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one page essay due tomorrow by 4 pm eastern time

OPTION 1: Care of the LGBTQ Community

After review of the sources provided under the week 6 content tab and the assigned readings, watch the following video and answer the following questions.

LGBT Healthcare Training Video: “To Treat Me, You Have to Know Who I Am”

Think back to your nursing school experience and reflect on the new hire orientation program in your employer organization.

– Was the care of special populations like the LGBTQ community addressed in your nursing education or orientation? If so, how? If not, what was missing?

-Based on the readings and video, what do you propose could be done to strengthen the orientation program at your organization or in your basic nursing education in regards to caring for special populations like the LBGTQ community?

-What changes will you make to your own personal nursing practice as a result of what you are learning this week?

-Must be in APA

-Must use journal articles attached as references and youtube video provided in link

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

Tania Israel
University of California, Santa Barbara

Cathleen E. Willging
Pacific Institute for Research and Evaluation,

Albuquerque, New Mexico

David Ley
New Mexico Solutions, Albuquerque, New Mexico

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 posttest 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: LGBTQ, mental health, peer, rural, training

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, anx-
iety, and suicidality within the LGBTQ popula-
tion may originate in “minority stress,” which
comprises chronic stigma, discrimination, and

violence (Meyer, 2003). Minority stress oper-
ates within cultural institutions and social struc-
tures, including health care systems (Meyer,
2003; Meyer, Schwartz, & Frost, 2008), and
may disproportionately affect gender noncon-
forming individuals, people of color, and rural
LGBTQ persons (Díaz, Bein, & Ayala, 2006;
McLaughlin, Hatzenbuehler, & Keyes, 2010;
Pinhey & Millman, 2004; Williams, Bowen, &
Horvath, 2005).

With regard to rural communities, LGBTQ
people may face social pressure to adhere to tra-
ditional gender roles and norms (Barefoot, Rick-
ard, Smalley, & Warren, 2015), as well as nega-
tive attitudes related to lack of contact with sexual
and gender minorities (Barefoot et al., 2015; El-
dridge, Mack, & Swank, 2006; Herek, 2002; Sniv-
ely, Kreuger, Stretch, Watt, & Chadha, 2004).
Victimization—verbal harassment, property dam-
age, and physical assault—is commonly reported
by rural LGBTQ people (Barefoot et al., 2015;

Tania Israel, Department of Counseling, Clinical, and
School Psychology, University of California, Santa Bar-
bara; Cathleen E. Willging, Pacific Institute for Research
and Evaluation, Albuquerque, New Mexico; David Ley,
New Mexico Solutions, Albuquerque, New Mexico.

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

Correspondence concerning this article should be ad-
dressed to Tania Israel, Department of Counseling, Clinical,
and School Psychology, Gevirtz School, University of Cal-
ifornia, Santa Barbara, CA 93106-9490. E-mail: tisrael@
education.ucsb.edu

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Journal of Rural Mental Health © 2016 American Psychological Association
2016, Vol.

, No. 1, 40 – 62 1935-942X/16/$12.00 http://dx.doi.org/10.1037/rmh000004

mailto:tisrael@education.ucsb.edu

http://dx.doi.org/10.1037/rmh0000046

Boulden, 2001; Cody & Welch, 1997; Leedy &
Connolly, 2008; Oswald, Gebbie, & Culton,
2003). Some LGBTQ people migrate from rural
to urban areas in search of robust LGBTQ com-
munity, leaving those who remain in rural areas
further lacking in social support. Geographic iso-
lation, 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, 2008;
Mathy, Carol, & Schillace, 2004; McCarthy,
2000; Oswald & Culton, 2003).

Rural residents in general, but especially
those who self-identify as LGBTQ, report hard-
ship accessing high quality mental health care,
often because services are in short supply (Wil-
liams, Williams, Pellegrino, & Warren, 2012).
The quality of support LGBTQ people can ex-
pect from available mental health and substance
use treatment providers varies. Clinical provid-
ers 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 influences care (Eliason & Hughes, 2004;
Israel, Ketz, Detrie, Burke, & Shulman, 2003;
Israel, Walther, Gortcheva, & Perry, 2011;
Mahdi, Jevertson, Schrader, Nelson, & Ramos,
2014; Walinsky & Whitcomb, 2010; Willging,
Salvador, & Kano, 2006a; Willging, Salvador,
& Kano, 2006b).

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 ap-
proaches 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, in-
cluding diabetes management (Tang, Funnell,
Gillard, Nwankwo, & Heisler, 2011), serious
mental illness among veterans (Chinman, Sal-
zer, & 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 advo-
cates,” 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 mem-
bers of, or strongly connected to, LGBTQ com-
munities and who were willing to develop
knowledge and skills to address LGBTQ mental
health issues. Peer advocates were expected to
undertake a wide range of complex tasks, in-
cluding needs assessment, goal setting, referral,
assistance navigating behavioral health systems,
and community outreach, and to enhance knowl-
edge about, and social support for, LGBTQ peo-
ple 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.

Preparation of peer advocates to perform
these complex roles is essential (Ruiz et al.,
2012). Training can increase the ability of para-
professionals, such as peer advocates, to use
basic helping skills (Aladağ & Tezer, 2009;
D’Augelli & Levy, 1978) and to provide effec-
tive support to people seeking mental health
services (Lenihan & Kirk, 1990), although ex-
tant research does not offer insight into the
effectiveness of training to prepare peer advo-
cates to perform complex tasks beyond individ-
ual helping relationships, such as organizing
events or building support networks. Although
training can increase mental health profession-
als’ knowledge and skills in working with gen-
der 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 spe-
cifically for lay members of LGBTQ communi-
ties to assist other sexual and gender minorities
with mental health concerns. Although mem-
bers of LGBTQ communities may have some
LGBTQ-specific knowledge based on their
lived experiences, distinctions among subpopu-
lations (Fassinger & Arseneau, 2007) necessi-
tates training on LGBTQ issues even for mem-
bers of these communities.

We report here on our effort to train LGBTQ
community members to function as peer advo-
cates. This study was part of a larger project to
design, implement, and assess the acceptability,
feasibility, and preliminary outcomes of the

41TRAINING RURAL LGBTQ PEER ADVOCATES

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overall LGBTQ peer advocate intervention
model. To obtain the knowledge and skills
needed to implement this model, peer advocates
took part in a 4-day series of didactic and in-
teractive training exercises that were evaluated
and subsequently refined based on feedback
from training participants. Because they were
based physically in dispersed rural communi-
ties, peer advocates were to participate in indi-
vidual 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 pre-
pare paraprofessionals for such roles is an im-
portant component of developing evidence-
based interventions (O’Brien et al., 2009; Ruiz
et al., 2012; Tang et al., 2011).

The aim of the present study was to use a
two-step process to develop, implement, evalu-
ate, and revise the LGBTQ peer advocate train-
ing. Evaluation involved quantitative measures
of knowledge, self-efficacy, and participant re-
sponses to specific aspects of the training, as
well as qualitative analysis of focus group and

individual semistructured interview data. This
study offers new insights by (a) focusing on
training rural residents, (b) training members of
LGBTQ communities to work within these
communities, (c) assessing helpers’ skills be-
yond those used in a one-on-one helping rela-
tionship, and (d) employing a mixed-method
evaluation approach to capture short- and long-
term impacts of the training.

Method

Description of Training

Development and initial training. The
training was developed and administered by the
authors, an academic psychologist/educator, a
medical anthropologist, and a practicing psy-
chologist/service agency administrator who col-
lectively have expertise in three areas pertinent
to this study: (a) LGBTQ mental health, (b)
engaging LGBTQ people in rural New Mexico
for research or clinical purposes, and (c) curricu-
lum development. As shown in Table 1, the initial
training was organized into 12 modules, with de-
scription, purpose, and learning objectives articu-

Table

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
LGBTQ people and suicide
Diversity within LGBTQ communities and cultural inquiry
Mental health and substance use treatment services for

LGBTQ populations

Mental health and substance abuse among
LGBTQ people

Mental health and substance use services for
LGBTQ populations

Helping skills
Suicide risk, crisis intervention, and other

emergencies

Part

Empowerment protocol Overview of Peer Advocate role
Ethics and boundaries
Communication with service providers and others
Conducting outreach and cultivating social

support resources
Challenging situations, closure

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

Working with service providers and others
Ethics and boundaries
Self-care
Outreach, advocacy, presentations, social support
Self-assessment of helping and leadership for LGBTQ

community (including privilege)

42 ISRAEL, WILLGING, AND LEY

lated for each module (for more details on the
modules see the Appendix). Suggestions for
participant recruitment, training content, for-
mat, and strategies to support the work of peer
advocates were provided by 32 rural commu-
nity members who participated in five focus
groups, and two community advisory boards
that met on a quarterly basis and included
mental health professionals, government offi-
cials, representatives from statewide LGBTQ
organizations, educators, and LGBTQ com-
munity members with lived experience re-
lated to mental health and substance use is-
sues. Both groups were characterized by
diversity in terms of ethnicity, gender, and
sexuality.

Based on the input from the focus groups and
community advisory boards, the training in-
cluded didactic presentations about the basics of
mental health and substance use, LGBTQ mi-
nority 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 commu-
nities (e.g., lack of awareness of Native Amer-
ican Two-Spirit experiences, erroneous beliefs
about bisexuality, and culturally situated imper-
atives to disclose sexual orientation). Finally,
the training included role plays, group discus-
sions, 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 eth-
ics, and bolster their capacity for both face-to-
face and community outreach. Initial training
took place over two consecutive weekends, with
a total of 28 hours across four day-long ses-
sions.

Revised training. As a result of the feed-
back following the initial training, we integrated
helping skills into each topical module rather
than relegate them to separate standalone mod-
ules (see Table 1). We also reorganized material
to reduce lengthy didactic segments, overly
conceptual material, and redundancies. The re-

vised training was implemented over two non-
consecutive weekends: Part 1 on the first week-
end, 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 pretest,
and then the training opened with an overview,
followed by introductions, an icebreaker activ-
ity, and discussion of communication tools. Key
information about LGBTQ populations was ad-
dressed, including distinctions among sex, gender
identity/expression, and sexual orientation; soci-
etal messages; and information about LGBTQ
subpopulations. Participants continued to have
opportunities to learn and practice helping skills
(including active listening, open-ended ques-
tions, 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.

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 iden-
tified from this smaller pool (see Figure 1 –
Timeline). We selected potential peer advocates
after Part 1 to make the broader community-
based training available to a wide range of in-
dividuals, 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 prep-
aration for those eligible to become peer advo-
cates. 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 appli-
cation that included queries regarding their in-
terest in being an LGBTQ Peer Advocate; their
current involvement in their local, statewide,
and/or national LGBTQ community; involve-
ment in local helping activities; and strengths,
challenges, and anticipated support needed. Ad-
ditional review criteria centered on primary res-
idence to ensure aspiring peer advocates would
not be concentrated in any one locality. Appli-
cants who were not selected for the second half
of the training 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

43TRAINING RURAL LGBTQ PEER ADVOCATES

observation of skills demonstrated in Part 1,
eight individuals were selected for inclusion in
Part 2 of the training, four of whom were ulti-
mately invited to become part-time, paid peer
advocates.

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: (a) individ-
ual work helping LGBTQ community mem-
bers access mental health and substance abuse
services; (b) increasing LGBTQ knowledge
and sensitivity among service providers, fam-
ily members, and others in rural areas; and (c)
promoting social support through outreach,
advocacy, and presentations. The participants
undertook a variety of activities to cultivate
both their understanding and their problem-
solving and implementation skills in each ar-
ea. Specific skills included solution-focused
interventions (Trepper et al., 2010), needs

assessment, negotiating communication con-
flicts, and conducting presentations. Partici-
pants were prepared for their paraprofessional
role with material and activities related to
ethical decision-making, boundaries, and self-
care. Reflection and self-awareness was en-
couraged through activities on privilege and
leadership roles in LGBTQ communities.

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 re-
ported in Table 2. We used a combination of
methods to recruit participants, including di-
rect advertisements circulated via Internet so-
licitations, email announcements, and local
press releases.

Figure 1. Timeline for revised training. See the online article for the color version of this
figure.

44 ISRAEL, WILLGING, AND LEY

Measures

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 Affir-

mative Counseling Self-Efficacy Inventory
(LGB-CSI; � � .83 to .97 for each subscale;
Dillon & Worthington, 2003). Items reflect ac-
tivities 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

Table 2
Description of Participants

Demographic Initial training
Revised training

(Part 1)
Revised training

(Part 2) Total

Number of participants 14 23 8 37
Age

M 41.07 41.65 36.38 41.4

SD 11.36 14.09 8.03 12.97
Range 25–58 19–63 29–51 19–63

Sex assigned at birth
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%)

Gender identity/expressiona

Woman 5 (35.7%) 12 (52.2%) 1 (12.5%) 17 (45.9%)
Man 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%) 3 (13.0%) 2 (25.0%) 3 (8.1%)
Missing 1 (7.1%) 0 (.0%) 0 (.0%) 1 (2.7%)

Sexual orientation
Lesbian/Gay 8 (57.1%) 9 (39.1%) 5 (62.5%) 17 (45.9%)
Bisexual 1 (7.1%) 2 (8.7%) 0 (.0%) 3 (8.1%)
Queer 1 (7.1%) 2 (8.7%) 1 (12.5%) 3 (8.1%)
Heterosexual 3 (21.4%) 8 (34.8%) 1 (12.5%) 11 (29.7%)
Other 1 (7.1%) 2 (8.7%) 1 (12.5%) 3 (8.1%)

Race/Ethnicitya

Hispanic 5 (35.7%) 1 (4.3%) 0 (.0%) 6 (16.2%)
European American/White 9 (64.3%) 11 (47.8%) 3 (37.5%) 20 (54.1%)
American Indian 1 (7.1%) 11 (47.8%) 5 (62.5%) 12 (32.4%)
Other 2 (14.3%) 1 (4.3%) 0 (.0%) 3 (8.1%)

Education
High school/GED 1 (7.1%) 0 (.0%) 0 (.0%) 1 (2.7%)
Trade/vocational school 0 (.0%) 2 (8.7%) 1 (12.5%) 2 (5.4%)
Some college, no degree 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%)

Monthly income
Less than $500 0 (.0%) 1 (4.3%) 0 (.0%) 1 (2.7%)
$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%)

Years in geographic area
M 9.23 13.96 12.29 12.

SD 13.30 14.60 16.34 14.12
Range 0–44 0–50 1–46 0–50

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

45TRAINING RURAL LGBTQ PEER ADVOCATES

Connect LGBTQ people in my community with
mental health resources and Demonstrate sen-
sitivity when interacting with transgender peo-
ple. 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 (� � .76 –.94). This
was similar to reliability reported for other sam-
ples of various types of self-efficacy, including
the LGB-CSI (� � .83–.97 for each subscale;
Dillon & Worthington, 2003); Bahora, Hanafi,
Chien, and Compton’s crisis intervention self-
efficacy measure (2008; � � .87–.92); Brous-
sard et al.’s Self-Efficacy Scale (Broussard et
al., 2011; � � .89 –.95); and King’s Self-
Efficacy Scale (King, 2011; � � .91–.93).

Peer advocate knowledge of LGBTQ
issues. We developed this measure as an ob-
jective assessment of participants’ knowledge
regarding LGBTQ issues, with a particular fo-
cus on content covered in the training. This
approach to knowledge assessment allowed par-
ticipants to demonstrate their objective knowl-
edge 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 sub-
sections consisting of (1) matching and (2) mul-
tiple choice questions. The matching section
prompts participants to match terms (e.g., gen-
derqueer, 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 some-
one has said?”), and expectations for persons
assuming the role of LGBTQ peer advocate
(e.g., “Which is NOT a recommended Peer Ad-
vocate response to a crisis?”). These items were
informed by national and statewide data, as well
as widely accepted models of helping (Hackney
& Cormier, 1996). 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.

We developed seven matching and 25 multi-
ple-choice items to assess these areas of knowl-
edge (32 items, scale score � 0 –32). The items
were modified based on input from two com-
munity advisory boards, described below. Fol-
lowing 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 com-
pleting 29 items following Part 1; only those
trainees who completed the entire training were
administered the six items pertaining to infor-
mation presented during Part 2 of the training.
The two versions of the knowledge measure
demonstrated moderate internal consistency at
posttest (� � .71–.83).

Participant response to training. During
the initial training, we gathered evaluation
data following implementation of each mod-
ule. 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 re-
sponses following each morning and after-
noon session by asking participants to indi-
cate 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 pre-
sented with four open-ended questions re-
garding 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 open-ended comments.

Demographics. Participants completed a de-
mographic 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.

Focus groups and semi-structured inter-
views. Focus groups were conducted with
eight participants after the first half of each

46 ISRAEL, WILLGING, AND LEY

weekend of the initial training, and 12 train-
ees participated in a semistructured individual
interview 12 months after the initial training.
The two 1-hr focus groups consisted of eight
questions that centered on participant reac-
tions to the training content, teaching modal-
ities utilized to convey this content and to
build practical helping skills, and areas for
improvement. The 1-hr semistructured inter-
views were administered over the phone and
included 12 questions concerning the per-
sonal and professional impacts of the training
over the past year; increases in and applica-
tion 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

Evaluation procedures. On the first day of
the initial and revised training, participants
completed a pretest 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 week-
end, participants completed the self-efficacy
measure and knowledge items pertaining to ma-
terial covered in Part 1. At the end of Part 2,
participants completed the self-efficacy mea-
sure and knowledge items pertaining to material
that was covered in the second half of the train-
ing. Participants put their first name on the
pretest and posttests so they could be matched
and to assist with screening for those who ap-
plied to be peer advocates. In addition, partici-
pants in the initial training provided anonymous
responses to items gauging their response to the
training after each module.

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 system-
atic 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 is-
sues described in the data. The coding and anal-
ysis 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 de-
veloped (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 “sui-
cide 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 in-
cluded 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 in-
formed the qualitative analysis. First, this pro-
cess was influenced by the “constructivist” tra-
dition in evaluation research. This tradition
opposes positivism and privileges iterative pro-
cesses of data analysis to understand diverse
participant perspectives in relation to interven-
tion objectives, encourages rich and deep de-
scription, and values consensus (and contesta-
tion) 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 ana-
lyzed 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 signif-
icance of the findings, organizing the qualitative

47TRAINING RURAL LGBTQ PEER ADVOCATES

data to highlight aspects of the training consid-
ered 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.

Results

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

Knowledge

Paired-samples t tests assessed changes in
participants’ knowledge of LGBTQ issues (see
Figure 2). Scores on the LGBTQ Peer Advocate
Knowledge of LGBTQ Issues for participants in
the pilot training were higher, but not signifi-
cantly so, at posttest (M � 15.36, SD � 33.2)
compared to pretest (M � 11.50, SD � 33.28).
For participants in the revised training, knowl-
edge 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 (�2 �
.55) demonstrated a large effect size. This sug-
gests that participants were more knowledge-
able 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 under-
stand and retain information more effectively.

Self-Efficacy

Paired-samples t tests assessed changes in par-
ticipants’ self-efficacy in working with LGBTQ
community members (see Figure 3). Participant
scores on the Peer Advocate Self-Efficacy Inven-
tory measure increased significantly from pretest
to posttest 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 cal-
culation demonstrated a large effect size for the
pilot study (�2 � 0.58) and a medium effect
size for the revised study (�2 � 0.11). This
suggests that participants felt more confident in
their ability to use specific LGBTQ affirming
skills after completing the training. When con-
sidering 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 self-efficacy regarding specific peer
advocate skills increased from before the train-
ing 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 signif-
icant. Because of the small number of partici-
pants in this category who completed the mea-
sure (n � 8), it is possible that the t test did not
detect differences (observed power � 0.52).

Participant Response to Training

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

11.

18.11

15.36

23.53

27.37

Pre-test

Post-test

Post-test 2

Figure 2. Comparison of knowledge pre- and post-test scores for pilot and revised training.

48 ISRAEL, WILLGING, AND LEY

LGBTQ people and communities, behavioral
health issues and services, suicide, working
individually with LGBTQ community mem-
bers, 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 pro-
viders 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 inter-
vention, and practice presentations. They
would have liked more information on privi-
lege and how to approach service providers.

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 ori-
entation, responding to suicidality, culture,
social support, crisis intervention, use of su-
pervision in ethical dilemmas, cultivating
compassion, and privilege. They were enthu-
siastic that the training was informative, in-
teractive, and included role plays and practice
presentations.

Focus Groups and Interviews

The focus groups underscored that the train-
ees were eager for the information provided,
with one participant making two 15-hr 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 pro-
fessions. 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 Doc-
torate program because they just do not 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.

Other trainees were already working as nat-
ural 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 threaten-
ing 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 train-
ing. 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.

3.96

4.56

5.07 5.15

5.61

1
2
3

5
6
Pre-test
Post-test
Post-test 2

Figure 3. Comparison of self-efficacy pre- and post-test scores for pilot and revised training.

49TRAINING RURAL LGBTQ PEER ADVOCATES

The focus groups also provided insight into
refining the nuts and bolts of the training pro-
cess. 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 peo-
ple that were relevant to the implementation
context of New Mexico. Overall, participants
appreciated the “pace” of the training, contend-
ing that there was no time to become “bored”
during the long training sessions. That said, they
also observed that the instructors were attempt-
ing to cover too much material, especially with
regard to standard diagnostic nosology, the con-
tent of which was later scaled back to accom-
modate more group discussion and activities.
Finally, to facilitate the building of rapport and
trust, focus group participants called on the in-
structors to disclose their own gender and sex-
ualities. 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.

During the initial focus groups and the later
interviews, the participants affirmed that they
benefited from the LGBTQ peer advocate train-
ing 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 knowl-
edge of diversity within the LGBTQ commu-
nity. 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 knowl-
edge 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 partici-
pants 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 conceptu-
alizations instead of rigid categories. One par-
ticipant 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 stu-
dents learning how to use advocacy in coun-
seling, while still others used it in their vol-
unteer work at the local LGBTQ community
center. Participants also recognized how gen-
der and sexuality intersect with ethnicity, re-
ligion, 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 sec-
ond trainee was empowered to help two of her
friends get help for mental distress, while yet
another utilized the knowledge and skills per-
taining to suicide prevention with a foster teen
in his home. The participant explained,

[The foster teen] was exhibiting signs of being de-
pressed 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 behav-
ior 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 advocat-
ing 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 infor-
mation on local and state providers who were
LGBTQ-friendly, and affirmative community
groups.

Participants in both focus groups and inter-
views expressed a desire to take part in future

50 ISRAEL, WILLGING, AND LEY

training opportunities related to LGBTQ mental
health. They commonly observed that the train-
ing had covered a lot of information in a short
period of time and that they would have appre-
ciated the opportunity to delve into specific
topics, such as bisexuality and transgender is-
sues, in much greater detail than the 4-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 limi-
tation, 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 train-
ings “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 prob-
lems to better refer peers for counseling or
treatment, diversity and cultural issues, and
more practice/modeling. The most frequently
suggested topics were outreach, rapport build-
ing, and communication skills, especially with
regard to consulting professional providers
about LGBTQ health needs. The trainees also
called for additional practical workshop activi-
ties focused on navigating local social environ-
ments and connecting to supportive profes-
sional providers and community advocates and
allies.

Trainees suggested that the training experi-
ence 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. Fi-
nally, to reinforce knowledge and skills, partic-
ipants called for additional online training op-
portunities of shorter duration, Web based
resources, and periodic conference calls for
group discussion, troubleshooting, and refresher
purposes.

Discussion

The evaluation offers ample evidence that the
LGBTQ peer advocate training successfully ac-
complished its goal to select and prepare peer
advocates to assist LGBTQ help seekers. Spe-

cifically, the training produced more knowl-
edgeable, confident, and skilled advocates who
were sensitive to diversity within LGBTQ com-
munities. 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 assessment prior to placing peer advocates
in the field.

The increase in knowledge, especially re-
garding diversity within LGBTQ communities,
demonstrates the gaps in knowledge before the
training and the ability of trainees to gain accu-
rate information through didactic and interac-
tive training. Notably, although all trainees
were either LGBTQ or allies, they did not nec-
essarily possess accurate information about all
LGBTQ subpopulations. Gender and sexual mi-
norities, especially in rural areas, may have
limited exposure to other LGBTQ people. Thus,
knowledge of segments of LGBTQ communi-
ties that differ from their own may be gleaned
primarily from widely available societal mes-
sages, many of which contain misinformation
and stereotypes. Indeed, segregation and dis-
crimination occur within LGBTQ communities
based on gender, gender identity/expression,
ethnicity, and socioeconomic 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.

A pilot phase has been included in develop-
ment 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 expe-
rience improved absorption and retention of in-

51TRAINING RURAL LGBTQ PEER ADVOCATES

formation and improved participant response to
helping skills. The choice to integrate helping
skills throughout the training rather than limit
them to one module appeared to improve par-
ticipant response to this aspect of the training.
In addition, the integration of skills likely sup-
ported acquisition of knowledge as trainees had
opportunities to apply knowledge immediately
through skills-based activities.

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 screen-
ing tool for peer advocates. The ability of the
trainers to interact with and observe participants
before 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 com-
munity service by educating the general public
about LGBTQ mental health, and we were able
to collect observational information about po-
tential peer advocate applicants, which proved
valuable in the selection process.

The direct influence on the trainees and LGBTQ
community-building in a rural area was an unan-
ticipated benefit of the training. Participation im-
proved 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 con-
nect with other LGBTQ people and allies in their
local community. These findings highlight the im-
portant 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 com-
munity organizing efforts concerning LGBTQ is-
sues, and described that their training had assisted
them in speaking knowledgably about these is-
sues. Thus, even a training to perform an inter-
vention can itself serve as an intervention.

Although laudable outcomes, these benefits to
the trainees may not justify the resources required
to plan and implement such training. Multisession,
high-quality training by national experts in rural
areas is desired, but not sustainable. There are
certainly more cost-effective 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: (a) distance learning tools,
such as webinars; (b) LGBTQ community orga-
nizations connected through a national network
(e.g., CenterLink); and (c) existing social net-
works. 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 founda-
tion of high-quality, accurate training content; and
it would maintain the beneficial aspect of bringing
together LGBTQ community members. Where
LGBTQ community organizations and social net-
works are lacking, broader mental health and so-
cial service agencies may have the capacity to
offer such outreach.

Mechanisms for outreach are necessary for
sustainable community-building for an invisible
or marginalized population (Minkler & Waller-
stein, 2005). Unfortunately, this was one area
for which the training did not adequately pre-
pare 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 commu-
nity 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 ac-
cess to professional and community support are

52 ISRAEL, WILLGING, AND LEY

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.

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 char-
acteristics with other rural areas, or places in
which LGBTQ people are isolated and have lim-
ited access to LGBTQ-specific expertise and re-
sources. 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 transgen-
der)—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.

Limitations and Directions for
Future Research

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 mem-
bers and students who were interested in learn-
ing more about LGBTQ mental health and sup-
port 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 dif-
ferently with these individuals compared to per-
sons who were more interested in becoming
LGBTQ peer advocates. Second, we were lim-
ited in assessing specific knowledge and self-
efficacy among the potential LGBTQ peer ad-
vocates. 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, al-
though 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. Re-
search using more standardized tools for evalu-
ating 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 observ-
able skills would be a valuable addition to fu-
ture studies.

Some studies that evaluated training for peer
leaders have used preestablished competency
criteria to determine readiness of peers to de-
liver an intervention (e.g., Tang et al., 2011).
Such an approach is ideal for screening poten-
tial peers following training; however, it is pos-
sible only when research on the intervention is
developed to the point of specifying compe-
tency 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 impor-
tant for future research in this area to consider
available data on LGBT peer advocate interven-
tions in the development of training objectives
and competency criteria.

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 po-
tential of training minority communities for mul-
tifaceted and nuanced roles. Evaluating the effi-
cacy of distance learning tools in providing
LGBTQ training could explore sustainable op-
tions for cost-effective capacity building for hard-
to-reach LGBTQ populations. This training strat-
egy 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.

53TRAINING RURAL LGBTQ PEER ADVOCATES

Conclusion

The current study demonstrated the efficacy of
training LGBTQ peer advocates in rural commu-
nities. 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 en-
hance 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 orga-
nizational and social networks to address the con-
siderable need for information and training on
LGBTQ issues in rural areas.

References

Aladağ, M., & Tezer, E. (2009). Effects of a peer
helping training program on helping skills and
self-growth of peer helpers. International Journal
for the Advancement of Counselling, 31, 255–269.
http://dx.doi.org/10.1007/s10447-009-9082-4

Alessi, E. J., Dillon, F. R., & Kim, H. M. (2015).
Determinants of lesbian and gay affirmative prac-
tice among heterosexual therapists. Psychother-
apy, 52, 298 –307. http://dx.doi.org/10.1037/a003
8580

Barefoot, K. N., Rickard, A., Smalley, K. B., &
Warren, J. C. (2015). Rural lesbians: Unique chal-
lenges and implications for mental health provid-
ers. Journal of Rural Mental Health, 39, 22–33.
http://dx.doi.org/10.1037/rmh0000014

Boulden, W. T. (2001). Gay men living in a rural
environment. Journal of Gay & Lesbian Social
Services, 12, 63–75. http://dx.doi.org/10.1300/
J041v12n03_05

Broussard, B., Krishan, S., Hankerson-Dyson, D.,
Husbands, L., Stewart-Hutto, T., & Compton,
M. T. (2011). Development and initial reliability
and validity of four self-report measures used in
research on interactions between police officers
and individuals with mental illnesses. Psychiatry
Research, 189, 458 – 462. http://dx.doi.org/10
.1016/j.psychres.2011.06.017

Burkard, A. W., Knox, S., Hess, S. A., & Schultz, J.
(2009). Lesbian, gay, and bisexual supervisees’
experiences of LGB-affirmative and nonaffirma-
tive supervision. Journal of Counseling Psychol-
ogy, 56, 176 –188. http://dx.doi.org/10.1037/0022-
0167.56.1.176

Carlson, T. S., McGeorge, C. R., & Toomey, R. B.
(2013). Establishing the validity of the affirmative
training inventory: Assessing the relationship be-
tween lesbian, gay, and bisexual affirmative train-
ing and students’ clinical competence. Journal of
Marital and Family Therapy, 39, 209 –222. http://
dx.doi.org/10.1111/j.1752-0606.2012.00286.x

Chinman, M., Salzer, M., & O’Brien-Mazza, D.
(2012). National survey on implementation of peer
specialists in the VA: Implications for training and
facilitation. Psychiatric Rehabilitation Journal,
35, 470 – 473. http://dx.doi.org/10.1037/h0094582

Cody, P. J., & Welch, P. L. (1997). Rural gay men in
northern New England: Life experiences and cop-
ing styles. Journal of Homosexuality, 33, 51– 67.
http://dx.doi.org/10.1300/J082v33n01_04

Corbin, J., & Strauss, A. (2008). Basics of qualitative
research: Techniques and procedures for develop-
ing grounded theory (3rd ed.). Thousand Oaks,
CA: Sage.

D’Augelli, A. R., & Levy, M. (1978). The verbal
helping skills of trained and untrained human ser-
vice paraprofessionals. American Journal of Com-
munity Psychology, 6, 23–31. http://dx.doi.org/10
.1007/BF00890097

Díaz, R. M., Bein, E., & Ayala, G. (2006). Homopho-
bia, poverty, and racism: Triple oppression and
mental health outcomes in Latino gay men. In
A. M. Omoto & H. S. Kurtzman (Eds.), Sexual
orientation and mental health: Examining identity
and development in lesbian, gay, and bisexual
people (pp. 207–224). Washington, DC: American
Psychological Association. http://dx.doi.org/10
.1037/11261-010

Dillon, F., & Worthington, R. L. (2003). The Les-
bian, Gay and Bisexual Affirmative Counseling
Self-Efficacy Inventory (LGB-CSI): Development,
validation, and training implications. Journal of
Counseling Psychology, 50, 235–251. http://dx.doi
.org/10.1037/0022-0167.50.2.235

Dunning, D. (2011). The Dunning-Kruger effect: On
being ignorant of one’s own ignorance In M. Olson
& P. Zanna (Eds.), Advances in experimental so-
cial psychology (Vol. 44, pp. 247–296). San Di-
ego, CA: Academic Press. http://dx.doi.org/10
.1016/B978-0-12-385522-0.00005-6

Eldridge, V. L., Mack, L., & Swank, E. (2006).
Explaining comfort with homosexuality in rural
America. Journal of Homosexuality, 51, 39 –56.
http://dx.doi.org/10.1300/J082v51n02_03

Eliason, M. J., & Hughes, T. (2004). Treatment coun-
selor’s attitudes about lesbian, gay, bisexual, and
transgendered clients: Urban vs. rural settings.
Substance Use & Misuse, 39, 625– 644. http://dx
.doi.org/10.1081/JA-120030063

Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather
be wet than be under that umbrella”: Differentiat-
ing the experiences and identities of lesbian, gay,

54 ISRAEL, WILLGING, AND LEY

http://dx.doi.org/10.1007/s10447-009-9082-4

http://dx.doi.org/10.1037/a0038580

http://dx.doi.org/10.1037/rmh0000014

http://dx.doi.org/10.1300/J041v12n03_05

http://dx.doi.org/10.1016/j.psychres.2011.06.017

http://dx.doi.org/10.1037/0022-0167.56.1.176

http://dx.doi.org/10.1111/j.1752-0606.2012.00286.x

http://dx.doi.org/10.1037/h0094582

http://dx.doi.org/10.1300/J082v33n01_04

http://dx.doi.org/10.1007/BF00890097

http://dx.doi.org/10.1037/11261-010

http://dx.doi.org/10.1037/0022-0167.50.2.235

http://dx.doi.org/10.1016/B978-0-12-385522-0.00005-6

http://dx.doi.org/10.1300/J082v51n02_03

http://dx.doi.org/10.1081/JA-120030063

bisexual, and transgender people. In K. J. Bi-
eschke, R. M. Perez, & K. A. DeBord (Eds.),
Handbook of counseling and psychotherapy with
lesbian, gay, bisexual, and transgender clients
(2nd ed., pp. 19 – 49). Washington, DC: American
Psychological Association. http://dx.doi.org/10
.1037/11482-001

Getrich, C., Heying, S., Willging, C., & Waitzkin, H.
(2007). An ethnography of clinic “noise” in a commu-
nity-based, promotora-centered mental health interven-
tion. Social Science & Medicine, 65, 319 –330. http://
dx.doi.org/10.1016/j.socscimed.2007.03.004

Hackney, H. L., & Cormier, L. S. (1996). Rapport
and relationship. In The professional counselor: A
process guide to helping (pp. 47–77). Boston, MA:
Allyn & Bacon.

Herek, G. M. (2002). Heterosexuals attitudes toward
bisexual men and women in the United States.
Journal of Sex Research, 39, 264 –274. http://dx
.doi.org/10.1080/00224490209552150

Institute of Medicine. (2011). The health of lesbian,
gay, bisexual, and transgender people: Building a
foundation for better understanding. Washington,
DC: National Academies Press.

Israel, T., & Hackett, G. (2004). Counselor education
on lesbian, gay, and bisexual issues: Comparing
information and attitude-exploration. Counselor
Education and Supervision, 43, 179 –191. http://dx
.doi.org/10.1002/j.1556-6978.2004.tb01841.x

Israel, T., Ketz, K., Detrie, P. M., Burke, M. C., & Shul-
man, J. L. (2003). Identifying counselor competencies
for working with lesbian, gay, and bisexual clients.
Journal of Gay & Lesbian Psychotherapy, 7, 3–21.
http://dx.doi.org/10.1300/J236v07n04_02

Israel, T., Walther, W. A., Gortcheva, R., & Perry,
J. S. (2011). Policies and practices for LGBT cli-
ents: Perspectives of mental health services admin-
istrators. Journal of Gay & Lesbian Mental Health,
15, 152–168. http://dx.doi.org/10.1080/19359705
.2010.539090

Killerman, S. (n.d.). The Genderbread person. Re-
trieved from http://itspronouncedmetrosexual.com/
2012/01/the-genderbread-person/

King, S. M. (2011). The impact of crisis intervention team
training on law enforcement officers: An evaluation of
self-efficacy and attitudes toward people with mental
illness. Dissertation Abstracts International: Section B:
The Sciences and Engineering, 72(10-B).

Kinnane, N. A., Waters, T., & Aranda, S. (2011).
Evaluation of a pilot ‘peer support’ training pro-
gramme for volunteers in a hospital-based cancer
information and support centre. Supportive Care in
Cancer, 19, 81–90. http://dx.doi.org/10.1007/
s00520-009-0791-3

Kirkpatrick, D. (1996). Great ideas revisited: Tech-
niques for evaluating training programs. Revisiting
Kirkpatrick’s four-level model. Training & Devel-
opment, 50, 54 –59.

Leedy, G., & Connolly, C. (2008). Out in the Cowboy
State: A look at lesbian and gay lives in Wyoming.
Journal of Gay & Lesbian Social Services, 19, 17–34.
http://dx.doi.org/10.1300/J041v19n01_02

Lenihan, G., & Kirk, W. G. (1990). Using student
paraprofessionals in the treatment of eating disor-
ders. Journal of Counseling & Development, 68,
332–335. http://dx.doi.org/10.1002/j.1556-6676
.1990.tb01385.x

Mahdi, I., Jevertson, J., Schrader, R., Nelson, A., &
Ramos, M. M. (2014). Survey of new Mexico
school health professionals regarding preparedness
to support sexual minority students. The Journal of
School Health, 84, 18 –24. http://dx.doi.org/10
.1111/josh.12116

Mathy, R. M., Carol, H. M., & Schillace, M. (2004). The
impact of community size on lesbian and bisexual
women’s psychosexual development: Child maltreat-
ment, suicide attempts, and self-disclosure. Journal of
Psychology & Human Sexuality, 15, 47–71. http://dx
.doi.org/10.1300/J056v15n02_04

McCarthy, L. (2000). Poppies in a wheat field: Ex-
ploring the lives of rural lesbians. Journal of Ho-
mosexuality, 39, 75–94. http://dx.doi.org/10.1300/
J082v39n01_05

McLaughlin, K. A., Hatzenbuehler, M. L., & Keyes, K. M.
(2010). Responses to discrimination and psychiatric dis-
orders among Black, Hispanic, female, and lesbian, gay,
and bisexual individuals. American Journal of Public
Health, 100, 1477–1484. http://dx.doi.org/10.2105/
AJPH.2009.181586

Meyer, I. H. (2003). Prejudice, social stress, and
mental health in lesbian, gay, and bisexual popu-
lations: Conceptual issues and research evidence.
Psychological Bulletin, 129, 674 – 697. http://dx
.doi.org/10.1037/0033-2909.129.5.674

Meyer, I. H., Schwartz, S., & Frost, D. M. (2008).
Social patterning of stress and coping: Does dis-
advantaged social statuses confer more stress and
fewer coping resources? Social Science & Medi-
cine, 67, 368 –379. http://dx.doi.org/10.1016/j
.socscimed.2008.03.012

Minkler, M., & Wallerstein, N. (2005). Improving
health through community organization and com-
munity building: A health education perspective.
In M. Minkler (Ed.), Community organizing and
community building for health (pp. 26 –50). New
Brunswick, NJ: Rutgers University Press.

O’Brien, M. J., Squires, A. P., Bixby, R. A., & Larson,
S. C. (2009). Role development of community health
workers: An examination of selection and training pro-
cesses in the intervention literature. American Journal of
Preventive Medicine, 37, S262–S269. http://dx.doi.org/
10.1016/j.amepre.2009.08.011

Oswald, R. F., & Culton, L. S. (2003). Under the
rainbow: Rural gay life and its relevance for family
providers. Family Relations, 52, 72– 81. http://dx
.doi.org/10.1111/j.1741-3729.2003.00072.x

55TRAINING RURAL LGBTQ PEER ADVOCATES

http://dx.doi.org/10.1037/11482-001

http://dx.doi.org/10.1016/j.socscimed.2007.03.004

http://dx.doi.org/10.1080/00224490209552150

http://dx.doi.org/10.1002/j.1556-6978.2004.tb01841.x

http://dx.doi.org/10.1300/J236v07n04_02

http://dx.doi.org/10.1080/19359705.2010.539090

http://itspronouncedmetrosexual.com/2012/01/the-genderbread-person/

http://dx.doi.org/10.1007/s00520-009-0791-3

http://dx.doi.org/10.1300/J041v19n01_02

http://dx.doi.org/10.1002/j.1556-6676.1990.tb01385.x

http://dx.doi.org/10.1111/josh.12116

http://dx.doi.org/10.1300/J056v15n02_04

http://dx.doi.org/10.1300/J082v39n01_05

http://dx.doi.org/10.2105/AJPH.2009.181586

http://dx.doi.org/10.1037/0033-2909.129.5.674

http://dx.doi.org/10.1016/j.socscimed.2008.03.012

http://dx.doi.org/10.1016/j.amepre.2009.08.011

http://dx.doi.org/10.1111/j.1741-3729.2003.00072.x

Oswald, R., Gebbie, E., & Culton, L. (2003). Rain-
bow Illinois: A survey of non-metropolitan les-
bian, gay, bisexual, and transgender people. Jour-
nal of Rural Community Psychology, E5(2).

Pinhey, T. K., & Millman, S. R. (2004). Asian/Pacific
Islander adolescent sexual orientation and suicide risk in
Guam. American Journal of Public Health, 94, 1204 –
1206. http://dx.doi.org/10.2105/AJPH.94.7.1204

QSR International. (2012). NVivo qualitative data analysis
software (Version 10). Burlington, MA: Author.

Ruiz, Y., Matos, S., Kapadia, S., Islam, N., Cusack, A.,
Kwong, S., & Trinh-Shevrin, C. (2012). Lessons
learned from a community-academic initiative: The de-
velopment of a core competency-based training for
community-academic initiative community health
workers. American Journal of Public Health, 102,
2372–2379. http://dx.doi.org/10.2105/AJPH.2011
.300429

Sawyer, R. G., Pinciaro, P., & Bedwell, D. (1997).
How peer education changed peer sexuality edu-
cators’ self-esteem, personal development, and
sexual behavior. Journal of American College
Health, 45, 211–217. http://dx.doi.org/10.1080/
07448481.1997.9936887

Snively, C. A., Kreuger, L., Stretch, J. J., Watt, J., &
Chadha, J. (2004). Understanding homophobia: Prepar-
ing for practice realities in urban and rural settings.
Journal of Gay & Lesbian Social Services, 17, 59 – 81.
http://dx.doi.org/10.1300/J041v17n01_05

Stufflebeam, D. L., & Shinkfield, A. J. (2007). Eval-
uation theory, models, & applications. San Fran-
cisco, CA: Jossey-Bass.

Tang, T. S., Funnell, M. M., Gillard, M., Nwankwo,
R., & Heisler, M. (2011). Training peers to provide
ongoing diabetes self-management support
(DSMS): Results from a pilot study. Patient Edu-
cation and Counseling, 85, 160 –168. http://dx.doi
.org/10.1016/j.pec.2010.12.013

Trepper, T. S., McCollum, E. E., De Jong, P., Kor-
man, H., Gingerich, W., & Franklin, C. (2010).
Solution focused therapy treatment manual for
working with individuals. Santa Fe, NM: Research
Committee of the Solution Focused Brief Therapy
Association. Retrieved from http://www.sfbta.org/
research

Waitzkin, H., Getrich, C., Heying, S., Rodríguez, L.,
Parmar, A., Willging, C., . . . Santos, R. (2011).
Promotoras as mental health practitioners in pri-
mary care: A multi-method study of an interven-
tion to address contextual sources of depression.

Journal of Community Health, 36, 316 –331. http://
dx.doi.org/10.1007/s10900-010-9313-y

Walinsky, D., & Whitcomb, D. (2010). Using the ACA
competencies for counseling with transgender clients to
increase rural transgender well-being. Journal of LGBT
Issues in Counseling, 4, 160 –175. http://dx.doi.org/10
.1080/15538605.2010.524840

Weeks, M. R., Convey, M., Dickson-Gomez, J., Li,
J., Radda, K., Martinez, M., & Robles, E. (2009a).
Changing drug users’ risk environments: Peer
health advocates as multi-level community change
agents. American Journal of Community Psychol-
ogy, 43, 330 –344. http://dx.doi.org/10.1007/
s10464-009-9234-z

Weeks, M. R., Li, J., Dickson-Gomez, J., Convey, M.,
Martinez, M., Radda, K., & Clair, S. (2009b). Out-
comes of a peer HIV prevention program with injec-
tion drug and crack users: The risk avoidance part-
nership. Substance Use & Misuse, 44, 253–281.
http://dx.doi.org/10.1080/10826080802347677

Willging, C. E., & Israel, T. (2012, May). Queering
mental health research: An example from rural
New Mexico. Paper presented at the Critical Inqui-
ries Workshop, Centre for the Study of Gender
Social Inequities and Mental Health, Simon Fraser
University, Vancouver, Canada.

Willging, C. E., Salvador, M., & Kano, M. (2006a).
Pragmatic help seeking: How sexual and gender
minority groups access mental health care in a
rural state. Psychiatric Services, 57, 871– 874.
http://dx.doi.org/10.1176/ps.2006.57.6.871

Willging, C. E., Salvador, M., & Kano, M. (2006b).
Brief reports: Unequal treatment: Mental health
care for sexual and gender minority groups in a
rural state. Psychiatric Services, 57, 867– 870.
http://dx.doi.org/10.1176/ps.2006.57.6.867

Williams, I., Williams, D., Pellegrino, A., & Warren,
J. C. (2012). Providing mental health services for
racial, ethnic, and sexual orientation minority
groups in rural areas. In K. B. Smalley, J. C.
Warren, & J. P. Rainer (Eds.), Rural mental
health: Issues, policies, and best practices (pp.
229 –252). New York, NY: Springer.

Williams, M. L., Bowen, A. M., & Horvath, K. J.
(2005). The social/sexual environment of gay men
residing in a rural frontier state: Implications for
the development of HIV prevention programs. The
Journal of Rural Health, 21, 48 –55. http://dx.doi
.org/10.1111/j.1748-0361.2005.tb00061.x

56 ISRAEL, WILLGING, AND LEY

http://dx.doi.org/10.2105/AJPH.94.7.1204

http://dx.doi.org/10.2105/AJPH.2011.300429

http://dx.doi.org/10.1080/07448481.1997.9936887

http://dx.doi.org/10.1300/J041v17n01_05

http://dx.doi.org/10.1016/j.pec.2010.12.013

http://www.sfbta.org/research

http://dx.doi.org/10.1007/s10900-010-9313-y

http://dx.doi.org/10.1080/15538605.2010.524840

http://dx.doi.org/10.1007/s10464-009-9234-z

http://dx.doi.org/10.1080/10826080802347677

http://dx.doi.org/10.1176/ps.2006.57.6.871

http://dx.doi.org/10.1176/ps.2006.57.6.867

http://dx.doi.org/10.1111/j.1748-0361.2005.tb00061.x

Appendix

LGBTQ Peer Advocate (PA) Curriculum Modules (for revised training)

Part 1

Module Module description Purpose Learning objectives

I. Introduction to
Part I of
training

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

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

• 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 self-
efficacy.

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 supportc

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

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

baseline knowledge and self-
efficacy related to PA role

II. LGBTQ
people and
communities

1. Concepts of sex, gender,
sexual orientation

2. Helping skills: non-verbal
attending and paraphrasing

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. Categories of

transgender experience
and people

b. Gender nonconformity
and gender dysphoria

c. Similarities and
differences from LGB
individuals

• Introduce trainees to
basic listening skills.
Describe
characteristics of
lesbian, gay male,
bisexual, and
transgender
individuals and
communities. Clarify
distinctions between
transgender people
and LGB people.

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

(Appendix continues)

57TRAINING RURAL LGBTQ PEER ADVOCATES

Appendix (continued)

Part 1
Module Module description Purpose Learning objectives

III. Mental
health and
substance
abuse among
LGBT people

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, post-
traumatic 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 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.

By the end of this module,
trainees will be able to:
a. Describe anti-LGBTQ

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 serious mental illness
or personality disorders)

e. Identify resilience among
LGBTQ people

f. Demonstrate open-ended
questions

IV. LGBTQ
people and
suicide

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

• 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.

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

(Appendix continues)

58 ISRAEL, WILLGING, AND LEY

Appendix (continued)
Part 1
Module Module description Purpose Learning objectives

V. Diversity
within
LGBTQ
communities

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
Œ Ethnicity
Œ Spirituality
Œ Generational status
Œ Physical abilities
Œ Social class
Œ Immigration status
Œ Sexual and relational

structures and activities
5. Development of sexual

orientation identity
6. Key New Mexico

demographics
7. Experiences of LGBTQ

people in rural New
Mexico

• 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 not generalize to
others).

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

VI. Mental
health and
substance use
services for
LGBTQ
populations

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

• 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.

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

skills, and self-efficacy related
to PA role

(Appendix continues)

59TRAINING RURAL LGBTQ PEER ADVOCATES

Part 2

Module Module description Purpose Learning objectives

VII. Introduction to
Part II of
training

1. Overview of PA points of
intervention

2. Training structure and
logistics

3. Communication goals for
training

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

intervention
b. Anticipate training

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

VIII. Working
individually with
LGBTQ
community
members

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

• 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.

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
solution-focused strategies

d. Conduct needs assessments
and prioritize needs

e. Develop collaborative plans
to address needs

f. Respond appropriately to
crisis situations

IX. Working with
service providers
and others

1. PA role with service
providers and family
members of LGBTQ
community members

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

3. Communication conflicts
4. Role plays with

individualized feedback

• Develop skills to share
knowledge gained from
previous modules. This
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.

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

work with service 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

(Appendix continues)

60 ISRAEL, WILLGING, AND LEY

Appendix (continued)
Part 2
Module Module description Purpose Learning objectives

X. Ethics and
boundaries

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 decision-making
8. Supervision and

consultation

• 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.

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
decision-making

g. Seek support through
consultation

XI. Self-care 1. Self-care—generating
strategies and developing
a plan

2. Compassion practice to
work with people who are
suffering

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

self-care for PAs
b. Identify a range of

strategies for self-care
c. Craft a self-care plan for

themselves
d. Implement compassion

practice when encountering
suffering

(Appendix continues)

61TRAINING RURAL LGBTQ PEER ADVOCATES

Appendix (continued)
Part 2
Module Module description Purpose Learning objectives

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

1. Engaging in activities to
cultivate LGBTQ
affirming rural community
environments

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. Organizing, delivering,
and practicing
presentations

7. Compiling and updating
resource and referral
directory

8. Preventing and diffusing
hostile situations

• 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.

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

cultivate LGBTQ-affirming
community environments

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

c. Establish relationships with
key community contacts

d. Implement on-the-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

XIII. Self-
assessment of
helping and
leadership for
LGBTQ
community

a. Privilege
b. Self-assessment of

helping and leadership for
LGBTQ community

c. Next steps
d. Post-assessment of

knowledge and self-
efficacy

• Post assessment will
provide a measure of
changes in knowledge,
attitudes, skills, and
perceived self-efficacy.

By the end of this module,
PAs will be able to:
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 self-
efficacy related to PA role

Received April 1, 2015
Revision received February 23, 2016

Accepted February 23, 2016 �

62 ISRAEL, WILLGING, AND LEY

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

Method
Description of Training
Development and initial training
Revised training
Participants
Measures
LGBTQ Peer Advocate Self-Efficacy Inventory
Peer advocate knowledge of LGBTQ issues
Participant response to training
Demographics
Focus groups and semi-structured interviews
Procedure
Evaluation procedures
Qualitative data analysis

Results
Knowledge
Self-Efficacy
Participant Response to Training
Focus Groups and Interviews
Discussion
Limitations and Directions for Future Research
Conclusion
References
AppendixLGBTQ Peer Advocate (PA) Curriculum Modules (for revised training)

QUAL
WOM

The580

LGBTQ E

ITY
EN
Me

Journa

ducation:
Earn Your “A”

The lesbian, gay, bisexual, transgender, and
queer/questioning (LGBTQ) community is
estimated to represent 3.5% of the adult popu-
lation in the United States, roughly 9 million
people.1 A substantial proportion of that
number are people

ho identify as female. This
group suffers significant health disparities linked
to a long-standing history of discrimination,
stigmatization, and the denial of many civil
rights.2 LGBTQ populations experience high
rates of substance abuse, suicide, mental health

CARE FOR
’S HEALTH
gan Spiekermeier,

DNP, WHNP

disorders, homelessness, obesity, sexually
transmitted infections (STIs), and violence.1-4

LGBTQ persons are less likely to seek preven-
tive services due to lack of insurance coverage or
fear of stigmatization and discrimination.1

Women already face significant health disparities
based on sexism; intersecting forms of discrim-
ination (homophobia, transphobia, stigmatiza-
tion, or even ambivalence) can compound the
negative effects on women’s physical and mental
health and overall well-being.5 Results from the
Lambda Legal Health Care Fairness Survey
revealed that respondents who identified as
female within the LGBTQ population surveyed
were more likely than their nonfemale coun-
terparts to experience barriers to health care
services, discrimination, and incompetent care.5

In the survey, female respondents were most
affected by the denial of infertility services and
taxation of same-sex partner benefits.5 There
were greater percentages of female respondents

l for Nurse Practitioners – JNP

that reported being treated differently than
other people at health care appointments and
who felt that health care providers were
unaware of LGBTQ-specific needs.5 Many
female respondents cited barriers to care
including: insufficient numbers of health care
professionals trained to care for LGBTQ people;
the possibility of being refused care based on
gender identity or sexual orientation; and the
fear of mistreatment.5 These barriers can lead to
reluctance to seek care, and thus, poorer health
outcomes for LGBTQ individuals and families.

Healthy People 2020 established a goal to
“improve the health, safety, and well-being of
lesbian, gay, bisexual, and transgender individu-
als.”2(p1) Although increased societal acceptance
and legal nondiscrimination policies have
improved access to health care and insurance for
the LGBTQ community, policies do not guar-
antee provider competence or freedom from
discrimination.1 Despite recommendations from
several expert panels for LGBTQ cultural
competency training for health care profes-
sionals, traditional medical and nursing education
curricula provide limited to no content on
LGBTQ issues.3 As a result, there is a shortage of
clinicians who are knowledgeable and culturally
competent in LGBTQ health.

Nurses comprise the largest portion of
direct patient care providers and are often the
first health care provider a patient encounters.
Yet, nurses report that they do not feel
comfortable or prepared to care for LGBTQ
patients and desire additional education.4 As
leaders in the nursing profession, advanced
practice registered nurses could address the
needs of the LGBTQ community. Proper
training and education on gender and sexual
minorities could foster trusting patient-
provider relationships, increase identification of
gender and sexual minority patients, and in-
crease provider competency in assessment and
diagnosis of health care problems impacting
LGBTQ persons. By decreasing barriers to

Volume 13, Issue 8, September 2017

http://crossmark.crossref.org/dialog/?doi=10.1016/j.nurpra.2017.05.091&domain=pdf

care, more LGBTQ persons may seek pre-
ventive health services, have more confidence
in the health care system, and live healthier and
longer lives. Addressing gaps in education may
benefit the LGBTQ population and the com-
munity at large in the form of increased quality
and quantity of life, reduction in disease
transmission and progression, and decreased
health care costs.2 For these reasons, it is
imperative that the nursing profession take
action within education institutions, health
policy, and within communities to insure
inclusive and culturally competent care for
the LGBTQ population. The National LGBT
Education Center of the Fenway Institute
offers many online training, education, and
resources for healthcare institutions to integrate
into their programs.6 To aid in the integration
of LGBTQ education into nursing curricula,
national nursing standards and competencies
should reflect stronger language or mandates
for the inclusion of LGBTQ cultural
competency training. Together these
recommendations will likely improve nursing
competencies in LGBTQ care and create a
competent nursing workforce across all health
care settings.

In conclusion, nursing has long been the
most trusted profession that places the
utmost importance on the role of patient
advocate, yet, we have failed in our ethical
responsibility to address the needs of our
LGBTQ patients and families. As criteria for
defining sexual orientation, gender identity
and expression continue to evolve, letters are

ww.npjournal.org

being added to the acronym. The letter “A”
has begun to appear to stand for “ally” to
acknowledge those that stand ready to
support the LGBTQ community. By advo-
cating for strong LGBTQ content in health
profession curricula, advanced practice regis-
tered nurses could enable more clinicians
to be prepared to apply evidence-based best
practice for this vulnerable population and
earn their “A.”

References

1. Kates J, Ranji U, Beamesderfer A, et al. Health and access to care and

coverage for lesbian, gay, bisexual, and transgender individuals in the

U.S. The Henry J. Kaiser Family Foundation. November 11, 2016.

http://kff.org/disparitiespolicy/issue-brief/health-and-access-to-care

-and-coverage-for-lesbian-gay-bisexual-and-transgender-individuals

-in-the-u-s/.

Accessed May 23, 2017.

2. Healthy People 2020. Lesbian, gay, bisexual, and transgender health.

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian

-gay-bisexual-and-transgender-health/. Accessed May 23, 2017.

3. Lim FA, Brown DV, Kim SM. Addressing health care disparities in the

lesbian, gay, bisexual, and transgender population: a review of best

practices. Am J Nurs. 2014;114(6):24-34.
4. Carabez R, Pellegrini M, Mankovitz A, et al. “Never in all my years.”:

nurses’ education about LGBT health. J Prof Nurs. 2015;31(4):
323-329.

5. Lambda Legal. When health care isn’t caring: LGBT women. 2010.

http://www.lambdalegal.org/sites/default/files/publications/

downloads/whcic-insert_lgbt-women /. Accessed May 23, 2017.

6. National LGBT Education Center: Fenway Institute. What we offer.

https://www.lgbthealtheducation.org/about-us/lgbt-health-education/.

Accessed May 23, 2017.

Megan Spiekermeier, DNP, WHNP, is a recent graduate of
the ASU Women’s Health NP program. She can be reached at
m.spiek14@gmail.com. Department Editor Denise G. Link, PhD,
WHNP, FAAN, FAANP, who would like to hear your ideas for
future columns, can be reached at deniseg.link@gmail.com.

1555-4155/17/$ see front matter

http://dx.doi.org/10.1016/j.nurpra.2017.05.091

The Journal for Nurse Practitioners – JNP 581

Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals in the U.S.

https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health/

http://refhub.elsevier.com/S1555-4155(17)30523-8/sref3

http://refhub.elsevier.com/S1555-4155(17)30523-8/sref4

http://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-insert_lgbt-women /

https://www.lgbthealtheducation.org/about-us/lgbt-health-education/

mailto:m.spiek14@gmail.com

mailto:deniseg.link@gmail.com

http://dx.doi.org/10.1016/j.nurpra.2017.05.091

http://www.npjournal.org

Reproduced with permission of copyright owner.
Further reproduction prohibited without

permission.

LGBTQ Education: Earn Your “A”

References

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