Mechanisms explaining a pay-it-forward approach: A qualitative analysis among men who have sex with men in China

Background: Pay-it-forward is when an individual receives a gift and is offered the opportunity to donate a gift to another person. This prosocial behavior has been used to develop health interventions, including strategies to increase sexually transmitted disease (STD) testing among men who have sex with men (MSM). Although pay-it-forward has improved service uptake across several settings, the underlying mechanism is unclear. This study aims to assess the participant experience to provide a theoretical basis for how pay-it-forward works among MSM in China. Methods: MSM participants of a pay-it-forward intervention were recruited from two STD clinics in Guangzhou, China, and underwent semi-structured interviews. Responses were translated verbatim into English. Transcripts were analyzed thematically. Results: Twenty-four MSM were interviewed. Despite many men feeling detached from other MSM, pay-it-forward engendered hope and solidarity among many participants. From an emotional perspective, reading handwritten postcards from other MSM induced gratitude, warmth, and support. From the perspective of the collective, receiving a free test and donating to other MSM solidified men's connection with the MSM community, even among men not yet out. Donation gave men an opportunity to pass on their gratitude and provide for MSM in need. Conclusions: Our data suggest that upstream reciprocity and warm glow explained pay-it-forward for some men, but this pathway was often complemented by a pathway aligned with principles of mutual aid. Further qualitative and mixed-methods research is needed to understand the basis for MSM decision-making about donating to support others.