Extensive research demonstrated that firms may pursue several advantages in hiring individuals with the set of emotional, social, and cognitive (ESC) competencies that are most critical for business success. Therefore, the role of education for competency development is becoming paramount. Prior studies have questioned the traditional methods, grounded in the lecture format, as a way to effectively develop ESC competencies. Alternatively, they propose experiential learning techniques that involve participants in dedicated courses or activities. Despite the insights provided by these studies, they do not take into account a comprehensive set of learning methods and their combined effect on the individual's competency portfolio within educational programs that aim to transfer primarily professional skills. Our study aims to fill these gaps by investigating the impact of the interplay between different learning methods on ESC competencies through a sample of students enrolled in the first year of a master's degree program. After providing a classification of three learning methods , the study delves into their combined influence on ESC competencies, adopting the Artificial Neural Network. Contrary to prior studies, our results provide counterintuitive evidence, suggesting that TL needs to be implemented together, on the one hand, with IEL to achieve a significant effect on emotional competencies and, on the other hand, with SEL to have an impact on social competencies. Moreover, IEL plays a prominent role in stimulating cognitive competencies. Our research contributes to educational literature by providing new insights on the effective combination of learning methods that can be adopted into programs that transfer technical knowledge and skills to promote behavioral competencies. Research has broadly acknowledged that behavioral competencies, namely emotional, social and cognitive (ESCs) competencies, account for a substantial and important amount of the variance in predicting job performance, career success, and personal wellbeing . After providing a classification of different learning methods , we investigated their combined influence on ESC competencies development.This paper is organized as follows. In the following section, we provide a literature review on competency development, formulating the research hypotheses on the combined effect of different learning modes on ESC competencies. Next, in the methods section, we illustrate the setting and the method adopted in this study, namely artificial neural networks. Afterwards, we present the results of the empirical analysis, and, in the final section, we discuss the implications and avenues of future research.A behavioral competency is defined as “the underlying characteristics of a person that lead to or cause effective and outstanding performance” : These refer to those teaching methodologies  that present a high-level theory of the field to the students. Individuals are then expected to solve problems by applying the theory to a specific context.- Individual Experiential Learning methods (IEL): These refer to methodologies  in which individuals are able to experiment and progressively discover knowledge and apply skills in a domain by trial and error.- Social Experiential Learning methods (SEL): These refer to methodologies  in which individuals acquire knowledge and skills by interacting with others and sharing their experiences.Drawing on management education literature  displays of emotional skills by others, such as striving to improve or meeting a standard of excellence, acting on opportunities congruently with one's values, or adapting plans, behaviors, or approaches to fit major changes. Therefore, we expect that:Hypothesis 1. The more individuals are involved in IEL and TL the more they possess emotional competencies.Experiential learning that offers opportunities for social interactions, such as in-class group discussions, group project works, role playings, and participation in online forums allow students to practice “real-life” situations that require them to become aware of the emotions of others and handle them. As maintained by Landau and Meirovich : 92 in tHypothesis 2. The more individuals are involved in SEL and TL the more they possess social competencies.Pattern recognition is the capability of recognizing patterns or trends in random information, events, or situations. It is an extremely important capability that allows individuals to learn from the past and to identify commonalities or similarities among various and often very different situations. On the other hand, systems thinking is the ability to identify the many and various factors that affect a complex situation or event and recognize both the causes and effects of actions and outcomes. This competency allows individuals to explain interactions among factors using, for instance, diagrams, flow charts, or detailed but simple discourses  repeatedly demonstrate to differentiate effective job performance across different professional roles  and social (SEL) learning methods individuals have the opportunity to acquire new knowledge and distill their observations and reflections into more general concepts and principles. Thus, they are more likely to add elements to their knowledge structures and build new connections between knowledge elements, facilitating the recognition of patterns. Furthermore, individual and social assignments, such as project work presentations and discussions or laboratory activities, may spur individuals to approach information processing and analysis as well as the explanation of phenomena through the identification of the various factors that affect situations or events. We also maintain that TL may stimulate cognitive competencies through the absorption of information from an expert (the instructor or invited lecturer). Listening and interacting with an expert may not only provide knowledge acquisition about a specific topic but may also favor new associations and similarities among concepts learned in prior learning experiences and the understanding of cause and effect relationships that explain events and situations. Therefore, we expect that:Hypothesis 3. The more individuals are involved in IEL, SEL, and TL the more they possess cognitive competenciesWe carried out the empirical research in a public university located in northern Italy that has approximately 20,000 students enrolled in four broad scientific and cultural areas: economics, foreign languages and literatures, humanities and sciences. The sample of students involved all those enrolled in the first year of five different master's degree courses in the academic year 2011–2012 . These programs were chosen because of their variety and because of the presence of non-conventional teaching methodologies .We set up a self-evaluation questionnaire to be filled in by each of the analyzed students at the end of the first semester of the first year of their master's degree program. The questionnaire, administrated online, was made up of two sections. In the first one we collected data on the level of possession of students' ESC competencies, asking students to rate themselves on a five-point scale, according to the Emotional Competence Inventory–University version (ECI-U). In the second section of the questionnaire, we gathered information on the learning methods students had been involved with during the academic courses they had attended in the first semester of the academic year and on a set of variables that could have influenced the student's competency portfolio. The questionnaire was tuned by applying a pilot test to a small sample of students not involved in the large-scale analysis. The population of students enrolled in these five courses was made up of 240 students, 45% of whom completed our questionnaire. All students gave explicit consent to participate in the research. All the authors are subject to the Ethical Code of their affiliating Institution (Ca' Foscari University of Venice), and all protocols governing the use of human subjects were followed. The research protocol was approved by the Scientific Committee of the Ca' Foscari Competency Centre, under which this research has been conducted.SD = 1.08) and the non-respondents were 25.33 years old on average (SD = 3.85). As regards the different master's programs in which the students were enrolled, the majority of the respondents belonged to the business administration (39.81%) and to the management of arts and cultural activities courses (31.48%), followed by global development and entrepreneurship (12.96%), international relations (1.11%), and computer science (4.63%). Considering the non-respondents, 37.12% were enrolled in management of arts and cultural activities, 24.24% in business administration, 20.45% in international relations, 9.85% in global development and entrepreneurship, and 8.33% in computer science. We also considered in which university the students pursued their bachelor's degree, and the 52.78% of the respondents attended it in the same University they were enrolled for the master's course (49.24% for non-respondents) whereas 47.22% came from a different University (50.76% for non-respondents). As far as the performance of the students, we took into account the evaluations obtained at the bachelor degree and high school levels. As regard the grade obtained at the end of the bachelor's degree program, the two groups of students showed very similar grades . Finally, the respondents achieved on average 83.56 out of 100 (SD = 11.62) as high school final grade, whereas non-respondents showed a slightly lower evaluation .To avoid the biases due to the selection process of respondents, we tested if the sample of respondents was statistically representative of the whole population of students enrolled in the five courses under analysis by considering some personal variables such as gender, age, type of course, the University in which they pursued their bachelor's studies, and evaluations obtained at the bachelor's degree and at high school level. Concerning the gender, the sample is composed by 24.07% of males and the remaining 75.93% of females, whereas the non-respondents are 34.85% males and 65.15% females. The respondents were 24.15 years old on average ; type of course  and previous University ; and we used the t-test and the Kolmogorov-Smirnov test for age , the evaluations obtained at bachelor's degree level  and the evaluations obtained in high school . These results show that there are no significant differences between the sample of respondents and the non-respondents, except for the age and the type of course they followed, which was slightly biased toward the students enrolled in the course in business administration. We restricted the original sample of 108 respondents to a sample of 95 students since we excluded part-time students and full-time students who did not attend, either partially or totally, the academic courses during the period under investigation from the subsequent analysis. This is because in our analysis we considered the relationship between ESC competencies and the didactic methodologies adopted in the course, and, consequently, the inclusion of students who did not experience the learning approaches under investigation could have biased our analysis.We used the chi-square test of independence to determine whether the type of respondents (students included in the sample and non-respondents) is related to gender  to 5 . The ECI-U is a proprietary instrument and a detailed description is reported in the Emotional competencies were measured with the 10 following competencies: Emotional Awareness, Accurate Self-Assessment, Self-Confidence, Optimism, Emotional Self-Control, Trustworthiness, Conscientiousness, Adaptability, Achievement Orientation, and Initiative (α = 0.86). Social competencies were measured with the 12 following competencies: Empathy, Organizational Awareness, Service Orientation, Cultural Awareness, Developing Others, Inspirational Leadership, Building Bonds, Influence, Conflict Management, Teamwork, Communication, and Change Catalyst (α = 0.94). Cognitive competencies included the final two competencies of Systems Thinking and Pattern Recognition (α = 0.78).n = 51) who obtained a complete external evaluation. All external raters (n = 85) gave explicit consent to participate in the research. Most of them were friends (34%), followed by parents (17.6%), siblings (16.5%), and partners (16.5%); only 11% of the external raters were fellow university students, 3.3% were other relatives, and only 1.1% were co-workers or bosses. We carried out the internal consistency reliability test on the self-ratings of the total sample of students (n = 95) as well as on the external ratings  aggregated by student and their corresponding students' self-ratings (n = 51). The results are presented in Table t-test—the self-ratings expressed by the students with the external evaluations  expressed about them, showing a high level of overlap between these two perspectives.To overcome the limits of the self-evaluation test, we compared the competency assessment of the students with the evaluation provided by their external raters. At the end of the students' questionnaire, we asked each respondent to provide the names and e-mail addresses of three external raters to carry out a multi-rater assessment on students' ESC competencies and to gather a honest and open evaluation based on the ECI-U framework. Prior studies involved external raters to make it possible to compare the self-perception with a third-party evaluation and, consequently, strengthen the assessment process. As an example, some studies used peer evaluation conducted among the course participants or among friends or family members ; four IEL techniques: data collection, presentation and discussion of individual project work, individual laboratorial activities outside class, and e-learning and testing laboratories (coefficient of reproducibility 0.921); and 11 SEL activities: reading, analysis, and discussion of articles and cases in groups in class; elaboration of group project works; discussion of group project works; group exercises during lesson; role playings; group laboratory activities outside class; business games; participation in seminars/conferences/festivals/exhibitions as a speaker; participation in seminars/conferences/festivals/ exhibitions as an organizer; e-learning chat discussion groups; and e-learning forums (coefficient of reproducibility = 0.925). For each student we computed the value of the Guttman scale for the three learning methods in terms of the number of techniques a student was involved in and the maximum number of techniques considered by each learning method.Our study is not longitudinal and for this reason we did not consider the dimension of competency development through the analysis of differences in participants' levels of behavioral competencies at the beginning and at the end of the training period. Therefore, to understand if the participants' learning activities really impacted their possession of ESC competencies, we included control variables that might have influenced students' level of behavioral competencies at the beginning of our study period. Indeed, prior studies suggest that demographic characteristics, such as gender and age, may affect the possession of ESC competencies Byron, . Since sCompetencies can be shaped by virtue of an individual's interaction with the environment and the experience he or she accumulates during the lifespan  show an impact on the behavioral competencies that tend to be related to self-awareness and self-management , and even if the combination of TL and IEL methods produces great improvement, the role of IEL methods appears to be more relevant than that of TL methods. In contrast, using methods that require interaction, SEL presents no effect on the competencies related to self-awareness and self-management. On the other side, a development of competencies related to understanding and managing others  may be obtained by using methods that require interactions with other participants (that is the most common way) and also by using TL methods (that is a less expected solution). This may be due to the fact that TL methods in any case imply some kind of interaction—even if limited—with a teacher or part of the class; participating in a a study visit or an interactive seminar are some examples of situations where competencies like Communication, Influence, and Organizational Awareness may be experimented with and trained. The results are even different for cognitive competencies, where IEL methods show high impact, whereby SEL and TL play a role in stimulating these types of competencies only if IEL is at its highest level. This can be ascribed to the fact that in our framework we included the only two cognitive competencies (systems thinking and pattern recognition) that prior research has demonstrated to distinguish between best and average performers, and that are specifically related to effectiveness in work and academic settings . Specifically, we introduced a distinction between individual and social learning within the general category of experiential methods. Our results demonstrated the importance of this distinction since the two learning approaches present different effects on the participants' competency portfolio. Finally, one additional contribution is about the adoption of the artificial neural network as a methodological approach that enabled us to unravel the combined effect of the three learning methods on each behavioral competency .These findings also offer some implications in terms of higher education and management development. At the institutional level the necessary changes of the academic educational programs are invoked, as demonstrated, for instance, by the initiatives that aim to implement a whole-person or student-centered learning approach within the higher educational programs  may have an impact not only on the acquisition of professional knowledge and skills but also on the development of behavioral competencies.Second, instructor's awareness concerning the importance of ESC competencies and how to stimulate their acquisition within existing course needs to be translated into explicit learning objectives to avoid the “hidden curriculum” in which the concepts of ESC competencies are not never fully explained in class, but are implicitly transferred through the application of a learning technique such as group exercises (Bedwell et al., Finally, since behavioral competencies are more complex and difficult to teach than disciplinary subjects, pursuing their development in educational programs can face obstacles. Implementing different learning approaches is time consuming and personally demanding for instructors that need to combine their traditional roles as experts with the new role of learning facilitators that gives more space for participants' reflection and interaction. Therefore, instructors may require different attitudes and mindsets to confidently blend traditional and experiential learning approaches into their courses.Beyond suggesting these substantive changes in the academic curriculum, our research also offers implications in terms of competency development at the organizational level. When firms invest in training activities with the aim to develop the competency profile of future leaders, they should select the educational programs by considering the impact of the different learning methods adopted. Companies may analyze their specific needs, defining the emotional, social, or cognitive competencies that need to be improved in their employees. Consequently, the training programs and the related teaching methods will be selected accordingly.This study also presents some limitations, which may constitute opportunities for further research. First of all, future studies can include the analysis of pre and post-test differences in the research design to evaluate the level of behavioral competencies at the beginning and at the end of the training period. Another limitation is that this study is not longitudinal and, for this reason, does not consider the dimension of competency development that occurred during the entire duration of the master's degree programs, focusing only on the relationship between the learning activities in which participants were involved during a semester and the level of possession of behavioral competencies at the end of this period. However, in our study we considered some variables—gender and prior experience—as possible factors that might have influenced the level of ESC competencies of the participants and we did not find any significant effect of these controls on the level of possession of behavioral competencies. The results of this analysis support the relevance of learning methods and their interplay as they influence competency development. In addition, the courses included in our study are part of the curriculum of master's degree programs that are all innovative in some respects, both in terms of contents and didactic methods used. During their 2-year program, the participants attend courses that have adopted similar learning approaches. A further promising line of research should consider differences in attained competency by investigating innovative courses that already blend traditional and experiential learning approaches and courses that continue to rely on traditional in-class lectures as the main teaching method. This study could also be complemented by a performance analysis conducted after participants' entry into the labor market. In this regard, future research should hypothesize that the learning methods and the subsequent competency would pay off in terms of better job placement and career progression. Furthermore, research should take into account the factors related to the learning climate, like instructor's style, classroom composition and size, which may influence the participants' motivation and effort in the didactic activities proposed as well as the extra didactic experiences that the academic institution can provide to the students. Other individual variables could be of interest as potential predictors of differential improvement in ESC competencies; for instance, some personality types may respond more favorably to the experiential learning approach than others.In conclusion, this research has contributed to the ongoing debate on the role of higher education to equip graduates and executives with the competencies required by the labor market to increase the level of productivity and innovation in the workplace. It would be valuable to explore how ESC competencies development can be integrated with existing courses and how the combined effect of traditional and experiential methods can maximize learning outcomes.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Voluntary medical male circumcision (VMMC) has been shown to be an effective prevention strategy against HIV infection in males –3. Since Voluntary medical male circumcision (VMMC) has been shown to be effective in preventing acquisition of HIV-1 infection. Three randomized controlled trial (RCT) studies in South Africa, Kenya, and Uganda demonstrated that male circumcision reduces female-to-male HIV transmission by approximately 60 percent . In 2007Significant progress has been made toward achieving the initial “catch up” targets of scaling up VMMC among sexually active adult males . Thus, sThis paper uses Zimbabwe as a case study to explore the epidemiological impact and cost implications of introducing EIMC in an existing adolescent/adult VMMC program for the maintenance phase, compared with a program that sustains adult MC coverage by circumcising adolescents. This analysis should provide decision makers and VMMC program managers in priority countries with much needed information on how they might address and manage issues of sustainability.IRB clearance was not required for this study, because patient records were not collected or reviewed.The Decision Makers Program Planning Tool, Version 2.0 (DMPPT 2.0) is described in detail in a separate manuscript in this collection . BrieflyA national DMPPT 2.0 model was created for Zimbabwe, and populated with population, mortality, and HIV incidence and prevalence projections from an external source. For the Zimbabwe country application, the authors used Spectrum/AIM (AIDS Impact Model), which projects population size, mortality, and HIV prevalence and incidence based on data empirically collected from the country. The 2013 national DMPPT 2.0 model was populated from the validated national Spectrum/AIM file obtained from the Joint United Nations Programme on HIV/AIDS (UNAIDS). Population by age and year, mortality by age and year, annual number of male births, and HIV incidence by age and year were exported from this Spectrum/AIM file into a national Zimbabwe DMPPT 2.0 file.The Zimbabwe Ministry of Health and Child Care (MOHCC) provided the numbers of VMMCs conducted in the country each year from the beginning of the VMMC program in 2009 through December 2014, disaggregated by client age. The prevalence of male circumcision by age group in the model base year (2014) was derived from the Zimbabwe Demographic and Health Survey 2010–11 [To examine the effect of client age on the impact of scaling up VMMC, we created a series of scenarios in which MC coverage was scaled up from baseline levels to 80% for infants (zero to sixty days old) and for each five-year age group between ages 10 and 39, while all other age groups were maintained at the same level as the baseline for each scenario see  below.Each scenario scaled up MC coverage between 2015 and 2019, inclusive, by applying a linear interpolation to the baseline MC prevalence for each age group in 2014 and the target coverage by the end of 2019. After 2019, the coverage for each age group was maintained at the target level. For each age group scenario, we recorded HIV incidence in each year of the model. We then divided this annual HIV incidence by the annual HIV incidence in the reference case in which VMMC was not scaled up over baseline levels for any age group; this was called the HIV incidence ratio. Please note that the same reference case  is used in all subsequent analyses, as well.To compare the impact, cost, and cost-effectiveness of adolescent VMMC, EIMC, or a mixed strategy as sustainability strategies, we created three scenarios  and projIf Zimbabwe decided to scale up EIMC, we wanted to look at the potential effects of introducing EIMC in the national VMMC program over different time frames, so that decision makers could assess these options for impact, cost, and cost-effectiveness. Thus we compared four scenarios that initiated EIMC and scaled it up at different rates. In the first scenario, EIMC is introduced immediately. Coverage levels for infants, adolescents, and adults are simultaneously scaled up to 80% over five years, and then maintained at that level into the future  at which neonatal and adolescent circumcision have the same cost per lifetime HIV infection averted, we used a different analytical approach, separate from DMPPT2.0 but with the same data sources. We created a simple cohort model in which equal numbers of infants and 15-year-olds are circumcised at the same time in 2015. The total HIV infections averted for each cohort, compared to the reference scenario in which MC prevalence remains at baseline levels for each age group, is calculated as follows: for each year in each cohort’s lifetime (until and including age 85), the model adds the age-specific HIV incidence from 2015, multiplied by the effectiveness of VMMC (60%), reduced by the age-specific mortality, and discounted by 3% annually. The initial population size of the EIMC cohort is reduced by the baseline MC prevalence among adolescents, to account for the fact that when infants are circumcised through the EIMC program, those boys are preempted from being circumcised as adolescents. In other words, EIMC is replacing the baseline circumcisions that would have happened when the boys grew older, so the replacement circumcisions do not count toward the HIV infections averted. The relative unit cost at which the cost per HIV infection averted by EIMC is the same as that for adolescent VMMC is given by the cumulative discounted HIV infections averted for the EIMC cohort divided by the cumulative discounted HIV infections averted for the adolescent cohort. For a range of discount rates, investigators calculated how much lower EIMC unit costs would need to be compared to adolescent VMMC unit costs in order to have the same cost per lifetime HIV infection averted.In A mixed strategy is presented in The costs and cost drivers of adolescent and adult VMMC are well understood, but currently there is little empirical data on the unit costs of EIMC in sub-Saharan Africa, and there is a lack of any data directly comparing the cost of EIMC with adolescent and adult VMMC. Only when EIMC is scaled up broadly will a better understanding of costs be possible. Therefore, the investigators conducted a sensitivity analysis with different assumptions of the relative EIMC cost compared with the cost of adolescent/adult VMMC. The previous scenarios modeled what VMMC scale-up and maintenance would look like if adolescent, adult, and early infant male circumcision were scaled up at the same time. Some countries, however, are considering either delaying the start of EIMC or taking a longer time to scale up. This paper provides important modeling of the potential cost and impact of introducing EIMC in existing national VMMC programs. The research was conducted using data from applications of the DMPPT 2.0 model in multiple countries, but focused specifically on Zimbabwe as a case study. The modeling explores scenarios countries may pursue for the long-term maintenance of the VMMC program: MC coverage may be maintained in the long term by circumcising adolescents or infants or a combination of the two. These scenarios affect the overall cost and cost-effectiveness of the program, but they do not substantially affect the impact on new HIV infections, because both infants and adolescents are circumcised before reaching sexual maturity. The cost and cost-effectiveness of introducing EIMC in a VMMC program are functions of the relative cost of EIMC compared to that of VMMC, the baseline levels of circumcision among adolescents, and the discount rate applied.The study has some limitations. The general limitations of the DMPPT 2.0 model are discussed in the methods paper in this collection  and alsoThis analysis has important implications for sustainability of VMMC programs once the initial coverage target has been met. The findings presented here suggest that consideration should be given to the cost of EIMC compared to that of adolescent and adult MC. The modeling data show that introducing EIMC in an existing VMMC program, while increasing the overall number of MCs required, does not necessarily increase overall cost. If the unit cost of EIMC is 50% or less of the cost of adolescent and adult VMMC, there is actually a cost savings and the cost per HIV infection averted is lower. However, as the cost of EIMC increases relative to that of adolescent and adult VMMC, the cost savings erodes, and the introduction of EIMC can actually increase the overall cost and decrease the cost-effectiveness of the program. If the unit cost were equal, the total cost of EIMC as well as the cost per infection averted would be about 20%–25% more than a program consisting entirely of adolescent and adult VMMC.This study’s modeling of the introduction of EIMC in existing national VMMC programs indicated that the timing (whether immediate or delayed) and the intensity of scale-up (over five or ten years) had only a marginal impact on the number of infections averted, on the cumulative cost of the program, and on the number of VMMCs required to avert a single HIV infection. This is good news for countries that are delaying EIMC because of the serious challenge its introduction might pose while they are at the same time trying to reach coverage targets for adults and adolescents.Furthermore, for countries with lower baseline MC prevalence, such as Zimbabwe, the cost at which EIMC is equally as cost-effective as adolescent VMMC is relatively high. Conversely, for countries such as Tanzania and South Africa, where MC prevalence is much higher, the cost of EIMC must be lower for its lifetime cost-effectiveness to be equal to that of adolescent VMMC. Thus, the cost point at which there is equilibrium between the lifetime cost-effectiveness of EIMC and adolescent VMMC is dependent upon the discount rate used and the country’s baseline MC prevalence among adolescents.However, the cost savings and impact of expanding EIMC is likely underestimated, because our analysis does not account for the full extent of the benefits of infant male circumcision, such as the prevention or reduction of urinary tract infections , sexually transmitted infections, phimosis, paraphimosis, and other medical conditions that could be prevented through MC at an earlier life stage. Integrating the provision of EIMC within existing maternal and child health services in resource-limited settings is likely to be easier and more acceptable to the government and ministry of health than maintaining parallel, vertical adult and adolescent VMMC programs, because EIMC can be combined with existing routine postnatal or vaccination services. Additionally, a vertical model requires dedicated staff redirected from the health delivery system to conduct MCs, whereas EIMC at the primary healthcare level could be delivered by current personnel who could continue to provide maternal and child health services alongside EIMC.Zimbabwe is currently completely dependent on external funding for its vertical adult and adolescent VMMC program. If external funding ceases, the Government will likely not be able to sustain a vertical adolescent VMMC program at the current costs, even if the number of adolescents aging into the 10–14 year age group to be circumcised is much lower than the number currently being circumcised in the scale-up phase. The government health providers will then have to look for less costly, more fully integrated models to sustain VMMC efforts, while improving existing health systems for maternal and child health.In addition, the model does not account for broader social, cultural, and logistical barriers to EIMC acceptability and implementation. However, acceptance of EIMC will likely rise as greater numbers of procedures are performed and adult and adolescent VMMC continues to be scaled up. With increased uptake, the unit costs of EIMC are likely to decrease further. Demand creation efforts and costs are important to consider to ensure efficient use of EIMC services and achievement of lower unit costs, owing to economies of scale. When selecting a strategy to sustain national VMMC programs, countries will need to consider the modeling and analysis in this paper in the context of other factors that may influence the course of decision making.In conclusion, the analyses presented here provide some factors for countries to consider when determining whether to base their long-term VMMC programs on EIMC, adolescent VMMC, or some combination of the two. Differences in epidemiological impact in terms of HIV infections averted are negligible between the different strategies. The relative total cost and cost-effectiveness of the different strategies are largely dependent on the relative cost of EIMC compared with that of adolescent VMMC, so more research is needed in terms of collecting comparable costs for sustainable models of EIMC and adolescent VMMC implementation. Cost and cost-effectiveness, while important, must be considered alongside other factors, such as acceptability of either approach to parents and health providers, health systems impacts of different implementation models, and feasibility concerns.


Body stalk anomaly is a rare and severe malformation syndrome in which the exact pathophysiology and trigger factors are still unknown. This is a case of a 30-year-old patient who underwent ultrasound at 9 weeks of gestation. It revealed an abnormal location of the inferior body of the embryo in the coelomic space. The findings suggested a short umbilical cord syndrome. In order to confirm the diagnosis, the patient was scheduled for a second ultrasonography at 11 weeks of gestation. The obtained images, confirmed the location of the inferior body in the coelomic space with no visible bladder, absence of the right leg, severe abdominal wall defect, consistent with an omphalocele, and a short 5 mm umbilical cord. These last ultrasonographic findings were consistent with body stalk anomaly. Because of severe malformation incompatible with life, the patient was offered termination of pregnancy. Pathologic examination confirmed the suspected pathology of body stalk anomaly. Body stalk anomaly is a severe defect of the abdominal wall in which there is evisceration of abdominal organs and in more severe cases of thoracic organs as well. This congenital malformation is accompanied by severe kyphoscoliosis and the presence of a rudimentary umbilical cord which is usually short or even absent . LikewisWhen it comes to pathogenesis, different theories have been proposed to explain the possible mechanism by which this anomaly is triggered. The actual mechanism, however, still remains unclear. In most of the described cases, the karyotypes of the affected fetuses have been completely normal, and only in two cases there have been chromosomal abnormalities associated with uniparental disomy of chromosome 16  and withWe report a case of a 30-year-old German woman who was first seen by the maternal-fetal medicine service for her first prenatal visit at 5 weeks of gestation at the Hospital Universitario Santa Fe de Bogota. This was her first gestation, and she had a history of recurrent urinary tract infections that required intravenous antibiotics. She was receiving a folic acid supplement and progesterone, and there was not any other relevant past medical or surgical. Her initial prenatal labs were within the normal limits.At 9 weeks of gestation, she had her first ultrasound examination which revealed a normal fetal crown-rump length of 2, 13 cm and an abnormal location of the inferior body of the embryo, in the coelomic space . These fBecause the malformation was considered to be incompatible with life, patient was offered to undergo voluntary termination of pregnancy. The embryo was sent to pathology after PG-induction. The embryo showed gross morphologic characteristics as follows: normal conformation of head with normal upper limbs, absence of the right leg, left leg bent toward the chest, and a severe omphalocele containing the bowels and liver.The placenta had a measurement of 5 × 4 cm. Fetal umbilical cord was identified anteriorly, with central insertion and a short length of 2 cm and 0.3 cm diameter, wrapped by amniotic membranes that trapped the fetus. The fetus was immature and malformed. Head, part of the trunk, upper extremities, and left lower extremity were recognized. The face was symmetrical and the nose was flattened and lowered. The upper lip was not recognized, the lower jaw was maintained, and eyes had hypotelorism. The external ear structures were rudimentary and with low implantation. The trunk had scoliosis. There was a defect of the anterior and lower abdominal wall, with exposure of the intestine, liver, and spleen. The left leg was folded into the trunk. The upper extremities were normal. Findings were compatible with limb-body-wall complex . The micBody stalk anomaly is a term used to describe a pattern of severe defects that in most of the reported cases proves to be incompatible with life. As described above, this condition should be suspected when a large abdominal defect is observed as well as abnormalities in the axial skeleton such as kyphosis or scoliosis, and a short or absent umbilical cord is present . Body stAn appropriate midsagittal view of the fetus for the measurement of the crown-rump length, together with the measurement of the nuchal translucency and adequate sweeps through the head and abdomen, should identify all the cases of body stalk anomaly between 11 and 13 weeks of gestation . Before In our case report, we did not observe any significant risk factor associated with the environmental exposure to teratogens. However, in some case series, it has been reported that 50% of women with fetuses affected by body stalk anomaly smoke cigarettes or drink alcohol and 30% of them smoked marijuana .Three major theories have been proposed to explain the origin of the main phenotypic features that are found in body stalk anomaly. The first and most accepted theory is an early rupture of the amnion before there is an obliteration of the coelom. Another theory proposed by Steeter et al. suggests an abnormal folding of the trilaminar disc in its cephalic, caudal, and lateral directions that might lead to the persistence of the coelomic cavity . FinallyBody stalk anomaly is a malformation syndrome in which the exact pathophysiology and trigger factors are still unknown. Much remains to be elucidated in terms of its real epidemiology, global distribution, and risk factors. Additionally efforts should focus on making an early diagnosis in order to avoid complications for the mother during the pregnancy and/or childbirth. Although most of the reported cases in the literature suggest that an early diagnosis can be made between 10 and 14 weeks of gestation, in our case the diagnosis was suspected earlier, at nine weeks of pregnancy. This turns out to be beneficial for both the expecting parents and the physician, as it enables a prompt knowledge of the fetus condition that permits giving an appropriate counseling and a timely management.


Social media platforms are increasingly being used to support individuals in behavior change attempts, including smoking cessation. Examining the interactions of participants in health-related social media groups can help inform our understanding of how these groups can best be leveraged to facilitate behavior change.The aim of this study was to analyze patterns of participation, self-reported smoking cessation length, and interactions within the National Cancer Institutes’ Facebook community for smoking cessation support.Our sample consisted of approximately 4243 individuals who interacted  on the public Smokefree Women Facebook page during the time of data collection. In Phase 1, social network visualizations and centrality measures were used to evaluate network structure and engagement. In Phase 2, an inductive, thematic qualitative content analysis was conducted with a subsample of 500 individuals, and correlational analysis was used to determine how participant engagement was associated with self-reported session length.P=.03, N=243). The content analysis of 1698 posts from 500 randomly selected participants identified the most frequent interactions in the community as providing support  and announcing number of days smoke free .Between February 2013 and March 2014, there were 875 posts and 4088 comments from approximately 4243 participants. Social network visualizations revealed the moderator’s role in keeping the community together and distributing the most active participants. Correlation analyses suggest that engagement in the network was significantly inversely associated with cessation status (Spearman correlation coefficient = −0.14, These findings highlight the importance of the moderator for network engagement and provide helpful insights into the patterns and types of interactions participants are engaging in. This study adds knowledge of how the social network of a smoking cessation community behaves within the confines of a Facebook group. Although the prevalence of smoking has been steadily declining, an estimated 42.1 million adults in the United States still currently smoke cigarettes [The Smokefree.gov program evolved from a single website to a suite of resources and supporting platforms as technology and literature for Web-based health interventions has advanced. There has been an emphasis on providing personalized resources for specific subgroups of smokers, and this analysis focuses on the Smokefree Women Facebook page, a resource developed specifically for women. Approximately 15% of women in the United States smoke , and femSystematic reviews of the literature on Web-based social networks for health indicate the need for further use and evaluation of tools such as Facebook for health-related information dissemination, surveillance, observation, prediction, and behavior change -7. MaherExisting research using social network analysis uncovers phenomena that may contribute to the efficacy of interventions. For example, in a controlled social network experiment, it was found that social reinforcement signals facilitated by clustering of social ties improved individual behavior adoption—adoption in this study being the act of registering for an Internet-based health forum . Beyond To our knowledge, few if any studies have performed social network analysis within Facebook groups. Given the nature of the platform, network behavior in a Facebook group is inherently confounded by the Facebook algorithm . In otheLaunched in 2009, the Smokefree Women Facebook group saw improved growth and engagement after a significant strategy shift documented by Post et al . The strThe goal of this study was to analyze patterns of participation, self-reported smoking cessation length, and interactions within the Smokefree Women Facebook group. In addition to visualizing the network structure, this study sought to analyze user content for potential themes and explore correlates of self-reported cessation length with placement within the network. The study combined quantitative and qualitative methods to answer the following exploratory research questions: (1) What are the characteristics of the network structure? and (2) How do people interact in the social networking site?The Smokefree Women Facebook page is an open-access smoking cessation community. Built as an extension of the NCIs’ Web-assisted tobacco cessation intervention, Smokefree.gov, the Smokefree Women Facebook page was specifically created for the purpose of helping individuals achieve sustained abstinence from smoking. On the Smokefree Women Facebook page, participants communicate and interact with one another and the moderator by likes, comments, comment likes, and shares  of the network do not have a direction and only indicate that 2 individuals have interacted. Moreover, the network was treated as unweighted (unless otherwise noted), meaning that an edge can represent 1 interaction with a person or 10 interactions with the same person. This unweighted approach focuses on interpretation of the breadth of interactions between people in the network, as opposed to depth of interactions between any 2 people.The network was visualized with the Smokefree Women Facebook moderator, both included and excluded. Therefore, when the moderator was not present, the visualization represented participant-to-participant interactions specifically. Moreover, there is a magnification of the network without the presence of the moderator and highlighted centrality with a blue-to-red increasing color scale, where blue nodes are the least central, and red nodes are the most central.A force-directed layout algorithm was used to position the nodes in the network for the visualizations. Specifically, Fruchterman-Reingold’s  algorithAll statistical analyses were conducted with the open-source computing tool, Python version 2.7.5, specifically using SciPy, package version 0.12.0 for plotting and positioning of the force-directed algorithm and NetWorx version 1.7 package for centrality calculations.Automated text analysis was used to see if a difference existed in topics discussed by participants who are highly engaged and those who are not highly engaged in the network. To identify hubs in the network  and characterize the content they contribute compared with other participants in the network, ordered centrality values were plotted, and a threshold for determining the 2 groups  was chosen to be near the elbow of this curve by visual inspection. To conduct automated analysis of content posted by participants, all participants in the network were divided into 2 groups, split according to the threshold. Subsequently, the top 30 terms preferentially used by those in each group were identified.To determine the propensity of a term to be used by one group versus the other, a ratio of smoothed relative frequencies was used. Although the moderator was included in the network for calculating the centrality scores, the moderator was excluded from the text analysis to focus on the language that participants use themselves.In Phase II of this study, mixed methods were used to further explore participant interactions on the site. For a randomly sampled subset of the population, qualitative content analysis was used to identify salient themes being discussed and self-reported cessation length. Furthermore, correlational analysis was conducted to determine how participant engagement, as measured by centrality, was associated with self-reported cessation length.A random sequence generator was used to identify a uniform random sample of 500 participants who interacted on the Smokefree Women Facebook page during the study period. Participants included in this subsample are also included in Phase I of the study. However, in Phase II of the study, qualitative content analysis is conducted to gather more detailed information about information shared by these participants. The sample size of 500 participants was chosen because the size of the dataset was feasible for manual coding, yet likely robust enough to provide a representation of participants in the network.Applied thematic analysis was conducted using an inductive methodology described by Guest et al . ResearcCorrelation between self-reported cessation length and the centrality of participants to the network was analyzed to determine the relationship between Facebook interactions and cessation behaviors. During the qualitative data analysis in Phase II, the longest self-reported cessation length for each of the 500 participants in the subsample was identified. One coder went through all the posts of the subsample of 500 participants and documented any posts reporting cessation length. If a participant reported cessation length in more than 1 post, the longest self-reported cessation length was used in this analysis.Spearman rank correlation was calculated between centrality in the network and longest self-reported cessation length. Spearman rank correlation was used due to the nonlinear nature of the data. Statistical significance of the correlation was evaluated with no correlation as the null hypothesis.To evaluate how those actively in the process of quitting compare with those who have been smoke free for some time, a subgroup analysis was performed to evaluate the aforementioned correlation for participants who report longest cessation length of less than 1 year and those who report longest cessation length of more than 1 year.Between February 2013 and March 2014, there were 875 posts and 4088 comments from participants on the Smokefree Women Facebook Page and 1166 posts from the moderator. Roughly 4243 people interacted on the page through posts and comments during the 13-month period of data collection. It is of note that participants who interacted on the page did not have to be fans of the Smokefree Women Facebook Page, and thus interactions observed may have been drawn from outside of the 22,000 fans of the page. Additional information about total and average participant interactions (posts and comments) for the entire time period is provided in A plot of the ordered centralities revealed a threshold for centrality of 0.025 . Approximately 100 participants were above this threshold, and 4129 fell below; thus, these participants were labeled as high- and low-engagement participants. Automated text analysis of topics discussed by hubs in the network, or participants with highest centrality compared with other less-engaged participants revealed that hubs, who are most connected to other participants, used more terms of encouragement and congratulations, whereas less-engaged participants discussed more issues related to seeking help, smoking status, and strategies for cessation. The top 30 ranked terms for each group are presented in Qualitative analysis of content posted by a subset of 500 randomly sampled participants yielded 1698 unique posts or comments from those participants. P=.03, N=243), meaning that participants who reported longer cessation lengths were less engaged.Of the random subsample of 500 participants, 243 people reported how long they had stopped smoking. The longest reported period of cessation was 35 years, and the shortest period was 1 day. Seven participants reported smoking cessation of exactly 1 year, and median time of smoking cessation was 5 months. There is a significant inverse correlation between cessation length and centrality at the 0.05 level  and a strong inverse correlation for those who have been smoke free for more than 1 year  a moderator post receives, the more Facebook participants are likely to see the post in their newsfeed .Although the moderator serves as a connector of each person in the network, there are several hubs in the network that serve as large connectors of other participants that are less engaged. This finding supports existing evidence for “super participants” in social network sites ,18. HaviAutomated text assessment of content in the network supports findings from the qualitative content analysis in this study, indicating that participants primarily come to the network to provide and receive support and advice, as well as to mark milestones in their smoke-free journey. When stratified by centrality, automated text analysis suggests that highly engaged hub participants use language that is more congratulatory and supportive, whereas other less central participants seek support, discuss strategies for cessation, and announce their smoke-free status.These findings are further enhanced by findings from the correlational analysis of self-reported smoke-free status, which suggest that participants become more central to the network as they maintain their smoke-free status and use the network for social support but become less involved in the network as maintaining their smoke-free status becomes less difficult and requires less community support. This is consistent with previous research, which found that social network site participants who had recently stopped smoking were more likely to be the first to respond to posts . It is pTaken together, findings from this study suggest that participants who are less central, or are not hubs, are a combination of people at the beginning of their smoke-free journey and people who have been smoke-free for an extended time and only come back to the network to announce their sustained smoke-free status. On contrary, participants who are more central and connect many people  appear to be those who are further along in their cessation journey and come to the network to provide support and perhaps in the process gain support.Limitations of this research include lack of analysis of participant demographics; lack of analysis of shares and likes for the study period; and use of self-report for cessation status. This study did not analyze participant demographic information due to privacy restrictions of Facebook that prevented this information from being publicly available. However, as this analysis was focused on properties of the network, demographic details were not central to the goals of this study.In addition, the study did not include data on shares and likes, additional actions that could be taken by participants in the network, because these data were not available in an automated fashion from Facebook. In a separate analysis, share and like data were manually collected for a period that spanned 3 months. Network visualizations conducted in Phase I were replicated for these 3 months, using all possible Facebook interactions . No observable differences were identified when comparing network visualizations for the full sample using only posts and comments as participant interactions, with the subset using all possible Facebook interactions (data not shown).Moreover, smoke-free status was self-reported by participants on their own volition, sometimes in response to comments on moderator posts asking how long they have been smoke free and at other times in general conversation. Given that the status of everyone in the network is not known, the possibility exists that the number of people who have made a cessation attempt while engaged with the network is underestimated in this study. Furthermore, the correlation analysis may be biased because it did not take into account potential relapse. Nonetheless, it is possible to gain insight on how many participants have made at least 1 cessation attempt through the subset analysis. Future research should explore opportunities to obtain this information from the entire study population and examine the association between cessation length and engagement prospectively.Ultimately, researchers of social network sites for health seek to understand whether participation in a social network site such as the Smokefree Women Facebook page can lead to better health outcomes . Although this study was not designed to answer that question, through observation of naturally occurring interactions of the social network and use of methods such as social network analysis, study findings provide insight into the network structure of the social networking site that stand to inform research and practice. Future research may seek to integrate social analysis data with survey data on use of smoking cessation–related social media sites and smoking status or cessation length data to determine the mechanisms by which social media sites can facilitate quit attempts and sustained cessation.Practitioners may use findings from this study to improve design, implementation, and program evaluation of social network sites focused on health behavior. On the basis of the findings from this study, practitioners may consider the following: (1) developing personas that mimic participants at various points of the cessation trajectory and tailoring the experience with the social network site to fit characteristics of each persona; (2) assessing the best strategies for moderation of the network to determine whether moderator posts that attract comments such as questions, requests for advice, and direct quotes are more effective in providing social support to participants than moderator posts that solicit likes and shares, given the large role the moderator plays in the network; (3) determining whether participants benefit from interaction with only other participants on the Facebook page, or if they also receive benefit from participants in their personal network that may not be participants in that particular social network site for health behavior; and (4) exploring the use of paid advertising on Facebook to boost posts to ensure that users who are new to the community and most in need of support see the posts that will benefit them most.


BackgroundDeveloping evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority.AimsTo outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia.MethodA mixed methods approach was used to develop the MHCP for the three levels of the district health system .ResultsThe community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability.ConclusionsThe MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC. Prompted by his first-hand experience of working in Ethiopia, the late Professor Robert Giel made the argument over four decades ago, well before the Alma Ata declaration, that if mental health services are to be expanded to address the mental health needs in LMIC, two things have to happen: (a) certain disorders have to be prioritised as targets of intervention given the resource constraints in LMIC; and (b) mental healthcare has to be provided by non-specialists through task-sharing and integration into primary care.6 In recognition of the ongoing pertinence of these recommendations, the Ethiopian Ministry of Health is committing itself to the integration of mental healthcare into primary care. Three key recent initiatives support the accelerated integration of mental healthcare: (a) the latest Health Sector Development Plan (HSDP-IV) published in 2010 proposes increasing the proportion of health facilities providing integrated mental healthcare to 50%;7 (b) the Federal Ministry of Health has piloted the World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) in selected sites in four regions of the country;8 and (c) the main road map for the scale up of mental health services in the country has been the launch of the national mental health strategy by the Federal Ministry of Health just over a year ago.9 The strategy mandates explicitly the integration of mental healthcare into every primary care facility in the country.Despite ongoing methodological challenges, epidemiological estimates are now available on the magnitude of unmet needs among the mentally ill in low- and middle-income countries (LMIC).However, evidence on the best approaches to support the practical integration of mental healthcare into primary care is still required. Key questions include the following. What kind of organisational (system-level) support is needed and what interventions are required to gain this organisational support? What kind of capacity strengthening support is required to enable primary care staff to provide safe, effective and inclusive care? What are the best approaches to improve accessibility of care in a traditional rural population that live in difficult to access terrains? This paper aims to answer these questions by describing a mental healthcare plan (MHCP), which defines the key intervention packages to be implemented in one rural district in Ethiopia.10The study was conducted as part of the PRogramme for Improving Mental health carE (PRIME), which is a research consortium involving five LMIC: Ethiopia, India, Nepal, South Africa and Uganda. The aim of PRIME is to develop evidence on the best approaches for integrating mental healthcare into primary care in LMIC.11 The district is geographically diverse with some of the most inaccessible terrains in the region. It has the second highest population and the largest surface area of any district in the SNNPR. Amharic is the official language of the district, as is the case for the region. The study district was selected because it represented the geographical, and to some extent, the cultural diversity of the country. The district was also in close proximity to the Butajira district, which hosts study sites for Addis Ababa University.The setting for the implementation of the MHCP is the Sodo district, Gurage Zone, Southern Nations, Nationalities and Peoples Region (SNNPR) , located about 100 km south of the capital city, Addis Ababa. The total population is 161 952 people (79 356 men and 82 596 women) with about 90% living rurally.Psychosis (including schizophrenia and bipolar mood disorder), depressive disorders , alcohol use disorder, suicidality and epilepsy were the priority disorders. The disorders were selected because they carry a known high public health burden, and there is a reasonably strong evidence base for cost-effective interventions for their treatment. The prevalence of these priority disorders in Ethiopia is presented in The development of the MHCP was informed and guided by the HSDP-IV, the national mental health strategy and the mhGAP. Within these broader frameworks, a mixed methods approach consisting of situational appraisal, asset mapping, theory of change (ToC) workshops and qualitative studies  were use11 was employed for collection of detailed cross-sectional data on health and factors that are likely to influence the health of the Sodo district population. The methods and results of this have been reported previously.11A situational analysis tool20 was adapted to collect information on resources available in the community. The inventory assesses various domains of community resources, including physical assets (for example forests), community associations, health facilities, faith and traditional healers, education facilities, justice system, recreational venues, agriculture, religious institutions and non-governmental organisations (NGOs). Health extension workers were trained for 2 days before administering the inventory. On average each health extension worker interviewed two key informants to complete the inventory, including community leaders, subdistrict chairpersons, district officials, teachers and community elders. A district-level summary of community resources with a potential for use during the implementation of the MHCP were collated.A community resource inventory21 and in elsewhere in this supplement.22 Two pre-ToC meetings and two ToC meetings were undertaken. The first pre-ToC workshop was conducted within the PRIME team, where the main outcomes of the intervention, and the pathways required for these outcomes, were conditionally mapped. This was further developed in a country pre-ToC workshop in which the PRIME team members met on two separate afternoons to describe in more detail the necessary steps, the interventions and assumptions for reaching the outcomes. Then two ToC workshops were carried out with key stakeholders in the district and with national-level policy makers.Details of the methods are described elsewheren = 5), community leaders (n = 3) and representatives from NGOs active in the area (n = 2). At the facility level, three focus-group discussions were conducted with primary healthcare front-line workers and supervisors. At the healthcare organisation level, we carried out four individual in-depth interviews with key stakeholders in the district health office and Federal Ministry of Health. Three research assistants  conducted the interviews in Amharic, the official language of Ethiopia. We used standardised case vignettes (based on those used in the WHO key informant survey23 and used in Ethiopia previously24) to orientate respondents to the type of disorder under consideration. Individual in-depth interviews and focus-group discussions were audiotaped, transcribed in Amharic and then translated into English by the interviewers prior to coding. A framework analysis approach was utilised, following the recommended four-step procedures.25 The data were managed using qualitative data analysis software .In the qualitative study, we explored the feasibility and acceptability of integration of mental healthcare into primary care. We conducted both individual in-depth interviews and focus-group discussions involving key stakeholders targeted by the MHCP intervention levels: community, health facility and healthcare organisation. At the community level, we carried out one focus-group discussion each with health extension workers, health development army volunteers  and families of people with mental and developmental disorders. We also conducted individual in-depth interviews with traditional and religious leaders  every 3 months; their links with community leaders; and their close relationship to the health facility . This approach to case detection fits closely with their expected roles and responsibilities for other disorders, and with the national mental health strategy. The disorders amenable for this type of case detection are psychosis and epilepsy. Given previous experience in case detection in other studies in Ethiopia,26 health extension workers will be supported by community leaders.Continuing care and community-based rehabilitation. Health extension workers will be trained to provide continuing care support primarily for people with psychosis and epilepsy and their families. Tasks to be carried out by health extension works during their visits every 3 months include the following.Psychoeducation about the illness:raising awareness of the need for continuing care even when the person is symptom free;safe management of aggressive behaviour;mental health first aid/first aid for seizures.Monitoring medication side-effects, providing adherence support and referring for review if needed.Monitoring of mental state, detecting early signs of relapse and referring for review when needed.Asking about physical health and supporting access to health facility for assessment and care.This additional support will only be part of their routine home visitations.For severe mental illness in mothers, in addition to the above, the care package considers the physical health needs of the mother , social support needs of the mother  and welfare of the children . For people with schizophrenia who fail to respond to 6 months of standard MHCP, community-based rehabilitation is provided. The main functions of community-based rehabilitation are as follows.Rehabilitation, for example supporting self-care.Community mobilisation to support:social inclusion and involvement in community activities; andsupport for families .Multisectoral collaboration to access opportunities for skill development and livelihoods support.Adherence support.Family intervention .Detection of side-effects, inadequately controlled symptoms or relapse.The focus of the PRIME intervention is to build capacity for competent and inclusive care in the healthcare facilities . PRIME MHCP has four intervention packages to achieve this: training of clinical staff; sensitisation workshops ; supervisory decision support; and support of staff well-being.Training of clinical staff. This is aimed at enabling case detection , prescription of psychotropic medications, provision of basic psychosocial care, referral and ongoing care. Training was provided for 2 weeks: 1 week theoretical training and 1 week clinical apprenticeship at a psychiatric clinic (3 days) and at a health centre (2 days). The core training tool is the mhGAP intervention guide.27 The delivery of the mhGAP intervention guide training was modified with additional training components, namely: (a) the training was provided for longer periods of time; (b) practical training included encounters with actual patients with mental health needs; (c) on the job support and supervision was provided for 1 additional month to ensure competent care; and (d) explicit training was added on maternal depression and the continuing (chronic) care model. Moreover, culturally adapted psychosocial intervention packages and intervention packages for alcohol use disorders were not available and a decision was made to develop these packages for a phased delivery of care in the future.Sensitisation of all staff. All staff, including non-clinical staff, were given half-day interactive workshops to enhance awareness and inclusiveness. Training used case vignettes and testimonials from patients.Decision support. Finally, the MHCP mandated provision of additional decision support mechanisms: pocket guides, posters and supportive supervision. Two forms of supportive supervision are incorporated. The first is an integrated supervision, which involves using staff who are designated to be supervisors within the health system. The second approach uses specialist (psychiatric nurse) supervisors.Health professional well-being. The final intervention package focused on improving health professional well-being. There are no culturally adapted intervention packages for supporting staff well-being and this will be developed following a comprehensive evaluation of the well-being of health professionals.The key intervention packages were programme management through proactive stakeholder engagement, advocacy and sensitisation. The stakeholders engaged in the healthcare organisation included those at the Federal Ministry of Health, and at the regional, zonal and district health administration bureaus and offices. Two structures were developed to support stakeholder engagement: a country management group and community advisory board. The country management group had seven members representing the Ministry of Health, the regional health bureau, zonal health bureau, district health office, a mental health coordinator of the district and two of the PRIME country investigators. The community advisory board had 17 members and was represented by key members of the district leadership , the community and a carer, and was chaired by the head of the district health office. Meetings every 6 months were held with both the country management group and the community advisory board. Each meeting lasted half a day and activities of the preceding 6 months and plans for the future were discussed in detail. These meetings were also for advocacy and sensitisation of the district leadership. To further support programme management, the district has allocated a mental health coordinator, funded by the Ministry of Health. This will be followed by allocation of mental health coordinators at the healthcare facilities. Other programme support mechanisms have included the training of trainers, which is being coordinated by the district. Two health officers are trained to be trainers.Here we consider the summary results of the qualitative study. In broad terms, participants considered the integration of mental health into primary care to be feasible and acceptable. However, three main preconditions were considered essential for the provision of integrated care. First, access to adequate staffing and training; second, providing ongoing supportive supervision to clinical staff; and third, focus on recovery and the basic needs of patients in relation to food, shelter and clothing.The emphasis in relation to developing the skills of staff to provide competent care was on averting potential negative consequences of poor skills. Perceived inability of staff to provide competent care could discourage them from taking on tasks that are considered a specialist area. Mismanagement of patients could put the patient and the community at risk of harm, which may eventually lead to mistrust of the service being provided and reduce motivation to access care. Related to this, the need to increase the number of staff was emphasised given the potential to increase the service load substantially in the longer term.The second theme of supportive supervision was also considered essential to evaluate the implementation process, to address emerging challenges and to support skill development in the area of patient assessment, care provision and clinical records. Ongoing and integrated supervision was emphasised. The participants proposed that the supervision should be offered as long as integrated mental healthcare is being provided.The third theme, ensuring recovery, was considered the core of care provision. Essential elements for recovery were: addressing basic needs, ensuring treatment adherence, supporting family, engagement with the community and reducing social exclusion. There was consensus that medication was not adequate to bring the person with mental illness back to their previous state of health because, in the words of one participant, they ‘have lost everything because of chronic illness’. Interventions should address the basic needs for food, shelter and livelihoods. Economic security, protection from stress, moral support and encouragement were considered essential components. The potential for learning from other programmes such as HIV/AIDS were discussed but participants were cautious, saying that large investment accompanied the HIV/AIDS programmes and that is difficult to replicate in other programmes. Ensuring medication supply and treatment adherence were the other issues. Participants proposed that the network of health extension workers and the health development army would be able to support treatment adherence and to invite patients back to care. The role of families should be recognised and their needs for both practical and emotional support met. Families carry a huge emotional burden caring for their loved ones. Families should be equipped to support and to provide a therapeutic environment for the individual with illness. The community was considered an essential part of the support mechanism for the patient and family. The participants acknowledged the long history of people supporting each other in rural Ethiopia. Nevertheless reliance on an ‘overstretched community’ to mobilise the necessary resources may not be feasible. Carers particularly underscored the limited capacity of the community to keep on giving after the initial crisis has passed and their disinclination to feel dependent on others who already had their own difficulties. Encouraging social inclusion within the community was important to achieve recovery. Mechanisms mentioned by participants that could encourage social inclusion were: public contact with people with severe mental illness, including discussions of mental illness in social gatherings, educating the community about the treatability of mental disorders and the involvement of people with mental illness in social activities and decision-making.The MHCP also included plans for how the intervention packages should be systematically cascaded from the PRIME team, with the support of the district administration and policy makers down through various providers to users and participants in the community .Pilot results describe the acceptability of the training, cases seen and key informant identifications. At the pilot site, 19 primary care staff  were trained. All the topics covered had very good acceptability. The methods of training that the trainees found particularly useful were the participatory methods, the case scenarios, the video clips and the practical training. In the practical training at the psychiatric clinic in Butajira, trainees saw over 200 patients. In addition to cementing their knowledge, the practical training had an impact on their attitudes. First, trainees appreciated the public health dimension of mental disorders, for example that mental disorders may be more common than they thought. Second, the trainees were encouraged to see the improvements of patients with treatment. As one participant said, ‘If we provide mental healthcare, we can change the life of people in need’. Some of the trainees expressed their interest in learning and practising psychiatry full time. For example, one health officer said to the psychiatric nurse supervisor, ‘I would love to get this opportunity ’.In the 2 weeks after the training, two health officers working in the out-patient clinics had seen 24 patients. One of the health officers said, ‘It is enjoyable when you do the work’, particularly when ‘people have confidence to talk to you’ about their difficulties. ‘People who come to see me are lucky’ because she now has a more ‘complete knowledge’. She found that using the mhGAP intervention guide in the clinic gave her confidence to make a diagnosis and provide treatment. Although some individuals struggled to accept the diagnosis of a mental illness and opt to go for traditional treatments, most attended for follow-up. For example, nine of the ten individuals with appointments attended for their appointment. Having the service nearby has also encouraged attendance for follow-up. What the staff find crucial is the time taken to explain the illness and treatment. One of the health officers said she often makes appointments to speak to the patients at the end of the clinic. The conditions seen by two health officers is presented in n = 13) and health extension workers (n = 15). The half-day training focused on the identification of severe mental illness and epilepsy. After the training, key informants were asked to give a list of potential patients with the two conditions. Health extension workers identified more cases than the community leaders for both conditions. For severe mental illness, health extension workers identified 67 potential cases with a male to female ratio of 2.7:1 and community leaders identified 33 cases, with a male to female ratio of 4.5:1. With regard to epilepsy, health extension workers identified 25 cases  and community leaders identified 15 cases .Two groups of key informants were trained: community leaders  participation of the district leadership and political buy-in. The second innovation was the willingness to look beyond the biomedical domain, into what is available in the community. This helped us to map potential community resources that may support the provision of sustainable care to people with mental illness and their families. Related to this is the focus on the community for continuing care and community-based rehabilitation. The fourth innovation is the modification of the mhGAP training to include practical training, which was found to be a useful addition in consolidating knowledge and skill, and in having an impact on attitude. Finally, additional interventions in future will focus on improving the well-being of health professionals. Staff turnover is high in health centres in Ethiopia. Although not formally studied in the Ethiopian setting, many risk factors for staff burnout are present, including high patient loads, poor quality of facilities and lack of available interventions (engendering a sense of helplessness).Although the MHCP is comprehensive, several components are yet to be piloted. Further evaluation is required to identify exactly what components of the intervention packages are feasible, acceptable and working. For example, providers in the folk sector are fully mapped, but how the relationship between the biomedical providers and the folk providers functions, and the impact of the evolving relationship on the delivery of care, has to be understood. The pilot data on training is limited to staff trained in one health centre. The actual patient data are limited to two health officers, who were trained at a pre-pilot stage. The key informant method of case detection requires further validation. It appears that, as it stands currently, this method has the potential to lead to inequitable care provision.28 as it is known in the West is not feasible, PRIME is working to support integration of mental healthcare into the work of community health workers. The role of psychiatrists will also need to be redefined29 so that they focus on service development and supporting policy.This study has the potential to make a substantial contribution to the scale up of mental healthcare in Ethiopia. But the success of the project will depend on whether the district, and ultimately the government, owns the integrated care approach. This will also depend on whether integrated mental healthcare is affordable and not just effective. Therefore, while introducing the MHCP, careful costing and exploration of other delivery options need to be looked into. For example, the integrated supervision may be a cheaper alternative if it is nearly as effective as the more expensive specialist supervision provided by psychiatric nurses. A larger-scale study, for example, nested during the scale-up phase of PRIME, may need to be conducted. Although community mental health service provision