Designing an interprofessional Facebook discussion group to teach about LGBTQ healthcare disparities and inclusive practices

Abstract

Objective:

Training on lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) healthcare and inclusive practice is lacking in curricula across health professions, contributing to health disparities. The purpose of this study was to evaluate an interprofessional learning activity on LGBTQ healthcare disparities and inclusive practices delivered in a closed Facebook group.

Design:

Asynchronous, online platforms, like social media, offer a simple means of connection and discussion for interprofessional education.

Setting:

An academic health centre in the Southern USA.

Methods:

The learning activity consisted of (1) pre- and post-quizzes assessing knowledge about LGBTQ healthcare, (2) content review of required readings and a video and (3) daily discussion threads. Students completed individual reflection essays about interprofessional education and practice and the Quadruple Aim.

Results:

Two cohorts of interprofessional students completed the activity. Average quiz scores increased post-activity. Both the Facebook discussion threads and reflection essays demonstrated that students recognised the need to incorporate LGBTQ-inclusive practices into their future professional practice, as well as recognised the valuable insight of their interprofessional team members. Students had mixed perspectives about Facebook as a discussion platform for interprofessional education.

Conclusion:

Facebook groups provide a feasible platform to implement interprofessional education on LGBTQ-inclusive healthcare practice and stimulate student discussion.

Keywords

Asynchronous learning inclusive practice interprofessional education LGBTQ LGBTQ health

Background

In the USA, there is an increasing awareness of the need for a culturally sensitive workforce to provide inclusive healthcare to the lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) persons (Kano et al., 2016) as a means to reduce LGBTQ health disparities. The specific need for education on LGBTQ healthcare is critical, considering that gender and sexual minorities have unique health needs and experience health disparities when compared to other individuals (Klein and Nakhai, 2016). These disparities persist for a variety of reasons, including lack of awareness among healthcare providers, limited education on LGBTQ health topics, poor patient–provider communication and discrimination in healthcare.

In 2010, Section 1557 of the US Affordable Care Act prohibited federally funded healthcare providers from sex discrimination, and in 2016, the Obama Administration issued a rule clarifying that Section 1557 prohibits discrimination against transgender individuals; however, in June 2020, the US Department of Health and Human Services under the Trump Administration issued a new rule, which rolled back these protections. Later in June 2020, the US Supreme Court held that LGBTQ discrimination is sex discrimination under the Civil Rights Act of 1964’s federal workplace protection (Title VII). While this decision will likely impact the US Department of Health and Human Services’ new rule, it is currently unclear how this will affect protection against LGBTQ discrimination in healthcare.

Studies suggest that there is limited education on LGBTQ-specific topics across diverse healthcare professional groups (Greene et al., 2018). A survey of 150 US and Canadian medical schools revealed that students are taught only 5 hours of LGBTQ health-related content in their entire medical school curriculum (Obedin-Maliver et al., 2011). More recently, an investigation by the Association of American Medical Colleges (AAMC, 2019) found that three of the four participating medical schools had some LGBTQ health content in their curriculum in 2017–2018, although half had three or fewer learning activities (e.g. lectures, discussion) on the subject. LGBTQ health information has also been historically lacking from nursing school curricula (Carabez et al., 2015; Greene et al., 2018). A 2015 qualitative study of 268 practicing nurses revealed that 80% had no education or professional training on LGBTQ health issues (Carabez et al., 2015). Since several healthcare issues are disproportionately observed in the LGBTQ populations, providers who lack awareness will be limited in their ability to offer optimal care (Knight and Jarrett, 2015, 2017).

Limited LGBTQ health and healthcare knowledge and awareness among healthcare providers can cause poor patient–provider communication, which can affect LGBTQ patients’ experience when accessing needed healthcare. LGBTQ patients’ reluctance to self-disclose their sexual orientation or gender identity, as well as healthcare providers’ hesitance to initiate dialogue about a patient’s sexual orientation or gender identity, may lead to delays in care and subsequent negative health outcomes (Mitchell et al., 2008). When sexual orientation and gender identity are not discussed freely, health conditions that are overrepresented in these populations may not be appropriately addressed (Knight and Jarrett, 2015, 2017).

LGBTQ patients report facing discrimination such as disrespectful comments, delay of care or outright refusal of care, in healthcare settings. In a 2018 nationally representative survey, 8% of LGBQ (not including transgender patients) respondents said that a healthcare provider refused to see them due to their actual or perceived sexual orientation (Mirza and Rooney, 2018). In the case of transgender patients, 29% said they had been turned away by a medical provider due to their actual or perceived gender identity (Mirza and Rooney, 2018). Multiple studies have revealed an overall lack of cultural competence, as well as discriminatory behaviours, by healthcare professionals, including derogatory comments to patients (Bonvicini, 2017). In some cases, overt discriminatory care has led patients to avoid subsequent clinical encounters and to search online to try to find healthcare advice on their own (Bonvicini, 2017). In addition to education to prepare health professionals to have inclusive conversations with LGBTQ patients, it is important to consider the inclusivity of health system operations and how nomenclature and data collection processes may impair inclusive conversations and environments of care (Butler-Henderson et al., 2018). For example, many electronic health records do not support an inclusive approach to collecting an individual’s sexual orientation or gender identity at the point of registration. It is common that fields only include responses for “male” or “female” sex and do not ask for preferred pronouns. This may perpetuate inappropriate assumptions based on a response to the limited selections available and/or may result in misgendering where an individual is described using a term that is not aligned with the way that person identifies their body, gender or relationship. In addition, it is not uncommon that these limited fields are included in decision algorithms that limit access to services, such as a specialty appointment/procedure in a women’s health clinic only being authorised for patients identified as female in the health information system (Butler-Henderson et al., 2018). It is imperative that students and professionals in health information management, healthcare analytics, informatics and health administration understand how health system policies and procedures are supportive or detrimental to inclusive environments of care as well as for clinicians to understand how policies, procedures and data collection methods influence patient conversations and clinical decision-making.

Educating the next generation of healthcare providers across health professions to provide LGBT-inclusive healthcare is an important but challenging goal due to the different geographical locations of learners (i.e. online students and students on different campuses). The educational literature supports that the training modality should be interprofessional (i.e. Leslie et al., 2017), and that asynchronous and online formats supported through social media-based platforms provide flexibility for active learning methods for current learners. In the midst of the COVID-19 public health crisis, online/distance options for educational delivery are even more important to continue to advance meaningful and relevant learning opportunities while maintaining recommended physical distancing norms (Tabatabai, 2020; Woolliscroft, 2020).

The Institute of Medicine Committee on Quality of Health Care in America has called for more focus on interprofessional teams to improve patient care (Bridges et al., 2011). Specific to serving the LGBTQ community, interprofessional education (IPE) (where learners from two or more professions learn about, from and with each other) serves as an educational modality for supporting an emerging culturally sensitive healthcare workforce (McCave et al., 2019). As the need for partnerships and collaboration of interprofessional teams in health profession education has grown in emphasis (Chen et al., 2020), especially as the workplace becomes more team-oriented (Fischer et al., 2018), collaborative practice skills have incorporated an ethical foundation with patient- and family-centred tenets that include cultural sensitivity as part of core competencies (IPEC Expert Panel, 2011; IPEC, 2016). Through the modality of IPE, students are more likely to demonstrate positivity and respect towards other healthcare professionals and work together to improve patient outcomes (Bridges et al., 2011), as well as develop affirmative healthcare practices for serving the LGBTQ community (McCave et al., 2019). However, most IPE learning events involve live classroom-, simulation- or clinic-based experiences and either do not include online learners or the number of types of learners is few (for details, see Evans et al., 2017; Potthoff et al., 2019).

Asynchronous, online platforms offer students a simple means of connection and discussion with one another, regardless of location and time availability. They are particularly helpful for interprofessional groups that do not meet in person for traditional coursework (Fischer et al., 2018) but require online facilitation skills on the part of instructors (Evans et al., 2019a, 2019b, 2020). Recent studies have shown that the use of online media to deliver IPE is becoming more common (Brooks et al., 2020; Evans et al., 2017; Smith et al., 2019). Specific to serving the LGBTQ community and reducing health disparities with this patient population, online modules have been used to promote culturally sensitive knowledge and skills with uni-professional learners but not yet with interprofessional learners (Streed et al., 2019).

Social media platforms provide opportunities for learners to engage with educational material in a range of formats (text, video, images, etc.), as well as engage with one another in discussion. Facebook is a popular, familiar social media platform easily accessed at no charge and with a simple account registration process. Some research indicates that Facebook may engage and interest students (Li et al., 2019) and encourage interaction between students and teachers (Fischer et al., 2018). With its interactive features, including its ability to host discussions, (Fischer et al., 2018) Facebook is a natural but somewhat underutilised platform for teaching (Fischer et al., 2018) that is compatible with adult learning theory concepts, such as active participation in the learning process, spacing of the learning and a personal learning environment (Li et al., 2019). Facebook also requires no extensive technical skill on the part of faculty (Li et al., 2019) and is unhindered by limitations of scheduling and budget (Brooks et al., 2020). Facebook allows for greater submitted text capacity per comment as compared to other social media platforms. Social networking platforms have been used to educate interprofessional students (Simpson et al., 2020), and the closed group feature in Facebook allows for privacy.

Aims

The specific aims of this project were to (1) design an asynchronous, Facebook-based discussion group on LGBTQ healthcare disparities and inclusive practices for use in educating interprofessional students and (2) compare knowledge and beliefs regarding LGBTQ healthcare and inclusive practices before and after participation.

Methods

Study setting

This study took place at the University of Arkansas for Medical Sciences (UAMS), an academic health centre with five colleges (medicine, nursing, pharmacy, health professions and public health) and a graduate school. At UAMS, degree-seeking students in every college must fulfil an IPE graduation requirement with a variety of activities available. These IPE activities may be completed as embedded course requirements or as stand-alone, co-curricular activities as determined at the programme level. The Quadruple Aim (to improve patient experience and outcomes, to improve population health, to reduce cost of care and to improve provider satisfaction and wellness) provides a centre point for all interprofessional curriculum requirements.

Study design

An online discussion group on LGBTQ-inclusive healthcare was delivered to an interprofessional group of students at UAMS. This learning activity took a didactic approach to IPE (Bridges et al., 2011), emphasising patient-centred care and the impact of culture on healthcare delivery. The learning activity was designed as a closed Facebook discussion group consisting of the following elements: (1) pre-/post-quiz assessing knowledge about LGBTQ healthcare, (2) content review of required readings (Hoffman, 2017; Keuroghlian et al., 2017) and an LGBTQ-themed video titled ‘To Treat Me, You Have to Know Who I Am’ (NYC Health and Hospitals, 2011) and (3) daily discussion threads. The required readings included content about how and when to initiate conversations regarding sexual orientation and gender identity, why this information is important to medical decision-making and patients’ expectations and response to these conversations. Each of these materials is publicly available online for further details. Instructions for creating a Facebook account were provided for participants who did not yet have an account or wished to create a separate account for the activity. A staff member was available to assist students in creating the account and joining the closed Facebook group.

Sample and recruitment

Two cohorts of students completed the LGBTQ Facebook discussion activity. Cohort 1 completed the initial pilot activity in the summer 2018 as a component of a 2-credit hour course on patient- and family-centred care offered to students in the College of Health Professions and College of Nursing. The Facebook discussion activity was advertised as available to all students to meet IPE requirements, and students from the College of Pharmacy and College of Public Health also elected to participate. For Cohort 2, the activity was offered to all students, both on-campus and online programmes, in autumn 2018. Students were recruited via an email sent out by the Interprofessional Education Office and notified that participation in this activity would satisfy a requirement of the IPE curricula for all students. An overview of the cohorts and elements is provided in Figure 1.

Figure 1.

Study design.

Students received instruction regarding expectations for discussion group posts including frequency of participation in the interprofessional conversation and content and perspective of contributed comments. Students were asked to consider four targeted goals for content: relevance, logic, integration and individuality.

Students were provided a discussion grading rubric (see Table 1) to provide additional guidance on expectations for the interprofessional conversation goals of the Facebook format and timelines. Assignments and discussion thread origination were posted by a Facebook group moderator. Interprofessional faculty facilitators monitored discussion thread posts to assist with depth of conversation development and to ensure students met discussion post expectations. The Facebook timeline and discussion questions are detailed in Table 2.

Table 1.

Discussion grading rubric.

Criteria	Expectation – For the content/substance of your posts, review the considerations for relevance, logic, integration and individuality below. All posts (Initial and Responses) should incorporate these considerations.
Initial Post	Student submits an Initial Post to at least two of the Discussion Threads 1–4. Information provided in posting is clearly presented and relevant to the topic. Student adds new information and provides supporting details and/or examples. Student demonstrates depth of knowledge for information learned in the module. Provides references when appropriate. (Example: one Initial Post on Discussion Thread 1 and one Initial Post on Discussion Thread 3 = minimum of two Initial Posts.)
Professionalism	Student demonstrates professional vocabulary and courtesy consistently in Initial Posts and Response to peers throughout discussion.
Meets Number of Responses to Peers	Student responds frequently throughout discussion. Must meet or exceed minimum number of posted Responses: two Responses to peers on at least two of the Discussion Threads 1–4 and one Response post in Take Away. (Example: two Responses on Discussion Thread 1, two Responses on Discussion Thread 3 and one Response in Take Away Thread = minimum of five Responses to peers.) Responses to peers are NOT the same as the Initial Post.
Take Away Response	Information provided in posting is clearly presented and relevant to the topic. Student adds new information and provides supporting details and/or examples.
Pass/Fail	Must complete ALL of the above to receive a ‘Pass’. Meet or exceed minimum number of Initial Posts and Responses and adhere to rubric expectations (Discussion Threads 1–4: two Initial Posts and four Responses to peers; Take Away Thread: one Initial Post and one Response to peers = eight total posts).

Table 2.

Facebook discussion timeline.

Day 1	Pre-quiz and required reading and video assignments
Day 4	Discussion Post #1 – From a patient-centred care perspective, why is it important to use appropriate terminology? Focused topic: Experience of Patients and Families.
Day 5	Discussion Post #2 – Why LGBTQ health? Focused topic: Communication.
Day 6	Discussion Post #3 – What are the unique issues LGBTQ patients face across the developmental spectrum (paediatrics, adolescents, adults, geriatric adults)? Focused topic: Values & Ethics.
Day 7	Discussion Post #4 – How can we create an LGBTQ-friendly healthcare practice? Focused topic: Professional Roles & Responsibilities.
Day 8	Discussion Post – Takeaway and Post-Quiz – Based on the concepts and conversations addressed in the readings, video and daily group discussions for this activity, select one of the areas below and describe a key takeaway for how this information impacts the item. 1. Education 2. Research 3. Clinical practice 4. Professional wellness

LGBTQ: lesbian, gay, bisexual, transgender and queer or questioning.

Data collection methods

To assess student learning and perceptions of the activity, data were collected in multiple forms, including pre- and post-quizzes, discussion responses and reflection essays. All participants were instructed to complete an electronic pre-quiz before accessing the activity materials. The quiz consisted of five questions (two multiple choice, two true/false and one ‘select all that apply’) assessing knowledge about LGBTQ healthcare disparities and LGBTQ-inclusive healthcare practices. After completing the discussion group, participants were asked the same five questions in a post-quiz (see Table 3).

Table 3.

Pre- and post-quiz questions.

Question 1: What percentage of LGBT adults have reservations about disclosing their sexual orientation or gender identity to their medical providers? (Multiple choice)

a. 60%

b. 30%

c. 20%

d. 10%

Question 2: Clinicians believe that information about sexual orientation is important to treat their patients. (True/false)

a. True

b. False

Question 3: Hospital intake forms routinely collect data on which of the following: Race, gender identity, ethnicity, sexual orientation. (Select all that apply)

a. Race

b. Gender identity

c. Ethnicity

d. Sexual orientation

Question 4: Being asked about sexual orientation and gender identity makes most patients uncomfortable. (True/false)

a. True

b. False

Question 5: What is the best way to collect data on gender identity and sexual orientation? (Multiple choice)

a. Have this information on the intake form

b. Doctor or nurse asks the patient about this

LGBT: lesbian, gay, bisexual and transgender.

Students in Cohort 2 also completed reflective essays for the learning activity. The reflection assignment asked students to consider the Interprofessional Education Collaborative (IPEC) domains of IPE and practice (Values and Ethics, Roles and Responsibilities, Interprofessional Communication, Teams and Teamwork) and Quadruple Aim goals (to improve patient care/patient experience, to improve population health, to decrease cost of care, to improve professional wellness/work satisfaction) as they developed their responses. Specific prompt questions asked students to reflect on the ‘team’ at work or behind the scenes and how the work impacted the Quadruple Aim.

Reflective essays from Cohort 2 participants were graded using a rubric adapted from Marchel (2004) and designed to evaluate reflective learning and sociocultural awareness in service-learning classes. The rubric evaluates three levels of reflection (descriptive, analytical and integrated) across three domains of learning (self-profession, interprofessional team member[s] and Quadruple Aim context) (see online supplemental material). We have previously reported on the pilot evaluation of this adapted rubric with Triple Aim context (Cooper et al., 2015). Reflective essays were graded by interprofessional faculty graders that had been trained to use the grading rubric.

Results

Cohort 1 included 56 students: health professions (46), pharmacy (5), public health (4) and nursing (1). Cohort 2 included 43 students: Master of Nursing Science (12), Doctor of Nursing Practice (6), heath information technology (2), medical laboratory sciences (17) and Registered Nurse to Bachelor of Nursing Science (6).

Pre- and post-quiz scores for Cohorts 1 and 2

Average quiz scores for Cohort 1 (n = 56) increased from 66% on the pre-quiz to 95% on the post-quiz. Cohort 2 (n = 43) increased from 64% to 87%. When the cohorts are combined, the average increase was from 65% to 92%.

Facebook discussion threads, Cohorts 1 and 2

Students in both cohorts were required to post comments in Facebook discussion threads. Sample comments representing a theme related to how students recognised the need to incorporate their learning from the discussion into their practice are shown in Table 4. Some students also directly addressed the suitability of Facebook for interprofessional interaction.

Table 4.

Sample comments from discussion threads.

‘It is our job as healthcare professionals to treat all patients with equality and respect, so that they may receive quality care’.
‘We can see that the gay and transgender patients shown [in the video] seem to feel nervous about their appointments. It could be determined that these patients had either already had a negative experience in a health care setting or knew someone who had. It’s our responsibility as providers to be as inclusive and professional as possible as to ensure that our patients trust what we suggest’.
‘These posts and this experience have taught us to treat all patients with respect. We can create a positive and comfortable environment for the LGBTQ population in the clinical practice, ensuring that these patients are receiving the proper care they deserve’.
‘My takeaway is that in practice we have the responsibility to do all we can to be sure LGBTQ patients are given the same rights and treatment as others. We must advocate for the rights of these patients and ensure that the treatment they are getting is not tainted by the biases of ourselves or others. This population has just as much right to quality treatment as those of other population’.
‘I was skeptical at first in joining this particular LGBT group, but I have really learned a lot and the information has opened my mind on issues about the LGBT community. Key take away is to not judge but have an open mind, and I keep reflecting on the phrase, “To treat me, you must know who I am”’.

LGBTQ: lesbian, gay, bisexual, transgender and queer or questioning.

Quantitative evaluation of the Facebook discussion threads was undertaken to provide information on the level of engagement in discussion threads. For Cohort 1, threads were initiated daily for 5 days starting on June 11. Total posts were 106, 82, 47, 21 and 95 for Threads 1–5, respectively. For Cohort 2, the five discussion threads were initiated on October 1 with a new thread started every 2 days. Total posts were 92, 66, 69, 81 and 67 for Threads 1–5, respectively. Further detail for breakdown of initial/reply posts and average number of posts per thread per student for each cohort are provided in Table 5. The number of posts by date and time of day is reflected in Figures 2 to 5. Days 1 and 2 had higher numbers with a dip in engagement in mid-week. No remarkable differences were observed for number of posts by discipline. For Cohort 1, prominent times for posting were midday and evening hours. Although the discussion period ended with the last post on June 15, several students continued to respond into the threads for several days. For Cohort 2, prominent times for posting were evening hours. The majority of students participated within the 2-day window of each new thread posted. Takeaway Thread 5 was posted on 9 October, but discussions remained open until 19 October when the post-assessment was due.

Table 5.

Facebook discussion threads analytics.

	Thread 1		Thread 2		Thread 3		Thread 4		Thread 5		Total
	Initial	Replies	Initial	Replies	Initial	Replies	Initial	Replies	Initial	Replies	Initial	Replies
Cohort 1	46	60	40	42	28	19	12	9	54	41	180	171
Avg/student	0.9	1.1	0.8	0.8	0.5	0.4	0.2	0.2	1.0	0.8	3.4	3.2
Cohort 2	43	49	26	40	26	43	34	47	37	30	166	209
Avg/student	1.1	1.3	0.7	1.0	0.7	1.1	0.9	1.2	0.9	0.8	4.3	5.4

Figure 2.

Cohort 1 – Number of posts by date.

Figure 3.

Cohort 1 – Number of posts by time of day.

Figure 4.

Cohort 2 – Number of posts by date.

Figure 5.

Cohort 2 – Number of posts by time of day.

A random sample of 15 reflections (40% of the 37 received) was evaluated for quantitative data. Average word count for this sample was 626 words per reflection. No significant differences were observed based on professional discipline other than a tendency that students in the advanced nursing programmes were more likely to include references with their reflection.

Reflective essays for Cohort 2

Thirty-seven students completed the reflective essay assignment. Mean scores for each category were self-profession (4.52; 92.4%), interprofessional team (4.22; 84.3%) and Quadruple Aim context (4.43; 88.6%). Descriptive statistics for rubric scores are provided in Table 5.

As assessed using the grading rubric, students reflected on the relevance of the material to their individual future professional practice as well as recognised the valuable insight of their interprofessional team members (see Table 6). Reflections also recognised students’ application of the material to the Quadruple Aim. Students also commented on their experience participating in the Facebook delivery format compared to other online learning platforms. Sample phrases from the reflective essays can be found in Table 7.

Table 6.

Reflection scores (n = 37).

	Total score	Self-profession	Interprofessional team	Quadruple Aim context
	(max of 15)	(max of 5)	(max of 5)	(max of 5)
M (SD)	13.27 (3.27)	4.62 (1.14)	4.22 (1.27)	4.43 (1.30)
Minimum	1	1	0	0
Maximum	15	5	5	5
Percentage of cohort scoring in each level of reflection		Self-profession (%)	Interprofessional team (%)	Quadruple Aim context (%)
Level 0 – Inadequate to assess (0 pt)		–	2.7	2.7
Level 1 – Descriptive (1 pt)		8.1	2.7	5.4
Level 2 – Analytic (3 pts)		2.7	27.0	10.8
Level 3 – Integrated (5 pts)		89.2	67.6	81.1

Table 7.

Sample phrases from reflective essays.

Self-profession
‘Thank you for helping students to see real issues impacting our community. I have learned valuable information to use in my practice as a nurse such as never assume, always be honest, be kind to others, treat all patients with respect, and always strive to provide the best care to all patients’.
‘The team provided valuable insight to the topic and participated weekly in discussions relevant to the subject matter. From the readings and discussions, I learned that my profession as a future advanced practice registered nurse is an essential point of contact for members of the LGBTQ community and may set the tone for further interactions with healthcare professionals’.
Interprofessional team members
‘It has been an eye opener to be a part of this discussion group this month. It has made me more aware of addressing sensitive subjects carefully. I have also learned how a team of clinicians from different disciplines can come together to undertake assessment, diagnosis, goal-setting and the creation of a care plan in a more efficient way than independently’.
‘This group is designed to address disparities in healthcare for the LGBTQ community. As we saw in the discussion threads, this impacts every area of healthcare. Many members of the discussion threads discussed how this relates to them. I didn’t see a person say “yes, great, but this doesn’t apply to my profession.” From intake to education to providing care and follow-up, applying the concepts of dignity and respect and care, no matter a person’s orientation or identification, this is relevant to every healthcare profession’.
Quadruple Aim context
‘Patient care improvement was addressed, and I am very relieved to see how accepting and willing all the professions were of the LGBTQ community. The unique health needs of the LGBTQ community could be somewhat daunting, but everyone stepped up their game and really made an effort to come up with ways to treat everyone with respect and compassion’.
‘To impact the Quadruple Aim in the LGBTQ community in the future I can do various things. With this community it is important to have an open and honest relationship, if we are unable to build rapport the patient will not feel comfortable telling us everything that is going on with them and holistic care will not be provided. I think it is also important that when a patient discloses this information to receive it in a non-judgmental way and continue treating the patient just as any other. As practitioners, we must be aware of any bias we have and not let that interfere in our practice. This will improve the patient care experience. Routine testing or screenings may be missed if the practitioner does not know the patient’s sexual orientation or identity. High rates of tobacco use, alcohol use, and STDs are seen in the LGBTQ community, which predisposes them to multiple diseases and cancers. Providing routine screening can help both improve population health and decrease cost of care’.
Facebook discussion group methodology
‘The Facebook posts were much easier than any Blackboard discussion I have ever participated in’.
‘The Facebook group worked. Good job’.
‘I felt the Facebook posts were a cool way to create discussion’.
‘This experience enhanced my team skills through the interactions on Facebook’.
‘I loved the interaction of the Facebook private community and would not change a thing about this activity’.
‘This online Facebook activity was interactive and creative. I cannot think of any way to improve it’.
‘Having this activity on Facebook had good and bad aspects. It was easy to reply and provided a social outlet for us to read and interact that is different from Blackboard activities, [but] there may be some students who don’t use social media’.
‘The Facebook platform was frustrating to me, especially for someone who doesn’t use Facebook that much. It made it feel less like an academic setting. I understand its use as a way to connect personally, but I think Blackboard would have worked better’.

‘I would have preferred to post through Blackboard to keep things a little more private and professional. I use Facebook for family and friends and felt a bit uncomfortable using my profile to access and complete this activity’.
‘While I know the idea of a Facebook group was done to be more accessible and more ‘new age’, it was not a good idea. Some of my peers had to create accounts just to do this project. It being in Facebook made it feel as though it wasn’t truly a professional assignment. Facebook is not a space for reliability or scientific speech’.
‘I found that Facebook was not the easiest channel of communication to navigate through. This experience was very informational and changed my perspective on being more personal with my patients. I would call this a successful interprofessional study’.

LGBTQ: lesbian, gay, bisexual, transgender and queer or questioning; STDs: sexually transmitted diseases.

Discussion

Findings from this study suggest that Facebook may be a particularly feasible method for delivering education on LGBTQ healthcare and disparities to interprofessional students during professional training. Discussion thread prompts were successful in stimulating conversation focused on patients’ experience of care and the impact of that experience on care outcomes at both the individual and population levels. Overall, this activity demonstrated promising results of the ability of a brief, Facebook-delivered interprofessional learning activity to improve short-term knowledge of LGBTQ healthcare disparities and practices. Other Facebook-delivered cultural competency training has demonstrated short- and long-term improvements in awareness of cultural competence generally (Chang et al., 2017).

In this study, comments from reflective essays focused on the need to incorporate learned material into daily practice and to work collaboratively across the continuum of care to provide a welcome environment for all patients. Students identified patients’ hesitation to seek care secondary to judgmental affectations from providers as being directly related to disparities for this community. Students also recognised that any point of contact with the healthcare team is an opportunity for a positive or negative interaction that influences a patient’s willingness to engage the health system as well as share the impact of those interactions with other members of that person’s shared community. Average scores for reflective domains were consistently high across domains and reflected students’ application of didactic information delivered via the learning activity to their perceived application to clinical practice. References were not requested in the reflection assignment, but it was more common that students in advanced nursing degree programmes provided citations with their reflection. Most of these degree programmes are delivered predominantly online, and regular class assignments require reference citations, so it was not unexpected that some students included this information. This activity was intended to provide introductory, exposure-level content to health disparities for the LGBTQ population to create a foundation on which students will continue to build knowledge, skills and inclusive attitudes. Required preparatory materials and discussion thread prompts focused on considerations for interpersonal conversations between clinicians and patients. Further offerings to educate on health system policy and practice implications will be considered for intermediate and advanced level curriculum activities.

For Cohort 1, we noted that more postings were received on Days 1 and 2 with a dip in engagement on Days 3 and 4 and upswing on Day 5. We interpret this to mean that many students completed their required postings early in the week (must post in two of the Threads 1–4) and then returned to the threads for the required takeaway post on Day 5. Most of these students were only participating in one summer class, so part of this tendency for engagement may be reflective of their not being in regular coursework consistently during the discussion period. Engagement across dates was more consistent with Cohort 2 which was completed during the fall semester. The continued engagement may be a result of students participating in multiple classes simultaneously and consistent assignment expectations across courses during this time period. A difference was noted in the time of day for postings being more common in evening hours for Cohort 2 which likely corresponded with conclusion of on-campus class or clinic time or workday for those students in online programmes that are also employed.

In this study, students reflected on the appropriateness of social media – Facebook in particular – as a format for discussion group participation. Comments ranged from those who found it to be an excellent platform for stimulating discussion to those who thought a different platform, perhaps Blackboard, would be more suitable for academic pursuits. Negative comments related to a sense that Facebook was less ‘formal’ for academic work were predominantly received from students in online programmes that use the Blackboard programme for regular course participation, so the Facebook social media platform was a different methodology from other courses currently in progress. Regardless, the depth of conversations within discussion threads and strong average scores for summary reflection essays indicate that the Facebook delivery platform was effective for achieving learning goals.

Limitations

The findings of this study are limited by the small sample size. They are limited also because students in both cohorts self-selected to participate in the activity. Some of them may have had an interest in and knowledge of LGBTQ health prior to enrolling, resulting in a possibility that their quiz scores were higher than might be expected in groups with little interest in or knowledge of this subject. Future studies with larger numbers of participants are needed, particularly involving students who are fulfilling a general requirement and not opting into an activity on a topic for which they may already have awareness. Investigation of the viability of online platforms other than Facebook is also warranted, as is a further analysis of student response and motivation to learning opportunities embedded in social media. Some students in this study indicated that they were unfamiliar with Facebook or found it to be less than appropriate for academic projects. Future research could address if there is a correlation between the age of the student and the appreciation of Facebook-based content, or if there are other reasons that make the use of social media less effective for some students. We did not attempt to evaluate difference in reflection rubric scores across disciplines as some groups had small numbers. This is an opportunity for future evaluation to explore whether students in advanced degree programmes score higher in one or more domains as compared to undergraduate students or if there are differences across professions. In addition, while this study found the asynchronous online format to be effective for this educational activity, which was especially important during adjustments for the COVID-19 pandemic, this study does not address the comparative effectiveness of this format with an active learning synchronous pedagogy led by a facilitator in a face-to-face environment. A comparative evaluation would further inform the usefulness of this delivery format for future offerings.

Implications

There is growing interest in the potential of social media platforms to be used for delivering education for health professionals. A recent systematic review of the use of social media in health professional education identified 99 studies investigating the use of social media as a delivery platform – 80% of which supported use of social media in education (Pollock and Rea, 2019). This interest has been heightened during the recent COVID pandemic where the need to engage students in meaningful dialogue is needed. This study’s success with an asynchronous format is a model for educators when learners are geographically distant (or need to be due to physical distancing requirements) and/or when learners have disparate schedules. Extrapolation of this methodology to other key public health or patient-centred care topics is warranted.

Conclusion

A Facebook-based interprofessional discussion group proved a promising method of teaching students about LGBTQ disparities in healthcare and engaging students in interprofessional discussion and self-reflection. Pre- and post-quiz scores showed improvements in knowledge regarding LGBTQ healthcare and inclusive practices, and responses to open-ended questions indicated that participants in the discussion group were able to identify how they could use their new knowledge to improve clinical care for LGBTQ patients. The online, social media-based format offered an opportunity for distanced learning, discussion and interaction.

Supplemental Material

sj-pdf-1-hej-10.1177_0017896921993846 – Supplemental material for Designing an interprofessional Facebook discussion group to teach about LGBTQ healthcare disparities and inclusive practices

Supplemental material, sj-pdf-1-hej-10.1177_0017896921993846 for Designing an interprofessional Facebook discussion group to teach about LGBTQ healthcare disparities and inclusive practices by Kathryn Neill, M Kathryn Allison, Diane M Jarrett, Masil George, Daniel Knight and Wendy Ward in Health Education Journal

Footnotes

Acknowledgements

We acknowledge and thank Wendy K. McCloud, Interprofessional Education Manager, and Misty Besancon, Programme Administrator, in the University of Arkansas for Medical Sciences (UAMS) Office of Interprofessional Education for their help in implementing this activity and as moderators for the Facebook discussions and educational platform support.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Kathryn Neill

M Kathryn Allison

Supplemental material

Supplemental material for this article is available online.

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