title: Association between a syndemic of psychosocial problems and unprotected anal intercourse among men who have sex with men in Shanghai, China.
abstract: Previous studies have discussed the overlapping and reinforcing effects (defined as a syndemic) of psychosocial problems on high-risk sexual behaviors among men who have sex with men (MSM). The present study aimed to apply the syndemic theory to verify the reinforcing effects of psychosocial problems on unprotected anal intercourse (UAI) among MSM in Shanghai, and determine if other important psychosocial factors fit into the syndemic theory.
  
  
  
  Data were collected from 547 MSM in Shanghai, China, through face-to-face interviews. The measures for psychosocial problems included the Rosenberg Self-Esteem Scale; the Generalized Anxiety Disorder-7; the Center for Epidemiological Studies Depression Scale; the University of California, Los Angeles Loneliness Scale; and the Sexual Compulsivity Scale. We used multivariate analysis and binary logistic regression to investigate the associations between psychosocial problems and high-risk sexual behaviors.
  
  
  
  The prevalence of UAI among MSM in the past 6 months was 54.5%. Education (graduate from college vs. high school) served as a protective factor against UAI (OR 0.59, 95% CI: 0.38-0.94). There was a high prevalence of psychosocial problems, and at least one-third of participants reported experiencing more than two psychosocial symptoms. Of these psychosocial factors that we investigated, lower self-esteem was associated with UAI in both univariate and multivariate regression model (P = 0.009). Result suggests that overlapping and reinforcing effects of psychosocial problems may increase high risk sexual behaviors among MSM in Shanghai, China (OR 1.65, 95% CI: 1.09-2.50; P = 0.018).
  
  
  
  We found further evidence for a syndemic of psychosocial problems among MSM in Shanghai, China. This syndemic may also increase high risk sexual behaviors among MSM. Most HIV prevention interventions are focused on behavior change and only have moderate effects; our findings suggest that a shift from behavior-focused interventions to a more comprehensive strategy that addresses psychosocial factors may be necessary.
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
authors.forename: Ying
authors.initials: Y
authors.lastname: Wang
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
authors.forename: Zezhou
authors.initials: Z
authors.lastname: Wang
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
authors.forename: Mengmeng
authors.initials: M
authors.lastname: Jia
authors.affiliation: Renji Hospital, affiliated with School of Medicine Shanghai Jiao Tong University, Shanghai, 200127, China.
authors.forename: Ajuan
authors.initials: A
authors.lastname: Liang
authors.affiliation: Shanghai Municipal Center for Disease Control and Prevention, Shanghai, 200336, China.
authors.forename: Dong
authors.initials: D
authors.lastname: Yuan
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
authors.forename: Zhe
authors.initials: Z
authors.lastname: Sun
authors.affiliation: School of Continuing Education, Shanghai Jiao Tong University, Shanghai, 200030, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Gan
authors.affiliation: Ruijin Hospital, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200032, China.
authors.forename: Yichen
authors.initials: Y
authors.lastname: Wang
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China. caiyong202028@hotmail.com.
authors.forename: Yong
authors.initials: Y
authors.lastname: Cai
authors.affiliation: School of Public Health, affiliated with School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China. zhangzhiruo@sjtu.edu.cn.
authors.forename: Zhiruo
authors.initials: Z
authors.lastname: Zhang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002681:China; D003863:Depression / Q000523:psychology; D015658:HIV Infections / Q000523:psychology*; D018451:Homosexuality, Male / Q000523:psychology*; D006801:Humans; D016015:Logistic Models; D008132:Loneliness / Q000523:psychology; D008297:Male; D008875:Middle Aged; D012649:Self Concept; D012725:Sexual Behavior; D012959:Socioeconomic Factors; D047568:Unsafe Sex / Q000523:psychology*; D055815:Young Adult
keywords: MSM; Psychosocial problems; Syndemic