Background and Purpose: This study, using an evaluative, cross-sectional design, explored the self-efficacy, knowledge, and attitudes of health care providers who treat people with spinal cord injury (SCI) who may be gay, lesbian, bisexual, or transgender (GLBT). The study also designed and implemented a diversity training program and measured its effect on participants’ perceptions of their ability to change their knowledge levels, attitudes, and self-efficacy with regard to sexual orientation diversity.
Subjects and Methods: Health care professionals (N=402) participated in a diversity training program that included a pre-briefing questionnaire, a videotape, a post-briefing questionnaire, and discussion. Descriptive and chi-square analyses were performed on all variables of interest.
Results: The majority of the participants reported low levels of knowledge, attitudes of tolerance versus respect, and 0% to 20% confidence levels for providing culturally sensitive services for patients with diverse sexual orientations. Three hundred seventeen participants strongly agreed that watching the videotape increased their confidence levels in providing services for people who may be GLBT.
Discussion and Conclusion: Health care providers who treat people with SCI self-report low levels of knowledge, tolerance versus respect, and low levels of self-efficacy with regard to sexual orientation diversity. If a health care provider has a low level of knowledge, tolerance versus respect, and a low level of diversity self-efficacy toward others, there may be direct physical and mental health consequences for the patient. A limitation of the study was that social desirability bias may have increased the number of participants who reported increased levels of self-efficacy following the videotape. Further research is recommended (1) to determine whether current diversity training for health care professionals includes diversity of sexual orientation and (2) to examine the knowledge levels, attitudes, and self-efficacy of health care professionals with regard to sexual orientation diversity while attempting to control for social desirability bias in participants’ responses.
This study, using an evaluative, cross-sectional design, explored the self-efficacy, knowledge, and attitudes of health care providers who treat people with spinal cord injury (SCI) who may be gay, lesbian, bisexual, or transgender (GLBT). The study also designed, implemented, and measured the effect of a diversity training program on participants’ perception of their ability to change. Several definitions are important to the presentation of this study. First, for the purposes of this report, spinal cord injury is defined as an injury to the spinal cord due to trauma or disease. Second, attitude is defined as “a predisposition to behave or react in a certain way toward people, objects, institutions, or issues.”1(p8) Third, sexual orientation is an individual's identity as either heterosexual or GLBT.2 Fourth, heterosexism is a world view that all people are or should be heterosexual.3 Previous studies4–8 have looked at negative attitudes held by health care providers toward the GLBT population. Negative attitudes toward patients with diverse sexual orientations may begin with a health care provider's assumption of heterosexism. A person may be heterosexist due to a lack of knowledge or to an attitude ranging from no respect to tolerance.3
In this study, the transtheoretical model was used to identify health care providers’ readiness to provide health care services to people with SCI who identify themselves as GLBT.9,10 Identification of health care providers’ readiness was measured via the 3 variables of knowledge, attitude, and self-efficacy. The transtheoretical model has been used in previous studies11–16 to explore how people change addictive behaviors such as cigarette smoking, excessive consumption of alcohol, and substance abuse. Behaviors such as violence and discrimination have more recently been studied using the transtheoretical model.17,18
The transtheoretical model uses 5 stages of change to explore a human's ability to change.19 Through a developmental process, people move through the following 5 stages: precontemplation, contemplation, preparation/determination, action, and maintenance. With regard to the current study, in the precontemplation stage, an individual has no interest in changing because he or she does not perceive heterosexism as a problem.20 In the contemplation stage, the individual has an interest in learning more about people who are GLBT but has not yet taken the steps to do so. In the preparation/determination stage, the individual is determined to change the behavior and has readied himself or herself for taking action. In the action stage, the person has actually enrolled in a course or taken steps such as modifying evaluations or treatment procedures to change the behavior. In the maintenance stage, a person has stayed with this action plan for more than 6 months and remains dedicated to learning more.
It is important to identify health care professionals’ knowledge, attitudes, and self-efficacy with regard to the continuum of providing high-quality health care to people who are GLBT. Heterosexual assumptions by physical therapists compete against potentially supportive provider/client interactions.4 For example, a physical therapist or any health care provider may use written or audiovisual health education material that does not include illustrations or language inclusive of the GLBT population. Another example of a health care provider working from a heterosexual framework would be for that person to use language in reference to the patient's social support system that excludes GLBT relationships. A third example of heterosexual assumptions would be for a health care provider to assume that every health care facility is equally knowledgeable and culturally sensitive to the GLBT population. Any health care provider with heterosexual assumptions may unintentionally or intentionally deny or reduce care.21 Diversity experts have noted that, to become better practitioners, providers of health care services first must understand their own motives, biases, and world views in the area of racist, sexist, and homophobic attitudes and behaviors. The Commission on Accreditation in Physical Therapy Education does include a professional expectation of cultural competence.22
Despite the negative attitudes held by health care providers toward the patient population who may be GLBT reported in the literature, the question remains whether diversity training is given high priority in physical therapist education programs. Experts in the area of diversity and health care claim that one of the primary reasons for ineffectiveness in treating clients who are culturally different is the lack of cultural sensitivity training in curricula.6,8,23 It is important to consider whether sexual orientation diversity is included in cultural sensitivity training for health care professionals.
Health care providers, including physical therapists, have had varied exposure to diversity training and, therefore, may be at various stages of change toward optimal diversity self-efficacy. Some health care providers may be monitoring their own experiences in practicing diversity self-efficacy in the workplace, whereas others may not have been thinking about diversity self-efficacy at all. Research, however, indicates that diversity self-efficacy continues to be a low priority in education and industry.24
The overall aims of this study were: (1) to determine levels of knowledge, attitudes, and self-efficacy of health care professionals who treat patients with SCI who are GLBT and (2) to determine whether a brief diversity training program has an immediate effect on the self-reported knowledge, attitudes, and self-efficacy of health care providers with regard to sexual orientation diversity.
In order to achieve the overall aims, the current study investigated the following research questions:
At what stage of change are health care professionals with regard to learning about diversity in sexual orientation among people with SCI?
In what ways have health care professionals sought to learn more about diversity in sexual orientation among people with SCI?
What is the level of knowledge of health care professionals with regard to diversity in sexual orientation among people with SCI?
What attitudes do health care professionals hold with regard to diversity in sexual orientation in the population with SCI?
What level of self-efficacy exists among health care professionals have with regard to interacting with and delivering health care services to people with SCI, given possible diversity in sexual orientation?
Do differences exist among health care professionals with respect to knowledge levels, beliefs and attitudes, and self-efficacy for providing culturally sensitive services to people with SCI who may be GLBT?
This study was conducted in response to a 2002 pilot study (unpublished research). The pilot study was conducted to gather information on what health care providers and individuals who identified as GLBT considered multicultural competence to actually constitute during patient/provider interactions. In this study, both health care providers and members of the GLBT community identified recommendations to current practice for increasing multicultural competence during patient/provider interactions.
The participants in this study were 402 health care professionals who provide health care services to patients with SCI, including nurses, physical therapists, occupational therapists, physicians, physical therapist assistants, and occupational therapist assistants. The majority of health care professionals participating in the study were physical therapists and occupational therapists between 21 and 40 years of age. The sample was diverse with regard to sex, educational background, sexual orientation, race or ethnicity, and occupation.
A diverse sample of health care professionals was used because I was interested both in the knowledge, attitudes, and self-efficacy levels of health care professionals as a whole and in whether differences among disciplines exist with regard to providing services to people who may be GLBT. Heterosexism is an obstacle to providing high-quality health care to the GLBT population regardless of the health care provider's professional affiliation. By using a diverse sample of health care professionals, results have the potential to point to recommendations for improving multicultural competence in the classroom and clinic for one or more than one discipline, depending on the findings. In addition, depending on the findings, health care professionals from one discipline may have, for example, attitudes of respect versus tolerance for people with SCI who identify themselves as GLBT. If attitudinal differences exist among health care professionals toward people with SCI who identify themselves as GLBT, it may be important to consider whether differences in cultural competence educational paradigms exist among health care professional educational programs and to determine differences in cultural competence among working health care professionals.
The demographic characteristics of the health care providers are presented in Table 1. Health care professionals who treat people with SCI versus other disabilities were selected as the sample population because SCI often changes sexual function and expression. Health care providers who evaluate and treat people with SCI often require knowledge of sexual practices of the patient in order to provide safe and effective care.
The participants in this study worked at 7 acute and subacute health care facilities in the United States. Procedures to recruit participants followed Columbia University Institutional Review Board protocol approval. Facilities were randomly selected from an online list of nationwide health care facilities that serve patients recovering from SCI. An e-mail describing the project was sent to rehabilitation managers of the facilities. If a site was interested and able to participate, the date and time of the training were scheduled. All training occurred between February 9 and April 1, 2005.
Investigator Procedures at the Study Sites
At each site, the rehabilitation manager or educational training coordinator distributed and collected a consent form from each study participant. On the date of the training, I explained the procedure to each sample group at each study site. A pre-briefing diversity training questionnaire was distributed, and a videotape titled Issues That Health Care Providers Confront When Providing Services to the GLBT Population25 was shown. A post briefing training questionnaire was distributed and collected after participants viewed the videotape. A discussion followed in order to allow for interdisciplinary dialogue among peers to further educate each other regarding the topic of sexual orientation diversity. Total time involvement for the participants was between 50 and 60 minutes.
Development of Novel Study Instrumentation
Instruments were created that would permit answering the study questions. The study questions, which explored the knowledge level, attitudes, and self-efficacy of health care professionals with regard to treating patients with SCI who are sexually diverse, were unique to this study. The study instrumentation created included pre-briefing and post-briefing questionnaires as well as a videotape/DVD.
The preintervention questionnaire was written to gather information on the participants’ level of knowledge, attitudes, and self-efficacy when providing health care to people with SCI who may be GLBT. Likert scale multiple-choice responses were used throughout the survey.
The internal consistency of the questionnaire was measured by means of the Cronbach alpha. The Cronbach alpha was found to be .67, which approached adequate consistency. Values greater than .70 are required for adequate consistency.26–28 The preintervention questionnaire had 24 questions. The questions were constructed to identify the stage of change that the health care providers were in when considering the population of patients who may be GLBT as the variable. The questions were organized according to information on knowledge, attitudes, and self-efficacy. The pre-briefing study questionnaire was tested for internal reliability by a group of students at a community college. Intrarater reliability of scoring was 100% on all items. The length and readability of the questionnaire were pilot tested a second time using a focus group of health care professionals and teachers at a local college.
The health care provider post-briefing diversity training questionnaire was a 6-item survey instrument. Questions 1 through 3 asked participants to rank their responses on whether the videotape changed knowledge, attitudes, and self-efficacy toward providing services to a patient who may be GLBT. Questions 4 through 6 asked participants to evaluate how the videotape changed the way they think about the written, verbal, and audiovisual language they use and whether this material is inclusive of all sexual orientations. The internal consistency of the post-briefing diversity training questionnaire was measured by means of the Cronbach alpha, which was found to be .68.26–28
Brief Diversity Training Videotape/DVD
A videotape titled Issues That Health Care Providers Confront When Providing Services to the GLBT Population25 was created to standardize the content of the diversity training delivered across all subject groups. The videotape uses the concept of vicarious experience as 1 of 4 principal sources of information that increase self-efficacy in individuals.29 The videotape was written by the principal investigator and edited by the faculty at Teachers College, Columbia University. The talk was filmed in front of a live audience of health care professionals. The audience was diverse in terms of race or ethnicity, sex, age, and sexual orientation. The text content was written based on the research questions of the study. The concept of motivational interviewing and the findings from preliminary focus group studies were used to shape the videotape/DVD script.
The results of the study's data analysis are organized according to the variables of interest, including: (1) stage of change for thinking about diversity in sexual orientation (Tab. 2), (2) knowledge level (Tab. 3), (3) attitudes (Tab. 4), (4) self-efficacy of health care professionals treating patients with SCI who may be GLBT (Tab. 5), (5) inclusion of information on GLBT health concerns in education received in the past (Tab. 6), and (6) self-report of the effect of the brief diversity training (Tab. 7). Seventy nine percent of the health care providers had never thought (precontemplation) about diversity in sexual orientation with regard to patients with SCI. Sixty-eight percent of the health care providers reported very low to average knowledge levels with regard to providing services to people with SCI who are GLBT.
The majority of the physical therapists, occupational therapists, speech therapists, and physical therapist assistants had attitudes of tolerance versus respect for patients with SCI who are GLBT. Forty-four percent of the nurses had full respect for this population, and 40% of the nurses reported some respect. Ninety-seven percent of the health care providers had 0% to 40% self-efficacy levels for providing services to people with SCI who are GLBT.
Seventy-nine percent of the participants answered that they had never considered that some patients with SCI may be GLBT. In the precontemplation stage, people have no interest in changing because they do not see the current behavior as a problem.20 If health care providers do not perceive lack of knowledge about a certain minority group to be problematic, then it is not likely that there will be positive behavioral change. The implication for physical therapist education is to consider whether enough is being done in educational institutions and health care institutions to include sexual orientation diversity in both educational programs and on-site training. A second implication for physical therapy educators is to consider whether outcome measures exist to identify the relationship between curricular content inclusion and behavior during clinical experience for multicultural competence with regard to sexual orientation diversity.
The Commission on Accreditation in Physical Therapy Education's Evaluative Criteria for Education Programs for the Preparation of Physical Therapists22 includes a professional expectation of cultural competence. The curricular criterion for this practice expectation is that a physical therapy program curriculum will include course objectives and content to graduate students ready to “identify, respect, and act with consideration with patients'/clients’ differences, values, preferences, and expressed needs in all professional activities.” The current study's findings suggest that physical therapy educational curricula should pay increased attention to educational strategies that lead to an attitude of respect toward people with diverse sexual orientations rather than an attitude of tolerance toward people with diverse sexual orientations. The results of the current study confirm previous research indicating that negative attitudes toward people who may be GLBT exist among health care providers.2,5,6 However, previous studies5,6,13 have focused on the attitudes of physicians and nurses. The current study included a wider range of health care professionals, including physical therapists and physical therapist assistants. The study also measured differences in attitudes among different health care professions. The results indicate that physical therapists, physical therapist assistants, occupational therapists, and speech therapists lag behind nurses with regard to having attitudes of respect versus tolerance for patients with SCI who are GLBT. Whether the findings in attitudinal differences across disciplines are related to educational content, educational method, differences in applicant pools, or other factors is unknown.
Educational programs preparing health care professionals need to look closely at what they are doing to increase self-efficacy with regard to sexual orientation diversity. Combs24 has defined diversity self-efficacy as a task capable of increased mastery in interactions with diverse others. Future studies are needed to measure the long-term effect of diversity training on health care providers’ self-efficacy for treating people who are GLBT. Diversity self-efficacy is not a behavior, yet self-efficacy has been determined as a predictor of behavioral change across multiple task settings.30–32 Low self-efficacy for providing high-quality health care services to the patients who are GLBT is a predictor of low-quality health care for this population.30–32 Diversity training programs as brief interventions may be effective in improving the self-efficacy of health care providers with regard to providing services to people with diverse sexual orientations. Brief interventions aimed at changing behavior are not types of treatment but rather a category of intervention.33 Such brief interventions usually include an assessment, advice, and counseling.34
The current study explored what stage of change health care providers are in with regard to knowledge, attitudes, and self-efficacy toward treating people who are GLBT. Findings determined that many health care providers are in the pre-contemplation stage with regard to sexual orientation diversity. Furthermore, diversity training that the health care providers have received often has not included information on people who may be GLBT, and, when that information is included, it is perceived as less than adequate to prepare health care providers to provide high-quality services to people who may be GLBT. The majority of health care professionals in this study self-reported attitudes of tolerance versus respect for people with SCI who are GLBT. Physical therapists, when compared with nurses, were more likely to report attitudes of tolerance versus respect toward this population. In addition, the majority of health care providers had 0% to 40% self-efficacy levels for providing health care services to people with SCI who are GLBT. Patients who are GLBT need a health care environment where the prevalent attitude from all health care providers is respect versus tolerance and one in which health care providers have the competence to provide high-quality services to this population. This study, using the concepts of motivational interviewing and brief intervention, developed a videotape to determine the immediate effect of this videotape on health care providers’ knowledge levels, attitudes, and self-efficacy for providing services to patients who are GLBT. The videotape had the greatest effect on self-efficacy.
This study was approved by the Institutional Review Board of Teachers College, Columbia University.
- Received January 29, 2006.
- Accepted October 12, 2007.
- Physical Therapy