Development and Evaluation of Training for Rural LGBTQ Mental Health Peer Advocates.

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Rural Ment Health. Author manuscript; available in PMC 2017 January 01. Published in final edited form as: Rural Ment Health. 2016 January ; 40(1): 40–62. doi:10.1037/rmh0000046.

Development and Evaluation of Training for Rural LGBTQ Mental Health Peer Advocates Tania Israel, Department of Counseling, Clinical, and School Psychology University of California, Santa Barbara Santa Barbara, CA

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Cathleen Willging, and Pacific Institute for Research and Evaluation Albuquerque, NM David Ley New Mexico Solutions

Abstract

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Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people in rural areas experience negative mental health consequences of minority stress, and encounter multiple barriers to accessing mental health and substance use treatment services. As part of a larger intervention study, we developed and piloted a unique training program to prepare peer advocates for roles as paraprofessionals who assist rural LGBTQ people with mental health needs. Thirty-seven people in New Mexico took part in either the initial training or a second revised training to improve their knowledge and skills to address LGBTQ mental health needs. Evaluation of this training consisted of self-administered structured assessments, focus groups, and open-ended interviews. Results for the initial training showed no significant increases from pre- and post-test scores on knowledge about LGBTQ people and their mental health issues, whereas significant increases were detected for the revised training. There also were significant increases in self-efficacy to perform tasks associated with the peer advocate role for all but a subset of tasks for the revised training. Qualitative data reveal that participants appreciated the opportunity to increase information and skills, especially concerning bisexual and transgender persons, and the opportunity to connect with others in the community who want to support LGBTQ people.

Keywords

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LGBTQ; rural; mental health; training; peer Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people in the United States experience tremendous mental health and substance use disparities (Institute of Medicine, 2011). High rates of depression, anxiety, and suicidality within the LGBTQ population may originate in “minority stress,” which is comprised of chronic stigma, discrimination, and violence (Meyer, 2003). Minority stress operates within cultural

Correspondence concerning this article should be addressed to Tania Israel, Professor, Department of Counseling, Clinical & School Psychology, Gevirtz School, University of, California, Santa Barbara, CA 93106-9490. The first author may be contacted by, ([email protected]) or phone (805-893-5008).

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institutions and social structures, including health care systems (Meyer, 2003; Meyer, Schwartz, & Frost, 2008), and may disproportionately affect gender non-conforming individuals, people of color, and rural LGBTQ persons (Diaz, Bein, & Ayala, 2006; McLaughlin, Hatzenbuehler, & Keyes, 2010; Pinhey & Millman, 2004; Williams, Bowen, & Horvath, 2005).

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With regard to rural communities, LGBTQ people may face social pressure to adhere to traditional gender roles and norms (Barefoot, Rickard, Smalley, & Warren, 2015) as well as negative attitudes related to lack of contact with sexual and gender minorities (Barefoot et al., 2015; Eldridge, Mack, & Swank, 2006; Herek, 2002; Snively, Kreuger, Stretch, Watt, & Chadha, 2004). Victimization — verbal harassment, property damage, and physical assault — is commonly reported by rural LGBTQ people (Barefoot et al., 2015; Boulden, 2001; Cody & Welch, 1997; Leedy & Connolly, 2007; Oswald, Gebbie, & Culton, 2003). Some LGBTQ people migrate from rural to urban areas in search of robust LGBTQ community, leaving those who remain in rural areas further lacking in social support. Geographic isolation, insufficient opportunity to socialize with other LGBTQ people, and the perceived need to conceal gender or sexual identities can contribute to mental distress, erode social support, and result in fewer visible LGBTQ role models in rural areas (Barefoot et al., 2015; Leedy & Connolly, 2007; Mathy, Carol, & Schillace, 2003; McCarthy, 2000; Oswald & Culton, 2003).

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Rural residents in general, but especially those who self-identify as LGBTQ, report hardship accessing high quality mental health care, often because services are in short supply (Williams, Williams, Pellegrino, & Warren, 2012). The quality of support LGBTQ people can expect from available mental health and substance use treatment providers varies. Clinical providers often lack culturally appropriate training and fail to recognize how minority stress affects LGBTQ people, while the broader setting where services are rendered may lack safeguards to ensure that neither individual nor institutional bias influence care (Eliason & Hughes, 2004; Israel, Ketz, Detrie, Burke, & Shulman, 2003; Israel, Walther, Gortcheva, & Perry, 2011; Mahdi, Jeverston, Schrader, Nelson, & Ramos, 2014; Walinsky & Whitcomb, 2010; Willging, Salvador, & Kano, 2006a; Willging, Salvador, & Kano, 2006b).

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One means of addressing such deficits within systems of mental health and substance abuse treatment is to employ people who are members of the target community to bridge the gap in culturally competent care. Peer-based approaches draw upon established community health worker models and represent a growing practice in mental health treatment (Getrich, Heying, Willging, & Waitzkin, 2007; Waitzkin et al., 2011; Weeks et al., 2009a; Weeks et al., 2009b). Peer helpers have been employed for a range of populations and medical concerns, including diabetes management (Tang, Funnell, Gillard, Nwankwo, & Heisler, 2011), serious mental illness among veterans (Chinman, Salzer, & O’Brien-Mazza, 2012), maternal/child health, and general health promotion (O’Brien, Squires, Bixby, & Larson, 2009). Consistent with such models, we recruited and trained community health workers, called “peer advocates,” to enhance social support and access to professional services for LGBTQ residents of rural areas (Willging & Israel, 2012). These peer advocates were lay people who were members of or strongly connected to LGBTQ communities and who were willing to develop knowledge and skills to address LGBTQ mental health issues. Peer

Rural Ment Health. Author manuscript; available in PMC 2017 January 01.

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advocates were expected to undertake a wide range of complex tasks, including needs assessment, goal setting, referral, assistance navigating behavioral health systems, and community outreach, and to enhance knowledge about and social support for LGBTQ people in rural communities. These peer advocates were employed as paid, part-time community health workers, who received regular coaching and support from the project staff.

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Preparation of peer advocates to perform these complex roles is essential (Ruiz et al., 2012). Training can increase the ability of paraprofessionals, such as peer advocates, to use basic helping skills (Aladag & Tezer, 2009; D’Augelli & Levy, 1978) and to provide effective support to people seeking mental health services (Lenihan & Kirk, 1990), although extant research does not offer insight into the effectiveness of training to prepare peer advocates to perform complex tasks beyond individual helping relationships, such as organizing events or building support networks. Although training can increase mental health professionals’ knowledge and skills in working with gender and sexual minorities (Carlson, McGeorge, & Toomey, 2013; Israel & Hackett, 2004), and LGB-affirmative supervision can enhance LGB counselors’ work with LGB clients (Burkard, Knox, Hess, & Schultz, 2009), prior research has not addressed training that is designed specifically for lay members of LGBTQ communities to assist other sexual and gender minorities with mental health concerns. Although members of LGBTQ communities may have some LGBTQ-specific knowledge based on their lived experiences, distinctions among subpopulations (Fassinger & Arseneau, 2007) necessitates training on LGBTQ issues even for members of these communities.

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We report here on our effort to train LGBTQ community members to function as peer advocates. This study was part of a larger project to design, implement, and assess the acceptability, feasibility, and preliminary outcomes of the overall LGBTQ peer advocate intervention model. To obtain the knowledge and skills needed to implement this model, peer advocates took part in a four-day series of didactic and interactive training exercises that were evaluated and subsequently refined based on feedback from training participants. Because they were based physically in dispersed rural communities, peer advocates were to participate in individual and group coaching sessions conducted remotely rather than receive onsite supervision. Thus, it was important for peer advocates to be able to deliver interpersonal and community interventions fairly independently. Research on the effectiveness of training initiatives that prepare paraprofessionals for such roles is an important component of developing evidence-based interventions (O’Brien et al., 2009; Ruiz et al., 2012; Tang et al., 2011).

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The aim of the present study was to use a two-step process to develop, implement, evaluate, and revise the LGBTQ peer advocate training. Evaluation involved quantitative measures of knowledge, self-efficacy, and participant responses to specific aspects of the training, as wells as qualitative analysis of focus group and individual semi-structured interview data. This study offers new insights by: (1) focusing on training rural residents; (2) training members of LGBTQ communities to work within these communities; (3) assessing helpers’ skills beyond those used in a one-on-one helping relationship; and (4) employing a mixedmethod evaluation approach to capture short- and long-term impact of the training.


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Method Description of Training

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Development and initial training—The training was developed and administered by the authors, an academic psychologist/educator, a medical anthropologist, and a practicing psychologist/service agency administrator who collectively have expertise in three areas pertinent to this study: (1) LGBTQ mental health; (2) engaging LGBTQ people in rural New Mexico for research or clinical purposes; and (3) curriculum development. As shown in Table 1, the initial training was organized into 12 modules, with description, purpose, and learning objectives articulated for each module (for more details on the modules see the Appendix). Suggestions for participant recruitment, training content, format, and strategies to support the work of peer advocates were provided by 32 rural community members who participated in five focus groups, and two community advisory boards that met on a quarterly basis and included mental health professionals, government officials, representatives from statewide LGBTQ organizations, educators, and LGBTQ community members with lived experience related to mental health and substance use issues. Both groups were characterized by diversity in terms of ethnicity, gender, and sexuality.

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Based on the input from the focus groups and community advisory boards, the training included didactic presentations about the basics of mental health and substance use, LGBTQ minority stress factors, protective factors (such as social support), suicide prevention, and rural treatment systems. The training also covered cultural competence, including information about LGBTQ subpopulations and experiences of LGBTQ people in rural New Mexico, based on specific suggestions provided by the focus group participants and the community advisory boards. These suggestions generally emphasized the importance of dispelling misinformation and confronting biases within local LGBTQ communities (e.g., lack of awareness of Native American Two-Spirit experiences, erroneous beliefs about bisexuality, and culturally-situated imperatives to disclose sexual orientation). Finally, the training included role plays, group discussions, and other interactive training techniques to refine the helping and self-care skills of the trainees, enable them to identify and critically reflect on their power and privilege in relation to others, ground them in professionalism and ethics, and bolster their capacity for both face-to-total of 28 hours across four day-long sessions.

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Revised training—As a result of the feedback following the initial training, we integrated helping skills into each topical module rather than relegate them to separate standalone modules (see Table 1). We also reorganized material to reduce lengthy didactic segments, overly conceptual material, and redundancies. The revised training was implemented over two non-consecutive weekends: Part 1 on the first weekend, and Part 2 on the second weekend, two weeks later. Part 1 was designed to include information and skills that could be useful for all members of LGBTQ communities, including their allies. Participants completed a pre-test, and then the training opened with an overview, followed by introductions, an icebreaker activity, and discussion of communication tools. Key information about LGBTQ populations was addressed, including distinctions among sex, gender identity/expression, and sexual orientation; societal messages; and information about


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LGBTQ subpopulations. Participants continued to have opportunities to learn and practice helping skills (including active listening, open-ended questions, and culturally-appropriate inquiry when working with a population that is diverse both socially and economically) by applying them within the context of the topical material.

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Participants were informed at the beginning of the training that only a limited number would be selected to complete the second half of the training, and that peer advocates would be identified from this smaller pool (see Figure 1 – Timeline). We selected potential peer advocates after Part 1 in order to make the broader community-based training available to a wide range of individuals, respect participants’ time by offering them a realistic idea of whether they might be selected as a peer advocate, and create a smaller training group to provide more intensive preparation for those eligible to become peer advocates. At the end of Part 1, participants had the option of applying to receive additional training to be eligible for selection as a peer advocate. Fourteen participants completed a written application that included queries regarding their interest in being an LGBTQ Peer Advocate; their current involvement in their local, statewide, and/or national LGBTQ community; involvement in local helping activities; strengths, challenges, and anticipated support needed. Additional review criteria centered on primary residence to ensure aspiring peer advocates would not be concentrated in any one locality. Applicants who were not selected for the second half of the training and as peer advocates were informed that we were not able to accommodate everyone who wanted to be a peer advocate from their particular geographic area because of limited resources. Based on the application and trainer observation of skills demonstrated in Part 1, eight individuals were selected for inclusion in Part 2 of the training, four of whom were ultimately invited to become part-time, paid peer advocates.

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Part 2 entailed more specific information and skill development relevant to functioning as peer advocates. Part 2 was structured around the three primary activities in which the peer advocates would engage: (1) individual work helping LGBTQ community members access mental health and substance abuse services; (2) increasing LGBTQ knowledge and sensitivity among service providers, family members, and others in rural areas; and (3) promoting social support through outreach, advocacy, and presentations. The participants undertook a variety of activities to cultivate both their understanding and their problemsolving and implementation skills in each area. Specific skills included solution-focused interventions (Trepper et al., 2010), needs assessment, negotiating communication conflicts, and conducting presentations. Participants were prepared for their paraprofessional role with material and activities related to ethical decision-making, boundaries, and self-care. Reflection and self-awareness was encouraged through activities on privilege and leadership roles in LGBTQ communities.

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Participants A total of 37 people took part in the initial or revised training. Fourteen participated in the initial training, and 23 participated in Part 1 of the revised training, 8 of whom were selected to participate in Part 2 of the revised training. Participant demographics are reported in Table 2. We used a combination of methods to recruit participants, including direct advertisements circulated via Internet solicitations, email announcements, and local press releases.


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Measures

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LGBTQ Peer Advocate Self-Efficacy Inventory—We designed this 8-item measure to assess participants’ confidence in carrying out specific activities required of LGBTQ peer advocates. The instructions and scaling are based on the Lesbian, Gay, and Bisexual Affirmative Counseling Self-Efficacy Inventory (LGB-CSI; α = .83 to .97 for each subscale; Dillon & Worthington, 2003). Items reflect activities required of LGBTQ mental health peer advocates. Each item was rated on a 6-point scale ranging from 1 (not at all confident) to 6 (extremely confident). Sample items include Connect LGBTQ people in my community with mental health resources and Demonstrate sensitivity when interacting with transgender people. This measure was scored by calculating the mean of the participants’ responses across items. Individual surveys in which an item was skipped could not be scored and were treated as missing data. The LGBTQ Peer Advocates Self-Efficacy Inventory demonstrated moderate to high internal consistency (α = .76 – .94). This was similar to reliability reported for other samples of various types of self-efficacy, including the LGB-CSI (α = .83 to .97 for each subscale; Dillon & Worthington, 2003); Bahora, Hanafi, Chien, and Compton’s crisis intervention self-efficacy measure (2008; α = .87 – .92); Broussard et al.’s Self-Efficacy Scale (2011; α = .89 – .95); and King’s Self-Efficacy Scale (2011; α = .91 – .93).

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Peer Advocate Knowledge of LGBTQ Issues—We developed this measure as an objective assessment of participants’ knowledge regarding LGBTQ issues, with a particular focus on content covered in the training. This approach to knowledge assessment allowed participants to demonstrate their objective knowledge rather than their perceptions of their own knowledge, as the latter may not accurately measure actual knowledge (Dunning, 2011). The current knowledge measure has two subsections consisting of (1) matching and (2) multiple choice questions. The matching section prompts participants to match terms (e.g., genderqueer, sexual orientation) to their respective definition. The multiple choice section covers information about LGBTQ subpopulations (e.g., “Which one of the following is TRUE about bisexuals?”), mental health and substance use (e.g., “If someone is feeling hopeless and isn’t enjoying activities they used to enjoy, which one of the following is she or he most likely experiencing?”), helping skills (e.g., “Which one of the following is NOT a good way to start a paraphrase or restate what someone has said?”), and expectations for persons assuming the role of LGBTQ peer advocate (e.g., “Which is NOT a recommended Peer Advocate response to a crisis?”). These items were informed by national and statewide data, as well as widely accepted models of helping (Hackney & Cormier, 1996). In order to score this measure, one point was provided for each correct answer (i.e., choosing the correct matching response or the correct multiple choice response); the total number of points earned reflected a participant’s overall score.

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We developed seven matching and 25 multiple-choice items to assess these areas of knowledge (32 items, scale score = 0 – 32). The items were modified based on input from two community advisory boards, described below. Following the initial training, several items were added to the instrument or altered to reflect modifications to the training, resulting in a 35-item measure that was used in the assessment of the revised training (35 items, scale score = 0 – 35). This measure was administered in two parts for the revised training, with trainees completing 29 items following Part 1; only those trainees who


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completed the entire training were administered the six items pertaining to information presented during Part 2 of the training. The two versions of the knowledge measure demonstrated moderate internal consistency at post-test (α = .71 – .83).

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Participant Response to Training—During the initial training, we gathered evaluation data following implementation of each module. We asked each participant to indicate on an anonymous written evaluation form the extent to which each objective was met by responding on a Likert-type scale from 1 (not at all met) to 4 (entirely met). During the revised training, we elicited participant responses following each morning and afternoon session by asking participants to indicate on a 4-point Likert-type scale how confident (1 = not at all confident to 4 = extremely confident) they were that they could accomplish the learning outcomes specified for each module. For both the initial and the revised training, participants also were presented with four open-ended questions regarding important things they had learned, lingering questions, what they liked best, and recommended changes. As recommended by Kirkpatrick (1996), items elicited quantifiable responses as well as openended comments. Demographics—Participants completed a demographic questionnaire that included age, sex, gender identity/expression, sexual orientation, race, ethnicity, education level, income, location of residence, and length of time in the area.

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Focus Groups and Semi-Structured Interviews—Focus groups were conducted with eight participants after the first half of each weekend of the initial training, and 12 trainees participated in a semi-structured individual interview 12 months after the initial training. The two one-hour focus groups consisted of eight questions that centered on participant reactions to the training content, teaching modalities utilized to convey this content and to build practical helping skills, and areas for improvement. The one-hour semi-structured interviews were administered over the phone and included 12 questions concerning the personal and professional impacts of the training over the past year; increases in and application of knowledge and skills; participant needs regarding additional support, training, or participation as an LGBTQ peer advocate; and recommendations for improving future iterations of the peer advocate training. Procedure

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Evaluation procedures—On the first day of the initial and revised training, participants completed a pre-test consisting of the LGBTQ Peer Advocate Self-Efficacy Inventory, the Peer Advocate Knowledge of LGBTQ Issues, and demographic items. At the end of the first weekend, participants completed the self-efficacy measure and knowledge items pertaining to material covered in Part 1. At the end of Part 2, participants completed the self-efficacy measure and knowledge items pertaining to material that was covered in the second half of the training. Participants put their first name on the pre-test and post-tests so they could be matched and to assist with screening for those who applied to be peer advocates. In addition, participants in the initial training provided anonymous responses to items gauging their response to the training after each module.


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Qualitative data analysis—The focus group and interviews were digitally recorded, transcribed, entered into an electronic database immediately upon collection and analyzed through a series of iterative readings. A systematic line-by-line categorization of data into codes using the qualitative software NVivo (Version 10: QSR International, 2012) allowed us to determine prominent or recurring key issues described in the data. The coding and analysis of the qualitative data were undertaken by the second author with assistance from a project research assistant. First, a descriptive coding scheme from transcripts based on the specific questions asked during the interviews was developed (e.g., “reactions to training content,” “applications of training-specific knowledge and skills,” “additional training and support needs,” and “areas for improvement”). Second, all transcripts were subjected to “open coding” to determine other possible issues that we did not anticipate during the initial coding of the data (e.g., “reactions to Genderbread Person,” “perceptions of instructor sexuality,” and “suicide prevention”). Third, “focused coding” was used to determine which of these issues were repeated most often and considered significant by the majority of participants (Corbin & Strauss, 2008). Finally, detailed memos were created to further describe and link codes included in or derived from this analysis. The coding and analysis of the qualitative data were undertaken by the second author with assistance from a project research assistant, and the first and third authors reviewed written drafts of the findings as they became available.


We acknowledge that several factors informed the qualitative analysis. First, this process was influenced by the “constructivist” tradition in evaluation research. This tradition opposes positivism and privileges iterative processes of data analysis to understand diverse participant perspectives in relation to intervention objectives, encourages rich and deep description, and values consensus (and contestation) when arriving at conclusions predicated on study findings (Stufflebeam & Shinkfield, 2007). Second, all three authors were engaged in design and implementation of the training, as well as extensive conversations during and after each training regarding our impressions and ideas for improvement. The research assistant attended parts of the training, conducted focus groups and interviews, and shared feedback with the authors following the initial training. The qualitative data were collected and analyzed simultaneously with the quantitative data. Throughout the process of data collection and analysis, we sought to remain attentive to not only our professional biases and possible self-interest in portraying the training in a positive light, but to how our own gender, sexual, and social identities and privileges might shape our interpretation of the data. We also maintained a pragmatic orientation when assessing the significance of the findings, organizing the qualitative data to highlight aspects of the training considered most beneficial or in need of modification, preliminary impacts on the participants, and suggested topics, formats, and other issues for instructors to consider for future LGBTQ peer advocate training.

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Results Quantitative results regarding knowledge and self-efficacy measures are presented first, followed by qualitative and quantitative analysis of participant response to training, and finally, summaries of qualitative data from focus groups and interviews.


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Knowledge

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Paired-samples t-tests assessed changes in participants’ knowledge of LGBTQ issues (Figure 2). Scores on the LGBTQ Peer Advocate Knowledge of LGBTQ Issues for participants in the pilot training were higher, but not significantly so, at post-test (M = 15.36, SD = 33.2) compared to pre-test (M = 11.50, SD = 33.28). For participants in the revised training, knowledge increased significantly from pre- to post-test, both for the participants who took part only in the first half of the training, t(18) = −7.01, p < .001; as well as for the smaller group of participants who were selected for Part 2 of the training, t(7) = −4.75, p = . 002. Further, an omega-squared effect size calculation (ω2 = .55) demonstrated a large effect size. This suggests that participants were more knowledgeable about LGBTQ issues after completing the training. This increase in knowledge offers some evidence that the changes made for the revised training helped participants to understand and retain information more effectively.

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Self-Efficacy

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Paired-samples t-tests assessed changes in participants’ self-efficacy in working with LGBTQ community members (Figure 3). Participant scores on the Peer Advocate SelfEfficacy Inventory measure increased significantly from pre-test to post-test for both the pilot (t(12) = −6.09, p < .001) and the revised training (t(19) = −2.48, p = .023). Further, an omega-squared effect size calculation demonstrated a large effect size for the pilot study (ω2 = 0.58) and a medium effect size for the revised study (ω2 = 0.11). This suggests that participants felt more confident in their ability to use specific LGBTQ affirming skills after completing the training. When considering only the participants in the revised training who were selected for Part 2 of the training, the scores on the subset of items that assessed selfefficacy regarding specific peer advocate skills increased from before the training to after it was completed, as well as from after the first half of the training to the end of the training, but these increases were not significant. Because of the small number of participants in this category who completed the measure (n = 8), it is possible that the t-test did not detect differences (observed power = 0.52). Participant Response to Training

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Participant response to the pilot training was generally positive. Trainers were rated on the written evaluation forms as meeting the stated objectives for most modules, including LGBTQ people and communities, behavioral health issues and services, suicide, working individually with LGBTQ community members, ethics and boundaries, and diffusing hostile situations. The two modules that least met the objectives were cultural competence and helping skills. Parts of other modules that had variable success in meeting the objectives focused on communication with service providers and outreach. In response to open-ended questions, trainees indicated that they learned about a range of LGBTQ experiences, statewide demographics, treatment barriers, listening skills, ethical dilemmas, and self-care. They appreciated engaging and expert instructors, visuals, role plays, suicide intervention, and practice presentations. They would have liked more information on privilege and how to approach service providers.


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Participant response to the revised training was positive, as well. Participants indicated that they grasped almost all of the information and skills presented, although they felt less confident about interacting with people with serious mental illness, recruiting people to attend LGBTQ outreach events, and dealing with hostile situations. The material that most stood out to them was models of sexual orientation, responding to suicidality, culture, social support, crisis intervention, use of supervision in ethical dilemmas, cultivating compassion, and privilege. They were enthusiastic that the training was informative, interactive, and included role plays and practice presentations. Focus Groups and Interviews

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The focus groups underscored that the trainees were eager for the information provided, with one participant making two 15-hour round trips from his home to attend. Much of the information was new and desired, even by the few participants with a footing in helping professions. One trainee, a graduate student in a counseling psychology program, observed: I really wish that it [the peer advocate training] was a mandatory part of our Master’s program or the Doctorate program because they just don’t touch on sexuality at all…. Even having something as basic as the difference between sex and gender and sexuality so that people can have that basic knowledge I think would be really helpful.

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Other trainees were already working as natural supports or de facto peer advocates, and wanted to enhance their knowledge and skills to better support other LGBTQ people. In fact, participants reported taking actions in the two weeks between the first and second weekend of the pilot training. For example, one participant reportedly intervened upon witnessing members of his church making disparaging and threatening remarks regarding a transgender person, noting that he had garnered the confidence to stop functioning as part of the “silent minority” within his faith community because of the training. A second participant shared that she was able to respond appropriately to a friend on the verge of killing herself, something she would not have done if she had not taken part in the suicide prevention component of the training.

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The focus groups also provided insight into refining the nuts and bolts of the training process. Participants were encouraged to critique training materials, resulting in suggestions to streamline the content provided in module-specific PowerPoint presentations and to include more visual graphics and images of LGBTQ people that were relevant to the implementation context of New Mexico. Overall, participants appreciated the “pace” of the training, contending that there was no time to become “bored” during the long training sessions. That said, they also observed that the instructors were attempting to cover too much material, especially with regard to standard diagnostic nosology, the content of which was later scaled back to accommodate more group discussion and activities. Finally, to facilitate the building of rapport and trust, focus group participants called on the instructors to disclose their own gender and sexualities. Such disclosures did not occur during the first weekend of the first training, which created a distraction for some participants, who admitted to becoming silently preoccupied with whether the instructors shared life experiences as LGBTQ people similar to their own.


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During the initial focus groups and the later interviews, the participants affirmed that they benefited from the LGBTQ peer advocate training and would take part in additional training if offered in their community, recommend the training to others, and would be happy to work in some capacity as an LGBTQ peer advocate. One of the most common comments concerned how the training increased participant knowledge of diversity within the LGBTQ community. One participant disclosed that the training “drastically” enhanced his ability to appreciate diversity: Being a closeted gay man for years at least partially I was not at all comfortable with any of the other groups within the community just because of lack of knowledge and lack of understanding. [The training] opened my eyes drastically and made it easier to see where they’re coming from and see what problems they may be having, etcetera.


In the interviews, almost all other participants noted how much the training enabled them to become more sensitive to variance within the LGBTQ community and be more aware of their own biases. The “Genderbread Person” (Killerman, n.d.), an image used to illustrate the nature of and distinctions among gendered constructs, was remembered fondly and was utilized by interview participants to help them and their peers better understand the difference between gender expression and sexual orientation in terms of fluid conceptualizations instead of rigid categories. One participant showed it to her father, a second translated it into Spanish to be used for clients within a counseling consultation group, a third presented some of the training to fellow classmates, a fourth taught some of it to students learning how to use advocacy in counseling, while still others used it in their volunteer work at the local LGBTQ community center. Participants also recognized how gender and sexuality intersect with ethnicity, religion, ability, and geographical location in the construction of identity. Three trainees stated that completion of the training helped them to become more comfortable with their own sexualities; one participant shifted from identifying as a lesbian to transgender man. Six participants emphasized the importance of the training’s suicide prevention component and the need for additional resources during their interviews. One participant was motivated to pursue further training on this topic. A second trainee was empowered to help two of her friends get help for mental distress, while yet another utilized the knowledge and skills pertaining to suicide prevention with a foster teen in his home. The participant explained,

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[The foster teen] was exhibiting signs of being depressed and I was able to utilize some of the things that I learned in the [LGBTQ] peer advocate training along with some things that I learned in terms of when [we] did mental health the first day to kind of talk him through what was going on and help figure out what a course of action would be other than [the] risky behavior that he was involved in. All interview participants noted an increase in their knowledge of resources and their own morale simply by attending the training and meeting other individuals interested in advocating on behalf of rural LGBTQ people with mental health needs. Further, four participants shared their desire to create, or at least have access to, a resource guide that contained information on local and state providers who were LGBTQ-friendly, and affirmative community groups. Rural Ment Health. Author manuscript; available in PMC 2017 January 01.

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Participants in both focus groups and interviews expressed a desire to take part in future training opportunities related to LGBTQ mental health. They commonly observed that the training had covered a lot of information in a short period of time and that they would have appreciated the opportunity to delve into specific topics, such as bisexuality and transgender issues, in much greater detail than the four-day schedule allowed. One participant explained, “Even doing it for two full weekends, it was a lot of stuff crammed into a little bit of time but it was also important stuff.” Despite this limitation, the participant added that taking part in the training “was a very worthwhile use of my time.” A second participant acknowledged the challenge of making the length of similar trainings “just right” and accessible to busy people. Suggested topics for future trainings varied and included leadership skills, analyzing privilege, relationship dynamics as applied to a variety of topics (e.g., grief and adoption), recognizing signs of mental distress and substance use problems to better refer peers for counseling or treatment, diversity and cultural issues, and more practice/modeling. The most frequently suggested topics were outreach, rapport building, and communication skills, especially with regard to consulting professional providers about LGBTQ health needs. The trainees also called for additional practical workshop activities focused on navigating local social environments and connecting to supportive professional providers and community advocates and allies.

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Trainees suggested the training experience could be enhanced through the addition of homework between sessions to facilitate further contemplation and “absorption” of key material, and that greater time needed to be devoted to collective review and discussion, as well as questions and answers of the instructors. Finally, to reinforce knowledge and skills, participants called for additional online training opportunities of shorter duration, web-based resources, and periodic conference calls for group discussion, troubleshooting, and refresher purposes.

Discussion

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The evaluation offers ample evidence that the LGBTQ peer advocate training successfully accomplished its goal to select and prepare peer advocates to assist LGBTQ help seekers. Specifically, the training produced more knowledgeable, confident, and skilled advocates who were sensitive to diversity within LGBTQ communities. Self-efficacy increased as a result of both the pilot and the revised training (except where changes could not be detected because of small sample size). Self-efficacy influences the effort and persistence an individual applies to a task and is, consequently, a key indicator of future behavior (Alessi, Dillon, & Kim, 2015). In fact, self-efficacy has been identified as a key element for counselors to engage in lesbian/gay-affirming practice (Alessi et al., 2015) and, thus, an important element to target in training and assess prior to placing peer advocates in the field. The increase in knowledge, especially regarding diversity within LGBTQ communities, demonstrates the gaps in knowledge prior to the training and the ability of trainees to gain accurate information through didactic and interactive training. Notably, although all trainees were either LGBTQ or allies, they did not necessarily possess accurate information about all LGBTQ subpopulations. Gender and sexual minorities, especially in rural areas, may have limited exposure to other LGBTQ people. Thus, knowledge of segments of LGBTQ


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communities that differ from their own may be gleaned primarily from widely available societal messages, many of which contain misinformation and stereotypes. Indeed, segregation and discrimination occur within LGBTQ communities based on gender, gender identity/expression, ethnicity, and socio-economic status (Willging et al., 2006a). Such divisions are problematic within a community that has the potential to serve as a natural social support buffer against the effects of minority stress (Meyer, 2003). The current study demonstrated the need and a possible remedy for this problem. By educating LGBTQ people about the diversity within their own communities, greater understanding may lead to increased support and cohesion within this vulnerable population.

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A pilot phase has been included in development of other peer training programs (Kinnane, Waters, & Aranda, 2011; Tang et al., 2011), and we also found that piloting the training was a worthwhile expenditure of time and resources. Conducting pilot training and then making changes to the curriculum based on this experience improved absorption and retention of information and improved participant response to helping skills. The choice to integrate helping skills throughout the training rather limit to one module appeared to improve participant response to this aspect of the training. In addition, the integration of skills likely supported acquisition of knowledge as trainees had opportunities to apply knowledge immediately through skills-based activities.

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Most published research on community health workers does not include a description of the selection process (O’Brien et al., 2009). One important facet of our training was as a screening tool for peer advocates. The ability of the trainers to interact with and observe participants prior to the application process enhanced their confidence in their ability to select the best candidates. Furthermore, preparation of peer advocates took place in a context in which all trainees were interested in performing this role in their community, which may have increased cohesion and engagement. Another unique aspect of the current project was the invitation for any interested members of the general public to attend the first training weekend. By opening this part of the training to a broad range of participants, we offered a community service by educating the general public about LGBT mental health, and we were able to collect observational information about potential peer advocate applicants, which proved valuable in the selection process.

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The direct influence on the trainees and LGBTQ community-building in a rural area was an unanticipated benefit of the training. Participation improved the trainees’ feelings about themselves as LGBTQ people and provided them with tools to talk with their friends and family. Additionally, participants appreciated the opportunity to connect with other LGBTQ people and allies in their local community. These findings highlight the important reminder that when we are teaching people to intervene with others, we are also covertly assisting them in intervening with themselves (see also Sawyer, Pinciaro, & Bedwell, 1997 on peer health educators). Though it was not an explicit goal, by training LGBTQ individuals to assist others in defining their own sexuality, asserting their needs and understanding themselves, the trainees themselves experienced some of those same effects, reporting greater feelings of self-efficacy and confidence in addressing issues of LGBTQ stigma in their own lives. Two of the peer advocates became increasingly involved in community


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organizing efforts concerning LGBTQ issues, and described that their training had assisted them in speaking knowledgably about these issues. Thus, even a training to perform an intervention can itself serve as an intervention.

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Although laudable outcomes, these benefits to the trainees may not justify the resources required to plan and implement such training. Multi-session, high-quality training by national experts in rural areas is desired, but not sustainable. There are certainly more costeffective ways to bring LGBTQ people together, but many areas may lack the infrastructure to implement such strategies. One possible solution is to combine the power of multiple resources: (1) distance learning tools, such as webinars; (2) LGBTQ community organizations connected through a national network (e.g., CenterLink); and (3) existing social networks. With these tools, rather than accessing online information in an isolated setting, LGBTQ people could gather through LGBTQ community organizations or natural social networks to obtain training. This strategy would build on the foundation of highquality, accurate training content; and it would maintain the beneficial aspect of bringing together LGBTQ community members. Where LGBTQ community organizations and social networks are lacking, broader mental health and social service agencies may have the capacity to offer such outreach.

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Mechanisms for outreach are necessary for sustainable community-building for an invisible or marginalized population (Minkler & Wallerstein, 2005). Unfortunately, this was one area for which the training did not adequately prepare the LGBTQ peer advocates. This is not entirely surprising as the training focused more on individual work than community outreach. Future iterations of the training may benefit from including more content related to community outreach, or even centralizing community outreach as the framework for the training. Such a model could help orient peer advocates to the community outreach role earlier in the training and reinforce this component throughout, much as the revised training did with helping skills. Unique experiences of rural LGBTQ residents make this training particularly important in these areas. Given the role of minority stress in negative mental health outcomes (Institute of Medicine, 2011; Meyer, 2003), interventions to increase access to professional and community support are critical. Participant positive feedback about the role of the training in community building draws attention to the needs of rural LGBTQ residents for emotional and community support to combat isolation, which contributes to minority stress.

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The training was designed for residents of rural settings, and it was effective in this geographic region. In terms of generalizability of the training and its effectiveness, the specific area shares characteristics with other rural areas, or places in which LGBTQ people are isolated and have limited access to LGBTQ-specific expertise and resources. The training likely benefited from the inclusion of state-specific information gathered by one of the trainers, and it may be important to consider how to gather such localized data if the training is replicated elsewhere. Some of the participants were not LGBTQ themselves, but were family members or allies of the LGBTQ community. In fact, with 78% of the participants identifying as cisgender (not


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transgender) – 30% of whom were also heterosexual – participants were interested in expanding their knowledge of gender and sexual minorities that they encountered in their professional lives (e.g., school nurses caring for youth) or for personal reasons (e.g., being the parent of a child who identified as LGBTQ). It may be important to consider how the content and format of training may need to be altered for LGBTQ-specific versus more general attendees.

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The primary limitations of this study include the trainee population and the lack of existing measures to assess LGBTQ peer advocate-specific knowledge and self-efficacy. First, the participants in the initial training and Part 1 of the revised training included community members and students who were interested in learning more about LGBTQ mental health and support needs, but were not necessarily interested in assuming a more formal role as LGBTQ peer advocates. Thus, it is possible that particular aspects of the training may have resonated differently with these individuals compared to persons who were more interested in becoming LGBTQ peer advocates. Second, we were limited in assessing specific knowledge and self-efficacy among the potential LGBTQ peer advocates. Although we based the self-efficacy measure on a similar, validated measure of counseling LGB clients, we did not have prior or concurrent validity data for either it or the knowledge measure. Future research would benefit from gathering validity data to support the use of both measures. Furthermore, although we observed participant skills in role-play simulations and used these observations in the selection of peer advocates, we did not conduct a structured assessment of skills. Research using more standardized tools for evaluating community health workers has noted the absence of direct assessment of skills (e.g., Ruiz et al., 2012), pointing to a need to develop means for conducting such evaluation within a training context. Direct evaluation of observable skills would be a valuable addition to future studies.

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Some studies that evaluated training for peer leaders have used pre-established competency criteria to determine readiness of peers to deliver an intervention (e.g., Tang et al., 2011). Such an approach is ideal for screening potential peers following training; however, it is possible only when research on the intervention is developed to the point of specifying competency criteria. Because the current study was conducted in the early stage of a project that was ultimately designed to assess feasibility and acceptability of the peer advocate intervention, it was premature to identify a priori cut-off levels for learning outcomes. It will be important for future research in this area to consider available data on LGBT peer advocate interventions in the development of training objectives and competency criteria.

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Researchers may launch from this study into a number of fruitful directions. Development and evaluation of a training framed in terms of LGBTQ community organizing could test the potential of training minority communities for multi-faceted and nuanced roles. Evaluating the efficacy of distance learning tools in providing LGBTQ training could explore sustainable options for cost-effective capacity building for hard-to-reach LGBTQ populations. This training strategy and material may be easily modified to offer in-person or distance-learning for therapists and clinicians interested in acquiring evidence-based strategies and competence at providing affirmative treatment, and assisting their clients in addressing bias and stigma from other clinical professionals.


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Conclusion The current study demonstrated the efficacy of training LGBTQ peer advocates in rural communities. In addition to increasing knowledge and self-efficacy, the training helped participants feel more positive about themselves, equipped them with tools to educate others, and reduced isolation. Moreover, receiving accurate information about diversity within LGBTQ populations increased knowledge that can combat stereotypes and enhance cohesion among LGBTQ people. Although the resources involved in providing the training may limit the generalizability of this particular model, our results call for further exploration of creative strategies for tapping into existing organizational and social networks to address the considerable need for information and training on LGBTQ issues in rural areas.

Acknowledgments Author Manuscript

The project described in this article was, supported by NIMH R34MH095238.

Appendix: LGBTQ Peer Advocate (PA) Curriculum Modules (for revised training) Part 1 Module I. Introduction to Part I of training

Module Description 1

Initial assessment of knowledge and self-efficacy related to LGBTQ mental health and substance use issues

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2

Introduction of trainers and participants

3

Icebreaker

4

Description of the training curriculum, communication tools, requirements, and logistics

5

Description of PA application and selection process

Purpose

Learning Objectives

Familiarize trainees with curriculum and expectations regarding their participation. Acquaint trainees with the PA position and application process. Establish baseline for measuring changes in knowledge and selfefficacy.

By the end of this module, trainees will be able to: a.

Identify trainers

b.

Anticipate training structure, content, and expectations regarding participation

c.

Recognize PA responsibilities and support

d.

Participate in PA application and selection process, if so desired.

By the end of this module, instructors will be able to: a.

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II. LGBTQ people and communities

1

Concepts of sex, gender, sexual orientation

2

Helping skills: non-verbal attending and paraphrasing

Introduce trainees to basic listening skills.


Determine participants’ baseline knowledge and selfefficacy related to PA role


Distinguish among

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Part 1 Module

Module Description

Purpose

3

Early messages about LGBTQ people

4

Characteristics of lesbian gay and male communities

5

Defining bisexuality

6

Other sexual orientation identity labels (e.g., queer, pansexual, fluid)

7

Transgender people a.


III. Mental health and substance abuse among LGBT people

Categories of transgender experience and people

b.

Gender nonconformity and gender dysphoria

c.

Similarities and differences from LGB individuals

1

Anti-LGBTQ discrimination, harassment, and violence

2

LGBTQ mental health and substance use

3

Common psychological problems for LGBTQ people (depression, anxiety, substance abuse, posttraumatic stress disorder [PTSD])

4

Particularly challenging conditions (chronic serious mental illness, personality disorders)

5

Resilience and positive aspects of LGBTQ experience

6

Open-ended questions

Describe characteristics of lesbian, gay male, bisexual, and transgender individuals and communities. Clarify distinctions between transgender people and LGB people.

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Describe sources and consequences of LGBTQ minority stress. Describe common psychological problems and people who may be particularly challenging to work with. Introduce strengths and resilience of LGBTQ people. Teach open-ended questions and apply to asking peers about their mental health and substance use concerns.


Learning Objectives concepts of sex, gender, and sexual orientation b.

Describe models of sexual orientation

c.

Demonstrate non-verbal attending and paraphrasing

d.

Describe characteristics of lesbian, gay male, bisexual, and transgender people and communities

e.

Recall a range of categories of transgender people

f.

Articulate similarities and differences between LGB and transgender people


Describe antiLGBTQ discrimination, harassment, and violence

b.

Identify factors contributing to LGBTQ mental health and substance use problems

c.

Recognize common psychological problems for LGBTQ people (depression, substance abuse, PTSD)

d.

Anticipate issues involved in interacting with people who have challenging conditions (chronic

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Part 1 Module

Module Description

Purpose

Learning Objectives serious mental illness or personality disorders)

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IV. LGBTQ people and suicide

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V. Diversity within LGBTQ communities

1

Fundamentals of the Question, Persuade, Refer (QPR) method for preventing suicide

2

Populations at risk for suicide (overview of national, New Mexico, and LGBTQ-specific statistics)

3

Suicide prevention/intervention lines and resources

4

Practice QPR method

1

Introduction of ourselves in terms of where we are from

2

Culture as context

3

Application of helping skills to gain insight into a peer’s cultural context

4

Diversity within LGBTQ communities ○ Ethnicity ○ Spirituality

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○ Generational status ○ Physical abilities ○ Social class ○ Immigration status ○ Sexual and relational structures and activities

Prepare trainees to identify and address risk for suicide using QPR model. Ensure that they know how to access appropriate experts and resources to handle the situation.

Broaden trainees’ understanding of “culture” to focus on context. Cultivate trainees’ ability to gain insight into people’s cultural context. Increase awareness of areas about which LGBTQ people may lack information or have information based only on their own experiences (which may


e.

Identify resilience among LGBTQ people

f.

Demonstrate open-ended questions


Distinguish between myths and facts about suicide

b.

Describe fundamentals of QPR

c.

Identify groups of people at risk for suicide, and the factors underlying this risk

d.

Access suicide prevention/ intervention lines and resources

e.

Apply QPR method


Describe culture in terms of context, process, and everyday circumstances

b.

Apply helping skills to gain insight into a peer’s cultural context

c.

Recognize variation in LGBTQ communities in terms of ethnicity, culture, spirituality, generational status, physical abilities, social

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Part 1 Module

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VI. Mental health and substance use services for LGBTQ populations

Module Description

Purpose

5

Development of sexual orientation identity

6

Key New Mexico demographics

7

Experiences of LGBTQ people in rural New Mexico

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a.

Systems of mental health care and substance use treatment

b.

Roles of various types of mental health care and substance use treatment professionals

c.

Barriers LGBTQ people face accessing services

d.

Conversion therapy

e.

Social support

Learning Objectives

not generalize to others).

Increase ability to identify challenges LGBTQ people face in accessing informal and formal assistance for their mental health and substance use issues. Establish foundation to aid LGBTQ help seekers in gaining better access and navigating service delivery systems. Enhance knowledge of how social support systems for LGBTQ people operate.

class, immigration status, and sexual activities d.

Describe a range of typical experiences of sexual orientation identity development and disclosure

e.

Recognize key New Mexico demographics

f.

Describe experiences of LGBTQ people in rural New Mexico

By the end of this module, trainees will be able to:

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a.

Describe various systems of mental health care and substance use treatment

b.

Identify the roles of various types of professionals in mental health care and substance use treatment

c.

Identify challenges LGBTQ people face accessing formal and informal assistance for mental health and substance use issues

d.

Describe the harmful effects of conversion therapy

e.

Recognize ways in which social support systems can influence LGBTQ people

By the end of this module, instructors will be able to:


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Part 1 Module

Module Description

Purpose

Learning Objectives a.

Part 2 Module

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VII. Introduction to Part II of training

VIII. Working individually with LGBTQ community members


IX. Working with service providers and others

Module Description

Purpose

1

Overview of PA points of intervention

2

Training structure and logistics

3

Communication goals for training

4

Theories of social empowerment and advocacy

5

Solution-focused strategies

6

Assessment and prioritization needs

7

Development of collaborative plans to address needs 8. Role plays with individualized feedback

9

Non-suicide crisis situations

1

PA role with service providers and family members of LGBTQ

Learning Objectives By the end of this module, PAs will be able to:

Further clarify the responsibilities of the PA per the empowerment protocol. Create opportunities for trainees to apply the knowledge and skills they acquired to scenarios to reinforce learning and provide instructors an opportunity to assess knowledge and skill level.

Develop skills to share knowledge gained from previous modules. This

a.

Identify the PAs’ points of intervention

b.

Anticipate training structure, content, and expectations regarding participation for Part II of training

By the end of this module, PAs will be able to: a.

Frame PA activities in terms of social empowerment/ advocacy

b.

Describe how PAs will work with individual LGBTQ community members

c.

Recognize and implement solutionfocused strategies

d.

Conduct needs assessments and prioritize needs

e.

Develop collaborative plans to address needs

f.

Respond appropriately to crisis situations

By the end of this module, PAs will be able to:


a.

Describe how PAs will work with service

Determine trainees’ knowledge, skills, and self-efficacy related to PA role

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Part 2 Module

Module Description

Purpose community members

2

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X. Ethics and boundaries


XI. Self-care

Challenges and strategies for communicating effectively with service providers and family members

3

Communication conflicts

4

Role plays with individualized feedback

1

Responsibilities and limits of the PA role

2

Professionalism

3

Confidentiality

4

Multiple relationships

5

Boundary maintenance

6

Sources of ethical guidance

7

Ethical decisionmaking

8

Supervision and consultation

1

Self-care – generating strategies and

Learning Objectives

application of the material will help trainees retain the information and strategize how best to communicate with LGBTQ help seekers and their providers, family, and friends.

Increase PA awareness of the personal and ethical dilemmas likely to arise in their helping interactions with peers, and the resources/ strategies to which they can turn to help resolve them.

providers and family members of LGBTQ community members b.

Identify strategies for communicating effectively with service providers

c.

Identify strategies for communicating effectively with service providers

d.

Recognize and respond effectively to communication conflicts

By the end of this module, PAs will be able to: a.

Describe the responsibilities and limits of the PA role

b.

Recall ways in which they can demonstrate professionalism in their role as PAs

c.

Anticipate ethical issues that may arise in their role as PAs

d.

Evaluate situations in terms of confidentiality, boundaries, and multiple relationships

e.

Identify sources of ethical guidance

f.

Follow a process for ethical decisionmaking

g.

Seek support through consultation



a.

Articulate the importance of

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Part 2 Module

Module Description

Purpose

Learning Objectives

developing a plan 2

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XII. Outreach, advocacy, presentations, and social support resources

1

Compassion practice to work with people who are suffering

Engaging in activities to cultivate LGBTQ affirming rural community environments

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2

Getting to know your community

3

Networking and partnering with local LGBTQ groups and other key community contacts

4

On-the-spot interventions

5

Establishing social support networks and other opportunities for interactions among LGBTQ community members, families, health care providers, and allies

6

7

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8

self-care for Pas

Prepare PAs to connect with individuals and organizations in rural communities with a stake in LGBTQ mental health and substance use issues, and to stay abreast of available resources for referral purposes. Impart strategies that the PA can use to mobilize these connections to enhance social support resources for LGBTQ help seekers, and that they can use to stay safe when conducting community outreach.

b.

Identify a range of strategies for self-care

c.

Craft a selfcare plan for themselves

d.

Implement compassion practice when encountering suffering


Organizing, delivering, and practicing presentations Compiling and updating resource and referral directory

a.

Describe how PAs will cultivate LGBTQaffirming community environments

b.

Gather information about organizations, services, and events in their community

c.

Establish relationships with key community contacts

d.

Implement onthe-spot interventions

e.

Establish support networks for LGBTQ community members, families, and service providers

f.

Recruit people to attend an event or meeting

g.

Plan and implement presentations to convey basic information on LGBTQ issues to lay audiences and service providers.

h.

Prevent and diffuse hostile situations

Preventing and diffusing hostile situations


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Part 2 Module XIII. Selfassessment of helping and leadership for LGBTQ community

Module Description a.

Privilege

b.

Self-assessment of helping and leadership for LGBTQ community

c.

Next steps

d.

Postassessment of knowledge and self-efficacy

Purpose

Learning Objectives

Post assessment will provide a measure of changes in knowledge, attitudes, skills, and perceived selfefficacy.

By the end of this module, instructors will be able to:

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a.

Reflect on the role of privilege in their lives

b.

Assess their strengths and challenges with respect to helping and leadership in LGBTQ communities

c.

Identify the next steps for PAs

By the end of this module, instructors will be able to: a.

Determine PA’s knowledge, attitudes, skills, and selfefficacy related to PA role

References


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Author Manuscript Author Manuscript Figure 1.

Author Manuscript

Timeline for Revised Training

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Figure 2.

Comparison of Knowledge Pre- and Post-Test Scores for Pilot and Revised Training

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Figure 3.

Comparison of Self-Efficacy Pre- and Post-Test Scores for Pilot and Revised Training


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Table 1

Author Manuscript

Content of Initial and Revised Training Initial Training

Revised Training PART 1

Introductions, icebreaker, communication

Introductions, icebreaker, communication

Key information about LGBTQ populations

LGBTQ people and communities; helping skills

Understanding LGBTQ populations in rural New Mexico

Mental health and substance use among LGBTQ people

Mental health and substance abuse among LGBTQ people

LGBTQ people and suicide

Mental health and substance use services for LGBTQ populations

Diversity within LGBTQ communities and cultural inquiry

Helping skills

Mental health and substance use treatment services for LGBTQ populations

Suicide risk, crisis intervention, and other emergencies

Author Manuscript

PART 2 Empowerment protocol

Overview of Peer Advocate role

Ethics and Boundaries

Working individually with LGBTQ community members (solution-focused approach, needs assessment, collaborative planning)

Communication with service providers and others

Working with service providers and others

Conducting outreach and cultivating social support resources

Ethics and boundaries

Challenging situations, closure

Self-care Outreach, advocacy, presentations, social support Self-assessment of helping and leadership for LGBTQ community (including privilege)


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Table 2

Author Manuscript

Description of Participants Initial Training

Revised Training (Part 1)


Total

14

23

8

37

M

41.07

41.65

36.38

41.43

SD

11.36

14.09

8.03

12.97

25 – 58

19 – 63

29 – 51

19 – 63

Female

7 (50.0%)

15 (65.2%)

4 (50.0%)

22 (59.5%)

Male

7 (50.0%)

8 (24.8%)

4 (50.0%)

15 (40.5%)

Woman

5 (35.7%)

12 (52.2%)

1 (12.5%)

17 (45.9%)

Man

Number of Participants Age

Range Sex Assigned at Birth

Author Manuscript

Gender Identity/Expression*

7 (50.0%)

5 (21.7%)

3 (37.5%)

12 (32.4%)

Transgender

1 (7.1%)

4 (17.4%)

2 (25.0%)

5 (13.5%)

Other

0 (0.0%)

3 (13.0%)

2 (25.0%)

3 (8.1%)

Missing

1 (7.1%)

0 (0.0%)

0 (0.0%)

1 (2.7%)

8 (57.1%)

9 (39.1%)

5 (62.5%)

17 (45.9%)

1 (7.1%)

2 (8.7%)

0 (0.0%)

3 (8.1%)

Sexual Orientation Lesbian/Gay Bisexual Queer

1 (7.1%)

2 (8.7%)

1 (12.5%)

3 (8.1%)

3 (21.4%)

8 (34.8%)

1 (12.5%)

11 (29.7%)

1 (7.1%)

2 (8.7%)

1 (12.5%)

3 (8.1%)

Hispanic

5 (35.7%)

1 (4.3%)

0 (0.0%)

6 (16.2%)

European American/White

9 (64.3%)

11 (47.8%)

3 (37.5%)

20 (54.1%)

1 (7.1%)

11 (47.8%)

5 (62.5%)

12 (32.4%)

2 (14.3%)

1 (4.3%)

0 (0.0%)

3 (8.1%)

High school/GED

1 (7.1%)

0 (0.0%)

0 (0.0%)

1 (2.7%)

Trade/vocational school

0 (0.0%)

2 (8.7%)

1 (12.5%)

2 (5.4%)

Some college, no degree

Heterosexual

Author Manuscript

Other Race/Ethnicity*

American Indian Other Education

Author Manuscript

2 (14.3%)

7 (30.4%)

3 (37.5%)

9 (24.3%)

Associate’s degree

1 (7.1%)

3 (13.0%)

1 (12.5%)

4 (10.8%)

Bachelor’s degree

2 (14.3%)

2 (8.7%)

1 (12.5%)

4 (10.8%)

Some graduate school

6 (42.9%)

2 (8.7%)

1 (12.5%)

8 (21.6%)

Grad/professional degree

2 (14.3%)

7 (30.4%)

1 (12.5%)

9 (24.3%)

0 (0.0%)

1 (4.3%)

0 (0.0%)

1 (2.7%)

Monthly Income Less than $500


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Author Manuscript

Initial Training



Total

$500 – $999

4 (28.6%)

4 (17.4%)

1 (12.5%)

8 (21.6%)

$1,000 – $1,999

5 (35.7%)

6 (26.1%)

3 (37.5%)

11 (29.7%)

$2,000 – $2,999

1 (7.1%)

3 (13.0%)

1 (12.5%)

4 (10.8%)

$3,000 – $3,999

2 (14.3%)

5 (21.7%)

2 (25.0%)

7 (18.9%)

Over $4,000

2 (14.3%)

4 (17.3%)

1 (12.5%)

6 (16.2%)

M

9.23

13.96

12.29

12.20

SD

13.30

14.60

16.34

14.12

Range

0 – 44

0 – 50

1 – 46

0 – 50

Years in Geographic Area

*

Participants could check all that applied, thus percentages may add up to more than 100%.

Author Manuscript Author Manuscript Author Manuscript Rural Ment Health. Author manuscript; available in PMC 2017 January 01.

Coaching mental health peer advocates for rural LGBTQ people.

Youth and caregiver access to peer advocates and satisfaction with mental health services.

Chapter Oral Health Advocates: A Nationwide Model for Pediatrician Peer Education and Advocacy about Oral Health.

Mental health training for clergy.

Training tomorrow's physician-advocates.

Rural parents' perceived stigma of seeking mental health services for their children: development and evaluation of a new instrument.

Mental health care training for practitioners in remote and rural areas.

Peer sex education training and evaluation.

Rural mental health matters.

[Development and Process Evaluation of the e-Mental Health Portal www.psychenet.de for the Hamburg Network for Mental Health].

[Practical guidelines for peer support programmes for mental health problems].

Training for rural health in Tanzania.

Innovative Approaches Address Aging and Mental Health Needs in LGBTQ Communities.

Sex workers as peer health advocates: community empowerment and transformative learning through a Canadian pilot program.

Peer support in mental health services.

Mental health training for the middle manager.

Integrating peer perspectives into mental health services.

Successful provision of emergency mental health care to rural and remote New South Wales: an evaluation of the Mental Health Emergency Care-Rural Access Program.

Mental health first aid training for Australian medical and nursing students: an evaluation study.

Skills for Psychological Recovery: Evaluation of a post-disaster mental health training program.

LGBTQ Health Surveillance: Data = Power.

AIDS in South Africa.

Peer health coaching for overweight and obese individuals with serious mental illness: intervention development and initial feasibility study.

Preventing Filipino Mental Health Disparities: Perspectives from Adolescents, Caregivers, Providers, and Advocates.