Socioecological Levels Research Articles

Health promotion at local level in Portugal: is childhood obesity a concern in municipal programs?

Abstract Health promotion programs targeted at distinct health outcomes such as childhood obesity, at local level are increasingly used worldwide. There is a need to better understand the role of local governments (municipalities) as key public health promoters namely in the prevention of obesity in children. This study aims to provide some input regarding this issue in Portugal. In order to achieve this goal, health enhancing programs promoted by Portuguese municipalities in which children could participate were identified. The search of such programs was limited to the municipalities that were part of the Portuguese Network of Healthy Municipalities in 2021 (N = 57). A subsequent document analysis was conducted to describe how municipalities conceptualized children’s health by retrieving information on which topics the programs were focused on, or acted upon, and identify which socio-ecological model levels of health determinants were addressed (or not) by each program. The 77 identified programs were promoted by 30 municipalities and only 11 programs addressed childhood obesity. Most programs focused on the individual health determinants (N = 27) and provided limited information overall, which hindered a more in-depth analysis. The findings suggest that Portuguese municipalities seem to disregard their potential as public health promoters. Childhood obesity is a major public health concern at national level, as reflected in the National Health Plans, but not perceived as such locally. Municipalities are the closest government entities to the population, and it is their responsibility to ensure the population’s quality of life, by addressing the social and environmental determinants of health. Hence, municipalities should instill health concerns in all their actions/interventions, taking in consideration the most recent evidence, specifically in the case of childhood obesity. Key messages • This study findings suggest that, despite childhood obesity being a major public health concern at national level, as reflected in the National Health Plans, it is not perceived as such locally. • There is a need to better understand the role of municipalities as key public health promoters considering they are responsible to intervene on the social and environmental determinants of health.

The mental health impacts of othering LGBTQ+ in Rwanda and Kenya: a mixed methods exploration

Abstract Background Globally lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons experience stigma across at multiple socioecological levels with health-harming impacts. The objectives of this study were to quantify and explore how stigma shapes mental health among LGBTQ+ persons living in Rwanda and Kenya. Methods Respondent-driven sampling was used in this mixed methods study of LGBTQ+ persons. In Rwanda, we surveyed 499 and conducted focus groups with 59 persons. In Kenya, we surveyed 1,573 persons, conducted focus groups with 40 persons, and conducted 113 individual interviews. We used thematic analysis for the qualitative data to examine how LGBTQ+ discuss what shapes their mental health. Results The average depression score was 6.3, which is categorized as mild depression. Additionally, 36% (n = 744) scored as mild, 14% (n = 289) as moderate, 5% (n = 110) as moderately severe, and 2.5% as severe (n = 52). Average scores were the same in Kenya and Rwanda. In regression models, as compared to cisgender males, cisgender females’ depression scores were 2.1 points higher (95% CI 1.5, 2.8), trans male scores were 1.6 points higher (95% CI 0.7, 2.5), trans female scores were 1.9 points higher (95% CI 1.1, 2.7), and gender non-conforming scores were 1.7 points higher (95% CI 1.0, 2.4). As compared to transgender people, lesbian & gay participants had depression scores that were 0.93 points lower and bisexual 1.3 points lower (p < 0.000). In adjusted regression models, we found that for every one-unit increase in discrimination, depression scores increased by 0.44 (95% 0.36, 0.52). Qualitatively, stigma was described as a prominent factor in negatively impacting mental health. Conclusions LGBTQ+ people in Rwanda and Kenya experience elevated mental health issues that arise from discrimination due to their stigmatized identity.

Characteristics of interventions that address racism in the United States and opportunities to integrate equity principles: a scoping review

BackgroundAs a driver of racial and health inequities, racism is deeply ingrained in the interconnected systems that affect health and well-being. Currently, no common frame is employed across researchers, interventionists, and funders to design, implement, and evaluate comprehensive interventions to address racism. Consequently, there is a need to examine the characteristics of interventions implemented in the United States that address racism across social and structural determinants of health and socio-ecological levels. Additionally, we utilized a Health Equity Action Research (HEART) framework to assess how interventions integrate equity principles.MethodsThis scoping review examined the characteristics of multi-level interventions that addressed racism and appraised the interventions using a Health Equity Action Research frame. A comprehensive search strategy was conducted across nine electronic databases between 24 October 2022 through 15 November 2022. Records were included if they were available in English, discussed or evaluated a multi-level intervention or program conducted in the United States, and discussed or evaluated the intervention or program regarding the health and well-being of racialized and ethnically minoritized groups.ResultsA total of 13,391 records were identified, of which 91 met the eligibility criteria and were included in the analysis. Most records reported the racialized group impacted by an intervention, of which the majority were racialized as African American or Black (n = 42) and Hispanic or Latino/a/x (n = 18). Eighty-one (89%) of interventions reported health outcomes and concentrated on the individual level. Most funders reported across the records, and 86 (51%) were a federal agency or department. A further 43 (25%) were private foundations, 12 (7%) were nonprofit organizations, 10 (6%) were private universities, and 4 (2%) were public universities. Regarding alignment with the HEART framework, 14% of interventions reported a mixed-methods approach, 45% reported community engagement, and less than 1% reported researcher self-reflection.ConclusionsMost interventions prioritized people who are racialized as Black and report health outcomes. Since intervention designs, objectives, and methodological approaches vary, no standard frame defines racism and health equity. Applying the HEART framework offers a standard approach for interventionists and researchers to examine power, integrate community voice, and self-reflect to advance health equity.

The relationships between resilience and child health behaviors in a national dataset.

Resilience mechanisms at the individual, family, and environmental levels may improve health outcomes despite potentially harmful stress exposure partly through the practice of positive health behaviors. We performed a secondary analysis of 2016-2021 National Survey of Children's Health data to assess the relationships between three resilience domains - child, family, neighborhood - and six health behaviors using multiple regression models adjusted for the other resilience domain(s) and potential confounders. Analysis revealed significant associations between each resilience domain and multiple health behaviors in a total weighted analytic sample of 70,156,540 children. For each outcome, the odds of better health behaviors were highest with high resilience in all possible domains. For example, among children ages 0-5 years, the adjusted odds of having "good quality" vs. "poor quality" sleep for those with "high" resilience in all domains were 2.21 times higher (95% CI 1.78, 2.63) than for those with "low" resilience in all domains. This line of research may help to inform the design of resilience and health behavior promotion interventions by targeting multiple socio-ecological domains of influence to improve health and development outcomes in children exposed to experiences or sources of potential stress. This study assessed the associations between three socio-ecological resilience domains (child, family, and neighborhood) and six child and family health behaviors in a national dataset. Resilience exists within multiple socio-ecological levels and supports healthy functioning despite experiencing stress. Studies in adults and limited pediatric sub-populations show associations between resilience and health behaviors, which in turn influence numerous health outcomes. Resilience at three levels of socio-ecological levels was found to be associated with the performance of multiple child and family health behaviors in a nationally representative general pediatric population. These findings have important implications for child and family health promotion efforts.

Qualitative Analysis of Micro-System-Level Factors Determining Sport Persistence.

Background/Objectives: Sport persistence is the embodiment of sports performance and mental toughness. It refers to our attempts concerning the performance plateau, failures, injuries, or even the resolution and processing of stressful situations associated with success and positive events. In our research, we used qualitative methods based on Bronfenbrenner's socio-ecological model to investigate the factors influencing sport persistence among high school and university athletes. Methods: The research was based on semi-structured interviews with 133 athletes. ATLAS.ti software and the grounded theory methodology were applied for data analysis. Our analysis grouped the responses according to Bronfenbrenner's categorisation system, highlighting motivational factors at the microsystem level. Our research question was as follows: What kind of factors dominate the development of sport persistence among adolescent (high school) and young adult (university) athletes along Bronfenbrenner's dimension of the microsystem? Results: Regarding the microsystem, family, peers, and coaches were mentioned as influential factors. Concerning the family, general, person-specific, family value-related, future-oriented, introjected, and disadvantage-compensating motivational components were identified. General, individual, community and relational factors were identified concerning peers. Concerning the coach, general, individual, community, and coach personality-driven motivational segments were detected. Conclusions: By recognising the complex interplay of systemic factors, we can design interventions targeting these factors at various socio-ecological levels, promoting youth sports and increasing physical activity among young people. These findings instil hope and motivation for the future of sports and physical activity.

Participation experiences of young people with limb difference in sports and recreation in Australia: a qualitative study

Purpose The primary objective was to investigate the experiences of young people with limb difference participating in sports and recreation. Materials and methods A qualitative study using an interpretive description approach was undertaken with nine family dyads (n = 9 young people; n = 9 parents) recruited across Australia via convenience sampling. Data were collected via 18 semi-structured interviews and analysed in line with the interpretive description approach. Young people were aged between 9-16 years (mean 14 y 1 m), with unilateral (n = 7) or bilateral (n = 2) limb differences. All participating parents were mothers. Findings Three themes were interpreted from the data: (1) “Just treat me like everyone else”: equitable participation in sports and recreation, (2) “Provide them opportunities and let them take the lead”: genuine choice within activities, and (3) “I wish they were easier to get”: the impact of sports-specific prostheses on participation. Facilitators and barriers to participation were mapped to illustrate the socio-ecological levels at which these influences operate, and a conceptual model was developed to guide application in practice. Conclusions This study provides guidance for practitioners, coaches, and families on how to support participation for young people with limb difference, and future research may operationalise this conceptual model into policy or practice interventions.

Using concept mapping to co-create implementation strategies to address maternal-child food insecurity during the first 1000 days of life.

Food insecurity (FI) has short- and long-term effects on maternal and child health, with persistent inequities within under-resourced communities of colour (e.g., Hispanic and Non-Hispanic Black). Interventions to mitigate maternal-child FI must engage the voices of under-resourced communities of colour to improve implementation and tackle socio-ecological drivers of inequities, leading to positive maternal-child outcomes. This exploratory sequential mixed-methods study aimed to co-create implementation strategies to tailor a culturally sensitive intervention to address FI during the first 1000 days of life in under-resourced communities of colour in Las Vegas. A Community Advisory Board (CAB) engaged in a two-step participatory process. First, through the concept mapping, hierarchical cluster analysis organized 125 strategies into seven thematic areas: policy and advocacy, access to food and resources, built environment, education across systems, social and peer support, cultural congruency and trust, and wellness and mental health. Second, through consensus-building, strategies were combined by similarity (n = 94) and excluded if unrelated to health and nutrition (n = 9). The CAB reached a consensus on 22 strategies classified across three socio-ecological levels. Examples of strategies at the community level (n = 16) included increasing utilization of federal nutrition assistance programmes; at the service level (n = 4), integrating FI screenings and referral coordination systems across services; and at the individual level (n = 2), providing mentorship, education, and support for families and moms. The co-creation of a culturally sensitive intervention to reduce inequities in maternal-child FI during the first 1000 days of life requires multi-level strategies across three socio-ecological levels in under-resourced communities of colour in Las Vegas.

Feasibility of an environmental scan-based approach to collecting information about factors impacting cancer genetics services in Latin American countries.

Clinical cancer genetics services are expanding globally, but national policy and health care systems influence availability and implementation. Understanding the environmental factors within a country is required to appropriately implement, adapt, and evaluate cancer genetics service delivery models. An environmental scan (ES) is an approach used in business, public health, health care and other sectors to collect information about an environment or system for strategic decision making and program planning. An ES has been previously used to assess cancer genetics clinic-level factors to inform quality improvement efforts in the United States. We assessed the feasibility of using an ES to collect information about factors that may influence cancer genetics service delivery in the outer-most socio-ecological model environmental levels (policy, national agencies, healthcare systems, cultural considerations) in three Latin American countries. Oncology and Genetics care team members at three participating sites used publicly available sources and personal experiences to complete a data collection form (DCF) that included questions about subtopics: laws and policies, relevant agencies and regulations, health care systems and insurance, and cultural considerations. Time to complete the DCF and DCF completeness were used to measure ES feasibility. Participating sites completed the DCF in 3 months, and most questions (average, 87.0%) were answered. Questions in the cultural considerations subtopic had the fewest answers (average, 77.8%). Overall, the ES was feasible and identified a lack of published literature related to cultural considerations impacting health care and genetics services uptake in Latin America. Environmental factors impact cancer genetics services, and identification of these factors will facilitate future collaborative research and genetics service delivery dissemination efforts.

Understanding COVID-19 and its Impact on Social connection at the Outdoor Recreational Spaces Among CQUniversity students

Preventive measures have been widely used to stop the COVID-19 outbreak, which may have a devastating impact on the social connection among university students. Particularly, Outdoor recreation has been limited due to the COVID-19 restrictions. This study seeks to understand Central Queensland University students’ knowledge about COVID-19 preventive measures and identify the consequence of this practice on the social connection at the outdoor recreational spaces by using a mixed-method design (online survey and interview). Central Queensland University students (CQU) enrolled in Participatory Health Research completed an online survey (N=22) and participated in an online interview (N=15). The results showed that students understood clearly about COVID-19 preventive measures (N=22, 100%). Students had a high number of social connections at the recreational areas, both in-person (Mean=7, Std=7) and virtually (Mean =2, Std=7) before COVID-19. Conversely, during the COVID-19 outbreak, social contacts at the recreational areas had dropped for in-person (Mean=4, Std=5.5) while connection via online platforms slightly increased (Mean =3, Std=5). Their level of social connectedness during COVID-19 moderately connected (N=8, 36%). Students’ experienced impact on the three socioecological levels of intrapersonal (e.g. stress, loneliness, and behavior change), interpersonal (e.g. contacting via social media) and environmental (e.g. parks needed for emotional support).

The Socio-Ecological Factors Associated with Mental Health Problems and Resilience in Refugees: A Systematic Scoping Review.

Despite the immense challenges to mental health faced by refugees, research consistently finds that many nevertheless demonstrate remarkable resilience. However, a systematic account of the scientific literature on resilience among refugees is currently lacking. This paper aims to fill that gap by comprehensively reviewing research on protective and risk factors affecting refugees' resilience and mental health problems across four socio-ecological levels: individual, family, community, and society. We conducted a systematic search in the databases PsycINFO, Web of Science, and SocINDEX, as well as contacted topic experts to seek out unpublished manuscripts. This yielded 223 studies (171 quantitative, 52 qualitative), which were subjected to systematic content coding. We found consistent evidence for substantive risk factors, including traumatic experiences and gender at the individual level and postmigration stress and unemployment at the societal level. We found social support to be a clear protective factor at the family and community levels. We discuss these findings in the context of policy and intervention programs and make recommendations at different socio-ecological levels for supporting refugees' resilience.

Socioecologies in shaping migrants and refugee youths’ sexual and reproductive health and rights: a participatory action research study

ObjectiveThis study explores socioecological factors facilitating the sexual and reproductive health and rights (SRHR) experiences of migrant and refugee youth (MRY) in Greater Western Sydney, Australia. MRY may be at higher risk for poorer SRH outcomes due to cultural, linguistic, and systemic barriers.MethodsUsing participatory action research, 17 focus groups were conducted with 87 MRY aged 15–29 from diverse cultural backgrounds. Data were analysed thematically, using socioecological framework.ResultsKey facilitators of MRY's SRHR were identified at the microsystem and exosystem levels, including (1) Peer dynamics and support, with friends serving as trusted confidants and sources of advice; (2) Safety and contraceptive choices, highlighting the importance of access to contraception and STI prevention; and (3) Digital platforms for SRHR information access, with online resources filling knowledge gaps.ConclusionFindings suggest the need for SRHR interventions to leverage peer support networks, expand access to contraceptive options, and develop culturally appropriate digital resources for MRY. Further research is needed to identify and enhance facilitators across all socioecological levels to comprehensively support MRY's SRHR needs.

How can community music shape individual and collective well-being? A case study of a place-based initiative.

There is an urgent need to investigate innovative and creative approaches in health promotion that support work towards health equity. In response, this study explores the potential for arts, and community music specifically, to strengthen individual and collective well-being. This study used a qualitative case study methodology that involved interviews, focus groups and ethnographic observation with participants (N = 13), facilitator (N = 1) and support staff (N = 2) of an established community music initiative conducted in an urban community. Data collection was conducted across 2023 and data analysis drew on a socioecological framework to explore potential individual and collective outcomes from the perspective of those involved in the initiative. Findings point to outcomes across socioecological levels with researchers identifying positive health and well-being implications for participants including joy, healing and a sense of purpose, creative self-expression, confidence, social connection and contribution. Positive outcomes for the wider community were also identified including developing community ties, promoting safety and shaping and sharing of collective identity. Findings suggest community-led opportunities for engagement can support healing and empowerment for people who are marginalised, and this can enable active community participation related to challenging the status quo and developing a shared set of values. Potential implications of these outcomes in relation to broader societal transformations are discussed. This study highlights how community music, and the arts more broadly are working in communities in ways that support potential personal, community and societal transformations towards health equity. SO WHAT?: By developing coalitions and collaborating with diverse sectors, including the arts and social sectors, health promotion practitioners and researchers can harness the creative strengths and resources that exist within a community to support positive individual and collective well-being.

Achieving Equity in Hypertension: A Review of Current Efforts by the American Heart Association.

The purpose of this article is to summarize disparities in blood pressure (BP) by race in the United States, discuss evidence-based strategies to increase equity in BP, review recent American Heart Association BP equity initiatives, and highlight missed opportunities for achieving equity in hypertension. Over 122 million American adults have hypertension, with the highest prevalence among Black Americans. Racial disparities in hypertension and BP control in the United States are estimated to be the single largest contributor to the excess risk for cardiovascular disease among Black versus White adults. Worsening disparities in cardiovascular disease and life expectancy during the COVID-19 pandemic warrant an evaluation of the strategies and opportunities to increase equity in BP in the United States. Racial disparities in hypertension are largely driven by systemic inequities that limit access to quality education, economic opportunities, neighborhoods, and health care. To address these root causes, recent studies have evaluated evidence-based strategies, including community health workers, digital health interventions, team-based care, and mobile health care to enhance access to health education, screenings, and BP care in Black communities. In 2021, the American Heart Association made a $100 million pledge and 10 commitments to support health equity. This commitment included implementing multifaceted interventions with a focus on hypertension as a seminal risk factor contributing to disparities in cardiovascular disease mortality and morbidity. The American Heart Association is one organizational example of advocacy for equity in BP. Achieving equity nationwide will require sustained collaboration among individual stakeholders and public, private, and community organizations to address barriers across multiple socioecological levels.

Colonialism as a Social Determinant of Health in Puerto Rico: Using the Socioecological Model to Examine How the Jones Act Impacted Health After Hurricane María.

Puerto Rico is a territory of the United States, making Puerto Ricans vulnerable to damaging colonial policy. The purpose of this article is to utilize the socioecological model (SEM) to evaluate how the Jones Act impacted Puerto Rico after Hurricane María, examining colonialist policy as a social determinant of health (SDOH) in Puerto Rico. Levels of the SEM used in this examination included: individual, institutional, community, policy, and context. Evaluation of the Jones Act using the model demonstrated relationships between all socioecological levels. The Jones Act caused delays and increased prices for goods needed to rebuild community utility infrastructure, which led to extended closures of institutions like workplaces, schools, and hospitals, and ultimately contributed to increased acute and chronic physical and mental illness among Puerto Ricans. This evaluation establishes that colonialist policy negatively impacts the health of Puerto Ricans, positioning colonialism as an SDOH.

Additive Benefits of Individual, Relational, and Community Factors on Physical- and Mental-Health Trajectories Among Black Americans

Black Americans have demonstrated significant resilience in the face of stress caused by systemic oppression. This resilience is likely to stem from several factors across socioecological levels, including those internal to the individual (assets) and those external to the individual (resources), but existing work has yet to consider these within an integrated framework. To address this gap, in the current study, we used longitudinal data from 692 Black adults living in the rural southeastern United States to examine the univariate and multivariate effects of individual (religiosity and spirituality), relational (romantic partner support, general social support), and community (neighborhood support) factors on trajectories of depressive symptoms, sleep problems, and general health. Findings revealed univariate and multivariate effects on health, providing evidence of additive benefits from these assets and resources. Greater consideration of strengths and supports across socioecological systems may help inform enhanced preventive interventions for and promote health equity among Black Americans.

“It Doesn’t Feel Easy at All”: Stressors and Supports of Parenting Sexual and Gender Minority Adolescents in the US Southeast

Parents/caregivers of sexual and gender minority (SGM) adolescents play a vital role in supporting their children, yet limited research considers the perspectives of these parents. We conducted semi-structured interviews and focus groups via Zoom with 16 parents of 17 SGM adolescents aged 13–17 residing in Alabama, Georgia, and Tennessee. Parents reported that their SGM adolescents were, on average, 15 years old, most were assigned female sex at birth, identified as transgender, non-binary, or gender-nonconforming, and had received mental healthcare treatment for serious mental health difficulties. A flexible thematic analysis approach identified themes structured around the social-ecological model. Parents described stressors at the structural level (e.g., ramifications of anti-SGM legislation), interpersonal level (e.g., breaking ties with unsupportive religious communities), and intrapersonal level (e.g., exhaustion with being forced into an advocacy position). Parents also reported several sources of support that cut across the three socio-ecological levels and helped them to overcome barriers, challenges, and stressors. This study underscores the difficulties confronted by parents of SGM adolescents in the US Southeast, particularly within an increasingly hostile socio-political climate. Findings highlight the necessity for resources tailored to parents of SGM adolescents to help them navigate multi-level stressors.

“As a patient I do not belong to the clinic, I belong to the community”: co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa

BackgroundAnticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.MethodsUsing a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.ResultsIntervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.ConclusionsDecreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

“Racism Happens Every Day, All the Time”: Black Families’ Outpatient Experiences of Racism Across a Large Pediatric System

ObjectiveTo qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families. MethodsWe conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus. ResultsWe conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1) “I just felt like we was a number”: Black families perceived experiences that felt impersonal and lacked empathy; 2) “Why is the doctor treating me like I don’t matter?”: Black families perceived experiences with poor care and worse treatment; 3) Black families experience racism across socioecological levels when interacting with pediatric health systems; 4) Positive perceived experiences can guide improvement; and 5) Improvement will require antiracist efforts across the levels of racism. ConclusionsIn this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

FRAP 2.0: a community engagement method applied to cervical cancer disparities among Hispanic women

focused Rapid Assessment Process (fRAP) 2.0 is a community engagement approach combining geospatial mapping with rapid qualitative assessment in cyclical fashion within communities to capture multifactorial and multilevel features impacting...

"Empowerment for Us by Us (E4UBU)": Developing a Model of Empowerment Using Feminist Participatory Methods with LBQT+ Persons Assigned Female at Birth in Western Kenya.

Lesbian, bisexual, queer, trans and other gender diverse persons assigned female at birth (heretofore referred to as "LBQT+ persons") in Western Kenya experience intersectional oppression and stigma. This stigma can manifest in acts of sexual and gender-based violence (SGBV) and sexual and gender minority (SGM)-based violence, as well as various forms of discrimination-all of which have been linked to disproportionately higher levels of negative health outcomes for this group. Despite these challenges, many LBQT+ persons have been able to gain personal and collective power and thrive in this oppressive environment. The Empowerment for Us by Us (E4UBU) project is a mixed methods feminist participatory research study focused on exploring how LBQT+ persons conceptualize and define empowerment for themselves, and to understand their perspectives on how feelings of power and powerlessness influence their physical and mental health. This paper focuses on data from the first phase of the study, in which qualitative in-depth interviews were conducted with 40 LBQT+ persons (ages 19 to 50) from Kisumu and Homa Bay in Western Kenya. A participatory interpretive phenomenological analysis was conducted to understand the lived experiences of LBQT+ persons as they navigate intersectional oppression and its influence on their experiences of empowerment and subsequent health outcomes. Findings from this analysis were presented to two different focus groups composed of participants who had participated in the in-depth interviews to gather their insights on the interpretations of the interviews as a form of member checking. Findings revealed that "empowerment" was not experienced and viewed by LBQT+ persons as a monolithic construct, but rather a process through which LBQT+ persons are able to transform negative forces of intersectional oppression and powerlessness into experiences of power and subsequent individual and collective action and impact-all leading to improved mental health and well-being. This process is facilitated at several junctures by participatory seeking and attainment of community-appropriate resources at multiple socio-ecological levels that, when accessed with sufficient intensity, frequency, and duration, enhance one's journey through the process of empowerment. These facilitation junctures are viewed as likely points of focus for public health intervention. Analysis also revealed that the process of empowerment is dependent on the context within which the process is occurring, the specific issues being faced, and the population of focus. Recommendations for how this model can be used for future research and practice to improve the lives of LBQT+ persons in Kenya are discussed.