A Qualitative Community Assessment of Racial/Ethnic Sexual Gender Minority Young Adults: Principles for Strategies to Motivate Action(s) for Realistic Tasks (SMART Thinking) Addressing HIV/AIDS, Viral Hepatitis, Mental Health, and Substance Abuse.

HIV/STI, substance use, and mental health issues disproportionately affect racial/ethnic sexual minority young adults. These health vulnerabilities intensify across the life course, most notably when young adults are independent college students. To identify the perspectives of racial/ethnic sexual gender minorities living on or near an urban university, we implemented an intersectionality-informed SWOT (strengths, weakness, opportunities, and threats) analysis, as a qualitative community assessment situated within in a campus-community setting. The community needs assessment was the first step in the strategic prevention framework (SPF) to co-locate substance abuse, mental health, viral hepatitis, and HIV prevention care services for Latinx and Black/African American sexual gender minority young adults at a minority-serving institution. The SWOT analysis identified principles for selecting, adapting, and implementing an evidence-based intervention. The significance of these principles demonstrates the value of intersectionality in evidence-based interventions to influence health education and behavior among racial/ethnic sexual gender minorities.

Racial/ethnic sexual gender minorities, defined as non-Caucasian individuals who identify among the multidimensional identities and expressions of the LGBTQ+ community and have sexual contact with the same (identified or biological) sex, increasingly face health disparities and continuous barriers to accessing health care and treatment for mental health, substance abuse, and sexually transmitted diseases and infections (Centers for Disease Control and Prevention, 2018; Mayer et al., 2008, 2014). Most notably, Latinx individuals have higher rates of sexually transmitted diseases and infections (STDs and STIs; Centers for Disease Control and Prevention, 2018), but one in six are unaware of their HIV status. Similarly, Black/African Americans accounted for 47% of HIV diagnoses, and within this population, more than half (58%) are gay, bisexual, or men who have sex with men (Centers for Disease Control and Prevention, 2018). Lack of awareness about one’s HIV status contributes to HIV risk exposures because people who do not know their HIV status and have not sought HIV care and treatment may unknowingly transmit HIV to other individuals. But for those who are aware of their HIV status, stigma, fear, discrimination, homophobia, transphobia, and the socioe-conomic issues associated with poverty—including limited access to high-quality health care, housing, and HIV prevention education—are barriers to health-care access, which directly and indirectly increase the risk for HIV infection and affect the health of those living with and at risk for HIV (Cyrus, 2017; Fisher et al., 2018; Smalley et al., 2016).

Studies that have included racial/ethnic sexual and gender minorities have consistently shown that the absence of culturally affirming health-care services contribute to the LGBTQ health disparities (Gamarel et al., 2014; Mayer et al., 2008; Sen & Östlin, 2008; White Hughto et al., 2015). Ignoring the multidimensional identities of this population is an additional burden that perpetuates chronic minority stress (Hatzenbuehler, 2009; Mayer et al., 2008). Chronic minority stressors compromise physical and mental wellness, thus underscoring LGBTQ health disparities and social marginalization for racial/ethnic sexual gender minorities in the United States (Mayer et al., 2008, 2014).

Colleges and University Campus Settings

On colleges and university campuses, racial/ethnic sexual and gender minority students are more inclined to experience chronic minority stressors when negotiating their identities and social functioning during the critical phase of becoming independent young adults (Friedman & Leaper, 2010; Rankin & Reason, 2005; Sheets & Mohr, 2009). Research studies (Brown et al., 2004; Evans & Broido, 2002) report that racial/ethnic sexual gender minority students experience harassment and violence as part of their daily lives in college (D’Augelli, 1992; Waldo et al., 1998) and are associated with high-risk behaviors such as substance use and exposure to chronic stress (Patton & Simmons, 2008; Tyler & Schmitz, 2018). Despite such insights, there is insufficient understanding about how racial/ethnic sexual gender minority students navigate such experiences at a minority-serving institution, where campus dynamics and institutional philosophy and mission are uniquely focused on serving minority students.

Building a Case for Prevention Services

Since the 1990s, prevention practices in the United States transitioned from single-component approaches focused on individual-level behavioral change to multicomponent strategies focused on both individual and environmental changes. This realignment prompted a dramatic expansion during the 1990s of community-based, or “community-directed,” prevention efforts employing multiple strategies (James et al., 2016; Lorion, 2018; Morrissey et al., 1997; Wandersman et al., 2008). The Center for Substance Abuse Prevention (CSAP), an entity of the Substance Abuse and Mental Health Services Administration (SAMHSA), has led the nation in funding such preventative community-building approach with institutions of higher education (Arthur et al., 2010; Kellam & Langevin, 2003; Piper et al., 2012). Of all SAMHSA-CSAP-funded programs, the strategic prevention framework (SPF) is promoted as the most effective preventative approach to promote mental health and to prevent substance use within the delivery of services. Offering action steps as tools for communities to plan and build effective prevention programs, the SPF is guided by five key principles:

Prevention is a continuum. It ranges from deterring diseases and behaviors that foster them to slowing the onset and severity of illnesses when they do arise.

Prevention is prevention. The methods of prevention are the same for many diseases, whether the aim is to prevent the onset or to reduce effects. In this model, prevention strategies consider how people think, feel, and act by focusing on messages and activities on areas of influence such as the individual, family, or community.

Successful prevention decreases risk factors and enhances protective factors.

Prevention strategies should use proven practices within systems that work. Research and experience have produced highly effective prevention programs to reduce risk factors and promote protective factors.

Systems of prevention services work better than isolated efforts. The best prevention results come from partnerships.

SPF categorically promotes sustainability and cultural competence by adapting existing evidence-based interventions (Substance Abuse and Mental Health Services Administration, 2017).

UIC Integrated PASEO

In 2015, SAMHSA took an innovative approach to fund CSAP programs that focused on building partnerships between minority-serving institutions (MSIs) and community-based organizations to promote substance abuse prevention, mental health services, and HIV/AIDS and Hepatitis C preventative services to young adults between 18 and 24 years old. The first CSAP award was issued in the state of Illinois to one of its twenty MSIs (Fox et al., 2017). The University of Illinois Chicago (UIC) has a diverse student body with no majority race. In 2014, among undergraduates, Caucasians accounted for the largest proportion at 35.8%, followed by Latinos (26.4%), Asians (22.7%), Black/African Americans (7.9%), mixed ethnicity (2.5%), international (2.5%), unknown (1.8%), and Native American/Pacific Islander (0.4%) [name deleted to maintain the integrity of the review process]. With such diversity among the student population, [name deleted to maintain the integrity of the review process] has been designated as an MSI by the Asian American and Native American Pacific Island-Serving Institutions (AANAPISI) and the Hispanic Association of Colleges and Universities (HACU) (UIC Student Data Book, 2014).

The CSAP-funded program at the University of Illinois Chicago, UIC Integrated PASEO (Promoting Actions that support prevention and recovery through Services, Education, and Outreach), was developed with SPF to expand and enhance co-located, evidence-based behavioral health and HIV and hepatitis prevention and treatment services for at-risk Latinx and Black/African American young adults between 18 and 24 years of age who attend the University of Illinois Chicago and/or live in catchment areas where non-university community members reside. The subpopulation of focus was sexual gender minority young adults. This paper illustrates how the implementation of an SPF needs assessment informed the development, adaptation, and implementation of an evidence-based intervention for racial/ethnic sexual gender minority young adults at this minority-serving institution.

Method

Procedures

This study’s needs assessment adopted a strengths, weakness, opportunities, and threats (SWOT) analysis approach guided by a feminist intersectionality framework to illuminate that social phenomena are often best understood by examining the overlap of institutional power structures such as race, class, gender identity, gender expression, and sexuality (Abern & Maguire, 2018; Choo & Ferree, 2010; Lombardi, 2017; Stroumsa, 2014). SWOT analysis is a systematic need assessment tool that can analyze internal and external environments and strategic factors (Hickerson et al., 2018; Kurttila et al., 2000) to inform planning (Woratanarat & Woratanarat, 2012) and has been used to improve health worker training and public health interventions in a range of settings (Hande, 2014; Wazir et al., 2013). The intersectional framework, as noted in other studies (Logie et al., 2011), when embedded with research inquiries, elevates the significance of gender identity, gender expression, and sexual experience—which hold different implications for racial/ethnic sexual gender minority young adults—as overlapping realities rather than as competing systems of inequality, ensuring that one system is not privileged over another (see Figure 1).

Figure 1.

Adapted conceptual model of intersectional stigma and coping.

Source: Logie et al. (2011).

Data Collection

Six qualitative focus groups were convened on campus and across neighborhoods of this urban setting (Balsam et al., 2011; Krueger, 2014). A purposeful sampling approach was used in the recruitment of participants who understood and related to racial/ethnic sexual gender minority young adults’ phenomena (Duan et al., 2015). Inclusion criteria focused on LGBTQ Black/African American and Latinx young adults, LGBTQ-inclusive service providers and practitioners, university and administrative officials, and LGBTQ allies and advocates with knowledge about student and young adult life at the university and across Chicago communities. A total of 25 university students, aged 18–24 years old, inclusive of the LGBTQ spectrum of sexual identities and gender expressions, participated in LGBTQ focus-group sessions. Fifteen community members and service providers also participated in a separate focus group session. Ten university officials and administrators participated in another focus group session. More than half the participants identified as members or allies of the LGBTQ community. All fifty (N = 50) participants provided written informed consent before enrolling in the study. The focus group discussions were audio-recorded.

All focus group sessions were conducted using a semistructured discussion guide that fostered open dialogues about substance abuse, mental health, viral hepatitis, and HIV prevention and care services in ways that allowed participants to compartmentalize those issues between on-campus and off-campus realities. We also explored a sample of issues such as risk exposures; access to resources; stigma; discrimination; coping and resilience among racial/ethnic sexual gender minority young adults. These discussions were conducted in English, convened in safe spaces, and implemented during the initial 6-month phase of the project lifespan. Strengths were identified as elements of existing LGBTQ health services that had positive impacts on health access and outcomes for racial/ethnic sexual gender minority young adults (Scheibe et al., 2017). Weaknesses included the environmental factors and social practices that contributed to poor health outcomes. Opportunities were viewed as elements that could enhance efficiencies, receptivity, coverage, and adherence. Threats were defined as apparent or clandestine barriers that hindered opportunities to sustain good health practices. These SWOT analysis inquiries also explored macro-level—societal factors; meso-level—group, communities, and institutions; and micro-level perspectives—social interactions of individuals and small groups (Figure 1).

Data Analysis

We used the qualitative analysis software Dedoose 8.0.35 to organize the transcribed focus-group data (DeDoose, 2018). After all audio-recorded qualitative data and research notes were transcribed into text passages, members of the research team initiated a constant comparative analysis. Constant constant comparison analysis was adopted to guide our data analysis activities because it is a proven strategy when conducting multiple focus groups within a study (Corbin & Strauss, 2014).

During the first stage of our analysis (open coding), the data were chunked into small units. A descriptor, or code, was then attached to each of the data units. During the second stage (axial coding), codes were grouped into categories of positive and negative macro, meso, and micro levels. In the third and final stage (selective coding), the team assigned coded materials into strengths, weaknesses, opportunities, and threats that expressed the content of each of the groups (Corbin & Strauss, 2014). The findings were triangulated into the SWOT categories based on coding patterns to ensure that the authentic voices of the participants were being accurately and fairly represented throughout this study (Bickman & Rog, 2008; Denzin et al., 2006; Jick, 1979) Once the data analysis was completed, we presented the summaries to the program’s community advisory board to affirm and contextualize our findings.

Findings

The following salient themes provided insights into the strengths, weaknesses, opportunities, and threats for racial/ethnic sexual gender minorities of UIC urban campus community. The themes demonstrated circumstances at all three levels (macro, meso, and micro) that influenced the values of adopting preventative strategies among racial/ethnic sexual gender minorities. To humanize the findings, we have included quotes from participants in the discussion below.

Socialization

While there is a plethora of LGBT-friendly spaces across the urban setting in which the university campus is situated, the hyper-segregation of city neighborhoods intrinsically influenced the concentration of LGBT resources and spaces. Since most LGBT-friendly services are in neighborhoods (predominately White) far from where, racial/ethnic sexual minority young adults tend to congregate, they were compelled to weigh the value of those services against the time, cost of seeking them and travel distances. For, those who did go to those neighborhoods, they contended with ever-present structural levels of racial profiling and microaggressions.

Most of the resources and programs we need are located in certain neighborhoods of the city. They are for the privileged that live in those communities. For us, we have to travel at least 45 minutes or more to go to those places. For those of us who do go, we are disappointed by the lack of diversity among those programs. (24-year-old Black gay man)

To avoid those experiences, racial/ethnic sexual gender minority young adults create their spaces among disenfranchised communities, which have higher rates of poverty, violence, and limited health-care resources. Such circumstances reflect the threats that underscore some of the LGBTQ health disparities inherent to racial/ethnic sexual gender minority young adults. Potential growth opportunities include building relations with the underutilized network of fraternities and sororities on campus that provide vital social support for minority young adults at UIC. Also, building relationships with the informal support groups and networks that racial/ethnic sexual gender minority young adults identified as their safe spaces would influence their likelihood of accessing preventative services.

Coming Out and Identity Formation

University of Illinois Chicago has been identified as the most LGBT-affirming campus in the state, provides an excellent space for LGBT identity exploration, affirmation and support for emerging independent young adults. Despite this strength, participants noted the school’s limited access to mental health services and, were angered by procedural practices such as wait-lists and the restrictions on the number of counseling sessions.

I was a transfer student from the suburbs. When I got to campus, and I found refuge in the Sexual and Gender Cultural Center to meet and interact with other students. At one point, I thought that I needed to speak with a counselor. I reached out to see someone and I was wait-listed for several weeks, and I also found out that our student health insurance would limit the number of sessions. Eventually, I decided that it would be better if I went to another provider off-campus. I had to pay out of pocket for those services. (20-year-old Queer Latinx female)

Other weaknesses noted were that some community-based agencies that provided services to the community, lacked sufficient role models, diverse leadership and administrative representatives, and culturally informed resources (e.g., language, racial affirmation, gender expressions) applicable to racial/ethnic sexual and gender minority young adults. Growth opportunities included understanding how racial/ethnic sexual and gender minority young adults negotiate and affirm their concurrent identities and provide appropriate care and support that values diversity. Such practices have profound influences on how resources would be received and utilized.

Transgender Discrimination

Discrimination toward transgender individuals was the barrier most common barrier cited by participants. Arising from the lack of empathy for transgender people and their lived experiences, discrimination occurred both within and outside of the LGBT communities. Blatant acts of prejudice, ignorance, and marginalization were commonly noted. Beyond LGBT settings in the Chicago context, employment prejudice, and discrimination forced many transgender people into housing instability and increased exposure to violence. Such realities have downstream implications if transgender individuals need to access routine health care, such as hormonal treatment disruptions.

I am a biracial transgender female. For some time, I lived on the streets with other transgender people. I constantly live in fear of violence. I tried to get a job, but I knew the company was uncomfortable with me being trans. In the trans community of color, we would share needles for our hormonal treatment because things were so bad. Finally, I came to [name deleted to maintain the integrity of the review process], where they have helped me with housing and medical treatment. I like coming here because it is a minority service provider. I am much better now than a year ago. (21-year-old Black and Latinx transgender female)

Potential threats identified were coping strategies that included substance use, transactional sex, and sharing medical resources (e.g., needles). Opportunities to address such pitfalls should targeted the ballroom scenes frequented by transgender individuals and is seen as a vital lifeline of support and stability.

Intersectional Realities

Participants brought to light that some entities did not completely understand and celebrate the intersection of race, ethnicity, class, gender, and sexual expression, a factor that inhibits young adults’ ability to access and stay engaged with most interventions. Many explained that there is no single aspect of their identities that predominates in their lives. Rather, there is an interrelationship of all of their identities that affects their whole experiences. Failure to understand and acknowledge their intersectional realities is a threat that influence participant engagement and service usage. Growth opportunities need to elevate practices of empathy that respect such realities.

I am a Black gay man. Wherever I go, I cannot dismiss some aspect of my identities to try to fit in. People need to understand that I cannot disentangle who I am. It is frustrating when I go to programs and they make the broad assumption that all of us in the room have had the same experience. If a program does not reflect what I have to deal with daily, I cannot guarantee that I will follow through on what they are telling us to do. (19-year-old Black gay young adult community peer)

Depression and Stress

Clear evidence of elevated stress levels existed among racial/ethnic sexual minority young adults for various reasons, including exposure to violence and economic instability and limited independence, housing, and access to local (easily accessible) health and mental health services. In the absence of these services, substance use was a coping mechanism, which exacerbated physical and emotional unwellness (Jeremiah et al., 2020).

There is a lot of stress being a first-generation college student of color. But even more, I am an LGBTQ person of color. Many of my classmates do not understand what I go through. I spend most of my time alone, so it is depressing. My other LGBT friends deal with these issues differently. They go out a lot more to meet and date other people. Moreover, they take drugs to feel included. I can’t afford to do it, because I am already struggling with school. (18-year-old Latinx gay male college student)

Holistic Approach to LGBTQ Health

When asked what could be done to improve or enhance the health status of racial/ethnic and sexual and gender minority young adults at UIC campus and in the surrounding areas, participants most often cited conduct sensitivity training, more housing, employment, and health resources. They also suggested that the university deliver programs in non-clinical settings and within community-based settings of their campus and adjacent communities; that it modify staffing practices to employ and promote individuals of color; and that it hire transgender facilitators to address transgender issues, such as hormone treatment, social safety, harm reduction, and clean-needle practices (Jeremiah et al., 2020).

Discussion

Racial/ethnic and sexual minority young adults—most notably when navigating a university setting—are disproportionately affected by HIV, STI, substance use, and mental health issues. Appealing to racial-ethnic sexual gender minority young adults requires an organic approach to motivate and engage participants, such as meeting them where they are and imparting new knowledge and resources to increase their understanding of how to operationalize preventative life skills (related to HIV/AIDS, substance use, viral hepatitis, and mental health) and their intersectional feelings as racial/ethnic sexual and gender minority young adults in college and citizens of the larger urban metropolitan community.

Most evidence-based interventions are packaged to be delivered at the individual level, but there is significant value in delivering some content at the level of the group, with complementary services that focused on bringing participants into social settings that reinforce group skills (Hossain & Ferreira, 2019). For example, consciously embedding program activities into popular venues and social circles such as student wellness and counseling centers, sports, and recreational centers, cultural centers, and fraternity and sorority groups and programs can be a model for success in reducing the feeling of isolation and dismay.

The featured findings of this qualitative community needs assessment of UIC Integrated PASEO illuminated the significance of selection, adapting, and implementing evidence-based interventions for racial/ethnic and sexual minorities must center on how their intersectional realities influence their health education and behaviors. Strategies to align an evidence-based intervention can be done with a biopsychosocial model to recognize the dynamic interactions among biological, psychological, and social factors (Griffith, 2016; Hatala, 2012; Pilgrim, 2015; Suls & Rothman, 2004). In particular, evidence-based intervention for racial/ethnic and sexual minority young adults must value their intersectional realities and not assume that such identities are distinct categories and experiences (Hankivsky, 2012; Lohan, 2007). In this work, it is apparent that transcending common proxies for determinants of health and applying an intersectionality framework provide a stronger case for reframing prevention and positive life skills that align with their lived experiences. Theses insights emerged after many intense discussions with the program’s community advisory board. Ultimately, these three principles were deemed essential to adaptation and implementation of an evidence-based intervention to offer preventive services of racial/ethnic sexual gender minorities: life-skills enhancement, communicating with confidence, and assertive negotiation.

Life-Skills Enhancement

Glaring challenges for racial/ethnic and sexual minority young adults attending campus community settings involved an intrinsic desire to identify their ideal self and operationalize the tenets of negotiation while engaging in assertive communication. Such gaps can be settled with the integration of two complementary theories: self-concept theory (SCT) and social identity theory (SIT).

SCT is based on the assumption that many of the successes and failures that people experience in many areas of life are closely related to their self-image and their relationships with others. Self-concept has at least three major qualities: it is learned, it is organized, and it is dynamic. That self-concept is learned has important implications when addressing such nagging problems as drug and alcohol abuse, drop-out rates, and dysfunctional families (Ryan et al., 1986).

SIT posits that the pursuit of positive self-esteem underlies in-group-favoring social comparisons (i.e., in-group bias) and efforts to improve the individual or collective status. However, researchers working both within and outside the social identity approach have suggested several other functions that are served by social identification. Groups act as a social resource for their members (Correll & Park, 2005; Haslam et al., 2009), providing social support, a sense of belonging, hope, and self-efficacy (Baumeister & Leary, 1995; Hogg & Abrams, 1990; Johnson, 2006). Vignoles et al. (2006) pointed out that in a comprehensive attempt to go “beyond self-esteem,” it is critical to offer an empirically validated typology of six identity motivations: self-esteem (the need to maintain and enhance a positive evaluation of the self), efficacy (the need to maintain or enhance feelings of competence and control), belonging (the need to maintain or enhance feelings of closeness to, or acceptance by other people), distinctiveness (the need to establish and maintain a sense of differentiation from others, continuity (the need to maintain a sense of consistency across time and situations), and meaning (the need to find significance in and purpose for the self’s behaviors and existence). According to this model, the degree to which a social identity satisfies these motivations determines its centrality to an individual’s sense of self. Identity formation involves personal, social, and sexual perceptions that must be addressed individually and equally. As individuals most strongly identify with the social identities that maximally fulfill these needs, they also come to cherish them emotionally and enact them often in daily life. Building upon these tenets to better understand the participant’s motivation to make the change is critical.

These theories can help resolve key questions that are frequently encountered, such as how individuals can identify and wholly accept themselves and how they can better communicate within a group that presents interpersonal communication challenges, especially concerning outside resistance to their intersectional identities (Paisley & Tayar, 2016). These questions were recognized as core roadblocks to self-acceptance, proper communication, and access to health care.

Communicating with Confidence

The assumption that participants were already operating at a heightened sense of self-awareness was disproved by the need assessment findings. With such a directive, communication needs to introduce the concept of passive-aggressive communication and identify strategies for implementing assertive communication techniques in place of passive-aggressive communication. Particular attention should also introduce recognizing verbal and nonverbal cues and using communication de-escalation techniques.

Assertive Negotiation

Negotiation tactics are essential to achieving desired outcomes in everyday interpersonal interactions, especially in situations where the negotiations are met with resistance to the target population’s multidimensional genders or sexual identities. Incorporating opportunities to enhance negotiation strategies, where individuals advocate for their needs in simulated social, professional, and health-care settings can be an effective empowering experience to assert for preventive services. Unlike many of the other evidence-based interventions, such strategies must seek to intentionally remove prescriptive solutions and reframe towards exploratory discussions that are centered on their lived experiences within the immediate social realities.

Focusing on life skill enhancement, communicating with confidence, and assertive negotiation within processes of adapting evidence-based interventions for racial/ethnic sexual gender minorities, health programs will be better poised to reflect their realities and offer life skills to avoid pitfalls and risk exposures. Such principles are even more vital for racial-ethnic sexual gender minority individuals that are becoming independent young adults in urban university campus community [reference deleted to maintain the integrity of the review process], allowing them to be confident in their decisions that may affect their future.

In conclusion, the intentional use of these principles in adapted evidence-based intervention would demonstrate a strong desire to address the intersectional needs and realities of racial/ethnic sexual and gender minority young adults and promote their academic success. By embodying preventative strategies, principles, and practices, racial/ethnic sexual and gender minority young adults can be better equipped to navigate the social and cultural landscapes of the urban campus community in ways that limit their exposures to risks and promote affirmative health behaviors.