Building resilience: Co-designing an online rainbow wellbeing toolkit for public health systems to promote wellbeing and resilience in LGBTQ+ youth

Despite rapid social progress LGBTQ+ adolescents often still experience distressing bullying and victimization. Mistreatment and socially hostile environments in turn negatively impact on their mental health (e.g. they are more likely to be depressed, self-harm and attempt suicide) as well as their physical health (e.g. they are more likely to smoke cigarettes). A pressing public health challenge is addressing the adverse effects of the social violence these adolescents experience on a day-to-day basis in the United Kingdom (UK). For example, Amos and colleagues' paper from the UK's nationally representative longitudinal Millennium Cohort Study of almost 10,000 14-year olds reported that sexual minority (e.g. LGB) adolescents had twice the odds of being verbally and physically assaulted in the past 12 months compared to their heterosexual peers. Less has been reported on the experiences of transgender and gender diverse adolescents, but studies have consistently documented a high prevalence of adverse health and wellbeing outcomes for these adolescents. In 2017 the UK Government conducted a survey of LGBT people and received responses from over 100,000 LGBT individuals who reported numerous examples of victimisation, bullying and discrimination. This survey has now been used to set an agenda for change, entitled the "LGBT Action Plan". This plan supports action in schools, health services and communities so that LGBT people can live safe, happy and healthy lives without fear of discrimination.

Typically, LGBTQ+ adolescents cannot simply leave harmful social environments due to the practical constraints around their schooling and their economic dependence on their families. Many are geographically isolated away from the LGBTQ+ charities or support groups clustered in large urban areas and most will not have parents who are LGBTQ+. Further exacerbating the challenges is that LGBTQ+ adolescents are thought to be 'coming out' earlier and as a result they frequently have not yet developed the more sophisticated psycho-social skills that LGBTQ+ people who come out as young adults possess, which means their older LGBTQ+ peers may be better equipped to handle harmful social environments. Hence, there is an urgent need for widely accessible and targeted help to assist these adolescents to develop the best possible skills to thrive. Strategies have been employed to recognise and improve harmful social environments, such as anti-bullying interventions delivered by LGBTQ+ organisations in secondary schools. However, the 'Inverse Care Law' demonstrates that health systems' policies often inadvertently restrict needs-based care in populations with the poorest health and greatest levels of disadvantage. This includes LGBTQ+ adolescents, not because they are hard to reach, but like other under-served populations they will be easy to neglect.

Although LGBTQ+ adolescents are a 'high risk' population, and despite sexual orientation and gender reassignment being protected characteristics in the Equality Act, few evidence-informed interventions have been developed for them. Two recent systematic reviews of psycho-social treatments identified only a single tested online tool to support the mental wellbeing of LGBTQ+ adolescents, which was developed in New Zealand by Lucassen (i.e. 'Rainbow SPARX'). Coping strategies that are evidence-based for the general population but are fine-tuned with LGBTQ+ adolescents in mind (e.g. with strategies that assist them to manage LGBTQ+ stigma and victimisation) proffers considerable potential. This is especially so if they are delivered online in an engaging manner and focus on enhancing coping skills and building resilience.

This project's main objective is to co-design a web-based "online rainbow wellbeing" toolkit with and for LGBTQ+ adolescents. For this project we will use the youth co-design participatory framework outlined by Hagen et al. (cited in our reference list). In addition to input from LGBTQ+ adolescents from every stage from the 'IDENTIFY' to 'USE' stages of the project (from Hagen and colleagues' co-design framework), there will also be input from key adult experts during the 'IDENTIFY', 'CONCEPT' and 'USE' stages, specifically input from: LGBTQ+ youth workers; teachers; local authority public health and healthcare providers; commissioners of health services; police; experts on bullying prevention; teachers; and, the parents/caregivers of LGBTQ+ adolescents.

The second main objective for this project is to explore how the online toolkit can be used within public health systems. We will determine how the toolkit could be used by LGBTQ+ young people. We will also establish how the online toolkit can be used by others (e.g. heterosexual peer allies, family members and professionals) to assist in improving the overall social milieu for LGBTQ+ adolescents (e.g. by providing guidance for teachers around how to adequately support an LGBTQ+ youth who is being mistreated) and potentially for professionals as a form of CPD (see also letters of support - Centre for Policing & Oxon County Council).

The third main objective for this project is to plan the delivery of the intervention and determine the design and measures for a future effectiveness study as well as further implementation of the toolkit. Assuming stop/go decision criteria (developed during the 'CREATE' stage) are met based on the small process evaluation conducted in the 'USE' stage (e.g. >80% of LGBT+ youth rate the online tool as acceptable), we will submit a bid for an effectiveness randomised controlled trial to NIHR - Public Health Research.