Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

Young men who have sex with men (YMSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs), yet are often reluctant to obtain healthcare services [1‐4]. YMSM, between the ages of 16 and 30, may be at higher risk of HIV acquisition than older MSM because they may be more likely to be sexually active, suffer from power imbalances in relationships, and report higher rates of condomless sex and substance use [5]. As a result, YMSM require more evidence-based, MSM-friendly healthcare services. Decentralization of healthcare services may improve service quality and coverage [6]. Decentralization refers to transferring clinical services away from a single organizational authority and towards multiple sites. However, service decentralization may also result in inconsistent quality of health services [7], making it difficult to meet the unique needs of YMSM. Physician mistrust and fear of discrimination also discourage YMSM from obtaining health services [3, 4], and thus may affect timely treatment and linkage to care [2]. In order to improve sexual health services and reduce HIV/STI transmission, linkage to care of YMSM to MSM-friendly physicians is urgently needed.

YMSM report inadequate HIV/STI information and insufficient healthcare seeking [8]. The proportion of MSM who visit a STI physician in clinic is low; only 36% of MSM with suspected STI have sought STI treatment in clinics in China [9]. YMSM attending an STI clinic may experience dual stigma stemming from same-sex practices and the STI treatment-seeking [10]. Missed office visits are also common for MSM living with HIV, leading to a higher likelihood of poor HIV-related outcomes [11]. At the same time, YMSM are increasingly using the Internet to seek health information [12, 13], particularly HIV/STI information [14, 15]. This may be an opportunity for enhancing the delivery of HIV/STI information. Online information can empower YMSM with STI knowledge and encourage them to visit a physician [16‐18]. Some studies have found that individuals who seek sexual health information online show an increase in safe sex behavior [17, 19], HIV/STI testing [20, 21], and service access [22].

When seeking health information online, multiple platforms are available. Search engines are a commonly used platform to initiate the searching process [23, 24]. Governmental websites offer official and authoritative health information [25, 26]. Counseling websites allow users to ask or answer health-related questions. In contrast, social media platforms allow users to generate health information available for searching. Social media platforms have also grown to include gay mobile apps and mobile medical apps, which characterize two-way interaction and emphasize connection [27]. Among online informational platforms, social media is emerging as an effective method of disseminating health information [28, 29]. Social media is an online platform that facilitates the creation and sharing of information via virtual communities and networks, and features participation, openness, conversation, and connectedness [27]. Social media can be used to collect the wisdom of crowds, build peer-mentored communities, and deliver HIV/STI prevention services [30]. Social media use is particularly prevalent among adolescents and young adults; and in some contexts, up to 30 % of young people use social media to obtain health information [13]. Social media-based health interventions targeting MSM have been found to be feasible and acceptable among YMSM at high risk [31, 32].

China has a large population of YMSM who use online information seeking platforms. Over 695 million people in China use social media [33], and gay-specific social media platforms such as “Blued” have over 27 million users in China [21]. Chinese YMSM have an HIV and syphilis prevalence of 6.7 and 8.3%, respectively [34]. This is likely related to low HIV/STD knowledge [35], high rates of unprotected anal intercourse [36], perceived low risk of HIV infection, and fears of being stigmatized [37]. Chinese YMSM are increasingly using online resources to seek partners as well as obtain sexual health information [38]. The aim of this study is to examine the relationship between online STI information seeking and offline STI physician visits among YMSM. We also sought to examine the role of social media as a source of STI information and as a method of linking care to STI healthcare providers.

This study examines YMSM’s online health information seeking behavior and its relationship with offline STI physician visits. This study extends the literature by exploring the role of social media as an emerging source of sexual health information. A majority of study participants had used online search engines and various forms of social media to seek sexual health information. YMSM considered gay mobile apps to be trustworthy sources of sexual health information, and utilized apps to seek health services. We also observed an association between online information seeking and offline physician visits, and found high rates of interest and willingness to use a MSM-friendly physician finding function.

We found that a majority of YMSM used generic social media and gay apps to seek sexual health information. This finding is consistent with prior surveys that have supported the emerging role of social media as searching tools [15, 23, 43, 44]. Compared with obtaining information from clinics and other institutions, online STI information seeking may be preferable because of its relatively anonymous, convenient, and confidential search process [45‐47]. Social media platforms extend these advantages with increased adaptability, usability, and customizability [48]. Users can generate content and improve information quality through repeated, iterative processes [49, 50]. Individuals tend to have more trust in information shared by friends and acquaintances on social media compared with conventional sources [51]. With increasing integration of social media into daily communication habits [52], social media platforms represent novel opportunities for STI information dissemination.

YMSM indicated high levels of trustworthiness of STI information on gay mobile apps. Gay mobile apps were next only to authoritative governmental websites in the perceived trustworthiness. High levels of media use may build trust in certain media platforms [53, 54]. The most popular gay mobile app in China is accessed on average 227.5 times a week per user [55]. Gay mobile apps also expand opportunities for sexual health services to reach YMSM who may fear disclosing their same-sex behaviors in other contexts [56, 57]. MSM-exclusive platforms may also provide a feeling of safety among YMSM, and thus build trustworthiness toward the information on gay mobile apps [58]. Information about HIV/STIs and sexual health services on gay mobile apps can increase YMSM’s exposure and access to guidance and services of prevention, linkage to care, and treatment.

As YMSM have demonstrated high rates of Internet use for information seeking [5], improving access to offline healthcare services through online information is critical. In this study, we observed that online information seeking among YMSM was correlated with offline STI physician visits. In particular, seeking for symptoms was strongly associated with offline STI physicians, indicating that YMSM tend to more likely visit physicians in case of symptoms than screening of asymptomatic STI. Online information-based interventions have been implemented in many fields to promote health care [59, 60], including increasing HIV/STI testing [61] and antiretroviral therapy (ART) adherence [62]. Online information seeking may help empower YMSM with medical literacy, enable self-advocacy, and increase confidence before seeing a physician [63, 64]. Nonetheless, the prevalence of misinformation online can also make information seeking difficult [8]. Linking the high-quality, and accurate information to offline health services for YMSM will be critical in developing potential social media health interventions.

Most men were interested and willing to use a MSM-friendly physician finding function within gay-specific apps. This finding highlights the need for creating a friendly and comfortable environment to provide clinic services for MSM [65]. In the context of decentralization of health services, informing and suggesting STI physicians based on the geographical locations within gay-specific apps can improve healthcare accessibility and approachability [7]. In addition, many YMSM may not access health services in fear of being outed and healthcare discrimination [66]. Identifying and recommending MSM-friendly physicians can remove some barriers that defer YMSM to visit a physician and access healthcare resources.

This study has several limitations. First, participants were all recruited through social media platforms with internet access and social media use, which may overestimate the rate of online information seeking. Second, the participants were required to have visited a physician in the past 24 months; this may also result in an overestimate of the rate of visiting physicians. Third, participants were relatively well-educated, had higher income and had higher proportion living in Eastern China, and our findings may not be generalizable in other contexts or settings. Fourth, our survey did not distinguish those who sought STI information online once or repeatedly sought STI information online. Fifth, this study used a cross-sectional survey and thus could not determine any causal relationships. Finally, men self-reported sexual behaviors and healthcare seeking behaviors, introducing potential recall or social disability bias.

Gay mobile apps and other social media platforms represent a unique opportunity to engage YMSM at high risk for HIV and STIs. Social media can be leveraged to disseminate STI information to YMSM. In addition, social media can be utilized to promote sexual health services, such as physician-finding functions. Our findings highlight the need to develop strategies to link YMSM to MSM-friendly physicians and health services.