Newborn screening (NBS) programs identify newborns at increased risk for genetic disorders, linking these newborns to timely intervention and potentially life-saving treatment. In the United States, the Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state NBS programs to screen. ACHDNC updated the Recommended Uniform Screening Panel to include Spinal Muscular Atrophy (SMA) in July 2018. As of June 2021, 34 state NBS programs had fully implemented SMA newborn screening, and at least 8 programs were pursuing implementation. This article will review current SMA screening processes, considerations, challenges, and status. Newborn screening (NBS) is a state-implemented public health program intended to identify newborns at increased risk of certain genetic disorders. Some disorders, if undetected and left untreated or detected later within the life course, might cause mild to severe disability and/or premature death for the individual. Through the timely implementation of the newborn screening process, infants detected with these disorders may receive early interventions, potentially reducing short-and long-term adverse health outcomes and improving their overall quality of life. The Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state NBS programs to screen . The appApproximately 1 in every 11,000 babies are born with SMA in the United States each year . However(SMN 1) gene. The SMN 1 gene provides instructions for producing the survival motor neuron (SMN) protein, which is essential for the maintenance of the motor neurons located in the spinal cord and brainstem [As one of the leading genetic causes of mortality for children under the age of 2 years, SMA is a group of genetic disorders that affects the motor neurons in the body. It is primarily caused by defects or mutations in the survival motor neuron 1 rainstem . Motor nThe exact course of the disorder and severity of symptoms differs by SMA type and age of onset. There are five types of SMA. Type 0 and type 1 are the most severe and may result in death in early infancy . IndividSMN1 gene identifies approximately 95% of newborns with SMA. All (n = 34) newborn screening programs currently screening for SMA utilize a real-time PCR (qPCR) first-tier methodology to detect the deletion of exon 7 in SMN1, as seen in SMN2 copy number as well (n = 8), while other programs repeat the first-tier methodology on the original dried blood spot on the next day (a confirmation duplicate). Five states offer a three-tier, high-throughput screening algorithm [n = 25) currently screening for SMA also multiplex the screening of SMA with severe combined immunodeficiency (SCID), a disorder that was added to the RUSP in 2010, and that all states have been screening for since at least 2018 [The exon 7 deletion in the lgorithm . Not allast 2018 .When pursuing full population screening of SMA, there are several phases of implementation, which vary by state, that NBS programs must complete and that impact how long a state may take to achieve population screening. A breakdown of these phases is found in As newborn screening programs prepare for and enter into the second phase  of implementation, there are several factors NBS programs need to consider to ensure readiness to screen for SMA. A summary of SMA laboratory and follow-up screening considerations and questions is elaborated in As of 8 June 2021, 34 state NBS programs are offering population-wide screening for SMA, as seen in The table includes NBS programs that selected “complete” for full implementation. Time is calculated from earliest start date entered by NBS program to the implementation date for statewide screening. Programs that did not provide dates are excluded.Several state NBS programs have noted that SMA is a relatively simple screen to implement since testing for the presence or absence of a gene yields minimal false-positive results, reducing the need to include a second-tier test . When imTo support state NBS programs as they implemented screening for SMA, the Association of Public Health Laboratories (APHL) Newborn Screening Technical assistance and Evaluation Program (NewSTEPs) provided funding and educational opportunities through a cooperative agreement from the Health Resources and Services Administration (HRSA). State NBS programs utilized funding for SMA screening implementation from NewSTEPs to purchase equipment and supplies, to travel to other state newborn screening laboratories for training, to hire staff, to develop educational resources, and to perform software modifications. State NBS programs applied for funding through a competitive and goals-driven request for proposals (RFP) process. State NBS programs also received direct funding from the Centers for Disease Control and Prevention (CDC) and other newborn screening stakeholders and partners to purchase equipment and supplies, hire staff, and complete other implementation activities.Programs receiving NewSTEPs funding achieved the following milestones during the funding period: completed on-site training with PerkinElmer to use Janus G3 Mini and Quant Studio DX instruments; received training on Evoya LIMS software; developed a validation plan, completed SMA-SCID validation and test implementation; procured and validated QuantStudio and Pro real-time PCR instruments; added the SMA screening instrument to the LIMS for testing and reporting; identified and procured needed Perkin Elmer SpecimenGate software modifications for SMA implementation; and developed educational materials. To address educational needs, APHL hosted two national webinar series in 2018 and 2019 to discuss SMA implementation with subject matter experts and to support states as they prepare for screening. Speakers discussed the following: SMA screening methodologies and follow-up requirements and processes, state educational strategies, current approved FDA treatments, long-term implications and outcomes of treatment, and physician experiences treating SMA using Spinraza and Zolgensma.Despite SMA screening being relatively simpler to implement than the other newer disorders added to the RUSP, the timing of implementation in 2020 for the five APHL NewSTEPs funded states coincided with the COVID-19 pandemic, and this confluence of events resulted in several challenges. The specific challenges as described by the funded programs to NewSTEPs via routine discussions and teleconference check-ins are described in States preparing to screen for SMA should consider the program’s capacity and testing needs and begin planning as early as possible to enhance capacity to screen. Planning should include staffing needs, spacing requirements, reagent needs, and instrument capacity to meet SMA screening requirements.When implementing a new disorder during a pandemic, state NBS programs receiving NewSTEPs funding recommend NBS programs perform the steps listed in The ACHDNC updated the RUSP to include SMA in July 2018. To expand and facilitate screening for SMA, the CDC, APHL NewSTEPs through funding from the Health Resources and Services Administration (HRSA), and other NBS stakeholders provided funding and educational opportunities to US newborn screening programs. Through these funding opportunities, state NBS programs purchased the equipment and supplies needed to perform screening. To provide further support to state programs, APHL hosted several webinars to discuss laboratory, follow-up, and treatment considerations for SMA NBS screening.As of June 2021, 34 states have implemented SMA screening, despite challenges and delays due to the COVID-19 pandemic. To assist the remaining states that intend to implement SMA screening, APHL will, through its HRSA-funded NewSTEPs program, continue to provide technical support, educational resources, and funding assistance. APHL will also continue to collect, collate, analyze, and disseminate challenges, successes, and lessons learned during the implementation process in an effort to enable continuous quality improvements and to strengthen the body of data around the national landscape for SMA newborn screening.


Australia’s mental health care system has long been fragmented and under-resourced, with services falling well short of demand. In response, the World Economic Forum has recently called for the rapid deployment of smarter, digitally enhanced health services to facilitate effective care coordination and address issues of demand. The University of Sydney’s Brain and Mind Centre (BMC) has developed an innovative digital health solution that incorporates 2 components: a highly personalized and measurement-based (data-driven) model of youth mental health care and a health information technology (HIT) registered on the Australian Register of Therapeutic Goods. Importantly, research into implementation of such solutions considers education and training of clinicians to be essential to adoption and optimization of use in standard clinical practice. The BMC’s Youth Mental Health and Technology Program has subsequently developed a comprehensive education and training program to accompany implementation of the digital health solution.This paper describes the protocol for an evaluation study to assess the effectiveness of the education and training program on the adoption and optimization of use of the digital health solution in service delivery. It also describes the proposed tools to assess the impact of training on knowledge and skills of mental health clinicians.The evaluation study will use the Kirkpatrick Evaluation Model as a framework with 4 levels of analysis: Reaction (to education and training), Learning (knowledge acquired), Behavior (practice change), and Results (client outcomes). Quantitative and qualitative data will be collected using a variety of tools, including evaluation forms, pre- and postknowledge questionnaires, skill development and behavior change scales, as well as a real-time clinical practice audit.This project is funded by philanthropic funding from Future Generation Global. Ethics approval has been granted via Sydney Local Health District’s Human Research Ethics Committee. At the time of this publication, clinicians and their services were being recruited to this study. The first results are expected to be submitted for publication in 2021.The education and training program teaches clinicians the necessary knowledge and skills to assess, monitor, and manage complex needs; mood and psychotic syndromes; and trajectories of youth mental ill-health using a HIT that facilitates a highly personalized and measurement-based model of care. The digital health solution may therefore guide clinicians to help young people recover low functioning associated with subthreshold diagnostic presentations and prevent progression to more serious mental ill-health.PRR1-10.2196/24697 Australia’s mental health care system has long been fragmented and under-resourced, with services falling well short of demand . Mental …” as a means of potentially addressing demand issues and facilitating effective care coordination [The World Economic Forum has recently called for the “…rapid deployment of smarter, digitally-enhanced health servicesdination . The recdination . Moreovedination . While tdination , it has dination . Consequdination . This indination -20. As sBMC Youth Model, a highly personalized  and measurement-based  model of care generated from over 10 years of longitudinal research led by the BMC to assess multiple clinical and functional domains in young people presenting for mental health care and treatment [Researchers at The University of Sydney’s Brain and Mind Centre (BMC) have developed the Youth Mental Health (YMH) and Technology Program, which adopts an innovative digital health solution to prevent further progression of mental ill-health for young people in care . This direatment ,23. Thisreatment . Findingreatment . The BMCreatment . Though The education and training program has been designed to encourage the adoption of highly personalized and measurement-based care in clinical practice, to ensure young people get the right treatment at their first point of entry into care. Specifically, the program focuses on teaching youth mental health professionals how to assess, monitor, and manage complex needs and illness pathways. The education and training program now delivers information via multimodal tools, including online seminars, case study webinars, and in-service workshops. The HIT is referred to throughout the training, as it aids in facilitating highly personalized and measurement-based care  and supports the choice of treatment options while tracking a young person’s progress.This paper briefly describes the education and training program and outlines a protocol for an evaluation study to assess the effectiveness of education and training on the adoption and optimization of use of the digital health solution in service delivery.The education and training program has been designed to be accessed in-person or online. This has been done to provide access to standardized, high-quality training delivered by experienced clinician-researchers from the BMC. This is particularly important for reaching out to those services that would not ordinarily have access to such opportunities, such as health services in regional Australia. The program is currently comprised of online seminars, case study webinars, and in-service training workshops.The online seminars introduce the theoretical, clinical, and scientific underpinnings of the YMH and Technology Program that provide the background knowledge necessary for clinicians to understand the digital health solution and begin to apply it to their own clinical practice. To date, 6 seminars delivered by experienced clinician researchers (authors ES and IH) have been recorded covering approximately 60 minutes each see  and are A highly personalized and measurement-based model of care to manage youth mental healthCombining clinical stage and pathophysiological mechanisms to understand illness trajectories in young peopleA comprehensive assessment framework for youth mental health careUsing the Brain and Mind Centre (BMC) Youth Model to personalize care options – right care, first time!A youth mental health service delivery model to support highly personalized and measurement-based careMaximizing the use of digital health solutions in youth mental health care, which detail practical application of the digital health solution and help to translate newly acquired knowledge into clinical skills [These online seminars are further enhanced by case study webinarsl skills . Two sucheadspace services in Northern New South Wales have attended in-service training workshops.In-service training workshops will be delivered by BMC clinician-researchers and focus on the practical application of the BMC Youth Model into the specific youth mental health service. The workshops typically include case studies common to the participating service. These workshops can be conducted either face-to-face or online. To date, 2 regional In order to encourage and reward participation in all components of the education and training program, continuing professional development points are available for psychiatrists, psychologists, mental health nurse practitioners, social workers, and occupational therapists. To further encourage engagement, additional specialized supplemental webinars  and case studies will be released, demonstrating how the BMC Youth Model can be applied to specific disorders and complex cases.The importance of a standardized and consistent framework for evaluation of education and training programs has previously been highlighted ,28. EvalThis study will utilize the Kirkpatrick Evaluation Model, which includes 4 levels of training evaluation including: Reaction, Learning, Behavior, and Results  see Tab. This evThe Kirkpatrick Evaluation Model  also higBefore commencing the education and training program, clinicians will be asked to complete a participant profile. This profile includes questions regarding their educational background, professional background, years of clinical experience, and reasons for participating in the education and training program..”). Lastly, participants will be invited to provide qualitative feedback on the education and training program regarding most liked and disliked aspects, major learnings, and expected results of the training .This form assesses clinician reaction (Level 1) to the education and training program, including satisfaction, engagement, and relevance. This form consists of 20 items, of which the first 15 are rated on a 5‐point Likert scale ranging from “1 = totally disagree” to “5 = totally agree,” and the remaining 5 questions represent an open-ended format. Clinician satisfaction will also be measured using the Training Satisfaction Rating Scale, an existing scale with good content validity . This scThis questionnaire assesses clinician learning (Level 2) of key concepts of the digital health solution through the online seminars. This questionnaire consists of 30 multiple-choice questions relating to multidimensional assessment and outcomes, clinical staging and illness trajectories, social and biological development, real-time monitoring, and technology-enabled practice. Clinicians must select correct answers out of a list of answers that includes equally plausible distractors. In order to keep the questionnaire brief and reduce the chances of participants learning the answers through repetition, clinicians will be asked to complete 5 randomly selected questions at each time point . Furthermore, at each time point, participants will be asked to identify which webinars and case studies they have watched in order to be able to link training engagement with outcomes.This scale assesses confidence in clinical skills (Level 3) central to the BMC Youth Model using 8 visual analogue scales coded as values “0” to “100.” Marks to the left represent low confidence in development of skills, and marks to the right indicate high confidence in development of skills. The 8 items relate to multidimensional assessment, clinical staging, case formulation and treatment planning, shared decision making, intervention skills, outcome monitoring, and care continuity and coordination. Respondents are asked to reflect on each of these areas and rate how well they feel they perform these tasks in clinical practice.This scale assesses clinician change in behavior (Level 3) using a scale consisting of 9 items that ask how frequently they utilized new knowledge and skills related to multidimensional assessment, clinical staging, intervention matching, shared decision making, monitoring, responding to increased suicidality, and continuity of care. Clinicians rate how often they employed a skill in their standard clinical practice in the past fortnight on a 5-point Likert scale ranging from “1 = not at all (with no clients)” to “5 = always .” For each item, clinicians can also indicate that the particular skill is not applicable to their service (0 = N/A).Change in clinician practice (Level 3) and impact on client outcomes (Level 4) will be assessed using real-time and aggregated data from the InnoWell Platform . IndicatThe timeline of procedures is summarized in Participants will be drawn from 11 participating headspace services in Australia who have previously agreed to implement the HIT. The services include 5 from Sydney, 5 on the North Coast of New South Wales, and 1 in South Australia. Participants will include mental health professionals  and service managers. The sample size will be determined by participating services, with all health professionals and service managers being invited to participate in the education and training program.In order to assess participants’ reactions to the training, a mixed methods approach will be utilized, specifically a Triangulation Design, Validating Quantitative Data Model . This deDescriptive statistics will be used to analyze quantitative data gathered from the combined evaluation form data, as well as individually for the online seminars, case study webinars, and in-service workshops. A thematic analysis will be conducted to analyze qualitative data collected via the evaluation forms to identify patterns or themes within the data . Procedut tests to understand short-term impacts, and repeated measures analysis of variance will be used to understand long-term changes in knowledge, skill, behavior, and client outcomes.In order to assess Learning, Behavior, and Results, pre- and postsurveys and clinical practice audit data will be compared using paired Ethics approval has been granted via Sydney Local Health District’s Human Research Ethics Committee (Protocol No X18-0499 & HREC/18/RPAH/715). Research findings will be disseminated through peer-reviewed journals and scientific conference presentations. Participant data will be nonidentifiable and aggregated.As of September 2020, clinicians and their services were being recruited to this study. Data collection is expected to be completed and the first results to be submitted for publication in 2021. Results will then be disseminated to the participants, the public, and researchers through publications in journals and presentations at conferences.This paper details a comprehensive protocol for an evaluation study to assess the effectiveness of the education and training program on the adoption and optimization of use of the digital health solution to provide the knowledge and skills to assess, monitor, and manage the complex needs of young people presenting with mental ill-health problems.Reaction), increasing clinicians’ knowledge of youth mental health (Learning), clinicians adopting the digital health solution in standard clinical practice (Behavior), and improving service performance .Evaluations of education and training programs within mental health generally focus on the perceived usefulness of such programs, increased knowledge, and confidence in using acquired skills, but frequently neglect assessing the impact on changing clinician knowledge, skills, behaviors, and client outcomes . By usinhow training can be improved [While the evaluation protocol will produce valuable insights, there are limitations that should be noted. First, the measures of knowledge and skill rely on self-rating, which are subjective and may be influenced by the participant’s level of self-awareness ,37. Secoimproved . Neverthimproved  and willThe research protocol presented here is the first of its kind to explore the education and training of mental health professionals in the use and benefits of technology-enabled solutions. As such, it has the potential to have a significant impact on determining how mental health professionals are trained as technology becomes more integrated into their practice ,14. The Ultimately, this research will help teach mental health professionals how to facilitate a highly personalized and measurement-based model of care. This may therefore guide clinicians to help young people recover from low functioning associated with subthreshold diagnostic presentations and prevent progression to more serious mental ill-health.


Despite the emerging literature linking information communicative technology (ICT) use and cognitive functioning in later life, whether the association varies as a function of social environment and birth cohort remain an open question. Using nine waves of panel data from the U.S. Health and Retirement Study (2002-2018), we examined within-person asymmetric effects of transitioning into and out of Internet use on cognitive functioning, and whether the associations vary depending on living arrangement and across birth cohorts. Results from the multilevel models indicated that transitioning into Internet use was associated with improved cognitive functioning at a given wave and decelerated cognitive decline over time. Similarly, ceasing to use the Internet was associated with worse cognitive functioning and accelerated cognitive decline. Further, such linkages between Internet use and cognitive functioning were moderated by living arrangement and birth cohort. The detrimental effect of ceasing Internet use was worse for those older adults who live alone. Transitioning into and out of Internet use was unrelated to changes in cognitive functioning among recent HRS cohorts, namely, the War Babies (b:1942-47) and Early Baby Boomers (b:1948-53). These findings highlight the interplay between technology, social environment, and cognitive functioning in later life. The salubrious effects of adopting an ICT technology, such as the Internet, as well as deleterious effects of ceasing to use such technology, underscores the importance of promoting digital literacy and access to ICT technologies among the older adult population.


Students’ active learning behavior determines learning performance. In post-COVID-19 period, Online Merging Offline (OMO) method become a common way of university students’ learning. However, at present, there are few studies in active learning behavior in the OMO mode. Combined with learning satisfaction and Technology Acceptance Model (TAM), this paper proposes an Online Active Learning (OAL) Model to predict the influencing factors of college students’ active learning behavior and then analyzes the differences between OMO model and pure online model by multi-group analysis (MGA) based on the model. The designed questionnaire was distributed, and a total of 498 valid questionnaires were collected. Using SmartPLS to analyze partial least squares structural equation modeling (PLS-SEM) and MGA, it is found that: (1) there are differences in the influencing factors of active learning between OMO and pure online model; the moderating effect of learning complaint in OMO mode is not established, and social isolation and age does not affect active learning in OMO mode; (2) learning quality, perceived ease of use, expectation, perceived usefulness, and social isolation indirectly affect active learning through learning satisfaction in both OMO model and pure online model; (3) learning satisfaction is an important mediating variable affecting active learning; and (4) learning complaints will negatively regulate the relationship between learning satisfaction and active learning only in pure online model. According to these findings, the paper provides theoretical and practical implementation suggestions implications for OMO teaching and OAL to ensure the expected learning outcome. The COVID-19 has brought about great changes to education. Compared with the traditional classroom face-to-face teaching, more and more schools organize and carry out teaching in Online Merging Offline (OMO) mode , and stuBefore the COVID-19, online learning research mainly focused on user attitude , online After the COVID-19 situation improved, the school reopened, teachers and students returned to school, and the OMO teaching mode was gradually accepted by most teachers  OMO modeRQ1: What are the core factors affecting students’ online active learning, and what is the internal structure and relationship between these core factors?RQ2: What are the differences of the influencing factors between OMO mode and online mode?To answer the research questions, this paper will first build a conceptual model of online active learning from the perspective of learners’ online learning behavior, based on the relevant theories of TAM and learning satisfaction. The next section of the paper will show the literature related to online active learning, TAM, learning satisfaction, and OMO, which is followed by the hypotheses for the study based on the literature. Then the section followed shows the study process, the instruments, and data analysis methods. The results are presented, and the differences of influencing factors of active learning between OMO mode and pure online mode are discussed, and guidance for OMO teaching in the post-COVID-19 era are also proposed. The paper finally concludes the strategies to promote active learning by OMO mode and an outlook toward future research directions.The implementation of online active learning is an important factor affecting students’ learning success . StudentLearning Satisfaction (LS) is a subjective judgment between learners’ gains and expectations in the learning process , which iH1: Learning satisfaction has a positive impact on online active learning.Learning Quality (LQ) refers to the extent to which the quality of the learning systems, learning service, and learning content meet the needs of learners . The staH2: Learning quality has a positive impact on learning satisfaction.TAM has been a common basic theory in online learning research . TAM canH3: Perceived ease of use has a positive impact on learning satisfaction.H4: Perceived usefulness has a positive impact on learning satisfaction.H5: Social isolation has a negative impact on learning satisfaction.H6: Expectation has a positive impact on learning satisfaction.As mentioned in the previous part, learning satisfaction in this study is learners’ perceived gain from online learning. Previous research also showed that learning satisfaction acted as the mediating variable to influence the active learning. The research of flipped classroom indicated that learning satisfaction had a partial mediating effect on learning effectiveness . In the H7: Learning satisfaction mediates the relationship between (a) perceived ease of use, (b) perceived usefulness, (c) social isolation, (d) expectation, and (e) learning quality.A customer complaint is an important antecedent affecting customer satisfaction and loyalty , and a cH8: Learning complaint has a negative moderating effect on the relationship between learning satisfaction and active learning.OMO refers to providing learners with online and offline learning space to meet their learning needs anytime and anywhere . It is aH9: The influencing factors of active learning behaviors between OMO students and pure online students are different.Research in e-learning usually concluded that male students were more willing to use and learn computers than female students , and malBased on the above analysis, the assumptions proposed in this paper are:H10: Gender has impacts on online active learning.H11: Age has impacts on online active learning.Supported by learning satisfaction theory and Technology Acceptance Model (TAM), this study constructs a conceptual model of online active learning see , to explDue to the research model proposed in this study containing latent variables that cannot be observed directly, so the research data will be collected by questionnaire after developing the measurement scale .To ensure the content’s effectiveness, all construct items were from or adapted from existing literature . The meaAfter the preliminary design of the questionnaire, the WJX (an online questionnaire platform) was used to publish the questionnaire online. 30 students participated in the presurvey. After collecting the feedback information in the presurvey process, the questionnaire was optimized . The forThe online questionnaire was used for the survey, and students from 4 Chinese universities and about 16 classes took part in the survey. Universities teachers invited students to participate in the survey through QR code during recess. The invited students can choose whether to participate in the survey according to their own wishes and have been informed the survey’s purpose. The online questionnaire was launched and collected for a month, and 498 valid questionnaires were obtained after data cleaning. Among the samples, 224 were male, accounting for 45%; 274 were female, accounting for 55%; 14 were aged 17 and below, accounting for 2.8%; 235 were aged 18–29, accounting for 47.2%; 124 were aged 21–23, accounting for 24.9%; 102 were aged 24–26, accounting for 20.5%; more than the number of people equal to 27 years old is 23, accounting for 4.6%. Among the respondents, 223 people were participating in OMO education, accounting for 44.8%; 275 people experienced online education during COVID 19 for more than 3 months, accounting for 55.2%.Compared with other analysis technologies, partial least squares structural equation modeling (PLS-SEM) is suitable for developing new theoretical models, exploring complex models, for prediction purposes, and conducting exploratory research . TherefoContent validity, discriminant validity, and convergent validity are used to test the validity and reliability of the study model. All measurement items in the questionnaire are from literature and have been verified by presurvey before, so they are considered to have acceptable content validity . The resThe analysis results show that the measurement model has good convergence validity and discriminant validity, because the factor loading between each measured variable and its latent variable is greater than the cross factor loading between other latent variables . The resThe data are from the questionnaire survey, and there is the possibility of common method bias CMB; . In thisWe analyzed the structural model with the help of SmartPLS 3 . The R2 This study uses Bootstrapping to test the mediating influence of learning satisfaction, as shown in According to the analysis method of mediation effect recommended by Using the test of the moderating effect of SmartPLS 3 on learning complaint , the anaPartial least squares multi-group analysis (PLS-MGA) can help researchers understand the differences in influence relations caused by specific grouping variables . This stβ = −0.080, p > 0.4), SOI  did not significantly affect SAT, Age  had no impact on OAL. Regardless of whether OMO or online education teaching methods were adopted, SAT positively affected OAL; PU, PEU, EPC, and LQ positively affected SAT; Gender did not affect OAL.In the group of students who adopt the OMO method, the moderating effect of CO is not significance  and complaints for online teaching could be relieved by integrating suitable offline teaching. OMO provides the opportunities for both teachers and students for flexible and resilient teaching and learning.Data analysis shows that perceived usefulness and perceived ease of use have impact on student’s active learning behavior whether in OMO model or pure online model, which shows consistence with the previous research in distance learning . In ordeThis sense of social isolation may come from two aspects: one is the isolation of the social environment caused by the outbreak of the COVID-19, and the other is the isolation of the online virtual environment. The effectiveness of online learning relies on a good sense of social presence and interaction . TeacherAccording to the results of data analysis, expectation significantly affects learning satisfaction, which proves that expectation is also an important factor affecting learners’ online active learning, which is also similar to the existing research results . ExpectaLearning quality is learners’ subjective feeling and evaluation of the learning effect. The understanding of knowledge and the growth of ability are important indicators to evaluate the learning quality. Information technology, multimedia technology, 5G and other new generation technologies provide important carriers for learners to carry out online active learning , which iThe results of data analysis show that learning satisfaction is a key factor in online active learning. Learning satisfaction mediates perceived ease of use, perceived usefulness, social isolation, expectation, learning quality, and its role in online active learning. Learning satisfaction involves expectation, learning process, learning results, individual emotional feelings, and other levels. It refers to learners’ subjective evaluation of knowledge mastery and ability development and points to the interaction between subjects, individual subjective feelings, and emotional states in the learning process. Therefore, to improve the learning satisfaction of online learners, teachers should pay attention to the subjective status of learners and take learners as the center. In addition, teachers should pay much attention to the interactions between subjects. For example, teachers and students should strengthen personalized answers and guidance, students should strengthen discussion and communication, family members should strengthen emotional communication, and give full play to the effective support role of multiple subjects for learners. By controlling the prefactors of learning satisfaction, we can improve learners’ learning satisfaction and promote the implementation and development of online active learning.This study uses learning complaints as a moderating variable for online active learning models. The moderating effect test results confirm that learning complaint has a negative moderating effect on the relationship between learning satisfaction and online active learning, indicating that when the level of learning complaint is higher, the impact of learning satisfaction on online active learning will also decline. Learning complaints often have a clear direction. The object of complaints often lies outside the learners themselves, and the specific content of complaints often does not meet the learners’ expectations. For example, learners will complain about unstable network signals, too slow network transmission speed, system jam, inability to get technical support, etc. Learning complaint has strong emotional color, which has a considerable negative impact on online active learning and learning satisfaction. This enlightens educators to pay attention to learners’ feedback and set up certain interactive spaces and feedback channels for communication between learners and education managers. On the one hand, learners can release and relieve learning complaints in time to reduce negative emotions and psychological pressure. On the other hand, let education managers know what is unsatisfactory in the current education process and make timely adjustments and repairs, to reduce learners’ learning complaints and improve learners’ satisfaction. Communication between learners is also an important measure to resolve learning complaints. Through mutual communication, learners find that other learners also encounter the same and similar problems, but these external factors have no substantive impact on the core part of problem-solving, which consciously reduces learning complaints, and may further enhance the implementation of online active learning and further find solutions to problems.Aiming at the emerging OMO teaching, this study explores the influencing factors of online active learning and compares the differences of influencing factors of online active learning between OMO teaching and online teaching. The samples are empirically analyzed by SmartPLS 3 analysis software, and the research hypothesis test is carried out with the help of partial least squares structural equation model, and an online active learning model is proposed. On this basis, this study explored the relationship between perceived usefulness, social isolation, ease of use, expectation and learning effect and online active learning, and analyzed the mediating effect of learning satisfaction and the moderating effect of learning complaint.By comparing OMO teaching with online teaching, we find that simple online teaching methods can easily lead to students’ sense of social isolation and learning complaints, while OMO mixed teaching method can well solve these problems. Face-to-face emotional interaction between teachers and students, hand-in-hand guidance and help, and face-to-face communication and cooperation between students reduce students’ sense of social isolation. It reduces students’ learning complaints, enhances students’ ability to grasp technology and other problems and improves the implementation probability and effect of students’ online active learning.Comparing with pure online mode, the OMO mode has the intrinsic advantages. To prepare the OMO mode, school and teachers should build the reliable environments, provide suitable digital tools and digital learning resources, change the assessment approach, and assist teachers and learners with necessary supports. However, the key is the pedagogical issue related to smart teaching. Whether online or offline, the teaching could follow the “SMART” principle to promote learning quality and meet expectation.This study also has a certain limit, the sample size and representativeness may be one-sided, and the application of online active learning model can be further expanded. In the future, it is planned to further explore the OMO teaching model, combined with the design of teaching process, and according to the online learning model proposed in this study, to further explore the influencing factors of OMO learning effect.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.HY, JY, and SW: conceptualization. SW: methodology and software. SW and JL: validation. HY: investigation. JY: resources, funding acquisition, and supervision. HY, JY, JL, and SW: writing—original draft preparation. HY, JY, GS, and SW: writing—review and editing. All authors have read and agreed to the published version of the manuscript.This research work was supported by 2021 Zhejiang Provincial Philosophy and Social Planning Project “The construction of cloud employment system for higher education institute in post-COVID-19 period” (No: 21GXSZ030YB).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.


Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy—dimensions of “financial toxicity”—need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients. Though technological and biomedical advances in cancer therapies have propelled the improvement of key oncology patient outcomes—survival, cancer progression, and treatment-related toxicity—cancer treatment, often costly, is a source of financial hardship for many cancer patients and their families , 2. CancThough cancer-related financial toxicity impacts patients across the spectrum of diseases, evidence suggests that there are particular aspects of financial toxicity that affect head and neck cancer patients, who make up an estimated 65 000 new cases annually in the United States and 550 000 annual cases worldwide. Only a small number of studies have focused solely on the financial hardship in head and cancer patients, but the limited evidence suggests that approximately one third of head and neck cancer patients report between moderate and catastrophic levels of financial hardship , 15. A dWith the rapidly evolving and increasingly implemented strategy of proton therapy for head and neck cancer, concurrent questions have arisen on how to address the economic impact of proton therapy. This economic impact is, undeniably, not only an individual patient concern but also a societal concern. With the costs of cancer care rising—annually, an estimated financial burden of $80 billion on the US healthcare system—calls abound to achieve higher value in cancer care, by developing and selecting treatments that optimize clinical outcomes yet minimize economic burdens, the critical component of value in care –20. Yet A primary aspect of the clinical comparative effectiveness of proton therapy is the capability of the physical properties of the Bragg peak to decrease normal tissue dose and, in turn, decrease normal tissue toxicity risks compared with conventional photon therapy. The need for continuing improvement of the toxicity profile of radiation treatment for head and neck cancer is evident. Prior studies, mainly dominated by patients treated with conventional photon treatment, demonstrate the high frequency of acute side effects, including as many as 92% of patients who experience radiation-associated mucositis and 26% with severe dehydration. There are also long-term, debilitating side effects— for example, 29% with xerostomia, 26% to 57% with dysphagia, 20% with dysgeusia, and 9% with a feeding tube –25. ThesMoreover, these toxicities and chronic survivorship issues contribute to excess health care costs in head and neck cancer patients. In a recent study, Massa and colleagues  used a nBesides the direct medical expenses related to illness, functional disabilities in head and neck cancer patients appear to be a risk factor that may contribute to a high frequency of missed and lost work with cancer treatment; an estimated half of head and neck cancer patients face persistent barriers to resuming employment , 28. TheP = .05). The benefit persisted also at the 1-year follow-up  [Accordingly, examinations of the clinical benefit and comparative toxicity profile of proton therapy in head and neck cancer treatment are directly relevant to developing approaches to mitigate financial toxicity. One such examination was a case-matched study of 50 oropharyngeal cancer (OPC) patients treated definitively with intensity modulated proton therapy (IMPT) and 100 patients with intensity modulated photon therapy (IMRT) combined with concurrent chemotherapy. Blanchard et al  demonstr = 0.01) . Sio et  = 0.01)  reported = 0.01) , includi = 0.01)  found th = 0.01) , these fNevertheless, the economic value of proton therapy for the treatment of head and neck cancer remains debated. At the heart of this debate is the high cost of delivering proton therapy; it requires as much as double the expenditures for capital investment, quality assurance, and operations along with radiation delivery . Accordifunction and consequently the economic value of therapy to the patient and society, thereby indirectly offsetting higher costs of treatment. Although not yet widely used to compare proton therapy versus IMRT, engaging studies through the lens of this framework would represent a patient-centered lens when comparing cost of illness, a lens that has already been applied for evaluating the value of systemic and targeted therapies for cancer of other disease sites [A second implication relates to the need to advance the conceptual framework and analytical approach to evaluating the value of proton therapy in head and neck cancer patients beyond measures of cost-effectiveness alone, since simply restricting the development and adoption of proton therapies based on cost-effectiveness metrics is unlikely to be an entirely long-term viable or equitable solution in a mixed-payer system such as the US health care system. Many US payers do not explicitly apply cost-effectiveness analysis in reimbursement decisions. Furthermore, as cost-effectiveness analyses alone do not fully incorporate an empiric comparison of critical aspects of patients' financial hardship—the loss of work and productivity—more data are needed to directly evaluate and compare the effect of proton therapy versus IMRT on patients' labor market participation, paid and unpaid work, and household and societal productivity, as well as on restoring patients' function, thereby identifying the optimal therapeutic strategies for recovering illness and disability-related functional and financial burdens. This approach to evaluation would therefore use a “cost-of-illness” framework to quantify patients' economic burdens –38. Suchse sites , 40. Ourse sites , is evalSeveral unique aspects of accessing proton therapy also impact patient financial toxicity. Since there are only just over 30 proton therapy centers geographically dispersed across the United States, tending to cluster in metropolitan areas and academic medical centers, for the vast majority of cancer patients, the burden of housing and transportation costs to obtain proton treatment is likely to be higher on average, than for the more widely accessible photon therapy facilities . And while a relative plethora of data exist on the out-of-pocket cost burden from cancer drugs , limitedThe lack of consistent insurance coverage for proton therapy—including coverage in the setting of clinical trials needed to establish Level I evidence for comparative effectiveness—as well as delays in care due to the lengthy approval process may increase the risk of financial toxicity at the patient level , 45. InnThe aspects of financial toxicity relevant to proton therapy suggest the need to implement proactive strategies for early financial toxicity intervention in care delivery for cancer patients initiating a course of proton therapy. Financial hardship screening and measurement, combined with stakeholder engagement, to channel patients toward early financial navigation is a strategy that has demonstrated early success in pilot studies –49. An iPatients with head and neck cancer are vulnerable to cancer-related financial toxicity due to high-risk associated sociodemographic factors, along with an intensive, often multimodality therapy strategy needed for cure and the related long-term toxicities of treatment. Financial toxicity burdens remain understudied in this patient group. The impact of proton therapy on financial toxicity from both the patient-centered perspective and the system-level perspective in head and neck cancer patients requires more accurate measurement, especially relative to photon-based strategies. This will require detailed evidence on the impact of treatment on restoring patients' ability to be productive, cope with lingering disability, and function at work, in households, and in society. Such evidence will be critical for assessing the value of proton therapy and selecting patients who are most likely to benefit from proton therapy for head and neck cancer; thereby maximizing clinical benefit while minimizing financial toxicity in head and neck cancer patients.


Despite the global agreements on adolescents’ sexual and reproductive health and rights, access to and utilisation of these services among the youth/adolescents remain unsatisfactory in low- and middle-income countries which are a significant barrier to progress in this area. This review established factors influencing access and utilisation of youth-friendly sexual and reproductive health services (YFSRHS) among the youth in sub-Saharan Africa to inform programmatic interventions.A systematic review of studies published between January 2009 and April 2019 using PubMed, Web of Science, EMBASE, Medline, and Cochrane Library, and Google Scholar databases was conducted. Studies were screened based on the inclusion criteria of barriers and facilitators of implementation of YFSRHS, existing national policies on provision of YFSRHS, and youth’s perspectives on these services.A total of 23,400 studies were identified through database search and additional 5 studies from other sources. After the full-text screening, 20 studies from 7 countries met the inclusion criteria and were included in the final review. Structural barriers were the negative attitude of health workers and their being unskilled and individual barriers included lack of knowledge among youth regarding YFSRHS. Facilitators of utilisation of the services were mostly structural in nature which included community outreaches, health education, and policy recommendations to improve implementation of the quality of health services and clinics for adolescents/youth to fit their needs and preferences.Stakeholder interventions focusing on implementing YFSRHS should aim at intensive training of health workers and put in place quality implementation standard guidelines in clinics to offer services according to youth’s needs and preferences. In addition, educating the youth through community outreaches and health education programs for those in schools can facilitate utilisation and scale up of the service.The online version contains supplementary material available at 10.1186/s12978-021-01183-y. Access and utilisation of Youth-friendly sexual and reproductive health is still a big challenge for the youth especially in sub-Saharan Africa. In this study, we explored the underlying reasons for the low access and utilisation of youth-friendly sexual and reproductive health services and potential solutions to the problem.Articles used in this study were retrieved from different data sources and those that contained barriers and facilitators of access and utilisation of youth-friendly sexual and reproductive health services implementation were summarised.The key barriers were negative attitude of health workers and their being unskilled emanating from the administrative section theme. The individual factor was the lack of knowledge among youth. The promoters of utilisation were community outreaches, health education and improvement of the quality of services in the clinics for adolescents/ young people’s needs.Moving forward, stakeholders should aim at increasing the training of health workers and improving the quality of services being offered to the youth. To address the individual barriers, youth should be reached with information through community outreaches and education in schools.The online version contains supplementary material available at 10.1186/s12978-021-01183-y. In many African countries, sexual and reproductive health (SRH) needs of young people / youth are often underserved and underestimated despite their demonstrated need and the urgency of these services . ContineSRH comprises a major component of the global burden of sexual ill-health. Nearly a quarter of girls aged 15–19 years are married with an estimated 16 million adolescents giving birth each year globally, 95% of whom are from low- and middle-income countries (LMICs) . SeveralIn sub-Saharan Africa, adolescents face many significant SRH challenges such as limited access to youth-friendly services (YFS) including information on growth, unsafe abortion, gender-based violence, sexuality, and family planning (FP). This has led youth into risky sexual behaviour resulting in high STI and HIV prevalence among young people, early pregnancy, and vulnerability to delivery complications resulting in high rates of death and disability . NumerouYouth-friendly services are an amalgamation of health facility characteristics, health service provision techniques, and health services offered which are key strategies for improving the health of adolescents in Africa. According to the WHO guidelines, in order to be considered Youth Friendly Health Services (YFHS), the services are required to be accessible, acceptable, equitable, appropriate and effective, gender-equitable and serve as a channel for access to FP and SRH . In 2015The protocol for this systematic review was developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines for reporting systematic reviews  along with adolescents (10–19) years, were included in this review. The review included studies on youth-friendly service scale-up, utilisation, and access to YFSRHS and were published in English.Studies or evaluations carried outside sub-Saharan Africa, multiple publications, systematic reviews or narrative reviews, letters to the editor, case reports were excluded from the review. Articles written in other languages than English were also excluded. Studies with participants predominately greater than 24 or less than 10 years of age or with unclear ages were excluded. Some studies used non-youth key informants and hence excluded.Title and abstract screening of all papers identified by the search strategy were independently performed by two researchers with reference to the published inclusion/exclusion criteria. Key themes were compiled for each article and these themes were grouped based on common traits for thematic synthesis, the result section of each article was analysed using line by line coding. Each category was designated a colour code blue for included and red for excluded. Initial screening of abstracts and titles was done using a process of semi automation while Rayyan QCRI software  allowed Quality assessment is crucial to ensure that the findings of the papers are correct and accurate. All studies that meet the eligibility criteria were assessed for quality independently and in duplicate. The included studies were appraised critically for methodological quality and rigour using the Critical Appraisal Skills Programme checklist , participants and demographics, study design, outcomes, analyses used, and key findings, how the databases or forms was used, how information was recorded and the number of reviewers. Two data extractors (NLR and NR) resolved the discrepancies and any remaining differences were resolved by the other team member (IKC). As part of the extraction process, each qualitative and quantitative study was assessed for methodological rigour. The retrieved data was analysed to answer the main research and specific objectives.Finally, the findings were summarized in a narrative synthesis. The synthesis is presented in the results and discussion chapter.. We identified studies focusing on access, utilisation and scale-up of A/YFSRHS conducted in sub-Saharan Africa and found articles from 7 countries  which were included. Nineteen studies used cross-sectional study design, nine selected studies from  used qualitative, six studies from Nigeria and Ethiopia used quantitative methods and the remaining six studies from Ethiopia, Nigeria, Tanzania and Kenya combined both methods in their studies. Eleven studies had their participants from the community; four studies were done among both rural and urban communities, one study among urban and peri-urban communities and one study in urban communities. In addition, seven studies used participants from health facilities and two recruited participants from schools.A total of 23,400 studies were identified through a database search and an additional five studies from other sources. After the full-text screening, 20 studies met our inclusion criteria Fig.  and wereNineteen articles focused on both males and females and one focused on only females Table .The studies presented in Table  had variThe barriers to access to YFSRHS were categorized as structural, individual, socio-economic, and socio-cultural. Individual barriers refer to a people having incomplete or incorrect knowledge of SRH, including myths and misconceptions around contraception; limited self-efficacy and individual agency; constrained ability to navigate internalized social and gender norms; and lack of access to information about what SRH services are available and where to seek services  structurThe study identified fourteen studies whose primary aim was to evaluate Individual barriers such as knowledge, individual perception, shame and stigma affecting YFSRHS. Studies evaluating the utilisation level of adolescents/ YFRHS found that only 38.5%) adolescents in South Africa and 21.5%) in Ethiopia were knowledgeable about the type of YFSRH services offered .5% in Et. Youths % adolescAlthough there YFRHS existed, most adolescents/youths were not aware of these services. According to a medium quality health facility, a cross-sectional study done in Kenya on young people’s perception, knowledge of younger girls (12–14 years) was limited with a majority reporting that they did not know much about condoms, however, boys the same age were more knowledgeable and reported that young people used condoms for prevention of HIV, pregnancy and other STI . AccordiIndividual perception, fear, shame and stigma affected the utilisation of YFRHS among youth which had a negative impact among those who believed that YFS can improve their health. Youth with stigma and fear about YFSRHS were less likely to utilize the service than their counterparts in a study carried out in Kenya . HoweverA study done in Ethiopia found that participants had the fewest misconceptions about SRH and the most outstanding being misconceptions about oral contraceptive pills causing illness and sterility compared to Rwanda . A studyEighteen studies in the review indicated structural barriers affecting the delivery of YFSRHS. High-quality studies from South Africa and Ethiopia addressed primarily provider attitudes and the clinical environment as barriers to adolescents’ access to healthcare during a focus group discussion, however, perceptions of provider attitudes towards adolescents appeared to be inconsistent , 28. DurAt the same time, the number of skilled health workers to offer these services is limited which was identified in a study carried out in South Africa, Ethiopia, and Uganda , 31, 32.Many operational barriers in health facilities also impact access and utilisation of these services, such as inconvenient operating times, lack of transportation, and high cost of services , 21, 26.Four studies were identified exploring the impact of religious and traditional beliefs on access to YFSRHS , 26, 34.Three studies reported that adolescents and young people mostly preferred low cost or no charges at all when seeking SRH services from youth centers. A high-quality study exploring barriers and perspectives of youth seeking FP services found that in one district participants some government providers charged fees for FP for both male and female youth. The other mentioned barriers were transport costs and long distances . SimilarThe studies included in this review only reported structural facilitators which are described below.Five studies reported on community outreach and involvement in terms of outreach activities in the community, schools and churches among the youth/adolescents. However, some indicated lack of information regarding different areas of YFSRH which was documented in the above studies. A medium quality study done in Ethiopia indicated that (45.9%) had information about the availability of services in the nearby facility and the most important sources of information were peers (54.6%), parents (27.1%), and mass media (7.6%) . The useIn a study done in Ethiopia, mass media messages (70.9%), advice from others (31.1%), illness of close relative (8.6%) and death of close relative 23(9.4%) were the most important factors that influenced the study participants to utilize the services . SimilarFour studies reported adolescents and young people mostly preferred in-school health education , 32, 36 Youths who participated in peer to peer discussions were more likely to know about and utilize sexual and reproductive health services than those who did not participate. Peer influence remains a strong factor as shown in this study where peers or friends were found to be the major source of information. Peers were mentioned as resources to support other youth if they shared news and information about FP, but they were also reported to sometimes mock and tease others who they knew wanted to use FP . FriendsTwo studies indicated how youth’s needs and preferences are to be considered in order to improve YFSRH services. In a high-quality study , particiRecommendations on the implementation of healthcare service provision should be characterized by a prompt, entertaining and welcoming environment that would encourage adolescents to interact freely. In high-quality study , health In two high-quality studies done both in Uganda  and MalaThe consensus was that providing a wide range of SRH services in either integrated health facilities or youth centres was more likely to ensure anonymity and that privacy could be maintained . MeetingTwo high-quality studies assessed another key factor in development and implementation of quality standards found in Tanzania  during tThis systematic review aimed at synthesizing evidence on barriers and facilitators affecting access and utilisation of YFSRHS together with recommendations to improve and scale-up these services for youth/adolescents in sub Saharan Africa. The most common barriers in the review were structural which included the negative attitude of health workers, inconvenient hours, quality of services and unskilled health workers. The health workers attending to the youth were reported to use abusive languages while others were not sympathetic enough to provide services like FP and contraceptives. Moreover, some were not trained adequately/not at all on how to deliver the services to the youth posing a great challenge. A similar observation was found in a context analysis assessing young people’s experience of SRH in sub-Saharan Africa .The review showed the second prominent barrier were at the individual level emanating from limited access to YFSRHS including limited knowledge and awareness among adolescent/youth about the services which is a key hindrance. Adolescents have limited and, in some cases, no access to SRH education and contraception, making adolescent girls more prone to early and unintended pregnancies . To summFew studies reported on socio-economic and cultural barriers due to the fact that some services were not free and the youth lacked money. Others findings from this study indicate that health workers or fellow peers and parental consent on FP services is not given even when these services are offered free. Some services are not free of charge such as FP and the cost of receiving them due to distance is costly, so the youth opted-out from using them. These barriers are due to the context and structure of the environment in which the youth live in.Only two studies were identified focusing on scale-up of YFS which were from one country (Tanzania) and still had scale-up challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints which still pose a barrier to utilisation of YFSRH . In addiThe review indicated that facilitators to the utilisation of YFSRHS included community outreaches and involvement, school health education, peer-led education and mass media campaigns, and sporting activities and entertainment activities at youth centres which were sources of information preferred by the youth and improved YFHRS access and all were structural in nature. The World Health Organization (WHO) review on universal access showed that actions to make SRHS user friendly and welcoming had led to an increase in the use of services by adolescents . The revYFSRHS whether offered in dedicated youth centers or public health facilities attract both male and female clients around the world. Similar findings to a study done in Sweden, which has youth centers throughout the country, liberal attitudes and few legal barriers to service provision, however, the majority of patient visits to youth centers were made by females .This review identified the need to improve access to and standardise the quality of health services for adolescents/youth needs along with integrating efforts such as educate, empower and support adolescents. A user-friendly SRHS does not necessarily ensure service utilization by adolescents/youth. Similarly, a review done on assessing YFSRHS indicated the need for standardisation and prioritisation of indicators for the evaluation of YFSRHS which include accessibility, staff characteristics and competency, and confidentiality and privacy favoring youth’s needs . During Evidence on attribution is particularly weak, with majority of studies using a cross-sectional design, with no control group. Qualitative studies have the potential to contribute rich perspectives from study populations on YFSRH service utilisation and barriers to access, but we found only three studies using this design, and six studies using mixed methods to assess YFSRH. Overall, only 65% of the studies (n=13) selected were graded as high quality, 30% as medium quality (n=6), and 5% as low quality (n=1). There was limited number of use of stratification, by gender and age as some studies indicated the differences, and so we were not able to capture potentially differing health access and utilisation outcomes among adolescents/youth.In terms of limitations, the narrow inclusion criteria may have led to the exclusion of some peer-reviewed literature and conference articles. Additionally, our language inclusion criteria, i.e. only studies published in English, imposed by the capacity of the research team may have limited the numbers of hits returned by our search and led to publication bias. Nevertheless, this review provides important information on barriers and facilitators of access and utilisation of YFSRHS implementation and proposes key recommendations which should inform design and implementation of effective YFSRHS programmes.The review has shown that most common barriers impeding YFSRH services were due to structural barriers such as the negative attitude of health workers and unskilled health workers, and individual barriers emanating from low levels of knowledge among the youth/adolescents. Regarding facilitators of utilisation, results showed that with sustained community involvement and outreach, school health education, recreational activities, and the provision of free or reduced-cost YFSRH to those with a financial constraint, there will be an increase in utilisation together giving the youth access to the health services hence promoting sustainability. The Global guidelines on standardisation of health services encourage that adolescent service providers prioritise quality however, YFSRHS are highly fragmented, poorly coordinated and uneven in terms of quality. Pockets of excellent practice exist, but, overall, services need significant improvement and should be brought into conformity with existing guidelines. The review emphasizes the need to educate and health train the youth/adolescent to know more about the reproductive health services being provided at youth-friendly centers and their involvement in the design and implementation of interventions targeting them. Stakeholder interventions focusing on implementing YFSRHS should aim at intensive training of health workers and put in place quality implementation standard guidelines in clinics to offer services according to youth’s needs and preferences. Additional file 1. PRISMA 2009 Checklist.Additional file 2. CASP checklist for Quality assessment tool.