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Background Premarital medical examination (PME) compliance rate has dropped drastically since it became voluntary in China in2003. This study aimed to establish a prediction model to be a theoretic framework for analyzing factors affecting PME compliance in Zhejiang province, China. Methods A culturally-tailored health behavioral model combining the Health Behavioral Model (HBM) and the Theory of Reasoned Action (TRA) was established to analyze the data from a cross-sectional questionnaire survey (n = 2,572) using the intercept method at the county marriage registration office in 12 counties from Zhejiang in 2010. Participants were grouped by high (n = 1,795) and low (n = 777) social desirability responding tendency (SDRT) by Marlowe-Crowne Social Desirability Scale (MCSDS). A structural equation modeling (SEM) was conducted to evaluate behavioral determinants for their influences on PME compliance in both high and low SDRT groups. Results 69.8% of the participants had high SDRT and tended to overly report benefits and underreport barriers, which may affect prediction accuracy on PME participation. In the low SDRT group, the prediction model showed the most influencing factor on PME compliance was behavioral intention, with standardized structural coefficients (SSCs) being 0.75 (P < 0.01), and the intention was positively determined by individual's attitude toward PME (SSCs = 0.48, P < 0.01) and subjective norms (SSCs = 0.22,P < 0.01) and negatively determined by perceived threat (SSCs = -0.08,P = 0.028). Attitudes and subjective norms were more crucial predictors for PME compliance than perceived threat (SSCs = 0.36, 0.269, and -0.06, respectively). County environmental factors played a role in PME compliance while less influential than behavioral determinates (16% vs. 84% in across factor variance partition coefficient). Conclusions PME compliance might be influenced by demographic, behavioral, and social environmental factors. The verified prediction model was tested to be an effective theoretic framework for the prediction of factors affecting voluntary PME compliance. It also should be noted that internationally available behavioral theories and models need to be culturally tailored to adapt to particular populations. This study has provided new insights for establishing a theoretical model to understand health behaviors in China. [ABSTRACT FROM AUTHOR]