By J.J. Thomas, MPH, MHA
Note: This is a copy of an assignment submitted for coursework in a Doctor of Healthcare Administration program and is slightly different than what is typically posted on this page. However, it may be beneficial for someone looking into the topic. The level of scrutiny is of a level of a course assignment vice peer reviewed publication.
Lesbian, Gay, Bisexual, and Transgender have collectively shown barriers when accessing healthcare (Lim, Brown, & Sung Min, 2014). Societal changes have occurred in the previous decade including major United States Supreme Court cases for marriage equality and the military’s repeal of Don’t Ask Don’t Tell. Even with still outstanding equality issues of employment, housing, and safety rights of members of the LGBT community, hospital and public health systems need to engage with the LGBT community to increase health equities. With these societal changes, the Human Rights Campaign has been quantitatively scoring health systems in what is called the Equality Index (Klotzbaugh, 2016).
Stigma is found to be one of the major factors that creates a barrier to accessing health systems (Whitehead, Shaver, & Stephenson, 2016). The magnitude of stigma can vary by setting where as rural areas have higher levels of stigma associated with the community. Additionally, stigma can be seen throughout the entire spectrum of care, to include palliative care (Maingi, Bagabag, & O’Mahony, 2018).
This literature review intends to compile academic research that identifies the current state of barriers to care for LGBT members of the community, locations most impacted, and best practices to adopt to improve health equities. Three themes were found: assessing hospitals, healthcare setting variances, and enacting best practices.
Due to the recent societal changes within the previous two decades, only articles found newer than 1999 are to be included. Any articles found dating prior are excluded. Sources will be identified via Ebsco Academic Search Complete, Google Scholar, PubMed, and LexisNexis. Search terms tried are identified from the following research questions:
- What are the best-case practices to improving access to care for LGBT populations as determined by a systematic review?
- What are the barriers to care for LGBT populations in the US healthcare markets?
- What evidence exists for changes to healthcare outcomes for LGBT populations over the previous decade? How does this vary geographically?
Articles are scrutinized individually prior to inclusion into this literature review for logic and suitability. Fitting articles identified for fitness into applicable themes.
Theme One: Assessing Hospitals
United States healthcare is incredibly varied by hospital type, funding method, ownership, size, and location (AHA hospital facts, 2019). Of the over 6,000 hospitals in the United States, approximately 3,000 are not-for-profit community hospitals, over 1,000 are for profit centers, and slightly less than 1,000 are state or locally ran. Approximately 931,203 hospital beds are present throughout the United States. Solely rural hospitals make up 1,875 hospitals in the United States.
All this variation considered, the approaches to creating equities and inclusive organizations for the LGBT population will vary as well by individual hospitals. Changes in society and acceptance also play into how care is delivered to the LGBT community. To address past and current states of LGBT equities in healthcare, literature has pointed to various surveys delivered to hospital systems to quantify how well systems are meeting needs of this community.
Surveys from the non-profit Human Rights Campaign were first distributed in 2006 and 88 hospitals voluntarily reported metrics (Zigmond, 2008). HRC as an entity has a history of ranking equities as part of their overall mission. This survey was built upon their other major survey, the Equality Index, which assessed workers’ rights at major corporations. To be successful in the first iteration, HRC partnered with a group called GLMA, a consortium of LGBT healthcare professionals (DuBias, 2006).
Looking at more recent iterations of the Health Equality Index, more than 1,600 hospitals are responding to questionnaires and allow for public access to this data (Klotzbaugh, 2016). By allowing wider dissemination of the results to the public, members of the LGBT community can identify hospitals that have better practices in reducing stigma and creating an environment of open access. Hospitals are also enabled to compete for ranking and share practices at professional organization meetings such as ACHE, AMA, APA, et cetera. Hospitals have also published favorable results from this survey on their websites, just as they would for accreditation.
When looking at Klotzbaugh’s article specifically, results from the HRC survey were further analyzed via descriptive statistics and chi-squared analysis to determine LGBT competency training for healthcare professionals is one factor that sets hospitals a part in rankings. Using a similar format, McElroy, Wintemberg, & Haller used GLMA and methods similar to look at a narrower set of hospitals: those in the state of Missouri (2015). This methodology could be employed elsewhere to create increased local stakeholder engagement in other regions.
Internationally, this surveying idea is taking off in Europe too (Zeeman et al, 2019). Zeeman et al created a systematic review of 57 articles to synthesize access to care and LGBT best practices across Europe. By doing so, differences in cultures and systems can be identified for the ultimate patron: possible patients.
Ranking hospitals by subject matter expert third parties was a major element found in literature searches. Doing rankings and surveys in this method helps direct the efforts of leadership to implement changes in hospital settings. As society changes as a whole, these surveys will likely reflect new opportunities to improve LGBT health equities. Assessing hospitals leads into the research question of identifying barriers, which can provide the current state snapshot to build metrics against.
Theme Two: Healthcare Setting Variance
Surveys also noted a major difference between urban and rural settings for LGBT inclusiveness (Fisher, Irwin, & Coleman, 2014). Digging deeper, Whitehead, Shaver, & Stephenson found that the major difference in their surveys was a perceived higher level of stigma at rural hospitals when compared to urban centers (2016). Stigma can be reduced by training providers to help provide greater cultural competence.
One of the starkest contrasts in rural versus urban LGBT healthcare came in the survey by Patterson, Jabson-Tree, and Kamen’s article (2019). Of n=85 rural providers, only 54.1% surveyed felt competent to provide for LGBT healthcare. Though 92.9% said they would not refuse care, that leaves an approximate 7.1% that would. This 7.1% is a significant figure if word of mouth of refusal travels which could create barriers to care.
Mental health provider shortages are felt across the United States. This domain is also studied for the LGBT population (Israel, Willging, & Ley, 2016). While the shortages are felt, members of the LGBT community may feel additional barriers accessing this care with provider misunderstandings, competencies for the population, and possible low LGBT patient populations to build knowledge, skills, and abilities. According to the non-profit Trevor project, this is especially felt in youth populations where suicide is the second leading cause of death for ages 10 to 24 (Facts about suicide, 2019). Lesbians, Gays, and Bisexuals are at a three times higher relative risk for suicide than heterosexuals. 40% of transgender adults have reported suicide attempts. Training providers in best practice approaches will help improve the mental health treatments of LGBT persons.
When considering the vast geographic area of the United States and the various sizes of hospitals, it would seem that perceived barriers to access, varying levels of stigma, and specialized community training is as vast as the country. Communicating best practices, identifying gaps, and providing training could significantly help members of the LGBT population access systems at greater rates. This theme addresses barrier identification and geographic variance in research questions.
Theme Three: Best Practices
Previous literature themes have identified that differences exist between hospitals, the ability to quantitatively and qualitatively rank hospitals with third parties, identify differences in rural and urban settings, and mentions the idea of stigma. Surveys such as the one listed by Whitehead, Shaver, & Stephenson have noted the need for trained providers to break down perceived stigma (2016). Collectively, these articles identify a need for best practices to guide continued improvements in hospital settings for members of the LGBT community.
Common tools to effect change could include continuous process improvement projects (Mitchell, Malatzky, Bourke, & Farmer, 2018). Using a formal process is key to show improvement of the population and define base metrics. This would need the use of subject matter experts that are familiar with differences between sub groups (Barker, 2008). Barker argues that process improvements can only occur after inequities are defined. Though general best practices can be defined by research, it must be known that people who are lesbian, gays, bisexual, and/or transgender each have group unique needs too (Lim, Brown, Sung Min, & Kim, 2014).
Each of these best practices can be consolidated and inform healthcare professionals (Schrager, Steiner, Bouris, Macapagal, & Brown, 2019). One best practice noted by Song, Poythress, Bocchini, & Kass is the use of medical students to spread the message and create generational change (2018). This is also recommended in nursing education (Orgel, 2017). Another practice is updating electronic health record prompts to create inclusive data entry and remind providers of preferred language terms (Nguyen & Yehia, 2015). When engaging in culture changes it still remains beneficial to survey and document progress just as Israel, Willging, and Ley did in 2016 with pre and post surveys.
Some settings create unique needs when developing programs. After the repeal of Don’t Ask, Don’t Tell for service members, active duty, veterans, and dependents were able to live openly as members of the lesbian, gay, and bisexual communities. However, there still was a stigma felt when accessing military and veterans’ health systems (Valentine, Shipherd, Smith, & Kauth, 2019). To foster greater inclusivity and improve outcomes of the veteran population, Veteran Care Coordinators were created for the LGBT community in the VA system. This allowed for better coordination of care.
Another unique setting requiring paradigm shifts was that in palliative care (Maingi, Bagabag, & O’Mahony, 2018). Open and inclusive palliative care needs new considerations with changed legal definitions of marriage in the United States. Spouses may be of the same gender seeking palliative care for one in the relationship.
As mentioned above, youth are at high risks for mental health concerns. Hadland, Yehia, & Makadon consolidated many of the concerns for younger LGBT populations (2016). Sexual education as traditionally developed does not include LGBT youths, STI transmission follows different epidemiological vectors, and social interactions use different terminology.
Best practices developed address the main research question. Problem identification is good to understand inequities. However, best practices show evidence based methods to create better equities in healthcare and are key to program development.
Societal changes have prompted increased analysis of the health needs of the LGBT population. Literature found for this review showed the ability to rank and access hospitals. Human Rights Campaign and GLMA have models to assess individual hospitals in a similar way the Human Rights Campaign assesses business inclusion. As the United States is a culturally and geographically diverse nation, variations are seen between the rural and urban healthcare settings.
When needs assessments and surveys are completed, improving equities can occur from a variety of models. These could include training medical students, for CEUs, and even creating engineered changes to electronic health records. Keeping in mind special populations such as youth or end of life care, best practices can be specific. Additionally, evidence based best practices could be communicated easily through literature. The biggest barrier could be a system’s desire for change and inclusivity.
Consolidated References Table
|Citation||Design/ Method||Sample/ Setting||Measurement or Framework||Data Analysis||Findings||Appraisal: Themes Present|
|Klotzbaugh, R. (2016).||Mixed Method Electronic Survey||US Hospital Centers||Electronic Survey, Satisfaction scores||Chi-Square and Descriptive Statistics||Better LGBT competency training needs to occur for staff working in patient settings||Hospital Ranking Overview, HRC has devised a basic scheme by survey to identify best hospital systems for LGBT|
|Zigmond, J. (2008).||Article||American Hospitals||N/A||N/A||Press related to the establishment of the HRC equality index||Hospital Ranking Overview, HRC initially reviewed 88 hospitals from 21 states (Background)|
|DoBias, M. (2006).||Article||American Hospitals||N/A: Discussion Format||N/A||Describes the initial phases of surveying||Hospital Ranking with HRC and GLMA|
|Zeeman, L., Sherriff, N., Browne, K., McGlynn, N., Mirandola, M., Gios, L., … Network, H. (2019).||Systematic Review||European Health Systems||57 Articles Synthesized into One Theme||Systematic Review||Health disparities due to minority stress, victimization, discrimination, and stigma. Age, gender, income, disabilities compound as factors||Though in European systems, this succinctly lists themes for measurement based on review of 57 articles|
|Whitehead, J., Shaver, J., & Stephenson, R. (2016).||Quantitative Survey||Rural Hospitals||Electronic Survey||Quantitative via STATA||Stigma is primary factor studied. Higher levels of stigma regarding LGBT identity correlated to lower levels of utilization||Rural versus Urban, Disparities found at higher magnitude in rural settings|
|Mitchell, O., Malatzky, C., Bourke, L., & Farmer, J. (2018).||CPI||Rural Hospitals in Australia||Continuous Process Improvement||Qualitative Description of a Quantitative Process||CPI builds upon existing initiatives to create greater inclusion of LGBT in rural areas||Rural disparities and inclusion|
|Fisher, C. M., Irwin, J. A., & Coleman, J. D. (2014).||Journal Editorial||Rural Hospitals US and EU||Journal Description||Qualitative||Introduces other research articles for that editions journal theme: rural LGBT health||Overviews numerous journal articles regarding rural healthcare access for LGBT|
|Barker, M. R. (2008).||Framework Method Analysis||US Hospitals||Framework Analysis||Qualitative||Comprehensive Themes regarding Health Disparities||Best Practices can be developed after inequities studied|
|Lim, F. A., Brown Jr., D. V., & Sung Min Justin Kim. (2014).||Systematic Review||US Hospitals||Systematic Review||Qualitative||Lists Best Practices||Consolidates best practices. Lists how LGBT members are unalike but can still create inclusivity|
|Maingi, S., Bagabag, A. E., O’Mahony, S., Maingi, S., Bagabag, A., & O’Mahony, S. (2018).||Framework Method Analysis||Palliative Care Settings||Framework Analysis||Qualitative||Best Practices||Consolidates Best Practices for LGBT in Palliative Care Settings|
|Nguyen, G. T., & Yehia, B. R. (2015).||Quantitative Study||US Hospitals||Report Review||Descriptive Statistics / Quant Analysis||Best Practice||Highlights use of EHR as best practice to document gender of partners|
|Valentine, S.E., Shipherd, J.C., Smith, A.M., & Kauth, M.R. (2019)||Quantitative Survey Study||VA Hospitals||Consolidated Framework for Implementation Review||Quantitative||Surveying VA Systems||Veteran Care Coordinators surveyed to see where VCCs stood on LGBT access|
|Song, A. Y., Poythress, E. L., Bocchini, C. E. & Kass, J. S. (2018)||Survey||Medical Students||SDHOP Method||Survey, Social Determinants of Health||Early Intervention in medical students||Public Health Best Practices: Early Training|
|Patterson, J.G., Jabson Tree, J.M., & Kamen, C. (2019).||Survey||Tennessee Hospitals||Survey||Quantitative||Cultural Competence Surveyed||Rural Care Barriers|
|Schrager, S.M., Steiner, R. J., Bouris, A. M. Macapagal, K., & Brown, C. H. (2019).||Consolidated Best Practices||Academic Researchers||SGM Dialogue||Thoughtful Research discussion||Limitations to researching SGM youths||Best Practices for Research|
|McElroy, J. A., Wintemberg, J.J., & Haller, K. A. (2015)||Listing of LGBT Health Indexes||Missouri Hospitals, US Focus||N/A||Listing of Common Indexes||Multiple Indexes Exist for Hospitals and Providers||Assessing Hospitals and Providers|
|Israel, T., Willging, C., & Ley, C. (2016).||Pre / Post Intervention Survey||Rural Mental Health Providers||Pre/Post||Mixed Methods||Rural Settings require additional provider training for LGBT patients||Rural Mental Health Care|
|Hadland, S.E., Yehia, B.R, & Makadon, H.J. (2016)||Consolidated Best Practices||Youth Treatment||Systems Analysis||Consolidated Strategies||Special Considerations Needed for Population||Best Practices|
|Smalley, K. B., Warren, J. C., & Barefoot, K. N. (2016)||Survey 3,1276||Georgia Rural Communities||Health Belief / Health Behaviors||Health Risk Questionnaire Consolidate Results||LGBT subgroups have different needs||Assessing Needs|
|Traynor (2016)||Case Study||LGBT Leadership in Health System||Case Study||Case Study||Cultural Competence Matters in Health||Best Practices: Leadership|
|Orgel (2017)||Systematic Review, DNP Project||Nursing Students||Systematic Review||Qualitative||Cultural Competence Required in Nursing Students||Best Practices|
|Hinrichs & Donaldson (2017)||Case Study/ Discussion||VA Hospital||Case Study||Qualitative||Older LGBT adults may benefit from affirmative psychotherapy||Best Practices|
|Foglia & Fredriksen-Goldsen (2014)||Study Review||National Survey||National Health, Aging, and Sexuality Study||Mixed Methods||Unconscious bias in older LGBT Adults is shown to exist||Background|
AHA Hospital Facts. (2019, January). Retrieved November 7, 2019, from https://www.aha.org/statistics/fast-facts-us-hospitals.
Barker, M. R. (2008). Gay and Lesbian Health Disparities: Evidence and Recommendations for Elimination. Journal of Health Disparities Research & Practice, 2(2), 91–120.
DoBias, M. (2006). Gay groups question hospitals. Modern Healthcare, 36(48), 21. Retrieved from https://search-ebscohost-com.links.franklin.edu/login.aspx? direct=true&db=a9h&AN=23509268&site=ehost-live
Facts about suicide. (2019). Retrieved from https://www.thetrevorproject.org/resource/preventing-suicide/facts-about-suicide/
Fisher, C. M., Irwin, J. A., & Coleman, J. D. (2014). Rural LGBT Health: Introduction to a Dedicated Issue of the Journal of Homosexuality. Journal of Homosexuality, 61(8), 1057–1061.
Foglia, M. B., & Fredriksen, G. K. I. (2014). Health Disparities among LGBT Older Adults and the Role of Nonconscious Bias. Hastings Center Report, 44, S40–S44. https://doi.org/10.1002/hast.369
Hinrichs, K. L. M., & Donaldson, W. (2017). Recommendations for Use of Affirmative Psychotherapy With LGBT Older Adults. Journal of Clinical Psychology, 73(8), 945–953. https://doi.org/10.1002/jclp.22505
Israel, T., Willging, C., & Ley, D. (2016). Development and evaluation of training for rural LGBTQ mental health peer advocates. Rural Mental Health, 40(1), 40-62.
Klotzbaugh, R. (2016). Lesbian, Gay, Bisexual, and Transgender Patient Inpatient Satisfaction Survey: Results and Implications. Nursing Research, 65(2), E111–E112.
Klotzbaugh, R., & Spencer, G. (2018). Lesbian, Gay, Bisexual, and Transgender Inpatient Satisfaction Survey: Results and Implications. Journal of Patient Experience. https://doi.org/10.1177/2374373518809503
Lim, F. A., Brown Jr., D. V., & Sung Min Justin Kim. (2014). Addressing Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices. AJN American Journal of Nursing, 114(6), 24–35.
Maingi, S., Bagabag, A. E., O’Mahony, S., Maingi, S., Bagabag, A., & O’Mahony, S. (2018). Current Best Practices for Sexual and Gender Minorities in Hospice and Palliative Care Settings. Journal of Pain & Symptom Management, 55(5), 1420– 1427. https://doi-org.links.franklin.edu/10.1016/j.jpainsymman.2017.12.479
McElroy, J.A., Wintemberg, J.J., & Haller, K.A. (2015). Advancing healthcare for lesbian, gay, bisexual, and transgender patients in Missouri. Missouri Medicine, 112(4), 262-265.
Mitchell, O., Malatzky, C., Bourke, L., & Farmer, J. (2018). A modified Continuous Quality Improvement approach to improve culturally and socially inclusive care within rural health services. Australian Journal of Rural Health, 26(3), 206–210. https://doi-org.links.franklin.edu/10.1111/ajr.12409
Nguyen, G. T., & Yehia, B. R. (2015). Documentation of Sexual Partner Gender Is Low in Electronic Health Records: Observations, Predictors, and Recommendationsto Improve Population Health Management in Primary Care. Population Health Management, 18(3), 217–222.
Orgel, H. (2017). Improving LGBT Cultural Competence in Nursing Students: An Integrative Review. ABNF Journal, 28(1), 14–18. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=a2h&AN=121353795&sit e=ehost-live
Patterson, J. G., Jabson-Tree, J. M., & Kamen, C. (2019). Cultural competency and microaggressions in the provision of care to LGBT patients in rural and Appalachian Tennessee. Patient Education and Counseling. 2081-2090.
Schrager, S. M. Steiner, R. J., Bouris, A. M., Macapagal, K. & Brown, C, (2019). Methodological considerations for advancing research on the health and wellbeing of sexual and gender minority youth. LGBT Health. 6(4), 156-165.
Song, A. Y., Poythress, E. L., Bocchini, C. E. & Kass, J. S. (2018). Reorienting Orientation: Introducing the social determinants of health to first-year medical students. MedEdPortal: the journal of teaching and learning resources, 14, 10752.
Smalley, K.B., Warren, J.C., & Barefoot, K. N. (2016). Differences in health risk behaviors across understudied LGBT subgroups. Health Psychology. 35(2), 103-114.
Traynor, K. (2016). Words, cultural competence matter in LGBT patient care. American Journal of Health-System Pharmacy, 73(14), 1022–1023. https://doi.org/10.2146/news160043
Whitehead, J., Shaver, J., & Stephenson, R. (2016). Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations. PLoS ONE, 11(1), 1–17.
Valentine, S. E., Shipherd, J. C., Smith, A. M., & Kauth, M. R. (2019). Improving affirming care for sexual and gender minority veterans. Psychology Services.
Zeeman, L., Sherriff, N., Browne, K., McGlynn, N., Mirandola, M., Gios, L., … Network, H. (2019). A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities. European Journal of Public Health, 29(5), 974–980. https://doi-org.links.franklin.edu/10.1093/eurpub/cky226
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