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New South Wales. South Australia. Western Australia. Sao Paulo. British Columbia. Nova Scotia. Niagara Falls. Chaoyang District. Dongcheng East City District. Xicheng West City District.

Baoshan District. Changning District. Nanhui District. Xuhui District. Hong Kong. Hong Kong Island. Quarry Bay. Kowloon City.

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Metro Manila. Santa Cruz. Santa Mesa. Misamis Occidental. Negros Oriental. Surigao del Sur. Ang Mo Kio. Bukit Merah. Central Area. Toa Payoh. Marine Parade. Bukit Panjang. Stockholms Lan. Kaohsiung City. Taichung County. Taipei City. Taoyuan County. Taoyuan City. Bang Kapi. Qualitative data from our group has shown that crowdsourcing contests empower individuals and result in a range of positive community engagement outcomes [ 23 ].

Furthermore, two preliminary studies conducted by our team suggest crowdsourcing may overcome challenges in expanding HIV services among MSM [ 22 , 24 ].

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In the first study, a crowdsourced HIV test promotion video was developed through an open contest, with its effectiveness evaluated against a conventional social marketing video. This was similar to the testing rate observed in the group that viewed a social marketing video, but cost substantially less [ 22 ]. Results demonstrated the crowdsourced condom promotion video was non-inferior to the social marketing video and cost substantially less [ 24 ]. In addition, the effectiveness of crowdsourced interventions has not been examined in a range of local settings. Most crowdsourcing studies have been single contests that focused on generating campaign content, such as videos and posters, stopping short of designing an overall implementation plan.

Our study aims to sustain crowd contribution through an entire intervention by implementing two serial contests - a content-focused contest followed by a second design-focused contest. Results will reveal insights into qualities that are key to the success of public health interventions. The purpose of this article is to describe the design of a pragmatic stepped wedge randomized controlled trial aimed to develop and evaluate a crowdsourced intervention for promoting MSM HIV testing in China.

Our study will develop an HIV testing intervention using crowdsourcing at multiple steps to sustain crowd contribution. The crowdsourced intervention will then be implemented and evaluated using a stepped wedge, randomized controlled trial RCT design. The control condition consists of conventional campaigns that are routinely conducted by local centers for disease control CDCs and community-based organizations CBOs.

Our first aim is to compare HIV test uptake associated with a crowdsourced intervention to that associated with conventional HIV test uptake campaigns. We hypothesize that a crowdsourced intervention is superior in eliciting HIV test uptake compared to conventional HIV test uptake campaigns. Our second aim is to compare secondary outcomes including incremental cost, condom use, HIV-testing social norms, syphilis testing, etc.

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We hypothesize that a crowdsourced intervention is superior in promoting a range of healthy behaviors and HIV testing social norms. This study will use an adaptation of the stepped wedge, RCT design. In the stepped-wedge RCT, study sites are randomized to begin the intervention at different times so that by the end of the study period all sites have initiated the intervention Fig. A total of eight major metropolitan cities - four from Guangdong Province Guangzhou, Jiangmen, Zhuhai, Shenzhen and four from Shandong Province Yantai, Jinan, Qingdao, Jining - will implement the crowdsourced intervention.

These cities were chosen based on the following criteria: 1 previous CDC MSM sentinel surveillance site; 2 capacity for campaign implementation; and 3 capacity for intervention implementation at community level. Four cities Guangzhou, Shenzhen in Guangdong Province, Qingdao, and Jinan in Shandong Province will implement more intensive in-person events to promote engagement during the intervention development phase.

Intervention development and implementation are overseen by our Social Entrepreneurship for Sexual Health SESH group and are detailed in later sections.

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Schedule of enrollment, interventions, and assessments. Time schedule of preparation and intervention phases are shown.

Intervention development, online cohort recruitment, and baseline Chinese Center for Disease Control and Prevention CDC surveillance survey will take place during the preparation phase. In the intervention phase, a total of eight major metropolitan cities in China will be randomized to sequentially initiate interventions at 3-month intervals.

A secondary CDC surveillance survey will take place during the last 3-month interval. A number of factors influenced our decision to adopt a pragmatic stepped wedge, RCT design. Unlike a tightly controlled explanatory trial, a pragmatic trial evaluates an intervention in a real life context [ 25 ]. This aligns with our aim of examining whether crowdsourced interventions work in a range of local settings. A pragmatic design allows us to examine this intervention in eight different city clusters.

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The rationale for a stepped wedge cluster randomized trial allows the evaluation of the study intervention at a city-level rather than an individual level, and the random and sequential crossover of clusters from control to intervention ensures all clusters are exposed. The study design is appropriate given that the intervention draws on city-level media and programs, in addition to individual-level programs.

In addition, previous studies demonstrate that crowdsourcing can enhance HIV interventions among MSM [ 22 , 24 , 26 ]. Given that we will recruit MSM, a key population with higher risk of acquiring HIV than the general population, withholding our intervention from a subgroup of participants would be difficult.

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A stepped wedge, RCT design addresses this concern by ensuring that all participants receive the intervention and by allowing each city to serve as its own control. The eight cities are randomized to initiate intervention in groups of two at 3-month intervals Fig. The order of intervention implementation at four cities within each province Guangdong and Shandong Provinces was randomized by a researcher WMT.

He assigned each city a number; the intervention order was based on results from random number generation using the Mersenne-Twister pseudo-random number generator in SAS software. One city in Guangdong Province and one city in Shandong Province will then begin the intervention simultaneously, i. While waiting to initiate the intervention, cities will be in the control condition.

CDCs typically work with the local education department to develop educational material on HIV prevention. Educational materials are then distributed at CDC surveillance centers, where testing services are also available [ 27 ]. CBOs provide prevention-oriented outreach programs and some testing services to their target communities [ 28 ]. We will establish an online cohort and build online survey tools using Sojump Survey Software Sojump, Shanghai, China see Additional file 1 for online survey instrument.

Eligible men will be invited to join the online cohort. No names or addresses will be collected from participants. In addition to direct recruitment through websites and social media advertisements, participating individuals will be invited to refer up to three friends from their social networks within the eight cities and will receive a 10 RMB incentive for each successfully invited eligible participant.

All individuals who enroll in the study will receive a 50 RMB 8.