The Health Belief Model: A Qualitative
Study to Understand High-risk Sexual
Behavior in Chinese Men Who Have Sex With Men
Xianhong Li, PhD, RN*
Yunxiao Lei, RN, BSN
Honghong Wang, PhD, RN
Guoping He, MD
Ann Bartley Williams, EdD, RNC, FAAN
The Health Belief Model (HBM) has been widely
used to explain rationales for health risk-taking
behaviors. Our qualitative study explored the appli-
cability of the HBM to understand high-risk sexual
behavior in Chinese men who have sex with men
(MSM) and to elaborate each component of the
model. HIV knowledge and perception of HIV preva-
lence contributed to perceived susceptibility. An
attitude of treatment optimism versus hard life in
reality affected perceived severity. Perceived barriers
included discomfort using condoms and condom
availability. Perceived benefits included prevention
of HIV and other sexually transmitted illnesses.
Sociocultural cues for Chinese MSM were elaborated
according to each component. The results demon-
strated that the HBM could be applied to Chinese
MSM. When used with this group, it provided
information to help develop a population- and
disease-specific HBM scale. Results of our study
also suggested behavioral interventions that could
be used with Chinese MSM to increase condom use.
(Journal of the Association of Nurses in AIDS Care,
27, 66-76) Copyright 2016 Association of Nurses
in AIDS Care
Key words: China, health belief, high-risk sexual
behavior, HIV, men who have sex with men
Male-to-male sexual behavior has become a pri-
mary transmission route for the HIV epidemic in
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 27, No. 1, January/February 2016, 66-76
http://dx.doi.org/10.1016/j.jana.2015.10.005
Copyright 2016 Association of Nurses in AIDS Care
China. Men who have sex with men (MSM) have
been the most rapidly increasing population of people
living with HIV in recent years. The percentages of
newly reported HIV cases in China that were attribut-
able to MSM were 0.2% in 2001, 12.2% in 2007, and
32.5% in 2009 (China Ministry of Health, Joint
United Nations Programme on HIV/AIDS, & World
Health Organization, 2010; Liu et al., 2006; State
Council AIDS Working Committee Office & United
Nations Theme Group on AIDS in China, 2007). A
high proportion of risky sexual practices and
multiple sexual partners were the main reasons for
the rapid increase of HIV prevalence in this
population. Studies have shown that 49% to 72% of
MSM engaged in unprotected anal intercourse in
the previous 6 months, and the average number of
sexual partners was around five (Choi, Gibson, Han,
& Guo, 2004; Ruan et al., 2008; Zhang, Bi, Iv,
Xianhong Li, PhD, RN, is an Associate Professor, Xiangya
Nursing School of Central South University, Changsha,
China. (*Correspondence to: xianhong_li228@hotmail.
com).Yunxiao Lei, RN, BSN, is a graduate student, Xiangya
Nursing School of Central South University, Changsha,
China. Honghong Wang, PhD, RN, is a Professor, Xiangya
Nursing School of Central South University, Changsha,
China. Guoping He, MD, is a Professor, Xiangya Nursing
School of Central South University, Changsha, China.
Ann Bartley Williams, EdD, RNC, FAAN, is a Professor,
Yale School of Nursing, New Haven, Connecticut, USA.

Zhang, & Hiller, 2007). Thus, understanding the
determinant factors of high-risk sexual behavior for
MSM and designing relevant interventions to
improve safe-sex practices are important goals for
HIV prevention in China.
The Health Belief Model (HBM) is a cognitive
model that has been used to understand the rationale
for peoples health risk-taking behaviors ever since it
was developed in the 1950s. It has addressed issues
such as smoking, substance abuse, obesity, sexually
transmitted infection (STI), and HIV (Rosenstock,
Strecher, & Becker, 1994). The model assumes that
individual willingness to engage in preventive health
behavior depends on five components: (a) perceived
susceptibility (vulnerability) to a certain disease, (b)
perceived severity of the disease, (c) perceived bene-
fits of taking preventive actions, (d) perceived
barriers to taking such action, and (e) cues to action
(e.g., illness of a friend, information about the disease
communicated by the media, internal stimuli;
Rosenstock et al., 1994). In an attempt to improve
its predictive ability, researchers expanded the
HBM to include the concept of selfefficacy
(Rosenstock, Strecher, & Becker, 1988).
Studies in a range of countries have examined the
capacity of the components of the HBM to predict
sexual risk-taking behaviors; however, findings
from these studies have been inconsistent and pro-
vided only partial evidence to support the model.
Some studies showed that almost all of the model
components could be the determinants of condom
use to prevent HIV infection (Adih & Alexander,
1999; Rosenstock et al., 1994; Steers, Elliott,
Nemiro, Ditman, & Oskamp, 1996). In contrast,
other studies found that only perceived barriers was
a significant predictor of condom use (Volk &
Koopman, 2001; Winfield & Whaley, 2002).
Another study found that only self-efficacy predicted
students intentions to use condoms and get tested for
STI and HIV (Zak-Place & Stern, 2004). Thus, some
researchers have argued that prevention strategies
based only on increasing perceived risk and perceived
severity might not be sufficient to improve condom
use (Hounton, Carabin, & Henderson, 2005).
In contrast, other scholars have suggested that the
HBM is powerful enough to predict health-related
behaviors and have pointed out reasons for apparent
inconsistencies. For example, HBM component vari-
Li et al. / High Risk Sex Among Chinese MSM 67
ables were measured in different ways in previous
studies (Bakker, Buunk, Siero, & van den Eijnden,
1997). In addition, the components of the HBM
might be socioculturally and population sensitive,
especially the cues to action component. One study
targeting Asian immigrants in the United States
found the HBM scale to be psychologically problem-
atic and suggested that acculturation needed to be
taken into account (Lin, Simoni, & Zemon, 2005).
Therefore, scales based on the HBM should be
operationalized to cultural and disease specifics in or-
der to achieve better predictive validity.
The HBM is widely used throughout China.
However, little is known about the effectiveness of
this model to contribute to improved understanding
of high-risk sexual behaviors by MSM. Whether the
HBM can be applied to Chinese MSM to improve
our understanding of high-risk sexual behavior is
not known. An HBM scale has not yet been designed
to target MSM in China. Therefore, our study aimed
to qualitatively describe and explore the applicability
of the HBM to understand high-risk sexual behavior
in Chinese MSM. Our study also sought to provide
information to develop a population- and disease-
specific HBM scale, and to suggest potential
behavioral interventions for Chinese MSM.
Methods
Study Design
We used a descriptive and exploratory qualitative
study design to describe male-to-male sexual
behavior and condom use status in Chinese MSM,
and to explore the rationale for high-risk sexual
behavior according to the HBM in the Chinese
culture context.
Study Site
From November to December 2013, 17 in-depth
semi-structured interviews were completed with
MSM in Zuo An Cai Hong, an MSM nongovern-
mental organization (NGO) located in the center of
Changsha, Hunan province, which has been affiliated
with the Changsha Center for Disease Prevention and
Control since 2008. Zuo An Cai Hong offered
68 JANAC Vol. 27, No. 1, January/February 2016

voluntary HIV counseling and testing, referrals for Table 1. Characteristics of Informants (N 5 17)
those who were found to be infected with HIV, Characteristics N (%)
Internet health education, and outreach interventions
Age (in years)
to improve condom use during anal intercourse. 2025 10 (58.8)
2630 4 (23.5)
Procedure and Participants 3040 2 (11.8)
$40 1 (5.9)
Purposive sampling was used to recruit partici- Married (legal marriage) 2 (11.8)
Sexual orientation
pants when they came in for HIV screening or coun-
Homosexual 14 (82.3)
seling. Potential male participants were 18 to Heterosexuala 2 (11.8)
65 years old, had had sex with men in their lifetimes, Bisexual 1 (5.9)
and had at least one unprotected anal intercourse Occupation
encounter with a man during the previous 6 months. College student 4 (23.5)
Those who were mentally ill, known to be infected Business 3 (17.6)
Office worker 6 (35.3)
with HIV, or had been senior peer educators for Services 2 (11.8)
more than 2 years were excluded. Participants were Money boy (male sex worker) 2 (11.8)
purposely recruited from different cultural groups Education background
such as college students, married MSM, bisexual High school (or in college) 6 (35.3)
MSM, those who performed sex for money, and Vocational school 2 (11.8)
College or higher 9 (52.9)
first-time HIV testers. The purposive recruitment
With Hunan residential status 9 (52.9)
strategy, intended to maximize the variation of partic- First time for HIV testing 5 (29.4)
ipant characteristics, was explained to a full-time
peer educator working in the NGO, who referred a. Men self-defined as heterosexual, but also self-reported male-
to-male sexual intercourse and met inclusion criteria.
potential participants to the study after an HIV
screening test was performed. Table 1 summarizes
pack as compensation. Demographic characteristics
the characteristics of the participants.
were collected during the structured interview on a
Interviews explored each subjects HIV knowl-
Demographic Form. The institutional review board
edge, sexual behavior during the previous 6 months,
at the School of Nursing of Central South University
HIV risk perception, HIV severity perception,
provided ethical approval.
barriers and benefits to maintaining safe-sex
behavior, and associated self-efficacy. The main
questions in the interview guide were: Data Analysis

 What do you know about HIV among MSM?
 Could you talk about your sexual behaviors
during the previous 6 months?
 Are you susceptible to HIV?
 What are the barriers for you to consistently use a
condom?
 What do you think are the benefits to consistently
using a condom?
 How much confidence do you have to consistently
use a condom?
All interviews were conducted in a private room by
the first author and tape-recorded after oral informed
consent was received. Interview time ranged from 20
to 50 minutes. Each informant received a small gift
Descriptive statistics were used to describe the
basic features of the data. All interviews were tran-
scribed into Word files and then imported into soft-
ware (NVivo 10.0) together with field notes and
memos. Thematic analysis was used because it is a
common approach in descriptive qualitative studies
to identify, analyze, and report themes within data
(Vaismoradi, Turunen & Bondas, 2013). The analyt-
ical process included six steps: (a) familiarization
with the data, (b) generating initial codes, (c) search-
ing for themes, (d) reviewing themes, (e) defining and
naming themes, and (f) producing the report (Braun
& Clarke, 2006).
Two authors coded the first three transcripts
together, discussed the present and potential codes

and themes, and came to an agreement on the coding
process. Then each author coded half of the
transcripts (interviews 4 to 10 for one researcher,
and interviews 11 to 17 for another researcher), and
reviewed each others codes to see whether they
agreed with the codes. Disagreements were discussed
until consensus was achieved.
Results
The operational components of the HBM demon-
strated in our qualitative study are presented in
Figure 1. HIV knowledge and perception of preva-
lence contributed to perceived susceptibility.
Attitudes of treatment optimism versus hard life in
reality affected perceived severity. Perceived barriers
included comfort with condom use and condom avail-
Figure 1. The operational components of the Health Belief Model tailored to men who have sex with men in a Chinese cultural
background. Note. STI 5 sexually transmitted infection.
Li et al. / High Risk Sex Among Chinese MSM 69
ability. Perceived benefits included HIV and STI pre-
vention. Sociocultural cues for Chinese MSM
included trust, subjective assessment of partner and
personal health status, positioning strategy by taking
the insertive role, knowing someone infected with
HIV, prior unprotected anal intercourse with a part-
ner who was believed to have HIV, HIV phobia and
stigma, difficulty maintaining one partner, difficulty
carrying condoms, uncommon use of condoms during
oral intercourse, and fulfilling family responsibilities.
Self-efficacy directly influenced safe-sex behavior.
Each component is elaborated in Figure 1.
Perceived Susceptibility
All of the informants had at least one instance of
unprotected anal intercourse (either receptive or in-
sertive) with a man during the previous 6 months,
70 JANAC Vol. 27, No. 1, January/February 2016
although most of them perceived very low personal
susceptibility to HIV infection. Frequent answers to
the question, How do you evaluate your risk to HIV
infection? were not too high, I am relatively
safe, and cant be me. ual) behavior (until 2 years ago). We had such
HIV knowledge. Inaccurate HIV knowledge was
a primary reason for low HIV risk perception.
Many of our participants believed that oral sex was
safe or very low risk (47%), and thus, oral sex did
not require condom use. They knew that HIV could
be transmitted by sex, but did not know the transmis-
sion mechanisms. One third of the informants did not
know that semen contained the virus. One informant
guessed that HIV was located in the anal canal, which
was why HIV could be transmitted by anal inter-
course, and that that was why oral sex was safe. A
23-year-old single, homosexual man said, I only
know it is transmitted by using drugs, and also inter-
course . I am not clear about why anal intercourse is
a higher risk behavior for HIV. Another man said,
The transmission routes include mother-child route,
and another is intercourse route, since the prostatic
fluid contains virus (32 years of age, married,
bisexual).
Perception of HIV prevalence. Although most of
the men knew that MSM were at a high risk for HIV,
11 informants (65%) did not know the extent of HIV
prevalence in MSM in Changsha or China. The
common answers to the prevalence question were
not clear or dont know. After the interviewer had, how many times not using condom, and
provided HIV incidence numbers for MSM nation-
wide and in Hunan province, most were surprised
with responses such as, so high?, really?, or like if he responded very seriously, I would
it is horrible. However, the largest rationale for
low perceptions of HIV risk was due to the sociocul-
tural cues of Chinese MSM, elaborated below.
Trust. Trust that a partner did not have HIV was
one of the most common themes. The partners our
participants usually trusted were their regular sexual
partners or people with whom they were acquainted.
They are the very, very good, can be trusted friends.
We go out and have fun, but the main aim is not for
sex . we seem to have similar personalities
(26 years of age, homosexual, office worker).
Another man said,
Because he does not belong to this quanzi (
, gay community), and I think I do not belong
to this quanzi either. We know each other for
almost 10 years, but didnt have such (homosex-
behavior by accident . the main reason (not
to use condom) is I trust him. (42 years of
age, married, bisexual, came for HIV and syph-
ilis test because his partner had been diagnosed
with condyloma acuminatum)
Assessing partner health status. Techniques to
assess partner health status were widely disseminated
in the MSM community and included observation,
touch, communication, or having an HIV test prior
to unprotected anal or oral sex. Usually, the men
used the adjective luan () to describe sexual part-
ner susceptibility to HIV. Luan was defined by the in-
formants as having multiple or stranger sexual
partners, having sex in bath centers or bars, or having
group sex. I definitely will (evaluate his health sta-
tus). One is through observing, to see whether he is
clean, the other is to ask in a joking way or implied
way (32 years of age, married, bisexual). Another
man said, My friends told me that if he had that
(HIV), his muscles would be flabby, not massive,
and could be differentiated by touching his muscles
(24 years of age, homosexual, services). And another
said,
I will ask him about how many friends he has
then I can evaluate whether he is luan or not
. I can get the sense from the communication,
believe he was healthy. (26 years of age, homo-
sexual, office worker)
Assessing personal health status. Most MSM
believed they were far away from HIV because
they were not in a high-risk group, which was
defined by them as drug users, have 419 (one
night of sex), or have multiple sexual partners.
One man indicated his susceptibility as: Not too
high, because, firstly I dont use drugs; secondly if
I want to have sex with someone, I will not be
very luan (25 years of age, homosexual, office
worker).

Positioning strategy. This was the last strategy to
avoid using a condom when men really wanted unpro-
tected sex. Although they were clear that they were at
risk without a condom, they thought they were at
minimal or no risk by taking the insertive role during
sexual behavior. I could not find one (condom). I
think I will be OK since I was the 1 (person in the
insertive role) and we then had it (anal sex) (22 years
of age, single, homosexual, Money Boy [male sex
worker]). Another participant said,
They like to have oral sex with me when I am in
bath centers . actually some of them do like
me to have anal sex without using a condom.
They told me: Anyway, you are the 1, you
dont need to worry about it. (28 years of
age, single, heterosexual)
On the other hand, sociocultural cues for Chinese
MSM could also be facilitators for safe-sex behavior
by increasing the perception of HIV susceptibility.
Two facilitators were discussed: (a) knowing some-
one who was infected with HIV or STI, and (b) prior
experience of having unprotected sex with someone
who was believed to have HIV.
Because I did not know who was infected with
HIV among the people around me before (I
knew my current partner), and now he knows
someone who is HIV positive just around us,
and tells me something, so I think it is really
necessary to use (condoms) . Unless people
really meet someone with HIV, they will not
take precautions and will believe HIV is far
from them. (24 years of age, single, homosexu-
al, started to use anal condom after meeting cur-
rent partner)
Not using a condom is not allowed (for me), I take
very good care of it, since I was infected with ure-
thritis maybe (he thought it was an STI), and had
infusion for 1 week, so I am afraid of it. (26 years
of age, homosexual, office worker)
Perceived Severity
How subjects perceived and interpreted the effec-
tiveness of antiretroviral therapy was the key deter-
minant in their perception of HIV severity. There
were two opposite attitudes.
Li et al. / High Risk Sex Among Chinese MSM 71
Treatment optimism. Seven informants held a
very calm attitude toward the possibility that they
could be infected with HIV. The information that
HIV can be controlled by medicine reduced the
horror of HIV, and was metaphorically considered a
ding xin wan (, a drug that can relieve the anx-
iety and horror). Medication can control it. The
country has a kind of organization that can distribute
medication for free . you can live with it for long if
you had an optimistic attitude (24 years of age, sin-
gle, homosexual). Another man said,
I happened to get to know this (treatment) today.
For most gay men, it is like giving them a ding
xin wan, it is not a death penalty to have this dis-
ease, not to die soon, rather like diabetes. It
cant be cured now, but I think it can be in
future. (28 years of age, single, heterosexual)
Hard life in reality. Only three informants
believed that although HIV could be controlled by
medicine, living with HIV was very hard. MSM
who held this point of view had more motivation
for safe sexual behaviors. It is not to say you will
die quickly, but to live with it will also be very
hard (21 years of age, homosexual, college student).
I think it is hard to live with HIV, if the regimen
doesnt work anymore; you need to change to another
one (26 years of age, homosexual, office worker).
Perceived HIV and homosexual stigma. Percep-
tion of HIV severity was affected not only by the
curability of the disease, but also by stigmatizing atti-
tudes toward HIV and homosexuality in Chinese soci-
ety. However, this could be a double-edged sword. On
one hand, the men were motivated to practice safe-sex
behaviors because of the high stigma; on the other
hand, some did not care about HIV infection and
took it as an extreme end of the high social stigma
and stress with which they coped daily. It is good
(to get HIV)! From another perspective, getting
AIDS is an end (of the high social stigma and stress),
because (I) dont need to get married, can go travel-
ling, and can do whatever I want (26 years of age,
homosexual, office worker). Another man said,
The taxis will not go there (designated hospital
for patients with HIV), AIDS is like a plague
72 JANAC Vol. 27, No. 1, January/February 2016
when people are talking about it . if you are
unlucky to get infected, it is horrible, not only
because it cant be cured, but also it is a dirty
disease, dirty disease . (32 years of age, mar-
ried, bisexual)
Perceived Barriers
The prevailing barriers mentioned by our partici-
pants came from the sociocultural cues of Chinese
MSM, except for condom comfort and availability.
The information and recognition about using con-
doms was mainly disseminated by peers, and some
of the information was inaccurate but was deeply
believed by the gay community.
Discomfort using condoms. Condoms affect
comfort and sexual pleasure was a very common
rationale given by our participants for not using con-
doms: I just like the feeling of ejaculating into in-
side (anal), with strong pleasure; (ejaculating) with
a condom is totally another feeling (22 years of
age, homosexual, college student). However, condom
type and quality could interfere with such feelings:
The condoms they distribute have tops, and are
thick, so you can always feel something in it
(anal canal); when you are doing (sex) it will
get longer and longer . I like the condoms
made in Japan, they are thin and without a
top, and have a suitable size. (26 years of age,
homosexual, office worker)
Condom availability. No condom at hand was
another common excuse for failing to use a condom.
One reason was that some sexual practices happened
in situational contexts that were not predetermined.
Another reason was the participants did not want to
always bring condoms along with them. I heard
from friends that they had such experience of car-
rying condoms, and then it lost the preventive effect.
It is easy to be broken if it is not in the large box
(24 years of age, single, homosexual, worker).
Condoms affect trust and love. Most MSM
believed that it was not necessary to use a condom
with their boyfriends, even if they had just met him
or had set up the relationship for a few days. Having
sex without a condom was considered an indication
of special trust and true love, especially by young
MSM in college.
It is based on the respect, affirmation, and trust
for your partner. Lets suppose you want to be
his boyfriend, and if you used condom or
required him to use condom, the feeling was
like you did not trust him, and insulted him.
(20 years of age, homosexual, college student)
I dont like to use a condom if I love that person;
if I dont love him I will strongly require its use.
Because having sex with someone I dont love
is just for physical sexual needs, but having
sex with someone I love is a horse of a different
color, with a feeling of happiness. (22 years of
age, homosexual, college student)
Difficulty maintaining one partner for a long time.
Those who tended to have multiple sexual partners
usually didnt believe there was true love between
MSM, nor that there could be a future for two gay
men in love due to lack of legal protection. I never
expected to find a man to get married or live together
for whole life. For me, male-to-male sex is just like
smoking or drinking behaviors of men (28 years
of age, single, heterosexual). True love means one
cant live without another one. This is rare (among
MSM), and I never saw such relationship (32 years
of age, married, bisexual). When society can not
give a promise to this quanzi, how can the individuals
give a promise to each other? (23 years of age, ho-
mosexual, office worker).
Condom use in oral intercourse was rare. It was
uncommon for Chinese MSM to use condoms during
oral sex. Also, oral condoms, which are more sensi-
tive, could not be purchased in pharmacies in China.
It seems not a situation that gay men must use oral
condom during oral sex. It (using an oral condom) is
weird in this quanzi (21 years of age, homosexual,
single, service worker). You can only buy it (oral
condom) through the Internet, there is no special
condom for oral sex in pharmacy stores (32 years
of age, married, bisexual).

Perceived Benefits
Generally, the benefits of safe-sex behavior
seemed obvious. All of the informants knew that con-
doms could prevent HIV and STI. They said it was
better to have it than nothing and to feel psycho-
logically safe. Maintaining consistent safe sex
behavior was considered not an individual issue,
but an indicator of family responsibility. I got mar-
ried, and my wife is living in the village. I am only
32 years and my son is just 12 years, so if I got a little
bit of that (HIV), it was irresponsible for the family
(32 years of age, married, bisexual).
Since I am the only son in my family, I cannot
hurt my parents by such things (being gay and
getting infected), this is my borderline (keeping
healthy). I believe that every son or daughter
could give up their own future, but can never
abandon their parents. (28 years of age, single,
heterosexual)
Self-efficacy
Self-efficacy directly influenced safe sex behavior.
We used self-efficacy to evaluate the extent of our
participants preparation and confidence to use safe
sex practices consistently. The barriers to high self-
efficacy were attributed to two reasons.
Lack of self-control. It was widely acknowledged
in the MSM community that passion could take over
during sex. According to my best knowledge, in
northern east of China (MSM) seldom consistently
use it (condoms) . just for fun and passion .
when passion comes, it (condom use) will be
forgotten (24 years of age, single, homosexual,
Money Boy and peer educator). During that
moment, I just want to enjoy that feeling, that ardor
. after sex, I begin to regret, but next time I still do
the same (have sex without condom), and then regret
(22 years of age, homosexual, college student).
Lack of negotiating capacity. Four informants
said they would give up condoms if a partner insisted.
I will try to persuade him (to use a condom), if I fail,
I will give up (33 years of age, single, homosexual,
office worker). Most of them are OK when I said to
Li et al. / High Risk Sex Among Chinese MSM 73
use a condom, but my former boyfriend just didnt
like it, so I didnt insist (24 years of age, single, ho-
mosexual, office worker).
Discussion
The results of our study clearly elaborated the ex-
pressions of each component of the HBM and
explored the possible reasons for inconsistent
condom use during anal sex. Unlike some other
studies (Hounton and colleagues, 2005; Zak-Place
& Stern, 2004), our study results supported a belief
that low perception of HIV vulnerability could be a
strong reason for high-risk sexual behavior by
MSM. None of our respondents wanted to have un-
protected anal or oral sex if they definitely knew
that their partners had HIV. The strong belief that
they were safe or far from HIV was influenced by
inaccurate HIV knowledge, a perception of low
HIV prevalence, the sociocultural norms of Chinese
MSM, and/or the dissemination of incorrect safe-
sex strategies. Other Chinese researchers, who have
explored sociocultural facilitators and barriers to
condom use in Guangzhou Province in an ethno-
graphic approach, had similar findings (Li, Lau,
Holroyd, & Yi, 2010).
One of the biggest challenges revealed by Li and
colleagues (2010) and our study was that the norm
of a true love or regular partner doesnt need a
condom, which was common, especially among
young college MSM who thought only persons who
were luan or ethically unfaithful had high susceptibil-
ity to HIV. Empirically, this notion has been
confirmed as wrong by a recent meta-analysis, which
indicated that the proportion of new infections
attributed to regular partnerships increased from
34% to 40%, whereas infections attributed to com-
mercial partnerships decreased from 29% to 23%
during 20022010 (Zhang, Chow, & Wilson,
2012, p.7). Thus, an important implication of our re-
sults was that future studies should focus on the
mistaken tie between condom use and trust or respect
to help formulate a new norm of regular condom use
by MSM.
Ding xin wan is a metaphor that showed an opti-
mistic attitude about HIV treatment, which was
demonstrated to be one of the main barriers to safe
74 JANAC Vol. 27, No. 1, January/February 2016
sex and has been called treatment optimism in the
United States (Rowniak, 2009). This attitude is still
prevalent in Chinese MSM. Our study showed that
how men interpreted the knowledge that HIV could
be controlled by medicine influenced their motivation
to practice safe-sex behavior. If it was interpreted as,
It is not a big deal to get HIV because it can be
controlled, the motivation for safe-sex practice was
reduced. In contrast, if it was interpreted as, It is still
hard to live with HIV because it has not been cured,
there was more motivation for condom use. A recent
cross-sectional study also showed that believing that
HIV meant death was a facilitative factor for consis-
tent condom use, while believing that HIV had
become a chronic illness was a risk factor for incon-
sistent condom use (Li and colleagues, 2013). There-
fore, HIV education programs targeting MSM should
include components such as transmission mecha-
nisms, treatment-specific information, and drug-
resistance information, in order to clarify that living
with HIV had many challenges. This was the second
major implication of our results.
The third implication for preventive studies was
that peer capacity to disseminate correct HIV knowl-
edge should be improved. Our study showed that
whether to use a condom or not was often based on
the sociocultural cues, including friends information
or experiences. Sexual social network theorists
believe that an individuals knowledge of HIV, cogni-
tion of how to protect oneself, and risky and safe sex-
ual behaviors are constructed by the interaction of
MSM in the sexually related social network (Liu,
Wu, & Pang, 2009). Thus, the belief held by the
group has great influence on ones behavior, whether
it is correct or not (e.g., incorrect beliefs about stra-
tegic positioning; not to be luan; assessing partner
health status by observing, touching, or simple
communication; that it is unnecessary to use condoms
with regular partners). A recent meta-analysis also
supported our recommendation by confirming that
intervention by popular opinion leaders was the
most effective strategy to improve condom use in
China (Zheng & Zheng, 2012).
One facilitator for condom use was found to be
family responsibility, which was deeply rooted in
Confucianism and characterized by family-oriented
values. However, it was controversial in terms of be-
ing a prevention strategy for MSM in China. On the
one hand, family responsibility puts stress on MSM
to enter into a heterosexual marriage. Participants
did not see a future with a regular homosexual partner
and, therefore, had multiple gay male partners. On the
other hand, they perceived that they needed to take
responsibility for caring for their parents and burying
them after they passed away. Therefore, they needed
to maintain their own health. Thus, the fourth impli-
cation for preventive education would be to carefully
emphasize filial piety in Chinese MSM and to
encourage them to consistently use condoms not
just for themselves but also for their parents.
A detailed elaboration of each component of the
HBM will help to develop a culture-adaptive and
disease-specific scale to predict consistent safe-sex
behavior by Chinese MSM. A qualitative approach
is usually the first step to develop a quantitative sur-
vey scale. As discussed in the literature review,
when introducing the HBM into a new cultural back-
ground, it must be adapted, especially for the cues to
action component (Lin et al., 2005). Our results
enhanced these components by adding themes, such
as inaccurate HIV knowledge, assessing personal
and partner health status (using incorrect strategies),
trust as an ethical issue, and family responsibility (see
Figure 1). All these elaborations could help generate a
pool of items to test for use in quantitative studies af-
ter appropriate evaluation survey psychometrics.
Our study had limitations. First, our sample size
was small, but it was based on category saturation
for sociocultural cues. Second, purposive sampling
was limited to the subgroup of MSM who voluntarily
came to one NGO for HIV testing. Therefore, the
operational components of the HBM might have
been biased against those who never came for testing.
Conclusions
The main significance of our study was to provide
preliminary evidence of the applicability of the HBM
to understand high-risk sexual behaviors in Chinese
MSM. The results also provided information that
could be used to develop a culturally appropriate
HBM scale for MSM in China. Based on HBM scale
development, more advanced statistical methods,
such as structural equation modeling, could be used
to examine the direct and indirect effects of the six

components of the HBM on consistent safe-sex
behavior.
Key Considerations
 The Health Belief Model can help to explain
high-risk sexual behaviors in Chinese men
who have sex with men (MSM), as long as
the components are appropriately measured in
terms of sociocultural parameters.
 Ding xin wan is a metaphor that shows an opti-
mistic attitude about HIV treatment, which
leads to inconsistent condom use. HIV educa-
tion programs targeting MSM should include
transmission mechanisms, treatment-specific
information, and drug-resistance information,
in order to be clear that living with HIV has
many challenges.
 Because most social cues are learned from
peers, health care providers should employ
MSM peers to disseminate prevention
information.
 Health care providers can emphasize the value
of filial piety during prevention education in or-
der to strengthen the cultural norm of family re-
sponsibility and staying healthy for the family.
Acknowledgments
This study was funded by the China Medical
Board (CMB) Nursing Faculty Research Grant (10-
020-201310). The authors report no perceived vested
interests or coercion from this grant, because the con-
tent is solely the responsibility of the authors. The au-
thors would like to thank all the participants for
sharing their sexual life experiences and opinions,
as well as Zuo An Cai Hong for organizing and
providing a private room for interviewing.
Disclosures
The authors report no real or perceived vested inter-
ests that relate to this article that could be construed
as a conflict of interest.
Li et al. / High Risk Sex Among Chinese MSM 75
References
Adih, W. K., & Alexander, C. S. (1999). Determinants of
condom use to prevent HIV infection among youth in Ghana.
Journal of Adolescent Health, 24(1), 63-72.
Bakker, A. B., Buunk, B. P., Siero, F. W., & van den
Eijnden, R. J. J. M. (1997). Application of a modified health
belief model to HIV preventive behavioral intentions among
gay and bisexual men. Psychology & Health, 12(4), 481-492.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psy-
chology. Qualitative Research in Psychology, 3(2), 77-101.
China Ministry of Health, Joint United Nations Programme on
HIV/AIDS, & World Health Organization. (2010). 2009 esti-
mates for the HIV/AIDS epidemic in China. Retrieved from
http://www.unaids.org.cn/download/2009%20China%20Esti
mation%20Report-En.pdf
Choi, K. H., Gibson, D. R., Han, L., & Guo, Y. Q. (2004). High
levels of unprotected sex with men and women among men
who have sex with men: A potential bridge of HIV transmis-
sion in Beijing, China. AIDS Education and Prevention,
16(1), 19-30.
Hounton, S. H., Carabin, H., & Henderson, N. J. (2005).
Towards an understanding of barriers to condom use in rural
Benin using the health belief model: A cross sectional survey.
BMC Public Health, 5, 8.
Li, H. C., Lau, J. T. F., Holroyd, E., & Yi, H. S. (2010). Socio-
cultural facilitators and barriers to condom use during anal
sex among men who have sex with men in Guangzhou,
China: An ethnographic study. Psychological and Socio-
Medical Aspects of AIDS/HIV, 22(12), 1481-1486.
Li, X., Liu, B., Zhao, J., He, G., Zhou, W., & Wang, H. (2013).
The impact of AIDS-related knowledge on condom use rate
among men who have sex with men. Chinese General Prac-
tice, 16(4A), 1170-1172.
Lin, P., Simoni, J. M., & Zemon, V. (2005). The health belief
model, sexual behaviors, and HIV risk among Taiwanese
immigrants. AIDS Education and Prevention, 17(5), 469-
483.
Liu, H., Yang, H. M., Li, X. M., Wang, N., Liu, H. J., Wang, B.,
. Stanton, B. (2006). Men who have sex with men and hu-
man immunodeficiency virus/sexually transmitted disease
control in China. Sexually Transmitted Diseases, 33(2), 68-
76.
Liu, K., Wu, Z., & Pang, L. (2009). Condom usage status and
HIV prevention challenge among men who have sex with
men in China. Chinese Journal of STD/AIDS, 5, 246-248.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988).
Social-learning theory and the health belief model. Health
Education Quarterly, 15(2), 175-183.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1994). The
Health Belief Model and HIV risk behavior change. In
R. J. DiClemente, & J. L. Peterson (Eds.), Preventing
AIDS: Theories and methods of behavioral interventions
(pp. 5-24). New York, NY: Plenum.
Rowniak, S. (2009). Safe sex fatigue, treatment optimism, and
serosorting: New challenges to HIV prevention among men
76 JANAC Vol. 27, No. 1, January/February 2016

who have sex with men. Journal of the Association of Nurses

in AIDS Care, 20(1), 31-38.
Ruan, S. M., Yang, H., Zhu, Y. W., Ma, Y. H., Li, J. X.,
Zhao, J. K., . Raymond, H. F. (2008). HIV prevalence
and correlates of unprotected anal intercourse among men
who have sex with men, Jinan, China. AIDS Behavior,
12(3), 469-475.
State Council AIDS Working Committee Office, & United Na-
tions Theme Group on AIDS in China. (2007). A joint assess-
ment of HIV/AIDS prevention, treatment and care in China.
Retrieved from http://www.unaids.org.cn/uploadfiles/20080
725151739.pdf
Steers, W. N., Elliott, E., Nemiro, J., Ditman, D., & Oskamp, S.
(1996). Health beliefs as predictors of HIV-preventive
behavior and ethnic differences in prediction. Journal of So-
cial Psychology, 136(1), 99-110.
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content
analysis and thematic analysis: Implications for conducting
a qualitative desriptive study. Nursing & Health Science,
15(3), 398-405.
Volk, J. E., & Koopman, C. (2001). Factors associated with
condom use in Kenya: A test of the health belief model.
AIDS Education and Prevention, 13(6), 495-508.
Winfield, E. B., & Whaley, A. L. (2002). A comprehensive test
of the health belief model in the prediction of condom use
among African American college students. Journal of Black
Psychology, 28, 330-346.
Zak-Place, J., & Stern, M. (2004). Health belief factors and
dispositional optimism as predictors of STD and HIV preven-
tive behavior. Journal of American College Health, 52(5),
229-236.
Zhang, D. P., Bi, P., Iv, F., Zhang, J., & Hiller, J. E. (2007).
Changes in HIV prevalence and sexual behavior among
men who have sex with men in a northern Chinese city:
2002-2006. Journal of Infection, 55(5), 456-463.
Zhang, L., Chow, E. P. F., & Wilson, D. P. (2012). Distributions
and trends in sexual behaviors and HIV incidence among
men who have sex with men in China. BMC Public Health,
12, 546.
Zheng, L. J., & Zheng, Y. (2012). Efficacy of human immunode-
ficiency virus prevention interventions among men who have
sex with men in China: A meta-analysis. Sexually Trans-
mitted Diseases, 39(11), 886-893.