Background: Inefficiency is widespread in health systems all over the world. The World Health Organization (WHO) estimates that 20%-40% of the global health spending is wasted. In African countries, inefficiency of this magnitude will seriously hamper progress towards achieving universal health coverage and other health system goals. It is thus, significant to assess the efficiency of health systems over time in order to set the ground for identifying the contextual factors leading to inefficiency and design appropriate efficiency-enhancing measures.
Methods: Using panel data for the years 2000, 2005, 2010, and 2015, the study employs a time-variant stochastic frontier production function to assess efficiency. The input measure used is current expenditure per capita in purchasing power parity (Int$) terms and the measure of output is health-adjusted life expectancy (HALE). Moreover, mean years of schooling, GDP per capita in Int$, and out-of-pocket payment as a share of current expenditure on health were used as technical inefficiency effect variables. Data were analyzed using Frontier Version 4.1.
Results: The mean technical efficiency scores were 79.3% in 2000, 81% in 2005, 85.6% in 2010 and 88.3% in 2015. Over the four periods of time, Cabo Verde registered the highest technical efficiency scores, while Eswatini and Sierra Leone had the lowest. The minimum technical efficiency scores were 58.7% (in 2000), 59.1% (2005), 67.4% (2010) and 71.8% (2015). These indicate that despite improvements, there is a significant degree of technical inefficiency. Most of the countries among those in the bottom 10% efficiency scores are countries in Southern Africa, which in 2015 had a very high prevalence of HIV among adults, compared to the top 10%, which had prevalence rates of less than 0.1%.
The mean efficiency score increased progressively over time – a nine percentage point increase between 2000 and 2015. The elasticity of current health expenditure was positive (0.06) and statistically significant. All the technical inefficiency variables had no statistically significant effect.
Conclusions: Over the period of time covered in this study, there was some improvement in the average technical efficiency scores. However, there was also marked inefficiency in many countries, which is likely to hamper their progress towards universal health coverage and other health system goals. In a context where health spending is too low to provide needed services, it is imperative to address the causes of technical inefficiency and produce more health for the money. Furthermore, low-performing health systems should learn from their relatively high-performing peers.

Objective: Poor adherence to antihypertensive medication occurs in 50%-80% of patients. An ongoing randomized controlled trial (RCT) is evaluating a personalized mobile-health intervention in poorly adherent hypertensive persons with bipolar disorder. To enhance efficacy, the ongoing trial elicited guidance from a Stakeholder Advisory Board (SAB) comprised of patients, family members, clinicians, and health system administrators. Our goal is to describe the formation, role, decision-making process, and key contributions of the SAB as a means of demonstrating meaningful community engagement in mental health research.
Methods: Using models and measures from the field of implementation science, eleven SAB members convened across three meetings followed by quantitative surveys that assessed SAB member satisfaction and engagement during the meetings.
Results: Significant suggestions from the SAB included 1) expanding inclusion/exclusion criteria, and 2) operationalizing remote implementation of the RCT. Primary study implementation challenges identified by the SAB were 1) participant difficulty engaging in the mHealth intervention, and 2) identification of procedures for monitoring participant adherence to the RCT protocol and contacting under-engaged participants. Quantitative surveys indicated that all SAB members believed that the objectives of the meetings were clear, perceived that they were able to participate in the discussions, and that they were heard.
Conclusions: Increasing evidence demonstrates the feasibility of engaging with SABs in clinical research and that this process improves intervention design, increases participant engagement, reduces mental health-related stigma, and produces more effective implementation strategies. We encourage future investigators to use an implementation science framework in partnership with SABs to refine their proposed interventions and improve clinical outcomes.

Growing research recognizes the importance of evaluating life satisfaction in promoting psychological well-being (PWB) among middle-aged and older adults due to its heightened importance for public health relevance. The current study assessed the relationship between life satisfaction and living arrangement among U.S. adults aged 50 years or older and whether this relationship varies by gender. We used the Health and Retirement Study data from 2010-2014 (7,163 respondents), a nationally representative cohort of U.S. adults aged 50 years or older. The outcome variable was the measure of satisfaction with life on a continuous scale (1-7). The categorical independent variable was individuals’ living arrangements status (living with a spouse/partners (reference category), living alone, living with others; measured in the 2012 wave. We conducted a Generalized linear model in our regression analysis. Controlling for demographic, socioeconomic, and health-related factors, individuals who lived alone or lived with others had significantly lower life satisfaction (β = -0.21, 95% CI [-0.31, -0.11]) and (β = -0.23, 95% CI [-0.38, 0.08]) respectively, compared to those who lived with a spouse/partner. These findings suggest public health policies and programs may need to find ways to increase supportive resources for people living alone or living with others to promote life satisfaction, which is a protective factor for good health.

Objective: To examine coaches’ knowledge, recognition of, and response to, concussion in the adolescent athlete population.
Methods: Using a non-experimental correlational design, adult coaches (N = 120) responsible in the coaching of adolescent junior high and high school athletes were recruited from sports associations and schools in the province of Newfoundland and Labrador (NL). A 28 item questionnaire called Coaches’ Knowledge of Sports Related Concussive Injury in the Adolescent Athlete Survey was provided online.
Results: Majority of participants were knowledgeable of what is a concussion, its causes, and what visual clues observed that indicate a possible concussion in a player. In relation to the Age of coach category, only the 55+ age group responded correctly to what is an example of sport specific activity with body contact. Years of coaching and return-to-play knowledge after a concussion showed incorrect responses for both the step wise approach and the 20-30 minute player participation with no contact. Having attended an education concussion session or not showed no difference on return-to-play knowledge in the step wise approach progression as the majority responded incorrectly with 71.4% (attended an education session) versus 91.7% of participants (no attendance on concussion education), respectively.
Conclusions: Benefits gained through this research study will serve to evaluate coaches’ knowledge and improve standardized concussion knowledge. Such preparation can assist in better recognizing and effectively managing a sports related concussion (SRC) and the potential to facilitate sport policy changes. Actions by coaches can impact preventative education, encourage safe behaviors and the reporting of concussive symptoms by the adolescent, therefore reducing burden on overall long term negative health outcomes.

Background: Mobile health (mHealth) interventions are being tested to improve contraceptive uptake in Sub-Saharan Africa (SSA). However, few attempts have systematically reviewed the mHealth programs to enhance family planning (FP) services among women in SSA. At the same time, more than half of low-income countries’ population have a cell phone. This review identifies and highlights facilitators and barriers to implementing cell phone interventions designed to target women FP services.
Methods: Databases including PubMed, CINAHL, Epistemonikos, Embase, and Global Health were systematically searched for studies from January 1, 2010, to December 31, 2020, to identify various mHealth interventions used to improve the use of FP services among women in SSA. Two authors independently selected eligible publications based on inclusion/exclusion criteria, assessed study quality and extracted data using a pre-defined data extraction sheet. In addition, a content analysis was conducted using a validated extraction grid with a pre-established categorization of barriers and facilitators.
Results: The search strategy led to 8,188 potentially relevant papers, of which 16 met the inclusion criteria. Most included studies evaluated the impact of mHealth interventions on FP services, access (n = 9), and use of FP outcomes (n = 6). At the same time, only one article was interested in implementing a mHealth intervention. The most-reported cell phone use was for women reproductive health education, contraceptive knowledge and use. Barriers and facilitators of the use of mhealth were categorized into three main outcomes: behavioral outcomes, data collection and reporting, and health outcomes. mHealth interventions addressed barriers to provider prejudice, stigmatization, discrimination, lack of privacy, and confidentiality. The studies also identified barriers to uptake of mHealth interventions for FP services, including decreased technological literacy and lower linguistic competency.
Conclusions: The review provides detailed information about implementing mobile phones at different healthcare system levels to improve FP service outcomes. Barriers to uptake mHealth interventions must be adequately addressed to increase the potential use of mobile phones to improve access to Sexual and Reproductive Health (SRH) awareness and FP services.

Quality in healthcare is achievable through quality management systems and enhances service quality, operations, and management. Health organizations that realize quality implementation have high staff satisfaction, client satisfaction, employee cooperation, and commitment from managerial to subordinate levels. However, health systems must address barriers and challenges to attaining desired quality. This study explores Tripoli hospitals’ challenges and obstacles affecting the implementation of quality management systems. It used a quantitative methodology with a semi-structured questionnaire for data collection to interview respondents comprising managerial, directorial, and administrative personnel. The hospital’s management staff consisted of nursing medical quality and general directors. Results from the semi-structured interview indicated that hospital directors in Tripoli city’s healthcare systems face barriers and challenges related to human resource management and organization structure to achieving quality using quality management systems. A total of 189 participants drawn from directorial capacities in Tripoli city’s hospitals participated in the study. Most participants (I = 115) asserted that lack of staff involvement and motivation were primary barriers to hospital quality implementation. Hypotheses 1 and 3 were proved using correlation analysis, but hypothesis 2 was statistically insignificant. The findings recommended that human resource management practices such as staff motivation, fair compensation, and involvement in decision-making are necessary for quality improvement. Furthermore, managerial professionalism and specialty are crucial for spearheading quality implementation, while robust quality policies, protocols, and systems are necessary for quality implementation in Tripoli hospitals. Despite these funds, further research was necessary to align findings with previous studies (achieve generalizability), which attributed that time is the primary barrier to quality implementation in hospitals situated in the region.