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Abstract While vaccine-critical activism has been widely documented and discussed, comparatively little has been said about the concerted response of pro-vaccine activists defending the majority view. This paper explores two case studies of pro-vaccine activism in Australia and the United States (US). It shows how pro-vaccine views and behaviours can take varying forms due to different aims and methods of engagement – oppositional counteractivities in favour of vaccination in Australia, and issue-based advocacy as part of a political alliance in the US. The focus in Australia comes from a pro-science stance and includes 'skeptics' against pseudoscience directly opposing vaccine-critical groups. In the US, the focus takes the form of an issue-specific campaign that has arisen from existing pro-vaccine parent blogs and discussion groups pushing for policy change rather than public confrontation. These case studies exemplify how pro-vaccine activism can take varying forms of either reinforcing the mainstream view or countering digression from it. Drawing on qualitative research, this paper aims to examine the types of practices and strategies employed by activists to voice their support of vaccination, and discusses the means, messages, and motivations of pro-vaccine activism. It ends with an argument for why a study – of public support for in addition to studying public opposition to vaccination – can help to better understand vaccination views and behaviours. These findings have wider implications for the study of counter-activism and the polarisation of civil society groups. Highlights • Pro-vaccine views and behaviours are understudied. • Case studies on pro-vaccine activist groups in Australia and the United States. • Pro-vaccine activism reinforces the mainstream or counters digression from it. [ABSTRACT FROM AUTHOR]

This paper examines the experiences of adolescents from mixed migratory status families affected by deportation. We analyze the impacts on their mental and emotional health when they are separated from one parent in the United States, forcibly displaced with another to Oaxaca, and experience the consequences of their deportation in Mexico. We use a qualitative and ethnographic methodology. This paper focuses on data from semi-structured interviews and focus groups with 15 parents who had been deported from the United States and 53 adolescents who moved with them to Mexico. The data was collected between 2018 and 2020. The main findings show the existence of emotions that are sustained in the transnational flow and acquire new nuances upon return. They also show the emergence of new conditions related to family separation, all of which have an impact on the adolescents' well-being and on important areas of their lives, such as education. The research contributes to knowledge in two main ways: 1) it addresses the impacts of parental deportation on the well-being of adolescents in mixed-status families, which have typically focused on children; 2) it studies how parental deportation affects the mental and emotional health of adolescents de facto deported to Mexico, a field still little studied. • De facto deportation has mental health consequences among adolescents. • The forced nature of de facto deportation produces helplessness, aggression and anger. • The code of silence associated with deportation generates fear, stress, anxiety. • Ambiguous loss is accentuated at important moments in academic and developmental life. • Family separation and de facto deportation affect school performance. [ABSTRACT FROM AUTHOR]

Puerto Rico (PR) has a growing physician migration problem. As of 2009, the medical workforce was composed of 14,500 physicians and by 2020 the number had been reduced to 9,000. If this migration pattern continues, the Island will not be able to meet the recommended physicians per capita ratio proposed by the World Health Organization (WHO). Existing research has focused on the personal motivations for movement to, or permanence in, a particular setting, and social variables that encourage physicians to migrate (e.g., economic conditions). Few studies have addressed the role of coloniality in fostering physician migration. In this article we examine the role of coloniality and its impact on PR's physician migration problem. The data presented in this paper stem from an NIH-funded study (1R01MD014188) that aimed to document the factors associated with physician migration from PR to the US mainland and its impact on the Island's healthcare system. The research team used qualitative interviews, surveys, and ethnographic observations. This paper focuses on the data from the qualitative interviews with 26 physicians who had migrated to the USA and ethnographic observations, which were collected and analyzed between September 2020 and December 2022. The results evidence that participants understand physician migration as a consequence of three factors: 1) the historical and multidimensional deterioration of PR, 2) the idea that the current healthcare system is rigged by politicians and insurance companies, and 3) the specific challenges faced by physicians in training on the Island. We discuss the role of coloniality in fostering these factors and how it serves as the backdrop for the problem faced by the Island. • Puerto Rico has a growing physician migration problem that impacts population health. • This qualitative study explored reasons for migration with Puerto Rican physicians. • Coloniality underlies the structural factors that foster physician migration. • Physicians, trainees, and patients are impacted by neoliberal views of health. [ABSTRACT FROM AUTHOR]

Many Latinx and Indigenous Mexican populations in the United States Southwest live in unincorporated communities in the US-Mexico borderlands called colonias. These environmental justice communities often lack basic infrastructure, including healthcare services, prompting many to seek services across the border. However, due to geopolitical factors more vulnerable caregivers are limited to utilize healthcare services in the US. This paper reports the experiences and healthcare decision-making of caregivers living in colonias in the US-Mexico border region who care for children with respiratory health conditions. This study was carried out from September to December 2020. Focus groups and interviews were conducted with Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress. Qualitative interviews elicited caregivers' perspectives on the environmental factors affecting children's chronic health conditions and use of healthcare services. The analysis employed the concept of structure vulnerability to theorize geography as a structural determinant of health for caregivers faced with making healthcare decisions for their suffering from respiratory health conditions. A survey was administered to collect basic sociodemographic information. A total of 36 caregivers participated in the study. Structural factors including unincorporated community status and government inaction intersected with social determinants of health to prompt caregivers to cross the US-Mexico border to access healthcare services in Mexico for their children. Yet, more vulnerable caregivers (i.e., those without documentation status in the US) and their children, accessing healthcare services in the US was not an option limiting caregivers' ability to meet their children's healthcare needs. In such cases, geography acts as a structural determinant of health. This study shows the importance of geography in health. Rural unincorporated colonias located in the borderlands are precariously located and lack basic critical infrastructure including healthcare access. Within such places, historically and socially marginalized populations become invisible, are subject to the health effects of environmental hazards, and are limited depending on their positionality and thus vulnerability to healthcare services. • Municipal unincorporation contributes to health disparities among Latinx families in US-Mexico borderlands. • Latinx children in colonias are disproportionately exposed to environmental toxins. • Geography acts as a structural determinant of health for Latinx families in colonias. • A binational approach to health services should be prioritized for families in the borderlands. [ABSTRACT FROM AUTHOR]

• Close oversight by a Community Coordinator, relationships built with community partners, and the use of telehealth were creative solutions used by the Infant Toddler Court Teams during COVID-19 to support timely access to services. • This study builds on a companion paper that examined receipt and access to child health services at multiple Infant-Toddler Court Teams prior to and during the first year of the pandemic and details the challenges faced and the solutions identified by ITCT partners to support access to child services in the context of the COVID-19 pandemic within the US. • Understanding the challenges and solutions faced by the Infant-Toddler Court Team Community Coordinators during COVID-19 will be important for future pandemics or crises that impact care for child welfare involved children. This qualitative study examines Infant-Toddler Court Teams' (ITCT) responses to the impact of the COVID-19 pandemic on the accessibility and timeliness of services for children involved with an Infant Toddler Court Team (ITCT) within the United States. ITCTs utilize collaborative practice to improve, align, and integrate systems and build community capacity to improve outcomes for very young children and their families. This study reports findings from 350 transcripts of community partner interviews and an analysis of written case notes from ITCT Community Coordinators related to more than 700 instances of child service needs. We describe challenges faced and solutions and innovations developed by ITCTs to support and maintain child health services during the first year of the pandemic, as well as findings related to challenges associated with other types of services that reduced accessibility and timeliness. Understanding the challenges experienced and solutions developed can provide the child welfare field with insight and guidance on how to approach disruptions in care in the future and the persistent lack of service providers for court involved families. [ABSTRACT FROM AUTHOR]

Heroin overdose, more accurately termed ‘heroin-related overdose’ due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black ‘tar’ heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007–12) and of users in San Francisco (1994–2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study. [ABSTRACT FROM AUTHOR]

A rising emphasis on patient involvement in clinical research and healthcare improvement has led to the steady incorporation of patients and caregivers into this work. However, interactional factors shaping recruitment processes are not well understood. In this paper, we present a qualitative analysis of interviews with twenty-six patients, family members, engagement staff and healthcare providers who are engaged in healthcare improvement work in the United States. We focus on how stakeholders account for recruitment decisions to participate in healthcare improvement work. We find that expressions of and judgments about patients' and caregivers' cultural health capital shape providers' decisions to extend invitations to participate in healthcare improvement work. These findings extend current conceptualizations of cultural health capital beyond the clinical encounter to reveal factors shaping patient recruitment into healthcare improvement work. In theorizing how cultural health capital shapes action in this new setting, we found that healthcare providers, engagement staff, and patients/caregivers attended to different aspects of cultural health capital when accounting for why they extended or received a recruitment pitch. We further found that participating in healthcare improvement work led to a boost in cultural health capital for patients and caregivers, which they could use to develop transmissible forms of cultural health capital for less centrally involved patients and caregivers. Finally, we describe how participants in healthcare improvement collaboratives account for a lack of diversity among partners. These findings help us hypothesize the consequences of recruitment processes that rely on displays and judgments of cultural health capital and identify possibilities for change. Using the case of healthcare improvement work in Collaborative Learning Health Systems, our findings advance past work on cultural health capital in medical sociology by theorizing the role of cultural health capital in recruitment processes. • Providers recruit patients for healthcare improvement work with subjective criteria. • Providers often recruit high-resourced, privileged patients that they "vibe" with. • Partners build cultural health capital from doing healthcare improvement work. • Recruiting for cultural health capital may exclude patients from diverse backgrounds. • The role of recruitment should be considered to improve partner representation. [ABSTRACT FROM AUTHOR]

Abstract: Urban policy transfer between the US and UK has long been of interest to researchers and practitioners. Given the recent wider context of reduced direct funding and the absence of a coherent regeneration policy, this paper considers the introduction of Tax Increment Financing (TIF) to the UK as a method of stimulating spatially targeted economic development initiatives. The paper explores whether TIF could be considered a form of policy transfer, and in doing so uncovers whether the transfer of TIF could – (a) be successful and unsuccessful under certain circumstances; (b) require the actions of certain stakeholders; and (c) be enabled via prescribed frameworks and negotiation. The results are evidenced using qualitative approaches and find that TIF is more of a modified policy ‘idea’ rather than transfer. Further discussion argues that TIF can be successful, if it considers flexible but local elements and has the capacity to balance stakeholders for development brokerage. [Copyright &y& Elsevier]

Juvenile court intake – the process in which state or local authorities determine whether to prosecute, divert, or dismiss alleged juvenile delinquency cases – is essential to juvenile justice administration and to juvenile justice goals. Yet it is generally under-studied and the roles of prosecutors and intake officers poorly understood. This paper operationalizes juvenile court intake using data from one southeastern state, with a focus on professionals' roles and relative power. Results demonstrate within-state variation in intake structures and procedures with regard to whether prosecutors or intake officers exert the greatest control. Further, results show that there is a geographic relationship to this variation – counties with heavy prosecutorial control are represented disproportionately among urban areas. Additional qualitative data offers insight into prosecutors' and intake officers' perspectives on each other's roles in intake. Findings indicate a range of questions to be explored in future research examining whether and how different intake structures affect intake decisions. • The roles and power of prosecutors and intake officers varies significantly. • Significant variation exists within a state subject to a uniform legal structure. • Counties with heavy prosecutorial control are disproportionately urban. • Proportion of African-Americans is higher among intake officers than prosecutors. • Qualitative data suggest prosecutors and intake officers view intake differently. [ABSTRACT FROM AUTHOR]

Abstract: This paper revisits the concept of medicalisation and considers its value as a framework for understanding the ongoing development of new reproductive technologies, and their impact on women’s reproductive decision-making. This evaluation is drawn from a qualitative discourse analysis of the public debate about the first extended cycle oral contraception (ECOC) to suppress menstruation in the United States of America in 2003/2004, and subsequent interviews with women living in Australia who had already extended their cycles without it being medically approved for widespread practice. Firstly, the debates about menstrual suppression are couched within a discussion of the ongoing usefulness of medicalisation as an analytical tool. It is posited that medicalisation occurs in a particular social and cultural moment, and is a dynamic process where dominant social relations can be both reproduced and challenged. Secondly, qualitative interviews with women about practices of menstrual suppression are used to explore the productive nature of agency in this particular medicalisation contest. Specifically, the ways in which these women engage with the discourses of ‘risk’, ‘choice’ and ‘nature’, as canvassed by menstrual suppression advocates, reveal accommodation and modification as much as resistance and contradiction. This paper suggests that if the concept of medicalisation is to have ongoing traction as a frame of analysis, such a critique must incorporate a generative discussion of agency. [Copyright &y& Elsevier]

Objectives: To identify what factors affect women's' decisions to delay childbearing, and to explore women's' experiences and their perceptions of associated risks. Design: Systematic procedures were used for search strategy, study selection, data extraction and analysis. Findings were synthesised using an approach developed from meta-ethnography. Data sources: We included qualitative papers, not confined to geographical area (1980–2009). Databases included CINAHL, MEDLINE, EMBASE, PsycInfo, ASSIA, MIDIRS, British Nursing Index and the National Research Register. We selected qualitative empirical studies exploring the views and experiences of women of advanced maternal age who were childless or primigravidae with a singleton pregnancy or primiparous. Review methods: Twelve papers fulfilled the selection criteria and were included for synthesis. Results: Women appear to face an issue of ‘informed and uninformed decision making’; those who believe they are informed but may not be, those who are not informed and find out they are at risk once pregnant, and those who are well informed but choose to delay pregnancy anyway. Maternity services could provide information to enable informed choice regarding timing of childbearing. Conclusions: Health professionals need to be mindful of the fact that women delay childbearing for various reasons. A strategy of pre-conception education may be beneficial in informing childbearing decisions. Obstetricians and midwives should be sensitive to the fact that women may not be aware of all the risks associated with delayed childbearing. [Copyright &y& Elsevier]

Summary: Continuous surface of river bathymetry (bed topography) is typically produced by spatial interpolation of discrete point or cross-section data. Several interpolation methods that do not account for spatial trend in river bathymetry produce inaccurate surfaces, thus requiring complex interpolation methods such as anisotropic kriging. Although isotropic methods are unsuitable for interpolating river bathymetry, issues that limit their use remain unaddressed. This paper addresses the issue of effect of spatial trend in river bathymetry on isotropic interpolation methods. It is hypothesized that if the trend is removed from the data before interpolation, the results from isotropic methods should be comparable with anisotropic methods. Data from six river reaches in the United States are used to: (i) interpolate bathymetry data using seven spatial interpolation methods; (ii) separate trend from bathymetry; (iii) interpolate residuals (bathymetry minus trend) by using all seven interpolation methods to get residual surfaces, (iv) add the trend back to residual surfaces; and (v) compare resulting surfaces from (iv) with surfaces created in (i). Quantitative and qualitative comparison of results through root mean square error (RMSE), semi-variograms, and cross-section profiles show that significant improvement (as much as 60% in RMSE) can be accomplished in spatial interpolation of river bathymetry by separating trend from the data. Although this paper provides a new simple way for interpolating river bathymetry by using (otherwise deemed inappropriate) isotropic methods, the choice of trend function and spatial arrangement of discrete bathymetry data play a vital role in successful implementation of the proposed approach. [Copyright &y& Elsevier]

Background: The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.Methods: A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.Results: (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.Conclusion: Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations. [ABSTRACT FROM AUTHOR]

Background Fatigue in hospital nurses is associated with decreased nurse satisfaction, increased turnover and negative patient outcomes. Addressing fatigue in nurses has been identified as a priority by many organizations worldwide in an effort to promote both a culture of patient safety and a healthy nursing workforce. Objectives The overall aim of this study was to explore barriers and facilitators within the hospital nurse work system to nurse coping and fatigue. The purpose of this paper is to describe emergent themes that offer new insight describing the relationships among nurse perceptions of fatigue, nursing professional culture, and implications for the nursing workforce. Design A qualitative exploratory study was used to explore nurse identified sources, barriers to addressing, and consequences of fatigue. Participants and setting: Twenty-two nurses working in intensive care and medical-surgical units within a large academic medical center in the United States participated in the interviews. Method Interviews with the participants followed a semi-structured interview guide that included questions eliciting participants' views on nurse fatigue levels, consequences of fatigue, and barriers to addressing fatigue. The interview transcripts were analyzed using directed content analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Additional themes that did not directly align with the SEIPS model were also identified. Results All nurses in the current study experienced fatigue; yet they had varying perspectives on the importance of addressing fatigue in relation to other health systems challenges. A new construct related to nursing professional culture was identified and defined as “Supernurse”. Identified subthemes of Supernurse include: extraordinary powers used for good; cloak of invulnerability; no sidekick; Kryptonite, and an alterego. These values, beliefs, and behaviors define the specific aspects of nursing professional culture that can act as barriers to fatigue risk management programs and achieving safety culture in hospital organizations. Nurse fatigue and attributes of nurse professional culture also have implications for nurse satisfaction and retention. Conclusions Findings from this study further support the role of nursing professional culture as an important barrier to effectively addressing fatigue in nursing work systems. Future work is needed to identify and evaluate innovative culture change models and strategies to target these barriers. [ABSTRACT FROM AUTHOR]

• This study examined engineering of consent research between 1947–2018 to provide empirical information on the progression of EOC research. • We used quantitative method to evaluate disciplines, publications by region, first author affiliation, methods and gathering techniques. • The study adopted qualitative methods to explore EOC frameworks and most used words. • Content analysis revealed important insights regarding the trend and other variables we explored. • Based on the paucity of EOC-focused research, we demand more scholarly efforts especially with the current use of new media to sway the publics. This study systematically analyzes Engineering of Consent (EOC)-focused scholarly papers published between 1947 and 2018 using content analysis and text mining. It aims to shed light on the progress of EOC research and related disciplines as well as the methodologies, data collection methods, major perspectives, and most frequent words used within these writings. Additionally, this study considers publications by region and the affiliations of first authors. The results show that only a small number of EOC-focused papers have been published since 1947; this area of public relations research has suffered from a lack of scholarly attention despite its relevance to various disciplines, and this is a situation that we hope improves. Recent trends have shown some reasons for optimism. We found that at least one EOC-focused paper has been published annually in most years since 2000 (the exceptions are 2001, 2006, 2010, 2011, and 2015). Our research shows that scholars in the fields of public relations, media studies, and political science published more papers on EOC than scholars in other fields. Research articles usually utilize qualitative research methodologies. Interviews stand out as the most widely used data collection method. Our analysis of publications by region and first-author affiliation shows that the majority of EOC papers were written by faculty and students working or studying in the United States. Seven perspectives frequently discussed by scholars and the most frequently used words within EOC papers are highlighted in a follow-up qualitative review. [ABSTRACT FROM AUTHOR]

Puerto Ricans experience disproportionately high levels of emotional distress and co-occurring adverse health outcomes. Our study sought to elicit Puerto Rican men's perceptions of health disparities while centering dialogue on stressors, coping mechanisms, and general well-being. This paper focuses on one pronounced finding in our study, that of internalized racism and the effect it has on both individual well-being and intra-group cohesion. A significant gap within racial health disparity work is the role of internalized racism and its connection to psychological distress, ruptures in social unity, and resulting ill-health of racial and ethnic populations. Based on this, we probed this particular finding to further understand internalized racism within this Puerto Rican population. Using a hybrid thematic analysis approach, this study presents qualitative findings from in-depth interviews with Latino (92.5% Puerto Rican) men living in Springfield, Massachusetts and conducted between October 2019 and January 2020. Our findings reveal a duality throughout: The acceptance and propagation of negative Latinx stereotypes and consequent intragroup division exists alongside expressions of community pride and desire for Latinx unity. This duality is analyzed by using W.E.B. Du Bois's theory of double consciousness. Double consciousness not only explains the self-disparagement toward oneself and one's own racial and ethnic group, but also elucidates a liberatory pathway toward political consciousness and well-being. The concept of "second sight" within double consciousness is particularly germane, speaking to one's awakening to the learned self-subjugation imposed by White supremacy. Internalized racism contributes to the persistent propagation of disparate health burdens in minoritized communities. Remediation can and should include community-led frameworks for the development of efficacious multilevel health interventions. The Young Lords community health activism provides such a model. These findings provide viable evidence-based examples of how the academy can synergize with community-led efforts to achieve collective agency. • Internalized racism is a key contributor to emotional distress and intragroup cohesion. • Men repeated disparaging Latinx stereotypes alongside a desire for unity. • Research and community-led efforts can synergize toward collective agency and equity. • Critical praxis counters individual "self-help" public health initiatives. • Internalized racism can be tackled by engaging in community struggle and collectivity. [ABSTRACT FROM AUTHOR]

Controlling population weight gain is a major concern for industrialized nations because of associated health risks. Although Japan is experiencing rising prevalence of obesity and overweight, historically they have had and continue to maintain a low prevalence relative to other developed countries. Therefore, Japan provides an interesting case study of strategies to curb population weight gain. In this paper we explore Japanese approaches to obesity and diet through observational and ethnographic interviews conducted between June 2009 and September 2013. Nineteen interviews were conducted at four companies and three schools in Tokyo, as well as at a central Tokyo community health care center and school lunch distribution center. Interviewees included physicians, a Ministry of Health bureaucrat, human resources managers, welfare nurses employed by health insurance organizations, school nurses (also government employees), school nutritionists, and a school counselor. We highlight the role of culture and social norms in encouraging healthful behavior in Japan, focusing on the Ministry of Health, Labor, and Welfare's metabolic syndrome screening program (implemented in 2005) and the Japanese national school lunch program. The Japanese government prescribes optimal body metrics for all Japanese citizens and relies on institutions such as schools and health insurance organizations that are in some instances closely affiliated with the workplace to carry out education. Japan's socio-cultural approach leads us reflect on the cultural and social conditions that make different policy prescriptions more politically feasible and potentially effective. It also provokes us to question whether limited behavioral modifications and “nudging” can lead to broader change in an environment like the United States where there are fewer broadly shared socio-cultural norms regarding acceptable health behavior. [ABSTRACT FROM AUTHOR]

This paper examines factors that contributed to critical conversations in teacher communities of inquiry (CI) as part of a statewide professional development initiative in the United States. Based on a three-year mixed method design, we use qualitative comparative analysis to investigate the influence of combinations of conditions on the depth of discussion. Results suggest that there were three conditions associated with the extent to which CI members engaged in discussions with substantive interaction and reflection: a clear purpose, coach questioning, and the connection of theory to practice. The findings contribute to the understanding of effective reform implementation in different contexts. [ABSTRACT FROM AUTHOR]

Abstract: In all states, public and private child welfare agencies partner in an effort to deliver effective and accountable services to children and families (Collins-Camargo, Ensign, & Flaherty, 2008). While anecdotal information suggests that managers in competitive markets have incentives to carefully select and implement performance management strategies (McBeath, Briggs, & Aisenberg, 2009; Smith, 2010), little is known about the effectiveness of these strategies. This paper explores managerial perceptions regarding the usefulness of three techniques for performance management: supervisory review within the human resources model; priority review within internal processes; and outcomes management within the rational goal model. Managerial perceptions of the effectiveness of these efforts are examined in relation to organizational characteristics, capacity, and interagency competition. [Copyright &y& Elsevier]

Abstract: This paper focuses on 30 couples who received a pension and other services from two private trusts in Detroit, Michigan beginning in 1929 or 1930. Results of the qualitative analysis of case files, which contain notes recorded chronologically for 17 of the couples and then surviving spouses, provide a portrait of older couples' lives prior to a partner's death, circumstances surrounding the death, and changes in the social support systems of widows and widowers until their deaths. Close examination of the experiences of these couples is a reminder of how old age and widowhood were experienced prior to the enactment of public pensions and health insurance in the United States. [Copyright &y& Elsevier]

As intuitive and inviting as it may appear, the concept of patient-centered care has been difficult to conceptualize, institutionalize and operationalize. Informed by Bourdieu's concepts of cultural capital and habitus, we employ the framework of cultural health capital to uncover the ways in which both patients' and providers' cultural resources, assets, and interactional styles influence their abilities to mutually achieve patient-centered care. Cultural health capital is defined as a specialized collection of cultural skills, attitudes, behaviors and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. In this paper, we report the findings of a qualitative study conducted from 2010 to 2011 in the Western United States. We investigated the various elements of cultural health capital, how patients and providers used cultural health capital to engage with each other, and how this process shaped the patient-centeredness of interactions. We find that the accomplishment of patient-centered care is highly dependent upon habitus and the cultural health capital that both patients and providers bring to health care interactions. Not only are some cultural resources more highly valued than others, their differential mobilization can facilitate or impede engagement and communication between patients and their providers. The focus of cultural health capital on the ways fundamental social inequalities are manifest in clinical interactions enables providers, patients, and health care organizations to consider how such inequalities can confound patient-centered care. [ABSTRACT FROM AUTHOR]

Abstract: This paper examines dark tourism consumption motivations. Using a qualitative and interpretative mixed-method approach, this study traces the dark tourism motivations related to “blackpackers” and fans of the musical performance art known as black metal. Steeped in anti-Christian motifs and themes, with a history of past violence, black metal is a long-existing and still burgeoning art form that is growing in popularity throughout Europe and the United States. Through examination that involved participant observation, nethnography and content analysis, simulation, coupled with the emotional contagion were found to be key motivating aspects of this dark tourism related to black metal. Additionally, it was found, that similar to media tourists, many black metal fans seek tourism activity to reconcile comparisons between imaged landscapes and topographical reality. In addition to discussing specific aspects of the blackpacking phenomenon, larger theoretical implications related to the greater realm of dark tourism motivations are discussed. [Copyright &y& Elsevier]

Abstract: In this paper we explore whether the enhancement of urban ecosystem services through large-scale, metropolitan tree-planting initiatives is being planned and executed as a component of traditional municipal government or represents new, transdisciplinary strategies in environmental governance. Drawing on qualitative interviews with stakeholders in six major cities (n =58) we further explore institutionalization of these initiatives and relationships. While much current discourse posits government cannot “go it alone” in providing preventative, “front-end” solutions to complex environmental problems, we found the public sector dominant in the visioning, planning, and management of these green infrastructure initiatives and the role of the private sector to be minimal. We also found that, despite this dominance, the initiatives had limited success in becoming institutionalized. This dichotomy reflects that while discourses labeling the public sector unable to grapple with complex environmental issues and the private sector dominant in environmental governance regimes are premature, institutionalizing the solutions into the machinery of government remains a contested arena. [Copyright &y& Elsevier]

Abstract: Historically, engineers at the National Aeronautics and Space Administration (NASA) had few opportunities or incentives to share their technical expertise across the Agency. Its center- and project-focused culture often meant that knowledge never left organizational and geographic boundaries. The need to develop a knowledge sharing culture became critical as a result of increasingly complex missions, closeout of the Shuttle Program, and a new generation of engineers entering the workforce. To address this need, the Office of the Chief Engineer established communities of practice on the NASA Engineering Network. These communities were strategically aligned with NASA''s core competencies in such disciplines as avionics, flight mechanics, life support, propulsion, structures, loads and dynamics, human factors, and guidance, navigation, and control. This paper is a case study of NASA''s implementation of a system that would identify and develop communities, from establishing simple websites that compiled discipline-specific resources to fostering a knowledge-sharing environment through collaborative and interactive technologies. It includes qualitative evidence of improved availability and transfer of knowledge. It focuses on capabilities that increased knowledge exchange such as a custom-made Ask An Expert system, community contact lists, publication of key resources, and submission forms that allowed any user to propose content for the sites. It discusses the peer relationships that developed through the communities and the leadership and infrastructure that made them possible. [Copyright &y& Elsevier]

Abstract: This paper, through the vignette of a three-year old boy''s case, examines how child welfare workers in three countries, Norway, England and the United States (California), decide whether to recommend forced adoption. Legislation and policy recommendations for the termination of parental rights and adoption vary among these three countries, but they all regard permanency for the child as the overarching goal for children in care. We find that a majority of the workers suggest forced adoption, and their main justifications were related to parental behaviour and their failure to fulfil visitation arrangements, followed by arguments about how adoption would provide both permanency and solid attachment for the child. It was Norwegian workers (41%) that decided against forced adoption, and their main objections were the lack of parental consent and the fact that forced adoption is uncommon in Norway. The findings of this study show that the reasoning of child welfare workers clearly reflects the policies and guidelines of their respective countries, which demonstrates the impact of each country''s policy instruments. The workers'' reasoning also reflects their knowledge of the basic premises for promoting adoption and permanency for children in care. As such, the state power that child welfare workers exercise rests on a rationale that is evidence oriented and extends beyond a mere reflection of policy guidelines and instructions. [Copyright &y& Elsevier]

When used appropriately, congregate care placements can provide children in foster care with the structure and treatment services they need. However, children are often placed in congregate care when their needs can be met in family settings, a practice that contradicts the child welfare mandate to place children in the least restrictive environment possible. In 2000, a class action lawsuit filed against the State of Tennessee highlighted that the state routinely placed children in congregate care settings contrary to their best interests. Since then, the state''s Department of Children''s Services (DCS) has been extremely successful in reducing its use of congregate care. This paper presents major findings from a qualitative research study that explored how DCS accomplished this critical system change. Fifty-one Tennessee child welfare stakeholders were interviewed using an open ended protocol. DCS administrative data, performance monitoring data, and official policy documents were also analyzed to provide context for the interviewees'' comments. Analysis of interview transcripts revealed three main change agents that helped set the stage for deinstitutionalization, as well as three types of systemwide reforms that were undertaken to ensure a successful reduction in congregate care use. Implications for jurisdictions embarking on similar reforms are discussed. [Copyright &y& Elsevier]

Abstract: During the first decade of the 21st century a new “dramatic story” about the growing global surrogacy industry brought renewed attention to surrogacy as a social problem and a health policy issue. This paper asks: What cultural assumptions about gender, family and the global reproductive health market are revealed in current U.S. media coverage of and public discourses about surrogacy? From a qualitative analysis of prominent news accounts of surrogacy that were published in 2008, New York Times articles and blogs published on the topic between 2006 and 2010, and over 1000 online reader comments to these articles, I identify key frames used to discursively construct and debate the international surrogacy market. This study reveals the distinct contrast between the occasions when reproductive labor is rhetorically distanced from commodification processes and when it is linked to those processes. The findings contribute to intersectional analyses of assisted reproductive practices and women’s health/bodies/gametes. In particular, this study’s analysis of recent media framings of and public discourses about surrogacy across the globe serves as another illustration that national/classed/racialized bodies continue to be reproductively stratified via differently gendered discourses about women, motherhood and family. [Copyright &y& Elsevier]

Abstract: Within the context of social and demographic transformation, including trend toward globalization, changing patterns of longevity and immigration, this study examines the informal support exchanges between older parents and their adult children in Indian (South Asian) multi-generational families in the United States. Guided by symbolic interactionist thought and a life course perspective, this paper draws on qualitative data from in-depth, semi-structured interviews with 10 older adults in Atlanta, Georgia to study their expectations of and experiences with family support and the principles of Grounded Theory Methods informed our analysis. Filial piety, known as seva in the Indian culture, was used as a framework by the participants to make sense of support exchanges and intergenerational relationships within their own families. Participants'' accounts of support exchanges with their parents in India do not always match with the support exchanged with their children in the U.S. The similarities and differences participants speak of as they compare themselves to the traditional practices surrounding seva suggest “individualized” practices of intergenerational relationships/familial support and the influence of and interplay between individual, familial, and wider societal forces. Our findings have implications for policy and practice with older immigrant adults and their families, and shed light on the experiences of growing old in a foreign land. [Copyright &y& Elsevier]

Abstract: Chinese tourists visiting the U.S. were interviewed to explore their shopping behaviours and to understand their shopping experiences. This study revealed that the Chinese tourists were interested in a very large variety of U.S. merchandise, ranging from antique watches and jewellery to health products and running shoes. They perceived the quality of American products to be consistent with prices lower than similar products at home. Male tourists in the study tended to be more satisfied with their shopping experiences than females, but all informants expressed a desire for more Chinese-speaking sales assistants as well as Chinese shopping guides and signage. Informants asked that Chinese credit cards be accepted in the U.S. stores, and would encourage banks of both countries to find ways to cooperate with payment methods to make tourists’ shopping experience more enjoyable and free from inconveniences. Informants had a positive image of shopping in the U.S., especially when compared to some European and Asian destinations. Implications of both the methods and the findings for destination marketing strategies are also discussed in the paper. [Copyright &y& Elsevier]

Abstract: This article addresses the main scholarly frames that supported the deservingness of unauthorized immigrants to health benefits in the United States (U.S.) following the passage of the Personal Responsibility Work Opportunity Reconciliation Act (PRWORA), known as the Welfare Reform bill, in 1996. Based on a critical literature review, conducted between January 1997 and March 2011, this article begins with an analysis of the public health rhetorics that endorsed immigrants’ inclusion into the U.S. health safety net. In this vein, the “cost-saving” and “the effortful immigrant” frames underscore immigrants’ contributions to society vis-à-vis their low utilization of health services. These are complemented by a “surveillance” account that claims to protect the American public from communicable diseases. A “maternalistic” frame is also discussed as a tool to safeguard families, and particularly immigrant mothers, in their roles as bearers and caretakers of their American-born children. The analyses of the “chilling” and the “injustice” frames are then introduced to underscore major anthropological contributions to the formulation of counter-mainstream discourses on immigrants’ selective inclusion into the U.S. health care system. First, the “chilling effect,” defined as the voluntary withdrawal from health benefits, is examined in light of unauthorized immigrants’ internalized feelings of undeservingness. Second, an “injustice” narrative highlights both the contributions and the limitations of a social justice paradigm, which advocated for the restoration of government benefits to elderly immigrants and refugees after the passage of PRWORA. By analyzing the contradictions among all these diverse frames, this paper finally reflects on the conceptual challenges faced by medical anthropology, and the social sciences at large, in advancing health equity and human rights paradigms. [Copyright &y& Elsevier]

Abstract: This paper develops the concept of “biosecuritization” to describe new instantiations of the technological imperative in healthcare. Many discourses and practices surrounding hospitals’ new investments in information and communication technologies tend to revolve around security provision. Oftentimes, however, scenarios of extreme and exceptional circumstances are used to justify the implementation of identification and tracking technologies that may be more about managerial control than patient care. Drawing upon qualitative research in 23 U.S. hospitals from 2007 to 2009, our analysis focuses on hospitals’ deployment of identification and location technologies that manage patients, track personnel, and generate data in real-time. These systems are framed as aiding in the process of managing supplies and medications for pandemic flu outbreaks, monitoring exposure patterns for infectious diseases, and helping triage or manage the location and condition of patients during mass casualty disasters. We show that in spite of the framing of security and emergency preparedness, these technologies are primarily managerial tools for hospital administrators. Just as systems can be used to track infection vectors, those same systems can be used on a daily basis to monitor the workflow of hospital personnel, including nurses, physicians, and custodial staff, and to discipline or reward according to performance. In other words, the biosecuritization modality of the technological imperative leads to the framing of medical progress as the “rationalization” of organizations through technological monitoring, which is intended to promote accountability and new forms of responsibilization of healthcare workers. [Copyright &y& Elsevier]

Abstract: Background: This paper reports on qualitative research on smoking in contexts associated with drinking among college students. Although a plethora of survey research has shown a positive association between smoking and alcohol use, little attention has been given to the utility functions of these co-occurring behaviors. Methods: Data are drawn from semi-structured interviews with college freshmen at a large Mid-western university in the U.S. (n =35). In addition, eleven focus groups with fraternity and sorority members were conducted (n =70). Interviews and focus groups focused on a range of issues including current smoking behavior, reasons for smoking, and smoking and drinking. Results: A review of qualitative responses reveals that smoking served multiple utility functions for this population including (1) facilitating social interaction across gender, (2) allowing one to structure time and space at a party, (3) enabling “party” smokers to smoke with fewer negative side effects, and (4) helping to calm one down when drunk. Conclusions: Whereas smoking was stigmatized during the context of one''s everyday life as a student, at parties while consuming alcohol, smoking was viewed as normative and socially acceptable. Preventive interventions are needed on college campus that target co-substance use and address widespread misperceptions about the harm of tobacco use and addiction. [Copyright &y& Elsevier]

People experiencing incarceration in the U.S. have a constitutional right to have access to health care. Yet actualizing this right is constrained by the everyday reality of an environment designed to punish and limit autonomy. The principal means for accessing health care in a carceral facility is for an individual to submit a written request, which then gets handled through the jail's bureaucratic processes. In this paper, we provide quantitative and qualitative analyses of the content and circulation of one month of these written requests—called "medical care request" (MCR) forms—at an urban, U.S. jail to understand the meanings of health and health care for a group of individuals who are systematically marginalized. In one month in 2012 at this jail housing 140 individuals, 527 MCRs were submitted. We coded requests into categories: medications, amelioration of living conditions, specific symptoms, and requests for a specific health care service. The most common request was for pain medication. In qualitative analysis, four key themes emerged: reliance on the clinic to mediate the needs of daily life; deservingness of health care; hyperawareness of bodily and psychic discomfort; and temporal techniques for asserting control over individuals' time and bodies in jail. We show that MCRs are a key mechanism through which incarcerated individuals seek recognition of their physical and psychic suffering, and more broadly, of their very existences. When considered in the broader context of controlling carceral regimes and health inequities that characterize U.S. society, MCRs become dynamic terrain through which jail health care providers and incarcerated people negotiate the tensions of deservingness of care. • Carceral health systems require incarcerated individuals to self-advocate for care. • Incarcerated individuals use bureaucratic forms to justify deservingness of care. • Medical request forms illustrate the medicalization of life in this punitive setting. [ABSTRACT FROM AUTHOR]

This paper compares a qualitative and a quantitative (Rasch) method of item assessment for developing the content of a food insecurity scale for Bangladesh. Data are derived from the Bangladesh Food Insecurity Measurement and Validation Study, in which researchers collected 2 rounds of ethnographic information and 3 rounds of conventional household survey data between 2001 and 2003. The qualitative method of scale development relied on content experts and respondents themselves to evaluate household food insecurity items generated through ethnographic research. The quantitative method applied the Rasch model to assess the fit of the same items using representative survey data. The Rasch model was then used to test for differential item functioning (DIF) across diverse demographic and geographic subgroups. The qualitative assessment flagged and discarded 10 items, leaving 13. The Rasch assessment of infit and outfit flagged 3 items, and the Rasch DIF test discarded another 10 items, leaving a total of 10 items in the Rasch-derived scale. The 2 scales contained 8 of the same items. The qualitatively and quantitatively derived scales were highly correlated (r = 0.96, P < 0.01), and the 2 methods located 90% of households in the same food insecurity tercile. This convergence lends added confidence to the use of either scale for identifying food-insecure households in different regions of Bangladesh. Multiple methods should continue to be applied in a systematic and transparent way to lend additional credence to the results when they converge and to pinpoint directions for further clarification where they do not. [ABSTRACT FROM AUTHOR]

In this paper, we argue that the U.S. immigrant apparatus is a racial project that jeopardizes immigrants' wellbeing through organizational failure (Omi and Winant, 2014; Meyer & Rowman, 1977; Mellahi and Wilkinson, 2004). We utilize Provine and Doty's (2011) work as a foundation to understand how this racial project is systemic and multifaceted in nature. It begins with the negative characterization and criminalization of certain immigrants, mostly Latinx, followed by a poor infrastructure of processing and detention riddled with impediments to their wellbeing, which ultimately pushes detainees to the edge, to poor mental health, and suicidality. ICE's system of detention consistently operates poorly and normalizes organizational failure, jeopardizing immigrant lives through basic human rights violations, family separation, substandard living conditions, and minimal consideration to poor mental health, suicide prevention, and prompt and adequate intervention. Utilizing qualitative data from ICE inspection reports, contracts, and detainee death reports, we examine suicide policies across 116 detention facilities in the United States to highlight how detention facilities supervised by ICE unsuccessfully prevents detainee suicide due to organizational failure. Under ICE's oversight, facilities are inadequately staffed and resourced, resulting in the failure to implement federally mandated protocols regarding detainees' well-being competently and promptly. Their organizational failure leads to unequal health outcomes for Latinxs who are overrepresented across immigrant detention. • Suicide in immigration detention as an acceptable outcome of organizational failure. • Deeper and comprehensive analysis of immigration detention policies. • Content analysis of ICE official documents to reveal lack of accountability. • Examination of ICE suicide through a critical lens. [ABSTRACT FROM AUTHOR]

In this paper we propose a new category of International Medical Graduates (IMGs) who are forced to leave their home countries: "refugee physicians." In US social science scholarship, IMGs are divided into US citizen IMG (USIMG) and non-US citizen IMG (non-USIMG). For purposes of US medical licensure qualifications and recordkeeping, US- and non-USIMGs are lumped together. These categorizations are too blunt to demonstrate important differences among non-USIMGs. The category of "refugee physicians" distinguishes non-USIMGs who are forced to flee their homelands from other IMGs. We define and develop this category based on qualitative in-depth interviews conducted in 2019 with 28 non-USIMGs who fled to the US within the past 15 years. Using narrative analysis, we constructed "flight biographies," storied chronological events and experiences, for each physician. The flight biographies highlight the medical and political contexts in which they were forced to flee and are situated in the US. Two representative cases demonstrate how and why lumping refugee physicians together with other IMGs obscures the constraints and challenges that set them apart from the other IMG categories. First, the term refugee physician focuses attention on how physicians are located among forcibly displaced people worldwide, including their distinct relationships to their home countries, transit countries in which some of them seek sanctuary, and the US, where some requested asylum and others have been resettled. Second, because refugee is an umbrella term that blends categories of law, policy, social science, and everyday usage it encompasses a wide variety of lived experiences along a continuum of compulsion to leave. Finally, refugee physician illuminates the group's distinct relationship to medical licensure and brings into focus structural barriers that impede their goal of gaining a US medical license. • Qualitative interviews with 28 forcibly displaced International Medical Graduates in the US. • Thematic narrative analysis of two representative cases. • Identifies unique challenges of forced migrants in the US who are IMGs. • Proposes a new category of International Medical Graduates – "Refugee Physicians". [ABSTRACT FROM AUTHOR]

Enthusiasm for so-called 'personalized' or 'precision' medicine has encouraged the growth of the molecular diagnostics industry and the proliferation of high-priced proprietary tests that can predict, diagnose or inform the treatment of diverse clinical conditions. Through a case study of non-invasive prenatal testing (NIPT), we explore how the mechanisms governing the development and dissemination of this novel prenatal screening test are most aptly understood as a 'regulatory regime.' We describe how private actors tied to the manufacturers of this test form a network of "experts" that contribute to the coordination of this regime by virtue of their efforts to navigate the governance of test adoption and also form spaces in which the standards governing test adoption are developed. We draw attention to private actors in this regime to demonstrate that they are a constitutive element of the public policy system governing biomedical innovation and adoption. Through this case study of NIPT we deepen our previous analysis of the role of consultants in navigating and shaping a regulatory regime (Holloway and Miller, 2020) and offer new insight about how scientists work with consultants to shape a regulatory regime that serves industry interests. Our work indicates that the private actors tied to the manufacturers of NIPT (experts employed by industry to court scientists and lobby payers, scientists collaborating with industry, key opinion leaders involved with clinical practice guidelines, lobbyists and consultants), constitute an 'invisible college' that navigates the governance of test adoption. The formations and negotiations over standards for NIPT identified in this paper comprise a new institutional norm: a polycentric regulatory regime permeated by commercial interests. The institutionalization of this regime has implications for accountability, transparency and test quality amidst a proliferation of new proprietary molecular tests.' • A case study of mechanisms governing the dissemination of NIPT in the US. • Private actors tied to the manufacturers of NIPT constitute an invisible college. • These actors engage in various levels of knowledge production. • The invisible college navigates test adoption in a regulatory regime.. • This regime has implications for accountability, transparency and test quality. [ABSTRACT FROM AUTHOR]

The purpose of this systematic review was to synthesize the evidence on experiences of aging in place in the United States. Systematic review and meta-ethnography of qualitative studies. We searched six bibliographic databases (PubMed, Embase, PsycINFO, CINAHL, Web of Science, Sociological Abstracts), with no limits on publication date. Eligible studies reported peer-reviewed qualitative research on experiences of aging in place in the United States with full-text available in English. Three reviewers independently used Covidence software to screen titles and abstracts followed by full texts. We assessed quality and risk of bias using a modified version of the Joanna Briggs Institute Checklist for Qualitative Research. Qualitative data analysis was conducted using meta-ethnography, following Noblit and Hare's seven-step method of translation and synthesis to generate a novel conceptual model. Of 2659 papers screened, 37 unique studies were eligible for inclusion, reported in 38 publications. The studies were conducted in 16 states and published between 1994 and 2018. The included samples represented 1199 participants in total, with mean ages ranging from 48 to 91 years. The gender of the samples ranged from 20% to 100% female, with a median of 77%. One-third of the included studies did not report participants' race/ethnicity, and half of the remaining study samples were at least 90% white; however, 20% of the studies focused exclusively on experiences of racial/ethnic minority older adults. Using meta-ethnography, we developed a new conceptual model of aging in place in the United States as a dynamic process of balancing threats and agency in relation to experiences of identity, connectedness, and place. We found that people aging in place were engaged in significant work to cope with unpredictable needs and challenges by changing their mindset, adapting their home environment to accommodate new needs, and finding different ways to connect with important people in their lives. Agency was shaped by resources and restrictions on choice, and where threats to aging in place outweighed an individual's sense of agency, the consequences included feelings of uncertainty, isolation, and dislocation. To the best of our knowledge, this is the first systematic review of qualitative studies to evaluate experiences of aging in place in the United States. The findings of our meta-ethnographic synthesis led to the development of a new conceptual model of aging in place highlighting the dynamic tensions involved in balancing threats and agency. [ABSTRACT FROM AUTHOR]

Abstract: Tobacco-cessation product packaging and instruction materials may not be appropriate for some smokers and may contribute to the underuse and misuse of evidence-based treatments. The dual goals of this project are to analyze literacy levels of Food and Drug Administration (FDA)–approved and non-approved tobacco-cessation product packaging, directions, and claims, and to identify and categorize claims found on product packaging. The Campaign for Tobacco Free Kids (CTFK) maintains the Quitting and Reducing Tobacco Use Inventory of Products (QuiTIP) database, which catalogs products marketed and sold to consumers to reduce or quit use of tobacco products. It also includes all medications approved by the FDA for tobacco cessation as well as a sample of non-approved products such as homeopathic, herbal, nutritional, or dietary supplements commonly marketed as either cessation aids or alternative tobacco/nicotine products. This paper assesses the reading levels required to understand product packaging, labeling, and instructions using the Simple Measure of Gobbledygook (SMOG) and identifies claims on the product package labels using standard qualitative methods. Key findings show that the average reading levels needed to understand instructions for both FDA-approved and non-approved cessation products are above the reading levels recommended to ensure maximum comprehension. Improving the packaging and directions of evidence-based tobacco-cessation products so that they are preferably at or below a fifth-grade reading level, along with using consumer-based design principles to develop packaging, may help smokers take advantage of and correctly use products that will greatly increase their chances of successful quitting. [Copyright &y& Elsevier]