In recent years, the Philippines has observed a rapid increase in the number of new HIV infections, with upward trends monitored and reported by the Philippine Department of Health—Epidemiology Bureau. Between 2008 and 2018, the Philippines recorded a total of 10,899 new HIV cases (Philippine Department of Health—Epidemiology Bureau, 2019). In 2000, the incidence of newly diagnosed HIV cases in the Philippines was less than one new HIV infection per day in contrast to 36 Filipinos diagnosed with HIV per day as of August 2019 (Philippine Department of Health—Epidemiology Bureau, 2019). In 2019, more than three quarters of the new infections were observed to be either among men who have sex with men (MSM) or transgender people, with the highest densities localized in urban to highly urban centers. The steadily increasing incidence of HIV cases, over the years, can be attributed to the government providing more centers that offer HIV testing services (HTSs), numerous community-based and nongovernment organizations mobilizing to increase access to HTS, and popular culture normalizing attitudes toward HTS (Philippine Department of Health—Epidemiology Bureau, 2019; Mangahas, 2018). Regretfully, the total number of Filipinos reached by HTS is not known. Development of research-based programs and policies are needed to achieve the Philippines' contribution to the 2030 global goal of 90% of the world's population knowing their HIV status.
Researchers have noted that HIV prevention education and HTSs programs in developing countries were moderately effective at improving behavioral outcomes but showed little to no substantial effect on HIV status (Evangeli et al., 2016; Fonner et al., 2012; Mangahas, 2018). A 2016 survey revealed that more than three fourths of Filipino men knew where they could access HTS (Philippine Statistics Authority, 2018). However, according to the World Health Organization, only 9% of Filipino MSM globally received an HIV test and knew their results in the past 12 months (WHO Western Pacific Region, 2016). Urban-dwelling Filipinos and those in the wealthiest quintile were more knowledgable of a place to get tested for HIV than rural-dwelling Filipinos and those in the poorest quintile (Philippine Statistics Authority, 2018). Despite knowing where they can get an HIV test, only 20% of Filipino men have ever been tested for HIV and, of that 20%, only 14% of them got tested in the 12 months prior and received a copy of their results (Philippine Department of Health—Epidemiology Bureau, 2016, 2019). Overall in the Philippines, participation in HIV testing is positively correlated with increasing income (Abrigo, 2017).
Health Belief Model
In the 1950s, social psychologists from the US Public Health Service developed the Health Belief Model (HBM) to explain the observable low uptake in an early disease detection program. The HBM has six constructs that were theorized to have effects on the likelihood of a health action to be taken. These constructs are (a) perceived severity, the perception of the gravity of the consequences of the disease; (b) perceived susceptibility, the belief of the personal risk of acquiring the disease; (c) perceived benefits; (d) perceived barriers of the health action proposed; (e) self-efficacy for the proposed health action; and (f) cues to action, which are various stimuli (i.e., prevention campaigns, health education programs, print or media materials) that may prompt individuals to participate in an early disease detection program (Strecher & Rosenstock, 1997). Individual level or modifying factors like the demographic profiles, exposures, and experiences are posited to affect the perceptions of the constructs of the HBM (Jeihooni et al., 2018).
Researchers using the HBM to study the HIV epidemic have revealed positive effects on HTS utilization when MSM perceived HIV to be of severe consequence (Evangeli et al., 2016). Perceiving HIV to be severe is not the only consideration in choosing to get tested for HIV. Studies have revealed various barriers to HTS utilization like lack of awareness or knowledge about HIV testing, fear of the results, fear of rejection, fear of disclosure, access issues, stigma, and unfriendly testing environments for young people (Mohlabane et al., 2016; Musinguzi, et al., 2015). It has been observed that unaddressed perceived barriers are the strongest negative predictors of HTS, whereas having a heightened perception of the benefits of HTS has a positive association on HTS utilization (Evangeli et al., 2016; Pham et al., 2019).
Cues to action, such as knowing someone with HIV, attending educational interventions, having had conversations about HIV and a partner's HIV status, and having had recent condomless anal intercourse, were generally observed to have a positive effect on HTS (Evangeli et al., 2016; Li et al., 2014, 2016; Teklehaimanot et al., 2016). Moreover, assisted voluntary partner notification was reported to be 1.5 times more likely to end in HTS utilization than passive referrals (Dalal et al., 2017). However, a study revealed that repeated exposure to HIV awareness campaigns over a long period was associated with a decline in HTS utilization over the years (Shrestha et al., 2017).
It was observed that higher self-efficacy scores correlated to higher rates of HTS (Pham, et al., 2019). Individual level or modifying factors (e.g., age, gender, ethnicity, personality, socioeconomic, knowledge) were later theorized to play an integral role in conditioning both individual perceptions and the perceived benefits of preventive actions (Evangeli et al., 2016). Higher educational attainment, being employed, higher socioeconomic status, absence of stigmatization against gender and HIV, knowledge about HIV, and where one can access HTS were separately observed to have positive effects on their utilization (Brito et al., 2015; Evangeli et al., 2016; Rodríguez-Díaz et al., 2015; Teklehaimanot et al., 2016). Younger age has been associated with both use and nonuse of HTS (Brito et al., 2015; Li et al., 2016; Teklehaimanot et al., 2016; Yi et al., 2015). Gender identity and sexual orientation were found to have mixed effects on the utilization of HTS (Baros et al., 2018; Evangeli et al., 2016).
This study was designed to investigate (a) the factors that promote and negate the intent of Filipino MSM to use HTS, (b) the utility of the HBM in understanding intent to use HTS, and (c) the identification of a clinically significant theoretical model that illustrates the direct effects of individual level and modifying factors on five of the HBM constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and self-efficacy), and finally the direct effects of cues to action and the five HBM constructs in relation to HTS utilization (Figure 1). To achieve these objectives, we used partial least squares structural equation modeling (PLS-SEM) because of its ability to analyze a variety of variables, not normally distributed data, and large numbers of constructs. PLS-SEM is also appropriate in the search for relationships between constructs, their directions, and strengths, although efficiently working with smaller sample sizes, such as the hidden population of Filipino MSM. The results could assist nurses and other public health professionals to understand the factors surrounding intent to use HTS and to develop appropriate interventions to aid in the prevention of new HIV infections or increased access to care through early screening and detection.
An analytic cross-sectional online survey study design was used to investigate the relationship individual-level factors have on the constructs of the HBM and the intent of Filipino MSM to use HTS. A priori power analysis using G*power v3.1 (Universität Düsseldorf) identifying 13 predictors, with a small to medium effect size of 0.085, a power of 0.80, and an alpha at 0.05, generated a minimum sample of 324. The study was designed using respondent-driven sampling, but tracing participants past the third generation becomes difficult; thus, nonprobability sampling of Filipino men aged 18 years or older, who self-identified as MSM and were Philippine residents, was adopted.
Community-based organizations facilitated the recruitment of potential participants. All potential participants were sent an email that included a cover letter, enclosed instructions, and a poster invitation that contained the inclusion criteria (identifies as MSM, at least 18 years old at the time of the survey, resides in the Philippines, and understands English) and the hyperlink to the study's instrument, which was fitted into a web-hosted survey software (Google Form). On opening the link, participants were given the study's background, purpose, and the electronic informed consent form. The consent explicitly mentioned that the study would not collect any identifying information such as the participant's name, email address, or IP address. A data storage policy was included in the informed consent form document, explicitly asking them how long they wished their data to be stored (maximum of 5 years), and whether they would allow their data to be used for other HTS-related research studies. After the informed consent was secured, the participants proceeded to answer the survey tool via the hyperlink. Data collection was completed between March and June 2019.
The English-only web-hosted instrument was developed after a comprehensive review of literature on the factors relating to intent to use HTS. The entirety of the instrument used was pretested for readability, understanding, and accessibility on 15 Filipino MSM, who were not part of the final sample. The instrument had multiple sections to measure the different constructs of the HBM, which are described next.
Individual level and modifying factors
Participant profiling included three sections: (a) biopsychosocial profile, there were questions designed to determine the participants' sexual orientation, gender identity, and expression using semantic differential scale; (b) assessment of their HIV testing knowledge and practices; and (c) sexual history and practices.
AIDS health beliefs
The 16-item AIDS Health Belief Scale (AHBS), in its original form, was used to measure four of the constructs of the HBM: perceived susceptibility, perceived severity to HIV, perceived benefits, and perceived barriers to condom use (Zagumny & Brady, 1998). Participants scored their health beliefs using a 6-point Likert scale with responses of strongly agree (weighted as 6) to strongly disagree (weighted as 1), where higher scores on all the subscales represented a greater extent of that belief. The AHBS (α = 0.82) was deemed reliable, exhibiting high internal consistency with each of the subscales and it also demonstrated high internal consistency: Perceived Susceptibility (α = 0.83), Perceived Severity (α = 0.83), Perceived Benefits (α = 0.93), and Perceived Barriers (α = 0.92; Zagumny & Brady, 1998). The AHBS has exhibited discriminant and convergent validity (Scandell & Wiazelek, 2002) and was observed to be reliable overall (α = 0.71) when administered to a sample of Thai men (Khumsaen & Stephenson, 2017).
Self-efficacy for, and intent to use, HIV testing service
The AHBS does not include a measure of self-efficacy, another component of the HBM. Thus, assessment for self-efficacy for HIV testing was measured using the single item used in a study done in Myanmar on a similar topic: “I feel confident that I could get tested for HIV,” measured against a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), responses of 1–3 were coded as low, 4 as moderate, and 5 as having high self-efficacy. To assess for the likelihood of behavior, the participants were asked, “Do you intend to get tested for HIV in the next 3 months?” (Pham et al., 2019).
Cues to action
Questions were based on previously tested items to assess various cues to action that may have been perceived and/or received by the participants. Among those assessed were “Do you have a relative/friend infected with HIV?”, “Do you have an acquaintance who is living with HIV (diagnosed to be HIV+)?”, and “Have you ever attended an HIV awareness campaign/seminar?” The participants were tasked to answer “yes” or “no,” and the affirmative responses were counted to represent the number of cues to action received/perceived by each of the participants (Strecher & Rosenstock, 1997).
Table 1 lists the computed reliability coefficients for the tested HBM constructs from this study.
IBM's Statistical Package for Social Scientists v23 software program was used to process the statistics used to describe the sample, and ScriptWarp Systems' WarpPLS v6.0 was used to carry out PLS-SEM to evaluate the simultaneous impact of biopsychosocial factors, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy on the intention to use HTSs. PLS-SEM was used to examine the correlation between the observed variable and the latent variable to identify the factors affecting the intent of Filipino MSM to use HTS and develop a model. The p-value was set at <.05 for determining the significance of findings.
In PLS-SEM, the recommended model's fit indices are average path coefficient (APC), average R-squared (ARS), average adjusted R-squared (AARS), average block VIF (AVIF), average full collinearity VIF (AFVIF), and Tenenhaus Goodness of Fit (GoF). APC, ARS, and AARS are measures of the model's variance, explanatory, and predictive capabilities. It is suggested that the p-values for the APC, ARS, and AARS all be equal to, or lower than, .05 and be significant at the .05 level (Kock, 2011). AVIF accounts for vertical collinearity within the model's latent constructs, whereas multicollinearity is measured by AFVIF; both are recommended to have individual values that are less than 3.3 (Kock & Lynn, 2012). GoF is the square root of the product between what is referred to as the average communality index and the ARS. The following thresholds were proposed for the GoF: (a) small if equal to or greater than 0.1, (b) medium if equal to or greater than 0.25, and (c) large if equal to or greater than 0.36 (Wetzels et al., 2009). A value lower than 0.1 for the GoF suggests that the explanatory power of a model may be too low to be considered acceptable.
This study was part of a larger study that also investigated the HIV-related sexual practices of Filipino MSM. The researcher diligently endeavored to protect and respect the participants' rights to full disclosure, self-determination, confidentiality, nonmaleficence, and privacy. The participants were made aware that the study was part of a larger project aimed at assessing the health beliefs and sexual practices of Filipino MSM through a standardized message enclosed in the Google form before securing their electronic informed consent. After submission for ethical clearance, the Holy Angel University Institutional Review Board adjudicated that all procedures done involving human participants were in accordance with the ethical standards of the institution and/or the national research ethics network, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards, and the Board assigned the study control number 2019-017-NPCALAGUAS-HEALTHBELIEFSEMHIVMSM.
A total of 471 MSM were included in the analysis, 6 were excluded from data analysis because they disclosed that they had already tested positive for HIV. Table 2 provides a description of the MSM participants in this study.
Table 3 lists the gender identity and expression of the sample of Filipino MSM. Most of the participants (61.15%) self-identified more with the sense of being men (M = 2.12; SD = 1.01) and reported their gender expression to be along with the gender-neutral to masculine end (M = 2.55; SD = 0.92) of the spectrum. When asked about their sexual orientation, many reported identifying as homosexuals (exclusively MSM; n = 280; 59.45%).
Many of the participants reported having had sex only with other males (88.54%). The majority reported several sexual partners over their lifetimes (between 1 and 19; n = 332; 70.48%), with a mean number of 33 sexual partners, and a median number of 8 sexual partners. Most participants reported not being fully aware of their sexual partners' HIV status (n = 369, 78.34%).
The majority of the participants reported that they had been tested for HIV at least once (n = 349; 74.10%), with only 158 (n = 158; 33.55%) of them having been tested for HIV in the 3 months before their participation in this study; a comparatively smaller majority reported having received the result of their last HIV test (n = 286; 60.72%). No participant scored lower than 50% on the comprehensive HIV knowledge assessment, with a majority (n = 402; 85.35%) scoring 75% or higher on the HIV knowledge assessment portion of the survey and intended to get tested for HIV in the next 3 months (n = 386; 73.4%).
Nonsignificant paths were removed, and a few additional paths were added to improve model fit. Specifically, the paths from cues to action, perceived barriers and perceived severity to intent to use HTS, alongside several individual level or modifying factors' paths to perceived benefits, perceived barriers, perceived severity, perceived susceptibility, and self-efficacy were dropped from the model for better fit. The final model (Figure 2) was assessed as a whole, and analysis revealed the model to be satisfactory using a variety of fit indices (APC = 0.132, p < .001; ARS = 0.075, p = .026; AARS = 0.067, p = .036; AVIF = 1.126, AFVIF = 1.261, GoF = 0.263).
Table 4 lists the significant parameter estimates of the final fitted model predicting the utilization of HTSs among Filipino MSM. The model predicting the intent to use HTS of Filipino MSM revealed that self-efficacy (β = 0.216), perceived susceptibility (β = 0.119), and perceived benefits (β = 0.089) were positively predictive of HTS utilization (p < .05). No significant relationship was observed between perceived barriers (β = −0.023; p = .309) and perceived susceptibility (β = 0.010; p = .411) to HTS utilization.
The following modifying factors were observed to have a significant relationship (p < .05) to the HBM constructs and eventual utilization of HTS: An increase in the number of sexual partners was negatively predictive of perceived benefits (β = −0.093), whereas increased HIV knowledge was positively predictive of perceived benefits (β = 0.136). Older age (β = 0.088), having disclosed their sexual orientation (β = 0.105), and the receipt of their last HTS result (β = 0.171) were all positively predictive of self-efficacy for HTS. It was observed that older age was negatively predictive of perceived susceptibility to HIV (β = −0.182), whereas having had sexual encounters with individuals who do not identify as MSM was observed to be positively predictive of increased perceived susceptibility to HIV (β = 0.122).
Three of the constructs of the HBM—perceived benefits of HTS, self-efficacy for HTS utilization, and perceived susceptibility to HIV/AIDS—were observed to be significant predictors of HTS utilization, with the HBM explaining 8% of the variance. This study is the first to explore the structural factors that affect the intent to use HTS of Filipino MSM. Although the model did not explain a significant amount of the variance associated with HTS among Filipino MSM, the findings are an important addition to the literature because they highlight the individual level and modifying factors in relation to the constructs of the HBM that predicted HTS in this population.
Men who have sex with men who were more knowledgeable of HIV were more likely to perceive the benefits of seeking HTS; this could be attributed to successful HIV awareness, education, and prevention programs (Brito et al., 2015; Evangeli et al., 2016; Regan & Morisky, 2013; Rodríguez-Díaz et al., 2015). Whereas, having more sex partners was negatively predictive for the perception of the benefits of being tested for HIV, which could be due to the Philippines' macho-patriarchal enculturation of males, which emboldens males to seek multiple partners (Lasco, 2017; Sullivan et al., 2017). Like other studies, the perception of the benefits of HTS does predict utilization; it is posited that MSM take into consideration the inherent benefits of HIV testing when deciding to take the test themselves (Evangeli et al., 2016; Pham et al., 2019).
Men who have sex with men who have had sex with women and/or transwomen viewed themselves to be more susceptible to HIV, suggesting that MSM may believe that HIV risk is greatly associated with some gender identities (feminine side of the spectrum) and not with their risky sexual behavior (Blair et al., 2016). The model demonstrated that as MSM age, their perceived susceptibility to HIV decreases, which suggests how older MSM view their susceptibility, due to either little representation and emphasis of their age group's HIV risk in mainstream education and prevention messaging (Prati et al., 2014) or the increased likelihood that they are in mutually monogamous relationships or are in relationships with safe sexual agreements (Mitchell & Petroll, 2011; Stephenson et al., 2015).
Higher self-efficacy for HIV testing was predicted by MSM's older age, receipt of their last HIV test result, and disclosure of their sexual orientation. As MSM age, their perception of their capability to seek needed care improves, as does having previously completed the HIV testing process, which leads to increased self-efficacy for HIV testing (Evangeli et al., 2016; Pham et al., 2019). MSM's internalized homophobia, nondisclosure of their sexual orientation, or not wanting to be associated with gays due to fear of stigmatization limit their exposures to discussions regarding gay-identified intervention services, which ultimately negatively affects their self-efficacy for HIV preventive behavior (Adebajo et al., 2012; Vu et al., 2012). Similar studies posit that higher ratings of self-efficacy for HIV testing suggest more intention and an increased likelihood of HTS utilization (Evangeli et al., 2016; Pham et al., 2019; Pinyaphong et al., 2018; Wang et al., 2018).
Of note, cues to action, perceived barriers, and perceived severity have not been observed to have significant relationship to HTS utilization. Studies note that cues to action have shown immediate uptake of HTS use, but the intended behavior change produced was temporary, failing to impart the medium-term to long-term effectiveness and importance of consistent and regular utilization of HTS (Prati et al., 2016; Shrestha et al., 2017). Perceived barriers not significantly predicting MSM's intent to use HTS could be due to possible limitations in measuring the construct's complexity (Evangeli et al., 2016). Perceived severity was also not significantly predictive of HTS utilization; this echoes the findings in the study by Evangeli et al. (2016), which could be due to the construct primarily focusing on the cognitive domain rather than emotional factors like fear, which has been shown to be negatively predictive of HTS utilization (Adam et al., 2014).
The model presents a relatively small effect size but is statistically significant in predicting utilization of HTS, which demonstrates the capability of PLS-SEM in testing relationships inherent to constructs of complex conceptual frameworks.
The addition of other individual level or modifying variables beyond those explicated in the model need to be examined, possibly to address the low (8%) variance associated with HTS utilization in this sample. Further, the cross-sectional design of this study limits its ability to examine cause–effect relationships. As such, future studies need to use a prospective, longitudinal design. Due to the sensitivity associated with sexual health topics, including HIV, there is a risk of participants reporting “socially desirable” responses. Yet, the fact that the study was primarily conducted through online mechanisms may have minimized this bias (McInroy, 2016). Despite the sufficiently powered study, with participants responding from across the Philippines, the difficulty in executing respondent-driven sampling may have limited the representativeness of the sample, thus diminishing the generalizability of the findings.
Implications to Nursing Practice
Nurses can lead and call for the strengthening of both government and community-based programs to make HIV testing information, and the actual services available, accessible, and affordable. The perceived benefit of, self-efficacy for HTS, and perceived susceptibility to HIV were observed to be significant predictors of HTS utilization. For this reason, nurses should focus their health education and health prevention interventions on the concept that HIV risk is associated with risky sexual behaviors like condomless anal intercourse rather than specific gender identities, although providing a nonthreatening, affirming testing environment. Nurses can plan and implement HIV preventive care with the necessary attached support services for education, treatment, and support to help achieve the global goal of increasing the total number of individuals who get tested and know their HIV status.
The HBM is still useful as a framework to understand and predict the intent of Filipino MSM to use HTS. The model specifically identifies that individual-level and modifying factors, such as age, the number of and gender identity of sexual partners, being in a long-term relationship, having received previous HTS results, educational background, the amount of correct HIV knowledge, monthly household income, whether the respondent has disclosed their sexual orientation to others, whether they have experienced gender-based stigma, and the knowledge of their own personal HIV status and that of their sexual partners, do unknowingly affect the health belief constructs of Filipino MSM, specifically, perceived benefits, perceived susceptibility, and self-efficacy, which ultimately affect their intention to use HTS. This could imply that MSM unwittingly factor in the value–expectancy constructs described in the HBM when deciding whether to use HTS.
The author reports no real or perceived vested interests related to this article that could be construed as a conflict of interest.
- Nurses involved in HIV prevention services should be sensitive to, or at the very least aware of, the various structural factors that promote or negate HTS utilization.
- Through population-based nursing care, nurses can look into how the individual level and modifying variables identified can be integrated into programs and policies to increase the utilization of HTSs.
- Patient-centered nursing care should take into consideration the value expectancy laden constructs of the HBM.
- Clinical nurse educators and case managers should be clear in emphasizing that the susceptibility to HIV is based on risky sexual behaviors, like condomless anal intercourse, and not to specific gender identities or expressions.
- Nurses play an important role in the prevention of HIV by ensuring that the care environment is free from gender-based and HIV-related stigma and discrimination.
- Self-efficacy for HIV testing is observed to be one of the strongest predictors of increased uptake of testing services.
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