Urban transportation systems are multimodal, sociotechnical systems; however, while their multimodal aspect has received extensive attention in recent literature on multiplex networks, their sociotechnical aspect has been largely neglected. We present the first study of an urban transportation system using multiplex network analysis and validated Origin-Destination travel demand, with Riyadh’s planned metro as a case study. We develop methods for analyzing the impact of additional transportation layers on existing dynamics, and show that demand structure plays key quantitative and qualitative roles. There exist fundamental geometrical limits to the metro’s impact on traffic dynamics, and the bulk of environmental accrue at metro speeds only slightly faster than those planned. We develop a simple model for informing the use of additional, “feeder” layers to maximize reductions in global congestion. Our techniques are computationally practical, easily extensible to arbitrary transportation layers with complex transfer logic, and implementable in open-source software. Multiplex network analysis –11 has eA standard summary of such demand is the Origin-Destination (OD) matrix, whose entries give the number of travelers between each possible pairing of origin and destination in the city. Until recently, OD matrices were typically prohibitively difficult to construct. As consequence, many existing system-level models of urban transportation make an a priori assumption on the structure of the OD matrix in the absence of data. Typical assumptions are that the OD matrix is uniformly and randomly generated in one  or both Such analysis contributes two layers of realism when compared to uniform and stochastic OD models. First, system-level indicators such as travel time distributions can be more accurately calculated by incorporating basic facts of urban geometry, especially the prefgerence of commuters to live closer to their workplace than would be predicted by uniform random chance . Second,Our contribution is to use empirical OD demand and the tools of multiplex network analysis in the systems-level study of urban transportation under congested travel. As we show, the incorporation of measured OD demand and congestion effects substantially alters both the quantitative metrics and qualitative behavior of multiplex systems. We focus on two major questions that may arise in planning contexts:How does the introduction of a fully new mode of transportation impact commuting flows at the city level?How can planners prioritize which areas and routes to target for adoption of the metro system, for example by providing “feeder” buses?multiplex module for multiplex transportation analysis with OD matrices.Our case study is the city of Riyadh, where the construction of a brand new metro system currently represents one of the largest urban planning projects in the world. We use data on Riyadh’s road network structure, the planned metro network, and OD demand for morning commutes derived from CDR data provided by a major phone service operator. We conduct all analyses in Python, for which we have developed a In order to focus on methodology in addressing these questions, we simplify the multiplex model by choosing not to model waiting times  or limitte is the free flow time on segment e, je is the flow through e on the current iteration, and ce is the capacity of the segment. A and B are tunable parameters; following standard practice, we set A = 0.15 and B = 4. Since the metro is assumed uncapacitated, travel time on those segments is always assumed to be equal to the free flow speed. We then allowed the next group to choose shortest paths through the network based on these updated edge costs, and continued this process until all groups were assigned.We constructed Origin-Destination (OD) matrices for the network using Call Detail Record (CDR) data representing 2.2 million in an area comprising a population of 5.8 million. To model the network at its most critical time, the OD matrix used corresponds to morning peak commuting flows between 7:30am and 8:30am. To assign routes based on the OD matrix, we performed a version of Iterative Traffic Assignment. We divided commuters into six groups, the first four containing a uniformly-distributed 20% of total flows, and last two containing 10%. We chose this grouping, rather than the traditional , in order to avoid unrealistic crowding around metro stations for high metro speeds. The first group of 20% was allowed to choose shortest paths through the network based on estimated free-flow travel times. Travel times for each segment were then updated in light of congestion according to the standard BPR formulavc/β, where β is a variable parameter and vc = 38km/hr is the mean travel speed on the street layer under congestion in the absence of a metro layer. Lower values of β correspond to faster metros. For example, at β = 0.5, the metro runs at 76km/hr, which is twice the mean speed of the street layer without a metro. Based on technical specifications for Riyadh and previous measurements of operational metro systems [β = 38/47 ≈ 0.8.In order to analyze the dependence of multiplex dynamics on the metro layer, we performed the above assignment for varying metro speeds. Following , we mode systems , we estiTo ensure the realism of our modeled flows, we compared our travel time estimates to those from Google Maps. Using a web crawler, we queried Google Maps for travel times for the top 679,085 OD pairs by flow volume under free flow and congested scenarios. The comparison between the ITA-estimated travel times and those of Google are shown in β. At each level of β, we have measured the empirical speed ratio α between the metro and the streets after routes have been assigned through ITA. While β is a modeling parameter and can be viewed as the (mean) ratio of “posted speed limits,” α is a system measurement and reflects actual speeds experienced due to congestion. The quantity α therefore estimates, on average, how attractive the metro might be to commuters given realistic congestion conditions, with higher values indicating greater adoption appeal.β, the metro is not substantially faster than the congested street layer, and adoption is very low. Our estimated realistic β = 0.8 corresponds to an empirical speed ratio of α = 1.7—the metro travels significantly faster than the congested streets, resulting in significant adoption of the metro layer. As β decreases, the benefits of using the metro increase, and progressively more travelers use the metro for progressively larger portions of their journeys, reducing congestion in most areas. As previously observed, however, congestion is not just reduced but also dispersed: key roads used to access the metro may become more congested than they were before the metro’s introduction [For high oduction .β, we observe the existence of a limiting behavior, in which 58% of total flow occurs on the metro network. Because it persists under further increases in metro speed, the limiting distribution reflects the fundamental geometrical relationship between the metro network and the street network: compared to the street network, the metro network’s spatial reach is limited. The remaining 42% of flow is irreducible by increases in metro speed, and reflects flow due to travel to and from metro stops, or trips for which it would take longer to drive to and from metro stops than it would to drive directly to the destination.For very low α of the metro to the street layer; however, this increase approaches an asymptotic boundary of Jm = 58%. The impact on travel times is more complex. Quantitatively, mean travel times reduce monotonically with metro speed down to a minimum of 43% of their original value. However, the amount of time spent driving rapidly levels off: over 85% of the total reduction in time spent on the road is realized when β = 0.6, which is 33% faster than our estimated realistic β = 0.8. The speed β = 0.6 also marks the speed at which maximum reduction in time spent in congestion is achieved. These two factors are of substantial interest for mitigating the environmental impact of urban transit. This result suggests that metro speeds slightly faster than currently planned could produce positive environmental impact, but that there may be diminishing returns to increasing metro speeds beyond that. Determining the precise rate at which returns diminish would require a more detailed transportation model.Metro speed impacts not only mean travel times, but also their standardized  distribution. This qualitative shift reflects the fact that the fast metro fundamentally alters the geometrical structure of the urban transportation network, closely connecting areas that were previously remote.The introduction of the metro network tends to reduce global congestion, but also disperse congestion to the periphery for sufficiently high speeds. In practice, cities may be able to further reduce congestion by operating “feeder” networks—such as buses—with the goal of making the main network more accessible to residents throughout the city. Implementing such a network may require substantial resources, however, underscoring the need for efficiency. The multiplex model can also shed light on how areas within the city can be prioritized for such service, with an eye toward reducing total congestion.j be vector whose eth component is the flow along edge e under a given assignment of flows. Then, the total time lost to congestion under the assignment j isTc(j) using the gradient of Tc, whose eth component isTc(j) may be interpreted as the steepest descent direction in the unconstrained minimization of Tc(j).Let p be a path (sequence of edges) through ep be the vector whose eth component is 1 iff e ∈ p. Then, the quantityp on the global congestion function Tc. Let Δod = Δp if p is the shortest path between origin o and destination d.To analyze the impact of changes in flow along a route, let od is spatially structured and highly heterogeneous. o—and d. It is clear that there are specific regions that make large contributions to global congestion, such as origins in the residential area in the southwest and destinations in the downtown area in the center-west. Furthermore, this spatial structure persists for all levels of β, though the magnitude of the differences vary.Importantly, the distribution Δod presents an opportunity to efficiently reduce global congestion by prioritizing these high-impact origins and destinations for public transportation access. To model such prioritization, we computed the congestion impact Δod for each route, and then deleted the flow in the OD matrix along the 50,000 routes with the highest values of Δod. The deleted flow accounts for 15% of the total represented in the data. This deletion models perfect adoption of public transportation by these congestion contributors. We then performed ITA to assign the modified travel demand to the road network. As a comparative baseline, we also deleted 15% of flow from the OD matrix at random, and performed ITA. We repeated this procedure at varying metro speeds as measured by β.The persistent, heterogeneous distribution of ΔThe results in od for connecting public transportation service could yield significant benefits for global congestion. Indeed, considering the estimated realistic case β = 0.8, the one minute difference in mean travel time between uniform and targeted strategies reflects 2.2 million person-minutes—or 4 person-years—saved every morning, and again every afternoon. The reduction in time spent specifically spent in congestion reflects 3.5 fewer person-years spent in congestion each day, a substantial boon for controlling environmental impact. We emphasize that these reductions are in addition to the reduced congestion experienced by the 15% of flow routed through public transit, who have been excluded from the analysis but would also benefit from improved traffic conditions.These results indicate that, regardless of the speed of the metro, prioritizing areas with high ΔIt is striking that, even for an arbitrarily fast, uncapacitated metro, mean travel times decrease by just 43%. This is a relatively small drop considering that the metro in the limiting case effectively serves as a teleporter. This phenomenon is due to the spatially-organized, partially-optimal structure of travel demand. A shortest-path-seeking traveler will use the metro system if and only if the metro offers an improvement on driving directly there. In a model with uniform demand, commuters are modeled as choosing home and work locations without any preferences about how long they spend commuting. These models therefore result in a large number of very long trips. The longer a traveler’s commuting time, the more likely that the metro will offer a substantial improvement. In contrast, real commuters generally have a strong preference for a shorter commute. Thus, the average (network) distance between home and work in Riyadh under a uniform demand model is 22.3km, but is barely half that—11.6km—under observed demand. For a realistic commuter, it is therefore substantially less likely that the metro offers a substantial improvement in commuting time, leading to dampened effects. Modeling with observed travel demand thus changes both the quantitative and qualitative multiplex dynamics.β = 0.6, which is only slightly faster than our estimated realistic speed. This corresponds to an adoption level of Jm = 39%, which is just two thirds the adoption rate of a “teleporter” metro with very low β. This finding suggests that extreme levels of adoption may have fewer environmental benefits than might otherwise be expected. While more sophisticated modeling is necessary, it is intriguing that some subways may already be operating at speeds close to optimal for mitigating the impact of commuting traffic on emissions.While increases in metro speed in our model lead to steady decreases in total travel time, the environmental benefits of extreme reduction are limited, as most of the benefit is achieved for metro speeds around We have demonstrated a modeling and planning framework for a simplified urban transportation model consisting only of automobiles and the metro system. These methods are readily generalizable to more complex cases. For example, it would be possible to add layers for walking, buses, or other transportation modes. It is also possible to encode complex transfer logic by controlling the directionality of transfer edges between multiplex layers. While these systems pose more complex questions and therefore invite more complex analysis, the underlying methods and software can remain the same.


Mothers living with small children in Fukushima prefecture may experience radiation anxiety and related symptoms after the Fukushima Dai’ich Nuclear Power Plant Accident. A behavioral activation (BA) program was developed to improve their psychosomatic symptoms. The purpose of this randomized controlled trial was to examine the effectiveness of a BA program for improving psychological distress and physical symptoms among mothers with preschool children in Fukushima-prefecture 3 years after the Fukushima Daiichi Nuclear Power Plant accident.Participants were recruited from mothers living with a preschool child(ren) in Fukushima city and surrounding areas though a newspaper advertisement, posters, and flyers. Participants allocated to the intervention group received a newly developed group-based BA program, which consisted of two 90- min lessons with a 1-week interval. Psychological distress and physical symptoms as a primary outcome, and radiation anxiety and positive well-being (liveliness and life satisfaction) as a secondary outcome, were measured at baseline, 1- and 3-month follow-ups.p = 0.051) and physical symptoms (p = 0.07) at 1-month follow-up, while the effect became smaller at 3-month follow-up. The effect sizes at 1-month were medium to large . There was a significant intervention effect on increasing liveliness at 3-month follow-up (p = 0.02); and there were marginally significant effects on life satisfaction at 1- and 3-month follow-ups (both p = 0.09).Participants were randomly allocated to either an intervention or a control group . The BA program showed a marginally significant intervention effect on psychological distress . Registered 27 May 2014.The UMIN Clinical Trials Registry (UMIN-CTR; ID =  On March 11, 2011, a huge earthquake hit northeast Japan, and the Pacific coast of this region suffered from a tsunami, with 15,882 casualties and 2,668 still missing. The tsunami also hit heavily the Tokyo Electric & Power Company Fukushima Dai-ichi nuclear plant. The plant lost control over regulating its nuclear reactors, which resulted in several explosions of the reactors and a discharge of radioactive substance, which flowed widely to a west-to-northwest direction from the plant. World Health Organization (WHO) and United Nations (UN) reports have estimated a cumulative effective dose in the first year following the accident for adults at 1–10 micro Sv in the sea-side area and other less affected areas of Fukushima prefecture  = 0.60 to 1.15), as compared with control conditions  to 4 [all of the time]) with which respondents reported the degree of psychological distress during the past 30 days. The total score ranges from 0 to 24. The internal reliability and validity found in previous studies are acceptable ), liveliness (1.47 [95 % CI 0.66 to 2.27]) and life satisfaction (1.19 [95 % CI 0.21 to 2.17]) at 3-month follow-up. The effect size was greater among housewives (n = 12 in each group) for life satisfaction (1.05 [95 % CI 0.32 to 1.77]) at 1-month follow-up. The effect sizes were greater among mothers who had university graduates or higher education (n = 10 in the intervention group and n = 5 in the control group) for liveliness (1.14 [95 % CI 0.21 to 2.08]) at 3-month follow-up and life satisfaction (1.56 [95 % CI 0.83 to 2.28]) at 1-month follow-up. The effect sizes were greater among mothers with two or more children for psychological distress (n = 10 in the intervention group and n = 12 in the control group) at 1-month (-1.24 [95 % CI -1.94 to -0.55]) and 3-month (-0.93 [95 % CI -1.73 to -0.14]), and for liveliness (1.12 [95 % CI 0.34 to 1.89]) at 3-month follow-up.There were a few subgroup differences observed in the effect of the BA program: the effect sizes were greater for employed mothers (N = 18) in the intervention group received the two lessons of the group-based BA program. A total of 17 (94.4 %) responded that the behavioral activation program was easy to moderately easy to understand; 17 (94.4 %) reported the program useful; and 18 (100 %) rated their satisfaction with the program as very much or mostly.All of the participants  at 1-month follow-up, with medium to large effect sizes. The BA program showed a significant intervention effect on improving a secondary outcome, liveliness, at 3-month follow-up with a large effect size. This BA program may be effective on improving psychological distress, physical symptoms and psychological well-being among mothers with preschool children after the nuclear power plant accident in Fukushima, even though a further large-scale study is required to confirm the intervention effects.To our knowledge, the present study is the first to examine whether a BA-based program could improve psychological distress and physical symptoms that were affected by radiation anxiety in a non-clinical community population. However, there were only marginally significant effects on psychological distress and physical symptoms at 1-month follow-up. A possible explanation for the lack of effect of the present BA-based intervention could be the low intensity and short duration of the intervention. A previous meta-analysis reported that the median number of clinical sessions with a therapist was eight and the number of sessions was not associated with effect size . HoweverThe present study failed to show significant effects of the BA program on improving radiation anxiety at 1- or 3-month follow-ups. However, radiation anxiety tended to improve at 1-month follow-up to some extent, as also did physical symptoms and psychological distress. A possible process of health anxiety causing hypochondriasis is that excessive anxiety about one’s health leads to believing oneself to be sick, because of misinterpretation of one’s physical symptoms as a signal of a serious health problem . The resIn the present study, liveliness significantly improved at 3-month follow-up; and life satisfaction marginally significantly improved at 1- and 3-month follow-ups. A previous meta-analysis reported that BA interventions significantly improved well-being . The preBased on the subgroup analyses, participating mothers who were employed, highly educated, or had two or more children seemed to enjoy benefits from the present BA program for a longer term . The BA program may remain more effective for employed mothers, since they may have more chance to exercise BA in a wider social network including their workplaces. The BA program may be more effective for mothers with higher education, because of their better understanding the program contents. The BA program may be more effective for mothers with multiple children. They may have more worry and burden in rearing their children under radiation anxiety, and thus feel a greater need to learn the BA program. Unfortunately, due to the small sample size, the present study could not confirm these subgroup differences, that should be fully investigated in future research.Possible limitations of the present study should be considered. A major limitation of this study was the small sample size. The sample size of the present study was too small. Preliminary sample size calculation showed that the necessary sample size was 30 participants per arm, while the present study had hardly two-thirds that number. The present study may have overlooked some effects of the BA program because of the limited statistical power. Second, participants were recruited from Fukushima city and neighboring municipalities, not from the entire aria of Fukushima prefecture. Most participants were housewives, and had a higher education. Participants in the present study may not be representative of mothers with radiation anxiety in the whole Fukushima prefecture. Therefore, the generalizability of the present findings may be somewhat limited. Third, all outcomes in the present study were measured by self-report, which may be affected by the perception of participants or by situational factors. A self-reported measure could be vulnerable to a cognitive bias. If participants answered the questionnaire in a socially desirable manner, the observed association may have been overestimated. Fourth, residence year of participants were not assessed. Fifth, follow-up period in this study was limited to estimate its long-term effect. Sixth, the present study did not examine the cost-effectiveness of the BA program. Seventh, there may be heterogeneity of the effect of the present BA program depending on educational attainment, employment status, and the number of children of participating mothers, which we could not investigated in detail in this study because of the small sample size. A further RCT should be conducted to examine whether the BA program is effective in a larger representative sample of mothers living in the whole Fukushima prefecture with a long-term follow-up.This BA program may be effective for improving psychological distress, physical symptoms, and well-being, at least for a short duration, among mothers with preschool children after the nuclear power plant accident in Fukushima, while a further large-scale study is needed. This program may possibly contribute to improve health and well-being of mothers living in Fukushima, provided by trained public health nurses at each local public health center in Fukushima prefecture.


Monitoring and evaluation of mental health and psychosocial support (MHPSS) programs is critical to facilitating learning and providing accountability to stakeholders. As part of an inter-agency effort to develop recommendations on MHPSS monitoring and evaluation, this scoping review aimed to identify the terminology and focus of monitoring and evaluation frameworks in this field.We collected program documents  and theories of change) from members of the Inter-Agency Standing Committee Reference Group on MHPSS, and systematically searched the peer-reviewed literature across five databases. We included program documents and academic articles that reported on monitoring and evaluation of MHPSS in low- and middle-income countries describing original data. Inclusion and data extraction were conducted in parallel by independent reviewers. Thematic analysis was used to identify common language in the description of practices and the focus of each monitoring and evaluation framework. Logframe outcomes were mapped to MHPSS activity categories.We identified 38 program documents and 89 peer-reviewed articles, describing monitoring and evaluation of a wide range of MHPSS activities. In both program documents and peer-reviewed literature there was a lack of specificity and overlap in language used for goals and outcomes. Well-validated, reliable instruments were reported in the academic literature, but rarely used in monitoring and evaluation practices. We identified six themes in the terminology used to describe goals and outcomes. Logframe outcomes were more commonly mapped to generic program implementation activities (e.g. “capacity building”) and those related to family and community support, while outcomes from academic articles were most frequently mapped to specialized psychological treatments.Inconsistencies between the language used in research and practice and discrepancies in measurement have broader implications for monitoring and evaluation in MHPSS programs in humanitarian settings within low- and middle-income countries. This scoping review of the terminology commonly used to describe monitoring and evaluation practices and their focus within MHPSS programming highlights areas of importance for the development of a more standardized approach to monitoring and evaluation. Humanitarian crises, such as disasters triggered by natural hazards and armed conflicts, are associated with high levels of psychological distress and increased risk for a range of mental disorders –3. In reThe IASC guidelines on MHPSS offer recommendations written by a task force of 27 agencies, including United Nations agencies,  non-governmental organizations, and the International Federation of Red Cross and Red Crescent Societies . After tThe IASC MHPSS guidelines include monitoring and evaluation guidance as part of minimum response in humanitarian settings. Monitoring is defined as “the systematic process of collecting and analysing information to inform humanitarian decision making related to ongoing or potential new activities”, and evaluation is defined as “the evaluation of the relevance and effectiveness of ongoing or completed activities” . By inclgoals (or impacts) refer to the highest-level long-term result of having achieved an overall objective, potentially through a portfolio of projects. Outcomes are the overall changes that can be directly traced to a specific project and that contribute to the overall goal. Indicators are units of measurement used to measure the impact of a goal  or of an outcome . Means of verification are tools used to quantitatively or qualitatively measure indicators [In 2014, the IASC reference group started an initiative to develop recommendations for monitoring and evaluation of MHPSS programs, with an interest in developing a common framework for use across humanitarian agencies. The initiative applied a logical framework approach. Logical frameworks (logframes) are often developed hierarchically, starting with the broad goal and then moving on to specific activities. In a logical framework approach, dicators –11. In pThis article describes a scoping review that was commissioned as part of the IASC reference group’s effort to develop a common framework for monitoring and evaluation of MHPSS programs. Such a common framework may be helpful for several reasons. First, systematic monitoring and evaluation may contribute to bridging the gap between research and practice in the MHPSS field. In practice, the most commonly applied MHPSS interventions are primarily non-specialized and community-based supports. In contrast, the focus of MHPSS intervention research has predominantly been on examining the effectiveness of more specialized interventions for people with symptoms of posttraumatic stress disorder, depression, and anxiety . Use of Second, a common framework for monitoring and evaluation may assist in consolidating learning across humanitarian agencies. Currently, humanitarian agencies use a range of different terms to describe impacts and outcomes of MHPSS activities and apply different indicators to assess progress on these impacts and outcomes. The use of different terminology and indicators inhibits learning across programs with similar objectives implemented by different humanitarian agencies. Over time, the application of a common monitoring and evaluation framework by humanitarian agencies would help to identify which types of program activities were successful in reaching similar MHPSS goals.The purpose of this scoping review was to examine monitoring and evaluation terminology and the focus of MHPSS programs in humanitarian settings in LMIC. We focused on LMIC because the large majority of populations affected by humanitarian crises reside in LMIC  and becaGiven the aim of the scoping review , a range of studies and program documents were included. Scoping reviews often “map” the existing focus within an area of study in order to identify gaps in knowledge, summarize research trends, and describe the scope of an area of study , 15.Logframes and theory of change documents (referred to hereafter as logframes) were collected on a voluntary basis from member agencies of the reference group. In collecting program documents, this study sought to represent MHPSS activities across agencies working within various humanitarian sectors in which MHPSS programming is often embedded . A call was put out to agencies through the IASC reference group’s email list and logframes were sent to the senior author (WT) by email.The search for academic articles was restricted to peer reviewed articles describing monitoring and evaluation of MHPSS programs in humanitarian settings in LMIC. Searches were carried out in EMBASE, PILOTS, PsycInfo, PubMed/MEDLINE, and the WHO regional databases. Databases were searched from their dates of origin to January 11, 2015. We applied search terms under four broad categories across the databases: “low- and middle-income countries” AND “monitoring and evaluation” AND “humanitarian settings” AND “mental health and psychosocial support interventions”. The detailed search strategy for PubMed/Medline can be found in Supplemental Materials. As part of our searches we identified relevant (systematic) reviews. These were hand searched for further identification of relevant documents.All logframes were anonymized, and duplicates were removed for both program documents and studies identified in the peer-reviewed literature. Subsequently, all identified documents were screened for relevance. Logframes and academic articles were screened in parallel by two independent reviewers. Screening of the logframes was comprised of reading of the complete document. Screening of academic articles was comprised of two phases. In the first, study inclusion was based solely on titles and abstracts, and in the second, inclusion was based on the full-texts of articles. If the two reviewers did not agree on the decision to include or exclude an article, a third reviewer was consulted.Logframes and academic articles were included for review if: 1) they contained original data from an MHPSS program; (2) detailed monitoring and evaluation was conducted ; and (3) they focused on study populations exposed to a humanitarian crisis in a LMIC. Academic articles not describing original data , as well as general advocacy papers, letters to the editor, and book reviews were excluded, as were studies describing monitoring and evaluation programs in settings of chronic adversity in the absence of humanitarian crisis. No restriction was placed on the age of the study population. Logframes and academic articles in a language not spoken by a member of our study team were excluded. Our study team was fluent in English, French, Spanish, German, and Dutch. The operational definitions used for the purposes of inclusion and exclusion are described in Table  they conData extraction forms were piloted among reviewers before extraction began. All data were double extracted in parallel by two independent reviewers and discrepancies were resolved by involving a third reviewer. From both logframes and academic articles we extracted the following: (1) descriptions of the program’s overall goal (impact) and outcomes ; (2) terminology used to describe indicators for impacts and outcomes; and (3) means of verification for the indicators.In addition, we extracted information on geographic region; type of humanitarian setting; age range of MHPSS participants; MHPSS activities implemented; and monitoring and evaluation approach. In accordance with UNICEF’s categorizations, geographic regions were categorized as: Central and Eastern Europe and the Commonwealth of Independent States; East Asia and the Pacific; South Asia; Eastern and Southern Africa; Middle East and North Africa; West and Central Africa; and Latin America and the Caribbean. Types of humanitarian settings were grouped as current armed conflict; post-conflict; refugee settings; disasters triggered by natural hazards; and disasters triggered by technological hazards. The recipients of MHPSS interventions were classified as children and adolescents (below 18 years), adults (18 years and older), or a mixture of both. The intervention name or a short description was extracted to describe the MHPSS activities reported in the academic articles. Monitoring and evaluation approach was classified as quantitative, qualitative, or both quantitative and qualitative.The primary objective of the study was not to review program results themselves, but to review the terminology used in describing programmatic approaches to monitoring and evaluation and the primary focus of monitoring and evaluation practices. A quality appraisal assessment was therefore not conducted.Data analysis involved both inductive (or “bottom-up”) and deductive (or “top-down”) approaches. The “bottom-up” analysis employed thematic analysis to (1) identify common trends in the language used to describe goals (impacts), outcomes, indicators, and means of verification; and (2) to examine common themes in content across goals (impacts), outcomes, and their indicators. Once grouped, the language used for goals, outcomes, indicators, and means of verification was compared across all content areas. Common themes and subsequent codes were then iteratively developed across each logframe component. First, we read all of the documents to gain an understanding of overall content. Second, we conducted an analytic reading of the data, in which we annotated descriptions of goals, outcomes, and their indicators. Third, we re-read the descriptions of goals, outcomes, and their indicators and looked for repetition within outcomes and indicators. In the third step we developed a code book. Fourth, we labeled all outcomes and indicators using codes from the code book. Analysis involved describing, comparing, and categorizing the coded data in order to conceptualize themes within outcomes and indicators.A deductive (i.e. “top-down”) analysis process was carried out using the 4 W’s  tool in order to map the focus of the outcomes in our sample of monitoring and evaluation frameworks . The 4 WReview consultations were carried out with a subset of members of the reference group at various stages throughout the review process. The first consultation occurred in June 2014 and was focused on preliminary analysis of goals and outcomes that had been extracted during the first phase of the review. Based on this consultation, it was decided that indicators and means of verification should be extracted, and that the review should be updated in a subsequent phase. As a result, the review and analyses were updated in May 2015 and a second consultation was held in November 2015. Analyses were again updated in December 2016 in preparation for publication.The flow diagram in Fig. to effectively meet the needs of people affected by the crisis” and “to respond to the most urgent needs of men, women, boys, or girls affected by the crisis”. Impact indicators were reported in a third of logframes, were identified in less than 5% of academic articles, and were similarly difficult to differentiate from outcome indicators, particularly among the academic articles. For example, impact and outcome indicators extracted from the same academic article were “Significant improvements of well-being at the individual and population levels” and “Status of psychosocial well-being as measured through the psychosocial assessment instrument”, respectively.The majority of academic articles described an evaluation of a specific intervention program as opposed to program monitoring. Within this context and the expected framework of an academic article, authors of academic articles frequently described the goal of their study, but not the goal of the overall program of which the specific intervention may have been a part. Moreover, the language describing program goals  and outcomes (the specific objective(s) that the project aims to achieve) was often similar within an article, which made it difficult to differentiate between pieces of information pertaining to these two levels of the logical framework. Surprisingly, the latter finding was also common among logframes. While information was intentionally categorized by program designers at goal and outcome levels within the logframes, the actual language used was frequently comparable. For example, one program goal and a corresponding outcome were “promote”, “support”, “reduce”, and “alleviate”, many did not describe a final desired state. For example, one outcome was “to prevent and reduce mental health problems due to war conditions”. While measurable quantities or qualities were included in the majority of logframe indicators, on occasion, indicators were described without reference to measurable quantities or qualities. For example, one logframe indicator was “Interaction and empathic connection to others”. The majority of indicators across documents did not make any reference to a time frame during which the specified change would occur.Across study documents, outcomes were frequently related to program expectations in general, but were less detailed regarding the direction of change. Among outcomes that included language pertaining to the direction of change, such as to “Both logframes and academic articles described quantitative and qualitative means of verification. The means of verification for quantitative indicators described in program documents differed from those used in academic articles. In reference to quantitative indicators, logframes frequently reported generic, non-standardized means of verification such as photos, updates, reports, assessments, work plans, questionnaires, or health facility records. Some logframes did report specific, standard means of verification for quantitative indicators, such as a “7-item resilience scale” and the Camberwell Assessment of Needs Appraisal Schedule . Academito enhance community structures”, “improved empowerment”, “to increase hope”, and “the number of prevention programs implemented”, respectively.Through thematic analysis, we identified six distinct themes in terminology used to describe goals, outcomes, and their indicators across logframes and academic articles. The first theme encapsulated programs seeking to promote individual resilience and psychosocial well-being, and prevent mental health and psychosocial problems. This theme emerged more often among logframes than among academic articles. Programs with goals and outcomes focusing on the first theme intended to support or enhance individual-level resilience most commonly by providing community-level supports. Examples of the language used for goals, impact indicators, outcomes, and outcome indicators for this theme included “to improve mental health symptoms and functioning through care”, “decreased prevalence of MHPSS problems”, “to reduce symptoms and distress”, and “percent reduction in symptoms”, respectively.The second theme described programs seeking to reduce particular mental health and psychosocial symptoms and functional impairment. This was a more dominant theme among academic articles. Examples of the language used to describe goals, impact indicators, outcomes, and outcome indicators for the second theme were “to build capacity for mental health services” and “MHPSS knowledge dissemination between stakeholders”. Examples of the language used for outcomes and outcome indicators included “to promote sustainability through training of trainers” and “number of trained MHPSS providers”, respectively.The third theme applied to programs that primarily aimed to build capacity to identify, intervene on, and monitor mental health and psychosocial problems. This theme often applied to both logframes (e.g. through integration of services) and to academic articles (e.g. through training). Examples of terminology used for goals and impact indicators included “to provide an environment where individuals are able to grow and thrive” and “for people with mental health problems to be included in the community”. The language used for impact indicators included “involvement of parents, teachers, and communities in children’s education” and “community awareness of MHPSS problems”. Examples of terminology used for outcomes and outcome indicators included “to promote child development through parental support” and “children’s cognitive improvement”, respectively.The fourth theme described programs that focused centrally on enhancing environments in which child development can flourish. Although related, this theme was differentiated from the second theme as it applied to programs that specifically attempted to support or enhance community-level systems (e.g. community resilience) rather than individual resilience, and focused on children and adolescents. The fourth theme included definitions of child development within social, economic, and physical health domains, and more commonly emerged from logframes. Examples of the terminology used for goals for the fourth theme included “to address underlying structural inequalities” and “to enable a participatory and human rights respecting democratic restoration of the social fabric”. “Change in policy” was an example of the terminology used for an impact indicator. Outcome-level language included “to support peaceful co-existence between and within communities” and “to foster collective trauma healing as part of peacebuilding”. An example of the language used for an outcome indicator was “improvement in social fabric”.The fifth theme applied to programs describing macro-level goals and outcomes, for example to build peace between groups in post-conflict settings, and to address structural problems within societies. This theme emerged less frequently from the data as compared to the other themes and was primarily described in logframes. Examples of the language used in goals for the fifth theme included “to protect vulnerable groups” and “number of families successfully re-unified”. Examples of the language used in outcomes and outcome indicators included “to reduce the risk of interpersonal violence including sexual and gender-based violence” and “percent of sexual and gender-based violence survivors who access safe spaces”.The sixth theme described programs that sought to protect vulnerable groups of people, such as women, children, the elderly, and people with disabilities. This theme almost exclusively emerged from logframe data. The terminology used for goals and impact indicators for the sixth theme included “general activities to support MHPSS” (60%) and “strengthening community and family supports” (39%). The largest proportion of the 159 outcomes described in academic articles were mapped to the “psychological intervention” activity code (45%).In addition to the inductive thematic analysis, we were interested in mapping the focus of outcomes in logframes and academic articles to common MHPSS activities. We identified 85 distinct outcomes in the logframes and 159 outcomes in academic articles. These were mapped onto the activities of the IASC 4Ws tool. The proportions of outcomes mapped to each of the 11 4 W’s activity codes  are showMonitoring and evaluation is critical to the evolution of MHPSS in humanitarian settings. The development of indicators for monitoring and evaluation in MHPSS was ranked as the top fourth most important research priority in a recent consensus-based setting of a research agenda . The curIn combining both programmatic and research documents, and by including academic articles from a range of databases, we believe this scoping review provides broader insight into the terminology used in monitoring and evaluation frameworks and the focus of these frameworks within the MHPSS field. Despite these strengths, this review has several limitations. Program documents were drawn from within the IASC reference group and only represent a small proportion of all MHPSS program documents that exist, introducing selection bias as those agencies more confident in their programming may have been more likely to respond, may have only submitted logframes of the highest quality, and may have submitted more than one logframe. Our review of published academic literature may also have resulted in selection bias since published studies may have been more likely to use a more restricted range of means of verification or those quantitative means of verification with particular psychometric properties compared to studies that were not published in peer reviewed journals. In addition, the search of the academic literature used English keywords and only articles written in five languages were included for review. Database searches were also limited to the fields of medicine, psychology, social work, public health, and nursing. All data was extracted to fit within a logical framework format, however our results should be interpreted with an understanding that academic articles are not typically written to fit such a format. No comprehensive search of the grey literature was performed as part of this scoping review, representing an important limitation. In order to gain rapid insight into monitoring and evaluation in practice, organizations were asked directly for logframes and these logframes represent only a small portion of the grey literature.In the remainder of this section we discuss the key findings of the scoping review and their implications for MHPSS monitoring and evaluation practice. First, we noted a lack of specificity in how goals and outcomes were phrased. A strong overlap in goals and outcomes, or a lack of differentiation between these two levels, may suggest challenges in conceptualizing a common overall goal for MHPSS practitioners. According to logical frameworks, the goal is intended to be a high-level achievement that is not necessarily attained by one program, but by a portfolio of programs. Each outcome is defined as an achievement set for a specific program. Within the field of project management, the inconsistent use of terminology in logframes has been one of the chief criticisms of this approach –23. In tSecond, we noted a lack of specificity in language used to describe outcomes and indicators. The IASC guidelines suggest that indicators should be SMART  and that for feasibility, only a few indicators should be selected for each program . In contThird, we draw attention to the finding that psychometrically tested instruments were frequently described in the peer-reviewed literature as means of verification, but that these were not commonly applied in the program documents. Among programs assessing quantitative indicators, problems that may stem from using non-validated instruments for quantitative indicators in monitoring and evaluation have been previously noted , pointinFourth, we note that our “bottom-up” analysis yielded broadly similar themes across content of both program documents and academic articles. While very few academic articles described monitoring and evaluation of programs pertaining to the theme of (child) protection and human rights, there were many program documents to which this theme applied. Several logframes described programs aimed toward peace-building, which was less commonly described in academic articles. As previously discussed as a limitation, this observation may reflect the content of the five databases we selected for our searches. At the same time, it may also reflect less emphasis in these fields on publishing monitoring and evaluation efforts in peer-reviewed journals, and for instance, a stronger focus on activism and implementation, or an emphasis on types of monitoring and evaluation techniques that may not be easy to publish in peer-reviewed journals . Regardless of the cause of this discrepancy, consensus on the importance of MHPSS activities across a broad range of sectors, including (child) protection, suggests that it will be important for efforts in developing a common monitoring and evaluation framework to understand and allow for different program activities and methodological preferences.general activities to support MHPSS” and “strengthening community and family supports”. This finding is not surprising given that indicators listed in the Sphere Handbook section on mental health service provision focus on activities such as training, staffing, and medication availability [psychological intervention” activity code. A recent review of the academic literature on public health interventions in humanitarian settings found that the majority of MHPSS publications focused on psychological interventions and that studies on psychosocial interventions offered weaker evidence and were of lower quality [Fifth, we carried out a mapping exercise where outcomes from logframes and peer-reviewed articles were mapped to the IASC’s 4Ws activity codes , 27 in alability . In cont quality . These f quality , 28. Tak quality .The purpose of this scoping review was to explore the language used to describe MHPSS program level goals, impact indicators, outcomes, outcome indicators, and means of verification as reported in logframes, theories of change, and published articles. We also sought to examine the focus of program goals, outcomes and indicators, and to investigate how outcomes from this sample of logframes and academic articles could be mapped to general categories of MHPSS activities. We identified conceptual gaps between research and practice ranging from ambiguous language used when describing program goals and outcomes to heterogeneity in measurement and instrument quality, and found six common themes across goals, outcomes, and indicators. The results of the “top-down” analysis highlight continued differences in the areas of focus in practice and in research. These conclusions may help inform the development of monitoring and evaluation frameworks for MHPSS in humanitarian settings.


The overarching purpose of this study is to examine the current trends in interprofessional education (IPE) within graduate medical education in the Unites States.A survey was sent to program directors across with different specialties between March and April 2016. The survey was completed by 233 out of 1757 program directors, which represents a response rate of 13.3%.IPE is currently being used by over 60% of the GME program directors that completed the survey. The median number of IPE hours is 60. Classroom learning (70.8%) and team-based approaches (70.1%) to patient care are the two most common forms of IPE. The two most prevalent reasons for implementing IPE are improving collaboration (92.2%) and communication (87%). More than half of the program directors agreed or strongly agreed that lack of time both for teachers (54.4) and for residents (51.5%) are barriers to IPE. About one third of the respondents whose programs do not include IPE are interested in implementing some IPE in the future.IPE in its varying formats has been implemented as a training model by many residency programs. Further studies are needed to explore the comparative effectiveness of the different modalities of IPE.The online version of this article (doi:10.1186/s12909-017-1104-z) contains supplementary material, which is available to authorized users. Interprofessional education (IPE) in health care is defined as the placement of learners from different health disciplines into an environment where they pursue shared educational goals, learning with one another, from one another, and about each other . IPE aimMedical errors are the third-leading cause of death in the United States , which mSince graduate medical education (GME) represents the pipeline for training future physicians, it is not surprising that incorporating IPE into GME has gained increasing interest. IPE in the GME setting often combines residents with members of other health care disciplines, including, but not limited to, the following: residents and faculty members who have other specialties, nurses and nursing students, psychologists and psychology interns, pharmacists, social workers, homecare providers, hospice care providers, clinical lab workers, and medical administrators –10. IPE While the literature supports the increased interest in IPE as a model of training for healthcare providers in general, little is known about the trend within GME specifically. Describing the current prevalence and modes of IPE will help direct and prioritize the limited resources and provide groundwork for further research on IPE in the GME setting to understand links between such training, on the one hand, and both learning and healthcare outcomes, on the other. Furthermore, understanding the common barriers to implementing IPE may inform efforts to mitigate these challenges. Finally, exploring the current beliefs among the directors of programs that do not have IPE will help identify ways of encouraging further implementation of IPE in the GME setting.This study was conducted with the overarching aim of examining the current trends of IPE within GME in the Unites States across several specialties. The study’s specific objectives are threefold: 1) To identify the prevalence and format of, the participants in, and the barriers to IPE; 2) to examine the goals and assessments of IPE experiences; and 3) to explore potential IPE models for programs that do not currently use IPE.This survey study was part of an omnibus survey sent to all the program directors in the following specialties: family medicine, internal medicine, pediatrics, psychiatry, obstetrics and gynecology, emergency medicine, and surgery. After reviewing the literature, we developed a questionnaire, and then we sought feedback from IPE experts at Indiana University. The Indiana University Institutional Review Board reviewed and approved the questionnaire. The survey questions are provided in Additional file We used the American Medical Association (AMA) database to identify program directors and obtain their email addresses. We identified 1757 directors and checked 1479 (84.2%) of their email addresses, using program websites to link directly to the program directors’ email addresses. The rest of the email addresses  were either generic program or coordinator email addresses. The IPE component of the survey was completed by 233 program directors, which represents a response rate of 13.3%.To analyze the results, we calculated descriptive statistics of frequencies and percentages. In addition, we used tables and graphs to present the results.The characteristics of the program directors and their residencies are included in Table Classroom learning and team-based approaches to patient care came first and second, respectively, among the forms of IPE and were mentioned in association with 102 (70.8%) and 101 (70.1%) programs. Simulations were used by 69 (47.9%) programs. Web-based learning was used by only 14 (9.7%) programs. Figure The top five reasons for engaging in IPE were: “to improve collaboration” (92.2%), 2) “to improve communication” (87%), 3) “to improve patient safety” (82.6%), 4) “to improve health care quality” (79.1%), and 5) “to improve attitudes towards teamwork” (71.3%). The most commonly assessed outcomes were: “skills for working on an interdisciplinary team” (53.9%) followed by “satisfaction with the learning experience” (49.6%), “attitude towards interdisciplinary teamwork” (44.4%), “content-specific knowledge” (32.2%), and “attitudes towards specific content” (33.9%). Outcomes were not assessed in 23.5% of the programs that had IPE.Among the programs that did not have IPE, 28 (32.94%) reported interest in implementing IPE. The duration of the experiences mentioned varied widely as well, with a median of 5 h. The contemplated experiences reported were single learning sessions for 38.46% and longitudinal sessions for 61.54% of the respondents. Nursing learners (nurses and nursing students) were again the most common group with whom IPE was contemplated (71.4%), followed by pharmacy learners (50%), residents from other disciplines (35.7%), nutrition and dietetics learners (25%), and physician assistant learners (21.4%).The top five reasons for wanting to engage in IPE were: “to improve collaboration” (85.7%), 2) “to improve communication” (78.6%), 3) “to improve patient safety” (75.0%), 4) “to improve attitudes towards teamwork” (75.0%), and 5) “to improve patient care efficiency” (46.4%). All the program directors (100%) indicated that some outcomes of IPE learning would be assessed. The outcomes that respondents wanted to assess were: “skills for working in an interdisciplinary team” (71.4%), “attitudes towards interdisciplinary teamwork” (71.4%), “attitudes towards specific content” (53.6%), “satisfaction with the learning experience” (53.6%), and “knowledge about other disciplines” (53.6%).To our knowledge, this is the first systematic exploration of medical residents’ experiences in IPE. Current IPE is reported by over half of the program directors who responded to our survey across GME specialties. This finding is encouraging, as IPE can have positive impacts on patient outcomes, adherence rates, patients’ satisfaction, clinical process outcomes, and collaborative behavior .IPE was not implemented equally across the specialties of the respondents to this survey. Emergency medicine and family medicine were the two specialties that most clearly incorporated IPE into their curricula. Over 70% of respondents from these two specialties reported ongoing IPE. This may indicate that these two specialties disproportionately value collaboration and good quality communication with other disciplines. This would not be surprising, given the high degree of interaction with other medical professionals that these two specialties experience daily.Classroom learning was the most commonly reported method of IPE. This points to a potential area for improvement in IPE because classroom learning may not be the ideal means to learn active skills such as collaboration, teamwork, and communication . DidactiTeam-based care and simulations do, however, allow for this type of active engagement and practice. Although the literature is rich in examples of IPE simulation, our study showed that simulation is only the third most common form of IPE. This finding may highlight the gap between IPE research findings and current IPE practices and reveals the need for further work in the area of IPE implementation.There were few differences in characteristics, goals, and measured outcomes between the programs that had implemented IPE and the programs considering it. It appears as though those interested in IPE have practical and feasible ideas for how to incorporate IPE into their programs. These programs may simply need support in overcoming barriers to the implementation of IPE.The most significant barriers reported by the program directors responding to this survey are: time, resources, and buy-in, which matches previous studies on barriers to IPE , 15. OneThere is a slight discrepancy in measuring IPE outcomes. While 23.5% of the responding GME program directors that currently implement IPE stated that they did not measure IPE outcomes, 100% of the responding program directors interested in implementing IPE stated that they would measure outcomes. This may be because it is more difficult to measure IPE outcomes in practice than directors anticipate. Without outcome data, program directors implementing IPE would have a difficult time assessing their IPE effectiveness. Future research should focus on how to most efficiently measure IPE outcomes.This study has its limitations. The response rate was less than 14% and therefore, our results should be seen as preliminary and should be generalized only with caution. It is possible that program directors who were more positively inclined towards IPE were more likely to respond to the survey, leading to an overestimate of the amount of ongoing IPE within GME programs. In addition, the quality of the responses depended upon the program directors’ knowledge of what occurs within their own programs. Some program directors likely overestimated how much IPE their residents receive and in what format, whereas others likely underestimated this. Overall, given that this is the first survey of its kind, the authors believe that these results at least begin to shed the light on important issues with IPE within GME.Future research should examine how programs have addressed the barriers to IPE. A qualitative study interviewing program directors could study programs as they implement IPE to understand how such barriers are overcome. The findings of future research could be shared with GME programs interested in implementing IPE to begin a dialogue and create opportunities for implementing IPE.IPE in its varying formats has been implemented as a training model by many residency programs. Further studies are needed to explore the comparative effectiveness of different IPE models and ways of overcoming common barriers to implementing IPE within the GME arena.


The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers. Faced with a vast shortage in physicians and nurses , task-shWhile there is a growing body of evidence on the effectiveness of CHWs in providing care for a variety of disease groups in developing countries –12, the To help address this gap in the literature and to inform the design of possible future interventions and program reforms in Swaziland, we carried out a qualitative study  mentors, HIV expert clients, and a community outreach team for HIV (henceforth referred to as “community counselors”). The basic characteristics of each program are outlined in Table We conducted semi-structured, face-to-face qualitative interviews with CHWs and CHW program managers resulting in 69 interviews in total Table —54 interWe interviewed all program managers of the four CHW programs. For the expert client, M2M, and community counselor program, we selected a purposive sample of CHWs for interview in each program to include females and males, a variety of ages, and CHWs working in urban as well as rural areas. For the RHM program, a stratified simple random sample of RHMs was selected whereby the strata were sex, 10-year age groups, and rural versus urban location of the RHM’s work area. Twenty-five RHMs, 5 expert clients, 13 M2Ms, and 11 community counselors were selected for interviews. We sampled a higher number of participants from the RHM cadre than for other cadres because the program was by far the largest CHW program in this study. We, therefore, expected a greater heterogeneity in the views on performance among the RHM cadre than among the other cadres. None of the selected CHWs refused to participate. The interviews took place at CHWs’ homes except for those with the community counselors, who were interviewed in the CHW program office. None of the potential participants who were approached for an interview refused to take part in the study. No remuneration was provided to participants. Participation in the study consisted of an informed written consent procedure and a semi-structured qualitative interview, which was 30–45 min in length on average. All interviews were conducted in a private space .Interviews were conducted between June 2, 2015, and August 19, 2015, by a team of 14 interviewers. The interviewers were graduate and undergraduate students in social science programs at the University of Swaziland. All interviewers were trained in qualitative data collection and fluent in siSwati. Interviews were conducted in siSwati, taped, transcribed, and then translated into English prior to analysis. To improve reliability between interviewers, an interview guide was developed and used in the interviews. However, interviewers were trained and encouraged to tailor the questions, and ask additional questions, based on the participant’s answers.We employed conventional content analysis . Thus, r“I do not feel I am being paid a fair amount because there is a lot of work that we do. Sometimes the families desert the ill patients and leave them in their own dirt until the day a RHM comes along and bathes the patient, feeds them, etc. So the work is quite a lot.” (RHM)“… and also they may need increased income. I feel the money is not enough for the job they do.” (M2M program manager)With the exception of the community counselors (the most highly paid cadre), CHWs and managers from all CHW programs generally felt that the monthly salary was insufficient for the amount of work CHWs were expected to accomplish:“I personally spent a rough sum of 50 Emalangeni on transport fees from home to the facility on a return trip, and when I move from my homestead to the community I have to pay for transport in a way that I use roughly 400 [Emalangeni] from home to work every month plus the money I pay from home to the bank.” (M2M mentor)“… but there are instances where your conscience tells you that if I do not leave this 10 Emalangeni that I have so that the client can at least have money for bread or to buy candles, there is absolutely no other place, from which they will get the money. So, in the spirit of humanity in terrible situations, I do find myself offering financial assistance to the clients.” (Community counselor)A consistent suggestion by CHWs and CHW program managers to increase their motivation was, therefore, an increase in compensation:“Money is the most special thing to everyone. It can really stimulate me to work harder. If they can increase the stipend, it can motivate me.” (Expert Client)Despite the large differences in their remuneration, CHWs of all cadres, including the community counselors, felt that increased pay would improve their performance.In fact, several CHWs mentioned that, given their low salary, they consider themselves to be volunteers rather than paid employees. Of note, when asked about their salary, many CHWs expressed concern that they face work-related expenses, which substantially reduce their net income. Examples of these expenses were the provision of transport money to a sick client to go to hospital and costs to receive their salary :“For me, what would make me work harder are the resources that we need when helping people like disposables and drugs. If the workers were given this to take with them when doing door-to-door visits, things would be much easier” (Expert client).“I can comment on the issue of supplies, they are very few and they limit the RHMs to work freely” (RHM program manager).“You then find that even the shoes we use are easily worn out as we travel a long distance and we are then unable to replace them because the salary is very low. We are really in need of uniforms. We have only one shirt and one skirt. You are then expected to wash your uniform in the evening when you come from work so that you can use it the following day. So, basically, these are the things that demotivate us when doing our work.” (M2M mentor)With the exception of the community counselor program, CHWs and program managers felt that a more reliable provision of equipment would improve CHWs’ motivation and the quality of their services. Interviewees felt that these additional resources were both needed for patient care and actively demanded by patients. Frequently mentioned items were disposable gloves, diapers, medications, and bandages. Some CHWs, particularly M2M mentors, also expressed that the insufficient provision and replacement of personal equipment, especially uniforms, shoes, and the lack of an umbrella or hat to protect from the sun and rain, discouraged them. The following quotes illustrate these points:“Sometimes you find that someone starts ART and suddenly stops taking treatment. I then ask myself if I performed the counseling well … or if I have done the job well but the client decided on her own not to continue taking treatment. It would be great if we could have refresher courses on the courses we have been trained on, so that the knowledge can be at our immediate disposal.” (Expert client)“As our services are expanding, I would like my knowledge to expand as well. For example, we now conduct CD4 counts. I would like to gain knowledge in that area and learn how to use the PIMA machine. I also feel the training on TB is very light. I would like extensive training on it.” (Community counselor)“There are other trainings that we need to get but that are not offered, such as psychosocial support. We need to be trained on how to see a person who is being abused, and we need to know where to refer such people since we are working in the community.” (M2M mentor)While CHWs’ views on the quality of their training, and whether it has adequately prepared them for their tasks, differed between both individual CHWs and CHW cadres, most CHWs expressed a wish for additional training and thought that this would significantly improve their performance. The desired training generally fell into the following categories: (i) training to deepen knowledge and skills in areas that had already been covered by previous trainings , (ii) training on new developments related to their work , and (iii) training to appropriately manage patients who do not fall into the CHWs’ standard tasks . The last category of training was mentioned less by RHMs as compared to other CHW cadres. Below we provide illustrative quotes for each of the three categories of training outlined above:“For me it is not entirely about the money. I have this passion to see the whole Swazi nation healthy at all times. Money is not my main drive.” (M2M mentor)“It inspires me very much when I see RHMs changing their behaviors, and take the teachings and encouragements that we offer them and apply them to themselves first before going to the public. For example, most of them know their HIV status.” (RHM program manager)Understandably, therefore, and related to the third category of training desired by CHWs outlined above, many CHWs expressed frustration about instances when they were not able to meet the community’s needs. Examples included not being able to answer a community member’s health-related question and being unable to manage patients who fell outside of their area of training. This frustration was most frequently expressed by the community counselor cadre, which exclusively focused on HIV, and less frequently by RHMs. CHWs who expressed this frustration generally felt that an expansion of the services that they were allowed to provide, along with the provision of additional training and equipment to competently deliver these services, would increase their motivation.“We face some cases that when people see a nurse, they want to tell you all that they are having problems with, only to find that some of the services we don’t provide.” (Community counselor)“What would stimulate me to work harder is expansion of the project, which would mean provision of more services to the community … like, as I mentioned earlier, I would like for us to be the ones to provide the treatment to our clients and TB screening. Basically, it would be providing more services.” (Community counselor)Both CHWs and program managers felt that helping and contributing to their community through their work was a great source of job satisfaction and motivation for them. In fact, this was mentioned as the main reason for continuing their work in the CHW program despite the low monetary compensation, as illustrated by the following quote:Analyzing the data from the semi-structured qualitative interviews with the 54 CHWs and 15 CHW program managers, we found that CHWs and program managers viewed the following four factors as needing improvement to increase CHW performance: (i) higher monetary compensation, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) extending CHW responsibilities to allow them to attend to a wider variety of healthcare needs. Despite the heterogeneity in how CHW programs were structured, including CHWs’ responsibilities and the program’s implementing organization, these views were generally held across all four cadres and across both CHWs and program managers. A notable exception was that community counselors tended to be more satisfied with their payment and the provision of equipment and consumables for their work than other CHW cadres. In addition, community counselors expressed a desire for an expansion of their responsibilities more frequently than other CHWs. These differences may reflect the fact that the community counselor program differed in several important respects from the other programs: community counselors were more highly paid, required to have a higher level of education, provided a narrower set of services than other cadres , and did not deliver services through household visits (but instead at community events and gatherings).Financial incentives, equipment and consumables, and training have all been recognized in existing conceptual frameworks for CHW program design as key factors influencing CHW performance , 16–18. A factor, which has been given little attention in frameworks for CHW program design, but which was frequently mentioned by our sample of CHWs as being a barrier to improved performance, was the degree to which the CHWs’ tasks meet the community’s healthcare needs (as perceived by the CHW). More specifically, many CHWs in our sample felt that broadening their tasks and training to meet a wider array of the community’s healthcare needs would positively affect their motivation and performance. CHWs related this to their drive to want to help their community, a finding that is in line with many other studies, which found that wanting to help one’s community was one of the primary reasons why CHWs take on, and maintain, their role –43. SimiThe degree to which CHWs feel their responsibilities meet their community’s healthcare needs, and the resulting impact on their motivation and performance, has thus far not been a central consideration in policy debates or research studies , 17, 45.Interestingly, our sample of CHWs and program managers infrequently mentioned a number of factors that are considered key aspects for CHW programs in conceptual frameworks on CHW program design , 16, 17.perceived to be related to their performance (but not which factors indeed influenced CHW performance). Second, although CHWs were assured that the information they provided would not be shared with their superiors, this may nonetheless have been a concern for participants and could have biased their responses. Third, as this research did not aim to interview a sample of CHWs and program managers that is representative for all CHW programs in Swaziland or programs in other countries, generalization of our findings beyond the four sampled CHW programs is limited.An important advantage of our study is that we were able to interview a large number of individuals covering all CHW delivery models in the country. Nevertheless, this study has several limitations. First, given the qualitative nature of this study, we were merely able to identify factors that CWHs and CHW program managers In our sample of interviewees, we found that CHWs and program managers perceived that each of the following changes to their program would likely lead to an improvement in CHW performance: (i) an increase in CHWs’ monetary compensation, (ii) a more reliable supply of clinical and personal equipment to CHWs, (iii) additional training, and (iv) an extension of CHWs’ responsibilities to cover a wider range of the community’s healthcare needs. In contrast, changes to (i) the programs’ supervision structure, (ii) opportunities for career progression, and (iii) CHWs’ relationship with the community—all factors thought important in conceptual frameworks on CHW performance , 16, 17—


The mainshock, which was not preceded by any significant foreshocks, occurred 98 days after the initial production of oil in Eocene strata at depths reaching 3 km, within ~1 km of the White Wolf fault (WWF). Based on this spatial and temporal proximity, we explore a potential causal relationship between the earthquake and oil production. While production would have normally be expected to have reduced pore pressure, inhibiting failure on the WWF, we present an analytical model based on industry stratigraphic data and best estimates of parameters whereby an impermeable splay fault adjacent to the main WWF could plausibly have blocked direct pore pressure effects, allowing the poroelastic stress change associated with production to destabilize the WWF, promoting initial failure. This proof-of-concept model can also account for the 98-day delay between the onset of production and the earthquake. While the earthquake clearly released stored tectonic stress, any initial perturbation on or near a major fault system can trigger a larger rupture. Our proposed mechanism provides an explanation for why significant earthquakes are not commonly induced by production in proximity to major faults.Several recent studies have presented evidence that significant induced earthquakes occurred in a number of oil-producing regions during the early and mid-twentieth century related to either production or wastewater injection. We consider whether the 21 July 1952 MThe online version of this article (doi:10.1007/s10950-017-9685-x) contains supplementary material, which is available to authorized users. The hazard associated with induced earthquakes has come to the fore in recent years with the rise in seismic activity, including events with magnitudes upwards of 4, in areas where there has been an increase in subsurface fluid injection and production operations, including both hydraulic fracturing  within a grid of Townships and Ranges. The sections of interest for this study are within Township 11 N, Range 20 W. Cross sections generated from surface and subsurface data revealed the asymmetry of the Wheeler Ridge anticline, leading to deep drilling along the south limb of the anticline in the late 1930s  of approximately 3 km, at a distance of ≈1 km from the WWF. The preferred mainshock epicenter is within ≈5 km of this well, and inferred surface rupture is within ≈2 km of the well. The 23 Feb. 1939 M4.6 earthquake , at time-variable distance L(t) from the fault  hypocentral depth of the 1952 Kern County earthquake are considerable, our review of available industry records demonstrates that there was a temporal and spatial association between deep production in the Wheeler Ridge oil field and the 1952 Kern County earthquake. The earthquake occurred 98 days after the start of production from Eocene strata at a depth of approximately 3 km; while hypocentral depth of the earthquake is unconstrained , the epicenters estimated by past published studies are within 2 to at most 7 km of the well. We have moreover proposed a mechanism based on simple analytical solutions with geologic structure and key reservoir parameters estimated from available industry data, that provides a plausible explanation for a causative relationship between industrial activities and the earthquake. While no such modeling exercise can be conclusive, and other triggering scenarios could be explored (for example involving nucleation on the Wheeler Ridge fault), our results demonstrate that production from deep Eocene strata could have caused sufficient stress change to perturb the nearby WWF significantly within ≈80 days of the start of production if, as we propose, an intervening secondary fault functioned as a hydrologic barrier. A delay on the order of 3 months would not be unprecedented: In a retrospective study of earthquakes in Oklahoma, Hough and Page  concludew4.6 . Drilling records are available from http://www.conservation.ca.gov/dog/Pages/wellfinder.aspx.Monthly “California Oil Fields: Summary of Operations” published by the State Oil and Gas Supervisor are available from (https://www.wunderground.com/history/airport/KBFL/2009/5/10/DailyHistory.html (last accessed 11 July 2017). The global earthquake catalog is available from https://earthquake.usgs.gov/earthquakes/search/ (last accessed 12 July 2017).Historical weather reports for the town of Bakersfield, California (approximately 40 km north of Wheeler Ridge), are available from ESM 1(DOCX 498 KB).