Digital Commons Network^™

Sunburns And Sun Protection Behaviors Among Male Hispanic Outdoor Day Laborers, Zhaomeng Niu, Mary Riley, Jerod L. Stapleton, Michele Ochsner, Germania Hernandez, Daniel P. Giovenco, Shawna V. Hudson, Denalee O’Malley, Carolina Lozada, Marién Casillas Pabellón, Carolyn J. Heckman, Elliot J. Coups, Louis Kimmel

Health, Behavior & Society Faculty Publications

Individuals who work outside are at increased risk for skin cancer due to excessive exposure to ultraviolet (UV) radiation. Little is known about UV exposures and sun safety practices of outdoor day laborers, who are disproportionately Hispanic. This study identified the correlates of sunburn and sun protection behaviors in a sample of male, Hispanic day laborers (n = 175). More than half of the participants (54.9%) experienced one or more sunburns when working during the past summer, and 62.9% reported having one or more symptoms of heat illness. The frequency of engaging in sun protection behaviors was suboptimal, including …

Prevention Is Political: Political Party Affiliation Predicts Perceived Risk And Prevention Behaviors For Covid-19, Marc T. Kiviniemi, Heather Orom, Jennifer L. Hay, Erika A. Waters

Health, Behavior & Society Faculty Publications

BACKGROUND: Many US politicians have provided mixed messages about the risks posed by SARS-CoV-2/COVID-19 and whether and to what extent prevention practices should be put in place to prevent transmission. This politicization of the virus and pandemic may affect individuals' risk perceptions and willingness to take precautions. We examined how political party affiliation relates to risk perception for one's own and other people's likelihood of SARS-CoV-2 infection/COVID-19 illness.

METHODS: We surveyed members of a nationally-representative, probability-sampling based survey panel (N = 410) to examine their risk perceptions, precautionary behaviors, and political party affiliation.

RESULTS: The more strongly one identified …

Limitations In American Adults’ Awareness Of And Beliefs About Alcohol As A Risk Factor For Cancer, Marc T. Kiviniemi, Heather Orom, Jennifer L. Hay, Erika A. Waters

Health, Behavior & Society Faculty Publications

Alcohol is a carcinogen. Recommendations to reduce alcohol use to lower cancer risk are increasingly common. However, neither the beliefs of US adults about alcohol consumption and cancer risk, nor factors influencing those beliefs, are well understood. We used data from the 2019 Health Information National Trends Survey (analysis N = 4,470) to examine beliefs about whether drinking too much alcohol increases cancer risk. We compared those beliefs to beliefs for three other health problems, and examined whether believing alcohol is a cancer risk factor was related to demographics, risk perceptions, other beliefs about the nature of cancer, and alcohol …

Development Of A Multilevel Intervention To Increase Colorectal Cancer Screening In Appalachia, Aaron J. Kruse-Diehr, Jill M. Oliveri, Robin C. Vanderpool, Mira L. Katz, Paul L. Reiter, Darrell M. Gray Ii, Michael L. Pennell, Gregory S. Young, Bin Huang, Darla Fickle, Mark Cromo, Melinda Rogers, David Gross, Ashley Gibson, Jeanne Jellison, Michael D. Sarap, Tonia A. Bivens, Tracy D. Mcguire, Ann Scheck Mcalearney, Timothy R. Huerta, Saurabh Rahurkar, Electra D. Paskett, Mark B. Dignan

Health, Behavior & Society Faculty Publications

Background

Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of “Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia,” a 5-year, National Cancer Institute Cancer Moonshot^SM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics.

Methods

Project development was theory-driven and included the …

Physician Skin Cancer Screening Among U.S. Military Veterans: Results From The National Health Interview Survey, Elliot J. Coups, Baichen Xu, Carolyn J. Heckman, Sharon L. Manne, Jerod L. Stapleton

Health, Behavior & Society Faculty Publications

Introduction

Although military veterans are at increased risk for skin cancer, little is known about the extent to which they have been screened for skin cancer. The study objective was to examine the prevalence and correlates of physician skin cancer screening among U.S. military veterans.

Methods

Data were drawn from the National Health Interview Survey. The study sample consisted of 2,826 individuals who reported being military veterans. Receipt of a physician skin examination was measured using a single question that asked participants whether they had ever had all of their skin from head to toe checked for cancer by a …

Authentic Youth Engagement In Environmental Health Research And Advocacy, Kathryn M. Cardarelli, Melinda J. Ickes, Luz Huntington-Moskos, Craig Wilmhoff, Angela Larck, Susan M. Pinney, Ellen J. Hahn

Health, Behavior & Society Faculty Publications

Training in environmental health (EH) engages and inspires youth to tackle health promotion and policy change. Yet, there is little guidance on how to successfully nurture and sustain youth engagement. This paper compares four case studies of youth engagement to promote EH in rural and urban communities using the Youth Empowerment Solutions (YES!) framework. Of the case studies in rural (Central Appalachia) and urban (Cincinnati, Ohio) communities, two employ citizen science approaches using PhotoVoice and environmental sampling; one engages youth in a science communication camp; and one focuses on policy advocacy. We compare and contrast these case studies using the …

Persistent Disparities In Smoking Among Rural Appalachians: Evidence From The Mountain Air Project, Kathryn Cardarelli, Susan C. Westneat, Madeline Dunfee, Beverly May, Nancy Schoenberg, Steven R. Browning

Health, Behavior & Society Faculty Publications

BACKGROUND: Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior.

METHODS: A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. …

Effects Of Website Interactivity On Skin Cancer-Related Intentions And User Experience: Factorial Randomized Experiment, Zhaomeng Niu, Jessica Fitts Willoughby, Elliot J. Coups, Jerod L. Stapleton

Health, Behavior & Society Faculty Publications

BACKGROUND: Digital media technologies provide users with the ability to interact with content and to receive information based on their preferences and engagement.

OBJECTIVE: We used skin cancer and sun protection as a health topic to explore how modality interactivity, interface tools that afford users greater activity, resulting in greater depth and breadth of mentally representing and experiencing mediated content, and message interactivity, the extent to which the system allows users to exchange messages back and forth on health websites, influenced users' attitudes, knowledge, behavioral intentions, and experience.

METHODS: We employed a 2×2 (modality interactivity: high vs low; message interactivity: …

Social Determinants Of Discrimination And Access To Health Care Among Transgender Women In Oregon, Jonathan Garcia, Richard A. Crosby

Health, Behavior & Society Faculty Publications

Purpose: Transgender women in the United States experience health disparities and limited access to gender-affirming health services. This study describes the social determinants of health that shape access to health services for transgender women in Oregon, a state with a high tally of gender-affirming policies.

Methods: We conducted qualitative interviews with 25 transgender women between 18 and 39 years of age. Interviews explored the social, economic, cultural, and legal factors that shape access to health. A Qualtrics survey captured sociodemographic characteristics. We identified facilitators and barriers to accessing gender-affirming services using thematic analysis of qualitative data.

Results: Our participants perceived …

The Influence Of Affect On Hpv Vaccine Decision Making In An Hpv Vaccine Naïve College Student Population, Lynne B. Klasko-Foster, Sarahmona M. Przybyla, Heather Orom, Elizabeth Gage-Bouchard, Marc T. Kiviniemi

Health, Behavior & Society Faculty Publications

The HPV vaccine is recommended for all adolescents starting at age 11, but coverage is low, especially in the young adult population. The CDC is prioritizing catch-up vaccination and has expanded recommendations for all young adults to age 26. College students may be ideal targets for HPV vaccine interventions as they typically have on-site clinics that offer prevention services and students are in the position to make decisions about their own healthcare. We examined the risk perceptions of 101 HPV vaccine-naïve college students, both in terms of risk cognition (beliefs about susceptibility to HPV-related cancers and genital warts) and affect …

An Experimental Investigation Into Promoting Mental Health Service Use On Social Media: Effects Of Source And Comments, Zhaomeng Niu, Lun Hu, David C. Jeong, Jared Brickman, Jerod L. Stapleton

Health, Behavior & Society Faculty Publications

Mental health is an increasingly prevalent topic of public interest, but remains a complex area requiring focused research that must account for negative perceptions surrounding mental health issues. The current work explores the roles of social media information source credibility and valence of social media comments on health outcomes in such a mental health context. We used a 2 (message source: professional vs. layperson) × 3 (valence of comments: positive vs. negative vs. mixed) online experiment to examine the effects of source and valence of comments on trust, attitudes and intentions related to mental health information and services among 422 …

Psychosocial Mediators Of Perceived Stigma And Suicidal Ideation Among Transgender Women, Krishna Kiran Kota, Laura F. Salazar, Rachel E. Culbreth, Richard A. Crosby, Jamal Jones

Health, Behavior & Society Faculty Publications

BACKGROUND: Transgender women (TGW) in the U.S. experience high rates of stigma, depression, and elevated rates of suicide. This study examined correlates of suicidal ideation and estimated the conditional indirect effects of perceived stigma and psychosocial mediators on suicidal ideation.

METHODS: Using a cross-sectional study design, TGW (N = 92) were recruited through snowball sampling in Atlanta, Georgia. Structured interviews were conducted. Suicidal ideation was assessed by combining two variables that measured suicidal thoughts. Logistic regression models were performed to identify the potential risk and protective factors for suicidal ideation. We examined hypothesized psychosocial factors, including anxiety, depression, psychosocial impact …

Integrative Approaches To The Undergraduate Public Health Major Curriculum: Strengths, Challenges, And Examples, Marc T. Kiviniemi, Sarahmona M. Przybyla

Health, Behavior & Society Faculty Publications

Many “first generation” undergraduate public health degree programs were designed based on “siloed” course structures centered around subunits in the discipline (e.g., Introduction to Epidemiology, Introduction to Environmental Health) that may be meaningful primarily to experts in the field. An alternative to the siloed approach is an integrative curricular design, in which courses are designed around meaningful thematic units (e.g., explaining public health problems, asking and answering scientific questions in public health), with an emphasis on drawing connections between knowledge from different but complementary disciplinary areas as a means to improve student learning and retention. The integrative approach shifts the …

Correlates Of Not Using Antiretroviral Therapy Among Transwomen Living With Hiv: The Unique Role Of Personal Competence, Richard A. Crosby, Laura F. Salazar, Brandon J. Hill

Health, Behavior & Society Faculty Publications

Purpose: This study tested three psychosocial measures for their potential to serve as counseling goals for promoting ART to transgender women living with HIV (TWLH).

Methods: Among 69 TWLH, 17.4% were not taking ART; these volunteers were compared to the remainder using multivariate regression analyses.

Results: Only one psychosocial measure achieved significance: Personal Competence (Adjusted Odds Ratio = 0.80, 95% CI = 0.67–0.97, P = 0.02). Because this was a continuous measure, assessed on a 7-point scale, the protective adjusted odds ratio of 0.80 represents a 20% reduction in the odds of not taking ART for each unit of increase …

Cross Jurisdictional Boundaries To Build A Health Coalition: A Kentucky Case Study, Angela L. Carman, Margaret L. Mcgladrey

Health, Behavior & Society Faculty Publications

Cross-jurisdictional sharing is accomplished through collaboration across jurisdictional boundaries to deliver essential public health services and solve problems that cannot be easily addressed by single organizations or jurisdictions. Partners across 10 counties and three public health jurisdictions of the Barren River Area Development District (BRADD) convened as Barren River Initiative to Get Healthy Together (BRIGHT), a community health improvement coalition. Focus groups and interviews with BRIGHT members indicate that the use of effective strategies to focus collaborative health improvement efforts fosters a cohesive coalition even when the group is populated by individuals from across public health jurisdictional boundaries. Focusing strategies …

Hiv Clustering In Mississippi: Spatial Epidemiological Study To Inform Implementation Science In The Deep South, Thomas J. Stopka, Lauren Brinkley-Rubinstein, Kendra Johnson, Philip A. Chan, Marga Hutcheson, Richard A. Crosby, Deirdre Burke, Leandro Mena, Amy Nunn

Health, Behavior & Society Faculty Publications

Background: In recent years, more than half of new HIV infections in the United States occur among African Americans in the Southeastern United States. Spatial epidemiological analyses can inform public health responses in the Deep South by identifying HIV hotspots and community-level factors associated with clustering.

Objective: The goal of this study was to identify and characterize HIV clusters in Mississippi through analysis of state-level HIV surveillance data.

Methods: We used a combination of spatial epidemiology and statistical modeling to identify and characterize HIV hotspots in Mississippi census tracts (n=658) from 2008 to 2014. We conducted spatial analyses of all …

Self-Collected Vaginal Swabs For Hpv Screening: An Exploratory Study Of Rural Black Mississippi Women, Richard A. Crosby, Michael E. Hagensee, Rebecca Fisher, Lindsay R. Stradtman, Tom Collins

Health, Behavior & Society Faculty Publications

Objectives. To determine the post-procedure acceptability of self-collecting a vaginal swab for HPV testing among a highly impoverished and geographically isolated population of medically underserved Black women residing in the Mississippi Delta. Further, to test correlates of reporting that self-collection is preferred over Pap testing. Finally, to determine the prevalence of any of 13 high-risk HPV types among this population and the correlates of testing positive.

Methods. Eighty-eight women were recruited from two churches located in different towns of the Mississippi Delta. After completing a survey, women were provided instructions for self-collecting a cervico-vaginal swab and completing a post-collection survey. …

Is Sex With Older Male Partners Associated With Higher Sexual Risk Behavior Among Young Black Msm?, Nicholas Chamberlain, Leandro A. Mena, Angelica Geter, Richard A. Crosby

Health, Behavior & Society Faculty Publications

Participants at a sexual health clinic completed a survey with questions regarding sexual risk behavior and partner characteristics. Of 585 participants eligible for analysis, 124 reported generally having older male partners. These participants were significantly more likely to be HIV-infected (p < 0.001), have four or more sex partners as a “bottom” (p = 0.04), have concurrent partners (p = 0.01), and have partners suspected of having an sexually transmitted infection (p = 0.05) than participants without older partners. With analysis restricted to HIV− individuals, risk behaviors did not differ significantly between the groups. HIV− individuals with older partners may be at increased risk of HIV infection due …

An Interactive, Mobile-Based Tool For Personal Social Network Data Collection And Visualization Among A Geographically Isolated And Socioeconomically Disadvantaged Population: Early-Stage Feasibility Study With Qualitative User Feedback, Katherine S. Eddens, Jesse M. Fagan, Tom Collins

Health, Behavior & Society Faculty Publications

Background: Personal social networks have a profound impact on our health, yet collecting personal network data for use in health communication, behavior change, or translation and dissemination interventions has proved challenging. Recent advances in social network data collection software have reduced the burden of network studies on researchers and respondents alike, yet little testing has occurred to discover whether these methods are: (1) acceptable to a variety of target populations, including those who may have limited experience with technology or limited literacy; and (2) practical in the field, specifically in areas that are geographically and technologically disconnected, such as rural …

Contextual Factors And Sexual Risk Behaviors Among Young, Black Men, Jamal Jones, Laura F. Salazar, Richard A. Crosby

Health, Behavior & Society Faculty Publications

Young Black men (YBM), aged 13 to 24 years, face a disproportionate burden of sexually transmitted infections (STIs). STI acquisition among YBM is due to incorrect and inconsistent condom use and is exacerbated by multiple sexual partners. Sexual and reproductive health is influenced by a complex interaction of biological, psychological, and social determinants that contribute to increased risk for STI acquisition. However, there are key social determinants of sexual health that play a major role in adolescent sexual risk-taking behaviors: gender norms, environment, peers, and families as well as a desire to impregnate a woman. Associations between contextual factors (risky …

Exploring Individual And Structural Factors Associated With Employment Among Young Transgender Women Of Color Using A No-Cost Transgender Legal Resource Center, Brandon J. Hill, Kris Rosentel, Trevor Bak, Michael Silverman, Richard A. Crosby, Laura Salazar, Michele Kipke

Health, Behavior & Society Faculty Publications

Purpose: The purpose of this study was to explore individual and structural factors associated with employment among young transgender women (TW) of color.

Methods: Sixty-five trans women of color were recruited from the Transgender Legal Defense and Education Fund to complete a 30-min interviewer-assisted survey assessing sociodemographics, housing, workplace discrimination, job-seeking self-efficacy, self-esteem, perceived public passability, and transactional sex work.

Results: Logistic regression models revealed that stable housing (structural factor) and job-seeking self-efficacy (individual factor) were significantly associated with currently being employed.

Conclusion: Our findings underscore the need for multilevel approaches to assist TW of color gain employment.

Promoting Teen Contraceptive Use By Intervention With Their Mothers, Richard A. Crosby, Tom Collins, Lindsay R. Stradtman

Health, Behavior & Society Faculty Publications

Introduction: The purpose of this pilot study was to test a community outreach model designed to help mothers in a rural, medically underserved area navigate their teen daughters to health department services for long-acting reversible contraception (LARC) or alternative contraception.

Methods: The pilot study used a single-group, post-test only design. Mothers of teen daughters (N=142) received a 1-hour, one-to-one intervention session (in outreach settings) from Community Liaisons. Mothers received training on how to communicate with their daughters about LARC and other contraceptive methods. Data were collected from June through October 2014, and analyzed in September 2015.

Results: The authors re-contacted …

Dealing With Pre-Exposure Prophylaxis-Associated Condom Migration: Changing The Paradigm For Men Who Have Sex With Men, Richard A. Crosby

Health, Behavior & Society Faculty Publications

The behavioural aspects of pre-exposure prophylaxis (PrEP) are challenging, particularly the issue of condom migration. Three vital questions are: (1) at the population-level, will condom migration lead to increases in non-viral sexually transmissible infections?; (2) how can clinic-based counselling best promote the dual use of condoms and PrEP?; and (3) in future PrEP trials, what are the ‘best practices’ that should be used to avoid type 1 and type 2 errors that arise without accounting for condom use behaviours? This communication piece addresses each question and suggests the risk of a ‘PrEP only’ focus to widening health disparities.

Correlates Of Sexual-Risk Behaviors Among Young Black Msm: Implications For Clinic-Based Counseling Programs, Richard A. Crosby, Leandro Mena, Janelle M. Ricks

Health, Behavior & Society Faculty Publications

This study applied an 8-item index of recent sexual-risk behaviors to young Black men who have sex with men (YBMSM) and evaluated the distribution for normality. The distribution was tested for associations with possible antecedents of sexual risk. YBMSM (N = 600), aged 16–29 years, were recruited from a sexually transmitted infection clinic, located in the southern US. Men completed an extensive audio computer-assisted self-interview. Thirteen possible antecedents of sexual risk, as assessed by the index, were selected for analyses. The 8-item index formed a normal distribution with a mean of 4.77 (SD = 1.77). In adjusted analyses, not …

Circumcision Status Is Not Associated With Condom Use And Prevalence Of Sexually Transmitted Infections Among Young Black Msm, Richard A. Crosby, Cynthia A. Graham, Leandro Mena, William L. Yarber, Stephanie A. Sanders, Robin R. Milhausen, Angelica Geter

Health, Behavior & Society Faculty Publications

This study investigated whether intact young Black MSM differed from their circumcised counterparts regarding condom use behaviors and perceptions and HIV/Chlamydia/gonorrhea. Young Black MSM completed a self-interview, including a pictorial item assessing circumcision status and measures of condom use. Twenty-seven percent of 388 participants reported not being circumcised. With one exception, no associations tested approached significance. The mean frequency of unprotected insertive anal sex for circumcised men was about twice as high compared to those intact (P = .04). Intact young Black MSM did not differ from circumcised men relative to prevalence of STIs (including HIV) or condom use behaviors …

Similarities And Differences In Sexual Risk Behaviors Between Young Black Msm Who Do And Do Not Have Sex With Females, Richard A. Crosby, Leandro Mena, Angelica Geter, Demarc Hickson

Health, Behavior & Society Faculty Publications

The objective of this study is to determine whether young Black MSM who also have sex with females report similar levels of sexual risk behaviors as those not having sex with females. YBMSM (N = 400) were recruited from an STI clinic, located in the Southern U.S. Men completed an audio-computer assisted self-interview and donated specimens for STI/HIV testing. Forty-three percent recently engaged in penile-vaginal sex. They were less likely to report having concurrent partners (P = .01), unprotected fellatio (P = .04), multiple partners as a bottom (P < .02), any unprotected anal sex as a bottom (P < .013), and any anal sex (P = .007). They were equally likely …

Fatalistic Beliefs And Completion Of The Hpv Vaccination Series Among A Sample Of Young Appalachian Kentucky Women, Robin C. Vanderpool, Emily Van Meter Dressler, Lindsay R. Stradtman, Richard A. Crosby

Health, Behavior & Society Faculty Publications

PURPOSE: Uptake and completion of the 3-dose human papillomavirus (HPV) vaccine is important for the primary prevention of cervical cancer. However, HPV vaccination rates among adolescent females and young women remain low in certain geographic areas of the United States, including Appalachia. Although greater fatalistic beliefs have been previously associated with lower rates of preventive cancer behaviors among adults, little research exists on the impact of fatalism on HPV vaccination behaviors, especially among younger individuals. Therefore, the purpose of this study was to examine the association between fatalistic beliefs and completion of the full HPV vaccine series among young women, …

Menthol Cigarette Smoking And Obesity In Young Adult Daily Smokers In Hawaii, Alyssa Marie M. Antonio, Pebbles Fagan, Faith D. Hamamura, Ian Joseph N. Lagua, Jenny Liu, Devin J. Park, Pallav Pokhrel, Thaddeus A. Herzog, Ian Pagano, Kevin Cassel, Angela Sy, Dorothy Jorgensen, Tania Lynch, Crissy Kawamoto, Carol J. Boushey, Adrian Franke, Mark S. Clanton, Eric T. Moolchan, Linda A. Alexander

Health, Behavior & Society Faculty Publications

This study investigates 1) the relationship between menthol cigarette smoking and obesity and 2) the association of body mass index with the nicotine metabolite ratio among menthol and non-menthol daily smokers aged 18–35 (n = 175). A brief survey on smoking and measures of height and weight, carbon monoxide, and saliva samples were collected from participants from May to December 2013 in Honolulu, Hawaii. Multiple regression was used to estimate differences in body mass index among menthol and non-menthol smokers and the association of menthol smoking with obesity. We calculated the log of the nicotine metabolite ratio to examine differences …

Condom-Associated Erection Problems: A Study Of High-Risk Young Black Males Residing In The Southern United States, Cynthia A. Graham, Richard A. Crosby, Stephanie Sanders, Robin Milhausen, William L. Yarber

Health, Behavior & Society Faculty Publications

Previous research indicates that young men may experience condom-associated erection loss and that these problems may lead to inconsistent or incomplete condom use. The primary aim of this study was to assess, using a retrospective recall period of 2 months, correlates of condom-associated erection problems among young Black men attending sexually transmitted infection (STI) clinics. Data were collected in clinics treating patients with STIs in three southern U.S. cities. Males 15 to 23 years of age who identified as Black/African American and reported recent (past 2 months) condom use were eligible. A total of 494 men participated. Nineteen percent reported …

Acceptability Of Condoms, Circumcision And Prep Among Young Black Men Who Have Sex With Men: A Descriptive Study Based On Effectiveness And Cost, Richard A. Crosby, Angelica Geter, Ralph J. Diclemente, Laura F. Salazar

Health, Behavior & Society Faculty Publications

The current study examined and compared the willingness of young Black men who have sex with men (YBMSM) to accept pre-exposure prophylaxis (PrEP), adult male circumcision, and condoms for reducing their risk of HIV acquisition. The majority (67%) reported unprotected receptive anal sex in the last six months. About three-quarters (71%) would accept using PrEP if it was 100% effective. Cost influenced PrEP acceptance with 19% indicating acceptance at $100 per month co-pay. Of those not circumcised, 50% indicated willingness if circumcision was 100% effective. Acceptance of circumcision decreased markedly to 17% with co-pays of $100. About 73% of men …