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Challapalli SD, Shetty KR, Bui Q, Osazuwa-Peters N, Adjei Boakye E. Sun protective behaviors among adolescents and young adults in the United States. J Natl Med Assoc 2023; 115:353-361. [PMID: 37142483 DOI: 10.1016/j.jnma.2023.04.002] [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: 12/23/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE We described sun protective behaviors in adolescents and young adults (AYA) compared to older adults. METHODS We used data from the 2013-2018 National Health and Nutrition Examination Survey, a nationally representative samples of the civilian, noninstitutionalized US population (10,710 respondents aged between 20 and 59 and without a history of skin cancer diagnoses). The primary exposure for the study was age group: aged 20-39 defined as AYA and aged 40-59 as adults. The outcome variable was sun protective behaviors: stay in the shade, wear a long-sleeved shirt, use sunscreen, at least one of the three; and all three measures. Multivariable logistic regression models were used to assess association between age group and sun protective behaviors adjusting for sociodemographic factors. RESULTS Overall, 51.3% of respondents were AYA, 76.1% reported staying in the shade, 50.9% using sunscreen, 33.3% wearing long-sleeved clothes, 88.1% engaging in one of the three behaviors, and 17.1% engaging in all three behaviors. In the adjusted models, the odds of engaging in all three behaviors among AYAs was 28% (aOR: 0.72, 95% CI: 0.62-0.83) lower than adult respondents. Compared to adults, AYAs were 22% less likely to wear long sleeved clothes (aOR: 0.78, 95% CI: 0.70-0.87). There were no significant differences in the odds of engaging in at least one sun protective behavior, using sunscreen, and staying in the shade between AYAs and adults. CONCLUSIONS More targeted interventions need to be implemented to decrease the risk of skin cancer in the AYA population.
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Affiliation(s)
- Sai D Challapalli
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, Houston, Texas, USA
| | - Kunal R Shetty
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, Houston, Texas, USA
| | - Quoc Bui
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Eric Adjei Boakye
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA; Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA.
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De Castro-Maqueda G, Gutierrez-Manzanedo JV, Ponce-González JG, Fernandez-Santos JR, Linares-Barrios M, De Troya-Martín M. Sun Protection Habits and Sunburn in Elite Aquatics Athletes: Surfers, Windsurfers and Olympic Sailors. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:312-320. [PMID: 30637576 DOI: 10.1007/s13187-018-1466-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The objective of this study was to analyse the sun exposure habits of elite aquatics athletes, together with their sunburn history and skin examination habits, taking into account differences by sex and between sports. A cross-sectional health survey was conducted at world championship events during which elite surfers, windsurfers and Olympic sailors from 30 different countries were invited to participate. The athletes were asked to complete a self-administered questionnaire focused on sun protection habits, sun exposure and sports practices. The survey was completed by 240 athletes, 171 men (71.3%) and 69 women (28.8%), with a mean age of 22 years (SD 5.86) and skin phototypes I (6.3%), II (3.3%), III (22.0%), IV (32.5%), V (9.2%) and VI (1.7%). There were significant differences between male and female athletes in skin self-examination (p < 0.001) and in the use of sunglasses (p < 0.001). In sunburn history during the last season, there were significant differences (p < 0.001) among the three sports analysed, in both sexes. The mean rate of sunburn during the previous season was 76.7%, and 27.5% of participants reported having experienced three or more sunburns that lasted at least 1 day. This type of athlete is at high risk of sunburn and hence of future skin cancer. However, there is a general lack of awareness of this risk. This study highlights the need to inform such athletes and to raise awareness of the dangers, through educational interventions on the importance of protecting against sunburn in order to reduce the future incidence of skin cancer.
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Affiliation(s)
- Guillermo De Castro-Maqueda
- Department of Physical Education, Faculty of Education Sciences, University of Cádiz, Av. República Saharaui s/n, 11519, Puerto Real, Cádiz, Spain.
| | - J V Gutierrez-Manzanedo
- Department of Physical Education, Faculty of Education Sciences, University of Cádiz, Av. República Saharaui s/n, 11519, Puerto Real, Cádiz, Spain
| | - J G Ponce-González
- Department of Physical Education, Faculty of Education Sciences, University of Cádiz, Av. República Saharaui s/n, 11519, Puerto Real, Cádiz, Spain
| | - J R Fernandez-Santos
- Department of Physical Education, Faculty of Education Sciences, University of Cádiz, Av. República Saharaui s/n, 11519, Puerto Real, Cádiz, Spain
| | - M Linares-Barrios
- Dermatology Service, Servicio Andaluz de Salud, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - M De Troya-Martín
- Dermatology Service, Hospital Costa del Sol. Servicio Andaluz de Salud, Marbella, Spain
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3
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Sun protective behaviours during maximum exposure to ultraviolet radiation when undertaking outdoor activities: an integrated literature review. J Public Health (Oxf) 2018. [DOI: 10.1007/s10389-018-0945-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Taber JM, Dickerman BA, Okhovat JP, Geller AC, Dwyer LA, Hartman AM, Perna FM. Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory. Prev Med 2018; 111:451-458. [PMID: 29277407 PMCID: PMC5949070 DOI: 10.1016/j.ypmed.2017.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/11/2017] [Accepted: 12/19/2017] [Indexed: 12/12/2022]
Abstract
The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.
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Affiliation(s)
- Jennifer M Taber
- Behavioral Research Program, National Cancer Institute, United States.
| | | | | | - Alan C Geller
- Harvard TH Chan School of Public Health, United States
| | | | - Anne M Hartman
- Behavioral Research Program, National Cancer Institute, United States
| | - Frank M Perna
- Behavioral Research Program, National Cancer Institute, United States
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Geller AC, Dickerman BA, Taber JM, Dwyer LA, Hartman AM, Perna FM. Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions. Prev Med 2018; 111:442-450. [PMID: 29425724 PMCID: PMC5930068 DOI: 10.1016/j.ypmed.2018.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 01/11/2018] [Accepted: 01/29/2018] [Indexed: 12/20/2022]
Abstract
While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.
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Affiliation(s)
- Alan C Geller
- Harvard TH Chan School of Public Health, United States.
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Andersen PA, Buller DB, Walkosz BJ, Scott MD, Beck L, Liu X, Abbott A, Eye R, Cutter G. A Randomized Trial of an Advanced Sun Safety Intervention for Vacationers at 41 North American Resorts. JOURNAL OF HEALTH COMMUNICATION 2017; 22:951-963. [PMID: 29161214 PMCID: PMC6309206 DOI: 10.1080/10810730.2017.1382615] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Taking vacations in sunny locations is associated with the development of skin cancer. This study tested a multi-component sun protection intervention based on diffusion of innovations theory and transportation theory designed to increase vacationers' comprehensive sun protection, i.e., use of clothing, hats, and shade, and use, pre-application, and reapplication of sunscreen. The trial enrolled 41 warm weather resorts in North America in a pair-matched group randomized pretest-posttest design and assessed samples of adult vacationers at resort outdoor recreation venues regarding sun protection at pretest (n = 3,531) and posttest (n = 3,226). While results showed no overall effect of the intervention on comprehensive sun protection across venues, the intervention produced statistically significant improvements in sun protection at waterside venues (pools and beaches). The intervention's overall effects may have been impeded by a lack of uniformly robust implementation, low interest in skin cancer prevention by guests, or shortcomings of the theories used to create prevention messages. The intervention may have worked best with guests in the highest-risk recreation venue, i.e., waterside recreation where they exposed the most skin. Alternative approaches that alter resort organizations, such as through changes in policy, environmental features, or occupational efforts might be more effective than targeting vacationers with behavior-change messages.
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Affiliation(s)
- Peter A. Andersen
- School of Communication, San Diego State University, San Diego, California, USA
| | | | | | | | - Larry Beck
- L. Robert Payne School of Hospitality and Tourism Management, San Diego State University, San Diego, California, USA
| | - Xia Liu
- Klein Buendel, Inc., Golden, Colorado, USA
| | - Allison Abbott
- School of Communication, San Diego State University, San Diego, California, USA
| | - Rachel Eye
- Klein Buendel, Inc., Golden, Colorado, USA
| | - Gary Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Buller DB, Andersen PA, Walkosz BJ, Scott MD, Beck L, Cutter GR. Effect of an intervention on observed sun protection by vacationers in a randomized controlled trial at North American resorts. Prev Med 2017; 99:29-36. [PMID: 28189810 PMCID: PMC5432386 DOI: 10.1016/j.ypmed.2017.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/05/2016] [Accepted: 01/29/2017] [Indexed: 11/15/2022]
Abstract
During vacations, many individuals receive high-risk sun exposure that is associated with skin cancer. Vacationers in outdoor recreation venues (pretest n=4347; posttest n=3986) at warm-weather destination resorts in North America (n=41) were enrolled in a pair-matched, group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Print, audiovisual, and online messages based on Transportation Theory and Diffusion of Innovation Theory and promoting advanced sun protection (e.g., use of clothing, hats, shade and pre-application/reapplication of sunscreen and reliable cues to high UV) were delivered through resort channels. Vacationers' sun protection practices observed by trained research staff (i.e., body coverage and shade use analyzed individually and in combined scores) did not differ by experimental condition (p>0.05) or intervention implementation (p>0.05). However, recreation venue moderated intervention impact. The intervention improved sun protection at waterside recreation venues (z-score composite: intervention pre=-22.74, post=-15.77; control pre=-27.24, post=-23.24) but not non-waterside venues (z-score composite: intervention pre=20.43, post=20.53; control pre=22.94, post=18.03, p<0.01). An additional analysis showed that resorts with greater program implementation showed more improvements in sun protection by vacationers at waterside (z=score composite: high implementation pre=-25.45, post=-14.05; low implementation pre=-24.70, post=-21.40) compared to non-waterside (z-score composite: high implementation pre=14.51, post=19.98; low implementation pre=24.03, post=18.98, p<0.01) recreation venues. The intervention appeared effective with the vacationers in recreation venues with the highest-risk for sun exposure, waterside venues. However, it was not effective throughout all the resort venues, possibly because of the sun-seeking desires of vacationers, information overload at the resorts, and constraints on clothing styles and sun protection by recreation activity.
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Affiliation(s)
- David B Buller
- Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA.
| | - Peter A Andersen
- School of Communication, San Diego State University, 5500 Campanille, San Diego, CA 92182-4560, USA
| | - Barbara J Walkosz
- Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA
| | - Michael D Scott
- Department of Communication Arts and Sciences, 400 W 1st Street, California State University, Chico, CA 95929, USA
| | - Larry Beck
- L. Robert Payne School of Hospitality and Tourism Management, San Diego State University, San Diego, CA 92182, USA
| | - Gary R Cutter
- School of Public Health, University of Alabama, Birmingham, 1667 University Blvd, Ryals 410b, Birmingham, AL 35294, USA
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Walkosz BJ, Scott MD, Buller DB, Andersen PA, Beck L, Cutter GR. Prevalence of Sun Protection at Outdoor Recreation and Leisure Venues at Resorts in North America. AMERICAN JOURNAL OF HEALTH EDUCATION 2017; 48:90-99. [PMID: 29147456 DOI: 10.1080/19325037.2016.1271755] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Exposure to solar ultra violet radiation (UVR) is a primary risk factor for skin cancer. Vacationers often fail to protect themselves from harmful UVR. Purpose The study assessed the sun protection practices of resort guests in various outdoor leisure and recreation venues during warm-weather seasons. Method 41 North American resorts were enrolled in a quasi-experimental randomized controlled trial. Adult guests were observed (n=4091) and surveyed (n=3694) in a cross sectional sample. Data collection was conducted in recreation and leisure venues with outdoors commons/reception areas acting as the comparison condition. Results The mean percent of vacationers at pools and beaches were more likely (p < 0.001) to wear sunscreen than in commons areas but less likely (p < 0.001) to wear cover-up clothing or use shade. In both samples, the combined sun protection scores were higher in commons areas compared to all venues except for outdoor dining (p < 0.001). Discussion Sun safety was suboptimal in all venues and was potentially mitigated by venue type. Translation to Health Education Practice Approaches are needed to encourage vacationers to practice comprehensive sun protection and to work with resorts to construct built environments that facilitate rather than act as barriers to sun safety.
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Affiliation(s)
- Barbara J Walkosz
- Senior Scientist, Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401
| | - Michael D Scott
- Professor Emeritus at California State University and President Mikonics, Inc., 40 B Old Road South, Santa Fe, NM 87540
| | - David B Buller
- Senior Scientist and Director of Research, Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401
| | - Peter A Andersen
- Professor Emeritus, School of Communication, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182
| | - Larry Beck
- Professor, L. Robert Payne School of Hospitality and Tourism Management, Room PSFA 445, San Diego State University, San Diego, CA 92182
| | - Gary R Cutter
- Professor, Department of Biostatistics, School of Public Health, RPHB 401B, University of Alabama, 1720 2Avenue South, Birmingham, AL 35294
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Stewart BW, Bray F, Forman D, Ohgaki H, Straif K, Ullrich A, Wild CP. Cancer prevention as part of precision medicine: 'plenty to be done'. Carcinogenesis 2016; 37:2-9. [PMID: 26590901 PMCID: PMC4700936 DOI: 10.1093/carcin/bgv166] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/30/2015] [Accepted: 11/12/2015] [Indexed: 02/06/2023] Open
Abstract
Cancer burden worldwide is projected to rise from 14 million new cases in 2012 to 24 million in 2035. Although the greatest increases will be in developing countries, where cancer services are already hard pressed, even the richest nations will struggle to meet demands of increasing patient numbers and spiralling treatment costs. No country can treat its way out of the cancer problem. Consequently, cancer control must combine improvements in treatment with greater emphasis on prevention and early detection. Cancer prevention is founded on describing the burden of cancer, identifying the causes and evaluating and implementing preventive interventions. Around 40-50% of cancers could be prevented if current knowledge about risk factors was translated into effective public health strategies. The benefits of prevention are attested to by major successes, for example, in tobacco control, vaccination against oncogenic viruses, reduced exposure to environmental and occupational carcinogens, and screening. Progress is still needed in areas such as weight control and physical activity. Fresh impetus for prevention and early detection will come through interdisciplinary approaches, encompassing knowledge and tools from advances in cancer biology. Examples include mutation profiles giving clues about aetiology and biomarkers for early detection, to stratify individuals for screening or for prognosis. However, cancer prevention requires a broad perspective stretching from the submicroscopic to the macropolitical, recognizing the importance of molecular profiling and multisectoral engagement across urban planning, transport, environment, agriculture, economics, etc., and applying interventions that may just as easily rely on a legislative measure as on a molecule.
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Affiliation(s)
| | - Freddie Bray
- International Agency for Research on Cancer, 69008 Lyon, France and
| | - David Forman
- International Agency for Research on Cancer, 69008 Lyon, France and
| | - Hiroko Ohgaki
- International Agency for Research on Cancer, 69008 Lyon, France and
| | - Kurt Straif
- International Agency for Research on Cancer, 69008 Lyon, France and
| | - Andreas Ullrich
- Noncommunicable Diseases and Mental Health, World Health Organization, 1121 Geneva 27, Switzerland
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Buller DB, Andersen PA, Walkosz BJ, Scott MD, Beck L, Cutter GR. Rationale, design, samples, and baseline sun protection in a randomized trial on a skin cancer prevention intervention in resort environments. Contemp Clin Trials 2015; 46:67-76. [PMID: 26593781 DOI: 10.1016/j.cct.2015.11.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Exposure to solar ultraviolet radiation during recreation is a risk factor for skin cancer. A trial evaluated an intervention to promote advanced sun protection (sunscreen pre-application/reapplication; protective hats and clothing; use of shade) during vacations. MATERIALS AND METHODS Adult visitors to hotels/resorts with outdoor recreation (i.e., vacationers) participated in a group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Hotels/resorts were pair-matched and randomly assigned to the intervention or untreated control group. Sun. protection (e.g., clothing, hats, shade and sunscreen) was measured in cross-sectional samples by observation and a face-to-face intercept survey during two-day visits. RESULTS Initially, 41 hotel/resorts (11%) participated but 4 dropped out before posttest. Hotel/resorts were diverse (employees=30 to 900; latitude=24° 78' N to 50° 52' N; elevation=2ft. to 9726ft. above sea level), and had a variety of outdoor venues (beaches/pools, court/lawn games, golf courses, common areas, and chairlifts). At pretest, 4347 vacationers were observed and 3531 surveyed. More females were surveyed (61%) than observed (50%). Vacationers were mostly 35-60years old, highly educated (college education=68%) and non-Hispanic white (93%), with high-risk skin types (22%). Vacationers reported covering 60% of their skin with clothing. Also, 40% of vacationers used shade; 60% applied sunscreen; and 42% had been sunburned. CONCLUSIONS The trial faced challenges recruiting resorts but result showed that the large, multi-state sample of vacationers were at high risk for solar UV exposure.
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Affiliation(s)
- David B Buller
- Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401, United States.
| | - Peter A Andersen
- School of Communication, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States.
| | - Barbara J Walkosz
- Klein Buendel, Inc., 1667 Cole Boulevard, Suite 225, Golden, CO 80401, United States.
| | - Michael D Scott
- California State University and President of Mikonics, Inc., 40 B Old Road South, Santa Fe, NM 87540, United States.
| | - Larry Beck
- L. Robert Payne School of Hospitality and Tourism Management, Room PSFA 445, San Diego State University, San Diego, CA 92182, United States.
| | - Gary R Cutter
- Department of Biostatistics, School of Public Health, RPHB 401B, University of Alabama, 1720 2nd Avenue South, Birmingham, AL 35294, United States.
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