Mental distress and its associations with behavioral outcomes during the COVID-19 pandemic: a national survey of Chinese adults.

OBJECTIVES: This study aimed to evaluate associations between mental distress and COVID-19-related changes in behavioral outcomes and potential modifiers (age, gender, educational attainment) of such associations. STUDY DESIGN: This was a cross-sectional study. METHODS: An online survey using anonymous network sampling was conducted in China from April to May 2020 using a 74-item questionnaire. A national sample of 10,545 adults in 31 provinces provided data on sociodemographic characteristics, COVID-19-related mental distress, and changes in behavioral outcomes. Structural equation models were used for data analyses. RESULTS: After adjusting for covariates, greater mental distress was associated with increased smoking (odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.20-1.68 and OR = 1.54, 95% CI: 1.31-1.82 per one standard deviation [SD] increase in mental distress) and alcohol consumption (OR = 1.67, 95% CI: 1.45-1.92 and OR = 1.47, 95% CI: 1.24-1.75 per one SD increase in mental distress) among current smokers and drinkers and with both increased and decreased physical activity (ORs ranged from 1.32 to 1.56). Underweight adults were more likely to lose body weight (≥1 kg; OR = 1.63, 95% CI: 1.30-2.04), whereas overweight adults were more likely to gain weight (OR = 1.61, 95% CI: 1.46-1.78) by the same amount. Association between mental distress and change in physical activity was stronger in adults aged ≥40 years (ORs ranged from 1.43 to 2.05) and those with high education (ORs ranged from 1.43 to 1.77). Mental distress was associated with increased smoking in males (OR = 1.60, 95% CI: 1.37-1.87) but not females (OR = 1.11, 95% CI: 0.82-1.51). CONCLUSIONS: Greater mental distress was associated with some positive and negative changes in behavioral outcomes during the pandemic. These findings inform the design of tailored public health interventions aimed to mitigate long-term negative consequences of mental distress on outcomes.

Influenza vaccination uptake and associated factors among elderly population in Hong Kong: the application of the Health Belief Model.

The impact of influenza on elderly can be severe and fatal. Influenza vaccination (IV) has been shown to be effective in reducing influenza-related complications, but the IV uptake among elderly in Hong Kong remains low. This study investigated the prevalence and factors associated with IV among Chinese elderly in Hong Kong using the Health Belief Model (HBM). A total of 1101 Chinese elderly aged over 65 was randomly selected and completed a phone interview. Background information, experience of and intention to receive IV and IV-related knowledge and perceptions based on the HBM were measured. Results showed that 48.5 and 49.5% of the participants have ever been vaccinated and intended to receive IV, respectively. Female gender, having chronic disease, and participating in community activities were significantly associated with previous IV. Knowledge of the fact that IV is required every year, lower perceived side effect, IV price lower than HK$150, and recommendations from health care providers was associated with both previous IV and intention to be vaccinated in the next year. Interventions promoting IV among elderly should disseminate knowledge regarding the necessity of IV and correct misconceptions about the side effects of IV.

Condoms used but sex not well protected.

Condom use is often equated to safer sex. The prevalence of condom use during sex work among female sex workers (FSW) in China is high. Condom use, however, co-exists with condom failure and improper use and hence risk of HIV transmission. In a cross-sectional study, we interviewed 195 FSW in Shenzhen, China. The prevalence of condom use in the last episode of sex work was 97.4 %, However, respectively 53.8 and 86.2 % had experienced at least one condition of condom failure that may lead to genital contact (wearing condoms after penetration, condom breakage/slippage, condoms removed by clients) and at least one condition of improper condom use (not removing air from the tip of the condom, not pulling it down to the root of penis and not choosing good quality condoms). Factors of individual level (e.g. never choosing high quality condoms for sex work), inter-personal level (e.g. agreement to have unprotected sex if fond of clients or paid more) and environmental/structural level (e.g. non-availability of condoms) were associated with various types of condom failure and improper use. Although HIV prevention interventions have increased prevalence of condom use among FSW, the risk of HIV transmission may still be high as "unsafe" sex due to condom failure and improper use is prevalent. Interventions promoting safer sex need to address such issues and take socio-ecological factors into account. Condom use during sex work is not equivalent to well protected sex as the protective effects could be compromised by frequent condom failure and improper use.

Prevalence of seasonal influenza vaccination and associated factors in people with chronic diseases in Hong Kong.

Chronic disease patients are at high risk of developing serious influenza-related complications. This study investigated the prevalence of seasonal influenza vaccination (IV) and associated factors in such patients. A random sample of 704 Chinese adults with chronic disease was anonymously interviewed by telephone; 35·8% of them had ever taken up IV and 22·7% did so during the last flu season. The most frequently mentioned facilitator was recommendation made by a healthcare worker (HCW). Knowledge that IV is required annually, perceived severe health impacts of influenza, and recommendation made by a HCW were positively associated with previous IV and intention to take up IV in the next year, while perceived side-effects was inversely associated with previous IV and intention to take up IV. The coverage of IV in this study population was low. HCWs should clarify IV-related health beliefs in chronic disease patients and actively advise them to take up IV.

Changes in knowledge, perceptions, preventive behaviours and psychological responses in the pre-community outbreak phase of the H1N1 epidemic.

To investigate the changes in community responsiveness during the pre-community-outbreak phase of the H1N1 epidemic in Hong Kong, a pooled sample of 999 adults was interviewed in three surveys (S1, S2, S3) from 7 May to 6 June 2009. Over time, fewer people felt confident in staying free from H1N1 infection in the following year (S1, 63·3%; S3, 46%; P<0·001). The level of distress due to H1N1 remained modest throughout the study period. People's confidence in the government's ability to control a large-scale H1N1 outbreak declined slightly at the third survey (S1, 80·5%; S3, 73·8%; P=0·025). Across the three surveys, respondents remained vigilant with frequent adoption of preventive measures (e.g. wearing face masks in public areas when suffering from influenza-like symptoms and frequent hand-washing). The public was generally supportive of the Hong Kong government although misconceptions regarding the disease were common. Provision of evidence-based public-health education is still warranted as the disease outbreak unfolds.

Psychological factors in association with uptake of voluntary counselling and testing for HIV among men who have sex with men in Hong Kong.

OBJECTIVES: To investigate the prevalence and factors associated with uptake of voluntary counselling and testing (VCT) for human immunodeficiency virus (HIV) among men who have sex with men (MSM) in Hong Kong. STUDY DESIGN: Cross-sectional study. METHODS: A total of 389 MSM were recruited from gay venues. An additional 188 MSM were recruited through the Internet. Data were collected via face-to-face interviews using a self-administered anonymous questionnaire or via an electronic questionnaire accessible via local gay-friendly websites. The associations between independent and dependent variables (VCT uptake in lifetime and in last 12 months) were examined by logistic regression models. RESULTS: The prevalence rates for lifetime and 12-month uptake of VCT were 56.5% and 39.4%, respectively. Adjusting for significant background variables, all cognitive variables (attitudes, subjective norms, perceived control and behavioural intention) that were derived from the Theory of Planned Behaviours (TPB) were significantly associated with both lifetime and 12-month uptake of VCT [adjusted odds ratio (AOR) 0.56-4.71, P < 0.05]. Perceived fear of contracting HIV and perceived discrimination towards local MSM were associated with a lower likelihood of 12-month uptake of VCT (AOR 0.63, P < 0.05) and lifetime uptake (AOR 0.65, P < 0.05). In the summary models, variables derived from the TPB (subjective norms, perceived control and behavioural intention) were independently associated with lifetime and 12-month uptake of VCT (OR 0.64-2.78, P < 0.05; OR 2.39-3.21, P < 0.05, respectively). Fear of contracting HIV was associated with VCT uptake in the last 12 months (OR 0.55, P < 0.05). CONCLUSIONS: Psychological factors are associated with VCT uptake. The TPB and other health behavioural theories should be taken into account when designing VCT promotion campaigns.

Public health challenges of the emerging HIV epidemic among men who have sex with men in China.

A large-scale national survey was conducted in 2008 across 61 cities throughout China, covering over 18,000 men who have sex with men (MSM). The prevalence of human immunodeficiency virus (HIV) was 4.9% and incidence ranged from 2.6 to 5.4 per 100 person-years. The prevalence of sexually transmitted diseases ranged from 2.0% to 29.9% among MSM in different parts of China. Syphilis status, recruitment of sexual partners mainly from gay saunas, duration of MSM experience, and unprotected sex with regular male sex partners and multiple male sex partners predicted HIV seroconversion. The prevalence of consistent condom use was low during anal sex, ranging from 29.4% to 37.3%. Within this context, this paper considers the factors surrounding HIV prevention activity, and identifies a number of public health challenges which need to be considered if optimum outcomes are to be achieved. HIV prevention targeting MSM is a delayed response. The high risk associated with gay saunas and the need for steady condom supply at these venues needs urgent consideration. In addition, approximately one-third of MSM in China reported bisexual behavior, which may be attributed to sociocultural reasons and stigma against MSM. Female sex partners of MSM are seldom aware of their exposure to high risk of HIV transmission. Finally, the primitive nature of non-government organizations for HIV prevention and issues around their sustainability pose another serious challenge for the future of HIV prevention campaigns targeting MSM in China.

A three-arm randomised controlled trial to evaluate the efficacy of a positive psychology and social networking intervention in promoting mental health among HIV-infected men who have sex with men in China.

AIMS: There is a lack of mental health promotion and treatment services targeting HIV-positive men who have sex with men (HIVMSM) in China. The aim of this study was to evaluate the mental health promotion efficacy of an online intervention that combined Three Good Things (TGT) with electronic social networking (TGT-SN) and an intervention that used TGT only (TGT-only), compared with a control group. METHODS: We conducted a randomised controlled trial among HIVMSM in Chengdu, China. The participants were randomly assigned to the TGT-SN, TGT-only, and control groups. The participants in the TGT-SN group were divided into five social network groups and asked to post brief messages to the group about three good things that they had experienced and for which they felt grateful. The participants in the TGT-only group were only required to write down their three good things daily without sharing them with others. The control group received information about mental health promotion once a week for a month. The primary outcome was probable depression. Secondary outcomes were anxiety, positive and negative affect, gratitude, happiness and social support. These outcomes were assessed at baseline, 1, 3, 6 and 12 months after the intervention. Repeated-measures analyses were conducted using generalised estimation equations. The study was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-13003252). RESULTS: Between June 2013 and May 2015, 404 participants were enrolled and randomly assigned to either the TGT-SN (n = 129), TGT-only (n = 139) or control group (n = 136). The main effects of TGT-SN (adjusted odds ratio (aOR) = 0.75, 95% CI 0.52-1.09; p = 0.131) and TGT-only (aOR = 0.83, 95% CI 0.57-1.21; p = 0.332) in reducing depression were statistically non-significant. The participants of the TGT-SN group showed significantly lower anxiety symptoms (aOR = 0.62, 95% CI 0.43-0.89; p = 0.009) and negative affect (ß = -1.62, 95% CI 2.98 to -0.26; p = 0.019) over time compared with those of the control group. No significant main effect was found for any secondary outcomes for the TGT-only group. CONCLUSIONS: The novel intervention combining the TGT exercise with electronic social networking was found effective in reducing anxiety and negative affect among HIVMSM.

Monitoring of perceptions, anticipated behavioral, and psychological responses related to H5N1 influenza.

BACKGROUND: The aim of this study was to monitor changes in behavioral and emotional responses to human H5N1 in the community over a 28-month period (from November 2005 to February 2008). METHODS: A total of 3,527 Hong Kong Chinese adults were interviewed by telephone within the framework of six identical cross-sectional surveys carried out during the 28-month study period. Given a hypothetical scenario that two to three new human-to-human H5N1 cases had been reported in Hong Kong, the trends of the respondents in various H5N1-related risk perceptions, anticipated personal psychological responses, and anticipated personal preventive behaviors were investigated. RESULTS: Over time, a decreased proportion of the respondents (1) felt susceptible to contracting H5N1, (2) expected a large outbreak would eventually occur, (3) believed that the impacts of H5N1 were worse than those of severe acute respiratory syndrome (SARS), and (4) anticipated adopting more types of preventive measures and experiencing mental distress in the case of a small-scale outbreak in Hong Kong (AOR from 0.27 to 0.43, p < 0.001), but the public remained vigilant on public health behaviors, such as hand-washing. The prevalence of misconceptions on the mode of transmission declined, but remained high; perceptions on the fatality of H5N1 remained largely underestimated. The SARS experience and unconfirmed beliefs about the transmission modes were associated with variables on anticipated preventive behaviors and emotional distress. CONCLUSION: Starting in 2005 through to 2008, respondents perceived a decreasing level of susceptibility, severity, and anticipated stress towards a hypothetical human-to-human H5N1 outbreak, possibly due to the low efficiency of transmission. The public's general preparedness was still relatively good and rational, even though individual preventive behaviors were less common. However, misconceptions were prevalent among the respondents. Based on these results, public education is warranted to rectify these misconceptions.

Suicidal ideation among HIV+ former blood and/or plasma donors in rural China.

Suicidal ideation is life-threatening and is prevalent among people living with HIV (PLWH). A dearth of such studies was conducted in China. This study investigated the prevalence of suicidal ideation and associated factors among PLWH who were former blood and/or plasma donors (FBPD) in a rural county in central China. Prospective respondents were randomly selected from a local registry; 176 PLWH who were FBPD joined the study. With informed consent, these PLWH and their spouse were interviewed separately and anonymously. Respectively, 34 and 8% of the sampled (index) PLWH self-reported having suicidal ideation and making a suicidal attempt in the last year. The multivariate analyses results showed that the index PLWH's Physical Function subscale score of the Medical Outcomes Study HIV Health Survey scale (Odds ratio (OR)=6.67, 95% CI=1.69-26.27, 75 percentiles), the Depression subscale score of the Depression, Anxiety, and Stress Scales (DASS; OR=9.26, 95% CI=1.32-64.77), and the spouse's Depression subscale score of the DASS (OR=7.64, 95% CI=1.37-42.77) were independently associated with the index PLWH's suicidal ideation. HIV-related variables (e.g., duration of diagnosis, treatment and side effects) and perceived discrimination of the index PLWH, and HIV status of the PLWH's spouse, were not significant factors. Depression is a risk factor for suicides. Moreover, depression may be contagious and the depression status of the spouse also matters. Treatments for depression and prevention intervention for suicides targeting PLWH in rural China are not readily available. Such services are greatly warranted and need to be provided to both the PLWH and his/her spouse.

Influence of country of study on student responsiveness to the H1N1 pandemic.

OBJECTIVES: University students, both travelling abroad on holiday or exchange students entering a country, can serve as mobile carriers of infectious diseases during a pandemic, and thus require special attention when considering preventive measures. The objectives of this study were to evaluate student compliance and opinions on preventive measures of a university before and during an H1N1 influenza pandemic, and to explore environmental and behavioural factors that might contribute towards compliance. STUDY DESIGN: Cross-sectional, self-administered questionnaire. METHODS: Local and foreign students attending an international summer school programme were invited to participate in a self-administered survey. RESULTS: Respondents complied with most of the preventive measures, excluding website viewing and mask wearing. Significant differences in compliance and perceived necessity were found amongst students from Singapore, Hong Kong and the USA. Singaporean students were significantly more likely to comply with all measures and consume antiviral medication in response to the pandemic than students studying in the US. CONCLUSIONS: Students' responses towards university pandemic measures were largely positive, but sensitivity towards these measures varied between groups by country of study. This should be considered in further comparative studies.

Changes in condom use behaviours among clients of female sex workers in China.

BACKGROUND: Clients of female sex workers (CFSWs) are at risk for HIV transmission; relevant surveillance and interventions for this vulnerable group are scarce. The China-UK HIV/AIDS Prevention and Care Project launched an enhanced intervention programme involving peer education, seminars, testing services and social gatherings and so forth, and two behavioural surveillance studies (BSS) targeting CFSWs in Suining, Sichuan. METHODS: Two cross-sectional BSS (a baseline survey and an evaluative survey) were conducted in September 2005 and May 2006, respectively. In total, 356 and 372 respondents who patronised some low-end sex services were interviewed by peer interviewers. Another triangulation condom audit exercise was conducted in June 2006. RESULTS: Prevalence of respondents using at least one prevention service increased from 50.3% in 2005 to 68.5% in 2006 (AOR = 2.2). Respondents of the evaluative survey compared with their counterparts of the baseline survey had lower prevalence of inconsistent condom users in the last 6 months (44.1% vs 77.0%; AOR = 0.2) and higher prevalence of condom use in the last episode of commercial sex (78.0% vs 41.5%; AOR = 4.9). The triangulation audit showed that condoms were used by 73.8% of CFSWs. The multivariate analysis shows that year of study (OR = 0.3), self-reported sexually transmitted disease symptoms (OR = 2.9), use of face-to-face counselling services (OR = 0.5) and so forth were significantly associated with inconsistent condom use during commercial sex in the last 6 months. CONCLUSIONS: Condom use and service use behaviours changed in the study population over a time period when an enhanced intervention programme was implemented. Such effective programmes may be applied to other locations in China.