Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework

Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework Yalan Wang¹, Renhai Tang², Qunbo Zhou², Yuecheng Yang, Song Duan², and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7500496/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background High-risk elderly constitute a vulnerable group for HIV infection. Age-specific barriers impede voluntary testing among elderly and limit the reach of traditional interventions. Existing models often oversimplify motivation and overlook older adults’ unique psychological and contextual challenges. This study addresses this gap by extending the dimension of motivation, and using a mixed-methods design to generate actionable insights for improving HIV testing among high-risk elderly men in China. Methods This mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in Dehong Prefecture from 2024 to 2025. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Chi-square test was employed to compare demographic characteristics. And multivariable logistic regression was used to identify independent predictors of HIV testing behavior. Finally, structural equation modeling (SEM) was utilized to decompose and quantify both direct and indirect effects of the predictors within a comprehensive framework. Results There were 300 and 15 participants included in quantitative and qualitative study respectively, achieving an HIV testing rate of 57.7% and a mean age of 57.2 years. Among participants, non-commercial sex with non-regular partners was reported by 56.0%, 31.0% of these forwent condoms due to reduced pleasure (42.3%). Commercial sex was reported by 85.3%—44.4% of non-condom users cited the same reason. Multivariate logistic regression identified older age (≥ 70 years), ethnicity, education level, occupation, and urban residency as significant predictors of HIV testing uptake. SEM analysis identified self-efficacy as the strongest positive predictor (total effect = 0.32, p < 0.05), while behavioral skills (-0.21, p < 0.05) and HIV information (-0.20, p < 0.05) exhibited significant negative effects. The model fit was acceptable (RMSEA = 0.073, CFI = 0.94). Qualitative data revealed that peer success stories bolstered self-efficacy, whereas stigma eroded it; testing was also hindered by procedural complexity, low-information transparency, and misaligned messaging and media channels among older adults. Conclusion Self-efficacy facilitates HIV testing among high-risk elderly men, whereas usability issues, ineffective messaging strategies, and cultural perceptions suppress testing behavior. Interventions should focus on enhancing self-efficacy, optimizing age-friendly self-testing tools, adopting non-fear-based messaging strategies, and integrating HIV screening into chronic disease check-ups to break cultural biases. Elderly HIV/AIDS HIV testing Mixed methods Figures Figure 1 Figure 2 Background The global aging population has led to an increasing number of elderly adults at risk of HIV infection, yet HIV testing rates among this demographic remain low[ 1 ]. In China, the proportion of late HIV diagnosis among elderly men is alarmingly high, with more than 65% of cases being identified at an advanced stage[ 2 ]. Insufficient testing is the fundamental reason for late HIV diagnosis[ 3 ]. Compared to younger populations, elderly men are less likely to undergo voluntary HIV testing, with most diagnoses occurring through routine medical visits or hospitalization for other conditions[ 4 ]. Despite government efforts to expand HIV testing coverage, elderly men continue to face persistent social and structural obstacles that hinder voluntary testing[ 5 ], including social misconceptions that HIV is a "young person's disease," HCP's discomfortable discussing sexual health with older patients, and fear of discrimination[ 6 , 7 ]. Previous studies have primarily focused on younger key populations, such as men who have sex with men (MSM)and female sex workers[ 8 , 9 , 10 ], leaving elderly high-risk men underrepresented in research and intervention strategies. In particular, studies exploring the psychological, behavioral, and social factors influencing HIV testing behavior among elderly men remain limited[ 11 ]. Existing interventions often fail to address age-specific barriers[ 12 ], such as lower health literacy, difficulty accessing testing services, and privacy concerns related to self-testing[ 13 , 6 , 14 ]. Building upon this knowledge gap, researchers have applied established health behavior theories—such as the Information-Motivation-Behavioral Skills (IMB) model, Health Belief Model (HBM), and Theory of Planned Behavior (TPB)—to understand and promote HIV testing behaviors[ 15 , 16 , 17 , 18 ]. These frameworks emphasize cognitive and motivational determinants such as perceived risk, behavioral skills, attitudes, and social norms. Empirical findings based on these theories suggest that increased knowledge, improved behavioral skills, and favorable peer support are significantly associated with higher HIV testing intention and behavior[ 19 ]. Despite these valuable contributions, several theoretical and empirical limitations persist. "Motivation" has been treated as a unidimensional and often superficial construct—frequently measured through general testing intention or willingness[ 20 , 21 , 22 ]. Such simplification fails to capture the complex psychological mechanisms underlying testing behavior, particularly in elderly populations. This limits the precision and effectiveness of interventions aimed at increasing HIV testing in this key population. To bridge this gap, this study extends the IMB model by decomposing motivation into threat perception, beliefs, and subjective norms[ 23 , 24 ]. Additionally, it employs a mixed-methods approach, combining SEM-based quantitative analysis with qualitative interviews, to both measure key behavioral determinants and uncover the contextual reasons behind HIV testing behaviors among high-risk elderly men in China. This intentionally integrates quantitative and qualitative methods rigorously to draw on the strengths of each other to ensure that the results of a study are more close to reality[ 25 , 26 , 12 ]. Findings from this research will provide evidence-based recommendations to improve HIV testing promotion strategies, develop age-friendly testing services, and ultimately reduce late-stage diagnoses in this population. Methods Study design This study adopted an explanatory sequential mixed-methods design. The quantitative phase was conducted first to identify key factors influencing HIV testing behavior among high-risk elderly men. The qualitative phase followed to explore underlying mechanisms and contextual influences through in-depth interviews. Structural equation modeling (SEM) was used to analyze quantitative data, while qualitative content analysis was employed for textual data interpretation. Participants Participants were recruited from Dehong Prefecture, Yunnan Province, China, which has successfully achieved the "90-90-90" HIV control target. Eligible participants were men aged 50 years or elderly who engaged in commercial sex or other high-risk behaviors in the past 12 months. Inclusion criteria were: (1) Aged ≥50 years; (2) History of commercial sex, multiple sexual partners, or other HIV high risk behaviors in the past year; (3) HIV-negative or never tested; (4) Willingness to participate and provide informed consent. Exclusion criteria included cognitive impairment, severe mental disorders, or active substance dependence. The eligible participants were compensated 200 Chinese Yuan (CNY) (about 29.24 USD) after completing the in-depth interview and a gift valued at 10 Chinese Yuan (CNY) after completing the structured questionnaire respectively for their time spent. Data collection Quantitative data collection From September to December 2024, 300 participants were recruited using non-probability sampling through local community-based organizations (CBOs) and sexual health clinics. Trained interviewers conducted face-to-face structured surveys, covering: (1) Sociodemographic characteristics (e.g., age, education, income, marital status). (2) HIV knowledge and risk perception. HIV testing history (voluntary vs. provider-initiated testing). (3) High-risk sexual behaviors (e.g., condom use, commercial sex). (4) Self-efficacy and behavioral skills related to HIV testing. A 30-item scale was developed based on the Information-Motivation-Behavioral Skills Model and Self-Determination Theory to assess testing determinants (See supplementary file). Qualitative data collection From January to February 2025, 30 participants (15 who had voluntarily tested, 15 who had never tested or tested passively) were purposefully sampled for in-depth semi-structured interviews. Interviews explored: (1) Cognitive and emotional barriers to HIV testing. (2) Social and cultural factors shaping testing decisions. (3) Perceived benefits and risks of testing. (4) Attitudes toward self-testing and facility-based testing. Data analysis Quantitative data analysis A chi-square test was conducted to compare demographic characteristics between urban and rural populations, P < 0.05 taken as statistically significant. And frequencies were used to describe sexual health status. Moreover, multivariate logistic regression analysis was used to examine factors associated with HIV testing behavior. SEM was applied using AMOS 24.0 to examine direct and indirect effects of predictors on HIV testing behavior with exploratory factor analysis (EFA) was conducted using SPSS 27.0 to validate measurement scales. Qualitative data analysis The qualitative data were analyzed using thematic framework analysis[27] to identify patterns in testing motivations, barriers, and cultural narratives. Interviews were audio-recorded, transcribed verbatim, and coded independently by two researchers to ensure reliability. Nvivo 12 was used for data management and analysis, with triangulation applied to compare findings from the quantitative and qualitative phases, enhancing the robustness of the interpretation. Ethical approval The study was approved by the Ethical Review Committee of NCAIDS, China CDC (X230222728). Results Quantitative results Sample characteristics A total of 300 elderly individuals from Dehong were recruited in this study. The HIV testing rate was 57.7%, with an average age of 57.18 years. Most participants were rural residents, Han Chinese, and married. Overall educational attainment was low, primarily at the primary school level or below. The majority were farmers, with monthly incomes generally ranging between 1,001 and 3,000 RMB. Most participants were local residents. Significant differences between urban and rural residents were observed in age, education, occupation, income, and residency status（Table 1）. Sexual health status Most participants reported normal sexual desire, with sexual activity typically occurring two to three times per month. The majority were able to achieve and maintain erections sufficient for intercourse, which generally lasted between six and ten minutes. The use of aphrodisiacs and the prevalence of male-specific health issues were relatively low. Overall, most individuals felt their sexual needs were adequately met. Among those who did not, the main reasons were a lack of interest in sex from their spouse or the absence of a sexual partner (Table 2) (At the end of the manuscript line564) . High-risk behaviors 77% (231 individuals) of participants reported having had sexual intercourse with a spouse or regular partner in the past six months. Among them, 63.2% (146/231) did not use a condom during their most recent sexual encounter. The main reasons were perceiving it as unnecessary(51.4%, 75/146) and reduced sexual pleasure (19.9%, 29/146). Additionally, 56.0% (168 individuals) had sex with non-regular partners (excluding commercial partners), with 24.4% (41/168) reporting no condom use during the last encounter, primarily due to reduced sexual pleasure (41.5%, 17/41). Furthermore, among the 85.3% (256 individuals) who had engaged in commercial sex, 27 participants did not use a condom during their most recent encounter, again mainly citing reduced pleasure (44.4%, 12/27) as the reason. Factors associated with HIV testing behavior using multivariate logistic regression analysis Logistic regression analysis was conducted to explore factors associated with HIV testing behavior. Multivariate analysis revealed that age, ethnicity, education level, occupation, and household registration status were significantly associated with testing behavior. Individuals aged 70 and above were more likely to undergo testing compared to younger age groups (OR: 3.95, 95% CI: 1.01–15.51). Han individuals showed lower testing rates than ethnic minorities (OR: 0.32, 95% CI: 0.17–0.62). Participants with primary education or below were more likely to be tested (OR: 1.78, 95% CI: 1.02–3.13), and urban residents were more likely to undergo testing than rural residents (OR: 2.18, 95% CI: 1.34–4.18). Other occupations were more likely to test(OR: 2.53, 95% CI: 1.40–4.55)(Figure 1). Factors associated with HIV testing behavior using SEM analysis SEM results showed that self-efficacy as the strongest positive predictor(total effect = 0.32, p<0.05). HIV information had a direct negative effect and an indirect positive effect via self-efficacy (total effect =0.199). Perceived threat influenced testing both directly and indirectly (total effect = 0.315), while subjective norms had a direct positive effect (total effect = 0.295). Behavioral skills showed a negative total effect (- 0.207). Model fit indices indicated acceptable fit (CMIN/DF = 2.605, GFI = 0.887, CFI = 0.935, TLI = 0.920, RMSEA = 0.073) (Figure 2). Qualitative results About information SEM analysis indicated that HIV information had a negative effect on HIV testing behavior among elderly at high risk. Qualitative findings revealed the following: Concerns about accuracy and reliability of information. Participants expressed doubts about the trustworthiness of some sources or found the information too inconsistent to judge. The HIV information on those flyers — I can’t tell if it’s true or not. It just makes me uneasy. (Participant M) When I search online, the information is all over the place. I don’t know what to believe, so I lose interest in testing. (Participant N) Issues with information presentation. Some participants found the information too technical or lacking relevance to their demographic. The pamphlets from the community are full of technical terms I don’t understand, so I lose interest in learning about testing. (Participant O) All the messages seem to be about young people. There’s nothing about older adults, so it doesn’t feel relevant to me. (Participant P) Misleading information. Participants felt that excessive emphasis on the dangers of HIV caused fear, while the benefits of testing were not clearly conveyed. The messages only talk about how terrible it is to get infected. It scared me so much I didn’t want to get tested. （ Participant Q ） I haven’t really heard about any benefits of testing. It just feels like it doesn’t matter whether I get tested or not. (Participant R) About self-efficacy SEM analysis indicated that high self-efficacy significantly promoted HIV testing behavior among elderly at high risk. Qualitative findings revealed the following: Internal mechanisms of self-efficacy promoting testing: participants who actively sought HIV testing often demonstrated a sense of responsibility for their health or a rational understanding of the testing process and outcomes. I’ve always taken my health seriously. I think regular testing is being responsible, so I’m not afraid of getting tested. ( Participant S) I looked into the testing process beforehand. It’s just a blood draw or a simple test — not scary. Even if the result is bad, at least I’ll know and can make a plan. (Participant T) Manifestations of low self-efficacy as barriers to testing. Those who did not undergo testing often lacked confidence or courage, or were influenced by negative views in their surroundings. I feel like I’m too old to face the results. If something is wrong, I don’t even know what to do. (Participant U) People in my neighborhood say if you get tested and they find something, it’s all over. So I got scared and didn’t go. (Participant V) Diverse factors influencing self-efficacy: education level and past experiences may play a role in shaping self-efficacy. I’ve had some education, so I understand the importance of health and trust that I can handle HIV testing. (Participant W, high school education) I had a serious illness before and recovered well after active treatment. That made me feel confident I could handle HIV testing too. (Participant X, previously treated for a chronic illness) About behavioral skills SEM analysis revealed that behavioral skills had a negative effect on HIV testing behavior among elderly at high risk. Qualitative findings identified the following: Difficulty with operational skills for HIV testing. Participants who had not undergone HIV testing commonly reported difficulties with the operational aspects, such as the complexity of using self-test kits, unfamiliarity with procedures at testing sites, and small print in instruction manuals that was hard to read. The self-testing kit requires sampling and adding reagents — too many steps. I couldn’t figure it out, so I gave up. (Participant Y) At the testing site, I had no idea what to do first. The staff didn’t explain clearly. I had to run around a lot, so I just didn’t want to go again. ( Participant Z) The instruction manual in the test kit is printed in such tiny font. Even with my reading glasses, I could barely read it, so I didn’t dare try it. (Participant EE ） Lack of skills to handle testing-related concerns. Some participants reported not knowing how to address privacy concerns or how to cope with a positive result. I was worried about my privacy during testing but didn’t know how to talk to the staff. I felt stuck, so I ended up not getting tested. （ Participant AA ） If the result turned out bad, I wouldn’t know how to tell my family or what to do next. That’s why I’ve been putting it off. ( Participant BB) Limited access to behavioral skill training. Participants noted a lack of training opportunities and said that previous community outreach efforts failed to cover practical testing skills. No one has ever taught us how to get tested, and I don’t know where to learn this stuff. ( Participant CC) Community campaigns only talk about how dangerous HIV is. They never explain how to get tested or what to pay attention to, so I still don’t know what to do. (Participant DD ） Cultural Metaphors Qualitative findings also revealed that cultural metaphors influenced HIV testing behavior. In rural areas, there was a common belief that ”older people do not need testing” and HIV was viewed as “a disease of the young”, which further reduced willingness to test. At our age, the days of being sexually active are over. What’s the point of getting tested now? (Participant EE ） AIDS is something only young people worry about. We’re old and live quiet lives — it doesn’t concern us. (Participant FF) Discussion This study provides empirical evidence on the psychosocial and structural factors influencing HIV testing behavior among high-risk elderly men in China. The quantitative analysis revealed that self-efficacy was the strongest positive predictor of HIV testing behavior, while behavioral skills and HIV-related information exerted significant negative effects. The qualitative findings further contextualized these results, showing that self-efficacy was shaped by peer experiences, stigma, and cultural beliefs[28,29,30], while difficulties in self-testing procedures and fear-based messaging discouraged testing[31]. Additionally, rural participants commonly perceived HIV as a "young person's disease," reducing their perceived need for testing. These results indicate that the development of HIV prevention strategies has predominantly focused on younger populations in recent years, especially with the advent of the digital age[32], which may be inadequate for elderly men and highlight the necessity for tailored interventions. Our findings align with prior research demonstrating that self-efficacy is a critical determinant of health-seeking behaviors, including HIV testing[33,34]. However, unlike younger populations, elderly men in this study exhibited greater psychological resistance to HIV testing due to moral stigma and generational attitudes toward sexual health. Previous studies have shown that information-based interventions can enhance HIV testing rates[35,36,37], but our results suggest that misaligned communication strategies, such as fear-driven messaging, can have a counterproductive effect among elderly individuals. Moreover, while previous research has emphasized access barriers such as cost and convenience[38], our study identifies behavioral skill deficits (e.g., difficulty navigating self-testing instructions or fear of asking for a test in clinics) as unique obstacles for this demographic. To improve HIV testing rates among high-risk elderly men, interventions should focus on enhancing self-efficacy while addressing structural and cultural barriers. One effective approach is peer engagement, where elderly men are encouraged to participate in peer-led education programs and hear success stories like youngers, which can boost their confidence in the testing process[39]. Additionally, HIV messaging strategies should be refined to move away from fear-based narratives and instead highlight the benefits of early detection. Using communication channels that align with elderly adults' preferences, such as radio broadcasts, community meetings, and printed materials, can increase outreach effectiveness. Moreover, simplifying HIV self-testing tools by providing clearer instructions, larger font sizes, and culturally appropriate packaging can help overcome operational barriers that discourage self-testing[40]. Finally, integrating HIV testing into routine healthcare visits, particularly alongside screenings for common chronic conditions like diabetes and hypertension[41], can help normalize the practice and reduce associated stigma. This study has several limitations. First, its cross-sectional design limits causal inference, and self-reported data may be subject to social desirability bias. Second, participants were recruited from one province, which may not fully represent elderly men in different sociocultural settings across China. Third, while the study explored behavioral skill deficits, further research should examine how digital literacy and mobile health interventions might enhance testing accessibility for elderly populations. Future studies should also assess the effectiveness of tailored interventions, such as self-efficacy training and community-based support programs. Conclusions This study highlights the urgent need for targeted HIV testing interventions for high-risk elderly men in China. While self-efficacy enhances testing uptake, barriers related to cultural stigma, information framing, and procedural complexity significantly hinder testing rates. By integrating peer-driven support, adjusting communication strategies, optimizing testing accessibility, and embedding HIV testing into routine healthcare services, public health efforts can improve early diagnosis and reduce HIV transmission in this aging population. Abbreviations SEM: Structural Equation Modeling; OR : Odds ratio; MSM : men who have sex with men; HCP: Healthcare Provider; IMB: Information-Motivation-Behavioral Skills; HBM: Health Belief Model; TPB: Theory of Planned Behavior; CNY: Chinese Yuan; NCAIDS: National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention; CDC: Chinese Center for Disease Control and Prevention; USD: United States Dollar; CBO: community-based organization; EFA: exploratory factor analysis; CI: Confidence interval. Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. The written informed consents were provided for all participants before in-depth interviews and questionnaire surveys. This study was approved by the Ethical Review Committee of NCAIDS, China CDC (X230222728). Consent for publication Not applicable. Availability of data and materials All data essential to the conclusion are included in this manuscript and additional data are available upon reasonable request from the first author. Competing interests The authors declare that they have no competing interests. Funding The study was supported by the National Natural Science Foundation of China (72404253), Capital's Funds for Health Improvement and Research (2024-2G-4331), and Young Scholar Science Foundation of Chinese Center for Disease Control and Prevention (2023A104). The funders had no role in study design; collection, analysis and interpretation of data; the writing of the manuscript; or the decision to submit the manuscript for publication. Authors’ contributions DS conceived and designed the study. RT, QZ, YY, SD made contributions to investigation and data acquisition. DS, YW transcribed and analyzed the data. YW, ZY, QW contributed the interpretation of the data and drafted the manuscript. 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Factors influencing self-efficacy for self-management among adult people with human immune deficiency virus on antiretroviral therapy in public hospitals of south-west Ethiopia. Front Psychol. 2024;15:1329238. doi:10.3389/fpsyg.2024.1329238. 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. doi:10.1097/JNC.0000000000000218. Mo PK, Xie L, Lee TC, Li AYC. Use of Behavior Change Techniques in Digital HIV Prevention Programs for Adolescents and Young People: Systematic Review. JMIR Public Health Surveill. 2025;11:e59519. doi:10.2196/59519. Liu H, Lai G, Shi G, Zhong X. The Influencing Factors of HIV-Preventive Behavior Based on Health Belief Model among HIV-Negative MSMs in Western China: A Structural Equation Modeling Analysis. Int J Environ Res Public Health. 2022;19(16):10185. doi:10.3390/ijerph191610185. Zhang C, Huang D, Goldsamt LA,Wang H, Wiley J, Shen Y et al. Self-efficacy mediates the effect of providing HIV self-testing kits on HIV testing frequency among Chinese men who have sex with men: results from a randomised controlled trial. Sex Health. 2023;20(2):118-125. doi:10.1071/SH22110. Wang Z, Chan PS, Xin M, Fang Y, Chidgey A, Yu FY et al. An Online Intervention Promoting HIV Testing Service Utilization Among Chinese men who have sex with men During the COVID-19 Pandemic: A quasi-experimental Study. AIDS Behav. 2024;28(Suppl 1):77-89. doi:10.1007/s10461-023-04100-5. Kelvin EA, George G, Mwai E, Kinyanjui S, Romo ML, Odhiambo JO et al. A Randomized Controlled Trial to Increase HIV Testing Demand Among Female Sex Workers in Kenya Through Announcing the Availability of HIV Self-testing Via Text Message. AIDS Behav. 2019;23(1):116-125. doi:10.1007/s10461-018-2248-5. Tan RKJ, Koh WL, Le D, Banerjee S, Chio MT, Chan RK et al. Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial. J Med Internet Res. 2022;24(5):e31401. doi:10.2196/31401. Sharma M, Ong JJ, Celum C, Terris-Prestholt F. Heterogeneity in individual preferences for HIV testing: A systematic literature review of discrete choice experiments. EClinicalMedicine. 2020;29-30:100653. doi:10.1016/j.eclinm.2020.100653. Rocha GM, Cândido RCF, de Carvalho NP, de Carvalho NP, Carvalho EGA, Costa AAM et al. Strategies to increase HIV testing among men who have sex with men and transgender women: an integrative review. BMC Infect Dis. 2023;23(1):240. doi:10.1186/s12879-023-08124-z. Conner LR, Fernández Y, Junious E, Piper C, Rowan D. Evaluating HIV Educational Materials for Older People. J Int Assoc Provid AIDS Care. 2019;18:2325958219849054. doi:10.1177/2325958219849054. World Health Organization. Risks, behaviour and stigma: understanding how to protect older men in rural China from HIV. https://www.who.int/westernpacific/newsroom/feature-stories/item/risks--behaviour-and-stigma--understanding-how-to-protect-older-men-in-rural-china-from-hiv?utm. Accessed 24 Aug 2025. Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile0908.docx Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers invited by journal 06 Oct, 2025 Editor assigned by journal 01 Oct, 2025 Editor invited by journal 09 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7500496","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528906817,"identity":"864a9588-6389-4639-bf44-120c19e1d310","order_by":0,"name":"Yalan Wang¹","email":"","orcid":"","institution":"National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Yalan","middleName":"","lastName":"Wang¹","suffix":""},{"id":528906818,"identity":"caa6dff5-9c8d-4cd9-9fca-753180c6bd77","order_by":1,"name":"Renhai 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1","display":"","copyAsset":false,"role":"figure","size":217474,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of factors associated with HIV testing behavior based on multivariate logistic regression analysis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7500496/v1/441ec77408559b34da5c14b3.png"},{"id":93776831,"identity":"c487d162-dc73-4097-b182-9851d3ffa9db","added_by":"auto","created_at":"2025-10-17 12:38:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":186425,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStructural Equation Model (SEM) of Relationships between Dimensions of Testing behavior\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7500496/v1/24076960f75f96b68b9e5135.png"},{"id":93777038,"identity":"f2057ccf-ff73-461c-9019-bb743228ccec","added_by":"auto","created_at":"2025-10-17 12:38:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1059734,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7500496/v1/08556b0b-b82c-4bc6-b9e2-94ceb3c7eb20.pdf"},{"id":93773116,"identity":"a7b7f570-ab70-4a35-bd8e-3093c2a84837","added_by":"auto","created_at":"2025-10-17 12:22:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30486,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile0908.docx","url":"https://assets-eu.researchsquare.com/files/rs-7500496/v1/27fe5beb05ffa2e66a0a7876.docx"},{"id":93775312,"identity":"3a880309-6df9-4490-b4ff-b24c37b0044f","added_by":"auto","created_at":"2025-10-17 12:30:36","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26408,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7500496/v1/953d432d815418a76fdc8465.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework","fulltext":[{"header":"Background","content":"\u003cp\u003eThe global aging population has led to an increasing number of elderly adults at risk of HIV infection, yet HIV testing rates among this demographic remain low[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, the proportion of late HIV diagnosis among elderly men is alarmingly high, with more than 65% of cases being identified at an advanced stage[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Insufficient testing is the fundamental reason for late HIV diagnosis[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Compared to younger populations, elderly men are less likely to undergo voluntary HIV testing, with most diagnoses occurring through routine medical visits or hospitalization for other conditions[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite government efforts to expand HIV testing coverage, elderly men continue to face persistent social and structural obstacles that hinder voluntary testing[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], including social misconceptions that HIV is a \"young person's disease,\" HCP's discomfortable discussing sexual health with older patients, and fear of discrimination[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious studies have primarily focused on younger key populations, such as men who have sex with men (MSM)and female sex workers[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], leaving elderly high-risk men underrepresented in research and intervention strategies. In particular, studies exploring the psychological, behavioral, and social factors influencing HIV testing behavior among elderly men remain limited[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Existing interventions often fail to address age-specific barriers[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], such as lower health literacy, difficulty accessing testing services, and privacy concerns related to self-testing[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBuilding upon this knowledge gap, researchers have applied established health behavior theories\u0026mdash;such as the Information-Motivation-Behavioral Skills (IMB) model, Health Belief Model (HBM), and Theory of Planned Behavior (TPB)\u0026mdash;to understand and promote HIV testing behaviors[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These frameworks emphasize cognitive and motivational determinants such as perceived risk, behavioral skills, attitudes, and social norms. Empirical findings based on these theories suggest that increased knowledge, improved behavioral skills, and favorable peer support are significantly associated with higher HIV testing intention and behavior[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Despite these valuable contributions, several theoretical and empirical limitations persist. \"Motivation\" has been treated as a unidimensional and often superficial construct\u0026mdash;frequently measured through general testing intention or willingness[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Such simplification fails to capture the complex psychological mechanisms underlying testing behavior, particularly in elderly populations. This limits the precision and effectiveness of interventions aimed at increasing HIV testing in this key population.\u003c/p\u003e\u003cp\u003eTo bridge this gap, this study extends the IMB model by decomposing motivation into threat perception, beliefs, and subjective norms[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, it employs a mixed-methods approach, combining SEM-based quantitative analysis with qualitative interviews, to both measure key behavioral determinants and uncover the contextual reasons behind HIV testing behaviors among high-risk elderly men in China. This intentionally integrates quantitative and qualitative methods rigorously to draw on the strengths of each other to ensure that the results of a study are more close to reality[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Findings from this research will provide evidence-based recommendations to improve HIV testing promotion strategies, develop age-friendly testing services, and ultimately reduce late-stage diagnoses in this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eThis study adopted an explanatory sequential mixed-methods design. The quantitative phase was conducted first to identify key factors influencing HIV testing behavior among high-risk elderly men. The qualitative phase followed to explore underlying mechanisms and contextual influences through in-depth interviews. Structural equation modeling (SEM) was used to analyze quantitative data, while qualitative content analysis was employed for textual data interpretation.\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from Dehong Prefecture, Yunnan Province, China, which has successfully achieved the \"90-90-90\" HIV control target. Eligible participants were men aged 50 years or elderly who engaged in commercial sex or other high-risk behaviors in the past 12 months. Inclusion criteria were: (1) Aged ≥50 years; (2) History of commercial sex, multiple sexual partners, or other HIV high risk behaviors in the past year; (3) HIV-negative or never tested; (4) Willingness to participate and provide informed consent. Exclusion criteria included cognitive impairment, severe mental disorders, or active substance dependence.\u003c/p\u003e\n\u003cp\u003eThe eligible participants were compensated 200 Chinese Yuan (CNY) (about 29.24 USD) after completing the in-depth interview and a gift valued at 10 Chinese Yuan (CNY) after completing the structured questionnaire respectively for their time spent.\u003c/p\u003e\n\u003cp\u003eData collection\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative data collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFrom September to December 2024, 300 participants were recruited using non-probability sampling through local community-based organizations (CBOs) and sexual health clinics. Trained interviewers conducted face-to-face structured surveys, covering: (1) Sociodemographic characteristics (e.g., age, education, income, marital status). (2) HIV knowledge and risk perception. HIV testing history (voluntary vs. provider-initiated testing). (3) High-risk sexual behaviors (e.g., condom use, commercial sex). (4) Self-efficacy and behavioral skills related to HIV testing. A 30-item scale was developed based on the Information-Motivation-Behavioral Skills Model and Self-Determination Theory to assess testing determinants (See supplementary file).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative data collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFrom January to February 2025, 30 participants (15 who had voluntarily tested, 15 who had never tested or tested passively) were purposefully sampled for in-depth semi-structured interviews. Interviews explored: (1) Cognitive and emotional barriers to HIV testing. (2) Social and cultural factors shaping testing decisions. (3) Perceived benefits and risks of testing. (4) Attitudes toward self-testing and facility-based testing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative data analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA chi-square test was conducted to compare demographic characteristics between urban and rural populations, P \u0026lt; 0.05 taken as statistically significant. And frequencies were used to describe sexual health status. Moreover, multivariate logistic regression analysis was used to examine factors associated with HIV testing behavior.\u003c/p\u003e\n\u003cp\u003eSEM was applied using AMOS 24.0 to examine direct and indirect effects of predictors on HIV testing behavior with exploratory factor analysis (EFA) was conducted using SPSS 27.0 to validate measurement scales.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative data analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative data were analyzed using thematic framework analysis[27]\u0026nbsp;to identify patterns in testing motivations, barriers, and cultural narratives. Interviews were audio-recorded, transcribed verbatim, and coded independently by two researchers to ensure reliability. Nvivo 12 was used for data management and analysis, with triangulation applied to compare findings from the quantitative and qualitative phases, enhancing the robustness of the interpretation.\u003c/p\u003e\n\u003cp\u003eEthical approval\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Review Committee of NCAIDS, China CDC (X230222728).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eQuantitative results\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 300 elderly individuals from Dehong were recruited in this study. The HIV testing rate was 57.7%, with an average age of 57.18 years. Most participants were rural residents, Han Chinese, and married. Overall educational attainment was low, primarily at the primary school level or below. The majority were farmers, with monthly incomes generally ranging between 1,001 and 3,000 RMB. Most participants were local residents. Significant differences between urban and rural residents were observed in age, education, occupation, income, and residency status（Table 1）.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSexual health status\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants reported normal sexual desire, with sexual activity typically occurring two to three times per month. The majority were able to achieve and maintain erections sufficient for intercourse, which generally lasted between six and ten minutes. The use of aphrodisiacs and the prevalence of male-specific health issues were relatively low. Overall, most individuals felt their sexual needs were adequately met. Among those who did not, the main reasons were a lack of interest in sex from their spouse or the absence of a sexual partner (Table 2) (At the end of the manuscript line564) .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHigh-risk behaviors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e77% (231 individuals) of participants reported having had sexual intercourse with a spouse or regular partner in the past six months. Among them, 63.2% (146/231) did not use a condom during their most recent sexual encounter. The main reasons were perceiving it as unnecessary(51.4%, 75/146) and reduced sexual pleasure (19.9%, 29/146). Additionally, 56.0% (168 individuals) had sex with non-regular partners (excluding commercial partners), with 24.4% (41/168) reporting no condom use during the last encounter, primarily due to reduced sexual pleasure (41.5%, 17/41). Furthermore, among the 85.3% (256 individuals) who had engaged in commercial sex, 27 participants did not use a condom during their most recent encounter, again mainly citing reduced pleasure (44.4%, 12/27) as the reason.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFactors associated with HIV testing behavior using multivariate logistic regression analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLogistic regression analysis was conducted to explore factors associated with HIV testing behavior. Multivariate analysis revealed that age, ethnicity, education level, occupation, and household registration status were significantly associated with testing behavior. Individuals aged 70 and above were more likely to undergo testing compared to younger age groups (OR: 3.95, 95% CI: 1.01\u0026ndash;15.51). Han individuals showed lower testing rates than ethnic minorities (OR: 0.32, 95% CI: 0.17\u0026ndash;0.62). Participants with primary education or below were more likely to be tested (OR: 1.78, 95% CI: 1.02\u0026ndash;3.13), and urban residents were more likely to undergo testing than rural residents (OR: 2.18, 95% CI: 1.34\u0026ndash;4.18). Other occupations were more likely to test(OR: 2.53, 95% CI: 1.40\u0026ndash;4.55)(Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFactors associated with HIV testing behavior using SEM analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSEM results showed that self-efficacy as the strongest positive predictor(total effect = 0.32, p\u0026lt;0.05). HIV information had a direct negative effect and an indirect positive effect via self-efficacy (total effect =0.199). Perceived threat influenced testing both directly and indirectly (total effect = 0.315), while subjective norms had a direct positive effect (total effect = 0.295). Behavioral skills showed a negative total effect (- 0.207). Model fit indices indicated acceptable fit (CMIN/DF = 2.605, GFI = 0.887, CFI = 0.935, TLI = 0.920, RMSEA = 0.073) (Figure 2).\u003c/p\u003e\u003cp\u003eQualitative results\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbout information\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSEM analysis indicated that HIV information had a negative effect on HIV testing behavior among elderly at high risk. Qualitative findings revealed the following: Concerns about accuracy and reliability of information. Participants expressed doubts about the trustworthiness of some sources or found the information too inconsistent to judge.\u003cbr\u003e \u003cem\u003eThe HIV information on those flyers\u003c/em\u003e\u003cem\u003e\u0026mdash;\u003c/em\u003e\u003cem\u003eI can\u0026rsquo;t tell if it\u0026rsquo;s true or not. It just makes me uneasy. (Participant M)\u003cbr\u003e\u0026nbsp;When I search online, the information is all over the place. I don\u0026rsquo;t know what to believe, so I lose interest in testing. (Participant N)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIssues with information presentation. Some participants found the information too technical or lacking relevance to their demographic.\u003cbr\u003e \u003cem\u003eThe pamphlets from the community are full of technical terms I don\u0026rsquo;t understand, so I lose interest in learning about testing. (Participant O)\u003cbr\u003e\u0026nbsp;All the messages seem to be about young people. There\u0026rsquo;s nothing about older adults, so it doesn\u0026rsquo;t feel relevant to me. (Participant P)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMisleading information. Participants felt that excessive emphasis on the dangers of HIV caused fear, while the benefits of testing were not clearly conveyed.\u003cbr\u003e \u003cem\u003eThe messages only talk about how terrible it is to get infected. It scared me so much I didn\u0026rsquo;t want to get tested.\u003c/em\u003e\u003cem\u003e（\u003c/em\u003e\u003cem\u003eParticipant Q\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\u0026nbsp;I haven\u0026rsquo;t really heard about any benefits of testing. It just feels like it doesn\u0026rsquo;t matter whether I get tested or not. (Participant R)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbout self-efficacy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSEM analysis indicated that high self-efficacy significantly promoted HIV testing behavior among elderly at high risk. Qualitative findings revealed the following:\u003c/p\u003e\n\u003cp\u003eInternal mechanisms of self-efficacy promoting testing: participants who actively sought HIV testing often demonstrated a sense of responsibility for their health or a rational understanding of the testing process and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;ve always taken my health seriously. I think regular testing is being responsible, so I\u0026rsquo;m not afraid of getting tested. ( Participant S)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI looked into the testing process beforehand. It\u0026rsquo;s just a blood draw or a simple test\u003c/em\u003e\u003cem\u003e\u0026mdash;\u003c/em\u003e\u003cem\u003enot scary. Even if the result is bad, at least I\u0026rsquo;ll know and can make a plan. (Participant T)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eManifestations of low self-efficacy as barriers to testing. Those who did not undergo testing often lacked confidence or courage, or were influenced by negative views in their surroundings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI feel like I\u0026rsquo;m too old to face the results. If something is wrong, I don\u0026rsquo;t even know what to do. (Participant U)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePeople in my neighborhood say if you get tested and they find something, it\u0026rsquo;s all over. So I got scared and didn\u0026rsquo;t go. (Participant V)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDiverse factors influencing self-efficacy: education level and past experiences may play a role in shaping self-efficacy.\u003cbr\u003e \u003cem\u003eI\u0026rsquo;ve had some education, so I understand the importance of health and trust that I can handle HIV testing. (Participant W, high school education)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI had a serious illness before and recovered well after active treatment. That made me feel confident I could handle HIV testing too. (Participant X, previously treated for a chronic illness)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbout behavioral skills\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSEM analysis revealed that behavioral skills had a negative effect on HIV testing behavior among elderly at high risk. Qualitative findings identified the following:\u003c/p\u003e\n\u003cp\u003eDifficulty with operational skills for HIV testing. Participants who had not undergone HIV testing commonly reported difficulties with the operational aspects, such as the complexity of using self-test kits, unfamiliarity with procedures at testing sites, and small print in instruction manuals that was hard to read.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe self-testing kit requires sampling and adding reagents\u003c/em\u003e\u003cem\u003e\u0026mdash;\u003c/em\u003e\u003cem\u003etoo many steps. I couldn\u0026rsquo;t figure it out, so I gave up. (Participant Y)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAt the testing site, I had no idea what to do first. The staff didn\u0026rsquo;t explain clearly. I had to run around a lot, so I just didn\u0026rsquo;t want to go again. ( Participant Z)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe instruction manual in the test kit is printed in such tiny font. Even with my reading glasses, I could barely read it, so I didn\u0026rsquo;t dare try it. (Participant EE\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLack of skills to handle testing-related concerns. Some participants reported not knowing how to address privacy concerns or how to cope with a positive result.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI was worried about my privacy during testing but didn\u0026rsquo;t know how to talk to the staff. I felt stuck, so I ended up not getting tested.\u003c/em\u003e\u003cem\u003e（\u003c/em\u003e\u003cem\u003eParticipant AA\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf the result turned out bad, I wouldn\u0026rsquo;t know how to tell my family or what to do next. That\u0026rsquo;s why I\u0026rsquo;ve been putting it off. ( Participant BB)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLimited access to behavioral skill training. Participants noted a lack of training opportunities and said that previous community outreach efforts failed to cover practical testing skills.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNo one has ever taught us how to get tested, and I don\u0026rsquo;t know where to learn this stuff. ( Participant CC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCommunity campaigns only talk about how dangerous HIV is. They never explain how to get tested or what to pay attention to, so I still don\u0026rsquo;t know what to do. (Participant DD\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCultural Metaphors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eQualitative findings also revealed that cultural metaphors influenced HIV testing behavior. In rural areas, there was a common belief that \u0026rdquo;older people do not need testing\u0026rdquo; and HIV was viewed as \u0026ldquo;a disease of the young\u0026rdquo;, which further reduced willingness to test.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAt our age, the days of being sexually active are over. What\u0026rsquo;s the point of getting tested now? (Participant EE\u003c/em\u003e\u003cem\u003e）\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAIDS is something only young people worry about. We\u0026rsquo;re old and live quiet lives\u003c/em\u003e\u003cem\u003e\u0026mdash;\u003c/em\u003e\u003cem\u003eit doesn\u0026rsquo;t concern us. (Participant FF)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides empirical evidence on the psychosocial and structural factors influencing HIV testing behavior among high-risk elderly men in China. The quantitative analysis revealed that self-efficacy was the strongest positive predictor of HIV testing behavior, while behavioral skills and HIV-related information exerted significant negative effects. The qualitative findings further contextualized these results, showing that self-efficacy was shaped by peer experiences, stigma, and cultural beliefs[28,29,30], while difficulties in self-testing procedures and fear-based messaging discouraged testing[31]. Additionally, rural participants commonly perceived HIV as a \"young person's disease,\" reducing their perceived need for testing. These results indicate that the development of HIV prevention strategies has predominantly focused on younger populations in recent years, especially with the advent of the digital age[32], which may be inadequate for elderly men and highlight the necessity for tailored interventions.\u003c/p\u003e\n\u003cp\u003eOur findings align with prior research demonstrating that self-efficacy is a critical determinant of health-seeking behaviors, including HIV testing[33,34]. However, unlike younger populations, elderly men in this study exhibited greater psychological resistance to HIV testing due to moral stigma and generational attitudes toward sexual health. Previous studies have shown that information-based interventions can enhance HIV testing rates[35,36,37], but our results suggest that misaligned communication strategies, such as fear-driven messaging, can have a counterproductive effect among elderly individuals. Moreover, while previous research has emphasized access barriers such as cost and convenience[38], our study identifies behavioral skill deficits (e.g., difficulty navigating self-testing instructions or fear of asking for a test in clinics) as unique obstacles for this demographic.\u003c/p\u003e\n\u003cp\u003eTo improve HIV testing rates among high-risk elderly men, interventions should focus on enhancing self-efficacy while addressing structural and cultural barriers. One effective approach is peer engagement, where elderly men are encouraged to participate in peer-led education programs and hear success stories like youngers, which can boost their confidence in the testing process[39]. Additionally, HIV messaging strategies should be refined to move away from fear-based narratives and instead highlight the benefits of early detection. Using communication channels that align with elderly adults' preferences, such as radio broadcasts, community meetings, and printed materials, can increase outreach effectiveness. Moreover, simplifying HIV self-testing tools by providing clearer instructions, larger font sizes, and culturally appropriate packaging can help overcome operational barriers that discourage self-testing[40]. Finally, integrating HIV testing into routine healthcare visits, particularly alongside screenings for common chronic conditions like diabetes and hypertension[41], can help normalize the practice and reduce associated stigma.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, its cross-sectional design limits causal inference, and self-reported data may be subject to social desirability bias. Second, participants were recruited from one province, which may not fully represent elderly men in different sociocultural settings across China. Third, while the study explored behavioral skill deficits, further research should examine how digital literacy and mobile health interventions might enhance testing accessibility for elderly populations. Future studies should also assess the effectiveness of tailored interventions, such as self-efficacy training and community-based support programs.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the urgent need for targeted HIV testing interventions for high-risk elderly men in China. While self-efficacy enhances testing uptake, barriers related to cultural stigma, information framing, and procedural complexity significantly hinder testing rates. By integrating peer-driven support, adjusting communication strategies, optimizing testing accessibility, and embedding HIV testing into routine healthcare services, public health efforts can improve early diagnosis and reduce HIV transmission in this aging population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eSEM:\u003c/strong\u003e Structural Equation Modeling; \u003cstrong\u003eOR\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eOdds ratio; \u003cstrong\u003eMSM\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003emen who have sex with men; \u003cstrong\u003eHCP:\u003c/strong\u003e Healthcare Provider;\u003cstrong\u003eIMB:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eInformation-Motivation-Behavioral Skills;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHBM:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHealth Belief Model;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTPB:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTheory of Planned Behavior;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCNY:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eChinese Yuan;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNCAIDS:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNational Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCDC:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eChinese Center for Disease Control and Prevention;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eUSD:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;United States Dollar;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCBO:\u0026nbsp;\u003c/strong\u003ecommunity-based organization;\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eEFA:\u0026nbsp;\u003c/strong\u003e\u003c/strong\u003e\u003cstrong\u003eexploratory factor analysis;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCI:\u0026nbsp;\u003c/strong\u003eConfidence interval.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. The written informed consents were provided for all participants before in-depth interviews and questionnaire surveys. This study was approved by the Ethical Review Committee of NCAIDS, China CDC (X230222728).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data essential to the conclusion are included in this manuscript and additional data are available upon reasonable request from the first author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by the National Natural Science Foundation of China (72404253), Capital's Funds for Health Improvement and Research (2024-2G-4331), and Young Scholar Science Foundation of Chinese Center for Disease Control and Prevention (2023A104). The funders had no role in study design; collection, analysis and interpretation of data; the writing of the manuscript; or the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDS conceived and designed the study. RT, QZ, YY, SD made contributions to investigation and data acquisition. DS, YW transcribed and analyzed the data. YW, ZY, QW contributed the interpretation of the data and drafted the manuscript. JW and DS made critical revisions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003eNational Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, People’s Republic of China. \u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003eAIDS Prevention and Control Department, Dehong Dai and Jingpo Autonomous Prefecture Center for Disease Control and Prevention, No.4, Guangnong 2nd Alley, Hedong Road, Mangshi, Dehong Prefecture, Yunnan Province 678499, People’s Republic of China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGuo Y, Sims OT. 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Sex Health. 2023;20(2):118-125. doi:10.1071/SH22110.\u003c/li\u003e\n \u003cli\u003eWang Z, Chan PS, Xin M, Fang Y, Chidgey A, Yu FY et al. An Online Intervention Promoting HIV Testing Service Utilization Among Chinese men who have sex with men During the COVID-19 Pandemic: A quasi-experimental Study. AIDS Behav. 2024;28(Suppl 1):77-89. doi:10.1007/s10461-023-04100-5.\u003c/li\u003e\n \u003cli\u003eKelvin EA, George G, Mwai E, Kinyanjui S, Romo ML, Odhiambo JO et al. A Randomized Controlled Trial to Increase HIV Testing Demand Among Female Sex Workers in Kenya Through Announcing the Availability of HIV Self-testing Via Text Message. AIDS Behav. 2019;23(1):116-125. doi:10.1007/s10461-018-2248-5.\u003c/li\u003e\n \u003cli\u003eTan RKJ, Koh WL, Le D, Banerjee S, Chio MT, Chan RK et al. Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial. J Med Internet Res. 2022;24(5):e31401. doi:10.2196/31401.\u003c/li\u003e\n \u003cli\u003eSharma M, Ong JJ, Celum C, Terris-Prestholt F. Heterogeneity in individual preferences for HIV testing: A systematic literature review of discrete choice experiments. EClinicalMedicine. 2020;29-30:100653. doi:10.1016/j.eclinm.2020.100653.\u003c/li\u003e\n \u003cli\u003eRocha GM, Cândido RCF, de Carvalho NP, de Carvalho NP, Carvalho EGA, Costa AAM et al. Strategies to increase HIV testing among men who have sex with men and transgender women: an integrative review. BMC Infect Dis. 2023;23(1):240. doi:10.1186/s12879-023-08124-z.\u003c/li\u003e\n \u003cli\u003eConner LR, Fernández Y, Junious E, Piper C, Rowan D. Evaluating HIV Educational Materials for Older People. J Int Assoc Provid AIDS Care. 2019;18:2325958219849054. doi:10.1177/2325958219849054.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Risks, behaviour and stigma: understanding how to protect older men in rural China from HIV. https://www.who.int/westernpacific/newsroom/feature-stories/item/risks--behaviour-and-stigma--understanding-how-to-protect-older-men-in-rural-china-from-hiv?utm. Accessed 24 Aug 2025.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elderly, HIV/AIDS, HIV testing, Mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-7500496/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7500496/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHigh-risk elderly constitute a vulnerable group for HIV infection. Age-specific barriers impede voluntary testing among elderly and limit the reach of traditional interventions. Existing models often oversimplify motivation and overlook older adults\u0026rsquo; unique psychological and contextual challenges. This study addresses this gap by extending the dimension of motivation, and using a mixed-methods design to generate actionable insights for improving HIV testing among high-risk elderly men in China.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in Dehong Prefecture from 2024 to 2025. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Chi-square test was employed to compare demographic characteristics. And multivariable logistic regression was used to identify independent predictors of HIV testing behavior. Finally, structural equation modeling (SEM) was utilized to decompose and quantify both direct and indirect effects of the predictors within a comprehensive framework.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThere were 300 and 15 participants included in quantitative and qualitative study respectively, achieving an HIV testing rate of 57.7% and a mean age of 57.2 years. Among participants, non-commercial sex with non-regular partners was reported by 56.0%, 31.0% of these forwent condoms due to reduced pleasure (42.3%). Commercial sex was reported by 85.3%\u0026mdash;44.4% of non-condom users cited the same reason. Multivariate logistic regression identified older age (\u0026ge;\u0026thinsp;70 years), ethnicity, education level, occupation, and urban residency as significant predictors of HIV testing uptake. SEM analysis identified self-efficacy as the strongest positive predictor (total effect\u0026thinsp;=\u0026thinsp;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while behavioral skills (-0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and HIV information (-0.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) exhibited significant negative effects. The model fit was acceptable (RMSEA\u0026thinsp;=\u0026thinsp;0.073, CFI\u0026thinsp;=\u0026thinsp;0.94). Qualitative data revealed that peer success stories bolstered self-efficacy, whereas stigma eroded it; testing was also hindered by procedural complexity, low-information transparency, and misaligned messaging and media channels among older adults.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSelf-efficacy facilitates HIV testing among high-risk elderly men, whereas usability issues, ineffective messaging strategies, and cultural perceptions suppress testing behavior. Interventions should focus on enhancing self-efficacy, optimizing age-friendly self-testing tools, adopting non-fear-based messaging strategies, and integrating HIV screening into chronic disease check-ups to break cultural biases.\u003c/p\u003e","manuscriptTitle":"Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:22:31","doi":"10.21203/rs.3.rs-7500496/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-13T07:30:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325278494632584676590620100135655932457","date":"2025-10-07T04:07:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165698447444328334930077798395297878591","date":"2025-10-06T16:37:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T04:59:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-01T09:17:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-09T06:35:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T03:16:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-09-08T13:37:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bfe1a0ac-f1c3-4089-916e-33366a9b69d3","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T12:22:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 12:22:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7500496","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7500496","identity":"rs-7500496","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}