Gender & Behaviour, Volume 20 No.

(2), June 2022 19489 - 19495

Copyright 2022 © Ife Centre for Psychological Studies/Services, Nigeria ISSN: 1596-9231

DEVELOPMENT AND VALIDATION OF PERCEIVED HEALTH PREJUDICE SCALE FOR SEXUALLY AND
GENDER DIVERSE PEOPLE

Abayomi O. Olaseni (Ph.D)

Department of Psychology
University of South Africa
South Africa
Email:olaseni.ao@unisa.ac.za

Abstract
This article aims to develop, validate and determine the psychometric properties of measures for the scale; Perceived Healthcare
Prejudice Scale for Sexually and Gender Diverse (PHPS-SGD) persons and communities. This scale presented two dimensions:
affective homophobia (the perception or feelings of being prejudiced by healthcare providers) and conative homophobia (the
perception of inclined prejudice by co-health seekers). The study adopted a non-probabilistic sample of 925 purposively selected
sexual and gender diverse (SGD) persons currently seeking health treatment. A confirmatory analysis was performed to assess the
scale structures and the Cronbach's Alpha coefficient was estimated to evaluate the instrument’s internal consistency. The
researcher conducted a convergent test through a correlation analysis between the PHPS-SGD scale and other similar-different
instruments. PHPS-SGD is therefore recommended as a reliable and valid screening tool for the measurement of perceived
prejudice and different dimensions among SGD individuals.
Keywords: Healthcare, PHPS-SGD, perception, prejudice, sexual orientation, gender identity

Introduction
Disparities in treatment experience among the sexually and gender-diverse persons and communities when compared to their
heterosexual counterparts have been proven to be rampant in Nigeria and the global spaces (Ogunleye et al., 2015; Subhrajit, 2014;
World Health Organisation [WHO], 2013). Globally, integrating people of diverse beliefs or values for peaceful coexistence
remained one of the greatest challenges. In the western communities, the governments, non-government agencies, and scholars are
working tirelessly to develop social strategies to mitigate the increasing reports of discrimination, especially the discrimination
melted toward individuals and people of diverse sexual orientations (Jones, 2020; Olanrewaju et al., 2015). Prejudice often emanated
from the interaction between the majority and the minorities, in which the dominated majority group does not give recognition to
some other minority groups as worthy of social recognition, access to social amenities, and other public spheres of needs (Licata et
al., 2011).

Numerous research outcomes suggest that health concerns (general health and mental health) are common among individuals with
diverse sexual orientations and gender identities (LGBT) and often surpass the prevalence rates in the general population (King et
al, 2017; WHO, 2013). It is an overwhelming fact that SGD people experience high rates of physical stigma, discrimination,
criminalisation, and social exclusion, which culminate in deteriorating social (sources), psychological (Horne et al, 2009; & Lick et
al, 2013) and health problems.

The feeling of discrimination may be worst in Nigeria, because the enacted same-sex marriage prohibition act (SSMPA) of 2014
and contrary to popular opinion, extends that the notional purpose of the law prohibiting marriage between persons of the same sex.
In reality, it criminalises lesbian, gay, bisexual, and transgender (LGBT) persons based on being minorities with diverse sexual
orientations, and gender identities. Also, criminalises any forms of support to the communities (International Lesbian, Gay, Bisexual,
Trans and Intersex Association [ILGA], 2020). It is therefore not unexpected that people with diverse sexual orientations and gender
identities living in Nigeria could witness more discrimination and prejudice than heterosexuals or counterparts in communities or
countries where same-sex has been legalised. There are indications that SGD persons and communities in developed societies gained
significant recognition, protections, and rights to quality healthcare and other social services (Drydakis, 2021; Ozeren, 2014;
Webster et al., 2018).

In recent times, local and international researchers are interested in conducting studies that enhance the lived experiences of the
LGBT people and communities (Horne et al, 2009; Human Rights Watch, 2003; Ogunleye et al., 2015; Nel, 2007), especially,
understudying the healthcare experiences and disparities among the LGBT. However, no published instrument/scale quantifies the
cognitive discrimination/prejudice experiences of the SGD persons and communities. Also, noting that, an instrument of this nature
is essential for quantitative studies, as the measurability of perception of healthcare prejudice should address the menace reported
by the ILGA (2020), that African environments are hostile to members of the LGBT communities, and therefore, examining the
treatment experience of the LGBT population is quite novel and necessary.

Although there are many related scales, such as; the index of homophobia (Hudson & Ricketts, 1980), attitudes toward lesbians and
gay men scale (Herek, 1994), homophobia and prejudice against sexual diversity scale (Costa et al., 2015), the scale of prejudice
against sexual and gender diversity (Costa, Flag & Nardiz, 2015), and host of others (Worthington et al., 2002), to the best of our
awareness, there is no specific-based instrument majorly focusing on prejudice being witnessed by SGD persons in accessing health
facilities. Also, gaps were identified in the developmental process of some of the identified scales, such that, evidence of validity

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and reliability; used samples for convenience and many used theoretical explanations that are related to prejudice. This study has
discovered these gaps and has decided to grind the PHPS-SGD in a way that will fill all the noted gaps.

Clinical practice and research among Africans especially Nigerian psychologists, psychiatrists, and other allied mental health
professionals has been premised on western researchers' scholarly studies and inputs without much focus on the contextual factors
existing in their societies; these have implications on assessment, diagnosis, and interventions (Nwankwo et al., 2010; Oguntayo et
al., 2020). The development and validation of a homegrown scale of measurements for use in African space could certainly control
for possible flaws in conclusion, which could arise due to the over-generalisation of western experiences (Oguntayo et al., 2020).

In Nigeria, the heterosexual attitudes toward SGD persons are hypothesised to reflect the interplay of sexual self-awareness;
systemic homonegativity, sexual prejudice, privilege; and potential for religious conflict. The prejudice pose threats to the victims
across all facets of life which may include accessing healthcare services. Prejudice against SGD persons in accessing quality
healthcare is of cause a clear threat and a challenge to the SGD population that needed to be measurable. A tool of this nature allows
individual victims to be identified and helped which will probably lead to an awareness that could also create help for this population.

To the best of the researcher’s knowledge, there is a dearth of an African psychometrically developed tool to measure prejudice
against SGD persons in the healthcare sector. Against the background, it is imperial to therefore develop the PHPS-SGD to assess
the perception of prejudice against LGBT persons seeking public health treatment. Therefore, this study seeks to fill the identified
gaps by the development of a psychometrically sound instrument that is set to explore the perception of prejudice experienced by
LGBT people and the community while soughing for healthcare attention in general health facilities in the country.

Methods
Study Approach
The study adopted the inductive research approach of scale development. There are two different approaches to scale development,
a deductive and inductive approach. The deductive approach does focus on the use of theory and the already existing concepts of
the construct to generate items within its literature domain. This approach is useful when the definition of the construct is known
and substantial enough to generate an initial pool of items (Tay & Jebb, 2017). On the other way round, an inductive approach is
most useful when there is uncertainty in the description, operationality, or dimensionality of a construct. In this case, experts or
organizational incumbents are consulted to provide definitions of the construct, and such concepts are conceptualised and then
derived; so that this could form the basis for item generation (Olley & Olaseni, 2016; Tay et al., 2017).

Participants
Twenty-four (n=24) LGBT persons participated in the qualitative phase of the study, through the Focus Group Discussion (FGD)
upon which themes emerges and items were generated and developed. The participants were majorly recruited from both Lagos and
Abuja (where this population could be easily located) in Nigeria. In addition, five (n=5) SGD individuals referred to be a victim of
ill-treatment in public hospitals were engaged through In-depth Interviewing (IDI). The participants who consented to participate in
the study were grouped thus; 6 participants were in FGD-1, 8 participants were in FGD-2 and 10 participants were in FGD-3. During
the survey study, a sample size of 925 respondents was selected purposively.

For the quantitative phase of the study, the respondents involved 60.0% (n=555) males and 40.0% (n=370) females. In terms of
religion, 60.6% (n=561) were Christians and 47.4% (n=352) were Muslims while those practicing other religions were 1.3% (n=12).
Level of education included senior secondary school certificate 45.9% (n=425), diploma and equivalent 16.5% (n=153), higher
diploma and bachelor degree 45.9% (n=425) and holders of postgraduate certificate 3.1% (n=29).
Instrument

Items Generation and Selection

To begin, the researcher explored the literature to see what constructs existed for measuring prejudice in a healthcare context towards
SGD people and what factors influenced it. Second, the researcher did a qualitative investigation with a select group of PHPS-SGD
patients to generate useful experiences. The participants were engaged in the focus groups and in-depth interviews, because they
had first-hand experiences of the phenomenon of interest in the study, this technique increased content validity (Nunnally, 1978).
The FGDs and IDIs focused on both personal experiences and perceptions. The interviews were taped, transcribed, and translated.
Three main themes emerged from the FGD's thematic analysis; (I) emotional factor, (ii) cultural factor, (iii) experience, and (iv)
self-comparison.

Items were created using these factors, yielding 15 items/questions. The produced themes were then put to test. The researcher
mainly engaged participants who are adults above the age of 18 years. The generated items for this construct were subjected to the
next phase of the study, i.e. face validation.

Face validation
Face validity was conducted to see whether the questionnaire had items that might be used to assess discrimination in healthcare
settings among SGD persons in Africa, particularly in Nigeria. The pool of items was provided to two clinical psychologists, two

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health psychologists, two medical doctors, two nurses, and two psychometrics, as well as four postgraduate psychology students
who were familiar with instrument developments, to see if they measured prejudice against SGD persons in the healthcare context.
They were asked to rate the items in the questionnaire for relevancy, clarity, and conciseness. The responders were unanimous in
their belief that the questions measured prejudice towards SGD persons in the hospital setting. All of the initial 15 things were kept
based on this preliminary evaluation, all the initial 15 items were retained.

Content Validity
On the PHPS-SGD, exploratory factor analysis was used to investigate the underlying dimensions of factors. The initial analysis
revealed a dimension structure with low factor loadings, as well as the necessity for two subscales and the overall scale reliability
coefficient (PHPS-SGD). After removing items with low factor loadings, ten items were kept (the highlighted items in red were
repeated), and the final ten items passed the Bartlett test of sphericity (p.0.001) and the Kaiser Meyer measure of meritorious
sampling adequacy, indicating that the data matrix could be factorized (KMO =.859, df = 45, p<0.001). For the PHPS-SGD, there
were 2 eigenvalue components greater than 1.0. On the PHPS-SGD, the two components accounted for 60.41 percent of the total
variation. The scree plot (see Figure 1) and scatterplot revealed that the component had two dimensions. The component loading
for the items is within the allowed range of 0.50, indicating that all of the items loaded well on the referred components.
Procedure

A complete research proposal was submitted to the chair of the Ethics Review Committee (ERC) and an ethical approval letter
(ERC/2020/s7733/0113) was subsequently issued. SGD individuals who had utilised public hospitals were subjected to the
administered questionnaires, which took up to two months before the collected data were submitted for data analysis. It took 5–11
minutes to complete the questionnaires. Data were collected in the Southwest (Lagos, Ondo, Ekiti, Osun, & Oyo) and North-central
(Kwara, Kogi, & Abuja) parts of Nigeria.

Design
This study adopted a mixed method. It was conducted in two phases; the first phase was a qualitative study where one Key Informant
Interview (KII) and three Focus Group Discussions (FGD) were conducted using SGD individuals. While the second phase was an
ex post facto design where the structured questionnaires of PHPS-SGD were administered to 925 participants to analyse the validity
and reliability of the new scale.

Results
The PHPS-SGD was subjected to the eight (8) comprehensive and standard procedures of new scale validation (Item-Total Statistics,
Correlation Matrix, KMO, and Bartlett's Test, Total variance explained the number of factors to be extracted, evaluating the
communalities, identification of the complex structure, screen plot, and principal components loadings). Thus, the number of valid
cases for this set of variables is 925 respondents. None of the retained 10 items after the EFA was below the recommended 0.30
minimum reliability. This suggests that all items have a strong relationship with the total scale. Principal components analysis
requires that there be correlations greater than 0.30 between the variables included in the analysis. For this set of items, there are
sufficient correlations in the matrix greater than 0.30 (factor loadings difference less than .20), and the items were removed. All
these conditions were satisfied to meet standard requirements (see Table 1).

Table 1
Showing the principal components analysis of the Perceived Healthcare Prejudice Scale for Sexual and Gender Diverse persons
Factor Loading Reliability
Factor Facto Com KMO Α
Items Bartle
1 r2 muna
tt test
lities
1 In my course of receiving healthcare services in the past, I sense no
.793 -- .681
discrimination based on being LGBT
2 I have a feeling of institutional barriers that inhibit lesbians, gays,
bisexuals, and/or transgender from accessing quality health care -- .475 .231
services like normative heterosexuals
6 In recent times, I feel unease with the dispositions and attitudes of
healthcare providers toward me based on diverse gender -- .794 .687
0.78
identities/sexual orientations 0.859 60.41
0
7 I often form the impression from the attitude of healthcare providers
that I was responsible for my presenting medical complaints simple -- .804 .666
because of my sexual orientation/gender identity
8 I feel so dissatisfied generally with the quality of healthcare services
.807 -- .711
when compared to counterparts who are heterosexual clients/patients
9 I feel so warm with the dispositions and attitudes of the healthcare
.750 -- .580
providers, even as a member of the LGBT communities

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12 I have the feeling that healthcare providers within medical facilities

believed that heterosexual patients/clients deserve more quality .769 -- .594
attention than same-sex patients/transgender
13 In my course of receiving healthcare services in the past, I sense a lot
.809 -- .655
of discrimination based on my membership in the LGBT communities
14 I assume a lot that healthcare providers believe I am a moral deviant
.748 -- .608
based on my member in the LGBT communities
15 I often have anxiety and worry anytime I feel the need to consult my
.780 -- .627
healthcare provider(s) or visit medical facilities
Items with complex structures were 3,4,5,10, and 11*deleted

Principal component analysis demands that the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (MSA) be larger than 0.50 for
each variable as well as the set of variables in condition three. The MSA for the retained 10 items was greater than 0.5 on the output.
Furthermore, the overall MSA for the set of variables studied was 0. 859, exceeding the minimum threshold of 0.50 for overall MSA
(see table 1). When using principal component analysis with KMO and Bartlett's Test table (Bartlett test of sphericity), the
probability associated with Bartlett's Test of Sphericity must be smaller than the level of significance. The Bartlett test probability
is responsible for approximately 60.41 percent or more of the total variance. 60.41 percent (60 percent) of the total variance may be
explained by a two-component solution (see table 1).

The study also explored the communalities, which are the percentages of variance in the original variables that the factor solution
accounts for. Because the factor solution explains at least half of the variation of each original variable, the communality value was
sufficient for all items, as all communality values were larger than 0.50. Items 3, 4, 5, 10, and 11 were eliminated from the list
because they did not meet up with the criteria for the communality value (see table 1). In the seventh criterion. The study explored
whether the items have a complex structure; if so, one variable has high loadings or correlations (0.40 or greater) on many
components. As a result, certain elements (items 3, 4, 5, 10, and 11), as shown in tables 7 and 8, were removed since they were
judged difficult or complex to comprehend (Oguntayo et al., 2020; Olley & Olaseni, 2016).

Recollect that, the EFA approach was used to achieve the 10 items of the PHPS-SGD when the data were not normally distributed,
as demonstrated by the P-P plots (see figure 1; Costello & Osborne, 2005). The emerging scale contained ten items with factor
loadings ranging from 0.45 to 0.81; additionally, the EFA yielded a two-factor structure in Table 1. The first component is made up
of seven variables (items 1, 8, 9, 12, 13, 14, and 15) with factor loadings ranging from.45 to.81, explained 45% of the overall
variance. This factor was termed "affective homophobia prejudice" according to the theme of these items (the perception or feelings
of being prejudiced against by healthcare providers). The second factor is made up of three components (item 2, 6, and 7) with
factor loadings ranging from.74 to.81, explained 15% of the overall variation. This factor was termed “conative homophobic
prejudice" according to the theme of these items (the perception of inclined prejudice by co-health seekers within the treatment
facilities).

Fig 1 shows the P-P plots of the PHPS-SGD

The factor was labeled "conative-homophobic prejudice" (experience here is based on subjective sentiments from persons who are
not privy to the sexual orientations of the participants), based on the emerging and loaded items. It was then required to examine
the internal reliability of the developed scale, which revealed a Cronbach's Alpha of 0.78 for the total scale (see table 1). Cronbach's
alpha was calculated to be around 0.78, meanwhile, the acceptable or dependable value for newly developed scales is between 0.60
and 0.70 (Oguntayo et al., 2020). This indicated that the Alpha coefficient for the new items is high, therefore implying a great

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internal consistency (Clark & Watson, 1995). As a result, the items were recovered in the following order: 1, 2, 6, 7, 8, 9, 12, 13,
14, and 15 were retained for this scale. With a value of 0.894, subscale 1 "affective-homophobic prejudice" stands out. With
coefficients of 0.531, items 9 and 10 were kept for "conative-homophobic prejudice" (table 1).

Validity report
Construct validity
Construct validity was accomplished through convergent and discriminant validity. The retained items were correlated with a similar
scale/instrument of prejudice against sexual and gender diversity (EPDSG) and a different scale of CORE-10 to establish both the
convergent and discriminant validity of the PHPS-SGD. The EPDSG was tested against the PHPS-SGD to determine the degree to
which the two similar measures are co-related (Costa et al., 2015). The PHPS and EPDSG had a substantial connection (r =.338, p
>.01) in Table 9, indicating excellent convergent validity. While the new scale PHPS-SGD was tested against the CORE-10, a
measure of psychological distress (Barkham et al., 2013), the result showed a negative (inverse) association (r = -.073, p >.01). This
indicates that the scales are moving in opposite directions, indicating discriminant validity. The scale's z-score is 44.92, with an
average standard deviation of 11.47.

Discussion
The PHPS-SGD has been revealed to sufficiently assess the perception of healthcare prejudice among individuals with diverse
sexual orientations and gender identities using the conventional systematic approach to tool development (Anastasi, 1999). The
effort produced a 10-item scale that provides a measure of perceived healthcare prejudice with proven reliability and validity. The
Cronbach alpha was employed in evaluating the level of acceptability of the observed values of reliability coefficients. The alpha
coefficient was strong for the overall and subscales items. The scale reported a considerable and acceptable level of internal
consistency. The validity of PHPS-SGD was also found recommendable for use.

The construct validity was reported through convergent and discriminant validity. The PHPS-SGD scale was correlated with the
scale of prejudice against sexual and gender diversity (EPDSG) and the outcome revealed a significant and positive relationship
between the two similar scales, indicating the establishment of convergent validity. Furthermore, the CORE-10 scale was correlated
with the PHPS-SGD scale and a negative relationship was established, indicating a strong discriminant validity of the development
of PHPS-SGD. The process of development and outcome of the validity and reliability report was similar to the recommended
process and outcomes of the widely used instrument developed by previous scholars (Anastasi, 1999; Olley & Olaseni, 2016). Few
limitations to be considered in this paper include self-reporting of items that may introduce response bias and under-reporting,
therefore, outcomes should be interpreted with caution.

Conclusion
The development and validation of the Perceived Healthcare Prejudice Scale for Sexual and Gender Diverse (PHPS-SGD) persons
and communities have demonstrated that a measure of perception of healthcare prejudice among sexually and gender diverse persons
through the conventional systematic test construction process is possible. The instruments could better inform the internalised
experiences of the LGBT people and communities and further help in proffering solutions to the identified problems.

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