A Mixed Methods Analysis of a Pay-it-forward Gonorrhea/Chlamydia Testing Program among Men Who Have Sex with Men in China

Katherine T Li1, Wenting Huang2,3, Weiming Tang3,4,5, Feng Wu6, Yang Zhao7, Dan Wu8, Fan Yang2,3, Tiange P Zhang2,3,9, Ligang Yang5, and Joseph D Tucker4,8


1 Weill Cornell Medical College, New York, NY USA

2 Social Entrepreneurship to Spur Health (SESH) Global, Guangzhou, China

3 University of North Carolina Project-China, Guangzhou, China

4 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

5 Southern Medical University, Guangzhou, China

6 Sun Yat-sen University, Guangzhou, China

7 School of Social Science, University of Queensland, Brisbane, Australia

8 London School of Hygiene and Tropical Medicine, London, UK

9 Loyola University Stritch School of Medicine, Maywood, Illinois


Neisseria gonorrhea and chlamydia trachomatis are common among Chinese men who have sex with men (MSM), but testing rates are low. We developed a pay-it-forward program for Chinese MSM, where each man receives a free gonorrhea/chlamydia test and can then choose to donate toward testing for future participants. Pay-it-forward was previously implemented through three community-based groups in China with high rates of testing uptake and donation. This study aims to investigate the drivers of testing uptake and donation using a mixed methods approach. 


We used a sequential explanatory design to explore drivers of testing uptake and donation unique to pay-it-forward. We collected survey data on socio-demographics and perceived benefits of pay-it-forward among men offered the pay-it-forward intervention across three sites in Guangzhou and Beijing, China. We analyzed testing uptake and donations using descriptive statistics and logistic regression. We then conducted thirty semi-structured interviews with men on their motivations for participation and donation. Interview data were coded to identify themes.



301 MSM were offered pay-it-forward and 55% (165/301) received gonorrhea/chlamydia testing. 91% (150/165) donated any amount with a mean of 58.31±53.39 RMB ($8.61±7.88 USD). Getting tested was not associated with income, but donations were higher in the highest income bracket (aOR = 7.12, 95% CI = 1.61-31.52). 58% (94/162) selected “more MSM can get tested” and 54% (88/162) selected “I can help someone else” as benefits of pay-it-forward. Qualitative themes for drivers of both testing and donation supported quantitative results and included flexible pricing; generosity and reciprocity; and community identity as MSM.



Both quantitative and qualitative results suggest that this pay-it-forward program may increase MSM gonorrhea/chlamydia testing rates by reducing barriers due to cost, leveraging generosity and reciprocity, and mobilizing community altruism. Pay-it-forward may be a useful model for expanding access to sexual health services.