According to the annual report of HIV/AIDS cases in China, the composition ratio of sexual transmission owing to men who have sex with men (MSM) had increased from 3.4% (2007) to 28.2% (2015) and had stabilized at 28% during 2016 and 2017 [
Although treatment as a means of prevention has been verified as efficacious [
Recently, belief factors have been verified as the crucial psychological factors associated with condom use behavior among MSM [
Currently, a limited number of studies related to HBM have been used to analyze the association between psychological factors and condom use behavior among MSM in China. A qualitative study carried out in China proved that the HBM could be applied to Chinese MSM and could provide information to help develop a population- and disease-specific HBM scale [
Participants in the study were recruited through snowball sampling, which was conducted in Sichuan, China, from November 2018 to April 2019. The inclusion criteria were (1) aged 16 or older, (2) having engaged in anal sex with males of any age, and (3) having lived in Sichuan Province for the past 3 months.
There were 35 cities in Sichuan Province in 2018. According to the information provided by the Sichuan Provincial Center for Disease Control and Prevention, 35 cities were categorized into high, medium, and low layers based on the estimated absolute number of MSM people. Then, in the three layers, we randomly selected one city as the research site, respectively. We firstly hired 15 investigators (9 from social communities and 6 from colleges) via a number of approaches, including gay communities, universities, and clubs. Then, 15 investigators were invited to participate in the training for the survey. Prospective participants were then recruited by the trained investigators; online (e.g., gay dating apps, such as
Eligible participants were screened according to the questionnaire filled in after survey. All participants under 16 years old or who had no sex with males were excluded from the study. All prospective participants provided written informed consent by electronic or pen signature. A total of 817 questionnaires were screened, of which 801 met the inclusion criteria and were analyzed. See the sampling flowchart for specific information (Figure
Sampling flowchart.
The questionnaire was designed by a panel consisting of two epidemiologists, one sociologist, one health psychologist, and four staff members from gay health and culture communities in Sichuan Province. The questionnaire was tested by ten eligible MSM and revised and finalized based on their feedback and panel discussion.
The sociodemographic characteristics included age, educational level, sexual orientation, marital status, vocation, monthly income, previous STD infection, and HIV infection status. For online recruitment, the HIV status of the participants was self-reported, while for offline recruitment, it was either self-reported or based on the result of voluntary tests provided for offline recruitment.
Sexual behaviors referred to two types: (1) anal sex with regular partners, which was specifically defined as having had anal sex with male sexual partners in the last 6 months, and the sexual or romantic relationship should have lasted over 3 months (e.g., a couple with a sexual relationship). (2) Anal sex with nonregular partners, which was specifically defined as having had anal sex with male sexual partners in the last 6 months, and the sexual or romantic relationship should have lasted less than 3 months (e.g., one-night stand). Then, all participants were asked: “Have you had anal sex with regular partners in the last 6 months?” and “Have you had anal sex with non-regular partners in the last 6 months?”, with exemplified definition notes or interpretations from investigators.
For both types of sexual behaviors, we asked about condom use behavior with the question: “Have you used condoms during anal sex with regular (or non-regular) partners?” The answers consisted of four categories of frequency (“never,” “seldom,” “usually,” and “always”). The answer of “always” was considered as consistent condom use, and the other three categories were considered as inconsistent condom use.
The HBM scale comprised five dimensions, and each dimension was taken as a separate subscale. These dimensions included (1) the Perceived Threats Scale with two items (e.g., perceived risk of contracting AIDS in the next 6 months). Response categories of both items ranged from “very low” to “very high” and were scored from 1-5. (2) The Perceived Benefits Scale with two items (e.g., condom use would reduce your risk of HIV infection or other STDs). Response categories of both items ranged from “strongly disagree” to “strongly agree” and were scored from 1-5. (3) The Perceived Barriers Scale with two items (e.g., condom use would reduce sexual pleasure). Response categories of both items ranged from “strongly disagree” to “strongly agree” and were scored from 1-5. (4) The Self-efficacy Scale with five items (e.g., confidence in consistent condom use during anal sex). Response categories of each item ranged from “extremely lacking in confidence” to “extremely confident” and were scored from 1-5. (5) The Cues to Action Scale with two items of external cues (e.g., people around you remind you to use condoms, especially with nonregular partners) and two items of internal cues (e.g., you feel satisfied when using condoms during anal sex). Response categories of each item ranged from “strongly disagree” to “strongly agree” and were scored from 1-5. For the item “Who do you think is responsible for condom use during anal sex”, the answers of “your partner,” “both yourself and your partner,” and “yourself” were scored 1, 3, and 5, respectively. The value of internal reliability (Cronbach’s alpha) of the HBM scale was 0.688.
Consistent condom use with regular partners and nonregular partners was chosen as the dependent variables (
All data were input by EpiData, version 3.1 (The EpiData Association, Odense, Denmark) for windows. The data analysis was implemented in SPSS, version 23.0 (SPSS Inc., Chicago, IL, USA) for windows.
Of the 801 participants in our questionnaire, 48.2% were less than 25 years old, 53.2% had received high school/technical school education, and 64.3% were identified as homosexual. 61.7% of the participants were unmarried, and 46.2% of them received a moderate monthly income of less than 2000 RMB (48.1% of them were students). For AIDS-related characteristics, 13.2% of participants had had previous STD infections, and 6.2% of them were diagnosed with HIV (Table
Basic information of participants (
Variables |
|
% |
---|---|---|
Demographics | ||
Age | ||
<25 | 386 | 48.2 |
25-49 | 190 | 23.7 |
≥50 | 225 | 28.1 |
Education level | ||
Primary school or lower | 218 | 27.2 |
Middle school | 113 | 14.1 |
High school/technical school | 426 | 53.2 |
College and above | 44 | 5.5 |
Sexual orientation | ||
Homosexual | 515 | 64.3 |
Bisexual/heterosexual | 286 | 35.7 |
Marital status | ||
Unmarried | 494 | 61.7 |
Married | 230 | 28.7 |
Divorced/widowed | 77 | 9.6 |
Vocation | ||
Employed | 284 | 35.5 |
Unemployed/retired | 132 | 16.5 |
Student | 385 | 48.0 |
Monthly income (in RMB) | ||
<1000 | 153 | 19.1 |
1000-1999 | 217 | 27.1 |
2000-2999 | 133 | 16.6 |
3000-3999 | 114 | 14.2 |
≥4000 | 184 | 23.0 |
AIDS-related characteristic | ||
Previous STD infection | ||
Yes | 106 | 13.2 |
No/unsure | 695 | 86.8 |
HIV infection | ||
Yes | 50 | 6.2 |
No/unsure | 751 | 93.8 |
Sexual behavior | ||
Had anal sex with regular male sexual partner(s) | ||
Yes | 313 | 39.1 |
No | 488 | 60.9 |
Condom use with regular partner(s) ( |
||
Yes | 177 | 56.5 |
No | 136 | 43.5 |
Had anal sex with nonregular male sexual partner(s) | ||
Yes | 429 | 53.6 |
No | 372 | 46.4 |
Condom use with nonregular partners ( |
||
Yes | 257 | 60.0 |
No | 172 | 40.0 |
Notes: STD: “sexually transmitted diseases;” RMB: “renminbi;”
Participants who had had anal sex with regular and nonregular partners were 39.1% and 53.6%, respectively. However, only 56.5% of them had consistently used condoms with regular partners, and only 60% of them had consistently used condoms with nonregular partners (Table
Regarding perceived threats, less than 10% of the two groups of participants (i.e., had anal sex with a regular partner; had anal sex with nonregular partner) perceived the risk of HIV infection in the next 6 months. Besides, 57.8% of the participants who had had anal sex with regular partners and 73.4% of participants who had had anal sex with casual partner acknowledged the risk of HIV infection without consistent condom use. In terms of the perceived benefits of consistent condom use, more than half of the participants in both groups agreed with these benefits. For the perceived benefits of consistent condom use, less than 40% of participants in both groups agreed with these barriers. For self-efficacy, over 60% of participants in both groups showed confidence in consistent condom use, condom availability, and persuading the partners to use condoms, etc. As for cues to action, nearly 80% of the participants in both groups reported that they had received the information on condom use from people around them. However, only 57.5% and 59.2% of the participants felt satisfied with condom use when they had had anal sex with regular and nonregular partners, respectively (Table
Health beliefs to condom use of participants.
Had anal sex with regular partners ( |
Had anal sex with non-regular partners ( |
|
---|---|---|
Perceived threats (% high/very high) | ||
Perceived risk of contracting AIDS in the next 6 months | 9.3 | 9.3 |
Perceived risk of contracting AIDS if condomless anal sex occurred in the next 6 months | 57.8 | 73.4 |
Perceived threats scale score | 5.2 (2.0) | 5.9 (1.8) |
Perceived benefits of condom use (% agree/strongly agree) | ||
Condom use would reduce your risk of HIV infection or other STDs | 54.3 | 64.8 |
Condom use would make you feel more at ease and no longer regret | 74.4 | 82.1 |
Perceived benefits scale score | 7.4 (1.7) | 7.8 (1.7) |
Perceived barriers toward condom use (% agree/strongly agree) | ||
Condom use would reduce sexual pleasure | 24.3 | 32.9 |
Condom use would damage your intimate relationship with your male partner | 31.9 | 38.9 |
Perceived barriers scale score | 5.4 (2.1) | 5.7 (2.1) |
Self-efficacy toward consistent condom use (% confident/extremely confident) | ||
Confidence in consistent condom use during anal sex | 76.0 | 84.6 |
Confidence in condom availability during anal sex | 71.2 | 79.7 |
Confidence in persuading the partner to use condoms even if he does not want to | 72.8 | 77.9 |
Confidence in refusing to have condomless anal sex with mutually affectionate males | 70.0 | 68.3 |
Confidence in refusing to have condomless anal sex with males who have been in contact for some time | 63.3 | 65.7 |
Self-efficacy scale score | 19.8 (4.7) | 20.3 (3.9) |
Cues to action | ||
People around you remind you to use condoms, especially with non-regular partners (% agree/strongly agree) | 86.9 | 79.3 |
People around you remind you that condoms are not just for contraception (% agree/strongly agree) | 85.3 | 82.8 |
You feel satisfied to use condoms during anal sex (% agree/strongly agree) | 57.5 | 59.2 |
Who do you think is responsible for condom use during anal sex (% yourself/both yourself and your partner) | 96.8 | 86.1 |
Cues to action scale score | 12.3 (1.5) | 12.2 (1.5) |
Notes: M: mean; SD: Standard deviation.
When taking consistent condom use with regular partners as the dependent variable, we found that age and marital status were significant in the univariate models and were therefore taken as covariates (Table
Single analyses between demographics and consistent condoms use with regular and nonregular partner.
Consistent condoms use with regular partner ( |
Consistent condoms use with nonregular partner ( |
|
---|---|---|
Demographics | ||
Age | ||
<25 | 1.00 | 1.00 |
25-49 | 0.79(0.46, 1.37) | 0.56 (0.34, 0.95) |
≥50 | 0.42 (0.23, 0.76) |
0.20 (0.13, 0.33) |
Education level | ||
Primary school or lower | 1.00 | 1.00 |
Middle school | 1.24 (0.54, 2.87) | 1.45 (0.80, 2.63) |
High school/technical school | 1.60 (0.87, 2.95) | 4.82 (3.02, 7.68) |
College and above | 2.24 (0.82, 6.12) | 3.73 (1.37, 10.18) |
Sexual orientation | ||
Homosexual | 1.00 | 1.00 |
Bisexual/heterosexual | 0.78 (0.46, 1.32) | 0.43 (0.29, 0.64) |
Marital status | ||
Unmarried | 1.00 | 1.00 |
Married | 0.56 (0.32, 0.99) |
0.23 (0.15, 0.37) |
Divorced/widowed | 0.22 (0.09, 0.55) |
0.26 (0.14, 0.47) |
Vocation | ||
Employed | 1.00 | 1.00 |
Unemployed/retired | 0.54 (0.21, 1.39) | 0.33 (0.19, 0.58) |
Student | 1.38 (0.86, 2.22) | 2.40 (1.51, 3.79) |
Monthly income (in RMB) | ||
<1000 | 1.00 | 1.00 |
1000-1999 | 0.92 (0.47, 1.79) | 2.15 (1.20, 3.85) |
2000-2999 | 1.72 (0.74, 1.96) | 1.92 (1.02, 3.62) |
3000-3999 | 0.57 (0.24, 1.39) | 0.75 (0.38, 1.45) |
≥4000 | 0.75 (0.38, 1.48) | 1.75 (0.96, 3.18)† |
AIDS-related characteristic | ||
Previous STD infection | ||
Yes | 1.00 | 1.00 |
No/unsure | 1.65 (0.81, 3.34) | 1.43 (0.85, 2.39) |
HIV infection | ||
Yes | 1.00 | 1.00 |
No/unsure | 1.63 (0.68, 1.89) | 1.80 (0.85, 3.79) |
Note: STD: “sexually transmitted diseases.” ORu: univariate odds ratios. †
Association between dimensions of HBM and consistent condoms use with regular and nonregular partner.
Consistent condoms use with regular partners ( |
Consistent condoms use with nonregular partners ( |
|||||
---|---|---|---|---|---|---|
ORu (95% CI) | ORm (95% CI)a | ORM (95% CI) | ORu (95% CI) | ORm (95% CI) b | ORM (95% CI) | |
Perceived threats scale | 1.14 (1.01, 1.27) |
1.20 (1.06, 1.36) |
1.28 (1.10, 1.49) |
0.80 (0.71, 0.89) |
0.89 (0.79, 1.01)† | 0.97 (0.83, 1.13) |
Perceived benefits scale | 1.01 (0.88, 1.15) | 1.07 (0.93, 1.24) | — | 0.91 (0.81, 1.02) | 1.16 (1.00, 1.34)† | — |
Perceived barriers scale | 0.69 (0.60, 0.78) |
0.69 (0.60, 0.78) |
0.70 (0.60, 0.82) |
0.74 (0.67, 0.82) |
0.71 (0.63, 0.79) |
0.77 (0.67, 0.89) |
Self-efficacy scale | 1.26 (1.18, 1.34) |
1.29 (1.20, 1.39) |
1.23 (1.14, 1.32) |
1.21 (1.14, 1.28) |
1.29 (1.20, 1.39) |
1.22 (1.13, 1.32) |
Cues to action scale | 1.44 (1.26, 1.64) |
1.34 (1.35, 1.82) |
1.21 (1.02, 1.43) |
1.60 (1.41, 1.81) |
1.78 (1.54, 2.07) |
1.53 (1.30, 1.80 |
Note: ORu: univariate odds ratios; ORm: single multivariate odds ratio; ORM: summary multivariate odds ratios. a include one dimension of HBM and variables of sociodemographic and AIDS-related characteristics marginally significant (
When taking consistent condom use with nonregular partners as the dependent variable, we found that all variables of sociodemographic characteristics were significant in the univariate models and were therefore taken as covariates (Table
A large number of HIV monitoring data systems in China and other countries showed that the failure on the prevention of HIV spread among the MSM population can be ascribed to inconsistent condom use [
Our findings are in line with a recent meta-analysis in China [
Despite the robust nature of the observed significant findings, several of the null findings are worth discussing. Firstly, perceived threats had effects on consistent condom use with regular partners, while had no effects on consistent condom use with nonregular partners. Such differences suggest us about the importance of segmentation (an effective principle in social marketing) [
Secondly, perceived benefits had no effect on consistent condom use with regular partners or nonregular partners. A possible explanation is that individuals’ belief in the benefits of consistent condom use is overwhelmed by perceived barriers (e.g., condom use would reduce sexual pleasure) [
The current behavior interventions or services for HIV prevention among MSM mainly focus on providing health packages, such as condoms and AIDS testing kits, videos, and digital interventions (e.g., using apps) [
Several limitations should be considered in this study. First, our questionnaire was self-designed according to the frames of HBM and was not fully verified by its reliability and validity. However, our items were designed to be possibly suitable for Chinese MSM. Second, the study was carried out in a city in China with a relatively high HIV prevalence; caution should be taken when generalizing the findings. Besides, the findings, to some degree, can only be generalized to the general MSM who had a regular partner or nonregular partners. For other subgroups, such as those who had both regular and nonregular partners, more studies should be invited. Third, the concealed characteristics of the MSM population make the unavailability of random sampling, and nonprobability sampling leads to a certain selection bias. Fourth, this research collected information in the form of self-filled questionnaires. The respondents may have concealed part of the real information due to personal privacy and social expectations, or they could not accurately recall the problems involved in the questionnaire, which might have led to an information bias.
Inconsistent condom use behaviors with regular and nonregular partners are commonly observed in the MSM population of the Sichuan Province, China. Based on HBM, among this population, perceived barriers, self-efficacy, and cues to action were significantly associated with consistent condom use during anal sex with regular and nonregular partners. More attention should be focused on how to decrease the obstructive factors of condom use, how to improve the confidence of condom use, and how to lay out more cues to action to promote consistent condom use behavior.
The data was collected by experienced scientists and health personnel. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
The ethics approval of this study was obtained from the ethics committee of the West China School of Public Health and the West China Fourth Hospital, and the study was carried out in accordance with the Helsinki Declaration of 1964.
All subjects voluntarily participated in our study and signed informed consent forms before enrollment.
The authors declare no conflict of interest.
YH, BY, SJY, and WL had taken a principal role in designing the study, developing the protocol and methodologies, and drafting the manuscript. PJ contributed to the proposal development and made critical revisions to the manuscript. WZ contributed to the writing of the study protocol and made revisions to the manuscript. BY, SJY, SFY, and CT contributed to the data analysis. SJY and WL supervised the study and edited the manuscript. All authors read and approved the final manuscript. Yuling Huang and Bin Yu contributed equally to this work.
We thank the Center for AIDS/STD Control and Prevention, Sichuan Center for Disease Control and Prevention, the devoted investigators of gay communities for their contribution. This study was funded by the National Natural Science Foundation of China (81703279), Sichuan Science and Technology Program (2019YJ0148), and Sichuan Provincial Foundation for AIDS Prevention and Control (2018-WJW-02). We also thank the International Institute of Spatial Lifecourse Epidemiology (ISLE) for the research support.
Supplement Table 1: subgroup analysis among the HIV-negative MSM.