Why risk persists: A social cognitive theory-based explanation of raw-fish consumption in clonorchiasis-endemic areas

Raw-fish consumption remains the primary driver of clonorchiasis in endemic areas, yet public health strategies emphasize disease awareness rather than the psychosocial factors sustaining this culturally embedded practice. Guided by Social Cognitive Theory (SCT), this study aimed to quantify the behavioral pathways underlying raw-fish consumption and identify actionable points for prevention.

A cross-sectional survey was conducted from May to June 2025 among residents in Xinhui District, China, a representative endemic area for raw-fish consumption. A path model incorporating key SCT constructs and sociodemographic characteristics was tested using weighted Partial Least Squares Structural Equation Modeling. Multi-group analyses examined heterogeneity by sex and age.

Among 1,167 participants, 59.13% reported having ever consumed raw fish in their lifetime. Raw-fish consumption was negatively associated with refusal self-efficacy and perceived value, but positively associated with positive outcome expectations, whereas negative outcome expectations showed no significant direct association. Refusal self-efficacy was strengthened by negative outcome expectations and preventive information exposure, but weakened by positive outcome expectations, social support, promotional information exposure, and positive experience. Social support, promotional information exposure and positive experience reinforced positive outcome expectations. Limited but significant heterogeneity by sex and age was observed in selected social cognitive pathways.

This study applied SCT to identify key factors associated with raw-fish consumption in a food-borne parasitic disease area. The findings suggest that interventions should move beyond knowledge dissemination alone by strengthening refusal self-efficacy, countering pro-consumption social norms, and promoting safer choices for sustainable behavior change and clonorchiasis control.