A key element for assessing seismic hazard and risk is the availability of a comprehensive dataset on past earthquakes. Here we present the rationale, structure and contents of CFTI5Med (10.6092/ingv.it-cfti5), the 2018 version of the Catalogue of Strong Earthquakes in Italy: a large multidisciplinary effort including historians, seismologists and geologists. It was conceived in 1989, following the inception of GIS technology, and first published in 1995 to offer a full account of Italy’s strongest earthquakes, of their territorial impact and associated social and economic upheaval. Subsequent versions  entailed a fine tuning of research methodologies, included additional research on Italian earthquakes, and were extended to large earthquakes of the Mediterranean area. CFTI5Med comprised an opportunity to streamline the structure of the Catalogue database and propose a renovated user interface. The new front-end (1) grants an easier, intuitive access to the data, including earthquake effects on the environment, and (2) allows all data to be displayed jointly with relevant topographic, geological and seismological overlays published as web services.  Understanding any natural, potentially adverse phenomena requires knowledge of their history and territorial impact. Whether it is geological or human history (or a combination thereof) depends on the characteristic return period of the phenomena under scrutiny. Learning about major global climate changes and sea level fluctuations can hardly rely on historical evidence, since these processes occur at time scales in the order of 100,000 years; but geological evidence, rock deposits and landforms, will help filling the gap. Conversely, we can rely on written sources - and occasionally even archaeological evidence - to investigate earthquakes, volcanic eruptions, tsunami, floods and major landslides, all of which occur at timescales ranging from a few decades to a few millennia. Eruptions, tsunami and landslides may leave a discernible geological record even in such a short timescale - as in the case of Pompeii and the Vesuvius, or the 1963 Vajont landslide in the Italian Alps - but earthquakes generally do not, as their characteristic geological signature is generally rather subdued.catastrophes.The tradition of keeping track of such phenomena dates back to the Greek and Roman civilizations. Ancient earthquakes went largely unnoticed when they occurred in rural or uninhabited areas, but not when they hit the first Mediterranean megalopolis, thus turning into full-fledged Not surprisingly, earthquakes have left a strong imprint on the Italy’s built environment, heritage and traditions. Italian scholars learned soon that mitigating seismic risk requires understanding where and why earthquakes occur. Major advancements were spurred by catastrophic events that attracted the interest of erudite contemporaries, such as the central-southern Italy earthquakes of 1456. Today this vast, inherently multidisciplinary field lying at the foundations of most investigations into seismic hazard and risk is referred to as Historical Seismology.intensity of earthquake effects objectively, turning Historical Seismology into quantitative science. Intensity allowed different events to be compared in terms of location and overall severity.In 1873 and 1883, respectively, Italian earth scientists Michele Stefano de Rossi and Giuseppe Mercalli proposed empirical scales for classifying the 1 published a catalogue including nearly 1,400 Italian earthquakes between the 1st century AD and 1898. Alfonso Cavasino2 (1935) updated and systematised Baratta’s work, eventually leading to the first fully computerised catalogue in 19733.In 1901 Mario Baratta4 published a “consensus” catalogue based on the results obtained by research groups of Italy’s Progetto Finalizzato Geodinamica (PFG). In-depth studies on several large Italian earthquakes appeared in the Atlas of isoseimal maps5, a crucial tool in highlighting the importance of using original historical sources to investigate past earthquakes. Earthquakes were no longer represented only by an epicentre, but were regarded as complex phenomena to be investigated through their global territorial impact.Spurred by the need to re-assess the seismic hazard of potential nuclear sites, in the 1980s Italian Historical Seismology entered its Golden Age. Between 1983 and 1988 specific investigations were appointed to SGA Storia Geofisica Ambiente private firm by ENEL . In 1985 Daniele PostpischlCatalogo dei Forti Terremoti in Italia, or CFTI: hereinafter “Catalogue”), a “new-generation” compilation summarising all research results available to date6. Its second release7 (1997) was paralleled by the Internet-based compilation of Italy’s National group for defence against earthquakes8 (GNDT). Both compilations were used for assembling the Italian Parametric Earthquake Catalogue9.When Italy dropped its plans for producing nuclear energy following the Chernobyl accident (1986), Historical Seismology studies resumed as part of the mandate of Istituto Nazionale di Geofisica (ING). In 1995 ING released the first version of the Catalogue of Strong Earthquakes in Italy .Our Catalogue hence draws from an extremely valuable and unique documentary and historical heritage17). This guarantees considerable data quality and homogeneity, and maximises the transparency of any interpretative decision-making concerning the retrieved parameters. This approach has been further developed and elucidated in a Guide to Historical Seismology published in 2009 by Guidoboni & Ebel18.The Catalogue brings together the results of research conducted by over a hundred historical researchers and some geophysicists since 1983. Their work was coordinated within specific research projects aimed at exploring the known and unknown seismicity of the areas selected by the booming nuclear industry. The research was systematic, centrally coordinated and conducted with a stable methodology, with stringent standards and with a specialised historical approach, specific to every investigated area and historical period  conducted with uniform methods and goals. It is also a unique example worldwide of a catalogue whose main information basis consists of historical sources, carefully interpreted and made readily accessible to everyone.). In order to cope with this diversity the working group that developed the Catalogue includes historians, seismologists, earthquakes geologists, GIS and software experts.For all of these reasons, modern Historical Seismology is an inherently multidisciplinary field Fig. . In ordeAlthough the Italian earthquake record is indeed an outstanding source of information, it does carry the inherent danger - and the paradox - of generating a misleading picture of the seismogenic potential of any area, often leading to an underestimation of the earthquake potential, but occasionally also to an overestimation; in both cases the misrepresentation of the earthquake potential may carry significant consequences, especially in areas undergoing fast economic development. Why is it so?parametric catalogues, a form of presentation that indeed provides the basic data required for the elaboration of conventional seismic hazard models, but also inevitably spoils much of the available information. In parametric catalogues, the severity of earthquakes of the pre-instrumental era was assessed by reference to the maximum intensity only. Basic principles of earthquake source physics show that two crustal earthquakes of magnitude 6.0 and 7.0 may cause the same peak acceleration and the same maximum damage effects; but the area of strongest ground shaking will be much smaller for the 6.0 magnitude quake with respect to the 7.0 event. In the absence of instrumental data, the relative importance of the two earthquakes can be understood only by drawing complete pictures of their dynamic effects and translating them into earthquakes intensities, as it is done systematically in the Catalogue; a type of representation that parametric earthquake catalogues, focusing only on epicentral intensity, failed to supangaly.Until recently, the results of historical research have been summed up in traditional Annali di Geofisica edited by Boschi et al. in 200010, the Catalogue proposed an entirely new approach to dealing with research on past earthquakes and to systematising the outcomes of the investigations. In addition to the standard source parameters, for each earthquake the Catalogue supplies a set of specifically prepared summaries, details on the effects suffered by each locality involved, and a list of references. It is hence an analytical catalogue, supplying all the information available for any given earthquake in a pre-defined and easily accessible format, including its effects on the social, built and natural environment; a wide spectrum of data and observations, some of which are not immediately relevant to seismic hazard applications, but may be of interest for broader seismic risk analyses and for many other applications. For every investigated earthquake sequence the Catalogue supplies also the relevant bibliography in an organised form, allowing the reader to navigate upstream from the parameters of a specific earthquake to the original sources that were used to investigate that event.As discussed in detail in the special issue of In summary, the information supplied by the Catalogue is both parametric and descriptive. The parametric information is similar to that supplied by conventional catalogues: conversely, the descriptive information on the earthquake effects and on their historical and administrative framework is unique to the Catalogue and, as far as we know, it is not supplied by any other earthquake catalogue worldwide. In fact, parametric data are used almost as an index to the non-parametric information. In this context, for instance, the assessment of the earthquake intensity at a given site takes on the role of a suggestion rather than of a rigid interpretation. The suggestion is generally qualified and motivated, but the user is free to develop his/her own evaluation by navigating back to the original information upon which the intensity assessment was based.Figure Instrumental catalogues generally supply one record per earthquake. In contrast, the earthquake effects described by historical sources often refer to the combined effect of multiple shocks belonging to a sequence. This is generally unavoidable, as it is always difficult to separate the effects of subsequent shocks; either because they occurred very close in space and time, or simply because of the limited resolution of historical sources.For all of these reasons, the Catalogue presents the data organised “by earthquake sequence”, after aggregating shocks that appear reasonably clustered in both time and space. Occasionally this aggregation has been quite difficult, in particular when two or more spatially and chronologically close sequences cannot be separated with confidence. The aggregation of multiple shocks into a single sequence has been crucial during the acquisition, filing and digitization of the retrieved historical information.To facilitate access to the historical information and prevent any loss of data that are not directly used to describe the earthquake effects, but that may be useful to reconstruct the seismic scenario from different viewpoints, we chose to describe each sequence through a set of synthetic historical-critical comments. Conversely, earthquake parameters have been compiled for each individual shock, and so are the intensities reported at each locality. This dual “per individual earthquake” and “per sequence” approach is summarised in the left- and right-hand side of the scheme shown in Fig. the full parameters of each shock of the sequence that can be analysed individually (see complete list below);felt, or was reported not felt (see complete list below);the intensity  assigned to individual localities where each shock caused damage, or was simply a list of effects on the natural environment associated with a single shock (whenever possible) or with the entire sequence, subdivided into 32 different categories Time: earthquake origin time expressed as Greenwich Mean Time (hour:minutes:seconds)I0: epicentral intensity (MCS)Imax: maximum intensity (MCS)NMO: Number of Macroseismic Observations for the given earthquakeMe: equivalent magnitude based on macroseismic observationsEpicentral areaNotes:Following is a list of the parameters supplied for any earthquake listed in the CFTI5Med:F: falseD: doubtfulS: epicentral parameters based on a single intensity datapointE: epicentral location from foreign catalogueRL: review level of the study Following is a list of the parameters supplied for any locality affected by a specific earthquake listed in the CFTI5Med.Is: MCS intensity at site, for the given earthquake (with parameters listed below). In addition to the degrees of the MCS scale, in some instances other letters are used, based on the following list:S(V) strongly felt, but lacking evidence to support or deny the occurrence of damageF(IV-V) feltNF not feltG generic indication of damage at a specific siteN no evidence found in contemporary sourcesNC unrated: please refer to the analytical comments for further infoEffects on a single building:A(IX) collapse or extensive damage to the load bearing wallsB(VIII) collapse of the top portion of the building C(VII) partial collapse of the roof, vaults, apsidal vault, etc.D(VI) falling eaves, cracking of the external wallsE(VI-VII) report of generic damage to the buildingNat: earthquake-induced effects on the natural environment associated with a single earthquake or with the entire earthquake sequenceDate: earthquake origin date (year month day)Time: earthquake origin time expressed as Greenwich Mean Time (hour:minutes:seconds)I0: epicentral intensity (MCS)Imax: maximum intensity (MCS)NMO: Number of Macroseismic Observations for the earthquakeMe: equivalent magnitude based on macroseismic observationsEpicentral areaN: no macroseismic observations availabledescriptions of the territorial impact and temporal evolution of the entire earthquake sequence;descriptions of the effects on the built and natural environment for each individual locality.In addition to the above parameters, we supply the following synthetic summaries (in plain text form):19, for a discussion of the reasons of this choice and for a thorough description of macroseismic scales.The MCS macroseismic scale was adopted as the most appropriate for evaluating the effects of damaging earthquakes of the past. The reader may refer to Ferrari and GuidoboniThe contents of the Catalogue can be accessed from three independent entry points relating to earthquakes, localities and effects on the natural environment, respectively referred to as “Access by earthquake”, “Access by locality”, and “Access by effects on the natural environment”. They refer to the three types of parametric data shown in Fig. In the following we provide more detailed descriptions of the information made available by the Catalogue and of the methodology used to build it.Earthquake parameters indeed comprise the core of the information supplied by any earthquake catalogue. They are used for a number of elaborations ranging from the construction of earthquake scenarios, to the calculation of earthquake productivity rates, to the derivation of empirical earthquake attenuation laws, to the calculation of the parameters of an “equivalent seismogenic source”. As we pointed out earlier, however, the parametric part of catalogue is just one of the possible products of the research.Determining the macroseismic intensity of historical earthquakes is made difficult by the need to classify descriptions that are inherently qualitative. Such descriptions generally lack standardisation as regards the information levels, that can be highly variable, and the semantic value of the statements. Furthermore, the inferred damage levels may change significantly in relation to the economic and building context of each individual earthquake.All intensity scales were designed for classifying the effects of earthquakes contemporary to the observers. The intensity is assessed by direct comparison between the testimonies supplied by historical research and the descriptions assigned to each degree of the adopted scale. The quality of the assessment is hence strongly controlled by the resolving power of the testimony.In the Catalogue all intensity values were assessed by identifying convergent patterns in contemporary sources alone. Sources are sometimes contradictory, however, forcing the analyst to use his/her own experience to assess the local intensity based on the significance of the effects reported by the historical sources.It must be stressed that proper use of intensity scales involves a statistical assessment of the effects of the earthquake. In other words, a specific intensity level should be assigned only as an average of the observed behaviour of a number of independent buildings in a settlement . In some instances, however, and especially for the oldest earthquakes, the available historical information concerns mostly single monumental buildings . Under such circumstances the assignment of an intensity is replaced by the assignment of a code  to somehow preserve the information.19 for a thorough description of the difficulties involved in the use of an earthquake intensity scale and of the criteria followed in the Catalogue for attributing an intensity to a given locality.The reader is encouraged to refer to Ferrari and Guidoboni20.One of the most critical steps in the parameterisation of historical earthquakes is the assessment of their epicentral location. When a sufficient amount of individual intensity data-points is available, earthquake source parameters can be determined through an analytical technique, giving a statistical basis to highly subjective historical data21. Boxer uses intensity data to assess the location, moment-magnitude, physical dimensions and orientation of the source of large historical earthquakes. The macroseismic epicentre is calculated as lying in the middle of the spatial distribution of all sites that suffered the largest intensities. The magnitude, referred to as “equivalent magnitude” or Me to clarify that is an inferred - non measured - estimate, is obtained based on the average epicentral distance  reached by each intensity level. As the magnitude is calibrated using 20th century earthquakes for which both the intensity pattern and the moment-magnitude Mw are known with confidence, the Me obtained using Boxer corresponds to the Mw. It is well known that the epicentral intensity I0 decreases for an increasing hypocentral depth, and vice-versa. This implies that Me may be substantially larger or smaller than the magnitude one could obtain from empirical laws using only I0, depending on hypocentral depth.To parameterise all earthquakes listed in CFTI5Med we used the Boxer computer code v. 3.3w through empirical relationships. The box is meant to represent either the actual surface projection of the seismogenic fault or, at least, the surface projection of the portion of the Earth crust where a given seismic source is likely to be located.Boxer may be hence used also to describe the source of an historical earthquake in terms of an “equivalent seismogenic source”, i.e. as an oriented “box” whose length and width are obtained from the Mcalculated from a sufficient number of intensity data-points (at least three);taken from foreign catalogues;hypothesised, when the distribution of intensity observations does not allow a full calculation;set coincident with the location of a single site for which there exists an intensity assignment;set as lying in the middle of a region identified by the historical sources as the area that suffered the largest effects, without specifying the names of individual localities;unparameterised: this condition refers to an earthquake for which the available information is insufficient or too generic for deriving analytical parameters.The very long chronological interval covered by the Catalogue - about 25 centuries for Italy - implies that earthquake locations may fall into different typologies, summarised in the following:22.For the new CFTI5Med we specifically focused on earthquake-induced effects on the environment. This goal was accomplished by re-analysing and broadening the scattered information supplied in previous version. More specifically, all testimonies reporting earthquake-induced effects on the natural environment were systematically analysed, geo-referenced and filed. This complex work was backed by the expert judgement of the analysts, including historians and geologistschanges in the landscape ;changes in watercourses and lakes;changes in groundwater (including liquefaction effects);changes in the coastline ;others, such as gas emissions and light phenomena.Earthquake-induced effects on the natural environment reported in CFTI5Med were classified into 32 categories belonging to 5 macro-groups  that are used when the available testimonies do not provide detailed enough descriptions of the phenomena.landslides and surface faulting, all of which fall into the first of the above groups. However, while landslides are often explicitly mentioned by the historical sources , surface faults are never mentioned as such, simply because the relationships between seismogenic faulting, surface faulting and ground shaking have been correctly recognised only in relatively recent times. As a result, any reports that may actually refer to genuine  surface faulting are included in the subcategory “Ground breakage, fractures, fissures, splitting” (553 testimonies). Unfortunately, deciding whether a single report of ground breakage corresponds to actual surface faulting or rather to other non-tectonic processes is extremely subjective. For this reason we decided to avoid the risk of over-interpretation of the reported evidence, leaving to the user the responsibility to explore its true nature.Two of the most significant categories of earthquakes-induced effects are The effects reported in CFTI5Med are located as points coincident with localities where the effects were observed. In some instances, where historical descriptions allowed us to do so, the effects were precisely located on the geographical spots where they were observed . While MCS intensities are in one-to-one relationship with localities for any given earthquake, natural effects are not, since more than one type of phenomena may have occurred at the same site. For this reason, for each locality we may provide a list of effect categories.As anticipated above, the effects on the natural environment are associated with individual earthquakes (whenever this is made possible by the accuracy of the testimonies) or with an entire earthquake sequence.The descriptive information includes synthetic historical-critical comments concerning the whole earthquake sequence and summaries of the effects suffered by each locality Fig. . All comThe descriptive information concerning the main features of the whole earthquake sequence was organised following seven key-areas, from which we may derive up to 16 sub-areas, depending on the quality of the information available for each earthquake , attributing to each estimate a reliability class ranging from 1, lowest, to 3, highest.When the number of victims is described non-numerically , we interpreted the available testimonies in view of the presumed number of inhabitants of the cities or villages involved. Notice that this number is not very accurate even for Italy, where official census data became available only after the unification of the country in 1861 .At any rate, the number of victims is hardly a robust indication of the earthquake territorial impact, as it depends on a combination of circumstance which include the date and time of the largest shock(s), the prevalent occupation of the population, and the occurrence of any foreshock(s) that may have forced everyone to leave all buildings and seek refuge in open spaces.The bibliography comprises the foundation of a compilation and database dealing with historical natural phenomena. It includes both published and unpublished sources: when listed by author the unpublished sources were ordered by the name of the site where they are kept: one of 465 archives and 320 libraries in Italy, plus about a dozen libraries abroad.All texts are classified based on the strength assigned to the testimony(es) they contain with respect to the earthquake sequence being considered Table : notice For further information on this topic the reader is encouraged to refer to the Info section of the Catalogue.As with any compilation of historical information, and despite our best efforts, the data supplied in the Catalogue are subject to various limitations. The worst possible limitation is the lack – or extreme paucity - of the available information, either because no source has supplied any testimony on a specific earthquake, or because the available testimonies have been lost. If only one source is available, the Catalogue will report it as evidence of the occurrence of an earthquake, but it will be nearly impossible to locate it and assess its magnitude, suggesting much caution in making any inferences that may affect public safety.There are at least two large areas of the Catalogue that could be improved in due course. The first area concerns a number of large medieval earthquakes generated by the Apennines seismogenic zones. There is room for a substantial improvement of their characterisation, based on available written sources but also on archaeoseismological evidence and on the new data arising from the restoration of damaged monumental buildings.The second area concerns the reconstruction of damage scenarios in art heritage cities, an important aspect of tourism-based economy. Further investigations of the damage suffered by monumental buildings would provide crucial information on the seismic vulnerability - and hence on seismic risk – for invaluable cities such as Venice, Florence, Rome and Naples, among many others.Revision Level (see RL and the adjacent field Notes in the “Access by Earthququake” page) and ranging from “low” to “medium” to “high”, indicates at first glance which earthquakes could be investigated in better detail;each earthquake is rated in terms of the quality of the investigations conducted to describe and parameterise it. The rating, expressed in terms of the Catalogue lists several tens of earthquakes that in its previous version were labelled “unknown”, to indicate that they were not reported in previous catalogues. In CFTI5Med they have been fully integrated in the earthquake list and rated “low level”. For most of them, however, there is ample room for further investigations, so that they could be taken to “medium level” or “high level”;so far the chronology of earthquake sequences has not been investigated in detail, and in most cases only the mainshock has been looked at in detail. This trend has already been reversed by previous versions of the Catalogue, and there is room for obtaining intensity data for individual large aftershocks, thus improving the resolution of the territorial impact of the earthquake sequence.More specifically, in at least three instances the Catalogue itself supplies an indication of what could be achieved with further analyses:23 with the following structure:a table supplying the source parameters for all individual earthquakes listed in the Catalogue;a table supplying MCS intensities at localities for all individual earthquakes listed in the Catalogue;a table supplying all known earthquake-induced effects on the natural environment for all individual earthquakes listed in the Catalogue;a table supplying names and geographical coordinates for all localities listed in the Catalogue;a set of XML files, one for each earthquake sequence, containing descriptive information (in plain text) and bibliography for the entire earthquake sequence and for each locality.CFTI5Med stores information on 1,259 earthquakes  that occurred in Italy from 461 B.C. to 1997, and 475 earthquakes that occurred in the extended Mediterranean area  from 760 B.C. to 1500. A summary of all the information contained in CFTI5Med is given in Fig. The connections between the different tables are based on univocal codes for each earthquake sequence, for each individual earthquake and for each locality listed in the Catalogue.23, the user may download data directly from the CFTI5Med web-site12. From each type of page of the web-interface , rounded to three decimal places.Of all possible earth science datasets, an earthquake catalogue is indeed one of the most difficult to validate. This statement applies fully to a compilation of historical earthquakes such as that presented here, but also to a catalogue of recent seismicity recorded by state-of-the art seismological networks. Earthquakes occur in the Earth crust following a sort of “random regularity”: they concentrate in areas that we refer to as “seismogenic”, but occasionally visit areas where the geodynamic activity of our planet is comparatively slower, making seismic activity appear more sporadic. On the one hand, past earthquakes tell us where we may expect future earthquakes to strike; on the other hand, contemporary earthquakes, which by definition are better located than those of the pre-instrumental era, somehow validate past seismicity. There are important exceptions, however, because large earthquakes are also rare, and may occur in areas where background seismicity is limited or apparently absent, at least during the short time interval - a few decades - resolved by instrumentally recorded data.24  collected all solutions made available in the literature for a number of significant European earthquakes. For instance, the great 25 January 1348 earthquake is a catastrophic event that destroyed a large region at the boundary between present-day Austria, Italy and Slovenia. From the relevant web page on AHEAD (https://www.emidius.eu/AHEAD/event/13480125_1530_000) we learn that the earthquake currently appears in seven earthquake catalogues and was investigated by an Italian group11, by an Austrian group25, and by seismologists of the French BRGM (http://www.sisfrance.net). It follows that the variability of the epicentral locations, indeed quite large (about 50 km in latitude and 30 in longitude), and the equally large range of the assigned magnitudes (6.4–7.1) may be taken as an indication of the uncertainty associated with the parameters of this earthquake. Incidentally, the study presented in CFTI4Med was selected as the most reliable by the compilers of AHEAD, who in this case acted as an independent authority.There is clearly no experiment that can be planned to formally validate an earthquake database, but there are ways to evaluate empirically the accuracy of the data presented. Most large European earthquakes have been investigated by more than one group or scientists, each of which generally elaborated a map of the intensity pattern and derived an epicentral location and a magnitude. The European initiative AHEAD26, that is the reference dataset for any seismic hazard elaboration in Italy. Such an implicit endorsement is important, also considering that historical seismicity data are constantly challenged by observations of different origin, from geological to seismographic to GPS.Over the past 20 years the Catalogue has been the main source of data for the CPTI catalogueFinally, it should be pointed out that unlike standard earthquake catalogues, our Catalogue allows the basic data - essentially earthquake intensities - to be accessed and re-evaluated by the user. This peculiar characteristic of the Catalogue necessarily reduces the emphasis on the validation of earthquake data.the page “Access by earthquakes” (website home-page) allows the user to display the list of all earthquakes contained in the CFTI5Med database and make queries concerning a specific time interval, epicentral intensity/equivalent magnitude interval, or area;the page “Access by locality” allows the user to display all localities, search among them and make queries based on a maximum intensity interval ;the page “Access by effects on the natural environment” allows the user to display all earthquake-induced effects on the natural environment and make queries based on the different categories of effects. Specific web-pages provide information on each individual earthquake and locality of the Catalogue  appears on the map (connected to the corresponding marker) and the corresponding table line is highlighted in yellow. The infowindow contains information on the selected earthquake/locality/macroseismic observation/effects on the natural environment, plus direct links to the page describing an individual locality or an individual earthquake Fig. .The infowindows contain also historical-critical comments describing the effects of the earthquakes on the built and on the natural environment at the given locality, along with references to relevant bibliography. Instead, the historical-critical comments describing the whole earthquake sequence can be accessed from the page of an individual earthquake by clicking on the “Comm.” button Fig. . Here thAll pages are available in Italian and English language. When the language is set to English, a button appears on the top-right corner of each historical-critical comment: by clicking the button the user may obtain a translation of the text by Google Translate.For further details on how to navigate the CFTI5Med web-interface, the reader is encouraged to visit the “Help” section of the database website (10.6092/ingv.it-cfti5).The Catalogue makes available as searchable PDF files 23,538 of the 47,211 testimonies used for compiling it. The PDFs may refer to papers, books, archival documents and letters that may be extremely difficult to find, or are kept in rather inaccessible libraries and repositories. The recovery and digitization of the bibliographic sources is an ongoing activity, and future versions of the database will feature a substantial number of new sources (in the order of a few thousands). Unfortunately, not all sources can be shown in the database: some are protected by copyright and can only be accessed by scientists, while others are stored in libraries and archives that do not allow the original materials to be reproduced.In most cases the PDF files contain an exact transcription (PDF_T) of the excerpts that are deemed useful for further investigations, whereas in a limited number of cases, and only for texts that were originally in printed form, they contain scanned, searchable images of the original sources (PDF_R). For texts written in languages other than Italian, such as ancient and medieval Mediterranean languages , or in modern European languages, the transcripts contain a literal translation into Italian.In some instances the Catalogue supplies both the PDF_T and the PDF_R files for the same testimony: while the transcript contains a faithful excerpt that may be useful for defining the full scenario of the macroseismic effects, the scanned version of the original source allows all historical-critical, geological and seismological contributions to be consulted in full . Each PDF file contains the text and its exact bibliographical reference: information on how credit should be given is supplied in the PDF header.Taking advantage of the most advanced public-domain web-GIS tools, the CFTI5Med web-interface allows its own georeferenced data to be plotted along with data obtained from a number of external resources, including administrative, topographic, tectonic, geological, geotechnical and seismological datasets (see list below). The external data are shown as map overlays chosen through selection panels that the user can access by hitting two buttons located on the top-left corner of the map.plotting intensity data for a specific earthquake along with topographic, geological or landslide data, to verify whether specific geomorphological and geological circumstances may justify apparently anomalous intensities;plotting historical seismicity data along with instrumental data from an ongoing earthquake sequence, to verify the spatial relationships between the current earthquake locations and the areas affected by large earthquakes of the past;plotting the intensity pattern of a specific historical earthquake along with the distribution of mapped faults or seismogenic sources, to verify if the given earthquake may be interpreted as a result of the activation of a known fault/seismogenic source;plotting intensity data for a specific earthquake along with administrative boundaries, settlement distributions and transportation networks. Such a comparison may serve different purposes; for example, verifying whether the extent of damage or the effectiveness of the post-earthquake recovery was affected by conditions pertaining to specific non-geological characteristics of the region hit by the earthquake.This new possibility allows the user to consult the Catalogue data in the context of other relevant pieces of information, thus improving the ensuing interpretations. Examples of this opportunity include:Comuni ;Borders of Italian Province ;Borders of Italian Regioni ;Borders of Italian IGM topographic map, 1:25,000 scale ;IGM topographic map, 1:100,000 scale ;DISS Individual Seismogenic Sources – ISS (from INGV-DISS website);DISS Composite Seismogenic Sources – CSS (from rom INGV-DISS website);DISS Subduction Zones -SZ (from rom INGV-DISS website);Geological map, 1:100,000 scale (from ISPRA);Landslide catalogue , with a web-interface that can be displayed by clicking on the “Legend” button;the first (top) button opens a list of map overlays that can be displayed on the basemap . This list currently includes:http://cnt.rm.ingv.it: from 1985 onward), based on queries made through a selection panel. The epicentres are shown on the map after hitting the ‘OK’ button.the other button opens a window that allows users to add to the map the instrumental earthquake locations supplied in real-time by INGV’s surveillance service /consultancy on buildings, on infrastructures and on cultural heritage;professionals (various)/urbanistic evolution of towns and cities located in earthquake-prone areas;http://zonesismiche.mi.ingv.it), identification of suitable scenario earthquakes, investigation of specific seismogenic sources, studies on the economic, social and demographic trends of a region struck by a large earthquake28;researchers /development of the reference national seismic hazard model (e.g. see general population/raising risk awareness.CFTI5Med may provide crucial data for a number of different applications. These data are easily accessible through the web-interface to potential users having different backgrounds and roles in the society. Potential users/applications include:Users may hence take advantage of the Catalogue “in bulk”, i.e. by downloading large portions of it and analysing them with automated procedures, for example to derive earthquake magnitudes; or they may access individual portions of the information supplied, for example to investigate in detail the effects of a specific large earthquake in a locality of interest.th century. Nevertheless, we envision a possible extension of the Catalogue to countries of ancient civilization such as China and Japan, but also Indonesia and the Philippines, as well as to high-seismicity countries of the New World such as Chile, Argentina, Bolivia, Perù, Colombia and Venezuela.We wish to remark that the method developed to construct the Catalogue, its current architecture and its software could rather easily be adopted by countries other than Italy. Every earthquake-prone country has its own ways of dealing with the historical earthquake record, depending on the nature and quality of the available historical sources and on the level of scientific interaction among historians, seismologists and earthquake geologists. Developing a Catalogue similar to CFTI5Med would be straightforward for several countries of the central and eastern Mediterranean area, that could benefit from the knowledge that already exists on earthquakes that occurred in the Antiquity and up to the 15Download metadata file


Mission Papillagou) on self-esteem, well-being, and risk behaviors among adolescents.Risk behaviors among young people are a major social and public health issue. This study aims to assess the impact of a life-skills-based prevention program  or usual lessons (control group). Participants self-reported on their self-esteem, well-being, behaviors, interests and opinions.In a two-arm controlled study involving 520 school pupils aged between 10 and 15 years old, participants taking part in the prevention program (the Papillagou group) were compared to pupils who did not take part (the control group). Two assessment sessions were performed, one at baseline, and one after either the Mission Papillagou program significantly improved Self-Esteem scores (ηρ2 = .035). Well-being (Cramér’s V = .14) and mood  also improved in the Papillagou group compared to the control group. Regarding risk behaviors, the prevention program produced a decrease in the frequency of insults (Cramér’s V = .267) and rumor-spreading (Cramér’s V = .440), and a change of opinion toward the possibility of smoking an electronic cigarette in the future (Cramér’s V = .372).The This study suggests that life-skills-based risk prevention programs are effective. Adolescence is a crucial period of human development, characterized by psychological, biological and behavioral changes, the establishment of self-identity, and an increase in risk behaviors. These risk behaviors are defined as ways of acting that are seen as potentially damaging to the health, such as violence, school bullying, and consuming toxic substances . A 2013/2014 collaborative international survey by the World Health Organization reported epidemiological data about risk behaviors in middle-schoolers, aged from 11 to 15, in 42 countries across Europe and North America .The development of risk behaviors from early adolescence could be explained by an increase in sensation-seeking during puberty, due to a remodeling of the brain’s dopaminergic system, which is involved in reward and motivation processing . This seInstitut National de Prévention et d’Education de la Santé  [Appropriate primary prevention programs may help prevent the initiation and development of risk behaviors from early adolescence. According to a report on the prevention of risk behaviors at schools by the  France) , the mos France) . Their a France) . Low sel France) . Moreove France)  and toxi France) .Life-skills-based interventions must be adapted, as closely as possible, to their target populations. The most effective intervention programs for children are those that take place in the school environment, as early as possible in the development of risk behaviors . In addiMission Papillagou has been implemented in several schools that are based in economically disadvantaged Parisian suburbs. Mission Papillagou aims to reinforce young teenagers’ self-esteem, to improve the atmosphere in the classroom, to prevent risk behaviors, and to develop interpersonal skills. This program promotes abilities such as: (i) solving problems and making decisions; (ii) communicating effectively and being socially comfortable; (iii) thinking creatively and critically; (iv) empathizing, and becoming aware of one’s emotions; and (v) coping with stress and being self-aware. Improving life skills could raise self-esteem among young people, and could constitute a protective factor against risk behaviors.Since 2012, a life-skills-based program called Mission Papillagou consists of a set of group activities which are performed over three separate three-hour sessions  over 2 weeks. The different activities, their duration and the life skills that are promoted during each session are described in Table Mission Papillagou encourages children to experience a series of situations or to solve problems themselves. The facilitators help children to develop their own preventive measures.Based on a science-fiction story, Mission Papillagou therefore needed to be evaluated to highlight its impact on risk behaviors in adolescents. The aim of this study was to examine the effectiveness of Mission Papillagou on the self-esteem, well-being and risk behaviors of young adolescents, compared to a control group who did not take part in the program.Since 2012, 95 classes, i.e. 2355 pupils, in the Seine-Saint-Denis district  have taken part in this program. Mission Papillagou program, (ii) being between 10 and 15 years old, and (iii) reading and writing French well enough to complete the questionnaires. As shown in Fig. The inclusion criteria were: (i) being pupils from sixth- or seventh-grade classes from four middle schools in two economically disadvantaged neighborhoods of Seine-Saint-Denis (a suburb of Paris) who volunteered to participate in the Mission Papillagou program was offered to the control group following the end of the study (the program occured in the months following the assessment sessions or the year after).The research protocol was approved by each school principal. Parents and children received clear, accurate and detailed information about the protocol, and gave written consent to participate. Data confidentiality was guaranteed by an identification number. For ethical reasons, the Mission Papillagou from spreading to other classes through time shared outside of the classroom by the pupils.A two-arm controlled trial was conducted. Nine sixth-grade classes and eight seventh-grade classes from three middle schools made up the Papillagou group (who received the prevention program); three sixth-grade classes and two seventh-grade classes from the other middle school made up the control group (who did not receive the program). It was necessary that the control group came from a different  middle school, to prevent the effects of Accueils Préventions Cultures: Intercommunautaire et Solidaire,apcis@wanadoo.fr, an association involved with specially adapting the Mission Papillagou program for middle schools). Data was captured on a computer by two members of a research team (from Unité de Recherche Clinique de Ville-Evrard) who also did not administer the program.Two assessment sessions were performed: one session at baseline (both groups) and one session after either the Papillagou program (Papillagou group) or lessons as usual (control group). The second session took place between 2 weeks and 1 month after the end of the program (depending on school holidays). On average, 43 (±21) days separated the two assessments. The evaluations consisted of self-questionnaires and did not require the help of adults to be filled in. To avoid bias, the questionnaires were handed out to participants by someone other than the educator who administered the program when possible. This was a member of APCIS  from a program called Mission Papillagou and Croc’Lune’s Children, which was created in 1997 by the National Association for the Prevention of Alcoholism and Addiction in collaboration with The Swiss Institute for the Prevention of Alcohol and Drug Problems [Mission Papillagou program ; ii) a description of its content and practical application through role-play games ; iii) focusing on the problem of violence in schools, including how to prevent it ; iv) focusing on addictive behaviors and their prevention ; v) development of life skills . Each session ended with a debriefing.The Problems . The adaMission Papillagou program was carried out in schools, an APCIS educator was on hand to help the nursing students implement the program correctly.In addition to this training course, when the Mission Papillagou program/lessons-as-usual, self-esteem, well-being, behaviors, interests and pupils’ opinions were assessed through self-reporting. The assessments took place at school, and lasted for around 1 h each time.At baseline, and after the two-week Self-esteem was measured with the Self-Esteem Scale of Toulouse (ETES), a validated self-administered questionnaire of 60 items . ParticiAn unvalidated Visual Analog Scale (VAS) was used to measure the adolescents’ sense of well-being. The VAS comprised of a horizontal line, 10 cm in length, anchored by two well-being verbal descriptors, from “I feel awful” on the left, to “I feel very well” on the right. The children were instructed to draw a cross on the line.“in the last two weeks, I have felt depressed” or “in the last two weeks, I have had headaches”); iv) risk behaviors, including toxic substance consumption , anti-social behaviors such as absenteeism , physical violence , and verbal violence ; v) activities and interests; and vi) opinions. Subjects had to rate the frequency of each assertion.A self-administrated questionnaire called “PEPS”, which had been adapted from a French national survey by Choquet & Ledoux  and a stSince the threshold of discrimination for changes in health-related instruments appears to be approximately one half a Standard Deviation (SD) , the samStatistical analyses were performed with SPSS®25 Software . Data entry on a computer was done by two people . Then, the accuracy of the data entry was randomly checked. Only data from pupils who completed the program was included in the analyses . A mixed analysis of variance (ANOVA) was performed to analyze Total Self-Esteem score, and a multivariate analysis of variance (MANOVA) with bootstrapping was performed to analyze the dimensions of Self-Esteem . Well-being was transformed into a categorical variable and was analyzed with a chi-squared test. Regarding the PEPS questionnaire, the categorical variables were recorded as binary (yes/no) variables in terms of improvement at the second assessment compared to the first. The proportion of subjects who improved was compared between the two groups using the chi-squared test. If the criteria for using the chi-squared test were not met, Fisher’s exact test was used.2) for mixed ANOVA and MANOVA ; 0.0588 (medium); 0.1379 (large)) and Cramér’s V for chi-squared or Fisher’s exact tests ; 0.3 (medium); 0.5 (large)). Benchmarks to define small, medium and large have been suggested by Cohen [Effect sizes were measured through partial eta squared (ηρby Cohen .Mission Papillagou program), and 96 in the control group (who did not take part in the program). The participants were aged between 10 and 15 years old: mean  age = 11.82 (.86) in the Papillagou group; mean (SD) age = 11.83 (.88) in the control group . In terms of gender distribution, there were 179 males/138 females in the Papillagou group and 47 males/49 females in the control group (no significant difference between groups: X2(1) = 1.417; p = .234). Regarding toxic substance consumption in the whole sample at the baseline, 16.5% of the pupils had already drunk alcohol (boy-girl ratio = 58/42%), 11.1% had already tried smoking tobacco (boy-girl ratio = 67/33%), 8.5% had already tried electronic cigarettes (boy-girl ratio = 71/29%) and 3.4% had already tried cannabis (boy-girl ratio = 69/31%). Among the adolescents who had already consumed toxic substances, 2.7% smoked cigarettes at least once a week (n = 11), 8.2% smoked hookah at least once a week (n = 33), 4.5% smoked electronic cigarettes at least once a week (n = 18), and 0.5% smoked cannabis at least once a week (n = 2). 2.5% of the pupils also reported regularly drinking alcohol (n = 10). Regarding interpersonal risk behaviors, 19.8% reported having skipped school at least once in the previous two weeks (n = 79), 44.7% had insulted someone in school (n = 178) and 18.4% reported fighting at least once in the previous two weeks (n = 73).The data from 413 pupils who participated in all assessments was analyzed: 317 in the Papillagou group (who took part in the p = .769). The Pearson correlation was used to study the relationship between self-esteem and age. Self-esteem was negatively correlated with the age of the adolescents .No significant difference was found between the two groups at baseline for all the variables of self-esteem . Significant main effect of time  and main effect of group  were found. There was no significant difference between the two groups at baseline (m(SD)Papillagou = 218.32(23.21) and m(SD)Control = 215.28(26.17); t411 = 1.091; p = .276), but there was a significant difference after the Program (m(SD)Papillagou = 218.85(25.13) and m(SD)Control = 209.18(28.56); t411 = 3.197; p = .001).Regarding total Self-Esteem score, the mixed ANOVA revealed a significant group-by-time interaction effect , especially on the Physical Self score. Table Regarding different Self-Esteem dimensions, MANOVA revealed that the program had a significant overall effect on Self-Esteem scores  and mean (SD) Control = 8.2 (2.6) .No significant difference in well-being was found between the two groups at baseline: mean (SD) 2 (2) = 8.048; p = .018; Cramér’s V = .14).Between both assessment sessions, well-being improved in 44% of Papillagou group participants (versus 32% in the control group), remained stable in 19% (versus 15% in the control group) and decreased in 37% (versus 53% in the control group). There was a significant change in well-being between the two groups when using the chi-squared test  waking up at night (X2 (2) = 10.679; p = .001; Cramér’s V = .343), ii) feelings of depression , iii) feeling hopelessness about the future , and iv) a non-significant tendency for feelings of sadness  = 4.54; p = .033; and ii) stealing (X2(1) = 8.24; p = .004), with a higher frequency in the control group. Among pupils reporting risk behaviors at baseline, either the chi-squared test or Fisher’s exact test was used to compare the improvement between the two groups after the second assessment. After the Mission Papillagou program, adolescents showed a significant improvement in comparison with the control group in: i) spreading a rumor in school (X2 (1) = 10.656; p = .001; Cramér’s V = .440); ii) having been insulted in school  (X2 (1) = 8.147; p = .004; Cramér’s V = .267).The frequency of risk behaviors in each group at baseline is reported in Table Mission Papillagou program, 57% of pupils no longer planned to smoke an electronic cigarette in the future, compared to 12% in the control group .Regarding the consumption of toxic substances, the number of substance users per group was insufficient to conduct statistical analyses. However, after the Mission Papillagou program on self-esteem, well-being and risk behaviors among middle-schoolers. The program was performed in the school environment over three separate three-hour sessions. It is designed to ameliorate and strengthen young people’s life skills, thus developing protective factors against risk behaviors. Our findings suggest an improvement in self-esteem, well-being, mood, and a reduction in some risk behaviors among adolescents who took part in the program, compared with the control group.The purpose of this study was to evaluate the impact of the Mission Papillagou program significantly improved both the total self-esteem and Physical Self scores. At the second assessment session, these mean self-esteem scores increased slightly in the Papillagou group, while they decreased in the control group. Self-esteem is highly associated with body image in young people [The g people –26. Satig people , 25, 26.r = −.117). Nevertheless this would tally with other studies that reported a decline in self-esteem [Mission Papillagou program could limit self-depreciation observed throughout adolescence. Other life-skills programs have reported a positive impact on self-esteem among young people [ESPACE, which focused on developing psychosocial skills and self-esteem in order to reduce the age of regular alcohol consumption among adolescents in middle schools, reported improved self-esteem (including self-confidence and body image) among adolescents who took part in the program compared to a control group [In addition, according to our results, self-esteem may be negatively correlated with age, but this result should be considered with caution because of its weak magnitude . Other prevention programs reported an improvement in well-being and lower levels of distress among program participants compared to a control group [Together with boosting self-esteem, the ll-being . Self-esll-being , 37. Lifol group . Howeverol group  .Depression and feelings of unease in adolescents are of great cost to public health. In early adolescence, the prevalence of depression is around 2%, and it increases throughout adolescence to reach about 18% in early adulthood . This prMission Papillagou program also resulted in a decrease in the frequency of risk behaviors, specifically insults and the spread of malicious rumors. Verbal harassment and rumor spreading are part of bullying, which is a key contributor to global mental health issues [The h issues . Being ah issues . The effRegarding the program’s effect on toxic substance consumption, the sample of consumers was not large enough to perform statistical analyses. Nevertheless, the program induced a change of opinion toward the possibility of smoking an electronic cigarette in the future.ESPACE study, which reported a positive impact on self-esteem and psychosocial skills among pupils who took part in the program compared to a control group, but no difference regarding their consumption of toxic substances [Our results are consistent with the bstances . This laMission Papillagou has the advantage of being shorter (thus it is easier to incorporate into the school curriculum), and less specialized (i.e. it does not focus on a single disorder). It addresses several issues by adapting to the specific problems encountered by the class. Finally, it is important to note that the Mission Papillagou program did not have any negative effects on participants.Compared to other prevention programs, However our outcomes should be treated with caution because the effect sizes were mostly small  or medium , except for the depressive feeling variable, which had a large effect size. This positive effect on mood may be explained by its lower inertia compared to more complex psychological concept, as self-esteem and well-being. The latter might require more time to show a larger fluctuation. The current study has some limitations. First, as mentioned above, there was a low proportion of toxic substance users among participants. This prevented any conclusion being drawn regarding the effect of the program on participants’ current toxic substance consumption. A study on a larger number of subjects would have made it possible. Secondly, regarding experimental design, schools were not randomly assigned in the Papillagou group or the control group for practical and organizational reasons, which could constitute a bias. Nevertheless, the schools that took part in this study had very similar socio-economic profiles. Moreover, participants and informants were not blind to study conditions. Thirdly, the scale used to assess well-being was not validated. A validated scale would have ensured greater reliability, and comparison with other studies. To our knowledge, there has never been a validated French-language scale to assess well-being in adolescents. Fourthly, days separating the two assessments were slightly different according to classrooms (depending on school holidays and availability schedule). In future studies, it would be better to control this factor more strictly.Mission Papillagou program over a longer period, such as 1 or 2 years. This project is currently under consideration, but it requires conducting a study with a larger cohort of children, because of high risk of lost to follow-up .Finally, the effect of the program was only assessed in the short term. It would be more valuable to assess the impact of the Mission Papillagou program has a generally positive effect on young adolescents, especially on self-esteem, well-being and mood. The implementation of this type of program in schools should therefore be encouraged.This study confirms the probable benefits of implementing risk prevention programs that promote life skills. Besides reducing risk behaviors, the


Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities ( Program impact pathways are a theory‐driven tool for real‐time monitoring of large‐scale global health pilots and provide essential information on supply and demand side factors, to allow for course correction during implementation.Multiple levels of engagement  are necessary for MNP program to be delivered effectively to intended beneficiaries.Effective counselling is essential for increased adherence to child feeding recommendations and use of MNPs.1−1; NFHS‐4, The state of child anaemia in Bihar, India, is alarming. In 2016, 63.5% of children 6–59 months were anaemic , including (a) Accredited Social Health Activists (ASHAs) and (b) Anganwadi workers (AWWs), who were trained and managed at the level of the HSC, under the supervision of auxiliary nurse midwives (ANMs) and lady supervisors. AWWs are permanent paid employees who receive monthly salaries, whereas ASHAs receive incentives based on completion of tasks, which include counselling mothers on nutrition, pregnancy care, and supporting women to engage in institutional deliveries. Home visits are a routine component of the job descriptions of both, with an average of 50–60 households per month per worker, depending on the number of pregnant, lactating women and children under 2 years of age per community  pamphlets on how to use the powders and recommended IYCF and hygiene‐related practices, with their first delivery of MNPs. Instructional materials for MNP use were presented in graphical form in both the pamphlets and on the box containing MNPs (refer to 2.2Program impact pathway (PIP) development is an iterative process and involves the documentation of hypothesized linkages between program activities and their expected immediate, intermediate, and final outcomes  were conducted with caregivers and focus group discussions (FGDs) with FLWs at midline. Table 2.4All checklists were pilot tested prior to implementation and revised continuously during the initial months of rollout in consultation with the program team and FLWs. This ensured that checklists were not excessively burdensome to complete for field workers (< 30 min), and captured key monitoring information.2.4.1During monitoring months , our study team randomly sampled six HSCs, four in intervention and two in control. From each HSC, 10 AWCs were randomly selected for a total of 30. Checklists were completed by our program staff in consultation with AWWs. Issues with the supply chain identified during data collection were reported to the study coordinator, and supplies were replenished through our network of CARE couriers or frontline program staff. Counselling pamphlets with IYCF messaging (in control and intervention communities) and instructions for MNP use (in intervention communities only) were also replenished via our program staff based on information gathered from these checklists.2.4.2HSC checklists refer to  were com2.4.3In intervention and control communities, program staff completed household monitoring checklists with caregivers and those responsible for the feeding of children aged 6–18 months. Checklists were collected monthly for Months 1 to 3 and then bimonthly for Months 6 to 12. Staff did not complete checklists in Month 4 or 5 as these coincided with the midline. During each monthly monitoring, four intervention HSCs and two control HSCs were selected randomly and checklists completed for 60 intervention and 30 control households. Program staff targeted two AWCs per HSC for household monitoring and randomly selected households for monitoring based on catchments targeted during that month.2.4.4The midline was conducted in Month 4 to assess program rollout and implementation. We used data from midline to determine the duration of rollout and the timing of program endline. To understand supply and distribution, we assessed FLW reported delivery of MNPs and caregivers reported receipt of MNPs at the household within the last month. To measure uptake, we looked at whether caregivers reported current use of MNPs/child having consumed MNPs in the last month and week.n = 20) and ANMs (n = 2) in addition to FGDs with FLWs (n = 4) from one low‐ and one high‐performing intervention HSC. The “high” and “low” performances were decided based on HSC and household level‐monitoring data and in consultation with our program staff and ANMs who supervised FLW attendance at meetings, using indicators of home visits and overall performance. The quantitative survey took 1 month to complete, whereas qualitative data collection was completed over the course of 14 days.Low program implementation was defined as <40% of households reporting receipt and uptake of MNPs in the last month, medium as <60%, and high as >60%; these cut‐offs were defined a priori by the team and were based on researcher judgement. At midline, we interviewed 840 caregivers with children 6–18 months of age, and 420 FLWs. All 70 HSCs were sampled; four AWCs were randomly chosen per HSC; four households per intervention Anganwadi and two per control Anganwadi were chosen randomly and interviewed by our program staff based on household lists provided by FLWs from their registers. We also conducted qualitative IDIs with caregivers  and assessed key themes using a thematic analysis approach  as generating information about the supply side and all data collected from households (HH checklists), informing demand side indicators. Monitoring was also carried out in the control group to track spillover receipt/use of MNPs. We did not identify issues with spillover and have therefore reported results from intervention group data only. Results from the midline mixed methods data complemented monthly monitoring results. Table 3.13.1.1In our intervention group, HSC meetings were held regularly throughout the course of the study with over 90% of HSCs reporting monthly meetings. In the initial months, CARE program staff helped coordinate meetings in collaboration with government staff. We saw a dip in the number of meetings held in Month 4. An a priori component of the program design required that all HSC meetings be coordinated and checklists be completed by ANMs, during monthly meetings without external support from our program team following handover after Month 3. The dip we see in our key indicators during Month 4 coincided with this planned handover of program leadership to ANMs and lady supervisors Figure .Overall knowledge of FLWs on MNPs remained high throughout the program and ranged between 87% (Month 1) and 100%  of workers surveyed using AWC checklists reporting the correct age for MNP introduction. Between 63% (Month 1) and 100%  of workers reported the correct age to stop MNP use, and 100%  of AWWs correctly reported amount for daily consumption over the study period. Additionally, between 86% (Month 4) and 100%  of all intervention group FLWs attending monthly HSC meetings reported receiving training on MNPs. We saw the lowest percentage in Month 4 of implementation when program staff activity was scaled back as part of program handover , with uneven decline thereafter, as seen in Figure 3.2To help us understand the demand side of program implementation, we collected data on home visit patterns from the perspective of households and uptake of MNP and IYCF practices using household checklists Figure . Our fin3.2.1“ever”‐receiving MNPs were relatively high  early in the study, dipped in Month 6 (67%), followed by a steady upswing . Additionally, 55% (45–73%) of households on average reported being visited by ASHAs and 57% (38–73%) by AWWs in the last month; 61% (47–78%) of households on average reported receiving IYCF pamphlets over the duration of the program, and 55% (25–64%) reported finding the pamphlets useful and informative.Receipt indicators at the household level show patterns similar to our supply side indicators for the first 3 months of the program. Percentages for households reporting 3.2.2In the intervention group, throughout the course of the study, a mean of 74% (63–87%) of households reported being visited by FLWs in the last month. Approximately 89% (82–97%) of households in intervention group reported correct knowledge about initiation of complementary foods at 6 months. Additionally, 67% (53–89%) of households on average, over the span of the program, reported currently using MNPs if received. Finally, on average, over the course of the program, 34% (11–51%) of eligible children were not consuming MNPs, as observed in household monitoring data.3.2.3FGD with AWW in low‐performing HSCA child between the ages of six to eight eats much less food, compared to that quantity of powder is more. Because of this imbalance in proportion of food and powder, child refuses to eat food. When food is more and powder is less, child does not recognize the presence of the powder in the food. We noted through household and HSC checklists and during routine contact with FLWs that children 6–9 months who had initiated complementary feeding concurrent to the introduction of MNPs more often reported side effects such as “vomiting” or spitting up of MNP fortified food, and blackened stools.FGD with ASHA in low‐performing HSCI ask the mother to take some cooked rice in a clean bowl and also bring pulses curry or vegetable curry or anything which is cooked. Then I mix one third of the powder by tearing the packet and telling her what she has to do, and also say that if you will give like this, the child will not vomit and eat the powder in mixed food. We addressed the issue of side effects such as vomiting, through retraining of FLWs. As well, we organized community meetings to support demand generation and to provide additional sources of counselling and support to community members. We modified FLW trainings on feeding recommendations for children experiencing side effects based on strategies, first suggested by FLWs themselves, elucidated through participatory consultations. To this end, all FLWs were advised to counsel mothers to split MNP sachets across 2–3 meals per day. These recommendations were well accepted and helped improve overall uptake.3.3The program implementation midline was conducted in Month 4 of MNP rollout. Our results show that overall implementation was low. Receipt of MNP in the last month, as reported at the household level, was low (40%), as was consumption (35%), as presented in 3.3.1HH IDI with mother in low‐performing HSCPeople told me that it is good for the health of the child. This will increase strength and weight of the child. So, for the good of the child I am giving this powder regularly to my child. FGD with ASHA in low‐performing HSCThere is no problem sir, child is getting fat and the mind also grows. Overall, program exposure and acceptance of MNPs, as measured at midline, was high. Approximately 76% of people in the intervention group reported ever having heard of or seen the MNP, and 71% of households reported consuming MNPs in the last week, if received supply in the last month. FLWs and households expressed positive opinions of the MNPs.3.3.2A lack of supply of the powders in the household was identified as the most common reason for not using the powders (21%), implicating bottlenecks in our supply chain. At midline, households also described several additional reasons for not using MNPs: forgot to give MNP (3.4%), side effects (5.9%), poor appetite of child (3.4%), and illness including cough, cold, or fever (3.0%).3.3.3HH IDI with mother in high‐performing HSCGenerally, child eats rice when it is mixed with oil, salt and chilli powder. When child is given rice mixed only with powder, she spits it out from her mouth. A lack of adequate counselling on how to use MNPs emerged as a common concern for poor uptake in both the quantitative household survey and qualitative IDIs with households. Some households reported mixing the MNPs in plain rice (without lentils or sauces) and feeding the child, often leading to children spitting out the powders.Additionally, we added messaging to advise use of MNPs in wet foods (rice mixed with lentils and vegetables to ensure it is moist), where the powders are mixed in completely and therefore undetectable to the child.HH IDI with mother in low‐performing HSCWhen child is sick, she does not eat just milk is given. HH IDI with mother in low‐performing HSCChild resists food when he feels sick. When child resist food we do not force much. The issue of side effects and feeding during illness emerged during qualitative work and in routine monitoring.We retrained FLWs on counselling mothers with ill children, by emphasizing the importance of responsive feeding with attention to quantity and frequency of feeds during illness.3.3.4IDI with ANM in high‐performing HSCMany people are not aware of the importance of the powder, for that at initial stage ASHA and Aanganwari worker have to go to each child's home for distribution of the powder. When people start using powder they themselves will collect it from the AWC. Additional findings from the program implementation midline show that 40% of families reported receiving the powders by visiting the Anganwadis as opposed to home visits. We revised our delivery approach to include pick‐up of MNPs at Anganwadis directly, in addition to home delivery by FLWs.To alleviate FLW work burden and ensure adequate household stock over the festival season, we amended recommendations to encourage FLWs to deliver three boxes of MNPs to each household at a time. This two‐pronged approach to dissemination of the powders catered to the needs and convenience of individual families and FLWs.3.3.5FGD with ASHAs in high‐performing HSCThe powder is dropped at AWC first, then Aanganwari worker informs the respective ASHA about the powder, and planning for the distribution is done based on the requirement of the households. The qualitative data showed that in areas where FLWs shared a good working relationship, effort was distributed relatively evenly between both cadres of workers. Approximately 21% of households reported receiving the powders from ASHAs and 35% reported receiving MNPs from AWWs.IDI with ANM in high‐performing HSCOne positive side of this program when ASHA and AWW are involved in such programs they are earning good will of people. People benefitting from this powder consider them the benefit provider. AWW FGD in high‐performing HSCIt was not like we have to give this powder to some and not to others. It has to be given to all the eligible children of the area who are of a certain age group. Since the beneficiaries are in almost each household, they get benefit. They think that the Aangawari sister has come with something for their children. And rest of the things are based on categories which create dissatisfaction, that few of them are getting and many are not. When asked, about their overall relationships with the communities they serve, FLWs reported that they had improved through the program:As shown in 3.3.6FGD with AWWs in high‐performing HSCKindly tell us Sir, is it possible for a family to survive on remuneration of Rs 3000? All the field work has to be done by us but the government is not thinking of us …. We observed that 92.6% of FLWs reported not receiving full payment of regular salaries during our midline. Additionally, 64.4% of AWWs and 63.8% of ASHAs reported never receiving their routine payment on time.No additional compensation was provided to FLWs for their participation in this program and resultant increase in workload. These issues collectively were an essential bottleneck in our supply chain that were beyond the scope of this program to address.3.3.7Results from midline data were leveraged to engage all levels of the government system within the district. We worked with the district program officer to improve supervision provided directly to FLWs by community development program officers, lady supervisors, and ANMs. We also increased community demand generation by hosting two rounds of additional community meetings in Months 8–10 and 11–12, to inform and educate beneficiaries about the program, MNP use, and provide information on IYCF, supplementing counselling during home visits by FLWs. We held block level meetings with all FLWs to go over data from midline and ongoing monitoring activities, as part of our stakeholder engagement strategy. We deliberately shared data with them to help boost morale and inform them of the results of their work. At the end of the program (Month 12), we distributed inexpensive household items as prizes, through block level government officials, to three top performing FLWs in each block to recognize their commitment, work ethic, and contribution to the study. In addition, all FLWs were provided with inexpensive program (MNP logo) carry‐bags to recognize their contributions.4PIP analysis was used to help understand the implementation and uptake of the MNP program in Bihar, India. We used our monitoring data to (a) guide MNP field distribution; (b) target systems, stakeholder, and community engagement activities; (c) dictate the overall duration of the program; and (d) track overall program progress.The mixed methods process evaluation approach informed ongoing decision‐making, allowing us to gather in‐depth information about issues arising in the field, develop responses that could be quickly integrated back into the program, and monitor whether responses adequately addressed issues. For example, an issue discovered during routine monitoring was the management of side effects, for which we revised MNP dosage recommendations.Routine monitoring also helped us track implementation, by having our field teams conduct surveys regularly, visit more remote study sites during the trial, and address supply chain issues in real time. Ongoing training was an essential component of program implementation and improves quality of care delivered and communication by FLWs as has been reported in prior research , however due to which we were able to ensure that stock‐outs were not an issue up to this point. Scale‐up of this intervention would require additional inputs from the government to manage these higher rungs of the MNP supply chain from manufacturer to storage facilities. Our program team was also involved at higher levels to boost performance by FLWs.We recognize the impact of potential Hawthorne effect created by intense monitoring activities such as those carried out during this study and that this may influence indicators more than would be seen if carried out solely by existing government structures , as opposed to several years, thus highlighting an important evidence gap and need for monitoring of MNP program that have a greater longevity.In addition to PIPs, other authors have devised a global framework for reporting of context and implementation for pilot studies to be utilized in intervention trials  was responsible for overall management of the project and data collection, analysis, and drafting of this manuscript. MY oversaw the implementation of this pilot. IC and RM (Mehta) oversaw field implementation and provided technical inputs to the midline for this pilot. MY, AWG, UR, IC, PV, PK, SS, and RM were involved in design of the monitoring strategy for this pilot. MY, AWG, PK, RM, and UR provided critical insights on the manuscript. SS and RM were responsible for procuring funds for this study. All authors have reviewed and approved the final draft of this manuscript.Data S1. Supporting informationClick here for additional data file.Table S1: Midline HH Survey SummaryTable S2: Midline FLW Survey SummaryTable S3: Health Sub‐Centre Checklist – InterventionClick here for additional data file.


Schizophrenia is a leading cause of disability, and a shift from facility- to community-based care has been proposed to meet the resource challenges of mental healthcare in low- and middle-income countries. We hypothesized that the addition of mobile texting would improve schizophrenia care in a resource-poor community setting compared with a community-based free-medicine program alone.p = 0.013; effect size 0.38). Among secondary and other outcomes we noted substantial reduction in the risk of relapse  and re-hospitalization . The program showed no statistical difference in all other outcomes. During the course of the program, 2 participants in the intervention group and 1 in the control group died. The limitations of the study include its lack of a full economic analysis, lack of individual tailoring of the text messages, the relatively short 6-month follow-up, and the generalizability constraint of the Chinese context.In this 2-arm randomized controlled trial, 278 community-dwelling villagers (patient participants) were randomly selected from people with schizophrenia from 9 townships of Hunan, China, and were randomized 1:1 into 2 groups. The program participants were recruited between May 1, 2015, and August 31, 2015, and the intervention and follow-up took place between December 15, 2015, and July 1, 2016. Baseline characteristics of the 2 groups were similar. The patients were on average 46 years of age, had 7 years of education, had a duration of schizophrenia of 18 years with minimal to mild symptoms and nearly one-fifth loss of functioning, and were mostly living with family (95%) and had low incomes. Both the intervention and the control groups received a nationwide community-based mental health program that provided free antipsychotic medications. The patient participants in the intervention group also received LEAN , a program that featured recruitment of a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary healthcare. The primary outcome was medication adherence (proportion of dosages taken) assessed by 2 unannounced home-based pill counts 30 days apart at the 6-month endpoint. The secondary and other outcomes included patient symptoms, functioning, relapses, re-hospitalizations, death for any reason, wandering away without notifying anyone, violence against others, damaging goods, and suicide. Intent-to-treat analysis was used. Missing data were handled with multiple imputations. In total, 271 out of 278 patient participants were successfully followed up for outcome assessment. Medication adherence was 0.48 in the control group and 0.61 in the intervention group  the treatment gap remains high, and even when treatment is available, adherence to antipsychotics is low.Mobile text messaging has been shown to be useful to strengthen community- and family-based care in resource-poor settings due to its availability, reliability, and ease of use.However, there has been no clear evidence that texting improves treatment adherence, symptoms, and functioning in people with schizophrenia.We developed an intervention called LEAN, involving the recruitment of lay health supporters; an electronic platform with mobile texting for medication reminders, health education, and monitoring; the awarding of token gifts for positive behavioral improvement, and integration of the texting with the health system.In this 2-arm randomized controlled trial, the control group received a free antipsychotic medication program (the 686 Program) while the intervention group received the 686 Program plus LEAN.We found significant improvement in medication adherence (0.48 in the control group versus 0.61 in the intervention group) and a substantial reduction in the risks of relapse and re-hospitalization with the intervention.LEAN demonstrated a 27% improvement in adherence, which is larger than the 15%–18% range reported in other text message interventions.Two unique features may have contributed to the relative superiority of LEAN: active engagement of lay health supporters and the use of texting to connect the entire treatment team from patients to lay health supporters to village doctors to psychiatrists, all in support of the patient.Texting effectively addressed the low adherence at marginal cost, and LEAN’s experiences may be useful for other LMICs with resource constraints.However, an adaptation of LEAN should fully consider some implementation details including keeping the program simple and integrated into routine care, maintaining low cost, and choosing existing texting platforms if available. Schizophrenia is a leading cause of disability, with a global prevalence of 0.4%  and contIn community- and family-based healthcare, mobile health  has gained increasing traction –16. WithThe LEAN intervention was intended to address some of the insufficiencies of the previous trials mentioned above and to have broad applicability for resource-poor settings in LMICs. This study was conducted as a pragmatic trial to test our primary hypothesis that lay health supporters (family members of the patients or community volunteers) aided by a simple texting system would increase patient adherence to antipsychotic medications, and improve symptoms and functioning in a community-based cohort of patients.We designed a 2-arm individually based randomized controlled trial. Details of the study design, methods, and analysis plan have previously been published as a study protocol . The triWe applied minimal inclusion and exclusion criteria . The incThe development of the intervention, LEAN , was guided by theory, empirical evidence, and our trial and error. In early 2015, challenged by low medication adherence among 686 Program enrollees, we piloted a program in rural Liuyang that tasked “village doctors”  to directly deliver and monitor medication ingestion in patient homes . HoweverThe acronym LEAN summarizes the 4 program components: Lay health supporters, E-platform, Award, and iNtegration. A lay health supporter was selected from the patient family or the community, who followed phone-texted instructions to perform simple tasks: supervising patient medication, monitoring side effects and relapse, and facilitating urgent care. We approached the people in the following order in identifying the lay health supporters: (1) the main family caregivers registered on the 686 Program registry, (2) family members accompanying the patients to collect medication refills, (3) family members nominated by the patients, and (4) community volunteers nominated by the mental health administrator with the agreement from the patients. The e-platform  texted 2 daily messages to both the patients and their lay health supporters: a message at 9:00 AM with educational information on schizophrenia and a reminder at 7:00 PM to take medicine , and continued training through our text messages on how to provide patient care and seek professional help. The patients were evaluated for their ability to use 3 basic phone functions: turning the phone on/off, charging the phone, and reading/returning text messages. The patients in need of training received up to 3 sessions (20 minutes per session) of hands-on demonstration on how to use their phones (details elsewhere ).After a 3-month pilot of LEAN, we made several design and implementation changes. Among the major changes, we decided to text medication reminders to both the lay health supporters and the patients rather than the patients alone, and to use an existing telemarketing platform rather than the one we developed on our own .While the intervention group received the 686 Program plus LEAN, the control group received the 686 Program alone. The 686 Program is a national public program covering 5.4 million people with psychosis in China, three-fourths of whom are people with schizophrenia . DespiteThe 686 Program registry included as high a proportion of villagers with schizophrenia as possible. We first selected 400 names from the registry with simple random sampling. Then we applied inclusion and exclusion criteria to this group and recruited those eligible after obtaining their informed consent. After the patients were recruited, a statistician not otherwise associated with the project allocated participants (1:1) by simple randomization to receive either the 686 Program plus LEAN (intervention group) or the 686 Program alone (control group). It was not possible to blind the program participants to allocation. However, outcome assessors were blind to group assignment and were physically separated from the program implementation team, which operated LEAN and monitored user experiences. The psychiatrists were also blind to the allocation status of participants. If unmasking occurred inadvertently during assessment, this was to be reported immediately, and a make-up assessment scheduled with separate assessors.Our published trial protocol provided details on measurements . In briet test, we calculated that a total sample size of 258 participants (129 per group) would have 85% power to detect an increase of medication adherence from 0.72 to 0.85, assuming a 5% type I error and 10% attrition. All analyses including the subgroup analyses were conducted as pre-specified in the protocol  8.0 [95% CI 4.2–85.2]) and the risk of re-hospitalization  with the intervention .We performed a sensitivity analysis to compare the results of the program effects on adherence, functioning, and symptoms with a raw analysis versus an adjusted analysis with covariates and data imputation for the missing data. The results were not sensitive to the choice of the methods, with almost identical results for adherence and functioning and a minor difference for symptoms see .In this study, we used a 2-arm randomized controlled trial to study the effect of mobile texting on medication adherence, functioning, and symptoms of community-dwelling people with schizophrenia in rural China. Our trial showed that the addition of texting to patients and their lay health supporters in a resource-poor community setting compared with a free-medicine program alone improved medication adherence  and substantially reduced relapses and re-hospitalizations, but our program did not lead to significant changes in patient functioning or symptoms. The program was also found to be generally well accepted by the patients and their families, was relatively easy to implement and use, and added little marginal cost.n = 1,139) showed no advantages of texting on any outcomes assessed at 12 months [n = 62] [n = 146]  ; Czech Rn = 146] ). One tr n = 55) , howeverWe would like to discuss 4 aspects of LEAN relative to prior studies. First, LEAN demonstrated a 27% relative improvement in adherence, which is larger than the 15%–18% range reported in other text message interventions ,58. ThreSecond, like most of the 6 randomized controlled trials discussed earlier ,50, the p = 0.117), but it had a medium and significant effect for the subset with good baseline adherence . As this improvement in the subset was not accompanied by improvement in medication adherence, we suspect that the text messages may have served as a rudimentary psychosocial intervention that was beneficial to functioning. Earlier studies indicated even simple messages asking “how are you?” or saying “thank you” reduced social isolation and improved functioning [Third, prior studies of texting for schizophrenia seldom reported the global functioning level of the patients. Our program had a small and statistically insignificant effect on reported patient functioning for the overall group   in interhttps://www.researchgate.net/project/LEAN-Trial-Lay-Workers-mHealth-for-Severe-Mental-Disorders).The trial used a waitlist control design whereby the control group would receive the intervention as well once the program demonstrated benefits after the initial 6-month implementation. We suspended LEAN from August 2017 to March 2018 due to our program evaluation. We resumed LEAN in both the original intervention and the waitlist control groups from April to October 2018. We are now in the process of cleaning the data from this extended program phase and will report the results in subsequent publications  , the useMany lessons learned from this trial can be potentially useful for other LMICs that face resource constraints. China’s 686 Program successfully implemented many WHO mhGAP recommendations for resource-poor settings. In particular, the 686 Program in Liuyang effectively removed the access barriers for antipsychotics by providing free medication routinely and conveniently. However, adherence to antipsychotics remained a serious challenge. Our texting intervention further improved the program by addressing the low adherence at marginal cost. Elements of LEAN may be adapted to other resource-poor settings with or without an existing community-based program. However, adaptation of LEAN should fully consider some implementation details including (1) keeping the program simple and integrated into routine care ,63 Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.