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

Abstract

Sexual health is an essential component of overall well-being, yet it is a neglected aspect of health care for older women in China, where cultural stigmas and structural barriers limit access to sexual health communication and services. This study protocol describes the co-creative and iterative methodological framework used to develop an evidence-based online intervention tailored to the sexual health needs of Chinese older women. The research follows a multi-phase approach that begins with a systematic literature review to consolidate key intervention strategies and is followed by co-design and iterative focus group sessions involving older women, their family members, healthcare providers, and digital platform developers. A WeChat mini-application is proposed as the digital intervention platform that can incorporate interactive learning modules, anonymous peer-support forums, and culturally adapted content. The intervention framework is evaluated using qualitative research methods including thematic analysis of focus group discussions and iterative refinement through SMART principles. This study contributes to health communication and digital intervention research on social problems in the context of digital intellectual social development by providing a structured, user-centered approach that bridges the gap between theoretical knowledge and practical application. Findings from this research will inform the development of scalable, culturally sensitive digital interventions that address critical gaps in sexual health education and access.

Keywords

sexual health older Chinese women digital health intervention co-design and iterative qualitative methodology health communication

Introduction

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.

Aims

The study that will employ this methodological framework aims to develop an evidence-based, culturally sensitive online intervention to promote the sexual health of older Chinese women. By systematically reviewing existing literature and engaging diverse Chinese stakeholders—including older women, healthcare professionals, policymakers, and digital technology experts—this research seeks to design and refine a WeChat-based sexual health intervention. Utilizing a co-design and iterative qualitative approach, coupled with rapid qualitative analysis and the SMART principles, the study aims to create an actionable, targeted, adaptable, and user-centered intervention framework that effectively addresses the sexual health needs of older Chinese women.

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.

Figure 1.

An Evidence-Based Qualitative Methodological Framework for Front-End Intervention Research and Design (adapted from He, 2024; He et al., Forthcoming).

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).

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)

Materials and Methods

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.

(2) Stakeholders: Health communication practitioners, Social workers, healthcare professionals, government administrators, and IT developers specializing in WeChat and AI. To contribute medical and technical expertise.

(3) Family Members: To provide additional context on the social dynamics influencing the sexual health of older Chinese women.

Inclusion Criteria of Older Chinese Women

Participants must be Chinese women aged 60 and above, residing in China, and capable of providing informed consent. Familiarity with basic digital tools (e.g., WeChat) is preferred but not mandatory, as technical support will be available.

Exclusion Criteria of Older Chinese Women

Individuals with severe cognitive impairments that prevent meaningful participation or those unwilling to engage in discussions about sexual health will be excluded.

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.

The Practice Phase: Co-Creative and Iterative Design

In this phase, the intervention framework will be developed using co-creative and rapid iterative design method to create a culturally relevant, technically feasible, and adaptable framework. Stakeholders will collaboratively design the intervention through a series of activities including brainstorming sessions, prototype testing, and feedback loops.

The In-Practice Phase 1: Multi-Stakeholder Rapid Qualitative Analysis

This phase will involve focus group discussions with older women, family members, counselors, and developers to gather diverse perspectives on the content and functionality of the intervention. Thematic analysis will be conducted to identify key themes related to psychological support, privacy, and user engagement. Feedback from these sessions will inform iterative refinements of the WeChat mini-application to meet the complex needs of the target population.

The In-Practice Phase 2: Situational Analysis and Dynamic Adjustments

Another round of focus group discussions with stakeholders following SMART principles will be held to gather feedback on the updated intervention. Guided by SMART principles, a situational analysis will also be conducted to evaluate the intervention’s effectiveness and adaptability. Each module will be evaluated using structured criteria, and rapid feedback cycles will enable continuous improvements. This process will support the flexibility, sustainability, and responsiveness of the mini-application to the evolving needs of older Chinese women regarding their sexual health.

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.

• Step 2 Initial Coding – Key data segments relevant to the research questions will be coded using NVivo. A shared codebook will document all coding decisions, ensuring consistency across researchers.

• Step 3 Theme Identification – Codes will be grouped into broader themes that reflect key concepts emerging from the data. Mapping tools within NVivo will assist in visually representing relationships between themes.

• Step 4 Refinement and Review – The identified themes will be refined through iterative discussions among the research team. Any discrepancies in coding will be addressed through consensus-building sessions.

• Step 5 Data Interpretation and Reporting – The final themes will be synthesized into a structured narrative supported by participant quotations. The findings will be contextualized within the existing literature to highlight their relevance for sexual health interventions among older Chinese women.

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.

Results and Discussion

Recruitment for the qualitative phases will begin in April 2025, with intervention recruitment scheduled for August 2025. Data collection and analysis are expected to conclude by November 2025. The findings from the co-design and iterative process will be published in 2026.

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.

Conclusion

This study highlights the need for accessible and culturally relevant digital sexual health interventions to be designed for older Chinese women. Using the “theory–practice–in-practice” framework described in this article will ensure that the secure and interactive WeChat mini-application developed to meet this need integrates evidence-based approaches with real-world user insights and is sustainable and scalable.

Footnotes

ORCID iD

Yu Hu

Author Contributions

FuLi Wang and Yu Hu conceived and designed the research. FuLi Wang conducted literature search; FuLi Wang and Yu Hu selected the final articles. FuLi Wang extracted the themes and wrote introduction, results, discussion, and conclusion sections; Yu Hu extracted relevant quotes and wrote the methods section draft and parts of the limitation.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data Sharing not applicable to this article as no empirical data were generated or analysed during the current study.*

References

Bauer

Haesler

Fetherstonhaugh

(2016). Let’s talk about sex: Older people’s views on the recognition of sexuality and sexual health in the health-care setting. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 19(6), 1237–1250. https://doi.org/10.1111/hex.12418

Biancalani

Orkibi

Keisari

(2023). The life stories of older gay men in Italy and their response to a tele-drama-based intervention: A qualitative study protocol. International Journal of Qualitative Methods, 22(2), 16094069231221368. https://doi.org/10.1177/16094069231221368

Binfa

Robertson

Ransjö-Arvidson

A.-B.

(2009). Chilean women’s reflections about womanhood and sexuality during midlife in a Swedish or Chilean context. Health Care for Women International, 30(12), 1093–1110. https://doi.org/10.1080/07399330903276777

Birtwell

Morris

Armitage

C. J.

(2022). Combining timelining and storyboarding to create a novel method for INtervention DesIGn with stakehOlders: INDIGO. International Journal of Qualitative Methods, 21(1), 16094069221127147. https://doi.org/10.1177/16094069221127147

Bokaie

Hejazi

N. S.

Jafari

Shabani

(2023). Effect of online solution-focused counseling on the sexual quality of life of women with a history of breast cancer: A clinical trial. BMC Women's Health, 23(1), 326. https://doi.org/10.1186/s12905-023-02468-z

Braun

Clarke

(2021). Thematic analysis: A practical guide.

Chen

(2024). Empower your wellness: Setting SMART goals to live healthy in the digital age. Journal of Disease Prevention and Health Promotion, 8(4), 5–8.

Deng

Rogers

Naslund

J. A.

(2023). The role of moderators in facilitating and encouraging peer-to-peer support in an online mental health community: A qualitative exploratory study. Journal of Technology in Behavioral Science, 8(2), 128–139. https://doi.org/10.1007/s41347-023-00302-9

Denniss

Lindberg

McNaughton

S. A.

(2022). Development of principles for health-related information on social media: Delphi study. Journal of Medical Internet Research, 24(9), Article e37337. https://doi.org/10.2196/37337

10.

Eleuteri

Toso

(2023). How the smartphone apps can improve your sexual wellbeing. International Journal of Impotence Research, 36(7), 1–5. https://doi.org/10.1038/s41443-023-00730-4

11.

Fathalian

Lotfi

Faramarzi

Qorbani

(2022). The effect of virtual cognitive-behavioral sexual counseling on sexual function and sexual intimacy in pregnant women: A randomized controlled clinical trial. BMC Pregnancy and Childbirth, 22(1), 616. https://doi.org/10.1186/s12884-022-04932-4

12.

Fileborn

Lyons

Heywood

Hinchliff

Malta

Dow

Brown

Barrett

Minichiello

(2017). Talking to healthcare providers about sex in later life: Findings from a qualitative study with older Australian men and women. Australasian Journal on Ageing, 36(4), E50–E56. https://doi.org/10.1111/ajag.12450

13.

Foley

(2015). Older adults and sexual health: A review of current literature. Current Sexual Health Reports, 7(2), 70–79. https://doi.org/10.1007/s11930-015-0046-x

14.

Gewali

Lopez

Dachelet

Healy

Jean-Baptiste

Harridan

Evans

Unger

J. A.

Bhat

Tandon

others . (2021). A social media group cognitive behavioral therapy intervention to prevent depression in perinatal youth: Stakeholder interviews and intervention design. JMIR Mental Health, 8(9), Article e26188. https://doi.org/10.2196/26188

15.

Gillespie

B. J.

(2017). Correlates of sex frequency and sexual satisfaction among partnered older adults. Journal of Sex & Marital Therapy, 43(5), 403–423. https://doi.org/10.1080/0092623X.2016.1176608

16.

(2024). Intervention design of an AI + palliative care social work wechat APP. Journal of East China University of Science and Technology, 39(6), 27–44.

17.

Xia

Liu

Guyatt

G. Y.

(Forthcoming). An evidence-based qualitative methodological framework for intervention design for cancer survivors care: Empirical insights from AI+ WeChat mini-application development. Asia Pacific Viewpoint.

18.

Hinchliff

Lewis

Wellings

Datta

Mitchell

(2021). Pathways to help-seeking for sexual difficulties in older adults: Qualitative findings from the third national survey of sexual Attitudes and Lifestyles (Natsal-3). Age and Ageing, 50(2), 546–553. https://doi.org/10.1093/ageing/afaa281

19.

P. J.

Goh

Y. S.

(2022). Health care professionals and care staff challenges and experiences of managing sexual expression among older adults≥ 60 years in long-term care facilities: A qualitative review and meta-synthesis. Age and Ageing, 51(1), afab230. https://doi.org/10.1093/ageing/afab230

20.

Hughes

A. K.

Lewinson

T. D.

(2015). Facilitating communication about sexual health between aging women and their health care providers. Qualitative Health Research, 25(4), 540–550. https://doi.org/10.1177/1049732314551062

21.

Kadri

Alami

K. M.

Berrada

(2010). Sexuality in Morocco: Women sexologist’s point of view. Sexologies, 19(1), 20–23. https://doi.org/10.1016/j.sexol.2009.03.005

22.

Kowalski

Finnes

Koch

Bujacz

(2024). User engagement with organizational mHealth stress management intervention–A mixed methods study. Internet Interventions, 35(1), 100704. https://doi.org/10.1016/j.invent.2023.100704

23.

Maasoumi

Sabetghadam

Keramat

Talebi

S. S.

Aghayan

S. S.

(2024). The Effect of a mobile app-based psychosexual intervention on promoting help-seeking behaviors for sexual health issues among Iranian newly married women: A randomized controlled clinical trial. Sexuality Research and Social Policy, 21(1), 465–475. https://doi.org/10.1007/s13178-023-00886-0

24.

Malloy

J. A.

Partridge

S. R.

Kemper

J. A.

Roy

(2024). Co-designing a social media health promotion for young women: A study protocol. International Journal of Qualitative Methods, 23(3), 16094069241230413. https://doi.org/10.1177/16094069241230413

25.

Malta

Temple-Smith

Hunter

McGavin

Lyne

Bickerstaffe

Hocking

(2018). Could an online or digital aid facilitate discussions about sexual health with older Australians in general practice? Australian Journal of General Practice, 47(12), 870–875. https://doi.org/10.31128/AJGP-04-18-4557

26.

Milne-Ives

Homer

S. R.

Andrade

Meinert

(2023). Potential associations between behavior change techniques and engagement with mobile health apps: A systematic review. Frontiers in Psychology, 14(4), 1227443. https://doi.org/10.3389/fpsyg.2023.1227443

27.

Minichiello

Rahman

Hawkes

Pitts

(2012). STI epidemiology in the global older population: Emerging challenges. Perspectives in Public Health, 132(4), 178–181. https://doi.org/10.1177/1757913912445688

28.

Nash

Willis

Tales

Cryer

(2015). Sexual health and sexual activity in later life. Reviews in Clinical Gerontology, 25(1), 22–30. https://doi.org/10.1017/S0959259815000015

29.

Nelligan

R. K.

Hinman

R. S.

Atkins

Bennell

K. L.

(2019). A short message service intervention to support adherence to home-based strengthening exercise for people with knee osteoarthritis: Intervention design applying the behavior change wheel. JMIR mHealth and uHealth, 7(10), Article e14619. https://doi.org/10.2196/14619

30.

Nyalela

Dlungwane

(2023). Men’s utilisation of sexual and reproductive health services in low-and middle-income countries: A narrative review. Southern African Journal of Infectious Diseases, 38(1), 473. https://doi.org/10.4102/sajid.v38i1.473

31.

Parker

Scott

Geddes

(2019). Snowball sampling. Sage Research Methods Foundations.

32.

Peng

Wang

Sun

Tucker

J. D.

Tang

Zou

(2024). Sexual attitudes and utilization of sexual and reproductive health services among older women in southern China: A qualitative study. Frontiers in Public Health, 12(5), 1327734. https://doi.org/10.3389/fpubh.2024.1327734

33.

Rullo

J. E.

Sood

Fokken

S. C.

Sood

Frohmader

K. S.

Croghan

I. T.

Schroeder

D. R.

Faubion

S. S.

(2021). Couples’ use of online stress management and resiliency training for sexual health concerns: A randomized controlled trial. Sexual Medicine, 9(4), 100404. https://doi.org/10.1016/j.esxm.2021.100404

34.

Schexnayder

Perry

K. R.

Sheahan

Majette Elliott

Subramaniam

Strawbridge

Webel

A. R.

Bosworth

H. B.

Gierisch

J. M.

(2023). Team-based qualitative rapid analysis: Approach and considerations for conducting developmental formative evaluation for intervention design. Qualitative Health Research, 33(8–9), 778–789. https://doi.org/10.1177/10497323231167348

35.

Simpson

Horne

Brown

L. J.

Wilson

C. B.

Dickinson

Torkington

(2017). Old (er) care home residents and sexual/intimate citizenship. Ageing and society, 37(2), 243–265. https://doi.org/10.1017/S0144686X15001105

36.

Sinković

Towler

(2019). Sexual aging: A systematic review of qualitative research on the sexuality and sexual health of older adults. Qualitative Health Research, 29(9), 1239–1254. https://doi.org/10.1177/1049732318819834

37.

Sun

C. J.

Anderson

K. M.

Kuhn

Mayer

Klein

C. H.

(2020). A sexual health promotion app for transgender women (trans women connected): Development and usability study. JMIR mHealth and uHealth, 8(5), Article e15888. https://doi.org/10.2196/15888

38.

Sun

Shu

Zong

Mao

Sun

Hearst

(2015). Unmet sexual and reproductive health needs of women aged 50 to 64 years in rural China. Menopause, 22(5), 505–511. https://doi.org/10.1097/GME.0000000000000346

39.

Thames

A. D.

Hammond

Nunez

R. A.

Mahmood

Jones

Carter

S. L.

Bilder

R. M.

Fisher

Bivens-Davis

Jones

(2018). Sexual health behavior and mental health among older African American women: The sistahs, sexuality, and mental health well-being project. Journal of Women's Health, 27(9), 1177–1185. https://doi.org/10.1089/jwh.2017.6777

40.

Wang

Peng

Liang

Tian

Liu

Wang

Zheng

Shi

Cao

Ouyang

Wang

Tucker

Tang

Meng

Zou

(2023). Sexual well-being among older adults in China (SWELL): Protocol for a multicenter cross-sectional study. BMJ Open, 13(1), Article e067338. https://doi.org/10.1136/bmjopen-2022-067338

41.

Wang

Zhao

Xiong

Tucker

J. D.

Ong

J. J.

Hall

B. J.

Sami

Zheng

Yang

(2021). New syphilis cases in older adults, 2004–2019: An analysis of surveillance data from South China. Frontiers of Medicine, 8(1), 781759. https://doi.org/10.3389/fmed.2021.781759

42.

Wong

Olusanya

Antonini

M. V.

Lyness

(2021). The use of social media and online communications in times of pandemic COVID-19. Journal of the Intensive Care Society, 22(3), 255–260. https://doi.org/10.1177/1751143720966280

43.

Yee

L. A.

Sundquist

K. J.

(2003). Older women’s sexuality. The Medical Journal of Australia, 178(12), 640–643. https://doi.org/10.5694/j.1326-5377.2003.tb05393.x