Promoting health with lesbian and bisexual women: It’s not just about behaviour change.
Abstract
Aim and objectives:To highlight different ways that healthcare professionals can promote health and reduce health inequalities of lesbian and bisexual women using a health promotion framework that focusses on the wider healthcare context.
Background:Lesbian and bisexual women experience numerous health disparities that place them at high risk of poor health outcomes. The FriedenHealth Impact Pyramid (2010) identifies five tiers of public health interventions. This pyramid could be used to promote health in lesbian and bisexual women in healthcare settings.
Design: A discursive paper.
Methods: Literature was searched from 2008 to 2015 using PubMed,ScienceDirect, and published grey literature. Individual key words were used to locate articles that focused on lesbian and bisexual women’s health inequalities and to identify interventions to address these.
Results:Examples are presented across the tiers of the Health Impact Pyramid in the context of healthcare settings that healthcare practitioners could action to promote health in lesbian and bisexual women.
Conclusions:The use of theFrieden triangle offers an alternative way to promote health by conceptualizing health promotion interventions that promote lesbian and bisexual womenwithout just focusing on behaviour change. The importance of changing areas of practice in healthcare organizations to be more supportive of lesbian and bisexual women and their healthcare needs is highlighted.
Relevance to clinical practice
This paper highlights ways that healthcare professionals can promote health of lesbian and bisexual women within their healthcarepractice to help reduce health disparities.
What does this paper contribute to the wider global clinical community?
This paper:
Emphasizes areas for change in healthcare using the Health Impact Pyramid that could reduce health disparities in lesbian and bisexual women.
Highlights that by challenging practices that discriminate, stigmatise or discourage population groups from seeking healthcare practitionerscan promote health and encourage lesbian and bisexual women to seek healthcare provision.
Healthcare practitioners can promote cultural competency by offering, or asking for, training in sexual orientation and health needs of sexual minority groups
Identifying local and national support networks and giving this information to patients can be a way to support patients with additional health needs
Key words: lesbian, bisexual, women, health inequalities, healthcare, health promotion
Aim
To highlight different ways that healthcare professionals can promote health and reduce health inequalities of lesbian and bisexual women using a health promotion framework that focusses on the wider healthcare context.
Background
Reducing health inequalities is a key goal of public health and some population groups continue to experience considerable health disparities and inequalities in health (Institute of Medicine (US) 2011). From a healthcare perspective addressing health inequalities and promoting health requires far more than just delivering healthcare. Whilst manypractitioners are ideally placed to be involved in behavior change with a patient, for example by offering smoking cessation advice, promoting health and reducing inequalitiescan involve more than simply offering advice.
Lesbian, gay, bisexual and transgender (LGBT) communitiesare diverse and includes a wide range of ages, ethnicities alongside different gender identifies (how someone thinks of their gender i.e. masculine or feminine) and sexual identities (how one thinks and feels about themselves in terms of who they are attracted to). This article focuses on lesbian and bisexual (LB) women based on their sexual identity as this group remains largely absent from public health research making it difficult to draw conclusions about how best to promote health. In additionL&B women’s needs may be ignored or assumed to be the same as women in general (LGBT Foundation 2013).
Whilst there is a rationale to grouping LGBT populations together in terms of their shared histories of discrimination it is not always appropriate to consider these populations groups together as their risks and behaviours may differ considerably. For example, in the area of sexual health the focus has been predominately among HIV and STIs in homosexual men (Corboz 2010). L&B women are largely excluded from research and preventive public health interventions, and very little is known about sexual health of L&B women. Whilst the risks of HIV and other STIs in L&B women are considerably lower than homosexual men (Women’s Institute 2009),this view is complacent when 17.4 million women are living with HIV globally (WHO 2014)accounting for half of all adults living with HIV (WHO 2015). In the UK for example the UK HIV rates are particularly high inAfrican women(Skingsley et al. 2015). L&B women may also experience additional vulnerabilities which elevate their risk of HIV infection such as social exclusion or violence (Logie et al. 2012). There is alsolimited evidence on the effectiveness of interventions to reduce vulnerabilities to HIV or STIs in L&B women (Logie et al. 2015a). This has a huge implication for L&B women in the future and represents a very unique public health challenge.
Lesbian and bisexual women health risks
Whilst many health problems that impact on women may also impact on L&B women, a number of risk behaviours are reported as being higher in L&B women compared to heterosexual women. Overall research suggestsL&B women are more likely to experience disparities in chronic disease and preventive behaviours (Minnis et al. 2016) along with increased reports of ill health or long-standing health conditions compared with heterosexual population groups(Conron et al 2010).
Health risks include alcohol use which is reported to be higher in L&B women than heterosexual populations (Nodin et al. 2015; Hunt and Fish 2008; King et al 2008). Substance use is also higher in L&B women compared to heterosexual populations in young L&B women (Marshall et al. 2008) and in numerous adult studies (Hunt & Fish 2008; King et al. 2008). Recent research has highlighted higher rates of tobacco smoking in L&B women than heterosexual women but makes reference to the lack of studies in this area (Emory et al. 2016).It has been noted by some studies that L&B women also have a higher BMI that heterosexual women (Brittain & Dinger 2015; Eliason et al. 2015) andsome studies also note the increased risk of disordered eating for example binge eating (Mason et al. 2016), however other studies have shown different findings, for example that disordered eating is only higher in bisexual or womenunsure of their sexuality (Shearer et al. 2015) or no difference between lesbian and bisexual women compared to heterosexual groups (Feldman and Meyer 2007).
There is also a strong evidence base that suggests L&B women have increased suicide risk compared to heterosexual females (Brittain & Dinger 2015; King et al. 2008). This risk is even higher in those who are bisexual compared to lesbian women (Pompili et al. 2014, Marshal et al. 2011). A recent study has examined non suicidal injury (intentional injury to the body’s surface without intention to die) which is more common in LGBT groups and recommends that nurses play an active role in reducing this risk (Jackman et al. 2016).
There are varying explanations for these trends. One popular explanation is the theory of ‘minority stress’ which suggests that discrimination, victimization and stigma experienced by those in a minority can result in increased stress which may result in increased risk of depression, mental health problems or suicide ideation (Meyer 2003). This is also reflected in debates that highlight society’s attitudes to sexual minority groups, for example Lick et al (2013) note physical health disparities in lesbian, gay and bisexual individuals and emphasize the role of stress caused by anti-gay stigma in these disparities. How society perceives and responds to L&B women can lead to higher levels of hostility, discrimination or violence as a result of homophobic culture and this may impact on physical and psychological functioning increasing susceptibility to ill health. Other authors argue that the emotional or psychological turmoil linked to being L&B may be important. For example, Nodin et al. (2015) suggest alcohol may be used to manage fear, anxiety or guilt about sexual orientation in L&B women.
Lesbian and bisexual women and healthcare
L&B women may face series of challenges in health care systems. These include accessing healthcare, culturally competent health care, and policies that reinforce social stigma or discrimination (Daniel et al. 2015). Issues that impact on LGBT healthcare access may be similar in L&B populations and relate to individual perceptions of how they will be treatedand availability of healthcare services. Some research has indicated that L&B women are more likely to report negative experiences of healthcare than gay and bisexual men or heterosexual women (LGBT foundation 2013) and in the UK are less likely to have seen a family practitioner in relation to heterosexual women (Urwin & Whittaker 2016). AlencarAlbuquerque et al (2016) suggest a range of barriers experienced by LGBT populations in healthcare which inhibit access to healthcare including prejudicial conduct by health professionals and institutional homophobia. Other barriers may include fear of disclosure of status, exposure to negative reactions, inappropriate language, heterosexual assumptions, incompetent staff or embarrassment.
One of the main differences in healthcare access for women in the evidence base has been highlighted in screening in cancer services. L&B women are less likely to have had a recent mammogram than heterosexual women (Buchmueller & Carpenter 2010; Brown et al 2015). Although Hunt & Fish (2008) suggest breast screening rates may be comparable to the heterosexual population they note a diagnosis of higher rates of breast cancer in L&B women which may warrant future investigation. L&B women are also less likely to have had a cervical smear test (Hunt & Fish 2008; Brown et al. 2015), or when questioned in one study a gynecological exam in the last 12 months (Brittain & Dinger 2015). Limited evidence suggests that HPV infection may be slightly higher in non-heterosexual women compared with heterosexual women especially bisexual women (Reiter & McRee 2016) but more evidence is needed in this area.
The Health Impact Pyramid
The Health Impact Pyramid (Frieden 2010) is a framework for public health action and Frieden (2015) argues that to maximize impact public health should work at five tiers and although all tiers are important the ones at the base of the pyramid generally improve health for more people at a lower cost, than those at the top. The top tier is counseling and education followed by clinical interventions, long lasting protective interventions, changing the context to make individuals default decision health and finally at the bottom tier socioeconomic factors. Figure 1 is an adaptation of the Health Impact Pyramid and illustrates these tiers. To give an example of each tier; tier 1 counseling and education includes individual advice i.e. dietary advice. Tier 2 is clinical interventions for example long term care such as daily medication, tier 3 are long lasting protective interventions such as a vaccination, tier 4 is changing the context to make individuals default decision health, for example a policy change such as adding fluoride to tap water. Tier 5 is socioeconomic factors and includes factors such as employment, income and education. Whilst this tier is not so obviously linked to healthcare, changes to wages or employment laws will have an impact on health. To give two examples; behaviour change interventions such as smoking cessation advice would be in tier 1: counseling and education. Stopping smoking requires the most individual effort but has the least impact on overall population health. A law to ban the sale of cigarettes to minors would be in tier 4: changing the context as it requires less individual effort and has a bigger population impact.
Figure 1. Health Impact Pyramid tiers adapted from Frieden (2010)
Frieden’sHealth Impact Pyramid has been used in a variety of public health initiativesparticularly in the US and is sometimes referred to as the CDC (Centers for Disease Control and Prevention) as this is where the author is based. This model has not been used to identify ways to promote health with lesbian and bisexual women before. However, it has the advantage of allowing consideration of a wide range of interventions to promote health (IOM 2012), and it has started to gain some recent support in specific public health areas i.e. unintentional injury (Mack et al. 2015). The pyramid also includes policy and socioeconomic factors which are represented in conceptual models of health determinants for example the Dahlgren and Whitehead (1991) which informs work on health inequalities in the UK.
Methods
Literature was searched from 2008 to 2016 using PubMed andScienceDirect. The limited evidence base was supported by published grey literature from relevant organisations. Papers were included if they were published in English, focused on L&B health inequalities or if they focused on interventions to promote health in L&B women and were suitable fordelivery by healthcare practitioners in a healthcare setting. Limited research is published in this area so papers were included that focused on LGBT populations if they were specifically highlighting L&B women within these papers, or if they could be adapted for L&B women. Papers were excluded that specifically focused on males, individual behaviour change and settings outside of healthcare i.e. nightclubs. Key words were used in varying combinations, these were: lesbian, bisexual, gay women, health promotion, public health, nurs* intervention, program*, healthcare. Individual key words were used to locate specific interventions to reduce inequalities in areas where L&B women were identified to be at high risk i.e. suicide. All papers were read multiple times and recurring themes were identified and analysed as a wider body of work. The literature is presented across the tiers of the health impact pyramid with particular emphasis on the lower tiers.
Discussion
An equal right to health and health care is a fundamental focus for public health research and practice (Branstrom & van der Star 2015). So why do institutions and communities continue to support or tolerate discrimination and inequality for sexual minority groups and do not actively challenge negative stereotypes, media coverage or bullying within these institutions?The society in which we live shapes the way we provide healthcare to L&B women. Therefore to promote health of L&B women we need to focus on all tiers of the pyramid with particular emphasis on the lower layers of the Frieden pyramid. This would mean the locus of change rests with organizations and theirstructures, policies and practice and not just with the individual patient.
Tier 1 Counseling and Education: individual behaviour change
This tier focuses on individual behaviour change to promote L&B women’s health.Research suggests the needs of L&B women might not be catered for in traditional health education messages, for example perception of risk of cervical cancer may be different in heterosexual women (Power et al. 2009). They may be excluded from health education materials for example in sexual health where the emphasis is on heterosexual sexual relationships. Distribution of health education messages or materials specifically designed for L&B women such as the LGBT foundation leaflets for cervical screening, alcohol, sexual health, breast cancer and mental health are essential (see LGBT foundation 2016). Promotion of health in these areas where lesbian women have high risks should also be considered as a priority, for example brief interventions to reducealcohol, tobacco smoking or promotion of positive mental health alongside promotion of screening campaigns. This tier can only be effectively achieved when Health Impact Pyramid lower tiersare also considered i.e.providing healthcare in non-discriminatory settings and culturally appropriate communication.
Tier 2 Clinical interventions: Supporting mental health
Tier 2 is classed as interventions such as the monitoring and surveillance of health risks i.e. high blood pressure. Generally this tier includes interventions that require regular support or monitoring. Suicide is a major risk for L&B women, and factors that increase vulnerability to suicide such as depression and poor mental health need to be proactively identified. Young people in particular may lack self-esteem and feel isolated and lack resilience skills (Evans 2012). Research suggests that support and understanding from families and significant others helps to promote self-worth and build resilience in LGBT young people alongside positive interventions from medical and professional staff (Nodin et al. 2015). Family acceptance and positive experiences of young people in sexual minority communities promote health within these groups and provides supportive networks for L&B women (Zimmerman et al. 2015).
Role models may play an important part in acceptance of L&B positive identity. For example, in healthcare staff visible LGBT role models have been suggested as a way to promote equality within staff (Stonewall 2015). Bränstöm & van der Star (2015) note the lack of social support and positive role models due to the lack of disclosure of sexual orientation. Bird et al. (2012) supports this and suggests that role models might be important in protecting young people from negative health outcomes but many have limited availability on a day to day basis and this inaccessibility (i.e. limited media role models) may be associated with negative mental health outcomes.
Healthcare practitioners should know what support mechanisms that are available to L&B women and their families. This may help reduce vulnerability to suicide, and promote positive mental health. In addition it may increase access to positive role models and encourage acceptance within families. In the UK the consortium of LGBT voluntary and community organizations has listing of UK wide organizations (Consortium of Lesbian, Gay, Bisexual and Transgendered voluntary and community organizations), so find the ones that are nearest to the area that you work using their directory. You will then be able to signpost those who need support to services that can cater for their needs.
As L&B population groups are less likely to access healthcare a proactive approach such as outreach work may also be beneficial. For example, the use of ‘community navigators’ in communities with different cultural and linguistic needs have been trialed in Australia to facilitate health promotion and help support people in accessing health services (Henderson & Kendall 2011). Community outreach may be considered by many healthcare practitioners to be outside the limit of their role, but there may be proactive opportunities for health promotion outside of a healthcare setting and community collaboration and engagement is an important way to support hard to reach populations.