A Men Who Have Sex With Men–Friendly Doctor Finder Hackathon in Guangzhou, China: Development of a Mobile Health Intervention to Enhance Health Care Utilization

Introduction

Background

Mobile health (mHealth)–based HIV and sexual health promotion interventions delivered through websites, text messages, or mobile apps are feasible and acceptable in reducing HIV risk behaviors and enhancing health care utilization among gay, bisexual, and other men who have sex with men (MSM) [1-4]. The use of these tools is especially feasible in low- and middle-income settings such as China, where smartphone ownership exceeded 68% in 2016 [5] and MSM face sexuality- and HIV-related discrimination and stigma in clinical settings [6-8]. However, most of the currently available mHealth intervention tools on the market were developed by the private sector for profit and have limited direct input from MSM communities [9,10], which may raise issues of acceptability and effectiveness of such tools among the target population.

Objectives

To fill the gap in engaging MSM communities in developing mHealth intervention tools to meet their specific needs in health care, we applied the crowdsourcing approach of a hackathon to solicit innovative designs of a mobile tool that aims to help MSM find, access, and utilize MSM-friendly health services. A hackathon is an intensive contest that brings together a diverse group of participants from multidisciplinary backgrounds to complete a health intervention–related task within a short period. Hackathons are an innovative approach to generate ideas from the target communities to address their needs [11,12].

Previous literature on health-related hackathons focused on translating biomedical innovations from laboratory settings or on general health care and health management [13-15]. A few hackathons focused on developing an mHealth intervention. The purpose of this paper was to describe a hackathon that aimed to develop an mHealth intervention to improve health care utilization (specifically HIV prevention and care) among Chinese MSM, summarize characteristics of the final prototypes, and discuss implications for future mHealth intervention development.

Methods

Pre-Hackathon Formative Work

Before this hackathon contest, in partnership with Social Entrepreneurship to Spur Health (SESH) and Blued (the largest gay social networking app in China), the Shenzhen University College of Mass Communication held a crowdsourcing contest from February 2018 to March 2018 for designing concepts of a mobile phone–based, MSM-friendly doctor mobile app. The contest generated 103 exceptional concepts about the name, logo, slogan, features, and functions of the MSM-friendly doctor mobile app.

We then conducted 4 focus group discussions with 38 MSM in Guangzhou and Shenzhen (July 2018), China, during which the researchers showed the participants a video of the concepts of an MSM-friendly doctor app platform; the platform’s name, logo, slogan, and functions were designed by SESH based on the abovementioned crowdsourcing outputs. Participants were asked for feedback on refining the prototype design. A thematic analysis of the results of the focus group discussions indicated that MSM had unmet needs in health care utilization and such a mobile, MSM-friendly doctor finder tool would be beneficial to them for attaining better health. Focus group participants highlighted the following functions that they wanted to see in such a tool: (1) GPS location–based doctor finder, (2) mental health support, (3) information and access to pre- and postexposure prophylaxis, and (4) health education [16]. To develop an mHealth prototype for this MSM-friendly doctor finder, we organized an MSM-friendly doctor finder hackathon contest between October 2018 and April 2019. Key information of the formative work (including crowdsourcing outputs and feedback from focus group discussions) was presented to hackathon participants via images and text in the hackathon contest handbook. A detailed description of the implementation of this hackathon contest and its outputs is reported below.

Steering Committee Establishment

We invited 9 experts in psychology, public health, computer science, social media, and clinical medicine to serve as steering committee members. All committee members attended the hackathon contest and provided guidance and advice to participants. They were encouraged to communicate with hackathon participants, but they were instructed to avoid providing specific examples. The guidance for steering committee members was based on a previous hackathon-like event organized by SESH [17].

Participant Recruitment and Inclusion Criteria

An open call for hackathon participants was disseminated on Blued, a free messaging app (WeChat), and a Chinese blogging website (Weibo). The open call described the problem statement, contest objectives, rules, timeline, and prizes (Textbox 1 and Figure 1). We encouraged individuals who self-identified as friendly to MSM and were interested in mobile app technology to sign up for the hackathon. All applicants were required to submit an application form that asked for information about demographics, professional background, personal interests, and self-reported strengths in terms of participating in a hackathon. Applicants were considered eligible for the hackathon if they met the following criteria: (1) aged 18 years or older, (2) interested in improving clinical services for MSM, and (3) were able to be physically present in Guangzhou during the entire hackathon.

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Creating Teams

The flow of preparation for the hackathon contest is illustrated in Figure 2. Applicants were independently evaluated and scored from 0 to 10 by 3 members from the steering committee based on 3 criteria, including background (relevant academic or working experience and ever attended any MSM-related activity), professional skills (good at Photoshop and Python), and teamwork capacity (“as a team member, how you will contribute to your team?”). The 3 scores of the applicants were averaged and ranked, and the top 40 applicants were selected as finalists. Finalists were further grouped into 8 teams based on their merits and expertise areas. Each team had 4 to 5 members, including 2 members with computer science skills, 1 member or 2 members with design skills, and 1 member with medical or public health knowledge.

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Hackathon Process

Considering the heavy workload of developing a complete mHealth app within a short period, each team was allowed to prepare for the hackathon 1 month before the in-person hackathon contest. During this 1 month, teams sketched concepts, conducted formative work to inform their designs, and started coding. An MSM-friendly hackathon manual (Multimedia Appendix 1) was shared with all participants, which provided information regarding the challenges MSM face when seeking health services and the hackathon process.

The final hackathon contest was held at a university building in Guangzhou, China. A total of 38 participants from the 8 teams attended the 72-hour in-person hackathon. Their transportation, accommodation, meals, and insurance were provided. Participants were instructed verbally and in writing in the hackathon manual (Multimedia Appendix 1) to follow all local laws and regulations during the hackathon contest and in the design of their prototype. Teams were encouraged to communicate and exchange ideas with on-site mentors. Mentors included the 9 experts from the steering committee. At the end of the 72-hour hackathon, each team had 15 min to present their prototype to the judging panel and had 5 min for questions and answers.

Judging Process

In addition to the 9 members of the steering committee, a leader from a local MSM community–based organization was invited to join the judging panel. This 10-person judging panel evaluated the final prototypes based on the following criteria: (1) the prototype should have innovative features that aim to help MSM access Web-based and/or offline health care services (innovation), (2) the prototype should have a user-centered design (usability), and (3) the prototype should be feasible to use (assessed based on technical feasibility, compatibility with the local context, regulations and laws, and whether the prototype could provide sustainable motivation to doctors and MSM for using the tool). Each criterion was given equal weight and was assigned a score between 0 and 10. The final score for a prototype was up to 30 points in total.

Ethical Statement

This hackathon contest was not a research activity with human subjects. Data from the event were deidentified and not considered human subjects research. All applicants to the hackathon and the final participants were required to use nicknames throughout the contest. A disclosure of what information would be requested and how the information would be used was presented to the applicant before the applicant agreed to submit the application.

Results

Participants

We received 92 applications in total. After the application screening and evaluation by the members of the steering committee, 40 finalists were invited to attend the hackathon, of which 2 applicants dropped out before the final contest because of time conflicts. We chose to limit the hackathon contest to 40 participants (8 teams) primarily for feasibility and resource considerations regarding funding, venue size, and staff capacity.

Table 1 presents the characteristics of the final 38 participants. A total of 9 participants were from Guangzhou and Shenzhen in Guangdong Province. Moreover, 5 participants were from Beijing, and 5 participants were from Shanghai. In addition, 33 of 38 (87%) participants were men. Furthermore, of the 48 participants, 24 (64%) self-identified as gay, 3 identified as bisexual, and 8 identified as heterosexual. Participants’ age ranged from 18 to 39 years, with 58% (22/48) of the participants aged between 18 and 23 years, with a median age of 23 years. Participants had diverse disciplinary backgrounds, including computer science (15/38, 40%), user interface/graphic design (11/38, 29%), clinical (5/38, 13%), business (4/38, 11%), and public health (15/28, 38%). Half of the participants had never participated in any MSM-related events or contests before.

Final Products

All 8 teams developed a prototype tool by the end of the 72-hour contest. A total of 4 prototypes were designed as a mini program that could be embedded within a popular Chinese social networking app, and 3 prototypes were designed as stand-alone mobile apps. Moreover, 1 prototype adopted a more flexible structure that could be adjusted to multiple platforms, including webpages, mini programs, and/or built-in app functions. Some common functions across all the prototypes include Web-based doctor searching based on one’s location (8 prototypes), health education (4 prototypes), Web-based health counseling with providers or lay health volunteers (6 prototypes), appointment scheduling (8 prototypes), and between-user communication (2 prototypes). All 8 prototypes included some designs of user privacy protection through offering anonymous counseling for both MSM and/or provider users

A total of 4 out of the 8 prototypes were selected as the finalists by the multidisciplinary judge panel based on the prototype’s innovation, usability, and feasibility (see Table 2 for detailed descriptions of the strengths and weaknesses of the first 4 prototypes). The prototype of the first prize winner (group 1) was designed as a cross-device Web-based platform that aims to recruit junior physicians and trained health counseling volunteers to provide Web-based text-based counseling services to MSM. It proposed multiple motivation strategies for physician engagement, such as MSM-friendly service trainings, continuation of medical education credit, and payment and bonus sharing mechanisms. At the same time, it allowed MSM users to start with a free trial period and then transition to fee-based services. The prototype of the second prize winner (group 2) integrated professional psychological counseling, peer support, and daily mood tracking into a single stand-alone app, which offers functions such as location-based physician recommendations, Web-based one-to-one counseling, and anonymous peer communication channel for social support.

The third prize winner (group 3) proposed a stand-alone app with a comprehensive range of functions, including Web-based counseling, referral, or appointment setting to offline health services, artificial intelligence–enabled dermatology assessment, health education, health self-management, and a search function for nearby physicians and MSM health-related volunteers. The fourth prize winner (group 4) designed a mini program embedded within a gay social networking app, including functions such as Web-based physician counseling, medical record and medication management, health education with MSM voluntary advisors, and HIV testing promotion through disbursing free testing toolkits. The remaining 4 prototypes (detailed descriptions are available in Multimedia Appendix 2) shared similar primary functions such as physician listings based on one’s location and Web-based counseling or making an appointment for offline services, but these were less responsive to MSM’s specific health needs as compared with the first 4 finalists.

After the contest, each team nominated 1 team member to be considered for an internship at Blued. These 8 nominees were then interviewed and assessed based on their professional background, performance at the contest, and other eligibility criteria (eg, time conflicts or noncompete clause). Ultimately, 5 nominees were selected by Blued for internships. Furthermore, the final 4 selected prototypes were all presented to Blued and were under technical review. A pilot study has been planned to test the acceptability and feasibility of the prototype of fourth prize winner (group 4) in an urban-based setting in central China.

Discussion

Principal Findings

Our hackathon event represents an innovative approach to engage multiple stakeholders to develop mHealth interventions. This hackathon event brought together diverse individuals to generate 8 complete prototypes that could help MSM access local health services. The major functions that were found innovative and responsive to MSM’s specific health needs include Web-based counseling and appointment for offline services, provider training, engagement of MSM volunteers or peer support, and user’s privacy considerations. This paper extends our knowledge in health intervention tool development for MSM by accelerating the translation of innovative intervention ideas from research findings to real-world application in middle-income settings such as China, thereby raising public awareness about the challenges faced by MSM in accessing health care services and engaging multiple community stakeholders in the health promotion process.

A Crowdsourcing Approach to Empower Community

Hackathons are a feasible approach to create tailored health interventions for marginalized populations such as MSM. Although the penetration rate of smartphones keeps rising in low- and middle-income countries where there are large numbers of sexual minorities [18], only a few interventions have incorporated the wisdom of MSM crowds into interventions [14]. Hackathons offer a platform for accelerating the development of digital solutions with input from multiple stakeholders, which could empower MSM communities and ultimately result in more effective interventions. Furthermore, a conventional public health intervention development process typically includes slower evolution from formative research to intervention design, pilot testing in a controlled environment, and eventual implementation [19]. In contrast, the hackathon approach bridges the gap among researchers, technology experts, and potential beneficiaries, while accelerating the translation of research-driven ideas into real-world solutions.

Hackathons may help to improve MSM community engagement in public health promotion. All 4 finalists focused on mobilizing MSM community resources through employing MSM as paid lay health advisors or unpaid voluntary peer supporters. This study provides a participatory approach to redress power imbalances among community, research, and technology partners. Previous mHealth interventions for HIV care services among MSM in Chinese settings were mainly delivered to MSM via preprogrammed messages or direct individual communication between MSM and trained interventionists, with little community mobilization [3,20,21]. Although 1 Web-based intervention with a component of peer support feature was found effective in promoting HIV testing among Chinese MSM in Chengdu, the selection and training of peers were still mainly driven by academic experts without sufficiently empowering the community to help identify and mobilize potential resources [2]. Even within the global literature, community mobilization has been traditionally used for developing in-person health interventions in low- and middle-income settings rather than being used for developing mHealth tools [22-24]. With the growth of digital health solutions, our project provides an innovative example of how to use hackathons as an effective and convenient way to mobilize MSM communities in generating mHealth solutions to meet their own health needs, which could further potentially reduce external stigma and self-stigma against sexual minority populations.

We found that all prototypes had a range of tools to safeguard MSM users’ privacy, such as anonymous counseling, anonymous peer communication, and Snapchat messages, which allows MSM users to individualize account settings according to their perceived risk of breaching privacy. Formative research findings suggest that Chinese MSM prefer not to include any HIV- or gay-related identification in the appearance of mHeath intervention designs to avoid unintended disclosure of sexual orientation or HIV status [25]. A study found that including a feature of between-user communication is not universally accepted as some MSM perceived that such virtual relationships may exacerbate one’s social isolation in real life [26].

Limitations

There are several limitations worth noting. First, this paper is a descriptive report of the hackathon’s process and results. The winning prototypes were chosen but not yet tested in real-world settings. Although we collected and analyzed all judges’ written comments on all final prototypes, we do not have robust qualitative or quantitative assessment data to comprehensively evaluate the 8 final prototypes. Second, the experience of a single hackathon within a single location, although the teams came from diverse backgrounds and geographic regions, may not reflect the diverse needs of MSM in China or elsewhere. Generalizing these findings to other settings should be done with caution. However, this paper breaks new ground in organizing and reporting hackathon events for mHealth intervention development in middle-income settings (advice for future events is reported in Textbox 2), which can help to set a solid foundation for future explorations.

Conclusions

Hackathons are a feasible approach to engage multiple community stakeholders in generating mHealth interventions. Similar community-based mHealth intervention development approaches could be used in other settings. More research is needed to evaluate the public health impact of the interventions.