Lebanon has approximately one million Syrian refugees (SR) registered with the United Nations High Commission on Refugees (UNHCR) and an unknown number of unregistered SR, who cannot benefit from formal assistance. This study aimed to examine the livelihoods, coping strategies, and access to healthcare among SR based on registration status and accompanying formal assistance. A mixed-method approach with more emphasis on the qualitative design was adopted. A purposive convenient sampling approach was used to recruit SR from informal tented settlements (ITS) in the Beqaa region in Lebanon. Data collection included 19 focus group discussions (FGDs) that were conducted with participants, who were further divided into three groups: registered refugees with assistance, registered without assistance and unregistered. Twelve in-depth interviews were conducted with key informants from humanitarian organizations. All interviews and FGDs were audio recorded, transcribed, and thematically analyzed. SR were highly dependent on formal assistance when received, albeit being insufficient. Regardless of registration status, refugees resorted to informal livelihood strategies, including informal employment, child labor, early marriage, and accruing debt. Poor living conditions and food insecurity were reported among all SR. Limited healthcare access and high out-of-pocket costs led to limited use of antenatal care services, prioritizing life-threatening conditions, and resorting to alternative sources of healthcare. Severity of these conditions and their adverse health consequences were especially pronounced among unregistered refugees. Our findings shed light on the economic and health disparities among marginalized SR, with the lack of registration and formal assistance increasing their vulnerability. More tailored and sustainable humanitarian programs are needed to target the most vulnerable and hard-to-reach groups.

Background: Many Indigenous communities across the USA and Canada experience a disproportionate burden of health disparities. Effective programs and interventions are essential to build protective skills for different age groups to improve health outcomes. Understanding the relevant barriers and facilitators to the successful dissemination, implementation, and retention of evidence-based interventions and/or evidence-informed programs in Indigenous communities can help guide their dissemination.Purpose: To identify common barriers to dissemination and implementation (D&I) and effective mitigating frameworks and strategies used to successfully disseminate and implement evidence-based interventions and/or evidence-informed programs in American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and Canadian Indigenous communities.Methods: A scoping review, informed by the York methodology, comprised five steps: (1) identification of the research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4) data charting; and (5) collation, summarization, and reporting of results. The established D&I SISTER strategy taxonomy provided criteria for categorizing reported strategies.Results: Candidate studies that met inclusion/exclusion criteria were extracted from PubMed (n= 19), Embase (n= 18), and Scopus (n= 1). Seventeen studies were excluded following full review resulting in 21 included studies. The most frequently cited category of barriers was “Social Determinants of Health in Communities.” Forty-three percent of barriers were categorized in this community/society-policy level of the SEM and most studies (n= 12, 57%) cited this category. Sixteen studies (76%) used a D&I framework or model (mainly CBPR) to disseminate and implement health promotion evidence-based programs in Indigenous communities. Most highly ranked strategies (80%) corresponded with those previously identified as “important” and “feasible” for D&I The most commonly reported SISTER strategy was “Build partnerships (i.e., coalitions) to support implementation” (86%).Conclusion: D&I frameworks and strategies are increasingly cited as informing the adoption, implementation, and sustainability of evidence-based programs within Indigenous communities. This study contributes towards identifying barriers and effective D&I frameworks and strategies critical to improving reach and sustainability of evidence-based programs in Indigenous communities.Registration number: N/A (scoping review)

Background: Marijuana is a widely used substance in the United States (US) and worldwide. We explored trends in self-reported marijuana use among US adolescents overall as well as by gender, race/ethnicity, and school grade. Methods: Biennial data from the Youth Risk Behavior Survey from 2011 to 2021 included 88,183 adolescents in grades 9th through 12th. We used percentage change as a measure of effect and the chi-square test for significance. All analyses were conducted at the national level. Results: The percentage of adolescents who reported current marijuana use dropped significantly from 23.1% in 2011 to 15.8% in 2021 (p < 0.05). The self-report of trying marijuana for the first time before age 13 also decreased significantly from 8.1% in 2011 to 4.9% in 2021 (p < 0.05). For current use, there were similar significant decreases by race/ethnicity, with Asian, Hispanic, and White adolescents experiencing the steepest declines. In 2021, the percentage of Black adolescents self-reporting marijuana use was significantly higher (20.5%) compared to White (14.8%), Hispanic (16.7%), and Asian (5.1%) adolescents. Although current marijuana use declined significantly for both girls and boys over time, in 2021 girls were more likely (17.8%) to currently use marijuana than boys (13.6%). In 2011, the opposite was true, with boys (25.9%) being more likely to use marijuana than girls (20.1%). Conclusions: In US adolescents in 2021, there were decreases in self-reports of marijuana use compared to 2011. Behavioral interventions within school and family environments may be critical in mitigating the risk of marijuana use.

Editorial on the Research Topic Period poverty Each month, half of the world's female population, estimated at 1.9 billion individuals, experience menstruation (1). Yet, as normal as it seems, menstruation is still stigmatized around the world, particularly in low-income countries with inadequate access to menstrual health and hygiene management resources (1, 2). Menstrual health is a critical global public health issue that has been impacting the physical, mental, and socioeconomic health of both women and girls (2). However, there still exists social, cultural, economic, and political barriers to accessing menstrual products, menstruation educational material, and sanitation facilities when needed (3, 4). The American Medical Women's Association defines period poverty as the lack of accessibility or affordability of menstrual hygiene tools and educational material, such as sanitary products, washing facilities, and waste management (5). The term also refers to the increased economic vulnerability menstruating people face due to the financial burden posed by menstrual supplies, which are not only limited to menstrual pads and tampons, but also include costs accrued from pain medication and underwear used during the menstruation cycle (6–8). Such resource-limited settings drive women and girls to improvise with unsanitary alternatives such as old blankets, chicken feathers, old rags, newspapers, and cow dung (4). Difficulty affording menstrual products can cause women and girls to stay home from school and work, with lasting consequences on their education and economic opportunities. It can also exacerbate existing vulnerabilities, pushing individuals closer toward dangerous coping mechanisms (9, 10). Period poverty does not only affect menstruating people in lower income countries; it also affects them in higher income countries (11). It is estimated that 500 million women in the United States have inadequate access to menstrual products and hygiene facilities (7, 5). One national survey among college students found that 14.2% of respondents reported experiencing period poverty in the year preceding the survey, while an additional 10% experienced it every month (12). The same study documented period poverty being associated with higher likelihood of symptoms consistent with moderate/severe depression (12), with those reporting monthly period poverty at greatest risk for reporting such symptoms. Period poverty has also been associated with mental health issues and urinary tract infections (3, 4). The gap in the literature and the lack of data on period poverty is a continuous challenge to measure its deteriorating impact on women's health. The following special issue aimed to address this gap by including a diverse set of qualitative, cross-sectional, and review studies exploring the menstrual experiences of girls and women from different regions across the world. For instance, the menstrual health challenges reported by adolescent girls in Myanmar ranged from access to information and social support, to behavioral restrictions, stigma surrounding menstruation, and difficulties managing menstrual bleeding and pain (Swe et al.). These findings were similar to those highlighted in the systematic review by Patel et al. on period poverty in lower and middle income countries, which included three emerging themes: 1. Availability and affordability of menstrual products, and accessibility to water, sanitation and health (WASH) services, 2. Availability of support system and coping with “period poverty,” and 3. Gender dimensions of menstrual hygiene management. Age appropriate education, using innovative approaches such as interpersonal practical guidance (IPG) as face-to-face communication and mediated practical guidance (MPG) as social and behavior change communication (SBCC), was successful in improving menstrual health and hygiene management (MHHM) knowledge, attitudes, and practices in India, while addressing the existing menstrual health challenges in similar settings (Block et al.). Another country that suffered drastically from the consequences of period poverty amidst an economic recession and political turmoil was Lebanon (Elhage Hassan et al., 11). A qualitative study exploring stakeholders’ perspectives on the Lebanese public health policy regarding menstrual health emphasized the need to decrease the monetary burden by subsidizing menstrual products or by implementing a coupon system. The study also reported the need for proper education on multiple levels, cooperation between key players in the private and public sectors, and encouragement of local production to ensure future sustainability (Elhage Hassan et al.). When it comes to the United States, low-income menstruating adults were seen to be disproportionately affected by period poverty during the COVID-19 pandemic because the pandemic acted as a barrier to period supplies and an underlying factor for missing work due to the lack of such products (Hunter et al.). Similarly, adults working with U.S-based communities of color revealed tension between school responsibility and family authority in providing menstruation and puberty education in schools, school- and teacher-related delivery challenges, and inadequate and disengaging menstruation and puberty content (Schmitt et al.). Social, physical, and mental issues imposed by period poverty and encountered by females globally are inhumane and require immediate attention of policymakers and healthcare professionals to attain positive and sustainable menstruation outcomes. Findings from this issue will provide the readers with an overview about the current situation of period poverty in high-income and low-income countries. It will also guide research experts in the design and implementation of interventions seeking to address structural, social, and individual factors among populations impacted by such a phenomenon. LS and CM: development of the editorial. JG and MP: critical review of the editorial. All authors contributed to the article and approved the submitted version. 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. 1. Alvarez A. Period poverty. American Medical Women’s Association (2019). Available at: https://www.amwadoc.org/period-poverty. 2. Rodriguez L. 9 Wins for menstrual equity in 2021. Global Citizen (2021). Available at: https://www.globalcitizen.org/en/content/wins-for-menstrual-equity-in-2021/. 3. ACMHM. The ark by KrTC. ACMHM (2021). Available at: https://acmhm.org/2021/06/28/the-ark-by-krtc/. 4. What is period poverty? Medical News Today (2021). Available at: https://www.medicalnewstoday.com/articles/period-poverty. 5. Vardapetyan A. Period poverty: the belittling of a basic need. American Medical Women’s Association (2021). Available at: https://www.amwa-doc.org/periodpoverty-the-belittling-of-a-basic-need/. 6. Hennegan J, Montgomery P. Do menstrual hygiene management interventions improve education and psychosocial outcomes for women and girls in low- and middle-income countries? A systematic review. PloS One. (2016) 11(2):e0146985. doi: 10.1371/journalpone.0146985 PubMed Abstract | CrossRef Full Text | Google Scholar 7. Michel J, Mettler A, Schonenberger S, Gunz D. Period poverty: why it should be everybody’s business. J Glob Health Rep. (2022) 6:1–4. doi: 10.29392/001c.32436 CrossRef Full Text | Google Scholar 8. United Nations Population Fund. Menstruation and human rights - frequently asked questions. United Nations Population Fund (2022). Available at: https://www.unfpa.org/menstruationfaq. 9. Michel J, Tanner M. Poverty is not poverty: the reality on the ground including the rural-urban divide and how we can turn the tide on NCDs. In: Monyeki KD, Kemper HC, editors. Lifestyle and epidemiology: The double burden of poverty and cardiovascular diseases in African populations. London, UK: IntechOpen (2021). 10. Tull K. Period poverty impact on the economic empowerment of women (2021). Available at: https://assets.publishing.service.gov.uk/media/5c6e87b8ed915d4a32cf063a/period.pdf. 11. Sacca L, Maroun C, Khoury S, Maroun V, Khoury J, Bouery P. Period poverty in Lebanon: a call for action. Womens Reprod Health. (2022):1–16. doi: 10.1080/23293691.2022.2079965 PubMed Abstract | CrossRef Full Text | Google Scholar 12. Cardoso LF, Scolese AM, Hamidaddin A, Gupta J. Period poverty and mental health implications among college-aged women in the United States. BMC Women’s Health. (2021) 21(1):14. doi: 10.1186/s12905-020-01149-5 CrossRef Full Text | Google Scholar Keywords: period poverty, menstrual equity, women's rights, sanitary facilities, menstrual hygiene, menstrual health, human rights Citation: Sacca L, Markham CM, Gupta J and Peskin M (2023) Editorial: Period poverty. Front. Reprod. Health 5:1140981. doi: 10.3389/frph.2023.1140981 Received: 9 January 2023; Accepted: 19 January 2023; Published: 7 February 2023. Edited and Reviewed by: Pamela Stratton, National Institutes of Health (NIH), United States © 2023 Sacca, Markham, Gupta and Peskin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: Lea Sacca lsacca@health.fau.edu Specialty Section: This article was submitted to Gynecology, a section of the journal Frontiers in Reproductive Health Period Poverty

Introduction: Despite the continuous increase in the incidence of metastatic breast cancer among Syrian and Iraqi refugee women residing in camp settings in Lebanon, mammography and chemotherapy adherence rates remain low due to multiple social, economic, and environmental interfering factors. This in turn led to an alarming increase in breast cancer morbidity and mortality rates among the disadvantaged population. Methods: Intervention mapping, a systematic approach which guides researchers and public health experts in the development of comprehensive evidence-based interventions (EBIs) was used to plan a health education and health policy intervention to increase breast cancer screening and chemotherapy adherence among Iraqi and Syrian refugee women aged 30 and older who are residing in refugee camps within the Beirut district of Lebanon. Results: The generation of the logic model during the needs assessment phase was guided by an extensive review of the literature and reports published in peer-reviewed journals or by international/local organizations in the country to determine breast cancer incidence and mortality rates among refugee women of Syrian and Iraqi nationalities. The underlying behavioral and environmental determinants of the disease were identified from qualitative and quantitative studies carried out among the target population and also aided in assessing the sub-behaviors related to the determinants of breast cancer screening and chemotherapy completion as well as factors affecting policy execution to formulate performance objectives. We then developed matrices of change objectives and their respective methods and practical applications for behavior change at the intrapersonal, interpersonal, organizational, and societal levels. Both educational components (brochures, flyers) and technological methods (videos disseminated via Whats app and Facebook) will be adopted to apply the different methods selected (modeling, self-reevaluation, consciousness raising, persuasion, and tailoring). We also described the development of the educational and technological tools, in addition to providing future implementers with methods for pre-testing and pilot-testing of individual and environmental prototype components. Conclusion: The use of intervention mapping in the planning and implementation of holistic health promotion interventions based on information collected from published literature, case reports, and theory can integrate the multiple disciplines of public health to attain the desired behavioral change.

Background: Artificial intelligence (AI) algorithms can be applied in breast cancer risk prediction and prevention by using patient history, scans, imaging information, and analysis of specific genes for cancer classification to reduce overdiagnosis and overtreatment. This scoping review aimed to identify the barriers encountered in applying innovative AI techniques and models in developing breast cancer risk prediction scores and promoting screening behaviors among adult females. Findings may inform and guide future global recommendations for AI application in breast cancer prevention and care for female populations. Methods: The PRISMA-SCR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was used as a reference checklist throughout this study. The Arksey and O’Malley methodology was used as a framework to guide this review. The framework methodology consisted of five steps: (1) Identify research questions; (2) Search for relevant studies; (3) Selection of studies relevant to the research questions; (4) Chart the data; (5) Collate, summarize, and report the results. Results: In the field of breast cancer risk detection and prevention, the following AI techniques and models have been applied: Machine and Deep Learning Model (ML-DL model) (n = 1), Academic Algorithms (n = 2), Breast Cancer Surveillance Consortium (BCSC), Clinical 5-Year Risk Prediction Model (n = 2), deep-learning computer vision AI algorithms (n = 2), AI-based thermal imaging solution (Thermalytix) (n = 1), RealRisks (n = 2), Breast Cancer Risk NAVIgation (n = 1), MammoRisk (ML-Based Tool) (n = 1), Various MLModels (n = 1), and various machine/deep learning, decision aids, and commercial algorithms (n = 7). In the 11 included studies, a total of 39 barriers to AI applications in breast cancer risk prediction and screening efforts were identified. The most common barriers in the application of innovative AI tools for breast cancer prediction and improved screening rates included lack of external validity and limited generalizability (n = 6), as AI was used in studies with either a small sample size or datasets with missing data. Many studies (n = 5) also encountered selection bias due to exclusion of certain populations based on characteristics such as race/ethnicity, family history, or past medical history. Several recommendations for future research should be considered. AI models need to include a broader spectrum and more complete predictive variables for risk assessment. Investigating long-term outcomes with improved follow-up periods is critical to assess the impacts of AI on clinical decisions beyond just the immediate outcomes. Utilizing AI to improve communication strategies at both a local and organizational level can assist in informed decision-making and compliance, especially in populations with limited literacy levels. Conclusions: The use of AI in patient education and as an adjunctive tool for providers is still early in its incorporation, and future research should explore the implementation of AI-driven resources to enhance understanding and decision-making regarding breast cancer screening, especially in vulnerable populations with limited literacy.