This research explores the contribution which systems theories, methodologies and models can make in the design and application of effective performance-evaluation processes. Approaches to performance assessment of organisations are reviewed, and the history and structure of the NHS, its objectives, and dimensions for evaluation are described. Drawing on questionnaire and interview data from health service and civil service staff, and secondary data, current performance evaluation and planning processes in the NHS are described and some problems identified. To test the hypothesis that attention to systemic factors could improve performance evaluation, eight topics are analysed by the application of systems methodologies or models. Four of the topic and methodology or model combinations have received detailed analysis: 1. Making and implementing strategic plans; the Open University's Hard Systems Methodology. 2. Controlling NHS performance through structure and process, e. g. the use of annual reviews, performance indicators; double-loop learning and cybernetic control model. 3. Improving the quality of NHS care; Stafford Beer's Viable System Model. 4. Assessing performance through the outcomes of care; Peter Checkland's Soft Systems Methodology. The areas studied in less detail are: 5. Planning for uncertainty and complexity; 6. Issues related to the politics of health; 7. Reducing the length of waiting lists and times; 8. Planning for health (health promotion and the prevention of ill health).

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Background: Preterm birth (PTM) (< 37 weeks gestation) has been associated with low economic status characteristics like rural residence, county with low average per capita income, poverty, and unemployment. Infants born PTM are at greater risk of health and developmental problems and mortality. The primary objective of this study was to explore the trends in the association between PTM and economic level for Appalachian counties in Tennessee. The results from this study will support hypothesis development for future study on PTM in this region. Methods: PTM data from year 2009 to 2013 for each county in Tennessee was used for the analysis of trend. Proportion of PTM live births for each county and each year was computed to estimate prevalence. Appalachian Regional Commission (ARC) uses an indexbased county economic classification system applying three economic indicators – three-year average unemployment rate, per capita market income, and poverty rate – to classify each county into one of the five categories, namely, Attainment, Competitive, Transitional, At-Risk, and Distressed, that is ranked from best off to worst off respectively. Using this classification by the ARC, Appalachian counties were stratified by economic level to explore the association with PTM prevalence. Results: Forty-three out of 95 counties in Tennessee are defined by ARC as Appalachian. When classified by economic level, none of the counties in the Appalachian region fell into the highest (Attainment) sub-category of economic level for any of the five years observed, and for years 2011 to 2013 none of the counties fell into the second highest sub-category (Competitive) of economic level. Moreover, just one county was categorized as Attainment in year 2009, and just two for the year 2010. Not much difference was observed in PTM prevalence for sub-categories of economic level of Appalachian counties over the five-year period (2013 Distressed 11.67%, At risk 11.47%, Transitional 11.64%; 2012 Distressed 11.51%, At risk 12.10%, Transitional 11.58%; 2011 Distressed 10.04%, At risk 11.52%, Transitional 11.50%; 2010 Distressed 12.03%, At risk 11.42%, Transitional 11.83%, Competitive 11.40%; 2009 Distressed 10.68%, At risk 11.75%, Transitional 11.04%, Competitive 10.85%). Regardless of the inconsistent pattern of PTM prevalence observed for both Appalachian and non-Appalachian counties, the average prevalence for Appalachian counties (2009 11.19%, 2010 11.73%, 2011 11.26%, 2012 11.75%, 2013 11.59%) has been higher than non-Appalachian counties (2009 10.77%, 2010 10.32%, 2011 10.35%, 2012 10.90%, 2013 10.70%) for all years observed. Interestingly, the national prevalence of PTM is declining while prevalence in Tennessee (2009 11.00%, 2010 11.09%, 2011 10.84%, 2012 11.36%, 2013 11.19%) has remained essentially unchanged. Conclusion: PTM prevalence is higher in Appalachian counties of Tennessee compared to nonAppalachian counties. No meaningful change in PTM prevalence was observed by categories of economic level. However, it is likely that analysis based on the aggregate data could have masked the true differences in PTM birth by economic status. Therefore, individual data on PTM and economic status would be necessary to make any inference on the association.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Healthcare providers' (HCPs) recommendations for the Human Papillomavirus (HPV) vaccine are likely to increase the vaccination uptake. However, little is known about Ghanaian HCPs' general practices regarding HPV vaccination. We used Multi-Theory Model (MTM) constructs (i.e. participatory dialogue, behavioral confidence, environment, social and emotional transformation) to examine Ghanaian HCPs' attitudes towards HPV vaccination and their vaccination recommendation practices. Methods We conducted three, 60-minute focus group discussions (FGDs) with HCP in the secondlargest government hospital in Ghana. Sixteen semi-structured open-ended questions based on MTM constructs were used to guide the FGDs. We explored HCPs' general knowledge about HPV, vaccination recommendation behavior, physical environment, and sociocultural factors associated with the HPV vaccination. Data from the FGDs were transcribed and thematically coded using NVivo software. Results The sample of (n = 29) HCPs consisting of males (n = 15) and females (n = 14) between the ages of 29 and 42 years participated in the FGDs. Our analyses showed that HCPs (a) rarely offered HPV vaccination recommendations, (b) showed varied understanding about who should be vaccinated regarding age eligibility, gender, and infection status. Perceived barriers to HPV vaccination include (a) low urgency for vaccination education due to competing priorities such as malaria and HIV/AIDS; (b) lack of data on HPV vaccination; (c) lack of awareness about the vaccine safety and efficacy; (c) lack of HPV vaccine accessibility and (d) stigma, misconceptions and religious objections. HCPs expressed that their motivation for counseling their clients about HPV vaccination would be increased by having more knowledge about the vaccine's efficacy and safety, and the involvement of the parents, chiefs, churches, and opinion leaders in the vaccination programs. Conclusion The study's findings underscore the need for a comprehensive HPV vaccination education for HCPs in Ghana. Future HPV vaccination education programs should include information about the efficacy of the vaccine and effective vaccination messages to help mitigate HPV vaccine-related stigma.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. It has been quite a challenge to diagnose Mild Cognitive Impairment due to Alzheimer's disease (MCI) and Alzheimer-type dementia (AD-type dementia) using the currently available clinical diagnostic criteria and neuropsychological examinations. As such we propose an automated diagnostic technique using a variant of deep neural networks language models (DNNLM) on the verbal utterances of affected individuals. Motivated by the success of DNNLM on natural language tasks, we propose a combination of deep neural network and deep language models (D2NNLM) for classifying the disease. Results on the DementiaBank language transcript clinical dataset show that D2NNLM sufficiently learned several linguistic biomarkers in the form of higher order n-grams to distinguish the affected group from the healthy group with reasonable accuracy on very sparse clinical datasets.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Reducing maternal mortality remains a priority for global health. One in five maternal deaths, globally, are from Nigeria. Objective This study aimed to assess the sociocultural correlates of maternal mortality in Nigeria. Methods We conducted a retrospective analysis of nationally representative data from the 2013 Nigeria Demographic and Health Survey. The analysis was based on responses from the core women’s questionnaire. Maternal mortality was categorized as ‘yes’ for any death while pregnant, during delivery or two months after delivery (as reported by the sibling), and ‘no’ for deaths of other or unknown causes. Multilevel logistic regression analysis was conducted to test for association between maternal mortality and predictor variables of sociocultural status (educational attainment, community women’s education, region, type of residence, religion, and women’s empowerment). Results Region, Religion, and the level of community women’s education were independently associated with maternal mortality. Women in the North West were more than twice as likely to report maternal mortality (OR: 2.14; 95% CI: 1.42–3.23) compared to those in the North Central region. Muslim women were 52% more likely to report maternal deaths (OR: 1.52; 95% CI: 1.10–2.11) compared to Christian women. Respondents living in communities where a significant proportion of women have at least secondary schooling were 33% less likely to report that their sisters died of pregnancy-related causes (OR: 0.67; 95% CI: 0.48–0.95). Conclusion Efforts to reduce maternal mortality should implement tailored programs that address barriers to health-seeking behavior influenced by cultural beliefs and attitudes, and low educational attainment. Strategies to improve women’s agency should be at the core of these programs; they are essential for reducing maternal mortality and achieving sustainable development goals towards gender equality. Future studies should develop empirically evaluated measures which assess, and further investigate the association between women’s empowerment and maternal health status and outcomes.

This is an open access article distributedunder the terms of the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproductionin any medium,provided the original author and source are credited. There is a limited evaluation of an independent linguistic battery for early diagnosis of Mild Cognitive Impairment due to Alzheimer's disease (MCI-AD). We hypothesized that an independent linguistic battery comprising of only the language components or subtests of popular test batteries could give a better clinical diagnosis for MCI-AD compared to using an exhaustive battery of tests. As such, we combined multiple clinical datasets and performed Exploratory Factor Analysis (EFA) to extract the underlying linguistic constructs from a combination of the Consortium to Establish a Registry for Alzheimer's disease (CERAD), Wechsler Memory Scale (WMS) Logical Memory (LM) I and II, and the Boston Naming Test. Furthermore, we trained a machine-learning algorithm that validates the clinical relevance of the independent linguistic battery for differentiating between patients with MCI-AD and cognitive healthy control individuals. Our EFA identified ten linguistic variables with distinct underlying linguistic constructs that show Cronbach's alpha of 0.74 on the MCI-AD group and 0.87 on the healthy control group. Our machine learning evaluation showed a robust AUC of 0.97 when controlled for age, sex, race, and education, and a clinically reliable AUC of 0.88 without controlling for age, sex, race, and education. Overall, the linguistic battery showed a better diagnostic result compared to the Mini-Mental State Examination (MMSE), Clinical Dementia Rating Scale (CDR), and a combination of MMSE and CDR.

To assess tobacco use among school-going adolescents and delineate determinants of their tobacco-use status. The study utilizes Global Youth Tobacco Survey data collected in 2006 (9,990 unweighted; 773,982 weighted). Univariate and bivariate analyses were performed to determine the relationship between the dependent (tobacco-use status) and independent variables. Logistic regression analyses were conducted to identify the key determinants of tobacco use among adolescents in Ghana. The gap in tobacco use between males and females was narrow (6.7% vs. 4.4% for ever cigarette smoker; 2.4% vs. 1.4% for current cigarette smoker; 6.8% vs. 5.2% for user of noncigarette tobacco products). Youth tobacco use was significantly associated with exposure to tobacco industry promotions and tobacco-use behavior of familial relations. Conversely, knowledge about the harmful effects of secondhand smoke was associated with decreased likelihood of tobacco use; however, it was significant only for users of noncigarette tobacco products. The narrow gap in tobacco use among school-going adolescents in a country where tobacco-use prevalence among adult males is more than 10 times that of females is a major policy concern. Additionally, the finding that about 15% of students have either acquired tobacco-branded merchandise or been offered a free cigarette suggest that tobacco marketing is reaching adolescents in the country, which demands urgent policy response. Dealing with such problems requires a comprehensive ban on tobacco industry advertising and promotion and marketing strategies, and policies that restrict youth access to and demand for tobacco products.

Tobacco use in Tennessee is higher than the national average and the decline in usage rate has stalled. The smokefree policy enacted to address this health issues contains several exemptions and does not repeal preemption that was introduced in 1994. In March 2013, the Governor unveiled Health and Wellness Initiatives, including reduction in the use of "tobacco products." To achieve this goal, two approaches should be considered and integrated into the initiative to facilitate the decline in tobacco use - policy and population. On the policy approach, the Governor should consider working for the repeal of state preemption of local tobacco control policymaking by the 1994 Prevention of Youth Access to Tobacco Act, and for removing exemption for certain venues from the Non-Smoker Protection Act. On the population approach, the Governor should consider focusing on young adults as an integral part of the target group and tobacco-free campuses as a strategy for addressing tobacco use among such group. All these conform to the Initiatives' strategy of "localized ownership."