School's out for stigma: Understanding the mental health needs of LGBTQ+ youth

Posted by Liam Spencer, Fuse Associate and Research Assistant at Newcastle University

February is LGBTQ+ History Month, an annual month-long observance of lesbian, gay, bisexual and transgender history, and the history of the gay rights and related civil rights movements. The 2024 theme celebrates LGBT+ peoples’ contribution to science and medicine both historically and today. 

In this blog, Liam reflects on his research of LGBTQ+ young people’s mental health.

As LGBTQ+ History Month unfolds, it offers us an opportunity to reflect on the strides we’ve made, the challenges we still face, and the incredible diversity within our communities. This month holds particular significance for me – a chance to not only honour the struggles of those who came before us, but also to celebrate the progress we’ve achieved and recommit to the work that lies ahead.

With a background in youth and community work practice, my research interests are primarily focused on children and young people’s mental health, particularly early and preventative interventions, and school-based interventions. My journey as a member of the LGBTQ+ community and as a researcher has been intertwined with a deep sense of purpose – to shed light on the unique mental health challenges faced by LGBTQ+ individuals. This is a mission born out of personal experience, and a desire to contribute meaningfully to the wellbeing of this community. 

I have recently been involved in several Fuse projects funded by the NIHR School for Public Health Research (SPHR) Public Mental Health programme, and I’ve had the privilege of being able to delve into the complex dynamics of LGBTQ+ mental health, particularly in school environments. One of these projects, led by Professor Liz McDermott, aimed to investigate the impact of school-based interventions on LGBTQ+ young people’s mental health.

In the first phase of our study, we did a realist review (a type of evidence review that assesses the specific contexts in which a certain intervention may or may not work) of published evidence and identified positive interventions that supported LGBTQ+ mental health in school environments. However, the focus tended to be upon outcomes and studies rarely detailed underlying processes. The second phase of our study aimed to develop a theory that explained how, why, for who, and in what context school-based interventions prevent or reduce mental health problems in LGBTQ+ young people, through participation with key stakeholders.

We interviewed LGBTQ+ young people aged between 13 to 18 years attending secondary schools; intervention practitioners; and school staff in the UK. We then analysed this data to identify relationships across different interventions that improved mental health outcomes. The theory we produced explains how school-based interventions that directly tackle dominant cisgender and heterosexual norms can improve LGBTQ+ pupils’ mental health. Specifically, our theory proposes three interventions that may improve these outcomes:

1. Interventions that promote LGBTQ+ visibility and facilitate usualising, school belonging, and recognition.
2. Interventions for talking and support that develop safety and coping.
3. Interventions that address institutional school culture (staff training and inclusion polices) that foster school belonging, empowerment, recognition, and safety.

Ultimately, our research underscores the importance of providing a school environment that affirms and normalises LGBTQ+ identities, promotes school safety and belonging, and addresses systemic issues within educational institutions. By implementing evidence-based interventions informed by our theory, we can pave the way for improved mental health outcomes for LGBTQ+ pupils.

This month serves as a powerful reminder of our collective resilience, our shared struggles, and our unwavering commitment to justice and equality. Let us continue to push boundaries, challenge norms, and advocate for a world where difference is celebrated and all are embraced for who they are – within academia, our personal lives, and beyond.

Adapted with thanks to the PHSI EDI Committee Newcastle University

Images:

Image 1: courtesy of Schools OUT LGBT+ History Month 2024

Game of Thrones: King in the NoRTH… Workshop is coming… but has anyone actually read the books?

Dr Sonia Dalkin, Senior Lecturer in Public Health and Wellbeing, Northumbria University

Unless you’ve been living in a box since 2011, it’s likely that you will have heard of the series Game of Thrones. For those of you still in your boxes – Game of Thrones is fantasy drama television series created by David Benioff and D. B. Weiss. It is an adaptation of A Song of Ice and Fire, George R. R. Martin's series of fantasy novels, the first of which is called A Game of Thrones. The series has been acclaimed for many things including its acting, complex characters, story, scope, and production values. Notably, it has also received praise from both The Guardian and The Times for what is perceived as a sort of medieval realism. Here, I want to talk about a different type of Realism, that of Scientific Realism, or more specifically Realist Approaches to Research.

What is realist research?

Just as Martin’s novels rely on believable characterisation and relatable motivation to create enough suspension of disbelief to enter a world of dragons and sorcery, realist research focuses on social interventions to explain not only whether an intervention works or not, but for whom and under which circumstances. The focus therefore embraces and explains the complexity of social interventions. It aims to understand the responses people have to programme resources, therefore understanding the reasoning and motivations behind their actions. In order to do this, we focus on programme theory and utilise context, mechanism and outcome configurations. It provides rich findings, explaining why interventions work in some contexts, but not in others. For example – why is Daenerys impervious to fire when others are burnt? Because she’s a decedent of House Targaryen. Context is important, people! Alongside context is its trusty friend mechanism – similar to Ghost (an albino dire wolf) and Jon Snow – they go hand in paw. Mechanisms can be referred to as a combination of intervention resources and participant reasoning. More information is available on mechanisms here.

Altogether, the analytical tools of realist evaluation described above are used in the following way: Intervention resources are introduced in a context, in a way that enhances a change in reasoning. This alters the behaviour of participants, which leads to outcomes.

The methodology is not without its difficulties. Often realist researchers describe feeling that they are in a ‘realist swamp’; going down different alleyways, trying to understand and explain how a programme works, for whom and in which circumstances, but not getting too far. Often in this phase, realist researchers are similar to the White Walkers (an ancient race of humanoid ice creatures who really aren’t too friendly), in both looks and temperament. This phase can be frustrating, but like Arya against The Waif (acolyte of the Faceless Men), in most projects there is a sudden moment of clarity, where the dark alley becomes your friend, it all comes together, and you come out fighting.

Here at Northumbria University we have engaged in many projects using realist methods and want to help other realist researchers beat The Waif as quickly as possible, where possible. In order to do this, we’ve engaged a three-pronged approach as sharp as Arya’s sword, ‘Needle’:

1. Realist research Team Hub (NoRTH)

We felt it was time to highlight ourselves as key players in the realist game and to create a hub of realist research. What does every hub need? An acronym! We are now the Northern Realist research Team Hub (NoRTH).

NoRTH’s priorities will be to: advance the implementation of the methodology; collaborate with others focusing on realist research; contribute to and host realist education platforms; support PhD students in realist research; and continue to offer methodological expertise to those who seek it.

One thing of importance to note here is that we don’t feel we are the only big players in the North in terms of realist research – The Starks (University of Leeds) are obviously the long term true Kings of the North, with Professor Ray Pawson at the helm (our Jon Snow) for many years, and Nick Emmel, Joanne Greenhalgh, and Ana Manzano (Bran, Sansa and Arya) now fighting strong. But being ‘Northumbria University’, the acronym NoRTH seemed too good to resist… please take this blog as a token of our affection and don’t give us a fate like that of the Red Wedding!

2. Winter’s coming… along with a workshop in realist approaches

Winter is coming and soon we’ll have dark nights and frosty mornings, but never fear; alongside winter we have a brilliant offer of a Realist Approaches Workshop. Like Daenerys, mother of dragons, we wanted to educate others and decided one way to do this would be to provide a workshop. Whilst we can’t promise dragons, rebirths in blood and fire, or steamy scenes with Jon Snow, we can offer a fantastic line up of realist researchers, ready to take you on an exciting methodological journey.

Day 1 of the workshop will focus on Basic Principles of Realist Research, whilst day two will focus on contemporary developments such as realist ethnography and realist economic evaluation. To find out more and to book, check out the website.

3. ‘Doing Realist Research’ – a new book

As much as a lot of people claim to be Game of Thrones fans, how many of them have actually read the original books? TV series and films can bring whole worlds to life before our eyes, make characters into living people, but books take you into the detail, the nooks and crannies of the story. For example, the maps in Martin’s book displaying the geography of the mythical Kingdom aren’t as well portrayed in the TV series, despite efforts in the opening titles. Books provide the details that are often overlooked yet important in really understanding the overall story or the characters. Thus, if interested in realist research, I would like to suggest you read the new book ‘Doing Realist Research’, available to pre-order now), which provides much more detail on realist approaches, covering topics such as: realist review problem-solving, literature searching for realist reviews and mechanisms at higher levels of abstraction.

Edited by Nick Emmel, Joanne Greenhalgh, Ana Manzano (The Starks), Mark Monaghan and myself, this book celebrates the possible ways in which realism can contribute to researching complex social puzzles, providing practical advice on the ‘how to’ of realist methods.

Similar to Game of Thrones, so far, it’s received rave reviews, like that from Professor Kieran Walshe, (University of Manchester): “I wish all social science researchers would read this book”. Best of all, it has absolutely no Game of Thrones references – and that’s a promise (similar to that of Ned Starks to Lynna Stark in the infamous Tower of Joy Scene)…



Acknowledgements

Many thanks to Dr Phil Hodgson (Northumbria University) for helping me in identifying so many obvious Game of Thrones parallels with realist research…


Image: "Game of Thrones. Xbox One. 1080.P. 😁 Gameplay Part.04.-06. On my YouTube Channel 😁 https://youtube.com/playlist?list=PLwsjII0MclEGZnmdii3LZb9FZLby_iP4Q 😁 by Rob Obsidian via Flickr.com, copyright © 2015: https://www.flickr.com/photos/65092514@N08/18679295525

Too stressed for words? Involving those experiencing stress in research (part 2)

Posted by Fuse members Sonia Dalkin, Lecturer in Public Health and Wellbeing, and Natalie Forster, Senior Research Assistant, Northumbria University

Following on from our post last year on National Stress Awareness Day, and in light of the current media attention paid to welfare benefits, we wanted to take the opportunity to reflect on the difficulties of involving those experiencing stress in research. This is in relation to our recent recruitment efforts for a realist evaluation of the impact of Citizens Advice (CA) on health.

"Stress" by Bernard Goldbach

CA provide independent, impartial, confidential, and free advice to everyone on their rights and responsibilities. This includes advice on debt, benefits, employment, housing and discrimination. Throughout the study, a recurrent theme of stress has been evident. The links between stress and health are abundant. This stress lens therefore formed the health focus of the study, overcoming the difficulties of recording the variety of outcomes leading to health improvements and capturing changes to health which would only be evident beyond the study timescale. Determining if and how CA services reduce stress should enable us to project the potential health impact of CA.

We carried out a mixed methods evaluation, detailed here. This required CA clients to complete a questionnaire when they first accessed CA and six weeks later. CA staff collected the questionnaire data for the research. Twenty-seven clients were also invited to participate in interviews. CA staff were initially apprehensive about data collection, due to clients often being in crisis and therefore having extremely high levels of stress.

Initially, recruitment was very slow. This was due to a variety of factors, some of which could be related to stress:

• Some clients were too stressed to engage in completing the questionnaire at Time 1 (initial contact with CA).
• CA staff found it extremely difficult at times to get in contact with clients at Time 2 (six weeks later). This was often due to their own heavy workload but also due to client reluctance to answer calls from unknown numbers (CA has a withheld number) and client wishes to move on with their lives once issues had been resolved.
• Clients were reluctant to participate in interviews because they were too stressed and had often been let down by other organisations when disclosing personal information. 
• Some clients also suffered from severe mental health issues which meant they found the prospect of an interview very stressful. 

To overcome these barriers, several strategies were employed. These were developed collaboratively with CA, and through engagement with the project steering group.

• We worked with CA staff to develop a bespoke questionnaire, meaning that CA staff felt confident that it was not over burdensome for clients. This included shortened versions of questionnaires where possible. Questionnaires were also carried out by a client’s named CA contact who they trusted and would be more comfortable disclosing information to.
• We ensured that CA staff had a detailed understanding of the research aims in order to explain the research clearly to participants and gain their trust in the research. They could therefore highlight the importance of completing the Time 2 questionnaire to participants. When participants understood that the research aim was to show the ‘good work’ CA do, as opposed to focusing on their issues, they were more likely to engage. 
• Offering interviews at a client’s home or via skype, in addition to the original offer of interviews at CA Gateshead allowed for participants to be in a location where they felt most relaxed.
• Offering clients the option of having their named and trusted CA staff member attend the interview for the first 10 minutes allowed this trusting relationship to be transported to the interviewer.
• Offering clients the option of having a relative or friend attend the interview also helped to put the client at ease. In one case, the client gave permission for their partner to do the interview on their behalf as they had been highly involved in the process of interacting with CA.

These improved strategies led to the collection of 261 Time 1 questionnaires with a 92 per cent follow up rate, and 23 clients participating in interviews.

Although CA staff were initially apprehensive about data collection, working in partnership and being flexible with recruitment strategies overcame this. It is important to provide all clients with the option of participating in research; presumptions of non-participation remove client autonomy which is unethical. In this research project and all research with people experiencing difficult circumstances it is essential to involve - where possible - any potential participants, the organisations working with clients, and experts, to find the most fruitful recruitment strategies.


The CA research team also consists of Monique Lhussier (Reader in Public Health and Wellbeing); Philip Hodgson (Senior Research Assistant) and Sue Carr (Professor of Public Health Research), who have all read and contributed to this blog post.

The study ‘Exposing the impact of advice services on health and inequalities’ is funded by the NIHR School for Public Health Research (SPHR), via the Public Health Practice Evaluation Scheme (PHPES). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Links:

• More information about this research is available on the NIHR SPHR project pages on the Fuse website.
• Fuse research brief: How do Citizens Advice Bureau services improve people’s health?

Photo attribution: “Stress” by Bernard Goldbach via Flickr.com, copyright © 2011: https://www.flickr.com/photos/topgold/6273248505