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Development of an Instrument to Assess Athletic Trainers’ Attitudes Toward Lesbian, Gay, and Bisexual Patients

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Instruments have been created to assess individuals’ attitudes toward lesbian, gay, and bisexual (LGB)1–5 and transgender patients.6,7 Most instruments are global and assume similarities across settings, with the exception of the recently developed Attitudes Toward Transgender Patients (ATTP), which assesses athletic trainers’ attitudes toward these patients. In the health care setting,8 most of the current instruments are not specific or applicable to health care settings.

The growing LGB population9 in the United States means that the likelihood of athletic trainers coming into contact with LGB patients is increasing. Researchers have examined attitudes toward sexual minority patients among health care professionals using established instruments, including previous explorations among athletic trainers.10,11 However, the instruments used were not specific to the type of interactions clinicians may have with LGB patients. Therefore, creating a specific measure to capture athletic trainers’ attitudes is important in determining the effect these attitudes might have on clinical practice toward sexual minority (LGB) patients. Data on health care providers’ attitudes toward LGB patients may assist in creating educational programming that facilitates cultural competency and multiculturalism. Cultural competency is important in the health professions because of the diverse scope of patients.12–15

In the context of athletic training, cultural competency has taken center stage as a significant area of interest for both researchers and clinicians.12,15 Maurer-Starks et al16 examined the impact of heteronormativity and homonegativity on the quality of health care provided to patients and how both may affect patient health. Sexual minority patients experience health disparities because of heteronormativity and homonegativity.17,18 In comparison to heterosexuals, sexual minorities are more likely to rate their own health as poor, report higher numbers of acute physical symptoms and chronic health conditions, report their physical activity is affected by their health status, and exhibit a higher prevalence of disabilities.17 The National Athletic Trainers’ Association (NATA) Code of Ethics19 lays the groundwork for professionals to be respectful and work effectively with diverse populations, including sexual minority patients. Athletic trainers must also consider their role as educators and the effect they may have on athletic training students. A learning environment free of bias is important for the well-being of not just patients but also future athletic trainers.16

Without focused efforts to create safe patient environments, LGB patients may be at risk of stigma and discrimination, adverse health outcomes, and avoidance of accessing health care.20 When LGB patients anticipate heteronormative or homonegative clinical encounters, they may be less likely to disclose their sexual orientation or gender identity to their health care provider, or avoid health care interactions altogether.20 LGB individuals face significant disparities in sexual health (ie, sexually transmitted infections and HIV), mental health (ie, depression, anxiety disorders, and suicidal ideation), and substance use.20,21 For example, a greater proportion of lesbians and bisexual women (73% and 72%, respectively) report use of alcohol compared to 51% of heterosexual women.22 Lesbians and bisexual women are also more likely to smoke tobacco (37% and 50%, respectively) compared to 14% of heterosexual women.22

Many LGB patients believe it is important for their physician to know their sexual orientation.23 However, LGB patients are unlikely to disclose their sexual orientation to their physician, even if they consider themselves to be “out.”23 Additionally, bisexual men and women are less likely to disclose their sexual orientation than gay and lesbian individuals, due to anticipation of negative responses from both heterosexual and gay or lesbian health care providers.21,23,24 Understanding clinicians’ attitudes is critical for improving the dialogue between health care professionals and LGB patients. We aimed to develop an instrument to assess athletic trainers’ attitudes toward sexual minority (LGB) patients.

Methods

We developed a scale based on the theoretical framework by Zanna and Remple.25 These authors posited that heterosexist attitudes comprise three prongs and are relevant to the understanding of attitudes toward LGBT individuals.26 The first prong is affective and refers to the emotions or feelings that an individual has. The second prong is cognitive and refers to the thoughts (beliefs) an individual has toward another person. The third prong is behavioral and refers to past behaviors or intended behavior toward someone.25,26 Because heterosexism and homonegativity affect attitudes toward LGB individuals, items used to develop the instrument portrayed both aspects.16,25 The development of our instrument occurred in three phases. The institutional review board of the study team’s primary institution (Indiana University) reviewed and approved methods, instruments, and protocols of the study. Phase 1 and Phase 2 methods were completed concurrently with methods used for the development of the ATTP instrument. Details of this process can be found in Ensign et al.8

Statistical Analysis

Data were analyzed using SPSS software (version 21.0; SPSS, Inc). The initial factor analysis for the LGB statements yielded 10 statements. Three items were reverse scored. The LGB statements loaded on three factors: patient openness, patient behavior, and clinician comfort.

Results

Responses to the initial interviews and item elicitation questionnaire resulted in the construction of the 79 LGB statements. The general themes of the 79 LGB statements included comfort with LGB patients, awareness of LGB patients, education on LGB identity, sport participation, and relevance to care.

Phase 1–Item Elicitation

Item elicitation occurred through a two-step process including interviews and a questionnaire with items referring to LGB patients.

Phase 2–Construct Validity and Item Reduction

The 79 statements referring specifically to LGB individuals were reviewed by the research team and integrated into a brief survey. A total of 507 athletic trainers responded to the electronic survey (17% response rate).

Of the 10 items retained, 3 items referred to LGB patients’ risk for HIV or other risky behaviors and loaded into the patient behavior factor in addition to one other item. After reviewing the results from the item reduction, the researchers reflected on the scale to ensure that statements were directed at the purpose of the development of the scale. Based on the interviews with athletic trainers, the researchers felt the HIV and risky behavior statements did not represent athletic trainers’ beliefs of LGB patient behaviors. The original loading of these items in the patient behavior factor did not get to the actual behaviors of all LGB patients and focused primarily on gay men. Thus, the statements in this factor were removed from the instrument. A new factor was created with statements that more appropriately represented clinician behaviors because this was deemed an important component of the purpose of this instrument. Additionally, the clinician education factor was added as a meaningful contribution to the instrument, although it did not initially separate out as an independent factor.

Of the original 10 statements, the researchers retained 6 statements and added 9 statements. The adjusted LGB scale resulted in 15 statements, 9 of which were reverse scored (Table 1). Four factors emerged on the LGB scale: patient openness, clinician behavior, clinician comfort, and clinician education. The original and final explanations of variance for each subscale are in Table 2. Additionally, a confirmatory factor analysis was conducted to confirm that the final adjusted Attitudes Toward Lesbian, Gay, and Bisexual Patients (ATLGBP) instrument was at least as good as the model identified from the initial principle axis factoring (Table 3). For root mean squared error of approximation (RMSEA), values closer to 0 represent a good fit with the cut-off being less than 0.08. The Comparative Fit Index compares the fit of a target model to the fit of an independent model. A cut-off value that indicates a good fit is 0.90 or greater. The Tucker-Lewis Index indicates the amount the model of interest improves the fit. A cut-off value that indicates a good fit is 0.95 or greater.27

Scale for Clinician Attitudes Toward Lesbian, Gay, and Bisexual Patients

Table 1:

Scale for Clinician Attitudes Toward Lesbian, Gay, and Bisexual Patients

Variance Explained for ATLGBP

Table 2:

Variance Explained for ATLGBP

Confirmatory Factor Analysis Goodness of Fit Results for ATLGBP

Table 3:

Confirmatory Factor Analysis Goodness of Fit Results for ATLGBP

Cronbach’s alpha was calculated for the ATLGBP instrument (α = .830) and for each factor, patient openness (α = .749), clinician behavior (α = .531), clinician comfort (α = .691), and clinician education (α = .806).

Phase 3–Criterion Validity

To assess validity, the LGB scale was compared to the Lesbian, Gay, Bisexual–Knowledge and Attitude Scale for Heterosexuals (LGB-KASH).4 The LGB-KASH is composed of five subscales: hate, LGB knowledge, religious conflict, LGB civil rights, and internalized affirmativeness.4 Each subscale is scored separately. A higher score on the hate and LGB knowledge subscales represents more negative attitudes and more limited knowledge, respectively. A higher score on the LGB civil rights, religious conflict, and internalized affirmativeness indicates more positive attitudes.4 The subscales have been shown to have test–retest reliability and convergent validity.4

A second electronic survey (Qualtrics) was sent to a random sample of 3,000 athletic trainers whose email addresses were obtained from the NATA. The survey included a brief demographics section, the ATLGBP instrument (15 items), and the LGB-KASH. Participants took approximately 10 minutes to complete the survey. Two reminder emails were sent at 2-week intervals to increase participation rates.

The number of participants who completed each section varied. In total, 428 participants completed the ATLGBP instrument, 392 participants completed the LGB-KASH hate subscale, 393 participants completed the LGB-KASH LGB civil rights subscale, 379 participants completed the LGB-KASH religious conflict subscale, 379 participants completed the LGB-KASH internal affirmation subscale, and 386 participants completed the LGB-KASH LGB knowledge subscale. This resulted in a response rate ranging from 13% to 14%.

Table 4 provides a summary of participant characteristics. The average score of the 428 participants on the ATLGBP was 29.6 ± 6.8 (range: 15 to 53). A higher score on each instrument indicates more negative attitudes. The possible range of scores on the ATLGBP is 15 to 75.

Demographics of Participants in ATLGBP Survey Validation (N = 428)

Table 4:

Demographics of Participants in ATLGBP Survey Validation (N = 428)

To assess the validity of the ATLGBP, the scores were summed individually. A Pearson correlation with an alpha level of .05 was conducted relative to the ATLGBP and each subscale of the LGB-KASH (the LGB-KASH does not have a total summed score). Scoring is done with each individual subscale, each of which is averaged. Scores for the ATLGBP and the LGB-KASH can be seen in Table 5.

Results of ATLGBP and LGB-KASH Subscales

Table 5:

Results of ATLGBP and LGB-KASH Subscales

Significant correlations (hate: r = .464, P < .001; civil rights: r = −.683, P < .001; religion: r = .532, P < .001; internal: r = −.612, P < .001; knowledge: r = −.430, P < .001) were found between the ATLGBP and all subscales of the LGB-KASH (P < .001). Because some of the subscales of the LGB-KASH are scored in an opposite direction, several correlations are negative. When reviewing the standard deviations and correlations for the subscales of the LGB-KASH (Table 6), high correlations were found between the ATLGBP and the LGB-KASH civil rights, religion, and internal subscales. Moderate correlations were found between the LGB-KASH hate and knowledge subscales.

Pearson Correlation of ATLGBP and LGB-KASH Subscales

Table 6:

Pearson Correlation of ATLGBP and LGB-KASH Subscales

Discussion

The primary goal of this study was to develop a measure to assess athletic trainers’ attitudes toward sexual minority (LGB) patients. The ATLGBP was developed through a multiphase process. The four subscales identified during the development of the ATLGBP included patient openness, clinician education, clinical comfort, and clinician behavior.

The patient openness subscale reflects whether clinicians think it is appropriate for patients to discuss their sexual orientation in the media, come out publicly, or share their sexuality in the treatment setting. The clinician comfort subscale covers how comfortable a clinician is with LGB patients in general and, more specifically, treating LGB patients. The clinician education subscale reflects clinicians’ cultural competence, their comfort and interest in learning about LGB topics, and how important it is to attain training on LGB issues. In the initial factor analysis, few items addressed clinician education. The authors believed that including these types of questions is important and will be helpful when planning education opportunities. Therefore, the instrument was adjusted to include more items related to clinician education.

The clinician behavior subscale addresses behaviors a clinician may have toward LGB and transgender patients. The items in the clinician behavior subscale loaded in the initial factor analysis and the authors believed the items (specifically 5 and 6) conveyed specific clinician behaviors that may demonstrate microaggressions or environments hostile to LGB patients. LGB patients may have negative health experiences, which then affects their willingness to seek health care or feeling safe doing so.20 Assessing a clinician’s behavior is important so that proper education can be pursued or issues with a clinician managed appropriately. For these reasons, we thought it was best to leave the items in. Interestingly, the clinician behavior subscale had the lowest correlation. It may be that these items may need to be addressed through further evaluation of the subscale.

When the ATLGBP was assessed in its entirety, good item correlations (α = .830 and .834 respectively) using the criteria of George and Mallery28 were identified. However, when the subscales were assessed individually, correlations varied. The clinician education subscale was good (α = .809) and the patient openness subscale was acceptable (α = .749). However, the clinician comfort subscale was questionable (α = .691) and the clinician behavior subscale was poor (α = .570). For this reason, the ATLGBP instrument may be better suited as a whole instrument versus using the specific subscales.

Testing instrument validity also yielded promising results. According to standards set forth by Cohen,29 there were strong correlations between the ATLGBP and the civil rights, religion, and internal subscales of the LGB-KASH. There was a moderate correlation between the ATLGBP instrument and LGB-KASH hate and knowledge subscales. The LGB-KASH knowledge subscale had very different kinds of statements compared to the statements in the ATLGBP instrument and, for this reason, it is not surprising that there was a lower correlation. On the surface, the LGB-KASH hate subscale would be expected to have a higher correlation, but the variance for it was lower than the ATLGBP. Larger variation in how people reacted to the statements resulted in the larger variance in the ATLGBP and in turn captured a broader array of attitudes. However, this may also suggest a greater measurement error of the ATLGBP. The statements on the LGB-KASH hate subscale were much more direct and may have caused individuals to respond more strongly than those items on the ATLGBP.

Although developed to understand issues that are specific to athletic trainers, the ATLGBP may have applicability beyond athletic training. Other health professions and organizations may find the ATLGBP instrument valuable to assess the attitudes their clinicians have toward LGB patients. With the knowledge provided by the instrument, organizations, and educational programs can develop curriculum and continuing education opportunities for clinicians.

Limitations

Support for the reliability and validity of this instrument was found in this sample, but there were some limitations to the development of the instruments. The interviews and surveys were completed from convenience samples and, as such, the results may not be generalizable to the broader population of athletic trainers. We attempted to alleviate this issue by recruiting a random sample of athletic trainers from a large database in the United States. Additionally, the instrument may not be reflective of other health care provider attitudes because only athletic trainers were used in the development.

A limitation of the ATLGBP instrument is that the resultant instruments are not based solely on the factor analysis. Because instruments like these had not yet been created, the authors used some subjectivity in finalizing the items on the ATLGBP instrument. Another limitation of the ATLGBP instrument was the moderate correlations with the LGB-KASH. This may be because the LGB-KASH was not the most appropriate instrument to compare the ATLGBP instrument to. The authors chose this instrument because there are few existing instruments that combine sexual minority (LGB) individuals. Thus, we believed that an instrument that does combine LGB individuals was important to assessing validity. The instrument may need to be validated against a different instrument.

The research will benefit from follow-up studies to check the applicability to other health care professions. Additionally, the ATLGBP reliability and validity will need to be investigated further. A confirmatory factor analysis may be beneficial to confirm the proposed subscales.

Implications for Clinical Practice

The ATLGBP assesses multifactorial expressions of clinicians’ attitudes toward LGB individuals. Clinicians can use this information to identify areas on which to focus continuing education. Because patient experience is an extremely important component of overall patient care, health care professionals should include sexual orientation and gender identity as a component of education and training activities.

References

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Scale for Clinician Attitudes Toward Lesbian, Gay, and Bisexual Patients

Clinican Attitude
Patient Openness
  1. It is appropriate for athletes to discuss their sexual orientation in the media.a
  2. It is appropriate for athletes to come out on national television.a
  3. It is inappropriate for patients to share their sexuality in the treatment setting.
Clinician Behavior
  4. I would be comfortable treating a patient whose sexual orientation was unclear.a
  5. I would tell a lesbian, gay, or bisexual person to act more straight in the patient area.
  6. I would not allow “out” lesbian, gay, or bisexual athletes into the athletic training clinic.
Clinician Comfort
  7. I would be able to ignore my patient’s sexual orientation.a
  8. I would be concerned that a gay, lesbian, or bisexual athlete of the same sex as me would make sexual advances toward me.
  9. I would be more comfortable working with a lesbian, gay, or bisexual patient in a group setting compared to one-on-one.
  10. I feel safer treating a lesbian, gay, or bisexual patient in a group setting.
Clinician Education
  11. I would stop someone who was calling someone names in relation to their perceived sexual orientation.a
  12. I feel I am culturally competent toward lesbian, gay, or bisexual individuals.a
  13. I would be comfortable learning more about the lesbian, gay, or bisexual population.a
  14. I would be interested in learning how to talk about sensitive issues with the lesbian, gay, or bisexual population.a
  15. I believe it is important to receive training on lesbian, gay, or bisexual issues.a

Variance Explained for ATLGBP

Factor Original Final
Patient openness 36.03% 9.63%
Patient behavior 15.08%
Clinician comfort 13.89% 6.87%
Clinician education 31.23%
Clinician behavior 11.63%

Confirmatory Factor Analysis Goodness of Fit Results for ATLGBP

Fit Indexes Original Final
Chi-square (32) 139.31a 299.97a
RMSEA 0.08 0.07
CFI 0.94 0.901
TLI 0.91 0.89
CD 1 1

Demographics of Participants in ATLGBP Survey Validation (N = 428)

Variable Value
Age, y (mean ± SD) 34.54 ± 10.282
Gender
  Male 37.9%
  Female 62.1%
Sexual orientation
  Heterosexual/straight 89.3%
  Gay/lesbian/homosexual 7.7%
  Bisexual 2.8%
  Uncertain .2%
Race
  American Indian/Alaskan Native 1.4%
  Asian or Asian American 2.3%
  Black or African American 3.0%
  Hispanic or Latino 2.6%
  Native Hawaiian or Pacific Islander 0.7%
  White 88.8%
  Other 1.2%
Athletic trainer setting
  Amateur/recreational/youth 1.4%
  Clinic 11.7%
  College/university 36.6%
  Corporate .5%
  Health/fitness clubs .7%
  Hospital 2.1%
  Independent contractor .9%
  Industrial/occupational 1.2%
  Military/government/law enforcement .7%
  Other 4.2%
  Professional sports 1.6%
  Retired 2%
  Secondary school 34.5%
  Student 2.3%
  Unemployed 1.4%

Results of ATLGBP and LGB-KASH Subscales

Subscale N Minimum Maximum Mean ± SD
ATLGBP 428 15 52 29.61 ± 6.81
LGB-KASH hate 392 6 18 7.61 ± 2.37
LGB-KASH civil rights 393 5 25 21.33 ± 4.58
LGB-KASH religion 379 7 31 15.18 ± 5.72
LGB-KASH internal 386 5 25 13.87 ± 5.18
LGB-KASH knowledge 392 5 25 10.31 ± 4.90

Pearson Correlation of ATLGBP and LGB-KASH Subscales

Subscales Pearson Correlation P N
LGB-KASH hate .464 < .001 392
LGB-KASH civil rights −.683 < .001 393
LGB-KASH religion .532 < .001 379
LGB-KASH internal −.612 < .001 386
LGB-KASH knowledge −.430 < .001 392

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