Discrepancies between subjective and objective risk perceptions of monkeypox infection among MSM in China

The global resurgence of monkeypox presents a growing public health concern, particularly among men who have sex with men (MSM). Accurate risk perception is critical for effective prevention. However, discrepancies between subjective and objective risk perceptions of monkeypox infection remain insufficiently studied in China. A nationwide cross-sectional survey was conducted from 2023 to 2024 across 30 provinces. MSM were recruited through community-based organizations (CBOs) and voluntary counseling and testing (VCT) clinics. Participants completed an anonymous online questionnaire assessing sociodemographic characteristics, sexual behaviors, monkeypox knowledge, and both subjective and objective infection risk perceptions. Stratified logistic regression was used to identify factors associated with risk misperceptions. A total of 14,325 valid responses were analyzed. Of these, 46.66% (6,684) were high-risk MSM, and 71.78% (10,283) reported awareness of monkeypox-related knowledge. Among high-risk MSM, 11.70% (782) reported unexplained rashes or lesions mainly in the genital or perianal regions, while 4.22% (33) adopted no preventive measures despite potential exposure. Discrepancies in risk perception were observed, with 9.14% (611) underestimating and 22.31% (1,491) overestimating their infection risk, and 1.15% (9) showing severe mismatches between subjective and objective assessments. Younger age (18-25 years), residence in western regions, and offline partner-seeking behaviors were associated with risk underestimation, whereas higher education and online partner-seeking behaviors were associated with risk overestimation. Significant discrepancies existed between subjective and objective monkeypox infection risk perceptions among MSM in China, with overestimation more prevalent despite adequate knowledge levels. Tailored interventions addressing cognitive biases and behaviors are essential to enhance risk accuracy and prevention.