Acceptability of WeChat as a platform to promote HIV self-testing
All participants described the transition from traditional text messaging (SMS) to WeChat that occurred throughout China. They said that they no longer used SMS texts for the purpose of general communication due to the inconvenience and expenses of text messaging. Although few participants had ever sent or received text messages to communicate about their health with a professional counselor, those who had done so expressed several concerns about this mode of mobile communication:
I used to consult doctors in CDC in Hefei and my hometown about the risk of getting infected by sexually transmitted diseases or AIDS and about the prevention of the infection... I think the telephone number would be revealed when sending SMS. Because the telephone number uses a real-name system now, I think the privacy cannot be protected. I mainly worried about privacy.
Whereas use of SMS text messaging has declined for general purposes, most participants reported regular use of WeChat and said that they took advantage of the numerous features of the app in daily communication. They described using the WeChat app for a range of personal communication needs including text-based messages, voice messages, and voice calls for both personal and work purposes, and considered SMS text messaging as outdated mode of communication.
I think the biggest advantage of WeChat is that I could send voice messages to my friends instead of text messages, after all people in the middle ages commonly don’t like typing.
Participants reported strong interest and use of the “Moments” feature of the app, which allows users to share their ongoing thoughts and activities, such as pictures and statuses, with their social network and comment on others’ postings. Features of the WeChat app enabled participants to maintain multiple social networks with family, friends and peers, and community affiliations.
I have a family group, some friend groups, Qinghui group (a group for gay) and Youth Health group. As for the official accounts, I have followed such accounts like environment related, scenery related, and literary related ones as well as public interests related ones.
A few participants also described following health-related official accounts, although few reported having used WeChat for communication with health service staff. Those who had used WeChat for health communication voiced their approval of its privacy and safety. For example, a participant described the convenience in communicating with a heath provider via WeChat:
As long as workers are professional and authoritative, I think there is no inconvenience. They were enthusiastic and gave me answers patiently. We don’t need contact with them directly or to meet face-to-face. In addition, we could consult with them whenever possible.
All participants believed it would be acceptable to create an information platform on WeChat to support the use of oral HIVST. A few participants proposed that “Blued” (a popular gay dating application in China) could provide targeted opportunities for reaching high-risk MSM, which can complement WeChat’s broad user appeal and multi-communication features. Moreover, because of the mass use of WeChat and the millions of people in China who can potentially create topical WeChat discussion groups, participants recommended the creation of an “official” WeChat account for promoting HIVST – in which individuals would be required to request access and be invited to join – to ensure that the health information was delivered by professionals with appropriate expertise, rather than by lay community members. Creation of an official WeChat account for HIVST promotion and education would also allow for more privacy and protect against disclosure of users’ personal identities, which could be possible if accounts were maintained by private lay individuals.
It’s better to open an official account because it is easy to reveal private information in groups. People can see each other in the groups and maybe they know each other. Because some people just don’t want others to know something about them. If you want to protect our privacy, you can open an official account. If you want to push information frequently, then you can set up a group. And some people join the group just for fun, so I think it’s better to open an official account.
Participants expressed concern that an official service account would cause them to receive too many regular message notifications (which might automatically appear on their smart phone screen unless that feature is disabled), which might compromise privacy or inadvertently disclose their MSM behavior. They preferred a subscription account that limits the amount of “push message” notifications, and recommended that these notifications appear only when they manually enter the WeChat application.
Specific user preferences for WeChat message development
We identified five domains described by participants as key considerations for implementation of WeChat interventions for HIVST promotion among MSM: message source, dosage, medium, tone, and content.
Due to the volume of information circulating on social media and mobile apps such as WeChat, participants primarily emphasized the credibility of the message source in order to enhance receptivity to mHealth messages. Participants perceived volunteers of recognized community-based organizations as highly credible sources of HIV and HIVST information delivered via WeChat. In particular, MSM-affiliated organizations were viewed as trustworthy sources of sexual health information. Participants described greater comfort engaging in two-way WeChat communication about sexual health with volunteers of these organizations compared with doctors, and the doctors were perceived as being insensitive and judgmental toward MSM. Participants further noted that endorsements by the Chinese Centers for Disease Control and Prevention (CDC) of WeChat accounts would confer scientific credibility alongside community credibility, thereby enhancing receptivity and trust of mHealth messages among MSM:
Because they [volunteers] are more intimate with us. Many members among them are our peers, it will be easier for us to communicate with each other. As for the doctors, there do exist some communication barriers.
It is better to emphasize that this account is run by homosexual groups, so people would think their privacy will be protected. Moreover, you can tell the public that this official account is under the support of CDC, so people would think this official account is professional.
The second key domain was message dosage, which included both frequency of WeChat messaging as well as the time of day during which messages are delivered. Most participants preferred to receive messages during non-working leisure times, and expressed caution that messages delivered during work time would be ignored. Messages delivered just prior to or after the end of the work day could maximize receipt by individuals commuting on public transportation to work. With regard to message frequency, most participants recommended sending messages two to three times a week – which was considered a balance between daily messages (perceived as too frequent and could lead to unsubscribing from the account) and weekly messages (perceived as too infrequent and could lead to concern that the account was no longer active).
Third, participants noted the need to balance across multiple types of WeChat media (text, graphic, video) to maximize interest among MSM. In order to facilitate interest in reading the WeChat messages, participants recommended the combination of text and pictures, especially cartoons/comics, to prevent them from becoming too text-heavy. Moreover, they urged that data on HIV and related health outcomes be presented in the form of simple histograms and pie charts, rather than as text. Participants expressed mixed opinions about video messages. Although participants suggested that well-produced, brief videos could effectively provide information about HIV and HIVST (e.g., demonstrations on how to self-administer HIVST kits, or videos about HIV risk in the local community), they also warned that video viewing typically requires Wi-Fi access which cannot be guaranteed at all locations. Furthermore, because video messages might openly address HIV testing and sexual behavior, participants indicated that these videos could potentially disclose their MSM behavior to people in nearby viewing distance.
For me, I think it would be better to use pictures and text. Because I often stay in my home and it is not good for me to watch the video when my family stay around me. And it would spend much traffic if I watch it without Wi-Fi and I think pictures are more clear for me.
The fourth key domain was message tone. Participants had previously encountered different tones by which app-based messages were delivered, ranging from formal tones, casual/friendly tones, and authoritative tones. In general, they recommended using attractive and accessible titles/content to gain people’s interest in viewing mHealth messages, especially targeted toward young people who often have high risk but little knowledge about HIV. However, participants believed that the most appropriate tone depended on the message topic; tones should vary depending on message content. For example, professional and authoritative messages may be better suited to deliver information about HIV-related medical referrals, whereas casual tones could be effective at communicating social norms about condom usage and behavioral risk reduction. Participants also recommended that messages should use simple, non-technical language to facilitate understanding, especially given the various educational backgrounds of potential recipients. For example, one participant who followed an official account specialized in disease research described that the content was difficult for him to understand due to the use of technical language. Additionally, participants agreed that the messages should avoid “preaching” and sensationalized stories, and cautioned about the use of scare tactics. They recommended that messages should be positively framed and encouraging.
Finally, participants suggested mHealth messages should present original content relevant to the MSM community, rather than repeat generic content from other mobile apps or information already available online.
I used to follow an official account for a week to find if it is something I like, then I will decide whether to follow or to cancel the following. Some accounts are really useful, so I will read them often. If it is just trying to attract people by its headlines, but the contents are hollow/useless, I will not follow anymore.
If the content is lively or novel, which could attract people’s attention, I think they will accept it even if you push information every day.
In order to reduce sexual risk behaviors and increase rates of HIV testing among MSM, participants suggested including educational messages about accurate and accessible information about the MSM-specific routes of HIV infection, high-risk behaviors that lead to the transmission of HIV, and evidence-based methods of HIV prevention in the MSM community. They also encouraged communicating local HIV epidemiological data in an accessible manner in order to raise recipients’ awareness of geographic distribution of HIV and immediate risks to themselves and their MSM peers.
In fact, for today’s China or Anhui Province, we are not well aware of the risk of infection and infection status. We only know that this thing might exist. For many people, this thing seems to be very far, you may not be aware that there is much risk around us. So I think, for many people, raising the awareness of vigilant and encouraging people to keep fixed sexual partner can ensure that everyone keeps a relatively safe, mature attitude to face these things.
Moreover, some believed that local HIV data was not adequately accessible to the public:
There is no official report of current infection condition. We don’t know which organization is responsible for this. For example, how many people were infected with HIV every month in 2015 in Hefei? Or how many people were sick and the proportion of people who died? We don’t know about this kind of information, and there is no specific publishing channel. Besides, we can’t search this data on the CDC website. For people in our gay community, they hope to access this information when they need it. Although I didn’t search this data, I hope this kind of data can be published like the weather forecast, so I can access to it when I need it.
A common recommendation about message content was to share first-person experiences from Chinese MSM living with HIV in order to personalize the epidemic.
I think the personal experience of HIV-infected [people] can touch people’s heart, or can frighten people.
Furthermore, to encourage HIV testing, they noted the need to include information about HIV testing times, locations, and a comparison of testing methods, and some suggested sending periodic testing reminders. Creation of a brief video of HIVST self-administration by a MSM peer was recommended to demonstrate the relative ease of use.
If you push a video in the App or WeChat official accounts to teach others how to take self-test and let people see it, I think many people will feel that taking a test is not so trouble. Some people don’t know how to take oral test on their own.
Privacy concerns about HIV-related messages via WeChat
Participants expressed privacy and/or security concerns about receiving HIV-related messages via the app. Most worried that their families and friends might see the messages, which could reveal their MSM behavior. They cautioned that explicit message titles, sensitive words, and HIV-related pictures would increase the possibility of inadvertent disclosure:
Its titles, slogans, and contents should not be too direct. It must not be recognized as HIV test related when seen by someone who isn’t a gay. If I follow it and there are some words like AIDS Prevention Office, it isn’t acceptable to me, because if it’s seen by someone else he’ll feel weird and think why I’m following such an official account.
Being a gay, I like to know more information about HIV transmission routes. But others may not be familiar with this disease. So if they see us viewing this kind of information by accident, they may think that I am infected.
Participants recommended safeguards to mitigate these possibilities, including disabling the appearance of messages on the phone’s main screen, using discrete languages and imagery, and avoiding explicit MSM and HIV headlines and message titles by using colloquial language and euphemisms known by MSM.
Because a cellphone is private, but it could be seen by many people. I hope you do not call HIV straightforwardly, but you can call it in a euphemistic way, like “red ribbon.”
Some participants reported having two WeChat accounts – one for general communication with family and friends, and one for MSM- or HIV-specific communication – to minimize risk of inadvertent disclosure. They described this as a possible strategy to alleviate users’ privacy-related concerns:
I have no worry about that because I have two WeChat IDs, and one of them is specifically used to focus on information related to HIV. So I have no worry about that. But I think for those people who have only one WeChat ID to receive the related information, it might better to avoid some sensitive words in the texts.