ResProt JMIR Res Protoc JMIR Research Protocols 1929-0748 JMIR Publications Toronto, Canada v15i1e82241 41499162 10.2196/82241 Protocol Protocol Interactive Internet-Based Motivational Interviewing Training for HIV Counseling Support Staff to Improve Health Communication in HIV Care Interactions: Protocol for Training Development and a Pilot Randomized Controlled Trial Sarvestan Javad Balán Iván C PhD 1 https://orcid.org/0009-0003-9954-5720 Brewer Onna R PhD 1
Center for Translational Behavioral Science, Department of Behavioral Science and Social Medicine College of Medicine Florida State University 2010 Levy Ave Building B Suite B0266 Tallahassee, FL, 32310 United States 1 850 644 2334 onna.brewer@med.fsu.edu
https://orcid.org/0009-0006-1753-9928 Kutner Bryan A MPH, PhD 2 https://orcid.org/0000-0002-4544-708X Giguere Rebecca MPH 1 https://orcid.org/0000-0002-6529-0550 Center for Translational Behavioral Science, Department of Behavioral Science and Social Medicine College of Medicine Florida State University Tallahassee, FL United States Division of General Internal Medicine Department of Psychiatry and Behavioral Sciences Albert Einstein College of Medicine Bronx, NY United States Corresponding Author: Onna R Brewer onna.brewer@med.fsu.edu 2026 7 1 2026 15 e82241 13 8 2025 8 10 2025 17 10 2025 19 11 2025 ©Iván C Balán, Onna R Brewer, Bryan A Kutner, Rebecca Giguere. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 07.01.2026. 2026

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 Background

HIV counseling support staff (CSS) play a crucial role in HIV care outcomes, providing essential access to HIV test counseling, linkage-to-care support, adherence counseling, peer support, and navigation. Effective training in evidence-based interventions like motivational interviewing (MI) is imperative to maximize the impact of CSS in enhancing HIV care outcomes. MI is a collaborative, goal-oriented communication method aimed at bolstering an individual’s motivation and movement toward specific goals by eliciting and exploring personal arguments for change. MI has demonstrated efficacy across various medical and mental health outcomes, including its significant impact on the status-neutral HIV Care Continuum.

 Objective

The objective of this study is to develop and pilot an interactive internet-based MI training program for HIV counseling support staff (iMI4HIV), aiming to enhance their communication skills in HIV care interactions.

 Methods

The iMI4HIV Study will have 2 phases. In phase 1, Development, we will conduct formative focus groups (FGs) with CSS (n=16) to identify HIV care interactions for demonstration videos and to assess acceptability of gamification components; create MI demonstration videos depicting key interactions from status-neutral HIV Care Continuum; program iMI4HIV (including skills development tasks, gamification components, etc); and pilot a virtual MI (VMI) workshop followed by iMI4HIV (n=8). We will also conduct qualitative interviews with 8 leaders from HIV care agencies to explore their use of existing online MI training programs, acceptability of iMI4HIV, and possible facilitators and impediments to its adoption for training HIV CSS. In phase 2, pilot randomized controlled trial (RCT), we will randomize 30 CSS at a 2:1 ratio (VMI workshop + iMI4HIV vs VMI workshop + waitlist control) to assess the feasibility and acceptability of iMI4HIV and to pilot the RCT processes and assessments for a future efficacy trial. We will also explore the preliminary impact of iMI4HIV on MI skills acquisition.

 Results

The CSS focus groups began in August 2024, and programming of the training is near completion. We plan to conduct a pilot with 8 participants by the end of 2025, to obtain feedback and conclude phase 1 of the study. The phase 2 pilot RCT is expected to be launched in February 2026, with all data collection to be completed by October 2026.

 Conclusions

Our pilot study aims to demonstrate the feasibility and acceptability of an internet-based MI training program for HIV CSS. If successful, this training program has the potential to enhance the delivery of evidence-based interventions in HIV care settings, ultimately improving patient outcomes and adherence to treatment protocols. Further research and larger trials will be needed to confirm these findings and refine the training approach.

 International Registered Report Identifier (IRRID)

DERR1-10.2196/82241

 HIV implementation science internet-based Motivational Interviewing training ext-peer-rev The proposal for this study was peer-reviewed by: HIBI - HIV/AIDS Intra- and Inter-personal Determinants and Behavioral Interventions Study Section, Risk, Prevention and Health Behavior Integrated Review Group(National Institutes of Health, USA). See the Multimedia Appendix for the peer-review report; Introduction Background

HIV counseling support staff (CSS) provide key services for HIV care outcomes, such as HIV test counseling, linkage to care, adherence counseling, peer support, and care navigation. Interventions delivered by CSS have increased HIV prevention [1,2], testing [3], linkage to care [4,5], treatment engagement [6], and adherence [4-7]. Nevertheless, to maximize patient outcomes, community-based CSS could benefit greatly from training to ensure competent delivery of evidence-based interventions, including motivational interviewing (MI).

MI is “a collaborative, goal-oriented method of communication aimed at strengthening an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change” [8]. MI has proven efficacy in improving substance use [9,10], mental health [11,12], medical [13-17], and other outcomes across the HIV Care Continuum (HCC) in adults and adolescents [3,6,18-36]. MI has also been shown to improve linkage to and retention in care as well as treatment adherence [8-16], including among adolescents [6,26,31]. MI is particularly useful as an intervention because it requires CSS to master one set of skills applicable across the HCC instead of a variety of interventions for each step of the HCC. Furthermore, because it is efficacious even during brief interactions [37], MI can be integrated into all aspects of work typically conducted by CSS in HIV care settings. MI is embedded in HIV care guidelines, including those of the US Department of Health and Human Services and the New York State Department of Health [32,34], and training in MI is often offered through the national network of regional AIDS Education and Training Centers (AETCs).

However, mastering MI is not easy [38-43]. MI entails adhering to standard counseling tools (ie, open-ended questions, affirmations, reflections, and summaries) with an empathic, client-centered, collaborative approach. MI also includes a more difficult, technical component—the systematic elicitation and reinforcement of change talk (statements made by clients that argue for change, eg, “I need to get better at taking my pills”) and avoiding evocation of sustain talk (statements made by clients that argue for not changing, eg, “It’s hard to remember taking my pills”). Research on MI’s mechanisms of action has shown that more change talk and less sustain talk during a session are related to better outcomes [44-46]. Also, counselor behaviors such as advising, confronting, directing, and warning clients are associated with greater sustain talk, whereas counselor behaviors such as affirming strengths or effort, emphasizing client autonomy, and being supportive are associated with increased change talk [47,48]. Thus, to facilitate behavior change, the goal of an MI counselor is to interact with the client in a manner that facilitates change talk and inhibits sustain talk [38,48].

Standard MI training often consists of a 2-day workshop (about 14 hours total) with didactic presentations and many practice and experiential exercises. After this, attendees typically demonstrate an increase in MI relational skills (eg, asking permission before sharing information and more collaborative interactions). Demonstration of MI technical skills, such as using more open-ended questions and reflections, especially complex reflections [49-52] that are key components of MI’s mechanisms of action, is less likely after a 2-day workshop. Furthermore, acquired skills tend to diminish over the following 8-12 weeks without postworkshop feedback and coaching [53-55].

Studies have shown that CSS can become competent in MI [6,56], but in real-world settings, the training needed for CSS to attain MI competency is not readily available. This is a key challenge to disseminating and implementing MI [38,42,43]. Thus, we need to develop novel training approaches that are effective at teaching the technical MI skills that are key to MI’s efficacy and make these trainings more easily accessible to CSS in community settings. To ensure that MI retains its demonstrated efficacy in improving HCC outcomes, these MI training approaches need to be scalable so that they can both reach CSS working in HIV care settings and effectively increase their MI skills.

The World Health Organization has called for digital training for health care providers [57] and the broad use of online training for other behavioral interventions [58-60]. However, the use of technology in MI training has remained mostly limited to video demonstrations and brief didactic webinars that describe MI and provide examples of MI skills—even among the many MI-based health interventions that have been developed [61-63]. Findings from studies of technology-driven MI training have been encouraging. For example, multisession synchronous online MI training is feasible and effective [63,64], with no difference in counselor skill acquisition between in-person and online workshops [64]. Mitchell et al [65] used Second Life, a virtual world, to train physicians to increase acceptance of colorectal screening using 3 sessions of combined prerecorded MI tutorials, two 90-minute group role-play and feedback sessions with an MI coach, and between session practices, and thereby increased physician’s MI global skills related to client-centeredness (there was no assessment of individual technical skills). Other projects have begun to use avatars and simulated patient interactions to build MI skills [66-68]. These allow users to interact with virtual patients who are trained to respond in a certain manner to the words being used by the provider. To date, however, there are no studies that report on the efficacy of these training approaches, whether they are best used for beginner or advanced learners, or whether they need to be combined with other training approaches. Also, there are significant concerns about the costs to develop these patient interactions, especially because each simulation has to be constructed individually using words that are typical in the subject area the training addresses [68]. Finally, although technology-based MI training has high acceptability among users [63-68] and has shown preliminary evidence of efficacy in building MI skills [64,65], there are challenges to participant engagement and retention [63,68,69], highlighting the need for further research on novel technology-based MI training approaches to improve user engagement.

This study seeks to address a critical need for novel training approaches to build skills among CSS to deliver MI in health care interactions across the status-neutral HCC. Referred to as “iMI4HIV” (internet-based motivational interviewing training program for HIV counseling support staff), this study will offer a new approach to online MI training, specifically for HIV care settings. First, it will offer comprehensive interactive online training (10-12 hours) aimed at helping users learn how to use MI across a range of HCC interactions. Second, it will approach asynchronous online MI training in a completely novel way, using multiple MI video demonstrations combined with gamified exercises to sequentially build skills that are key to MI’s mechanisms of action, specifically the relational and technical skills essential for increasing change talk and inhibiting sustain talk. Third, it will integrate a variety of gamification and skills training components to increase engagement and appeal across a range of users [70-84]. Finally, this study includes a detailed framework for developing and evaluating the iMI4HIV strategy that includes HCC stakeholders, MI subject matter experts, and HCC learners in the development and piloting phases of the study, using mixed methods to evaluate the learner experience, engagement, and outcomes for MI learning.

 Study Objectives

The overall goal of the study is to develop and pilot an interactive, gamified, online training program in MI for HIV CSS to improve health communication in status-neutral HIV care interactions. This National Institutes of Health (NIH) R34 (Clinical Trial Planning Grant) study will allow us to pilot all the components and build the necessary research infrastructure for a subsequent randomized controlled trial (RCT) that is fully powered to assess the efficacy of iMI4HIV in increasing MI skills among CSS in HIV care interactions. The specific aims of this R34 study are as follows:

Develop iMI4HIV, an interactive, online, gamified MI training program specifically tailored toward CSS in HIV care settings to improve their MI skills with HIV care clients.

Conduct a pilot RCT of a virtual motivational interviewing (VMI) workshop + iMI4HIV versus VMI workshop + waitlist control (n=30) to (1) assess the feasibility and acceptability of iMI4HIV as measured by participant completion rate and retrospective acceptability ratings of iMI4HIV, and (2) explore preliminary findings on the effects of iMI4HIV on MI skills acquisition using Standard Patient Interactions (SPIs).

Explore experiences (including engagement, obstacles, and facilitators) of completing iMI4HIV via in-depth interviews with pilot study participants.

In this paper, we present the proposed procedures for developing iMI4HIV, conducting the pilot RCT, and assessing its acceptability among HIV CSS.

 Methods Study Design Overview

This study will have 2 phases. In phase 1 (Development), we will conduct formative focus groups (FGs) with CSS (n=16) to identify HIV care interactions for iMI4HIV videos and to assess the acceptability of gamification components; create MI demonstration videos depicting key interactions from status-neutral HCC and program iMI4HIV (including skills development tasks, gamification components, etc); and pilot the VMI workshop and iMI4HIV (n=8). We will also conduct qualitative interviews (QIs) with 8 leaders from HIV care agencies to explore their use of existing online MI training programs, acceptability of iMI4HIV, and possible facilitators and impediments to its adoption for training HIV CSS. In phase 2 (Pilot RCT), we will randomize 30 CSS at a 2:1 ratio (VMI workshop + iMI4HIV vs VMI workshop + waitlist control) to assess the feasibility and acceptability of iMI4HIV and to pilot the RCT processes and assessments for a future efficacy trial. We will also explore preliminary findings on the impact of iMI4HIV on MI skills acquisition. At the outset of the study, we will convene a Community Advisory Board (CAB) composed of 7 members, including individuals involved with HIV-related community health worker (CHW) training programs and HIV CSS with at least 1 year of experience providing services in HIV care settings. The CAB will meet via videoconferencing quarterly throughout the study.

 Recruitment of CSS

Recruitment of participants will occur through 2 main recruitment streams. First, we will work with our partners at the Northeast and Caribbean AIDS Education and Training Center (NECA AETC) to help us recruit CSS through their network of collaborating HIV care agencies (a maximum of 2 CSS per clinic). Second, we will recruit through HIV-focused CHW training programs. These 2 recruitment streams will provide us with a group of CSS trainees that will be diverse in terms of HIV counseling experience and training. Eligibility criteria for all CSS study participants will be (1) aged 18 years or older, (2) currently works in a CSS role to improve HIV care outcomes, (3) English-language fluency (since iMI4HIV will only be developed in English during this study), and (4) access to a laptop, desktop, or tablet computer to attend the virtual training and complete iMI4HIV.

 Phase 1: Development MI Training Content Development

We envision approximately 10-12 hours of training content organized by HCC component (Textbox 1). For each component, videos (each 8-18 minutes in duration) will be developed, highlighting different HCC-related interactions. The videos, by themselves, will serve as a resource to demonstrate proficient MI practice in these interactions. Furthermore, we will incorporate game-like interactive exercises aimed at building key MI skills that are critical to triggering its mechanisms of action, such as differentiating between open and closed questions, simple and complex reflections, and identifying and responding to change talk and sustain talk. In iMI4HIV, we will include some of the most frequently used gamification components (eg, points, feedback, levels, and badges of recognition) [75-78] while eschewing others, such as leaderboards (sharing a user’s points with all users to create competition), which may be counterproductive for this type of learning intervention [84]. The gamification components likely to be embedded in iMI4HIV include points to award learners for correct responses, feedback to encourage or prevent specific activities in order to improve performance, levels to stipulate that only users who attain a certain achievement can progress to the next level, and badges as a symbolic representation of a user’s achievement or competence.

Components of an internet-based motivational interviewing training program for HIV counseling support staff.

Video content

Motivational interviewing (MI) basics

MI spirit

Four tasks of MI

MI micro skills: open-ended questions, affirmations, reflections, and summaries

Evoking, recognizing, and reinforcing change talk

Responding to sustain talk

Planning for change

HIV testing

Overcoming ambivalence to testing

Facilitating regular testing

Reducing risk behaviors

Linkage to care

Overcoming ambivalence to entry to care after HIV-positive results

Linkage to pre-exposure prophylaxis or other prevention services

Building motivation for linkage to care to ancillary services (mental health and substance abuse treatment)

Retention in care

Exploration of the patient’s perceived benefits of staying in care

Collaborative planning to overcome obstacles to retention in care

Overcoming ambivalence to entry into care after HIV-positive results

Linkage to pre-exposure prophylaxis or other prevention services

Building motivation for linkage to care to ancillary services (ie, mental health and substance abuse treatment)

Treatment adherence and viral suppression

Exploring the client’s views on adherence

Building motivation for adherence

Using viral load and CD4 lymphocyte counts to build motivation to adhere

Sample tasks

Self-reflection exercises

Brief didactic presentations

Animation

Gamification (points for picking open-ended questions or choosing the best reflection; clicking when you hear change talk)

Coding brief segments for MI fidelity

Development of iMI4HIV will be guided by the User Centered Rapid Application Development process (UCRAD) [85,86]. UCRAD merges the streamlined, iterative Rapid Application Development (RAD) approach [87] with the User Centered Design approach [88,89], which engages intended users throughout the development process. This integrated approach aims to develop successful computer apps with good functionality, simple features, and a usable interface [90]. As such, intended users are given access to prototypes of the program, allowing them to provide feedback before the next iteration. We expect the process to take approximately 12 months in this study to produce the many scenarios and components of iMI4HIV. UCRAD uses a 3-stage process:

 Predesign and Interface Prototyping

To accomplish this stage, we will obtain feedback from the CAB regarding the preliminary plans for iMI4HIV, FGs with CSS, and QIs with HIV care agency leaders:

FG processes. We will conduct 2 real-time, 90-minute synchronous online FGs, each with 8 CSS, using a HIPAA (Health Insurance Portability and Accountability Act)-compliant video conference platform that allows for quantitative polling of participants regarding key attributes of iMI4HIV. The FGs will elicit individual- and group-level perspectives on topics that include (1) challenges faced in helping patients engage in care and obtain or sustain viral suppression, (2) prior MI training and use with patients, (3) challenges to learning and delivering MI, (4) feedback on iMI4HIV and different gamification components (eg, accumulating certain number of points before being able to proceed to next stage; preferences for types of games), and (5) other recommended training content. To obtain feedback on the gamification components, simple gamification components will be integrated into the FG discussion so that participants can provide feedback based on the gamification experience.

QIs with HIV Care Agency Leadership. We will interview 8 leaders (including program directors who directly oversee CSS) from HIV care agencies associated with the NECA AETC. Given the extensive existing literature on barriers and facilitators to MI implementation, these interviews will focus more specifically on (1) knowledge and use of internet-based MI training, (2) barriers and facilitators to internet-based MI training they are currently using, (3) presentation and feedback on iMI4HIV, (4) recommendations for additional content, and (5) barriers and facilitators to CSS completing iMI4HIV.

Rapid data analysis. Within 48 hours of completing each FG and QI, we will initiate a rapid data analysis [91,92] using a qualitative matrix [93,94] onto which participant responses will be entered to quickly organize and summarize FG findings. Summarized findings will be shared with the CAB and the external MI training consultants to obtain their feedback.

 System Architecture and Coding

We will convene an iMI4HIV development team composed of MI trainers, program developers, and 4 CSS (selected from FG participants for their contributions and comfort in providing feedback). This team will meet monthly online over 6 months. Prior to each meeting, CSS will be asked to use prototype versions of a different iMI4HIV module (including the video, MI learning tasks, and gamification) and provide feedback. During the meeting, we will explore their experience completing the module, including what they liked or disliked, their reactions to the learning tasks and gamification components, and their overall experience of interacting with iMI4HIV.

 Deployment

We will recruit 8 CSS from HIV care agencies and CHW training programs to pilot all training components. They will complete a 15-hour (3 days, 5 hours per day) HIV-focused VMI workshop conducted by experienced MI trainers that will consist of an overview of MI and extensive opportunities for joint interactive and experiential exercises conducted as a group and in dyads in different virtual rooms.

After completing the VMI workshop, participants will be sent an online questionnaire to provide feedback on the workshop and will be given access to iMI4HIV, which they will be asked to complete within 4 weeks. After completing iMI4HIV, or 5 weeks after being provided access, they (including those who were assigned to but did not complete iMI4HIV) will be asked to complete (1) an online questionnaire to assess acceptability of iMI4HIV and (2) an audio-recorded qualitative telephone interview to assess (a) overall acceptability of training program (workshop and iMI4HIV), (b) likes and dislikes of the program, (c) experience with gamification components, (d) difficulties encountered, and (e) feedback for the final version of the training program.

 Phase 2: Pilot RCT Overview

The overall aim of phase 2 is to assess the feasibility and acceptability of iMI4HIV and prepare the necessary research infrastructure and processes for a future fully powered RCT to test its efficacy in increasing MI skills among CSS in HIV-related interactions. Thus, we will recruit 30 CSS and randomize them using a 2:1 ratio (VMI workshop + iMI4HIV vs VMI workshop + waitlist control).

Figure 1 presents an overview of the phase 2 RCT procedures, detailing an RCT with a waitlist control arm which will gain access to iMI4HIV after completion of the Follow-Up 1 assessment. This design allows us to achieve the specific aims of the study as well as gain initial insights into the effects of iMI4HIV on MI skills and how these skills may be retained after 3 months. After all participants complete a baseline computer-assisted self-interview (CASI), they will complete SPI-1, then take part in the VMI workshop. After that, they complete SPI-2 and are then randomized into iMI4HIV versus a waitlist control. After 4 weeks, all participants complete Follow-Up 1, which consists of SPI-3, a follow-up CASI, and for only those in the iMI4HIV arm a qualitative interview. This will allow us to assess the feasibility and acceptability of iMI4HIV among those who were randomized into that arm (n=20). At this assessment point, we will also explore the effects of iMI4HIV on MI skills by comparing MI fidelity ratings of the SPI-3 between the intervention and control groups.

After Follow-Up 1, those in the control arm will be given access to iMI4HIV; after 4 weeks, only this group will complete Follow-Up 2, which will consist of SPI-4, a follow-up CASI, and an in-depth interview, which will provide additional acceptability data. Participants originally randomized into iMI4HIV will undergo their Follow-Up 2 after 12 weeks (SPI-4 and CASI, no QI). This will allow us to gain insights into retention of MI skills after 3 months, a key data point for a subsequent efficacy trial of iMI4HIV in which we would want to assess maintenance of MI skills. Community-based organizations rarely offer MI coaching to staff after a training workshop. Thus, we will not offer MI coaching in either study arm to focus on assessing the preliminary effects of iMI4HIV on participants’ MI skills.

Phase 2 pilot randomized controlled trial overview. CASI: computer-assisted self-interview; iMI4HIV: internet-based Motivational Interviewing training program for HIV CSS; MI: Motivational Interviewing; QI: qualitative interview.

 Recruitment of CSS

We will work with HIV care clinics associated with the NECA AETC and CHW training program partners to enroll 30 CSS in the RCT. Interested CSS will be instructed to contact the study research assistant who will screen them for eligibility. Eligibility criteria will be as described above for the phase 1 CSS participants. If these criteria are met, research staff will send them an “enrollment email,” which will include a link to an online informed consent form.

Our assessment of acceptability of iMI4HIV will be guided by the Theoretical Framework of Acceptability [95] (TFA; refer to components in Textbox 2), which was derived from a review of the literature on acceptability, and views acceptability as “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” [95]. The TFA has guided qualitative and mixed methods research on the acceptability of health care interventions among patients and providers [96-99]. The TFA’s 7 domains have informed the development of a generic TFA quantitative assessment with Likert-type items to assess each component of the model [100].

Components of the Theoretical Framework of Acceptability.

Theoretical Framework of Acceptability construct definitions

• Affective attitude: how the individual feels about the intervention

• Burden: perceived amount of effort that is required to participate in the intervention

• Ethicality: the extent to which the intervention has a good fit with an individual’s value system

• Intervention coherence: the extent to which the participant understands the intervention and how it works

• Opportunity costs: the extent to which benefits, profits, or values are given up to engage in the intervention

• Perceived effectiveness: the extent to which the intervention is perceived as likely to achieve its purpose

• Self-efficacy: the participant’s confidence that they can perform the behaviors required to participate in the intervention

 Baseline Assessments

After enrolling, participants will receive an email with a link to the CASI to be completed within 7 days and will be scheduled for their SPI-Baseline session, which will be audio-recorded and rated for MI fidelity. The CASI and the SPI-Baseline must be completed prior to the MI workshop. The baseline CASI assessment will include the following:

Demographics. This will capture information on age, gender, race, ethnicity, education, primary language, counseling training, and prior MI training.

MI Knowledge and Attitudes Test (MIKAT) [101], a 29-item assessment that has shown sensitivity to detect change in MI consistent and inconsistent behavior in pre- and posttraining comparisons [101-104], with acceptable internal consistency [104]. The MIKAT will be adapted to diminish its focus on MI for substance use treatment.

Perceptions of Evidence-Based Practices (EBPs) will be evaluated using 4 self-report measures:

The Evidence-Based Practice Attitudes Scale-15 [105] is a 15-item assessment of providers’ attitudes toward EBPs, with 4 factors: Appeal, Requirements, Openness, and Divergence. Participants will also complete 2 assessments of their perceptions of how EBPs are viewed by their supervisor and at the agency.

The Implementation Climate Scale [106], reliably assesses the extent to which a clinic fosters EBP implementation.

The Implementation Leadership Scale [107] assesses leadership support for EBP implementation.

TFA quantitative questionnaire [100]. Finally, we will assess the prospective acceptability of iMI4HIV using a tailored version of the generic TFA questionnaire. This questionnaire is composed of a 5-point Likert-type scale for each of the TFA components and 1 general question on acceptability. Findings from phase 1 will also identify other areas of inquiry for the baseline CASI.

SPIs. We will use scheduling software for study participants to schedule their SPIs. At the specified time, the SPI actor will contact the participant by phone to conduct a 15-minute MI session focused on an HIV care scenario. The session will be audio-recorded and then rated using the Motivational Interviewing Treatment Integrity ratings (MITI 4.2) [108], a valid and reliable measure of MI skills [109]. MI skills will be assessed at baseline, postworkshop, post iMI4HIV, and 3 months later (for participants randomized into iMI4HIV).

 MI Virtual Workshop

Synchronous VMI workshops will be conducted through Zoom (Zoom Video Communications, Inc). We expect 2 to 3 workshops with 10-15 CSS in each to facilitate individualized feedback during the workshops. Afterward, participants will receive a brief survey asking for feedback on the workshop.

 Randomization

As shown in Figure 1 above, after completing the SPI-2, participants will be randomized into iMI4HIV or waitlist control at a 2:1 ratio. After completing the VMI workshop, iMI4HIV participants will be sent a link to set up their account and access iMI4HIV. They will be asked to complete the online training within 4 weeks. Participants will receive weekly reminders to complete the training within 4 weeks, at which time access to the program will end. Waitlist control individuals will not have access to iMI4HIV during the 4 weeks following the VMI workshop but will get access once their follow-up assessment and SPI-3 are completed.

 Follow-up Assessment 1

Four to 5 weeks after randomization, participants in both arms will complete the first follow-up assessment, which forms the basis for comparing the 2 RCT arms and will consist of a CASI and SPI #3. Participants in the iMI4HIV arm will also take part in a QI. Participants in the iMI4HIV arm who did not complete the program will still be invited to complete the follow-up assessment (for which there is an incentive) so we can learn about obstacles to completing the program and obtain their recommendations.

Follow-up CASI. This assessment will repeat those measures conducted at baseline but tailored to each study arm. For the intervention arm, the follow-up CASI will additionally include iMI4HIV-specific assessments: (1) TFA-based questions to assess acceptability of iMI4HIV, (2) obstacles to completing iMI4HIV, and (3) self-report of any additional MI training (eg, watching YouTube videos and reading MI articles or books) in which participants engaged. Findings from phase 1 will also identify other areas of inquiry for the follow-up CASI.

SPI-3. After completing the follow-up CASI, participants in both arms will complete the third SPI as previously described, but using a different HIV-related patient scenario.

QIs with CSS. Participants in the iMI4HIV arm will then have a QI to explore topics including (1) the TFA constructs, (2) iMI4HIV components deemed enjoyable, educational, and helpful, (3) acceptability of different gamification components, (4) facilitators and obstacles to completing iMI4HIV, (5) perceptions of current competency in MI, including strengths and weaknesses, (6) factors that have facilitated or hindered the use of MI in HIV care interactions, and (7) recommendations for further revisions of iMI4HIV. QIs are expected to be approximately 60 minutes in duration, and will be audio-recorded, transcribed, and verified for accuracy before being deidentified and uploaded to NVivo (Lumivero) for coding and analysis.

 Follow-up Assessment 2

The second follow-up assessment will vary based on the study arm. Once participants in the control arm have completed their Follow-up Visit 1, they will be given access to iMI4HIV. They will be asked to complete the program within 4 weeks, at which point they will complete Follow-up Visit 2, consisting of (1) follow-up CASI assessment, (2) SPI-4, and (3) a QI. This follow-up CASI will be the same as that completed by participants in the active iMI4HIV arm at their first follow-up assessment. The SPI-4 will use a different scenario from those used in previous SPIs and will be conducted using the same procedures as the baseline SPIs. The QI will use the same as guide for the first follow-up assessment for those in the iMI4HIV arm; however, it will include additional questions exploring the impact of delayed access to iMI4HIV after completing the virtual workshop. Intervention arm participants will complete their Follow-up Visit 2 three months after their Follow-Up Visit 1. The assessment will repeat the CASI assessment from the first follow-up assessment and they will complete SPI-4. This will allow us to explore the degree to which gains in MI skills at SPI-3 are retained after 3 months.

 Data Analysis Qualitative Data Analysis for QIs

Transcripts from the phase 2 QI audio-recordings will be reviewed for accuracy and uploaded into NVivo for management and analysis. Codebook development will begin when 8 transcripts are available. First-level codes will be guided by the TFA components, while second- and third-level codes will emerge from themes identified in the narratives. An initial set of codes will be generated independently by 2 research staff, compared, then synthesized to compile shared coding categories and subcategories, all with definitions, inclusion and exclusion criteria, and examples. As transcripts become available, coding will continue, refining definitions that will be used to process the remainder of the manuscripts. Coders will discuss discrepancies until they achieve 80% intercoder convergence. As per Patton [110], we will identify indigenous (ie, participant-generated) as well as analyst-constructed typologies. Once data are coded, analysis of coding reports will include categorization, abstraction, comparison, integration, iteration, and refutation of themes.

 Integration of Quantitative and Qualitative Data

We will exploit the richness of our mixed methods approach, with quantitative and qualitative findings enriching each other. Quantitative assessments allow us to systematically explore variables of interest across all participants. Qualitative data will add nuance and new insights to quantitative findings. During data analysis, interpretation of quantitative results will be enriched by the summary of codes for specific components of iMI4HIV. In NVivo, we will categorize participants based on their responses in the quantitative assessment and use these categories to compare and contrast themes and concepts that emerge from the qualitative data.

 Quantitative Data Analysis Primary Outcomes

The primary outcomes of the pilot study will be based on the phase 2 RCT pilot, including (1) the percent of study participants that complete iMI4HIV within 4 weeks posttraining workshop (feasibility) and (2) the percentage of participants that respond Acceptable or Completely Acceptable to the question, “How acceptable was iMI4HIV to you?” from the TFA generic acceptability questionnaire (acceptability).

 Exploratory Outcomes

We will also explore the following outcomes:

MI skills acquisition. MITI-4.2 ratings for (1) Technical Component, (2) Relational Component, (3) Percent Complex Reflections, (4) Reflection:Question Ratio, (5) Total MI Adherent, and (6) Total MI Non-Adherent. Although the pilot RCT is not powered to detect differences between the intervention and control groups, we will compare these scores between the 2 groups for the SPI-3 assessment and within groups for each of the SPI assessments.

Feasibility. Metadata from iMI4HIV, including mean (1) duration to complete specific iMI4HIV tasks, (2) number of times a lesson was completed prior to achieving a passing score, and (3) score for each task.

Acceptability. Mean ratings on each of the generic TFA items (Affective Attitude, Burden, Intervention Cohesiveness, Self-efficacy, Ethicality, Perceived Effectiveness, and Opportunity Cost).

Data collected via assessments will be imported into IBM SPSS Statistics to calculate descriptive statistics for the sample. Estimation of the feasibility and acceptability outcomes (primary and exploratory) will be accomplished by generating the point estimate with its corresponding 95% CI. We will use a t test for continuous outcomes, and Fisher exact test for binary outcomes for the above comparisons. Adjustment for covariates, if necessary, with control baseline values, will be accomplished by multiple linear (continuous outcomes) or logistic (dichotomous outcomes) regression. While this study will not recruit a large enough sample to provide adequate power for assessing the efficacy of iMI4HIV, we will use data from MITI-4 ratings to explore specific changes in MI skills (listed in exploratory outcomes, above). To examine the efficacy of the addition of iMI4HIV on MI skills, the generalized linear model with identity and logit link function will estimate model parameters and their SEs for continuous and dichotomous variables, respectively. The generalized estimating equation method, with a robust SE estimator, will account for the within-subject correlation due to repeated measures from the same participant. Accompanying each of these tests will be point and interval estimates for the parameters of interest, such as group mean differences and odds ratios.

 Power Considerations

There is some controversy regarding the use of pilot data to estimate an actual effect size [111]; clinically meaningful effect sizes should be decided based on extrinsic, clinical judgment grounds, and not based on pilot data which are too few, typically, to obtain reliable conclusions. We can use pilot data to rule out unusually large or small true effects through standard 95% CI procedures. We will confirm that extrinsic effect sizes are contained within our CIs from the pilot. We will examine the distribution of each variable and calculate summary statistics by intervention condition. We will estimate key intervention parameters with sample means and proportions together with 2-sided 95% CIs and test the primary null hypotheses at the traditional 2-sided level α=.05 (to simulate the subsequent RCT). For planning the RCT, we will also consider 1-sided 90% confidence limits for mission-critical design parameters such as SDs and reference group end point rates and proportions in the conservative direction. This is because we intend to plan the sample size for the RCT so that power will be “excellent” (at least 80% power) for the clinically relevant effect size to be specified if our estimate of SDs is at the 1-sided 90% confidence limit in the conservative direction. This strategy will make proper allowance for the limited sample size of the pilot study with its consequent uncertainties, and still yield appropriate sample sizes for the future RCT. We will examine the strength of association between our primary outcome and key variables, with the view toward seeing if stratifying on such factors (eg, age and gender) would substantially reduce variability and increase the power of a future RCT. “Mission-critical” parameters include proportions for dichotomous end points; means and SDs for continuous end points; and response profiles for longitudinal studies. Large sample sizes are not required to locate these parameters approximately, but adequately, for planning the subsequent trial, whereas testing the study hypothesis in the pilot will generally not have sufficient statistical power. Estimation of mission-critical design parameters with point and CI estimates will be very important; continuous outcome measures make it feasible to detect promising effects even in small samples. For the continuous measures, means and SDs will be estimated. For approximately normally distributed variables, an upper 1-sided 90% confidence limit for the population SD, sU, will be constructed from sU = s × [(n – 1)/x20.10,n–1]1/2, where s is the sample SD and x20.10,n–1 is the upper 10th percentile of the chi-square distribution with n – 1 degrees of freedom. For approximately log-normally distributed variables, a logarithmic transformation will be applied to achieve approximate symmetry and normality. For the dichotomous variable, exact binomial methods will be used.

 Ethical Considerations

The study was reviewed and approved by the Florida State University (FSU) Institutional Review Board (ID: STUDY00004477). This study does not assess health-related biomedical or behavioral outcomes; thus, it does not meet NIH criteria for a clinical trial and will not be registered in ClinicalTrials.gov.

All participants are provided with a written informed consent form to read before participating in the study. The consent form includes an overview of the study, study procedures, risks of participation, procedures to minimize risks of participation, a statement of voluntary participation, and contact information for the principal investigators, along with contact information for the FSU Institutional Review Board.

The results of the study may be published or presented, but no information that can identify individual participants will ever be provided or released in publications or presentations. To protect the privacy and confidentiality of participants, the study staff will keep any records containing identifying information in a locked cabinet accessible only to the research staff. The computer programs used in tablet-based interventions are compliant with US regulations on personal health information, as are the servers on which the data are stored. All data captured on the tablet, although it do not include identifying information, are encrypted in transit to maintain confidentiality. Any other study data will be stored on a secure computer that is protected by passwords. All records will be kept confidential. This is consistent with the guidelines of the US NIH. After removing all identifying information, the remaining deidentified information collected during the study could be used for future research studies or distributed to another investigator for future research studies without additional consent.

All participant incentives will be paid via gift cards. In phase 1, FG participants received US $75; agency leaders received US $100 for the interview; and iMI4HIV pilot participants will receive US $50 plus the opportunity to win a US $250 prize for completing the intervention within the 4-week allotted period. This incentive is provided to motivate the timely completion of the online training program among these participants to inform any final revisions that are necessary before the phase 2 RCT; main study outcomes are based on the phase 2 RCT results, which do not include this raffle incentive. Phase 2 RCT participants will receive up to US $205 for completing questionnaires (3 timepoints), 4 standard patient interactions, and a qualitative interview.

 Results

The study launched in February 2024. During the summer of 2024, we conducted 2 FGs (n=11) and QIs (n=8) with HIV Care Agency Leadership to inform the content and interactive components of the iMI4HIV. Preliminary findings from the FGs and QIs were shared with the CAB and expert consultants. In the Fall of 2024, we recorded a series of training videos focused on using MI in key HIV care interactions. Since then, we have been developing the content and layout of the training program. We expect to conduct the phase 1 pilot study in the Fall of 2025 and the pilot RCT during 2026.

 Discussion Overview

To address the need for online MI training geared specifically for the HIV care setting, this mixed methods study seeks to develop iMI4HIV, an interactive, gamified, online MI training program specifically tailored for CSS to improve their MI skills in HIV care communications. The goal is to train CSS to deliver MI competently so they can integrate MI into their health care communications with individuals seeking or receiving HIV-related services (status-neutral). If successful in building MI skills among CSS, iMI4HIV has the potential to shift how MI training is provided to CSS who work in HIV care settings. Furthermore, the program can be housed at FSU for use by AETCs throughout the country to provide additional MI training to their client agencies, used to train HIV treatment counselors in research studies, and provide training opportunities for other community-based agencies working to end the HIV Epidemic.

 Strengths

This proposed study has numerous strengths. First, contrary to the currently available simulations for MI training, iMI4HIV will offer an innovative, sequenced approach to comprehensive online MI training with a range of interactive and gamification components used in novel ways to build key MI technical skills. As such, it will also be the first to assess user acceptability, feasibility, and engagement of this new approach to online MI training. Second, at an expected 8-10 hours, iMI4HIV will be the first and most comprehensive interactive online MI training that addresses the full status-neutral HIV care cascade. The only existing interactive HIV-focused MI training is approximately 1 hour in duration and only addresses treatment adherence counseling for nurses. Third, this is the first online MI training study to systematically engage targeted end users throughout the development and testing process to obtain their feedback for revisions. Fourth, based on current scientific literature, this study will be among the first to conduct a rigorous assessment of efficacy (even within an underpowered RCT).

 Limitations

Although we anticipate high interest in MI training and iMI4HIV, recruitment and retention challenges can always arise and we consider these the main potential challenges to this study. Additionally, acceptability data (both quantitative and qualitative) are subject to social desirability. To minimize this risk, we will highlight for participants the importance of openly sharing their experiences and opinions, whether positive or negative.

 Conclusions

As designed, this study specifically responds to the Notice of Special Interest: Advancing Health Communication Research on HIV Prevention, Treatment and Cure (NOT-MH-21-105) announced by NIH, which includes an interest in studies that seek to “optimize effective communication and engagement practices between PLHIV and healthcare providers.” This R34 begins to address a critical need for novel approaches to train CSS in MI, a counseling or communication approach with proven efficacy in improving health care outcomes across the HIV care cascade. With its focus specifically on MI in HIV care interactions, iMI4HIV gives CSS in HIV care settings an invaluable opportunity to solidify MI skills gained during MI training workshops. Furthermore, as an asynchronous training program, iMI4HIV provides significant flexibility in when it can be completed, increasing accessibility to potential users. If findings on feasibility (≥70% of participants complete the iMI4HIV modules within 4 weeks) and acceptability (≥80% of participants rate iMI4HIV a “4” or “5” on the TFA overall acceptability rating) are favorable, we will submit a proposal for a fully powered RCT to assess the efficacy of iMI4HIV to achieve MI competence. In that study, we may even consider a study arm using an expanded version of iMI4HIV to allow for fully asynchronous MI training, which was cost-prohibitive in this study.

Peer-review report from HIBI - HIV/AIDS Intra- and Inter-personal Determinants and Behavioral Interventions Study Section, Risk, Prevention and Health Behavior Integrated Review Group (National Institutes of Health, USA).

 Abbreviations AETC

AIDS Education and Training Center

 CAB

Community Advisory Board

 CASI

computer-assisted self-interview

 CHW

community health worker

 CSS

counseling support staff

 EBP

evidence-based practice

 FG

focus group

 FSU

Florida State University

 HCC

HIV Care Continuum

 HIPAA

Health Insurance Portability and Accountability Act

 iMI4HIV

internet-based motivational interviewing training program for HIV counseling support staff

 MI

motivational interviewing

 MIKAT

Motivational Interviewing Knowledge and Attitudes Test

 MITI

Motivational Interviewing Treatment Integrity

 NECA AETC

Northeast and Caribbean AIDS Education and Training Center

 NIH

National Institutes of Health

 QI

qualitative interview

 RAD

Rapid Application Development

 RCT

randomized controlled trial

 SPI

Standard Patient Interaction

 TFA

Theoretical Framework of Acceptability

 UCRAD

User Centered Rapid Application Development

 VMI

virtual motivational interviewing

 Funding

This research was supported by a grant from the US National Institute of Mental Health (R34 MH133468, Principal Investigator ICB). The authors are solely responsible for the content, which does not necessarily represent the official views of the National Institutes of Health (NIH).

 Data Availability

Data to be shared will be deposited with the digital repository of the Inter-university Consortium for Political and Social Research (ICPSR) to ensure that the research community has long-term access to the data. Once data have been deidentified and uploaded to a data repository, it will also be available on request from the investigators.

Conceptualization: ICB, BAK

Methodology: ICB, BAK, RG

Funding acquisition: ICB

Project administration: ICB, RG

Investigation: ICB

Supervision: ICB

Writing – original draft: ICB (study protocol). ORB (manuscript adaptation)

Writing – review & editing: ICB, ORB, BAK, RG

None declared.

 Ambia J Mandala J A systematic review of interventions to improve prevention of mother‐to‐child HIV transmission service delivery and promote retention Journal of the International AIDS Society 2016 04 06 19 1 20309 10.7448/ias.19.1.20309 Coleman LM Ford N An extensive literature review of the evaluation of HIV prevention programmes Health Educ Res 1996 09 11 3 327 38 10.1093/her/11.3.327 10163565 Outlaw AY Naar-King S Parsons JT Green-Jones M Janisse H Secord E Using motivational interviewing in HIV field outreach with young African American men who have sex with men: a randomized clinical trial Am J Public Health 2010 04 01 100 Suppl 1 Suppl 1 S146 51 10.2105/AJPH.2009.166991 20147689 AJPH.2009.166991 PMC2837438 Mwai GW Mburu G Torpey K Frost P Ford N Seeley J Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review J Int AIDS Soc 2013 09 10 16 1 18586 10.7448/IAS.16.1.18586 24029015 18586 PMC3772323 Global Health Workforce Alliance Will we achieve universal access to HIV/AIDS services with the health workforce we have? A snapshot from five countries: Literature review Report of the Technical Working Group on Human Resources for Health and Universal Access 2010 2020-04-23 https://www.who.int/workforcealliance/about/taskforces/access/universalaccesslitrev_en.pdf Naar-King S Outlaw A Green-Jones M Wright K Parsons JT Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care AIDS Care 2009 07 21 7 868 73 10.1080/09540120802612824 20024744 912787813 Kenya S Chida N Symes S Shor-Posner G Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature HIV Med 2011 10 12 9 525 34 10.1111/j.1468-1293.2011.00921.x 21518221 Miller WR Rollnick S Motivational Interviewing: Helping People Change 2013 New York, NY Guilford Press DiClemente CC Corno CM Graydon MM Wiprovnick AE Knoblach DJ Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness Psychol Addict Behav 2017 12 31 8 862 887 10.1037/adb0000318 29199843 2017-53537-001 Lundahl BW Kunz C Brownell C Tollefson D Burke BL A Meta-Analysis of Motivational Interviewing: Twenty-Five Years of Empirical Studies Research on Social Work Practice 2010 01 11 20 2 137 160 10.1177/1049731509347850 Randall CL McNeil DW Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature Cogn Behav Pract 2017 08 24 3 296 311 10.1016/j.cbpra.2016.05.003 28871216 PMC5580948 Marker I Norton PJ The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-analysis Clin Psychol Rev 2018 06 62 1 10 10.1016/j.cpr.2018.04.004 29727863 S0272-7358(17)30408-7 Miller SJ Foran-Tuller K Ledergerber J Jandorf L Motivational interviewing to improve health screening uptake: A systematic review Patient Educ Couns 2017 02 100 2 190 198 10.1016/j.pec.2016.08.027 27599713 S0738-3991(16)30401-3 PMC5318209 Keeley RD Brody DS Engel M Burke BL Nordstrom K Moralez E Dickinson LM Emsermann C Motivational interviewing improves depression outcome in primary care: A cluster randomized trial J Consult Clin Psychol 2016 11 84 11 993 1007 10.1037/ccp0000124 27599229 2016-42725-001 Lundahl B Moleni T Burke BL Butters R Tollefson D Butler C Rollnick S Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials Patient Educ Couns 2013 11 93 2 157 68 10.1016/j.pec.2013.07.012 24001658 S0738-3991(13)00288-7 Ekong G Kavookjian J Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review Patient Educ Couns 2016 06 99 6 944 52 10.1016/j.pec.2015.11.022 26699083 S0738-3991(15)30137-3 Palacio A Garay D Langer B Taylor J Wood BA Tamariz L Motivational Interviewing Improves Medication Adherence: a Systematic Review and Meta-analysis J Gen Intern Med 2016 08 31 8 929 40 10.1007/s11606-016-3685-3 27160414 10.1007/s11606-016-3685-3 PMC4945560 Hill S Kavookjian J Motivational interviewing as a behavioral intervention to increase HAART adherence in patients who are HIV-positive: a systematic review of the literature AIDS Care 2012 24 5 583 92 10.1080/09540121.2011.630354 22292452 Douaihy A Amico KR Motivational Interviewing in HIV Care 2020 New York, NY Oxford University Press Dillard PK Zuniga JA Holstad MM An integrative review of the efficacy of motivational interviewing in HIV management Patient Educ Couns 2017 04 100 4 636 646 10.1016/j.pec.2016.10.029 27838113 S0738-3991(16)30498-0 Kiene SM Bateganya MH Lule H Wanyenze RK The Effect of Motivational Interviewing-Based Counseling During Outpatient Provider Initiated HIV Testing on High-Risk Sexual Behavior in Rural Uganda AIDS Behav 2016 09 20 9 1928 36 10.1007/s10461-016-1377-y 27037546 10.1007/s10461-016-1377-y PMC4996713 Alemagno SA Stephens RC Stephens P Shaffer-King P White P Brief motivational intervention to reduce HIV risk and to increase HIV testing among offenders under community supervision J Correct Health Care 2009 07 15 3 210 21 10.1177/1078345809333398 19477803 1078345809333398 Bendetson J Dierst-Davies R Flynn R Beymer MR Wohl AR Amico KR Bolan RK Evaluation of a Client-Centered Linkage Intervention for Patients Newly Diagnosed with HIV at an Urban United States LGBT Center: The Linkage to Care Specialist Project AIDS Patient Care STDS 2017 07 31 7 283 289 10.1089/apc.2017.0057 28628349 Okeke NL Ostermann J Thielman NM Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings Curr HIV/AIDS Rep 2014 12 11 4 376 92 10.1007/s11904-014-0233-9 25323298 PMC5907797 Camacho-Gonzalez AF Gillespie SE Thomas-Seaton L Frieson Krystal Hussen Sophia A Murray Ashley Gaul Zaneta Leong Traci Graves Chanda Sutton Madeline Y Chakraborty Rana The Metropolitan Atlanta community adolescent rapid testing initiative study: closing the gaps in HIV care among youth in Atlanta, Georgia, USA AIDS 2017 07 01 31 Suppl 3 Suppl 3 S267 S275 10.1097/QAD.0000000000001512 28665885 00002030-201707013-00010 PMC5497786 Naar-King S Outlaw AY Sarr M Parsons JT Belzer M Macdonell K Tanney M Ondersma SJ Adolescent Medicine Network for HIV/AIDS Interventions Motivational Enhancement System for Adherence (MESA): pilot randomized trial of a brief computer-delivered prevention intervention for youth initiating antiretroviral treatment J Pediatr Psychol 2013 07 38 6 638 48 10.1093/jpepsy/jss132 23359664 jss132 PMC3701125 Goggin K Gerkovich MM Williams KB Banderas JW Catley D Berkley-Patton J Wagner GJ Stanford J Neville S Kumar VK Bamberger DM Clough LA A randomized controlled trial examining the efficacy of motivational counseling with observed therapy for antiretroviral therapy adherence AIDS Behav 2013 07 17 6 1992 2001 10.1007/s10461-013-0467-3 23568228 PMC3672512 DiIorio C McCarty F Resnicow K McDonnell Holstad M Soet J Yeager K Sharma SM Morisky DE Lundberg B Using motivational interviewing to promote adherence to antiretroviral medications: a randomized controlled study AIDS Care 2008 03 20 3 273 83 10.1080/09540120701593489 18351473 791591352 PMC3103182 Parsons JT Golub SA Rosof E Holder C Motivational interviewing and cognitive-behavioral intervention to improve HIV medication adherence among hazardous drinkers: a randomized controlled trial J Acquir Immune Defic Syndr 2007 12 01 46 4 443 50 10.1097/qai.0b013e318158a461 18077833 PMC2666542 Parsons JT Rosof E Punzalan JC Di Maria L Integration of motivational interviewing and cognitive behavioral therapy to improve HIV medication adherence and reduce substance use among HIV-positive men and women: results of a pilot project AIDS Patient Care STDS 2005 01 19 1 31 9 10.1089/apc.2005.19.31 15665633 Naar-King S Parsons JT Murphy DA Chen X Harris DR Belzer ME Improving health outcomes for youth living with the human immunodeficiency virus: a multisite randomized trial of a motivational intervention targeting multiple risk behaviors Arch Pediatr Adolesc Med 2009 12 163 12 1092 8 10.1001/archpediatrics.2009.212 19996045 163/12/1092 PMC2843389 Bartlett J Cheever L Johnson M Paauw D A Guide to Primary Care of People With HIV/AIDS 2004 Rockville, MD US Department of Health and Human Services Magnus M Jones K Phillips G Binson D Hightow-Weidman LB Richards-Clarke C Wohl AR Outlaw A Giordano TP Quamina A Cobbs W Fields SD Tinsley M Cajina A Hidalgo J YMSM of color Special Projects of National Significance Initiative Study Group Characteristics associated with retention among African American and Latino adolescent HIV-positive men: results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special project of national significance initiative J Acquir Immune Defic Syndr 2010 04 01 53 4 529 36 10.1097/QAI.0b013e3181b56404 19755914 Substance use and dependence among HIV-infected adolescents and young adults Information for Practice 2010 2018-12-31 New York State Department of Health https://ifp.nyu.edu/2010/guidelines-plus/substance-use-and-dependence-among-hiv -infected-adolescents-and-young-adults/ Community health workers American Public Health Association 2020-04-23 https://www.apha.org/apha-communities/member -sections/communityhealth-workers Giblin PT Effective utilization and evaluation of indigenous health care workers Public Health Rep 1989 104 4 361 8 2502807 PMC1579943 Rubak S Sandbaek A Lauritzen T Christensen B Motivational interviewing: a systematic review and meta-analysis Br J Gen Pract 2005 04 55 513 305 12 15826439 PMC1463134 Mitcheson L Bhavsar K McCambridge J Randomized trial of training and supervision in motivational interviewing with adolescent drug treatment practitioners J Subst Abuse Treat 2009 07 37 1 73 8 10.1016/j.jsat.2008.11.001 19150203 S0740-5472(08)00214-6 Barwick MA Bennett LM Johnson SN McGowan J Moore JE Training health and mental health professionals in motivational interviewing: A systematic review Children and Youth Services Review 2012 09 34 9 1786 1795 10.1016/j.childyouth.2012.05.012 Smith JL Carpenter KM Amrhein PC Brooks AC Levin D Schreiber EA Travaglini LA Hu M Nunes EV Training substance abuse clinicians in motivational interviewing using live supervision via teleconferencing J Consult Clin Psychol 2012 06 80 3 450 64 10.1037/a0028176 22506795 2012-09580-001 PMC3365649 Darnell D Dunn C Atkins D Ingraham L Zatzick D A Randomized Evaluation of Motivational Interviewing Training for Mandated Implementation of Alcohol Screening and Brief Intervention in Trauma Centers J Subst Abuse Treat 2016 01 60 36 44 10.1016/j.jsat.2015.05.010 26117081 S0740-5472(15)00136-1 PMC4669233 Hallgren KA Dembe A Pace BT Imel ZE Lee CM Atkins DC Variability in motivational interviewing adherence across sessions, providers, sites, and research contexts J Subst Abuse Treat 2018 01 84 30 41 10.1016/j.jsat.2017.10.011 29195591 S0740-5472(17)30286-6 PMC5718367 Schwalbe CS Oh HY Zweben A Sustaining motivational interviewing: a meta-analysis of training studies Addiction 2014 08 109 8 1287 94 10.1111/add.12558 24661345 Moyers TB Martin T Houck JM Christopher PJ Tonigan JS From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing J Consult Clin Psychol 2009 12 77 6 1113 24 10.1037/a0017189 19968387 2009-22711-010 PMC2819223 Vader AM Walters ST Prabhu GC Houck JM Field CA The language of motivational interviewing and feedback: counselor language, client language, and client drinking outcomes Psychol Addict Behav 2010 06 24 2 190 7 10.1037/a0018749 20565145 2010-12599-002 PMC2891547 Apodaca TR Longabaugh R Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence Addiction 2009 05 104 5 705 15 10.1111/j.1360-0443.2009.02527.x 19413785 ADD2527 PMC2756738 Magill M Apodaca TR Barnett NP Monti PM The route to change: within-session predictors of change plan completion in a motivational interview J Subst Abuse Treat 2010 04 38 3 299 305 10.1016/j.jsat.2009.12.001 20149571 S0740-5472(10)00002-4 PMC2835844 Moyers TB Martin T Therapist influence on client language during motivational interviewing sessions J Subst Abuse Treat 2006 04 30 3 245 51 10.1016/j.jsat.2005.12.003 16616169 S0740-5472(06)00007-9 Moyers TB Manuel JK Wilson PG Hendrickson SML Talcott W Durand P A Randomized Trial Investigating Training in Motivational Interviewing for Behavioral Health Providers Behav. Cogn. Psychother 2007 11 22 36 2 149 162 10.1017/s1352465807004055 Tsai J Klee A Shea N Lawless M Payne KA Goggin E Alix J Tam E Smith K Martino S Training peer specialists with mental illness in motivational interviewing: A pilot study Psychiatr Rehabil J 2017 12 40 4 354 360 10.1037/prj0000226 27786521 2016-51873-001 Allicock M Carr C Johnson LS Smith R Lawrence M Kaye L Gellin M Manning M Implementing a one-on-one peer support program for cancer survivors using a motivational interviewing approach: results and lessons learned J Cancer Educ 2014 03 29 1 91 8 10.1007/s13187-013-0552-3 24078346 PMC4066630 Dewing S Mathews C Cloete A Schaay N Shah M Simbayi L Louw J From research to practice: lay adherence counsellors' fidelity to an evidence-based intervention for promoting adherence to antiretroviral treatment in the Western cape, South Africa AIDS Behav 2013 11 17 9 2935 45 10.1007/s10461-013-0509-x 23666183 Madson MB Loignon AC Lane C Training in motivational interviewing: a systematic review J Subst Abuse Treat 2009 01 36 1 101 9 10.1016/j.jsat.2008.05.005 18657936 S0740-5472(08)00088-3 de Roten Y Zimmermann G Ortega D Despland J Meta-analysis of the effects of MI training on clinicians' behavior J Subst Abuse Treat 2013 08 45 2 155 62 10.1016/j.jsat.2013.02.006 23537923 S0740-5472(13)00058-5 Miller WR Yahne CE Moyers TB Martinez J Pirritano M A randomized trial of methods to help clinicians learn motivational interviewing J Consult Clin Psychol 2004 12 72 6 1050 62 10.1037/0022-006X.72.6.1050 15612851 2004-21587-015 Henshaw MM Borrelli B Gregorich SE Heaton B Tooley E Santo W Cheng N Rasmussen M Helman S Shain S Garcia R Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in Public Housing JDR Clin Trans Res 2018 10 3 4 353 365 10.1177/2380084418794377 30238060 10.1177_2380084418794377 PMC6139579 Report of the consultation meeting on digital health interventions and health workforce capacity building World Health Organization 2019 2020-05-04 https://www.who.int/hrh/news/2019/meeting_report_Digital-health-interventions-health-work force-capacity-building.pdf Jackson CB Quetsch LB Brabson LA Herschell AD Web-Based Training Methods for Behavioral Health Providers: A Systematic Review Adm Policy Ment Health 2018 07 45 4 587 610 10.1007/s10488-018-0847-0 29352459 10.1007/s10488-018-0847-0 PMC6002894 Frank HE Becker-Haimes EM Kendall PC Therapist training in evidence-based interventions for mental health: A systematic review of training approaches and outcomes Clin Psychol (New York) 2020 09 27 3 e12330 10.1111/cpsp.12330 34092941 e12330 PMC8174802 Calder R Ainscough T Kimergård A Witton J Dyer KR Online training for substance misuse workers: a systematic review Drugs Educ Prev Policy 2017 24 6 430 442 10.1080/09687637.2017.1318113 Shingleton RM Palfai TP Technology-delivered adaptations of motivational interviewing for health-related behaviors: a systematic review of the current research Patient Educ Couns 2016 99 1 17 35 10.1016/j.pec.2015.08.005 26298219 S0738-3991(15)30043-4 PMC4691359 Jiang S Wu L Gao X Beyond face-to-face individual counseling: a systematic review on alternative modes of motivational interviewing in substance abuse treatment and prevention Addict Behav 2017 73 216 235 10.1016/j.addbeh.2017.05.023 28554033 S0306-4603(17)30201-0 Shafer MS Rhode R Chong J Using distance education to promote the transfer of motivational interviewing skills among behavioral health professionals J Subst Abuse Treat 2004 26 2 141 148 10.1016/s0740-5472(03)00167-3 Mullin DJ Saver B Savageau JA Forsberg L Forsberg L Evaluation of online and in-person motivational interviewing training for healthcare providers Fam Syst Health 2016 34 4 357 366 10.1037/fsh0000214 27571542 2016-41514-001 Mitchell S Heyden R Heyden N Schroy P Andrew S Sadikova E Wiecha J A pilot study of motivational interviewing training in a virtual world J Med Internet Res 2011 13 3 e77 10.2196/jmir.1825 21946183 v13i3e77 PMC3222158 Radecki L Goldman R Baker A Lindros J Boucher J Are pediatricians "Game"? Reducing childhood obesity by training clinicians to use motivational interviewing through role-play simulations with avatars Games Health J 2013 2 3 174 178 10.1089/g4h.2013.0020 24761323 10.1089/g4h.2013.0020 PMC3833373 Czart M Using 3D virtual standardized patients to teach motivational interviewing J Virtual Worlds Res 2014 7 2 10.4101/jvwr.v7i2.6411 Oster C Schoo A Litt J Morello A Leibbrandt R Antonello C Powers D Lange B Maeder A Lawn S Supporting workforce practice change: protocol for a pilot study of a motivational interviewing virtual client software tool for health professionals BMJ Open 2020 10 2 e033080 10.1136/bmjopen-2019-033080 32041854 bmjopen-2019-033080 PMC7045188 Talley R Chiang IC Covell NH Dixon LB Comparative initial and sustained engagement in web-based training by behavioral healthcare providers in New York State J Technol Behav Sci 2018 3 2 41 48 10.1007/s41347-017-0027-1 29732398 PMC5931788 Banna J Grace Lin M Stewart M Fialkowski MK Interaction matters: strategies to promote engaged learning in an online introductory nutrition course J Online Learn Teach 2015 11 2 249 261 27441032 PMC4948751 Bernard RM Abrami PC Borokhovski E Wade CA Tamim RM Surkes MA Bethel EC A meta-analysis of three types of interaction treatments in distance education Rev Educ Res 2009 79 3 1243 1289 10.3102/0034654309333844 Conrad RM Donaldson JA Engaging the Online Learner: Activities and Resources for Creative Instruction 2011 San Francisco, CA John Wiley & Sons Lou Y Bernard RM Abrami PC Media and pedagogy in undergraduate distance education: a theory-based meta-analysis of empirical literature Educ Technol Res Dev 2006 54 2 141 176 10.1007/s11423-006-8252-x Norris DM Mason J Lefrere P Transforming E-Knowledge: A Revolution in the Sharing of Knowledge 2003 Ann Arbor, MI Society for College and University Planning Saleem AN Noori NM Ozdamli F Gamification applications in E-learning: a literature review Tech Know Learn 2021 27 1 139 159 10.1007/s10758-020-09487-x Majuri J Koivisto J Hamari J Gamification of education and learning: a review of empirical literature CEUR Workshop Proc 2018 2186 11 19 van Gaalen AEJ Brouwer J Schönrock-Adema J Bouwkamp-Timmer T Jaarsma ADC Georgiadis JR Gamification of health professions education: a systematic review Adv Health Sci Educ Theory Pract 2021 26 2 683 711 10.1007/s10459-020-10000-3 33128662 10.1007/s10459-020-10000-3 PMC8041684 Khaldi A Bouzidi R Nader F Gamification of e-learning in higher education: a systematic literature review Smart Learn Environ 2023 10 1 10 10.1186/s40561-023-00227-z 40478066 227 PMC9887250 Deterding S Dixon D Khaled R Nacke L From game design elements to gamefulness: defining 'gamification' 2011 Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments 2021 Sep 28 New York, NY ACM 9 15 10.1145/2181037.2181040 Hamari J Koivisto J Sarsa H Does gamification work? - a literature review of empirical studies on gamification 2014 2014 47th Hawaii International Conference on System Sciences 2014 Mar 10 Washington, DC IEEE 3025 3034 10.1109/hicss.2014.377 Brull S Finlayson S Importance of gamification in increasing learning J Contin Educ Nurs 2016 47 8 372 375 10.3928/00220124-20160715-09 27467313 Larson K Serious games and gamification in the corporate training environment: a literature review TechTrends 2019 64 2 319 328 10.1007/s11528-019-00446-7 Gentry S Ehrstrom BLE Gauthier A Alvarez J Wortley D van RJ Serious gaming and gamification interventions for health professional education Cochrane Database Syst Rev 2016 6 CD012209 10.1002/14651858.cd012209 da Rocha Seixas L Gomes AS de Melo Filho IJ Effectiveness of gamification in the engagement of students Comput Hum Behav 2016 58 48 63 10.1016/j.chb.2015.11.021 Lank E Withee K Schile L Parker T User centred rapid application development Rapid Integration of Software Engineering Techniques 2006 Berlin, Germany Springer 34 49 Kumar S Sharma T User-centric rapid application development Int J Res 2014 1 10 959 964 10.1007/11751113_4 Martin J Rapid Application Development 1991 New York, NY Macmillan Publishing Co Arsand E Demiris G User-centered methods for designing patient-centric self-help tools Inform Health Soc Care 2008 33 3 158 169 10.1080/17538150802457562 18850399 903428481 De Vito Dabbs A Myers BA Mc Curry KR Dunbar-Jacob J Hawkins RP Begey A Dew MA User-centered design and interactive health technologies for patients Comput Inform Nurs 2009 27 3 175 183 10.1097/NCN.0b013e31819f7c7c 19411947 00024665-200905000-00011 PMC2818536 LLC Simmersion 2025-11-25 https://www.simmersion.com/mi Taylor B Henshall C Kenyon S Litchfield I Greenfield S Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis BMJ Open 2018 8 10 e019993 10.1136/bmjopen-2017-019993 30297341 bmjopen-2017-019993 PMC6194404 Gale RC Wu J Erhardt T Bounthavong M Reardon CM Damschroder LJ Midboe AM Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the veterans health administration Implement Sci 2019 14 1 11 10.1186/s13012-019-0853-y 30709368 10.1186/s13012-019-0853-y PMC6359833 Al-Khanbashi M Using the matrix as a qualitative data display for landscape research and a reflection based on the social constructivist perspective Modern Approaches to the Visualization of Landscapes 2020 Wiesbaden, Germany Springer VS 103 118 Miles MB Huberman AM Saldaña J Qualitative data analysis: a methods sourcebook 2018 Thousand Oaks, CA Sage Publications Sekhon M Cartwright M Francis JJ Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework BMC Health Serv Res 2017 17 1 88 10.1186/s12913-017-2031-8 28126032 10.1186/s12913-017-2031-8 PMC5267473 Murphy AL Gardner DM Pharmacists' acceptability of a men's mental health promotion program using the theoretical framework of acceptability AIMS Public Health 2019 6 2 195 208 10.3934/publichealth.2019.2.195 31297404 publichealth-06-02-195 PMC6606526 Brook J Aitken LM MacLaren JA Salmon D An intervention to decrease burnout and increase retention of early career nurses: a mixed methods study of acceptability and feasibility BMC Nurs 2021 20 1 19 10.1186/s12912-020-00524-9 33435972 10.1186/s12912-020-00524-9 PMC7805097 Chakrapani V Shunmugam M Rawat S Baruah D Nelson R Newman PA Acceptability of HIV pre-exposure prophylaxis among transgender women in India: a qualitative investigation AIDS Patient Care STDS 2020 34 2 92 98 10.1089/apc.2019.0237 31951490 PMC7611172 Msosa TC Phuka F Sumari-de Boer M Mhango O Twabi HH Mukoka M Swai I Aarnoutse R de Wit TFR Ngowi K Lunda E Mphande W Msefula C Nliwasa M The acceptability of a real-time medication monitoring-based digital adherence tool among young people living with HIV in Malawi AIDS Behav 2025 10.1007/s10461-025-04885-7 40983785 10.1007/s10461-025-04885-7 Sekhon M Cartwright M Francis JJ Development of a theory-informed questionnaire to assess the acceptability of healthcare interventions BMC Health Serv Res 2022 22 1 279 10.1186/s12913-022-07577-3 35232455 10.1186/s12913-022-07577-3 PMC8887649 Leffingwell TR Motivational interviewing knowledge and attitudes test (MIKAT) for evaluation of training outcomes MINUET 2006 13 10 11 10.1002/9781119057840.ch160 Doran N Hohman M Koutsenok I Motivational interviewing training in juvenile corrections: a comparison of outside experts and internal trainers Legal Criminol Psychol 2011 18 2 262 273 10.1111/j.2044-8333.2011.02036.x Hohman M Doran N Koutsenok I Motivational interviewing training for juvenile correctional staff in California: one year initial outcomes J Offender Rehabil 2009 48 7 635 648 10.1080/10509670903196108 Madson MB Schumacher JA Noble JJ Bonnell MA Teaching motivational interviewing to undergraduates Teach Psychol 2013 40 3 242 245 10.1177/0098628313487450 Aarons GA Mental health provider attitudes toward adoption of evidence-based practice: the evidence-based practice attitude scale (EBPAS) Ment Health Serv Res 2004 6 2 61 74 10.1023/B:MHSR.0000024351.12294.65 Ehrhart MG Aarons GA Farahnak LR Assessing the organizational context for EBP implementation: the development and validity testing of the implementation climate scale (ICS) Implement Sci 2014 9 157 10.1186/s13012-014-0157-1 25338781 s13012-014-0157-1 PMC4210525 Aarons GA Ehrhart MG Farahnak LR The implementation leadership scale (ILS): development of a brief measure of unit level implementation leadership Implement Sci 2014 9 1 45 10.1186/1748-5908-9-45 24731295 1748-5908-9-45 PMC4022333 Moyers TB Manuel JK Ernst D Motivational Interviewing Treatment Integrity Coding Manual 4.2.1 2014 Albuquerque, NM University of New Mexico Moyers TB Rowell LN Manuel JK Ernst D Houck JM The motivational interviewing treatment integrity code (MITI 4): rationale, preliminary reliability and validity J Subst Abuse Treat 2016 65 36 42 10.1016/j.jsat.2016.01.001 26874558 S0740-5472(16)00014-3 PMC5539964 Patton MQ Qualitative Research & Evaluation Methods 2014 Thousand Oaks, CA Sage Publications Leon AC Davis LL Kraemer HC The role and interpretation of pilot studies in clinical research J Psychiatr Res 2011 45 5 626 629 10.1016/j.jpsychires.2010.10.008 21035130 S0022-3956(10)00292-X PMC3081994