Accessibility settings

This paper is in the following e-collection/theme issue:

Cross-Sectional Studies in Public Health (491) mHealth for Wellness, Behavior Change and Prevention (3517) HIV/AIDS/STI Prevention and Care (1114) LGBTQ Issues (575)

Published on in Vol 12 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/85543, first published .
Doctor performing nasal swab test on a patient; man taking a COVID-19 test at home.

Willingness to Undergo Human Papillomavirus Testing Among Men Who Have Sex With Men in China Based on the Information-Motivation-Behavioral Skills Model: Online Cross-Sectional Study

Willingness to Undergo Human Papillomavirus Testing Among Men Who Have Sex With Men in China Based on the Information-Motivation-Behavioral Skills Model: Online Cross-Sectional Study

Authors of this article:

Xin Liu1, 2 Author Orcid Image ;   Xuelin Yang1 Author Orcid Image ;   Mohan Lyu3 Author Orcid Image ;   Zhenwei Dai4 Author Orcid Image ;   Shu Jing1 Author Orcid Image ;   You Xin1 Author Orcid Image ;   Fei Yu5 Author Orcid Image ;   Shenglan Tang3 Author Orcid Image ;   Xiaoyou Su1, 6 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 9, Dongdan 3rd Street, Dongcheng District, Beijing, Beijing, China

    2MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, United Kingdom

    3Duke Global Health Institute, Duke University, Durham, NC, United States

    4Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China

    5Danlan Public Welfare, Beijing, China

    6State Key Laboratory of Respiratory Health and Multimorbidity, Beijing, China

    *these authors contributed equally

    Corresponding Author:

    Xiaoyou Su, PhD


    Background: Men who have sex with men (MSM) are at high risk of human papillomavirus (HPV) infection, and HPV testing can facilitate early detection and timely intervention. However, evidence on the willingness to undergo different HPV testing modalities among MSM remains limited. The information-motivation-behavioral skills model provides a theoretical framework for understanding factors associated with the willingness to undergo HPV testing.

    Objective: This study aimed to investigate the current status of HPV testing and screening among MSM in China; assess their willingness to undergo professional-collected HPV testing, self-collected HPV testing, and regular HPV testing; and identify associated factors.

    Methods: A cross-sectional study was conducted through the Blued application (Danlan Public Welfare) from July 15, 2024, to August 2, 2024. The questionnaire collected information on participants’ sociodemographic characteristics, sexual behaviors, willingness to undergo HPV testing, HPV testing and infection history, HPV knowledge level, motivation, and behavioral skills related to HPV testing. Chi-square tests and 2-tailed t tests were used to compare the distribution of variables between groups. Multivariable logistic regression analyses were used to identify factors associated with willingness to undergo each HPV testing modality among MSM.

    Results: Among the 1080 participants recruited, 88.3% (n=954) were willing to receive professional-collected HPV testing, 83.6% (n=903) were willing to receive self-collected HPV testing, and 78.7% (n=850) were willing to engage in regular HPV testing. In multivariable analyses, willingness to undergo professional-collected HPV testing was positively associated with higher HPV knowledge (odds ratio [OR] 1.04, 95% CI 1.00‐1.08), greater perceived susceptibility (OR 1.24, 95% CI 1.01‐1.53), and higher self-efficacy (OR 1.69, 95% CI 1.14‐2.50), while it was negatively associated with perceived barriers (OR 0.61, 95% CI 0.47‐0.78). Participants who were retired or unemployed (OR 0.48, 95% CI 0.27‐0.83) and those with prior testing experience (OR 0.49, 95% CI 0.33‐0.73) were less likely to undergo self-collected HPV testing. Moreover, willingness to undergo regular HPV testing was positively associated with perceived susceptibility (OR 1.20, 95% CI 1.02‐1.40), whereas living with a partner (OR 0.54, 95% CI 0.33‐0.88) and living with family members (OR 0.69, 95% CI 0.48‐0.99) were negatively associated.

    Conclusions: This study suggests that willingness to undergo HPV testing among MSM in China is high, whereas prior HPV testing uptake remains low, indicating a gap between testing intention and behavior. By applying the information-motivation-behavioral skills framework to different HPV testing modalities, this study extends the previous evidence from testing willingness to understanding of testing initiation and sustained HPV screening behavior. These findings suggest that personalized health education initiatives and differentiated, privacy-sensitive, and accessible HPV testing strategies may help improve HPV testing uptake and support sustained HPV testing among MSM in China.

    JMIR Public Health Surveill 2026;12:e85543

    doi:10.2196/85543

    Keywords

    men who have sex with men; human papillomavirus; testing willingness; information-motivation-behavioral skills; associated factors 


    Human papillomavirus (HPV) is one of the most common sexually transmitted infections (STIs), with over 200 different types [1,2]. According to a global meta-analysis, the prevalence of HPV infection among males was estimated to be 31%, peaking in the 25‐29 years age group and remaining at a high level before the age of 50 [3]. High-risk HPV types, which are responsible for malignancies such as cervical cancer, penile cancer, and anal cancer, accounted for 21% of cases. HPV-16 was identified as the most prevalent genotype (5%), followed by HPV-6 (4%) [3]. Although HPV-6 is classified as a low-risk HPV type, it can still cause benign lesions such as genital warts. Men who have sex with men (MSM) bear a disproportionately high burden of HPV infection due to their sexual networks and behavioral characteristics. Previous research showed that the prevalence of anal high-risk HPV was 41.2% among MSM, compared to only 6.9% in other male populations [4]. Another meta-analysis of 107 international studies, including 36,773 MSM, reported pooled prevalences for anal, oral, and urethral HPV infections at 78.4%, 36.2%, and 17.3%, respectively [5].

    Screening and vaccination are central strategies for preventing HPV infection and related diseases among MSM. Previous research has shown that HPV vaccines provide long-term protection, and vaccination among MSM has been reported to be cost-effective in multiple settings [6,7]. Accordingly, several countries have implemented targeted HPV vaccination programs for MSM [8,9]. In January 2025, the quadrivalent HPV vaccine (Gardasil) developed by Merck was approved in Chinese mainland for males aged 9 to 26 years, making it the first HPV vaccine indication for males in Chinese mainland [10]. This provided new opportunities for HPV prevention and control among MSM in China. However, in the short term, achieving high vaccine coverage among MSM may remain challenging due to limited vaccine supply, vaccine hesitancy, and cost-related factors [11]. Additionally, due to the sexual behavioral patterns of MSM, the herd immunity established by female HPV vaccination may provide limited protection for MSM. Moreover, some MSM also engage in sexual activity with women, which may contribute to HPV transmission to their female partners and thus have implications for cervical cancer elimination efforts in China.

    HPV testing can help MSM understand their infection status, enabling them to take timely actions to reduce HPV transmission, facilitate early detection of persistent infections or lesions, and thereby reduce the risk of HPV-related diseases [12-14]. Several approaches are available for detecting HPV infections and associated lesions among MSM, including visual inspection, HPV testing, anal cytology, digital anorectal examination, and high-resolution anoscopy [15,16]. In some developed countries, regular anal screening is recommended for HIV-positive MSM to detect precancerous lesions at an early stage [17,18]. Therefore, improving HPV awareness and promoting proactive HPV testing remain critical for controlling HPV transmission among MSM. Even if HPV vaccination coverage expands in the future, regular testing and screening among MSM will still be necessary to facilitate early detection and treatment of HPV-related lesions and to reduce the disease burden.

    However, implementing HPV testing and screening among MSM still faces multiple challenges. A systematic review reported that the uptake of anal cancer screening among MSM was relatively low, and limited knowledge of HPV-related risks was identified as a significant barrier, whereas greater perceived understanding was the primary facilitator [19]. Additionally, stigma and embarrassment, fear of abnormal results, and concerns about disclosure of sexual orientation in health care settings have been identified as barriers to undergoing HPV screening [20]. In China, although some institutions and community-based organizations have initiated HPV testing and screening programs for MSM, supportive programs and research evidence on HPV testing and anal screening for MSM remain limited [21]. Meanwhile, advances in HPV testing technologies have facilitated the development of self-collected HPV testing, which is considered a potential strategy for improving testing coverage among MSM due to its greater privacy, convenience, and high acceptability [22]. Therefore, it is necessary to investigate the willingness to undergo HPV testing and regular testing among MSM, to better understand their behavioral patterns and identify modifiable determinants, providing evidence for developing more targeted health education and service strategies.

    This study uses the information-motivation-behavioral skills (IMB) model as its theoretical framework [23]. The IMB model categorizes behavior-influencing factors into 3 components: information (knowledge and awareness related to diseases and health behaviors), motivation (the willingness to adopt health behaviors based on personal factors and social support), and behavioral skills (the ability and skills necessary to change health behaviors). According to the IMB model, individuals with sufficient health information and motivation can initiate and maintain health behaviors through behavioral skills. The IMB model has been widely applied in research and interventions related to STIs [24-26]. A previous study used a modified IMB model to identify predictors of condom use among MSM in China, providing evidence for interventions to promote condom use [27]. Some researchers have combined mobile reminder tools with the IMB model, such as medication reminders and risk feedback, to promote pre-exposure prophylaxis adherence among MSM [28]. Another study applied an online intervention based on the IMB model to improve awareness of and willingness to receive HPV vaccination [29]. Guided by the IMB model, this study aimed to investigate the current status of HPV testing and screening among MSM in China, assess willingness to undergo professional-collected HPV testing, self-collected HPV testing, and regular HPV testing, and identify associated factors.


    Study Design and Participants

    This study was an internet-based cross-sectional survey conducted from July 15, 2024, to August 2, 2024, using the Blued platform (Supplier: Danlan public welfare), one of the most popular social networking apps for MSM in China. The technical team randomly selected 300,000 users nationwide who had logged into Blued within the past month and sent them a recruitment poster. Interested users could click the link or scan the QR code on the poster to access the questionnaire. All participants were required to provide informed consent before completing the questionnaire. The inclusion criteria were as follows: (1) aged 18 years and older; (2) male at birth; (3) had anal intercourse with a male partner in the past 6 months; and (4) consented to participate in this study. Each IP address was allowed to submit the questionnaire only once, and all items were required to be completed before submission.

    Study Size

    The sample size was estimated using the formula for cross-section studies (Eq. 1). Based on our pilot survey, the willingness to undergo HPV testing among MSM was 95% (57/60). With a 95% CI and an allowable absolute error set at 1.5%, the required sample size was 811. Allowing for an anticipated 20% invalid response rate, the minimum required sample size was 1014.

    n=Z1−α/22p(1−p)d2(1)

    Here n is the sample size, Z is the z-score (the critical value from the standard normal distribution), p is the anticipated or estimated population proportion, and d is precision or margin of error.

    Measurements

    The survey questionnaire used in this study was designed by a panel consisting of epidemiologists, physicians, statisticians, nongovernmental organization workers, and linguists, based on the findings of prior research and preliminary studies [24,30]. The questionnaire development followed a 4-step process. First, a targeted review of previous studies on HPV testing, HPV vaccination, and the IMB framework was conducted to identify candidate items. These items were adapted and translated to form an initial item pool. Second, we recruited 28 MSM and conducted semistructured interviews guided by the IMB model. Themes derived from the qualitative analysis were used to refine the constructs and revise item wording. Third, the draft questionnaire was reviewed by the panel to assess content relevance, clarity, and scientific accuracy. Fourth, a pilot survey was conducted among MSM to evaluate feasibility, comprehensibility, and skip logic, and the questionnaire was finalized accordingly.

    The questionnaire included sections on sociodemographic information, sexual behavioral characteristics, health status, the constructs of the IMB model, including scales and items assessing the HPV-related knowledge, motivation, and behavioral skills regarding HPV testing, and MSM’s willingness to undergo HPV testing. In total, 1094 questionnaires were completed. After quality control, 14 questionnaires were excluded, leaving 1080 valid questionnaires for analysis. Exclusions were made for the following reasons: response time of less than 200 seconds (n=10), residing outside of China in the past 6 months (n=3), and inconsistent or nonsensical responses (n=1).

    Sociodemographic Characteristics

    We collected sociodemographic information on participants, including age, gender at birth, gender identity, sexual orientation, city of residence, educational level, current employment status, monthly personal income, and cohabitation status. Sexual behavioral characteristics were also collected, including sexual role, number of sexual partners, whether they had engaged in anal sex, oral sex, commercial sex, or group sex in the past 6 months, and whether they had sex with regular partners, temporary partners, or female partners in the past 6 months. Health-related variables included circumcision status, history of HIV testing, HIV status, history of STIs, and history of HPV testing.

    Willingness to Undergo HPV Testing

    Participants were first introduced to professional-collected HPV testing. “Professional-collected HPV testing requires visiting a testing site (such as a hospital), where a professional uses a swab to collect samples from the anus, coronal sulcus (glans penis), and/or oral cavity.” Participants were then asked whether they would be willing to undergo professional-collected HPV testing if the test were free. Subsequently, participants were introduced to self-collected HPV testing. “Self-collected HPV testing requires users to obtain a testing kit online, follow the instructions to collect samples from the anus, coronal sulcus (glans penis), and/or oral cavity by themselves, and then send the samples in a preservation tube to a designated lab for testing.” Participants were then asked whether they would be willing to undergo self-collected HPV testing if it were free. Among MSM who were willing to undergo at least 1 type of HPV testing, further inquiries were made regarding their reasons for acceptance. Moreover, all participants were asked about their preferred testing frequency if testing were needed (response options: 1=every 6 months, 2=annually, 3=only when necessary, and 4=other). Participants who chose every 6 months, annually, or any other specific frequency were classified as having an intention for regular HPV testing. MSM who were unwilling to undergo either type of HPV testing were asked about their reasons for refusal.

    Information of HPV Testing

    HPV knowledge among MSM was assessed using a scale developed by Waller [31] in 2013. This scale includes general HPV knowledge subscale (GK), HPV testing knowledge subscale (TK), and HPV vaccine knowledge subscale (VK), which assess individuals’ knowledge of HPV. It has been applied in Chinese populations and has demonstrated good reliability among college students [32]. In this study, we used the GK including 16 items to measure participants’ general understanding of HPV and TK consisting of 6 items to assess knowledge related to HPV testing. Each item offers 3 response options: “True,” “False,” and “Don’t know”. Correct answers were scored as 1, whereas incorrect or “Don’t know” responses were scored as 0. Higher scores indicated greater knowledge level of HPV. In this study, the Cronbach α for GK and TK were 0.927 and 0.839, respectively.

    Motivation for HPV Testing

    Motivation for HPV testing was assessed using 17 items across 5 domains, adapted from previous studies and our unpublished qualitative study (Table S1 in Multimedia Appendix 1) [24,33]. Perceived susceptibility was assessed by 3 items evaluating the perceived risk of HPV infection and related diseases among participants. Perceived severity was measured using 3 items that assessed participants’ perceived seriousness of HPV-related diseases. Perceived benefits were evaluated through 3 items that gauged participants’ perceived health benefits of HPV testing. Perceived barriers included 5 items assessing perceived difficulties that might be encountered during decision-making or action-taking processes. Subjective norms were assessed by 3 items measuring perceived support from family and peers for the participants’ decision to undergo HPV testing. All items were rated on a 5-point Likert scale (1=Strongly disagree, 2=Disagree, 3=Neutral, 4=Agree, and 5=Strongly agree). Higher scores indicated stronger motivation for HPV testing, except for perceived barriers, for which higher scores indicated greater perceived barriers. In this study, the Cronbach α of motivation for HPV testing was 0.850.

    Behavioral Skills for HPV Testing

    Behavioral skills for HPV testing were assessed through 5 items across 3 domains, based on previous studies and our unpublished qualitative study (Table S1 in Multimedia Appendix 1) [24,34]. Decision-making was assessed by 1 item evaluating participants’ agency in deciding whether to undergo HPV testing. Self-efficacy contained 2 items assessing participants’ confidence in overcoming potential difficulties to take action. Objective skills consisted of 2 items evaluating participants’ skills and abilities necessary for undergoing HPV testing. All items were rated on a 5-point Likert scale (1=Strongly disagree, 2=Disagree, 3=Neutral, 4=Agree, and 5=Strongly agree). Higher scores indicated greater behavioral skills for HPV testing. In this study, the Cronbach α of behavioral skills for HPV testing was 0.884.

    Bias

    Several measures were taken to address potential sources of bias. The survey was administered anonymously, which may have reduced social desirability bias when participants reported sensitive sexual behaviors and STI history. For questions on sexual behaviors, a 6-month recall period was used to improve recall accuracy. Explanations of professional-collected and self-collected HPV testing were provided to reduce differences in participants’ understanding of the testing procedures. All questionnaire items were mandatory to ensure completeness of responses and avoid missing data. No financial compensation was provided to participants, which may have reduced participation driven by monetary incentives. However, because this was a cross-sectional survey based on self-reported data, bias could not be fully eliminated.

    Statistical Analysis

    In this study, the distribution of variables between participants who were willing and unwilling to undergo the HPV testing was reported using means and SDs for continuous variables and frequencies and percentages (%) for categorical variables. Chi-squared tests and 2-tailed t tests were used to compare differences in variable distributions between groups. To reduce the risk of excluding potentially important predictors, variables with a P value of <.10 in the univariate analysis, as well as variables with professional relevance, were included in the multivariable logistic regression analysis. Multivariable logistic regressions using the Enter method, in which all selected covariates were entered into the model simultaneously, were used to identify factors associated with willingness to undergo HPV testing among MSM. Adjusted odds ratios [OR] and their corresponding 95% CI were calculated. Multicollinearity was assessed using the variance inflation factor, and all variance inflation factor values were <5, indicating no significant multicollinearity in the model. Statistical significance was assessed using 2-sided tests with a P value <.05 for all analyses.

    Ethical Considerations

    This study received ethics approval from the institutional ethics committee of the Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS&PUMC-IEC-2022-078). The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [35]. Digital informed consent was obtained from all participants. All data used in this study were deidentified, and no participants were identifiable in any images included in the manuscript or supplementary material. Participants received no compensation.


    Sociodemographic Characteristics of Participants

    This study recruited 1080 participants, with a mean age of 31.14 (SD 9.45) years. Most of them were identified as male participants (n=1002, 92.8%), homosexual (n=825, 76.4%), were employed full-time (n=840, 77.8%), and lived in the northern (n=258, 23.9%) and eastern (n=258, 23.9%) regions of China. Among the participants, 34.1% (n=368) of MSM reported monthly incomes ranging from CN ¥3000 to ¥6999 (US $435-$1015), and 42.6% (n=460) lived alone (Table 1).

    Table 1. Baseline characteristics of men who have sex with men (MSM) recruited online in China, 2024.
    VariablesOverall (N=1080)
    Age (y), mean (SD)31.14 (9.45)
    Gender identity, n (%)
     Male1002 (92.8)
     Transgender woman78 (7.2)
    Region, n (%)
     Northeast73 (6.7)
     North258 (23.9)
     Central135 (12.5)
     East258 (23.9)
     South177 (16.4)
     Southwest125 (11.6)
     Northwest54 (5)
    Education level, n (%)
     High school and below210 (19.4)
     High school above870 (80.6)
    Current employment status, n (%)
     Full-time840 (77.8)
     Student163 (15.1)
     Unemployed or retired77 (7.1)
    Personal monthly income (CN ¥; CN ¥1=US $0.14)
     <3000232 (21.5)
     3000‐6999368 (34.1)
     7000‐9999191 (17.7)
     ≥10,000289 (26.7)
    Cohabitation status, n (%)
     Alone460 (42.6)
     Partner118 (10.9)
     Family318 (29.5)
     Friends or roommates172 (15.9)
     Others12 (1.1)
    Sexual orientation, n (%)
     Homosexuality825 (76.4)
     Bisexuality190 (17.6)
     Heterosexual and others65 (6)
    Sex role, n (%)
     Receptive366 (33.9)
     Versatile393 (36.4)
     Insertive321 (29.7)
    Number of sexual partners, n (%)
     1354 (32.8)
     ≥2726 (67.2)
    Condom usage frequency during anal sex, n (%)
     Every time531 (49.2)
     Often use210 (19.4)
     Occasionally use252 (23.3)
     Never use87 (8.1)
    Performed oral sex in the past 6 mo, n (%)
     No250 (23.1)
     Yes830 (76.9)
    Received oral sex in the past 6 mo, n (%)
     No423 (39.2)
     Yes657 (60.8)
    Condom use frequency during oral sex, n (%)
     Every time33 (3.1)
     Often use12 (1.1)
     Occasionally use65 (6)
     Never use926 (85.7)
     No oral sex before44 (4.1)
    Had sex with regular partners in the past 6 mo, n (%)
     No464 (43)
     Yes616 (57)
    Had sex with temporary partners in the past 6 mo, n (%)
     No465 (43.1)
     Yes615 (56.9)
    Had commercial sex in the past 6 mo, n (%)
     No1013 (93.8)
     Yes67 (6.2)
    Had group sex in the past 6 mo, n (%)
     No897 (83.1)
     Yes183 (16.9)
    Had sex with female in the past 6 mo, n (%)
     No962 (89.1)
     Yes118 (10.9)
    Had a circumcision, n (%)
     No861 (79.7)
     Yes219 (20.3)
    Self-reported HIV status, n (%)
     Positive105 (9.7)
     Negative790 (73.2)
     Unknown185 (17.1)
    History of STIsa, n (%)
     No702 (65)
     Yes378 (35)
    Information (score), mean (SD)
     Knowledge of HPVb13.45 (5.40)
    Motivation (score), mean (SD)
     Perceived susceptibility3.23 (1.02)
     Perceived severity3.79 (0.99)
     Perceived benefits4.24 (0.82)
     Perceived barriers3.33 (0.94)
     Subjective norms3.44 (0.78)
    Behavioral skills (score), mean (SD)
     Decision-making4.11 (0.88)
     Self-efficacy3.98 (0.82)
     Objective skills3.83 (0.89)

    aSTI: sexually transmitted infection.

    bHPV: human papillomavirus.

    Characteristics of Sexual Behaviors and Health Status

    In the past 6 months, all 1080 participants had engaged in anal sex with men: 36.4% (n=393) of them were versatile, 49.2% (n=531) consistently used condoms, and 95.9% (n=1036) had engaged in oral sex. Additionally, 76.9% (n=830) reported that they had performed oral sex and 60.8% (n=657) had received oral sex in the past 6 months. However, only 3.1% (n=33) reported using condoms during oral sex. Furthermore, 57% (n=616) of the MSM had sex with regular partners, 56.9% (n=615) with temporary partners, 6.2% (67/1080) had commercial sex, 10.9% (n=118) had sex with females, 16.9% (n=183) had group sex, and 67.2% (n=726) had 2 or more sexual partners. Additionally, 20.3% (n=219) had undergone circumcision, 9.7% (n=105) reported being HIV-positive, and 35% (n=378) had a history of STIs (Table 1).

    Dimensions of the IMB Model

    In this study, participants had a mean HPV knowledge score of 13.45 (SD 5.40). Regarding motivation for HPV testing, the mean scores were 3.23 (SD 1.02) for perceived susceptibility, 3.79 (SD 0.99) for perceived severity, 4.24 (SD 0.82) for perceived benefits, 3.33 (SD 0.94) for perceived barriers, and 3.44 (SD 0.78) for subjective norms. In terms of behavioral skills for HPV testing, the mean scores were 4.11 (SD 0.88) for decision-making, 3.98 (SD 0.82) for self-efficacy, and 3.83 (SD 0.89) for objective skills (Table 1).

    Characteristics and Reasons for HPV Screening Among MSM

    Among participants, 35.2% (380/1080) had previously undergone HPV screening and 23.3% (252/1080) had undergone HPV testing, with 43.3% of them (109/252) testing positive. Additionally, 17.8% (192/1080) had undergone an acetic acid test, 16.9% (182/1080) had undergone anoscopy, 5.5% (59/1080) had undergone anal cytology, and 22.6% (244/1080) reported a history of genital warts. This study investigated the reasons for HPV screening among participants with an HPV screening history. The most common reasons were “appearance or suspected appearance of HPV-related symptoms” (224/380, 58.9%), “voluntary proactive testing” (211/380, 55.5%), “engagement in high-risk sexual behavior” (96/380, 25.3%), “recommendation by healthcare professionals” (57/380, 15%), “had sex with an HPV-positive individual” (33/380, 8.7%), and “participation in an HPV vaccine clinical trial” (13/380, 3.4%) (Table 2 and Table S2 in Multimedia Appendix 1).

    Table 2. HPVa testing history and HPV infection status among men who have sex with men (MSM) recruited online in China, 2024.
    VariablesTotal (N=1080)HIV status
    Negative or unknown (n=975)Positive (n=105)
    Ever received any HPV-related examination, n (%)
     No700 (64.8)639 (65.5)61 (58.1)
     Yes380 (35.2)336 (34.5)44 (41.9)
    Ever received HPV DNA testing, n (%)
     No828 (76.7)751 (77)77 (73.3)
     Yes252 (23.3)224 (23)28 (26.7)
    Ever received acetic acid test, n (%)
     No888 (82.2)806 (82.7)82 (78.1)
     Yes192 (17.8)169 (17.3)23 (21.9)
    Ever received anoscopy, n (%)
     No898 (83.1)816 (83.7)82 (78.1)
     Yes182 (16.9)159 (16.3)23 (21.9)
    Ever received anal cytology, n (%)
     No1021 (94.5)921 (94.5)100 (95.2)
     Yes59 (5.5)54 (5.5)5 (4.8)
    HPV test result (n=252), n (%)
     Positive109 (43.3)93 (41.5)16 (57.1)
     Negative143 (56.7)131 (58.5)12 (42.9)
    History of genital warts, n (%)
     No836 (77.4)779 (79.9)57 (54.3)
     Yes244 (22.6)196 (20.1)48 (45.7)

    aHPV: human papillomavirus.

    Willingness to Undergo HPV Testing and Regular HPV Testing

    The overall willingness to undergo HPV testing in this study was 97% (1048/1080). Of the participants, 74.9% (n=809) were willing to undergo both types of HPV testing, 13.4% (n=145) were willing to undergo only the professional-collected HPV testing, and 8.7% (n=94) were willing to undergo only the self-collected testing. The willingness to undergo the professional-collected HPV testing was 88.3% (n=954), the willingness to undergo self-collected HPV testing was 83.6% (n=903), and the willingness to engage in regular HPV testing was 78.7% (n=850).

    Reasons for Unwillingness to Undergo HPV Testing

    In this study, among 1080 participants, 32 (3%) expressed their unwillingness to undergo either type of HPV testing. The 3 most common reasons were as follows: “I am reluctant to expose my genital area to others” (22/32, 68.8%); “I am concerned that sampling myself may affect the accuracy of the results” (20/32, 62.5%); and “I am concerned about the leakage of my private information” (18/32, 56.3%). Additionally, 94 (8.7%) participants were unwilling to undergo the professional-collected HPV testing. The 3 most common reasons were as follows: “I am reluctant to expose my genital area to others” (65/94, 69.1%); “I am concerned about the leakage of my private information” (61/94, 64.9%); and “Undergoing HPV testing may bring negative comments to me” (45/94, 47.9%). Furthermore, 145 (13.4%) participants expressed unwillingness to undergo self-collected HPV testing, with the 3 most common reasons being as follows: “I am concerned that sampling myself may affect the accuracy of the results” (119/145, 82.1%), “I suspect the accuracy of self-collected HPV testing” (97/145, 66.9%), and “I think the testing process is complicated” (62/145, 42.8%) (Table S3 in Multimedia Appendix 1).

    Factors Associated With Willingness to Undergo Professional-Collected HPV Testing

    The factors associated with willingness to undergo professional-collected HPV testing are presented in Table S4 of Multimedia Appendix 1. The multivariable logistic regression analysis showed that participants with greater HPV knowledge (OR 1.04, 95% CI 1.00‐1.08), perceived susceptibility (OR 1.24, 95% CI 1.01‐1.53), and self-efficacy (OR 1.69, 95% CI 1.14‐2.50) had a higher intention to undergo the professional-collected HPV test. Conversely, those with higher perceived barriers (OR 0.61, 95% CI 0.47‐0.78) were less likely to be willing to undergo the professional-collected HPV test (Figure 1).

    ‎
    Figure 1. Factors influencing willingness for professional-collected human papillomavirus (HPV) testing among men who have sex with men (MSM) in China (N=1080). OR: odds ratio; STI: sexually transmitted infection; VIF: variance inflation factor.

    Factors Associated With Willingness to Undergo Self-Collected HPV Testing

    The factors associated with the willingness to undergo self-collected HPV testing are presented in Table S5 of Multimedia Appendix 1. The multivariable logistic regression analysis showed that retired and unemployed participants (OR 0.48, 95% CI 0.27‐0.83) were less likely to be willing to undergo the self-collected HPV test compared with those with full-time jobs. Additionally, compared with MSM who had never undergone HPV testing, those who had previously undergone testing were less willing to undergo self-collected testing (OR 0.49, 95% CI 0.33‐0.73) (Figure 2).

    ‎
    Figure 2. Factors influencing willingness for self-collected human papillomavirus (HPV) testing among men who have sex with men in China (N=1080). OR: odds ratio; VIF: variance inflation factor.

    Factors Associated With Willingness to Undergo Regular HPV Testing

    In this study, we explored factors associated with the willingness to undergo regular HPV testing (Table S6 in Multimedia Appendix 1). The results of the multivariable logistic regression analysis indicated that participants with higher perceived susceptibility (OR 1.20, 95% CI 1.02‐1.40) were more likely to accept regular HPV testing. However, MSM living with a partner (OR 0.54, 95% CI 0.33‐0.88) and those living with family members (OR 0.69, 95% CI 0.48‐0.99) were less likely to undergo regular HPV testing (Figure 3).

    ‎
    Figure 3. Factors influencing willingness for regular human papillomavirus (HPV) testing among men who have sex with men in China (N=1080). OR: odds ratio; VIF: variance inflation factor.

    Principal Findings

    This study investigated willingness to undergo HPV testing and its associated factors among MSM in China. Although most participants were willing to undergo HPV testing, the prior HPV testing uptake was only 23.3% (252/1080), which was similar to that reported in a study conducted in Hong Kong from 2019 to 2020 (67/350, 19.1%) [30]. However, the main reason for undergoing HPV testing was the presence or suspected presence of HPV-related symptoms, indicating a significant gap in HPV prevention among MSM. The analysis guided by the IMB model indicated that the gap between high willingness and low uptake of HPV testing among MSM reflects insufficient knowledge of HPV prevention, as well as multiple barriers that hinder the translation of willingness into actual testing behavior. These findings provide evidence for the development of more targeted public health intervention strategies.

    In line with other studies [36,37], this study found that the level of HPV-related knowledge among MSM in China was relatively low. According to previous research, higher levels of knowledge are associated with a stronger intention to undergo HPV screening [38]. Individuals with greater HPV knowledge are generally more health-conscious and better able to understand the benefits of HPV testing, which is associated with a higher willingness to undergo HPV testing. Furthermore, due to sociocultural factors that contribute to unequal access to health information, many MSM lack sufficient awareness of the harms of HPV infection [39]. This was reflected in an underestimation of the threat posed by HPV to male health and inadequate recognition of the role of high-risk sexual behaviors in facilitating HPV transmission [40]. An intervention study in the United States showed that, after receiving HPV-related health education, participants’ awareness that “HPV infection may cause anal cancer” increased, and their willingness to seek HPV testing improved [41]. These findings suggest that health authorities should work together with community-based organizations to deliver targeted health education for MSM and make greater use of internet-based platforms and new media technologies to expand outreach and improve HPV-related knowledge among MSM.

    Perceived susceptibility was significantly associated with the willingness to undergo HPV testing and regular testing among MSM [42]. Previous research has shown that perceived risk of HIV infection significantly increases the intention to undergo regular testing among MSM [43]. Similarly, when MSM recognize that their sexual behaviors place them at higher risk of HPV infection, they are more likely to actively seek testing to identify their infection status [44]. Additionally, regular screening for HPV and anal cancer has been shown to increase life expectancy among MSM and is considered a cost-effective intervention [45]. Previous research also suggests that individuals with a better understanding of their potential health risks are more likely to engage in self-protective behaviors [46]. Therefore, MSM with higher perceived susceptibility to HPV tend to be more aware of their infection risk, show greater concern about their health status, and are more likely to initiate and maintain HPV testing behaviors [47]. This finding suggests that HPV-related services could be integrated with HIV prevention and other sexual health services within a broader STI prevention framework, which may provide a more effective approach to improving testing uptake and reducing STI transmission in this population.

    In addition, perceived barriers also affect the willingness to undergo HPV testing among MSM. According to structural barriers theory, limited access to health care services and sociocultural pressures can significantly inhibit health behaviors [48]. A study on HIV testing willingness among MSM found that concerns about privacy leakage led 30% of respondents to avoid testing [49]. Moreover, STIs testing can cause stigma, which may increase their perceived barriers and reduce their willingness to undergo HPV testing [50]. When MSM are faced with issues such as shame, inadequate privacy protection, and stigma during the testing process, they may become more reluctant to undergo professional-collected HPV testing. Therefore, exploring the feasibility of delivering confidential and MSM-friendly professional-collected HPV testing, or professionally supported self-collected HPV testing, through community-based organizations may be a valuable strategy. Such service models may better meet the diverse needs of MSM and help improve testing coverage and adherence.

    Improving self-efficacy among MSM is beneficial for promoting testing [51]. Previous research has shown that women with higher self-efficacy are more likely to undergo HPV testing [52]. MSM with greater awareness of self-protection and stronger confidence in HPV testing are more likely to overcome barriers associated with professional-collected HPV testing. Moreover, self-collected HPV testing provides a rapid, confidential, and cost-effective option [53]. Therefore, comprehensive efforts are needed to strengthen social advocacy that raises public awareness of HPV infection and reduces discrimination and stigma toward MSM. A meta-analysis showed that offering home-based self-collection kits contributes to higher participation rates compared with clinic-based professional sampling [54]. Self-sampling HPV testing has also been found to be acceptable and feasible among MSM [30]. Optimizing professional-collected HPV testing procedures to ensure greater privacy protection and promoting self-sampling HPV testing may help reduce psychological resistance and improve testing coverage among MSM [55].

    In this study, retired or unemployed participants were less likely to be willing to undergo self-collected HPV testing compared with those who were employed. This may be related to lower occupational stability, which is often associated with reduced access to health care services [56]. Retired or unemployed individuals may face unstable income or insufficient health insurance coverage, making them more reliant on free or low-cost medical services [57]. Although self-collected HPV testing offers greater privacy, it typically requires purchasing test kits, which may impose an additional financial burden on retired and unemployed MSM [58]. Additionally, these groups are less likely to obtain testing information through online platforms or social media, leading to lower awareness and acceptance of self-collected HPV testing [59]. Therefore, governments and communities should consider providing subsidized or free HPV testing services or kits for retired and unemployed MSM. Targeted health education initiatives delivered through community for older adults may help improve awareness and acceptance of HPV testing [60].

    This study extends existing evidence on HPV prevention among MSM by providing a theory-informed assessment of HPV testing willingness. First, this study distinguished between professional-collected and self-collected HPV testing, which helped identify modality-specific factors associated with different testing approaches. Second, by including regular HPV testing, this study extended the focus from one-time testing acceptance to sustained HPV screening behavior among MSM. Third, by applying the IMB model, this study interpreted testing initiation and sustained HPV testing behavior through the dimensions of information, motivation, and behavioral skills, providing a theoretical basis for designing differentiated interventions.

    Limitations

    This study has several limitations. First, participants were recruited using online convenience sampling, which may have introduced selection bias and limited the representativeness of the sample, as MSM with lower digital access and health literacy may have been underrepresented. Second, the data were collected through self-administered questionnaires, which may have resulted in recall bias and social desirability bias for sensitive information such as sexual behaviors and history of STIs. Third, motivation and behavioral skills related to HPV testing were assessed using self-developed, nonvalidated items, which may not have fully captured all relevant domains. Fourth, because this was a cross-sectional study, causal relationships between outcomes and associated factors could not be established. Accordingly, the findings should be interpreted with caution, and further longitudinal studies are needed to validate and extend these results.

    Conclusion

    This study investigated the willingness of MSM in China to undergo different HPV testing modalities and, based on the IMB model, explored the gap between willingness to undergo HPV testing and actual testing uptake in this population. The findings support the applicability of the IMB model in explaining willingness to undergo HPV testing among MSM and provide a basis for future research and strategy development. Our findings suggest that personalized health education should be strengthened through internet platforms and new media technologies to improve HPV knowledge among MSM. Meanwhile, diversified and privacy-sensitive testing service models should be explored to enhance the convenience and accessibility of HPV testing. These strategies may help translate testing willingness into actual testing behavior and promote the sustainable implementation of HPV testing services among MSM in China.

    Acknowledgments

    XL and XY are joint first authors of this work. The authors are grateful to Danlan Public Welfare and WenJuanXing. The authors confirm that no generative artificial intelligence tools were used to write, analyze, or interpret data in this manuscript.

    Funding

    This research was supported by the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (grant 2022-ZHCH330-01).

    Data Availability

    The data that support the findings of this study are available from the corresponding author upon reasonable request.

    Authors' Contributions

    Conceptualization: XL, XS

    Data curation: XL, XY, ML, SJ, YX

    Investigation: XL, XY, ML, ZD, YX, FY

    Formal analysis: XL

    Funding acquisition: XS

    Software: FY

    Supervision: ST, XS

    Writing – original draft: XL, XY

    Writing – review & editing: ZD, ST, XS

    All authors approved the final version of the manuscript.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Items assessing motivation and behavioral skills related to human papillomavirus (HPV) testing, reasons for HPV screening and unwillingness to undergo HPV testing, and univariate analyses of factors associated with willingness to undergo professional-collected HPV testing, self-collected HPV testing, and regular HPV testing among men who have sex with men (MSM) in China.

    DOCX File, 68 KB
    1. de Sanjosé S, Brotons M, Pavón MA. The natural history of human papillomavirus infection. Best Pract Res Clin Obstet Gynaecol. Feb 2018;47:2-13. [CrossRef] [Medline]
    2. Muñoz N, Bosch FX, de Sanjosé S, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med. Feb 6, 2003;348(6):518-527. [CrossRef] [Medline]
    3. Bruni L, Albero G, Rowley J, et al. Global and regional estimates of genital human papillomavirus prevalence among men: a systematic review and meta-analysis. Lancet Glob Health. Sep 2023;11(9):e1345-e1362. [CrossRef] [Medline]
    4. Wei F, Gaisa MM, D’Souza G, et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. Sep 2021;8(9):e531-e543. [CrossRef] [Medline]
    5. Farahmand M, Monavari SH, Tavakoli A. Prevalence and genotype distribution of human papillomavirus infection in different anatomical sites among men who have sex with men: a systematic review and meta-analysis. Rev Med Virol. Nov 2021;31(6):e2219. [CrossRef] [Medline]
    6. Goldstone SE, Giuliano AR, Palefsky JM, et al. Efficacy, immunogenicity, and safety of a quadrivalent HPV vaccine in men: results of an open-label, long-term extension of a randomised, placebo-controlled, phase 3 trial. Lancet Infect Dis. Mar 2022;22(3):413-425. [CrossRef] [Medline]
    7. Soe NN, Ong JJ, Ma X, et al. Should human papillomavirus vaccination target women over age 26, heterosexual men and men who have sex with men? A targeted literature review of cost-effectiveness. Hum Vaccin Immunother. 2018;14(12):3010-3018. [CrossRef] [Medline]
    8. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Aug 29, 2014;63(RR-05):1-30. [Medline]
    9. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. Aug 16, 2019;68(32):698-702. [CrossRef] [Medline]
    10. Merck’s GARDASIL receives expanded approval for males in China. Merck; 2025. URL: https://www.merck.com/news/mercks-gardasil-receives-expanded-approval-for-males-in-china [Accessed 2025-03-31]
    11. Shen F, Du Y, Cao K, et al. Acceptance of the human papillomavirus vaccine among general men and men with a same-sex orientation and its influencing factors: a systematic review and meta-analysis. Vaccines (Basel). Dec 22, 2023;12(1):16. [CrossRef] [Medline]
    12. Clarke MA, Deshmukh AA, Suk R, et al. A systematic review and meta-analysis of cytology and HPV-related biomarkers for anal cancer screening among different risk groups. Int J Cancer. Dec 1, 2022;151(11):1889-1901. [CrossRef] [Medline]
    13. Viciana P, Milanés-Guisado Y, Fontillón M, et al. High-risk human papilloma virus testing improves diagnostic performance to predict moderate- to high-grade anal intraepithelial neoplasia in human immunodeficiency virus-infected men who have sex with men in low-to-absent cytological abnormalities. Clin Infect Dis. Nov 27, 2019;69(12):2185-2192. [CrossRef] [Medline]
    14. Giuliano AR, Anic G, Nyitray AG. Epidemiology and pathology of HPV disease in males. Gynecol Oncol. May 2010;117(2 Suppl):S15-S19. [CrossRef] [Medline]
    15. McGovern J, Fuller C, Burris K. Anal cancer screening and prevention: a review for dermatologists. J Eur Acad Dermatol Venereol. Aug 2021;35(8):1622-1627. [CrossRef] [Medline]
    16. Leeds IL, Fang SH. Anal cancer and intraepithelial neoplasia screening: a review. World J Gastrointest Surg. Jan 27, 2016;8(1):41-51. [CrossRef] [Medline]
    17. Stier EA, Clarke MA, Deshmukh AA, et al. International Anal Neoplasia Society’s consensus guidelines for anal cancer screening. Int J Cancer. May 15, 2024;154(10):1694-1702. [CrossRef] [Medline]
    18. Rao S, Guren MG, Khan K, et al. Anal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. Sep 2021;32(9):1087-1100. [CrossRef] [Medline]
    19. Sam I, Dang W, Iu N, Luo Z, Xiang YT, Smith RD. Barriers and facilitators to anal cancer screening among men who have sex with men: a systematic review with narrative synthesis. BMC Cancer. Apr 1, 2025;25(1):586. [CrossRef] [Medline]
    20. Truesdale MD, Goldstone SE. The fear factor: drivers and barriers to follow-up screening for human papillomavirus-related anal cancer in men who have sex with men. Int J STD AIDS. Jul 2010;21(7):482-488. [CrossRef] [Medline]
    21. Ni Y, Lu Y, He X, et al. Self-sampled specimens demonstrate comparable accuracy and consistency to clinician-sampled specimens for HPV detection among men who have sex with men in China. Sex Transm Infect. Mar 2023;99(2):104-109. [CrossRef] [Medline]
    22. Wang Z, Chen S, Wong NS, et al. Differences in intention to receive clinician-collected and self-collected samples for HPV DNA testing and its determinants between heterosexual males and females in Hong Kong, China: findings of a territory-wide household survey. BMC Med. Dec 2, 2024;22(1):569. [CrossRef] [Medline]
    23. Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull. May 1992;111(3):455-474. [CrossRef] [Medline]
    24. Si M, Jiang Y, Su X, et al. Willingness to accept human papillomavirus vaccination and its influencing factors using information-motivation-behavior skills model: a cross-sectional study of female college freshmen in Mainland China. Cancer Control. 2021;28:10732748211032899. [CrossRef] [Medline]
    25. Sheinfil AZ, Giguere R, Dolezal C, et al. Information and motivation predict HIV-serostatus among a population of high-risk men and transgender women who have sex with men. AIDS Behav. Oct 2020;24(10):2863-2871. [CrossRef] [Medline]
    26. Kinuthia J, Ronen K, Unger JA, et al. SMS messaging to improve retention and viral suppression in prevention of mother-to-child HIV transmission (PMTCT) programs in Kenya: a 3-arm randomized clinical trial. PLoS Med. May 2021;18(5):e1003650. [CrossRef] [Medline]
    27. Jiang H, Chen X, Li J, Tan Z, Cheng W, Yang Y. Predictors of condom use behavior among men who have sex with men in China using a modified information-motivation-behavioral skills (IMB) model. BMC Public Health. Mar 4, 2019;19(1):261. [CrossRef] [Medline]
    28. Kawichai S, Songtaweesin WN, Wongharn P, et al. A mobile phone app to support adherence to daily HIV pre-exposure prophylaxis engagement among young men who have sex with men and transgender women aged 15 to 19 years in Thailand: pilot randomized controlled trial. JMIR Mhealth Uhealth. Apr 21, 2022;10(4):e25561. [CrossRef] [Medline]
    29. Si M, Su X, Jiang Y, et al. An internet-based education program for human papillomavirus vaccination among female college students in Mainland China: application of the information-motivation-behavioral skills model in a cluster randomized trial. J Med Internet Res. Sep 30, 2022;24(9):e37848. [CrossRef] [Medline]
    30. Wang Z, Fang Y, Wong NS, Ip M, Guo X, Wong SYS. Facilitators and barriers to take up clinician-collected and self-collected HPV tests among Chinese men who have sex with men. Viruses. Apr 19, 2021;13(4):705. [CrossRef] [Medline]
    31. Waller J, Ostini R, Marlow LAV, McCaffery K, Zimet G. Validation of a measure of knowledge about human papillomavirus (HPV) using item response theory and classical test theory. Prev Med. Jan 2013;56(1):35-40. [CrossRef] [Medline]
    32. Hu Q, Rui Y, Jiang J, et al. Awareness regarding human papillomavirus and willingness for vaccination among college students with or without medical background in Guizhou Province. Hum Vaccin Immunother. Dec 31, 2024;20(1):2295992. [CrossRef] [Medline]
    33. Gerend MA, Madkins K, Crosby S, et al. A qualitative analysis of young sexual minority men’s perspectives on human papillomavirus vaccination. LGBT Health. Oct 2019;6(7):350-356. [CrossRef] [Medline]
    34. Forster AS, McBride KA, Davies C, et al. Development and validation of measures to evaluate adolescents’ knowledge about human papillomavirus (HPV), involvement in HPV vaccine decision-making, self-efficacy to receive the vaccine and fear and anxiety. Public Health (Fairfax). Jun 2017;147:77-83. [CrossRef] [Medline]
    35. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. Apr 2008;61(4):344-349. [CrossRef] [Medline]
    36. Lau JTF, Wang Z, Lau M, Lai CHY. Perceptions of HPV, genital warts, and penile/anal cancer and high-risk sexual behaviors among men who have sex with men in Hong Kong. Arch Sex Behav. May 2014;43(4):789-800. [CrossRef] [Medline]
    37. Li X, Cao X, Li Z, et al. Human papillomavirus awareness and vaccine acceptability among men who have sex with men from Mainland China. Sci Rep. Jun 19, 2019;9(1):8763. [CrossRef] [Medline]
    38. Shrestha AD, Andersen JG, Gyawali B, et al. Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis. Public Health. Sep 2022;210:16-25. [CrossRef] [Medline]
    39. Fenkl EA, Jones SG, Schochet E, Johnson P. HPV and anal cancer knowledge among HIV-infected and non-infected men who have sex with men. LGBT Health. Feb 2016;3(1):42-48. [CrossRef] [Medline]
    40. Natipagon-Shah B, Lee E, Lee SY. Knowledge, beliefs, and practices among U.S. college students concerning papillomavirus vaccination. J Community Health. Apr 2021;46(2):380-388. [CrossRef] [Medline]
    41. Ong C, Winer J, Margolies L, Dai F, Patridge E, Chagpar AB. Awareness of HPV and its vaccine among lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations. J Clin Oncol. May 20, 2013;31(15_suppl):e17597. [CrossRef]
    42. Chan PSF, Fang Y, Chidgey A, Fong F, Ip M, Wang Z. Would Chinese men who have sex with men take up human papillomavirus (HPV) screening as an alternative prevention strategy to HPV vaccination? Front Med (Lausanne). 2022;9:904873. [CrossRef] [Medline]
    43. Lin Y, Li C, Wang L, Jiao K, Ma W. The mediated effect of HIV risk perception in the relationship between peer education and HIV testing uptake among three key populations in China. AIDS Res Ther. Mar 25, 2021;18(1):8. [CrossRef] [Medline]
    44. Reiter PL, McRee AL, Katz ML, Paskett ED. Human papillomavirus vaccination among young adult gay and bisexual men in the United States. Am J Public Health. Jan 2015;105(1):96-102. [CrossRef] [Medline]
    45. Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Palefsky JM. Cost-effectiveness of screening for anal squamous intraepithelial lesions and anal cancer in human immunodeficiency virus-negative homosexual and bisexual men. Am J Med. Jun 1, 2000;108(8):634-641. [CrossRef] [Medline]
    46. Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. Mar 2007;26(2):136-145. [CrossRef] [Medline]
    47. Alyafei A, Easton-Carr R. The health belief model of behavior change. In: StatPearls. StatPearls Publishing; 2026. URL: https://www.ncbi.nlm.nih.gov/books/NBK606120/ [Accessed 2026-05-21]
    48. McConnell EA, Janulis P, Phillips G 2nd, Truong R, Birkett M. Multiple minority stress and LGBT community resilience among sexual minority men. Psychol Sex Orientat Gend Divers. Mar 2018;5(1):1-12. [CrossRef] [Medline]
    49. Zhang C, Li X, Heilemann MV, Chen X, Wang H, Koniak-Griffin D. Facilitators and barriers of HIV self-testing among Chinese men who have sex with men: a qualitative study. J Assoc Nurses AIDS Care. 2021;32(5):599-609. [CrossRef] [Medline]
    50. Philbin MM, Hirsch JS, Wilson PA, Ly AT, Giang LM, Parker RG. Structural barriers to HIV prevention among men who have sex with men (MSM) in Vietnam: diversity, stigma, and healthcare access. PLoS ONE. 2018;13(4):e0195000. [CrossRef] [Medline]
    51. Tan RKJ, Kaur N, Kumar PA, et al. Clinics as spaces of costly disclosure: HIV/STI testing and anticipated stigma among gay, bisexual and queer men. Cult Health Sex. Mar 2020;22(3):307-320. [CrossRef] [Medline]
    52. Tiraki Z, Yılmaz M. Cervical cancer knowledge, self-efficacy, and health literacy levels of married women. J Cancer Educ. Dec 2018;33(6):1270-1278. [CrossRef] [Medline]
    53. Yared NF, Horvath KJ, Baker JV, Thyagarajan B, Waterboer T, Kulasingam S. Concordance of self- and clinician-collected anal swabs to detect human papillomavirus in a sample of HIV-negative men. J Low Genit Tract Dis. Jul 2019;23(3):200-204. [CrossRef] [Medline]
    54. Verdoodt F, Jentschke M, Hillemanns P, Racey CS, Snijders PJF, Arbyn M. Reaching women who do not participate in the regular cervical cancer screening programme by offering self-sampling kits: a systematic review and meta-analysis of randomised trials. Eur J Cancer. Nov 2015;51(16):2375-2385. [CrossRef] [Medline]
    55. Heid-Picard B, Cochand-Priollet B, Rozenberg F, et al. Ambulatory anal self-sampling in MSM living with HIV, an acceptable and reliable screening method. PLoS One. 2021;16(2):e0246338. [CrossRef] [Medline]
    56. Driscoll AK, Bernstein AB. Health and access to care among employed and unemployed adults: United States, 2009-2010. NCHS Data Brief. Jan 2012;(83):1-8. [Medline]
    57. Figueroa JF, Tosin-Oni M, Phelan J, Orav EJ, Epstein AM. Changes in employment status and access to care during COVID-19 pandemic among low-income adults in 4 southern states. J Gen Intern Med. Aug 2022;37(11):2795-2802. [CrossRef] [Medline]
    58. Melon M, Kombo B, Mugambi M, et al. Expanding options for HIV testing: a process evaluation of a community-led HIV self-testing intervention among men who have sex with men in Kenya. Gates Open Res. 2023;7:127. [CrossRef] [Medline]
    59. Vera JH, Soni S, Pollard A, et al. Acceptability and feasibility of using digital vending machines to deliver HIV self-tests to men who have sex with men. Sex Transm Infect. Dec 2019;95(8):557-561. [CrossRef] [Medline]
    60. Zhao YC, Zhao M, Song S. Online health information seeking behaviors among older adults: systematic scoping review. J Med Internet Res. Feb 16, 2022;24(2):e34790. [CrossRef] [Medline]

    ‎
    GK: general HPV knowledge subscale
    HPV: human papillomavirus
    IMB: information-motivation-behavioral skills
    MSM: men who have sex with men
    OR: odds ratio
    STI: sexually transmitted infection
    STROBE: Strengthening the Reporting of Observational Studies in Epidemiology
    TK: HPV testing knowledge subscale
    VK: HPV vaccine knowledge subscale

    Edited by Stefano Brini; submitted 09.Oct.2025; peer-reviewed by Jeb Jones, Siyu Chen; final revised version received 27.Apr.2026; accepted 02.May.2026; published 08.Jun.2026.

    Copyright

    © Xin Liu, Xuelin Yang, Mohan Lyu, Zhenwei Dai, Shu Jing, You Xin, Fei Yu, Shenglan Tang, Xiaoyou Su. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 8.Jun.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org, as well as this copyright and license information must be included.