BackgroundIncreased education of girls in developing contexts is associated with a number of important positive health, social, and economic outcomes for a community. The event of menarche tends to coincide with girls' transitions from primary to secondary education and may constitute a barrier for continued school attendance and performance. Following the MRC Framework for Complex Interventions, a pilot controlled study was conducted in Ghana to assess the role of sanitary pads in girls' education.MethodsA sample of 120 schoolgirls between the ages of 12 and 18 from four villages in Ghana participated in a non-randomized trial of sanitary pad provision with education. The trial had three levels of treatment: provision of pads with puberty education; puberty education alone; or control (no pads or education). The primary outcome was school attendance.ResultsAfter 3 months, providing pads with education significantly improved attendance among participants, (lambda 0.824, F = 3.760, p<.001). After 5 months, puberty education alone improved attendance to a similar level (M = 91.26, SD = 7.82) as sites where pads were provided with puberty education (Rural M = 89.74, SD = 9.34; Periurban M = 90.54, SD = 17.37), all of which were higher than control (M = 84.48, SD = 12.39). The total improvement through pads with education intervention after 5 months was a 9% increase in attendance. After 3 months, providing pads with education significantly improved attendance among participants. The changes in attendance at the end of the trial, after 5 months, were found to be significant by site over time. With puberty education alone resulting in a similar attendance level.ConclusionThis pilot study demonstrated promising results of a low-cost, rapid-return intervention for girls' education in a developing context. Given the considerable development needs of poorer countries and the potential of young women there, these results suggest that a large-scale cluster randomized trial is warranted.Trial RegistrationPan African Clinical Trials Registry PACTR201202000361337

Despite notable progress in girls' education over the last decade, gender-based differences continue to shape educational outcomes. One of the most overlooked of these differences is the process of maturation itself, including menstruation. This paper presents the findings of a study that assessed the impact of sanitary care on the school attendance of post-pubertal girls, as well as the implications of menarche for their well-being. The study found that the provision of adequate sanitary care represents a relatively unrecognized but potentially fruitful tool in strategies that aim to improve girls' educational outcomes, one that warrants policy consideration among development planners.

Key Points Question Is there an association between perceptions of medical school learning environment and burnout among gay, lesbian, and bisexual (sexual minority [SM]) students? Findings In this cross-sectional study of 25 757 graduating medical students, SM students had less favorable perceptions of the medical school learning environment compared with heterosexual students. There was an association between poorer perceptions of medical school and increased levels of burnout. Meaning These findings suggest that improving the medical school learning environment and inclusivity of medical school is key in mitigating burnout among SM students.

ImportanceHousing instability and other social determinants of health are increasingly being documented by clinicians. The most common reasons for hospitalization among patients with coded housing instability, however, are not well understood.ObjectiveTo compare the most common reasons for hospitalization among patients with and without coded housing instability.Design, Setting, and ParticipantsThis cross-sectional, retrospective study identified hospitalizations of patients between age 18 and 99 years using the 2017 to 2019 National Inpatient Sample. Data were analyzed from May to September 2022.ExposuresHousing instability was operationalized using 5 International Classification of Diseases, 10th Revision, Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; and other related problems.Main Outcomes and MeasuresThe primary outcome of interest was reason for inpatient admission. Bivariate comparisons of patient characteristics, primary diagnoses, length of stay, and hospitalization costs among patients with and without coded housing instability were performed.ResultsAmong the 87 348 604 hospitalizations analyzed, the mean (SD) age was 58 (20) years and patients were more likely to be women (50 174 117 [57.4%]) and White (58 763 014 [67.3%]). Housing instability was coded for 945 090 hospitalizations. Hospitalized patients with housing instability, compared with those without instability, were more likely to be men (668 255 patients with coded instability [70.7%] vs 36 506 229 patients without [42.3%]; P &amp;lt; .001), younger (mean [SD] age 45.5 [14.0] vs 58.4 [20.2] years), Black (235 355 patients [24.9%] vs 12 929 158 patients [15.0%]), Medicaid beneficiaries (521 555 patients [55.2%] vs 15 541 175 patients [18.0%]), uninsured (117 375 patients [12.4%] vs 3 476 841 patients [4.0%]), and discharged against medical advice (28 890 patients [8.4%] vs 451 855 patients [1.6%]). The most common reason for hospitalization among patients with coded housing instability was mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%]), which cost a total of $3.5 billion. Other common reasons included injury (69 270 patients [7.3%]) and circulatory system diseases (64 700 patients [6.8%]). Coded housing instability was also significantly associated with longer mean (SD) hospital stays (6.7 [.06] vs 4.8 [.01] days) and a cost of $9.3 billion. Hospitalized patients with housing instability had 18.6 times greater odds of having a primary diagnosis of mental, behavioral, and neurodevelopmental disorders (475 575 patients [50.3%] vs 4 470 675 patients [5.2%]; odds ratio, 18.56; 95% CI, 17.86 to 19.29).Conclusions and RelevanceIn this cross-sectional study, hospitalizations among patients with coded housing instability had higher admission rates for mental, behavioral, and neurodevelopmental disorders, longer stays, and increased costs. Findings suggest that efforts to improve housing instability, mental and behavioral health, and inpatient hospital utilization across multiple sectors may find areas for synergistic collaboration.

In a disaster, physicians are forced to make challenging and heartbreaking ethical decisions under conditions of physical and emotional exhaustion. Evidence shows that the conditions of stress that mark disasters can undermine the process of ethical decision-making. This results in biased allocation of scarce resources, fewer utilitarian and altruistic decisions, and a wider variation in decisions. Stress also predisposes clinicians to decision strategy errors, such as premature closure, that lead to poor outcomes. The very ability to make sound and ethical decisions is thus a scarce resource. Ethical frameworks underpinning disaster protocols enumerate many physician obligations, but seldom articulate the risk posed by having decisions made ad hoc by decision-makers who are compromised by the stress of the concurrent crisis. We propose, therefore, that a "duty of mind"-the obligation to make critical decisions under the clearest possible state of thought-be added to ethical frameworks for disaster response. Adding the duty of mind to the pillars on which planning is based would force attention to a moral imperative to include decision support tools in disaster planning. By moving the consideration of possible choices to a moment when time and consultation facilitate clear and considered thought, the duty of mind is upheld. (Disaster Med Public Health Preparedness. 2018;12:657-662).