An Evidence-Based Co-Design and Iterative Approach to Developing an Online Sexual Health Intervention for Older Chinese Women: A Qualitative Study Protocol

Sexual Health of Older Chinese Women

The World Health Organization (WHO) defines “sexual health” as a state of physical, emotional, mental, and social well-being in relation to sexuality, rather than as merely the absence of disease, dysfunction, or infirmity. Ho and Goh (2022) contend that, among older adults in particular, sexuality plays a vital role and influences their relationships and overall quality of life and Simpson et al. (2017)make a case for supporting sexual health among older adults to benefit their overall physical and mental well-being. However, as some women age, they gradually lose interest in sexual activity and redirect their focus toward caregiving roles (Binfa et al., 2009; Kadri et al., 2010). Moreover, in heterosexual relationships, men often make key decisions regarding sexual activity that limit women’s opportunities for self-reflection and autonomy over their own sexual behavior (Sinković & Towler, 2019). Despite the personal and social influences that diminish sexual activity among women as they age, some women continue to maintain an active sex life in later years and reject the notion that older adults should be sexually inactive (Thames et al., 2018).

Engaging in sexual activity later in life presents multiple challenges, including exposure to sexually transmitted diseases (STDs). The proportion of older adults diagnosed with newly acquired STDs in China is rising (Minichiello et al., 2012; Wang et al., 2021), and the syphilis diagnosis rate among older women in China has increased significantly (Peng et al., 2024). Given the diverse sexual health needs of older women, it is crucial to focus on their sexual well-being and reduce their risk of contracting STDs.

Internationally, studies have found that the barriers older people face when trying to access sexual health services may stem from both external (institutional) and internal (personal) factors. At the institutional level, healthcare professionals may hold biases that lead them to perceive late-life sexual activity as inappropriate or assume that older adults are asexual. If older adults perceive these biases, they might internalize them and hesitate to seek medical care (Bauer et al., 2016; Fileborn et al., 2017; Hughes & Lewinson, 2015). An example of a personal factor is the finding by Thames et al. (2018)that older women tend to be more reluctant than their male counterparts to discuss sexual health issues during medical consultations.

Positive Prospects for Online Sexual Health Services

The availability of digital media technology provides a new direction for solving the above problems. One way to overcome the aforementioned barriers could be to provide online sexual health services that offer a private and secure environment where older adults can express their needs and concerns and receive timely emotional support and health education. Digital services can overcome geographical and time constraints by enabling users and their families to access relevant information and support at any stage of a given health problem. Once established, online platforms are typically more cost-effective for the patient than traditional in-person services, reducing costs associated with travel to and from and time spent in a consultation (Foley, 2015; Malta et al., 2018; Nash et al., 2015).

In recent years, researchers and organizations have begun developing online sexual health education applications for women that provide professional guidance and resource links for both service users and health communication practitioners. Internationally, several online mini-programs have been structured around sexual health services, covering topics ranging from the definition of sexual health to STDs and sexual abuse prevention (Eleuteri & Toso, 2023). However, the existing Chinese-language mini-applications are yet to be fully launched and do not entirely meet local cultural needs. Given the promise inherent in online health services and applications, the design, development, and implementation of a WeChat mini-application that can provide sexual health information, services, and resources to older Chinese women—and potentially to the broader public—holds significant practical value for advancing their sexual health and overall well-being.

Research Gap: Lack of Research Investigating Intervention Design

Most online intervention studies on women’s sexual health education utilize randomized controlled trials (RCTs) or non-randomized controlled trials to assess intervention effectiveness (Rullo et al., 2021; Sun et al., 2015). These studies, which primarily focus on evaluating the outcomes of interventions and highlighting their applications in specific health domain, often lack detailed descriptions of the design process that supported the online intervention or address the ways in which theoretical knowledge and practical experiences are translated into scientifically validated digital interventions.

Intervention design serves as a critical bridge between theoretical knowledge and practical application. In order to achieve the overall well-being of older Chinese women, current health communication intervention research must go beyond outcome measurement (i.e., back-end evaluation) and investigate the early-stage design of interventions. Since intervention design requires that theoretical knowledge and practical experience are integrated to identify and address the diverse needs of target populations, it is particularly important to set out the theoretical and methodological underpinnings to any design process (Biancalani et al., 2023; Gewali et al., 2021).

The literature identifies two primary approaches to integrating theory into intervention design. The first, which involves replicating or making minor theoretical adjustments to existing intervention frameworks, does not engage in intervention design and is therefore beyond the scope of this study. The second approach entails designing interventions based on specific theoretical models, such as the health belief model, behavior change theory, and social cognitive theory, to better align interventions with the needs of a target population (Nelligan et al., 2019). However, many studies that take this approach only partially incorporate theoretical frameworks, fail to clearly articulate how theories inform intervention strategies, and/or do not provide empirical validation. For example, Maasoumi et al. (2024) in their application of the help-seeking theory to the design of a psychosexual intervention for newly married Iranian women, did not explain how the intervention effectively promoted help-seeking behaviors within this population. In contrast to theoretical approaches, evidence-based approaches, often based on systematic reviews of established studies, generate practical guidelines for intervention design that offer scope for assessment and measurement (He, 2024).

Just as a review of the literature has identified two approaches for integrating theory, two primary qualitative methodological approaches to the design of interventions tailored to specific contexts and target populations have been found to exist. The first is co-creative intervention design, a method which emphasizes collaboration and participation. In this approach, researchers, service users, and stakeholders work together to obtain real-world feedback on the WeChat mini-program to increase the likelihood that interventions are more targeted and practical. Studies by Kowalski et al. (2024) and Milne-Ives et al. (2023)highlight the importance of user participation in designing effective interventions. The integration of both theoretical and empirical insights gained through the collaborative co-creative intervention design approach enhances the scientific rigor, effectiveness, and practicality of interventions.

The second approach, which emphasizes flexibility and continuous improvement, is iterative design, a method that involves rapid prototyping and small-scale pilot testing so that the design team can identify issues early and refine the design accordingly. Doing this facilitates the intervention’s overall effectiveness and feasibility. Schexnayder et al. (2023)successfully applied this iterative design method in the early stages of intervention research to quickly generate reliable results. By enabling researchers to refine interventions through continuous testing and evaluation, the iterative approach also increases their adaptability across different contexts.

Iterative intervention design commonly employs the SMART principles (Specific, Measurable, Achievable, Relevant, Time-bound) to assess project feasibility and other key characteristics. Chen (2024)argues that, by establishing concrete, detectable, and fixed-term objectives, researchers can more effectively design, implement, and evaluate interventions. Additionally, the SMART principles provide structured goals and evaluation criteria that can clarify the roles and responsibilities of multiple stakeholders in co-designing interventions.

Each of these approaches has unique strengths. Integrating both co-creative and iterative methods can establish a comprehensive methodological framework, referred to in this study protocol as an evidence-based qualitative co-design and iterative qualitative method, that effectively bridges the gap between theoretical knowledge and practical intervention design.

Methodological Framework

This study adopts an evidence-based qualitative methodological framework developed by Longtao He (as shown in Figure 1, adapted from He, 2024; He et al., Forthcoming) that will provide both theoretical insights and practical guidance for designing sexual health interventions tailored to older Chinese women. By integrating validated practice guidelines and co-creative, stakeholder-driven design methods, this innovative framework blends scientific rigor with practical complexity and enhances both methodological soundness and responsiveness to diverse user needs (Birtwell et al., 2022; Schexnayder et al., 2023). It follows a “theory–practice–in practice” approach that will establish the intervention based on guidelines set out as a result of a review of the literature and then refines it through empirical research and multi-stakeholder feedback to ultimately establish a dynamic, adaptable model for online sexual health services for this specific population. Beyond its ability to inform the design of a tool to provide sexual health care to older Chinese women, the framework’s cultural adaptability and technical sustainability make it a scalable, evidence-based tool for diverse digital interventions.OPEN IN VIEWER

Summary of the Four Study Phases

The initial phase of the study, which was completed in Feb 2025, involved conducting a systematic review of both international and domestic literature, focusing on interventions that address the psychological, social, and physiological sexual needs of older Chinese women and present relevant recommendations. By integrating global best practices, the researchers formulated a preliminary set of guidelines to serve as a foundation for the development of a WeChat mini-application that caters to the unique sexual health needs of older Chinese women. Throughout this phase, the researchers carried out careful evaluation and refinement of the theoretical framework to ensure its scientific rigor and practical relevance.

In the second phase, the framework for sexual health interventions will be developed using co-creative and rapid iterative design methods. This approach will integrate Chinese cultural elements, the specific needs of older Chinese women, and global app design practices to create a framework that is both culturally relevant and technically sound. The researchers will carefully consider cultural complexity and user requirements to ensure the design of sexual health WeChat mini-program aligns with local practices and is adaptable.

The third phase will involve rapid qualitative analysis of discussions with multiple stakeholders, including older Chinese women, their families, counselors, and developers, through focus group discussions (Schexnayder et al., 2023). Participants in these discussions will provide critical feedback on intervention content and relevant functions, and the findings that emerge through the thematic analysis of their feedback will inform further design enhancements.

In the fourth phase, situational analysis and dynamic adjustments guided by SMART principles will be applied through another round of focus group discussions to further develop the mini-application to address the personalized needs of older Chinese women in regard with sexual health (Wong et al., 2021). The use of the SMART framework in this round of discussions will facilitate structured evaluation of each module, and rapid feedback cycles will enable continuous refinement; both approaches will serve to enhance both the flexibility and the sustainability of the mini-application.

Details of Phase One: Online Intervention Guideline for Sexual Health Among Older Chinese Women

To develop a comprehensive guideline for an online intervention program aimed at promoting sexual health among older Chinese women, relevant existing literature for review was identified through a systematic search strategy designed for both English and Chinese academic platforms. English-language databases such as PubMed, Web of Science, Scopus, PsycINFO, CINAHL, and Google Scholar were utilized, and search terms like “sexual health,” “older women,” “China,” “online intervention,” and “digital health promotion” were employed. Simultaneously, Chinese databases CNKI (中国知网), Wanfang Data (万方数据), VIP (维普), and SinoMed (中国生物医学文献数据库), were searched using relevant Chinese terms such as “老年女性,” “性健康,” and “线上干预.” Inclusion criteria limited the review to studies published within the last decade that addressed online or digital interventions targeting the sexual health of older women. All relevant studies were considered, and those that were of most interest were those that featured Chinese or Asian populations. Studies were excluded if they focused on non-digital interventions, investigated unrelated populations, or exhibited poor methodological quality.

A rigorous literature quality appraisal process was employed to ensure the inclusion of high-quality studies. Using the CONSORT guidelines, quantitative studies were assessed with respect to sample size, control of confounding variables, validity, reliability of measurement tools, and statistical significance. Qualitative studies were evaluated using the Critical Appraisal Skills Programme (CASP) checklist, which emphasizes clarity of research objectives, methodological appropriateness, data analysis rigor, and credibility of findings. Systematic reviews were appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess transparency in search strategies, inclusion and exclusion criteria, and synthesis of results. Only 16 studies with clear research aims, robust methodologies, culturally relevant findings, and publication in reputable peer-reviewed journals were selected, while those with methodological weaknesses and inconclusive results as well as those that had not been subject to peer review were excluded.

Based on the findings from these 16 high-quality studies, a guideline was formulated to structure the online intervention program (see Table 1 below).

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Table 1.

Guideline for Online Intervention Program Promoting Sexual Health Among Older Chinese Women.

Component	Detailed Description	Evidence Source
Target Audience	Older Chinese women aged 60+, considering variations in urban versus rural settings, marital status, and generational beliefs about sexuality.	(Ho & Goh, 2022; Yee & Sundquist, 2003)
Intervention Format	Multi-modal approach: 1. WeChat mini-application for interactive learning modules; 2. Pre-recorded culturally relevant educational videos; 3. Anonymous peer-support forums for open discussions.	(Eleuteri & Toso, 2023; Maasoumi et al., 2024; Rullo et al., 2021; Sun et al., 2020)
Core Topics	1. Basics of sexual health and aging; 2. Safe sexual practices post-menopause; 3. Managing physical and emotional changes; 4. Partner communication and intimacy; 5. Addressing myths and misconceptions; 6. Recognizing, preventing, and responding to sexual harassment and violence; 7. Medical resources older women will feel comfortable using.	(Peng et al., 2024; Wang et al., 2023; Wang et al., 2021)
Cultural Adaptation	1. Incorporate Confucian and traditional Chinese values towards aging and sexuality; 2. Address social stigma via testimonials from respected community figures; 3. Use culturally sensitive language and imagery.	(Peng et al., 2024; Wang et al., 2023; Wang et al., 2021)
Privacy & Confidentiality	1. Ensure platform security with encrypted data protection; 2. Allow anonymous participation with pseudonyms; 3. Clear guidelines for data use and participant confidentiality.	(Bauer et al., 2016; Eleuteri & Toso, 2023; Maasoumi et al., 2024; Sun et al., 2020)
Stakeholder Involvement	1. Co-create content with older women to ensure relevance; 2. Collaborate with healthcare professionals specializing in geriatrics and sexual health; 3. Involve IT experts to support user-friendly platform design.	(He, 2024)
Evaluation Metrics	1. Pre- and post-intervention surveys measuring knowledge, attitudes, and self-confidence in sexual health; 2. Qualitative focus groups for in-depth feedback; 3. Usage analytics (login frequency, module completion rates).	(Gillespie, 2017; Hinchliff et al., 2021; Nyalela & Dlungwane, 2023; Simpson et al., 2017)
Follow-Up Support	1. Scheduled virtual counseling sessions with sexual health experts; 2. Peer support groups facilitated by trained moderators; 3. Regular content updates based on user feedback and emerging research.	(Bokaie et al., 2023; Deng et al., 2023; Fathalian et al., 2022)

Study Design

This research process consists of three key phases (Figure 1), the first one of which, “Theory”, has been completed. The dynamic and iterative nature of co-design maintains the flexibility of the study framework; it allows for adjustments as the research progresses. The process may not follow a strictly linear path, as previous phases may be revisited to refine the intervention based on new insights.

Research Sampling Strategy

In the “Practice” and “In-Practice” phases of this process, a diverse and representative sample of older Chinese women aged 60 and above will be recruited to participate in co-design focus groups. Participants will be recruited through community health organizations, online platforms such as WeChat, and networks of healthcare professionals. Advertisements will be disseminated via community bulletins, health clinics, and social media channels to ensure broad outreach. Special attention will be given to ensuring representation from both urban and rural settings, as well as from different socio-economic backgrounds. Snowball sampling whereby current participants refer others within their networks will be used to recruit additional participants if initial recruitment yields limited responses (Parker et al., 2019). Additionally, healthcare providers, social workers, government administrators, and IT professionals specializing in WeChat mini-application and AI technology will be invited to participate as stakeholders in the design process.

Data Collection and Storage

All focus groups will be conducted via Tencent and WeChat conferencing tools, with audio recordings made for transcription purposes. Transcripts will be stored in a secure, password-protected folder on a university-managed storage system, accessible only to the research team via two-factor authentication. Participants will be assigned anonymized codes to ensure confidentiality, and all identifying information will be removed during the transcription process. Screenshots of digital whiteboards and de-identified notes from the research team may also be collected for analysis. Data will be retained securely for a minimum of five years before being permanently deleted.

Data Quality Control

Verbatim transcripts will be generated from audio recordings using transcription software, and these will be manually verified to correct any software-generated errors. This dual process minimizes transcription inaccuracies and ensures data reliability. To reduce translation bias, transcripts will be reviewed by two researchers with different backgrounds (one in health communication, another in social work). To prevent potential breaches of confidentiality and to maintain data integrity, participants will not review transcripts.

Data Collection Limitations and Challenges

Potential challenges include recruitment difficulties due to the sensitive nature of the topic and potential technological barriers for older participants unfamiliar with digital tools. To mitigate these issues, recruitment efforts will include both digital and in-person strategies, and technical support will be provided to participants as needed. The research team, comprising members from diverse professional backgrounds, will work collaboratively to minimize confirmation bias and ensure the accuracy of data collection and interpretation.

Study Population

The study will involve three groups of participants the Practice and In-Practice phases:

(1) Older Chinese Women: Aged 60+, from diverse backgrounds, including urban and rural areas. To contribute lived experience.

The Evidence-Based Co-Design and Iterative Qualitative Method

The research will employ co-design focus groups and iterative feedback sessions to ensure the intervention is tailored to the needs of older Chinese women. The Theory phase has already been completed to generate the methodological framework as illustrated in Figure 1.

Outcome Measures

Given the exploratory nature of this co-design process, specific outcome measures will not be pre-defined for the early preparation phases. However, potential outcomes may include increased knowledge of sexual health, improved psychological well-being, enhanced ability to communicate with partners and healthcare providers, and higher engagement levels with the WeChat mini-application. Other possible outcomes include greater access to support services, heightened awareness and reporting of sexual harassment or violence, and positive feedback regarding the cultural relevance and usability of the intervention. Outcomes will emerge organically as the intervention evolves and finally be decided collaboratively by the researchers and the participants.

Qualitative Data Analysis

Qualitative data will be analyzed using thematic analysis, guided by the frameworks of Braun and Clarke (2021). NVivo qualitative research software will be employed for coding and developing thematic frameworks. To ensure systematic and rigorous data interpretation, the analysis process will follow the five key steps of thematic analysis set out by Braun and Clarke:

• Step 1 Data Familiarization – The research team will review the audio recordings and transcripts to gain a general understanding of the data. NVivo software will be used to generate word frequency and cloud queries to identify recurring keywords and patterns.

Ethical Considerations and Quality Assurance

Ethical approval for this study has been granted by the Institutional Review Board of Southwestern University of Finance and Economics. Given the sensitive nature of sexual health discussions involving older Chinese women, careful steps will be taken to ensure participant comfort and confidentiality. Prior to participation, informed consent procedures will clearly communicate participants’ rights, including their freedom to withdraw at any time without any penalty. To protect privacy, all collected data—audio recordings, notes, and transcripts—will be anonymized and securely stored on a password-protected university server accessible only by authorized researchers. Participants will not be required to use video during online focus groups, further safeguarding their anonymity. Additionally, due to the potential for emotional discomfort during discussions, participants will receive information about accessible psychological support services following their involvement. Small incentives, such as supermarket vouchers, will be offered as recognition for participation, with care taken to ensure they do not unduly influence participation decisions. The quality of intervention content will be assessed using the Principles for Health-Related Information on Social Media (PHRISM) framework, which evaluates factors such as accuracy, credibility, inclusivity, and visual appeal (Denniss et al., 2022).

Rigor of the Study

To ensure the rigor of this qualitative study, a structured yet flexible evidence-based methodological framework will be applied consistently throughout the research process. Data collection will involve co-design sessions and iterative focus groups to capture detailed, context-specific insights from multiple stakeholder perspectives, including older women, family members, healthcare providers, and IT experts. Transcripts will undergo careful, verbatim transcription and will subsequently be checked by multiple members of the research team to ensure accuracy and minimize errors. Data analysis will follow Braun and Clarke’s thematic analysis method, with two or more researchers independently coding the data and then collaboratively discussing and resolving any discrepancies. This iterative consensus-building approach enhances both credibility and reliability. Transparent documentation of the research process, including comprehensive coding schemes and detailed analytical notes, will be maintained to provide clarity and facilitate external validation.

Methodological Contribution to Evidence-Based Qualitative Research

For an applied discipline to develop effectively, it must ensure that knowledge production informs practice, while practice-based experiences, in turn, contribute to the advancement of knowledge. High-quality medical research, for example, can be directly translated into intervention guidelines for treatment, and robust public health research can provide the foundation for policymaking. Similarly, the outcomes associated with intervention guidelines or policies derived from clinical and practice-based research help shape subsequent intervention designs, forming a continuous feedback loop between theoretical knowledge and applied research.

As an emerging discipline, health communication intervention has continuously sought to learn from more established fields. However, direct replication of existing models does not always yield ideal outcomes, and gaps exist between theoretical knowledge and applied research that need to be bridged. Currently, intervention research in health communication largely focuses on the latter stages, evaluating, for example, overall intervention outcomes and practitioners’ reflections on intervention implementation. However, early-stage intervention design—how theoretical knowledge is translated into practical applications—has been underexplored. As a result, a fully integrated cycle between theory and practice has yet to be established in health communication interventions.Conducting in-depth research on the intervention design process itself can illuminate ways to effectively integrate existing research findings and practice-based experiences while addressing the diverse needs of service recipients in the development of targeted intervention designs (He, 2024).

A co-design approach was chosen for the development of this sexual health intervention to ensure that the final product is closely aligned with the values, experiences, and needs of older Chinese women. The iterative multi-phase framework set out in Figure 1 follows best practices in co-design and digital health interventions and allows for continuous refinement of the intervention model (Malloy et al., 2024). Given the cultural sensitivities surrounding sexual health among older Chinese women, co-design provides a mechanism to address stigmas and tailor content in a culturally appropriate manner. This approach, which maintains methodological rigor and inclusivity, can be more widely applied to the design of digital health interventions adapted to different populations. If the WeChat mini-application developed through this approach/research process proves effective, this evidence-based co-design qualitative framework can serve as a model for future digital interventions aimed at addressing stigmatized/culturally taboo health topics within marginalized or underrepresented populations.

The structured “theory–practice–in-practice” approach to intervention design set out in this framework (He, 2024) starts with a strong theoretical and empirical foundation built on existing literature, formulates an initial intervention model, and refines it through empirical research and co-design input. This iterative cycle ensures a continuous feedback loop between theoretical knowledge and practical application to provide a theoretically and empirically validated framework for the design of digital health interventions.

Qualitative Rigor

This study follows its structured evidence-based qualitative design methodology to ensure that the resulting intervention is both scientifically rigorous and user-centered. By integrating perspectives from diverse stakeholders—including older women, their family members, healthcare professionals, and digital technology developers—the intervention is designed to be comprehensive and adaptable. The research employs a mixed-methods approach, combining qualitative and quantitative evaluation tools such as outcome surveys, focus groups, and digital analytics from WeChat to comprehensively assess engagement and effectiveness.

To maintain data integrity, verbatim transcription and thematic analysis will be conducted using NVivo software, with multiple researchers involved in the coding process to minimize bias (Braun & Clarke, 2021). Ethical approval from Yunnan Minzu University and Southwestern University of Finance and Economics has been obtained, ensuring participant confidentiality and informed consent protocols are strictly followed. Additionally, the quality of the intervention’s content will be evaluated using recognized frameworks for health communication to ensure that the information provided is accurate, inclusive, and accessible.

Potential Limitations and Challenges

Conducting evidence-based qualitative research on sexual health with older Chinese women presents several challenges. Participants might not be able to openly discuss sensitive topics in online focus gropus and co-design sessions. Additionally, cultural taboos surrounding sexual health may deter some individuals from fully engaging in discussions aimed to inform intervention design. To mitigate these barriers, facilitators will employ culturally sensitive discussion techniques and offer options for anonymous participation.

Another common challenge in co-design is balancing stakeholder input while ensuring that the intervention remains evidence-based and actionable. Strategies such as structured facilitation techniques and predefined co-design objectives will be used to maintain focus and productivity during focus groups.

Researcher bias, a potential risk in qualitative studies, will be minimized through the implementation of multiple coding rounds and external validation from expert reviewers (Malloy et al., 2024).

Finally, there is a chance that the intervention will be limited to addressing the themes generated in the initial study and fail to meet as-yet-unidentified needs among Chinese older women. The iterative nature of this research allows for multiple rounds of feedback and refinement to address evolving user needs. Future scalability and adaptability to broader aging populations will be considered as part of the feasibility study which will be done in the next few months.