Abstract
Background
Men who have sex with men (MSM) are at high risk for HPV infection. While economic barriers to vaccination are well documented, factors influencing their decision-making in a cost-free scenario remain unclear. This study aims to explore these core factors.
Methods
From April to August 2024, MSM aged 18 years and older were recruited in Jinan through social organization networks. A cross-sectional survey was conducted using face-to-face questionnaires to collect information on sociodemographics, sexual behaviors, knowledge about AIDS and HPV, and willingness to receive free HPV vaccination. The sample size was estimated using the formula for cross-sectional studies, with a minimum required sample size of 291 (after adjusting for 10% invalid questionnaires). Data were entered using EpiData 3.1, sorted with Excel, and analyzed with SPSS 22.0. The chi-square test or Fisher’s exact test was used for univariate analysis, and multivariate binary logistic regression was performed for variables that were statistically significant in the univariate analysis. The significance level was set at α = 0.05.
Results
A total of 401 MSM were included, of whom 371 (92.5%) were willing to receive free HPV vaccination. Univariate analysis showed that willingness was significantly higher among those with fixed same-sex partners, those who had heard of PrEP drugs, those who sought partners online, and those who believed that men could be infected with HPV (all P < 0.05). Multivariate analysis revealed that having a fixed partner (aOR = 7.61, 95% CI: 2.38–24.34), awareness of PrEP drugs (aOR = 7.61, 95% CI: 2.65–21.83), and belief in male HPV susceptibility (aOR = 25.85, 95% CI: 8.57–77.96) were positively associated with willingness.
Conclusions
Fixed same-sex partner relationships, awareness of PrEP drugs, and perception of male susceptibility to HPV are important factors influencing MSM’s willingness to receive free HPV vaccination. It is necessary to further promote free HPV vaccination, reduce the burden of HPV infection and related diseases among MSM, prevent HPV transmission in the general population, and strengthen public health defenses.
Keywords: Men who have Sex with Men (MSM), Human Papillomavirus (HPV), Vaccine, Vaccination willingness
Background
HPV infection is one of the most prevalent sexually transmitted diseases worldwide and is closely associated with the development of various cancers, including cervical, anal, vaginal, vulvar, oropharyngeal, and penile cancers [1]. Although the health protection system for women is gradually improving, men who have sex with men (MSM), as a high-risk group for HPV infection, should not be overlooked. Studies indicate that the rates of anal HPV infection and penile HPV infection among MSM are as high as 78.4% and 36.2%, respectively [2], with their HPV-related disease burden significantly exceeding that of the general population.
HPV vaccination is an effective measure to prevent HPV infection and related diseases [3]. Currently, some developed countries and regions have gradually included HPV vaccines in immunization programs targeting MSM populations. However, even in these regions where relevant policies have been implemented, the actual vaccination rate remains suboptimal [4–6], making it difficult for this high-risk population to obtain adequate vaccine protection. Under cost-free intervention scenarios—i.e., when vaccines are freely available—it remains unclear which factors still influence vaccination decisions among MSM. Therefore, this study aims to investigate the willingness of MSM in Jinan, China, to receive free HPV vaccines and to identify key factors associated with this willingness, in order to provide evidence for developing targeted public health strategies for this high-risk population.
Methods
Study participants
From April to August 2024, male participants aged 18 years and older who had engaged in insertive oral or anal intercourse with a same-sex partner within the previous year were recruited in Jinan through social organization networks. Recruitment was assisted by the local community-based organization (CBO) “Jinan Rainbow.” Recruitment methods included convenience sampling via the organization’s social media platforms (e.g., WeChat) and snowball sampling—encouraging initial participants to refer eligible MSM from their social networks. Owing to the anonymity of online recruitment, a precise response rate could not be calculated; nevertheless, a total of 401 participants were successfully enrolled. All participants provided informed consent and voluntarily took part in the survey. This study was approved by the Public Health Ethics Committee of Shandong University (Approval No.: LL20220906).
Sample size estimation
The sample size was estimated using the formula for cross-sectional studies:
 |
where Z is the statistical value, α = 0.05, Zα/2 = 1.96; P is the expected incidence or probability of the event. Based on previous studies, the acceptance rate of HPV vaccine among MSM was approximately 62.23% [7], so P = 0.62; δ = 0.1 × P. Considering the possibility of invalid questionnaires, the sample size was increased by 10%, resulting in a minimum required sample size of 291.
Questionnaire design and data collection
The questionnaire was based on the China AIDS Sentinel Surveillance Questionnaire [8]. Demographic characteristics, sexual behaviors, and AIDS-related knowledge were directly adopted from this questionnaire, which is used nationwide annually and has high validity. HPV-related knowledge and willingness to receive free HPV vaccination were jointly designed by epidemiology experts and community organizations, and reviewed by three epidemiologists and two community organization representatives to ensure content validity.A pilot survey was conducted among 20 MSM to assess the questionnaire’s comprehensibility and response fluency, with subsequent fine-tuning of question wording based on feedback.
Statistical analysis
Data were entered using EpiData 3.1, sorted with Excel, and analyzed with SPSS 22.0. Categorical data were described using frequencies, constituent ratios, or rates. Univariate analysis of factors associated with HPV vaccination willingness was performed using the chi-square test or Fisher’s exact test. Variables that were statistically significant in the univariate analysis were further analyzed using a multivariate binary logistic regression model. The significance level was set at α = 0.05.
Results
Sociodemographic characteristics of participants
A total of 401 participants were recruited, aged 18–68 years, with 44.4% aged 25–<35 years; 79.1% had a college degree or higher; 68.3% had no spouse; 94.8% were registered in Shandong Province; and 99.0% had lived in Jinan for more than 2 years (Table 1).
Table 1.
Univariate analysis of willingness for free HPV vaccination among MSM in Jinan
| Variables | Number (Constituent ratio/%) (n = 401) |
Number of participants willing to receive free HPV vaccination (Proportion/%) (n = 371) |
Univariate analysis | |
|---|---|---|---|---|
| χ² | P | |||
| Age group (years) | 0.625a | |||
| 18 ~ < 25 | 33(8.2) | 30(90.9) | ||
| 25 ~ < 35 | 178(44.4) | 168(94.4) | ||
| 35 ~ < 45 | 120(29.9) | 109(90.8) | ||
| 45 ~ < 55 | 43(10.7) | 40(93.0) | ||
| ≥ 55 | 27(6.7) | 24(88.9) | ||
| Educational level | 0.301 | |||
| Junior high school or below | 26(6.5) | 24(92.3) | ||
| Senior high school or technical secondary school | 58(14.4) | 51(87.9) | ||
| College or above | 317(79.1) | 296(93.4) | ||
| Marital status | 0.357 | 0.540 | ||
| No spouse | 274(68.3) | 252(92.0) | ||
| With spouse | 127(31.7) | 119(93.7) | ||
| Household registration | 0.201a | |||
| Shandong Province | 380(94.8) | 353(92.9) | ||
| Other provinces | 21(5.2) | 18(85.7) | ||
| Duration of residence in Jinan | 1.000a | |||
| years | 4(1.0) | 4(100.0) | ||
| ≥ 2 years | 397(99.0) | 367(92.5) | ||
| Main partner for same-sex anal sex | 5.862 | 0.015 | ||
| Casual partner | 100(24.9) | 87(87.0) | ||
| Fixed partner | 301(75.1) | 284(94.4) | ||
| Multiple sexual partners in the past 6 months | 0.151a | |||
| Yes | 31(7.7) | 31(100.0) | ||
| No | 370(92.3) | 340(91.9) | ||
| Heard of HIV PrEP drugs | <0.001a | |||
| Yes | 367(91.5) | 351(95.6) | ||
| No | 34(8.5) | 20(58.8) | ||
| Coerced into sexual activity in the past year | 1.000a | |||
| Yes | 21(5.2) | 20(95.2) | ||
| No | 380(94.8) | 351(92.5) | ||
| Sought same-sex partners through the Internet in the past 6 months | 14.616 | <0.001 | ||
| Yes | 330(82.3) | 313(94.8) | ||
| No | 71(17.7) | 58(81.7) | ||
| Belief that men can be infected with HPV | <0.001a | |||
| Yes | 344(85.8) | 336(97.7) | ||
| No | 57(14.2) | 35(61.4) | ||
ᵃ Fisher’s exact test was used
Sexual behaviors and knowledge about AIDS and HPV
Among the 401 participants, 75.1% reported having fixed same-sex partners as their main partners for anal sex; 7.7% had sexual relations with multiple partners in the past 6 months; 91.5% had heard of PrEP drugs; 5.2% had been coerced into sexual activity in the past year; and 85.8% believed that men could be infected with HPV (Table 1).
Willingness to receive free HPV vaccination and associated factors
Willingness to receive free HPV vaccination was assessed by a single question: “If a free HPV vaccine were offered to you, would you be willing to receive it?” Responses were binary (yes/no). A total of 371 (92.5%) participants answered “yes” and were classified as willing.
Univariate analysis showed that the proportion of participants willing to receive free HPV vaccination was significantly higher among those with fixed same-sex partners, those who had heard of PrEP drugs, those who had sought same-sex partners through the Internet in the past 6 months, and those who believed that men could be infected with HPV (all P < 0.05) (Table 1).
Prior to multivariate binary logistic regression analysis, we assessed multicollinearity among the independent variables. The variance inflation factor (VIF) for all variables was below 2, indicating no substantial multicollinearity. The Hosmer-Lemeshow test indicated a good model fit (χ² = 3.770, P = 0.287).
Multivariate binary logistic regression analysis revealed that having a fixed same-sex partner (aOR = 7.610, 95% CI: 2.379–24.342), having heard of PrEP drugs (aOR = 7.612, 95% CI: 2.654–21.829), and believing that men could be infected with HPV (aOR = 25.853, 95% CI: 8.574–77.955) were positively correlated with willingness to receive free HPV vaccination (Table 2).
Table 2.
Multivariate analysis of willingness for free HPV vaccination among MSM in Jinan
| Variables | Multivariate analysis | ||
|---|---|---|---|
| aOR (95% CI) | P | ||
| Main partner for same-sex anal sex | |||
| Casual partner | 1 | ||
| Fixed partner | 7.610(2.379 ~ 24.342) | 0.001 | |
| Heard of HIV PrEP drugs | |||
| Yes | 7.612(2.654 ~ 21.829) | <0.001 | |
| No | 1 | ||
| Sought same-sex partners through the Internet in the past 6 months | |||
| Yes | 1.646(0.533,5.086) | 0.387 | |
| No | 1 | ||
| Belief that men can be infected with HPV | |||
| Yes | 25.853(8.574 ~ 77.955) | <0.001 | |
| No | 1 | ||
Variable coding for multivariate analysis: willingness (1 = willing, 0 = unwilling); main partner for same-sex anal sex (1 = fixed partner, 0 = casual partner); heard of PrEP drugs (1 = yes, 0 = no); belief that men can be infected with HPV (1 = yes, 0 = no); sought same-sex partners through the Internet in the past 6 months (1 = yes, 0 = no)
Sensitivity analysis
To address potential bias arising from the small number of participants unwilling to vaccinate (n = 30), we conducted a sensitivity analysis using Firth’s penalized likelihood logistic regression. The results were consistent with the primary analysis in terms of direction and significance. The Firth-adjusted odds ratios were 6.08 (95% CI: 2.20–18.58) for having a fixed same-sex partner, 7.74 (95% CI: 2.80–21.61) for having heard of PrEP drugs, and 25.42 (95% CI: 9.57–77.13) for believing that men can be infected with HPV, confirming the robustness of the primary findings.
Discussion
In this study, 92.5% of MSM expressed willingness to receive free HPV vaccination, which is higher than the 61.8% acceptance rate for self-paid vaccination reported previously [9]. When financial barriers are removed, most MSM are willing to be vaccinated, highlighting the potential value of including HPV vaccines in public health programs.
Multivariate analysis showed that having a fixed same-sex partner, having heard of PrEP drugs, and believing that men can be infected with HPV were positively associated with vaccination willingness.
MSM with fixed partners reported higher willingness to be vaccinated than those with casual partners. This may reflect greater health responsibility and a tendency to protect both themselves and their partners [10]. Notably, MSM with casual partners face higher HPV infection risk [2] but showed lower willingness, underscoring the need for targeted outreach to this subgroup.
Consistent with previous studies [6], PrEP awareness was associated with higher willingness. PrEP awareness may serve as a marker of greater engagement with preventive services [11], suggesting that integrating HPV vaccination into existing HIV/PrEP care settings could be an efficient strategy. The dissemination of PrEP information may also indirectly increase HPV vaccine awareness [12–14].
Belief that men can be infected with HPV was strongly associated with willingness, aligning with the health belief model, which posits that perceived susceptibility is a key driver of preventive action [15]. This highlights the importance of health education that corrects the misconception that HPV only affects women.
Implications for public health practice
Our findings suggest actionable strategies. First, integrating HPV vaccination into HIV/PrEP services could leverage existing health-seeking behaviors and provide a trusted, one-stop setting. Second, health campaigns should explicitly communicate that men can acquire and transmit HPV, framing vaccination as protective for both oneself and one’s partner. Third, targeted efforts are needed to reach MSM with casual partners, who have higher risk but lower willingness. Fourth, digital tools such as AI chatbots could provide confidential, on-demand information, appointment assistance, and reminders, reducing stigma and access barriers [16]. These strategies could be implemented through collaboration with community-based organizations and integration into existing public health infrastructure, facilitating scalable and sustainable vaccination programs.
Limitations
This study has several limitations. First, the cross-sectional design precludes causal inference; associations should be interpreted as correlates. Second, selection bias is likely, as recruitment through a single community-based organization may have captured more health-engaged MSM, limiting generalizability. The high willingness rate (92.5%) may also reflect social desirability bias, likely overestimating true willingness. Third, important unmeasured factors—vaccine safety concerns, convenience of vaccination sites, and provider recommendations—were not assessed. Although we performed a sensitivity analysis using Firth’s penalized likelihood logistic regression to address bias arising from the small number of unwilling participants (n = 30), odds ratios should still be interpreted cautiously. Fourth, high willingness does not guarantee actual vaccination, which can be hindered by practical barriers (e.g., clinic access, appointment availability, privacy concerns). Prospective studies are needed to assess whether expressed willingness translates into uptake. Fifth, formal reliability testing (e.g., internal consistency) of the HPV knowledge items was not conducted due to the small pilot sample size; however, content validity was ensured through expert review.
Conclusions
Fixed same-sex partner relationships, PrEP awareness, and belief that men can be infected with HPV are positively associated with MSM’s willingness to receive free HPV vaccination. Public health strategies should integrate HPV vaccination into existing PrEP services, address the intention–behavior gap through practical support, and use targeted health communication to correct misconceptions. Expanding free HPV vaccination programs could reduce HPV-related disease burden in MSM and the general population.
Acknowledgements
We would like to thank the social organization “Jinan Rainbow” for participating in the survey of this study.
Authors’ contributions
Wanying Teng: **study** implementation, data collection, data analysis/interpretation, statistical analysis, manuscript drafting and revision. Ying Han: data collection, data analysis/interpretation. Xiaonan Yang, Yujie Huang: supporting contributions. Xinrui Li: study conception and design, critical review of the intellectual content of the manuscript.
Funding
None. Not Applicable.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Public Health of Shandong University (Approval No.: LL20220906). All participants provided informed consent and voluntarily participated in the survey. The study was conducted in accordance with the Declaration of Helsinki, International Ethical Guidelines for Health-related Research Involving Humans, Universal Declaration on the Human Genome and Human Rights, Measures for the Ethical Review of Life Science and Medical Research Involving Humans, Measures for the Ethical Review of Science and Technology (Trial), Regulations on the Administration of Human Genetic Resources, Regulations on the Administration of Laboratory Animals, Guidelines for the Ethical Review of Welfare of Laboratory Animals (GBT 35892-2018), Guiding Opinions on the Humane Treatment of Laboratory Animals, Guidelines for Euthanasia of Laboratory Animals (T-CALAS 31-2017), Good Clinical Practice (GCP), as well as internationally and domestically recognized ethical norms for life science, medical research involving humans, and animal experiments.
Consent for publication
Not applicable. This manuscript does not contain any identifiable images or personal or clinical details of participants that would compromise anonymity.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
The authors confirm that the data supporting the findings of this study are available within the article.