Claire J Niemet* and Kelly Rice
Department of Surgery, American College of Surgeons, Chicago, USA
Received Date: November 24, 2021 Accepted Date: December 07, 2021 Published Date: December 14, 2021
Citation: Niemet CJ, Rice K (2021) Development of a Mixed-Method Needs Assessment to the Improve Quality of Life of LGBTQ Older Adults. Health Sys Policy Res Vol.8 No.S4 : 15.
While health-related research on Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) older adults has grown, more research is necessary to understand this population. Howard Brown Health (HBH) conducted a mixed method needs assessment in Cook County, IL. The purpose of this article is to describe the development of the community survey, focus group guidebook, and study protocol. HBH created the needs assessment to increase knowledge about access to and need for services and barriers to care among LGBTQ aging patients. Furthermore, the study explored how subgroups based on sexual orientation, gender identity, race, ethnicity, and veteran status differed in access, needs, and barriers to care. Study participants were 50 years and older, self-identified as LGBTQ, and resided in Cook County. With this knowledge, HBH plans to launch culturally competent wellness programs to improve the quality of life of its LGBTQ older adult patients.
Aging; Health disparities; LGB; LGBTQ; Older adults
By 2030, the older adult population, 65 years and older is expected to increase to 71 million individuals in the United States (Centers for Disease Control & Prevention, 2015). Paralleling this growth, the Lesbian, Gay, Bisexual and Transgender (LGBT) older adult population will double to about five million . Current studies on LGBTQ older adults indicate that this population experiences greater health disparities in comparison to heterosexual older adults. For instance, LGBTQ older adults exemplify elevated rates of depression and loneliness, demonstrate higher rates of disability and report overall poorer health compared to their heterosexual peers . According to Kuper and Fokkema, environmental stressors such as internal stigma and hiding one’s identity can negatively impact health. Furthermore, LGBTQ older adults may avoid utilizing health care-related services because of past inferior care or fear of provider discrimination [2,3]. However, healthrelated needs and community service utilization among LGBTQ older adults is not well represented in aging studies. If studies do measure service utilization, age is often not included as part of the analyses . Therefore, more research about LGBTQ older adults as a population and their subgroups is needed in order to improve the health-related quality of life for LGBTQ older adults.
For over 40 years, Howard Brown Health (HBH) has served the LGBTQ community in Cook County, IL to "eliminate the disparities in health care experienced by lesbian, gay, bisexual, and transgender people through research, education, and the provision of services that promote health and wellness" . As the number of patient’s 50-years and older increased at HBH, the staff realized that more information about the health and wellness of LGBTQ older adults was needed within their service area. As a result, HBH developed and launched a need assessment focused on access, needs, and barriers to healthrelated services experienced by their older LGBTQ adult patients. HBH plans to use the needs assessment results to inform the development of comprehensive and culturally competent aging health and wellness program. This article focuses on the steps taken to develop the community survey and focus group guidebook, in addition to, how the study protocol was created for HBH’s internal IRB.
Developing a needs assessment from start to finish can be a daunting task because it requires multiple moving parts: Assembling a team, creating the questions, gathering data, and analyzing results. It can be difficult to know where to begin. To start the process, HBH determined the short-term and long-term goal of the needs assessment. The short-term goal was to increase knowledge about which community and government services LGBTQ older adults currently access, what types of services they needed to lead healthy lives, and what barriers or challenges were preventing them from accessing services. While the initial intent of the study team was to contribute to generalizable knowledge about the health of the LGBTQ older adult population, resource constraints narrowed the study focus to HBH and the patients and community members they served. Ultimately, HBH’s long-term goal was to improve the healthrelated quality of life for LGBTQ older adults in Cook County, IL by offering culturally competent health and wellness services that would incorporate the knowledge gained through the needs assessment.
Although there are gaps in the literature about LGBTQ older adults, the research has grown over the decades. To understand what was known so far, the next step was to conduct a comprehensive literature review on the LGBTQ older adult population, health disparities, and socioeconomic factors impacting health status. Public health theories and organizational frameworks also played a vital role in providing guidance such as the Anderson Model, the social-ecological model, and intersectionality framework. These three models helped provide explanations about human behavior, direction on what topics to focus on, and justification for utilizing certain methodologies. The Andersen Model served as a logic model to understand why older adults use community services and what factors impede them from using services. The community survey incorporated concepts from the social-ecological model to provide a holistic viewpoint on the internal and external factors impacting access to needs, services and barriers to care. Finally, the study team approached the needs assessment with the intersectionality framework in mind to move beyond the description of the LGBTQ community as a homogenous group and explore how multiple identities, such as race, age, sexual orientation, and gender identity impact engagement with programs and services.
The needs assessment utilized a mixed-method approach because quantitative and qualitative methodologies both present benefits to studying small and diverse populations, such as LGBTQ older adults. According to, surveys are a common methodology to study the LGBTQ older adult population . Surveys are an inexpensive method to collect large amounts of data in a short period of time. Also surveys are anonymous, meaning information cannot be traced back to participants . This is especially important for LGBTQ older adults who may have experienced discrimination based upon their multiple identities . In the 33-question community survey, study participants were asked about demographics, participation in programs, types of services used, barriers to services, knowledge, needs and satisfaction with services. The community survey was organized according to the social-ecological model which included questions on the individual, intrapersonal and institutional levels.
The community survey data were reviewed by the study team to identify any results or patterns that emerged that would benefit from further exploration. In order to engage study participants in a conversation manner, gain feedback and ask clarifying questions about the community survey, focus groups were included as part of the study design. The focus group guidebook was divided into five main subject areas: Knowledge and perceptions of HBH, aging issues and concerns, experiences with providers, identity specific issues and concerns and social groups and successful aging. Recognizing the heterogeneity within the LGBTQ older adult population, HBH included identityspecific questions in each focus group based upon the participant composition of each group. The ten identity-specific focus groups were: Bisexual women, bisexual men, gay men, heterosexual men (HBH patients), heterosexual women (HBH patients), lesbian women, LGBTQ veterans, queer individuals, transgender men and transgender women. Heterosexual men and women were included in the sample to understand why they chose HBH as their healthcare provider given that the majority of its patients identify as LGTBQ.
The step-by-step process of how HBH developed the community survey, focus group guide books, and the study protocol can serve as a blueprint to empower other community organizations to develop their own needs assessment in order to better understand the LGBTQ older adult population within their service areas. With more organizations conducting research, the literature about LGBTQ older adults can grow and research gaps can be filled. Furthermore, with this knowledge, comprehensive and culturally competent programming for older LGBTQ adults can be created to address the health disparities experienced by this diverse population.
As part of a 9-month practicum with Howard Brown Health (HBH), I collaborated with a very supportive team to create the needs assessment. Through this practicum, I had the opportunity to practice public health essential services such as monitoring health status, in addition, to diagnose and investigate health problems. Hopefully, this article can help community organizations explore the needs and concerns of their LGBTQ older adults within their communities.
Finally, the survey protocol served as the road map detailing the sample size, recruitment strategy and analysis plan of the needs assessment. Since the actual number of LGBTQ individuals residing in Cook County remains unknown, the overall sample size was based on HBH’s patient population. Study participants were 50 years and older, self-identified as LGBTQ (with the exception of the heterosexual HBH patients) and resided in Cook County, IL. The recruitment plan entailed soliciting participants from different community organizations and neighborhoods throughout Cook County. By varying the venues and geographic locations, the study attempted to recruit a demographically and geographically diverse participant sample to gather a range of experiences, opinions and feedback. All materials including the community survey, consent forms, and palm cards were translated into Spanish and available in electronic and paper format to expand accessibility.