https://orcid.org/0000-0002-0854-1667
Abstract
Linking identified MPOX cases to care is essential for MPOX control. This study aims to investigate the intentions of healthcare seeking and self-isolation for MPOX among men who have sex with men (MSM) in China. A cross-sectional online survey was conducted in early August 2023 in China. Respondents were recruited by community-based organizations (CBOs), collecting information on demographics, health status, behavioral and psychological characteristics. Univariate and multivariate logistic regression analyses were performed to examine the predictors of intentions to seek healthcare and self-isolate for MPOX within the MSM population. A total of 7725 participants were recruited, with a median age of 30 years. 92.21% of the participants would seek healthcare for MPOX-like symptoms, but only 52.50% intended to self-isolate if diagnosed. Intentions to seek healthcare were lower among those with MPOX-like symptoms in the past 3 months (standardized prevalence ratio (SPRs) = 0.82, 95% CI: 0.74-0.89) and the willingness to self-isolate was reduced among those diagnosed with MPOX in the past 3 months (SPRs = 0.65, 95% CI: 0.48-0.87). Participants free of sexually transmitted infections (STIs) and those aware of their HIV status were more likely to seek healthcare and self-isolate than those with STIs or unaware of their HIV status. Regular followers of MPOX information and those perceiving a low risk of infection were more inclined to take preventive measures. These findings highlight the need for targeted MPOX prevention strategies for high-risk groups and the importance of addressing barriers in infectious disease prevention response.
Disclaimer
As a service to authors and researchers we are providing this version of an accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proofs will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to these versions also.Introduction
MPOX, formerly known as monkeypox, is an emerging zoonosis disease caused by the MPOX virus. This disease was historically confined to central and west Africa [1], but has recently seen an alarming spread beyond these non-endemic regions. This expansion has raised global concerns, prompting the World Health Organization (WHO) to declare a Public Health Emergency of International Concern (PHEIC) on July 23 2022 [2, 3]. As of November 2023, the worldwide outbreak of MPOX has escalated to 92,783 confirmed cases and 171 deaths across 116 countries and territories. Notably, in the WHO Western Pacific region, China reported 2024 out of the 2760 confirmed cases [4]. The first imported case in China was detected in Chongqing in September 2022 [5], with several provinces reporting cases in 2023, predominantly among men who have sex with men (MSM), reflecting a global pattern [5, 6]. The epidemic in China has been escalating since June 2023, indicating a risk of further transmission.
Significant to the outbreak, research indicates that the MPOX virus has undergone evolution, in which the B.1 lineage is closely related to the current human MPOX outbreak. This evolution highlights a shift in the epidemiology and potential virulence of the disease [7, 8]. Furthermore, the coinfection of the MPOX virus with SARS-CoV-2 and HIV has been well established, establishing a complex clinical scenario [9]. Among MPOX cases with known HIV status, up to about 50% are HIV positive, presenting and additional challenge in managing the outbreak [10, 11].
In response to the growing threat of MPOX, the Chinese government issued the Technical Guidelines for MPOX Prevention and Control (2022 edition) in June 2022 [12], followed by an updated plan for MPOX prevention and control in July 2023 [13]. These measures, coupled with the classification of MPOX as a Class B national notifiable infectious disease since September 20, 2023 [14], underscore the commitment to a standardized and legally grounded management approach. The national prevention and control plan mandates prompt medical attention for symptomatic individuals, reporting within 24 hours, and self-isolation following infection confirmation, which are critical for the timely tracking and evaluation of the disease’s spread.
Central to the management of MPOX is the role of public health and social measures, which significantly reduce transmission risks. Key strategies include promoting healthcare engagement for those showing symptoms and emphasizing the importance of self-isolation post-diagnosis. Effective isolation aids in outbreak containment, facilitates contact tracing, and allows for the allocation of resources and implementation of targeted preventive measures. Additionally, linking cases to healthcare services is vital for public health surveillance, community education, and vaccine research, playing a crucial role in minimizing the impact of MPOX.
Despite MPOX typically being self-limiting and causing mild illness that resolves without treatment, the limited availability of vaccines and antiviral treatments poses challenges. Until recently, no vaccines or antiviral treaments (like tecovirimat) are available in China. Chinese authorities, like those in many other countries, advise individuals with MPOX-like symptoms to seek healthcare and self-isolate upon diagnosis until recovery [15]. Therefore, this study seeks to identify barriers to early diagnosis and self-isolation for MPOX among MSM population in China. By understanding their willingness to seek healthcare and intentions towards self-isolation, the study aims to tailor further public health responses more effectively.
Methods
Study design and population
We conducted an anonymous, cross-sectional online survey targeting MSM in the first half of August 2023. The survey covered 30 provinces in China, excluding Xizang due to the absence of established contacts with community-based organizations (CBOs) prior to the survey. The sample size was carefully determined based on the estimated MSM population size in each province, ensuring the proportional representation [16].
To facilitate participant recruitment, we leveraged the network of CBO staff members. These staff underwent extensive training, enabling them to serve as recruiters for the survey. They were responsible for sending invitation messages to potentially eligible MSM within their networks through preferred messaging apps. This approach allowed us to reach a diverse and geographically dispersed population of MSM.
To ensure the eligibility of participants, interested individuals were screened based on predefined criteria, including being men aged 18 years or above, having engaged in sexual activities with men in the past 12 months, and residing in China. Before engaging in the survey, all potential participants were required to provide informed consent, safeguarding their rights and ensuring voluntary participation.
To mitigate biases in the process of the survey, we implemented several measures. First, the recruitment was conducted anonymously, preserving the privacy of participants and eliminating potential biases related to disclosure. Second, the use of an online questionnaire allowed for self-administration, thereby reducing interviewer biases. Moreover, the integration of an automatic logic check within the questionnaire helped identify and address inconsistencies or incomplete responses in real-time, thus enhancing data reliability. Additionally, CBO staff provided necessary guidance on questionnaire completion throughout the survey, ensuring participants fully comprehended the questions and responded accurately.
Measures
The data collection process encompassed self-reported information from participants on various socio-demographic, health, behavioral, and psychosocial factors. Specifically, socio-demographic variables included age, marital status (living alone vs married), education level (below high school, high school, college), employment status (unemployed vs employed), type of residence (rural vs urban), and regional location (east, central, west). The region classification was detailed as follows: East (Beijing, Tianjin, Hebei, Liaoning, Shanghai, Jiangsu, Zhejiang, Fujian, Shandong, Guangdong, Hainan), Central (Shanxi, Jilin, Heilongjiang, Anhui, Jiangxi, Henan, Hubei, Hunan), and West (Inner Mongolia, Guangxi, Chongqing, Sichuan, Guizhou, Yunnan, Shaanxi, Gansu, Qinghai, Ningxia, Xinjiang).
Regarding health and behavioral characteristics, participants reported on the presence of MPOX-like symptoms and MPOX infection status in the past 3 months, sexual behaviors (including the number of sexual partners and participation in group sex in the past 3 months), current STIs status (yes or no), and current HIV status (positive, negative, unknown). MPOX-like symptoms were clearly defined, encompassing fever, headache, back pains, muscle aches and pains, swollen lymph nodes, rash and mucosal rash, etc. Participants also reported their MPOX, STIs, and HIV infection status, with specific inquires about whether they had received diagnostic results from medical institutions. Here, STIs referred to a range of sexual diseases such as syphilis, gonorrhea, condyloma acuminatum, genital herpes and genital chlamydia trachomatis, etc.
Psychosocial characteristics, such as the frequency of following MPOX information and perceived risk of contracting MPOX, were also collected during the data collection process.
The outcome included intentions to seek healthcare and self-isolation. Healthcare-seeking intention was operationally defined as the willingness to actively seek healthcare when experiencing MPOX-like symptoms, aiming to early detection and diagnosis of MPOX. Self-isolation intention was described as the willingness to isolate post-diagnosis of MPOX until recovery.
Ethical statement
This study protocol was reviewed and approved by the Institutional Review Board of the National Center for AIDS/STD Control and Prevention, China CDC (KX180503512). All participants provided informed consent before taking part in the study.
Statistical analysis
Descriptive statistics were calculated to illustrate the demographic characteristics of the study participants. Continuous variables were expressed as median and interquartile range (IQR), and categorical variables were presented in counts and percentages (%). Pearson’s chi-square and Mann-Whitney tests were employed to discern differences among participants with MPOX-like symptoms and those with MPOX infection. The crude prevalence and standardized prevalence ratio (SPR) for intentions of healthcare seeking and self-isolation were compared based on the status of MPOX-like symptoms and MPOX infection, as these are indicative of the current priority populations for MPOX prevention and management. To address the potential socioeconomic confounding, SPRs were adjusted for age, a key socioeconomic status (SES) indicator.
Univariate and multivariate logistic regression analyses were performed to examine differences in healthcare-seeking and self-isolation intentions among MSM, identifying subgroups adhering to current policies. In the multivariate models, all the independent variables were incorporated, given their potential association with behavioral intentions, as supported by previous studies [17-19]. To assess the robustness of results, we performed sensitivity analysis on the above two multivariate models, excluding individuals who reported having experienced MPOX-like symptoms or infection. All statistical tests were two-sided with a significance level set at p < 0.05. The analyses were performed using SPSS software (version 20.0).
Results
In the study, 7762 MSM were initially surveyed, with 7725 included in the analysis after excluding individuals under 18 years. The median age of participants was 30 years (IQR: 25, 36). The majority were living alone, highly educated, employed and residing in urban areas, predominantly from the eastern region. Over 10% have engaged in sexual activities with four or more partners and participating in group sex within the past 3 months. Only 5.2% and 23.9% reported living with STIs and HIV ().
Table 1. Characteristics of MSM population by MPOX-like symptoms and MPOX infection in China
7.7% participants had recent MPOX-like symptoms, and 1.6% were infected with MPOX. Those with MPOX-like symptoms or infections were typically married, less educated, from rural areas, and more often from the eastern and western regions. These individuals were also more likely to consistently follow MPOX information and perceived themselves at a high risk of MPOX.
Participants who participated in sexual activities with more partners or group sex had higher prevalences of MPOX-like symptoms and infection. MSM with STIs had a higher likelihood of these symptoms and infections than those without STIs. Furthermore, individuals infected with HIV or unaware of their HIV status exhibited a greater proportions of MPOX-like symptoms and infections compared to those who were HIV negative ().
A significant 92.21% of MSM expressed a willingness to seek healthcare when experiencing MPOX-like symptoms, while 52.50% (4056/7725) would like to self-isolate upon a MPOX diagnosis. Even after adjusting for MPOX-like symptoms and MPOX infection, the standardized prevalence ratios (SPRs) for healthcare-seeking and self-isolation intentions were significantly higher among MSM with MPOX-like symptoms or infections ().
Table 2. Prevalences and SPRs of MPOX healthcare seeking and self-isolation intentions among MSM in China
In the adjusted analysis, the intention to seek healthcare was more prevalent among MSM who had higher education level, lived in the eastern region, had not experienced MPOX-like symptoms or infections, had fewer sexual partners in the past 3 months, were not living with STIs, and were aware of their HIV status. Likewise, a greater intention for self-isolation was observed among younger MSM, those with higher education, without MPOX-like symptoms or infections, not engaging in group sex, and with known HIV status. The likelihood of seeking healthcare or self-isolating was also higher among those who regularly followed MPOX information and perceived their risk of MPOX infection as moderate to low ( and ). In the sensitivity analysis, the results were stable excluding individuals having experienced MPOX-like symtoms or infection (suppl table 1 and suppl table 2)
Table 3. Unadjusted and adjusted ORs for factors associated with MPOX healthcare seeking intentions among 7725 MSM in China, August 2023
Table 4. Unadjusted and adjusted ORs for factors associated with MPOX self-isolation intentions among 7725 MSM in China, August 2023
Discussion
Globally, the response to MPOX outbreaks in non-endemic regions among MSM communities has been well-documented [17-25]. Our study extends the existing literature by conducting an extensive survey across various provinces in China, capturing a wide spectrum of socio-demographic, health, sexual behavior, and psychosocial factors and identifying barriers in willingness to seek healthcare and self-isolate for MPOX. We found that MPOX-like symptoms and infections are significantly more prevalent among married, less educated MSM residing in rural areas, as well as in the east and west regions. This disparity could be attributed to a combination of factors, including limited medical resources, lower health awareness, and insufficient access to and response to public health measures in rural settings [25]. Moreover, regional variations in population density, mobility patterns, and socioeconomic environment may exacerbate the spread and impact of MPOX. Furthermore, the influence of sexual behaviors on MPOX prevalence cannot be understated. Moreover, factors such as STIs and HIV status, along with psychosocial considerations like the frequency of monitoring MPOX information and perceived personal risk, greatly impact both MPOX-like symptoms or infection prevalence.
We found that the vast majority of Chinese MSM intended to seek healthcare for MPOX-like symptoms, representing effective public health communication and proactive measures initiated in response to the global MPOX outbreak of 2022. Chinese public health authorities have been collaborating with CBOs to disseminate information about MPOX and preventive measures among the most affected population. These measures effectively raised their awareness about MPOX and timely curtailed the local epidemic [6]. Given the short incubation period for infection through mucous membranes and damaged skin [27], it is recognized that crucial to promptly detect and diagnose MPOX infections to minimize further transmission. This underscores the significance of high-risk populations actively seeking healthcare when experiencing a rash-like illness, particularly in resource-limited regions where there is no vaccine or treatment available for MPOX.
Furthermore, in alignment with regulations in other countries, China recommends self-isolation for individuals diagnosed with MPOX until symptoms resolve, as outlined in the latest national guideline. However, our results showed only half of MSM are willing to comply with this recommendation. This suggests that, despite its effectiveness in containing the epidemic, the practice of self-isolation remains challenging. Similar findings in Netherlands highlights low acceptance of self-isolation for MPOX [18], citing barriers such as low health sexual health literacy, stigma, and the importance of maintaining intimacy [28]. The results emphasize the need for concerted efforts to identify and address barriers to the effective implementation of self-isolation at the personal, institutional, and societal levels.
Our study revealed that MSM with MPOX-like symptoms or MPOX infection are less likely to adhere to healthcare seeking or self-isolation measures. This highlights a notable discrepancy between the intended and actual practice of public health measures before and after disease infection. Fear of disclosing homosexual identity and associated social stigma plays a significant role when individuals are suspected or diagnosed with MPOX, particularly as 93.8% of infections in November 2023 occurred among MSM in China [6]. This association creates a trade-off between privacy disclosure and the personal health, limiting engagement with preventive measures. Some people isolate only when symptoms were visible [28], possibly influenced by previous experiences during the COVID-19 period and concerns about the impact on daily life, such as job loss and economic expenses. Strict public health measures, including lockdowns and isolation, have been reported to have a detrimental impact on well-being and social connections, particularly for vulnerable individuals with chronic conditions like HIV [29, 30]. The realization that there is currently no specific treatment for MPOX infections further leads to individuals to consider seeking healthcare unnecessary unless the common home remedies provide relief [24]. To enhance compliance with public health policies, efforts should focus on eliminating harsh environments and reducing stigma in the publicizing and implementation of MPOX guidelines.
Our study reveals a concerning trend as individuals engaging in risky sexual behavior, including activities such as having multiple partners and engaging in group sex in the past 3 months, demonstrate hesitancy in seeking medical attention or practicing self-isolate even when there is clear evidence of an increased risk of MPOX infection [12, 13, 21]. This highlights a gap in MPOX prevention efforts and underscores the necessity for targeted interventions to promote safer sexual practices. A key factor contributing to this behavior may the lower socioeconomic status and poorer health awareness of individuals with recent involvement in multiple sexual partners and group sex [31]. Their inadequate understanding of disease prevention, particularly for novel infectious diseases like MPOX, makes them unlikely to adopt risk-reducing measures. The study emphasizes the urgency of health education and intervention efforts tailored to vulnerable groups with high-risk behaviors to enhance health literacy and self-efficacy in enacting public health measures [28, 32].
Our study further confirms significant variation in healthcare seeking intentions within MSM population based on their STI and HIV statuses. Individuals with STI infections show a lower intention to seek healthcare, whereas those with either HIV-positive or HIV-negative status exhibit a higher intention. This aligns with findings from a qualitative study in the UK [28]. As MPOX is primarily transmitted through close contact during sexual intercourse, individuals tend to compare it with HIV and other STIs. There is a perception that MPOX is less problematic than HIV, with the belief that it can be self-limiting or recover with home remedies. Some MSM individuals may perceive themselves as relatively young and less susceptible to severe outcomes if infected. On the contrary, individuals with severe pre-existing conditions like HIV may worry about the possibility of severe MPOX infection or worsening of their condition [33]. Furthermore, those who are aware of their HIV status are more likely to undergo regular testing and possess an increased awareness of health protection [34, 35]. This group benefits from peer support and a positive community atmosphere fostered through connections with community organizations or CDC [36, 37]. These results highlight the need to incorporate the perceived severity of MPOX infection on personal health into risk-reducing education, particularly to those who perceive the risk to be low. This approach is crucial for promoting the acceptance of public health measures and encouraging behavioral change during outbreaks of emerging infectious diseases. Simultaneously, reinforcing multi-disease testing and prevention initiatives is essential, encompassing MPOX screening within existing HIV and other STI prevention programs, particularly among individuals with low healthcare seeking intentions, such as those with STI infections. This integrated approach optimizes resource utilization and enhances the overall effectiveness of healthcare interventions, aligning with a holistic public health perspective.
This study found people with less frequency in following MPOX information are less likely to seek healthcare and self-isolate due to lower awareness of prevention measures. Surprisingly, in contrast to previous research [38, 39], individuals perceiving a high infection risk showed a negative association with adopting preventive measures. First, this may be influenced by experiences of depression and self-stigma [40, 41], which hampers their ability to cope with a negative event and affects their decision-making on risk reduction behaviors [16]. In addition, if individuals perceive privacy disclosure risks outweighing personal health benefits, they may be less motivated for health-protective behaviors [42-44]. This insight is crucial for risk communication professionals to address the specific needs of their stakeholders. Further research is needed to comprehend barriers to preventive measures for those perceiving a high infection risk.
Limitation
While our study is the first nationwide investigation into the intentions of core prevention measures for MPOX among MSM in China, it comes with certain limitations. First, the distribution of questionnaires by CBOs primarily in urban areas might lead to overestimation of results, as participants are likely to be young, active, and familiar with new media. This necessitates further research incorporating older and rural populations for a more comprehensive understanding. Second, self-reported information might be influenced by recall bias, reporting bias or social desirability bias, potentially overreporting preventive intentions, while understimating the actual prevalences of MPOX-like symptoms and infections due to stigama or fear of discrimination. To enhance accuracy, corroborating the key health indicators with medical diagnostic record is advisable in future. Furthermore, despite broad provincial representation, covering 30 provinces, the study’s internet-based recruitment might not fully capture the diverse MSM population in China, implying a potential selection bias. Consequently, these considerations call for a prudent interpretation of our findings and emphasize these limitations in future research, to enrich our understanding of MPOX prevention intentions among this group. Lastly, it is important to note that our study did not explicitly and directly explore the barriers to healthcare seeking or self-isolation. Future qualitative studies are warranted to delve deeper into pivotal factors such as fear of stigma, disclosure of personal privacy.
Conclusion
Despite the extensive health education and intervention efforts for MPOX through media and community in China, there remains a need to address existing gaps in aligning public health strategies with their execution. Further efforts should focus on customized risk communication, particularly aimed at populations most vulnerable to MPOX but least likely to engage in preventative actions. Enhancing their willingness to embrace public health measures is vital. Our findings enlighten the significance of identifying and overcoming barriers in infectious disease prevention and control, and underscores the role of raising public health awareness and encouraging adherence to preventive practices.
Contributions
FC, FL, and HT conceived the study.
PL, HC, QQ, YJ, LG, JY, and HT performed the study design, and data collection.
FC and JZ conducted the analyses.
FC, WT, HT, and FL wrote the draft paper.
All authors contributed to the final version of the manuscript.
FL and HT had final responsibility for the decision to submit for publication.
Declaration of interest
We declare no competing interests.
Acknowledgments
We thank all study participants contribute to our study.
Data availability
The datasets and questionnaire in the study are subject to privacy or ethical restrictions but are available from the corresponding authors on reasonable request.
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