Screening in High Schools to Identify, Evaluate and Lower Depression (SHIELD) was a randomized clinical trial of school-based universal depression screening conducted with public high schools in Pennsylvania, United States. Screened adolescents were twice as likely to initiate depression treatment compared to peers who were not screened. The purpose of this qualitative study was to understand the experience of communities participating in universal screening via SHIELD. Semi-structured interviews were conducted with school staff (n = 11), parents (n = 4) and adolescents (n = 7) from April-October 2021. A codebook was developed with 20 % of audio transcripts coded for inter-rater reliability . The two coders divided and individually coded remaining transcripts for thematic content analysis. Three themes were identified: 1) Depression screening was well-received; 2) The main challenge with screening was inadequate staffing to manage referrals; and 3) School staff suggested alternate formats and methods for future screening. In summary, school-based depression screening was well-received, but schools experienced challenges with staffing and resources to support identified adolescents and offered alternative suggestions for future screening. Schools interested in depression screening need education and capacity building focused on barriers and challenges with the process. Learning from staff who have realized this evidence-based practice in their respective districts will support next steps towards implementation. ParalleSHIELD was a randomized clinical trial (RCT) conducted from November 2018–2020 . SHIELD There is precedent for schools to conduct universal mental health screening . An RCT Understanding that adolescent depression and mental health can be a complicated and stigmatizing topic , the sucAfter the study, the team went back to participating communities to better understand the experience of the screening. Prior work supports that school-based depression screening is acceptable to parents and adolescents and that schools are willing to partner in this space . HoweverThe main study purpose was to understand the barriers and successes related to the screening process from the perspectives of school staff, parents and adolescents who participated in universal screening. Specifically, the research team sought to understand what individuals recalled from the experience, what elements were handled well, what pieces of the screening process needed improvement, and if participating schools planned to continue universal depression screening independently of the SHIELD study.22.1Semi-structured interviews were conducted with all participants. This format was selected to protect confidentiality, as some participants may have had a positive PHQ-9 screen requiring treatment and be reluctant to discuss this in a focus group. Interview guide questions were developed and refined by the research team. The parent interview guide questions were updated after completing three interviews, and the adolescent interview guide after facilitating five interviews due to recognition by the research team that most individuals had little recollection of completing the PHQ-9, especially if the screen was negative. With a negative PHQ-9 screen, any follow-up questions regarding the referral process could not be answered by the interviewees. The interview guides were revised to allow for more hypothetical questions, e.g., “If the screen were positive, what would you expect should happen?” Both versions of the parent and adolescent interview guides are included as appendices (A and B). However, only the second or “B” version of the parent and adolescent transcripts were used in the current analysis. This study was approved by the Penn State College of Medicine Institutional Review Board.2.2Participating SHIELD study high schools sent an electronic message and flyer to eligible high school adolescents and parents, similar to previous strategies . EligibiTo determine eligibility, parents completed a brief screener in Research Electronic Data Capture (REDCap), a secure, web-based application for research study support . ParentsFor students under 18, a study coordinator scheduled the interview by emailing the student and copying the parent. For students over 18, the study coordinator emailed only the student. All interviews occurred virtually via zoom. Interviews were conducted individually, even for students under 18. Parents were not required to be home during the interview if their student was underage. Adolescents (<18 years old) provided assent before starting the interview in addition to parental consent documentation. The study team did not develop a protocol for medical or psychological resources; risks involved in participating were low and questions were not sensitive.An electronic message was also sent to school staff for participation. Eligibility criteria required that school staff had been involved with the SHIELD study and universal MDD screening at their respective schools. Upon screening eligible, and providing consent and contact information, a study team member reached out to request completion of an online demographic questionnaire and to schedule the interview.2.3The 30-minute zoom-audio interviews were conducted from April-October 2021 by AM and KA after receiving training from a qualitative expert (HS). After brief introductions, background information, and time for questions, the participant was instructed to turn off their camera so that only the audio recording was captured. The interviewee notified the participant when the recording began and followed the semi-structured facilitator guide. The recorded audio files were transcribed by a professional service, from which the project team members reviewed the transcripts and imported them into a qualitative software management system (Nvivo 12 Plus).2.4The study used qualitative description as described by Sandelowski, et al. . A purpoA portion of the transcripts (20%) of each group were coded for inter-rater reliability , and then two coders divided and completed coding of the remaining transcripts individually. Team members determined themes by reviewing the codebook and grouping categories into larger overarching themes.3Participants came from 4 of the 14 schools involved in the SHIELD RCT. As shown in Theme 1: The PHQ-9 depression screen was well-received by school staff, adolescents and parents.…If students learn now at this age level, how to handle anxiety, stress, depression at this level, it can only benefit them in the future…Mental health has…for far too long, been shoved under the carpet or hidden in the closet. People don't want to talk about it and it needs to be talked about…School staff shared positive comments about the school-based depression screening process, and that mental health “plays a huge role in daily life,” and the screening sets them up “for a good situation from now into their…future.” Staff commented that parents were “quite pleased” that staff were able to identify that their child had a need.I know my kids, sometimes they feel better talking to somebody else than me. And that's fine as long as they get help.Parents believed the school was a good environment to screen, and school should be involved in the follow-up of identified adolescents. It was important that their student have someone with whom they could confide if there was a problem, and school was a place to allow adolescents to raise mental health issues with adults other than their parents. Parents would prefer notification of positive screen results by phone and would appreciate the school providing some resources to assist them in getting their adolescent help, whether a guidance counselor or a social service agency. Several interviewees had already gone through this process with the school for their other children and reported overall positive experiences.Parents indicated they would talk to their adolescent about the results, as a first step to “understand what’s going on.” They would also reach out to their pediatrician or family physician in their network for assistance in securing help for their adolescent.Not that we have anything against medication, but I just feel like trying to understand what you're going through first is important before this prescription.I feel like a lot of adults might freak out when they hear, “Oh, your child might be dealing with something like that.” And they might automatically go to medication because they want the problem solved right away, but that's not always the best thing to just rush into stuff like that because medication isn't a small thing.Adolescents were comfortable with the school counselor having the screening results. They identified others, e.g. siblings and teachers, whom they would preferentially involve prior to parents, though most ultimately were accepting of parental notification. As a form of follow-up treatment, students were more comfortable with receiving counseling than medication.Adolescents were more interested in counseling outside of school or after school hours to avoid being seen or having others know that they see a counselor.Theme 2: The main challenge with screening was inadequate staffing to manage referrals.The biggest challenge on the day of the screening was…getting the results back and then making sure we had enough people to follow up with the students that were… [an]…immediate threat to themselves. There was a long list of them. And there was only so many of us that were available while also managing the rest of the guidance suite.While logistics on the screening day were efficient and clear, school staff shared the challenge of inadequate staffing..When we hit 10 to 12, that's when we called the screener off for the day, because we were…overwhelming our mental health provider that was assisting us. Even though we had three or four of them at a time, it was overwhelming because by the time they did the whole process, each screener covered two to three kids throughout the day, which…would take…sometimes several hours.Schools planned their own processes for following up with students identified at risk based on the screening. One staff member recalled that two adolescents were hospitalized after the screening. Several schools decided to have a maximum number of positives for suicide risk based on PHQ-9 item number nine, after which screening stopped for the day.Typically,…our school has…an overall struggle…getting people to follow through with the services, but many of those kids that showed up on the screening are either already receiving services, or it was like a misunderstanding of…not misunderstanding, but just the way it's worded, they answered it, “yes”, and it wasn't really exactly what they were thinking.…I did know that a lot of kids came out of the woodwork, so to speak, with elevated levels of anxiety and obviously depression.Additional challenges were adolescent question comprehension, e.g., some did not notice the screener referred to how adolescents felt in the past two weeks. School staff mentioned that after adolescents understood their positive responses would lead to being called to the office for further discussion, some may have answered dishonestly to avoid this. Staff also discussed the difficulty in contacting parents and getting individuals to follow through with treatment recommendations. However, many of the identified adolescents were already in treatment and/or known to the school.Theme 3: School staff suggested alternate formats and methods for future screening.…Our ninth graders, for example, they spent their eighth grade year at home. Their level of maturity may not be where it needs to be. They came from a home environment. Now they're in a very demanding high school, depending on their academic program. Some people handle things better than others, but I would say the state of the world is affecting us locally and directly in the schools, and that's why we still need…the depression screener.School staff recognized a need for ongoing screening. In trying to navigate the pandemic, staff saw “a lot of issues with mental health, isolation concerns, anxiety.” Adolescents had to deal with loss of life due to COVID and an extraordinary amount of grief.…We're not using the survey that you used … but…[use]…data so we can call in a speaker or do some sort of school-wide tier one intervention training with teachers.…We're going to be basing it [the screener] on that [depression] as well as if there's some sort of drug and alcohol use, or if you're having difficulty in your classes, how do you deal with if you're having an argument with your friend, that kind of stuff. Not specifically directly for depression.Despite the need, staff were unsure about specific plans to continue the screening in future years. In some cases, staff shared general future screening plans that would be broader than depression alone . It was suggested screening might also be altered to link with a broader social-emotional curriculum for adolescents.…With the change of leadership…there were other things they were trying to get situated, but I don't think it's a bad idea to implement that. Just to be aware, it almost red flags the kids, to keep an eye on certain kids.Staff shared that administrative turnover meant those currently in charge were unaware of prior efforts in this space. Thus, even while they had an interest in continuing, the information had to be vetted with the new administration.4A series of follow-up interviews with school staff, parents and adolescents who participated in the SHIELD RCT universal screening arm suggested that school-based depression screening was overall well-received. Confidentiality, raised in the prior focus groups , was a cParents and adolescents had little recollection of the universal school-based depression consent and screening process itself, which may be related to recall bias. SHIELD used an opt-out consent process . The conSimilar to the previous focus groups conducted for the SHIELD study , adolescDespite the positive aspects of school-based depression screening, screening was a significant task for participating schools. Different from physical health screens, a treatment delay for depression may have more significant consequences. School staff agreed on the value of screening, but how to implement and sustain depression screening was not clear. Compared to the healthcare sector, even well-resourced schools struggle from a significant implementation gap with regard to evidence-based practices . At the Specifically, schools need clear screening guidelines . Resource mapping can be used to identify additional school and community-based supports. Also, professional development can expand the capacity of existing staff to manage screen positive students. All identified students do not require psychiatric services, and for some a one-to-one check in with a school counselor or parental notification regarding positive symptoms with recommendation for primary care follow-up will be sufficient. Additional implementation supports for screening logistics, e.g., the number of students per day, where and when in the building to screen, and addressing stigma from a positive screen also require thoughtful discussion and planning.5The results reported here have several limitations. Those who chose to participate in the interviews may have held more favorable views on the topic of depression and school-based screening. Acknowledging the well-documented disparities in mental health for minority populations , inclusiLike many other studies conducted during this time, the COVID-19 pandemic and its impact on school closures and the mental health of adolescents likely influenced our findings . DepressFinally, though the participants were a unique sampling of school staff, parents and adolescents who participated in the MDD screening, the overall sample size was smaller than planned and included four of the 14 SHIELD schools. Saturation is difficult to determine because it is the prediction of the unobserved based on the observed ; however6The results of this qualitative analysis indicate that school-based depression screening is viewed favorably by communities who have participated in this process. Yet, the qualitative data indicate that additional education and capacity building will be required for schools to independently sustain implementation of this evidenced-based practice. Beyond existing toolkits of available resources  additionDeepa L. Sekhar: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration, Funding acquisition. Elizabeth Hivner: Methodology, Software, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Alissa Molinari: Software, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization. Kathleen Allen: Software, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing. Heather Stuckey: Methodology, Software, Validation, Formal analysis, Resources, Data curation, Writing – review & editing, Supervision, Project administration.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


As COVID-19 continued to impact society and health, maternity care, as with many other healthcare sectors across the globe, experienced tumultuous changes. These changes have the potential to considerably impact on the experience of maternity care. To gain insight and understanding of the experience of maternity care during COVID-19, from the perspectives of women and maternity care providers, we undertook a qualitative evidence synthesis (QES).The population of interest for the QES were pregnant and postpartum women, and maternity care providers, who provided qualitative data on their experiences of maternity care during COVID-19. The electronic databases of MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane COVID study register were systematically searched from 01 Jan 2020 to 13 June 2021. The methodological quality of the included studies was appraised using a modified version of the quality assessment tool, based on 12-criteria, designed by the Evidence for Policy and Practice Information coordinating Centre (EPPI-Centre). Data were extracted by two reviewers independently and synthesised using the Thomas and Harden framework. Confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research .Fifty records relating to 48 studies, involving 9,348 women and 2,538 maternity care providers, were included in the QES. The methodological quality of the studies varied from four studies meeting all 12 quality criteria to two studies meeting one quality criterion only. The synthesis revealed eight prominent themes. Five of these reflected women’s experiences: 1) Altered maternity care (women), 2) COVID-related restrictions, 3) Infection prevention and risk, 4) ‘the lived reality’ – navigating support systems, and 5) Interactions with maternity services. Three themes reflected maternity care providers’ experiences: 6) Altered maternity care (providers), 7) Professional and personal impact, and 8) Broader structural impact. Confidence in the findings was high or moderate.Although some positive experiences were identified, overall, this QES reveals that maternity care during COVID-19 was negatively experienced by both women and maternity care providers. The pandemic and associated changes evoked an array of emotive states for both populations, many of which have the potential to impact on future health and wellbeing. Resource and care planning to mitigate medium- and longer-term adverse sequelae are required.CRD42021232684.The online version contains supplementary material available at 10.1186/s12884-022-04724-w. Over two years from being declared a global pandemic, COVID-19 continues to impact society and health. Maternity care, as with many other healthcare sectors across the globe, has experienced tumultuous change. Unlike many other healthcare sectors, however, individuals accessing maternity care, for the most part, are healthy women and their families, with unique healthcare needs that can differ to those who have pathological ill-health. Additionally, in providing maternity care, the health and wellbeing direct needs of two individuals, that is the women and her baby, rather than one individual, must be considered. Changes to healthcare provision, in this sense, can impact the care recipients differently, depending on the health sector concerned. Some of the changes to healthcare as a result of COVID-19 involved a move towards telehealth and remote antenatal and postnatal appointments, redeployment of midwives across the sector, for example, for screening and vaccination, and reduced or altered postnatal support . In addiAlthough pregnant women are no more likely to contract COVID-19 than other population groups, the risk for pregnancy complications in women who are COVID-19 positive appears heightened. For example, studies have reported increased risks for preterm birth, caesarean birth, and, in rare cases, maternal death , 7. OtheMidwives, obstetricians, and other allied maternity care providers have also experienced significant challenges during the COVID-19 pandemic. Adapting, in many cases overnight, to an altered system of care, maternity care providers experienced fear of the unknown, unpreparedness and fear of contracting COVID-19 –15. AcceAlthough the global vaccination programme has offered optimism and a sense of anticipation that approaches to tackling the coronavirus are moving in a positive direction, new variants of COVID-19 continue to emerge. As a result, health care advisors and the community at large remain on heightened alert, and global healthcare continues to be affected, including that of maternity care. Understanding the experiences of those directly involved in receiving and providing maternity care during COVID-19 is critically important for optimising quality care as the pandemic continues and beyond. As qualitative studies exploring stakeholder experiences of maternity care, from across the globe, are being made available, bringing the findings together from these studies through evidence synthesis will help establish a greater understanding of the emerging issues from the perspectives of those directly involved. For this reason, we conducted a qualitative evidence synthesis (QES) of pregnant and postpartum women’s and maternity care providers’ views and experiences of maternity care during COVID-19. By collating the existing evidence, the findings from this QES will uncover new information and create an awareness of the impact of COVID-19 from the perspectives of those directly affected, which may guide resource and care needs, including mental health care needs, now and into the future.CRD42021232684) and the protocol is published and openly available The pandemic resulted in considerable changes in how maternity care was structured, which affected care provision and access to care. Examples of these changes included: women attending clinics for care on their own, care transferred from in-person to virtual , reduced choice for childbirth, inconsistent care, altered continuity of care (reduced and enhanced), schedules of fewer, postponed or cancelled antenatal or postnatal appointments, and altered maternity pathways based on COVID-19 test results , 58, 79.Cancelled or postponed maternity care appointments, arising as a direct result of the pandemic, were commonly experienced by women , 49, 52.Altered systems of maternity care were identified in all studies contributing to this sub-theme, irrespective of country and birth setting, however, the extent of the changes appeared varied. For example, in Meaney’s international study , with pa“And this telehealth situation, this monitoring from home, that’s a joke. It’s not going to work. How can you tell me that my C-section isn’t hurting when I’m telling you that it is hurting but you can’t see it” The sub-theme of Telehealth reflects women’s views and experiences of virtual rather than in-person maternity care during COVID-19. Telehealth was noted by women to confer some benefits; for example, avoiding travel time to the hospital or clinic for antenatal or postnatal appointments, overcoming long waiting times in clinics, being in the comfort of their homes and minimising exposure to risk of COVID-19 infection , 74, 79.“And over the phone just doesn’t do it like. You don’t get the same, to look into somebody’s eyes and to trust them and for them to say, you’re okay” Online consultations for breastfeeding were described as ‘awkward’ and ineffective , 55, 75,Women described feeling ‘embarrassed to talk about mental health concerns over the phone’  such that telehealth was deemed inappropriate by women for discussing sensitive health issues. It also left some women feeling unprepared for birth, as in-person support mechanisms such as childbirth and parenting education classes were moved to the virtual space or were cancelled altogether , 74. TelEighteen studies contributed data on women’s views and experiences of pandemic imposed restrictions. The synthesis of these data is represented in two sub-themes; ‘It felt cruel’—restricting partners attendance and Restrictions in general: pros and cons.Sub-theme 2.1: ‘It felt cruel’ – restricting partners attendance“I’m so angry that neither I, nor [name], will ever get that day back. I will never be able to correct it or make it a better experience … it felt cruel “… denying my husband, the right to be there, or me the support he provides is a disgusting standard of care which will have lifelong effects” The degrees to which COVID-related restrictions were imposed on women’s partners or primary support person varied. For example, for some women, partners could remain throughout the birth and postpartum periods , 55, or “It’s made it definitely a more somber experience and it has been difficult to be excited because you can’t share it with people.” This sub-theme reflects women’s experiences and views of restrictions beyond those related to restrictions on partner attendance. Restrictions, based on hospital policy, because of being positive for COVID-19 or restrictions imposed when babies were admitted to the neonatal intensive care unit (NICU) appeared especially harrowing and distressing for women , 58, 75.“It is a lot quieter, more time to adjust and try to get a hang of breastfeeding without an audience” Attending or being in hospital alone without visits from friends and family was difficult for many women , 44, 56.Visiting restrictions and being isolated encouraged women to form close relationships with other women in a similar situation , 44. On “We’re more concerned about whether we came into contact with anything in the hospital” Narratives around risks associated with contracting COVID-19, as well as infection prevention were evident in 29 of the included studies. Many women, perceiving the maternity care facility as a source of infection risk, were fearful, worried, and wary of visiting the facility for fear of contracting the virus , 75, 77.“At present, all that matters is keeping the baby safe and keeping the mother well enough to give birth, disregarding the humanized dimensions of pregnancy, birth care, and the lived experience of the birthing mother” The interplay between balancing fear of contracting COVID-19 and the risk of not attending for care was a source of emotional conflict for some women, presenting them with a challenging dilemma , 46, 77.Women, however, were appreciative of efforts in maternity care settings to minimise virus transmission and felt reassured by these. Measures described by women included separate areas or entrances for pregnant women attending for antenatal care , high leThis theme reflects the reality of navigating support during pregnancy and the postpartum period, and the activities that women undertook to address challenges associated with this. Twenty-three studies contributed data to this theme, with findings reflected across the two sub-themes of Information and psychosocial support and Women’s solutioning.“One doctor would say one thing and then the next would say another.” Navigating information and psychosocial support during the pandemic appeared especially challenging for women. Women experienced navigation difficulties for various reasons and due to different causes. Information support, for example, was affected by a lack of consistent messaging, conflicting information or a lack of clear guidance surrounding the virus and how this affected women’s care, both during pregnancy and postnatally , 53, 56.“…and I think probably one thing that maybe could be improved is just that extra information of what you are doing with the COVID stuff in terms of precautions, what it's going to look like when I come in to have bubs, just what to expect.” This resulted in women feeling lost, confused, or helpless , 46, 55.“I was struggling breastfeeding. I would have gone to breastfeeding group, but that’s been cancelled…. I was in pain and I felt let down” Navigating psychosocial support also featured considerably in women’s narratives. Although some women recounted receiving good support from maternity care providers , 55, 58,“And you know if you were kind of just worried, but you were able to talk to each other. And just comfort each other.” Women, in navigating their maternity experience during the pandemic, self-implemented solutions as a means of coping, including adjusting their plans or exploring other options for care , 47, 56.“I am forced to continually fight to be seen and have to reiterate my situation and reasoning over and over …. and now I have no choice but to advocate for myself but it has been very difficult.” Women spoke of advocating for themselves to achieve the maternity care they desired or needed, amidst the constant changes occurring within maternity systems , 46, 56.Other women, alternatively, found themselves simply accepting of and being adaptive to the present situation which helped them feel prepared , 51, 76.“…The education given by the OB has dramatically shifted from normal pregnancy concerns to 95% about coronavirus. I feel like my questions about non-COVID issues are getting overlooked.” The theme of Interactions with maternity care providers reflects women’s experiences, both positive and negative, of their engagement with the maternity services and maternity care providers. Fifteen studies contributed data to this theme. Women recounted being either unable to contact, or experienced fewer interactions with, their care providers antenatally, while in the hospital, or during the postnatal period , 74, 75.On several occasions they told me ‘Stay away, stay away, keep the 1-meter distance, go to that corner in the lift…. When they came in the room to wake me up at 6am they used to open the door shouting ‘masks!’ This ‘hands-off’ style of care resulted in a ‘colder birthing experience for women’  or left women feeling neglected by their care providers , 49, 75.Those who were positive for COVID-19 used intense language in describing their overall birth experience including words such as ‘traumatic’, ‘tragic’, ‘difficult’, ‘strenuous’, ‘sad’, ‘disheartening’, ‘terrible’, ‘negative’, ‘odd’ and ‘unfortunate’ and used the analogies of being in a ‘nightmare’ or a ‘war’ to convey perceptions of their experience. Women also spoke of unmet expectations arising from interactions with their maternity care providers , 44, 56.The theme of Altered maternity care represents narratives from maternity care providers on how the provision of care substantially changed during the pandemic and the impact that this had on their capacity to provide appropriate and effective care. Twenty-two studies contributed data to this theme. The two sub-themes of Altered care structures and provision and Capacity to provide care were identified within this analytical theme.Sub-theme 6.1: Altered care structures and provision.“Departmental protocols…were changing rapidly, leading to confusion and unclear interpretation by staff members… variation in practice and misinterpretation of guidance were expressed…especially where limited evidence is available” .Across all settings, the provision of care had substantially changed for maternity care providers. There was a focus on reducing in-person appointments with a move to virtual or telephone appointments, where possible, which required maternity care providers to be innovative and adaptive in identifying alternative ways to provide care , 71, 72.Many maternity care providers, however, acknowledged that such uncertainty lessened over time as clear national guidelines became established and implemented, and the communication around care protocols improved , 66, 73.“Restrictions and regulations in the time of COVID-19 have allowed for a resurgence of the racist and sexist policies…Black women’s bodies have continued to be seen as risky…leading to a lack of care and touch that continues to put Black birthing people in danger” .Some providers also held a belief that other maternity care providers were using pandemic associated changes as an excuse for inadequate care , 75.“COVSome practice changes, however, were viewed as having a positive impact on care due to fewer women attending services which increased the time available to spend with each woman and which facilitated a more efficient service . Despite“To decrease the risk of transmission, we usually compromise the routine antenatal care service. For instance, we may not perform physical examination or draw blood, even if necessary” Most maternity care providers felt that the changes due to COVID-19 had resulted in a reduced capacity to provide safe and effective care. A lack of access to adequate resources, such as PPE and training on safe practices, left maternity care providers feeling that they were not adequately protected , 74, 77.“Virtually the screen is small, I’m at the mercy of the person holding the phone…I have to verbally direct the mom over the phone, and many interrupt[ion]s on both sides of the conversations” .COVID-19 related restrictions, such as reduced in-person appointments, cancelled support groups, and reduced numbers of maternity care providers in the birthing suite, were viewed as barriers to care , 74, 75.“Over the telephone, it is harder to read all the non-verbal cues as you would in an in-person counselling session” A move to telehealth was viewed positively by some as it enabled the continuation of care in a safe environment and allowed for a more responsive approach to care in some circumstances. However, telehealth was described as having limitations. Due to the lack of personal contact, it was viewed as hampering the ability to build a trusting relationship with women which impacted on providing effective care , 69, 71.“One of the biggest challenges reported was poor internet connection and/or regular interruptions in connectivity. This was a global problem reported by providers from both LMICs and HICs” Furthermore, language barriers and insufficient access to digital resources or a lack of digital literacy sometimes hindered the provision of care in this mode. This was an issue especially for maternity care providers in low- and middle-income countries, or for disadvantaged populations in high income countries , 67, 71.The theme of Professional and Personal Impact describes the impact of the COVID-19 pandemic, as expressed by maternity care providers, on their professional careers and their personal lives. Nineteen studies contributed data to this theme. The two sub-themes of Professional impact and Personal burden were identified within this analytical theme.“It was ‘on the frontlines’ that I felt the most the distant from the pandemic itself. I felt guilty responding to messages from family and old friends, those not in medicine but trapped in their homes by an invisible enemy ravaging their cities and towns” Professional impact was predominantly negative for maternity care providers. Staff shortages , 73, add“The pandemic has impacted the medical culture in Puerto Rico, emboldening doctors to ‘protect’ their ‘domain’… medical professionals have taken to social media…gone on the news to argue that the absolute safest place to give birth is the hospital” Contrastingly, in some settings, divisions emerged as particular professions pitted themselves against others, for example, midwives and doctors , 74, 76.“Nurse participants described ...wanting more compassion and respect from hospital administration…a need to be seen as an individual who is being placed at risk” Different professional beliefs or perceptions about status in the ‘hospital hierarchy’ also contributed to these divides. Altman and colleagues described how nurses working in perinatal settings felt that they were expected to take additional risks to those of other staff members, including consultants . This co“Respondents themselves faced financial burdens from the use of telemedicine on two levels: not being able to afford the equipment and lack of reimbursement…for costs they incurred while providing telemedicine ” The pandemic presented a personal burden for all maternity care providers “including issues that affected personal health and well-being; challenges with family and parenting; and mental health concerns, stress, finances and loss of income. This was universal regardless of personal circumstances, type of practice, years in practice or geographical area” 73, p.4]. COVID-19 was considered a significant threat, and due to a fear of acting as a vector, to either patients or family members, maternity care providers isolated themselves from or interacted less with their families , p.4. CO, 78. Thi“[the] lack of time and staff will lead to mothers and babies going home with very little feeding support or knowledge which will have a short- and long-term impact on their health and ability to deal with infections” While much of the focus in the studies included in this QES was on the immediate implications for maternity care providers, important findings were also identified in relation to the perceived broader impact of the pandemic on maternity care, with data from 10 studies contributing to this theme. Some maternity care providers were worried about the impact of restrictions on the future health outcomes of parents and babies. They believed that the restrictions led to reduced care and support being provided, which they believed would have a negative impact on future health:“I feel management will see the changes made i.e. shorter inpatient stay, increased VMS (Visiting Midwifery Service) personnel as economically beneficial and it will be difficult to revert back” There were also concerns that some of the changes introduced due to COVID-19 would be retained in the post-pandemic era as they were viewed as economically beneficial by management, or for reasons of self-interest by certain providers who wished to minimise in-person care. The potential retention of such changes was viewed as being detrimental for future maternity care , 69, 76.“Going through this dual pandemic of COVID-19 and systemic racism is exhausting, to say the least. I reminisce of the “before” times but it’s been long overdue for the veil to be lifted - and for that reason I am grateful for the chaos” While maternity care providers largely experienced and described the COVID-19 pandemic as negative, there were some who viewed the situation as an opportunity , 76, 78.“With telehealth and remote appointments there is a lot of emphasis on self-care and being aware of your health - it is empowering for women” COVID-19 related restrictions also prompted maternity care providers to take a different perspective of their role and how best they could support parents , 66, 68.Due to this change in perspective, some maternity care providers considered the pandemic as a period of growth as they gained confidence in their role by successfully addressing uncertain situations and were looking for further opportunities for development , 66, 68.n = 14 findings) or moderate (n = 13 findings), providing reassurance for the applicability of the findings for informing clinical practice and care. Most of the downgrading in confidence related to the adequacy of the data, whereby the richness, depth and quantity of data contributing to a finding was affected by the diversity of study designs, especially survey design. Importantly, all findings were judged to have no, very minor or minor concerns on coherence. This means that the extent of support for each review finding from the underlying data was high; in other words, the individual included studies were reporting similar information in terms of how women and providers experienced maternity care during this time. Some minor concerns were applied to the relevance of some findings, which relates to how closely the inclusion criteria of the included studies mirrors that of the review question. Although all studies met the aim and inclusion criteria of our QES, due to the specific focus that some studies took, we judged this to have a potential impact on relevance. For example, studies that focused on women who were COVID-19 positive only [Twenty-seven discrete findings were subjected to GRADE-CERQual confidence assessments; of which 16 were from the synthesis of women’s data and 11 were from the synthesis of maternity care providers’ data. Table ive only , women wive only , or womeive only .Table 5GThis comprehensive QES based on the inclusion of 50 records of primary studies, provides insight and understanding of how women and maternity care providers experienced maternity care during the COVID-19 pandemic. Reassuringly, all 27 discrete findings were judged to have either high or moderate confidence. The narratives in many of the included studies were similar in content, even though contexts differed. For example, irrespective of country, region or maternity care setting, maternity care for both women and maternity care providers altered significantly and rapidly because of the pandemic. The move towards telehealth brought some benefits, although, more often, challenges. Digitalisation is advancing internationally, including in health. There are currently more than 10,000 computerised programs or m-health apps for promoting positive mental health . DigitalThe QES findings that maternity care during COVID-19 evoked an array of adverse and negative emotions for both women and maternity care providers are significant as they provide insight into possible future health challenges that women and maternity care providers may experience. Future mental wellness, healthy maternal-infant bonding, coping, resilience and burn-out are examples that warrant careful consideration. Unlike distress during other life periods, the perinatal period appears particularly critical, with negative psychological or psychosocial events in pregnancy, birth and early life appearing to have exaggerated life-long consequences, not only for mothers, but also for their infants. In a systematic review of 122 studies on maternal postpartum depression and the consequences for infant health up to 6 years of age, infants of mothers experiencing postpartum depression were found to have poorer weight gain in infancy, a greater proportion of child illnesses, increased infant night-time awakenings, and other problematic sleep patterns . The revWomen and maternity care providers recounted some positive experiences that arose from the alterations to care which warrant consideration for future maternity services. For example, as a result of visiting restrictions women recounted creating bonds with other women that might not have arisen otherwise, and having a calm space to establish breastfeeding. Maternity care providers recounted increased comradeship and bonding with their colleagues, which led to a more positive working environment. This will be important in the future as the pandemic endures whereby reliance and support from clinical colleagues will be more critical than ever. The structural and psychological challenges imposed by the pandemic on care providers has impacted on their reported ability to provide quality maternity care , 87. Althttps://osf.io/bzt38/ for the list of excluded studies with reasons). Given the extent of data contributing to the QES, however, we feel reassured that the potential for language bias based on the exclusion of these records is minimal.The strength of this QES lies in the broad approach of including both women’s and maternity care providers’ views. This has enabled perspectives from both populations to be considered and compared in gaining insight and in understanding maternity care experiences in these unusual times. The rapidity with which studies on this topic were being published, however, could introduce a potential limitation for our findings. Although we updated our search prior to our synthesis, there is the likelihood that further studies will have since become available that meet the inclusion criteria for this QES. Reassuringly though, our updated search revealed only eight additional codes in total, from those already developed. In this sense, further studies are unlikely to significantly alter the findings of the QES. We accept however, that how maternity care has been experienced as the pandemic continued may have temporally changed, especially in the wake of the vaccination programme which may have helped reduce fears, lessened restrictions or impacted on how care was structured or provided. To assess for temporal trends, an update or, ideally, a second review from the time of our last search would be beneficial. A follow-on review would allow findings based on the initial year of the pandemic and later years to be compared or contrasted. We also acknowledge that maternity care experienced by women can be influenced by their partner’s feelings and experiences or by those of their wider family or circle of friends. To advance the evidence overall on the experience of maternity care, we plan to conduct a QES on partners’ experiences of maternity care during COVID-19 and explore further complementarity. A further limitation to our QES was the inclusion of studies in the English language only. To assess the potential for language bias, however, we unrestricted our search based on language. Seven records were retrieved that potentially might have meet the review’s inclusion criteria but were excluded as they were non-English language publications  to mitigate such risks are required. To add further understandings of the experience of maternity care during COVID-19 overall, and to explore temporal trends and complementarity, additional QES updating the current QES and a QES to explore the views and experiences of partners and support persons are recommended; the latter of which is currently being planned.Additional file 1: Supplementary File 1. Minimum criteria for quality assessment m Thomas  et al. 2Additional file 2: Supplementary File 2. Methodological characteristics of included studies  Additional file 3: Evidence Profile - GRADE CERQual


Virtual LimitLab—a virtual-reality simulation for training refusal skills under peer pressure to consume alcohol. Qualitative interviews with 16 LGBTQIA+ adolescents were conducted after individual simulation testing. Using a thematic analysis with reflexive orientation, four themes were identified: Statements on relevance of gender, opinions on tailoring- and flirting options, and opinions on characters. Participants called for greater diversity representation among the characters, regarding gender identity and sexual orientation, as well as for representing, e.g., racialised peers. Moreover, participants suggested expanding the simulation’s flirting options by adding bisexual and aromantic/asexual options. Divergent views on the relevance of gender and wishes for tailoring options reflected the participant group’s heterogeneity. Based on these findings, future gender-sensitive interventions should conceptualise gender in a complex and multidimensional manner that intersects with further diversity categories.Gender-sensitive interventions in alcohol-prevention that target adolescents often lead to binary tailoring for girls and boys. However, increased societal and legal recognition of sexual and gender minorities as well as research with this age group demand a broader understanding of gender. Therefore, the present study addresses the question of how interventions should be further developed to include sexual and gender diversity by exploring LGBTQIA+ adolescents’ perceptions of gender portrayal and gender-tailoring using  People who belong to sexual and gender minorities—including but not limited to individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, and aromantic/asexual (LGBTQIA+)—often face stigma and discrimination and thus additional health risks and health disparities ,2,3,4,5.Compared with other substances, alcohol is the most frequently used and misused substance among LGBTQIA+ subgroups  as well Blurred Minds, the Danish VR FestLab application, and Virtual LimitLab, which is the German version of the VR FestLab. All these interventions target the training of refusal skills and aim to increase users’ resistance to peer pressure when offered alcohol. Research on these VR tools for alcohol prevention has demonstrated promising results in terms of both user engagement during development  went both ways, anyway, and [gender] was therefore irrelevant” (H). In addition, another participant supported the unimportance of gender by explaining that in VR, users do not see themselves. An additional reason given for the unimportance of gender was perceived societal change: According to one participant, at least for the younger generation, in urban contexts, gender is less relevant. Furthermore, the unimportance of gender was described by many participants as a wish or desired ideal state: In an equal society, these participants felt that gender should not play a role and that no difference in the scenes should therefore be conceptualised, as reflected in the following demand: “Gender is not so pronounced. That’s also what I actually want because I do not fit into that system, anyway” (G). Moreover, participants frequently expressed that the personal context —rather than gender as a category—matters in real-life parties. According to participants, it is more important for the simulation that the individual user is able to decide on the plot development than that scenarios are presented which are tailored to gender. For example, as one participant described:Initially during the interviews, many participants stated that gender played no role in their experience of the simulation and that gender was ““That’s why I think the avatar selection is so unimportant. You wouldn’t need to pre-select [an avatar gender] because it’s more important how I feel right now, how I’m doing at the party, and how I see things through my eyes rather than which category I belong to”.(G)If you just play the way you play, you feel like yourself, anyway” (O).Another participant concluded that the first-person perspective and the users’ decisions on the plot were decisive when it came to identifying with the simulation figure by explaining: “people would feel like they are being better addressed” (I). According to some participants, gender does matter, especially at real parties, and these participants mentioned that different genders lead to different experiences. Therefore, as one participant explained, the simulation should reflect gender-specific experiences:On the other hand, some participants felt that gender was relevant both in the simulation and at real parties. In general, the importance of gender was mentioned as a possible tailoring category for better reaching certain groups in order that ““In real life, we all don’t experience the same night at the same party. And I think that when you simulate something like that, I think it’s good to pay attention to what different people experience”.(B)reflect reality… unfortunately” (G). Participants mainly voted for a predominantly neutral design but wished to include some gender-specific scenes. Then, the interviewer asked for gender-specific experiences and ideas as to what represented a gender-specific experience within the simulation. Next, the following statements were further divided into the sub-codes of specific experiences for male, female, and queer adolescents.Moreover, before advocating for the unimportance of gender, one participant later stated that tailoring the simulation to gender-specific experience could “bro-like” (A) for hetero peers and mainly involved “how to hit on someone” (E). Furthermore, boys were regarded by one participant as being more prone to excessive alcohol intake, which led another participant to the idea of depicting a male-specific scene with aggression and fights in the simulation.The typical male experience at parties was seen in verbal expressions, especially among boys. This experience was described as “more dangerous” (L) for girls, and in combination with alcohol consumption, harassment was considered to be especially frequent and was deemed a relevant topic. Some participants declared that boys could also be affected by sexual harassment, albeit less frequently, but when harassment did occur, boys were reported to experience an even stronger taboo than girls. Some participants concluded that harassment should be presented in a female simulation scenario and that alcohol prevention should be combined with the prevention of sexual harassment, as illustrated, for example, in the following quote:Similarly, the participants saw typical female-specific experiences via a specific form of interaction among girls—namely giggling. Aside from the verbal expressions and specific interactions among these two gender groups, the most crucial differences were seen in the frequently mentioned gender-related topic of sexual harassment. Parties were reported to be generally ““I think it’s a good idea to combine [alcohol prevention and the prevention of sexual harassment] because many things happen under the influence of alcohol and drugs that you don’t want to happen. Also, from my own experience, I can say a lot about what can happen, again and again, at mainstream parties and everywhere else. At my [queer] parties, unfortunately, that is also an issue, especially under the influence of alcohol”.(G)At the same time, participants were unsure as to whether and how to depict harassment in the simulation since the display might send the wrong message, for example, by teaching girls to have less fun and to be less outgoing, or it might trigger re-traumatisation. Therefore, some participants suggested including trigger warnings and the option to skip a scene. One participant brought up the idea of using VR for consent education and of including positive examples of asking for consent.faggot” or a “fucking lesbian” (G)), excluded from athletic locker rooms, and physically attacked. These adverse experiences were reported to have taken place both in school and in public as well as in private contexts with peers and parents alike. The need to always adapt and explain oneself was described several times. According to some participants, including hostility in the simulation would make it more realistic, as indicated, for example, by the following quote:A typical queer-specific experience in real life reported in many sections of the interviews was hostility towards queers. Negative experiences ranged from getting views that were perceived as strange or confused to being stared at and being asked inappropriate personal questions. Additionally, participants reported having been insulted tailoring options and comprised statements on customising the simulation with different avatar options, different depictions of these avatars, and different consequences for the following scenarios. Codes among this theme included perceptions regarding the current design of the simulation, in which a female or male avatar—represented by bathroom figures—had to be chosen before entering the simulation (two options) as well as ideas about and reflection on further options of tailoring .The second identified theme was named difficult” , “not so great” (P), “stupid” (I), “restrictive” (D), “cliché” (P), and “violent” (F). Participants additionally expressed feelings, such as “I hate it [the binary choice] so much. It always scares me” (O) and “somehow, I felt tricked” (A). For some participants, this led to the feeling of not being addressed. Moreover, the scene in which the choice had to be made was perceived as taking place too fast, which led some participants to not be able to recall which option they had chosen. Other participants reported having no particular feelings about this scene and described it as being “no problem”  and “quite normal” (M), whereas others viewed the scene with ambivalence and described it as “sub-optimal, but not disturbing” (J) and “irritating, but [I’m] used to it” (D). The choice was phrased as follows: “Who would you like to attend the party as?” This phrase was interpreted as a free choice, leaving room for trying out different genders and thus was rated positively by some participants as opposed to the question “What gender do you identify as?”.The existing version of gender-tailoring by a female and male option was perceived differently by the participants. Some participants stated that they had chosen the avatar with which they identified and that they had perceived themselves as being this particular gender during the simulation. In contrast, predominantly negative perceptions were mentioned regarding the choice of a bathroom figure, which was described as “three or more options. Many participants mentioned the idea of introducing a third, fourth, or even further avatar gender options that could be selected prior to entering the simulation. Having more than a binary choice was considered to be more modern and to diminish the above-mentioned negative perception of the obligatory choice between girl or boy since the existence of more choices was viewed as “being better for well-being” (A). Another participant explained that adolescents who do not (exclusively) identify as a girl or a boy could be made to feel more included: “That way, people would know, ’Yeah, there’s an option for me, too’” (E). Participants were unsure regarding the accurate number, appropriate names, and representation  of additional gender-identity options. In fact, the implementation of three or more avatars was described as difficult, and respective terms were thought to possibly not be commonly known. Initially, some participants mentioned or favoured the idea of having a third avatar with the term “diverse”—which is the most well-known term in the German context—even if the participants personally disliked the term: “I don’t like the word ’diverse’, but it’s what people would usually click on” (F). At the same time, the term was discussed by participants as an often not-applicable collective term, as illustrated by one participant’s explanation:Alternative ways of tailoring were brought up by participants or were asked for by the interviewer, including the idea of introducing more gender identities, which was summarised among the code of “Maybe ‘diverse’ [should be used] because it’s acknowledged by law as the third gender. But, of course, that’s not true because there are more than three genders”.(J)non-binary” , “genderqueer” , and “no gender” (A). However, some participants stated that introducing this variety would take too much time since the “the list would be too long” (J). Furthermore, according to participants, the choice would be superfluous if it did not result in in-simulation consequences. The same applied to the idea that one participant had for designing the choice of gender as a spectrum bar between the two poles of female and male; however, after further reasoning, this idea was rejected since it was found to be sub-optimal, technically challenging, and not adequate if it was reduced in the end to three different scenarios. Some participants who advocated for more than three avatars thus finally concluded that it might be better to leave out the choice entirely, as summarised in the code of no selection.Many participants mentioned additional possible gender self-descriptions than these three. Other terms suggested were “no selection for avatars by leaving out the choice entirely. This was thought to lead to no tailoring during the simulation and was favoured by most participants when explicitly asked. A few counter-arguments that were mentioned included the idea that different experiences according to different genders should be addressed in the simulation and that trying out other gender avatars would no longer be possible without a selection option. Regarding the scenes that are presented later in the simulation, one participant doubted that the simulation could be appealing without a gender selection since the simulation might become too non-specific. In contrast, numerous positive descriptions of having no selection were mentioned, with some participants describing it as a better option compared with gender-tailoring and as being more direct, easy, and ideal. Some participants explained that the simulation was perceived mainly as being neutral and that gender was not at all or only marginally relevant to the simulation (cf. the code of unimportant). Furthermore, some participants wished for gender to be irrelevant when entering the simulation. Moreover, designing the scenarios in a neutral way was seen as a good option for not reproducing stereotypes, as illustrated by one participant:Some participants brought up the idea of having “Because if you differentiate between the scenes, it leads to stereotypes. And if, for example, you distinguish between… yeah, if you choose the male avatar, you get into a fight, and the girls end up on the toilet throwing up or something, then I think you’re really reinforcing stereotypes. So, I think it [the simulation] should be kept neutral”.(L)Because if there are no options at all, then I play as myself, anyway” (O).In addition, withholding possibly relevant scenes for certain genders was regarded as problematic. In summary, some participants stated that without a gender selection, they would have identified as themselves in the simulation, as clearly illustrated in the following participant statement: “other options for tailoring that involved categories other than gender identity were mentioned or commented on, including:Building one’s own avatar with an individual look (which was considered exciting but overly complicated for a short simulation if this option did not have consequences within the scenes);Entering the user’s exact height and weight in order to personalise the BAC to a more precise body mass index ;Possibly including other relevant identity categories (which was considered irrelevant to the avatar choice in context of this simulation), and most prominently;Inclusion of a queer party scenario in the simulation.Furthermore, white, as illustrated by one participant, who described the simulated house party as follows: “[The simulation included] mainly white people with white names and very binary-looking peers (…) with straight couples” (F). The simulation represented an event that some of the participants had never attended and would not even attend. One participant made the connection between the idea of having a queer scenario and the wish for a safer space:Some participants felt that including a queer party scenario was a possible tailoring option. The current house party was described as being stereotypical, gender-conforming, and mainly “But also, the same game doesn’t necessarily work for everyone. So, we cannot assume that a cis white male person would feel super safe at a BIPoC  queer party. I would also find it okay that it’s not like that. That’s also allowed to be, because we experience things much more often the other way around. Yeah, it would be interesting to have more options and to be able to choose a party”.(F)characters). A further possible version of tailoring that was mentioned involved changing the plot according to each individual’s actual behaviour by providing answer options from within the simulation that differed based on the level of alcohol intake. This option was described by many participants as being highly important and potentially effective for identifying with and becoming immersed in the simulation.Therefore, participants were asked about what differences they saw between straight and queer parties as well as about how they would design a queer party scenario. The responses described queer parties as being basically the same as non-queer parties in terms of the types of interaction but as being more caring and socially inclusive and as having participants with greater social awareness and who give less importance to gender. However, the idea of a queer scenario was rejected by other participants since the simulation was intended to be the same for all simulation users. Moreover, upon reflection, some participants felt that having a queer scenario could be too different. Other participants suggested having a mix of a straight and a queer party by representing more gender diversity and possible orientations , especially as the party was perceived as a straight party. For example, another participant stated:The third identified theme consisted of statements regarding the “I just noticed that another male character asked me if I wanted to dance when I was playing as the male character. That’s really good because that’s so… I didn’t notice it at first because it was so normal. And that was really good”.(O)both”  for bisexual and “none”  for aromantic/asexual users. Other users suggested adding the question “What´s your type?” (G), which could be designed to be less attached to gender. Another point of critique was related to the conceptualisation of flirting as being irritatingly fast and extreme, and more answering options between kissing and leaving were desired, such as continuing to talk with the person.A point of critique of the current version of the simulation was that it retains the binary conceptualisation of either/or. Suggestions for improvements were made regarding the answering options in the above-described scene, in which the user is asked which gender is the desired one. Participants wished for more options, such as “the cool kids, the outsider, the funny guy playing beer pong, and so on” (G), as one participant phrased it. On the one hand, this variety was described as being positive, and as being stereotypical and representative of clichés, on the other hand.Among the fourth identified theme, statements regarding the other characters and these characters’ appearance and behaviour as well as wishes and suggestions for interaction with these characters were gathered. Participants generally appreciated the fact that the actors were teenagers and that the simulation was filmed and not animated. Furthermore, they noticed that different typical characters were portrayed, such as “a token black guy, like in advertisement, then I just don´t feel seen” (D); rather, the wish was to normalise BIPoC main characters. Further suggestions included having physically disabled peers and characters with diverse economic family backgrounds. Additionally, home problems and psychological problems were mentioned as topics that could be represented in conversations since these issues were considered especially important in the context of alcohol prevention. Participants stated that by including these topics, they would feel personally addressed and more societally accepted. For example, one participant stated that having greater diversity representation would lead them to feel “more comfortable and identified. That way, you could see that society is ready [for greater diversity]” (H). All these suggestions were brought up in the interviews upon reflection. Some participants expressed the core wish of having greater representation in the simulation, whereas other participants expressed the desire for this representation, even if they felt that it was not a necessity, as illustrated in the following quote:In general, many participants expressed the wish for more representation of diversity among the characters. Wishes included the representation of non-binary characters, characters with non-gender-conforming clothing, and couples that were gay, lesbian, or queer. Furthermore, the wish for more BIPoC peers as well as Black-, Arabic-, and Turkish-looking individuals and characters with headscarves was expressed. Some participants further explained that their wish was not to have ““Me, as a non-German-looking person, you are somehow used to it [the lack of representation]. Basically, you already have it in your head as a standard that everyone is white. You don’t even pay attention to it anymore […]. So, the way [the simulation] was didn’t bother me. But it would also be a bonus if it [the simulation] were more diverse. And, of course, it’s always good to re-evaluate things. That is important. So that this standard way of thinking is not shaped. You can’t do it wrong, but better. And I would find it [the simulation] better with with more diversity. It would be a plus. Exactly. If there were more diversity, you might feel a little more seen. Not totally consciously, but perhaps subconsciously”.(O)The importance of representation can also be found in the positive perception of one character that had been designed to be an outsider at the party. This character was mainly viewed positively by several participants, who expressed that they could see themselves in the character, who was sitting alone.offensive” (N), “disrespectful” (C), “homophobic” (A), and “anti-gay” (F). However, the scene was considered good in terms of how realistic it was. According to the participants, hostility towards homosexuality is even harsher in reality, and in a straight party context, gay flirting would be even less well-accepted than lesbian flirting. One participant suggested removing this scene, whereas others suggested changing it to have a nicer tone. Some participants even developed the idea of offering counter-reactions, including providing positive social feedback to the user if the offensive character is verbally defied. Other participants developed the idea of designing a VR simulation to learn “how to survive in an anti-homo world” (O) and how to counter toxic masculinity for anti-discrimination purposes.One scene changed according to the chosen gender of the avatar, and the interviewer asked the participants explicitly about this scene as well as about one specific character in it. In the male-specific scenario, this character reacts to flirting by the user with the exclamation, “Hey, bro, I’m not gay. But we can have a beer.” This reaction was mostly perceived negatively by the participants. The character’s reaction was described as being “relevance of gender) comprised heterogeneous statements on the importance of gender, the other themes were characterised by two divisions; namely, the division between the self and others, on the one hand, and the division between identity and orientation, on the other hand. The latter division reflects the conflation of sexual orientation and gender identity under the umbrella term of LGBTQIA+, which encompasses both concepts. The second theme (tailoring options) comprised views on different options for customising the simulation with gender identities by including different avatars and scenarios, while the third theme (flirting options) encompassed perceptions on orientational aspects. In contrast, the fourth theme (characters) involved the views and wishes of the participants regarding the depiction of others within the simulation, with a clear desire for a greater representation of diversity having been found.Overall, the present study contributes to the research field of gender-sensitive alcohol prevention by including the feedback and evaluation of LGBTQIA+ adolescents. Four themes were identified by applying a reflexive-oriented thematic analysis. While the first theme , ,52, 51,5Virtual LimitLab. As the results of Morgan et al. [Furthermore, no consensus was observed among the study participants as to how the goal of including sexual and gender minorities could be realised by tailoring the simulation to particular avatars and scenarios. The current design of two options  was met with divergent reactions that ranged from approving to indifferent and mostly elicited negative emotions. Therefore, many participants mentioned or agreed with the idea of including further gender identities. However, the number and specific labelling of further gender identities was discordant. The introduction of a third option with the label of “diverse” was primarily mentioned by participants. This option reflects the introduction of the new administrative and statistical category of “diverse” as the third legally possible gender category in Germany in 2018. At the same time, participants considered this term to be problematic since as a collective term, it fails to reflect actual gender diversity. Therefore, the participants supported the idea of leaving out the selection entirely in order to not reinforce stereotypes or create an overly complex and time-consuming selection process for designers and users. Compared with Morgan et al. , who stun et al.  indicateVirtual LimitLab [Moreover, participants in the present study commented divergently on the idea of designing a queer scenario, which was described to have both advantages  and disadvantages . Instead, several participants stated that immersion was sufficiently achieved—as is already the case in the current version—by changing the plot according to the multiple-choice and behaviour options rather than by pre-choosing an avatar category. This finding regarding tailoring options is in line with the results of our previous focus group study on LimitLab , in whicLimitLab —which poOverall, most of the adolescents in the present study wished for the simulation to be designed in a gender-neutral way and appreciated the mostly neutral appearance of the current simulation. Considered together, the heterogeneity in terms of perceptions and suggestions among LGBTQIA+ adolescents is an important finding and indicates that this group cannot be conceptualised as homogeneous. This finding is in line with our previous study, which also found heterogeneity in the opinions presented by the participating girls and boys .One of the main strengths of the present study is its inclusion of the difficult-to-reach group of LGBTQIA+ adolescents in the evaluation of a generic digital intervention. The diversity of sexual orientations and gender identities in the sample can be seen as a further strength of the study since this diversity enabled a broad variety of perspectives to be assessed. The interviews yielded rich insights into the research question of gender portrayal and tailoring and thus contributed to an emerging research field on the use of VR in alcohol prevention. At the same time, several limitations must be acknowledged.First, due to the explorative qualitative design of the present study, its results cannot be generalised and should thus be restricted to the particular context and study sample. As no sample size was pre-defined and the time for data collection was limited, data saturation was neither targeted nor possible. Nevertheless, within the dataset of the sixteen conducted interviews, data saturation could be regarded as having been achieved in orientation towards Francis et al.  since nowhite Germans, had no religion, and had experience with both alcohol and VR. Regarding further characteristics, other diversity categories, e.g., Muslim, Turkish, People of Colour, and adolescents with learning difficulties (as reported in the open-ended short questionnaire) were minimally represented. Another selection bias might have been the requirement of parental consent for participants aged below 18 years, which may have precluded the participation of some adolescents. Even though the potential of outing participants was avoided in parental information sheets, the ethical requirement of receiving consent by parents for minors may have impeded participation. Furthermore, recruitment was limited to Berlin, Germany, in order to guarantee in-person testing of the simulation as well as in-person interviews. Therefore, this study represents an urban, central European setting, and its results should be interpreted in light of this context.Second, self-selection bias may have occurred due to the chosen convenience and snowball sampling in the study. These sampling strategies run the risk of resulting in homogeneous groups and thus in limited perspectives and results. However, the heterogeneous results contradict this risk of bias. While the broad and open use of the term LGBTQIA+ during recruitment can be regarded as acceptable, this use might have led to the limited participation of certain subgroups. None of the participants identified themselves with the label of gay or intersex. Although specialised organisations and youth groups for these two subgroups were contacted, none of these participants could be included in the sample. This led to an unbalanced representation of LGBTQIA+ subgroups, and the transferability of our findings to all LGBTQIA+ adolescents is thus limited. In addition, the majority of participants attended an upper-level secondary school or grammar school, assumed themselves to be usually perceived as VR FestLab team) with the goal of ensuring greater openness among participants.Third, interviews may have been influenced by social desirability. Indeed, it is conceivable that participants were less critical or extra critical toward the virtual simulation. In order to counteract this issue, effort was made to emphasise that the development itself had been carried out by another research group  among the characters;Inclusion of sexual diversity via open flirting options ; andConducting further research on whether and how to combine and address gender-specific experiences  within alcohol-prevention interventions.Regarding gender portrayal, the central finding was the wish for a greater representation of diversity not only in regard to sexual orientation and gender identity, but also, for example, in terms of the inclusion of racialised peers. Regarding tailoring options, the study identified divergent positions among participants on a wide range of pre-selectable avatars and on the inclusion of a unique queer scenario. This finding highlights the importance of not conceptualising the LGBTQIA+ community as a distinct entity that has homogenous views and makes similar suggestions. Indeed, participants felt that “merely” adding a third avatar for sexual and gender minorities would not be sufficient. In fact, it might be best to tailor the studied simulation toward individual users via their actual behaviours rather than using a possibly stereotyped pre-selectable avatar gender. This idea would not represent a failure to acknowledge sexual and gender diversity in design and conceptualisation. However, based on our findings, for short prevention simulations, such as In this sense, acknowledging sexual and gender diversity indicates addressing the specific experiences of hostility toward LGBTQIA+ adolescents as part of a broader, multi-level approach since hostility toward these sexual and gender minorities is a far-reaching problem that is situated within societal power imbalances. In other words, more collective approaches are necessary. Inclusion of LGBTQIA+ adolescents in gender-sensitive prevention research is only a starting point in the research field.Indeed, both LGBTQIA+ adolescents and the topic of gender need to be integrated into research, while maintaining a complex understanding of gender and sexuality that goes beyond binarity and reflects the intersectionality of diversity. Considering this, future digital strategies could thus result in interventions that are more inclusive of diversity-conscious approaches with and for all young people.