Construction of risky sexual behaviors intervention program for college students based on Behavior Change Wheel theory: A mixed-methods study

Abstract

Background: Risky sexual behaviors (RSBs) among college students pose a substantial threat to both physical and mental health and are associated with sexually transmitted infections and unintended pregnancies. However, many existing interventions demonstrate limited sustainability in achieving lasting behavioral change. Objective: This study aimed to develop a theory-driven, evidence-based intervention program to reduce RSBs among college students in China.
Study design: A sequential mixed-methods study design was employed.
Methods: Program development was guided by the Behavior Change Wheel (BCW) and conducted in two phases. Phase 1 involved developing a preliminary intervention draft informed by a systematic literature review and semi-structured interviews with college students who reported RSBs, with the aim of identifying barriers and facilitators mapped to the Capability, Opportunity, Motivation-Behavior (COM-B) model. Phase 2 consisted of a two-round Delphi consultation with multidisciplinary experts to evaluate and refine the program. Data were analyzed using thematic analysis and descriptive statistics, including the authority coefficient and Kendall’s coefficient of concordance (W).
Results: The literature review identified 1893 records, of which 21 studies were included in the synthesis. Fifteen students participated in qualitative interviews, generating three themes and eight subthemes that mapped directly onto COM-B components. Thirteen experts completed both rounds of the Delphi consultation, yielding a 100% response rate and a high authority coefficient (Cr = 0.819). Kendall’s W increased from 0.313 (Round 1) to 0.437 (Round 2; P < 0.05), indicating improved consensus. The finalized intervention program comprises six primary indicators (COM-B domains), 12 secondary indicators (intervention functions), and 39 tertiary indicators (specific activities). The program is delivered as a six-week, group-based peer intervention (90 min per week), integrating education, skills training, and environmental restructuring.
Conclusions: A theory- and evidence-informed intervention program targeting RSBs among Chinese college students was developed and refined through expert consensus. The program provides a structured blueprint for potential implementation in university settings; however, its feasibility, acceptability, and effectiveness should be examined in future pilot and evaluation studies.

Keywords

Risky sexual behaviors / Intervention program / College students / Behavior Change Wheel / COM-B model / Mixed-methods

CRediT authorship contribution statement

Hui Zhang: Conceptualization, Study design, Writing - review & editing, Supervision, Funding acquisition, Project administration. Qiusha Luo: Methodology, Validation, Writing - review & editing, Supervision, Project administration. Ying Li: Writing - review & editing. Tao Peng: Conceptualization, Resources. Jinwei Yang: Conceptualization, Methodology, Validation, Supervision. He Xu: Resources, Formal analysis. Xinya Xu: Investigation, Resources, Data curation. Rong Zhang: Investigation, Formal analysis, Writing - original draft. All the authors have read and approved the final version of this manuscript.

Ethics approval

This study was approved by the Ethics Committee of Harbin Medical University, Daqing Campus (Approval No: HMUDQ20231116201). All participants provided written informed consent. All methods were performed in accordance with the Declaration of Helsinki (2013) guidelines and regulations.

Funding

This study was funded by the National Social Science Foundation of China (Grant/Award Number: 22BRK009). The funder had no role in study design, data collection, analysis, interpretation, or manuscript writing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary materials

The following are available online: Supplementary File contains: Table S1: Characteristics of Included Sexual Health Intervention Studies; Table S2: Cochrane's evaluation of RCTs; Table S3: JBI evaluation of quasi-experimental studies; Table S4: Semi-structured Interview Guide Mapped to the COM-B Framework; Table S5: APEASE-based Evaluation of Candidate Intervention Functions Table S6: The Draft Intervention Program.

Data Availability

The datasets generated and analyzed during the current study are not publicly available due to the sensitive nature of the interview data but are available from the corresponding author (Hui Zhang) on reasonable request and with appropriate ethical approvals.

Declaration of Competing Interest

No conflicts of interest.

Declaration of Generative AI and AI-assisted technologies in the writing process

DeepSeek-V3.2 was used solely for language polishing and formatting, and did not participate in data processing or the generation of conclusions. The content was reviewed throughout by the author, who assumes full responsibility for the entire work.

Acknowledgments

We sincerely thank all the college students who shared their experiences and time with us, and the experts who generously contributed their knowledge to the Delphi consultation.

Appendix A. Supplementary material

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.hcr.2026.100065

References

[1] Kebede A, Molla B, Gerensea H. Assessment of risky sexual behavior and practice among Aksum University students, Shire Campus, Shire Town, Tigray, Ethiopia, 2017. BMC Res Notes. 2018; 11(1):88. https://doi.org/10.1186/s13104-018-3199-7

[2] Jin Z, Cao W, Wang K, et al. Mental health and risky sexual behaviors among Chinese college students: a large cross-sectional study. J Affect Disord. 2021; 287:293-300. https://doi.org/10.1016/j.jad.2021.03.067

[3] O’Brien D, Long J, Quigley J, Lee C, McCarthy A, Kavanagh P. Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis. BMC Public Health. 2021; 21(1):954. https://doi.org/10.1186/s12889-021-10935-1

[4] Joint United Nations Programme on HIV/AIDS (UNAIDS). Young People and HIV. UNAIDS; 2024. Accessed February 1, 2026. 〈https://www.unaids.org/sites/default/files/media_asset/young-people-and-hiv_en.pdf〉.

[5] Bellizzi S, Pichierri G, Menchini L, Barry J, Sotgiu G, Bassat Q. The impact of underuse of modern methods of contraception among adolescents with unintended pregnancies in 12 low- and middle-income countries. J Glob Health. 2019; 9(2):020429. https://doi.org/10.7189/jogh.09.020429

[6] Rong FJ. The factors of the knowledge and risk behaviors of reproductive health among undergraduates in Hubei province [master’s thesis]. Wuhan, China: Huazhong University of Science and Technology; 2021.

[7] Xu JW, Luo MY, Dong YY, et al. Analysis of knowledge, attitudes and behaviors related to sexual and reproductive health and influencing factors among college students in Shanghai. Chin J Hum Sex. 2020; 29(7):136-140. https://doi.org/10.3969/j.issn.1672-1993.2020.07.040

[8] Li X, Zhang H, Zhao S, Tang K. Predicting risky sexual behavior among college students through machine learning approaches: cross-sectional analysis of individual data from 1264 universities in 31 provinces in China. JMIR Public Health Surveill. 2023; 9:e41162. https://doi.org/10.2196/41162

[9] Keto T, Tilahun A, Mamo A. Knowledge, attitude and practice towards risky sexual behaviors among secondary and preparatory students of Metu town, south western Ethiopia. BMC Public Health. 2020; 20(1):1394. https://doi.org/10.1186/s12889-020-09371-4

[10] Yuan Y, Ruan F, Liu Y, et al. Prevalence of and factors associated with unintended pregnancies among sexually active undergraduates in mainland China. Reprod Health. 2022; 19(1):165. https://doi.org/10.1186/s12978-022-01461-3

[11] Aynalem BY, Alemu AA, Zeleke LB, Kassa GM. Risky sexual behavior and associated factors among secondary and above-education-level students in Ethiopia: a systematic review and meta-analysis. J Fam Med Prim Care. 2022; 11(9):5024-5030. https://doi.org/10.4103/jfmpc.jfmpc_1962_21

[12] Mulubwa C, Hurtig AK, Zulu JM, Michelo C, Sandøy IF, Goicolea I. Can sexual health interventions make community-based health systems more responsive to adolescents? A realist informed study in rural Zambia. Reprod Health. 2020; 17(1):1. https://doi.org/10.1186/s12978-019-0847-x

[13] Wong JY, Zhang W, Wu Y, et al. An interactive web-based sexual health literacy program for safe sex practice for female Chinese university students: multicenter randomized controlled trial. J Med Internet Res. 2021; 23(3):e22564. https://doi.org/10.2196/22564

[14] Sewak A, Yousef M, Deshpande S, Seydel T, Hashemi N. The effectiveness of digital sexual health interventions for young adults: a systematic literature review (2010-2020). Health Promot Int. 2023; 38(1):daac104. https://doi.org/10.1093/heapro/daac104

[15] Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 6(1):42. https://doi.org/10.1186/1748-5908-6-42

[16] DiCenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs. 2009; 12(4):99-101. https://doi.org/10.1136/ebn.12.4.99-b

[17] Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. https://doi.org/10.1136/bmj.l4898

[18] Tufanaru C., Munn Z., Aromataris E., Campbell J., Hopp L. Chapter 3:Systematic reviews of effectiveness. In: Aromataris E.,eds. Joanna Briggs Institute Reviewer’s Manual. The Joanna Briggs Institute; 2017. Accessed February 1, 2026. https://synthesismanual.jbi.global.

[19] Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017; 12(1):77. https://doi.org/10.1186/s13012-017-0605-9

[20] Michie S, Richardson M, Johnston M, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013; 46(1):81-95. https://doi.org/10.1007/s12160-013-9486-6

[21] Keeney S, Hasson F, McKenna H. The Delphi Technique in Nursing and Health Research. Chichester, United Kingdom: Wiley-Blackwell; 2011.

[22] von der Gracht HA. Consensus measurement in Delphi studies: Review and implications for future quality assurance. Technol Forecast Soc Change. 2012; 79(8):1525-1536. https://doi.org/10.1016/j.techfore.2012.04.013

[23] Long L. Intervention Effect Evaluation and Demand Analysis of Reproductive Health on Undergraduates in Art College [master’s thesis]. Wuhan, China: Huazhong University of Science and Technology; 2010.

[24] Liang ZJ, Wei T, Zhou ZR, Gao L, Pan JP. Analysis of the effect of micro film mode on AIDS health education among freshmen of a university. Chin J Sch Health. 2017; 38(6):828-831. https://doi.org/10.16835/j.cnki.1000-9817.2017.06.010

[25] Lei PC, Wu YY, Zhou H, Liu J. Effect of sexual education on KAP among college students by using WeChat public platform. Chin J Health Educ. 2017; 33(9):842-844,863. https://doi.org/10.16168/j.cnki.issn.1002-9982.2017.09.016

[26] Ding YX. Intervention Study of College Students’ Sexual Health Education in Nan Chang [master’s thesis]. Nanchang, China: Nanchang University; 2018.

[27] Pan Z, Yao N, Qin B, Huang LR. Effectiveness analysis of AIDS education method for minority students in college of Guangxi. Chin J Sch Health. 2019; 40(8):1148-1150. https://doi.org/10.16835/j.cnki.1000-9817.2019.08.008

[28] Guo LF, Lai ZZ, Li YM, Liu S, Liu WL. Evaluation of comprehensive sexuality education course on sexual knowledge and attitude of college students. Chin J Sch Health. 2019; 40(12):1808-1811. https://doi.org/10.16835/j.cnki.1000-9817.2019.12.012

[29] Song GH, Miao JL, Jiao YN, Liu XQ, Tang SS. The Investigation of female college students’ sexual and reproductive health knowledge status and the effect of the intervention. Chin J Sch Health. 2019; 40(3):374-377. https://doi.org/10.16835/j.cnki.1000-9817.2019.03.016

[30] Dong MJ, Yin LX, Zhang LH. Effect and evaluation of the cognitive intervention of sexual and reproductive health on science and engineering undergraduate students. Chin J Human Sex. 2020; 29(4):153-156. https://doi.org/10.3969/j.issn.1672-1993.2020.04.044

[31] Lin R, Cheng XS, Jiang JJ, et al. Study on the effect of AIDS health education in universities based on structural equation model. Chin J School Health. 2020; 41(10):1485-1487. https://doi.org/10.16835/j.cnki.1000-9817.2020.10.011

[32] Wong WC, Sun WH, Chia SMC, et al. Effectiveness of a peer-led web-based intervention to improve general self-efficacy in using dating apps among young adults: randomized clustered trial. J Med Internet Res. 2020; 22(10):e16378. https://doi.org/10.2196/16378

[33] Di LH, Xiang B, Zeng J, et al. Intervention effect of sexual health education courses on sexual knowledge by general education platform among college students. Chin J Health Educ. 2021; 37(3):234-238. https://doi.org/10.16168/j.cnki.issn.1002-9982.2021.03.009

[34] Shen QJ, Zhao CM, Li JM, Xiong WW, Han BQ, Zeng LQ. Effectiveness evaluation of the reproductive health education intervention for undergraduates from four colleges in Guangzhou. Chinese Journal of Family Planning. 2020; 28(7):986-989. https://doi.org/10.3969/j.issn.1004-8189.2020.07.004

[35] Gong GD, Zhou LL, Yang LZ, et al. Evaluation of AIDS health education intervention effect of MOOC mixed teaching. Chin J Health Educ. 2021; 37(12):1125-1129. https://doi.org/10.16168/j.cnki.issn.1002-9982.2021.12.014

[36] Sanz-Martos S, López-Medina IM, Álvarez-García C, Álvarez-Nieto C. Educational program on sexuality and contraceptive methods in nursing degree students. Nurse Educ Today. 2021; 107:105114. https://doi.org/10.1016/j.nedt.2021.105114

[37] Zizza A, Guido M, Recchia V, Grima P, Banchelli F, Tinelli A. Knowledge, information needs and risk perception about HIV and sexually transmitted diseases after an education intervention on Italian high school and university students. Int J Environ Res Public Health. 2021; 18(4):2069. https://doi.org/10.3390/ijerph18042069

[38] Francis DB, Zelaya CM, Fortune DA, Noar SM. Black college women’s interpersonal communication in response to a sexual health intervention: a mixed methods study. Health Commun. 2021; 36(2):217-225. https://doi.org/10.1080/10410236.2019.1673949

[39] Wu L, Xu JJ. The impact of comprehensive intervention strategies on the knowledge of HIV/AIDS prevention among college students. Chin J Sch Health. 2022; 43(10):1484-1487. https://doi.org/10.16835/j.cnki.1000-9817.2022.10.010

[40] Yang T, Qing LY, Wang YN, et al. Effect of AIDS health education intervention on undergraduate students in colleges in Chongqing. Chin J Health Educ. 2023; 39(3):237-241,253. https://doi.org/10.16168/j.cnki.issn.1002-9982.2023.03.009

[41] Boti Sidamo N, Hussen S, Shegaze Shimbre M, et al. Effectiveness of curriculum-based sexual and reproductive health education on healthy sexual behaviors among year one students at Arba Minch University: a quasi-experimental study. PLoS One. 2023; 18(10):e0288582. https://doi.org/10.1371/journal.pone.0288582

[42] AbdiShahshahani M, Hashemi M, Kohan S. The effect of the reproductive health self-care educational booklet on the self-care ability of female university students. Iran J Nurs Midwifery Res. 2023; 28(6):659-664. https://doi.org/10.4103/ijnmr.ijnmr_8_22

[43] Asare BY, Zegeye B, Ahinkorah BO, Ameyaw EK, Seidu AA, Yaya S. Early sexual debut and its associated factors among young women aged 15-24 in Mali: a multilevel analysis. Arch Sex Behav. 2023; 52(6):2491-2502. https://doi.org/10.1007/s10508-023-02591-w

[44] Giguere R, Fernandez MI, Bauermeister JA, et al. The Young Adult Centered Healthforce Training (YACHT) program to increase HIV testing and pre-exposure prophylaxis referrals among young sexual minority men in Florida: protocol for a type 2 implementation-effectiveness hybrid trial with a stepped wedge design. JMIR Res Protoc. 2024; 13:e63191. https://doi.org/10.2196/63191