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    Gender Awareness Inventory VA A Measure

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    Nihaya Kamalatan

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    ‘Sex Ror, Vol 46, No 78, April 2002 (6 2602) Gender Awareness Inventory-VA: A Measure of Ideology, Sensitivity, and Knowledge Related to Women Veterans’ Health Care Dawn M. Salgado,!? Dawne S. Vogt,'” Lynda A. King,'> and Daniel W. King'* Within the Veterans Health Administration, it has become increasingly important to assess health-care workers’ attitudes toward and beliefs about female patients, sensitivity to the lunigue needs of female patients, and knowledge about women veterans and the programs and services available to them, The current study descr ‘Avareness Inve the development of the Gender ry-VA, an instrument that assesses 3 components: enderrole ideology, fender sensitivity, and knowledge amoag health-care stall. Data were drawn from various Samples of Veterans Health Administration employees ina large geographical region (overall 1N > 1, 100; nationally, this population includes roughly 37% minorities). Ina series of psycho- metric inquires, evidence for reliability and validity was established, and preliminary evidence was provided forthe instrument's underlying factor structure. KEY WORDS: gender, employee Over the past two decades, a steady stream of research has revealed problems in the provi- sion of health care to women. Findings suggest that ‘many negative health outcomes among female pa tients may be accounted for, in part, by gender in- equities in preventative care, diagnosis, and weat- ment (Gallant, Coons, & Morokoff, 1994; Matthews et al., 1997; Rossouw et al, 1995; Stanton & Gallant, 1995), As a result, multidisciplinary studies such as the Women’s Health Initiative (see Matthews et al., 3097; Rossouw et al., 3995; Sbumaker et al., 1998, for background and specific information) have been conducted to document gender differences within the health-care system, investigate the effects of ‘National Cente for Postuaumasie Sess Disorder, VA Botton Healtheare System, Boston. Massachusetts preset aadress Depattinent of Psychology University of Rhode Mand, Kingron, Rhode Ila Department of Papen, Boston University School of Medicine, orton, Massachusetts To whom correspondence should be addressed st Nation Centr for Posttraumatic tres Disorder (1168-2), 150 South Huntington Avene, Boson, MasachisettsU2130emailine® world atdcom. tude; women’ health female patents genderspecific treatment and practices on health- related outcomes, and examine possible causes of gender-based inequities (Bernstein & Kane, 1981; Tobin et al, 1987; Van Wijk, Van Vilet, & Kolk, 1996), ‘Within the United States’ largest health-care sys- tem, the Veterans Health Administration, gender is- sues in health-care delivery are particularly germane ‘because the vast majority of its patients historically hhave been and continue to be men. According to Miller, King, Wolfe, and King (1999), Skinner and Furey (1998), and Wolfe, Daley, Stern, and Wilson (2996), among others, one possible explanation of gender inequities in veterans’ health care is a sheer lack of familiarity and experience with—and conse- quent deficits in responsiveness to—female patients, Perhaps as a result, recent findings indicate that one in five women do 201 feel welcome receiving health- care services within the Veterans Health Adminis- tration (Kressin et al., 1999; Skinner, 2000). A lack of familiarity with female patients on the part of health-care workers is likely to become an even more salient issue as projections suggest that the number of ‘Women veterans with access to veterans health-care 247 ‘oxoamsaapcoant.6 20 Funan Pattie Capen 248 services will increase by 40% from 1990 10 2020 (Furey, 2000; Klein, 2001). ‘Accordingly, the current study involved the de- velopment of a reliable and valid measure of health- care workers’ gender awareness, conceptualized it terms of three subsidiary componenis: gender-role “ideology, the extent to which a healthcare worker does of does not rely on negative sereotypes about female patients to make judgments about aspects of their cares gender sensitivity, the degree to which = health-care worker is aware of and sympathetic t0 the unique needs and requirements of female pa tients; and knowledge, the extent to which a health- care worker possesses accurate information regarding, women veteransand general aspects oftheir ease. Our model of gender awareness is an original conceptual- ization (see Miller et al, 1999) based on an integration ‘and synthesis of important findings from a number of disciplines (eg. health and social psychology, social cognition, public health, medical sociology, and other relevant medical esearch oth inside and outside the veterans health-care system) related to quality health ‘care and disparities in the care of female and male patients Previous researchers (€., Bell, Micke, & Kasa, 1998; Gross, Zyzanski, Borawski, Cebul, & Stange, 1998: Hall, 'Irish, Roter, Ehrlich, & Miller, 1994, Heesacker et al., 1999; Ross & Duff, 1983: Willer & Grossman, 1995) have suggested that characteris ties of the patient-provider relationship are associ- ated wit important treatment judgments by health care workers as wel a service utilization and patient satisfaction. Moreover, characteristics of the patient provider relationship predict differential ievelsot slf- disclosure by the patient, differential adherence to preseribed medical pracedures by the patient, and dif- ferential diagnosis of symptoms by the provider (eg, Bell etal, 1998: Floyd, 1997; Kerssens, Bensing, & Andella, 1997; Roter & Hall, 1997). Within tis con- text, a health-care worker's gender-role ideology may bequite salient: thatis, ender inequities the health- care system may be influenced by the health-care worker's use of negative gender-hased stereotypes Badgeret al 1999:Fowers, Applegate, Tredinnick, & Slusher, 1996; Heesacker eta, 1999; Redman, Webb, Hennrikus, Gordon, &: Sanson-Fisher, 1991; Turpin, Darey, Weaver, & Kruse, 1992: Willer & Grossman, 1995)” Previous findings suggest that patient stereo- types are typically more negative for female patients than male patients, possibly due to @ more androcen- tie focus within the medical profession (Heesacker etal, 1999; Miller etal, 1999). Infact, the recognition Salgado, Vogt, King, and King of the role that negative stereotypes play in health- caro service delivery has resulted in the development of ethical guidelines to raise providers’ awareness of the harmful effects of these judgments and biases in the treatment of patients (American Psychological Association, 1992; Heesacker et al., 1999; Miller etal., 1999) Another factor that may impact the quality of ‘are provided io female patients is the degree 1o which health-care workers age sensitive to the unique needs and requirements of female patients. Researchers concerned with health-care utilization, treatment, and ‘outcomes have focused on the health-care system’s lack of gender-specific sensitivity toward health-care delivery for women (Falik & Collins, 1996; Rynne, 1985). As the majority of normative information ‘within the medical field (e.,, preventative practices, reported symptomatology, and treatment strategies) continues to depend on primarily male patient pop: ulations, disparities can be seen in such phenomena as the underdiagnosis of certain medical conditions (eg, chronic heart disease) and less effective treat- ments for female patients (Altman, 1991; Ayanian & Epstein, 1991). Other gender sensitivity concerns are sociocultural, for example, health-care workers’ need to recognize women’s disproportionate burden for family caregiving responsibilities (Miller etal, 1999) ‘and the consequences of lower socioeconomic status ‘on health-care seeking and health outcomes (Cotton, 1999; Weiss & Ashton, 1994) ur third component of gender awareness is knowledge. Knowiedge about a patient population— in this ease, women Veterans—and available services ‘and special programs within the bealtb-care sysiem should jogically lead to more effective patiemt assess- ‘ment and treatment and, hence, sounder health out comes, Because women make up only 5% of veier- fans with access to health-care services inthe Veterans Health Administration, or approximately 1.4 million of 2 total veteran population of 25.5 million, there is an obvious lack of exposure to female patients. In turn, there is likely 10 be fess Knowledge about the services available to female patients on the part of health-care workers, which necessarily may impact, the quality of cate delivered (Cotton, 1999; “Hearing ‘on Departiaent of Veterans Affairs 2000), ‘The present psychometric study complements existing research on gender inequities within the health-care system by focusing op the health-care staffs level of gender-ole ideology, gender sensitiv. ity, and knowledge as they pertain to the delivery of health care to women veterans. The developrieat of Gender Awareness Inventory-VA, an instrument 1 assess staff gender awareness within the Veterans Health Administration seems both ap- propriate and timely given the increasing numbers of ‘women who are accessing this system for care and the already identified problemsin the provision of care to this population of patients. Although measures are al ready available to assess more global gender-related attitudes (e¢, Sex-Role Egalitarianism Scale [Beere, King, Beere, & King, 984], Atitudes Toward Women Scale |Spence, Helntrech, & Stepp, 1973), the Gen. der Awareness Inventory-VA is intended to provide ' face and content valid measute of gender-related construc that is specific to the health-care seting Previous research suggests that general attitudes of ten differ somewhat {rom attitudes about individu. asin particular contexts or settings (Kleiapenaing & Hagendoorn, 1991). Thus, thisinsirumentis unique in ins ability to assess attitudes about female patients in the heallh-care setting Another strength ofthe Gen dex Awareness laventory-VA lis in its integration of literature related to the care provided to female pa- tients, As a result t should be @ valid measure of characteristics that actuslly impact the provision of care “This five-part study was undertaken to develop a reliable and valid measure of gender awareness in the Veterans Health Administration. Part 1 of the stucly was the instrument development phase; it ia volved defining the gender awareness components in detail and operationalizing these definitions via item generation and refinement, Part 2 involved the de- termination ofthe psychometric properties of the re- fined instrument and an assessment of the intercor- refations among its component measures, Patt 3 was an examination of the evidence for convergent and ‘discriminant validity. Part 4 was an evaluation of ad- ditional psychometric evidence for eriterion-related validity. Finally, Pact S was an exploratory inquiry into the factor structure thac underlies pattern of re- sponses tothe three affective components of gender awareness: genderrole ideology, gender Sensitivity, and knowledge. PART 1 INSTRUMENT DEVELOPMENT Defining the Gender Awareness Components We used a rational approach to test construe- tion (Jackson, 1971; Nunnally, 1978). Our fust seep in the development of the gender awareness mea- sure was to define clearly the three core components 29 that comprise the global construct and elaborate on their content domains. As noted pseviousy, our def intoas of the ideology, sensitivity, and knowledge components were drawn from literature in the areas ‘of health and socal psychology. social cognition, pub- licealth,ané medica sociology regarding important fectorsrelatedto gender disparities within healthcare settings (see prior explication, Milicr ea, 1999), Fu ther, these definitions were informed by a series of structured interviews with health-care personnel om a diverse range of services. The forme] definitions follow. Heatihcare-elated genderrole ideology repre- sents a healthcare worker's attitude toward female patients. It is the degree to which the health-care worker does or doesnot employ negative stereotypes about femele patients to make judgments about their ‘are, Health-care-telated gender ideotogy reflect im plicit and explicit compatisons between the genders regarding beliefs about essential differences between ren and women (e8, intelligence, personality, and ‘emotionality). Health-care-elated gender ideology is germane 10 a number of different arenas, including judgments about the appropriateness or legitimacy of female patients’ use of health services, and jad, rents about the manner in which female patients present themselves and communicate with health- care workers Health-care-related gender sensitivity i the de gree to which a health-care worker is aware of and sympathetic to the nceds or requiremeats of female patients These needs may be anatomically based and gender-specific. They may also arise from the current sociocultural or economic contexts in which women receive their health care and may concern the alioca- tion of resources to female patients’ medical necds; proper awareness of female-specific disease mani- festation; privacy, personal safety, courtesy and re spect in the health-care setting, of parenting and other family demands that are placed on women in ener The knowledge component of gender awareness is defined in terms ofthe extent to which the Veterans Health Administration employee possesses accurate information relatedtowomen's health-care needsand the programs and services available to women veter- ans This includes knowledge about the populations ‘of women currently and previously serving in the US. ‘Armed Forees and seeking healtt-care as military vet- exans, eligibility requirements for routine and spe- cial services, and health initiatives and programs for women veterans. 250 Item Generation and Refinement Guided by the above definitions, and with on- going reference to the literatures on female patients health care in general and women veterans in partic- ular, we generated an initial pool of items to reflect the content of each of the three core components of gender awareness. Ideology items focused mainly on the assessment of attitudes and beliefs about essen- differences between the genders as patients and also explicit or implici comparisons between men and Women within the health-care setting (Bernstein & Kane, 1981; Lopez, 1989). Sensitivity items focused ‘on the awareness of gender-specific conditions and tunderidentified conditions in female patients, the mi- nority status of female patients within the Veterans Health Administration, and sociocultural and eco- nomic realities women face in accessing health care ‘Belle, 1990; Clancy & Massion, 1992; McBride, 1990; O'Leary & Hegelson, 1997). Additional items were included on topics that have been identified as rel evant to female patients’ health care such as inter personal violence and childhood abuse, The initial item pool for the knowiedge dimension came from factual information extracted primarily from recent government documents about women veterans eligi bility criteria for health-care services, available pro- grams for women veterans, and their utilization statis+ tics (Miller etal, 1999). ‘Once the items were written, we progressed through series of steps to ensure that they were clear, unambiguous, and appropriate to the general popu: lation of health-care workers. First, two research as- sistants and five expert judges familiar with gender issues in health care sorted each item into one of the three defined categories and rated the items accord- ing to how well they represented each component, lems were revised or discarded if they were not at- tributed to the target component or if there was some level of disagreement as to how well the item was as- sociated with the specific component. The readability ofeach item was then assessed, and, where possible, words, phrasing, and sentence length were changed to simplify language. The readability level of know! ledge items was somewhat higher than the readabil- iny of items in the other two components, given that some technical terms typically used in the health- care setting were unavoidable. The Flesch-Kincaid Grade Level score (Flesch, 1949) was 8.7 across all item statements Next, the list of candidate items was presented to 19 health-care workers from a variety of job wypes Salgado, Vogt, King, and King (professional and nonprofessional) to ascertain clar- ity of presentation, These individuals were asked 10 identify any words or terms they did not understand. ‘The items were reviewed and edited once again as, necessary. In the end, this multistage item genera. tion and refinement process resulted in a pool of 83 items: 24 ideology items, 22 sensitivity items, and 37 knowledge items. These items together comprised ‘our preliminary version of the Gender Awareness Inventory-VA. Initial Kem Analysis Participants ‘A sample of 619 health-care workers was drawn {com two lage Veterans Health Administration med- ical centers in the noxtheast using proportional szat ifed random sampling by ste, employee gender, and employee's amount of patient contact. Patient eon- tact was composed of three categories: direct patient contact as a routine part ofthe job (eg. physicians, nurses, social workers) direct patient contact but not health-care contact as a part of the job (@.recep- tionists admissions clerks); and no patient contct as ‘formal partof the job (eg ,payroll personnel, phys ical plant). Although direct providers of health care say play a particularly important role in shaping the experience of female (and male) patients, employees {rom across the spectrum of hospital services also con tribute to the milieu and quality of the care environ- rent (Miler etal, 1999) The overall response rate across the two facilities was 60% for a total sample size of 374 (60% worsen, 40% men). A summary of respondent characteristis is shown in the fist col umn of Table I. Although our participants were not asked in this or other parts of the study to provide information on race/ethnicity or identifying informs tion including service and job itl, human resources data indicate that the distribution of employees is ap- proximately 63% White and 37% various minority groups National figures for the distibusion of Vet tans Health Administration employees with regard to gender closely mirrored our sample characteristics for each part of the study. In addition, our inclusion ofemployeesin each ofthe three patient-contact cat- egories likely ensured that our samples were quite diverse in terms of social class Sor addiona ables odin rom the present sudy ‘by type of patient contact, please conta Lyada King, Gender Awareness Inventory-VA. ble Demographics and Respondent Caracas for APs of he Stu 251 Testromest’ Computation ol Convergent and Factor evelopment pryehometrc_deeiminant_Catenon-eated analyte Vase (earl) properties (Part2) vary Part3)_vahdty (Pat 4) structure (Par 5) Ae aroup Ce I 3) <0 0 @ 0) 1) 10) 2036 36 (10) 76) 908) 516) 210) 31-40 73.09) 65 (22) BOs), san 7 4-30 14037) 10936) 301) 3263) 1900) 516 3928) 92/30) 4) 205) 1513 0 236 (10) 716) 40) 607) 36) Gender ne3Tl(%) 2 300(%) 14(%6) n= 80(%) w= 475(%) Female 224 (ea) 176(39) 63) 5(@) 300(53) Male 147 (60) mm4(81) aa) uO) 73) Previows service inthe military n=305(%) ALIS) ne) ATE) Yes 99,30) RGN 209) 1195) No mc 6708) 3909) Yes tization of VA mesh) ma26(%) wae I2%) Health Care within the post year Yer 50154) 48049) 158) 15462) 6332) No 8 (6) 2665) 16032) 98) 3848) Patent contact n= 383 (%) 05 (%) 14%) maith) memaTS(%) ‘Contactar drat health are 213658) 365055) oo) *6(50) 254 65) Contzet button dtect heath eae 67(18) 709) 36a) 2c) No official patent catct 8324) 708) 2G) Be) Length of employment 10369 (%) naLit() =I) ATIC 02 years au sea) 14) 50) 7010) BSyeart S515) 003) 208) #709) a) 5-10 sears 935) mn) 310) 1102) 9600) 11S year, ous, aan ms) 157) 909) 133) 560) 290) 2) 1338) Highest evel afedueaton nas) 16%) aS) ATT) ft rade or leet. 10) 010) 10) Some high schoo! 1 30) 8a) High choo! praduate 30) roan 4610) Some callge wy 180) C8) ‘Vocational ev techni taining, 703) 30) ssa Four-year cllege graduate 2.08) 38020) 7509) Some graduate or profesional school 518) 565) 2) [Gracateo proesional degree 310) 2) 7009) This eategory was adden pobsequentramples Procedure Allpartcipants received a packet that costained a coves letter that explained the voluntary neture of the task and the anonymity oftheir responses, are sur postcard to track participation, and the prelim inary version of the Gender Awareness Inventory- VA. The questionnaire was divided into three main secuons: demographics (incleding gender, ag, previ ‘ous military serece, Veterans Health Administration health-care utilization, and level of education) and smiployment information (including amount of pa tient contact and length of employment) sensitivity and ideology items, each employing a 5point Likert response format, with possible responses from 1 strongly disagree to 5 = strongly agree, and knowl. edge items in a standard multiple-choice format. ‘A multistage Mangione (1995) method was used in this and all succeeding parts of the study to maximize response rates while retaining anonymity for respondents, First, an inital letter to introduce the project was mailed approximately 1 week prior to the mailing ofthe questionnaire itsell Next, the ques tionnaire was mailed accompanied by a preaddressed and number-coded tracking card fos the respondent to mail separately from but simultaneous with the ‘questionnaire. If this response card was not recsived within a 2-week period, individuals were contacted @ 252 third time via a reminder postcard, followed by a re- ‘peat mailing of the full questionnaire packet approx- imately 2 weeks later. The data collection sequence ‘ended with the mailing of a final reminder postcard to individuals who had still not returned a tracking card. Analyses Various characteristics were computed for the ideology and sensitivity items: frequency distribu tions, means, standard deviations, and corrected item- total correlations, that is, the correlation of each item With the total of all other items within that compo: neat measure, Items for which the item-total corre lation was low (<30) were discarded, and coefficient alphas were then calculated on the remaining item sets Probabilities of endorsement of knowledge items for percent correct, as well as the frequency af re- sponses to each of the multiple-choice options, were computed and reviewed. To select the best knowledge items at this stage, particular attention was given 10 ‘optimizing content validity, that is, the breadth and representativeness of information about women vet- erans and their health care. Similar to other know edge or achievement-oriented test, this component ‘as intentionally multifaceted; it represents & variety ‘of content areas concerning characteristics of women veterans, guidelines and eligibility requirements for care, and specific services offered to female patients. Therefore, internal consistency reliability estimates were expected to be relatively low for the know!- edge component in this and other parts of the study (see Aiken, 1994; Anastasi, 1982; or Nunnally, 1978, for further discussion of the preeminence of con: tent validity over scale homogeneity in achievement ‘tiented testing). Resultsand Discussion In our intial analyses of data from the prelimi- nary Gender Awareness Inventory-VA, the average item-total correlations were .49 and .33 for ideology and sensitivity items, respectively. After items with low item-iotal correlations were discarded (values, <.30), the internal consistency reliability estimate for idcology was .88 (n = 339), and the internal consis tency reliability estimate for sensitivity was 75 (n = 346). An additional nine items were developed for the sensitivity measure at this point, :o improve its reliability inthe next round of data collection, In ad- Salgado, Vogt, King, and King dition, knowledge items that were overly redundant visei-vis their content were removed, The internal ‘consistency rliability estimate for knowledge was 67 (v= 371), and as expected, somewhat lower than it ‘was or the other components of gender awareness. At the close of Part 1 of this study, the Gender Aware ress Inventory-VA consisted of a total of 69 items: 20 ideology items, 29 sensitivity items (including the ‘now items), and 20 knowledge items Table Il shows 2 sample of five representative items from each of the three component measures along with associated means and standard deviations for the total sample and stratified by gender ® PART2, COMPUTATION OF PSYCHOMETRIC PROPERTIES In Part 2 of the study we used the revised version of the Gender Awareness Inventory-VA. The objec: tive was to derive new reliability estimates and other scale and item properties on the refined component measures and to examine their intercorrelations. Method Participants and Procedure In this part of the study a sample of employees ‘was drawn from the same two Veterans Health Ad- ‘ministration medical centers, with appropriate strate- gies employed to assure that no participants from Part 1 were solicited for Part 2. Individuals were se- lected using proportional stratified random sampling bysite, gender, and type of patient contact. Of625 per- sons who received questionnaire packets, 307 (59% women, 41% men) returned the instrument, for a 49% response rate. The second columa of Table I presents demographic characteristics for these respondents, Analyses Estimates of internal consistency reliability for the ideology and sensitivity measures were computed. In addition, means, medians, ranges, and standard deviations were calculated for all three measures ‘Next, independent samples ¢-tests were computed to to request «copy ofthe complete Gender Awareness Inventory Va, please contact Lynda King, Gender Awareness Inventory-VA. 253 “Table I, Sample Gender Awareness Inventary-VA Remt Wore Me ology items a) MD a MSD ‘Compared to men, women's physical complaint are or Ow Ta 093 ioe 1a? 105 ‘ore likely o be eaused by mectal robles. Women are no mire likely han en to use health ym az7 1st 13317 hsp ame gas Las ‘serves they don't realy need (Compared to men, women more often gotothe doctor «30 «18101 175-65 O98 L9H LOL for reasons that have ite to 0 mith eat ‘Women eset more to pain than men. soa 107 1 468 628 208-80 ‘Women ae no more likly than mento ignore thsi 30% 136 1 345137 e Sas doctors advice Sensi test Womenveteraasartishorptalshoudhaveaccewto «3014470455964 10H ‘care by experts in womer's health, eis too expansive fr tis hoptal to provide health ms im 108 165103 18a Services that ony women nee, ‘This bospical shouldbe more alert tosgnsofabuse at ——«303,=«SSMTOT TE GODS 3g) home among female patients spin souldofer Gulcatetomomerswhen ey «50H BUS 1287S 2H MaMa ‘ome fora medal vis Tne VAsdouldnotbeempected oprovidespeciatheath 50ST 1001734]? LT ‘ecvce for women, Knowledge items nm Cones % x Comet % on Comrect% {Tine of there services rouioly avalae vo SSCS me female VA patients? (a) abortions; ()ntertity sercer (¢) menopause management (Wb and 2-Fliiity of VA healt Denes dove nordepend.om: = «HMA 1S wD (2) come; () gender ()rciation expanse () service connected dab 43 Today’ female soldiers have sutere cichood oT SD ewlabige a ales the eilan rate (lower than (0) about the sre (6) greater fan, 4 Women have servedin US Miliary efor offcally 5061777817: sad unofcially in all of Ameriea's major coats fine: (a) the American Revolution (B) the Civil War; {@) World Wer (a) Woets War 1. Since 1965,the proportion of women nthe milzry ««3W6_=«25D_—««HSS1TH:CMS DAS ns (a) decrenae (0) increased (9 sla the a TRespomse scaler 1 strongly doagree srroniyegree Emenee 2 (03 (4 (5.0) test respondent gender differences for each compo: neat of gender awareness, Finally, Pearson product ‘moment correlation coefficients were computed t0 index the associations amang scores on the three com- ponents of gender awareness. Reso and Discussion ‘The internal consistency reliability estimate for the 20-item ideology measure was 87 (n = 286) with an average item-total cortelation of $2. The internal consistency reliability estimate for the 29item sen- lsagree but not sronahy T= no opinion orwndnles; A mapree bulnor rangi 5 sitivity measure was 83 (1 = 282) with an average item-total correlation of 46. Thus, both measures attained good levels of item homogeneity or preci sion of measurement. The internal consistency reli ability estimate for the 20-item knowledge measure was .67 (n= 306) with an average item-total corre- lation of 26. As discussed previously, this estimate ‘was expected to be somewhat lower than the other gender awareness components given its multifaceted content. ‘Table III contains descriptive statistics and inter- correlations for the total sample as well as stratified Salgado, Vogt, Kin ions Among the Thee Gender Awareness Componen! Desriptiven Trtercorelationst Man spi uaeeee 3 Toalampe T Keeologs wo mm B 4137 2Semitwiy E195 20/30 Knowledge = 6 Women 1 Kéeoloey mms oe soryeraT 66 ZSenstvny 178115387 soar Knowledge = 2). Men Teolgy 24 8 sere eps 2 Sensi mm ue arias 3. Knot 12 15 "Upcoecedcorelatonsae intedbeTor the sash and corrected onelatons are Tver he slash “peat by gender. The distributions of scores on ideology and sensitivity are slightly negatively skewed, and most respondents portray moderate to high levels of gen der awareness. Yet there is a fair degeee of disper. sion or individual differences in the distribation of these scores, and a portion of respondents scared at the lower end of each dimension. Regarding kaow!- ledge, the average number of items correct was dose tothe middle of the range of possible scores (12 out of 20, or approximately 60%). Also, the range and stax- ard deviation suggest that this measure is abie to capture successfully individual differences in know- edge about women veterans and their healthcare. ‘Results from the independent samples -tsts re vealed that female health-care workers scored sig- nificantly higher on both the ideology and sensiiv~ ity components of gender awareness, 1(296) = ~3.70, p< 05, and 1(296) = -1.99, p «05, respectively, ‘whereas no difference was found on the knowledge ‘component, (298) = 1.20, ns. These findings suggest that female health-care workers tend to have more favorable attitudes and beliefs about female patients and are also more sensitive to their unique needs than male workers in the Veterans Health Administration Setting. This ideology finding is consistent with other research on gender-role stereotyping, which suggests that women possesssomewhat more postive attitudes, ‘on gender issucs (King & King. 1997) ‘As shown in Table III, the measures of ide ology, sensitivity, and knowledge were modestly to moderately correlated, as indicated by the corrected correlations. The two more affective dimensions (ide- ‘logy and sensitivity), which shared a common item format, were most strongly related for the total sample (.62), and were strongly correlated for women (61) and men (61) separately as well, Allcorrelations are sufficiently low to support the argument that each of the gender awareness components are distinct from fone another, elthough they share a common theme, and hence contribute uniquely tothe global construct. PART 3, CONVERGENT AND DISCRIMINANT VALIDITY In Part 3 we explored evidence for conver. gent and discriminant validity by examining hypoth- esized patterns of expected relationships between scores on each of the three gender awareness mea- sures and scores on two prominent instruments that assess gender-role ideology in a broad sense (the SowRole Egalitarianism Seale and Attitudes To- ward Women Scale), a measure of sociat desirabil- lay (the Marlowe-Crowne Social Desirability Scale), and a measure of negative affect (from the Positive AlfectiNegative Affect Schedule). It was predicted that these individuals who scored higher on the Gen- Ger Awaieness Inventory-VA would be more cgali- tarlan in their atitudes toward women and men (as shown by the Sex-Role Egalitarianism Seale) and have more positive attitudes toward women (as shown by the Attitudes Toward Women Scale) than wouldin- dividuals who scored lower on the Gender Awareness Inventory-VA; this outcome would provide evidence for convergent validity. It was also predicted that gen- derawareness would not be significantly influenced by social desirability or negative affectivity, which would provide support for iseriminant validity. ‘Gender Awareness Inventary-VA. Method Pantciponts and Procedure Assubset (1 = 114;59% women, 41% men)ofthe participants in Part 2 was administered the additional ‘measures of gender-role ideology, social desirability, ‘and negative affectivity. Information in the third col ‘umn of Table { profiles this group. To ease respondent burden for many of our participants and to enhance response rates, different combinations ofthese vali ity measures were randomly assigned for inclusion in the main questionnaire packet: thus, these individu- als received a questionnaire packet that contained the Gender Awareness Inventory-VA and 2 counterbal- anced combination of the other measures. Measures ‘The Sex-Role Egalitarianism Scale—Form KK (King & King, 1990, 1993) is a 25-item gender-role ideology measure (a = 93) that assesses attitudes to ward the equality of women and men across content domains that represent marital, parental, employ: ‘ment, Social-interpersonal-heterosexual, and educa- tional roles. Respondents are asked to judge the ex- tent of their agreement or disagreement with each statement using a S-point, 1 = srongly disagree 10 = strongly agree, Likest response format. A total score is computed as the sum across all items, with higher values indicating a more egalitarian attitude. Sample items include “Keeping track of a child’ ac tivities should be mostly the mother’s task [reverse- scored],”* Women can handle job pressures as well as men can,” and “A worsan should have as much right to ask a man for a date as 2 man has to ask a woman fora date” ‘We used the 25-item short form (a = 86) of the Attitudes Toward Women Scale (Spence, Helmreich, & Stapp, 1973) to assess participants’ attitudes regard ing women's roles in society, Each item statement on this instrument was judged by means of a 4-point Likert response format, with 1 = disagree strongly and 4 = agree strongly. A total score across items was derived; higher scores indicated more positive atti= tudes toward women, Sample items are “A woman should not expect to go to exactly the same places or to have quite the same freedom of action as a man [reverse-scored}," “In general, the father should have ‘greater authority than the mother in the bringing up of children freverse-scored],” and “There should be a 255 strict merit system in job appointment and promotion without regard to sex” ‘The Marlowe-Crowne Social Desirability Scale (Crowne & Marlowe, 1964) is a 33item instrument {a = 84) that measures an individual's tendency to Sescribe himsel herself favorably or i a socially de- sirable manner. Scores were computed asthe number of items responses in the Keyed direction based on a ‘nvelfese format, Higher seores indicate more social desirability. Sample items are “Thave never intensely disliked anyone T sometimes feel resentful when I don't get my way” and “There have been occasions when I took advantege of someone [reverse-sored]” ‘The index of negative affectvity was taken fiom the Positive AflecuNegative Affect Schedule (Watson, Clack, & Tellegen, 1988), a measure of ‘ood stes The negative afectivty subscale consists Of 10 items (« = 5) such as “distressed” “guilty.” and “irritable.” which are judged on a S-point Likert scale that ranges from 1 = very slightly or nota all 105 = extremely Analyses ‘Fo establish evidence for convergent and dis- criminant validity, Pearson product-moment corre- lations were computed between scores on each of the three Gender Awareness Inventory-VA measures and scores on the four measures described immedi- ately above. In addition, corrections for attenuation clue to unreliability in measurement were applied to the correlations. Asin Part2, tests for respondent gen der differences were computed for each component of the Gender Awareness Inventory-VA. Results and Discussion Table IV presents the results of the correlational sunalyses for the cotal sample and stratified by gender. For the total semple, each of the gender awareness components was significantly correlated with scores on both the Sex-Role Egalitarianism Seale (range 32-58 for uncortected correlations, range = 5-5 for corrected correlations) and the Attitudes Toward Women Scale (range = .33-.65 for uncorrected cor relations, range = .52~.76 for correcied correlations). ‘Moreover, asexpected, the largest correlations within ‘each set were found for the associations between mea- sures oflike constructs, thats, gender role ideology as assessed by the Gender Awareness Inventory-VA and the two more general gender-role ideology measures, the Sex-Role Egalitarianism Scale and the Attitudes 256 Salgado, Vogt, King, and King “Table IV. Correlations Berween Scureson the Gender Awareney ventory. VA and Other Measures RES AWS MCSD PANAS Negative atleetviy ‘Toatample Tdeslogy 119. SBS" 85 6ST. T6 102 ~-08/—-10 1H 1/08 Sensitivity 13 “aor/as* 95 Serysst 102 —0/—04 He a7 Knowledge 114 32/49" 96 3B/S0 05 “aT/-27 tS iny=a8 Women Ideology 6 aBISY 7 SLO ot a Sensi 66 yA ST anys ot 81 16/39 Knowledge 67 alta" 58 Soya 2 a aynas Mea Ideology er Bas 4 a -24)—28 Senstivty se Joys 4 a 13/43 Knowledge ae ary7s & 3 Now SRES= rm Seale AWS = Atitudce Toward Women Sal; MCSD ity Scale: PANAS = Postve AfectNegntie Affect Schedule. Uncorrected ‘correlations at ted before the sh and corrected correlations se listed ater the ash “p< 05 ‘Toward Women Scale. With the exception ofthe neg: lgible correlations between the sensitviy measure and the Sex-Role Egalitariaism Seale for women, the coztelaions computed separately for women and men were consistent with those computed forthe to tal sample. The low cortelations between sensitivity and Sex-Role Egalitaranism Seale scores for women ray recapitulate previously documented differences Jn what is measured by the Sex Role Bgalitarianism Scale vis--vis what is measured by the Attitudes To- ward Women Scale (see King & King, 1993, 1997) With regard to discriminant validity, the associations between the genderawarenessmeasures and the mea- sures of social desirability and negative aifectivity were negligible and nonsignificant for the total sample aswellas for womenand men separately. This suggests that scores on the Gender Awareness Inventory-VA, are not influences by the tendency to present one self in a postive light nor by one's negative mood state. Overall, the pattern of relaiorshigs shown in Table JV support both convergent and disrio: nant validity, a8 hypothesized. There were no signifi cant differences between male and female health-care workers on the ideology, sensitivity, and knowledge components, (111) = —1.29, ns; (111) = ~0.24, ns and (12) = 1.72, ne: respectively PART 4. CRITERION-RELATED VALIDITY In order to examine evidence for criterion. related validity in Part 4, a series of vignettes Were constructed to assess health-care judgments related to female patients. It was predicted that those individuals who scored higher on the Gender Awareness Inventory-VA would provide more posi- tive health-care related judgments of female patients than would individuals who scored lower on the Gen: der Awareness Inventory-VA. Method Participants and Procedure A sample of 281 health-care workers were drawn from two additional Veterans Health Admin- istration facilities using proportional stratified ran- dom sampling by site, employee gender, and em- ployee’s amount of patient contact. Of those sampled, 147 completed the Gender Awareness Inventory-VA, 252% response rate. Respondents later received a vignette measure; 92 (63%) of these were completed. (Characteristics of those who returned both the G der Awareness Inventory-VA and the vignette mea- sures (V = 90, 62% women, 38% men) are shown in the fourth coluron of Tabie 1 Because wo waves of data collection were neces- sary for this part of the study, an abridged Margione method (1995) was used to reduce participant bur- den. The frst wave of data collection included (a) an initial Jetter to introduce the project and provide information about the two tasks that would follow, (b) the Gender Awareness Inventory-VA packet, and. (e) a teminder postcard. The second wave of data Gender Awareness Inventory-VA. collection occurred approximately 3 months after the administration of the Gender Awareness Inventory VA, and included (a) an inital letter to reintroduce the’ project and provide information about the vi- gnetie component, (b) the vignette component itsel, and (c) a reminder postcard. Although participant numbers were assigned to link responses across the ‘wo measures, care was taken to ensure both the con- fidentialty and anonymity of responses. Measures Inaddltion to the Gender Awareness Inventory. ‘VA. each participant received a vignette measure that included five short scenarios. Four of these required respondents to make judgments relevant tothe cate provided to female patients, and the fifth was a fol Vignettes were developed on the basis of their impi- cations forthe care provided to female patients, “The first of these vignettes required respon: dents to judge the appropriateness of a Veterans Health Administration committees decision not 19 take disciplinary action against a health-care worker ‘who revealed confidential information from a female patients medical records. The second vignette re- {quired respondents to judge the appropriateness of 4 doctor’ decision not to address privacy concerns raised by a female patient. Both of these vignettes pertain tothe important issue of the extent ro which female patients are provided with an appropriate evel of privacy within the Veterans Health Administra tion setting. Although there have been impressive im- provements in the facilitation of privacy to women veterans, probleme still remain in this area (General Accounting Office, 1999). Each ofthese vigneitesre- quired respondents to provide ratings on a sale rang- ing from 1 = strongly disagree to 7 = strongly agree. ‘The third vignette required respondents to make Judgments of the importance of programs and set vices that specifically benefit female patients com- pared with other, mote general, programs and ser Vices proposed for a hypothetical veterans hospital Clearly, optima} pealth-care occurs when needed pro- ‘grams and services are available to female patients “Tis vignette requited respondents to choose one of two options fom & total of six pais of programs and services. Four of the pairs contained an option that specifically benefited female patients (eg. hie ing health-care providers who are expes's in women's health cafe) contrasted with a more general pro- tram or service (€. educating patients about teat- 257 ‘ments and programs offered by the Veterans Health ‘Administcation); the remaining to pairs served as foils After examining trequenties of endorsement and intercortelations among scores onthe service and. ‘program pairs, one pair of program and services was Aetermined 0 be inappropriate due toits inability to discriminate among participants (Le, slmost all p ticipants selected one of the options) and was elimi- naied from further analyses. ‘A fourth vignette cequired respondents to rate the appropriateness of an employee's decision to di rect 0 distraught patient to the psychiatry service, based on the assumption thatthe patient's problems are psychiatric in nature, Halt of the respondents e- ceived a vignette in which the patient was male and the other half ofthe respondents received a vignette in which the pauient was female, Past research (¢ Turpin, Darcy, Weaver. & Kruse, 1992) has suggested that healthcare workers tend to interpret women's health problems 28 mote likely than men’s health problems to originate from psychitsc causes, and that this tendency has negative implications for the care provided to female patients. Analyses ‘We first examined the responses to each of the ‘ocal vignettes with attention to descriptive statistics, ‘most notably frequency distributions ofthe responses to each scenario. We then calculated bivasiate corre- lations between scores on the three measures of the Gender Awareness Inventory-VA and scores on the vignette messures to examine the eriterion-related validity of the Gender Awareness Inventory-VA. Fi- nally, tests for respondent gender differences were ‘computed for eech component of the Gender Aware- ‘ness laventory-VA. Results and Discussion Although participants generally tended toward a ‘more “gender-aware” perspective in their responses to the vignettes, there were individual differences in judgments related to the health care of female pa- tients. Responses to the vignettes that assessed judg- ents of confidentiality and privacy revealed the least variance; many healin-care workers indicated that vi lations of these standards of care are not acceptable. About two thirds of the respondents (67%) strongly disagreed with the hypothetical committee’s decision not to take disciplinary action against a seceptionist’s violation of patient confidentiality, and an even larger 258 number ofthe respondents (88%) strongly disagreed with the hypothetiea! doctor's decision not to address 4 woman veteran’s privacy coneemns. On the other hand, support for programs and services that specif. ically benefit women was weaker. Although slightly more than one third ofthe respondents (35%) en- dorsed at least one gender-specific program or se vice, nearly two thirds of she respondents (64%) dia not endorse even one program or service that speci icaly benefits female patients. With regard to the psychiatic judgments, although nearly half of the respondents (49%) strongly disagreed that it was ap propriate to assign psychiatric causes to the health problem of the female patient in the vignette, 25% ‘endorsed a possible psychiatric origin tothe woman's health problem. Iti interesting to note tht a simi- Jar pattern was obtained in the responses to the by- pothetical male veteran; there was litle difference In the average agreement scores between those who judged the woman and those who judged the man, 1(89) = ~0.32, ns. It is possible that veterans, both women and men, are seen by health-care stati as a patient population that is likely 1o have health prob- lems that originate in psychiatric eauses. Inthe next set of analyses, we examined the 1e- lationship between scores on the Gender Awareness Inventory. VA and the vignetic judgments for the to- tal sample and for men and women separately. We first corzelated scores on the confidentiality and pri- vacy vignettes with the three gender awareness com- ponents While gender-sole ideology was unrelated to confidentiality judgments for he sample as a whole, r= ~07, and for women, r = .05, gender-role ide- logy was related to confidentiality judgements for ale tespondents, r = —42, p< 1, More specie cally, men who had less positive autudes and be- liefs about fermale patients were more likely to agree with a hypothetical committe’s decision not 10 Lake action against a health-care employee who revealed ‘confidential information from a female ptients med- ical records On the other hand, gender-role ideol- ‘ey was significantly elated to privacy judgmeats for the sample as a whole,r = ~.23, p < 65.for women, 1 = —25, p= 05, and was in the expected direc. tion for men, although it did rot reach a conven- tionat level of significance, r = ~.18. Thus, men and women (Laken together) who fad less positive ati- tudes and beliefs about female patients were more likely to agree with a doctor's decision not to adress 2 female patients privacy concerns. Theze was also a trend for knowledge to be related to privacy judg- tmenis,r = -.17, p < 10, for the sample as @ Whole, Salgado, Vogt, King, and King which suggests that individuals who were less know!- edgeable about women veterans were slightly more likely to agree with @ doctor's decision not to ad- dress a fomale patient's privacy concerns. The cor- relations between knowledge and privacy judements were similar for men and women when computed separately, r = ~.18 and —20 respectively, although these correlations did not meet conventional levels of significance, ‘We then computed a summed score of the num- beer of endorsed programs and services that benefit female patients and correlated this Score with scores ton each of the gender awareness measures. Findings revealed a significant relationship between sensitiv. ity and endorsement of progrants and services that benefit female patients for the sample as a winole, = 27, p <.05,anda trend in this direstion for both women and men, r= 25, p< 10;r= 29, p= 10, respectively. These findings suggest that individuals, ‘who were more sensitive to the needs of female pa- tients were more likely to support initiatives that bet efit female patients, Finally, we correlated psychiatric judgments of the female patient with scores on each ‘ofthe three gender awareness components for the to- tal sample. There was no relationship between any of the gender awareness components and judgments of the appropriateness of referring a distressed fe- ‘male patient to the psychiatry service for the sample as 2 whole or for women and men separately. There was, however, a marginally significant negative corre Iation between psychiatric judgments and knowledge for women, r = ~38, p = .07. This finding, although based on a fairly small sample size (n = 24), suggests, that more knowledgable female health-care staff were less likely to agree with the employee's judament that the female patients’ problem was psychiatricin nature than female health-care staff who were less knowl edgeable about women veterans and their health-care needs. ‘Taken altogether, these findings provide prelim- inary support for the criterion-related validity of the Gender Awareness Inventory-VA. and suggest that scores on this measure may have significance for a ange ofjudgments related to the health care provided to women veterans. It might be noted that there was a 3.month interval between the administration of the Gender Awareness Inventory-VA and the vignette judgments, which provided a rather conservative test ‘of validity, as the size of the computed correlations ‘was likely to attenuate with the passage of time, ‘The independent samples ‘tests once again yielded no significam differences between male and ‘Gender Awareness Inventory-VA. female health-care workers on the ideology, sensi- tivity, and knowledge components, (89) = 1.6, ns; 1(89) = 0.01, ns; and #(89) = 1-72, ns, respectively PARTS. FACTOR STRUCTURE Part § was an inital examination of the factor structure of the Gender Awareness Inventory-VA. Method Pantcipants and Procedure For this part of the study, we used the responses from 481 individuals (63% women, 37% men) who completed the Gender Awareness Taventory-VA, ei- ‘ther as participantsin Parts?,3,or or ascontributors to anormative evaluation of gender awareness among health-care workers (Vogt et al, 2001). The fifth co: ‘umn of Table [ presents demographic characteristics {or these respondents, Anatyses We used Browne, Cudeck, Tateneni, and Mels (1998) Comprettensive Exploratory Facior Anly- sis (CEFA) procedures and software. Unlike more conventional exploratory factor analysis programs, ‘CEFA provides extensive statistical information con- cerning the viability of the solution, including a dis- ‘crepancy index or chi-square statistic, the root mean square error of approximation (RMSEA; Steiger, 1990), and standard errors for the factor loadings in the rotated solution. The maximum likelihood est mator was employed; three factors were initially ex- tracted; and the Solution was rotated t0 an oblique criterion in which the 20 ideology items were targeted tooad on one factor, the 29 sensitivity tems were tar- geted toload on another factor, and the 20 knowledge inems were targeted to load on a final factor. As pre scribed by Browne et al, the matrix of correlations among items was analyzed, Please note that results fare not reported separately for men and women, a5, the available number of cases did not warrant sepa: rate factor analyses for these subgroups. Results and Discussion The three-factor solution that coincided with the throe components of gender awareness yielded 259 reasonably good fit to the data, x2(2142, N= 481) = 4086.50, p <.01, with RMSEA = 0.043, and its ‘9% confidence interval = 0.041-0.046, Browne and ‘Cudeck (1993) judged RMSEA values in the range of (0.05 or lower to indicate “close fi." With regard tothe loadings for the rotated solution, 15 ofthe 20 items proposed to load on the ideology factor had critical ratios that exceeded 2.00 and 90% confidence inter vals that didnot include 0;24 ofthe 29 items proposed toload on the sensitivity factor had critica ratios that exceeded 2.00 and 26 of 29 had 90% confidence in- tervals that did not include O; and 15 of the 20 items proposed to load on the knowledge factor had criti ‘al ratios that exceeded 2.00 and 90% confidence in tervals that did not include 0. Thus, in general, there eassupportforastructure that differentistes between {he three components, roughly indexed Dy the sets of items designated to load on each factor. Of the three factors, the more interpretable ap- peared to be gender-role ideology. For this factor, 15, ‘of the 20 items constructed to be indicators of ideo! ‘ogy had loadings greater than 0,40 (average of 0.59), and forall items the cross-ioadings on gender sensi- tivity and knowledge were quite low, with all but two hhaving values less than 0.15 for sensitivity and all but five having values less than 0.15 for knowledge, As expected, the loadings were considerably lower for knowledge, a possible function of the restricted renee introduced by the dichotomous scoring ofthese items. For this factor, 10 of the 20ivems constructed to be in- dicators of knowledge had Joadings greater than 0.25, (average of 0.34), and forall items, the cross-loadings fon gender sensitivity and gender-role ideology were quite low, with all but three having values less than 0.10 for gender sensitivity and all but one having val ues less than 0.10 for gender roe ideology. ‘The strength and pattern of loadings for gender sensitivity, however, were much morecomplex. Asub- set of nine items with strong loadings on sensitivity refers to empathy and concern for women as care- aivers (eg. “Hospitals should have flexible hours to rect the needs of mothers,” “Women who bring chi dren with them to appointments disrupt hospital rou- tine.” [reverse-scored]); these items had loadings that ranged from 0.20 00.83 (mean = 0.57). The loadings were weaker on the remaining 20 items; they ranged from 0.04 to 033 (average of only 0.17), and a few had rather strong associations with the ideology fac: tor(eg,,"Women complain too much abouthow hard itis to get to the hospital” [reverse-seored], 0.53 with ideology, “Women who tell their doctors about abuse at home often make it sound worse than it realy is” 260 {peverse-scored], 0.56 with ideology, and “Women ask for to0 many extra police and safety services in this hospital” [reverse-scored], 0.61 with ideology). The ‘correlation between the ideology and sensitivity fac- tors was 030, sll indicative of the discriminant vali ity ofthese two affective components

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