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

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.

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.