Digital and Out-of-Facility Care-Seeking Pathways After Acute Respiratory Infection Symptoms in China: Multicity Population-Based Cross-Sectional Study (Preprint)

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Abstract
BACKGROUND Digital technologies increasingly shape responses to acute respiratory infection (ARI) symptoms through information seeking, consultation, medication purchase, monitoring, and access to diagnostic products or services. However, how digital health engagement overlaps with in-person facility attendance and whether digital and other out-of-facility behaviors provide complementary signals for episodes that are less visible in routine facility-based surveillance remain unclear. OBJECTIVE This study estimates the distribution of ARI episodes by in-person facility attendance and digital health engagement, describes digital and nondigital out-of-facility actions and the reported ordering of these actions, and examines subgroup differences. METHODS We conducted a population-based cross-sectional survey in 11 Chinese cities using multistage stratified random sampling. Participants reported ARI symptoms within the preceding 14 days and subsequent health-related actions. The primary digital composite included online health information seeking, AI-assisted consultation, telemedicine, online medication purchase, wearable device–based self-monitoring, digitally accessed self-administered rapid antigen testing, and at-home pathogen specimen collection. Participants were cross-classified by in-person facility attendance and digital health engagement. Weighted descriptive proportions were estimated using poststratification weights, with 95% CIs calculated using Wilson score intervals based on the Kish effective sample size. Behavioral sequences were descriptively reconstructed from retrospectively reported timing of actions using 1 representative action per reported day, with adjacent-transition CIs estimated by participant-level bootstrap resampling. Modified Poisson regression with individual-level robust variance estimation was used to estimate adjusted associations with in-person facility attendance, expressed as adjusted prevalence ratios (aPRs). RESULTS Among 247,530 participants, 68,650 reported ARI symptoms. Among symptomatic participants, 19.18% (95% CI 18.87%-19.48%) reported in-person facility attendance, and 18.94% (95% CI 18.64%-19.24%) reported at least one digital health behavior. Digital health engagement without in-person facility attendance comprised 11.20% (95% CI 10.95%-11.44%) of ARI episodes, while 7.74% (95% CI 7.54%-7.95%) involved both dimensions. Digital health engagement was positively associated with in-person facility attendance during the same episode (aPR 2.12, 95% CI 2.05-2.20). Compared with participants reporting 2 or fewer symptoms, the aPRs were 3.31 (95% CI 3.16-3.46) for 3 symptoms and 4.69 (95% CI 4.51-4.88) for 4 or more symptoms. Among participants with nonempty sequences, the most common sequence beginning with an out-of-facility action was offline medication purchase followed by no subsequent reported action (6058/26,494, 22.87%). Digital health engagement was lowest among adults aged 60 years or older. CONCLUSIONS Most reported ARI episodes did not involve in-person facility attendance and may be underrepresented in routine facility-based surveillance. Digital health behaviors identified potential complementary signals for some episodes, while common pathways involving offline medication purchase suggest that pharmacy-derived data may provide additional information. These data sources require direct validation, and lower digital health engagement among older adults indicates that digital signals may not represent all population groups equally.
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