Rice is one of the vital foods consumed in most countries throughout the world. To estimate the yield, crop counting is used to indicate improper growth, identification of loam land, and control of weeds. It is becoming necessary to grow crops healthy, precisely, and proficiently as the demand increases for food supplies. Traditional counting methods have numerous disadvantages, such as long delay times and high sensitivity, and they are easily disturbed by noise. In this research, the detection and counting of rice plants using an unmanned aerial vehicle (UAV) and aerial images with a geographic information system (GIS) are used. The technique is implemented in the area of forty acres of rice crop in Tando Adam, Sindh, Pakistan. To validate the performance of the proposed system, the obtained results are compared with the standard plant count techniques as well as approved by the agronomist after testing soil and monitoring the rice crop count in each acre of land of rice crops. From the results, it is found that the proposed system is precise and detects rice crops accurately, differentiates from other objects, and estimates the soil health based on plant counting data; however, in the case of clusters, the counting is performed in semi-automated mode. Precision farming is observing, measuring, and responding to a system that sustains the structure used for managing the farm and producing the extreme yield in existing resources . OutdateImprovements such as precision farming, fertilizers, etc., are helping to utilize the earth’s resources most efficiently, but there is still much room for advancement. Consequently, in the present era, there are several developments in agriculture for growing crop productivity.Among several other important crops, over half of the world’s population uses rice as their main source of energy because it is a complex carb. No other crop provides as much food, as much employment for farmers, or as much support for the environment. For 70% of the impoverished in Asia, for whom rice is frequently the only source of income, it is much more than just a food crop . The amoWhile the number of rice seedlings within the field is one of the most agronomical elements for defining rice yield, this investigating task, however, remains chiefly performed manually. It includes the exploitation of human vision instead of computer vision and is so cumbersome and long . TherefoDeveloped countries have already started the use of unmanned aerial vehicles (UAVs) in their precision agriculture. Automation pilotless aeronautical vehicles (UAVs) ,6, normaFarmers face many problems during the crop cycle as they do not have sufficient water, lesser use of modern equipment, dependencies on traditional farming techniques, poor storage facilities, transportation problems, high-interest rates, and government schemes . The solIn this research, there is a tendency to propose an associated economical technique that uses computer vision to accurately count rice seedlings during a digital image. First, an associate UAV equipped with red–green–blue (RGB) cameras acquires field pictures at the phanerogam stage. The UAV flies over the rice fields for approximately 10 min and captures imagery data. It takes a total of 8 flights. Next, it employs an ArcGIS to regress the density map and estimate the number of rice seedlings for a given UAV image. ArcGIS is a geographical information system (GIS) application that enables the handling and analysis of geographic data by visualizing geographic statistics through layer-building maps, such as climate data or trade movements. Subsequently, rice crop counting is performed to identify soil health and indicate fertile or barren land. The area planted with rice is classified by employing the Iso cluster unsupervised classification technique using the ArcGIS program. This research contributes a novel data set with a customized technique of using a combination of UAV and ArcGIS. It is based on a deep learning model to estimate crop yield. Furthermore, it indicates soil health based on productivity. In this context, we have monitored two different regions of rice crops. In the first region, the monitoring of rice crops is performed after 1 week of sprouting. The region is 4 acres . In the second region, the monitoring of 35 acres  is performed. The monitoring of the field is performed using a UAV. The aerial imagery, captured by UAV, is processed with ArcGIS for plant counting. The ArcGIS is used for pointing the coordinates to map the data on the image.The proposed solution helps to identify the crop count and indicate soil health. This research also helps to indicate fertile and barren land. Consequently, it helps to take all the necessary steps to make barren land fertile for the next agriculture cycle. The result aids farmers or landmen in taking safety precautions for increasing yield and treating land according to its health. The research is based on identifying crop yield and identifying soil health. The output of the proposed system is 0.99 percent efficient (in terms of accuracy).This article comprises six sections. This section comprises two sections. In Each touchpoint in our life today is being etched with a new deoxyribonucleic acid (DNA), thanks to the data and technology. The barriers between the physical, digital, and biological domains are disappearing as we live and breathe, thanks to the fourth industrial revolution and its convergence of technology.The fourth industrial revolution  is prepaIndustrialization AnalyticsData IntegrationCollaborative Cross-functionalAugmented IntelligenceBy increasing the efficiency of farming operations by increasing agricultural production, reducing environmental impact, and automating farmers’ work, they contribute to the growing body of knowledge about the potential role of blockchain technology in promoting the idea of smart farming  UAVs 1313 naturaThe experimental work satisfies the demands of automatic and real-time environmental parameter monitoring by employing both above- and below-ground sensors . In thisThe term “smart farming” refers to the management of farms using the Internet of Things (IoT), robotics, drones, and AI to improve product quantity and quality while minimizing the amount of human labor needed for production. A growing number of people are becoming interested in smart farming technologies and precision agriculture  because Another ground-breaking innovation with enormous promise in precision agriculture is the use of unmanned aircraft systems (UAS) as sensing and/or communication platforms . It was In agriculture, there is a quick adaptation to AI in its various farming techniques. The concept of cognitive computing is one that imitates human thought processes as a model in the computer. This results in turbulent technology in AI-powered agriculture, rendering its service in interpreting, acquiring, and reacting to different situations (based on the learning acquired) to enhance efficiency. To harvest benefits in the field by catching up with the recent advancements in the farming sector .Recent improvements in the accessibility of pertinent data, processing, and algorithms have enabled AI to start delivering on its promise of creating real value. In this essay, by enhancing what is being detected and monitored, the most immediate application will be to increase the accuracy of information about what is happenning on the farm. This has the effect of providing farmers with more precise warnings .One of the typical employments for UAVs in precision farming is found in , where aThe calculations dependent on deep neural systems are proposed to recognize tobacco plants , corn plThe work in  presentsThe technique used in this article indicates the health of land according to the density of growing seedlings, and the gaps show the ungrown area of land. The research in the same area is presented below in In , the autIn , L-systeThis section is divided into two sections. In The study was carried out in Tando Muhammad Khan, Sindh, Pakistan, in June 2020. A total area of 40 acres was chosen for the study and divided into two regions. Region 1 (5 acres)  and region 2 (35 acres) . For the acquisition of images, a DJI Phantom 4 Pro drone was used. The UAV, flight assignment, and specifications of the camera are shown in The UAV used in the experiments has a 1388 g weight with a LiPo battery capacity of 5870 mAh. It can fly for approximately 10 min at an altitude of 35 m. The total eight flights of the UAV are used for data collection for the duration of 80 min, as shown in The camera specification for monitoring fields for estimating yield and indication of soil health is represented in The imagery data set of rice seedlings is about 1200 RGB images using an unmanned aerial vehicle. The imagery data set consists of images of rice seedlings that are manually and mechanically planted over 40 acres of land. Region 1 (35 acres)  and region 2 (approx. 5 acres)  are shown in These highlights enhanced a certain organization called picture chips’ deep learning methodology. Picture chips are tiny symbolism-filled squares that were sliced from the original image. It will be easy to trade them as image chips with metadata once they have achieved a sufficient number of highlights in the image classification board. The detection objects using a deep learning device in ArcGIS Pro 2.5, which relies on well-established learning structures, can be prepared using these preparatory tests.The aim of this research is to provide a sustainable and easy method of identification of crop yield and soil health in terms of productive or barren lands. The use of aerial vehicles provided ease in monitoring and capturing the data for the identification of soil health and crop yield by counting them and estimating the results by mapping according to acres. This research is carried out in the area where mechanical plantation and manual plantation are both carried out, and it has to find out the number of crops and estimation of soil health.In Inventorying each rice plant on the field manor would take a great deal of time and an enormous workforce. To improve the procedure, you′ll utilize a profound (deep) learning model in aeronautical reconnaissance coverage geographic information system (ArcGIS) programming to distinguish rice plants. The principal step is to discover symbolism that has a fine enough spatial and unearthly goal to distinguish plants and seedlings. The plantation is carried out mechanically and manually. Firstly, in region 1, point out mechanical plantation and manual plantation areas, as shown in After discrimination of mechanical and manual plantation areas, the next step is to perform point demarcation of plants or crops, which indicates the growing rice crop as shown in the figure below. Ortho-amended pictures were produced utilizing the boundaries that appeared in Region 2, which is approx. 5 acres and is geolocated at 25°08′12.9″ N, 68°36′08.9″ E, carried only mechanical plantation, and below is the point demarcation of region 2 to point out live plants for estimating yield according to acers and indicate soil health concerning dead plants either the soil is productive or barren. Once having the imagery, at that point, prepare tests and convert them to a configuration that can be utilized by a profound learning model. For the model to perceive what it’s entrusted with finding, it has to characterize pictures of rice plants/seedlings so it can recognize comparative pixels. Making reasonable training tests is vital once instructing a profound learning model or any picture grouping model. It is additionally frequently the most tedious advance all the while. To furnish a profound learning model with the data, it needs to extricate all the rice plants or seedlings in the picture and make the highlights for various rice plants or seedlings to show the model the size, shape, and mark of rice plants or seedlings. These preparation tests are made and overseen through the Label Objects for Deep Learning instrument.While capturing samples of plants in the territory, highlights were digitized all through the picture. These highlights added something extra to the profound learning model in a particular organization called picture chips. Picture chips are little squares of symbolism cut from the source picture. When they have made an adequate number of highlights in the Image Classification board, it will be anything but difficult to trade them as picture chips with metadata. These preparation tests can be utilized to prepare a model utilizing the Detect Objects utilizing a Deep Learning device in ArcGIS Pro 2.5, which depends on profound learning structures, for example, TensorFlow, Keras, or CNTK. To introduce these profound learning libraries, clone the default Python condition utilizing the Python Command Prompt.The Train Deep Learning Model geoprocessing apparatus utilizes the picture chips that are marked to figure out what blends of pixels in a given picture speak to rice plants. Geospatial software called ArcGIS is used to view, edit, manage, and analyze geographic data. For mapping on PC, mobile, and the web, Esri creates ArcGIS. The science of where is their slogan. As a result, location intelligence and analytics are the main focus of ArcGIS. Professional software called Agisoft Metashape analyses digital photos, generates digital models and point clouds for 3D spatial data, and combines snapshots to produce orthogonal images. Additionally, the software’s features include the ability to create visual effects and take indirect measurements of things at different scales.Agisoft Metashape Professional Software is based on a deep learning architecture. The background of their inputs and producing output depends on deep learning. The input image is integrated with a set of K kernels.Each of these operations creates a new feature map The system block diagram explains the working model adopted in this work. In The experiment is carried out in Tando Muhammad Khan in an area of 40 acres where both mechanical and manual plantation is carried out. Drone DJI is used for monitoring and capturing images from fields of rice. A predefined flight plan was developed using a mission planner Map Pilot for DJI software. The UAV flew autonomously over the rice field at 35 m and captured images, and monitored fields to identify the land condition and health. The experimental findings and the outcomes of the proposed technologies are explained in this section. The plant count of mechanical and manual plantation is presented below in region 1. The mediocre gapping in the plantation in area 2 is visible in Finally, The rice crop originates in tropical lowlands and needs an extended heat season. Moreover, it is grown up where the night-time temperatures keep on the top of sixty degrees for a minimum of 3 months of the year. Furthermore, it is grown in water. Therefore, there is always water on land where the rice is growing. Consequently, to avoid reflection, early photography before the sun and after 1:30 pm is carried out for the data collection. If the data are required to collect at any time, the reflector camera  is placed with the drone camera, which avoids the reflections in the image. A drone camera is used for collecting images of rice fields which is processed for learning and labeling rice crops, and then ArcGIS is used for counting themThe maximum yield per acre rice field is from 80,000 to 150,000 plants. The amount of rice calculated is shown in To obtain maximum paddy yield, from 80,000 to 150,000 plants are recommended per acre. This can be accomplished by preserving a plant-to-plant and row-to-row separation of 22.5 cm or 9 inches. However, in farmer’s fields plant populace of 60,000–65,000 has been detected . Table 6The aim of this research is to provide a sustainable and easy method of identification of crop yield and soil health in terms of productive or barren lands. The use of aerial vehicles provided ease in monitoring and capturing the data for the identification of soil health and crop yield by counting them and estimating the results by mapping according to acres. In , with thThe technique used in this article is a combination of UAV, AgiSoft Metashape Professional, and ArcGIS with deep learning. The UAV is used to gather imagery data, which are then processed to extract features on AgiSoft Metashape Professional software. Subsequently, ArcGIS is capable of counting the rice crop based on deep learning. This outcome helps the farmer to treat the affected area of land, which in turn saves assets. The assets include the sprays of medicines required to treat the land or water. These sprays only apply to the area of land where the crop is not grown and minimum growing areas. Therefore, the proposed system is cost-effective, saves assets, and reduces human efforts. To summarize, the agricultural sector has a well-defined task for this new progress in the computer vision sphere—crop counting for better yield prediction, segmentation of problematic crop areas such as plants beaten down due to weather activity, flooded regions of the fields, detection of plant diseases, etc. Solving described tasks allows farmers to better prepare for upcoming dangers to their yield, minimize their losses and maximize harvest and profits.In this research, the counting of rice crops using aerial imagery was performed to increase the yield. Aerial images of the rice crop were captured in the area of 40 acres of rice crop in Tando Adam, Sindh, Pakistan, using a UAV equipped with a GIS system. The results show that the per acre count is less than the standard count of rice per acre in some areas due to the soil, not loam which affects the seeds. The findings are that mechanical plantation is an effective way of growing plants and increasing yield count. The results are due to improper soil that affects the overall count of regions. The software identifies the plant based on specified width and height, which is later checked via manual quality control. In the quality control process, visual interpretation is conducted based on the pattern, the cluster size, and the shadows that are present in between the plants. The proposed system detects rice crops accurately, differentiates from other objects, and estimates the soil health based on plant counting data, which are approved by the aggrotech. The capability of the software is limited to a specified pattern; however, in the case of clusters, the count is semi-automated. Several attention-grabbing directions might be explored by future analysis in this domain. First, efforts could also be created to deploy our technique into an Associate in Nursing embedded system on a UAV for online yield estimation and exactitude agriculture applications. Second, the precise location of rice seedlings and, therefore, the practicability of rising investigation performance from the angle of object detection needs exploring; as a result, the precise location of crops may be a key step in exactitude agriculture. Third, since coaching knowledge square measure invariably the key to smart performance, particularly the range of such knowledge, it might be attention-grabbing to still enrich the RSC dataset as a precursor to more modeling work. Finally, the matter of object investigation in large-scale associations in nursing high-density environments continues to be an open issue, with lots of scope for exploring the practicability of rising investigation performance during this context.


Family physicians play a key role in responding to the growing demand for primary healthcare due to aging. The work attitude of family physician team members (FPTMs) impacts their work efficiency and quality. Knowing how satisfied they are with their jobs can help identify potential directions and entry points for incentives. The purpose of this study is to analyze the job satisfaction status and influencing factors of grassroots health service personnel after the implementation of the family physician contract system in China.The study conducted a cross-sectional survey with 570 FPTMs in three prefecture-level cities in the Shandong Province. Satisfaction was measured using 30 items across seven dimensions. Responses were recorded on a 5-point Likert scale. Descriptive statistical analysis was used to analyze the general information and satisfaction of FPTMs. Multiple linear regression analysis was used to analyze the factors influencing job satisfaction.The overall job satisfaction among FPTMs was not high. Among the seven dimensions, interpersonal relationships had the highest satisfaction (4.10 ± 0.78), while workload had the lowest satisfaction (3.08 ± 0.56). The satisfaction levels of the three sample regions were different, and the results were opposite to their regional economic development levels. The results of the multifactor analysis showed that gender, income level, educational background, working years, daily working hours, number of training sessions per year and the proportion of performance pay had significant impact on overall job satisfaction.The development of a family physician contract system has increased the workload of FPTMs. In addition to the implementation of the new policy, attention should be paid to the workload and working attitude of family physicians. The fundamental measures should focus on attracting more personnel to work at the grassroots level by accelerating education and training to solve the problem of insufficient health personnel at the grassroots level. Simultaneously, attention should be paid to the improvement of the medical staff's salary level and the need for self-promotion, such as training. As the aging process accelerates, demand for primary healthcare services continues to increase . Family The work attitudes of family medical team members have an impact on their work efficiency and quality. Those who are satisfied with their work can maintain high enthusiasm, put more energy into their work, and are willing to continue working on their own posts to complete medical service work , 10. InvChina's family physician system started relatively late. In 2016, the Guiding Opinions on Promoting Contracted Family Physician Services were predominantly aimed at speeding up contracted family physician services in combination with the comprehensive reform of community-level medical and health institutions, and the construction of the general practitioner system . Since tThe signing system is a new policy, which not only brings performance income to grass-roots medical personnel, but also brings new workload. With the development of contracted services, a shortage of family physicians in China has also been exposed. Statistics show that China is still far from its goal of having five qualified general practitioners for every 10,000 urban and rural residents by 2030 . In addiThis study conducts a survey with FPTMs to analyze the current situation and influencing factors of job satisfaction of FPTMs in China under the condition of more work tasks than that before China began to implement the new policy of signing contracts. Additionally, we explore the differences in job satisfaction of FPTMs across different dimensions, providing a reference for improving the overall efficiency and service quality of FPTMs, and encouraging institutions to implement incentive measures.Multistage stratified random sampling was used within this study. Jinan City, Weifang City, and Heze City of Shandong Province were selected based on their economic development levels. Counties or districts were randomly selected from each district. Three community service centers and one township central health center were selected from each county (district). A specific sampling plan, combined with the actual local situation, adopted the local community service agency manager's opinion and selected the appropriate agency. All members of the family physician team in the sample institutions were surveyed. Members include general practitioners, nurses, public health personnel, pharmacists, and psychological counselors. A total of 570 members of the family physician team participated in the survey. Among them, 179 were from Jinan, 148 were from Weifang, and 243 were from Heze.The questionnaire was adapted from the short Minnesota Satisfaction Questionnaire developed by Weiss, Dawis, England, and Lofquist , which iAfter the questionnaire was completed, we conducted a pre-survey in Weicheng District, Weifang City. In view of the problems in the pre-survey process, we modified the questionnaire. The formal investigation was conducted between January and February 2018. The investigation was led and assisted by the local health administrator, and the investigation team found and completed a survey of all family physician team members. During the survey, members of the family physician team completed a self-administered questionnaire, which was then examined one by one by an investigator. If the investigator found any vacant items, the questionnaire was sent to the respondents and corrected.P-value was set to be 0.05.Epidata 3.1 software was used to establish the database and input the questionnaire. Statistical analysis was performed using IBM SPSS Statistics 24 software. General data and satisfaction with FPTMs were analyzed using descriptive statistical analysis. In the absence of data for a variable, the effective percentage was calculated. The differences in satisfaction with FPTMs in general and among different regions were demonstrated using radar maps. Multiple linear regression was used to analyze the factors influencing job satisfaction, including cumulative satisfaction and the factors influencing each dimension of satisfaction. The significance level of the P < 0.05) (As shown in  < 0.05) .As shown in The radar chart in Since the implementation of the family physician contract system in 2016, China has established a family physician system that conforms to local characteristics through practical exploration in various regions. This has played a positive role in the rational utilization of health resources, reduction of medical and health costs, and improvement of residents' health conditions. However, the implementation of contracted services also increases the daily workload of the FPTMs. In the case of a small number of staff and a large number of work tasks, whether this will affect the work enthusiasm of family physician teams is an urgent issue that needs to be studied. This study conducted a survey on the job satisfaction of FPTMs and divided it into seven dimensions, which is conducive to finding the link of work enthusiasm, and provides a theoretical basis for the government and primary medical and health institutions to carry out targeted incentive measures.Overall, the satisfaction of FPTMs was not high, which is consistent with the results of a study conducted in a city in eastern China (3.60 ± 0.70) . SatisfaThere are differences in the level of satisfaction between different regions, which follows the opposite trend to the level of economic development. This is not consistent with the conclusion that general practitioner satisfaction is higher in countries with higher GDP per capita based on the study of 34 countries . But thiRegression analysis showed that the satisfaction level of FPTMs was affected by factors such as “number of training sessions per year,” “qualifications,” “working hours per day” and “education level.” The first regards the number of training sessions, which had a positive effect on cumulative satisfaction and the seven dimensions of satisfaction. This demonstrates that medical personnel are highly satisfied with training opportunities, the fairness of opportunities, and training costs, which is related to the importance of grassroots medical and health institutions for training since the new medical reform. This also reflects that grassroots medical personnel have the most obvious desire for self-improvement. Research has confirmed that training can effectively improve the medical technology of grassroots medical personnel, and enhance their satisfaction , 30. TheDespite these findings, our study has some limitations. First, although the internal consistency of the measurement tools was good, there may have been some reporting bias in the self-reported data regarding job satisfaction. Second, although the factors of different levels of economic development were considered in the selection of sample areas, the selection of a wider geographical area will give rise to more robust and externally valid research conclusions, and future research should; therefore, be extended to more provinces and sample areas. In addition, although the selection of samples in this study has been scientifically selected and calculated, the number of samples selected by the three cities is not consistent, which may lead to sample bias to a certain extent, thus affecting the validity of the results of this study. Third, this study only reflects the cross-sectional survey status of satisfaction. After the policy has been implemented for a longer time, in future longitudinal research, we should continue to pay attention to the changes in the satisfaction of FPTMs and determine the positive factors to improve satisfaction.Family physicians play a key role in responding to the growing demand for primary healthcare due to aging. Conducting a survey with FPTMs, this study analyzed the current job satisfaction of FPTMs and its influencing factors after the implementation of the contract signing system in China. (1) The cumulative satisfaction of FPTMs is not high, so while developing contracted services for family physicians, China should also pay close attention to the workload and attitude of the medical staff, and adopt multiple approaches to increase the allocation of healthcare personnel at the community level and attract more general practitioners to work at the community level. (2) There are regional differences in FPTMs' satisfaction, which are influenced by many factors. Therefore, it is necessary to raise the salaries of primary healthcare workers, improve their material conditions, and pay attention to their self-improvement needs, which will contribute to increasing family physicians' satisfaction. Different incentive measures and strategies should be adopted in different regions to improve the overall work efficiency and service quality of FPTMs and the level of primary medical and health services.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the Local Legislation and Institutional Requirements. Written informed consent from the participants was not required to participate in this study in accordance with the National Legislation and the Institutional Requirements.WC and YD wrote the preparation, visualization, and data management of the original draft, and organized the formation of the final manuscript. CW conceived the idea and designed the questionnaire. QJ organized the survey and data collection. RG, QG, FH, and WL participated in the fieldwork, discussion, and revision of the manuscript. All authors read and approved the final manuscript.This study was funded by the Youth Program of the National Natural Science Foundation of China (grant numbers 72104186 and 72004165), the Humanities and Social Science Research Youth Fund program of the Ministry of Education (grant number 20YJCZH002), the Natural Science Foundation Program of Shandong Province (grant number ZR2021MG019), and the Shandong Higher Medical Education Research Center Planning Program (grant number YJKT202126).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Nurturing Care Framework (NCF) describes “nurturing care” as the ability of nations and communities to support caregivers and provide an environment that ensures children's good health and nutrition, protects them from threats, and provides opportunities for early learning through responsive and emotionally supportive interaction. We assessed the extent to which Kenyan government policies address the components of the NCF and explored policy/decision makers' views on policy gaps and emerging issues.A search strategy was formulated to identify policy documents focusing on early childhood development (ECD), health and nutrition, responsive caregiving, opportunities for early learning and security and safety, which are key components of the NCF. We limited the search to policy documents published since 2010 when the Kenya constitution was promulgated and ECD functions devolved to county governments. Policy/decision-maker interviews were also conducted to clarify emerging gaps from policy data. Data was extracted, coded and analyzed based on the components of the NCF. Framework analysis was used for interview data with NCF being the main framework of analysis. The Jaccard's similarity coefficient was used to assess similarities between the themes being compared to further understand the challenges, successes and future plans of policy and implementation under each of the NCF domains.n = 91 were assessed against the inclusion criteria, and n = 66 were included in final analysis. The 66 documents included 47 County Integrated Development Plans (CIDPs) and 19 national policy documents. Twenty policy/decision-maker interviews were conducted. Analysis of both policy and interview data reveal that, while areas of health and nutrition have been considered in policies and county level plans (coefficients >0.5), the domains of early learning, responsive caregiving and safety and security face significant policy and implementation gaps (coefficients ≤ 0.5), particularly for the 0–3 year age group. Inconsistencies were noted between county level implementation plans and national policies in areas such as support for children with disabilities and allocation of budget to early learning and nutrition domains.127 policy documents were retrieved from government e-repository and county websites. Of these, Findings indicate a strong focus on nutrition and health with limited coverage of responsive caregiving and opportunities for early learning domains. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains. More than 250 million children 43%) younger than 5 years in low- and middle-income countries (LMICs) do not reach their developmental potential due to adversities in the early years including poverty, undernutrition and a lack of nurturing care and stimulation –3. The L% youngerThe NCF aims to inspire multiple sectors including health, nutrition, education, labor, finance, water and sanitation, and social and child protection to work together in new ways to address the needs of the youngest children . It artiThe Early Childhood Development (ECD) Index has been designed to measure progress and generate action toward the SDGs, particularly SDG 4.2 of ensuring that all girls and boys have access to quality ECD, care and pre-primary education by 2030 . This haChanging working patterns driven by migration to urban areas is exacerbating these challenges as low-income families, particularly women, must work long hours outside the home and this has created demand for non-parental childcare in many LMICs , 13. TheIn Kenya, child health and development face many challenges particularly in deprived urban neighborhoods and remote rural communities. Nationally, under five mortality remain stubbornly high with 41.9 deaths per 1,000 live births in 2020, and 19.4% of under 5s are stunted . As the To establish the extent to which government policies and plans address the components of the NCF, particularly in relation to center-based childcare, and explore policy makers' views, we carried out a policy review as part of a study that explored feasible models to improve the quality of center-based childcare in informal settlements in Nairobi . The objA search strategy was formulated to identify the extent to which the NCF is addressed in Kenyan national policies and county government plans. Following the analysis of the policies and plans, qualitative interviews were conducted with national policy makers and county-level decision-makers to explore the extent to which nurturing care, including quality center-based childcare has been addressed within national and county level policies and plans.As the components of the NCF focus on multiple sectors including health, nutrition, education, labor, finance, water and sanitation, and social and child protection , our seaTo retrieve policy documents, the first author (MA-O) conducted a primary search in the e-repository for Kenyan government documents, government ministries  websites, county websites and national councils' websites among others. Search terms used include policy  and ECD  and center-based care  and terms related to under-fives. We limited the search to policy documents published since 2010 when the Kenya Constitution was promulgated and the ECD function devolved to county governments.We included national policy documents and county integrated development plans (CIDPs) that addressed issues relating to ECD and components of the NCF  for children under 5 years. These documents were published in English spanning from 2010 onwards (the Kenya constitution was promulgated and the ECD function devolved to county governments). All the most recent 4-year CIDPs from all counties in Kenya were included. Policy documents that focused on topical issues other than ECD and components of the NCF, those focusing on children above age 5 and published prior to, and beyond 2010, were excluded including those published in languages other than English.The titles of all policy documents were first scanned and reviewed by two members of the project team (MA-O and HE), to remove duplicates and other unrelated documents that did not address the objective of the review. Policy documents meeting the inclusion criteria were labeled “yes” and those not meeting the inclusion criteria were labeled “no”. To avoid incorrectly excluding policy documents that met the inclusion criteria, we erred on the side of caution: when in doubt we reviewed the full text of policy documents and discussed it with some of the review team based in Kenya . Any disputes were resolved after consultation with senior members of the team  as well as a policy expert in Kenya (GEO).Eleven members of the review team  initially extracted policy details including title and year of publication, aims/goals, focus on center-based care, ECD and related terms, urban poor/ informal settlements, components of the NCF as detailed in good health, adequate nutrition, responsive caregiving, opportunities for early learning, and security and safety) as detailed in To comprehensively extract policy documents to reflect the NCF components addressed by each of the policy documents, a coding key was developed to match each detailed element listed under the five main NCF components  levels to understand the policy and planning context, the extent to which the components of the NCF have been addressed within policies and plans and any perceived gaps or challenges to their inclusion in future. Nairobi County was the only county involved in the qualitative interviews as this policy review has been nested within a larger feasibility study being conducted in Nairobi . This inParticipants were selected using purposive sampling including national policy makes and county-level decision-makers of different levels of seniority within departments that focus on child health, child protection, development, and early years education. Both telephone and face-to-face interviews were utilized based on participant's availability, prevailing COVID-19 restrictions, and convenience. All the face-to-face interviews were conducted at the participants' workplace and the telephone interviews were held at a time convenient to the participant. A semi-structured interview guide was used to facilitate the interviews and included views on ECD and its perceived importance to government policy, details of any policies, plans or guidance at national and county level relating to child health and ECD and the extent they aligned to the NCF domains, the age groups addressed and any specific focus on childcare centers for vulnerable communities. The questions were open-ended and allowed flexibility to focus on areas of relevance to the participants. The interviews were conducted by LO, PA, MN, KO and PW, all of whom had experience in qualitative methods. Before the interviews, the researchers introduced themselves to the participants, explaining the objectives of the study.n = 20 participants were anticipated and interviews continued until data saturation was achieved . The audio recorded interviews were transcribed soon after the interviews, anonymized and combined with the notes taken by the interviewers during the interview sessions. Due to time constraints, the transcripts were not returned to the participant for comments and/or corrections. However, findings were shared at engagement events with policy and decision makers.An initial sample size of The analysis process followed the stages outlined in the Framework Approach  with then = 15 duplicates were removed, n = 21 were excluded after title screening and n = 91 were assessed against the inclusion and exclusion criteria. More than half (n = 66) met the inclusion criteria and n = 25 was excluded .“Responsive caregiving received limited coverage within national policies and CIDPs, see Responsive feeding was one area that did have a budget allocation in 21% of the CIDPs. This reflects the general trend for a stronger focus on health and nutrition than early childhood development particularly for the youngest children. Several policy makers highlighted the challenges of addressing areas such as responsive care and other aspects of early childhood development as the issues often fell between sector ministries:I must agree we have had a challenge before because we really did not bring out the ECD the way it's supposed to be. You remember this thing cuts across two ministries. That's where the challenge is: there is the Ministry of Education, then there is the Ministry of Health. Education will say our work is to take care of these children in school from PP1 [pre-primary 1].The Ministry of Health will just say we take care of them when they are at home. Under whose supervision are these centers [childcare centers for 3 years and below], we are not sure whether they are under the Ministry of Health or under the Ministry of Education and that's why we must have a policy in place.” .“National and County level decision-makers highlighted that the challenge of working across sectors was also experienced at County level:The gap which is there is the collaboration. This is lacking because they devolved the health and they devolved ECD” .“National policies indicated strong coverage for the sub-domains of play, reading and story-telling groups, support for early learning and quality day-care and pre-primary education, see The high proportion of CIDPs allocating budget to day-care and pre-primary reflects the progress made on provision of ECDE centers. Across all 47 CIDPs we found the implementation plans mentioned a total of 33,919 ECD centers, both public and private that are already up and running. Seven counties specified plans to increase the number of ECDE centers potentially adding a further 1,455 nationally. Policy and decision-makers, particularly at County and sub-County levels highlighted challenges with the regulation of the ECDE centers. This was seen as a particular problem in urban areas such as Nairobi where a plethora of private and NGO centers have sprung up to meet the high demand, yet lack of policies guiding engagement and regulation with the private sector undermines progress on implementation:We don't have that clear guideline on supporting private institutions, private institutions that are the majority” .“Attention to quality is a key aspect of this sub-domain, and it should be noted that of the 19 counties that specified a child: staff ratio in public sector ECDE centers, average ratio was one staff member to 47 children. The National Pre-Primary Education Policy Standard Guidelines (2018) specify no more than 25 children (age 4–5 yrs) per class so even for this age group, this ratio is clearly above the 13 recommended level. Several policy makers also indicated concerns about the quality of ECDE centers:They should offer directions especially on issues regarding nutrition and WASH. They should ensure they offer supportive supervision and mentorship and coaching to the managers of these ECDEs because most of them don't know which food to give the children that have been brought to their 403 facilities, issues to do with water, sanitation and hygiene is also not well looked up, and also during Covid, they broke covid protocols.” .“Most CIDPs did not specify the age-range of children targeted by these ECDE centers. In the CIDPs that did specify the target age for child attending the ECDE centers, none covered children from 0 to 3 years old. This reflects the national policy position with a National Pre-Primary Education Policy addressing the 4–5 year olds, but with little policy focus on those 0–3 years. While the provision of daycare and pre-primary education category scored highly in policy and CIDP coverage, it should be noted that this was limited to pre-primary ECDE centers, and there was very limited mention of center-based care for children 0–3 years. Participants in the qualitative interviews explained that provision for those children 0–3 years was at the discretion of each county:One of the roles of the county government is that, to undertake the early childhood education which now takes care of the three to five years. So, each and every county is supposed to factor that one as a budget proposition. The other area is that Nairobi County right now we have started talking about childcare centers” .“While some counties, such as Nairobi are addressing the challenges of day-care provision for children 3 years and below, an interview with a sub-county level manager, indicates that there may well be a perception that children of this age are cared for at home by their mothers, and therefore center-based care is not necessary:I think mainly children under three years you know have not started school, most of them, so you find them at home. So we give them services at the household level this includes health education to 424 the mothers, treatment of minor illnesses at household level by the CHVs like diarrhea.” .“Furthermore, similar to the challenges of addressing the wider domains of responsive care and learning opportunities, was the lack of a clear ministerial remit for early years' child-care centers. However, several policy makers alluded to recent activity to address this gap:Then the question is for example where are the early centres or centres for taking …. your small baby to be taken care of? Under whose supervision are these centres? We are not sure whether they are under the Ministry of Health or under the Ministry of Education and that's why we must have a policy in place. And it's like a month ago the division brought together key partners from the Ministry of Education different departments nutrition, social services just to try and bring out– Come up with a policy that will address this early childhood development.” .“Within the “safety and security” domain, the provision of safe water and sanitation was given good consideration both within national policies  and withDecision-makers highlighted the importance of water and sanitation which was consistent with the focus on this element within current policies and county budgets. County and sub-county policy makers within Nairobi frequently mentioned the difficulties of implementation of adequate water and sanitation for children within urban environments and the impact this would have on health. The other aspect of this domain that emerged as a priority for policy makers was the security of children within schools in terms of protection from violence, security and allowing safe places for play, again, this emerged as a particular issue for decision-makers within Nairobi:A safe environment at school is provided. We have taken care of them in school and also a very good environment for them to play” .“Again, the challenges of providing this within urban environments was recognized:Learners should be in an enclosed place with security, you know the urban areas have a lot of 337 challenges” .“The analysis of the qualitative coding displayed in Budget allocations, particularly within the devolved structures, were identified as one reason behind the limited focus on ECD beyond health and nutrition. There was also a concern of limited clarity on which level of government should fund implementation, with concerns from the national level that despite counties having devolved budgets, activities were left to the national level:Now the only problem is who should carry that burden! You see, like now we are carrying it. The National government may not have allocated funds and money for the National ECD office. It is saying those are devolved functions.” .“To our knowledge, this review is the first to systematically scrutinize health and education national policies and all 47 CIDPs in Kenya to assess coverage of the NCF. The review, coupled with the qualitative findings highlight the priority given to nutrition, water, sanitation and hygiene and the limited coverage, particularly in terms of budget, given to the domains of responsive caregiving and Opportunities for early learning domains. This reflects the historical focus on child health in both policy, practice and research, but it is disappointing given the initial progress in Kenya with the integrated ECD Policy Framework of 2006. However, this does reflect the global situation across many LMICs where ECD and education are still an emerging area of government responsibility and scholarship . In partOur findings, particularly from the qualitative interviews highlight that the complexities of addressing this multi-sectoral challenge require more than funding alone. The challenge of working across sectors in an integrated fashion was a consistent view across our respondents. Yet the need for this multi-sectoral action to address ECD is frequently emphasized , 31. TheConsideration of responsive care and early learning for children below 4 years of age is a clear gap within national policy and county plans in Kenya. The lack of policy and plans for this age group undermines services and support for nurturing care both within the home and out-of-home interventions such as childcare centers. This is acknowledged as a global policy and practice gap and means that services for the youngest children are often uncoordinated across a plurality of public, private and informal providers with varying quality and inequitable access . Where AAnother consistent gap was the limited attention given to the role of fathers within policy and plans. This is despite evidence from national surveys across 38 LMICs identifying a significant relationship between fathers' interaction with their 3 and 4 year olds and their ECDI scores . TraditiAlthough we made efforts to retrieve all relevant documents, county level laws and acts were not available. Furthermore, the qualitative interviews with policy makers only covered Nairobi County and without the remaining 46 counties in Kenya, hence views expressed by the Nairobi County policy makers may not be representative of other counties. As the qualitative interviews were only conducted with officials from health and education departments, the presented perspectives lack the views of those from other departments which deal with children's issues such as social protection.Given the rapidly changing context of families including growing participation of women in the labor force, there is a need to ensure Acts and policies reflect the realities of childcare, as well as those in the informal sector.A thorough review of the Labor Laws of Kenya to understand the extent to which they provide a family-friendly environment for parents, particularly working mothers, through the provision of childcare facilities, maternity and parental leave would be a valuable addition to this research.As much childcare happens in the home in rural areas, good support for this is needed especially in relation to responsive caregiving and support for early learning that can build on existing strengths in the community health strategy.Policies specifying minimum standards and plans which provide support for improvements across all domains of the NCF are needed including family-friendly policies in the workplace and affordable childcare services.Understanding the values and strengths of the local context and community participation is key to feasibility, effectiveness and sustainability of strategies that address ECD.There is also the need to identify responsible department(s) in relation to childcare services and to conduct further research that will help countries to develop appropriate models of care that are feasible for implementation at scale, build capacities for implementation, and obtain context-specific cost data. This data will also support identification of innovative solutions to increase access, quality, and coverage of services.Given the time and resources available for this review, we were unable to analyse budget allocations to the elements of the NCF at national or county levels. Extending this analysis to also cover the extent to which county governments meet the targets set out in their monitoring and evaluation plans would allow a thorough review of progress toward implementation of the NCF.This research aimed to establish the extent to which Kenyan government policies address the components of the NCF and to explore policy/decision makers' views on policy gaps and emerging issues. Findings indicate a strong focus on nutrition, water, sanitation and hygiene with clearer policies for children aged 4–5 years and gaps in the provision for children under 3 years in both national policies and county integrated development plans. Furthermore, limited coverage of responsive caregiving and opportunities for early learning domains were found in the CIDPs particularly with a lack of budgeting and plans to involve fathers within early years care. The NCF provides a roadmap for action to address wide range of stakeholders and sectors, conveying key roles involved in giving children the best start in life. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains. Although some Counties within Kenya are ahead of others, this offers opportunities for cross learnings between Counties with inputs required from a range of sectors through policies, services, infrastructure, and information to improve the holistic development of children. Furthermore, early integration of nurturing care relevant content is needed, complemented by in-service training and continuing education of existing workforce. Nurturing care is so embedded within the lives of each family and child thus, communities can play a major role in creating enabling environments that benefit both caregivers and children.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Health Sciences Research Governance Committee, University of York and Amref Research, and Ethics and Scientific Review Committee. The patients/participants provided their written informed consent to participate in this study.HE, MA-O, MN, GO, EH, RH, and PG developed the protocol and concept of the review. MA-O, PK-W, KO, IC, MW, RM, LO, EH, MM, EM, and HE screened and extracted data from the included policy documents. MA-O and HE synthesized the policy data findings, conducted the overall synthesis of results, and drafting of the manuscript with input from MN, GO, PA, LO, RH, and PG. All authors read and approved the final manuscript.This research was funded as part of a British Academy Award Grant Ref: ECE190115 and Medical Research Council GCRF Impact Fund Ref: G0086101 0026 for funding the article publication charge.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Although cost-effective, it lacks a broader roll-out. This might be attributable to undefined context, mechanisms of change, and a lack of communication; therefore, this study explores how the new model works and where problems occur. (2) Methods: Semi-structured interviews on motivation, expectations and experiences with 20 involved experts. Experts were members of the company health promotion team, service users, and cooperating mental health specialists. Analysis was conducted with ATLAS.ti. (3) Results: The conceptual framework comprises three main topics: (a) structured implementation concept; (b) persons involved, shaping the concept’s processes; (c) and meaning and function of the offer within the given context. Concerning (c) we found three potential areas of conflict: (1) intra-corporate conflicts, (2) conflicts between company and employee, (3) and conflicts between the company health promotion and the health care system. Category (c) comprises the offer’s core characteristics which were described as low-threshold and preventive. Furthermore, the offer was perceived as convenient in handling, confidential, and having immediate impact on a person’s well-being. (4) Conclusions: Here we define structures, address the needs of the involved persons, and communicate foreseeable areas of conflict influences whether the implementation of the intervention succeeds. Common mental disorders (CMDs) such as depression and anxiety place a substantial burden on the economies of many developed countries . DespitePsychotherapeutic consultation in the workplace (PSIW) stands for mental health care that is offered at the worksite. In the context of this collaborative care model, a mental health specialist visits a company to offer consultation for employees. This kind of model resembles the consultation–liaison model applied in psychosomatic medicine , the outCollaborative worksite mental health care allows to improve mental health, facilitates return to work ,19,20,21Although being efficient and cost-effective , such moIn the study context of the German health care system, patients with common mental disorders are regularly treated with psychotherapy by physicians specializing in psychiatry or psychosomatic medicine or by psychological psychotherapists. Treatment is usually delivered through private practices, the outpatient clinics of psychosomatic hospitals, and psychosomatic departments or psychosomatic outpatient clinics at general hospitals . In the When implementing a new health care offer within an organization, the challenge consists in understanding the complex field being characterized by an intensive interplay of medical, psychological, social, and cultural factors . A few PDue to a missing conceptual framework, the application or further implementation of an intervention such as PSIW is largely limited . As a reAs design we chose an explorative, cross-sectional, qualitative case study. It was part of the mixed methods study entitled ‘Psychosomatic consultation in the workplace—a new model of care at the interface of company supported mental health care and consultation-liaison psychosomatic’ . For theThree companies piloting the PSIW model and collaborating with external mental health specialists were included in the study. The health care service has been established regardless from study conditions and is based on individual contracts between local health providers and the company or the company’s health insurance fund.Any person involved in the new model of care was qualified as an expert. We conducted the study with persons from three companies and two hospitals in two regions in southern Germany. The participating companies and hospitals, representing two local networks of collaboration decided to start a research project funded by a third party . The comAt that time, the investigated company sites employed between 80 and 90% men working in technique-based occupations . Representatives of the company’s health promotion team were recruited in all three companies. External experts in mental health were working in two clinics and collaborating in three companies. Service users were recruited consecutively from one company specializing in security systems. Workplace health promotion representatives are persons within the company who foster and implement interventions or policies within the organization to maintain and promote employees’ health. Within this framework, the teams were comprised of occupational health physicians, members of the work council, and HR professionals. The two participating outpatient clinics provide mental health care specialists from the Department of Psychosomatic Medicine and Psychotherapy at Ulm University Medical Center and Sonnenberg Klinik, Division of Psychosomatic Medicine of the ZfP Südwürttemberg, Stuttgart, a local provider for in- and outpatient mental health care.At that time, the investigated company sites employed between 80 and 90% men working in technique-based occupations . Representatives of the company’s health promotion team were recruited in all three companies. External experts in mental health were working in two clinics and collaborating in three companies. Service users were recruited consecutively from one company specializing in security systems. Workplace health promotion representatives are persons within the company who foster and implement interventions or policies within the organization to maintain and promote employees’ health. Within this framework, the teams were comprised of occupational health physicians, members of the work council and HR professionals.The goal was to conduct 20 semi-structured interviews see . While cOn average, an interview took 24 min ranging from 13 to 38 min. Interviews were conducted by AA at the Department of Psychosomatic Medicine and Psychotherapy in Ulm or at the interviewees’ workplaces from November 2012 until February 2014. The PSIW offer was implemented in each company at least 1 year before  we started with the interviews. The quantitative data assessment took place from November 2011 until June 2013.At the beginning, a semi-structured interview guide see  was deveBefore establishing the interview guide for the rest of the process, adjustments were made after the first interviews. During the process, data were obtained via interviews and afterwards digitally audio recorded, anonymized, and transcribed verbatim by a professional transcription service. The transcripts were imported into ATLAS.ti for further analysis.The basic procedural rules of grounded theory  were appReflexivity was maintained by the research team during the process of analyzing and challenging established assumptions. The study design was developed by ER, RK, HG, MH, and DM. ER, TP, EB, HG, JW, and MH were involved in organizing PSIW services. DM accompanied this process as an occupational health physician. In addition, DM, KM, and AA, who were not involved in the offer, took care of the data analysis. A group of various experts in sociology, psychology, psychosomatic medicine, and occupational medicine developed the concept in cooperation.The conceptual framework comprises three main elements that are important in implementing an intersectoral offer of cooperation between statutory health care and company health promotion . FirstlyImplementation comprises the steps that should be performed in preparation for the process from an interviewee’s perspective and which, from an organizational and structural point of view, have proved to be helpful in the process of implementation.At the beginning of the implementation process a needs assessment is required and distinct key events need to be defined . The question was raised whether PSIW should be situated on the company premises or outside of the company. Concerns about privacy on the one hand and convenience on the other hand were noted. The fear of being stigmatized by peers or supervisors in case of being seen when using this mental health care service was reflected by the interviewees. Keeping private matters private was indicated to be more difficult with PSIW being situated at the company site , A2.8. FReflections on the role of the occupational health service, the company, the service users, and the external mental health specialist are outlined together with general statements .The company doctor was perceived as the primary in-house contact for all health issues by the company health promotion team and the external psychotherapists. Service users did not share this view see . In the The occupational health service was considered to pave the way for PSIW. In detail, the utilization of PSIW was supported by structures such as the occupational health service facilities, procedures such as appointment making and encouraged by the atmosphere of confidentiality and preparatory consultation by the occupational health physician .Service users felt empowered by the PSIW offer  was stated to require ongoing or acquired specialization in psychosomatic medicine (or a referring discipline such as psychotherapy or psychiatry). A clear definition of the role of an external psychotherapist has been requested by the service users and the members of the company health promotion team. The external psychotherapist should be the same person for a while and not being employed by the company to keep the distance (Quote B4.1). Furthermore, their role should imply knowing the company’s workflows and being informed about work-related mental health problems (Quote B4.2).Concerns and positive appraisals about the offer .The topics were perceived to be the same in PSIW and regular care, while the changed structural preconditions in PSIW were reported to have an impact on how therapy was delivered: For example, seeing a patient less often or only in a very fixed time frame .Offers in regular care were mentioned to be insufficient. The company mental health promotion team perceived the existing mental health care system as fear-inducing, and difficult to access and utilize. Inflexibility to use tailored interventions was reported by the external psychotherapists. Efforts to overcome this barrier were only experienced in cases with individuals with high levels of suffering. Bad experiences, stated by service users, enforced this impression (Quote C1.3_7 to Quote C1.3_9)Too long waiting times in external offers were raised as a topic from different perspectives. It was noted that especially persons in need, with an ambivalent motivation for treatment, often gave up seeking help in the face of long wait times (Quote C1.3_10 and C1.3_11).The societal context is comprised of statements dealing with the work environment, stigmatization, and perception of mental health problems.High workload and flexibility requirements for employees were stated as a challenging working environment and as a risk factor for developing mental health problems. The meritocratic labor market was blamed for leaving no space for slowdown or weakness. There was general agreement that more and more stress is put on the individual person these days. Service users perceived stress-related disorders as consequences resulting from these circumstances (Quote C2.1 and C2.2).The stigma of mental health problems poses a barrier to qualify certain problems as mental health issues. Thus, it hinders help-seeking behavior for adequate treatment. The fear of jeopardizing their career was expressed. A different perception of PSIW is expected to change attitudes (Quote C2.3 and C2.4).With regard to the implemented structures, the interacting parties and the context workplace, key features of PSIW can be defined as follows:A low threshold access: PSIW was stated to be easily accessible. Referrals were reported to be predominantly performed by the company doctor. Due to the missing sterile hospital atmosphere, service users can be more relaxed (Quote C3.1–3);Preventive character: The company health promotion team experienced PSIW as a tool to reach individuals early in the course of disease. External psychotherapists reported it as a means to prevent severe mental disorders and chronification (C3.4–5);Convenient and simple handling: local closeness of worksite, rapid appointment allocation, little expenditure of time, and easy integration into daily work routine were stated to contribute to convenient and simple handling of PSIW from all three perspectives (Quote C3.6–8);Confidentiality and sense of security: Users and staff alike described the offer as being confidential, which means that they users can have access to it, without being recognized by colleagues. Having the possibility to go there unseen was named an important feature of the service . For an overview of quotations on the above-mentioned points, see We found that PSIW appears to be a plain and simple intersectoral offer but must deal with several conflicting interests: the employer must balance between support and control; the employee between obtaining support while keeping privacy and the two involved sectors between competition and collaboration. Regarding these aspects and as stated above, our participants reported a favorable evaluation of the PSIW, but also mentioned potential or even reoccurring problems and conflicts. In the following section we discuss potential problems concerning the main elements that emerged in our study.As we showed in our results, there are some problems concerning PSIW which need solutions to enhance PSIW. Often, certain aspects of the PSIW can be interpreted both as unique advantages and as disadvantages, depending on the point of view, role, and subjective perception of the stakeholder. Therefore, we would like to outline these fields of tension in the following section, discuss the disadvantages from different perspectives, and try to find solutions.The results showed that part of the preparation of PSIW is a prior needs assessment and a sensitization in a way that the organization and stakeholders must open up for the intervention. There often is a tension between an unrealistic and rising need for treatment and the realistic possibilities and capacities of PSIW. It is therefore important to provide detailed and transparent information about what PSIW can perform and who its target group is.Another tension described in the interviews was between ‘need for privacy vs. closeness to the workplace’. This conflict should be considered when implementing a PSIW. While employees were concerned about being seen on their way to therapy, psychotherapists saw the proximity to the work environment primarily as a strength, in order to gain an insight into the reality of work life of employees. To reconcile these two needs, the PSIW can possibly offer therapy sessions also outside the workplace, for example in the rooms of the provider of the PSIW. Vice versa, one possibility to facilitate treatment by making the therapist familiar with the working environment can be by offering factory tours for the therapists as an opportunity to become familiar with the workplace.Problems can also occur when the persons involved are perceived in an ambiguous way. This was evident in our data when, for example, the service users’ perception of the role of the company doctor differed too much from the self-perception of the doctor. This for example can lead to problems of trust when employees perceived the doctor as being more loyal to the company than to the employees. Such problems should first of all be clarified by the persons themselves, and if possible also by the company. Issues of trust might also generalize on other providers of the PSIW, when the relation between employee and company are too damaged. If trust cannot be restored, PSOC might be a more effective alternative.Under point 3.2.5 we stated several general problems which were named in the interviews. Namely these were a limited time frame, organizational challenges, disappointment, limited power to influence the organizational part of work-related problems, and misuse of PSIW. The interviewees addressed these issues directly. These problematic areas should be considered in the further development of the PSIW. Making the possibilities and limitations of PSIW clear to all stakeholders is a prerequisite to avoid unfulfilled expectations and disappointment.Nevertheless, it should be examined whether psychotherapists can be provided with a framework within the organization where they can discuss frequent work-related problems which are not related to the employees but to the working conditions and work organization.Under C1 we analyzed areas of potential conflict. Firstly, a tension between PSIW as enriching vs. competing to the company health program, was described. This means that conflicts between the company health promotion team and the PSIW employee can occur, if responsibilities are not clearly defined. Some points seem necessary here to provide a fruitful collaboration of the PSIW and other actors in the company and prevent such conflicts: 1. The employees of the company health program should be closely involved in the implementation of the PSIW; 2. responsibilities and duties should be mutually clarified between employees of the PSIW and the company. This seems to be essential to ensure that PSIW complements the company’s offerings meaningfully without disrupting existing structures.Secondly, another problem field identified in the interviews is the role of PSIW as a bridge between company health promotion and PSOC. From a company’s perspective, PSOC was often seen as fear-inducing and difficult to access, especially for patients with ambivalent motivation for treatment. Here again, it is necessary to clarify existing limitation of the PSIW. For reasons of duration of treatment, it cannot replace the regular care of mentally ill people. The limitations of the offer should therefore be openly discussed with company health service and service users to adapt expectations and provide an eventual transfer of a service user to PSOC. Furthermore, structures between PSIW and PSOC should be created to facilitate a pathway to further treatment. Patients who have used PSIW as a low-threshold offer can be motivated and supported in finding therapists in the regular care system.Finally, the problem of the role of mental illness in the social context exists. Mental illness is strongly stigmatized and misunderstood in many social structures and it often takes time to develop an understanding of the subject. Therefore, a more open perception of mental illness (in a company) is important for the successful establishment and use of PSIW in the company. If service users feel ashamed when visiting a PSIW, they will probably not use it. One option is to run additional campaigns to raise awareness about mental illness at the time of the introduction of PSIW.Regarding PSIW intervention, the context is crucial for understanding the mechanism of change because it is an intersectoral offer. Even though it is designed for the individual, the offer and its meaningful characteristics largely depend on its context. From an organizational perspective, there is a strong input if and how the offer works. This is why there is a need to describe a conceptual framework for organizational interventions . FurtherTo benefit the most from the intersectoral nature of the PSIW offer, it is crucial to define a framework and discuss the issues we written under A2 Organizational and Structural framework. Anticipating areas of potential conflicts can help to find which representative should be involved. We found that making PSIW part of an existing health promotion program is crucial. This goes hand in hand with the conclusion by Rothe and colleagues  which stMaking the intersectoral offer work means understanding the social space. With our list of involved persons, we propose who should be taken into account, as these persons or the organization itself, such as Damschroder et al.  posited,A question yet to be discussed is the applicability of the PSIW for companies of different size and there is little research on this issue. One attempt to close this gap is a recent study, that tried to examine how a service such as PSIW works in small- or medium-sized companies . TheoretThrough our interviews, the following six main characteristics of the PSIW were identified:1. Low-threshold access: all interviewed parties appreciated and acknowledged the low-threshold access;2. Preventive character of the offer: Company professionals as well as professionals working in the mental health care system confirmed the preventive character of the offer. These two aspects comply with the early intervention urgently drafted by the OECD . The sta3. Convenient and simple handling: Users and providers described the offers as being easy to integrate into daily (working) structures of the participants. The PSIW was easy to reach by the participants and thus compatible with regular working days. Thus, another structural barrier of PSOC can be overcome with a workplace-based offer ;4–5. Confidentiality and sense of security: Both of these features are crucial for the offer and need to be installed actively and not simply taken for granted. This holds true for any medical treatment, especially for an initial psychotherapeutic contact . In ligh6. Quick fix: At last, PSIW has proven to be a prompt answer to acute mental health problems, avoiding a lot of bureaucracy in order to obtain a first appointment. This has been confirmed and complies with other offers managing waiting periods within 2 weeks for a first interview . In thisThe six characteristics reported above describe desirable features of the offer. It seems that the PSIW offers useful support of employees as long as these features are fulfilled.This study is the first study to develop a comprehensive conceptual framework of a new and collaborative mental health care offer in the workplace. The comprehensive design of the offer, its context, and significant relations were noted in detail by interviewing stakeholders from the company, service users, and collaborating specialists from the existing mental health care system. Yet, there remain some limitations to this study. The overall impression of the offer PSIW appears quite positive, even though a large part of the results deals with ‘areas of potential conflict’. The positive appraisal might be due to the fact that only involved stakeholders were interviewed. However, earlier studies of our group with persons involved and not involved drew a similar picture ,39. FurtAs mentioned above, the interviews were conducted between 2012 and 2014. One limitation therefore can be that some reports refer to an earlier state of PSIW. In our region, PSIW has been further implemented. Recent studies  have shoMembers of the research group were involved in making the collaborative PSIW model and are convinced that it is beneficial. In order to allow critical discussion, a mixed research team according to the level of involvement and educational background  was built.As mentioned above, research on PSIW should be continued. Questions regarding the generalization of our results to other regions or companies are yet to be answered. One attempt to examine these questions in more details is the recently started ‘friaa project’ , that inWhat makes the intersectoral offer PSIW work is a well-dosed interplay of structures, persons, and institutions as well as the corresponding context. Areas of potential conflict within the company, between employer and employee, as well as between company health promotion and the existing health care system should be considered in advance. Addressing these issues helps to prevent them from being obstacles to implementation. In addition, it fosters synergies and the build-up of the aforementioned characteristics of ‘Psychotherapeutic Consultation in the Workplace’. Even though PSIW has only been implemented in central and northern European countries, the concept can be adapted to other global areas when paying attention to the abovementioned aspects of implementation and conflict. Here, basic requirements such as the presence of an occupational health service should exist to guarantee its functioning. However, since realization  primarily depends on the company and an institution providing the service, it functions are relatively independent of local factors such as the health care system and can be flexibly applied to varying circumstances.