INTRODUCTION:Annual anal cancer screening for sexual minority men and transgender women with HIV has been recommended by experts for more than 15 years and is now endorsed by the U.S. Department of Health and Human Services. The prevalence of anal cancer screening in these populations was estimated in the Chicago, Houston, and Milwaukee metropolitan areas, which are in U.S. regions with the highest anal cancer incidence among people with HIV. METHODS:Survey responses collected in 2020-2022 from individuals in the Prevent Anal Cancer studies were analyzed. The prevalence of anal cytology within the prior year and any history of high-resolution anoscopy was stratified by HIV status in individuals of screening age (≥35 years for people with HIV and ≥45 years if HIV negative). Factors associated with cytology and high-resolution anoscopy were assessed using logistic regression. Barriers to anal cancer screening were assessed and stratified by HIV status. RESULTS:A total of 540 individuals were of screening age and reported HIV status and anal cytology screening within the prior year. Most participants (84.4%, 456 of 540) were aged ≥45 years, and 52.0% (281 of 540) reported having HIV. The prevalence of anal cytology in the prior year was 8.3% (45 of 540) and did not differ by HIV status. Only a history of anal warts was associated with cytology (AOR=2.57, 95% CI=1.31, 5.06). A history of undergoing high-resolution anoscopy among people with HIV differed by metropolitan area: 35.9% (28 of 78) in Chicago, 18.1% (27 of 149) in Houston, and 20.8% (11 of 53) in Milwaukee (p=0.001). People with HIV had more than double the odds of reporting a history of high-resolution anoscopy (AOR=2.36, 95% CI=1.32, 4.22) than HIV-negative people. CONCLUSIONS:Among communities highly vulnerable to anal cancer, screening uptake was low and differed by metropolitan area. Interventions are urgently needed at clinical, provider, and individual levels to increase uptake.

Importance:Anal cancer screening is recommended for high-risk populations, particularly sexual and gender minority (SGM) individuals. However, the cost-effectiveness of home-based self-sampling in increasing anal cancer screening uptake has not yet been evaluated in the US. Objective:To evaluate the cost-effectiveness of home-based anal self-sampling compared with clinic-based screening among SGM individuals. Design, Setting, and Participants:This economic evaluation used data from a 2-group randomized clinical trial conducted in Milwaukee, Wisconsin, from January 2020 to August 2022, enrolling SGM individuals aged 25 years or older. Participants were randomized to home-based self-sampling or clinic-based screening. Costs for home-based screening were obtained from the trial, and clinic-based costs were sourced from the Medicare reimbursement schedule. Travel and time costs were derived on the basis of participant self-reports. The analysis was performed between February and October 2025. Intervention:Participants in the home-based screening group received self-sampling supplies and instructions, and those in the clinic-based screening group were instructed to visit a clinic for anal cancer screening. Main Outcomes and Measures:The primary outcome was the incremental cost-effectiveness ratio (ICER), measured as the additional cost needed to increase screening participation by one person. The 95% CIs for the ICERs were estimated using a bootstrap method with 1000 iterations. Net benefit regression and cost-effectiveness acceptability curves were used to assess the likelihood of cost-effectiveness across different willingness-to-pay (WTP) thresholds. Results:The study included 240 SGM individuals (227 with gender identity as a man [95%]; median [IQR] age, 46 [33 to 57] years), of whom 65 (27%) had HIV. The cost per participant was $64.18 for home-based screening and $60.40 for clinic-based screening from a societal perspective, and $61.91 for home-based screening and $42.06 for clinic-based screening from a health care payer perspective. Home-based screening was associated with increased screening participation vs clinic-based screening (107 participants [89.2%] vs 89 participants [74.2%]). The ICER per additional screened participant was $25.19 (95% CI, -$27.66 to $104.60) for the societal perspective and $132.36 (95% CI, $74.54 to $402.20) for the health care payer perspective. Home-based screening had a 49.6% probability of being cost-effective at a WTP of $25, 99.99% at a WTP of $100 (societal perspective), and 90.9% at a WTP of $200 (health care payer perspective). The ICERs for home-based screening compared with clinic-based screening were highly sensitive to screening participation rates. Conclusions and Relevance:The findings of this economic analysis suggest that home-based anal cancer screening is a cost-effective approach to increasing screening participation among SGM individuals. Home-based screening may serve as a valuable and efficient tool for expanding screening rates.

Background:While anal cancer screening is now recommended in several countries for high-incidence populations, barriers impede screening uptake. It is well known that patient recognition of symptoms increases cancer screening uptake, and we previously demonstrated that patients can detect small masses at the perianus and in the anal canal. In this current analysis, we aimed to longitudinally assess the effect of repetition and practice on patient self-recognition of small masses. Methods:Individuals and couples of sexual minority men and transgender women were taught to conduct an anal self-examination or anal companion examination (ASE/ACE) at visit 1 and then randomized to a practice or control condition. Six months later, at visit 2, the effect of practice and repetition of the ASE/ACE on detection of abnormalities was assessed by comparing the lay exam results to those of a clinician. Concordance, κ, and area under the receiver operating characteristic curves (AUC) was used to quantify the comparison. Findings:Concordance between lay exam and clinician exam increased from visit 1 (73%, 524/714) to visit 2 (95%, 535/561) (κ = 0.87, 95% CI 0.82-0.92). Overall AUC at visit 2 was 0.93 (95% CI 0.90-0.96). Although there was no difference in concordance between the practice (95%, 267/281) and control arms (96%, 268/280) (p = 0.69), concordance increased with ASE/ACE repetition (ptrend < 0.001) and was 98% (354/363) for individuals performing the ASE/ACE ≥2 times between visits. For individuals with incident abnormalities at visit 2, concordance was 100% (27/27). Results did not differ by age or HIV status. False positive and false negative results by the ASE/ACE were 2% (10/561) and 3% (16/561), respectively. Interpretation:Because lay individuals can detect anal abnormalities, clinicians conducting an anal examination may suggest that the patient's own lay exams may detect early invasive anal cancer. Funding:National Cancer Institute.

Introduction Forced anal examinations are used to prosecute sexual and gender minorities (SGM) in multiple countries under the presumption that decreased sphincter tone, assessed by a finger inserted into the anal canal, can detect persons practising receptive anal intercourse. Using baseline data from a longitudinal study, we aimed to determine factors associated with sphincter tone and the accuracy of sphincter tonality to detect persons engaging in receptive anal intercourse.Methods Clinicians in Chicago, Houston and Milwaukee, USA conducted digital anal rectal examinations (DARE) to score sphincter resting tone (RT) and squeeze tone (ST). On a separate survey, individuals reported their preferred position for anal intercourse, that is, either always/mostly insertive anal intercourse, always/mostly receptive anal intercourse or both receptive and insertive anal intercourse. Multivariable regression assessed factors associated with decreased sphincter tone while the area under the receiver operating characteristic curves (AUC) estimated the accuracy of sphincter tonality to detect receptive anal intercourse.Results Of 838 participants, 94.0% of whom were cisgendered males, 11.3% had decreased RT (95/838) and 6.3% had decreased ST (53/838). The accuracy of DARE to detect any receptive anal intercourse was little better than random guessing (AUC 0.53, 95% CI 0.51 to 0.55 and AUC 0.51, 95% CI 0.49 to 0.53, respectively). RT and ST decreased with age regardless of sexual behaviour (ptrend<0.01 for both). Compared with individuals having always/mostly insertive anal intercourse, individuals having always/mostly receptive anal intercourse were associated with decreased RT, but not ST, while those equally preferring both insertive and receptive anal intercourse were not associated with decreased RT or ST.Conclusion Decreased sphincter tone is uncommon among SGM who prefer receptive anal intercourse. Given virtually no accuracy, a finger inserted into the anus has no utility to detect individuals practising receptive anal intercourse and thus should not be used as such.Trial registration number NCT04090060.

Background Although self-sampling could help address anal cancer screening barriers, no studies have investigated annual engagement with this method or compared it with annual screening with a provider. Building on our baseline article, we compared annual anal screening engagement between home-based self-sampling and clinic-based clinician sampling. Methods The Prevent Anal Cancer Self-Swab Study recruited and randomized sexual and gender minority individuals 25 years and older who have sex with men to a home or clinic arm. Home-based participants were mailed an anal human papillomavirus self-sampling kit at baseline and 12 months, whereas clinic-based participants were asked to schedule and attend 1 of 5 participating clinics at baseline and 12 months. Using Poisson regression, we conducted an intention-to-treat analysis of 240 randomized participants who were invited to screen at both timepoints. Results More than half (58.8%) of participants completed annual (median = 370 days) anal screening. In the home arm, 65.0% of participants engaged in annual screening compared with 52.5% of clinic-based participants (P = 0.049). When stratified by HIV status, persons living with HIV had a higher proportion of home (71.1%) versus clinic (22.2%) annual screening (P < 0.001). Non-Hispanic Black participants participated more in home-based annual anal screening (73.1%) than annual clinic screening (31.6%; P = 0.01). Overall, annual screening engagement was significantly higher among participants who had heard of anal cancer from an LGBTQ organization, reported “some” prior anal cancer knowledge, preferred an insertive anal sex position, and reported any prior cancer diagnosis. Conclusions Annual screening engagement among those at disproportionate anal cancer risk was higher in the home arm.

Background Anal cancer disproportionately affects sexual and gender minority individuals living with HIV. High-resolution anoscopy (HRA) is an in-clinic procedure to detect precancerous anal lesions and cancer, yet prospective data on factors associated with HRA attendance are lacking. We examined whether anal HPV sampling at home versus in a clinic impacts HRA uptake and assessed HRA acceptability. Methods Sexual and gender minority individuals were randomised to home-based self-sampling or clinical sampling. All were asked to attend in-clinic HRA 1 year later. We regressed HRA attendance on study arm using multivariable Poisson regression and assessed HRA acceptability using χ2 tests. Results A total of 62.8% of 196 participants who engaged in screening attended HRA. Although not significant (P = 0.13), a higher proportion of participants who engaged in clinic-based screening attended HRA (68.5%) compared to home-based participants (57.9%). Overall, HRA uptake was higher among participants with anal cytology history (aRR 1.40, 95% CI 1.07–1.82), and lower among participants preferring a versatile anal sex position versus insertive (aRR 0.70, 95% CI 0.53–0.91), but did not differ by race or HIV serostatus. In the clinic arm, persons living with HIV had lower HRA attendance (42.9%) versus HIV-negative participants (73.3%) (P = 0.02) and Black non-Hispanic participants had lower HRA attendance (41.7%) than White non-Hispanic participants (73.1%), (P = 0.04). No differences in attendance by race or HIV status were observed in the home arm. Conclusions HRA uptake differed significantly by race and HIV status in the clinic arm but not the home arm.

Objective: Telecontraception platforms are a growing market aiming to minimize barriers to obtaining contra-ception in the United States by delivering birth control directly to consumers through the mail or pharmacy pickup. However, access is not patterned equally for women due to state-level differences. This research ex-amines how social, political, and economic state conditions combine and operate with one another to pattern access to telecontraception platforms across the United States.Methods: An original dataset of state-level factors was constructed from a variety of public-use websites. Fuzzy-set qualitative comparative analysis (fsQCA) was used to examine the influence of state-level conditions (state po-litical control, proportion of women legislators, percent uninsured women, and percent rural population) on telecontraception platform availability across the United States. Results: Findings uncovered three combinations of state factors linked to telecontraception platform availability with high consistency. States with high proportions of women legislators in combination with other state-level conditions were linked to telecontraception platform availability in both Democrat and Republican-controlled states. Republican states with high proportions of uninsured women and non-rural populations were also linked to telecontraception availability. Combinations illustrated distinct groupings of geographical regions.Conclusion: Using fsQCA to examine conditions associated with telecontraception provides an informative approach for health policy because it considers diverse state-level contexts. Women legislators were associated with telecontraception platform availability regardless of the political control of a state, suggesting that the gender makeup of legislative bodies may operate as an important factor in influencing reproductive health policies.Public interest summary: Telecontraception platforms such as Nurx, Favor, and Planned Parenthood Direct aim to address barriers to obtaining birth control in the U.S. by providing contraception directly to women through the mail or pharmacy pickup. Access to telecontraception platforms can vary by state, yet less is known about what shapes these differences. This research aimed to address this gap by examining state conditions associated with telecontraception platform availability. Women legislators, state political control, uninsured women, and rural population all combined in different ways to pattern telecontraception platform availability. States with high proportions of women legislators, in combination with other conditions, were linked to telecontraception plat-form availability in both Democrat and Republican states. Gender makeup of legislative bodies thus may be an important factor in influencing reproductive health policies. Combinations were also clustered geographically, illustrating that communication and networks may operate to influence telecontraception platform availability.

Purpose. Self-sampling is increasingly being used in screening programs, yet no studies to date have examined the impact of bodily characteristics on self-sampling experiences. Our objective was to assess whether body mass index (BMI) and physical disability were associated with anal self-sampling difficulty. Methods. We recruited sexual minority men (SMM) and trans persons in Milwaukee, Wisconsin to participate in an anal cancer screening study. Between January 2020 and August 2022, 240 participants were randomized to a home (n=120) or clinic (n=120) screening arm. Home participants received a mailed at-home anal self-sampling kit and were asked to attend a baseline clinic visit where biometric measurements were collected. Participants were asked to complete a survey about their experience with the kit. This research utilizes data from participants who used the kit and completed a baseline clinic visit and post-swab survey (n=82). We assessed the impact of BMI and physical disability on reported body or swab positioning difficulty. Results. Most participants reported no or little difficulty with body positioning (90.3%) or swab positioning (82.9%). Higher BMI was significantly associated with greater reported difficulty with body positioning (aOR=1.10, 95% CI 1.003–1.20, p=.04) and swab positioning (aOR=1.11, 95% CI 1.02–1.20, p=.01). Physical disability was not significantly associated with body or swab positioning difficulty. Specimen adequacy did not differ by BMI category (p=.76) or physical disability (p=.88). Conclusion. Anal self-sampling may be a viable option to reach obese persons who may be more likely to avoid screening due to weight-related barriers.

Sexual minority men are at increased risk for anal squamous cell carcinoma. Our objective was to compare screening engagement among individuals randomized to self-collect an anal canal specimen at home or to attend a clinic appointment. Specimen adequacy was then assessed for human papillomavirus (HPV) DNA genotyping. A randomized trial recruited cisgendered sexual minority men and transgender people in the community and assigned them to use a home-based self-collection swabbing kit or attend a clinic-based swabbing. Swabs were sent for HPV genotyping. The proportions of participants completing screening in each study arm and the adequacy of their specimens for HPV genotyping were assessed. Relative risks were estimated for factors associated with screening. A total of 240 individuals were randomized. Age (median, 46 years) and HIV status (27.1% living with HIV) did not differ by study arm. A total of 89.2% and 74.2% of home-arm and clinic-arm individuals returned the swab, respectively (P = .003), difference between groups, 15.0% (95% CI 5.4%-24.6%). Among black individuals, 96.2% and 63.2% in the home and clinic arms screened (P = .006). Among individuals with HIV, 89.5% and 51.9% in the home and clinic arms screened (P < .001). Self-collected swabs and clinician-collected swabs were comparable in adequacy for HPV genotyping (96.3% and 93.3%, respectively). People at highest risk for anal cancer may be more likely to screen if they are able to self-collect swabs at home rather than attend a clinic.

BACKGROUND:Home-based self-sampling may be a viable option for anal cancer screening among sexual minority men (SMM). Yet limited research has compared home-based self-collected with clinician-collected anal swabs for human papillomavirus (HPV) genotyping. METHODS:The Prevent Anal Cancer Self-Swab Study recruited SMM and transgender persons 25 years and over in Milwaukee, WI to participate in an anal cancer screening study. Participants were randomized to a home or clinic arm. Home-based participants were mailed an anal self-sampling kit to complete and return via postal mail. They were also asked to attend a clinic appointment where a clinician collected an anal swab. Swabs were HPV-genotyped using the SPF 10 -LiPA 25 assay. We analyzed 79 paired self and clinician swabs to determine HPV prevalence, percent agreement, and sensitivity and specificity of the mailed home-based anal self-swab to detect HPV genotypes using the clinician-collected swab as the reference. RESULTS:The median number of days between the home and clinic swab was 19 days (range = 2 to 70). Human papillomavirus was detected in 73.3% of self and 75.0% of clinician anal swabs ( P = 0.99). Prevalence of any HPV, any high-risk HPV, any low-risk HPV, and individual HPV types did not significantly differ between self and clinician anal swabs. Agreement between self and clinician swabs was over 90% for 21 of the 25 HPV genotypes. Mailed home-based self-collected swabs had a sensitivity of 94.1% (95% confidence interval, 82.9-99.0) for detection of high-risk HPV versus clinician-collected sampling. CONCLUSIONS:Mailed home-based self-collected and clinician-collected anal swabs demonstrated high concordance for HPV genotyping.

OBJECTIVE:Multiple organizations recommend an annual digital anal rectal examination (DARE) for people at highest risk for anal cancer. The authors assessed DARE usage among sexual minority men and transgender women. METHODS:Community-recruited and asymptomatic individuals from a mid-sized US city were enrolled into the Prevent Anal Cancer Self-Swab Study, a longitudinal clinical trial of anal cancer screening. Self-reported data from the baseline survey were used to assess usage of DARE in the last year and during the lifetime. Adjusted odds ratios (aORs) and CIs for factors associated with each outcome were determined using multivariable logistic regression. RESULTS:Among 241 participants, median age was 46 years (interquartile range, 33-57 years), 27.0% were living with HIV, and 24.5% reported a previous diagnosis of anal warts. A total of 13.7% (95% CI = 9.4%-18.0%) of individuals reported a DARE in the previous year, whereas 53.9% (95% CI = 47.7%-60.2%) reported a DARE during the lifetime. The following were associated with a DARE in the previous year: increasing age (aOR = 1.04; 95% CI = 1.01-1.08 for each additional year), any previous anal cytology (aOR = 2.62; 95% CI = 1.19-5.80, compared with no previous test or no knowledge of a test), and preferred receptive position during anal sex (aOR = 4.93; 95% CI = 1.17-20.86 compared with insertive). CONCLUSIONS:Despite guidelines recommending an annual DARE, it was uncommonly reported. There is an urgent need to understand barriers to conducting DARE among individuals most vulnerable to anal cancer and their health care providers.

Purpose: Anal cancer has disproportionately high incidence among sexual minority men. We compared acceptability of home versus clinic human papillomavirus (HPV) anal swabbing. Methods: The Prevent Anal Cancer Self-Swab Study recruited sexual and gender minority individuals in Milwaukee, Wisconsin. Eligible participants were randomized to a home or clinic arm. Home participants received a mailed anal HPV self-sampling kit. Clinic participants attended a clinic appointment where a clinician collected an anal HPV swab. We examined acceptability (overall thoughts, comfort with method, pain, and future willingness to swab) of home versus clinic swabbing using postswab survey responses. Results: A total of 191 individuals completed swabbing and a postswab survey (home = 53.4%, clinic = 46.6%). Mean age was 47 years (range = 25-78). Reported overall thoughts about home (71.6%) and clinic (69.7%) swabbing were mostly positive (p = 0.83). Overall thoughts about the home kit did not differ by participant characteristics, but overall thoughts about clinician swabbing differed by race (p = 0.04) and HIV status (p = 0.002). Nearly all participants (98.4%) reported they were comfortable receiving the kit or getting the swabbing in the clinic, reported little or no pain (98.4%), and reported willingness to undergo swabbing in the future (97.9%). After swabbing, clinic participants reported greater trust that swabbing can give accurate information about anal cancer risk (89.9%) than home participants (69.6%) (p < 0.001), and that swabbing will help them avoid anal cancer (clinic = 79.8%, home = 59.8%) (p = 0.01). Conclusion: Anal swabbing acceptability was high and did not differ between home and clinic. Participants reported high confidence and knowledge using the mailed anal self-sampling kit. Clinical Trial Registration number is NCT03489707.

Purpose. Self-sampling is increasingly being used in screening programs, yet no studies to date have examined the impact of bodily characteristics on self-sampling experiences. Our objective was to assess whether body mass index (BMI) and physical disability were associated with anal self-sampling difficulty. Methods. We recruited sexual minority men (SMM) and trans persons in Milwaukee, Wisconsin to participate in an anal cancer screening study. Between January 2020 and August 2022, 240 participants were randomized to a home (n=120) or clinic (n=120) screening arm. Home participants received a mailed at-home anal self-sampling kit and were asked to attend a baseline clinic visit where biometric measurements were collected. Participants were asked to complete a survey about their experience with the kit. This research utilizes data from participants who used the kit and completed a baseline clinic visit and post-swab survey (n=82). We assessed the impact of BMI and physical disability on reported body or swab positioning difficulty. Results. Most participants reported no or little difficulty with body positioning (90.3%) or swab positioning (82.9%). Higher BMI was significantly associated with greater reported difficulty with body positioning (aOR=1.10, 95% CI 1.003-1.20, p =.04) and swab positioning (aOR=1.11, 95% CI 1.02-1.20, p =.01). Physical disability was not significantly associated with body or swab positioning difficulty. Specimen adequacy did not differ by BMI category ( p =.76) or physical disability ( p =.88). Conclusion. Anal self-sampling may be a viable option to reach obese persons who may be more likely to avoid screening due to weight-related barriers.

Caregiver substance misuse (SM) and mental illness (MI) are risk factors for child abuse and neglect and are associated with more intensive CPS involvement including increased risk of foster care placement and multiple re-reports. This study examines the prevalence of SM and MI among 929 CPS-involved caregivers during the early phases of CPS involvement and explores the extent to which family and CPS-case characteristics predict referral and service receipt. We used a machine learning approach to identify the strongest predictors of SM and MI service receipt by comparing the predictive strength of random forest and logistic regression models. Results indicate a high prevalence of self-reported need for SM (13%) and MI (34%) services among caregivers. Nearly one-quarter (23.5%) of caregivers with SM needs and 34% of caregivers with MI needs did not receive needed services. Frequent contact with CPS workers, adverse experiences in adulthood, and court involvement were strong predictors of both SM and MI service uptake. Findings suggest the need for consistent screening for SM and MI among primary caregivers at the early stages of CPS-involvement, as well as enhanced referral practices. Machine learning applications for applied social science researchers are also discussed.

Background: Anal cancer incidence has increased in Western countries in recent decades and currently there are no consensus screening guidelines. Home-based self-sampling kits might facilitate screening for anal precancer/ cancer but could require travel through postal mail where they may experience extreme temperatures or long transport times.Objective: To determine the effect of the environment on specimen adequacy for HPV genotyping of a mailed home-based self-sampling anal cancer screening kit.Study design: The Prevent Anal Cancer (PAC) Study in Milwaukee, Wisconsin recruited men who have sex with men (MSM) and transgender persons 25 years of age and older. Participants were randomized to receive a mailed self-sampling kit or attend a clinic for screening. Kits were insulated with foam and included a device to record temperature every twenty minutes. Samples were returned via mail and underwent HPV genotyping using the SPF10-LiPA25 assay which also detected human RNase P to determine specimen adequacy by qPCR. For the first 93 kits, logistic regression assessed associations between specimen inadequacy and temperature, freeze-thaw cycle, presence of fecal matter, and number of days in an uncontrolled environment.Results: Most specimens (92.5%) were adequate for HPV genotyping. Specimen inadequacy was not associated with temperature, freeze-thaw cycle, or transit time. Fecal matter was present more often in inadequate (71.4%) compared to adequate specimens (16.3%) (p = .004).Conclusions: These real-world data from mailed home-based anal self-sampling kits found that environmental conditions did not affect specimen adequacy. While over 90% of specimens were adequate, presence of fecal matter predicted specimen inadequacy.

BACKGROUND Telecontraception is a novel method that aims to address existing barriers associated with obtaining contraception in the United States, yet research examining user experiences with these apps is lacking. METHODS Qualitative data analysis was used to conduct a content analysis of user reviews from two major telecontraception platforms, Nurx and Planned Parenthood Direct. RESULTS Access and timeliness, clinician interaction, cost and affordability, support for the idea of telecontraception, and platform experience were the main themes across both platforms. Telecontraception alleviated many barriers related to in-person visits for contraception, such as waiting months for a booked provider appointment or having to take time off from work to visit a healthcare facility. Information and education, birth control options, and largely positive interactions with clinicians indicated that telecontraception has the potential to improve user experiences of contraceptive counselling by facilitating on-demand access to clinicians and contraceptive information. Cost and affordability had mixed reviews, with varying experiences depending on insurance. CONCLUSIONS Similar themes across both platforms highlight shared motivations for turning to telecontraception platforms and uncover currently unmet needs in the traditional in-person reproductive healthcare system. Telecontraception platforms eradicate many barriers present in traditional in-person healthcare visits yet are limited by existing institutional frameworks such as insurance. Addressing cost and reach barriers could help ensure all women can utilise telecontraception.

Rationale: It is well established that exposure to a greater number of adverse childhood experiences (ACEs) increases the risk of poor physical and mental health outcomes. Given the predictive validity of ACE scores and other cumulative risk metrics, a similar measurement approach may advance the study of risk in adulthood. Objective: We examined the prevalence and interrelations of 10 adverse adult experiences, including household events such as intimate partner violence and extrafamilial events such as crime victimization. We also tested the relation between cumulative adult adversity and later mental health problems, and we examined whether adult adversity mediates the link between childhood adversity and mental health. Methods: Data were collected from 501 women in the Families and Children Thriving Study, a longitudinal investigation of low-income families that received home visiting services in Wisconsin. We conducted correlation analyses to assess interrelations among study measures along with multivariate analyses to test the effects of childhood and adult adversity on three outcomes. depression, anxiety, and posttraumatic stress disorder (PTSD). We then fit a structural equation model to test whether the effects of childhood adversity on mental health are mediated by adult adversity. Results: Over 80% of participants endorsed at least one adverse adult experience. Adult adversities correlated with each other and with the mental health outcomes. Controlling for ACEs and model covariates, adult adversity scores were positively associated with depression, anxiety, and PTSD scores. Path analyses revealed that the ACE-mental health connection was mediated by adult adversity. Conclusion: Our findings indicate that mental health problems may be better understood by accounting for processes through which early adversity leads to later adversity. Pending replication, this line of research has the potential to improve the identification of populations that are at risk of poor health outcomes.