The Texas Medical Center Library DigitalCommons@TMC UT School of Public Health Dissertations (Open Access) School of Public Health Spring 5-2020 A MIXED- METHODS EXAMINATION OF THE HEALTHCARE, SOCIAL SUPPORT, AND RELIGIOUS NEEDS OF SEXUAL AND GENDER MINORITY (SGM) OLDER ADULTS IN TEXAS JENNIFER LYNN HOLCOMB UTHealth School of Public Health Follow this and additional works at: https://digitalcommons.library.tmc.edu/uthsph_dissertsopen Part of the Community Psychology Commons, Health Psychology Commons, and the Public Health Commons Recommended Citation HOLCOMB, JENNIFER LYNN, "A MIXED- METHODS EXAMINATION OF THE HEALTHCARE, SOCIAL SUPPORT, AND RELIGIOUS NEEDS OF SEXUAL AND GENDER MINORITY (SGM) OLDER ADULTS IN TEXAS" (2020). UT School of Public Health Dissertations (Open Access). 135. https://digitalcommons.library.tmc.edu/uthsph_dissertsopen/135 This is brought to you for free and open access by the School of Public Health at DigitalCommons@TMC. It has been accepted for inclusion in UT School of Public Health Dissertations (Open Access) by an authorized administrator of DigitalCommons@TMC. For more information, please contact [email protected]. Copyright by Jennifer Lynn Holcomb, MPH, DrPH 2020 DEDICATION To Sandy and Chris A MIXED- METHODS EXAMINATION OF THE HEALTHCARE, SOCIAL SUPPORT, AND RELIGIOUS NEEDS OF SEXUAL AND GENDER MINORITY (SGM) OLDER ADULTS IN TEXAS by JENNIFER LYNN HOLCOMB MPH, The University of Texas School of Public Health, 2016 Presented to the Faculty of The University of Texas School of Public Health in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PUBLIC HEALTH THE UNIVERSITY OF TEXAS SCHOOL OF PUBLIC HEALTH Houston, Texas May, 2020 PREFACE My dissertation was inspired by the stories of those I met during this work. Their lives and advocacy led to the rights we have today and inspire me to continue to serve SGM communities through service, advocacy, and research. ACKNOWLEDGEMENTS The study participants, for their time and stories. Sandy Johnston and Chris Kerr, I never worked on Paper 3 without thinking of you. I hold your stories in my heart. The Montrose Center, Especially Judy Woods for her friendship, Fred Reninger for his work, and Dr. Ann Robison for supporting me in this research. Sharon Ferranti, for her great work on the Montrose Center video. My dissertation committee, Drs. Vanessa Schick, Gretchen Gemeinhardt, and Mike Wilkerson for their support, guidance and expertise, and humor along the way. Dr. Melissa Valerio-Shewmaker, for being my supporter, advocate, and mentor. My SPH team, especially Daniella Chambers and Laura Witte, for their support throughout this process both as friends and colleagues. Kat Panas, for their data cleaning and coding skills. Deanne Hernandez, for her flexibility and support. Albert Schweitzer Fellowship Houston-Galveston, UTHealth School of Public Health, and the Hogg Foundation for Mental Health, for their contributions to this work. My friends and family, especially my wonderful parents, Bob and Karen, for their unwavering, unconditional love and support and for instilling in me hard work and humility. Julie Hudsonpillar, for being my person. Anthony Gaskill, for his love and patience, also for the laptop. A MIXED- METHODS EXAMINATION OF THE HEALTHCARE, SOCIAL SUPPORT, AND RELIGIOUS NEEDS OF SEXUAL AND GENDER MINORITY (SGM) OLDER ADULTS IN TEXAS Jennifer Lynn Holcomb, MPH, DrPH The University of Texas School of Public Health, 2020 Dissertation Chair: Vanessa R Schick, PhD Shared historical and social contexts influence a generational group’s needs, risk factors, and resiliency mechanisms. Sexual and gender minority (SGM) older adults have experienced structural exclusion and systematic discrimination throughout their lifetime. The minority stress model posits that SGM individuals experience stressors, like discrimination, unique to their social status which affect physical and mental health. SGM older adults experience worse physical and mental health outcomes than their heterosexual peers suggesting unique needs for SGM older adults. Research also points to resiliency mechanisms that offset the impact of stressors on SGM older adults. The examination of these needs and resiliency mechanisms help to better understand how to improve quality of life and health outcomes among SGM older adults. To identify needs and resiliency mechanisms, a concurrent mixed method study was conducted with SGM older adults (50 years and older). First, a secondary data analysis of a statewide cross-sectional online survey examined the community needs of SGM older adults in Texas. A total of 104 SGM older adults completed the survey (7.63% of survey participants). Comparisons across gender and sexual identity were conducted using chi- square and Fisher’s exact tests to probe for significant findings. Three categories of needs were identified: culturally sensitive healthcare, mental health and suicide, and social determinants of health. Second, primary data collection through focus groups and semi-structured interviews further explored community needs. Three one-hour focus groups were conducted with SGM older adults. Emerging needs for SGM women included the role of social support, pets, and religion/spirituality in health. Thirty- seven semi-structured interviews were then conducted to better understand these needs as well as the emerging resiliency mechanisms of SGM women and gender non-binary adults. Two resiliency mechanisms were identified from the interviews, social networks and religiosity or spirituality. Common themes were identified surrounding experiences influencing support networks types and their influence on health. Another important source of resiliency was an individual’s religiosity or spirituality. There were differences among those who reported conflict between their SGM and religious identity during their lifetime. These findings suggest implications for interventions tailored to specific SGM older adult populations to increase healthcare and social support resources especially for those experiencing isolation and/or conflict between SGM or religious identity. TABLE OF CONTENTS List of Tables ................................................................................................................................... i List of Figures ................................................................................................................................. ii List of Appendices ......................................................................................................................... iii Background ..................................................................................................................................... 1 Introduction/Statement of the Problem ....................................................................................... 1 Research Questions and Study Aims .......................................................................................... 4 Literature Review ........................................................................................................................ 4 Public Health Significance ........................................................................................................ 15 Methods ......................................................................................................................................... 17 Aim 1 Study Design .................................................................................................................. 17 Study Setting and Data Collection ......................................................................................... 17 Study Subjects ....................................................................................................................... 18 Sample Size and Power ......................................................................................................... 19 Analysis Plan ......................................................................................................................... 20 Aim 2 & 3 Study Design ........................................................................................................... 22 Study Setting, Subjects, and Data Collection: Aim 2 – Focus Groups ................................. 23 Study Setting, Subjects, and Data Collection: Aim 2 and 3 – Interviews ............................. 23 Analysis Plan ......................................................................................................................... 27 Journal Article 1 ............................................................................................................................ 29 A community and academic partnership to identify community needs of sexual and gender minority (SGM) older adults in Texas ...................................................................................... 29 Journal Article 2 ............................................................................................................................ 58 A qualitative study examining the social networks types of sexual and gender minority (SGM) older women and gender non-binary adults .............................................................................. 58 Journal Article 3 ............................................................................................................................ 86 Reconciling sexual and gender (SGM) identity and religious beliefs among older adults ....... 86 Conclusion .................................................................................................................................