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Robinson-Dooley V, Sterling E, Collard C, Williams J, Collette T. Introducing Healthy Together: A Monograph of African American Men, Chronic Disease, and Self-Management. SOCIAL WORK IN PUBLIC HEALTH 2024; 39:750-766. [PMID: 39101808 PMCID: PMC11408104 DOI: 10.1080/19371918.2024.2387021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Previous research has outlined evident disparities in the prevalence of chronic conditions among African Americans compared to other groups, with low-income African American men disproportionately affected by almost every disorder. Self-management programs are useful tools for managing chronic disorders beyond the doctor's office. This monograph provides a detailed looking into the current state of the research on low-income African American men with chronic health conditions. An intersectional approach is used to provide a nuanced synthesis of relevant literature. The project outlines the need for programs designed to engage low-income African American men with skills, resources, and tools for managing chronic conditions. Authors argue that improvements to traditional self-management programs can be realized by emphasizing culture, including end-users in the creation of programs, and offering culturally tailored strategies to improve health. Thus, any targeted program must include culturally detailed information about nutrition, exercise, stress, mental health, and leveraging social support.
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Affiliation(s)
| | - Evelina Sterling
- Department of Sociology & Criminal Justice, Kennesaw State University, Kennesaw, Georgia, USA
| | - Carol Collard
- Department of Social Work & Human Services, Kennesaw State University, Kennesaw, Georgia, USA
| | - Jordan Williams
- Department of Social Work & Human Services, Kennesaw State University, Kennesaw, Georgia, USA
| | - Tyler Collette
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
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Fang Y, Jiang Y, Ma L, Chen H, Li Z, Luo F, Jiang W, Cai S, Guo Q, Yin Z. Effects of Social Support Provided by Disabled Older Adults to Others on Their Own Depressive Symptoms: A Moderated Mediation Model. Psychol Res Behav Manag 2024; 17:3049-3065. [PMID: 39192967 PMCID: PMC11348934 DOI: 10.2147/prbm.s468342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024] Open
Abstract
Purpose While previous studies have extensively examined the impact of receiving positive social support during social support interactions on depressive symptoms among older adults, adverse effects experienced, such as being rejected or ignored, are often overlooked. Moreover, there has been limited discussion on the effects of giving social support to others. Thus, this study investigates the impacts of social support given by disabled older adults to others on their own depressive symptoms, as well as the mediating role of receiving social support (both positive and negative aspects) and the moderating effect of the activity of daily living (ADL). Patients and Methods This cross-sectional, community-based study was conducted in Wenzhou and Jiaxing City, China, from September 2021 to September 2022, with a total of 255 disabled older adults meeting the inclusion and exclusion criteria. The data were collected face-to-face using a structured questionnaire. The participants were asked to complete the Barthel Index Scale, the Chinese version of the Positive and Negative Social Exchange Scale, the Giving Social Support questionnaire, and the Short Form Chinese Geriatric Depression Scale to measure disability, receiving positive and negative social support, giving social support, and depressive symptoms, respectively. Descriptive statistical analysis, correlation analysis, mediation effect tests, and moderation effect tests were used to analyse the questionnaire data. Results The social support provided by disabled older adults to others primarily involved companionship and care. The positive aspect of social support received was largely emotional support, while the negative aspect was mainly characterised by failure to obtain help and unsympathetic behaviour. Providing social support was found to be associated with a potential beneficial effect on depressive symptoms, linked to lower severity, with this effect fully mediated by receiving social support. Specifically, receiving emotional support accounted for 56.63% of the effect size, while failure to obtain help and unsympathetic behaviour contributed 21.55%, and rejection and neglect collectively accounted for 21.83%. Additionally, the effect was partially moderated by ADL, with older adults exhibiting lower ADL scores showing a greater benefit from both giving and receiving social support compared to those with higher ADL scores. Conclusion It is imperative to recognise and encourage disabled older adults to provide social support to others, especially emotional support, while reducing negative feedback, such as neglect and unnecessary blame. This could alleviate their depressive symptoms and promote psycho-social well-being.
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Affiliation(s)
- Yi Fang
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Yuqi Jiang
- The First Hospital of Jiaxing City, Jiaxing City, Zhejiang Province, People’s Republic of China
| | - Linlin Ma
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Huixian Chen
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Zhi Li
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Fen Luo
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Wen Jiang
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Shuya Cai
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Qiaoqiao Guo
- College of Renji, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
| | - Zhiqin Yin
- School of Nursing, Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China
- Wenzhou Health Promotion Research Center, Wenzhou City, Zhejiang Province, People’s Republic of China
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Molina Y, Kao SY, Bergeron NQ, Strayhorn-Carter SM, Strahan DC, Asche C, Watson KS, Khanna AS, Hempstead B, Fitzpatrick V, Calhoun EA, McDougall J. The Integration of Value Assessment and Social Network Methods for Breast Health Navigation Among African Americans. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1494-1502. [PMID: 37301367 PMCID: PMC10530024 DOI: 10.1016/j.jval.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 05/10/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES A major strategy to reduce the impact of breast cancer (BC) among African Americans (AA) is patient navigation, defined here as individualized assistance for reducing barriers to healthcare use. The primary focus of this study was to estimate the added value of incorporating breast health promotion by navigated participants and the subsequent BC screenings that network members may obtain. METHODS In this study, we compared the cost-effectiveness of navigation across 2 scenarios. First, we examine the effect of navigation on AA participants (scenario 1). Second, we examine the effect of navigation on AA participants and their networks (scenario 2). We leverage data from multiple studies in South Chicago. Our primary outcome (BC screening) is intermediate, given limited available quantitative data on the long-term benefits of BC screening for AA populations. RESULTS When considering participant effects alone (scenario 1), the incremental cost-effectiveness ratio was $3845 per additional screening mammogram. When including participant and network effects (scenario 2), the incremental cost-effectiveness ratio was $1098 per additional screening mammogram. CONCLUSION Our findings suggest that inclusion of network effects can contribute to a more precise, comprehensive assessment of interventions for underserved communities.
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Affiliation(s)
- Yamilé Molina
- University of Illinois at Chicago, Chicago, IL, USA.
| | - Szu-Yu Kao
- University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Carl Asche
- University of Illinois at Chicago, Chicago, IL, USA; Huntsman Cancer Institute, Salt Lake City, UT, USA
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Chen C, Sun X, Liu Z, Jiao M, Wei W, Hu Y. The relationship between resilience and quality of life in advanced cancer survivors: multiple mediating effects of social support and spirituality. Front Public Health 2023; 11:1207097. [PMID: 37701908 PMCID: PMC10493315 DOI: 10.3389/fpubh.2023.1207097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/15/2023] [Indexed: 09/14/2023] Open
Abstract
Background While previous studies have revealed a positive association between resilience and quality of life in advanced cancer survivors, the mechanisms of the relationship is still unclear. This study aimed to explore the relationships between resilience, social support, spirituality, and quality of life and determine the multiple mediation effects of social support and spirituality on the relationship between resilience and quality of life. Methods With 286 advanced cancer survivors, a cross-sectional, correlational survey was adopted using convenience sampling. Resilience, social support, spirituality, and quality of life were evaluated by self-report questionnaires. The PROCESS macro for SPSS was used to test the multiple mediation model. Results The scores for resilience, social support, spirituality and quality of life were positively correlated with one another. Resilience was found to be directly impact quality of life. Meanwhile, the relationship between resilience and quality of life was mediated by social support (effect = 0.067, 95% CI [0.019, 0.120]) and by spirituality (effect = 0.221, 95% CI [0.134, 0.332]), respectively, and by these two serially (effect = 0.036, 95% CI [0.015, 0.067]). Conclusion Social support and spirituality played multiple mediating roles in the relationship between resilience and quality of life. Interventions aimed at increasing resilience, and then boosting social support and spirituality may be beneficial for promoting quality of life of advanced cancer survivors.
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Affiliation(s)
- Cancan Chen
- Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, Henan, China
| | - Xiaofei Sun
- Department of Publicity, Zhengzhou Vocational University of Information and Technology, Zhengzhou, Henan, China
| | - Zhenya Liu
- Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, Henan, China
| | - Miaorui Jiao
- Department of Traditional Chinese Medicine, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wanhong Wei
- School of Nursing and Rehabilitation, Zhengzhou University, Zhengzhou, Henan, China
| | - Yanli Hu
- School of Nursing, Guangzhou Medical University, Guangzhou, China
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Chu WM, Tange C, Nishita Y, Tomida M, Shimokata H, Otsuka R, Lee MC, Arai H. Effect of different types of social support on physical frailty development among community-dwelling older adults in Japan: Evidence from a 10-year population-based cohort study. Arch Gerontol Geriatr 2023; 108:104928. [PMID: 36649669 DOI: 10.1016/j.archger.2023.104928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
PURPOSE Social support is associated with multiple positive health outcomes and is negatively associated with frailty in older adults. However, most evidence came from cross-sectional research. This study aimed to longitudinally explore the relationship between different types of social support and incident physical frailty. MATERIALS AND METHODS A 10-year prospective cohort study data from the National Institute for Longevity Sciences - Longitudinal Study of Aging (NILS-LSA) database, from 2000 to 2012 on older adults aged ≥65 years were analyzed excluding those with physical frailty at baseline, missing data, or not attending follow-up. We measured three kinds of social support, whether from within or outside family members, including emotional, instrumental, and negative support. The generalized estimating equation (GEE) model was used to examine the longitudinal relationships between social support and subsequent frailty. RESULTS The final analysis included 466 participants, with an average age of 71.3 (standard deviation [SD], 4.3) years and 7.33 years of follow-up (SD, 3.11). GEE analysis showed that emotional and instrumental supports from within and outside family members were associated with a significantly lower risk of physical frailty (odd ratio (OR) and 95% confidence interval (CI): 0.80 [0.64-1.00] and 0.74 [0.58-0.95]; 0.77 [0.60-0.99] and 0.79 [0.63-0.99], respectively). Both negative support from within or outside family members had no significant relationship with the risk of physical frailty. CONCLUSIONS This longitudinal study suggested that emotional, and instrumental support both from within or outside family members can reduce future physical frailty among older adults.
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Affiliation(s)
- Wei-Min Chu
- Education and Innovation Center for Geriatrics and Gerontology, National Center for Geriatrics and Gerontology, Aichi, Japan; Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chikako Tange
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Yukiko Nishita
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan.
| | - Makiko Tomida
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan; Graduate School of Humanities and Social Sciences, Nagoya City University, Aichi, Japan
| | - Hiroshi Shimokata
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan; Graduate School of Nutritional Sciences, Nagoya University of Arts and Sciences, Japan
| | - Rei Otsuka
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Meng-Chih Lee
- Department of Family Medicine, Taichung Hospital, Ministry of Health and Welfare, Taichung, Taiwan; Institute of Population Sciences, National Health Research Institutes, Miaoli County, Taiwan; College of Management, Chaoyang University of Technology, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Aichi, Japan
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Ofei SD, Teye-Kwadjo E, Amankwah-Poku M, Gyasi-Gyamerah AA, Akotia CS, Osafo J, Roomaney R, Kagee A. Determinants of Post-Traumatic Growth and Quality of Life in Ghanaian Breast Cancer Survivors. Cancer Invest 2023; 41:379-393. [PMID: 36794324 DOI: 10.1080/07357907.2023.2181636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
This study assessed the psychosocial factors associated with post-traumatic growth (PTG) and health-related quality of life (HRQoL) in women breast cancer survivors. Women (N = 128) completed questionnaires on social support, religiosity, hope, optimism, benefit-finding, PTG and HRQoL. Structural equation modeling was used to analyze the data. Results showed that perceived social support, religiosity, hope, optimism, and benefit finding were positively associated with PTG. Religiosity and PTG were positively associated with HRQoL. The results suggest that interventions aimed at increasing religiosity, hope, optimism, and perceived support can help survivors cope better with breast cancer.
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Affiliation(s)
| | | | | | | | | | - Joseph Osafo
- Department of Psychology, University of Ghana, Legon, Ghana
| | - Rizwana Roomaney
- Department of Psychology, Stellenbosch University, Matieland, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Matieland, South Africa
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Navigated African American breast cancer patients as incidental change agents in their family/friend networks. Support Care Cancer 2021; 30:2487-2496. [PMID: 34783907 DOI: 10.1007/s00520-021-06674-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient navigation is an increasingly widespread intervention to address the persistent, severe, and disproportionate breast cancer (BC) burden that African Americans (AA) face. Navigation may have more widespread effects than previously estimated due to patient-driven diffusion of BC information. METHODS This pilot study examined the network effects of a randomized controlled trial via recruitment of navigated and non-navigated AA BC patients as well as their network members. We estimated study arm differences in patient BC promotion (i.e., number of individuals to whom BC patients promote BC screening) and network BC screening (i.e., % BC screening among network members). RESULTS Among our sample of 100 AA BC patients, navigated patients promoted BC screening to more individuals than non-navigated patients. BC patients were more likely to promote BC screening to children and individuals with whom they communicated more frequently. Some models further suggested more network BC screening among "navigated" network members relative to "non-navigated" network members. CONCLUSIONS Navigated AA patients promoted BC screening more widely throughout their networks than non-navigated AA BC patients. There were also suggestive findings regarding increased BC screening among their network members. Our pilot study highlights the potential for social network analysis to improve the precision of intervention effect estimates and to inform future innovations (e.g., integrating navigation and network-based interventions) with multilevel effects on cancer health disparities.
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Hurtado-de-Mendoza A, Gonzales F, Song M, Holmes EJ, Graves KD, Retnam R, Gómez-Trillos S, Lopez K, Edmonds MC, Sheppard VB. Association between aspects of social support and health-related quality of life domains among African American and White breast cancer survivors. J Cancer Surviv 2021; 16:1379-1389. [PMID: 34655040 PMCID: PMC10166003 DOI: 10.1007/s11764-021-01119-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/01/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Social support is associated with breast cancer survivors' health-related quality of life (HRQoL). More nuanced information is needed regarding aspects of social support associated with different HRQoL domains among diverse populations. We assessed the association between emotional/informational and tangible support and five HRQoL domains and evaluated race as an effect modifier. METHODS African American and White women (n = 545) diagnosed with hormone-receptor-positive breast cancer completed a survey that assessed sociodemographic, clinical, and psychosocial factors. We assessed bivariate relationships between emotional/informational and tangible support along with overall HRQoL and each HRQoL domain.We tested interactions between race and emotional/informational and tangible social support using linear regression. RESULTS The sample included African American (29%) and White (71%) breast cancer survivors. Emotional/informational social support had a statistically significant positive association with emotional well-being (β = .08, p = 0.005), social well-being (β = 0.36, p < 0.001), functional well-being (β = .22, p < .001), breast cancer concerns (β = .16, p = 0.002), and overall HRQoL (β = .83, p < .001). Similarly, tangible social support had a statistically significant positive association with emotional well-being (β = .14, p = 0.004), social well-being (β = .51, p < .001), functional well-being (β = .39, p < .001), and overall HRQoL (β = 1.27, p < .001). The interactions between race and social support were not statistically significant (p > 0.05). CONCLUSIONS Results underscore the importance of the different social support types among breast cancer survivors, regardless of survivors' race. IMPLICATIONS FOR CANCER SURVIVORS Population-based interventions can be standardized and disseminated to provide guidance on how to increase emotional/information and tangible support for all breast cancer survivors by caregivers, health providers, and communities.
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Affiliation(s)
- Alejandra Hurtado-de-Mendoza
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA. .,Fisher Center for Hereditary Cancer and Clinical Cancer Genomics, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA.
| | - Felisa Gonzales
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA.,The Colorado Trust, Denver, CO, USA
| | - Minna Song
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Esther J Holmes
- Department of Health Behavior and Policy, VCU School of Medicine, Richmond, VA, USA
| | - Kristi D Graves
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA.,Fisher Center for Hereditary Cancer and Clinical Cancer Genomics, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Reuben Retnam
- Department of Health Behavior and Policy, VCU School of Medicine, Richmond, VA, USA
| | - Sara Gómez-Trillos
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA.,Fisher Center for Hereditary Cancer and Clinical Cancer Genomics, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Katherine Lopez
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Megan C Edmonds
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, VCU School of Medicine, Richmond, VA, USA.,Office of Health Equity and Disparities Research, VCU Massey Cancer Center, Richmond, VA, USA
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Cui C, Wang L, Wang X. Health-related quality of life and social constraints among Chinese breast cancer patients: a cross-sectional study. Health Qual Life Outcomes 2021; 19:238. [PMID: 34641883 PMCID: PMC8507183 DOI: 10.1186/s12955-021-01871-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/26/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Most research studying social constraints has been performed among Caucasian or Asian American breast cancer (BC) patients, but few studies have evaluated social constraint levels and explored the effect of social constraints on the integrative health-related quality of life (HRQOL) of Chinese BC patients. Therefore, our study aimed to examine the association of social constraints with HRQOL among Chinese women with BC. METHODS This was a cross-sectional study of 136 Chinese women diagnosed with BC in Liaoning Province, China, from December 2020 to May 2021. Questionnaire information contained HRQOL, social constraints, social support, social stigma, and sociodemographic and clinical characteristics. Multiple linear regression was used to analyse the association of psychological factors with HRQOL. RESULTS The mean score of FACT-B was 96.05 (SD = 18.70). After controlling for potential confounders, social constraints (Beta = - 0.301, P < 0.001) and social stigma (Beta = - 0.241, P = 0.001) were negatively associated with HRQOL and social support (Beta = 0.330, P < 0.001) was positively associated with HRQOL, which explained 44.3% of the variance in HRQOL. CONCLUSIONS The findings of the current study suggest that Chinese BC patients' HRQOL needs to be enhanced after treatment. Social constraints have a strong association with HRQOL. Intervention strategies focusing on less personal disclosure should be considered to avoid social constraints and improve HRQOL among Chinese patients with BC.
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Affiliation(s)
- Chunying Cui
- Department of Social Medicine, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, Liaoning, People's Republic of China
| | - Lie Wang
- Department of Social Medicine, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, Liaoning, People's Republic of China
| | - Xiaoxi Wang
- Medical Basic Experimental Teaching Center, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, Liaoning, People's Republic of China.
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