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Enrollment in Medicaid expansion may improve financial outcomes for low-income adults, but this association has not been studied in the longer-term postenrollment period. To estimate the association of enrollment in Medicaid expansion with financial outcomes for enrollees as long as 7 years after enrollment. This longitudinal cohort study used an event study analysis to compare changes in credit outcomes after relative to before enrollment, controlling for changes in outcomes over time, differences between individuals who enroll at different times, and linear trends in outcomes prior to enrollment. Participants included first-time enrollees in the Healthy Michigan Plan (HMP), Michigan's Medicaid expansion plan, between April 1, 2014, and December 31, 2017. Enrollees were linked with their credit reports from a large national credit agency at 6-month intervals from 2013 to 2021, with outcomes obtained on the final business day of January and July of each calendar year. Data were analyzed from January 4, 2023, to December 9, 2025. Enrollment in HMP. The event study analysis compared changes in 4 credit outcomes: medical debt in collections, nonmedical debt in collections, a subprime credit score (<600), and bankruptcy in the prior 2 years. The study cohort included 575&#x202f;283 enrollees (308 814 male [53.7%]; mean [SE] age, 42.1 [10.6] years). HMP enrollment was associated with large reductions in medical debt in collections (from -$101.9 [95% CI, -$127.6 to -$76.3] in postenrollment quarter 8 to -$983.0 [95% CI, -$1090.8 to -$875.1] in postenrollment quarter 29) and rates of subprime credit scores (from -0.038 [95% CI, -0.041 to -0.035] in postenrollment quarter 8 to -0.234 [95% CI, -0.247 to -0.221] in postenrollment quarter 29), with the magnitude of association increasing over time. No associations were observed between HMP enrollment and nonmedical debt in collections or bankruptcy. In this cohort study of HMP enrollees, Medicaid expansion enrollment was associated with reductions in medical debt in collections and rates of subprime credit scores as long as 7 years after enrollment. These results suggest enrollment in Medicaid expansion was associated with excellent protection from out-of-pocket costs of medical care and overall improved financial stability, which in turn may be associated with improvements in enrollees' health and well-being.

The rise of Mental Illness diagnoses in the United States unique to the criminal justice system. Specifically in Ohio, individuals with mental illness diagnoses have increased within the criminal justice system leading to the implementation of the Mental Health Court Docket. The Mental Health Docket has led to a decrease in recidivism by providing Defendants with appropriate mental health treatment. Within Ohio there is no universal standard for individuals being admitted into the Docket which has led to inconsistencies throughout the State and restrictive clinical requirements like requiring a diagnosis with psychosis. These inconsistencies contribute to higher recidivism rates and limit access to rehabilitative services designed to address the underlying causes of criminal behavior. To combat recidivism, Michigan applies broad and uniform eligibility standards that emphasize treatment and rehabilitation over incarceration, resulting in substantially lower recidivism rates among participating defendants. This Note examines the development and implementation of Mental Health Dockets in Ohio and compares Ohio's Mental Health Docket with Michigan's Mental Health Docket model under Michigan Legislation &#xa7; 600. By modeling legislation after Michigan's framework, Ohio can reduce confusion within the court system, increase access to treatment-oriented alternatives to incarceration, and improve procedural fairness for defendants with mental illness. Ultimately, decreasing recidivism, reducing the incarceration of mentally ill individuals, and better serving both public safety and rehabilitation goals within Ohio's criminal justice system.

The US healthcare system, despite its resources, faces persistent health inequities. Paradoxically, highly effective, community-centric innovations often emerge from resource-constrained low- and middle-income countries. This paper describes how the field of global learning can be an approach for translating these global insights into actionable strategies and that implementation science (IS) provides a methodology to guide the process. Two case studies are described as examples: (1) the adaptation of Community Health Worker best practices from Togo to the Bronx, New York, to address local health disparities; (2) the localized, integrated care model at Michigan's Corner Health Center, which adopted principles from women's groups in India. By applying an IS framework to global learning innovations, the US can effectively adapt proven global solutions to close domestic health gaps and foster a more resilient healthcare system.

The coronavirus disease 2019 pandemic highlighted vulnerabilities in the nursing workforce needing attention before future crises. Clinical nurse specialists (CNSs) led teams, provided clinical expertise for policies and patient care, and adapted rapidly; however, the pandemic experiences of CNSs are not understood. We aimed to explore the lived experiences of Michigan's CNSs throughout the pandemic. Using a descriptive phenomenological design, semi-structured, one-on-one interviews were conducted between January and April 2021. Interviews were audio-recorded and transcribed to allow for rigorous analysis. Nine CNSs participated. Three themes emerged from the data. Within each of those 3 broad themes were 3 to 4 subthemes. Theme 1: nurses adapting to a crisis mindset consists of constant stress and work, rapid and unpredictable change, adapting with the science, and feelings toward the public. Theme 2: CNSs adapting to the crisis in unique ways is comprised of bearing extra emotional weight, losing a sense of control, role representation and clarity, and pride and responsibility. Theme 3: CNSs as holistic beings consists of coping mechanisms, support systems, and persistent life demands. The stress experienced by CNSs was distinct from the stress felt by other health care professionals as they were expected to lead teams through 3 spheres of impact. The magnitude and uniqueness of their stress identifies a priority for adequate preparation of CNSs and highlights an opportunity for specific areas of improvement prior to any future crises.

Latinos are among the fastest growing populations in the United States. While previous work indicates racial/ethnic differences in fibroid prevalence, little is known about the prevalence of this condition among Latina females in the United States. To determine the prevalence of fibroids among reproductive-aged Latina females and identify associated factors in this population. Environment, Leiomyomas, Latinas, and Adiposity Study is a prospective cohort study of Latina females, based in Southeast Michigan, and conducted using Community Based Participatory Research (CBPR) principles. Data were collected between October 2017 and October 2022, a community health clinic in Detroit, MI and at the University of Michigan's Center for Reproductive Medicine in Ann Arbor, MI. Eligible participants self-identified as Hispanic or Latina; were assigned female sex at birth; were aged 21 to 50 years at enrollment; could speak, read, and write in either English or Spanish; were not currently pregnant; and did not have an implantable electrical device, history of malignancy, or other conditions requiring chemotherapy or radiation. Fibroid symptoms were not a requirement of participation. Fibroid prevalence was rigorously established via self-reported medical history and expert administration of transvaginal ultrasounds. Participant features-including demographics, health, acculturation level, and other factors of interest-were established via surveys, interviews, and in-person measurement. Among Environment, Leiomyomas, Latinas, and Adiposity Study participants who completed a vaginal ultrasound (N=609 of 621 eligible), the mean age was 37.3&#xb1;7.0 years and 68 (11.2%; confidence interval, 8.6%-13.8%) presented with fibroids. The majority had a single fibroid (75.0%), while 25.0% had 2 or more. The mean size of the largest fibroid-most often intramural (80.9%)-was 2.9&#xb1;1.2 cm in diameter. Fibroid prevalence was found to be higher in older age groups, rising from 3.5% (confidence interval, 1.4%-10.0%) among participants aged 21 to 30 years, to 8.3% (confidence interval, 4.9%-11.7%) in those aged 31 to 40 years, and 18.7% (confidence interval, 13.3%-24.1%) in those aged between 41 and 50 years (P<.001). Logistic regression models indicated that fibroid presence was associated with younger age at menarche (adjusted odds ratio, 0.84; 95% confidence interval, 0.72-0.99) and increasing gravidity (adjusted odds ratio, 0.80; confidence interval, 0.66-0.97). Findings indicated no significant association with parity (adjusted odds ratio, 0.85; confidence interval, 0.68-1.07). Environment, Leiomyomas, Latinas, and Adiposity Study is among the first prospective studies of its size to use an ultrasound confirmation approach to establish fibroid prevalence among Latina females in the United States. Our findings suggest the prevalence of fibroids among Latina females is much lower than previously reported in the literature and markedly lower than that in Black and White women. More research is needed to understand why burden may be lower in this population and how such findings can be used to benefit all women.

Dam removals and fish passage can enhance aquatic connectivity but may also promote upstream transport of legacy contaminants by migratory fish. This study assessed the potential for contaminant biotransport in Michigan's Boardman River following the planned removal of the Union Street Dam and installation of FishPass, a selective fish passage facility. We quantified polychlorinated biphenyls (PCBs), mercury (Hg), and organochlorine pesticides in carcass and egg samples from migratory species including Chinook and coho salmon, migratory rainbow trout, common white and longnose sucker, lake trout, walleye, and sea lamprey. Chinook salmon exhibited the highest PCB concentrations in both carcasses and eggs, exceeding those of rainbow trout and native suckers. Similarly, Chinook salmon were predicted to deposit up to 2,200&#x2009;mg PCBs upstream under a high run size scenario, over 80 and 100 times greater than rainbow trout and native suckers. Although suckers had lower individual contaminant burdens, their relatively large run sizes contributed moderately to potential contaminant biotransport compared with rainbow trout, indicating an interaction between abundance and spawner contaminant burden. Stream-resident brook and brown trout in reaches open to migratory fish had higher PCBs and lower Hg concentrations than in closed reaches, likely reflecting dietary exposure to eggs and growth dilution. These results demonstrate that the potential for contaminant biotransport varies widely among migratory species and highlights the need for managers to consider both contaminant burden and run size when making fish passage decisions to balance ecological restoration with contaminant exposure risk.

Advances in global satellite-based remote sensing, big data, and machine learning are making large-scale geographic analysis increasingly accessible. Archaeology can benefit from multitemporal and multisensor satellite data even when direct archaeological site and feature detection is not possible by using these data to examine relationships between archaeological, ecological, and climactic variables across vast geographies. With this, archaeologists can ask questions about diverse landscape matrices and how these shaped the flow of past cultural processes. We demonstrate the value of thermal sensor data-common in satellite arrays-by developing an automated routine for analyzing Landsat 8 Thermal Infrared Sensor time series data. We fit a harmonic regression to extract amplitude and phase shift values for thousands of inland lakes in Michigan's lower peninsula and computed perimeter-to-area ratios. Treating these thermal data not as absolute equivalents to past conditions but as relative indices, we compared lakes with and without Late Precontact (ca. 1200-1600 CE) burial mounds. Results show lakes with mounds warmed later in the spring, cooled later in the fall, and were more regularly shaped, suggesting Late Precontact communities placed mounds on lakes with specific resource benefits, including extended growing seasons. Considering our findings alongside emerging evidence for widespread precontact Indigenous agriculture in the Great Lakes region, it is important to reconsider maize's subsistence and ceremonial significance. The analytic workflow-leveraging free, global Landsat data in Google Earth Engine-offers a replicable framework for archaeologists worldwide to integrate relative thermal patterns into cultural landscape studies.

As the overdose crisis continues to devastate communities, expanding access to harm reduction services, such as drug checking, is essential. Drug checking services (DCS) enable people who use drugs (PWUD) to identify the likely active ingredients within their substances, supporting safer use and reducing overdose risk. However, implementing DCS in community settings may encounter barriers such as stigma, legal ambiguity, and organizational constraints. This study examines harm reduction staff perspectives on the implementation and delivery of a community-based DCS program in Michigan. This study explored the perceptions of staff from a harm reduction organization before and after implementing Michigan's first community-based DCS using Fourier-Transform Infrared spectroscopy. Six focus groups, each composed of 2 to 5 staff members, were conducted before and after implementing DCS. Rapid qualitative methods, informed by the Consolidated Framework for Implementation Research, were used for analysis. Prior to implementation, staff anticipated that DCS would empower PWUD and provide crucial drug supply information to communities. Staff also believed that strong relationships with PWUD and effective service integration would facilitate uptake. Post-implementation, staff noted there was considerable engagement with DCS among PWUD, enhanced by dissemination via peer networks and strategic communication approaches. However, staff encountered several barriers to smooth implementation, including ongoing concerns about legal risks and criminalization, as well as organizational capacity constraints. Findings from this study highlight the need for legal protections, adequate staffing, and community support to sustain and expand drug checking programs.

OBJECTIVE: We evaluated the dimensionality of an Anti-Asian racism (AAR) measure, informed the development of a brief measure, and validated a brief AAR measure. METHOD: We conducted a national survey of 748 Asian American adults in 2023 (64.6% female). Bi-factor analysis was used to evaluate the dimensionality of the AAR measure, and Graded Response Models (GRM) informed the development of the brief measure of AAR. We also evaluated concurrent validity. RESULTS: The AAR scale is unidimensional. GRM was conducted to derive a brief (6-items), reliable, and valid measure of AAR. Our brief measure of AAR yielded valid and reliable scores, and was associated with firearm purchasing, depressive symptoms, anxiety symptoms, and appraisals of safety, demonstrating concurrent validity. CONCLUSIONS: The brief measure of AAR includes items related to subtle, blatant, and cultural racism. The brief scale offers opportunities for real-time, momentary assessments and opportunities to discuss AAR in the community health setting.

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Adult weight management interventions are complex; better understanding of the intervention components that may impact eating disorder (ED) risk is required. Weight management randomized controlled trials (RCTs) for adults with overweight/obesity that measured ED risk were systematically searched in four databases and two trial registries. A project-specific codebook was used to code 84 delivery features and 89 intervention strategies of trials. Individual strategies were grouped into 20 clusters which were further grouped into five broad categories. Trial investigators verified coding and narrative synthesis using descriptive statistics of findings was reported. Of 14,880 identified, 58 eligible trials were coded, of which 26 trials with 64 intervention arms were verified and therefore included. Intervention arms included a mean (SD) of 24 (11) intervention strategies. Commonly used intervention strategy clusters were nutrition education (91%), dietary behavior change strategies (84%), physical activity education (81%), and dietary self-monitoring (80%). Few interventions used strategies in the category of psychological components (13-41%). The median (range) intervention duration was 27 (4-104) weeks, and contacts with participants typically included a staged approach of weekly to monthly contact. Adult weight management interventions are multifactorial with varying delivery features and intervention strategies. Despite this, psychological (e.g. weight stigma) and sleep-health related strategies are either rarely used or are underreported. Breaking down intervention components using our framework can help identify which strategies influence outcomes, including eating disorder risk, and inform the design and reporting of future interventions. Some adults seeking weight management for obesity may have an eating disorder or disordered eating behaviors. Research shows most people who take part in behavioral weight management programs have an improvement in eating disorder symptoms, however a small number may experience worsening symptoms. In this study, we break down behavioral weight management programs that measure eating disorder risk to better understand the features they use. We found that these programs vary widely in the number and type of strategies they use, as well as in how they are delivered, such as the length of the program. Strategies that focus on psychological factors (for example, addressing weight stigma) and sleep health were rarely used or reported. These findings are useful in guiding the design and reporting of future behavioral weight management programs. They can also be used in future research to determine which specific program features improve or worsen outcomes such as eating disorder risk.

We describe population-level trends in the prevalence of any tobacco use, combustible and non-combustible tobacco use in US adults, by age and sex, from 2015 to 2023. Cross-sectional data collected in the annual US National Health Interview Surveys (NHIS) conducted between 2015 and 2023 were used to characterize trends in adult current prevalence of any tobacco use, combustible and non-combustible tobacco product use. All NHIS participants with valid data on tobacco use, age and sex were included in the analyses. Joinpoint regression was used to estimate the annual percentage change (APC) from 2015 to 2023 and 95% confidence intervals (CIs) overall for each outcome and by different age groups (18-24, 25-34, 35-54, and &#x2265;55 years) and for males and females. All statistical tests were two tailed and based on a p<0.05 significance level. Between 2015 and 2023 any tobacco use decreased at a statistically non-significant APC rate of -1.0% (95% CI: -2.1-0.12) across all age and sex groups combined. Overall, combustible tobacco decreased at a statistically significant APC rate of -3.6% (95% CI -4.6 - -2.6), with differences by age group (18-24: -12.2%, 95% CI: -14.6 - -9.7; 25-34: -5.2%, 95% CI: -6.6 - -3.8; 35-54: -2.5%, 95% CI: -4.2 - -0.9; &#x2265;55: -1.2%, 95% CI: -1.8 - -0.5). Non-combustible tobacco product prevalence increased at a statistically significant APC of 8.9% (95% CI: 6.5-15.8) after 2017, with increases in all age groups and both sexes. The decrease in combustible tobacco was due to decreasing cigarette use while the increase in non-combustible tobacco products after 2017 was due to increases in electronic cigarette (EC) use. Tobacco products use by US adults shifted between 2015 and 2023, with combustible use decreasing, particularly in young adults, while non-combustible use increased.

This article explores the conceptualization, design, and implementation of the University of Michigan's inaugural Leadership and Technology Global Course in Cape Town, South Africa. This 3-week study abroad experience centered the perspectives of gender-minoritized leaders in science, technology, engineering, and math (STEM) to demonstrate the importance of diversity, inclusion, and cultural competency for effective leadership practice. The values of Ubuntu (i.e., interconnectedness, community, compassion/empathy, responsibility, reconciliation/healing) frame the themes that emerged each week of the course and illuminate leadership best practices. With the voices of the 12 participants foregrounded, this article presents counternarratives, to disrupt both leadership and study abroad stories most often told.

This article explores the gendered emotional labour done by participants or "Burners" at Lakes of Fire, an annual regional Burning Man event held in Michigan. This paper conceptualizes Burners as embracing culturally dominant forms of hybrid masculinity and femininity, which also structure their emotional labour. Drawing on 42 one-on-one semi-structured interviews with male and female-identifying participants, I respond to calls from scholars to produce more relational analyses of gender within cultural studies scholarships. Results from the interviews demonstrate that, in taking on roles as empowered maternal figures and sexually progressive caretakers, the women embraced progressive but maternal communal mothering roles which require intensive feminine emotional labour. These "Burner femininities" enabled them to carry out the emotional labour required to sustain Lakes communally. In contrast, male Burners constructed hybrid forms of Burner masculinity by rejecting toxic and hyper masculinity while embracing more progressive masculine role and identities. However, men also embodied more leadership and managerial roles when undertaking emotional labour, in contrast to the explicitly maternal roles held by women. Burner masculinity and femininity therefore act relationally, by mutually reinforcing certain types of emotional labour as the largely separate domains of women and men. This paper also discusses the ways in which cultural events such as Lakes of Fire hold the possibility to both subvert and replicate more traditional understandings of gender.

Perinatal mental health conditions are more prevalent, yet less commonly treated, among people of color compared with white women. We conducted an interrupted time series analysis using 2014-2022 Michigan Medicaid claims data to assess the impact of Michigan Medicaid's 2018 requirement to screen for postpartum depression during well-child visits on racial/ethnic differences in maternal mental health diagnosis and treatment outcomes. The sample included 254,890 women and was composed of 137,769 white, 81,257 Black, and 16,358 Hispanic women. Compared with white women, the 2018 policy introduction led to a greater level change in rates of postpartum depression diagnosis for Hispanic women (adjusted odds ratio [aOR] 1.26; 95% confidence interval [CI] [1.03, 1.54]) and a greater level change in rates of medication for those with depression or anxiety among Black (aOR 1.13; 95% CI [1.04, 1.23]) and Hispanic women (aOR 1.23; 95% CI [1.06, 1.44])-reducing but not eliminating inequities in diagnosis and treatment of depression and anxiety. Black women saw a decline in diagnosis (aOR .91; 95% CI [.85, .98]) and treatment (aOR .91; 95% CI [.85, .98]) for substance use disorder compared with white women. After the policy introduction, Black and Hispanic women experienced larger trend increases in all outcomes, moderately reducing inequities. Sensitivity analyses changing the interruption date to 2017 showed stronger differences in trend changes for most outcomes. Although inequities in diagnoses and treatment for those with postpartum depression or anxiety between 2014 and 2022 modestly improved, Michigan's 2018 Medicaid policy did not eliminate inequities in maternal mental health conditions. Policymakers at the federal and state levels should consider additional ways to improve treatment of perinatal mental health conditions among Black and Hispanic women.

Value cues can promote selective processing of words in lists of 12 or more items leading to better recall of memoranda associated with higher value. The current study examined whether value cues can also benefit memory for words studied in shorter lists, including those within the normative range of verbal working memory span (~four items). Across four experiments, participants studied words randomly paired with different point values in lists of three to 12 items, followed by immediate free recall. When list length varied randomly and participants could not anticipate memory set size, value-directed effects were evident for all list lengths: Words of higher-value were better recalled than lower-value words, even for lists lengths 3 and 4, demonstrating value-directed memory (VDM) effects within the canonical parameters of working memory. In contrast, with advanced knowledge of list length, value effects emerged only for lists of five or more words and overall recall was better for lower value words than when list length was unexpected, especially for shorter lists. Serial position and output order analyses corroborated these results. The current VDM effects, found in-person, and replicated with online testing, extend prior evidence indicating prioritization based on value within the parameters of working memory. The results also underscore the importance of metamemory in value-based effects: When anticipating word lists with relatively few items (three or four words), value cues can be ignored in favor of more efficient memory strategies, which results in discontinuities in VDM effects for shorter versus longer lists.

Records with temporary names, such as Babygirl, BoyA, etc. are sometimes submitted to immunization information systems (IIS) with vaccinations that are administered before the child has a legal name. To 1) apply probabilistic record linkage to assist in the deduplication of children with temporary names in an IIS and 2) assess the impact of that deduplication on vaccination coverage rates. Cross-sectional study of vaccination records. The Michigan Care Improvement Registry (MCIR), Michigan's statewide, population-based IIS. Records in MCIR with a temporary first name and date of birth between 1/1/2020 and 12/31/2023. Percentage of temporary name records matched to legal name records, and the difference in both temporary name and statewide primary childhood vaccination series (i.e. 4:3:1:3:3:1:4 series) coverage among 19-35&#xa0;month olds after reconciliation of these records. Of the 16,806 temporary name records submitted to MCIR for births between 1/1/2020 and 12/31/2023, 9803 (58&#xa0;%) were linked to a legal name record using probabilistic linkage. Among the subset of children aged 19-35&#xa0;months who were assigned a temporary name at birth (n&#xa0;=&#xa0;8548), 4:3:1:3:3:1:4 series completion coverage increased substantially, from 1.5&#xa0;% to 39.6&#xa0;% after reconciliation of vaccination histories. Statewide, 4:3:1:3:3:1:4 series coverage among children aged 19-35&#xa0;months (n&#xa0;=&#xa0;162,666) increased from 66.2&#xa0;% to 68.2&#xa0;% after reconciliation of vaccination histories. Probabilistic linkage was found to be an effective method for identifying duplicate temporary name records in IIS.

BACKGROUND: Cognitive impairment is a major public health problem. This study aimed to examine the association between long-term visit-to-visit resting heart rate variability (RHRV) and cognitive dysfunction among the general population. METHODS: Data was derived from the Health and Retirement Study (HRS) and the China Health and Retirement Longitudinal Study (CHARLS). Variation independent of mean (VIM) was used to assess participants&#x2019; RHRV in the main analyses. Cognitive functions in both cohorts were measured by using tests including memory, attention, and orientation, and a standardized Z score was calculated. Linear mixed models and restricted cubic splines were adopted to explore the association between RHRV and cognitive decline. RESULTS: There were 7,582 and 4,085 eligible participants from the HRS and the CHARLS in the analyses, respectively. After adjusting for covariates, VIM of RHRV was significantly associated with global cognitive function (HRS: &#x3b2; for per-SD increment&#x2009;=&#x2009;&#x2212;&#x2009;0.022 [95% CI, &#x2212;&#x2009;0.040 to &#x2212;&#x2009;0.005]; CHARLS: &#x3b2; for per-SD increment = -0.023 [95% CI, &#x2212;&#x2009;0.045 to &#x2212;&#x2009;0.000]). Similar results were observed from several sensitivity analyses, including using average real variability and coefficient of variation for RHRV, additionally adjusted for physical activity, excluding participants who had heart problems at baseline, and further adjusting for the C-reactive protein in the CHARLS. CONCLUSION: Our results suggest that RHRV was independently associated with cognitive function in the general population.

Movements such as MAHA (Make America Healthy Again) and the resurgence of anti-vaccine rhetoric promoted by figures like Robert F. Kennedy, Jr. have amplified skepticism, particularly in Black communities already burdened by structural inequities and historical medical racism. These contemporary patterns of resistance reflect a broader continuity between COVID-19 vaccine hesitancy and ongoing distrust toward public health institutions, underscoring the need for culturally grounded engagement strategies that honor lived experience and community leadership. This qualitative study examines how Black women in Michigan made decisions about the COVID-19 vaccine for themselves and their families, and how their choices influenced broader community responses to the vaccine. Using a community-based participatory research (CBPR) approach, we conducted 34 interviews between 2022 and 2023. In the current study we focus on the 20 Black women who were interviewed as part of the larger study. Categorized by Self-Determination Theory constructs, we found that relatedness, through a desire to protect others, was the dominant motivator, expressed through caregiving rooted in cultural traditions. Using the frameworks of Inventive Mothering and Black Mothering, we explore how maternal leadership shaped vaccine acceptance and alternative protective strategies.