Epidemiological research on marginalized groups implies major validity challenges; lesbian health as an example

Decolonizing Epidemiological Research: A Critical Perspective

Decolonizing epidemiological research is a crucial endeavor. Historically, colonial and imperialistic ideologies have pervaded epidemiology, leading to an emphasis on Western perspectives and the neglect of indigenous and other marginalized communities' needs and experiences. To effectively address health disparities and promote justice and equality, acknowledging and addressing these power imbalances are imperative. In this article, I highlight the need of decolonizing epidemiological research and make recommendations. These include increasing the representation of researchers from underrepresented communities, ensuring that epidemiological research is contextually relevant and responsive to the experiences of these communities, and collaborating with policymakers and advocacy groups to inform policies and practices that benefit all populations. Moreover, I underscore the importance of recognizing and valuing the knowledge and skills of marginalized populations, and integrating traditional knowledge-the distinct, culturally specific understanding unique to a particular group-into research efforts. I also emphasize the need of capacity building and equitable research collaborations and authorship as well as epidemiological journal editorship. Decolonizing epidemiology research is a continual process that requires continuing discourse, collaboration, and education.

Oversampling as a methodological strategy for the study of self-reported health among lesbian, gay and bisexual populations

AIMS

Epidemiological research on lesbian, gay and bisexual populations raises concerns regarding self-selection and group sizes. The aim of this research was to present strategies used to overcome these challenges in a national population-based web survey of self-reported sexual orientation and living conditions-exemplified with a case of daily tobacco smoking.

METHODS

The sample was extracted from pre-established national web panels. Utilizing an oversampling strategy, we established a sample including 315 gay men, 217 bisexual men, 789 heterosexual men, 197 lesbian women, 405 bisexual women and 979 heterosexual women. We compared daily smoking, representing three levels of differentiation of sexual orientation for each gender.

RESULTS

The aggregation of all non-heterosexuals into one group yielded a higher odds ratio (OR) for non-heterosexuals being a daily smoker. The aggregation of lesbian and bisexual women indicated higher OR between this group and heterosexual women. The full differentiation yielded no differences between groups except for bisexual compared with heterosexual women.

CONCLUSIONS

The analyses demonstrated the advantage of differentiation of sexual orientation and gender, in this case bisexual women were the main source of group differences. We recommend an oversampling procedure, making it possible to avoid self-recruitment and to increase the transferability of findings.

Lesbian womens' access to healthcare, experiences with and expectations towards GPs in German primary care

Background

Lesbian women have higher rates of physical and psychiatric disorders associated with experiences of discrimination, homophobia and difficulties with coming out. Therefore, easy access to specialized healthcare in an open atmosphere is needed. We aimed to describe women’s access to and experiences with healthcare in Germany, and to assess the responsibility of the general practitioner (GP) compared to other specialities providing primary health care.

Methods

A questionnaire study was conducted via internet and paper-based sampling. Using current literature, we designed a questionnaire consisting of sociodemographic data, sexual orientation, access to care and reasons for encounter, disclosure of sexual orientation, experience with the German health system (discrimination, homophobia), and psychological burden. Depression was assessed using the depression screening from the Patient Health Questionnaire (PHQ-2).

Results

We obtained responses from 766 lesbian women. Although 89% had a primary care physician, only 40% had revealed their sexual orientation to their doctor. The main medical contacts were GPs (66%), gynaecologists (10%) or psychiatrists (6%). Twenty-three percent claimed they were unable to find a primary care physician. Another 12.4% had experienced discrimination. Younger lesbian women with higher education levels and who were less likely to be out to other physicians were more likely to disclose their sexual orientation to their primary care physician. GPs play an important role in healthcare for lesbian women, even in a non-gatekeeping healthcare system like Germany. Study participants suggested improvements regarding gender neutral language, flyers on homosexuality in waiting areas, involvement of partners, training of physicians, directories of homosexual physicians and labelling as a lesbian-friendly practice.

Conclusions

GPs should create an open atmosphere and acquire the respective knowledge to provide adequate treatment. Caring for marginal groups should be incorporated in medical training and further education. Ideally, physicians address patients’ sexual orientation pro-actively in order to address individual needs accordingly.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0562-4) contains supplementary material, which is available to authorized users.

Sexual rights but not the right to health? Lesbian and bisexual women in South Africa's National Strategic Plans on HIV and STIs

Synergies between securing sexual rights and the right to health have been pursued where there are clear public health gains to be made, such as lowering incidence of HIV and other sexually transmitted infections (STI). South Africa's 1996 Constitution outlawed discrimination on the basis of sexual orientation and promoted the right to health. This qualitative health policy analysis sought to understand why and how interventions to improve sexual health of lesbian and bisexual women and address sexual violence were initially proposed in the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 and why and how these concerns were deprioritised in the National Strategic Plan (NSP) on HIV, STIs and TB 2012-2016. A conceptual framework considered several determinants of political priority for the inclusion in NSP development in 2007 and 2011 around sexual health concerns of women who have sex with women. This article presents findings from 25 in-depth key informant interviews and document review and highlights results of application of categories for a framework on determinants of political priority for lesbian and bisexual women's issues to be included in South Africa's NSP including: actor power, ideas, political context and issue characteristics. The article demonstrates how the epidemiological and structural drivers of lesbian and bisexual women's vulnerability to HIV and STIs, including sexual violence and other violations of their sexual rights, have been expressed in policy forums and whether this has made an impact on lesbian and bisexual women's ability to claim the right to health.

Comparing health survey data from Internet- and paper-based convenience samples of lesbian women in Germany

Background Members of populations that are measured online should be compared with paper-based samples in order to determine whether data from these different sources can be merged or must be analysed separately due to substantial differences. Methods: A sample of lesbian women recruited via the Internet were compared with a paper-based sample. Both groups used a questionnaire consisting of demographic variables, questions regarding dealing with homosexuality, psychological burden, access to care, and discrimination experience within the German healthcare system. Results: Only small differences emerged in dealing with homosexuality between both groups. Moderately more women in the Internet-based sample suffered from nervous tension and the impression of being out of balance. Moderately more women in the paper-based sample stated that their main contact person regarding health matters was informed about their sexual orientation. Most differences had small effect sizes. No substantial differences occurred between the two groups in the area of discrimination experience. No large differences in socioeconomic data, psychological burden, healthcare utilisation, or dealing with or experiences with homosexuality were found. Conclusions: Health survey data derived from Internet- and paper-based samples of lesbian women in Germany are not too dissimilar. Further research in additional contexts is needed to decide whether they can be merged for further analyses.

[The lesbian population in health studies: contributions for a critical reflection]

For decades, lesbian sexuality was associated with pathology in the attitudes to and practices of health sciences and psychology. During the twentieth century that position changed gradually. This article analyzes these changes in a theoretical reflection on the domain of lesbian health, dominated by heteronormative and heterosexist concepts and practices both in research and in health care. By means of a critical contextualization of the literature, specific health needs of lesbians were identified and the interventions of health care professionals and services were questioned. Specific concrete actions are proposed in the fields of health promotion and in the eradication of discrimination and inequality in health care.

Lesbians on Medical Encounters: Tales of Heteronormativity, Deception, and Expectations

The experiences of lesbian women in medical encounters prove particularly relevant for understanding their difficulties in their relationship with professionals and health services. We carried out semistructured interviews with 30 women aged 21 to 63 years, who define themselves as lesbian. The analysis highlights the difficulties experienced in disclosure of sexuality in medical encounters, the tendency for doctors to come across as heteronormative, and also medical practices experienced as appropriate by interviewees. Analysis of participant experiences demonstrates the need for reflection and decision making to promote the recognition of the sexual citizenship of lesbian women and their empowerment.

Nursing's silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts

The purpose of this study was to selectively review the nursing literature for publications related to lesbian, gay, bisexual, and transgender health, using (1) a key word search of CINAHL, the database of nursing and allied health publications; (2) from the top-10 nursing journals by 5-year impact factor from 2005 to 2009, counting articles about lesbian, gay, bisexual, and transgender issues; and (3) content analysis of the articles found in those journals. Only 0.16% of articles focused on lesbian, gay, bisexual, and transgender health (8 of nearly 5000 articles) and were biased toward authors outside of the United States. We discuss the impact of this silence.

[Lesbian women's health-promoting experiences]

BACKGROUND

For lesbian women, we know more about causes of health problems than health-promoting factors. The aim of this study was to explore what lesbian women have perceived as health-promoting experiences.

MATERIAL AND METHODS

Focus group study with two group interviews (with nine lesbian women aged 40-55 years). Participants were required to be "out of the closet" regarding sexual orientation and to feel comfortable with their lives as lesbians. The interviews were audiotaped, transcribed, and analyzed with systematic text condensation supported by a salutogenic frame of reference.

RESULTS

The women told about how a perception of being different could translate into opportunities and a positive strength. A good "coming-out process" could lead to companionship and strategies for coping with challenges. Furthermore, feelings of exemption from expectations of a narrow gender role had a positive impact on identity and sexuality. Finally, the liberating consequences of being able to organize personal relationships and family according to own priorities opened up new possibilities, especially regarding choosing to have children or not.

INTERPRETATION

Health promoting strategies and initiatives must be grounded in what individuals consider to be important in their own lives. Knowledge about lesbians' health-promoting experiences may contribute to a positive focus on coping with minority stress and challenge an established understanding of pathology in a marginalized group.

Preventing obesity: challenges and pitfalls for health promotion

OBJECTIVE

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

METHODS

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

RESULTS

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

CONCLUSION

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

PRACTICE IMPLICATIONS

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Lesbian women's experiences with health care: a qualitative study

BACKGROUND

Although the social situation for gay, lesbian, and bisexual people has improved over the last decades, lesbian women still face unique challenges when seeking healthcare services.

OBJECTIVES

To explore lesbian women's healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.

METHODS

Qualitative study based on written stories, with recruitment, information, and data sampling over the internet. Data consisted of 128 anonymously written answers to a web-based, open-ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity. Main outcome measures. Patients' histories of experiences where a lesbian orientation was significant, when seeing a doctor or another healthcare professional.

RESULTS

Analysis presented three different aspects of healthcare professionals' abilities, regarded as essential by our lesbian participants. First, the perspective of awareness was addressed--is the healthcare professional able to think of and facilitate the disclosure of a lesbian orientation? Second, histories pointed to the attitudes towards homosexuality--does the healthcare professional acknowledge and respect the lesbian orientation? Third, the impact of specific and adequate medical knowledge was emphasized--does the healthcare professional know enough about the specific health concerns of lesbian women?

CONCLUSION

To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to be a necessary prerequisite.