Perceived Importance of Health Concerns Among Lesbian, Gay, Bisexual, and Transgender Adults in a National, Probability-Based Phone Survey, 2017 Health Promotion Practice September 2020 Vol. 21, No. (5) 764 –768 DOI: 10.1177/1524839920908226 Perceptions of the importance of health problems can drive advocacy, policy change, resource distribution, and individual behaviors. However, little is known about how lesbian, gay, bisexual, and transgender (LGBT), that is, sexual and gender minority (SGM) adults view the health problems facing SGM populations. In a 2017 national, probability-based survey of U.S. SGM adults (N = 453), we asked respondents to identify the most serious health problem facing SGM people today. Participants also rated the seriousness of five specific health problems (HIV/AIDS, suicide, hate crimes, harm- ful alcohol use, tobacco use). Analyses accounted for the complex sampling design and were stratified by gender identity. One quarter of U.S. SGM adults identified the most serious health problem facing SGM people to be HIV/AIDS (95% confidence interval [20.3, 31.2]). More respondents stated there were no serious LGBT health differences compared with straight/cisgender adults (4.2%, confidence interval [2.6, 5.9]) than identified tobacco use, hate crimes, chronic diseases, cancer, or suicide as the most serious. Importance ratings differed by gender and tobacco/alcohol use were perceived as less serious compared with HIV/AIDS, suicide, and hate crimes. Attention paid to HIV/AIDS by the SGM public, while important, may hinder efforts to address chronic diseases and other health issues affecting SGM people. Keywords: sexual and gender minorities; tobacco smoking; surveys and questionnaires >>IntroductIon There are substantial differences in health by sexual orientation and gender identity that disadvantage sexual and gender minority (SGM, e.g., lesbian, gay, bisexual, and transgender) populations. To address these inequi- ties, SGM communities have organized to improve health care, develop health centers that serve SGM pop- ulations, adapt interventions for SGM communities, and build networks and coalitions to address specific health topics (e.g., HIV/AIDS, tobacco control, violence, can- cer). Prominent have been efforts to address HIV and AIDS, including iconic activism by the AIDS Coalition to Unleash Power (ACT-UP) and others (Halcli, 1999). Similarly, community and public attention to SGM sui- cide and hate crimes have been driven by attention to 1University of North Carolina at Chapel Hill, Chapel Hill, NC, USA 2East Carolina University, Greenville, NC USA Authors’ Note: The authors thank Kurt Ribisl, Noel T. Brewer, and Quirina Vallejos for assistance with development of the survey items and Anna Hoffmeyer for her expertise in managing admin- istration of the telephone survey. Research reported in this pub- lication was supported by the National Cancer Institute of the National Institutes of Health and Food and Drug Administration Center for Tobacco Products (CTP) under Award Number P50CA180907. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration. The funder had no role in the design of the study or in data collection, data analysis, interpretation, and writing of the article. Address correspondence to Marcella H. Boynton, NC TraCS Institute, Brinkhous-Bullitt Building, 160 Medical Drive, Chapel Hill, NC 27599, USA; e-mail: marcella_boynton@med. unc.edu. Perceived Importance of Health Concerns Among Lesbian, Gay, Bisexual, and Transgender Adults in a National, Probability-Based Phone Survey, 2017 Marcella H. Boynton, PhD1 Jeffrey Gilbert, MPH1 Bonnie E. Shook-Sa, MAS1 Joseph G. L. Lee, PhD, MPH1,2 http://crossmark.crossref.org/dialog/?doi=10.1177%2F1524839920908226&domain=pdf&date_stamp=2020-02-26 problems in communities and coverage in the media (Savage & Miller, 2012). Several theoretical and conceptual approaches illus- trate why public attention to a health problem matters to addressing inequities. Theories of agenda setting suggest that policy agendas are driven in part by atten- tion and media coverage (Scheufele, 2000). Similarly, the “issue attention cycle” posits that attention to a problem can drive interventions (Downs, 2016). Finally, public health practice recognizes the importance of media advocacy to drive changes (Drabble et al., 2006). In addition to mobilizing communities and driving policy agendas, perceptions of health issues important to SGM communities can also influence individual health behaviors. The importance of HIV to the SGM community may drive individual testing behaviors and safer-sex practices by, for example, changing individu- als’ perceived vulnerability and motivation to protect oneself. Despite the historic and current importance of SGM communities’ perceptions of health problems, there is little data regarding what health issues SGM communi- ties view as most salient. Only limited evidence is avail- able about what those perceptions are. For example, one venue-based (i.e., bar and club) study (N = 660) found HIV and sexually transmitted infections were rated high- est of issues of importance among gay and bisexual men and smoking was rated least important (Grov et  al., 2013). In a Houston, Texas, convenience sample (N = 99), just 6% of participants listed smoking or second- hand smoke exposure as a top-three health problem (Tami-Maury et al., 2015). It is important to understand where perceptions of problems may not align with premature death and dis- ease. That is, not all problems receive attention propor- tionate to their actual contribution to premature death and diseases. For example, SGM populations smoke at much higher rates than other groups (Buchting et  al., 2017; Wheldon et al., 2018). As such, tobacco use is a leading cause of death among SGM people given existing disparities (Max et al., 2020). Nonetheless, the dispro- portionate effect of tobacco use on the SGM community has received scant media attention and is not viewed as an important community issue by community members (Smith et al., 2008). Given the theoretical and practical importance of media and public attention to health problems, substan- tial health inequities for SGM populations, and limited probability-based data, we sought to (1) assess the sali- ence of health issues relevant to SGM adults, and (2) assess how tobacco use is perceived in relation to other key health issues in a national, probability-based survey. >>MEtHod From July to October 2017 we administered a cross- sectional phone survey to a sample of English speaking SGM adults living in the United States (Lee et al., 2020) who were recruited as a follow-up to a larger, probabil- ity-based tobacco use survey study implemented in two waves of data collection (Boynton et  al., 2016; Jeong et al., 2020). SGM individuals were recruited to the par- ent tobacco use survey as part of the probability-based sampling procedure or as part of a supplemental respondent-driven sampling chain. In all cases, partici- pants had a known probability of selection and therefore weights could be constructed to generate nationally rep- resentative estimates. A minimum of six call attempts were made to contact every eligible SGM participant, yielding a final sample of 453 SGM adults. After the screening and consent process was complete the interviewer made the statement, I’d like to start by asking you about issues important to the LGBT community. I will be using the term LGBT throughout this survey to refer to anyone who is lesbian, gay, bisexual, transgender, or queer. I appreciate your understanding if the term LGBT does not completely capture your identity. The interviewer then asked, “What do you think is the most serious health problem facing LGBT people today?” and typed the response verbatim. Respondents were then asked how serious of a problem each of five randomly ordered health issues are for people who are LGBT (alcohol abuse,1 hate crimes, HIV/AIDS, smoking, suicide) where 0 = not at all serious, 1 = somewhat serious, 2 = very serious, and 3 = extremely serious. For the open-ended response, two coders developed a code- book, independently coded a sample of responses (n = 60), and achieved acceptable reliability, Krippendorff’s α = .90 (95% confidence interval [CI; 0.80, 0.98]; Hayes & Krippendorff, 2007). To further ensure reliability, we then double coded all responses, and any differences were reconciled through discussion. These measures were adapted from prior work by Grov et al. (2013) and by Gallup (2018). The full survey instrument is available in our institutional repository (University of North Carolina Dataverse, accession doi:10.15139/S3/BX0RZE, available from https://dataverse.unc.edu/dataset.xhtml? persistentId=doi:10.15139/S3/BX0RZE). Because there are substantial differences by gender in SGM health and because HIV/AIDS disproportionately affects sexual minority men and transgender women, we https://dataverse.unc.edu/dataset.xhtml?persistentId=doi:10.15139/S3/BX0RZE https://dataverse.unc.edu/dataset.xhtml?persistentId=doi:10.15139/S3/BX0RZE conducted analyses stratified by gender identity. The University of North Carolina at Chapel Hill Institutional Review Board reviewed and approved the study proto- col (No. 13-2779). >rESuLtS Participant characteristics are provided in our online Dataverse repository cited above and in Lee et al. (2020). Table 1 shows frequencies and weighted propor- tions of responses identifying the most serious health problem facing LGBT people today, stratified by gender identity. For all groups, HIV/AIDS (25.7%) and sexually transmitted infections/unprotected sex (17.6%) were the most common responses; limitations in health ser- vices access, care, and information were also com- monly cited (11.0%). More participants reported that they thought no disparity existed (4.2%) than those that indicated discrimination/exclusion, tobacco use, hate crimes, chronic diseases, cancer, or suicide. As shown in our institutional repository supplemen- tal table cited above, when we asked participants to rate the seriousness of five topics presented in random order, participants rated suicide (mean [M] = 2.26, 95% confidence interval [CI; 2.17, 2.36]), hate crimes (M = 2.21, 95% CI [2.11, 2.30]), and HIV (M = 2.12, 95% CI [2.03, 2.21]) as significantly more serious health prob- lems for the LGBT community compared with harmful alcohol use (M = 1.69, 95% CI [1.59, 1.78]) and smok- ing (M = 1.64, 95% CI [1.54, 1.74]). We identified sig- nificant differences in the ratings for hate crimes by gender identity, with cisgender sexual minority women rating hate crimes as a more serious health issue (M = 2.36, 95% CI [2.25, 2.46]) compared with cisgender sexual minority men (M = 2.01, 95% CI [1.85, 2.16]) and cisgender sexual minority women rating smoking as a less serious problem (M = 1.52, 95% CI [1.39, 1.65]) compared with cisgender sexual minority men (M = 1.78, 95% CI [1.64, 1.93]). >DISCUSSION Our findings suggest that health issues connected to immediate harms (e.g., HIV infection, health ser-vices access, violence) are more salient, and therefore perceived as more serious, to SGM adults as compared to health issues associated with more distal harms such as chronic disease. For example, smoking, which is a leading cause of death and disability for U.S. adults and for LGBT individuals (Max et  al., 2020), was not generally perceived as a serious health risk to LGBT people. Access to quality health care is a major concern in the U.S. population and an important political topic. However, our findings suggest that the top health con- cerns for SGM populations may differ from those of the general public in important ways, specifically, by includ- ing a focus on HIV/AIDS. Addressing inequities in HIV/ AIDS for SGM men and gender minority women remains an important area of work, given, for example, the strik- ing inequities in HIV prevalence by race and gender identity among SGM populations (Matthews et  al., 2016). HIV/AIDS has historically been viewed as a core issue of SGM health; however, improvements in care (e.g., antiretroviral therapy) are resulting in chronic dis- eases replacing HIV/AIDS as leading causes of death for people living with HIV/AIDS (Helleberg et al., 2015). Our findings may be of particular concern for advo- cates working to address chronic diseases among SGM populations. For example, our findings may help explain the lack of traction that SGM tobacco control advocates report when speaking to SGM community leaders (Smith et  al., 2008) and why certain messaging around SGM health disparities performs poorly (Lee et al., 2017). Lack of SGM public attention to more distal health issues may, in turn, hinder efforts to successfully encourage SGM organizations to address health issues such as tobacco use and cardiovascular disease and hinder media advo- cacy efforts (Drabble et al., 2006). Regarding public health and health promotion prac- tice, our findings suggest the importance of engaging with SGM communities and SGM community organiza- tions on a broad range of health topics. For example, this could include invitations to SGM community leaders to participate in advisory boards and as community part- ners. The findings also highlight the importance of health advocates working on chronic disease topics par- ticipating in community events. And, it suggests the important need for getting chronic disease topics cov- ered by media tailored to SGM populations. This study’s strengths of probability sampling of a mar- ginalized population and use of an open-ended response option for health problems must be balanced against its limitations. First, our weights are based on the National Health Interview Survey and are thus limited by the ways in which that survey captured SGM identity. Second, we asked our questions in the context of a survey explicitly about tobacco use and SGM health and we used the term “alcohol abuse” as opposed to less potentially stigmatizing terms such as “alcohol use,” “alcohol use disorder,” or “harmful alcohol use.” This measurement approach may have affected the stated levels of concern for smoking and alcohol use in the SGM community. Third, our small sam- ple of transgender/nonbinary adults did not allow for meaningful comparisons with the cisgender groups. t A B L E 1 t o p ic I d en ti fi ed a s M o st S er io u s H ea lt h P ro b le m F a ci n g L G B t P eo p le t o d a y, c o d ed F ro m o p en r es p o n se s, u n w ei gh te d n s a n d W ei gh te d P ro p o rt io n s (N = 4 5 3 ), 2 0 1 7 T o p ic U n w ei gh te d F re q u en ci es W ei gh te d % [ 9 5 % C I] T o ta l (N = 4 5 3 ) F em a le s (n = 2 6 8 ) M a le s (n = 1 5 9 ) T ra n sg en d er o r N o n b in a ry ( n = 2 6 ) H IV o r A ID S 1 0 8 2 5 .7 [ 2 0 .3 , 3 1 .2 ] 2 0 .8 [ 1 4 .0 , 2 7 .6 ] 3 1 .1 [ 2 2 .7 , 3 9 .5 ] 3 3 .5 [ 8 .3 2 , 5 8 .6 ] S T Is o r u n p ro te ct ed s ex 8 3 1 7 .6 [ 1 3 .2 , 2 2 .1 ] 1 5 .9 [ 1 0 .3 , 2 1 .5 ] 2 0 .2 [ 1 3 .0 , 2 7 .4 ] 1 2 .6 [ 3 .3 1 , 2 1 .9 ] H ea lt h s er v ic es a cc es s, c ar e, o r in fo rm at io n 5 3 1 1 .0 [ 6 .6 1 , 1 5 .4 ] 1 2 .8 [ 6 .6 0 , 1 9 .0 ] 9 .8 5 [ 3 .0 5 , 1 6 .7 ] 0 .1 2 [ 0 .0 0 , 0 .3 7 ] M en ta l h ea lt h 5 2 1 0 .7 [ 7 .0 2 , 1 4 .3 ] 1 4 .6 [ 9 .1 8 , 2 0 .0 ] 6 .8 5 [ 1 .8 9 , 1 1 .8 ] 0 .0 3 [ 0 .0 0 , 0 .1 0 ] S u b st an ce u se ( al co h o l, d ru gs , o p io id s) 3 8 1 0 .1 [ 5 .3 5 , 1 4 .8 ] 5 .8 4 [ 1 .9 2 , 9 .7 7 ] 1 4 .7 [ 5 .1 7 , 2 4 .2 ] 1 6 .4 [ 0 .0 0 , 3 7 .0 ] D o n ’t k n o w 2 4 5 .0 6 [ 2 .6 1 , 7 .5 0 ] 6 .2 1 [ 3 .1 0 , 9 .3 2 ] 4 .1 1 [ 0 .3 5 , 7 .8 7 ] N o d is p ar it y w it h s tr ai gh t/ ci sg en d er p eo p le 2 0 4 .2 4 [ 2 .5 8 , 5 .9 1 ] 4 .8 5 [ 2 .4 1 , 7 .2 9 ] 3 .5 2 [ 1 .2 9 , 5 .7 5 ] 4 .1 1 [ 0 .0 0 , 1 2 .6 ] D is cr im in at io n o r so ci al e x cl u si o n 1 4 2 .7 5 [ 0 .8 9 , 4 .6 2 ] 4 .7 1 [ 1 .3 0 , 8 .1 2 ] 0 .6 2 [ 0 .0 0 , 1 .4 9 ] T o b ac co u se 1 4 2 .2 7 [ 0 .6 8 , 3 .8 7 ] 1 .9 9 [ 0 .0 0 , 4 .0 7 ] 2 .0 2 [ 0 .0 0 , 4 .3 7 ] 8 .7 6 [ 0 .0 0 , 1 8 .4 ] H at e o r h at e cr im es 1 1 2 .4 0 [ 0 .5 5 , 2 .2 4 ] 2 .4 5 [ 0 .0 0 , 4 .9 2 ] 1 .6 8 [ 0 .0 0 , 4 .3 9 ] 9 .4 5 [ 0 .0 0 , 1 9 .8 ] O b es it y, c ar d io v as cu la r is su es , o r d ia b et es 1 1 3 .3 8 [ 0 .5 7 , 6 .1 9 ] 4 .9 2 [ 0 .4 6 , 9 .3 8 ] 1 .8 0 [ 0 .0 0 , 5 .1 7 ] C an ce r 8 1 .6 9 [ 0 .3 0 , 3 .0 8 ] 2 .7 3 [ 0 .2 7 , 5 .1 9 ] 0 .5 7 [ 0 .0 0 , 1 .6 9 ] S u ic id e 7 1 .0 8 [ 0 .1 1 , 2 .0 5 ] 1 .4 1 [ 0 .0 4 , 2 .7 7 ] 0 .7 8 [ 0 .0 0 , 2 .3 3 ] C u rr en t p o li ti ca l cl im at e 6 0 .9 3 [ 0 .0 0 , 1 .9 9 ] 0 .2 6 [ 0 .0 0 , 0 .6 2 ] 1 .0 9 [ 0 .0 0 , 3 .1 5 ] 7 .9 4 [ 0 .0 0 , 1 7 .9 ] O th er 6 1 .1 0 [ 0 .0 0 , 2 .2 9 ] 0 .6 1 [ 0 .0 0 , 1 .4 2 ] 1 .1 4 [ 0 .0 0 , 3 .3 9 ] 7 .1 6 [ 0 .0 0 , 2 0 .9 ] N O T E : L G B T = l es b ia n , ga y, b is ex u al , o r tr an sg en d er ; S T Is = s ex u al ly t ra n sm it te d i n fe ct io n s. >>concLuSIon Efforts to address SGM health beyond HIV/AIDS may be hindered by the focus of the SGM public on the importance of HIV and other sexually transmitted infec- tions. 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