Researchers purposively recruited participants from a nursing rehabilitation clinic at Hubei Cancer Hospital in China between May and September 2024. They conducted semistructured interviews and analyzed the transcripts using combined deductive and inductive content analysis. Data collection continued until both code saturation and meaning saturation were achieved, and agreement for 20% of transcripts assessed by two coders was substantial, with a Cohen’s kappa of 0.79.

The analysis identified seven themes. Exercise experience, habitual exercise cues and routines, and emotional support were classified primarily as system 1 processes. Reflective appraisal of dysphagia, consideration of medical-service resources, weighing benefits and risks, and the gap between expectations and effects were classified primarily as system 2 processes.

The findings therefore linked adherence to both immediate patterns of behavior and patients’ conscious assessment of their condition, resources, and possible outcomes. Cross-system interactions added a dynamic element to the findings. The study reported that immediate bodily and emotional responses were continually reshaped by reflective appraisal, contextual resources, and perceived progress.

In other words, patients’ assessments could affect how they interpreted immediate experiences, while situational conditions and perceptions of progress could influence reflective judgment. Adherence was thus understood as a changing product of interacting automatic and reflective processes. Emotional support was one of the themes associated with system 1 processes, indicating that support from other people formed part of the context in which exercises were performed.

The study also identified the consideration of medical-service resources as a reflective factor, showing that patients evaluated the services surrounding their care when thinking about exercise adherence. These findings should not be interpreted as evidence that any particular support strategy improves swallowing outcomes, because the study did not test such an intervention. The authors’ clinical-relevance section proposed combining habit-supportive cues and affective support with education, expectation management, accessible follow-up, and individualized goal setting.

They suggested that clinicians could anchor exercises to stable daily cues, involve family members as proximal habit coaches, offer flexible or abbreviated protocols for working patients, and provide motivational interviewing and tele-rehabilitation support to reduce uncertainty and sustain adherence. These are recommendations derived from the qualitative findings rather than results from a clinical trial of the proposed approaches. The study’s scope was limited by its design and setting.

It included 18 patients from one rehabilitation clinic in China, all of whom had experience with swallowing exercises. The findings describe reported processes behind adherence; they do not establish that the same patterns hold for every person with head and neck cancer or measure changes in swallowing function, treatment response, or survival. The research was also intended to explore mechanisms, not to demonstrate that swallowing exercises produce clinical benefits.

Overall, the study presents swallowing-exercise adherence as a context-sensitive process shaped by routines, emotional support, conscious appraisal, service resources, expectations, and perceived effects. For rehabilitation teams, that distinction points to a broader view of support, one that considers both the conditions surrounding daily exercise and the judgments patients make about their difficulties and progress.

Subject of Research: Factors influencing swallowing-exercise adherence among patients with head and neck cancer

Article Title: Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study

Article References: Liu, Y., Liu, S., Hu, L., Jia, J., Wang, Y., Lin, H., Zou, L., & Shi, L. (2026). Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study. Supportive Care in Cancer, 34(11), Article 1134. https://doi.org/10.1007/s00520-026-11360-z

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11360-z

Keywords: head and neck cancer, swallowing exercises, exercise adherence, dual-process model, qualitative research, rehabilitation, health behavior, patient support, Swallowing, exercise, adherence, patients

The research team, led by Ayşe İspirli Turan of the Department of Health Management at Samsun University in Türkiye, used a phenomenological design, a qualitative approach that aims to capture the lived experience of a phenomenon directly from those who have experienced it. Rather than surveying a large population with fixed questionnaires, the researchers conducted in-depth, semi-structured interviews with 20 participants, each of whom had used at least one TCIM practice. Participants were recruited through purposive sampling, which deliberately selects people with direct experience of the topic, and snowball sampling, in which early participants refer others from their own networks. The interviews were then transcribed and analyzed using thematic analysis, a systematic method for identifying recurring patterns of meaning across qualitative data.

The analytical process yielded five main themes and 23 subthemes, a granular structure that reveals just how many distinct forces shape a person’s orientation toward complementary practices. The most prominent theme was health-based motivation. Participants reported turning to TCIM primarily for disease prevention, disease treatment, and strengthening immunity. These are not vague wellness aspirations but concrete health goals, and the study suggests that many users approach herbal products, dietary regimens, and physical practices with the same instrumental logic they would apply to a prescription: they expect a measurable benefit for a specific health problem.

Yet health goals alone did not explain the pattern. A second cluster of motivations centered on disappointment with modern medical treatment. Participants described situations in which they failed to achieve the expected benefits from conventional therapies, or in which they harbored reservations about long-term medication use. For these users, TCIM functioned as a response to a perceived gap in modern care, a way of addressing problems that pharmaceuticals had not solved or of reducing dependence on drugs they viewed with suspicion. This finding aligns with a well-documented phenomenon in health services research: patients who feel that conventional medicine has exhausted its options often begin searching for alternatives, and the search itself is driven by unmet clinical need rather than by anti-science sentiment.

Religious and cultural beliefs emerged as a third determining factor. Participants explained that their engagement with certain practices was grounded in faith traditions and cultural inheritance, frameworks that give healing practices meaning beyond their biochemical effects. The influence of family and social environments ranked among the strongest social drivers: recommendations from relatives, friends, and community members frequently initiated first use. In many cases, the pathway into TCIM was not an advertisement or an internet article but a trusted person in the user’s immediate circle, which helps explain why these practices spread so persistently through populations despite limited formal promotion.

Two psychological factors stood out as key supports for continued use. Participants expressed a belief that the practices would be beneficial, an expectation that researchers recognize as related to placebo and expectancy effects, and they reported seeking psychological relief. The act of doing something active for one’s own health, whether preparing an herbal infusion or attending a cupping session, appears to deliver a sense of control and comfort that participants valued in its own right. This suggests that part of TCIM’s appeal is not the treatment’s direct physiological action but the psychological experience of care, agency, and hope that accompanies it.

Perhaps the most striking finding concerns how users position TCIM relative to modern medicine. Contrary to the popular narrative of a war between alternative and conventional care, participants viewed the two as complementary rather than competing approaches. They did not describe abandoning doctors for herbalists; they described using both, often simultaneously, and they explicitly supported integrating TCIM into the modern healthcare system. This perception challenges the binary framing that dominates public debate and suggests that, from the user’s perspective, the question is not which system is superior but how the two can be combined safely.

Participants did not support integration without conditions. They emphasized three requirements: scientific evidence, professional supervision, and accessibility. In other words, users themselves want complementary practices evaluated by research, delivered under qualified oversight, and available within the formal healthcare system rather than in an unregulated gray market. This is a notable result because it indicates that the demand for integration is not a demand for exemption from scientific standards. Users appear to want the cultural and psychological benefits of traditional practices delivered with the safety infrastructure of modern medicine, a combination that health systems in many countries are only beginning to experiment with.

The study’s methodological choices deserve attention when weighing its conclusions. With 20 participants interviewed in depth, the research prioritizes richness of experience over statistical generalizability, which is standard for phenomenological work. The findings describe how these particular users perceive and experience TCIM, and they generate hypotheses about the motivations that likely operate in broader populations: unmet treatment expectations, medication concerns, cultural embeddedness, social recommendation, and expectancy of benefit. Quantitative follow-up studies would be needed to test how frequently these motivations occur at scale, but the thematic structure identified here provides a concrete map for that future research.

For clinicians and policymakers, the implications are direct. Because patients are already using TCIM widely and view it as a partner to conventional care, ignoring or dismissing the phenomenon risks losing sight of real health behavior, including potential herb-drug interactions and delayed treatment-seeking that clinicians should know about. The study suggests that the more productive path is engagement: asking patients about their complementary practices, understanding the motivations documented here, and working toward the evidence-based, professionally supervised, accessible integration that participants themselves called for. The shadow cast by modern medicine, the study’s title suggests, may be less a hiding place than a waiting room, where traditional practices stand ready to step into the light of scientific evaluation.

Subject of Research: Complementary and Alternative Medicine

Article Title: Traditional and complementary health practices in the shadow of modern medicine: a qualitative study of users’ perceptions and experiences

Article References: Turan, A. İ., Uluğ, M. E., Sarıyıldız, A. Y., & Küçük, Y. S. (2026). Traditional and complementary health practices in the shadow of modern medicine: a qualitative study of users’ perceptions and experiences. BMC Complementary Medicine and Therapies. https://doi.org/10.1186/s12906-026-05649-z

Image Credits: AI Generated

DOI: 10.1186/s12906-026-05649-z

Keywords: traditional medicine, complementary medicine, integrative medicine, qualitative research, patient perceptions, healthcare integration, TCIM, modern medicine, health behavior, Samsun University, Traditional, complementary

The study exploited a uniquely rich data resource: the National Health Insurance Service Health Screening Cohort, known as NHIS-HEALS. Korea operates a universal single-payer system that covered approximately 97 percent of the population as early as 1989, and enrollment in the system mandates biennial health screenings that record anthropometry, laboratory markers, and self-reported behaviors. Because the cohort is built from administrative claims rather than surveys, it avoids the recall bias and measurement error that plague self-reported data. The researchers selected a 10 percent random sample of adults aged 40 to 79 who underwent national health screening in 2002 and 2003, then applied strict exclusions to remove former smokers, people with baseline chronic diseases such as hypertension, diabetes, stroke, or cancer, and anyone with missing behavioral data across the trajectory estimation waves.

To capture the joint evolution of the four behaviors, the team used group-based multi-trajectory modeling, a statistical technique designed to identify qualitatively distinct subgroups within a population rather than describing average change around a single mean. Smoking was categorized by cigarettes per day, alcohol intake by grams per day, physical activity by weekly frequency of moderate-to-vigorous exercise, and BMI by Korean obesity guidelines. Model fit was assessed using the Akaike Information Criterion, the Bayesian Information Criterion, entropy, and average posterior probability, and a six-group solution emerged as optimal for both males and females. This approach matters because single-behavior analyses fail to capture the clustering and interactive effects of co-occurring risk behaviors, which is precisely where much of the health burden hides.

The six trajectories told a striking story. Among the 95,226 men, roughly 30 percent maintained a stable healthy pattern of non-smoking, low alcohol intake, increasing physical activity, and normal BMI, while 28 percent showed progressive improvement across all behaviors. Two moderate-risk groups, together comprising about 40 percent, sustained smoking, moderate drinking, and low physical activity, differing mainly in whether they carried overweight or normal BMI. Two small severe-risk groups, each around 1 percent, combined light smoking, minimal activity, and either persistent underweight or severe obesity. Among the 72,117 women, the picture differed: nearly 35 percent were stably healthy, and the moderate-risk groups were defined primarily by overweight or obese BMI rather than by smoking or drinking, since most women were nonsmokers and nondrinkers.

The associations with healthcare outcomes were assessed using generalized estimating equations stratified by sex, with adjustments for age, region, insurance type, income, disability status, and the Charlson Comorbidity Index. For inpatient expenditure and length of stay, which showed substantial zero-inflation with roughly 80 percent of observations at zero, the researchers applied a two-part modeling framework: a logistic model for the probability of any hospitalization, and a gamma model with a log link for the magnitude among those hospitalized. Outpatient expenditure and visit counts, with fewer than 0.3 percent zero observations, required only single-part models. An autoregressive order 1 correlation structure was selected because healthcare spending in a given year correlates most strongly with the immediately preceding year.

The results were dramatic and sex-specific. Among men, the higher severe-risk trajectory was associated with outpatient expenditure 12.5 percent higher and inpatient expenditure 60.6 percent higher than the stable healthy group, along with 4 percent more outpatient visits and 22 percent longer hospital stays. But the most intriguing finding concerned the higher moderate-risk group: these men, despite normal BMI, younger age, and lower comorbidity, showed 3.7 percent fewer outpatient visits yet 24.4 percent longer hospital stays. This pattern echoes what epidemiologists call the lean paradox, in which normal-weight individuals with poor smoking, drinking, and activity profiles visit outpatient care less but hospitalize more, possibly because they engage in less preventive care and present with more advanced disease when they finally do.

Among women, the higher severe-risk trajectory, affecting less than 1 percent of the cohort, was linked to outpatient expenditure 14.8 percent higher, inpatient expenditure 74.7 percent higher, 6 percent more outpatient visits, and 45.4 percent longer hospital stays. Smoking lowers estrogen levels, and women show greater physiological susceptibility to alcohol-related harm, which may partly explain why adverse behaviors carry such heavy costs in this group. More paradoxically, the female decreasing-risk trajectory, representing women who improved their behaviors over time, showed higher expenditure and utilization than the stable healthy reference group, unlike their male counterparts. The authors propose several mechanisms: health-conscious women may simultaneously adopt broader health-promoting behaviors that elevate short-term utilization, the benefits of behavioral improvement may require a longer time horizon than the 11-year follow-up to manifest as cost savings, and estrogen-mediated protection in younger women may attenuate observable benefits while its withdrawal after menopause amplifies residual damage from prior unhealthy behaviors.

Age-stratified analyses added another layer of nuance. Among men under 65, severe-risk trajectories showed the strongest associations with inpatient expenditure and length of stay, likely reflecting early disease onset and intensive treatment needs. Among men 65 and older, moderate-risk trajectories dominated, consistent with the cumulative damage of persistent smoking and heavy drinking in later life worsening comorbidities and hospitalization rates. Among women, the higher severe-risk trajectory was strongly associated with higher inpatient expenditure and longer stays in both age groups, with coefficients of 0.624 in the younger group and 0.477 in the older group. These patterns suggest that the behavioral drivers of healthcare demand shift across the life course, and that prevention strategies must be tailored accordingly.

The stakes are enormous. Non-communicable diseases account for approximately 71 trillion Korean won annually in Korea, nearly 85 percent of total healthcare costs, and Korean healthcare expenditure has been growing at the fastest rate among OECD countries. The socioeconomic losses attributable to smoking, high-risk drinking, physical inactivity, and obesity reached approximately 42 trillion won in 2019. Out-of-pocket spending remains above the OECD average, and the long-term financial sustainability of the health system is under pressure. The authors argue that community-level health policies in Korea have focused primarily on interventions after disease onset, and that adopting prevention-oriented approaches, as demonstrated in Japan where community-based health promotion programs reduced healthcare expenditure, could enhance the effectiveness of preventive policy.

The study has limitations worth noting. Substantial sample exclusions, including 258,970 individuals removed for missing data or death and 83,918 for baseline chronic conditions, likely produced a healthier-than-average analytic sample, and excluded participants differed significantly in age, income, and disability status. Unmeasured confounders such as diet, sleep, education, occupation, and health literacy may have influenced both behaviors and utilization. Physical activity was measured only by weekly frequency, without duration or intensity, and pharmacy costs were excluded because Korean claims data do not disaggregate pharmaceutical expenditure by care setting, which may underestimate the total financial burden of unhealthy trajectories. Nevertheless, the core message stands: healthcare demand is shaped by long-term, multidimensional behavioral patterns rather than by single risk factors, and preventive interventions should address not only high-risk groups but also individuals with normal BMI who continue to smoke, drink, or remain inactive. Strengthening community-based prevention may be the key to reducing the healthcare burden and sustaining Korea’s health system for decades to come.

Subject of Research: Health

Article Title: Joint trajectories of health behaviors and their associations with healthcare utilization and expenditure

Article References: Yang, J. M., Kim, J. M., Jang, T. S., & Hwang, J. (2026). Joint trajectories of health behaviors and their associations with healthcare utilization and expenditure. International Journal of Public Health, 71, Article 1609686. https://doi.org/10.3389/ijph.2026.1609686

Image Credits: AI Generated

DOI: 10.3389/ijph.2026.1609686

Keywords: health behavior, healthcare expenditure, South Korea, NHIS-HEALS, trajectory modeling, public health, preventive medicine, Joint, trajectories, health, behaviors, associations

The scale of the problem provides urgent context for the research. Globally, cervical cancer is the fourth most common cancer among women, with an estimated 662,000 new cases and 349,000 deaths reported in 2024. In Nigeria, it is the second most common cancer in women, contributing approximately 15,000 new cases and nearly 10,000 deaths annually. Human papillomavirus, the primary etiologic agent of cervical cancer, is a common sexually transmitted infection with more than 100 genotypes, including 13 high-risk types linked to cervical carcinogenesis. HPV types 16 and 18 alone account for about 70 percent of cervical cancer cases worldwide. Persistent infection with high-risk HPV can progress to precancerous lesions, invasive cervical cancer, and ultimately death, making early detection and vaccination critical tools in interrupting this trajectory.

Despite the proven benefits of HPV vaccination and screening, uptake in Nigeria remains strikingly low. Only 8.7 percent of women aged 18 to 69 have ever been screened, mainly due to limited awareness, cultural beliefs, stigma, and inadequate access to affordable services. HPV self-collection, though promising as a convenient, private, and empowering alternative to clinic-based pelvic examinations, is still emerging and underutilized, constrained by low awareness, limited self-efficacy, minimal provider recommendations, and scarce kit availability. Evidence demonstrates that HPV self-collection is equally effective at detecting high-grade cervical precancer and can substantially increase screening uptake. HPV vaccination continues to be a key element in primary prevention for eligible adolescents, lowering the risk of HPV infection and cervical cancer by as much as 90 percent. Notably, Nigeria recently achieved 71 percent first-dose HPV vaccination coverage among girls aged 9 to 14, immunizing nearly 12 million girls, a remarkable public health achievement that contrasts sharply with the persistent barriers to screening.

The study employed semi-structured, in-depth interviews lasting 45 to 60 minutes, conducted privately and in a culturally appropriate manner in English or Yoruba. Participants were recruited through purposive sampling from community-based settings including schools, marketplaces, churches, mosques, and health facilities across Lagos State, which has an estimated population of about 21 million distributed across 20 Local Government Areas. The research team, trained in semi-structured qualitative interviewing techniques and culturally sensitive research practices, applied the Consolidated Criteria for Reporting Qualitative Research to ensure rigorous and transparent reporting. Thematic analysis was guided by the PEN-3 Cultural Model, which organizes health behavior influences into three domains: Cultural Identity, Relationships and Expectations, and Cultural Empowerment. Data collection continued until saturation was reached, assessed separately within each age group, and coding was performed by two independent researchers who met regularly to resolve discrepancies.

The results revealed significant variations in knowledge about HPV and cervical cancer across age groups. Many younger participants had never heard of HPV, with statements like, “I have never heard about it,” and “This is like the first time I am hearing about it.” Among older women, knowledge was similarly limited, with one participant stating, “I don’t know anything about cervical cancer,” and another explaining, “It is cancer that occurs in the women in their private parts.” A few participants who were health professionals demonstrated accurate understanding, while some older women expressed confidence and self-efficacy in managing their health needs independently, with one 39-year-old stating, “I can do it myself as long as I am taught.” Conversely, others expressed hesitation, admitting, “I don’t think I can do it; I’d rather go to the hospital.”

Family influence emerged as a central theme shaping health decisions in both age groups. For HPV vaccination, girls reported that recommendations from the health ministry (86 percent), health providers (86 percent), and family and friends (64 percent) strongly influenced their decisions. Younger participants indicated that decisions about vaccinations heavily depended on family approval, with one stating, “Yes, they will have to allow me, for me to take it.” Among older participants, male partners played a pivotal role as either facilitators or barriers, with one woman noting, “Men can encourage us, like reminding you and all that,” while another stated, “If my husband says no, then I can’t go.” Some participants reported that family opinions would not ultimately prevent them from seeking preventive services, with one 35-year-old explaining, “It is necessary so I’ll make him understand… I will lecture him on why it is important.” For HPV self-collection, adult women prioritized messages from health providers (96 percent) and health ministry officials (89 percent).

Misinformation, stigma, and spiritual beliefs created significant barriers to prevention behaviors across both groups. Some participants voiced concerns about vaccine safety and quality within the Nigerian health system, with one stating, “You know Nigeria and expired vaccine, I don’t really trust Nigeria.” Misinformation about the vaccines was shared, including the belief that “the vaccine may prevent me from having children.” Among older participants, misconceptions about cervical cancer origins were evident, with beliefs such as “maybe somebody put it on the chair… It’s a curse,” and fears that self-collection samples “may use it for ritual… people are afraid.” Stigma towards reproductive health was demonstrated through statements like, “Women don’t want to talk about things that affect the private part,” and “Some people think it’s an abomination.” One participant reflected reliance on spiritual protection, stating, “I am not praying to get that kind of sickness… the sickness will not know me.”

Financial constraints and accessibility emerged as prominent structural barriers. Younger participants expressed concerns about the cost of vaccines, noting a narrow affordability range of 3,500 to 5,000 naira per dose, with one stating, “Cost, if it’s too expensive, then I can’t.” Older participants indicated willingness to pay small amounts, with one explaining, “I want it to be free… but maybe 500,” and another adding, “If it’s free, I’ll take my daughter for the vaccine, but I can only pay maybe 200 naira per dose.” While low costs were preferred, some participants were willing to pay more, typically 500 to 1,000 naira, and in a few cases up to 10,000 naira, depending on perceived importance and financial capacity. Participants across both groups expressed a strong preference for affordable, accessible vaccines and self-collection kits available at health facilities and pharmacies, with proximity and trust in the service provider being recurring themes.

Trust in healthcare providers and formal institutions emerged as a central determinant of HPV vaccine acceptance and self-collection participation. Participants expressed strong preferences for receiving services in trusted settings such as hospitals, pharmacies, and schools. Younger participants articulated a desire for vaccinations at recognizable healthcare facilities, with one stating, “I would prefer to get it from my hospital. I would least prefer an outreach like this.” Older participants echoed this sentiment, emphasizing the importance of local health facilities for accessibility, with remarks like, “I would prefer it at the pharmacy because it is nearby,” and “They should make it closer to the market.” Some participants expressed preference for hospitals over pharmacies, with one noting, “I prefer to get it from the hospital. I don’t know about these pharmacy people; they can just give you anything.”

The study’s findings carry significant implications for designing culturally grounded cervical cancer prevention strategies in Nigeria and similar low-resource settings. The researchers emphasize that future HPV prevention efforts should be community-based and family-inclusive, engaging parents, spouses, religious leaders, and community gatekeepers to ensure cohesive, informed, and sustained uptake of vaccination and self-collection services. Endorsements from health ministries, religious leaders, and high-profile public figures could enhance the perceived legitimacy of HPV vaccination. Equipping clinicians and pharmacists to actively recommend HPV vaccination and self-collection may enhance confidence in these preventive interventions. The authors suggest promoting positive cultural values, such as emphasizing cancer control rather than HPV as a sexually transmitted infection, and highlighting the maternal role in health decision-making. Addressing misinformation and stigma through targeted, socio-culturally appropriate educational initiatives within schools, faith-based institutions, and media platforms can help dispel misconceptions, normalize cervical cancer prevention, and support informed decision-making. The study acknowledges limitations including self-reported data subject to social desirability bias, a sample limited to Lagos State, and underrepresentation of younger adolescents due to consent and logistical issues. Nevertheless, the findings underscore that addressing structural, social, and cultural factors is crucial for increasing HPV vaccine coverage and promoting equitable cervical cancer prevention in Nigeria.

Subject of Research: Cultural and social facilitators and barriers influencing HPV vaccination and HPV self-collection preferences among Nigerian girls and women

Article Title: Her health, her choice: a PEN-3 exploration on facilitators, and preferences for HPV vaccinations and HPV self-collection among Nigerian girls and women

Article References: Olusanya, O. A., Kabutey, P., Koledowo, A., Wapmuk, A., Kokelu, E., Gbaja-biamila, T., Ojo, T., Akinsolu, F., Nwaozuru, U., Obi-Jeff, C., Anikamadu, O., Musa, A. Z., Kalulu, P., Veluri, R., Ong, J. J., Zhang, L., Smith, J. S., Xian, H., Azuogu, B., … Iwelunmor, J. (2026). Her health, her choice: a PEN-3 exploration on facilitators, and preferences for HPV vaccinations and HPV self-collection among Nigerian girls and women. Frontiers in Cancer Control and Society, 4, Article 1790326. https://doi.org/10.3389/fcacs.2026.1790326

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1790326

Keywords: HPV vaccination, cervical cancer, HPV self-collection, Nigeria, PEN-3 Cultural Model, qualitative research, cervical cancer screening, health behavior, Lagos, cultural beliefs, women's health, misinformation

Breast cancer has become the most diagnosed malignancy in the world, with 2.3 million new cases and 670,000 deaths recorded in 2022, and projections suggest annual incidence could climb to 3.2 million cases by 2050. In sub-Saharan Africa, the burden is particularly punishing: late-stage presentation is common in Rwanda, Nigeria, Uganda, and Ethiopia, where limited treatment options and reliance on traditional medicine often delay diagnosis until the disease is advanced. Somaliland is no exception. The first cancer burden report from Hargeisa’s Needle Hospital identified breast cancer as the most common malignancy in the region, accounting for 15.9 percent of cases, with the majority of patients presenting at stage III or IV when survival odds are worst.

In settings where mammography machines are scarce and clinical breast examination infrastructure is thin, breast self-examination has long been championed as a cost-effective, non-invasive tool that empowers women to detect early pathological changes themselves. The technique is operationally defined as a three-step process: visual inspection of the breasts, palpation while lying down, and palpation while bathing, performed ideally three to five days after menstruation begins. The research team, led by Nafisa Abdihamid Mohamed of Amoud University, framed their investigation around the Health Belief Model, a psychological framework holding that people adopt preventive behaviors when they perceive a meaningful health threat and believe a specific action will effectively reduce it. Notably, the World Health Organization does not currently endorse self-examination as a population-based screening strategy, citing the absence of demonstrated mortality benefit and the risk of false positives and unnecessary biopsies, but the method remains influential in awareness campaigns across low-resource settings.

To quantify the drivers of practice in Borama, the researchers administered a structured, self-administered questionnaire between April and May 2024, using convenience sampling with proportional quotas to ensure representation from both institutions. The instrument was piloted among health science students, achieved a content validity index of 0.86 and a Cronbach’s alpha of 0.850, indicating solid validity and internal consistency. Of 217 students approached, 202 provided complete data, a response rate of 93.1 percent. The sample skewed young, with 82.7 percent of respondents aged 20 to 24, and predominantly single at 90.6 percent. Institutional quotas reflected enrollment figures, with 66.3 percent from Amoud University and 33.7 percent from Adal University, and participation was heaviest among third- and fourth-year students, who collectively made up more than half the cohort.

The descriptive results painted a picture of an exceptionally well-informed population. Fully 97 percent of respondents had received prior information about breast cancer or self-examination, drawn mainly from university instruction at 54.5 percent and social media at 24.3 percent. Some 63.4 percent correctly identified the recommended starting age of 20 to 25 years, 98.5 percent agreed that early detection improves survival, and 70.8 percent could name all the major risk factors, including family history, aging, unhealthy lifestyle, and hormonal therapy. Attitudinal measures were equally strong: every single respondent agreed that regular self-examination is important for women’s health, 99.5 percent believed the practice gives women control over their health, and 80.7 percent strongly agreed they felt confident encouraging other women to perform it.

Yet behavior lagged far behind belief. Only 94 of the 202 students, or 46.5 percent, had ever performed the examination. The 108 who had not cited the absence of symptoms rather than lack of awareness. Among those who did practice, timing adherence was encouraging, with 87.2 percent correctly examining themselves a few days after menstruation, but frequency was weaker, and intriguingly, 30.8 percent reported weekly examinations, exceeding the recommended monthly cadence, a pattern the authors suggest may reflect either proactive vigilance or misunderstanding of guidelines that warrants further investigation. Motivations for practice also revealed anxiety-driven triggers: 7.9 percent had previous breast problems, and 8.9 percent began the practice out of fear of breast cancer because of a family history.

The inferential analysis, conducted with binary logistic regression in SPSS while controlling for multicollinearity using variance inflation factors with a mean of 1.64, isolated the factors that truly predicted behavior. Age emerged as a powerful determinant: students in older age categories were more than five times as likely to perform self-examination as their 20-to-24-year-old peers, with an odds ratio of 5.012 and a confidence interval of 1.978 to 12.705. The authors attribute this to academic maturity and cumulative clinical exposure, which may heighten perceived severity as students witness late-stage cancer cases during their rotations. Knowledge, measured as a continuous score, contributed incrementally, with each additional point raising the odds of practice by 16.1 percent. Family monthly income, by contrast, showed no statistically significant association whatsoever, an odds ratio of 1.011 that diverges sharply from general population studies where economic status often dictates screening access.

Attitude proved to be the strongest predictor of all. Students with positive attitudes were 3.25 times more likely to perform the examination than those with poor or neutral attitudes, an odds ratio of 3.251 with a confidence interval of 2.214 to 4.774 and a p-value below 0.001. The finding carries a crucial caveat about psychological barriers: 18.3 percent of respondents reported feeling uncomfortable during the examination, and the authors interpret this discomfort, rooted in cultural modesty or fear of finding a lump, as a perceived barrier that can outweigh knowledge of personal susceptibility. In Health Belief Model terms, knowing you are at risk is not enough if the emotional cost of the action feels prohibitive. The authors caution that their framework was exploratory, since they measured only perceived benefits and barriers rather than deploying fully validated psychometric scales covering susceptibility, severity, and cues to action.

The study’s limitations are acknowledged candidly. The cross-sectional design precludes causal inference, self-reported practice was not clinically verified, and social desirability bias may have inflated prevalence figures among students aware of professional expectations. Convenience sampling from two urban universities also limits generalizability to remote and non-academic populations. Still, the pattern mirrors regional data from Ethiopia and Nigeria, and comparisons with a Mogadishu knowledge-attitude-practice study, in which 89 percent of healthcare professionals knew about breast cancer but awareness of preventive tools was strikingly limited, suggest the gap is systemic rather than local. The policy prescription is clear: Somaliland’s medical faculties should institutionalize hands-on simulations using breast models, mandate training for first- and second-year students before clinical pressures mount, and build peer-led advocacy programs that normalize the conversation around breast health, while the Ministry of Health reframes self-examination as an act of empowerment rather than a response to disease.

The deepest lesson of the Borama study may resonate far beyond Somaliland. Knowledge dissemination through lectures, posters, and social media campaigns is merely a precursor to behavior, not behavior itself. When 77.7 percent of a cohort knows and 46.5 percent act, the bottleneck is psychological, not informational. Bridging that divide demands interventions that build self-efficacy, desensitize discomfort through clinical practice, and transform abstract awareness into a sustained monthly habit. For the future physicians of Somaliland, who will be expected to lead their communities in early detection, the difference between knowing and doing could ultimately shape survival outcomes across an entire region where late-stage diagnosis remains the deadliest obstacle.

Subject of Research: Determinants of breast self-examination practice among female medical students in Somaliland

Article Title: Factors associated with breast self-examination practice among female medical students in selected universities in Borama, Somaliland

Article References: Mohamed, N. A., Abdi, K. M., Odero, V. O., & Abdikarim, H. (2026). Factors associated with breast self-examination practice among female medical students in selected universities in Borama, Somaliland. Frontiers in Cancer Control and Society, 4, Article 1850142. https://doi.org/10.3389/fcacs.2026.1850142

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1850142

Keywords: breast cancer, breast self-examination, Somaliland, medical students, Health Belief Model, early detection, cancer screening, knowledge-practice gap, cross-sectional study, health behavior, Amoud University, low-resource settings

The analytical foundation of the study is a cross-sectional secondary analysis of 1,600 adults who gave valid responses to the hesitancy item in the 2024 Turkish General Social Survey. Responses were recorded on a five-point agreement scale, from strong disagreement to strong agreement. The researcher treated the item in two complementary ways: descriptively, as a binary indicator of hesitancy, and analytically, as an ordinal outcome that preserves the graded intensity of doubt. Covariates were organized into three conceptual domains — sociodemographic and socioeconomic characteristics, health-related characteristics, and information, belief, and attitudinal factors. All analyses were unweighted, and the core statistical engine was ordinal logistic regression, a technique suited to outcomes that are ordered but not continuous.

Ordinal logistic regression estimates the odds of falling into a higher rather than a lower category of an ordered outcome, and its results are expressed as odds ratios with 95 percent confidence intervals. The modeling strategy proceeded in two stages. Univariable models first screened each covariate individually for an association with hesitancy. A multivariable model then adjusted simultaneously for all covariates, allowing the researcher to identify which factors retained independent associations after accounting for the others. The researcher also reported the Akaike information criterion, a measure that penalizes model complexity and helps compare the fit of competing models, and used variance inflation factors to check for multicollinearity — the statistical problem that arises when predictor variables overlap so heavily that their individual effects become impossible to separate.

The results paint a striking picture of hesitancy as a social and attitudinal phenomenon rather than a medical one. After adjustment, higher vaccine hesitancy was independently associated with being aged 35 to 44 years, with an adjusted odds ratio of 1.67 and a confidence interval of 1.14 to 2.44. Having only a primary school education raised the odds by a factor of 1.44, with a confidence interval spanning 1.07 to 1.93, and living in the Aegean region carried an adjusted odds ratio of 1.48, ranging from 1.05 to 2.09. Higher self-rated religiosity also predicted greater hesitancy. In other words, midlife adults with limited formal education, stronger religious self-identification, and residence in a specific geographic context formed the demographic core of vaccine skepticism in the sample.

The protective side of the ledger is equally informative. University education was associated with lower hesitancy, with an adjusted odds ratio of 0.68 and a confidence interval of 0.51 to 0.90, and a master’s degree was associated with a far steeper reduction, at an adjusted odds ratio of 0.40 with a confidence interval of 0.22 to 0.73. The single most powerful attitudinal buffer was confidence in scientists: respondents with high trust in the scientific community had an adjusted odds ratio of 0.52, with a confidence interval of 0.32 to 0.85, meaning their odds of scoring higher on the hesitancy scale were roughly half those of people lacking that confidence. The gradient across educational levels suggests that each additional tier of schooling compounds the effect, a dose-response pattern that strengthens the causal plausibility of the education-hesitancy link.

Perhaps the most surprising finding concerns health itself. Most health-related characteristics — the conditions one might expect to shape personal experience with medicine — were not independently associated with hesitancy once sociodemographic and attitudinal factors were taken into account. The main exception was arthritis or rheumatism, which retained its own association with higher hesitancy. The study also found that general vaccine hesitancy was not significantly associated with COVID-19 vaccine uptake, a decoupling that suggests people may accept a specific emergency vaccine while still harboring generalized doubts about immunization, or vice versa. For public health planners, this means that the population most likely to refuse vaccines cannot be reliably identified from medical records or chronic disease registries alone.

The methodological choices deserve scrutiny because they shape what the study can claim. By analyzing hesitancy as an ordinal outcome, the study respects the psychological reality that doubt comes in degrees — someone who slightly agrees that vaccines do more harm than good is not equivalent to someone who strongly agrees. The unweighted analysis is a limitation worth noting: because the survey data were not weighted to match the national population structure, the reported associations describe the analytic sample rather than precise national estimates. The cross-sectional design also means that all findings are correlational; the study can identify which factors travel together with hesitancy, but it cannot establish whether education, for example, causes lower hesitancy or whether both are downstream of some deeper variable such as cognitive style or social trust.

The regional signal from the Aegean adds a geographic layer that is easy to overlook in attitudinal research. Türkiye’s regions differ in economic structure, health service density, and cultural orientation, and the NUTS classification used in the study allows these contextual differences to enter the statistical model directly. Why the Aegean stands out is not answered by the data, but the finding echoes a broader lesson from vaccination research: hesitancy clusters geographically, and regional context can carry information that individual-level measures miss. Clustering matters practically because localized pockets of low acceptance can sustain disease outbreaks even in populations with acceptable overall coverage, as measles resurgences in several countries have demonstrated.

The prominence of religiosity and trust in scientists places this study squarely within the international literature on the behavioral and social drivers of vaccination, the framework that the World Health Organization’s Strategic Advisory Group of Experts on Immunization has promoted through instruments such as the BeSD framework. Across many countries, generalized trust — trust in institutions, in expertise, in the people who make and regulate vaccines — has proven to be a more consistent predictor of acceptance than any particular medical fact. The Turkish findings align with that pattern: confidence in scientists cut the odds of hesitancy nearly in half, while religiosity raised them, and both effects survived adjustment for education, age, region, and health status. Attitudes, not biology, appear to carry the explanatory weight.

What emerges is a coherent set of priorities for intervention. Communication campaigns that simply restate vaccine safety may be preaching to the converted if they reach audiences whose skepticism is rooted in low institutional trust or in religious framing that the messages never address. The strong educational gradient points to the long game — investment in education as structural immunization policy — while the centrality of trust in scientists suggests that trusted local messengers, including physicians who hold community credibility, may be more effective than centralized messaging. The study’s limitations, including its cross-sectional design, unweighted analyses, and reliance on a single general hesitancy item, mean the findings should be read as a map of associations rather than a causal blueprint. But as a nationally grounded snapshot of vaccine doubt in a country of over 85 million people, the analysis delivers a clear message: to understand hesitancy, look first at who people are, where they live, and whom they trust — not merely at what illnesses they carry.

Subject of Research: Sociodemographic, health-related, and attitudinal correlates of general vaccine hesitancy among adults in Türkiye

Article Title: Vaccine hesitancy in Türkiye: sociodemographic, health-related, and attitudinal correlates in the 2024 Turkish general social survey

Article References: Sönmez, Ö. F. (2026). Vaccine hesitancy in Türkiye: sociodemographic, health-related, and attitudinal correlates in the 2024 Turkish general social survey. BMC Public Health. https://doi.org/10.1186/s12889-026-29795-8

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29795-8

Keywords: vaccine hesitancy, Türkiye, Turkish General Social Survey, public health, trust in scientists, religiosity, education, ordinal logistic regression, BMC Public Health, immunization, health behavior, social determinants

The study, led by Bezawit Kassaw Hailu and colleagues, set out to quantify how long victims of dog bites wait before beginning post-exposure vaccination, known clinically as PEV, and to identify the factors that influence that timing. Between January and June 2025, the researchers conducted face-to-face interviews with 260 dog bite victims or their guardians across the Gondar zones. The team defined delayed initiation as beginning vaccination more than 48 hours after the exposure incident, a threshold grounded in the biology of the rabies virus, which travels along peripheral nerves toward the central nervous system and can reach the brain before protective immunity develops if prophylaxis is postponed.

The numbers were stark. Of the 260 participants, only 36, or 13.9 percent, commenced vaccination within 48 hours of being bitten. The remaining 224 individuals, representing 86.1 percent of the cohort, crossed the two-day threshold before receiving their first injection. Because rabies is virtually 100 percent fatal once clinical symptoms appear, and because post-exposure prophylaxis is among the most effective interventions in all of medicine when administered promptly, every hour of delay narrows the window in which the vaccine can reliably intercept the virus on its journey to the nervous system.

What makes the finding especially striking is the knowledge landscape the researchers documented. A majority of respondents, 88.5 percent, were aware that rabies exists in their area. Some 71.5 percent could identify the signs of the disease, 75.4 percent knew how it is transmitted, and an overwhelming 96.5 percent understood its fatal nature. Even more encouraging, 95.4 percent recognized the need for post-exposure vaccination after a bite. Knowledge of the disease itself, in other words, was widespread and remarkably detailed for a rural setting where health literacy resources are often scarce.

Attitudes toward the vaccine were similarly favorable. A majority of respondents believed the cost of the vaccine was fair, and 95 percent considered post-exposure prophylaxis effective. When the researchers probed the reasons for delay, cost of vaccination emerged as a barrier for only a minority of participants; 76.2 percent said the expense was not a reason they postponed treatment. This combination of high awareness, positive attitudes toward vaccination, and minimal financial barriers presents a genuine scientific puzzle: if victims know the disease is deadly, know the vaccine works, and do not cite cost as an obstacle, why do so few seek timely care?

The authors’ conclusion points toward a critical gap in understanding. Respondents, they suggest, may simply not be aware of the risk posed by delay itself. Knowing that rabies kills and knowing that a vaccine exists are not the same as knowing that the effectiveness of that vaccine is time-sensitive, and that the difference between seeking care on the day of the bite and two days later can be the difference between survival and death. Health messaging in endemic regions has traditionally emphasized the lethality of rabies and the availability of treatment, but this study indicates that the urgency of timing has not been communicated with comparable force.

Using logistic regression models, the researchers identified two factors significantly associated with the timing of vaccination initiation. The first was the severity of the bite. Victims who suffered deep bites were substantially less likely to delay, with an odds ratio of 0.22 and a 95 percent confidence interval of 0.07 to 0.66, and a P value of 0.008. In practical terms, a deep bite more than halved the odds of postponement compared with superficial wounds. This pattern is consistent with the intuitive logic of threat perception: the more dramatic and painful the injury, the more urgently the victim recognizes the danger and seeks medical attention.

The second significant factor was the ownership of the biting animal. People bitten by stray dogs were also less likely to delay initiation of vaccination, with an odds ratio of 0.51, a 95 percent confidence interval of 0.27 to 0.95, and a P value of 0.033. This finding may seem counterintuitive at first glance, since stray dogs cannot be observed for signs of illness the way a neighbor’s vaccinated pet can. But it makes sense in the context of risk assessment: a bite from an unknown, unowned animal carries unmistakable uncertainty about the animal’s rabies status, prompting swifter action, whereas a bite from a familiar dog may lull victims into a false sense of security, encouraging them to wait and watch the animal for symptoms that may never become obvious before the virus has already taken hold.

The implications of these findings extend well beyond the Gondar zones. Rabies remains one of the most lethal zoonotic diseases worldwide, claiming an estimated tens of thousands of lives annually, with the vast majority of deaths occurring in Asia and Africa and with children in rural communities bearing a disproportionate burden. The virus is a lyssavirus transmitted through the saliva of infected mammals, most commonly dogs, and it hijacks peripheral nerve fibers to reach the central nervous system. Once neurological symptoms such as hydrophobia, agitation, and paralysis begin, no treatment has ever been shown to halt the disease. Post-exposure prophylaxis, which combines wound washing, rabies vaccine doses, and in severe cases rabies immunoglobulin, works because it stimulates immunity during the days or weeks the virus spends traveling from the wound site to the brain. That window, however, is finite, and every study that documents delay in initiation helps explain why deaths persist in regions where vaccines are nominally available.

The Ethiopian study’s authors conclude that the high rate of delay, despite widespread knowledge and few reported barriers, underscores the need for interventions focused specifically on the risk of delayed PEV initiation. Such interventions might include community education campaigns that emphasize the 48-hour benchmark as explicitly as they emphasize the disease’s fatality, integration of bite management guidance into school and community health programs, and strengthening of access points so that victims can reach vaccination services quickly when the urgency is understood. The research also highlights the value of targeting messaging toward owners of domestic dogs, who may underestimate risk when the biting animal is familiar. As the authors note, respondents in their study knew many aspects of rabies control and faced fewer barriers to uptake than might have been expected, yet delay remained the norm rather than the exception. Closing that gap between knowledge and timely action may prove to be one of the most important steps toward reducing rabies deaths in Ethiopia and across the endemic world.

Subject of Research: Delay in initiation of rabies post-exposure vaccination among dog bite victims in the Gondar zones of Ethiopia

Article Title: Delay in initiation of rabies post-exposure vaccination and influencing factors in Gondar zones of Ethiopia

Article References: Hailu, B. K., Demessie, Y., Berihun, A. M., Bitew, A. B., & Mekonnen, S. A. (2026). Delay in initiation of rabies post-exposure vaccination and influencing factors in Gondar zones of Ethiopia. PLOS Neglected Tropical Diseases, 20(10), e0014729. https://doi.org/10.1371/journal.pntd.0014729

Image Credits: AI Generated

DOI: 10.1371/journal.pntd.0014729

Keywords: rabies, post-exposure prophylaxis, Ethiopia, dog bite, vaccination delay, Gondar, zoonotic disease, public health, PLOS Neglected Tropical Diseases, stray dogs, health behavior, logistic regression

The research team, led by investigators at Guangzhou Medical University with collaborators at The Hong Kong Polytechnic University and The Chinese University of Hong Kong, analyzed data from 47,939 women aged 50 to 74, the age band in which routine mammography is most strongly recommended. Poor adherence was defined conservatively as a self-reported absence of mammography within the previous two years. Even after statistical adjustment for the many confounders that typically muddy observational research, 21.5 percent of respondents fell into the non-adherent category, and the gradient across adversity scores remained robust. This is not a marginal effect confined to a small, severely affected subgroup; it is a population-level signal that touches roughly one in five eligible women.

Adverse childhood experiences, commonly abbreviated as ACEs, encompass a range of early-life stressors including physical, emotional, and sexual abuse, emotional and physical neglect, household substance abuse, household mental illness, parental separation or divorce, and witnessing domestic violence. Decades of research have tied cumulative ACE exposure to depression, substance use, cardiovascular disease, and early mortality, but the specific pathway from childhood adversity to cancer screening behavior has remained comparatively underexplored. The new study addresses that gap directly, and its findings suggest that the long shadow of childhood trauma may extend all the way into the radiology suite, quietly shaping whether women show up for a test that can detect breast cancer at its most treatable stages.

Methodologically, the study went beyond the conventional tally of adversities. The researchers deployed logistic regression to quantify the association between ACE scores and screening non-adherence, but then turned to a more sophisticated analytical framework borrowed from statistical physics: the Ising model. Originally developed to describe interactions among magnetic spins, the Ising network approach treats each adversity type as a node in a system, with pairwise statistical dependencies as the connections between nodes. This allows researchers to map the architecture of adversity itself, revealing which experiences act as hubs that hold the network together and which are peripheral. The team then applied the NodeIdentifyR algorithm, or NIRA, to simulate what would happen if individual nodes were targeted for intervention, effectively running virtual experiments on the network before any real-world program is designed.

The network analysis produced findings with immediate practical implications. Household substance abuse emerged as the node with the highest betweenness centrality and expected influence, meaning it sat on the shortest paths connecting most other adversities and carried the greatest capacity to activate the network as a whole. In plain terms, growing up in a home where drugs or alcohol were abused appears to function as a gateway experience, statistically intertwined with nearly every other form of childhood adversity and potentially amplifying their downstream effects. Meanwhile, the simulation showed that reducing the impact of emotional abuse would yield the greatest projected decrease in a woman’s cumulative adversity load, making it the single most efficient target for intervention within this network.

Perhaps the most striking individual finding concerned sexual abuse, which showed the strongest independent association with screening non-adherence of any single ACE category. This detail matters because it suggests that certain forms of trauma may carry consequences that persist even when the broader adversity count is taken into account. Clinicians and screening program designers have long recognized that mammography can be an intimate, uncomfortable, and psychologically loaded procedure; for survivors of sexual violence, the experience of a mammogram may evoke memories and anxieties that make avoidance feel protective. The study’s results give that clinical intuition quantitative weight and argue for screening environments that are sensitive to trauma histories rather than blind to them.

The concept of trauma-informed care has gained traction across health systems in recent years, but this study provides one of the clearest quantitative rationales yet for applying it to cancer prevention. A trauma-informed mammography program might include routine, private inquiry about past abuse; the option to have a female technologist; clear narration of each step of the procedure; and explicit permission to pause or stop at any moment. It might also involve longer appointment slots, sensitivity training for staff, and follow-up protocols that treat missed appointments not as patient negligence but as a potential signal of unaddressed psychological burden. The authors’ conclusion points in exactly this direction: strategies addressing the sequelae of emotional abuse, in particular, may most effectively improve screening uptake among women with high adversity burdens.

The study’s scale and design lend it credibility, but its limitations deserve honest acknowledgment. The data are cross-sectional and self-reported, drawn from survey waves in 2020, 2022, and 2024, which means the analysis captures association rather than proven causation. ACE exposure was recalled retrospectively by adults, and recall bias, particularly among respondents with depression or other trauma-related conditions, could distort the measured relationships. Self-reported screening dates may also diverge from medical records. Because the analysis was secondary and based on publicly available, de-identified data, the authors note that institutional review board approval and additional informed consent were not required. None of these caveats erases the central signal, but they do mean that intervention trials, rather than further observational work, are the logical next step.

The public health stakes are considerable. Breast cancer remains one of the most common cancers among women worldwide, and mammography screening is among the best-evidenced tools for early detection, yet adherence rates persistently lag behind targets in many populations. If more than a fifth of eligible women in this large sample were non-adherent, and if childhood adversity meaningfully raises that risk, then screening programs that ignore trauma histories are systematically missing the women who need outreach most. The dose-response structure of the finding also implies a triage opportunity: a simple ACE questionnaire, administered in primary care, could flag patients who warrant more intensive reminder systems, patient navigation, or counseling before their next screening window closes.

What makes this research resonate beyond epidemiology is its reframing of a familiar problem. Missed mammograms are often attributed to cost, access, insurance status, or simple forgetfulness, and those factors certainly matter. But this study adds a developmental dimension that has been largely invisible in screening policy: the behavioral fingerprints of childhood adversity, laid down decades before a woman becomes eligible for mammography, may quietly govern her engagement with preventive medicine. By combining a classic dose-response analysis with network science and intervention simulation, the researchers have moved the conversation from whether adversity matters to which specific adversities matter most and where a targeted intervention would do the greatest good. That shift, from description to actionable targeting, is precisely what translational psychiatry promises, and it offers screening programs a concrete starting point: address the network at its hubs, beginning with household substance abuse and emotional abuse, and the entire structure of risk may begin to loosen.

Subject of Research: The association between cumulative adverse childhood experiences and non-adherence to mammography-based breast cancer screening among middle-aged women.

Article Title: Cumulative burden of adverse childhood experiences (ACEs) and non-adherence to breast cancer screening: A dose-response and network intervention analysis

Article References: Chen, F., Shao, J., Cai, J., Ho, Y.-S., Takemura, N., Yorke, J., Li, J., & Ye, Z. (2026). Cumulative burden of adverse childhood experiences (ACEs) and non-adherence to breast cancer screening: A dose-response and network intervention analysis. Translational Psychiatry. https://doi.org/10.1038/s41398-026-04523-3

Image Credits: AI Generated

DOI: 10.1038/s41398-026-04523-3

Keywords: adverse childhood experiences, breast cancer screening, mammography, dose-response, Ising model, network analysis, trauma-informed care, BRFSS, preventive care, emotional abuse, household substance abuse, health behavior

The research, led by Tia El Kazzi of the Lebanese University with co-authors Nazek Mansour and Mirna N. Chahine, set out to measure knowledge, attitudes, and practices related to sunscreen use, sun-protective behavior, and skin cancer among the country’s medical trainees. The team surveyed 1,063 participants between April 29 and June 15, 2023, drawing respondents from all eight medical faculties in Lebanon: the seven private schools, the American University of Beirut, Beirut Arab University, the Lebanese American University, Saint George University of Beirut, Holy Spirit University of Kaslik, the University of Balamand, and Saint Joseph University, along with the public Lebanese University. Because the sample spanned every medical school in the country, the authors argue it offers an unusually broad picture of how Lebanon’s next generation of doctors approaches photoprotection.

Participants were recruited through an English-language online questionnaire distributed via WhatsApp and Instagram using snowball sampling, a technique in which early respondents forward the survey to their peers. The instrument was designed around established behavioral frameworks. Sun-protective behavior was assessed using the stages-of-change construct from the Transtheoretical Model, which classifies individuals along a continuum from not considering a behavior to maintaining it consistently. Attitudes were captured with two validated instruments: the Decisional Balance Scale, which weighs the perceived pros and cons of adopting sun protection, and the Self-Efficacy Scale, which measures confidence in one’s ability to perform protective behaviors across different situations. Knowledge of sunscreen and skin cancer was tested with dedicated items, and the team used multivariate linear regression to identify independent predictors of the three main outcome scores.

The headline numbers reveal a paradox. On one hand, 75.2 percent of participants said they used sunscreen, a figure that might seem encouraging at first glance. On the other hand, 78.6 percent reported having experienced a prior sunburn, the single best-documented behavioral risk factor for later melanoma and other skin cancers. In other words, the majority of these future doctors had already sustained the kind of acute ultraviolet injury that dermatologists warn the public about, despite knowing precisely how such injury occurs and how to prevent it. The authors describe this as a clear disconnect between knowledge and preventive behavior, one that persists even in a group with privileged access to medical education.

The quantitative scores reinforce that impression. Participants demonstrated moderate knowledge, averaging 53.23 percent with a standard deviation of 14.31. Decisional balance scores averaged 14.15 out of a possible 20, and self-efficacy scores averaged 26.39 out of 45, both indicating middling rather than strong attitudinal readiness. Notably, the three measures were positively correlated with one another, with correlation coefficients ranging from 0.219 to 0.547 and all reaching statistical significance at p less than 0.001. This interdependence matters theoretically: it suggests that knowing more about skin cancer, feeling more confident about sun protection, and perceiving greater benefits from it tend to travel together, forming a psychological cluster that could be targeted as a whole rather than piecemeal.

The regression models, which adjusted for multiple variables simultaneously, identified who scored highest on each dimension. Higher knowledge was independently associated with being further along in medical training, having experienced a prior sunburn, higher self-efficacy, higher household income, attendance at a private university, and being at an advanced stage of sunscreen adoption; this model explained 21.4 percent of the variance in knowledge scores. Higher decisional balance scores were linked to higher self-efficacy, sunscreen use, female gender, higher knowledge, and advanced behavioral stage, with the model accounting for 40.5 percent of the variance. Higher self-efficacy, in turn, was predicted by higher decisional balance, sunscreen use, and advanced behavioral stage, explaining 36.6 percent of the variance. The pattern is consistent: behavioral readiness, attitudinal confidence, and factual knowledge reinforce one another in a loop, and academic progression only partially breaks through.

Several of these predictors deserve closer attention. The association between higher academic year and greater knowledge is reassuring in one sense, since it suggests that medical education does incrementally deliver content about skin cancer and photoprotection. But the fact that knowledge remained only moderate even among senior trainees hints that this content is thin, fragmented, or delivered too late. The link between prior sunburn and higher knowledge is equally double-edged: it may reflect heightened awareness after a personal scare, but it also means that the educational system is being outpaced by ultraviolet exposure itself. Socioeconomic gradients, visible in the independent effects of household income and private university affiliation, point to structural inequities in access to both information and protective products, a reminder that sun safety is not only a matter of individual willpower.

The role of self-efficacy emerges as perhaps the most actionable finding. In behavioral science, self-efficacy, the belief that one can successfully carry out a behavior in real-world conditions, is often the strongest lever for change, because knowledge alone rarely translates into action. Here, self-efficacy was independently tied to both knowledge and decisional balance, and it clustered tightly with advanced stages of sunscreen adoption. Participants who believed they could apply sunscreen before class, reapply it during hospital shifts, or seek shade during long outdoor commitments were far more likely to actually do so. This suggests that interventions should go beyond lecturing about ultraviolet radiation and instead build practical confidence: rehearsing routines, addressing barriers specific to hospital life, and normalizing sun protection as part of professional identity.

The authors argue that the findings carry implications well beyond Lebanon. Medical students and residents occupy a dual role in skin cancer prevention: they are future counselors who will advise patients on sunscreen, protective clothing, and skin checks, and they are role models whose own behavior shapes what patients perceive as normal. A physician who preaches daily sunscreen but arrives at clinic sunburned undermines the message before saying a word. The study’s conclusion is that preventive competencies are strongly associated with academic progression, behavioral readiness, and self-efficacy, and that integrating structured, stage-specific sun protection education early in medical training could improve trainees’ own behaviors while strengthening their capacity to guide patients. Stage-specific means matching the intervention to where the learner sits on the Transtheoretical Model continuum, nudging precontemplators toward awareness and helping maintainers sustain their habits.

For a country with abundant sunshine and a Mediterranean climate, the stakes are concrete. Lebanon’s medical trainees will spend decades working under high ultraviolet conditions and treating a population similarly exposed. The study, which received no external funding and was approved by the Institutional Review Board of Al-Zahraa Hospital University Medical Center, offers a baseline that other countries in the region could replicate. Its core message is deceptively simple: knowing about skin cancer is not the same as preventing it, even for people trained to do exactly that. Closing that gap, the authors contend, requires embedding sun protection into the earliest years of medical curricula, treating it not as an optional dermatology footnote but as a core preventive skill that future physicians must first practice on themselves.

Subject of Research: Knowledge, attitudes, and practices regarding sunscreen use, sun protection, and skin cancer prevention among medical students and residents in Lebanon

Article Title: Knowledge, attitude, and practice towards sunscreen use, sun protective behavior, and skin cancer among Lebanese medical students and residents

Article References: El Kazzi, T., Mansour, N., & Chahine, M. N. (2026). Knowledge, attitude, and practice towards sunscreen use, sun protective behavior, and skin cancer among Lebanese medical students and residents. BMC Cancer. https://doi.org/10.1186/s12885-026-17074-z

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17074-z

Keywords: skin cancer, sunscreen, sun protection, medical students, residents, self-efficacy, Transtheoretical Model, melanoma, Lebanon, health behavior, cancer prevention, dermatology

The study, published in SSM – Population Health by Yeongmi Jeong, Meghan M. Skira, and Robbee Wedow, focuses on two polygenic scores, which are numerical summaries of the many small genetic differences scattered across a person’s genome. The first, called the smoking initiation score, aggregates variants associated with whether a person ever becomes a regular smoker. The second, the cigarettes-per-day or CPD score, aggregates variants associated with how heavily someone smokes once they start. Both scores were built from genome-wide association studies, or GWAS, that scanned the genomes of more than a million people of European ancestry to find single-letter DNA differences, known as single nucleotide polymorphisms, that statistically track with smoking behavior. Each person’s score is calculated by adding up the number of copies of the risk-increasing variants they carry, with each variant weighted by the strength of its estimated association.

Neither score is a crystal ball. Out-of-sample predictions indicate that the initiation score explains only about 4 percent of the variation in whether people start smoking, and the CPD score explains about 4 percent of the variation in how much they smoke. Within the study sample itself, a one standard deviation increase in the initiation score raised the probability of ever smoking by roughly 9 percentage points, while a one standard deviation increase in the CPD score was associated with about two additional cigarettes smoked per day among smokers. These are modest effects, but they are large enough, in a sample of this size, to reveal patterns that would otherwise remain invisible.

To measure health, the researchers constructed a standardized index combining thirteen distinct outcomes: self-reported general health, hospitalization, body mass index, seven doctor-diagnosed chronic conditions including high blood pressure, diabetes, cancer, lung disease, heart problems, stroke, and arthritis, and limitations in basic and instrumental activities of daily living. The analysis covered 48,444 person-wave observations from 9,515 unique participants aged 50 to 65, drawn from survey waves between 1994 and 2018. The age range was chosen deliberately, to minimize survival bias, since people with the worst health may not survive to be surveyed at older ages, and to avoid conflating genetic associations with the health effects of retirement.

The central finding is stark. A one standard deviation increase in the CPD score was associated with a 0.043 standard deviation increase in the health index, where higher values indicate worse health. Adding detailed controls for smoking behavior, including current and lifetime smoking status, the exact number of cigarettes smoked per day, the maximum ever smoked, the age of starting and quitting, and teenage smoking, attenuated the association only modestly, to 0.035 standard deviations. For context, that residual association is roughly 38 percent of the average health gap between ever smokers and never smokers in the sample. In other words, even after accounting for everything the surveys record about smoking, the genetic score still carries substantial information about health.

The most provocative result emerged when the researchers restricted the analysis to never smokers, a group of more than 20,000 observations with no reported smoking behavior to explain away. Among these individuals, a one standard deviation increase in either the CPD score or the initiation score was associated with roughly a 0.03 standard deviation increase in the health index. The CPD score also tracked with higher body mass index and obesity among never smokers, with a one standard deviation increase associated with 0.645 units of additional BMI. Because these individuals never smoked, the association cannot be attributed to their own tobacco use, although it could still reflect secondhand smoke exposure, unmeasured smoking-related environments, or something else entirely.

One obvious candidate is the family environment. Because children inherit genes from their parents, a person’s smoking-related genetic score may be correlated with parental smoking, parental substance use, parental education, and childhood socioeconomic conditions, all of which shape later health. The researchers tested this by adding controls for whether parents smoked during the respondent’s childhood, whether parents drank or used drugs heavily enough to cause family problems, parental mortality timing, parental years of schooling, and self-reported childhood financial status. These factors accounted for a modest share of the association, but more than 75 percent of the CPD score’s relationship with health remained, and about 60 percent of the initiation score’s relationship among never smokers survived the most comprehensive specifications.

The researchers then turned to psychology. Prior work has shown that smokers tend to be more impatient, risk-tolerant, and impulsive than non-smokers, and the team asked whether people with higher smoking-related genetic scores differ along similar dimensions. They found little evidence of a link with measured risk preferences, but higher scores were significantly associated with shorter financial planning horizons, greater pessimism, and lower conscientiousness, traits that economists and psychologists have long connected to lower investment in health. When these behavioral and psychological characteristics were added to the models simultaneously, they explained at most 21 percent of the remaining association between the CPD score and health, and 18 percent of the initiation score’s association among never smokers. Even with the fullest set of controls, at least 69 percent of the CPD score’s association with health persisted.

The authors are careful to emphasize what the study does not show. Polygenic scores are not clean measures of direct genetic effects. The GWAS estimates underlying them can absorb indirect genetic effects, such as parental genotypes shaping the environments children experience, as well as confounding from assortative mating, population stratification, collider bias, and case-control ascertainment. There is also the problem of pleiotropy: the same genetic variants that predict smoking may influence other biological processes and traits that affect health directly. Genetic correlation analyses have indeed documented significant overlap between smoking behaviors and a wide range of health, behavioral, and socioeconomic traits. The associations reported here are descriptive, not causal, and the study’s restriction to individuals of European ancestry, a consequence of the limited predictive power of European-derived scores in other populations, means the findings may not generalize more broadly.

Even with those caveats, the implications are significant. Economists studying smoking have long suspected that people who smoke differ from those who do not in ways that extend beyond the behavior itself, and some modeling work has speculated that genetics or correlated risk-taking might explain why smokers face elevated chronic disease and mortality risks beyond what smoking alone explains. This study provides some of the most direct evidence yet that such unobserved heterogeneity is real and partially visible in the genome. Smoking-related polygenic scores, the results suggest, contain information about health that detailed behavioral histories do not capture, pointing toward shared genetic architecture linking tobacco use, personality, and long-run wellbeing. Untangling those threads, the authors argue, will be essential for interpreting genetic risk scores in health research, and for understanding why two people with identical smoking histories can end up with very different health outcomes decades later.

Subject of Research: Associations between smoking-related polygenic scores and health outcomes in midlife

Article Title: Exploring Links Between Health and the Genetic Risk for Smoking

Article References: Jeong, Y., Skira, M. M., & Wedow, R. (2026). Exploring Links Between Health and the Genetic Risk for Smoking. SSM – Population Health, Article 101982. https://doi.org/10.1016/j.ssmph.2026.101982

Image Credits: AI Generated

DOI: 10.1016/j.ssmph.2026.101982

Keywords: polygenic scores, smoking initiation, smoking intensity, Health and Retirement Study, GWAS, pleiotropy, chronic disease, health behavior, genetic risk, conscientiousness, never smokers, population health