More attention is being paid to the wellbeing of staff working in stressful situations. However, little is known about staff experience of providing end-of-life care to children within a hospice setting. This study aims to explore the experiences of care team staff who provide end-of-life care within a children’s hospice.Qualitative research incorporating interviews and a focus group. Data were analysed using thematic analysis. Purposeful sampling led to a total of 15 care team staff recruited from a children’s hospice offering palliative and specialist care to life-limited children and young people.The hospice setting provides a model of excellence in supporting staff and mitigating challenging aspects of their role, which includes peer/organisational support, and regular ongoing training in key aspects of children’s palliative care. Key recommendations for improving their experience included advanced communication training and knowledge sharing with other children’s palliative care specialists within the acute setting.Service and policy initiatives should encourage open, informal peer/organisational support among the wider children’s palliative care sector. Further research should focus on paediatric palliative care education, particularly in relation to symptom management and communication at end-of-life, harnessing the expertise and breadth of knowledge that could be shared between children’s hospices and hospital settings.The online version of this article (doi:10.1186/s12904-017-0189-9) contains supplementary material, which is available to authorized users. There is an increasing focus on examining the experiences and wellbeing of healthcare staff providing key services in order to improve patient/carer experience . Staff wPrevious research suggests that staff who provide end-of-life care to children across a range of settings such as hospital and community, do report positive experiences, including rewarding relationships with children and their families –4, and mAlthough the impact of providing end-of-life care to children is well documented , 6, 8, tThe aim of this study was to explore the impact of providing end-of-life care to children on staff within a hospice setting, how they cope, and draw recommendations for improving staff wellbeing, thereby improving the quality of paediatric care for both children and their families.This research took a qualitative approach to draw out the depth of staff’s experience. Individual interviews were used to explore in-depth experiences , and focn = 40). Potential participants were contacted by administrative staff on the researcher’s behalf inviting them to take part in interviews, a focus group, or both if they wished. Information sheets for both interview and focus groups were attached, describing the purpose and nature of the research, along with assurances of confidentiality. The researcher’s details were provided with a request to get in contact if they wished to take part. A follow-up email was sent to non-responders after two weeks in order to aid recruitment.This study focused on the experience of the Care Team within a children’s hospice in Northern Ireland, who provide specialist palliative care services to children and their families. These include planned and emergency short breaks, symptom management, family support, end-of-life care, and bereavement support. Services are provided within the hospice facilities, as well as in the child’s own home. Care staff were recruited using a purposeful sampling approach from the total population of all care team staff working within the hospice .A lot of families would describe it as a big hug, like they feel arms like round them… (S8)Staff repeatedly spoke of ‘making a difference’ as one of the most positive experiences. Staff acknowledged that end-of-life situations were the most difficult things families could ever go through, and the thing that brought them the most satisfaction was being able to make that time somewhat easier, through supporting them, managing their child’s symptoms, and providing individualised care and activities.And then, the care that we have for one another, as a team, is a really positive experience I’ve had in here. (S6)All the nurses on the team are fantastic and they’re so supportive. The entire management are very supportive as well… it’s about everybody knowing what stage the child’s at, and working and sharing experiences together for that child’s benefit. (S9)Staff found great comfort in knowing that they were never alone, on a personal or professional level, in providing end-of-life care to a child:I find that [symptom management] difficult because you’re aware that you don’t want the parents to have that lasting memory of their child having seizures or being in pain (S5)When it’s challenging, like when it’s difficult to control pain or symptom management is difficult, that can be when it gets really stressful because you are just thinking, oh, I need to do more, you really just want to make sure, all the time, that we’re doing 100%, (S2)While staff identified a number of rewarding experiences, it was also clear that providing end-of-life care to children was associated with many challenging experiences, such as finding the right combination of medications to alleviate end-of-life care symptoms and reduce any distress for the child and family;You’re almost afraid of saying the wrong thing, because that time is what families are going to remember, so you feel a lot of pressure to get it right for them. (S8)Knowing what to say… like after the child has passed, because nothing you can say really is going to…benefit them… So that’s definitely I think the hardest. (4)Communication with families;I think…if you didn’t grieve after a family…you couldn’t just bottle all that up. You couldn’t just keep building that up and not letting any of that out. (S1)Managing their own grief; andthe stressful situations are whereby, you’ve all that going on in the mix as well as having children in for respite, and quite complex children, and you’ve got that family there, and they’re in an end-of-life situation, absolutely devastating.(S2)Balancing complex respite care alongside end-of-life care.However, staff also reported a number of coping strategies and unique aspects of the hospice setting that helped mitigate the challenging aspects of their role. These findings indicate a number of recommendations for the hospice setting and the wider children’s end-of-life care sector.I’ll go home and I’ll be in like super like tidy mode or like, like just need to do something in the house… like a distraction, to distract me, I like reading as well, and I’ll like read and like kind of use that to get myself into a different place. (S6)Staff talked about the importance of having an outlet outside of work in order to maintain energy for both their work and home life. Staff exercised self-care in a variety of ways such as focusing on the positives of their work, taking comfort from their religious faith, keeping busy with housework, reading, exercise, hobbies, practising mindfulness, or talking to their work colleagues. Most of these practices helped staff clear their heads and get into a better place psychologically or emotionally.I have a couple of really good friends in here, and because they work here, it’s easy to sound off to somebody because you know it doesn’t go any further. Unless you’re working in this environment, you wouldn’t understand just how intense it can be. (S12)One of the key areas of support for staff was being able to talk openly with their colleagues, which provided a safe place where they did not have to worry about not being understood or breaking confidentiality. Coming into work was seen as a positive because of the support they received.Even from a management point of view, they’re very involved on the floor in what’s going on. I mean, there’s always a chance to talk, and they definitely encourage that as well. (S2)Another key source of support came from managers and the Senior Social Worker. Staff found this really helped in terms of releasing the pressure they sometimes felt.At the start, we used to have debriefs all the time when somebody died, but it was very formal type of thing, sitting in a room with one of your managers and just talking about it, which a lot of people didn’t feel comfortable with. (S12)The managers have…they’re kind of called sticky-bun sessions … just after there’s been maybe, a child that we’ve been caring for for a long time who has died or, just a difficult time, and we would come round here with a cup of tea and just talk about it, and even that in itself is just a bit of a safe space where you can kind of bounce off each other. (S5)Nursing staff also spoke of how beneficial their clinical supervision was for reflecting on end-of-life situations and receiving reassurance that they had done all they could for the child and family. However, some staff felt that formal debriefing did have a place for some people, especially care assistants who did not have clinical supervision. While some liked the idea of formal debriefing sessions, others did not like sharing in a formal group setting. Hospice leadership appeared to be proactively trying to find a middle ground by providing a safe but more informal space for all staff to share their experiences. For example, all staff mentioned ‘sticky bun days’. This simple act of getting together over a cup of tea and buns provided a safe place for staff to unwind, and was seen as a more relaxed and spontaneous response to a particular situation.I think further development in communication is paramount for all staff, especially working in this area. …some people have gone to maybe communication days, but that’s been at a more senior level. (S3)Communication was mentioned often as an area requiring ongoing education, especially in relation to having difficult conversations.I think we get good training, mostly though cascaded down from, previous experience, and that experience is invaluable, of people that have obviously worked here for a long time. (S5)I think the more experienced nurses do feel more like confident in what to say, and I know that the bereavement counsellor in here, all the nurses talk about her. She always says the right thing, and I think it is just through experience. (S4)While some staff felt role-play would be useful, others felt that learning by experience was more beneficial. Most staff referred to the wealth of knowledge that could be drawn from more experienced staff, including both healthcare assistants and nurses who had worked at the hospice for a long time.I do think that we have a lot to offer and that should be shared. I think…just bringing, again, professionals in and saying, “Hey, we’re the Hospice, our door is open – come and see us!” I just feel that they’re very insular, all the specialisms, and they should actually open themselves up to discussions, because they’ve a lot of experience to offer and learn from each other. (S14)Staff also recognised the hospice as a leading organisation in this aspect of care, with great potential for sharing their experiences with other organisations who care for children with potentially life threatening illnesses, and also learning from their experiences.The findings presented in this study provide unique insights into the experience of healthcare staff providing end-of-life care within a children’s hospice, and, as such, add to the paucity of studies conducted in this setting.Such experiences highlight important implications for consideration for both service and policy level initiatives within the children’s’ palliative care sector, particularly areas of excellence that could be translated to other settings, and recommendations on how to improve staff experience.In line with findings from both hospital and community settings, staff viewed their role as rewarding in terms of the meaningful relationships developed with children and their families . HoweverA number of challenges, similar to those in the hospital and community setting were identified, such as symptom management , and comOur findings support previous research conclusions that the hospice setting provides the gold standard in terms of peer and organisational support to staff who provide end-of-life care to children . This haWhile formal debriefing has been recommended by previous research as a key strategy for helping support staff , 18, newRegular training sessions were also offered, and staff were free to suggest any additional education or training needs. Staff also saw more experienced colleagues as invaluable for easing anxieties in relation to communicating with families about end-of-life issues. However, there was also consensus that advanced communication skills training should be available to all staff, not just more senior staff. Harnessing the expertise of experienced staff would be a cost-effective way to deliver this training.Similarly to findings from other paediatric palliative care settings, psychological self-care was identified as an important coping strategy , 21. TheAnother key finding highlighted by staff, and reiterated in the literature , was theThe findings consider a single children’s hospice, with a small sample size, limiting transferability to other settings. Nonetheless, many of the findings substantiate results from previous research in a range of settings. However, further research in different children’s hospices would be useful to triangulate our findings and assess the degree to which our recommendations would be helpful in other contexts. While being open to healthcare assistants, the sample was mostly comprised of nurses, which makes it less representative of all care staff. Healthcare assistants may have unique experiences which should be explored further in future studies. Nonetheless, this study adds to the limited understanding of staff experience of providing end-of-life care within a children’s hospice.With the increasing recognition of the key relationship between staff wellbeing and patient/carer reported experience, the impetus is on both service and policy level initiatives to improve staff experience. Findings suggest areas for dissemination of learning and good practice from the children’s hospice setting should include open, informal peer/organisational support, regular, ongoing research, education and training in symptom management and communication skills, drawing on the expertise of more experienced staff. Knowledge transfer should also be encouraged between children’s hospice and hospital settings to draw from others expertise, so that ultimately the best possible end-of-life care is available to children regardless of setting.


In the report, “Impact of Requiring Influenza Vaccination for Children in Licensed Child Care or Preschool Programs — Connecticut, 2012–13 Influenza Season,” on page 183, in the Figure, the groups of vertical bars were labeled incorrectly, and the legend was difficult to follow. The corrected Figure is as follows.


New York Times article, “Do We Really Need Negative Book Reviews?,” published on February 11, 2014, by Francine Prose and Zoe Heller [Mobile Technologies for Every Library.I open this book review with a quote from the The book’s author, Ann Whitney Gleason, AHIP, is more than qualified to write on the subject, given that her vast experience includes director for resources and systems, educational technology specialist, technology director, and chief information officer (CIO). This book’s shortcomings are in its timeliness and lack of insight into emerging technologies.Don’t Make Me Think, Revisited: A Common Sense Approach to Web Usability, retain usefulness. I found a great deal of value in the 2005 edition (and still do), even though the latest edition was published in 2014 . Some topics, like writing for the web, usability, and information architecture do not need to be updated every year because the overall concepts do not necessarily change greatly. But I think if authors are going to write about specific devices, apps, and emerging technologies, their objective is get their books in their readers’ hands quickly before the books go stale.Like the author, my research interests are educational technologies in libraries, specifically mobile technologies, so when I had the opportunity to review this book, I was excited to learn something new. Admittedly, having written a fair amount on technology, I acknowledge how difficult it is to remain current. Some books, like Steve Krug’s Mobile Technologies for Every Library is helpful jumping-off points for beginning research or familiarizing oneself with the material. By the author’s own admission, her audience is someone who is wondering how to get started adopting mobile technology (p. vii). One of my first criticisms is why the first chapter included the history of mobile technology, complete with a simplistic illustration of the “brick” type of cell phone. I do not think the reader who wants to learn how (and why) to begin a mobile technology initiative would need this information. What difference does it make what cell phones were in use in the 1980s?For the uninitiated reader, the inclusion of notes, further readings, and resources at the end of each chapter of Chapter two gives the reader a broad overview of mobile devices, which is useful when first thinking about designing and implementing a mobile presence. These descriptions are compact, but the market share information is outdated, and the pie chart tallying 2013 world smartphone market shares (p. 13) has illegibly miniscule type, and the nuanced shades of gray are impossible to decipher. Chapter three, by far the most helpful chapter in this book, starts with a goal, asserting it will guide the reader through some of the “options, best practices, tips, and tools” (p. 25). It gives steps for preparing for a mobile presence, creating a mobile strategy, designing a mobile-friendly web presence, selecting content to include, and testing usability. The only thing I would take issue with is the brevity of the list of resources that are included in the testing section at the end of the book.Chapters four to eight discuss mobile apps, mobile information seeking, best practices of mobile technology uses in libraries, and use of mobile technology in education. These general overviews are helpful for those readers who are completely new to the subject area. Fortunately, chapter four provided me with a bit of chuckle when I saw that Figure 4.2, “Android versions currently in use,” was three versions behind .Scientific American, and so on), and an overview of “wearable technology” describes devices like the Pebble watch and FitBit but does not mention the wildly popular GoPro camera and nothing about the usefulness of these devices in libraries. Furthermore, virtual reality (VR) and augmented reality (AR) are not new and exciting, nor is Google Glass, for that matter.Chapter nine opens with a Wikipedia definition of “library out-reach” and moves through some worthwhile information, such as how librarians “must proactively seek integration into teaching and learning, as well as into community activities, in order to provide value and return on investment or risk losing funding in these competitive budgetary times” (p. 99). Chapter ten closes the book with a look into the future of mobile technology. Sadly, this chapter is woefully out of date  article in Mobile Technologies in Libraries . As Prose asserts in the previously mentioned New York Times article, “Needless to say, criticism is a matter of opinion,” and this review, although critical, is my opinion.I do not recommend this book to any librarian looking for an affordable book that thoroughly covers the topic of mobile technologies in libraries. Instead, look to Ben Rawlins’


Active play has become a critical focus in terms of physical activity participation in young children. Unstructured or child-led play offers children the opportunity to interact with the environment in a range of different ways. Unstructured materials, often called loose parts, encourage child-led play, and therefore may also promote physical activity. The purpose of this scoping review was to determine what is currently known about how loose parts may influence physical activity participation. Following a systematic literature search, a total of 16 articles were retrieved, reviewed and categorized according to: (1) types of loose parts; (2) types of play; and (3) types of thinking. We found that there are currently a range of loose parts being used to support play, but the way in which they are implemented varies and there is a lack of clarity around how they might support the development of active outdoor play and physical literacy skills. Through the affordance theory, connections can be made between loose parts and physical activity participation among children 2.The current review is considered a scoping review, as it focuses primarily on the extent of information available, as opposed to the quality of the articles reviewed To search for relevant scholarly reports related to “loose parts”, a literature review was completed using the following online databases: Canadian Research Index, CBCA Complete, ERIC, Periodicals Archive Online, ProQuest Research Library, Social Services Abstracts, and Sociological Abstracts through the ProQuest search engine along with Academic Search Premier, SPORTDiscus, PsychINFO, PsychArticles, the Teacher Reference Center and CINAHL, searched collectively through EBSCO host. The keywords used were: “loose parts”, “objects”, “plaything”, “toy(s)”, “material”, “natural”, “open ended”, “idiosyncratic”, “informal”, “free”, “outdoor”, “unstructured”, “informal”, “creative”, “explore”, “active”, “imagination”, “creative”, and “play”. The inclusion criteria required that articles be full-text editions from the year 1970-onwards, relating to children or youth. To narrow down initial findings, subjects were tailored to early childhood education, recreation, educational psychology, and teaching education. These criteria were included in order to ensure that the findings were relevant to the purpose of this research. Results provided 60 potentially relevant articles from the EBSCO group and 15,000 from the ProQuest group. An additional search was completed in Google Scholar using key words “loose parts”, “play” and “preschool” which generated a list of 572 potentially relevant articles. The compiled 15,632 articles were then assessed and only those whose titles and keywords that were related to the current understanding of loose parts were included for a final number of 192 relevant citations. Duplicates were then removed resulting in a total of 176 articles for review. See Throughout the search a number of set inclusion and exclusion criteria were developed to narrow the search and tailor results to the specific topic of interest. Focus was to be on loose parts use in normally-developing school aged children (12 years and under), specifically on the child's development or use as opposed to teacher development. Work had to be focused on the use of loose parts, not on the design of playgrounds/play settings, or the type of play . Finally, those that focused on other learning outcomes such as literary or art-based skill development as opposed to physical activity-related outcomes were excluded. Using these inclusion and exclusion criteria a partial review of titles and abstracts was completed, narrowing the results to 44. Seven thesis and PhD dissertations were included in this list but were not included in the present review, which focused on published data only. The focus of the thesis and PhD dissertations includes the role of nature and outdoors in dramatic play, behaviours with open-ended materials, and role of nature on children's development. The reference lists of the compiled articles were also scanned to check for additional sources that had not been generated during the search. Articles were removed if they did not contain sufficient information to be adequately summarized for the current review. For example, magazine articles comprised solely of lists of materials that could be found around the house and used to stimulate play, were not considered to be loose parts. A final total of 16 articles were included in the current review.3.3.1.There is currently a very broad understanding as to what makes up a loose part, and the terms used to actually define these loose parts are not clearly defined. For example, the term “loose parts” is used interchangeably with “open-ended materials”. Both natural and synthetic materials were included in the lists of loose parts that were described in the reviewed articles. Nicholson originally described loose parts as materials that are variable, meaning they can be used in more than one way so that children can experiment and invent through play 3.2.Incorporating loose parts into a play environment opens up the possibility for various types of play. Whether the child chooses to use them for creative, dramatic, exploratory, cooperative, or constructive play, the loose parts are flexible and can be selectively chosen to ensure that they are appropriate for any particular age group, with children being able to use them in ways that are reflective of their own individual development Maxwell, Mitchell and Evans conducted a two-part study that first observed the type of play behaviours on different playgrounds and then observed the additional effects of adding loose parts to enhance play behaviours in an outdoor setting Drew and Nell supported the idea that loose parts provide the opportunity for a range of different types of play 3.3.Similar to types of play, some studies focused more on types of thought or thinking that might be stimulated through loose parts play. Convergent thinking is based on logic and a set of rules or guidelines that are followed Szekely emphasizes how loose parts in outdoor environments can foster a creative play setting, while also encouraging children's artistic abilities 4.This review has identified the scope of literature on loose parts materials through the analysis of several published, peer-reviewed studies that focus on the use of loose parts for active outdoor play, along with several magazine articles. The review provides an overview of the potential that loose parts might have as a means to promote physical activity participation and develop physical literacy in children through unstructured play. However, the available evidence is limited, particularly in how active play with loose parts might impact physical literacy. The search strategy used was kept broad, resulting in a similarly broad range of information that then had to be narrowed down manually. Furthermore, the term itself, “loose parts”, is ambiguous and unfortunately, many of the generated articles related in no way to the concept of loose parts for play. Another major limitation is that there was little comparability between the outcome variable that studies were exploring. Some studies were interested in how loose parts affected creativity Neill argues that the implementation of loose parts encourages a range of types of play including creative play, exploratory play, or dramatic play Another limitation, inherent to loose parts, is that there is no way to predict how children will choose to play with them. This makes it challenging to assess how loose parts might support physical activity and physical literacy and reveals an important gap in the literature. While the malleability of the term loose parts is beneficial for providing ample opportunities to incorporate these types of materials into play, it does complicate research into the benefits associated with loose parts. Prior to further exploration on the impact of loose parts, it would be beneficial to agree on a common definition for the term, as well as the specific parts that should be considered “loose parts” for research purposes. A common definition would allow for a mutual understanding of the concept, while also allowing for research in this area to become more focused and comparable. However, as discussed previously, what and how children use various materials for play is very hard to predict and therefore harder to define. While there does seem to be a fair amount of research on the use of loose parts, the quality is quite variable. For example, Oncu provided children with loose parts and then had them explain how each would be used When school-aged children are given the opportunity for more outdoor free play after school, physical activity participation increases and sedentary behaviours decrease 5.The existing articles relating to loose parts provide an overview of the loose parts that are being used, how they are used, and the types of thought and play that these materials can encourage. It is clear that the information currently available regarding the implementation and impact of loose parts is both very broad and limited with respect to promoting physical activity and physical literacy. Loose parts may include anything from logs and rocks to ropes and boxes, highlighting that it is both natural and synthetic parts that fit into this category


Varpio et al. lay out challenges that new faculty face in negotiating different meanings of scholarly contribution, teaching and service in a quest for promotion and tenure within their universities . PromotiNavigating this future means first developing a deeper sense of our heritage. Universities first formed in Europe as self-regulating communities of scholars and learners that determined the qualifications of their members. Today, that spirit lives on in the form of communities of tenured peers, who rely upon specific processes and practices in the pursuit of advancing knowledge. Formal definitions of terms that are broadly shared across universities, such as ‘teaching’, ‘research’, and ‘service’, carry a veneer of uniformity, yet their meanings have evolved over time. In turn, local connotations of these terms held by faculties – even within the same institution – are highly particular and contingent upon more immediate assumptions of ‘what matters’. Echoing Wenger-Trayner’s description of communities as ‘landscapes of practice’ , engagedThe highly particular comes to be embodied in the members of the local community and, in turn, the record of their work. Academic accomplishments may powerfully resonate locally and within one’s discipline, yet in most universities, faculty reviews are conducted at multiple levels: department, faculty and university-wide. As evidenced within institutional documents, policies and procedures, scholarly contribution must be translatable from the unit to the broader university community in order to achieve promotion and tenure. Both of our examples above fit into the broader framework of legitimate university activities, yet a shared sense of these activities is rarely well articulated.The complexity increases even more when we recognize that our world of Health Professions Education (HPE) is not a well-demarcated discipline; rather, it is a creative interdisciplinary field in which different perspectives and healthy debates flourish. Debate is the lifeblood of academic communities, and the debate about the nature of evidence, proof, truth and knowledge is fundamental to HPE . As a fiWhile junior faculty can be drawn into and come to share the implicit nuances of terms within their own disciplines, this can be more challenging for those who invest in HPE. Different perspectives and approaches may indeed flourish within the field and lead to a creative intellectual ferment, yet one’s contributions may be greeted with skepticism beyond the borders of this space. Young faculty members in HPE, drawn from distinct disciplines, may stumble in the dark as they integrate into a field positioned academically within faculties of health sciences with their positivist leanings. Scholars must cross out of their disciplinary field in order to enter HPE, and at some point must decide whether to fully embed (and leave their discipline behind), whether to straddle – creating meaning for both HPE and their own discipline – or whether to use HPE as their lab for contributions to their own discipline. This boundary crossing can be fraught and this subtext of leaving disciplines behind is rarely explicit in conversations about promotion and tenure . Young fAs individual faculty members, we are constrained by the processes of the institutions to which we belong. Those processes differ from one university to the next, as Varpio et al. point out, and so they should. Such processes were designed and crafted by individuals and undergo constant change in interpretation. How scholarship is interpreted has changed in both the long-term (philosophy) and the short term . In turnPromotion and tenure may indeed be an odyssey, and an uncertain one. Indeed, Socrates did not have to contend with this maze, but without tenure he also lacked academic freedom. He irritated everyone in the pursuit of understanding the world, and his road ended abruptly in custody and a cup of hemlock. Even so, he helped lay the groundwork for our heritage. Specifically, one in which we challenge assumptions, confront how we think, and reconsider our assumptive definitions. In contemporary universities, we follow his path when we challenge and reinterpret how we might demonstrate teaching, scholarship, and service to our community of peers. Just as Socrates did for Plato, and as Plato did for Aristotle, we in turn open new pathways through the labyrinth for scholars treading in our footsteps.


There are unequivocal health disparities, both physical and mental, between the Indigenous and non-Indigenous peoples of Canada.Utilizing narrative inquiry, 15 néhiyawak (Plains Cree people) between 18 and 71 years of age from Thunderchild First Nation were interviewed to explore what improved their mental health and well-being and what they needed to attain optimal mental health and well-being. By posing questions that focused on the positive, the strengths and resilience of the néhiyawak came to the forefront.Narrative thematic analysis of interview data consistently revealed four overarching themes that highlighted what positively impacted néhiyawak mental health and well-being and their perceived needs to attain optimal mental health and well-being: relationships; spiritual beliefs and cultural practices; tānisīsi wāpahtaman pimātisiwin (worldview); and ēkwa ōhi kikwaya piko ka-ispayiki kīspin ka-nohtē-miyo-mahcihoyān . The néhiyawak in this study described holistic health determinants that correlate with the medicine wheel and the determinants of health, and described these holistic health determinants as making a positive difference to their mental health and as necessary for them to obtain optimal mental health and well-being.These results suggest that mental health programming and interventions should be harmonious with Indigenous culture; utilize a holistic approach that takes physical, emotional, mental, and spiritual well-being into consideration; and address the existing mental health disparities using the determinants of health as a framework, with an increased focus on the current socio-economic status of Indigenous peoples in Canada. There is an abundance of literature that clearly describes the existing health disparities between Indigenous and non-Indigenous people in Canada. It is timely to collaborate respectfully with Indigenous peoples to ask them what contributes to their mental health and well-being. Having this first-hand knowledge is an important first step in mental health program planning and in delivering effective mental health care to Indigenous peoples.néhiyawak from Thunderchild First Nation and what they perceived as necessary to attain optimal mental health and well-being. Secondly, the first author, an Indigenous woman, wanted to conduct research that was strength-based and would give voice to contemporary Indigenous (Plains Cree) people from her community of Thunderchild First Nation, Saskatchewan.The primary goal of this research project was to explore factors that improve the mental health and well-being of the Indigenous peoples were historically autonomous, then colonized, and now, approximately 500 years later, continue to be disproportionately represented in most physical and mental health issues when compared to non-Indigenous people in Canada , 26, 60.Why does the health and mental status of Indigenous people continue to lag behind non-Indigenous people in Canada? This is an important question, and the answer is embedded within the Indigenous/non-Indigenous historical relationship, specifically colonization. This historical relationship is the fundamental root of the current health disparities experienced by Indigenous people on a daily basis , 43, 62.A range of epidemiological studies have documented high levels of mental health problems in many Canadian Aboriginal communities , 53, 61.More recently, Khan  identifiIn addition, as a result of the colonization process, Indigenous peoples have been subjected to a multitude of traumatic experiences , 62. UnfAccording to Health Canada , suicideGiven the growing awareness of the many social and economic issues that have and continue to have an impact on First Nations communities, there has been increased urgency to develop and implement effective community interventions to address existing mental health issues.Narrative inquiry was used to guide the research process, and thematic narrative analysis was used to analyze the data. Clandinin and Connelly  describeA variety of mediums were used to inform the community members in Thunderchild First Nation of the research study. Posters were hung in the school, Band office, and the health clinic. Alongside the poster, there were recruitment letters for potential néhiyawak to take that included information on the nature and purpose of the research, criteria to participate, and contact information for both researchers. Some of the néhiyawak saw the primary researcher hanging the posters in the community, which led to conversations about the project, and they often expressed their interest to participate at that time. Snowball sampling  was utilNéhiyawak who participated in this study met the following criteria: (a) Band member of Thunderchild First Nation, living on or off reserve, (b) 18 years of age and over, and (c) interested in participating in this project. Within this study, Elders were: (a) Band members of Thunderchild First Nation, living on or off reserve, (b) greater than 50 years of age, (c) identified by Chief and Council or other members of the community, and (d) interested in participating in this project.Fifteen néhiyawak agreed to participate in a semi-structured narrative interview. néhiyawak were between 18 and 71 years of age; seven were male and eight were female. Of these 15 participants, three were Elders: two female Elders were 62 and 70 years old, one male Elder was 62 years old. The néhiyawak level of education varied from grade 4 to completion of an undergraduate university degree. In addition, 13 of the 15 néhiyawak had a source of income either from being employed, receiving a pension, or living with their parents while attending high school.A semi-structured interview guide comprised of six questions ? How have you coped with the stressors in your life (if required ask: share an example)? Tell me what has helped you deal with the stressors in your life (if required ask: share an example)? Tell me what gives you hope (for the future/keeps you going) (if required ask: share an example)? Imagine yourself as mentally healthy/well as possible, what would have to happen for you to achieve that?) was used to broadly structure the interview process. The primary researcher ensured each participant had ample opportunity to share their stories in their own ways, in their own time.néhiyaw received the same information about the process. After the participants answered the first question, the primary researcher shared two descriptions of mental health. The first description was from a Western paradigm and the second was from an Indigenous worldview. The script was: “The Canadian Mental Health Association …nagging…really had an impact on the way I think…mom’s always said, ‘life is tough, life is what you make it.’” When the néhiyawak were asked what gave them hope, what kept them going, their first response was generally related to their relationships. One middle-aged man spoke about his children giving him hope and keeping him going: “My kids give me hope. I don’t want my kids to see me as being a quitter or giving up.”These relationships allowed them to express their feelings; provided acceptance and a sense of belonging, pride and respect; provided the opportunity to reflect on their past experiences, different perspectives, and new ideas; ending and beginning new relationships fostered personal growth and self-awareness; and finally, relationships provided them with hope, knowing that they can always turn to a family member or friends for support.The significance of relationships positively impacting mental health and well-being is not a new concept. However, given the history of colonization and especially the residential school legacy, it is essential to understand the increased significance of relationships on contemporary Indigenous peoples’ mental health and well-being.enculturation as “the extent to which individuals identify with their ethnic culture, feel a sense of pride in their cultural heritage, and participate in traditional cultural activities” (p. 296). Ross  when those parents came home, they didn’t go to church and they didn’t practice Indian culture. I often … wonder when they have hard times or when they struggle, how do One woman shared how her spirituality was making a positive difference to her mental health. She explained how spirituality had been integrated into her daily life and that to her was religion. She wondered how others cope without having spiritual connections and expressed empathy for those who attended the residential schools and were forbidden to practice their spirituality and culture:Really, my mind was confused, my way of life was confused…in time I met an Elder and found out that I had to find my identity, who I really was as a Cree person. I needed to find out about my morals, my beliefs and my values as a Cree person. Which I did!One male elder shared his healing journey involved exploring his identity as a Cree man:Colonization has disrupted Indigenous peoples’ spiritual beliefs and cultural practices , 43, 52.Aboriginal cultures are rich with ceremonies designed to build strength, restore balance, and promote healing . The néhtānisīsi wāpahtaman pimātisiwin, when translated means worldview, how you see life, how you see the whole piece of life. The néhiyawak in this study described how their worldview was influenced by their past experiences, formal, and informal education. The néhiyawak spoke about three primary areas that affected their tānisīsi wāpahtaman pimātisiwin (worldview) that improved their mental health and well-being: (a) taking personal responsibility, (b) their attitude, and (c) wícihisowin. This Cree phrase, wícihisowin, means helping oneself.This Cree phrase, A male Elder shared how taking personal responsibility to make the changes in his life, attending Alcoholics Anonymous (AA), dealing with his anger, addressing his low self-esteem, focusing on positive thoughts, and having therapists who believed in him contributed positively to his mental health and well-being. He voiced, “what helped me is to really work hard on my problems, to listen, to practice, and to make changes in my life. Not just talking about it, but to make that change!” He acknowledged that he “couldn’t drink, be with people that use, or be in high-risk places such as bars or parties.” In addition, he stated he had “to deal with my anger, my resentment toward people who had hurt me.”A lot of people create their problems, because their lives or stories catch up with them. So, it’s best to be honest with yourself… It doesn’t matter how difficult, or negative a story is, I [change] it to something positive. I don’t focus and concentrate on the negative because I know that’s what causes stress and for people to become depressed. It doesn’t matter what other people say or think about you. What really matters, is how you feel about yourself!The néhiyawak explained that their attitude made a difference to their mental health and well-being. They described appreciating every day, thinking positively, accepting things as they are—believing there will be a positive outcome, having mutual respect, helping others, and having hope to improve their mental health. One young woman asserted, “just living every day to the fullest!” improved her mental health and well-being. A female Elder stressed the importance of being positive all the time and not worrying about the gossip. She was adamant in her belief that people often create their own stressors as a result of their lifestyle choices. She asserted:It’s the way I look at life…be positive. You have got to work hard at everything you do. Anything you want, work hard for it… I don’t wake up in the morning feeling negative. This was passed on to me by my grandfather, and my parents, be happy when you wake up every morning, somewhere along the way things might change, but at least start your day off right. In my house, I don’t allow anybody to be grumpy, or mad, in the morning, I just say, ‘not now, don’t do that now, it’s the morning, let’s get up happy.’ And you never give up, you never ever give up!… It is important to abstain from drugs and alcohol because it never was a part of our culture and it doesn’t fit in our culture. I’ve never done drugs of any kind, including pain killers.A middle-aged man improved his mental health and well-being by having a positive attitude, working hard to achieve goals, and engaging in daily self-reflection. In addition, he stressed the importance of abstinence from drugs and alcohol made a difference to his mental health. He said:mino-pimatisiwin,” meaning “the good life” (p. 44). Mussell  anymore.One very young woman attributed her past experiences, environment, and her children as her inspiration to make changes and improve her mental health. She spoke about the difficulty of living in an area that was “surrounded by alcoholics.” When she was incarcerated she continued to be surrounded by negativity. Thus, these life experiences provided the impetus for her to change the direction of her life. She talked about the importance of the courses she completed while incarcerated. These courses helped her to understand and manage her emotions, addressed relationships, and parenting. She spoke with enthusiasm about graduating this year, making new friends, and celebrating two years of abstinence from marijuana. She articulated:healing activities as described by McCormick  and say, ‘Ok big baby, life goes on.’The remaining néhiyawak clearly articulated what they required to attain optimal mental health and well-being. They voiced physical and intellectual  needs that correspond with the medicine wheel  the money… I can do more.”The ability for the néhiyawak to meet their physical needs is related to their income, whether or not they have employment. Income determines an individual’s living conditions, such as safe housing or whether they will be able to buy sufficient healthy food . Health Another young woman improved her mental health and well-being by exercising regularly, she shared “[Being] active, exercising. I go to the track in the evenings.” In McCormick’s  study ofAccording to the medicine wheel as described by Mussell , the intI don’t want to die as a statistic from alcohol or from abuse. Both of my biological parents had passed away that way. Even to this day my biological sisters and my brother, I think that they’re going to die from alcohol abuse. I just don’t want to be like that.One middle-aged woman said that she didn’t want to die as a statistic related to alcohol abuse even though both her parents did and she feared her biological siblings would die in the same manner. In addition, she said that she would have to change her social circle of friends to include non-drinkers. She proclaimed:According to the First Nations Regional Longitudinal Health Survey , communiwe need to have careers, not I want.”Several of the néhiyawak in this study identified the importance of continuing their education as being necessary for them to obtain optimal mental health and well-being. One very young man who was currently in grade 12 said, “School, just having a feeling of going there every day … something to do … nothing bugs me there.” Another very young man was emphatic that he and his spouse required careers in order for him to achieve optimal mental health and well-being. He declared, “we would both have to have a career… Education and literacy is a determinant of health, and health status improves with an individual’s level of education . EducatiThere are many factors that can influence one’s health, including one’s mental health. These factors are commonly known as the determinants of health , 47. It A Framework for a Mental Health Strategy for Canada [The second goal in r Canada , acknowlr Canada .Irrefutably, there are unacceptable disparities between the economic and social conditions of Indigenous people and non-Indigenous people in Canada , 58. TheIn a previous study , the perWhen the néhiyawak were asked what was making a difference for them in terms of their mental health, they responded by sharing concepts and values that are inherent within Indigenous worldviews and they mentioned the necessity of self-sufficiency as making a difference for their mental health and required for them to obtain optimal mental health and well-being. Given the historical and current context of colonization, it is not surprising that the néhiyawak in this study identified and are using the same concepts and values to improve their mental health and well-being that were disrupted and in some cases destroyed by colonization , 43, 62.Interestingly, the themes derived from this study appear analogous with Indigenous worldviews that have been described by various Indigenous and non-Indigenous scholars. McCormick  describeThe findings from this study were organized and presented as separate themes; yet from an Indigenous worldview, one can see the interconnectedness and relationships between the themes and the relational concepts inherent within the teachings of the medicine wheel. These four themes, as described by the néhiyawak, have elements that parallel the needs for development of human potential as described by the medicine wheel  and the Connectedness is fundamental to Indigenous worldviews and colonization was the beginning of “dis-connection” , p. 44).Recognizing that Thunderchild is only one of many First Nations communities, this research represents a contribution to the current body of knowledge addressing néhiyawak miyo-mahcihoyān (well-being). The insight gathered from an Indigenous perspective is essential for planning effective health promotion for Indigenous populations , 19, 22.Despite the resilience of the néhiyawak in this study, the current statistics portray unacceptable health disparities between the Indigenous and non-Indigenous peoples of Canada , 58, 60.


This paper introduces a bibliometric, citation network-based method for assessing the social validation of novel research, and applies this method to the development of high-throughput toxicology research at the US Environmental Protection Agency. Social validation refers to the acceptance of novel research methods by a relevant scientific community; it is formally independent of the technical validation of methods, and is frequently studied in history, philosophy, and social studies of science using qualitative methods. The quantitative methods introduced here find that high-throughput toxicology methods are spread throughout a large and well-connected research community, which suggests high social validation. Further assessment of social validation involving mixed qualitative and quantitative methods are discussed in the conclusion. The validation of novel scientific methods takes place at two levels. On the first level, or formal validation, methods are validated by showing that they are theoretically well-supported, their results can be replicated, they agree with established methods, and so on. The second level, or social validation, is the acceptance of methods by the relevant scientific community. Ideally, high formal validation would be both necessary and sufficient for novel methods to be broadly accepted by the scientific community. However, these two levels can operate independently. A novel method can have high formal validation when performed by its developers, but fail to be generally accepted by the scientific community. This might happen because the novel method is difficult to use, requires equipment or materials that are expensive or otherwise difficult to obtain, is very slow, or depends on assumptions that are not widely accepted or mathematical techniques that are not widely understood. Conversely, a method can become so widely adopted as the standard and expected technique in the field that it is applied and in ways that significantly weaken its formal validity. For example,  argues tSocial validation has been frequently studied in science and technology studies [STS] and philosophy of science for decades –5, primaThe US Environmental Protection Agency’s Chemical Safety for Sustainability [CSS] program is developing HTT data sources and analytical techniques to address limited toxicity and exposure data for tens of thousands of commercial chemicals . TraditiFor some particular applications, HTT methods have been shown to have degrees of formal validation comparable to those of traditional, in vivo methods . In otheCitation networks have been used in bibliometrics since the 1970s, and today are a standard tool of the field –16. Fig Q is the modularity statistic, i indexes the communities in a given partition of the network (in k = 2), ei is the number of intracommunity edges in i , di is the total degree of all nodes in i, and m is the total number of edges in the network. Q is meant to capture the thought that a well-defined community has more intracommunity edges (corresponding to the term ei/m) than would be expected in a random rewiring of the network (corresponding to the term (di/[2m])2).The strength of a partition—a division of a network into mutually exclusive and jointly exhaustive communities—can be quantified using the modularity statistic , definedtwork in , k = 2, Q ranges between Q are interpreted as a sharper division of the network into subcommunities  and custom Python scripts. A conceptual model for the construction process is given in http://dev.elsevier.com. For this purely practical reason, I chose to work with Scopus here. finds th describeGiven these limitations of previous methods for constructing a citation network, the method developed here involves a novel, iterative construction. See This construction approach is somewhat similar to the method used by  to constgraph-tool is then used to construct, manipulate, analyze, and visualize the citation network  program is developing novel methods for testing chemical safety. The citation network methods described in the previous section were developed to investigate the social validation of these novel methods within the broader research community. A list of CSS publication titles was retrieved from STICS, a USEPA-internal database of research products; DOIs were identified for these publications using semi-automated title searches. The CSS publications for which DOIs were found formed the core publications for the citation network , that comparison was skipped for this use case.Both of the reference networks had on the order of 30 thousand nodes and 400 thousand edges; these values were on the same order of magnitude as the constructed network, and the constructed network was larger in terms of both nodes and edges. However, the reference networks had relatively more edges.  In the reference networks, for the random partitions, modularities were on the order of −1 × 10Again, these statistics indicate that the core publication’s modularity and insularity were low, though not as low as a random sample of nodes.Q = .44 and insularities of .97 and .95. Modularity is more than three orders of magnitude larger than the modularity for the core partition. Insularities are also very high, although this should be interpreted with caution; as noted above, with large partitions, large insularities reflect the low “surface area” to “volume” ratio. Note that these values are similar to those produced by the noisy community detection algorithm. When the 2011 threshold is used instead, these values are only trivially different: Q = .45, S = .94, .92.The partition produced by the stable, blockmodel community detection method is shown in χ2 test for independence on this table is conventionally highly statistically significant (p = 3.0 × 10−10). However the effect size—as measured by Cramér’s V, a correlation coefficient—is conventionally small and—given a significance level of 5%—this χ2 test reaches 99% power at an effect size of just .015, suggesting that it could be overpowered for this case [Within the partition produced by this stable community detection algorithm, CSS nodes are 33% less likely to be in Community 0 than non-CSS nodes, and a All together, this analysis has the following key findings for the case of CSS research:CSS publications appear in a single large, connected citation network.CSS publications have very low modularity and insularity, indicating that they are not isolated within the citation network.CSS publications are not distributed evenly across the communities of the network, or as though they were a random subset, though this bias is small.All together, CSS publications are well integrated into the research community.The above findings are robust when 2011 is used as the publication date threshold rather than 2006.These findings provide evidence that CSS research enjoys high social validation.The analytical approach presented in this paper could be extended in several ways in future work. The CSS program is divided into four different topics and several different projects. These divisions could be used for a more complex, community-based analysis, i.e., the integration and distribution of these four topics across the citation network. Unfortunately, in this project there was no efficient way to associate individual papers with their USEPA topics or projects.This paper focuses on publications using a citation network. The Python code developed for this project also constructs and analyzes coauthor networks. For CSS, the findings of this coauthor network analysis were qualitatively similar to the citation network findings reported above. However, for other cases the coauthor network analysis could be more relevant, or notably disagree with the citation network analysis.Further use of community detection algorithms could also be useful in some cases. For example, the stable community detection algorithm could be applied (without the limitation to produce a binary partition) to both the core nodes and the entire citation network, and membership in the two partitions could be compared. This might reveal, for instance, that the core nodes enjoy high social validation in some parts of the literature but low social validation in others. Because the CSS nodes taken by themselves were highly disconnected, this algorithm did not find any further structure in the core nodes, and thus this use of community detection was not applicable to the case examined in this paper.As discussed above, for practical reasons the primary code developed for this project does not store article abstracts or other text data. Extensions to the code, supported by sufficient computational resources, could be used to conduct more sophisticated text analysis.  develops describeA tractable sample of 25 generation +1 papers was drawn, and the citations to core papers were examined manually. These generation +1 papers cited 30 core papers. For 2 of the generation +1 papers papers, fulltext was not available, and so the citations could not be examined. 23 of the remaining 28 citations were classified as “point citations,” a single citation to the core paper as the source of a value, description of an experimental method, etc. A further 3 citations were classified as “repeated point citations,” in which the core paper was referred to more than once (in the given generation +1 paper), but each time as a source of a value, description of an experimental method, or other point-like reference. 1 generation +1 paper referred to the core paper as a “companion paper” by the same authors, and 1 generation +1 paper gave a paragraph-length discussion of the cited core paper. None of the 28 available citations were considered negative.This small sample suggests that, while CSS research is well-integrated to the scientific community, a typical citation to a CSS publication treats it as “just another data point,” rather than a radically new approach. However, it could be that the typical CSS publication is only meant to report “just another data point,” rather than present HTT as a radical new approach to toxicology. In Kuhnian terms, perhaps a typical CSS publication is “normal science,” and only a few papers are intended to announce “revolutionary science” . In thisThis paper has introduced a method for quantitatively assessing the social validation of a body of research using an iteratively-constructed citation network. This method was applied to the case of high-throughput toxicology research, showing that this research enjoys high social validation.S1 Topic Analysis of the Core Set Abstracts(PDF)Click here for additional data file.


Promoting consistent HIV testing is critical among young, Black Men Who Have Sex With Men (MSM) and transgender women who are overrepresented among new HIV cases in the United States. New HIV test options are available, including mobile unit testing, one-minute testing, at home or self-testing and couples HIV testing and counseling (CHTC). In the context of these newer options, the objective of this study was to explore whether and how preferences for specific characteristics of the tests acted as barriers to and/or facilitators of testing in general and consistent testing specifically among young Black MSM and transgender women aged 16 to 29.We conducted 30 qualitative, semi-structured, in-depth interviews with young, Black, gay, bisexual or MSM and transgender women in the New York City metropolitan area to identify preferences for specific HIV tests and aspects of HIV testing options. Participants were primarily recruited from online and mobile sites, followed by community-based, face-to-face recruitment strategies to specifically reach younger participants. Thematic coding was utilized to analyze the qualitative data based on a grounded theoretical approach.We identified how past experiences, perceived test characteristics  and beliefs about the “fit” between the individual, and the test relate to preferred testing methods and consistent testing. Three major themes emerged as important to preferences for HIV testing methods: the perceived accuracy of the test method, venue characteristics, and lack of knowledge or experience with the newer testing options, including self-testing and CHTC.These findings suggest that increasing awareness of and access to newer HIV testing options  is critical if these new options are to facilitate increased levels of consistent testing among young, Black MSM and transgender women. Addressing perceptions of test accuracy and supporting front line staff in creating welcoming and safe testing environments may be key intervention targets. Connecting young Black MSM and transgender women to the best test option, given preferences for specific characteristics, may support more and more consistent HIV testing. New HIV infections among gay, bisexual and other men who have sex with men (MSM) ages 13 to 24 increased by 133% between 2001 and 2011 in the United States (US)  . Recent HIV testing is the entrance point to a range of HIV prevention and treatment options, such as pre-exposure prophylaxis (PrEP) and ART  treatment, and is therefore a critical public health tool to help contain the HIV epidemic in the US –20. It iYoung Black MSM and transgender women are more likely to be unaware of their HIV infection , 27–29. consistent HIV testing among young Black MSM and transgender women in an era of increased test options.Barriers to HIV testing among Black MSM and transgender women include fear, stigma, disclosure of sexual/gender identity, lack of anonymity, concerns about confidentiality, discomfort talking to a counselor and concerns about the accuracy of rapid tests –34. FaciThe emergence in recent years of several new testing methods and technologies have increased HIV testing options, which may contribute to the goal of increasing consistent testing among higher risk groups. These newer methods address some of the established barriers to HIV testing described above. For example, home-based or self-testing uses a 20-minute, oral fluid-based technology and allows individuals to operate the test and receive results privately and at their convenience, alleviating the burden of having to access traditional testing venues or a health care provider, which may elicit stigma and confidentiality concerns , 42–44. In the context of these newer options and the need for consistent HIV testing among high risk MSM, we explored whether and how preferences for specific characteristics of the tests acted as barriers to and/or facilitators of testing in general and consistent testing specifically among young Black MSM and transgender women aged 16 to 29. We also evaluated perceptions of the “fit” between available methods and their characteristics and participants’ past and future testing needs. The findings presented here result from a formative research phase of a larger study designed to inform the development of a communication technology-based intervention to increase consistent HIV testing among this age group.Participants were recruited between February and May 2014 through online and mobile applications (apps) used by young, Black MSM and transgender women in the New York City metropolitan area  and the homepage of a local organization for gay men of African descent. Face-to-face recruitment was used to reach the participants aged 16 to 19. Recruitment language and ads explicitly included transgender women. Using these methods, 396 individuals  completed the online screener and 78 (20%) were eligible. Face-to-face recruitment occurred at two events  where young, Black MSM and transgender women often gather; 18 contacts were collected and 14 were eligible (78%).To be eligible for the study participants had to: (1) report being male at birth; (2) self-identify as Black, African American, Caribbean Black, African Black or multiethnic Black; (3) be able to read and respond in English; (4) be between 16–29 years of age; (5) not be known to be HIV-infected; (6) report insertive or receptive anal intercourse with a man or transgender woman in the last 12 months; (7) reside in the NYC metropolitan area; and (8) provide informed consent or assent for the study. Participants who were enrolled in any other HIV research study involving HIV testing or who had been a participant in an HIV vaccine trial were not eligible. Sexual identity was not a criterion, as self-reported behavior was used to establish eligibility. To provide appropriate contrasts, we attempted to interview participants who had and had not tested for HIV at least once in the last six months. The recruitment methods resulted in a sample of 30 participants, which was the target sample for the study and where we reached saturation with regard to the themes emerging around preferences for, barriers to and facilitators of HIV testing in the context of newer options.Participants who screened as preliminarily eligible were contacted by telephone to confirm eligibility and set up a study visit appointment. All participants provided written informed consent or assent and the study was reviewed and approved by the Institutional Review Boards (IRBs) of all participating institutions . Eligible participants under the age of 18 years were considered mature minors by the IRBs and thus provided written informed assent. After providing information about the study and prior to obtaining assent, the minor participant was introduced to and met with the minor advocate. The advocate was a staff member who was not involved in the assent or this study’s procedures. All information provided by the participant during the meeting with the advocate was confidential and not shared with any other staff members. At the end of the study visit, the participant was provided the opportunity to meet with the advocate again and given the advocate’s contact information for any future questions. Eligible participants completed a 60-minute, qualitative, semi-structured, in-depth interview and a brief web-based survey on demographics, health characteristics, and sexual behavior. Participants who completed the study visit received $30 compensation for their time, along with a two-way Metrocard for travel. Interviews were conducted by trained and experienced interviewers in a private room and were audio-recorded and professionally transcribed. All interviews were checked for accuracy by the primary qualitative study co-investigators (VF and LW).® , approved in July 2012, and the Home Access® HIV-1 Test System , noting the cost of, process used, and specimen collected with each method.The in-depth interview was semi-structured, employing a guide that explored a variety of issues including: personal background; experience of and connection to communities; thoughts and feelings about HIV testing and most recent testing experience; experiences with and perceived facilitators of and barriers to newer testing methods , venues , and operators ; and use of and thoughts about web- and smart phone app-based technologies for health and testing purposes. The interview guide was based on a conceptual model that identified factors at four levels, the test level, the individual level, the situation level, and the socio-contextual level. At the test level, we asked questions designed to elicit accounts of the influence of test characteristics, such as availability, cost, fluid used/specimen collected, test operator, familiarity, complexity, time for results, and privacy/confidentiality on testing and test preference. At the individual level, we explored the influence of fear, anxiety, stigma, past experiences and “type” of tester,  as well Using a grounded theoretical approach, we applied both contextualizing and categorizing strategies to code and analyze the in-depth interview data –48. ImmeThe mean age of the sample was 23.7 (SD = 3.4), with one 17-year old participant and eight participants who were between 18 and 21 years of age; 21 participants were aged 22 to 29. Forty percent reported residing in the Bronx, 30% in Brooklyn, 27% in Manhattan, and 3% in Queens. The majority (87%) self-identified as African-American, with 23% identifying as Caribbean or West Indian or 20% as Afro-Latino. Ninety-three percent of participants self-identified as male, with two participants identifying on the computer-based survey as transgender male-to-female. During the interviews, however, another two participants revealed that they self-identified as gender fluid and sometimes identified as male-to-female transgender, sometimes as female and sometimes as male. We confirmed results of previous research that several factors continue to act as barriers to and facilitators of HIV testing in this population. These included: knowledge of and access to HIV testing sites and test methods, fear of a reactive HIV test result, HIV stigma, and concerns around confidentiality and privacy. In terms of access to newer testing methods, the majority of participants were unaware of the CHTC option (which was not widely available at the time of the interviews), although they were open to and enthusiastic about CHTC. One participant noted its usefulness in planning for safety with a future partner, saying “I would do the Testing Together to get to know the person and where they stand.”  Another participant noted that if the new methods were widely disseminated, they would be used, stating “I think maybe I could be—not really comfortable with it, but I feel like if it was much more available, then I would possibly take advantage of it.”  A transgender participant said in response to being told of the various testing options that there were “a lot more options than what I am aware. I’m excited. I’m excited.” Some participants noted that access to existing testing methods was still a problem, particularly in the Bronx, with too few fixed testing sites available. One participant said, “New York City has facilities specifically for that spread around the borough, but there’s only like two a borough.”  Related to access to the self-test, the cost of the test emerged as a barrier, consistent with preliminary reports in the literature and our analysis of these data . The majority of participants expressed anxiety or nervousness when asked their “first thoughts” on HIV testing, reinforcing that the testing experience continues to be fraught with anxiety for most young, Black MSM and transgender women. One participant said, “I’m high anxiety so, you know, that will definitely get my anxiety going and stuff, just yes, worrisome.”  Another participant simply said “fear,” whereas another stated “sickness, depression, condoms, wrap it up, and depression.”  One stated “It’s draining.”  The role of stigma associated with testing also emerged for several participants when asked about their first thoughts on testing; one participant said “I guess shame. Even though I work with the disease itself, I’m not scared of it. I respect it. But it still holds a stigma. You don’t necessarily want that stigma attached. … So it’s not a nice feeling.”  Finally, as in previous research, issues related to confidentiality emerged, with some participants perceiving fixed site waiting rooms and mobile units to be antithetical to privacy, for example.In this section, we present novel results describing how preferences for selected characteristics may constitute barriers to and facilitators of testing and explore how some of these preferences interacted with each other. We describe preferences that emerged from the data most strongly, organized by test characteristics , individual/personal characteristics , and the situational or contextual characteristics .Related to the test characteristics, factors such as type of specimen collected, reported accuracy, familiarity with the actual testing process and speed of the test results emerged as important to test preferences. Several participants expressed a strong preference for blood-based tests and venipuncture due to greater accuracy of these tests and fewer false negative test results, as compared to oral fluid-based tests. Some participants believed that blood-based tests, venipuncture with a western blot test in particular, were more sensitive, resulting in shorter window periods and greater confidence in blood-based tests. For example, one participant said:“But like I said, with me it’s not so much the convenience and stuff like that. Sometimes I just don’t trust the results for somebody to swab your mouth and a little thing of blood to detect. I mean—I know that this has been tested for ages before we even got it, so I know that there is, you know, they know what they’re doing, but it’s just me up in my head. … I prefer to get a needle in my arm and I’ll see you in a week to ten days.”“For me, it’s more accurate. HIV lives in the blood. … Check the blood.”  Another said: “I really don’t trust it [the oral fluid], so every time I go in there and get it I think I don’t trust it.”  Another asked, “Isn’t the blood test more accurate? I really—I want to know. I want to be 100% sure. Every time I get tested, I want to be 100% sure that it’s correct—there’s no ands, ifs, or buts about it.”  One participant worried that the preference for blood-based tests may prevent some people from getting rapid HIV tests. This participant said: “I believe the only obstacle would be the fact of their preference of venipuncture over the rapid testing. I hope that doesn’t stop them from getting it. I hope they still think, you know, this is good enough for right now. Even though my preference is venipuncture, I hope they feel like I should do this right now just to at least know my status some way.”  This participant recognized the potential for the perception of significantly reduced accuracy of rapid HIV tests, oral fluid-based in particular, to act as a barrier to consistent or needed testing.Expressing greater confidence in blood-based rapid tests, another participant said, In terms of situational or contextual characteristics, factors such as relationship status, past testing patterns, prior negative experiences with testing , counselor skill and compassion, and venue culture  emerged as important to preferences for specific testing methods or test characteristics. Of special importance for several participants was the relationship they developed with their counselors and/or perceived attitudes of counselors towards the clients. One participant who sought testing every four months noted, “I mean it’s one of those—they’re there to do their jobs. So it’s not like they’re enthusiastic or they have enthusiasm to do the test for you. So it’s like a regular job for them.”  Counselor skill at taking a sample emerged as well in terms of wanting to return to either the venue and/or use the specimen collection method again. The same participant described an adverse oral fluid specimen collection experience where “the lady doing it—because they’re supposed to do it for you. So when they do it, it looks like they’re fighting with your mouth…and I’m like, ‘Is this really supposed to happen?’”  Another participant said that the attitude of the clinic workers to their roles was important noting:… The people [waiting to be seen], whatever they were doing, they looked upset as well. And they were on the phones arguing and stuff like that, so it was…”“I went to one in [NYC neighborhood] and I really didn’t like it. [Why not?] I don’t know. The whole environment, the people that were there, and the workers, they weren’t—they sounded like they were pissed the whole day, so I was like, ‘This is not the place for me.’Other participants noted that selected testing venues, specifically mobile testing units, were not conducive to confidentiality, comfort, or confidence. For example, one participant who said that they would not seek a test on a mobile unit or van said:“I don’t think I feel comfortable in vans. I just feel like vans are for delivering things that you need. I don’t think I should be getting my results while you’re parking or while you’re parked in the yellow line. It just doesn’t feel comfortable for me. It doesn’t feel like it’s real, honestly.”The impermanence and mobility of the vans disconcerted some participants; when asked what disturbed them about the van one participant replied “Just the idea that they could just lock the doors and run off with you.” . Another noted, “I walk by them every single time. It’s—I don’t trust it.”  In contrast, a few participants appreciated the convenience and easy access that mobile testing units provide. One participant who was never tested said they would feel “less exposed” when testing on a van, suggesting that they did not want to be seen going into a fixed testing site . Another participant noted that the vans often allowed testing with friends or had a positive energy .In addition to identifying characteristics of the tests and situation that drive preferences for testing methods, we asked participants about hypothetical preferences for various methods and test characteristics at different stages of their lives. Participants believed that they may benefit from a range of test options, noting that some methods would be good for them at different times in their lives. For example, a few participants felt that their current living situations would preclude their use of a self-test; for example, one participant noted “And the at-home test, my parents know that I’m sexually active and I identify as a homosexual, but I don’t think I would want to do it while they’re there…I don’t want them questioning anything like, “What are you doing?” I don’t want to have to go through those conversations.” In contrast, another participant imagined that they would combine self-testing at home  with venipuncture at their health care provider’s office at a different stage in their life:“Okay, the oral tests I would probably do every once in a while, at home, but, you know, to get the blood draw, I would probably do it every time I had my doctor’s visit. That would be the only times that I would change it up.”Another resident of the Bronx noted that having access to the self-test would allow them to test at home and would save them time during life stages characterized by time pressure and a hectic schedule .Most participants indicated that CHTC (with a sex partner) would be of interest at time of life when they were partnered or “settled down,” although some said that the complexity of and commitment inherent in the method, specifically testing with a sex partner and discussion of sexual agreements, etc., would be a barrier. Further, the issue of trust while testing with a sex partner or friend emerged as a strong barrier to using this method at any life stage for several participants. With that said, a few participants reported that CHTC was an ideal way to test, particularly in the event of a reactive test result; one participant said this of having a friend or partner present:“You have people to fall back on. You always want somebody to talk to after, you know, on the train ride home or something. People could calm you down. They could tell you things, they could tell you experiences, share stories.”We explored with participants whether the existence of one of the options described, including the self-test, CHTC and the 1-minute test, would have increased the chance that participants would have tested at a time in their lives when they “thought they should have tested, but had not.” One participant noted that the 1-minute test would have made it more likely that they would have tested; another participant said they would have used the self-test to keep things private when they were younger and in need of testing. Similarly, another said that if the home test had been available when he was younger, he would have tested sooner. Another participant indicated that in the past if a testing option had been nearby, quick and convenient and he’d had a higher risk sexual experience, he would have been more likely to test at a time when a test was needed but not accessed. In terms of options that are missing from the current testing environment and that would potentially increase consistent testing, one participant lamented that results could still not be delivered by phone, which would reduce anxiety associated with receiving results. One participant noted that a more sensitive test would make them more likely to test more frequently, saying “if they said maybe it can be detected, I guess, in like a shorter time frame, then, I guess, that would maybe make me go every two or three months, if I was like really, really active.”  Most participants could not imagine another testing option that would significantly increase their chances of testing or testing consistently. One participant said:“I’m not really sure that anything’s missing, because I think they’re all kind of convenient in a way. So, it’s like there’s not really a reason why you can’t go get yourself tested. They’re kind of available everywhere you go now at this point. So, it’s like there’s no excuse to not get tested.”Finally, when asked if “certain tests were a better fit for certain people”, most responses focused on use of the home or self-test. Numerous participants indicated that the self-test is useful to those who could afford the higher price, noting that they would gain the benefit and flexibility inherent in the test. A few participants stated with concern that self-testing may be preferred by a “certain type of person” , one who does not intend to disclose a positive result. They speculated that the type of person who uses a self-test may be afraid to be seen attending a clinic or asking for a test from their doctors. In terms of the preference for blood-based or venipuncture, one participant articulated what was described by several other participants: that the person who strongly prefers venipuncture is the person who “worries a lot, that needs to know and, you know, that wants to do it the perfect way the first time, that kind of a person.” The numerous HIV testing options that are now available provide more choices to individuals at higher risk for HIV infection, for whom consistent HIV testing is recommended. However, there is limited understanding of how newer testing options are perceived, including what aspects of the new options are preferred, and how these preferences could increase the likelihood of testing and/or consistent testing –50. In tA driver of preference for blood-based specimen collection was consistently described in terms of the greater perceived accuracy of blood as opposed to oral fluid sample-based tests. This preference was evident among both recent and not recent testers, suggesting that it acts as a barrier to testing for some but not all potential testers. It is likely that, despite the young age of the participants and thus relative lack of testing experience, the actual reduced sensitivity of oral fluid tests has been communicated to them and may be acting as a barrier to testing venues or methods that rely on oral fluids , 51. In Two related situational or contextual factors emerged as drivers of preference and desire to return for future testing: counselor interpersonal skills and venue culture. Several participants reported that they felt that HIV test counselors were only “doing a job” or “going through the motions,” suggesting that the importance and gravity of the testing process was not appreciated consistently by counselors and reflected in interactions with clients. This perception, based on actual experiences, may inhibit future consistent testing. Although recent research reported that the counseling component of voluntary counseling and testing (VCT) does not prevent incident STIs, –55 it coTwo additional findings emerged that have implications for HIV prevention and social services. First, the young people sampled here were able to imagine using a range of test approaches at various points in their lives, based on where they were in their lives. Although some participants noted that reluctance to test was unconnected to access and knowledge, and rather reflected fear of HIV, several stated that had the self-test been available to them when they were younger they would have used it. Similarly, the lack of easy access to all the testing approaches was perceived as a barrier to testing for very young, emerging adults. This strongly suggests that in addition to efforts to increase knowledge of and access to the full range of testing approaches, the public school system should integrate information on all testing approaches currently available as well as provide access to HIV testing in high schools and provide HIV self-tests to students who seek them . Second,There are several limitations that deserve mention. First, despite an effort to focus on younger people, we interviewed just one person younger than age 18 and thus our findings derive primarily from a young adult population. Along these same lines, just four participants self-identified as either transgender  or gender fluid. Given the significant heterogeneity within the transgender population, for example preferred gender identity, pre-operative or post-operative status, health care history, we cannot draw strong conclusions related to the communities and subpopulations within the transgender population. In addition, we recruited participants primarily using web-based approaches, supplemented by in-person recruitment efforts to reach younger participants. Thus, the sample may over-represent individuals who gather on-line, as opposed to people who gather face-to-face at venues. This sampling strategy was, however, designed to reach young MSM and transgender women who would be likely to encounter our web-based testing intervention. Related to sampling, the results cannot be generalized to the larger population of young, Black MSM and transgender women; rather, these qualitative analyses are meant to generate novel findings around preferences for specific test characteristics in an era of increased testing options. Finally, most of our sample had tested for HIV within the last six months and few had direct experience with the testing options that we explored in the interviews. As CHTC and self-testing options are scaled up and formally disseminated, it will be important to conduct ongoing research into how these options are experienced by the groups at highest risk and most in need of testing options. If added options continue to be perceived as options for other people or other times of life, they will do little to increase the consistent testing that is required to trigger clinical evaluation for PrEP.These findings suggest that increasing awareness of and access to newer HIV testing options , among young, Black MSM and transgender women is necessary if these new options are to facilitate increased levels of consistent testing in these at-risk populations. Effective dissemination of the methods, leading to easy access and uptake, is critical to this goal . FurtherS1 File(DOC)Click here for additional data file.