never bring their children to the US unless they could do it by legal means. Natalia, for example, was determined not to subject her other children to the abuse she and her daughter had endured during the journey. She reflected,The smugglers demanded Isabel send more money, ultimately totaling almost $20,000, which she did in desperation to secure the safety of her children, pleading to see them again. The smuggler said to her, “sí te los voy a entregar, cierto que eres una buena persona, una buena mamá, porque a pesar de que no sabes nada de ellos, sigues insistiendo”  Women took advantage of opportunities to care for other women’s children, putting their strengths and skills to use while separated from their own children and in the absence of unaccompanied children’s mothers.Sierra travelled with her own child and took care of two other children who were travelling alone and hoping to reunite with their respective mothers in the US. To protect them from harm, she told people that they were her own children and her travel group did not realize they were not her children until after they had crossed the Rio Grande. While women cared for unaccompanied children as if they were their own, these relationships were temporary. During or shortly after crossing into the US, they separated. Lorena continued to worry about what happened to the child she took care of in Mexico, who was passed to other smugglers. She questioned, “¿Y porque va a estar mejor que contigo si a ti no te conoce? A mi tampoco pero ya tiene dos o tres días de estar conmigo, pero a ti ni una vez te ha visto.”  that they had experienced or witnessed pregnancies following rape prior to, during, or post migration. Beatriz, for example, became pregnant resulting from sexual abuse by the man (“coyote” or smuggler) helping her cross through Mexico and into the United States. Lorena described immigration officials making women take a pregnancy test after they were apprehended while crossing the border into the US. She went on to say,Casi la mayoría de muchachas que vienen llegando y tienen sus hijos aquí fueron violadas en el camino y el bebé es consecuencia del camino. Es traumante. Porque aparte de que pasa esas penas en el camino todavía te queda un recuerdo para toda tu vida. (llorando)Almost all the women who arrive and have their kids here were raped on the way, and the baby is a consequence of the trip. It is traumatic, because in addition to experiencing these challenges on the journey, you are left with a memory of it for your entire life. (crying)Gloria, a mother of seven children, described what became a lengthy period of commercial sexual exploitation upon her arrival in the US after fleeing IPV in Honduras,Cuando llegamos aquí nos amarraban de las manos y de los pies y un pañuelo en la boca y nos tiraban a una camioneta como una pelota. Cuando llegamos a una casa, nos compraban una ropa y nos obligaban a que nos vistieramos y traían una señora que los peinara y los pintara. Y nos obligaban a cosas que no queríamos. Y eso fue duro para mi. Pues mis hijos son de todo eso. Los tres hijos de aquí fueron del abuso.When we got here they tied our hands and feet up, a handkerchief in our mouths and they threw us in a truck like a ball. When we got to a house, they bought us clothes and they made us put it on and there was a woman who brushed our hair and did our make-up. And they made us do things we didn’t want to do. That was difficult for me. My children are from all of that, the three children here are from the abuse.The spontaneous disclosures of these three women about the ways that violence forever marked motherhood in complex ways provide an additional and significant facet of transnational motherhood, deserving of further attention.The findings revealed the ways in which women who had migrated from Central America to the U.S. made meaning of their identities and roles as mothers, highlighting the centrality, power, and fluidity of motherhood at the intersection of migration and violence. Their roles as mothers and the imperative to risk everything to secure safety for themselves and their families served as constants in shaping their internal motivations and decisions to act. Women endured multiple separations from their children to secure safety, and braved the implications of reunifying with children who did not accompany them in their original journeys. In transit, they stepped in to mother children who were making the journey without a parent, fulfilling their roles as mothers even if only in passing. Some women would not make it to the U.S. without being sexually assaulted and experiencing motherhood as a direct result of violence. Together, the themes provide insights into complex processes shaping notions of motherhood and inform next steps for research, policy, and community practice.Motherhood intricately intertwined with the violence-migration nexus, as women sought to protect their children from harm and create a violence-free future for their children and themselves. Experiences and possibilities of violence and migration rendered transnational mothering fraught and heavy with impossible decisions. In fleeing violence both at home from an intimate partner and in the public sphere , they confronted additional threats and assaults, as well as continued structural violence. A dominant factor in a mother’s migration is often to ensure the economic survival of the family, which is largely interconnected with gendered poverty and structural oppression as well as the interpersonal economic coercion and control common in IPV . Thus, aThe findings from the current study add to the growing migration-related literature by highlighting the effects of family separation on mothers. The effects of temporary and enduring separations have profound and varied effects on parents, children, and caregivers ,14,15,37The findings must be considered in the context of US immigration, detention, and deportation policies and practices, which directly influence and often manufacture family separation and exacerbate experiences of IPV. Contemporary policies, for example, have extended the duration of and uncertainty around family separation, restricted cross-border travel for transnational caretaking, and generally have made family reunification more difficult ,16,20,38It is important that conceptualizations of transnational mothering acknowledge the power women exert as mothers. As this study illuminates, migrating with children and migration-related separation from children involves fluid and interconnected forms of coercion and/or force but also encompasses choice, autonomy, and self-determination. Even in the midst of the aforementioned policies and practices that restrict and criminalize the human experience of parenting, this study highlights the multiple ways in which women resist and challenge conditions and strategies that threaten to limit and constrict their roles as mothers. In warning of the dangers of maternal narratives that so easily blame mothers, rob women of agency, and promote one-dimensional and damaging narratives, Geraldine Pratt suggests that scholars instead aim to present “responses that affirm the testifier’s capacity to respond and hence their agency and subjectivity”  (p. 10).It is important to note certain limitations associated with this study, as it explored the process of migration in the context of violence for a narrow snapshot of migrating women and cannot represent all Central American women. Any research that focuses on migrating women runs a risk of essentializing migrant women and mothers, in particular, and it remains crucial to recognize the heterogeneity of migrating women and of migrants in general. In addition, researchers faced common impediments with recruiting, which were likely due to the social isolation and climate of fear experienced by undocumented and precariously documented immigrants, in addition to participant and resource constraints that did not allow for multiple interviews with each participant nor member-checking. There also exists potential bias related to participants’ prior engagement with legal immigration systems and having already told, constructed, or re-constructed their stories for a different audience ,45,46. SThe findings from this analysis highlighted facets of transnational motherhood at the intersection of violence and migration, amplifying the perspectives and experiences of mothers as they “risked everything” to secure a safe future for themselves and their children. Transnational motherhood encompasses a multitude of parenting configurations, as mothers continue to parent from afar and to reconfigure their caretaking pre-migration, during migration, and after reunification. Centering the voices, perspectives, and experiences of women who embark on the migration journey to fight for themselves and their children is imperative to research, practice, and advocacy to address structural violence spurring migrations and to change oppressive immigration policies. The study reiterates the importance of understanding how violence shapes and informs women’s migrations and decision-making, and the consequences women endure in taking action to change the inevitability of violence in their own and their children’s lives.


This research examines the form in which undergraduates use video cameras during videoconferencing class sessions in a Smart Classroom context and, more specifically, the reasons why a considerable number of students opt to turn off their cameras when videoconferencing during the sessions while others keep them on. The study was carried out in an institution that had previously switched from face-to-face teaching to an Emergency Remote Teaching solution, initially adopted in 2019–2020 to cope with the COVID-19 pandemic restrictions. Findings suggest that using cameras when videoconferencing is associated with increasing and enhancing the interaction between the student and the rest of the class, although not all students agreed with this conclusion. In addition, having the video cameras switched fomented socialization and improved the overall online learning experience for students. However, the surveyed students pointed out diverse negative elements, such as why they had to turn on their personal cameras, privacy concerns, and limitations derived from the available technology infrastructure, in addition to other factors such as distractions, anxiety, and cognitive load. This work discusses how these elements can influence the well-being and the user experience of the students, both positively and negatively. Coronavirus Disease 2019 (COVID-19) pandemic that outburst in March 2020 [The outbreak of the rch 2020  at all srch 2020 ,5 to facrch 2020 ,7,8, thuA considerable number of research works have focused on analyzing various aspects of the policies adopted to fight the pandemic and the effects that these measures have had on people in different facets of their lives ,11,12. TOne of the theoretical advantages of the SC system over the ERT format is that the installation of cameras and microphones deployed in the classrooms and the laboratories enabled live broadcasts of the class sessions. Furthermore, the SC solution that was implemented allowed participants who were attending classes off-campus to be seen and heard by the rest of the class thanks to the audio and video devices of their personal devices, typically a personal computer, used to connect to the class session. From our previous research works, students rated the different features offered by the SC format highly ,19. HoweDifferent research works have focused on studying the feelings and the thoughts of the students on the use of cameras when videoconferencing. Videoconferencing is a technological solution implemented by a wide range of institutions that can be carried out by means of diverse online meeting platforms , such asRecently, diverse issues have been raised in the research arena about the use of cameras when videoconferencing, such as: (1) why students turn their cameras on or off ,35,36,37Having analyzed the use of cameras when videoconferencing, different research works have found that users experience an increase in cognitive load as a consequence of the use of cameras ,68,69,70Students’ well-being can be defined as “a population-based term targeting positive feelings about oneself and reflecting an inner capacity—a resourcefulness—to deal with the pressures and challenges of student life and learning” . In factThe aim of this research work is to shed light on the undergraduates’ feelings about the use of cameras in the videoconferencing system through a qualitative approach. To perform this exploratory research about the use of cameras, a User Experience (UX) approach was applied to shed light on the topic. Since ICT engineering undergraduates are sufficiently digitally capable, this work does not include areas such as reluctance, fear, and the potential incompetence associated with the use of ICT technology.This research has been carried out by surveying second-year ICT engineering students who experienced a Smart Classroom system during their first year at the university ,14, whicBipolar Laddering (BLA) assessment tool, as detailed in The participants were engineering undergraduates from La Salle-URL enrolled in seven different ICTs specialties who attended the second-year annual subject ‘Value Chain and Financial Economics’ in the 2021–2022 academic course. The total number of enrolled students in the subject was 133, and 85 of the students that attended the last session of the class of the fall term were invited to complete an open-ended questionnaire voluntarily and anonymously on the use of cameras through a pocket The sample of respondents can be considered homogeneous since (1) all of the students had physically attended classes on campus, (2) all of the students attended class sessions by a videoconferencing system through an SC deployment on campus, and (3) all of the surveyed undergraduates were studying an ICT engineering degree.The qualitative research was planned following the guiding principles of other research works ,87,88,89UX enables the collection of feedback from the users once they have experienced a product or a service , being ttabula rasa, in Socratic words [BLA usage has been described in various research works, e.g., ,19, and ic words . The mecic words , values As a result of the BLA tool, different proposals to improve each of the elements pointed out by the students were collected. Once all of the students’ contributions were analyzed by the researchers, the most notable are listed as follows. The most repeated improvement was to remove the compulsory use of cameras when attending class sessions through videoconferencing when referring to different elements: PcE_04, PcE_11, NcE_01, NcE_07, NcE_13, and NcE_14. In this line, different ideas mentioned by the students are listed next: “Do not make the use of cameras when attending classes off campus compulsory”; “Not mandatory to switch cameras on”; “Allow the student to choose whether to switch on their camera or not”; “Do not force students to switch on the cameras; displaying the name of the student would be enough instead of showing his image”; “Convince the student to switch on the camera, instead of making it compulsory”, “Flexibility in camera use” or “Non-mandatory use of the students’ camera except in evaluations”. However, other students emphasized the idea that if connecting the camera was compulsory, instructors should be strict in demanding that all the students had their cameras on, as shown in the following opinions: “Force the student who is speaking to switch their camera on”; “Make all students have their cameras switched on” or “Force the student to have the camera activated at all times, except on specific occasions”.The students also detailed diverse opinions about how to improve interaction issues when referring to PcE_01, PcE_02_PcE_11, and NcE_15. Here, different thoughts may be mentioned as follows: “Improve interaction”; “More interaction”; “Improve interaction techniques by creating small and more participatory groups”; “Make class sessions more participatory”; “Include more interaction with students” or “Increase interaction with off-campus students”. When referring to privacy concerns, the students pointed out: “Despite allowing class sessions to be followed well, different mechanisms should be enabled to preserve privacy” or “Having the camera switched on can cause privacy issues when other colleagues see your home or take screenshots; it should be avoided”. To cope with distractions, “Make class sessions more participatory”, “Make class sessions more pleasant and fun, so that the student has an enjoyable time and thus avoids distractions”, or “Make the sessions of class much more enjoyable”. Students assessed the SC formats PcE_04, PcE_11, and PpE_06 to be very satisfactory, as shown in the following: “Take more advantage of the benefits offered by cameras” or “The off-campus format has been very useful during the confinement, it is an option that should be maintained in the future”. However, other students preferred the face-to-face format: “Make the class sessions in face-to-face format”. Being able to see the recorded class sessions was highly appreciated, and suggestions to improve that choice were: “Make recorded classes accessible for a month, instead of just for a week”; “Continue with the practice of recording class sessions in the future” or “Keep the recordings of the class sessions since they enable students to review concepts that have not been understood”.This research was carried out on students who had both attended classes on campus and been taught using the online format during their first year at the university. On the one hand, classrooms and laboratories were adapted to facilitate F2F teaching on campus . On the Strong student-to-student and student-to-instructor interaction top the ranking of the list of positive elements highlighted by the undergraduates surveyed in terms of mention index while appearing as a negative element for a group of students in line with ,36. ThisThe most mentioned negative item was the obligation to switch cameras on when attending classes off campus, cited by twenty students. A research study found that students used their cameras at the start of the class sessions in order to solve their socio-affective needs, then turned off their cameras after some sessions . In diffOur findings suggest the presence of cognitive load. Among the most common negative elements, we found items related to computer slowdown (NcE_02), distractions (NcE_04), poor audio quality (NcE_08), less instructors’ availability (NcE_10), and difficulty in reading what is written on the blackboard (NcE_11). These elements may hinder understanding and increase the students’ feeling of complexity, unclarity, and ineffectiveness of instructions and explanations, which have been previously identified as components of cognitive load . HoweverRegarding student well-being, among the most mentioned items, we found those referring to interaction and socialization (PcE_01 and PcE_03), flexibility and comfort (PcE_04), a feeling of better communication (PcE_05), and more enjoyable class sessions (PcE_11), among others, which may positively affect students’ satisfaction and may be related to lower levels of anxiety. However, other items such as “Feeling of being watched” (NcE_07) and “Shame, insecurity, feeling uncomfortable” (NcE_13) suggest that the use of cameras may also increase dissatisfaction and anxiety or stress levels. Differences in the perception of well-being have been previously explained by individual differences , and theThe limitations of this research work are presented in the following. Firstly, the undergraduates surveyed are engineering students who are tech-savvy in ICTs topics and, therefore, less likely to suffer from the issues associated with the use of the analyzed technology. This may mask concerns about the use of cameras by less digitally-adept users. To remedy this, further studies using other profiles that are not specifically oriented to technology could be carried out to generalize the findings on the use of cameras. Secondly, since all of the responses to the single open-ended question were requested to be given in a short format, some of the comments and suggestions given by the students were limited and most of the answers used less than fifteen words. Once the findings are identified, a qualitative survey can be performed to quantify the elements that have been mentioned by the student. Finally, as this study was conducted using second-year students, expanding this survey to first-, third-, and fourth-year students would enable us to check if the perceptions about the use of cameras in the analyzed context vary depending on the year of study. As far as further research directions are concerned, this UX-Based qualitative work on the use of cameras when videoconferencing in a tech-oriented undergraduates’ context may lead to diverse research lines. On the one hand, by replicating this study to non-tech-oriented students, on the other hand, by conducting quantitative research work to shed light on this research topic.Various conclusions can be drawn from the analysis of the data collected from the survey to capture student perceptions on the use of cameras when videoconferencing in a Smart Classroom system. The fact that respondents highly rate the option of being able to see their instructors and classmates in real-time through the cameras when videoconferencing is reflected in two main outcomes: better interaction, despite the fact that this element was considered a negative element for a smaller group of students; and more socialization. Moreover, the students stressed that thanks to the videoconferencing system based on the use of cameras, they have a high degree of flexibility in terms of class attendance as they can choose whether to take classes on campus or remotely. However, many students said that in terms of interaction, they preferred the F2F to the SC format and requested the implementation of mechanisms to improve interaction with other online students, which was consistent with previous findings presented in . With re


PRevention of Toxic chemicals in the Environment for Children Tool (PRoTECT), to examine people's knowledge and attitudes about the influence of toxic chemicals on child development. We used best practices for developing and validating scales. First, we drafted items to assess knowledge of the impact of toxic chemicals on brain development, levels of concern regarding exposures, and preferences for prevention of neurodevelopmental disorders. Second, we received feedback on item clarity from five focus groups consisting of 46 community participants. In addition, 17 experts completed a content validity scale for each item and provided qualitative feedback. We administered the revised 18-item questionnaire to 190 participants of child-bearing age for scale development, and using exploratory factor analysis, we found evidence for a four-factor model of PRoTECT, RMSR = 0.05, of which 16 of the 18 items had adequate content validity with loadings >0.40 on a derived factor. We discuss future directions and applications of PRoTECT.Early-life exposures to toxic chemicals can adversely impact brain development. Understanding people's knowledge of the impact of toxic chemicals on brain development is critical to reduce widespread exposure to chemicals. Yet it is unknown what people know about risks of toxic chemicals and how to reduce exposures. We developed and validated the questionnaire,  Toxic chemicals are an insidious threat to children. Toxic chemicals elevate the risk for neurodevelopmental disorders, including learning disabilities, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) . The devOver the last two decades, scientists and physicians have called for increased education on children's environmental health in the healthcare setting –5. In 20Education of parents and pregnant women has received less attention than healthcare providers, even though mothers are eager for information about pregnancy and early childhood . In 2009In fact, several studies have shown that educating parents about the impacts of toxic chemicals on children's health can influence their behaviors. One recent American study found that greater parental concern about toxic chemicals was associated with lower urinary concentrations of phthalates and phenols in children's urine . AnotherAcknowledging the impact of toxic chemicals on brain development may help prevent neurodevelopmental disorders by encouraging the public to find ways to reduce widespread exposure to chemicals and advocate for stricter regulations to prevent chemicals from entering the environment. While advocations for regulatory policies on the widespread commercial use of toxic chemicals continues, families can be educated on how to make safer choices for their children's health. Yet, it is unknown what people know about the risks of toxic chemicals, and with the absence of information on their knowledge, it is unknown how clinicians and researchers can better support parents. While people may not understand the risks, or how to manage exposures, information disseminated by the chemical industry about the safety of their products further undermines public awareness of the scientific evidence of developmental health risks associated with toxic chemicals. Lastly, documenting parents' preferences for prevention of neurodevelopmental disorders may also accelerate the development of regulations and enhance parental advocacy.PRevention of Toxic chemicals in the Environment for Children Tool (PRoTECT) to assess parents' knowledge about toxic chemicals and brain development. We also wanted to assess their level of concern about toxic chemicals and preferences for the prevention of neurodevelopmental disorders.We designed and validated the PRoTECT using best practices for developing and validating scales  collective expertise in children's environmental health, collaboration with stakeholders and funders, and a literature review to identify areas that were lacking in the field. We identified three domains of interest: (1) knowledge of developmental neurotoxicity, (2) level of concern about exposure to toxic chemicals, and (3) preferences for the prevention of neurodevelopmental disorders.*” OR “chemicals” OR “environment*” AND “neurodevelopment” OR “ADHD” OR “autism” OR “cogniti*” OR “behav*” AND “attitude” OR “knowledge” OR “preference”. After identifying key papers on this subject, we used the references from the papers to identify additional relevant articles. The scoping review only identified nine empirical studies on parents' and pregnant women's knowledge and attitudes of children's environmental health. Thus, we extended our search to include healthcare providers' knowledge of developmental neurotoxicity.To define the domains of interest and generate items, we conducted a scoping review using the following key terms: “toxic chemicals” OR “toxilow levels of toxic chemicals on brain development, the ubiquity of toxic chemical exposure present in the environment and everyday products, children's and fetuses' unique vulnerability to toxic chemicals, and the government's oversight and regulation of toxic chemicals. The second domain, level of concern, was defined as people's perceptions of the risks associated with exposure to toxic chemicals, including where they are found, whom they trust to provide information on toxic chemicals, and whether reducing exposure is important. The final domain, attitudes toward prevention, included people's preferences toward prevention relative to treatment of neurodevelopmental disorders, their knowledge of the government's expenditures to prevent neurodevelopmental disorders, their preferences, if any, for the government to prioritize funding into prevention, and their understanding of the prevention paradox .The first domain, knowledge of developmental neurotoxicity, was defined as knowledge of the relation between toxic chemicals and neurodevelopmental outcomes. Specifically, this domain included knowledge of the impact of No validated scales have examined parental knowledge of developmental neurotoxicity and preferences for prevention, so we used the articles obtained in the scoping review to develop phrasing and rating scales. For example, we looked at terms that refer to “toxic chemicals” and found that studies have used “environmental exposures” , “enviro(strongly agree) to 5 (strongly disagree) based on previous research of health-related knowledge surveys , 2 (unable to assess relevance without revision), 3 (relevant but needs minor revision), and 4 (very relevant and succinct)]. Following each item, experts were asked to provide general qualitative feedback on the item and specific qualitative feedback about how it was worded. At the end of the questionnaire, experts provided their general impressions on key words used throughout the survey, as well as whether any content was missing or any item should be removed.We assessed content validity by having experts evaluate the questionnaire items and using focus groups of the target population. We contacted 20 international experts in epidemiology, psychology, environmental health advocacy, neurodevelopment, and public education to assess the content validity of questionnaire items and provide feedback using a Google Survey platform. Each expert was asked to rate the content relevance of each item using a four-point response scale  and fitThe first round of expert review consisted of six experts in epidemiology, psychology, children's environment health advocacy, and medicine. In the first round, 17 of 18 items had excellent content validity ratings (CVI ≥ 0.83). The second round consisted of six additional experts and 17 of 19 items (one item was added based on results from the first round) had excellent content validity ratings (CVI ≥ 0.83). Two items were dropped in the second round based on low ratings. In the third and final round of expert review, four experts participated, and 13 of 17 items had excellent content validity ratings (CVI = 1.00). The CVI of the total questionnaire in round three was 0.76  could elicit blame in parents, suggesting that “[we] need to be very careful not to infer ‘blame' in this type of query” and to “take care not to induce potentially unproductive feelings of guilt in parents”. Therefore, the item was restructured to reduce its potential to incite guilt in parents . In other examples, experts rephrased items in their own words to reduce jargon or added words to make the item more specific. For example, an expert suggested adding the word “effective” before regulations (see item 4 on round 3).The experts' general impressions revealed several themes. First, experts reported that certain terms  needed to be defined at the beginning of the questionnaire. For example, one expert wrote, “I would try to use as widely accessible terminology as possible. I think that may mean having a few lead-in comments that help to define terms that are going to be used in subsequent questions”. Another theme that emerged was whether some items may be leading to get an “agree” response. One expert wrote, “wonder if some questions may be leading” and another wrote, “seems like it is loaded to get an ‘agree' response”. Thirdly, experts reported that many items had “too many clauses” in it or “lots of nuances” that would make it difficult for a parent to understand. Lastly, experts expressed support for our project and shared that it is “so great that this is being done!!!”.We also asked experts if any content was missing. If two or more experts suggested the same item, we considered adding it to the survey. This process led to a new item asking about genetics vs. environmental exposures in determining health outcomes. For example, one expert suggested “do respondents perceive developmental disorders as random or pre-determined ?”. Two experts suggested adding items on “pesticides” and “labeling like natural vs. organic”. Experts also suggested adding what parents are “already using to minimize chemical exposure or what strategies they currently think are helpful” as well as “what entity respondents trust to be effective at ensuring the safety of their food, consumer products, etc”. Still, most experts did not feel any content was missing. One expert wrote “one can always think of other questions, but I think the survey hits the right mark and is a good length”.The purpose of the focus groups was to understand participant's grasp of phrases or terminology of the items, as well as their preference. For each item, we coded focus group transcripts to indicate participant agreement, dissent, and significant statements suggesting either agreement or dissent . For exaParticipants provided qualitative feedback for each item and their general impressions. Many themes overlapped with the expert reviews. For example, participants shared that some of the items elicited blame or guilt. In reference to item 5 referenced above, one participant mentioned “this felt like a moment of blame”, and another said, “[there is] something triggering in this question for me as a parent”. Participants also indicated that certain wording was too technical. For example, with respect to item 12 on rounds 1 and 2 , one participant “was wondering if we could break it down because I had some trouble understanding”, another mentioned that “people who aren't involved in science may be confused”, and a third participant said “it took me a few times and I'm not sure if I even understand it right”. Participants also expressed that they wanted the items to be specific and not too vague. For example, in reference to item two (rounds 1 and 2), one participant asked, “can we be more specific what ‘more resources' means”, and another said “resources is very broad…could be almost anything”. When asked whom people would trust to get this information in item eight (rounds 1 and 2), participants expressed that they would want the information coming from scientists who study the topic. For example, one participant said, “I would overall trust a health professional or scientist in a specific field”. In some instances, participants suggested rewriting the item altogether. One participant said, “I would suggest rewording the whole thing”.Participants said that they wanted key definitions before terms that would be used several times . For instance, participants asked “can we add in brackets what these learning and behavioral conditions might be” and “I'd like to know a bit more about what the toxic chemicals are”. Thus, we added key definitions to the beginning of the measure . SimilarOverall, qualitative results revealed good content validity , and the Likert-type response was understood .PRoTECT administered to participants consisted of 18 items and included a brief introduction to define key terms  was removed due to poor ratings from both experts and focus group participants. The version of ey terms .PRoTECT questionnaire. Of those, 190 (81%) completed the questionnaire , providing a ratio of over 10 participants per item.A total of 235 participants were recruited and began the r = 0.02) to r = 0.65. To determine the optimal number of factors to explain the pattern of inter-item correlations, we first plotted the eigenvalues of the correlation matrix with a scree plot, which suggested that four factors account for the pattern of inter-item correlations .The strength of the inter-item polychoric correlations ranged from approximately zero  was substantially better than the RMSR from the 3-factor model (RMSR = 0.08) or 2-factor model (RMSR = 0.10). Therefore, we present the results from the four-factor model with an oblimin rotation of the factor pattern matrix . ImportaA four-factor model fitted to the inter-item product moment correlations also had an adequately low RMSR statistic = 0.04, and the oblimin-rotated factor pattern led to similar conclusions about how each item related to each of the four factors.PRoTECT, a questionnaire assessing knowledge about toxic chemicals and neurodevelopment, level of concern, and preferences for prevention of neurodevelopmental disorders. The participants, including potential and current parents, said that the questionnaire was important and contained information that they do not hear about in their day-to-day lives. Similarly, expert reviewers indicated that this kind of research needed to be done and asked to be contacted with the results.This study developed and described Feedback from several rounds of expert and participants generated a questionnaire consisting of 18 items. Considering this is the first questionnaire to measure knowledge and preferences surrounding toxic chemicals and brain development, we used factor analysis to provide meaning to the pattern of inter-item correlations and apply conceptual labels to the four factors described below.prevent developmental conditions as they spend to treat these conditions” and “All parents have equal opportunities to protect their children from toxic chemicals like pesticides or heavy metals, regardless of income level, race and ethnicity, or where they live” , and included items such as “Toxic chemicals in our day-to-day lives, like air pollution or lead in drinking water, can increase a child's risk of developing conditions like ADHD or autism” and “Reducing exposure to toxic chemicals during pregnancy and in early childhood can help lower a child's risk of developing a condition like ADHD or autism”. Lastly, Factor 4 represented knowledge about toxic chemicals and society, and included items such as “Most governments invest about the same amount to ey live” .Since item 18  had a loading that was <0.40 and could be tapping more into emotional feelings (“worried”) as opposed to knowledge or attitudes, we removed it from the questionnaire.Exposure to toxic chemicals is particularly harmful to babies and children.” The final version of PRoTECT can be found in Item 11 , a knowledge-based item that we felt was important to retain, did not have a substantial factor loading on any factor, indicating that it is not strongly influenced by any of the four constructs represented by the factors. Theoretically, it should be related to factor 3 ; however, it could be phrased such that the item was not understood. For example, participants may have disagreed with the item if they thought it suggested that babies and children have more opportunity to be exposed to toxic chemicals, as opposed to its intended meaning of greater susceptibility to the adverse impacts of toxic chemicals. Considering that this item had been revised multiple times following focus groups and expert reviews, it could be that it is not self-explanatory. Therefore, to avoid confusion about opportunity for exposure between children and adults, we changed item 11 to: “r = 0.30), suggesting that people who knew more about developmental neurotoxicity were also more likely to want to reduce their exposure to toxic chemicals.The highest inter-factor correlation was between factors 3 and 4  with inclusion of a knowledge translation tool in which half of the respondents will watch a video on the impact of toxic chemicals on brain development. The large sample will provide opportunities for further psychometric evaluation of PRoTECT and investigate whether the four-factor model of PRoTECT remains across a larger sample and more diverse group. A six-week follow-up survey will be conducted to assess differences in responses to PRoTECT after exposure to the video or its material, and whether any intent to change behaviors persist or increase after completing the questionnaire.We are currently administering PRoTECT represents a potentially useful tool for assessing knowledge as it pertains to toxic chemicals found in the environment and their impact of children's development. In turn, parents' understanding of the impact of toxic chemicals on children's development may accelerate the promulgation of protective policies and regulations.While we await stronger legislation to reduce toxic exposures among pregnant women and children, it is important to find ways to effectively communicate these risks with parents and caregivers. Thus, The raw data supporting the conclusions of this article will be made available upon request by the authors, without undue reservation.The studies involving human participants were reviewed and approved by York University Ethical Review Board. The patients/participants provided their electronic informed consent to participate in this study.RG, BL, EP, and CT: study conception and design. RG, CG, SR, and JJ: data collection. RG, BL, CG, and DF: analysis and interpretation of results. RG and CG: draft manuscript preparation. RG, BL, EP, CG, DF, and CT: manuscript review. All authors reviewed the results and approved the final version of the manuscript.This work was supported by Passport Foundation, the Minderoo Foundation, and the Forsythia Foundation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.