Sexual health among older adults in China and the United Kingdom: A multi-disciplinary study

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Infectious and Tropical Diseases

Abstract

People who lived beyond the age of fifty years were uncommon in the mid-1800s. Remarkable advances in medicine have created substantial demographic changes, resulting in larger numbers of older adults, defined in this application as 50 years and older. This greying of the world's population has important implications for sexual health. An increasing number of older population sustain vibrant sexual lives and intimate relationships for a long period, needing support and medical advice on optimizing their sexual health. At the same time, a range of related frailties and disabilities alongside power imbalances may increase the risk of unprotected sex and HIV/sexually transmitted infections among some older adults. Sexual health is an increasingly important topic among elderly individuals across the world, but our conventional disciplinary approaches shy away from the topic. Much of the sexual health research has focused on youth, ignoring the tremendous demographic changes underway and incorrectly assuming that "age is a condom." Our UK-China joint team has a rich experience in behavioural science, sociology, anthropology, medicine, and public health. The common greying of the population in the UK and China demands innovative solutions to identify needs and barriers relevant to sexual health and gaps in sexual health services and ensure that they are inclusive, empowering, and reliable. Leveraging our multi-disciplinary team, we propose the following specific aims:

Aim 1: Using an epidemiological study to understand sexual health and wellbeing among older adults in China, in comparison to existing data from National Survey of Sexual Attitudes and Lifestyles (NATSAL 3) in the UK.

Aim 2: Determine preferences for sexual health services among diverse older adults, using discrete choice experiments (DCEs).

Aim 3: Identify high-quality messages to promote uptake of inclusive sexual health services among older adults in China and the UK through two parallel crowdsourcing contests.

Aim 4: Create policy recommendations about how to make sexual health services more adaptive to older adults' needs and preferences in diverse settings.

DCEs are a survey-based method that quantifies participants' preferences for health care delivery, evaluating which attributes are most important to participants by observing how participants trade-off between various attributes. A crowdsourcing contest allows a group to solve a problem and then shares solutions with the wider public. Crowdsourcing interventions have successfully engaged marginalized groups in HIV testing program development, improved HIV test and condom use.

Planned Impact

The long-term outcome of our proposal is to improve sexual health outcomes for older adults by creating demand for sexual health services among older adults and developing more inclusive sexual health services that are age-appropriate in both the United Kingdom and China, accommodating people with disabilities. The World Health Organization has defined sexual health as "a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence." Our project will contribute to the attainment and maintenance of sexual health which is fundamental to the overall health and well-being of individuals (Sustainable Development Goals 3, or SDG 3), reduce inequality (SDG 10) between older and younger generations and help bridge gaps in sexual health among people with disabilities, and international partnerships using a multidisciplinary approach (SDG 17).

The project grant will allow us to achieve our short-term outcomes in generating evidence in older adults' sexual health, wellbeing and needs for sexual health services. Through our proposed DCE surveys and crowdsourcing contests, we will determine preferences for sexual health services and identify locally appropriate solutions for designing tailored campaigns to create demand and meet older adults' needs leading to our ultimate aim of improved health outcomes. Our project will also create policy impact by engaging multiple key stakeholders in multiple stages of the project, such as local leaders and/or think tanks in public health policy changes, advocates and community representatives, research experts in multiple disciplines. Crowdsourcing in particular holds potential to inform bottom-up evidence-based policy changes which can help reduce structural and systematic barriers to sexual health access for older people. Although our target population are older adults in the UK and China, our long-term outcomes would focus on developing and expanding inclusive and tailored sexual health services for older and other neglected populations in other countries to maximise the reach and impact of our work.

Our proposal provides a clear route for the project to generate impact. Our study will use a creative, participatory, multidisciplinary approach to determine gaps and solutions which will inform policy changes and future design of tailored sexual health programs for older people. First, the epidemiological survey will allow us to have a better understanding of sexual health and wellbeing among the target group, especially among older people in China and people with disabilities in both countries. Then, the DCE and crowdsourcing approaches will enable us to determine potential barriers and optimize solutions. With a strong multidisciplinary team and engagement of key stakeholders, the crowdsourcing contest can additionally serve as an effective approach to facilitate interactions and understanding between health professionals and end users by involving both groups in multiple stages of the contest. By making the exceptional crowdsourced solutions publicly available on an open access platform and mass media, the project can improve the public awareness of the importance of sexual health among older adults, help reduce the perceived embarrassment or stigma about discussing the topic, and potentially increase public acceptance of future sexual health campaigns tailored for older adults, leading to impact on a societal level. Finally, organizing a policy workshop with multiple key stakeholders will help open dialogues surrounding the topic between different stakeholders, and spur interest among policy makers, with the potential of creating impact on a structural or systematic level.

Publications

10 25 50
 
Description By conducting an analysis to identify unobservable subgroups among older people for their sexual lifestyle and practices, we found four latent subgroups. These are a subgroup with relatively good overall sexual health, a subgroup with infrequent sex, a subgroup who had a low sexual function score, and a subgroup who reported multiple partners and unsafe sex practices. Better understanding these subgroups will help us to tailor sexual health services for older people in the UK.
Exploitation Route These results will help inform the design of our subsequent research activities including the qualitative study and questionnaire survey development of the DCE to identify older people's sexual health services seeking preferences.
Sectors Communities and Social Services/Policy,Healthcare

 
Title Development and refinement of a Chinese sexual health survey instrument 
Description The LSHTM and China teams have developed and refined a Chinese sexual health survey instrument based on the NATSAL 3 questionnaire for the epidemiological survey in China. 
Type Of Material Improvements to research infrastructure 
Year Produced 2021 
Provided To Others? No  
Impact Our China team is now carrying out data collection using the instrument in Guangzhou city and will also collect data in Shanghai, Chongqing and Tianjin. 
 
Title Latent class analysis 
Description Latent class analysis was used in our study to identify subgroups of older people related to sexual health characteristics. This method uses responses to survey questions in order to create new subgroups. 
Type Of Material Data analysis technique 
Year Produced 2021 
Provided To Others? No  
Impact Our analyses extend the literature by examining sexual lifestyle and sexual health outcomes, identifying four new subgroups among older adults in Britain. These subgroups were good sexual health group, infrequent sex group, low sexual function score group, and multiple partners group. Many older adults remained sexually active and healthy overall. The identification of these subgroups can help tailor future sexual health programs for older adults with different sexual health needs. 
 
Description Multi-disciplinary collaboration 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Department Department of Global Health and Development
Country United Kingdom 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Multi-disciplinary collaboration 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Department International Centre for Evidence in Disability
Country United Kingdom 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Multi-disciplinary collaboration 
Organisation Monash University
Country Australia 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Multi-disciplinary collaboration 
Organisation Sun Yat-Sen University
Country China 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Multi-disciplinary collaboration 
Organisation University of North Carolina at Chapel Hill
Department Gillings School of Global Public Health
Country United States 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Multi-disciplinary collaboration 
Organisation Xi'an Jiaotong Liverpool University 
Country China 
Sector Academic/University 
PI Contribution The LSHTM team has obtained the dataset, technical report, questionnaires, and the codebook of NATSAL 3 for secondary data analyses via the open data repository UK Data Service (https://beta.ukdataservice.ac.uk/myaccount/login?referrer=%2fmyaccount). The team recently completed a latent class analysis to identify subgroups of older people. Our latent class analysis identified four distinct groups of older people including the good sexual health subgroup, infrequent sex subgroup, low sexual function score subgroup, and multiple partners subgroup. We have drafted a manuscript which will be submitted to an international peer-reviewed journal. These results will also inform the subsequent discrete choice experiment study. The team is designing the discrete choice experiments to better understand older adult preferences for sexual health services. Regarding training activities, we recruited two public health students as winter interns with statistical expertise to help with the project. Dr Dan Wu has been mentoring these two students and provided guidance since the launch of the project. These two students have made wonderful contributions to data analyses and manuscript writing.
Collaborator Contribution Sun Yat-Sen University (SYSU) team has been preparing and adapting a sexual health survey instrument using the questionnaire from NATSAL 3. The LSHTM and SYSU teams have been working together to design and hone the instrument since the launch of the project. We have completed the development of a Chinese survey instrument and a pre-test for face- and content validity. Culturally and contextually appropriate amendments were made based on respondents' feedback. The recruitment of respondents commenced in late March 2021 in Guangzhou and they will also collect data in Shanghai, Chongqing, and Tianjin. Our external consultants Drs Jason Ong from Monash University and Stephen Pan from Xi'an Jiaotong University are helping us design the discrete choice experiment (Aim 2) as well as prepare a protocol for IRB application at the LSHTM. Both of them were involved in this project since the launch and attending regular work meetings to provide feedback to our data analyses and questionnaire development. Dr Weiming Tang from UNC Project China will help design and implement the crowdsourcing contests (Aim 3) in both the UK and China and he has been participating our regular work in progress meetings since the launch.
Impact We assembled a multi-disciplinary team that includes Dr. Clare Tanton from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) team, Drs Hannah Kuper and Tom Shakespeare from the International Centre for Evidence in Disability (ICED) of LSHTM, Drs Weiming Tang, an epidemiologist with rich experience of organizing crowdsourcing events, and Suzzane Day, a global public health researcher, from UNC-Chapel Hill, Dr Huachun Zou in public health research in sexuality from Sun Yat-Sen University, Dr Jason J Ong, an experienced health economist from Monash University, Dr Stephen Pan, a DCE research expert with rich research experiences in China from Xi'an Jiao Tong Liverpool University.
Start Year 2020
 
Description Informally interviewing potential respondents for feedback on sexual health issues 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Given the sensitivity of the topic, we have approached more than 50 older adults in community-based facilities including community health organizations, senior centers etc to pre-test the acceptability of the questionnaire content and subsequent research activities.

We have also examined potential community partners for the qualitative research, DCE, and crowdsourcing activities, ie, civil society groups focused on older people, especially those with disabilities in the UK. The group has found several potential ones and determined to start with Age UK, the leading charity for older people, which is an established connection of Drs Hannah Kuper and Tom Shakespeare.

For subsequent DCE and crowdsourcing activities, we are convening a community advisory board that would review our plans every 6 months. This could include people with disabilities, older people, and help provide input.
Year(s) Of Engagement Activity 2020,2021