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18 Using Community-Based Participatory Research to Understand and Eliminate Social Disparities in Health for Lesbian, Gay, Bisexual, and Transgender Populations Mary E. Northridge, Brian P. McGrath, and Sam Quan Krueger

1 Introduction In the United States, public health developed to a large degree as a voluntary movement—or, more accurately, a set of different voluntary movements—each campaigning for some particular health reform. As these movements became professionalized, as the first health departments were created, and as the first schools of public health were developed, scientific education was seen as the necessary basis of rational social and health reform. Over time, and especially after World War II, pressures on schools of public health led to an ever greater emphasis on research than on practice, a tendency fueled by the funding mechanisms of the National Institutes of Health. By the 1980s it had become clear that the schools of public health and their research productivity had become ever more clearly divorced from the activities of public health departments. The movement to community-based participatory research (CBPR) was, then, an attempt to reconnect the research enterprise with the actual needs of public health as defined by the people whose health was to be affected. In this, the final methodologic chapter of this volume, we build on the foundation presented in earlier chapters and introduce a research approach that we have found useful for confronting social disparities in health for disadvantaged communities. The credit (blame?) for including this chapter goes to our devoted colleague, Ilan H. Meyer, who has been encouraging us for years to apply participatory research approaches to issues of concern in lesbian, gay, bisexual, and transgender (LGBT) communities and finally succeeded in cajoling

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(pushing?) us to give it a go. Hence, we draw heavily on our experiences in designing and conducting participatory research, practice, and advocacy work in population health initiatives, urban design projects, and Asian and Pacific Islander (API) coalitions. Our hope is that by writing this interdisciplinary chapter together, we can clarify our own thinking and perhaps motivate future research and interventions by our group and others that address egregious social disparities in health for LBGT populations. We begin with a brief history of participatory research and why we believe it has the potential to contribute meaningfully to the scientific basis for both understanding and eliminating social disparities in health for LGBT populations. Second, we draw apt examples from the peer-reviewed public health literature of studies that have explicitly used participatory research to understand and/or address social disparities in health for LGBT communities. Third, we present a conceptual framework entitled Social Determinants of LGBT Health to trace pathways whereby factors at various levels [e.g., heterosexism, workplace policies, human immunodeficiency virus (HIV) screening] may lead to inequalities in health and well-being for LGBT individuals and communities. In doing so, we include examples drawn from our own participatory research, practice, and education initiatives that were explicitly designed to intervene to eliminate social disparities in health for LGBT populations. In closing, we emphasize the importance of extracting the core issues from the context in which they are researched and practiced to derive best principles and best processes that may be transferable to other settings (Green, 2001; Sclar et al., 2005). This is essential if public health research and practice in LGBT populations is to benefit from the seminal participatory work conducted in other politically and socially oppressed communities. It is important to note that CBPR has a long history. During the 1940s, social psychologist Kurt Lewin (1946) developed the action research school, which emphasized active involvement in the research of those affected by the problem through a cyclical process of fact finding, action, and reflection. During the 1970s, more revolutionary approaches to research emerged—often independently of one another—from work in oppressed communities throughout the developing world (Minkler, 2005). In particular, Brazilian educator Paulo Friere (1970) provided critical grounding for CBPR in his dialogic method accenting co-learning and action based on critical reflection. Scholars in the developing countries of South America, Asia, and Africa fostered their alternative approaches to scientific inquiry as a direct counter to the colonizing nature of research to which oppressed communities were routinely subjected. More recent efforts by feminists and racial/ethnic minorities have added further conceptual richness to CBPR approaches (Maguire, 1987; Duran & Duran, 1995). Although these historical efforts around participatory research vary, they share the same impulse and commitment: to make health research and public health services responsive to the expressed needs of people in communities. Although many of the individual efforts were shortlived, their legacy is impressive, and their examples serve as models today. One continuing structural problem is that the most successful of

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such participatory experiments tend to provoke political opposition— they are vulnerable to being closed down (e.g., by the imprisonment of their leaders) or slowly starved of energy (e.g., by the withdrawal of funds). Indeed, one historical lesson is that such pioneering efforts need continued support and energetic political pressure to keep the doors of opportunity open. Next we provide examples from the public health literature of the use of participatory research approaches to address needs and concerns in LGBT communities.

2 Use of Participatory Research Approaches to Examine Social Disparities in LGBT Health It is essential when discussing CBPR and LGBT health to stress the critical role that ACT UP (AIDS Coalition to Unleash Power) and other LGBT groups have played in bringing vital government attention and resources to HIV-acquired immunodeficiency syndrome (HIV/AIDS) and other health research focused on LGBT concerns (ACT UP, 2005). Indeed, ACT UP is credited with fostering revolutionary changes in research procedures, including those involved in clinical trials. LGBT individuals, through ACT UP and other organized efforts, responded to the HIV/AIDS crisis by starting their own community-based research projects inside and outside the academic world. They raised funds to advance their agendas in the face of governmental inaction and pushed a collection of activist organizations into a national civil rights movement that challenged some of the most powerful U.S. institutions (Andriote, 1999). Other sections of this volume are devoted to health services for LGBT populations (see especially Chapter 28 on the Fenway Community Health model, previously described by Mayer et al., 2001). In this chapter, we deliberately focus attention instead on the social determinants of health of special concern for LGBT individuals and populations to ensure vital coverage of this emerging public health research area. We make no claim of being comprehensive. Rather, we have selected from the peer-reviewed public health literature those studies we believe are illustrative of an assortment of health issues addressed by a variety of participatory approaches. According to Minkler (2005, p. ii5), “CBPR is not a method per se but an orientation to research that may employ any of a number of qualitative and quantitative methodologies.” Cornwall and Jewkes (1995) have argued that what is distinctive about CBPR is the attitudes of the researchers, which in turn determine how, by, and for whom research is conceptualized and conducted, and the corresponding location of power at every stage of the research process (italics are our own). Our hope in this section is that by highlighting thoughtful examples of participatory research in LGBT populations across a range of concerns using various methods, the conceptual model and best principles we later invoke might be better grounded in the reality of people’s lives and more readily applied to improve their health and well-being. Photovoice (Wang & Burris, 1997) is a form of participatory action research that uses documentary photography and storytelling. Using

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this approach, Graziano (2004) examined how Black gay men and lesbians view themselves in relation to White gay men and lesbians in South Africa. Participants included four women and three men from four South African townships who reported being sexually and physically assaulted for challenging the heterosexual status quo. Themes that emerged from this study were that class bias, cultural traditions of visiting African healers, and segregated social spaces are important issues to consider in future efforts to understand and address LGBT health in South Africa. Notably, Graziano (2004) concluded that amidst oppression and despair study participants showed signs of strength, hope, and optimism. MacQueen et al. (2001) conducted qualitative interviews with 25 African Americans in Durham (North Carolina), 26 gay men in San Francisco, 25 injection drug users in Philadelphia, and 42 HIV vaccine researchers across the United States to identify strategies to support community collaboration in HIV vaccine trials. Verbatim responses to the question, “What does the word community mean to you?” were analyzed. Cluster analysis was used to identify similarities in the way community was described. A common definition of community emerged as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographic locations or settings. The salience of the various elements of community for each of the four participant groups had implications for the ways in which collaborations developed. In particular, for gay men in San Francisco, a strong sense of shared history and perspective was a dominant theme, followed by a sense of identity with a specific location, the creation of strong and lasting social ties, established avenues for joint action, and the role of diversity. This profile is superficially similar to the one elicited from the vaccine researchers; however, particular elements were discussed less frequently than in San Francisco. Significant differences also existed with regard to how the elements were discussed. Most of the San Francisco participants had thought about community, and many were struggling to reconcile their need for community with a sense of marginalization from society at large. In contrast, the scientists tended to describe themselves as well grounded in multiple communities. Griffin (1992) described the experiences of 13 lesbian and gay educators in a participatory research project that aimed to empower the participants through collective reflection and action. Each participant was interviewed and given a copy of her or his audio-tape and transcript. Using these materials, each participant developed a profile of himself or herself to share with the other participants. During a series of group meetings that spanned 15 months, participants discussed their experiences, searched for common themes, and planned two collective actions. Griffin relates the professional experiences of these lesbian and gay educators and the process of empowerment that changed their lives. Finally, Mulvey et al. (2000) collected stories about community work in New Zealand and Scotland so they could describe and reflect on issues central to feminist community psychology. Organizing a lesbian festival, Ingrid Huygens describes feminist processes used to equalize


resources across Maori (Indigenous) and Pakeha (White) groups. Heather Hamerton presents her experiences as a researcher using collective memory work to reflect on adolescent experiences related to gender, ethnicity, and class. Sharon Cahill chronicles dilemmas and insights from focus groups about anger with women living in public housing in Scotland. Each story chronicles experiences related to oppression and privilege and describes the author’s emotions and reflections. Individually and collectively, the stories illustrate the potential offered by narrative methods and participatory processes for challenging inequalities and encouraging social justice. Together, these studies examine a range of health concerns that affect LGBT communities to a larger extent than other communities, namely, sexual and physical violence, HIV/AIDS, and individual and community mental health. To trace the pathways whereby factors operating at various levels (e.g., heterosexism at the societal level in South Africa, collaboration in HIV vaccine trials at the community level, and empowering lesbian and gay educators at the interpersonal level) may lead to or rectify inequalities in health and well-being for LGBT communities, we next present a conceptual model.

3 Social Determinants of LGBT Health: Ecologic Model The authors of this chapter have previously been involved in efforts to understand how social, political, economic, and historical processes generate the urban built environment and shape population health and well-being. By the built environment, we mean that part of the physical environment made by people for people, including buildings such as houses, schools, and workplaces; transportation systems such as highways and railways; and open spaces such as parks and vacant lots (Northridge & Sclar, 2003). To clarify our thinking, we previously developed an ecologic model entitled Social Determinants of Health and Environmental Health Promotion (Northridge et al., 2003; Schulz & Northridge, 2004) to trace the pathways whereby social factors operating at different levels (societal, community, interpersonal) affect population health and well-being. In meeting the challenge to adapt this conceptual framework to focus particularly on the research needs of LGBT populations, we drew heavily on the work of Meyer (2003), who had formerly examined minority stress processes in lesbian, gay, and bisexual populations. The result is a combined ecologic model we refer to as Social Determinants of LGBT Health (see Fig. 18.1). We posit with our new model that the natural environment (including topography, climate, water supply, and air quality), macrosocial factors (including historical conditions, political and economic orders, and human rights doctrines), and inequalities (including those related to the distribution of wealth, employment and educational opportunities, and political influence) are fundamental factors operating at the societal level that underlie and influence the health and well-being of LGBT individuals and populations via multiple pathways through differential access to power, information, and resources (Link

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FUNDAMENTAL (societal level)

INTERMEDIATE (community level)

PROXIMATE (interpersonal level)

Natural environment • topography • climate • water supply • air quality

Built environment • land use (industrial, residential; mixed use or single use) • transportation systems • services (shopping, banking, health care facilities) • public resources (parks, museums, libraries) • zoning regulations • buildings (housing, schools, workplaces)

Macrosocial factors • historical conditions • political orders • economic orders • legal codes • human rights doctrines • social and cultural institutions • ideologies (heterosexism, sexism, racism, social justice, democracy) Inequalities • distribution of material wealth • distribution of employment opportunities • distribution of educational opportunities • distribution of political influence

Social context • minority identity (gay, lesb ian, bisexual, transgender) • community investment (economic development, maintenance, police services) • policies (public, fiscal, environmental, workplace) • enforcement of ordinances (public, environmental, workplace) • community capacity • civic participation and political influence • quality of education

Stressors/Buffers • environmental, neighborhood, workplace, and housing conditions • violent crime and safety • police response • financial insecurity • environmental toxins (lead, particulates) • unfair treatment (stigma, prejudice, discrimination ) Health behaviors • health screenings (HIV, ca ncer, hypertension) • physical activity • dietary practices • substance use (tobacco, alcohol, other)

HEALTH AND WELLBEING (individual and population levels) Health outcomes • mental health • injury/violence • HIV/AIDS • obesity/overweight • cardiovascular diseases • diabetes • cancers • infectious diseases • sexually transmitted diseases • respiratory health • all-cause mortality

Well-being • hope/despair • life satisfaction • psychosocial distress • happiness • disability • internalized homophobia • concealment of identity • expectations of rejection • body size and body image

Social integration • social participation and integration • shape of social networks • available resources within networks • coping and social support

Figure 18.1 Social determinants of LGBT health: This ecological framework for thinking about pathways whereby social determinants at various levels (societal, community, and interpersonal) influence LGBT health and well-being for both individuals and populations is adapted from a conceptual model entitled Social Determinants of Health and Environmental Health Promotion that first appeared in Northridge et al. (2003). In keeping with our emphasis here on social determinants of LGBT health, the model has been modified to incorporate insights from the conceptual framework entitled, Minority Stress Processes in Lesbian, Gay, and Bisexual Populations originally reported in Meyer (2003).


& Phelan, 1995). Note that we have added heterosexism and sexism to the list of ideologies delineated under macrosocial factors that operate to undermine the health and well-being of LGBT individuals and populations. Fundamental factors, in turn, influence intermediate factors. We added minority identity (gay, lesbian, bisexual, transgender) to the factors currently listed under social context that may positively and/or negatively affect the health and well-being of LGBT populations. That is, characteristics of minority identity may be both a source of harm (e.g., when they are associated with discrimination in employment or anti-gay violence) and strength (e.g., when they are associated with opportunities for enhanced social integration and social support). Intermediate factors comprise both the built environment (including land use, transportation systems, services, public resources, zoning regulations, and buildings) and social context (including community investment, public and fiscal policies, and civic participation, among others). An example of such work is Brian P. McGrath’s installation for the 1994 Queer Space exhibition at the Store Front for Art and Architecture in New York City. McGrath’s project was entitled There Is No Queer Space, Only Different Points of View. This statement ran at eye level along a semicircular plexiglass screen showing computer-generated images of various Manhattan locales (Reed, 1996). As McGrath et al. (1994) explained: This project is not about the making of queer space, but it is a representation of the possibilities of individual and minority appropriations of majority space. My intention is to describe the appropriation of public space, not to define a minority realm which exists separated from normative space. We must not make exclusive ghettos or enclaves, queer or straight. Queer space exists potentially everywhere in the public realm. Unbounded and ever-present, it is the individual’s appropriation of the public realm through their personal, everchanging points of view. An acoustical guide and navigational chart are provided in this project to describe a space which can barely be perceived by those outside of it, but vividly present to those who occupy it. The installation aims to invite others to occupy New York City from many different points of view.

The intention of community-based urban design work is to examine new possibilities for creating aesthetically experimental (i.e., queer) participatory design practices. Queer theory provides tools to mix and hybridize what are now separate and marginalized wings in architectural and urban design practices: aesthetic experimentation and participatory design. Our challenge is to create opportunities for LGBT populations and other marginalized groups to benefit from great design through their own curiosity and interest, not as a prescription from on high. This is where queer theory might provide some compelling clues and examples with its techniques of irony, camp, theatricality, irreverence, ambiguity, and style. Self-seriousness, self-importance, and aesthetic conservatism in participatory methods can be turned around through humor, humility, and a bit of style. Queer theory knows no, nor respects, any boundaries or margins. Change and invention occur at the margins, not at the center. Queer aesthetic experiments learned in

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the harsh life and death reality of the HIV/AIDS crisis are not light or frivolous diversions from the seriousness of the design issues we face. We use queer aesthetics to get at truths that are often disguised by the rhetoric and images deployed by power. In the physical design of healthy urban neighborhoods, we must utilize participatory approaches to understand and rebuild vibrant cities from the household up through city blocks and entire neighborhoods, with due respect for individual and group differences and ample time and space for voicing these differences. Similarly, our colleague Erika S. Svendsen of the USDA Forest Service used participatory research principles to design memorials to the victims of terrorism after September 11, 2001, their families, our communities, and the entire nation (USDA Forest Service, 2005). The Living Memorials Project (Svendsen & Campbell, 2005) invokes the resonating power of trees to bring people together and create lasting, living memorials. Explains Svendsen: This research goes beyond examining the practice of planting commemorative trees. It looks at the creation and maintenance of living memorials as physical, social, emotional, and spiritual acts, examining these places as intersections of human and natural systems. . . . This study shows a living memorial as any place that over time rises to meet people where they are rather than where they are expected to be. . . . Living memorials can be the physical, mental, and social spaces for thought, reflection, teaching, community action, and resilience. Often, participants comment that the healing aspects of living memorials come not just from the finished site, but also from the process of conceptualizing a project, finding a site, creating events, and working with others on the project. These values are both challenging to document and to quantify, but may be an example of how participatory design can create and strengthen community. (Erika S. Svendsen, personal communication, italics added)

There are two important points we wish to emphasize about the intermediate or community level in our model as it pertains to participatory research to advance LGBT health and well-being. First, it is here that we believe interventions may be the most effective in pushing up against the more entrenched factors at the societal level (e.g., heterosexism) to improve the health and well-being of sexual minorities. Such interventions may include providing safe shelters for LGBT youths and enforcing workplace policies that forbid discrimination on the basis of sexual orientation. Second, most of the interventions at the community level necessarily involve organizations and agencies outside the health sector per se. We believe that interdisciplinary and participatory collaboration among urban planners, civic organizers, educators, and public health practitioners holds the greatest promise for devising effective, sustained community-based interventions. The more proximate factors influencing health and well-being at the interpersonal level are depicted in our conceptual model as stressors/ buffers (including violent crime and safety, financial insecurity, and unfair treatment), health behaviors (including health screenings, physical activity, and dietary practices), and social integration (including the shape of social networks and the resources available within networks). This is the more familiar terrain of public health, although Meyer (2003) warns that relying overly much on, for example, the coping abilities of


the oppressed rather than the transgressions of the oppressor, could lead to ignoring the need for important political and structural changes. Nonetheless, individual agency and resilience are no doubt important in affecting the health and well-being of sexual minorities. For instance, Sexually Liberated Art Activist Asian People! (SLAAAP!), originated by Sam Quan Krueger and seven other queer community organizers of Asian descent living in New York City, is an example of community-originated response to the needs of an underserved LGBT community. SLAAAP! members identified the absence of healthy Asian images in the queer visual environment and joined together to initiate research and an intervention to address it. Members noted that the visual environment in New York City’s LGBT communities was largely vacant of constructive images of Asian people. Instead, perverse notions of Orientals continued to fill the visual lexicon. Asians were often depicted as kung-fu fighters, sexually servile geishas, turbaned gurus, asocial scientists, or kowtowing foreigners from exotic lands. Historical stereotypes persist and limit the utility of public health interventions aimed at people of Asian descent. Intuitively, SLAAAP! members understood that a visual environment dominated by White sexuality can lead to low self-esteem, compromised decision-making regarding sexual behaviors, and isolation from Asian-specific resources in sexual health among Asian queers. SLAAAP! sought to address these health risks through a visual campaign in service to its own community. The initial SLAAAP! team consisted of eight organizers representing various LGBT groups, including the South Asian Lesbian and Gay Association (SALGA), Iban/Queer Koreans of New York (QKNY), the Audrey Lorde Project (ALP), Kilawin Kolektibo, and the Asian Pacific Islander Coalition on HIV and AIDS (APICHA, 2005). Relevant skill sets and knowledge bases within SLAAAP! included community organizing, HIV/AIDS prevention, graphic design, illustration, photography, political art history, fundraising, project management, marketing, and proficiency in English and various Asian languages. APICHA provided umbrella support, which included $500 in production costs, partial financial support for one staff member, and meeting space. Based on an internal needs assessment, SLAAAP! members developed a 4-month schedule that culminated in social action at the June 1998 Manhattan Gay Pride Parade. The schedule began with an education and training component consisting of workshops on political art history and social action, team building, current themes germane to queer Asians living in New York City, and the process of marketing ideas. Discussions focused the following themes and questions: • Creativity: using history as imagination; generating a visual vocabulary; managing an equitable, collaborative effort. • Sexual determination and determinants: the conflict between and hybridization of Asian and U.S. cultures and their effect on sexual determination; the relation between our sexualities and our communities and families. • What is the “queer Asian community” in New York City? Who are the constituents? What are the productive resources to build and

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strengthen the community? What are the opportunities for growth as well as threats to growth? How might social service provision be used as a venue for organizing around or creating identity? The two primary objectives for the campaign were (1) to promote affirmative images of queer Asians; and (2) to connect individual queer Asians to health-related resources specific to their needs. To reach these objectives, SLAAAP! members designed a comic logo as a consistent identifier of SLAAAP!’s presence and values, which was later popularized through distributed materials. Next, a postcard campaign consisting of four vignettes was created as part of a social action, with a design intended to stand apart from typical nonprofit outreach materials. One of the four original SLAAAP! postcards is presented here as Figure 18.2 (APICHA, 2005).

Figure 18.2 Drawing on your cultural past can help forge a community in the present (APICHA, 2005).


Figure 18.2 Continued

During the 1998 Manhattan Pride Parade, SLAAAP! members marched in drag and costumes with members from other queer Asian and HIV/AIDS organizations and handed out postcards to people of Asian descent along the parade route. In sum, nearly 400 postcards were distributed. Moreover, SLAAAP! involvement transformed its members by providing a formal structure where they shared skills, talents, experiences, and friendship. In 1999, APICHA incorporated SLAAAP! into its ongoing educational programming, thus providing sustainability for the campaign. In its first year, SLAAAP! established a process that could be modified

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and repeated each year. Subsequent visual campaigns followed the approach of the first season, and word-of-mouth further propagated SLAAAP!’s work throughout the queer Asian community in New York City. Finally, the last column in the conceptual model represents health and well-being, and lists a wide range of health outcomes (including mental health, injury/violence, and obesity/overweight) while also embracing various measures of well-being (including hope/despair, life satisfaction, and psychosocial distress). We expanded the list of well-being measures to include internalized homophobia, concealment of identity, and expectations of rejection in concert with Meyer’s (2003) notions of proximal minority stress processes. It is important to emphasize that health and well-being can be measured at both the individual and population levels; that is, societal, community, and interpersonal determinants may affect the health and well-being of individual members of the LGBT community as well as various subpopulations within it.

4 Moving from Best Practices to Best Processes and Best Principles to Guide Future Participatory Research in LGBT Health Community-based participatory research rarely follows a strict set of guidelines, notwithstanding efforts to identify key principles (Israel et al., 1998). Barbara A. Israel has been at the forefront of CBPR efforts in the United States and has enumerated nine principles of CBPR (Israel, 2000): 1. 2. 3. 4. 5. 6. 7. 8. 9.

Recognizes community as unit of identity Builds on strengths and resources Facilitates collaborative partnership Integrates knowledge and intervention for mutual benefit of all partners Promotes co-learning and empowering process Involves a cyclic, iterative process Addresses health from positive and ecologic perspectives Disseminates findings and knowledge gained to all partners Involves a long-term commitment by all partners

Israel and her colleagues in Detroit never intended this set of principles to be static or universal and actively encouraged adaptation depending on needs and contexts. Many if not all of these CBPR principles may be useful to consider in LGBT health issues. Another central figure in CBPR in the United States and especially in Canada is Lawrence W. Green (e.g., Green et al., 1995). Green (2001) recently argued for replacing best practices with best processes in health promotion and other applications of health behavioral research, in concert with our focus in this chapter on the process involved in CBPR initiatives. His reasoning is that, “[H]ealth promotion needs to be pursued not as a reductionist exercise in changing individual behav-


ior, but as an empowering process of giving people and populations greater control over the determinants of their health” (Green, 2001, p. 165). In light of the diversity in LGBT populations and the difficulty that exists when attempting to generalize from clinical to community settings, we stress the need to develop new research, practice, and education programs with an emphasis on transferable principles (as per Israel, 2000) and participatory processes (as per Green, 2001) to profit meaningfully from CBPR conducted in other historically oppressed and marginalized populations. The term best principles is invoked here rather than the more customary term best practices to underscore the need—especially at an early stage of development of new research, practice, and education programs in LGBT health—to extract the core issues from the context in which they are carried out. We are confronting situations in which community and institutional settings vary greatly, even as the ostensible research activities are the same. In such cases, best practices do not always easily transfer across either population or institutional boundaries. Best principles are invoked to remind us that although communities and settings can be critically different the encompassed research questions and practice applications that we are seeking to answer and bring about often have underlying principles that can be readily adapted. The application of best principles requires that we develop a more critical understanding of the goals and constraints of different organizational structures as we develop new programs. Put slightly differently, process is as important as plan in the creation of innovative research to address the challenges of LGBT health and well-being (Sclar et al., 2005).

5 Summary In writing this chapter, the authors came together with histories of involvement in participatory research, design, and outreach in other populations as well as those related here that are specific to LGBT health. We maintain that a hopeful promise of CBPR lies in its capacity to promote civil society and help eliminate egregious disparities in health and health care for those without sufficient resources to pay high costs for safe and affordable housing, education across the life course, and adequate and respectful medical care (Northridge et al., 2002, 2005). A contribution of this chapter, we believe, is the extension of our previous CBPR scholarship and applications to embrace the varied yet particular needs of sexual minorities and to address explicitly the pathways whereby heterosexism, sexism, and racism lead to social disparities in health and well-being for LGBT individuals and populations. Specifically, we began this chapter with a brief history of participatory research in public health and then examined the peer-reviewed literature for evidence of participatory approaches to understand and address social determinants of LGBT health. To motivate future research, we presented a conceptual model entitled Social Determinants of LGBT Health and then traced the pathways whereby factors

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operating at various levels (societal, community, interpersonal) might effect health and well-being for LGBT individuals and populations. In doing so, we incorporated case studies with an emphasis on participatory processes, rather than research tools and methods per se. Finally, we proposed moving from best practices to best processes and best principles to guide future CBPR intended to advance the health and well-being of LGBT communities. If we have learned anything from former community-based interventions, including those centered on HIV prevention for young gay men (Kegeles et al., 1996), it is that the active involvement of disadvantaged and oppressed populations in creating health programs embedded in their social activities and community lives are likely to be more effective and sustained than top down approaches. Our own future CBPR initiatives will no doubt aim to intervene on what Meyer (2003) has termed both the subjective and objective views. The subjective view—which highlights individual processes—suggests that interventions should aim to change the appraisal process, that is, the person’s way of evaluating her/his condition and coping with stress and adversity. This corresponds to the interpersonal level in our conceptual model and is no doubt effective in helping individuals advance their own health and well-being. The objective view—which highlights the external properties of the stressors—points to remedies that would aim to alter the stress-inducing environment. This corresponds to the community level in our conceptual model and is where we believe that interventions are especially subject to policy manipulation. A corollary is that interventions at the community level may have the greatest potential benefit for improvements in the health and well-being of LGBT populations. Hence, a hopeful promise in writing this chapter is to inspire our team and others to forge collaborations among public health, urban planning, urban design, and social activists united in the commitment to advancing LGBT health and thereby the health of all of us. Acknowledgments: The authors thank Elizabeth Fee for her contributions to the section on the history of participatory research in public health, Erika S. Svendsen for her analysis of the participatory process involved in the Living Memorials Project, and Elliott D. Sclar for originating the concept of transferable best principles and providing essential foundations for the conceptual model we advanced here entitled Social Determinants of LGBT Health. A special thanks to Ilan H. Meyer for his intellectual inspiration and expert editing, and to Jennifer L. Northridge, Jessica M. Northridge, and John F. Duane for their constant support throughout the long journey of writing this chapter.

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