Supporting LGBTIQA+ communities in small rural settings: a case study of health promotion in a community health service

Keywords: community connectedness, community health: services, health promotion, health services: accessibility, LGBTIQA+ health, LGBTIQA+ wellbeing, preventive health services, rural health: services.

Findings from Australia’s largest national survey of the health and wellbeing of LGBTIQA+ (lesbian, gay, bisexual, transgender, intersex, queer, asexual) people (Hill et al. 2020) indicate that they continue to experience significant disparities across a range of health and wellbeing indicators, and concerning levels of discrimination, harassment and violence, and significant levels of suicide ideation compared with the general population.

LGBTIQA+ people underutilise much needed health care for fear of actual or perceived discrimination and stigma. Less than half of LGBTIQA+ participants in the survey felt accepted when accessing health or support services (Hill et al. 2020). Furthermore, the survey report found that >75% of participants indicated that they would be more likely to use a service if it is accredited as LGBTIQA-inclusive (Hill et al. 2020). The report also noted that:

LGBTIQ who live outside urban areas may face additional challenges, such as accessing inclusive and affirmative health and support services. For example, LGBT people residing in rural areas have been found to face higher levels of stigma and discrimination in accessing healthcare than those residing in urban areas… Depending on where they live, establishing community networks and support that involve other LGBTIQ people may also be challenging, which may have further implications for health and wellbeing. (Hill et al. 2020, p.113)

Similar findings were also documented by the Victorian Agency for Health Information (2020). This report highlights mental health and physical health challenges for people from the LGBTIQA+ community, demonstrating that particular subgroups within this community, such as people who are transgender, experience even greater disparities in wellbeing.

International studies identify the need for social connectedness as a response to discrimination and isolation. Nic Golla Espaig et al. (2022) conclude from a systematic review of the health and health care of rural sexual and gender minorities in five countries that LGBTIQA+ face additional challenges to attaining wellbeing.

A meta-analysis of literature on loneliness by Gorczynski and Fasoli (2022) noted people from LGBTIQA+ communities significantly experienced loneliness, which is associated with poor physical, mental and social health. These authors argue that environments that create safe spaces and foster social connectedness may be the most helpful intervention to reduce loneliness and related health concerns. Ceatha et al’s. (2019) in-depth qualitative study undertaken in Ireland drew on Honneth’s recognition theory to argue that LGBTIQA+ communities benefit significantly from the power of recognition through social groups as a major contributor to health and wellbeing. The social groups in the Irish study were diverse, including sporting, creative and social groups, and played an important role at both an individual and community level.

With the onset of the COVID-19 pandemic, Equality Australia (2020) released a report into the challenges that COVID-19 presented for LGBTIQA+ communities. The report noted that Australia has a network of community controlled LGBTIQA+ health organisations, but these are underresourced and ill equipped to respond to increasing demand. The report highlighted the need to ensure that COVID-19 responses accounted for the specific needs and circumstances of LGBTIQA+ people and communities, especially people who may be socially or economically marginalised, or at greater risk from COVID-19 or its impacts. The report also outlined specific areas of concern for people from LGBTIQA+ communities, including access to essential services, such as health services, specifically mental health services, and access to information focusing particularly on social isolation and dislocation, family violence, and caring for older LGBTIQA+ people and people with a disability.

In light of this evidence, together with experience gained from an earlier local LGBTIQA+ partnership project, Castlemaine District Community Health, a small community health service known locally as CHIRP (Community Health Information Resources and Programs), secured funding from the Victorian government to appoint an LGBTIQA+ health promotion officer (HPO) to both respond to the COVID-19 environment and also address the ongoing need for social connectedness for the local LGBTIQA+ community. The rationale for the funding bid was that a health promotion position would provide structured support for a range of local LGBTIQA+ community activities and gather further information about community needs.

The dearth of health promotion literature focusing on rural and regional LGTBIQA+ communities, particularly in regard to the impact of COVID-19 on their health and wellbeing, is indicative of Nic Golla Espaig et al.’s (2022) claim that a comprehensive understanding of these communities’ experiences is lacking. This article contributes to filling this gap from a practice perspective.

Castlemaine (population 8000), where CHIRP is located, is the regional centre of Mount Alexander Shire, on Djaara land in central Victoria. One of Victoria’s smallest municipalities, Mount Alexander’s 19 000 residents are distributed across eight towns and numerous rural properties. Population health data show the shire has a higher aged population and a higher number of people identifying as LGBTIQA+ than the Victorian state average (Victorian Agency for Health Information 2020). The development of the LGBTIQA+ health promotion program is illustrative of CHIRP’s founding rationale to provide accessible services that meet local community needs. However, as a small rural service, CHIRP has struggled financially over the years. This is primarily due to inadequate funding at both the state and national level for preventative and community health services, and policy preferences for regional consolidation and rationalisation of health services, in spite of evidence of the spatial and service inequities that such policies introduce (McGrail and Humphreys 2015). As a consequence, in 2021, CHIRP merged with the local hospital provider, now known as Dhelkaya Health, to ensure maintenance of local services, including the health promotion role.

In 2018, with a grant from the Victorian government, CHIRP led a project with local partners, the Central Victorian Primary Care Partnership (a state government-funded health care network), Castlemaine Community House (a non-government organisation) and Mount Alexander Shire Council (MASC; the local government authority) to strengthen the LGBTIQA+ supports in the region. This was in response to a divisive debate in Australia prior to legalisation of same-sex marriage in 2017, during which members of the local LGBTIQA+ community felt they were unsupported and subject to discrimination.

The project developed a strategic plan titled Let’s Get Proud, with three priorities: (1) developing a supportive ecosystem in the wider community, (2) fostering connections between businesses and the LQBTIQA+ community, and (3) establishing a support group for young people outside of school.

Much was learned from this work. The plan enabled greater visibility of local community members and created a positive environment to discuss local needs. The expectation was that the plan’s implementation would be led by a committee of volunteers. However, it was difficult to sustain a voluntary leadership group and it became evident that the partner services needed to provide greater organisational resources to ensure continuity. Consequently, at the end of the project, MASC took on support for an LGBTIQA+ Steering Committee to continue the work. CHIRP continued to engage with the local community and completed the Rainbow Tick Accreditation process (a quality framework developed by Rainbow Health Australia to help human service organisations show they are safe and inclusive services and employers for the LGBTIQA+ community) in early 2020.

One of the Victorian government responses to the social and economic disruption of COVID-19 was the establishment in July 2020 of a local employment scheme titled Working for Victoria. CHIRP applied to this scheme to fund a role to support the LGBTIQA+ community. At this time, CHIRP was providing COVID-19 testing services, telehealth and support for the local community food pantry, in addition to onsite clinical services. However, the research literature discussed above suggested that LGBTIQA+ community members would be more at risk of isolation during Victoria’s extensive lockdown periods than the wider population, requiring additional support to maintain social connectedness and wellbeing. The LGBTIQA+ health promotion role was developed to respond to the COVID-19 crisis by reaching out and linking with community members, building on the partnership work already completed, and coordinating with the ongoing MASC LGBTIQA+ Steering Group and CHIRP’s internal Rainbow Committee.

The role enabled engagement with a wide range of community members during and after COVID-19 lockdowns, and development of support groups and activities. The HPO also connected people with health practitioners. Commencing initially as a 4 day a week role in October 2020, it was quickly determined that longer-term investment was required for this type of work, so the role reverted to a 2 day a week position to extend available funds.

The HPO undertook a needs assessment to determine the focus of the work. Given CHIRP’s long-standing facilitation of walking groups, a Rainbows Steps Walking Group was established as an early activity. The HPO presented an existing community radio program and this was also used as a point of connection.

As part of the needs assessment, a survey was distributed via a contact list of people who had participated in previous LGBTIQA+ projects or activities, seeking views on desired activities and forms of engagement. A total of 100 responses were received, which identified a range of needs, but particularly support of Rainbow families, young people in the school setting, trans community members and opportunities for social connection. Survey responses highlighted the importance of the Pride Week picnic for social and service provider connection.

The range of programs and activities conducted over 2020–2022 was varied, and involved facilitating volunteers and partners to conduct programs, as well as the HPO delivering them directly. A partnership approach has been essential to achieve the breadth and reach of programs and activities. A full list of activities is included in Table 1.

Table 1.  LGBTIQA+ programs and activities 2020–2022.

Evaluation data included in this Practice and Innovation note was obtained with the informed consent of participants.

The work of the HPO in facilitating activities was evaluated through a de-identified survey administered in 2022 and direct feedback from participants. The survey was sent electronically to the 100 people on the LGBTIQA+ contact list mentioned above, resulting in 53 responses. The survey gathered quantitative and qualitative data on participation in and impact of activities through questions with Likert-style scaled responses and opportunities for unstructured comments. Respondents ranged in age from 25 to ≥75 years across groups within the LGBTIQA+ community, including lesbian, gay, trans, queer and bi. Younger people in the youth-specific groups were not surveyed, preferring face-to-face engagement.

Survey respondents participated in a range of activities, with the Yellow Brick Road, Castlemaine Pride Picnic, Castlemaine Pride Choir, Walking, and Listening to Queer and Now being the most popular. The most common outcome of participation identified by respondents was feeling more connected with the LGBTIQA+ community (94% of respondents nominated this), making new friends (87%), feeling seen because there are LGBTIQA+ initiatives in the local area (79%), feeling prouder (72%) and an increased positive sense of self (66%).

Respondents indicated that if these activities were not running that they would feel less connected to the LGBTIQA+ and wider communities (96%), more isolated (85%), their mental health would be negatively impacted (36%), and they would feel less safe and more fearful of stigma and discrimination (45%). Respondents agreed that participating in the activities made the pandemic more bearable (94.3%). They made social connections (90.6%), felt less isolated (94.3%) and the activities had an overall positive impact on their mental health (92.5%). A total of 69.8% of respondents also said they were extremely or somewhat likely to engage with Dhelkaya Health following participation in these activities. A further 13.2% said they had already engaged with Dhelkaya Health. The survey also indicated that the main barrier to ‘enjoying any of our services’ was not knowing what support is available (26%), followed by personal issues (23%). These data are important in terms of future work and the need to better understand these barriers for the LGBTIQA+ community.

Qualitative data also strongly supported the work of the HPO. These data indicated the importance of social connectedness and support for wellbeing. Some respondents commented on the HPO’s ability to connect people through the various groups and the value of cross-connections within the local LGBTIQA+ community. Other feedback indicated that access to activities was a significant factor in preventing respondents from leaving the local area, and in building social cohesion and an increased sense of connectedness with the local community. As one respondent commented: ‘the model here could go a long way to address LGBTIQ isolation in other country regions as well, long may it continue’.

The importance of the position was noted by another in this way:

The role is like a pebble dropped in the centre of our pond, it may be hard to measure the ripples as they expand outwards, but the change that is created is meaningful and far reaching.

The role’s significance as a connector is also echoed in other comments:

I’ve noticed there is less segregation between the identities within our community, I believe this is a direct result of programs such as Pride Choir, which encourages friendship across genders and ages.

I moved to Castlemaine just over a year ago and the effects of the LGBTIQ+ groups have had on myself and my partner is profound, we have a great network of really good mates out here now because of the social connections we made at Castlemaine Pride Choir and Rainbow Steps.

We had a baby in 2020 and didn’t meet anyone in the first 4 months…having the rainbow playgroup we have met other queer families…I now have to explain that some families have a mother and a father, instead of two mums or dads or three parents, which is a nice place to be.

The survey results support the research literature’s focus on the importance of social connectedness for the health and wellbeing of people from LGBTIQA+ communities (Ceatha et al. 2019; Hill et al. 2020; Grant et al. 2021). The results point to the value of a dedicated health promotion role working with the local LGBTIQA+ community, specifically the role’s facilitation of partnerships and community volunteers to lead activities. The skills of the person in the role, particularly their ability to successfully create a range of what Grant et al. (2021) describe as integrative spaces, or spaces of social networking and interpersonal support through the activities, as demonstrated in Table 1, was also a key factor.

Historical attempts to establish a voluntary committee to support the local LGBTIQA+ community were unsuccessful, with previous attempts placing too much responsibility on volunteers. Shifting major responsibility onto volunteers to provide services and supports is symptomatic of fragmented and discontinuous funding for health professional roles in rural and regional Australia (National Rural Health Commissioner 2020). This has a particular impact on groups of people who are more at risk of experiencing disadvantage and discrimination, such as people who identify as LGBTIQA+, particularly in rural areas (Hill et al. 2020; Grant et al. 2021; Nic Giolla Espaig et al. 2022). The outcomes of this project suggest that even modest ongoing funding of a 2 day a week health promotion role, in combination with existing partner support, means that volunteers are more willing to lead community activities and participate in creating a wider network of supportive activities.

The implementation of this role was a critical place-based intervention in a local rural setting to supplement specialist LGBTIQA+ services offered by statewide agencies. We conclude that local roles, such as the HPO, should be more readily available in all regional community health settings to support LGBTIQA+ communities address ongoing discrimination and stigma, and develop a network of pride and support. This is a small resource in health funding terms. However, if focused on enhancing social and other activity-based connectedness, it can have a positive impact on the health and wellbeing of LGBTIQA+ people in their local communities.

The data that support this study will be shared upon reasonable request to the corresponding author.

The authors declare no conflicts of interest.

This research did not receive any specific funding.