Andersen’s model was adapted to identify factors associated with HIV health services by including sets of variables. The model helped uncover factors that may be ignored before, especially among MSM. Among the health services utilization projects examined in this study, the utilization of HIV counseling and HIV testing was good, but the status of consistent condom use was not optimistic, which is accordant with the description of Mengran: a low level of intentions to use condoms consistently has been reported in Chinese MSM population.
According to the Anderson behavioral model, need factor reflects how people view their own health, subjective cognition of disease and clinical diagnosis for individual physical condition, is the most direct and important factor which influences health services utilization. Therefore, it is considered to be one of the powerful predictor in health services. It can also be seen from this study that need factor is the main factor affecting HIV health services. Among them, HIV knowledge had statistically significant effects.
In the 2908 valid questionnaires collected this time, the average HIV knowledge score was 9.60±2.50, among which, ≥11 accounted for 42.26% and <11 accounted for 57.74%, indicating that the degree of HIV knowledge was generally moderate. HIV knowledge is the main factor affecting HIV testing and HIV counseling, which is also consistent with the research ideas of Sofia. In fact, as early as 10 years ago, scholars proposed the Information, Motivation and Behavioral Skills (IMB) Model, which has guiding significance in HIV risk reduction interventions. The information in the IMB model mainly includes subjective information and objective information, of which objective information includes knowledge. More and more studies have found that HIV knowledge plays a key role in the prevention and control of AIDS. The studies of Simukai and Doris[28, 29] also indicated that HIV knowledge and attitude were associated with non-condom use and high-risk sexual behavior, so knowledge promotion and popularization based on media platforms were urgently needed. At the same time, Chilot has pointed out that a very low comprehensive knowledge of HIV/AIDS is one of the major reasons for the increase of HIV infections.
It has been confirmed in the literature that educational programs, sexual education and communication activities can contribute to the improvement of knowledge. However, it remains to be discussed whether increased HIV knowledge will necessarily lead to improved behavior, because of the phenomenon of "knowledge-practice separation". According to the theory of Knowledge, Attitude and Practice (KAP) and the study of Min-Jin Peng, we can see that the phenomenon of "knowledge-practice separation" does exist, and at the same time, improving self-efficacy may help to solve this problem. Therefore, in the future, more studies are needed to evaluate the HIV knowledge of high-risk groups and explore relevant influencing factors, so as to solve the problem of "knowledge-practice separation" or "knowledge-attitude separation" in this group for reducing the incidence of new HIV infection.
In addition to the above factors, other factors will also affect HIV health services. The enabling factor in the Anderson Behavioral Model refers to the resources or means by which an individual has access to health services, usually involving individual and community resources such as health insurance, income, wealth, availability of services and urban classes. User fees for healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases. Because in China, HIV testing and counseling is free only in CDC, and in other institutions such as hospitals is charged. They are also not covered by medical insurance. At the same time, the location of HIV testing and counseling is only under some settings, which makes it easier for MSM living in urban areas to access health services. It is therefore proposed to increase the number of health service points in rural areas in order to address the uneven distribution of resources between regions.
In addition, the Internet has become popular in MSM as an online platform for seeking relationships and sexual partners, such as using social networks to date with other men. Previous studies have shown an association between finding sexual partners through the Internet and risky sexual behavior. It indicated that MSM who use the Internet to find sexual partners are more likely to engage in unprotected anal sex[35, 36], which is consistent with the results of our study. Nemoto's research also suggests that sexual risk behavior may be related to psychosocial factors. Another aspect is commercial sex. Research figures that sexual partnerships and unprotected sex increase the likelihood of HIV/AIDS infection and transmission in China, especially in the low-level commercial sex industry[37, 38]. Because the commercial sex is illegal in China, HIV prevention services are difficult for sex workers and their clients to access. The Chinese government should pay more attention to the dangerous environment of commercial sex in order to prevent the spread of AIDS. Internet usage and commercial sex, as a part of enabling factor, reflect more realistic social problems in health services. For a specific group like MSM, we recommend more public health campaigns in local communities and more HIV-related knowledge on social networking platforms. It is also beneficial to promote free condoms in rural areas and urban communities.
The third influencing factor in Anderson Behavioral Model is the predisposing factor, which refers to the nature of the individual that cannot be easily changed. Our study found that MSM with age (18-25) and lower educational attainment (junior high or below) were more likely to use condoms consistently. Although this is contrary to the findings of many studies[39–41], we considered that it might be related to increased risk perception in this population. Both a cross-sectional study and a population-based longitudinal analysis showed an association between risk perception and condom use. Also, the results of the Algarin's study showed that people with high school or lower education were more likely to use condoms, similar to the results of our study. They propose that sociodemographic attributes (e.g., age, nationality, education) will influence condom use. Future knowledge-based HIV prevention interventions that are sensitive to different levels of education, age, and ethnic identity should consider recognizing the classification and describing its efficacy and when it is most appropriate to use it.
Of course, there are other problems in HIV health services, such as limited data, unreasonable organization of health institutions, and high cost (time cost and human resources) for a health service. The need to combine medical, sociological and psychological considerations also poses a great challenge to the development of health services. Especially for MSM, it needs to be more cautious and careful. In this paper, a widely used and relatively mature theoretical model (Anderson Behavioral Model) is applied to HIV health services, and the 8-year health services survey also ensures the consistency and robustness of the study to better understand and explain the factors that influence health services. However, there are several problems as follows. (1) As a sensitive group, MSM pay great attention to privacy issues. As our survey was conducted in the form of face-to-face questionnaire, some sensitive issues (such as sexual behaviors, condom use, and sexual partners) may be concealed. In the future, more attention should be paid to privacy protection of sensitive groups. (2) There are only three health service utilization items included in the analysis, which may not necessarily representative of all health services. Because health services a complex phenomenon and has multiple dimensions of access outcomes. We hope that more studies will focus on the health services of this population in the future, investigate more needs and utilization, and provide new directions and ideas for AIDS prevention and policy making.
In conclusion, based on Anderson Behavioral Model, this paper studies the factors affecting HIV health services from 2013 to 2021. Finally, we conclude that MSM population has a good utilization of health services, but the consistent condom use is not ideal. HIV knowledge, household registration and income are the main factor affecting HIV testing and HIV counseling. Younger and less educated MSM are more likely to use condoms consistently. Internet commercial sex use is associated with consistent condom use. Need factor is the main factor determining the utilization of HIV health services. The government and relevant departments should strengthen the popularization of disease knowledge and the diagnosis and treatment of individual physical and mental diseases. MSM population with high-risk characteristics should be identified as a priority in the future public health service delivery strategy. It is the focus of future research to provide new ideas for health services policy formulation by combining regional, economic, health resources, privacy, psychological problems and other factors. We hope that our study can encourage discussions of HIV health services,and set the stage for sharing and creating for service innovation.