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Although tobacco smoking, pan chewing and alcohol drinking are important risk factors for head and neck cancer (HNC), the HNC risks conferred by products available in Nepal for these habits are unknown. We assessed the associations of tobacco smoking, chewing habits, and alcohol drinking with HNC risk in Nepal. A case–control study was conducted in Nepal with 549 incident HNC cases and 601 controls. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using unconditional logistic regression adjusting for potential confounders. We observed increased HNC risk for tobacco smoking (OR: 1.54; 95% CI: 1.14, 2.06), chewing habits (OR: 2.39; 95% CI: 1.77, 3.23), and alcohol drinking (OR: 1.57; 95% CI: 1.14, 2.18). The population attributable fraction (PAF) was 24.3% for tobacco smoking, 39.9% for chewing habits and 23.0% for alcohol drinking. Tobacco smoking, chewing habits, and alcohol drinking might be responsible for 85.3% of HNC cases. Individuals who smoked tobacco, chewed products and drank alcohol had a 13‐fold increase in HNC risk (OR: 12.83; 95% CI: 6.91, 23.81) compared to individuals who did not have any of these habits. Both high frequency and long duration of these habits were strong risk factors for HNC among the Nepalese with clear dose–response trends. Preventive strategies against starting these habits and support for quitting these habits are necessary to decrease the incidence of HNC in Nepal.

Objective Exposure to early adversity carries long term harmful consequences for children's health and development. This study aims to 1) estimate the prevalence of childhood adversity for Australian children from infancy to 10-11 years, and 2) document inequalities in the distribution of adversity according to socioeconomic position (SEP), Indigenous status, and ethnicity. Methods Adversity was assessed every two years from 0-1 to 10-11 years in the nationally representative birth cohort of the Longitudinal Study of Australian Children (N=5,107). Adversity included legal problems; family violence; household mental illness; household substance abuse; harsh parenting; parental separation/divorce; unsafe neighborhood; family member death; and bullying (from 4-5 years). Adversities were examined individually and summed for a measure of multiple adversity (2+ adverse experiences). Results By 10-11 years, 52.8% (95% CI 51.0-54.7) of children had been exposed to two or more adversities. When combined with low SEP, children from ethnic minority and from Indigenous backgrounds had four to eight times the odds of exposure to two or more adversities than children from higher SEP Anglo-Euro backgrounds, respectively (OR 4.3, 95% CI 2.8-6.6 and OR 8.1, 95% CI 4.4-14.8). Ethnic minority and Indigenous children from higher SEP backgrounds had increased odds of exposure to multiple adversity than similarly advantaged Anglo-Euro children (OR 1.8, 95% CI 1.4-2.3 and OR 2.3, 95% CI 1.3-4.3, respectively). Conclusions Addressing early adversity is a significant opportunity to promote health over the life course, and reduce health inequalities experienced by marginalized groups of children.

Recent studies reveal public-sector healthcare providers in low- and middle-income countries (LMICs) are frequently absent from work, solicit informal payments for service delivery, and engage in disrespectful or abusive treatment of patients. While extrinsic factors may foster and facilitate these negative practices, it is not often feasible to alter the external environment in low-resource settings. In contrast, healthcare professionals with strong intrinsic motivation and a desire to serve the needs of their community are less likely to engage in these negative behaviors and may draw upon internal incentives to deliver a high quality of care. Reforming medical education admission and training practices in LMICs is one promising strategy for increasing the prevalence of medical professionals with strong intrinsic motivation.

This study examines the effect of inconsistent  Medicaid coverage  on  parenting stress , maternal depression, and child behavior in a sample of teen mothers and their children. The majority (54%) of mothers experienced inconsistent coverage. After 24 months, mothers experiencing inconsistent coverage had significantly higher  parenting stress  and depressive symptoms, and their children had more internalizing behaviors than families with consistent Medicaid. These differences existed despite no initial differences and controlling for numerous covariates. Policies and practices that stabilize  Medicaid coverage  for teen parent families may reduce unnecessary stress, depressive symptoms, and early childhood behavior problems.

We inquire how early in childhood children most at risk for problematic patterns of internalizing and externalizing behaviors can be accurately classified. Yearly measures of anxiety/depressive symptoms and aggressive behaviors (ages 6–13;  n  = 334), respectively, are used to identify behavioral trajectories. We then assess the degree to which limited spans of yearly information allow for the correct classification into the elevated, persistent pattern of the problem behavior, identified theoretically and empirically as high-risk and most in need of intervention. The true positive rate (sensitivity) is below 70% for anxiety/depressive symptoms and aggressive behaviors using behavioral information through ages 6 and 7. Conversely, by age 9, over 90% of the high-risk individuals are correctly classified (i.e., sensitivity) for anxiety/depressive symptoms, but this threshold is not met until age 12 for aggressive behaviors. Notably, the false positive rate of classification for both high-risk problem behaviors is consistently low using each limited age span of data (< 5%). These results suggest that correct classification into highest risk groups of childhood problem behavior is limited using behavioral information observed at early ages. Prevention programming targeting those who will display persistent, elevated levels of problem behavior should be cognizant of the degree of misclassification and how this varies with the accumulation of behavioral information. Continuous assessment of problem behaviors is needed throughout childhood in order to continually identify high-risk individuals most in need of intervention as behavior patterns are sufficiently realized.

Purpose:  We examined how substance use differed as a function of sex assigned at birth and gender identity (cisgender, transgender, or nonbinary/genderqueer) by type of substance. We sought to test whether current gender identity and sex assigned at birth were key factors in substance use among a large contemporary sample that included transgender and nonbinary/genderqueer adolescents. Methods:  We analyzed data from a large national U.S. sample of sexual and gender minority (SGM) adolescents (n = 11,129) collected between April and December 2017. Chi-square tests of independence were used to test whether substance use behaviors varied by sex assigned at birth and gender identity. A series of multivariate logistic regression models tested the odds of substance use by sex assigned at birth and gender identity, as well as the interaction between sex assigned at birth and gender identity. Results:  More than half of our sample reported lifetime alcohol use, and one-fourth of the sample reported lifetime marijuana use. Adolescents assigned male at birth had higher prevalence of substance use compared with adolescents assigned female at birth (AFAB). Multivariate models elucidated greater risk for most substance use outcomes for transgender adolescents compared with cisgender adolescents. We found significant interaction effects between gender identity and sex assigned at birth for recent alcohol use and lifetime and recent cigarette use among adolescents AFAB. Conclusions:  These findings have implications for stakeholders who develop nationally representative surveys, researchers who examine substance use disparities among SGM adolescents, and mental health professionals who treat underage substance use among vulnerable populations.

Introduction: Sexual minorities are disproportionately more likely than heterosexuals to suffer from substance use disorders, but relatively little is known about differences in substance use disorders across diverse sexual minority subgroups. There is also limited understanding of how different social stressors account for sexual orientation disparities in substance use disorders. Methods: Using nationally representative data collected in 2012−2013 (n=34,597), differences in past-year DSM-5 alcohol, cannabis, and tobacco use disorders were assessed across 4 sexual orientation groups (heterosexuals and 3 sexual minority subgroups, lesbian/gay-, bisexual-, and heterosexual-identified sexual minorities). This study assessed whether stressful life events mediated substance use disorder disparities between heterosexuals and each sexual minority subgroup, and whether stressful life events and lesbian, gay, and bisexual discrimination events mediated these substance use disorder differences. Analyses were conducted in 2019. Results: For both men and women, substance use disorders and stress experiences varied by sexual identity. For example, compared with heterosexual men, larger proportions of gay and bisexual men had a past-year alcohol use disorder. Among women, all sexual minority subgroups had higher rates of each substance use disorder than heterosexuals. For each substance use disorder, stressful life events mediated disparities between heterosexuals and sexual minority subgroups, except for heterosexual-identified sexual minority men. Both stressful life events and lesbian, gay, and bisexual discrimination mediated substance use disorder differences between sexual minority subgroups, with stronger indirect effects through lesbian, gay, and bisexual discrimination for lesbians/gay men and stronger indirect effects through stressful life events for bisexual adults, generally. Conclusions: Sexual minority subgroups have a greater prevalence of substance use disorders, mediated through both stressful life events and lesbian, gay, and bisexual discrimination. More research is needed to comprehensively assess the processes underlying sexual orientation substance use disparities.

Background Suicidal ideation due to abortion has been used to justify restrictive US abortion policies. Much research examining abortion and mental health has relied on self-report, has had low participation rates, and did not consider confounding factors. In the present study, we used data that do not rely on self-report and are not affected by low participation rates to examine the association between abortion and non-fatal suicide attempts, adjusting for confounding factors. Methods In this longitudinal cohort study of Danish population registries, we linked data on a cohort of women born in Denmark between Jan 1, 1980, and Dec 30, 1998, who did not die or emigrate from Denmark before their 18th birthday or before study entry. Follow-up started on the woman's 18th birthday or Jan 1, 2000, whichever came last. Follow-up ended at the date of first suicide attempt, date of emigration from Denmark, date of death, or Dec 31, 2016, whichever came first. Women were between the ages of 18 and 36 years during the study period. We used a survival analysis to examine the risk of first suicide attempts or self-harm associated with a first abortion compared with no abortion, in the complete study cohort. To examine incidence rate ratios (IRRs) associated with abortion, we used Poisson regression with the logarithm of woman-years at risk as an offset. We also examined whether the risk of suicide attempts changed before and after the abortion, adjusting for age, calendar year, socioeconomic status, and history of childbirth, mental health, parental mental health, and physical health. Findings Data on 523 280 women were included in this study. Of these, 48 990 (9·4%) women had a record of at least one first-trimester abortion, and 10 216 (2·0%) had a suicide attempt during the study period. Among 48 990 women who had an abortion, 1402 (2·9%) had a first suicide attempt after the first abortion. In our fully-adjusted model which adjusted for all covariates, the risk of first-time non-fatal suicide attempts was similar in the year before an abortion (IRR 2·46 [95% CI 2·22–2·72]) and the year after an abortion (IRR 2·54 [2·29–2·81], p=0·509) compared with women who had not had an abortion, and decreased with increasing time since the abortion (1–5 years IRR 1·90 [1·75–2·06]; ≥5 years IRR 1·73 [1·53–1·96]). Interpretation We found that women who had abortions had a higher risk of non-fatal suicide attempts compared with women who did not have an abortion. However, because the increased risk was the same both the year before and after the abortion, it is not attributable to the abortion. Thus, policies based on the notion that abortion increases women's risk of suicide attempts are misinformed.

Introduction:  Increased psychosocial stress and obesity are both associated with elevated risk of cardiovascular disease (CVD). However, the effect of change in cumulative psychosocial stressors (stressors) on change in body mass index (BMI) over time is unknown, particularly among older women, a population in whom weight change characterization is complex. Methods and Results:  We examined change in stressors in relation to change in BMI among 20,750 women without CVD or cancer at baseline (2012-13) participating in the Women’s Health Study (WHS) follow-up cohort. Stressors and BMI were collected at two time points 2012-13 (Baseline: T1; mean age=71.8 ± 5.8 years) and 2014-15 (Follow-up: T2; mean age=73.8 ± 5.8 years). Our measures of stressors were comprised of a composite of 8 domains, including acute (e.g. negative life events) and chronic (e.g., financial) stressors. We defined stressors over 3 years of follow-up into four categories: chronically low, delayed, acutely high, and chronically high; and BMI change was grouped into three categories (BMI: loss >3%, gain >3%, and maintenance ± 3%). Women with chronically high stress and delayed stress were younger, current smokers and reported more anxiety/depressive symptoms compared to other women. Women with chronically high stress were more likely to have diabetes, hypertension and hypercholesterolemia than their counterparts. Compared to women who maintained both their BMI and had low stress over time, women with delayed stress or chronically high stress had higher odds of decreased BMI [Delayed: Odds Ratio (OR)  1.16,  95% Confidence Interval (CI):  1.03-1.30 ; Chronically High:  OR=1.12, 95% CI 1.01-1.24 ] ( Table 1 ). Conclusion:  Chronically high and delayed cumulative stress were associated with higher odds of weight loss in older women over 3 years. Future studies are needed to test associations between stressors and metabolic, hormonal and autonomic factors resulting in adiposity or musculoskeletal changes.