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author:("nhl, Eric")
1.  Healthcare provider intervention on smoking and quit attempts among HIV-positive versus HIV-negative MSM smokers in Chengdu, China 
AIDS care  2014;26(9):1201-1207.
Given the implications for smoking among HIV-positive individuals and high smoking and HIV rates among men who have sex with men (MSM) in China, we examined sociodemographic, smoking-related, psychosocial, and substance use factors in relation to HIV status; receiving some sort of healthcare provider intervention regarding smoking; and having made a quit attempt in the past year in a sample of MSM smokers in Chengdu. We conducted a cross-sectional survey of 381 MSM smokers recruited by a nongovernmental organization in Chengdu in 2012–2013. Of these, 350 disclosed their HIV status and 344 (188 HIV-positive and 156 HIV-negative) provided completed data. Half (50.0%) reported at least one quit attempt in their lifetime; 30.5% reported a quit attempt in the past year. The majority (59.4%) reported that a healthcare provider had intervened in some way (assessed smoking, advised quitting, provided assistance), most commonly by assessing smoking status (50.0%). HIV-positive individuals were more likely to report a healthcare provider intervening on their smoking (p < .001). Those who received provider intervention were more likely to have attempted to quit ever (p = .009) and in the past year (p < .001). Those HIV-positive were more likely to have attempted to quit since diagnosis if a provider had intervened (p = .001). Multivariate regression documented that being HIV-positive (p < .001), greater cigarette consumption (p = .02), less frequent drinking (p = .03), and greater depressive symptoms (p = .003) were significant correlates of healthcare provider intervention. Multivariate regression also found that healthcare provider intervention (p = .003), older age (p = .01), and higher autonomous motivation (p = .007) were significant correlates of attempting to quit in the past year. Given the impact of healthcare provider intervention regarding smoking on quit attempts among MSM, greater training and support is needed to promote consistent intervention on smoking in the clinical setting among HIV-positive and HIV-negative MSM smokers.
PMCID: PMC4303341  PMID: 24601710
HIV; men who have sex with men; smoking; smoking cessation; healthcare provider
2.  Alternative Tobacco Use among College Students: Who is at Highest Risk? 
To examines smoking status, substance use, sociodemographics, and psychosocial characteristics in relation to alternative tobacco use among college students.
Current tobacco use (cigarettes, cigar-like products, hookah, chew, snus) and correlates (sociodemographics, sensation-seeking, attitudes toward tobacco and smokers, social factors) were assessed among students aged 18-25 at 6 Southeastern US colleges using an online survey.
Those who were younger, male, black, cigarette and marijuana users, and demonstrating at-risk psychosocial factors were at increased risk of alternative tobacco product use (p < .001). Among current smokers, never daily nondaily smokers were 3 times as likely as former daily non-daily smokers and daily smokers to use alternative tobacco products (p < .001).
Important risk factors for alternative tobacco use included important sociodemographic and psychosocial characteristics.
PMCID: PMC4043211  PMID: 24629547
alternative tobacco; never-daily nondaily smokers; former-daily nondaily smokers; young adults
3.  Newspaper coverage of HIV/AIDS in China from 2000 to 2010 
AIDS care  2013;25(9):1174-1178.
Mass media in China play a significant role in the dissemination of HIV/AIDS knowledge to the general public. Previous studies have described how the Chinese mass media portray HIV/AIDS in general, but no study has yet to examine changes in patterns of HIV/AIDS reporting over time. This study aims to describe and examine newspaper coverage of HIV/AIDS in China from 2000 to 2010. A systematic search of the China Core Newspapers Database was conducted to identify HIV/AIDS-focused news articles; we found 3648 articles. Results show that coverage rates of HIV/AIDS in newspapers remained low, with only about three articles published per newspaper per year between 2000 and 2010. The sources focused primarily on prevention methods (23.7%), development of a cure or vaccine (21.2%), and education and awareness (17.2%). The HIV/AIDS-related topic covered in an article varied significantly depending on scope (national vs. local)of the newspaper (χ2 = 130.37, p<0.001)and article type (χ2 = 455.72, p<0.001). Totally, more articles were classified as positive than negative from 2002 to 2010. Findings indicate that the HIV/AIDS news-reporting pattern has shifted in the past decade, with more news stories disclosing information about prevention or treatment. However, coverage of HIV/AIDS remains insufficient. Enhancing collaboration between health educators and media sources can be an important strategy in disseminating HIV/AIDS knowledge.
PMCID: PMC4111132  PMID: 23320470
HIV/AIDS; newspapers; China; coverage
4.  Sexually transmitted infection testing practices among ‘money boys’ and general men who have sex with men in Shanghai, China: objective versus self-reported status 
Sexual health  2014;11(1):94-96.
Little is known about sexually transmitted infection (STI) testing among Chinese men who have sex with men (MSM). This study describes the prevalence of STI testing, associated factors and the validity of STI self-reporting among Chinese MSM. Findings indicated a high prevalence of STIs and low testing rates among MSM in Shanghai. Monthly income was significantly associated with STI testing (odds ratio: 0.37, 95% confidence interval (CI): 0.18 to 0.76). Depression was significantly associated with STI testing for general MSM (odds ratio: 1.09, 95% CI: 1.01 to 1.17). Syphilis self-reported status had the highest validity (k = 0.33, χ2 = 3.76, 95% CI: −0.003 to 0.65). Efforts are needed to ensure that STI testing services are accessible to MSM in China. Future HIV and STI interventions should be tailored to the needs of different subsets of MSM.
PMCID: PMC4083592  PMID: 24636349
associations; male sex workers; prevalence; testing rates
5.  Problem Drinking Behaviors: Differential Effects of Stress and School Type on College Students 
Given that alcohol use is highly prevalent at US colleges, we explored factors related to problem drinking behaviors (PDB; binge drinking, driving after drinking, sexual intercourse after drinking) among 4098 Black and White students from two- and four-year colleges who completed an online survey. We found an interaction between race and sex such that, among Whites, females had less PDB than males (B = 0.09, CI: 0.05; 0.40, p = 0.01). An interaction between race and school type also existed, such that White students from four-year schools had greater PDB (B = 0.11, CI: 0.20; 0.54, p < 0.001). An interaction between race and stress suggested that Black students were more negatively affected by stress in terms of PBD (B = 0.12, CI: 0.01; 0.07, p = 0.01).
PMCID: PMC4079051  PMID: 24999445
Problem Drinking Behaviors; College Students; Binge Drinking; Alcohol Use
6.  Psychographic Segments of College Females and Males in Relation to Substance Use Behaviors 
Social marketing quarterly  2013;19(3):172-187.
A common commercial marketing segmentation technique is to divide a population into groups based on psychographic characteristics (i.e., attitudes and interests). We used this approach to define segments of female and male college students and examine substance use differences.
We administered an online survey to 24,055 students at six colleges in the Southeastern United States (response rate 20.1%, n = 4,840), obtaining complete data from 3,469 participants. We assessed sociodemographics, psychographic factors such as those used by the tobacco industry to define market segments, and substance use (cigarettes, other tobacco products, alcohol, and marijuana). Cluster analysis was conducted among females and males using 15 psychographic measures (sensation seeking, Big Five personality traits, and nine measures adapted from tobacco industry documents), identifying three segments per sex.
Safe responsibles were characterized by high levels of agreeableness, conscientiousness, emotional stability, academic achievement, and religious service attendance. Stoic individualists were characterized by low extraversion, sensation seeking, and openness. Thrill-seeking socializers were characterized by high levels of sensation seeking and extraversion. Among females, thrill-seeking socializers were significantly more likely than safe responsibles to have used any substance in the prior 30 days (odds ratio [OR] = 2.04, 95% confidence interval [CI] [1.65, 2.52]; Nagelkerke R2 = .084). Among males, stoic individualists (OR = 1.50, CI [1.08, 2.08]) and thrill-seeking socializers (OR = 1.53, CI [1.09, 2.13]) were more likely than safe responsibles to have used substances in the past 30 days (Nagelkerke R2: .109).
Psychographic segmentation can identify young adult subgroups with differing psychographic and substance use profiles and inform health campaigns and messaging targeting youth.
PMCID: PMC3981460  PMID: 24729744
youth; audience; alcohol consumption; health; substance abuse; tobacco cessation
7.  Disparities and Risks of Sexually Transmissible Infections among Men Who Have Sex with Men in China: A Meta-Analysis and Data Synthesis 
PLoS ONE  2014;9(2):e89959.
Sexually transmitted infections (STIs), including Hepatitis B and C virus, are emerging public health risks in China, especially among men who have sex with men (MSM). This study aims to assess the magnitude and risks of STIs among Chinese MSM.
Chinese and English peer-reviewed articles were searched in five electronic databases from January 2000 to February 2013. Pooled prevalence estimates for each STI infection were calculated using meta-analysis. Infection risks of STIs in MSM, HIV-positive MSM and male sex workers (MSW) were obtained. This review followed the PRISMA guidelines and was registered in PROSPERO.
Eighty-eight articles (11 in English and 77 in Chinese) investigating 35,203 MSM in 28 provinces were included in this review. The prevalence levels of STIs among MSM were 6.3% (95% CI: 3.5–11.0%) for chlamydia, 1.5% (0.7–2.9%) for genital wart, 1.9% (1.3–2.7%) for gonorrhoea, 8.9% (7.8–10.2%) for hepatitis B (HBV), 1.2% (1.0–1.6%) for hepatitis C (HCV), 66.3% (57.4–74.1%) for human papillomavirus (HPV), 10.6% (6.2–17.6%) for herpes simplex virus (HSV-2) and 4.3% (3.2–5.8%) for Ureaplasma urealyticum. HIV-positive MSM have consistently higher odds of all these infections than the broader MSM population. As a subgroup of MSM, MSW were 2.5 (1.4–4.7), 5.7 (2.7–12.3), and 2.2 (1.4–3.7) times more likely to be infected with chlamydia, gonorrhoea and HCV than the broader MSM population, respectively.
Prevalence levels of STIs among MSW were significantly higher than the broader MSM population. Co-infection of HIV and STIs were prevalent among Chinese MSM. Integration of HIV and STIs healthcare and surveillance systems is essential in providing effective HIV/STIs preventive measures and treatments.
Trial Registration
PROSPERO No: CRD42013003721
PMCID: PMC3933676  PMID: 24587152
8.  Lessons from an Evaluation of a Provincial-Level Smoking Control Policy in Shanghai, China 
PLoS ONE  2013;8(9):e74306.
The Shanghai Public Places Smoking Control Legislation was implemented in March 2010 as the first provincial-level legislation promoting smoke-free public places in China.
To evaluate the compliance with this policy as well as its impact on exposure to secondhand smoke (SHS), respiratory symptoms, and related attitudes among employees in five kinds of workplaces (schools, kindergartens, hospitals, hotels, and shopping malls).
A cross-sectional survey was conducted six months before and then six months after the policy was implemented. Five types of occupational employees from 52 work settings were surveyed anonymously using multistage stratified cluster sampling.
Six months after implementation, 82% of the participants agreed that “legislation is enforced most of the time”. The percentage of self-reported exposure to secondhand smoke declined from round up to 49% to 36%. High compliance rates were achieved in schools and kindergartens (above 90%), with less compliance in hotels and shopping malls (about 70%). Accordingly, prevalence of exposure to SHS was low in schools and kindergartens (less than 10%) and high in hotels and shopping malls (40% and above). The prevalence of respiratory and sensory symptoms (e.g., red or irritated eyes) among employees decreased from 83% to 67%.
Initial positive effects were achieved after the implementation of Shanghai Smoking Control legislation including decreased exposure to SHS. However, compliance with the policies was a considerable problem in some settings. Further evaluation of such policy implementation should be conducted to inform strategies for increasing compliance in the future.
PMCID: PMC3769237  PMID: 24058544
9.  Changes in sunburn and tanning attitudes among lifeguards over a summer season 
Skin cancer is one of the most common cancers in the United States. Lifeguards are at increased risk of excessive sun exposure and sunburn.
We sought to examine changes in: (1) sunburn frequency over a summer while controlling for sun exposure, sun protection habits, and participation in a skin cancer prevention program; and (2) tanning attitudes while controlling for participation in the program.
Participants in this study were lifeguards (n = 3014) at swimming pools participating in the Pool Cool program in 2005. Lifeguards completed surveys at the beginning and end of the summer. Sequential regression analyses were used to assess changes in sunburn frequency and tanning attitudes.
Sunburn frequency decreased between baseline and follow-up. Having a sunburn over the summer was significantly predicted by baseline sunburn history, ethnicity, skin cancer risk, and sun exposure. The tanning attitude, “People are more attractive if they have a tan,” was significantly predicted from baseline tanning attitude and ethnicity. The second tanning attitude, “It helps to have a good base suntan,” was significantly predicted by baseline tanning attitude, ethnicity, basic/enhanced group, and moderate skin cancer risk.
Self-reported data and limited generalizability to lifeguards at other outdoor pools are limitations.
The findings showed that previous sunburn history is an important predictor of sunburn prospectively. In addition, a more risky tanning attitude is an important predictor of future attitudes toward tanning. Active involvement in targeted prevention programs may help to increase preventive behavior and health risk reduction.
PMCID: PMC3728666  PMID: 21745696
prevention; skin cancer; sun exposure; sun protection habits; sunburn; tanning attitudes
10.  Measured Occupational Solar UVR Exposures of Lifeguards in Pool Settings 
The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices.
Lifeguards (n = 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure.
The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards’ PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate.
At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year.
PMCID: PMC3728671  PMID: 19572325
lifeguards; occupational UVR exposure; sun protection behaviors
11.  A Controlled Trial of Objective Measures of Sunscreen and Moisturizing Lotion 
Taking an alcohol swab of a person’s forearm and analyzing it using a spectrophotometer has been shown to be a reliable method for detecting the presence of sunscreen. The aims of this study were to determine if moisturizing lotions or other non-sun-screen products influence the absorbance readings from skin swabs in a controlled setting, and to establish the cutoff point in determining the presence or absence of sunscreen using a crystal cuvette instead of a plastic one. In a controlled trial of 30 volunteer office workers, absorbance readings from two popular brands of sunscreen with sun-protection factors (SPF) of 30 and 45 were compared with absorbance readings from two different moisturizing lotions, one with an SPF of 15 and another with no stated SPF. Moisturizers with SPF 15 tested positive for sunscreen, with absorbance readings (mean, 3.77; min, 3.30) comparable to sunblock with SPF 30 or 45 (mean, 3.51; min, 2.02). Moisturizers with no stated SPF factor tested negative for the presence of sunscreen, with extremely low absorbance readings (mean, 0.06; max, 0.19) similar to control readings. The skin swabbing technique remains a valid and useful method for detecting the presence of sunscreen and does not result in false positives when moisturizers with no stated SPF are present. Using a conservative cutoff point of 0.30 with a crystal cuvette reduces any chance of false-positive readings and remains robust when sunscreen of SPF 15 or higher is present.
PMCID: PMC3725572  PMID: 19423519
12.  Characteristics of swimming pools with high rates of objectively measured sunscreen use 
A combination of verbal reports, observations, and physical assessments can improve understanding of prevention programs.
Skin swabbing techniques were used to detect the presence of sunscreen as part of a sun protection measurement study at 16 swimming pools. Three pools demonstrated much higher sunscreen use (>95%) than the others (47.1%). This paper compares these three pools to the other 13 to examine whether they have common features and if different sources of data can help interpret the findings.
Data were collected from skin swabs detecting the presence of sunscreen; observations of participants; observations of pool environments; and surveys.
Pool observations showed a higher use of shade structures, sun safety signs, and other supporting items at the three high–sunscreen use pools. These three pools had significantly more year-round and long-term employees than did the other 13 pools.
Sunscreen characteristics could not be determined using the swabbing technique. Publicity about the study, or the weather, may have influenced behaviors at the pools.
Supportive environments were associated with consistent high levels of sunscreen use. This study also confirms the importance of using multiple data sources to interpret findings.
PMCID: PMC3724408  PMID: 19293015
13.  Validity of covering-up sun-protection habits: Association of observations and self-report 
Few studies have reported the accuracy of measures used to assess sun-protection practices. Valid measures are critical to the internal validity and use of skin cancer control research.
We sought to validate self-reported covering-up practices of pool-goers.
A total of 162 lifeguards and 201 parent/child pairs from 16 pools in 4 metropolitan regions in the United States completed a survey and a 4-day sun-habits diary. Observations of sun-protective behaviors were conducted on two occasions.
Agreement between observations and diaries ranged from slight to substantial, with most values in the fair to moderate range. Highest agreement was observed for parent hat use (κ = 0.58–0.70). There was no systematic pattern of over- or under-reporting among the 3 study groups.
Potential reactivity and a relatively affluent sample are limitations.
There was little over-reporting and no systematic bias, which increases confidence in reliance on verbal reports of these behaviors in surveys and intervention research.
PMCID: PMC3715114  PMID: 19278750
concurrent validity; measurement; observation; self-report assessment; sun protection
14.  HIV testing and care systems focused on sexually transmitted HIV in China 
Sexually transmitted infections  2012;88(2):116-119.
Over three-quarters of new HIV infections in China during 2009 were estimated to be from sexual transmission. Over half of those living with HIV do not know their serostatus and identifying and treating individuals with sexually transmitted HIV infection has been challenging.
This global assessment explores Chinese systems for detecting and treating those with HIV infection with a particular focus on groups at increased risk of sexually transmitted HIV.
Published literature, grey sources and non-governmental reports were reviewed to describe HIV testing and care systems in China.
HIV testing and care in China involve several parallel health systems and have been largely successful in reaching large numbers of vulnerable individuals. Provider-initiated testing and counselling has been more effective than voluntary counselling and testing programmes for expanding HIV testing efforts in China. Individuals with sexually transmitted HIV infection are underrepresented in the antiretroviral care system compared with other high-risk groups.
Comprehensive HIV testing and care bring together a number of Chinese health systems, but there are still gaps and challenges. Research and programmes focused on HIV testing and care for those with increased sexual risk are needed.
PMCID: PMC3627180  PMID: 22345024
15.  HIV Testing and Management: Findings from a National Sample of Asian/Pacific Islander Men Who Have Sex with Men 
Public Health Reports  2012;127(2):186-194.
We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S.
We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations.
Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications.
HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.
PMCID: PMC3268803  PMID: 22379218
16.  Smoking frequency among current college student smokers: distinguishing characteristics and factors related to readiness to quit smoking 
Health Education Research  2011;27(1):141-150.
Given the increased prevalence of non-daily smoking and changes in smoking patterns, particularly among young adults, we examined correlates of smoking level, specifically motives for smoking, and readiness to quit smoking among 2682 college undergraduates who completed an online survey. Overall, 64.7% (n = 1736) were non-smokers, 11.6% (n = 312) smoked 1–5 days, 10.5% (n = 281) smoked 6–29 days and 13.2% (n = 353) were daily smokers. Ordinal regression analyses modeling smoking level indicated that correlates of higher smoking level included having more friends who smoke (β = 0.63, 95% CI 0.57–0.69) and more frequent other tobacco use (β = 0.04, 95% CI 0.02–0.05), drinking (β = 0.04, 95% CI 0.02–0.07) and binge drinking (β = 0.09, 95% CI 0.06–0.13). Bivariate analyses indicated that daily smokers (versus the subgroups of non-daily smokers) were less likely to smoke for social reasons but more likely to smoke for self-confidence, boredom, and affect regulation. Controlling for sociodemographics, correlates of readiness to quit among current smokers included fewer friends who smoke (P = 0.002), less frequent binge drinking (P = 0.03), being a social smoker (P < 0.001), smoking less for self-confidence (P = 0.04), smoking more for boredom (P = 0.03) and less frequent smoking (P = 0.001). Specific motives for smoking and potential barriers to cessation particularly may be relevant to different groups of college student smokers.
PMCID: PMC3605919  PMID: 22156071
17.  The Development and Validation of a Scale Assessing Individual Schemas Used in Classifying a Smoker: Implications for Research and Practice 
Nicotine & Tobacco Research  2011;13(12):1257-1265.
Half of college students who have smoked in the past month do not consider themselves smokers. Understanding one’s schema of smokers is important, as it might relate to smoking behavior. Thus, we aimed to develop a scale assessing how young adults classify smokers and establish reliability and validity of the scale.
Of 24,055 students at six Southeast colleges recruited to complete an online survey, 4,840 (20.1%) responded, with complete smoking and scale development data from 3,863.
The Classifying a Smoker Scale consisted of 10 items derived from prior research. Factor analysis extracted a single factor accounting for 40.00% of score variance (eigenvalue = 5.52). Higher scores (range 10–70) indicate stricter criteria in classifying a smoker. The scale yielded a Cronbach’s alpha of .91. Current smoking (past 30-day) prevalence was 22.8%. Higher Classifying a Smoker Scale scores (p = .001) were significant predictors of current smoking, controlling for sociodemographics. Higher scores were related to being nondaily versus daily smokers (p = .009), readiness to quit in the next month (p = .04), greater perceived smoking prevalence (p = .007), not identifying as smokers (p < .001), less perceived harm of smoking (p < .001), greater concern about smoking health risks (p = .01), and less favorable attitudes toward smoking restrictions (p < .001). Among current smokers, higher scores were related to greater smoking frequency (p = .02), not identifying as smokers (p < .001), and less perceived harm of smoking (p < .001), controlling for sociodemographics.
This scale, demonstrating good psychometric properties, highlights potential intervention targets for prevention and cessation, as it relates to smoking, risk perception, and interest in quitting.
PMCID: PMC3223577  PMID: 21994337
18.  Vitamin D Beliefs and Associations with Sunburns, Sun Exposure, and Sun Protection 
The main objective of this study was to examine certain beliefs about vitamin D and associations with sun exposure, sun protection behaviors, and sunburns. A total of 3,922 lifeguards, pool managers, and parents completed a survey in 2006 about beliefs regarding vitamin D and sun-related behaviors. Multivariate ordinal regression analyses and linear regression analysis were used to examine associations of beliefs and other variables. Results revealed that Non-Caucasian lifeguards and pool managers were less likely to agree that they needed to go out in the sun to get enough vitamin D. Lifeguards and parents who were non-Caucasian were less likely to report that sunlight helped the body to produce vitamin D. A stronger belief about the need to go out in the sun to get enough vitamin D predicted more sun exposure for lifeguards. For parents, a stronger belief that they can get enough vitamin D from foods predicted greater sun protection and a stronger belief that sunlight helps the body produce vitamin D predicted lower sun exposure. This study provides information regarding vitamin D beliefs and their association with certain sun related behaviors across different demographic groups that can inform education efforts about vitamin D and sun protection.
PMCID: PMC3407911  PMID: 22851950
sun exposure habits; vitamin D knowledge; sunscreen use; sun protection behavior
19.  Prevalence and Correlates of Tobacco Use Among a Sample of MSM in Shanghai, China 
Nicotine & Tobacco Research  2010;13(1):22-28.
Men who have sex with men (MSM) have higher smoking rates than the general population in the United States, but less is known about smoking among MSM in developing countries. Thus, we examined the prevalence and correlates of smoking among MSM in China.
We conducted a cross-sectional study of 404 MSM in Shanghai, China (half of whom were male sex workers), recruited through respondent-driven sampling. Assessments included sociodemographics; tobacco, alcohol, and drug use; the Center for Epidemiological Studies Depression Scale (CES-D); the Social Provisions Scale (SPS); and the Lesbian, Gay, and Bisexual Identity Scale (LGBIS).
Smoking prevalence was 65.9% in this sample. Recent smoking (i.e., in the past 3 months) was significantly associated with lower education, greater alcohol use, and higher LGBIS scores, after controlling for important sociodemographics. Among smokers, smoking ≥10 cigarettes per day (CPD), in comparison with <10 CPD, was related to older age and lower LGBIS scores and marginally related to heavy alcohol use. Although bivariate analyses indicated a relationship of CES-D and SPS scores to recent smoking, these factors did not contribute to the regression models.
Smoking rates among MSM in China are higher than MSM in the United States and men in China. Less comfort with one’s sexual orientation was related to smoking, particularly light smoking. Heavier alcohol consumption, lower education, and older age were also associated with smoking. Future research should confirm these findings and examine mediators and moderators of these relationships in order to inform cessation interventions and tobacco control policy.
PMCID: PMC3107608  PMID: 21059821
20.  Validity of Self-Reported Solar UVR Exposure Compared to Objectively Measured UVR Exposure 
Reliance on verbal self-report of solar exposure in skin cancer prevention and epidemiologic studies may be problematic if self-report data are not valid due to systematic errors in recall, social desirability bias, or other reasons.
This study examines the validity of self-reports of exposure to ultraviolet radiation (UVR) compared to objectively measured exposure among children and adults in outdoor recreation settings in four regions of the United States. Objective UVR exposures of 515 participants were measured using polysulfone film badge UVR dosimeters on two days. The same subjects provided self-reported UVR exposure data on surveys and 4-day sun exposure diaries, for comparison to their objectively measured exposure.
Dosimeter data showed that lifeguards had the greatest UVR exposure (24.5% of weekday ambient UVR), children the next highest exposures (10.3% ambient weekday UVR) and parents had the lowest (6.6% ambient weekday UVR). Similar patterns were observed in self-report data. Correlations between diary reports and dosimeter findings were fair to good and were highest for lifeguards (r = 0.38 – 0.57), followed by parents (r = 0.28 – 0.29) and children (r = 0.18 – 0.34). Correlations between survey and diary measures were moderate to good for lifeguards (r = 0.20 – 0.54) and children (r = 0.35 – 0.53).
This is the largest study of its kind to date, and supports the utility of self-report measures of solar UVR exposure.
Overall, self-reports of sun exposure produce valid measures of UVR exposure among parents, children, and lifeguards who work outdoors.
PMCID: PMC3005549  PMID: 20940277
skin cancer; sun exposure; UVR; dosimeters; validation; biomarkers
21.  Spontaneous Diffusion of an Effective Skin Cancer Prevention Program Through Web-Based Access to Program Materials 
Preventing Chronic Disease  2010;7(6):A125.
Little information exists about the diffusion of evidence-based interventions, a process that can occur naturally in organized networks with established communication channels. This article describes the diffusion of an effective skin cancer prevention program called Pool Cool through available Web-based program materials.
We used self-administered surveys to collect information from program users about access to and use of Web-based program materials. We analyzed the content of e-mails sent to the official Pool Cool Web site to obtain qualitative information about spontaneous diffusion.
Program users were dispersed throughout the United States, most often learning about the program through a Web site (32%), publication (26%), or colleague (19%). Most respondents (86%) reported that their pool provided educational activities at swimming lessons. The Leader's Guide (59%) and lesson cards (50%) were the most commonly downloaded materials, and most respondents reported using these core items sometimes, often, or always. Aluminum sun-safety signs were the least frequently used materials. A limited budget was the most commonly noted obstacle to sun-safety efforts at the pool (85%). Factors supporting sun safety at the pool centered around risk management (85%) and health of the pool staff (78%).
Diffusion promotes the use of evidence-based health programs and can occur with and without systematic efforts. Strategies such as providing well-packaged, user-friendly program materials at low or no cost and strategic advertisement of the availability of program materials may increase program use and exposure. Furthermore, highlighting the benefits of the program can motivate potential program users.
PMCID: PMC2995596  PMID: 20950532
22.  Individual and setting level predictors of the implementation of a skin cancer prevention program: a multilevel analysis 
To achieve widespread cancer control, a better understanding is needed of the factors that contribute to successful implementation of effective skin cancer prevention interventions. This study assessed the relative contributions of individual- and setting-level characteristics to implementation of a widely disseminated skin cancer prevention program.
A multilevel analysis was conducted using data from the Pool Cool Diffusion Trial from 2004 and replicated with data from 2005. Implementation of Pool Cool by lifeguards was measured using a composite score (implementation variable, range 0 to 10) that assessed whether the lifeguard performed different components of the intervention. Predictors included lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors, pool characteristics, and enhanced (i.e., more technical assistance, tailored materials, and incentives are provided) versus basic treatment group.
The mean value of the implementation variable was 4 in both years (2004 and 2005; SD = 2 in 2004 and SD = 3 in 2005) indicating a moderate implementation for most lifeguards. Several individual-level (lifeguard characteristics) and setting-level (pool characteristics and treatment group) factors were found to be significantly associated with implementation of Pool Cool by lifeguards. All three lifeguard-level domains (lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors) and six pool-level predictors (number of weekly pool visitors, intervention intensity, geographic latitude, pool location, sun safety and/or skin cancer prevention programs, and sun safety programs and policies) were included in the final model. The most important predictors of implementation were the number of weekly pool visitors (inverse association) and enhanced treatment group (positive association). That is, pools with fewer weekly visitors and pools in the enhanced treatment group had significantly higher program implementation in both 2004 and 2005.
More intense, theory-driven dissemination strategies led to higher levels of implementation of this effective skin cancer prevention program. Issues to be considered by practitioners seeking to implement evidence-based programs in community settings, include taking into account both individual-level and setting-level factors, using active implementation approaches, and assessing local needs to adapt intervention materials.
PMCID: PMC2901365  PMID: 20513242
23.  Validity of Self-Reported Sunscreen Use by Parents, Children, and Lifeguards 
Verbal self-report is the method most often used to assess sunscreen use, but the data may be confounded by recall error and social desirability. Sunscreen swabbing is a non-invasive procedure to objectively assess the presence of sunscreen on the skin. This study examined the agreement between verbal reports of sunscreen use from survey and diary measures and objectively measured sunscreen use.
Participants were 564 parents, children aged 5–10 years, and lifeguards at 16 swimming pools in four regions of the U.S. Participants completed self-reported measures, including baseline and final surveys, as well as a 4-day diary and objective swabbing measures of sunscreen presence on 2 separate days. Data were collected in 2006 and analyzed in 2006–2007.
Levels of sunscreen use were relatively high based on surveys (65.7%); diary data (40.3%); and swabbing measures (59.1%). Agreement between swabbing and diary measures of sunscreen use was fair to good, with κ statistics for children at 0.40, followed by lifeguards at 0.34 and parents at 0.27. Validity coefficients across measures of sunscreen use were higher for lifeguards and parents than for children, and diary measures were higher than surveys. No systematic errors were found across groups or by gender, latitude, study arm, or risk category.
These findings are comparable to those in other validation studies, including studies of the validity of dietary assessments. Self-reported estimates of sunscreen use by diaries or surveys appear to be as good as objective measures.
PMCID: PMC2626407  PMID: 18945582

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