Safety Science 78 (2015) 173178

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/ssci

Safety climate, safety behavior, and worker injuries in the Chinese

manufacturing industry
Xinxia Liu a,b, Guoxian Huang b, Huiqiang Huang b, Shuyu Wang b, Yani Xiao a, Weiqing Chen a,
a
Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
b
Center for Disease Control and Prevention, Zhongshan, Guangdong, China

a r t i c l e i n f o a b s t r a c t

Article history: It is estimated that over 10,000,000 occupational injuries occur in China each year. This study explored
Received 8 October 2014 the relationships between four dimensions of safety climate (management commitment, safety supervi-
Received in revised form 31 March 2015 sion, coworker support, and safety training), three dimensions of safety behavior (safety compliance,
Accepted 27 April 2015
personal protective equipment, and safety initiatives), and occupational injuries among Chinese manu-
Available online 14 May 2015
facturing workers. A cross-sectional survey was conducted using a sample of 3970 manufacturing work-
ers from 42 companies in Zhongshan City, China. A structured questionnaire was used to capture
Keywords:
participants socio-demographic characteristics, occupational safety climate, occupational safety behav-
Occupational safety climate
Safety behavior
ior, and occupational injuries in the previous year. Path analysis was used to test the relationships
Unintentional occupational injury between safety climate, safety behavior and injuries at each workplace. The results revealed signicant
associations between different safety climates, safety behavior, and unintentional injuries, and provided
evidence that safety behavior strongly mediates the relationship between safety climate and uninten-
tional injuries. Our study reinforces the empirical association of occupational safety climate and safety
behavior with occupational injuries and identies some effective measures to prevent and control inju-
ries in Chinese workplaces.
2015 Elsevier Ltd. All rights reserved.

1. Introduction organization, promoting the safety program within the workplace,

A safety climate is the sum of employees shared perceptions of
the policies, procedures, and practices relating to safety in their
work environment (Zohar, 1980; Huang et al., 2006). Although
the constructs used to assess safety climate have varied from study
to study, measured domains generally include management com-
mitment, supervisor support, safety awareness, safety training,
safety policy, safety knowledge, safety communication, and
co-worker support (Seo et al., 2004; Olsen, 2010; O Connor et al.,
2011; Brondino et al., 2012; Huang et al., 2012).
Previous studies have used the theory of task and contextual
performance to divide safety behavior into two types: safety par-
ticipation and safety compliance (Grifn and Neal, 2000). Neal
et al. (2000) rstly dened safety compliance as complying with
safety procedures and carrying out work in a safe manner, and
safety participation as a safety-oriented behavior that involves
the individual providing safety suggestions within the
Corresponding author. Tel.: +86 20 87332199; fax: +86 20 87330446.
E-mail addresses: xinxialiu@126.com (X. Liu), chenwq@mail.sysu.edu.cn
(W. Chen).
demonstrating initiative, and putting effort into improving safety
in the workplace.
In recent decades, it has been well documented that safety cli-
mate is related to safety behavior and unintentional injuries in
workplaces in Western countries. A recent meta-analytic review
revealed that safety climates offer robust predictions of objective
safety criteria (the occurrence of occupational injury) and subjec-
tive safety criteria (better self-reported safety behavior) across
industries (Clarke, 2006a) and countries (Christian et al., 2009).
Moreover, it was found that a positive safety climate can encour-
age safe performance either through rewards or through principles
of social exchange (Zohar, 2000; Clarke, 2006b) and that safety cli-
mate might indirectly affect safety behavior through some media-
tion variables (Grifn and Neal, 2000; Zohar and Luria, 2003). A
number of studies showed that safety climate was directly associ-
ated with safety performance (Zohar, 2000; Siu et al., 2004; Smith
et al., 2006; Clarke, 2006a; Wu et al., 2008; Brondino et al., 2012;
Zohar et al., 2014). In contrast, Clarke found that safety climate
was signicantly related to safety behavior (i.e., safety participa-
tion and compliance), but weakly related to occupational injuries
(Clarke, 2006a).

http://dx.doi.org/10.1016/j.ssci.2015.04.023
0925-7535/ 2015 Elsevier Ltd. All rights reserved.
174 X. Liu et al. / Safety Science 78 (2015) 173178

Due to Chinas rapid industrialization, occupational injuries
have become an important public health problem in recent dec-
ades. The Chinese Ministry of Human Resources and Social
Security (2012) reported that there were approximately 1.17 mil-
lion workplace injuries in 2012. However, the reason for the high
occurrence of occupational injuries in China is still unclear. The
present study examined whether the association between safety
climate, safety behavior, and occupational injuries found in
Western countries also exists in Chinese manufacturing
enterprises.
2. Methods
2.1. Participants
The convenience sampling method was used to select 50 man-
ufacturing enterprises in Zhongshan City in Southern China for the
study. The surveys were distributed between May 2011 and
December 2012, and eight enterprises did not respond. Among
the 42 enrolled enterprises, 19 were medium-size enterprise and
23 were small-size enterprises, involved in lighting processing,
metal, shoes, electronics, and toys.
A retrospective survey was administered to the front-line pro-
duction workers of the 42 enrolled enterprises. Of the 3970 work-
ers who received the survey, 3375 completed the whole
questionnaire, giving a response rate of 85.0%. The average age of
the surveyed workers was 32.67 years (SD = 8.31) with a range
from 18 to 59. The average years of experience in their current
job was 6.71 years (SD = 5.82). Other demographic traits are shown
in Table 1.
survey, the content of the questionnaire, and how to complete it.
During the data collection, the investigators answered any queries
raised by the workers. All of the questionnaires were immediately
checked for missing data or errors to ensure they were correctly
completed.
2.3. Relevant measures
2.3.1. Occupational safety climate
Building on previous occupational safety climate scales (Varonen
and Mattila, 2000; Mearns et al., 2003; Cooper and Phillips, 2004;
Huang et al., 2006; Lin et al., 2008; Lu and Tsai, 2008), we developed
an occupational safety climate scale in Chinese. Barbaranellis nd-
ings provided initial empirical evidence of the cross-country mea-
surement equivalence of the safety climate scales (Barbaranelli
et al., 2015). It consisted of twenty-two items, and each item was
rated on a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = nei-
ther disagree nor agree, 4 = disagree, 5 = strongly disagree).
Exploratory factor analysis (EFA) was used to evaluate the safety cli-
mate scale. Variables with factor loadings of 0.45 or greater were
grouped and judgments were made about their applicability to an
underlying concept (Pett et al., 2003). The KaiserMeyerOlkin
value of 0.94 indicated that the data were suitable for factor analy-
sis, and the Bartlett Test of Sphericity (v2 = 42766.47, p < 0.01) sug-
gested that correlations existed between some of the response
categories. A reliability test was performed to evaluate the internal
consistency; the Cronbachs alpha coefcient of 0.70 is generally
accepted as the minimum desired value (Litwin, 1995).
The results of the exploratory factor analysis (EFA) of the safety
climate and reliability test are presented in Table 2. The factor

2.2. Data collection

Table 2
The selected workers were asked to complete a Factor loadings of the occupational safety climate scale.

self-administered structured questionnaire in Chinese asking Item description (variance proportion; Cronbachs alpha Factor
about their socio-demographic characteristics, perceived safety coefcient) loading
climate, occupational safety behavior, and work-related injuries Factor 1: Co-workers support(18.41%; 0.88)
in the past 12 months. Before the survey, several well-trained Coworkers mention safety compliance 0.802
investigators explained to all of the workers the objectives of Coworkers maintain safe conditions 0.797
Coworkers focus on their own work safety 0.716
Coworkers comply with safety procedures 0.685
Coworkers pay close attention to the safety of our team 0.662
Table 1
Demographic traits of participants. Factor 2: Management commitment(18.12%; 0.90)
Management invites employees to safety improvement 0.766
Demographic traits n % sessions
Gender Management encourages employees to participate in security 0.760
Male 2352 69.7 goal setting
Female 1023 30.3 Management encourages safety participation 0.753
Management accepts advice about safety 0.658
Marital status
Management is concerned about our well-being 0.632
Unmarried 835 24.8
Management offers enough safety information 0.492
Married 2424 71.8
Other 116 3.4 Factor 3: Safety supervision (15.63%; 0.86)
Supervisors frequently check the production situation 0.713
Educational level
Supervisors warn employees of no-smoking rules in the 0.701
Primary or below 366 10.8
workplace
Lower secondary 2100 62.2
Supervisors frequently check the PPE 0.681
Upper secondary 786 23.3
Supervisors frequently talk about safety 0.628
Tertiary or above 123 3.7
Supervisors draw employees attention to production safety 0.492
Years of work experience guides or warning labels
65 y 1821 54.0 Supervisors remind employees to wear PPE 0.473
615 y 1324 39.2
Safety training (10.52%; 0.73)
1625 y 195 5.8
I have been offered enough training in PPE 0.697
P26 y 35 1.0
I have been offered enough safety training during new staff 0.557
Monthly income (RMB) induction
61000 60 1.8 I had an occupational health examination during new staff 0.556
10012000 984 29.2 induction
20013000 1729 51.2 I have been offered enough training in health information 0.506
30014000 405 12.0 I have been offered regular and useful safety training 0.469
>4000 197 5.8
PPE: personal protective equipment.
 X. Liu et al. / Safety Science 78 (2015) 173178
analysis identied four factors that explained 62.7% of the total
variance. According to the nature and content of the items included
in each factor, the four factors were as follows: coworker support,
management commitment, safety supervision, and safety training.
The Cronbachs alpha coefcients were high, ranging from 0.73 to
0.90.
2.3.2. Occupational safety behavior
We used onsite observations and discussions with occupational
physicians and safety managers to develop a Chinese scale to mea-
sure workers occupational safety behavior. Each of the twenty-one
items asked a participant to state how often he followed the rele-
vant behavior; for example, Use the machine shield correctly.
Each item was rated on a 5-point Likert scale (1 = always,
2 = mostly, 3 = occasionally, 4 = never, and 5 = never encounter).
The factor analysis identied three factors that explained 56.66%
of the total variance. Based on the nature and contents of the items
included in each factor, the three factors were dened as follows:
personal protective equipment, safety compliance, and safety
initiatives.The KaiserMeyerOlkin value was 0.90 and the
Bartlett Test of Sphericity was v2 = 34630.14 (p < 0.01). The
Cronbachs alpha coefcients were high, ranging from 0.77 to
0.89 (Table 3).
2.3.3. The work-related injury experience
In this study, a work-related injury was dened as any injury
that occurred at the workplace; the workplace was dened as
any location in which the worker was present in the course of
his or her duties. All of the workers were asked whether they
had been injured at work during the past 12 months. The responses
were coded as 1 for yes and 0 for No. The frequency and sever-
ity of the injuries were also recorded. Injuries were categorized as
serious injuries (required hospital treatment), moderate injuries
(involving at least a days work lost), and light injuries (needed
immediate treatment but did not inuence work, such as minor
Table 3
Factor loadings of safety behavior scale.
Item description (variance proportion; Cronbachs alpha
coefcient)
Personal protective equipment (22.23%; 0.89)
Wear respirators or breathing mask
Wear ear defenders in noisy workplace
Wear gloves as safety procedure
Wear gloves while using chemicals
Use the machine shield correctly
Wear respirator although there is a local ventilation system in
workplace
Replace my respirator regularly
Wear ear defenders in noisy workplace, even when talking
with coworkers
Safety compliance (17.23%; 0.89)
Turn off the power and inform the supervisory when a machine
is working abnormally
Adjust posture at work to avoid fatigue
Do not smoke in workplace
Use a tool to adjust a dangerous part of a machine
Use a cart or other hand barrow when carrying heavy goods
Stop working when not offered protective equipment
Read instruction manual carefully before I use a new machine
Clean work bench before going off-duty
Safety initiatives (17.21%; 0.77)
Read material safety data sheet before using a new chemical
Check the containers to prevent chemicals from leaking
Cover the containers after using chemicals
Inform the supervisory of chemicals without labels
Use local ventilation equipment to discharge poisonous waste
175
bruising). In this study, only the serious and moderate injuries
were included in the nal data analysis.
The injury frequency was transformed by logit transformation
(Fullarton and Stokes, 2007) to make the data suitable for regres-
sion analyses such as path analysis. The frequency of injuries (i)
was divided by the number of employees (N) for each site (g).
This provided a measure of the injury risk at each site. The injury
data display a Poisson distribution, and as such, did not t a normal
distribution (Hosmer and Lemeshow, 2000). The transformed log
scores were then made negative to return the direction of scores,
where the scores become larger when transformed. This variable,
thereafter referred to as injury probability, was calculated as
follows:
0 1
ig
b g  log @ Ng
Y  A
i
1  Ngg
2.4. Statistical analyses
The database was constructed using EpiData 3.0. Missing data
accounted for no more than 2% of any variable and were imputed
using the mean replacement method.
Descriptive statistics and correlations between variables were
computed using SPSS 17.0 for Windows. Path analysis was per-
formed with Amos 20.0. To examine the signicance of each path,
the signicance levels of the regression parameters for the rela-
tionship between the variables in the estimated models (path coef-
cients) were denoted by the critical ratio or t-value
(t-value > 1.96, p < .05), and the chi-square test was used to evalu-
ate the t. The model t was considered to be good if the
goodness-of-t (GFI), the Comparative Fit Index (CFI), and the
Tucker-Lewis index (TLI) were greater than 0.95, the root mean
square error of approximation (RMSEA) was less than 0.05, and
the normed chi-square index (v2/df ratio) was less than 3.0
(Kline, 2005).
3. Results
Factor 3.1. Inter-correlations between occupational safety climate, behavior,
loading
and injury
0.842
The descriptive statistics and inter-correlations between the
0.818
0.763
latent variables of occupational safety climate, behavior, and
0.763 work-related injury are presented in Table 4. Except for the corre-
0.728 lations between coworker support and personal protective
0.710 equipment, between safety supervision and personal protec-
tive equipment, and between safety training and
0.706
0.686 work-related injuries, the correlations between the variables
were signicant with correlation coefcients ranging from 0.068
to 0.712.
0.736
0.705 3.2. Path analysis
0.592
0.588 The path model t the data well (GFI = 0.999; CFI = 0.996;
0.588
TLI = 0.992; RMSEA = 0.011; v2/df = 1.385). The path coefcients
0.584
0.548
in the path diagrams showed that the occupational safety climates
0.544 may affect the work-related injuries indirectly through occupa-
tional safety behavior (Fig. 1). Both safety supervision and man-
0.839 agement commitment to safety reduced the work-related injuries
0.824 by improving personal protective equipment use, safety compli-
0.797 ance, and safety initiatives.Coworkers support decreased the
0.697
work-related injury by promoting personal equipment use and
0.587
safety compliance, whereas safety training lessened the
176 X. Liu et al. / Safety Science 78 (2015) 173178

Table 4
Inter-correlation matrix for safety climate, safety behavior, and work-related injury.

Mean SD CS MC SS ST PPE SI SC
CS 1.998 0.468
MC 2.099 0.570 0.695**
SS 1.871 0.484 0.619** 0.712**
ST 2.216 0.517 0.485** 0.540** 0.540**
PPE 1.376 0.768 0.022 0.068** 0.016 0.099**
SI 1.833 0.818 0.169** 0.232** 0.324** 0.174** 0.192**
SC 2.258 1.375 0.213** 0.268** 0.293** 0.157** 0.298** 0.629**
INJ N/A 0.068** 0.155** 0.201** 0.020 0.160** 0.243** 0.267**

N/A: not applicable.

MC: management commitment; SS: safety supervision; CS: coworker support; ST: safety training; PPE: personal protective equipment; SI: safety initiatives; SC: safety
compliance; INJ: injury.
**
p < 0.01.

SS
PPE

CS
SC
INJ

MC
SI

ST

Fig. 1. Path model with occupational safety climates as predictors, occupational safety behavior as mediators, and work-related injuries as outcomes. MC: management
commitment; SS: safety supervision; CS: coworker support; ST: safety training; PPE: personal protective equipment; SI: safety initiatives; SC: safety compliance; INJ: injury

p < 0.01. p < 0.05.

Table 5
Direct, indirect, and total effects of occupational safety climate and behavior on work-related injury.

ST MC CS SS SI SC PPE
SI
Direct effect 0.114** 0.301**
Indirect effect
Total effect 0.114** 0.301**
SC
Direct effect 0.169** 0.119** 0.127**
Indirect effect
Total effect 0.169** 0.119** 0.127**
PPE
Direct effect 0.121** 0.064** 0.043* 0.116**
Indirect effect
Total effect 0.121** 0.064** 0.043* 0.116**
Work-related injury
Direct effect 0.130** 0.145** 0.146**
Indirect effect 0.018 0.049 0.011 0.041
Total effect 0.018 0.049 0.011 0.041 0.130** 0.145** 0.146**

MC: management commitment; SS: safety supervision; CS: coworker support; ST: safety training; PPE: personal protective equipment; SI: safety initiatives; SC: safety
compliance.
*
P < 0.05.
**
P < 0.01.

work-related injuries by increasing the use of personal protective work-related injuries. Of all the standardized total effects, the
equipment. absolute value of the use of personal protective equipment was
Table 5 shows the estimates of the standardized direct, indirect, the greatest, followed by safety compliance, safety initiative,
and total effects of occupational safety climates and behavior on management commitment, safety supervision, safety
 X. Liu et al. / Safety Science 78 (2015) 173178
training, and coworker support.For the standardized direct
effects, the absolute value of the use of personal protective equip-
ment was the greatest, followed by safety compliance and
safety initiative. For the standardized indirect effects, the abso-
lute value of the use of management commitment was the great-
est, followed by safety supervision, safety training, and
coworker support.
4. Discussion
The results of this study suggest that safety climate predicts
safety behavior, and that safety behavior mediates the relationship
between safety climate and occupational injury in China. These
ndings are in line with previous studies in other countries
(Hofmann and Stetzer, 1996; Cavazza and Serpe, 2009). In their
meta-analysis, Christian et al. (2009) developed a theoretical
model in which safety climate was the antecedent of safety perfor-
mance and had an indirect effect on occupational injury through
safety performance. The study of mediation factors is important
because it allows us to understand the mechanisms through which
safety climate operates on workers behavior and reduces the risk
of injury. Our study established empirical links between specic
dimensions of safety climate, such as safety supervision (SS), man-
agement commitment (MC), coworker support (CS), safety training
(ST), and safety behavior, such as safety initiates (SI), personal pro-
tective equipment (PPE), and safety compliance (SC). SS and MC
had a positive relationship with three different dimensions of
safety behavior. Safety initiatives (SI), personal protective equip-
ment (PPE), and safety compliance (SC) had similar associations
with occupational injury.
Our results revealed that safety supervision (SS) was the most
proximal antecedent of safety initiative behavior, which also
increased the use of PPE and employees safety compliance.
Zohar and Luria (2003) carried out an intervention in which super-
visors were trained to participate in safety-oriented communica-
tion with subordinate workers; they found that the intervention
reduced minor injury rates and increased PPE use. In a study of
the maintenance of heavy duty equipment, Zohar (2002) found
that improved communication between line workers and supervi-
sors resulted in decreasing micro accidents and increasing PPE use.
Sampson suggested that supervisors use of communication had a
positive effect on safety compliance and safety participation
(Sampson et al., 2014). According to the LeaderMemberexchan
ge (LMX) theory (Graen and Uhl-Bien, 1995), supervisors can
increase safety initiatives among employees by inspiring safety
and improving PPE use, and they can increase employees safety
compliance by using safety monitoring (Grifn and Hu, 2013).
Our results expanded upon these ndings by suggesting that com-
munication between supervisors and workers might also improve
the safety behavior of workers.
Coworker support (CS) was also an important dimension of
safety climate. Our results showed that coworker support was pos-
itively associated with SC and PPE (b = 0.119, p < 0.001; b = 0.043,
p < 0.05). Work group safety mainly involved coworkers involve-
ment in and commitment to safety issues: if an employee per-
ceived that his/her coworkers were concerned about safety, the
whole group tended to practice safe behavior (Hayes et al.,
1998). In a study of manufacturing industries in Italy, researchers
showed that coworkers safety climate had a stronger inuence
on safety behavior, especially on safety participation, than supervi-
sors safety climate (Brondino et al., 2012). However, in our study,
the path CSSI was non-signicant, indicating that in Chinese man-
ufacturing groups, the mutual inuence between colleagues is not
sufcient to encourage workers to participate in active safety
behavior. It is necessary for higher-level managers, using
177
techniques such as increasing support with incentive policies to
strengthen supervision and promote safe behavior.
Management commitment (MC) (b = 0.169, p < 0.001) was the
most proximal antecedent of safety compliance behavior and had
an indirect effect on occupational injury. Like the SS dimension,
MC also had a signicant effect on three dimensions of safety
behavior. These results were consistent with previous scholars
conclusions that MC is a major factor in safety climate and is crit-
ical to employee safety performance (Christian et al., 2009). Kao
used a structural equation model to test the relationship between
management commitment and safety performance, including
safety initiatives, compliance behavior, and occupational injury
(Kao et al., 2009). Their ndings revealed that MC had no direct
correlation with compliance behavior and injury, but a positive
correlation with SI, which was partly consistent with the results
of our study. MC assesses the extent to which people perceive that
management values safety, how they communicate safety issues,
and their actions that support safety. MC is a sign of the extent
to which top management demonstrates positive and supportive
attitudes toward worker safety. In China, when top management
is committed to safety, they may set goals for safe production,
establish an occupational safety management organization,
increase communication and feedback, and provide enough sup-
port and resources for safety activities. All of these measures help
increase the three types of safety behavior.
Safety training was positively associated with the use of per-
sonal protective equipment (b = 0.121, p < 0.001). However, in the
present study the SSSI and SSSC paths were
non-signicant, indicating that safety training did not signicantly
alter safety behavior encourage employees to comply with safety
procedures. This is not consistent with previous studies (Cooper
and Phillips, 2004; Huang et al., 2012), which suggested that safety
training (one dimension of the safety climate) could predict the
actual levels of safety behavior among manufacturing employees.
Our results may reect the fact that in China, safety training is
mainly for new employees and aimed at improving their safety
knowledge (i.e., operating the machine correctly and wearing
PPE). Other types of daily safety training are conducted sporadi-
cally and have limited effects on safety behavior.
Personal protective equipment, safety compliance, and initia-
tive behavior were all associated with lower rates of
self-reported occupational injury (b = 0.146, b = 0.145, b = 0.130,
p < 0.001). Our ndings about EFA support the trend in the occupa-
tional safety research literature toward conceptualizing safety
behavior as multi-dimensional (Grifn and Neal, 2000; Martnez-
Crcoles et al., 2011; Zhang and Wu, 2014). For example, in this
study, personal protective equipment was distinguished from
safety compliance behavior as in the other recent studies
(Cavazza and Serpe, 2009; Arcury et al., 2012; Tholn et al.,
2013). According to the American National Safety Council, failure
to use protective gear provided at the workplace accounts for
approximately 40% of work accidents (Olson et al., 2009). Safety
compliance refers to voluntary behavior that is required to carry
out normal operations and safety initiatives. PPE, SC, and SI had
similar effects on lowering the occurrence of occupational injury,
suggesting that future interventions in manufacturing industries
should pay more attention to the three dimensions of safety
behavior.
Although this study extends the existing safety climate litera-
ture by demonstrating several safety climatebehaviorinjury
relationships, it has some limitations worth mentioning. First, like
other safety climate studies, the results of this study were derived
from a cross-sectional survey, preventing us from making deni-
tive causal conclusions due to the nature of the cross-sectional
design. In further eld studies, a longitudinal design could be used
to clarify these associations. We used a self-reported questionnaire
178 X. Liu et al. / Safety Science 78 (2015) 173178
to measure occupational safety climate, behavior, and injury,
although the injury reports were conrmed using the companies
medical records, the data need to be interpreted cautiously. In
addition, as a result of the limitations in the data collection, focus
was placed on only four main dimensions of safety climate in the
manufacturing industries; other dimensions such as safety motiva-
tion and risk perception were not considered and should be further
investigated (Neal and Grifn, 2006; Ma and Yuan, 2009).
Furthermore, as a chemical plant is different from a laundry, a
logistics company, or manufacturing company, intercompany anal-
ysis should be investigated in future studies.
In summary, occupational safety climate and safety behavior in
the workplace are related to the occurrence of occupational injury
in Chinese manufacturing factories. Improving the occupational
safety climate and safety behavior may decrease the number of
occupational injuries in the workplace.
Acknowledgements
This study was supported with funds from the following
sources: The China Medical Board (Grant No. 08-924),
Guangdong Provincial Science and Technology Department
Projects Fund (Grant No. A2013B021800034), and Zhongshan
Health Major Science and Technology Project (Grant No.
20132A003). The authors express their deep gratitude to
Benjamin Anderson for the help of the English Language Editing
and the Zhongshan CDC, which helped with data collection.
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