Running head: LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL: COMPARING
PATIENT SATISFACTION
By
Gayle Kempinski, DNP(c), MSN, APNP, ANP-BC, OCN
MSN, Marian University, 2012
ASD, Cardinal Stritch University, 2004
MBA, Concordia University, 1998
BA, Mount Mary University, 1993
A DNP Research Project Submitted to Clarion and Edinboro Universities
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
December, 2021

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LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL: COMPARING
PATIENT SATISFACTION
Committee Signature Page

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Acknowledgements
I would like to start out by expressing my sincere gratitude to my committee chairperson,
Dr. Jill Rodgers, DNP, FNP-BC, PMHNP-BC. Thank you for your unwavering commitment to
my success and for seeing me through this to the very end! I am forever grateful to you for your
constant leadership, support, and guidance.
A special thanks to my program instructors, Dr. Meg Larson, DNP, CRNP, FNP-BC and
Dr. Cate Stiller, PhD, RN, CNE. Thank you for laying the firm foundation that prepared me for
this journey.
I would also like to thank my loving husband and best friend, Scott. Thank you for the
perpetual encouragement and for never giving up on me. You were always my biggest fan,
cheering me on, and I love you for that! The emotional rollercoaster was unrelenting at times,
but you held on tight alongside me. You would always pick me up when I was down, and you
never let me give up. The never-ending faith and confidence you had in me was all the
encouragement I needed to keep pressing on. I am forever grateful for your ongoing love,
encouragement, and support throughout this journey. I never could have done this without you.
Thank you! I love you always.

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LGBTQIA+ Inclusive Healthcare Versus Traditional: Comparing Patient Satisfaction
Gayle Kempinski, DNP(c), MSN, APNP, ANP-BC, OCN
Abstract
Study Aim: The aim of this study was to evaluate the difference in patient satisfaction scores
between lesbian, gay, bisexual, transgender, questioning or queer, intersex, and asexual
(LGBTQIA+) individuals who receive healthcare from LGBTQIA+ inclusion clinics and
LGBTQIA+ individuals who receive healthcare from traditional clinics. Background:
LGBTQIA+ individuals have unique healthcare needs and require safe, affirming, culturally
competent, and inclusive healthcare environments that will meet these unique needs, eliminate
health disparities and inequities, and improve patient reported outcomes such as patient
satisfaction. Theoretical Framework: This study was guided by the Health Equity Framework,
centered on three foundational concepts: equity at the core of health outcomes; multiple,
interacting spheres of influence; and a historical and life-course perspective. Methodology:
Study protocol review and approval were obtained from Edinboro University’s Institutional
Review Board. This study was an on-line questionnaire study and was conducted using a
nonexperimental, nonrandom, cross-sectional study adhering to a quantitative methodology. A
nonrandom convenience sample of LGBTQIA+ individuals (n=56) was selected, and study
participants were invited to participate in this study via an on-line survey link by way of
Qualtrics. Data were collected using the Short-Form Patient Satisfaction Questionnaire (PSQ18). Results: To test for differences in patient satisfaction between groups, the independent
samples t-test statistical method was utilized. There was not a statistically significant difference
in mean values between groups. Due to assumption violations, the Communication sub-scale
was tested using the independent samples Mann-Whitney U test to determine if the distributions

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in the two groups were significantly different from each other. It was found that the distributions
in the two groups significantly differed. Conclusions: LGBTQIA+ inclusion health plays a
critical role in improving patient satisfaction and the health and well-being of LGBTQIA+
individuals. Implications for Nursing Practice: Nursing professionals play an integral role in
transforming healthcare for LGBTQIA+ individuals and must align their practices with their
professional duty of delivering equitable and culturally competent and sensitive care to
LGBTQIA+ individuals. Recommendations: Further research is needed with larger sample sizes
to investigate the relationship between receiving healthcare from LGBTQIA+ inclusion clinics
and improved patient satisfaction and whether there is a difference in patient satisfaction
between those who receive healthcare from LGBTQIA+ inclusion clinics and those who do not.
Because study respondents who went to LGBTQIA+ inclusion clinics had significantly higher
communication satisfaction than those who did not go to inclusion clinics, the impact of
culturally competent communication on improved patient satisfaction should also be investigated
further in future research.

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Table of Contents
List of Tables ............................................................................................................................. 9
List of Figures and Charts ...................................................................................................... 10
List of Appendices ................................................................................................................... 11
Abstract ..................................................................................................................................... 4
Chapter 1: Introduction .......................................................................................................... 12
Demographics........................................................................................................................ 12
A Vulnerable Population........................................................................................................ 13
Healthcare Inequities ............................................................................................................. 13
Barriers to Healthcare ............................................................................................................ 14
Limited Access .................................................................................................................. 15
Discrimination from Healthcare Providers ......................................................................... 16
Healthcare Provider Lack of Knowledge ............................................................................ 16
Healthcare Disparities ............................................................................................................ 17
Unique Healthcare Needs ...................................................................................................... 18
Inclusion Health and Patient Satisfaction ............................................................................... 19
Background of the Problem ................................................................................................... 20
Statement of the Problem ....................................................................................................... 22
PICO Question ...................................................................................................................... 23
Hypothesis ............................................................................................................................. 23
Definition of Terms ............................................................................................................... 24
Operational Terms ............................................................................................................. 24
Conceptual Terms .............................................................................................................. 25
Need for the Study ................................................................................................................. 26
Significance of the Problem ................................................................................................... 27
Assumptions .......................................................................................................................... 28
Summary of the Problem ....................................................................................................... 28
Chapter 2: Review of the Literature ...................................................................................... 29
Literature Search ................................................................................................................... 30

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Inclusion Criteria ................................................................................................................... 30
Critical Appraisal................................................................................................................... 31
Life Course Health Disparities ............................................................................................... 31
Healthcare Access and Utilization.......................................................................................... 32
Cultural Competence ............................................................................................................. 35
Cultural Competency Education and Training ........................................................................ 36
Medical Education ............................................................................................................. 36
Nursing Education ............................................................................................................. 37
Non-Clinical Staff Education ............................................................................................. 39
Theoretical Framework .......................................................................................................... 39
Background........................................................................................................................ 40
The Health Equity Framework ........................................................................................... 40
Development of Framework ............................................................................................... 40
Foundational Concepts of Framework ................................................................................ 41
Equity at the Core of Health Outcomes .......................................................................... 42
Spheres of Influence ...................................................................................................... 42
Systems of Power .......................................................................................................... 43
Relationships and Networks........................................................................................... 43
Individual Factors .......................................................................................................... 43
Physiological Pathways ................................................................................................. 44
Historical and Life-Course Perspective .......................................................................... 44
Applicability of Framework to Doctor of Nursing Practice ................................................. 44
Applicability of Framework to Study ................................................................................. 46
Summary of the Review of Literature................................................................................. 47
Chapter 3: Methodology ......................................................................................................... 47
Study Design ......................................................................................................................... 47
Sample and Setting ................................................................................................................ 48
Procedure and Ethical Considerations .................................................................................... 49
Measure ................................................................................................................................. 50
Data Collection ...................................................................................................................... 51
Study Timeline ...................................................................................................................... 53
Summary of Methodology ..................................................................................................... 53

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Chapter 4: Results and Discussion ......................................................................................... 53
Data Analysis ........................................................................................................................ 53
Missing Data ......................................................................................................................... 54
Discussion of Results ............................................................................................................. 54
Sociodemographic Characteristics ...................................................................................... 55
Comparing Survey Respondents by Clinic Type................................................................. 64
Assumption Check ............................................................................................................. 64
Parametric Independent Samples t-test ............................................................................... 67
Nonparametric Tests .......................................................................................................... 68
Mann-Whitney U ........................................................................................................... 68
Point-Biserial Correlation .............................................................................................. 69
Descriptive Statistics of Scales of Satisfaction.................................................................... 70
Study Limitations............................................................................................................... 71
Summary of Study Results and Discussion ......................................................................... 73
Chapter 5: Summary, Conclusions, and Recommendations ................................................. 73
Summary of Findings ............................................................................................................ 73
Implications for Nursing Practice ........................................................................................... 74
Recommendations for Further Research ................................................................................. 76
Conclusion ............................................................................................................................ 79
Disclosure Statement ............................................................................................................. 80
Funding ................................................................................................................................. 80
References................................................................................................................................ 81
Appendices .............................................................................................................................. 89

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List of Tables
Table 1: Frequency Distribution of Sexual Orientation of Respondents by Clinic Type .......... 56
Table 2: Frequency Distribution of Gender Orientation of Respondents by Clinic Type ............ 57
Table 3: Frequency Distribution of Race/Ethnicity of Respondents by Clinic Type ................ 58
Table 4: Frequency Distribution of Age of Respondents by Clinic Type ................................. 59
Table 5: Frequency Distribution of Education Level of Respondents by Clinic Type ............. 60
Table 6: Frequency Distribution of Health Insurance Status of Respondents by Clinic Type .. 61
Table 7: Frequency Distribution of Employment Status of Respondents by Clinic Type ........ 61
Table 8: Frequency Distribution of Income Level of Respondents by Clinic Type.................. 63
Table 9: Levene’s Test for Equality of Variances ...................................................................... 66
Table 10: Parametric Independent Samples t-test Findings ........................................................ 68
Table 11: Mann-Whitney U Test for Communication and Financial Aspects Sub-scales............ 69
Table 12: Correlations Between High- and Lower-Income Level and Overall Satisfaction ........ 70
Table 13: Descriptive Statistics of Scales of Satisfaction by Clinic Type ................................... 70
Table 14: Descriptive Statistics of Scales of Satisfaction ........................................................... 71

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List of Figures and Charts
Figure 1: The Health Equity Framework Applied ..................................................................... 46
Chart 1: Sexual Orientation of Survey Respondents by Clinic Type ........................................ 56
Chart 2: Gender Orientation of Survey Respondents by Clinic Type ....................................... 57
Chart 3: Race/Ethnicity of Survey Respondents by Clinic Type .............................................. 58
Chart 4: Age of Survey Respondents by Clinic Type ............................................................... 59
Chart 5: Education Level of Respondents by Clinic Type ........................................................ 60
Chart 6: Health Insurance Status of Survey Respondents by Clinic Type ................................ 61
Chart 7: Employment Status of Survey Respondents by Clinic Type....................................... 62
Chart 8: Income Level of Survey Respondents by Clinic Type ................................................ 63
Chart 9: Normality Assumption of Scales .................................................................................. 65
Chart 10: Point-Biserial Correlation .......................................................................................... 69

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List of Appendices
Appendix A: Theoretical Framework – The Health Equity Framework ..................................... 89
Appendix B: Edinboro University’s IRB Approval of Human Subjects Protocol .................... 91
Appendix C: Informed Consent Form........................................................................................ 92
Appendix D: PSQ-18 Cover Letter and Instructions .................................................................. 94
Appendix E: Instrument: Short-Form Patient Satisfaction Questionnaire (PSQ-18) ................... 95

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Chapter 1
Introduction
The lesbian, gay, bisexual, transgender, questioning or queer, intersex, and asexual
(LGBTQIA+) community is a multifaceted community involving considerable complexity
(Goldberg et al., 2018). Individuals who self-describe or self-identify as LGBTQIA+ represent
every community (Centers for Disease Control and Prevention [CDC], 2014). The LGBTQIA+
community is remarkably diverse and embodies all genders, all races and ethnicities, all ages,
and all socioeconomic statuses across the nation (CDC, 2014). According to Bonvicini (2017),
historically, the terms gay and lesbian were utilized to encompass sexual minorities. Later, to
include bisexual and transgender individuals, the initialism LGBT was adopted. Over the years
the nomenclature continued to expand to become even more broadly defined with added initials
of Q, I, and A (Bonvicini, 2017). To represent individuals who identify along the continuum of
LGBTQIA+ and to signify diversity and inclusion, the initialism LGBTQIA+ will be used when
referring to sexual and gender minority individuals throughout this study. This initialism is well
understood by the LGBTQIA+ community. It extends beyond discreet boundaries and
encompasses all gender and sexual minorities (Goldberg et al., 2018).
Demographics
Due to a variety of factors, it is difficult to determine the size of the LGBTQIA+
population (National LGBTQIA+ Health Education Center, 2016). Factors include the
heterogeneity of LGBTQIA+ communities, the paucity of research concerning these
communities, and the reluctance of LGBTQIA+ individuals to answer state surveys. In fact,
most national or state surveys do not ask sexual orientation or gender identity questions, making

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it challenging to approximate the percentage of U.S. adults who self-describe or self-identify as
LGBTQIA+ (HealthyPeople.gov, 2021).
According to Jones (2021), approximately 5.6% of U.S. adults self-describe or selfidentify as LGBTQIA+. From Gallup’s 2017 data, the estimate has risen more than one
percentage point and is up from 4.5% (Jones, 2021). The estimate rise is thought to correlate
with the increase in support of equal rights for LGBTQIA+ individuals in the U.S. As a result,
younger persons are more freely identifying themselves as something other than heterosexual,
such as sexually and gender fluid (Jones, 2021).
A Vulnerable Population
Although support of equal rights for LGBTQIA+ individuals in the U.S. has increased,
LGBTQIA+ individuals remain a vulnerable population due to prejudice and exclusion.
According to Ekmekci (2017), because of their mere state of existence, LGBTQIA+ individuals
experience disadvantages in relation to equal and fair opportunities. “Lesbian, gay, bisexual,
transgender (LGBT) people are among the vulnerable populations with significant disadvantages
related to health and the social determinants of health” (p. 335). Legal discrimination in access
to health insurance, lack of social programs, and shortage of healthcare providers who are
knowledgeable and culturally competent in LGBTQIA+ health are considered social
determinants that affect the health and well-being of LGBTQIA+ individuals and are largely
related to oppression and discrimination (HealthyPeople.gov, 2021).
Healthcare Inequities
Social and structural inequalities, such as oppression and discrimination, as well as
stigmatization, remain significant obstacles to the health and well-being of LGBTQIA+
individuals. Discrimination, societal stigma, and denial of civil and human rights put

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LGBTQIA+ individuals at increased risk for health disparities and poor health outcomes
(HealthyPeople.gov, 2021). According to Marbury (2017), social norms, and institutions that
stigmatize, marginalize, and devalue the lives of LGBTQIA+ individuals, continue to be the root
causes of health disparities amongst these vulnerable individuals. Research suggests that “health
equality, and appropriate and specific care, for the LGBTQ community starts with abolishing
discrimination, ending stigma, and addressing disparities” (“Meeting the Unique Health-care
Needs,” 2016). To advance toward health equity and achieve the best possible health and wellbeing, LGBTQIA+ individuals need personal agency and equitable access to resources and
opportunities (Peterson et al., 2020). Health inequities will persist for LGBTQIA+ individuals if
inequitable access to resources and opportunities are left unmitigated (Peterson et al., 2020).
Sexual orientation and gender identity contribute to an individual’s ability to achieve
good health (HealthyPeople.gov, 2021). Although diversity initiatives within the healthcare
system remain on the rise, treatment standards continue to be grounded in a sociocultural
privileging of heteronormativity, rendering LGBTQIA+ individuals invisible (Goldberg et al.,
2018). Compared to their heterosexual counterparts, LGBTQIA+ individuals are at increased
risk for a number of health-related threats due to their sexual orientation (CDC, 2014). Like an
individual’s age, sexual orientation and gender identity are irrelevant when it comes to an
individual’s right to health (Ekmekci, 2017). However, based on their sexual orientation and
gender identity, systematically, LGBTQIA+ individuals experience greater barriers to health
(HealthyPeople.gov, 2021). Healthcare systems have both an opportunity and a responsibility to
provide equitable care to all LGBTQIA+ individuals regardless of their sexual orientation and
gender identity (Furness et al., 2020).
Barriers to Healthcare

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Common experiences of stigma and discrimination are what bind LGBTQIA+
individuals together as social and gender minorities (Giri et al., 2019). More precisely, with
respect to healthcare, LGBTQIA+ individuals are further bound by a lengthy history of prejudice
and a dearth of awareness of health needs by healthcare professionals (National LGBTQIA+
Health Education Center, 2016). Unfortunately, these shared experiences also create barriers to
health for LGBTQIA+ individuals, resulting in decreased access to culturally competent
healthcare and poor health and mental health outcomes. According to Bouma (2016),
dissatisfaction with healthcare creates a barrier to access and exacerbates health concerns
amongst LGBTQIA+ individuals. Although the reasons LGBTQIA+ individuals face barriers to
accessing healthcare are many, they can be placed into three major categories: limited access,
discrimination from healthcare providers, and healthcare provider lack of knowledge in caring
for LGBTQIA+ individuals (National LGBTQIA+ Health Education Center, 2016).
Limited Access
LGBTQIA+ individuals often remain under- and ill-served, and access to health and
mental health services continues to be a major health concern for them (Romanelli & Hudson,
2017). There are a variety of factors that prevent LGBTQIA+ individuals from accessing highquality healthcare, such as availability of appropriate care, lack of affordability of care, financial
barriers, and socioeconomic barriers (Giri et al., 2019). Basic access to healthcare is an
unrelenting problem for LGBTQIA+ individuals, as they are more likely to be uninsured as a
consequence of homelessness and unemployment status (National LGBTQIA+ Health Education
Center, 2016). Additionally, regardless of their insurance status, LGBTQIA+ individuals may
outright be denied healthcare solely based upon their sexual orientation or gender identity (Giri
et al., 2019). To adequately address the numerous health and mental health disparities faced by

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LGBTQIA+ individuals, it is imperative that these individuals gain access to high-quality
healthcare (Romanelli & Hudson, 2017).
Discrimination from Healthcare Providers
In addition to limited access to healthcare, the attitudes, behaviors, and beliefs of
healthcare providers create significant barriers to accessing and receiving healthcare for
LGBTQIA+ individuals as well: “Research suggest that attitudes of healthcare providers may be
a contributing factor in both accessing and receiving care” (Dorsen & Van Devanter, 2016, p.
3716). While seeking healthcare services, LGBTQIA+ individuals may experience
discrimination or prejudice from healthcare providers (National LGBTQIA+ Health Education
Center, 2016). In fear of being discriminated against, they may postpone receiving medical care,
even while sick or injured. According to Giri et al. (2019), “LGB persons’ previous negative
experiences with the health care system or perceptions of discrimination in the system may cause
them to delay seeking health care” (p. 19). Further perpetuating their reluctance to seek
healthcare, LGBTQIA+ individuals frequently engage in undesirable interactions in doctor’s
offices as well (Marbury, 2017). The ability to effectively serve LGBTQIA+ individuals will
require healthcare providers to understand the cultural context of the lives of LGBTQIA+
individuals and to modify their behavior and language to be inclusive and non-judgmental when
providing care (National LGBTQIA+ Health Education Center, 2016).
Healthcare Provider Lack of Knowledge
A lack of knowledge persists in the healthcare system, and LGBTQIA+ individuals
continue to report negative experiences with their healthcare providers (Bonvicini, 2017).
Negative experiences reported included encountering homophobia and unsatisfactory or unequal
healthcare treatment (Bonvicini, 2017). Poor encounters with intolerant and improperly

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educated healthcare professionals are a sizeable reason as to why LGBTQIA+ individuals either
delay or refuse to seek healthcare (National LGBTQIA+ Health Education Center, 2016). When
being cared for, they may discover that healthcare providers have a paucity of knowledge,
expertise, and understanding of their unique healthcare needs, further contributing to ongoing
health disparities and discrimination (American Nurses Association [ANA], 2018). LGBTQIA+
individuals also fear being “outed” when seeking healthcare from non-LGBTQIA+ friendly
providers (Marbury, 2017). Creating a LGBTQIA+ friendly environment will require healthcare
providers to receive adequate didactic and clinical training regarding the role of stigma and
discrimination, as well as the unique healthcare needs of LGBTQIA+ individuals (Dorsen & Van
Devanter, 2016).
Healthcare Disparities
Health disparities exist when health outcomes are seen to a greater or lesser extent
between populations and are strongly associated with social, economic, and environmental
disadvantages (HealthyPople.gov, 2021). According to CDC, “health disparities are preventable
differences in the burden of disease, injury, violence, or in opportunities to achieve optimal
health experienced by socially disadvantaged racial, ethnic, and other populations, and
communities” (2017). Based on their sexual orientation or gender identity, which historically are
correlated with discrimination or exclusion, LGBTQIA+ individuals are adversely affected by
health disparities (HealthyPeople.gov, 2021). Furthermore, discrimination and exclusion “(…)
place disparities in health status between sexual- and gender-minority and heterosexual
individuals” (Giri et al., 2019, p. 15).
Health-seeking behavior and access to healthcare for LGBTQIA+ individuals continues
to be shaped by a long-history of anti-LGBTQIA+ bias within the healthcare system (National

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LGBTQIA+ Health Education Center, 2016). Thus, LGBTQIA+ individuals suffer a multitude
of health disparities related to social and structural inequalities, including higher prevalence of
human immunodeficiency virus (HIV) and other sexually transmitted infections, higher rates of
substance use and abuse, mental health issues and suicide, increased odds of obesity and eating
disorders, and higher rates of violence victimization. These health disparities are primarily driven
by the social determinants of health, such as legal discrimination in access to health insurance,
employment and housing, limited access to appropriate healthcare, social discrimination, and
shortage of knowledgeable and culturally competent healthcare providers. Although social and
structural inequalities, as well as differences in sexual behavior are often associated with poorer
health status amongst LGBTQIA+ individuals, the physical environment also contributes to the
health disparities experienced by these individuals. It is essential that LGBTQIA+ individuals
have access to healthcare, safe meeting places, and safe neighborhoods and housing
(HealthyPeople.gov, 2021).
To address these health disparities experienced by LGBTQIA+ individuals, specific
attention to LGBTQIA+ health is required from healthcare professionals (HealthyPeople.gov,
2021). Healthcare professionals must abandon the historical heteronormative and gender binary
approach to LGBTQIA+ health and pay specific attention to the unique healthcare needs of
LGBTQIA+ individuals. Institutional norms must be abandoned as well, and in order to
transform institutional norms, specific attention must be given to the wholeness of LGBTQIA+
individuals (Goldberg et al., 2018).
Unique Healthcare Needs
LGBTQIA+ individuals have unique healthcare needs from those healthcare needs of
heterosexual individuals. Addressing the unique healthcare needs of LGBTQIA+ individuals

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begins with understanding the unique needs of each individual and creating an environment that
is aimed at providing culturally affirming care and inclusive of all LGBTQIA+ individuals.
Historically, the healthcare needs of LGBTQIA+ individuals have been seen through a
heteronormative and gender binary lens, assuming their healthcare needs are comparable to the
healthcare needs of their heterosexual and cisgender counterparts (Colpitts & Gahagan, 2016).
The unique healthcare needs of LGBTQIA+ individuals are dismissed by this heteronormative
and gender binary approach and further impedes their access to culturally affirming and inclusive
care (Colpitts & Gahagan, 2016).
LGBTQIA+ inclusion health will improve healthcare quality and eliminate health
disparities and inequities. Recognizing LGBTQIA+ individuals experience social, structural,
and interpersonal challenges can be helpful for understanding the impact these challenges can
have on their health. Addressing the unique healthcare needs of LGBTQIA+ individuals and
lowering health disparities have many benefits, including reductions in disease transmission and
progression, increased mental and physical well-being, reduced healthcare costs, and increased
longevity (HealthyPeople.gov, 2021).
Inclusion Health and Patient Satisfaction
A variety of factors affect health outcomes and patient satisfaction among LGBTQIA+
individuals. According to McClain et al. (2016), “health outcomes are affected by patient,
provider, and environmental factors” (p.387). “Environmental factors include both the context in
which care is delivered (…) as well as how care is delivered” (McClain et al., 2016, p. 387). For
instance, while some LGBTQIA+ individuals may interact well with their healthcare providers,
others postpone or even fail to seek healthcare because of being subjected to discrimination in
the healthcare setting as a result of their sexual orientation and gender identity (McClain et al.,

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2016). From the patient’s viewpoint, every interaction they have with their healthcare provider
may contribute to their overall satisfaction with their healthcare experience (Bonvicini, 2017).
According to Bonvicini (2017), “patient satisfaction is significantly enhanced when all members
of the healthcare team communicate respectfully and sensitively with patients” (p. 2359).
Considering the effect of the physical environment on health outcomes, patient
satisfaction, and on the unique healthcare needs of LGBTQIA+ individuals, enhancing clinical
spaces where LGBTQIA+ individuals can receive safe and inclusive healthcare is vital (McClain
et al., 2016). Because safe and healing clinical spaces are especially important to LGBTQIA+
individuals, creating such spaces should have two foci: the environment and the provider
(McClain et al., 2016). By creating safe and inclusive clinical spaces free from discrimination
and judgement, LGBTQIA+ individuals are afforded an opportunity to receive quality
comprehensive healthcare in an entirely “out” environment. Seeking healthcare in an entirely
“out” environment will positively affect health outcomes and increase patient satisfaction among
LGBTQIA+ individuals.
Viewed as safe and welcoming spaces where stigma and bias are absent, inclusion clinics
offer LGBTQIA+ individuals with a sense of community (McClain et al., 2016). Highlighting
their specialized attention on the LGBTQIA+ community, inclusion clinics strive to establish the
warmest and culturally competent settings for LGBTQIA+ individuals. Inclusion clinics also
strive to offer LGBTQIA+ individuals an LGBTQIA+ patient centric and patient friendly
environment. Because these environments aim at improving patient satisfaction and providing
the LGBTQIA+ community with sensitive, quality health and wellness services, the overall
physical, emotional, and social well-being of LGBTQIA+ individuals may be enriched.
Background of the Problem

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According to HealthyPeople.gov (2021), achieving the highest degree of health for all
individuals is health equity defined. It is achieved by abating the pervasive inequalities,
injustices, and health disparities that still exist, and it requires valuing each individual equally
(HealthyPeople.gov, 2021). “The absence of disease does not automatically equate to good
health” (HealthyPeople.gov, 2021). Rather, according to World Health Organization [WHO]
(n.d.), “Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity”. “The enjoyment of the highest attainable standard of health is
one of the fundamental rights of every human being without distinction of race, religion, political
belief, economic or social condition” (WHO, 2017).
Before LGBTQIA+ individuals can achieve the highest degree of health, the systemic
roots of inequity must first be acknowledged (Peterson et al., 2020). According to Peterson et
al., (2020), health inequities are “the systematic and preventable differences in health outcomes
closely linked to social, economic, and environmental conditions” (p. 2). Health equity for
LGBTQIA+ individuals begins with eliminating social and structural inequalities, such as
oppression, discrimination, and stigmatization. The physical and mental health of individuals are
jeopardized when they are marginalized or encounter stigma or discrimination (WHO, 2017).
Achieving sustainable and comprehensive health equity for LGBTQIA+ individuals goes far
beyond the individual level. Rather, according to Keuroghlian et al., (2017), it will require a
significant societal shift to adequately address an array of adverse health outcomes experienced
by LGBTQIA+ individuals.
The Health Equity Framework focuses on health outcomes at the population level rather
than the individual level to raise and swing our understanding and attention to health equity
(Peterson et al., 2020). According to Peterson et al. (2020), “health equity is defined as having

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the personal agency and fair access to resources and opportunities needed to achieve the best
possible physical, emotional, and social well-being” (p. 1). To achieve health equity,
LGBTQIA+ individuals must be provided with equal access to resources and opportunities that
enable healthy lives (Peterson et al., 2020). The Health Equity Framework acknowledges equal
distribution of resources and opportunities, as well as access, are hindered by prejudices, such as
racism, sexism, homophobia, and transphobia (Peterson et al., 2020). Targeting these hindrances
is critical for LGBTQIA+ individuals to achieve health equity.
Health and social inequities are a consequence of cumulative experiences across the
lifespan (Peterson et al., 2020). Because LGBTQIA+ individuals encounter these inequities
across their lifespan, they require an approach to healthcare that can meet their unique health
needs (Goldhammer et al., 2018). Inclusion health is a promising approach that aims to remedy
the excessive health and social inequities felt by vulnerable and excluded individuals (Luchenski
et al., 2018). Focusing efforts on the unique health needs of LGBTQIA+ individuals through
inclusion health may reduce discrimination and stigma, as well as promote patient satisfaction,
empowerment, equality of care, and health equity.
Statement of the Problem
In spite of the considerable progress and recent advances that have been made in the
sociocultural-political landscape, the present-day healthcare environment remains markedly
influenced by social, political, and economic norms that perpetuate gender binaries,
heteronormativity, and discriminatory practices, rendering LGBTQIA+ individuals vulnerable
(Goldberg et al., 2018). Healthcare systems that continue to embrace gender binaries,
heteronormativity, and discriminatory practices as the assumed norms, further perpetuate the
pervasive harms suffered by LGBTQIA+ individuals (Goldberg et al., 2018). Vulnerable to a

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vast array of healthcare disparities and inequities based on their sexual orientation and gender
identity, LGBTQIA+ individuals, compared to gender binary and heterosexual individuals,
endure higher rates of health problems, both physical and mental, as well as poorer health
outcomes and health status.
Attention to these healthcare disparities and inequities that negatively impact the physical
and mental health of LGBTQIA+ individuals is vital in order for these individuals to gain
optimal physical, mental, and social well-being. With an extensive history of discrimination in
healthcare and a dearth of LGBTQIA+ competent environments and healthcare professionals,
there is a call for action to create environments where LGBTQIA+ individuals wish to seek
healthcare. Advocating for LGBTQIA+ inclusion health, as well as healthcare environments that
welcome, include, and protect LGBTQIA+ individuals will redress these disparities and
inequities and provide LGBTQIA+ individuals with access to safe and affirming, high-quality
healthcare (Keuroghlian et al., 2017).
PICO Question
Using the Population, Intervention, Comparison, and Outcomes (PICO) approach, the
following PICO question was formulated to further investigate this research topic and to guide
this study: Do LGBTQIA+ individuals who receive healthcare from LGBTQIA+ inclusion
clinics feel more satisfied with their healthcare than those LGBTQIA+ individuals who receive
healthcare from traditional clinics? Following the PICO approach, the Population of interest is
LGBTQIA+ individuals, the Intervention is inclusion healthcare clinics, the Comparison is
traditional healthcare clinics, and the Outcome is patient satisfaction.
Hypothesis

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It was hypothesized that (H1) LGBTQIA+ individuals receiving healthcare from
LGBTQIA+ inclusion clinics will have greater satisfaction with their healthcare compared to
LGBTQIA+ individuals receiving healthcare from traditional clinics. In this case, the null
would be rejected. The null hypothesis that was tested was that (H0) LGBTQIA+ individuals
receiving healthcare from LGBTQIA+ inclusion clinics will not have greater satisfaction with
their healthcare compared to LGBTQIA+ individuals receiving healthcare from traditional
clinics. In this case, the null would be accepted.
Definition of Terms
Operational Terms
1. LGBTQIA+ represents lesbian, gay, bisexual, transgender, questioning or queer,
intersex, and asexual individuals. The “+” signifies the diversity and inclusivity within
the LGBTQ community and encompasses individuals of all genders and sexualities
(Goldberg et al., 2018).
2. Cisgender is defined as a person who identifies as their sex assigned at birth (Jennings et
al., 2019).
3. Transgender is defined as a person whose gender identity differs from their sex assigned
at birth (Jennings et al., 2019).
4. Questioning is defined as an individual exploring and considering his or her sexual
orientation and gender identity (Bonvicini, 2017).
5. Intersex is defined as an individual whose anatomy is not solely male or female and
describes an individual who is born with sex chromosomes, external genitalia, or an
internal reproductive system that is not exclusively male or female (Bonvicini, 2017;
LGBT Center UNC-Chapel Hill, n.d.).

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6. Asexual is defined as someone who lacks feelings of sexual attraction toward individuals
of any gender and is considered a sexual orientation (LGBT Center UNC-Chapel Hill,
n.d.).
7. Gender Binary is defined as a person who identifies as either a male or female.
8. Gender Fluid is defined as being a person whose gender identity is not fixed (MerriamWebster, n.d.).
9. Gender Identity is defined as a person’s internal sense of being a man/male,
woman/female, both, neither, nor another gender (National LGBTQIA+ Health Education
Center, 2021).
10. Sexual Orientation is defined as how a person describes their attraction to others both
sexually and emotionally (National LGBTQIA+ Health Education Center, 2021).
11. Heteronormative is defined as heterosexuality as the natural expression of sexuality
(Merriam-Webster, n.d.).
Conceptual Terms
1. Health Inequity is defined as differences in health outcomes across sectors of the
population that are systematic, unfair, and avoidable (Penman-Aguilar et al., 2016).
2. Health Equity is defined as fairness and justice in health and the absence of that which is
inequitable (Penman-Aguilar et al., 2016).
3. Health Disparities are defined as differences in health or determinants of health that
unfavorably impact marginalized groups (Braveman et al., 2017).
4. Personal Agency is defined as self-agency and the sense of being in control of our actions
and the consequences they have on our lives (Owusu, 2021).

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5. Inclusive Healthcare is defined as healthcare that is specifically designed to
comprehensively meet the unique healthcare needs of the LGBTQIA+ community.
6. Traditional Healthcare is defined as healthcare that is not specifically tailored toward
meeting the unique healthcare needs of the LGBTQIA+ community.
Need for the Study
The need for this study aligned with Healthy People’s goal to “improve the health,
safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals”
(HealthyPeople.gov, 2021). The need for this study further aligned with Healthy People’s
expanded goal to attain health equity, remove disparities, and improve the health of all groups
(HealthyPeople.gov, 2021). According to Peterson et al., (2020), health equity is a public
health priority requiring health strategies that recognize the systemic origins of inequity.
Congruent with the Health Equity Framework, to advance toward health equity, improve
health outcomes, and effectively remove health disparities and inequities for LGBTQIA+
individuals, health equity approaches must consider the interplay of structural, relational,
individual, and physiological factors (Peterson et al., 2020).
Furthermore, the need for this study was to illustrate the necessity for LGBTQIA+
culturally affirming healthcare environments that welcome, include, and protect LGBTQIA+
individuals (Keuroghlian et al., 2017). This study will close a gap in this field of research by
including marginalized voices on LGBTQIA+ inclusion health. According to HealthyPeople.gov
(2021), spanning the next decade, a multitude of LGBTQIA+ health-related concerns will require
continued evaluation and attention. These health-related concerns include the following:
•
•
•
•

Prevention of violence toward LGBTQIA+ individuals
Resilience amongst LGBTQIA+ individuals
Health and well-being for aging LGBTQIA+ individuals
Necessity for a LGBTQIA+ model of wellness

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27

As deemed medically necessary, identification of transgender health needs

Approaches to further close the gaps in health disparities and inequities specific to
LGBTQIA+ individuals and advance toward equitable and inclusive care must be identified
and explored further.
Significance of the Problem
LGBTQIA+ individuals face various health concerns because of their sexual
orientation and gender identity (Ekmekci, 2017). More specifically, as sexual- and gender
minorities, they experience disparities and inequities in health outcomes due to unfair access to
resources that foster positive physical, mental, and social health. Such resources include
education, health services, support systems, safe environments, and social capital (Peterson et al.,
2020).
No one facing health concerns should also have to worry about receiving inequitable or
substandard care because of their LGBTQ status. Yet many LGBTQ Americans
experience these challenges when seeking health care, which can intensify whatever
worries they may have about their health (Healthcare Equality Index [HEI], 2020).
According to the HEI 2020 Report, 56% of lesbian, gay, or bisexual patients, and 70% of
transgender or gender non-conforming patients reported having experienced some level of
discrimination in healthcare, and 29% and 73% respectively, reported that they believed they
would be treated differently by healthcare professionals due to identifying as LGBTQ (HEI,
2020). Consequently, it is crucial that the provision of healthcare for LGBTQIA+ individuals be
equitable, knowledgeable, sensitive, and welcoming, as well as free from discrimination (HEI,
2020).

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There is an urgent need to provide inclusive, high-quality health services to LGBTQIA+
individuals so they can achieve the highest possible level of health (National LGBTQIA+ Health
Education Center, 2016). If inclusive, high-quality health services are not accessible,
LGBTQIA+ individuals will continue to experience disparities and inequities in health outcomes,
both physical and mental, compared to their heterosexual and cisgender counterparts (Valdiserri
et al., 2019). LGBTQIA+ individuals can suffer life-long health disparities if their health is
neglected and their unique healthcare needs are marginalized (“Meeting the Unique Health-care
Needs,” 2016). Eliminating LGBTQIA+ health disparities and enhancing efforts to improve
LGBTQIA+ health are necessary to ensure that LGBT individuals can lead long, healthy lives
(HealthyPeople.gov, 2021).
Assumptions
For this study, it was assumed that LGBTQIA+ inclusive healthcare would eliminate
health inequities and disparities, as well as promote social justice and health equity for
LGBTQIA+ individuals. It was also assumed through inclusion health that the unique
healthcare needs of LGBTQIA+ individuals would be adequately met. Further, it was
assumed that LGBTQIA+ individuals receiving inclusive healthcare, rather than non-inclusive
healthcare, would result in greater patient satisfaction, access to high-quality healthcare, and
improved health outcomes. Another assumption was that through welcoming, culturally
affirming, and inclusive healthcare, LGBTQIA+ individuals would have improved physical,
mental, and social health, safety, and well-being. Last, it was assumed that all individuals
who participated in this on-line questionnaire study were members of the LGBTQIA+
community and answered the questionnaire honestly.
Summary of the Problem

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The LGBTQIA+ community is one that is multilayered, of great complexity, and
profoundly diverse. Encompassing all walks of life, at present, it is estimated that 5.6% of
U.S. adults either self-describe or self-identify as LGBTQIA+. Despite equal rights efforts,
LGBTQIA+ individuals remain vulnerable and continue to encounter considerable social and
structural inequalities, such as discrimination, exclusion, oppression, and stigmatization. These
pervasive social and structural inequalities persist as major barriers to high-quality healthcare
and place LGBTQIA+ individuals at significant risk for disparities in health outcomes due to
their sexual orientation and gender identity.
Mitigating these health-related disparities and meeting the unique healthcare needs of
LGBTQIA+ individuals necessitates healthcare settings that are inclusive, safe, and welcoming,
and healthcare professionals that are LGBTQIA+ culturally competent. Creating an inclusive,
safe, and welcoming environment in which LGBTQIA+ individuals can establish trust and open
and honest communication with their healthcare providers can improve provision of care, patient
satisfaction, and ultimately their health and well-being (National LGBTQIA+ Health Education
Center, 2016). The following chapter discusses the review of the literature on this study topic.
Chapter 2
Review of the Literature
To establish the value of previous research on LGBTQIA+ health and health-related
disparities and inequities, a comprehensive literature search and critical appraisal were
conducted. The guiding PICO question for this literature review and synthesis was: Do
LGBTQIA+ individuals who receive healthcare from LGBTQIA+ inclusion clinics feel more
satisfied with their healthcare than those LGBTQIA+ individuals who receive healthcare from
traditional clinics? Three major themes emerged as a result of this literature review: life course

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health disparities; healthcare access and utilization; and cultural competence. These three
themes, along with this study’s guiding theoretical framework, the Health Equity Framework, are
discussed in this chapter.
Literature Search
Several on-line databases and resources were used to conduct the electronic literature
search. Electronic databases included APA PsycInfo, Business Source Complete, Cumulative
Index to Nursing and Allied Health Literature (CINAHL), Directory of Open Access Journals,
EBSCOhost, Education Source, Google Scholar, Humanities Source, MEDLINE Complete
PubMed, and SocINDEX. The electronic literature search was filtered by peer-reviewed, by
publication date from 2016 to 2021, academic journal, subject (i.e., LGBT), and English
language. Using the keywords “LGBTQ health”, “barriers to LGBTQ healthcare”, “LGBTQ
healthcare disparities”, “sexual minority health disparities”, “LGBTQ perceptions of health”,
“LGBTQ healthcare access”, “LGBTQ supportive healthcare environments”, “LGBTQ
vulnerable”, “vulnerable populations in healthcare LGBTQ”, “unique healthcare needs of
LGBTQ”, “holistic care”, “patient-centered care”, “LGBTQ inclusion health”, “LGBTQ focused
healthcare”, “LGBTQ specific clinics”, “lack of competent inclusive LGBTQ healthcare”,
“LGBTQ competent healthcare providers”, “LGBTQ culturally competent healthcare”, “health
equity”, “LGBTQ health equity”, “LGBTQ health inequalities” and “health equity framework”
in the search criteria yielded 42 results.
Inclusion Criteria
Inclusion criteria were based on the PICO framework of this study. Only articles that met
the inclusion criteria were included in the literature review. Inclusion criteria included articles
that were full-text articles, were undertaken in the past five years from 2016 to 2021, have been

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peer reviewed, have appeared in academic journals, published in the English language, and were
relevant to the research topic of this study. Articles that did not meet the inclusion criteria were
excluded from the literature review.
Critical Appraisal
Following further evaluation, synthesis, and critical appraisal of the research articles, 22
articles were eliminated from the literature review and 20 articles that were relevant to the
research topic of this study were included and used in the final literature review. Research
articles reviewed and synthesized bring relevance to the PICO question under investigation.
Life Course Health Disparities
Based on a review of the current literature, research suggests across their life course,
LGBTQIA+ individuals are confronted with a plethora of health disparities (Goldhammer et al.,
2018). In part, these health disparities may be further precipitated by biases of healthcare
providers (Morris et al., 2019). Further, compared to heterosexual and cisgender individuals,
LGBTQIA+ individuals endure significant disparities in physical and mental health outcomes
(Valdiserri et al., 2019). They are plagued with higher rates of anal cancer, asthma,
cardiovascular disease, obesity, substance abuse, cigarette smoking, and suicide (Morris et al.,
2019). Additionally, there are fewer lifetime Pap tests reported by sexual minority females
(Morris et al., 2019). Lower healthcare utilization by LGBTQIA+ individuals may further
contribute to these disparities in physical and mental health outcomes (Morris et al., 2019).
Mitigating these life course health disparities experienced by LGBTQIA+ individuals will call
for expanded access to LGBTQIA+ inclusive healthcare (Goldhammer et al., 2018).
The literature also suggests that shared experiences amongst LGBTQIA+ individuals,
such as perceived discrimination from healthcare providers and overt refusal of healthcare, may

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also contribute to disparities in healthcare access and health outcomes (Morris et al., 2019).
According to Morris et al. (2019), “implicit physician biases may result in LGBTQ patients
receiving a lower standard of care or restricted access to services as compared to the general
population” (p. 2). In a study conducted by Dorsen and Van Devanter (2016), nurse
practitioner’s attitudes toward working with LGBTQIA+ patients were examined, and although
study results illustrated their desire to provide quality care to LGBTQIA+ individuals, they
reported having conflicting attitudes about caring for these patients. Attitudes varied from open
and accepting, to uncomfortable and uncertain. More specifically, they reported having
insecurities regarding their lack of knowledge to provide appropriate care to LGBTQIA+
individuals (Dorsen & Van Devanter, 2016).
According to Goldberg et al. (2018), “LGBTQ+ identities thus continue to be unsettling
and disrupting for many nurses and health care providers; they evoke discomfort; they can
disarm and disquiet” (p. 264). Biases of healthcare providers are linked to inequitable access to
healthcare, reduced quality of care, and less favorable physical and mental health outcomes
(Morris et al., 2019). To ensure they do not play a part in the healthcare disparities LGBTQIA+
individuals contend with, healthcare providers must acknowledge and direct their attention to
their own biases (Morris et al., 2019).
Healthcare Access and Utilization
LGBTQIA+ individuals are challenged with numerous obstacles when accessing quality
and timely healthcare (Margolies & Brown, 2019). In contrast to heterosexual and cisgender
individuals, LGBTQIA+ individuals are twice as likely to be uninsured and, in most cases, do
not have a regular healthcare provider (Margolies & Brown, 2019). According to Morris et al.
(2019), access to healthcare for transgender youth is challenging and LGBTQIA+ individuals,

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even when medical care is needed, are less apt to seek care. Jennings et al. (2019) concluded,
compared to non-LGBTQIA+ individuals, LGBTQIA+ individuals faced detrimental differences
in healthcare access and utilization and in the quality level of the healthcare they received.
Further, Jennings et al. (2019) reported transgender respondents had a greater tendency to
postpone seeking healthcare, as they were 2.76 times more likely to receive subquality healthcare
and to be discriminatorily treated when seeking healthcare compared to cisgender respondents.
The demand for improving healthcare access and utilization for LGBTQIA+ individuals cannot
be underestimated (Ortelli, 2020). To promote health equity and encourage healthcare
utilization, improved access to high-quality healthcare for LGBTQIA+ individuals is warranted
(Jennings et al., 2019).
Data from the literature reveals LGBTQIA+ individuals face an array of issues and
profound disadvantages in terms of access to healthcare because of their sexual orientation and
gender identity (Ekmekci, 2017). In a study conducted by Giri et al. (2019), 42.5% of the study
participants reported fear of being discriminated against by healthcare staff on the basis of their
sexual orientation and gender identity. LGBTQIA+ individuals describe observing deleterious
attitudes and behaviors from their healthcare provider upon disclosure of their sexual orientation
and gender identity, and recent research has clarified that healthcare providers express feelings of
conflict when asking questions about sexual orientation (Kuzma et al., 2019; Margolies &
Brown, 2019). Results of a study conducted by Goldhammer et al. (2018) discovered 55.4% of
clinicians surveyed disclosed they infrequently inquired about a patient’s sexual orientation, or
not all, and 71.9% infrequently inquired about a patient’s gender identity.
Additional obstacles to accessing healthcare for these individuals include scarcity of
culturally sensitive and competent healthcare providers, as well as scarceness of LGBTQIA+

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inclusive clinics (Qureshi et al., 2018). In a study conducted by Banerjee et al. (2018) to assess
healthcare providers’ knowledge concerning caring for LGBTQIA+ individuals, of those
healthcare providers surveyed, only 4.6% could correctly answer all knowledge questions,
signifying that healthcare providers possess substantial knowledge gaps. The delivery of
culturally competent healthcare is of particular importance to LGBTQIA+ individuals, as health
disparities they experience are in part a result of poor cultural competence amongst healthcare
professionals (Ruben, 2017).
An essential component of the healthcare environment for LGBTQIA+ individuals is
LGBTQIA+ inclusion health, but access to quality healthcare remains a significant obstacle to
utilization for these individuals (Martos et al., 2019). Confronted with a lengthy history of
socially mediated stigma and systemic discrimination within the healthcare setting, LGBTQIA+
individuals avoid utilization of the healthcare system and seeking healthcare services. According
to Giri et al. (2019), approximately 60% of the study participants reported fear of mistreatment
by healthcare providers as the primary reason for delaying their medical treatment. The
corrosive and sustained effect of socially mediated stigma and systemic discrimination on health
outcomes of LGBTQIA+ individuals underscores the professional responsibility of healthcare
providers to create safe, affirming, and inclusive healthcare environments and to provide
culturally sensitive and competent care (Bonvicini, 2017; Morris et al., 2019).
Although research is limited on how LGBTQIA+ individuals utilize LGBTQIA+
inclusion clinics, these clinics offer alternative spaces where issues of stigma and discrimination
may be avoided (Martos et al., 2019). According to Luchenski et al. (2018), “inclusion health is
a service, research, and policy agenda that aims to prevent and redress health and social
inequities among the most vulnerable and excluded populations” (p. 266). Inclusive and

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culturally affirming care environments can increase LGBTQIA+ engagements in healthcare and
have the potential to greatly advance health outcomes for LGBTQIA+ individuals (Furness et al.,
2020).
Cultural Competence
Because LGBTQIA+ individuals have unique physical and mental health problems, there
is a need to understand how to improve healthcare quality and delivery for these individuals
(Ruben, 2017). One novel approach noted in the literature is the field of cultural competence
combined with cultural humility (Kuzma et al., 2019). According to Kuzma et al. (2019),
cultural humility encompasses reflecting on one’s own knowledge, beliefs, and attitudes,
building partnerships with LGBTQIA+ patients and learning from them, committing to ongoing
personal and professional growth, and considering one’s own conscious and unconscious biases.
Cultural humility prepares healthcare personnel to rid themselves of their personal biases and to
take an inclusive, holistic, and patient-centered approach to caring for LGBTQIA+ individuals.
In contrast, cultural competence comprises a vast array of aptitudes, including cultural
knowledge, welcoming attitudes toward the LGBTQIA+ community, and the adeptness to
effectively communicate with this community, respectively (Margolies & Brown, 2019).
Cultural competence lays a firm foundation for learning about the unique physical, mental, and
social health problems suffered by the LGBTQIA+ community, but alone, it does not adequately
provide healthcare personnel with the appropriate cultural perspective concerning this vulnerable
population (Kuzma et al., 2019).
According to Bonvicini (2017), “in the effort to reduce health disparities between specific
patient populations, cultural competence and cultural humility programs have been the primary,
yet broadly defined approach for training interventions for clinicians and healthcare personnel”

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(p. 2358). To adequately address cultural and health-related issues specific to the LGBTQIA+
community, cultural competence and cultural humility must be employed by healthcare
personnel in tandem, as these two approaches work synergistically and are necessary to deliver
culturally congruent care to LGBTQIA+ individuals (Kuzma et al., 2019).
Cultural Competency Education and Training
Cultural competency education and training concentrating on clinical assessment and
treatment of LGBTQIA+ individuals is lacking for healthcare professionals across disciplines
and creating a supportive environment that is non-judgmental and welcoming for all patients
requires all members of the healthcare team to be properly educated and trained (Bonvicini,
2017). To reduce the healthcare disparities felt within the LGBTQIA+ community, the profound
knowledge gap in cultural competency that still exists must be closed. Healthcare providers are
long overdue for cultural competency education and training that will enrich their professional
development and shape their knowledge, attitudes, and beliefs toward LGBTQIA+ individuals
(Bonvicini, 2017).
Medical Education
A key driver in increasing physicians’ awareness and sensitivity toward LGBTQIA+
individuals is knowledge of LGBTQIA+ healthcare, yet substantial knowledge gaps and gaps in
practice suggest the need for more education and training for physicians (Banerjee et al., 2018;
Goldhammer et al., 2018). In spite of growing efforts to incorporate LGBTQIA+ specific
content into medical school curricula, education on LGBTQIA+ health in medical school is still
lacking (Goldhammer et al., 2018). In fact, approximately a third of medical schools in the U.S.
reported 0 h of LGBTQIA+ specific content (Bonvicini, 2017, as cited in Obedin-Maliver et al.,
2011). Julia Applegate from Equitas Health was quoted in an article published by Marbury

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(2017) and stated, “On average, medical providers receive five hours of LGBT cultural
competence training in their entire medical education”. Congruent with the current literature,
studies conducted nationally have found that LGBTQIA+ specific content in medical school and
residency programs is profoundly scarce (Goldhammer et al., 2018).
Education and training on LGBTQIA+ health for physicians in the clinical environment
are scarce as well (Goldhammer et al., 2018). Sixteen percent of academic medical institutions
in the U.S. provided cultural competence education and training, and more than half provided no
training (Goldhammer et al., 2018, as cited in Khalili et al., 2015). In an organizational needs
assessment conducted by Goldhammer et al. (2018), 20% of physicians conveyed unfamiliarity
with LGBTQIA+ health issues. Such scarcities in cultural competence education and training for
physicians could be the result of a number of barriers, including ineffective curricular materials,
lack of trained faculty, limited instruction time, perception by faculty that LGBTQIA+ specific
content is irrelevant, and the absence of LGBTQIA+ specific content on medical boards
(Bonvicini, 2017, as cited in Tamas et al., 2010). Cultural competence education and training are
critical next steps in increasing physicians’ awareness and sensitivity toward LGBTQIA+
individuals.
Nursing Education
The discipline of nursing is the largest discipline amongst healthcare professionals.
Consequently, this puts nursing professionals in a prime position to exceedingly impact the
healthcare experiences of LGBTQIA+ individuals (Ortelli, 2020). The degree to which
LGBTQIA+ specific healthcare issues are incorporated into nursing school curricula is unclear
(Bonvicini, 2017). Disappointingly, nursing students receive an average of 2.13 hours of
LGBTQIA+ related content across their entire nursing school curriculum, leaving several nurses

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poorly educated on the delivery of LGBTQIA+ culturally competent and sensitive healthcare
(Kuzma et al., 2019, as cited in Lim et al., 2013; Ortelli, 2020). Findings from a study of
practicing nurses illustrated most had not received any education or training in LGBTQIA+
health (Margolies & Brown, 2019, as cited in Carabez et al., 2015). In a study conducted by
Dorsen and Van Devanter (2016), study participants noted no recollection of LGBTQIA+
cultural competence content in their undergraduate or graduate nursing programs. Study
participants also noted that they did not learn about LGBTQIA+ health in their clinical training.
These findings may in part be due to nursing educators being uncomfortable with and illprepared to deliver such content, as 72% reported being unprepared (Bonvicini, 2017, as cited in
Sirota, 2013). This gap in knowledge may to some extent elucidate the claim that the nursing
profession has historically disregarded LGBTQIA+ health-related needs and concerns (Ortelli,
2020).
Lack of cultural competency education and training hinders nurses’ ability to provide
high-quality healthcare to LGBTQIA+ individuals. However, “the literature is unclear about
what constitutes best practices and acceptable measures for evaluating LGBT competency
training” (Bonvicini, 2017, p. 2359). According to Jennings et al. (2019), to redress health
disparities amongst LGBTQIA+ individuals, additional research must be conducted on how to
construct and deploy interventions that improve training in caring for persons that self-describe
and self-identify as LGBTQIA+ for nursing professionals.
A study conducted in 2015 revealed that nursing professionals possessed implicit
heteronormative preferences (Margolies & Brown, 2019, as cited in Sabin et al., 2015). Even
well-intended nurses, ones that believe they treat all patients the same regardless of their sexual
orientation and gender identity, have not received adequate cultural competence education and

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training (Margolies & Brown, 2019). If nurses are not adequately educated and trained about the
unique healthcare needs of LGBTQIA+ individuals, they might, as a consequence, harbor poor
attitudes and discomfort toward caring for LGBTQIA+ individuals, as well as condone
stereotypes (Margolies & Brown, 2019). To provide LGBTQIA+ individuals with high-quality
healthcare, LGBTQIA+ culture, language, and healthcare barriers must be well understood by
nursing professionals (Margolies & Brown, 2019, as cited in Margolies & Brown, 2018).
Non-Clinical Staff Training
Creating a culturally competent and inclusive healthcare environment for LGBTQIA+
individuals requires the involvement of all members of the healthcare team, including the
involvement of non-clinical staff from the parking lot attendant to the custodian. Patients’
healthcare experiences begin the moment they arrive to the healthcare facility. “From the
patient’s perspective, every interaction contributes to the care experience beginning with the
security guard at the hospital or clinic entrance, front office staff for registration, medical
assistants, nurses, technicians, physicians, and billing staff” (Bonvicini, 2017, p. 2359). To
guarantee the most optimal healthcare experience for LGBTQIA+ individuals, it is essential that
non-clinical staff members receive cultural competency education and training. Ensuring all
members of the healthcare team both clinical and nonclinical are appropriately and adequately
trained will translate into patient-centered care and improved patient satisfaction.
Theoretical Framework
The Health Equity Framework developed by ETR, a not-for-profit organization dedicated
to improving health outcomes and promoting health equity (ETR.org, n.d.), was selected as the
theoretical framework to guide this study and to guide this study’s PICO question under
investigation: Do LGBTQIA+ individuals who receive healthcare from LGBTQIA+ inclusion

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clinics feel more satisfied with their healthcare than those LGBTQIA+ individuals who receive
healthcare from traditional clinics?
Background
According to Peterson et al. (2020), “health equity is a public health priority” (p. 1).
However, according to research, present strategies to mitigate health disparities and inequities
may be difficult for researchers and health professionals to adopt and may not gain public
endorsement. Because present strategies fail to recognize the systemic roots of inequity, these
health strategies often do not succeed in mitigating health disparities and inequities (Peterson et
al., 2020). Consequently, to guarantee joint efforts of researchers and health professionals
exemplify mutual views and opinions in reducing health disparities and advancing equity,
gaining clarity on present health equity strategies is crucial (Peterson et al., 2020). Necessitating
a single framework based on shared assumptions and practices, the Health Equity Framework
was formulated to improve inequities of priority health outcomes.
The Health Equity Framework
The Health Equity Framework as shown in Appendix A is a science- and justice-based
framework that demonstrates how health outcomes are influenced by complex interactions
between individuals and their environments and highlights how cumulative experiences across
the life-course give rise to health inequities (Peterson et al., 2020). Designed to address health
inequities and advance health equity, the Health Equity Framework focuses on three core
constructs: equity at the core of health outcomes; multiple, interacting spheres of influence; and a
historical and life-course perspective (Peterson et al., 2020).
Development of Framework

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The Health Equity Framework was developed as a unifying framework to support
researchers and health professionals in employing a health equity strategy that would effectively
address social determinants of health, decrease health disparities and inequities, improve health
outcomes, and promote health equity (Peterson et al., 2020). The Health Equity Framework was
developed in two phases (Peterson et al., 2020). During the first phase of development,
researchers and health professionals evaluated several theoretical and conceptual frameworks
that studied influences on health at various levels. Influences such as socio-political,
neighborhood and community, family and relationships, and development of biology were
studied. The advantages and disadvantages of these frameworks were discussed, and the
researchers and health professionals could not reach consensus, as no one framework met their
criteria. Therefore, features from a number of frameworks were modified to develop a single
and simplistic framework to describe and investigate strategies to address social determinants of
health (Peterson et al., 2020).
During the second phase of development, frequent interviews occurred with stakeholders
in health equity, public health, and social science (Peterson et al., 2020). “The interviews
centered on conceptual understanding of the framework and its functionality in application in
research and practice” (Peterson et al., 2020, p. 2).
Foundational Concepts of Framework
The Health Equity Framework focuses on three core concepts: equity at the core of health
outcomes; multiple interacting spheres of influence; and a historical and life-course perspective
(Peterson et al., 2020). The Health Equity Framework encourages researchers and health
professionals to think beyond traditional approaches in addressing health inequities and to

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42

recognize the interplay between structural, relational, individual, and psychological factors as the
systemic roots of inequity (Peterson et al., 2020).
Equity at the Core of Health Outcomes. Health equity, as defined by the Health Equity
Framework, is possessing the personal agency and just access to resources and opportunities
necessary to reach optimal physical, emotional, and social health (Peterson et al., 2020).
Conversely, according to ETR (n.d.), “health inequities are the preventable differences in health
outcomes closely linked to social, economic, and environmental conditions”. Historically,
interventions aimed at modifying an individual’s personal agency to achieve optimal health
outcomes (Peterson et al., 2020). Unfortunately, modifying an individual’s personal agency
alone was not sufficient, as this approach neglected to address the upstream social determinants
that prohibited individuals and communities from achieving the best possible health and wellbeing (Peterson, et al., 2020). Rather, acknowledging that resources and opportunities are
inequitably distributed amongst communities and access is thwarted by institutional and
interpersonal prejudices, interventions must be aimed at modifying factors at a community level
to shift our focus to health equity (Peterson, et al., 2020). If left unrectified, health inequities and
suboptimal health outcomes will endure.
Spheres of Influence. Unlike other theoretical or conceptual frameworks where factors
that impact health outcomes are either stratified or demonstrate pathways from factors to health
behaviors, the Health Equity Framework illustrates four interconnected and interacting spheres
of influence that shape health outcomes and inhibit or advance health equity and health inequities
(Peterson et al., 2020). These four intersecting spheres of influence include systems of power,
relationships and networks, individual factors, and physiological pathways. They embody both

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risk factors and protective factors that determine health outcomes, as well as represent strategies
and interventions that address those factors (Peterson et al., 2020).
Systems of Power. Distribution and access to resources and opportunities necessary to
live healthy lives are governed by systems of power, which refers to policies, processes, and
practices (Peterson et al., 2020). These policies, processes, and practices comprise both
institutionalized and interpersonal signs of prejudice and perpetuate systematic and differential
treatment amongst populations (Peterson et al., 2020). Though systems of power may foster
health equity through unbiased access to resources and opportunities, they may conversely
exacerbate health inequities through the allowance of biased social, economic, or environmental
advantages for some populations, undermining fair access to resources and opportunities that
afford populations the ability to live healthy lives (Peterson et al., 2020).
Relationships and Networks. The numerous associations and support systems comprised
of family, friends, loved ones, and communities concurrently act as protective measures from
behaviors that are detrimental to an individual’s health, as well as sources that reinforce stigma,
discrimination, or social pressure that result in worse health outcomes (Peterson, et al., 2020).
Although social networks may facilitate health equity through support structures that ease the
social handicap generated by systems of power, they may simultaneously worsen health
outcomes either by the adverse effects of these social networks, or the social pressures to
participate in risky behaviors that are health-harming (Peterson et al., 2020).
Individual Factors. Frequently driven by other spheres of influence such as systems of
power, an individual’s attitudes, skills, and behaviors are molded by their personal experiences
and affect how they respond to social, economic, and environmental situations (Peterson et al.,
2020). There is a strong correlation between improved health outcomes, greater life satisfaction,

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and longer life expectancy when an individual possesses healthy social and emotional skills such
as relationship skills and coping skills (Peterson et al., 2020).
Physiological Pathways. The Health Equity Framework acknowledges an individual’s
biological, physical, cognitive, and psychological aptitudes make a significant contribution to
health outcomes (Peterson, et al., 2020). However, these aptitudes cannot be simplistically, or in
certain instances, ethically altered through intervention. In a similar vein, the Health Equity
Framework also acknowledges how other determining factors, and their respective timing and
intensity may change biological, physical, cognitive, and psychological progression, which will
lead to poor health outcomes (Peterson et al., 2020).
Historical and Life-Course Perspective. The Health Equity Framework emphasizes the
effects the historical and developmental stages of the lifespan, from infancy, through
adolescence, to adulthood, have on forming an individual’s attitudes, behaviors, and outcomes
(Peterson, et al., 2020). The Health Equity Framework also underscores that health inequities are
a consequence of culminating factors throughout an individual’s lifetime and spans generations.
Applicability of Framework to Doctor of Nursing Practice
According to Braveman et al. (2017), “health equity means that everyone has a fair and
just opportunity to be as healthy as possible” (p. 1). Providing LGBTQIA+ individuals with an
equal opportunity to live the best life possible involves eliminating the most ubiquitous barrier to
LGBTQIA+ health, discrimination. Although recognition and acceptance of LGBTQIA+
individuals has increased, discrimination remains a major issue for these individuals, as many
have reported encountering some degree of discrimination when seeking healthcare services
(ANA, 2018).

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According to the Robert Wood Johnson Foundation [RWJF] (n.d.), “discrimination has
been widely shown to have significant, harmful effects on health and well-being”. In a study
conducted by the Harvard T.H. Chan School of Public Health, RWJF, and National Public Radio
(NPR), findings revealed extensive encounters of both institutional and individual discrimination
amongst LGBTQIA+ Americans because of their LGBTQIA+ identity (RWJF, n.d.). More
specifically, of the 489 LGBTQIA+ adults surveyed, 18% reported avoiding healthcare
altogether in fear of being discriminated against (RWJF et al., 2017). Transgender individuals
also reported extensive encounters of discrimination, as 22% reported avoiding healthcare
altogether and 31% reported having no regular doctor or form of healthcare (RWJF et al., 2017).
Despite recent advances in equality for LGBTQIA+ individuals, the LGBTQIA+
community remains an excluded and marginalized population. LGBTQIA+ individuals have
been pushed to society’s margins, often suffering discrimination, exclusion, and marginalization
from society and the health promoting resources it has to offer (Braveman et al., 2017). “Health
disparities among LGB persons are attributed to the common experience of stigma and
marginalization, including that from healthcare providers and health institutions (Dorsen & Van
Devanter, 2016, p. 3716).
At the core of healthcare is the nurse-patient relationship, and regardless of an
individual’s sexual orientation or gender identity, nurses have a professional and an ethical duty
to practice with compassion and respect for the human rights of all LGBTQIA+ individuals
(ANA, 2018). According to Goldberg et al. (2018), “Nurses are guided by a code of ethics and a
commitment to provide equitable and ethically sensitive care” (p. 262). However, developing a
more authentic, compassionate, and politicized understanding of how to render LGBTQIA+
individuals visible in the context of their daily care is challenging (Goldberg et al., 2018).

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To decrease health disparities and achieve greater health equity for this marginalized
group, the Health Equity Framework can be integrated into nursing practice. Integrating the
Health Equity Framework into nursing practice will allow the nurse to adopt an unbiased,
science- and justice-based approach to caring for LGBTQIA+ individuals. Moreover, it will
allow the nurse to deliver culturally congruent, safe care and advocate for LGBTQIA+
individuals (ANA, 2018). To demonstrate cultural congruence and safe care, nurses must
advocate for equal access, services, and resources for LGBTQIA+ individuals (ANA, 2018). By
employing a health equity strategy into nursing practice that would effectively address social
determinants of health, decrease health disparities, and improve inequities of priority health
outcomes, nurses could provide LGBTQIA+ individuals with an equal opportunity to live the
best life possible.
Applicability of Framework to Study
Figure 1 below illustrates the applicability of the Health Equity Framework in creating
inclusive and equitable healthcare for LGBTQIA+ individuals. See Appendix A for complete
infographic of ETR’s Health Equity Framework and permission from ETR to reprint the Health
Equity Framework infographic in this study.
Figure 1
The Health Equity Framework Applied
Healthy relationships and robust
networks positively influence
health-promoting behaviors of
LGBTQIA+ individuals

Health equity is fostered through
unbiased access to LGBTQIA+
inclusive healthcare, affording
LGBTQIA+ individuals opportunities
to live healthy lives

Inclusive healthcare environments
build confidence, increase patient
engagement and satisfaction, and
decrease stress and anxiety amongst
LGBTQIA+ individuals

Inclusion health lessens stress and
trauma from oppression,
victimization, discrimination, and
stigma and improves health outcomes
among LGBTQIA+ individuals

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47

While healthcare is an immense policy matter that drives health outcomes for
LGBTQIA+ individuals at the population level, health equity policies that mitigate the effects of
big policies on health disparities for LGBTQIA+ individuals at the institutional level must be
endorsed as well (Peterson et al., 2020). To improve health outcomes for LGBTQIA+
individuals, the healthcare environment, and strategies to restore justice and equity must shift
healthcare practices toward repairing harm, elevating the voices of LGBTQIA+ individuals, and
improving the healthcare climate (Peterson et al., 2020).
Summary of the Review of Literature
Earlier research revealed LGBTQIA+ individuals continue to be threatened by stigma
and discrimination, plagued with an overabundance of health-related disparities and inequities,
and confronted with significant obstacles when accessing high-quality healthcare. As a result,
LGBTQIA+ individuals underutilize the healthcare system, underscoring the high demand for
LGBTQIA+ inclusion health services and culturally competent and sensitive healthcare
providers. The following chapter outlines the study’s methodology.
Chapter 3
Methodology
This study was an on-line questionnaire study aimed at evaluating the difference in
patient satisfaction scores between LGBTQIA+ individuals who receive healthcare from
LGBTQIA+ inclusion clinics and LGBTQIA+ individuals who receive healthcare from
traditional clinics. This chapter describes the methods and procedures that were used to
conduct this research study.
Study Design

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This study adopted a nonexperimental, nonrandom, cross-sectional study adhering to a
quantitative methodology.
Sample and Setting
This study was an on-line questionnaire study. Research subjects were located through
the Wisconsin LGBT Chamber of Commerce, the Outreach LGBT Community Center in
Madison, Wisconsin, and LGBTQIA+ on-line communities such as Oncology Nursing Society
Member Community and Facebook, an on-line social media and social networking service. A
nonrandom convenience sample of LGBTQIA+ individuals was selected from these respective
LGBTQIA+ organizations and on-line communities and invited to participate in this on-line
questionnaire study by way of Qualtrics, a web-based survey tool. The on-line survey link was
sent to these respective LGBTQIA+ organizations and on-line communities for dissemination
to their members. Snowball sampling by study participants was encouraged, and study
participants were instructed to share survey links with other potential study subjects. A
nonrandom convenience sample of 56 study participants (n=56) participated in this on-line
questionnaire study. Study inclusion criteria included self-describing or self-identifying as
LGBTQIA+, being a member of the LGBTQIA+ community, and being > 18-years old.
To determine an adequate sample size for this study, a power analysis was conducted. To
allow for a closer estimate of the sample size needed, preliminary calculations were conducted
at different values of d using G*Power (Faul et al., 2017). Based on preliminary calculations,
it was determined that an adequate sample size needed for this study with an estimated
cohen’s d of .5 (medium effect) was 210. This sample size would be needed to achieve a 95%
power rate, correctly rejecting our null hypothesis 95% of the time, with a p-value of .05
assuming equal sample sizes.

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Procedure and Ethical Considerations
To protect human study subjects from violation of human rights, study protocol review
and approval was obtained from Edinboro University’s Institutional Review Board (IRB)
prior to recruitment and participation of human subjects. Edinboro University’s IRB awarded
expedited review for this study protocol. The study protocol approval memo from the IRB is
available in Appendix B. Informed and written consent as shown in Appendix C was
obtained electronically from all study participants. The consent to participate in this research
study was embedded in the Qualtrics on-line survey. Prior to entering the on-line survey,
study participants were asked whether they consent to completing the survey. If study
participants answered yes, they were allowed to enter the survey. If study participants
answered no, the survey was discontinued.
Study participants were members of the LGBTQIA+ community and active members
of the Wisconsin LGBT Chamber of Commerce, the Outreach LGBT Community Center in
Madison, Wisconsin, LGBTQIA+ on-line communities such as Oncology Nursing Society
Member Community and Facebook, and potential referrals from other study participants.
Permission to distribute the on-line questionnaire to members of these respective organizations
was requested and obtained. Permission was requested from the Milwaukee LGBT Community
Center in Milwaukee, Wisconsin, the LGBT Center of Southeastern Wisconsin in Racine,
Wisconsin, and the University of Wisconsin – Milwaukee LGBT Resource Center to distribute
the on-line questionnaire, but permission was not granted
Following informed and written consent, study participants were asked to complete an
electronic version of the Short-Form Patient Satisfaction Questionnaire (PSQ-18). The
questionnaire was administered by way of Qualtrics, a web-based survey tool. The survey

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link was sent to the respective LGBTQIA+ organizations and on-line communities for
dissemination to their members as previously described. A cover letter as shown in Appendix
D describing the questionnaire, along with questionnaire instructions, was included. An
explanation regarding who qualifies as a “Doctor” was provided within the questionnaire at its
start. Similarly, an explanation of “Inclusion” health clinic was also provided when study
participants were asked whether they seek healthcare from an LGBTQIA+ inclusion health
clinic. Study participants’ consent to participate in this study was required to access the
questionnaire. Study participants must have been > 18-years old and self-described or selfidentified as LGBTQIA+.
Measure
The Short-Form Patient Satisfaction Questionnaire (PSQ-18) as shown in Appendix E
was utilized to evaluate the difference in patient satisfaction scores between LGBTQIA+
individuals who receive healthcare from LGBTQIA+ inclusion clinics and LGBTQIA+
individuals who receive healthcare from traditional clinics. The PSQ-18 is a public document
obtained from RAND Health Care and is available without charge. Permission from RAND
Health Care to use the PSQ-18 was not required. The PSQ-18 was derived from the Patient
Satisfaction Questionnaire (PSQ-III), which is a 50-item questionnaire evaluating universal
satisfaction with medical care, as well as satisfaction with six aspects of care (RAND Health
Care, n.d.). The six aspects of care include technical quality, interpersonal manner,
communication, financial aspects of care, time spent with doctor, and accessibility of care.
The short-instrument, the PSQ-18, retains many features of the PSQ-III (RAND Health
care, n.d.). It is a18-question instrument drawing from each of the seven aspects of satisfaction
with medical care measured by the PSQ-III: general satisfaction, technical quality, interpersonal

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manner, communication, financial aspects, time spent with doctor, and accessibility and
convenience (RAND Health Care, n.d.). The PSQ-18 uses a 5-point Likert-type scale where 1 is
strongly agree and 5 is strongly disagree. These 18 questions align well with the three
foundational concepts of the Health Equity Framework: equity at the core of health outcomes;
multiple, interacting spheres of influence; and a historical and life-course perspective (Peterson
et al., 2020). Each question of the PSQ-18 questionnaire is constructed as a statement of opinion
(RAND Health Care, n.d). The PSQ-18 takes nearly three to four minutes to complete.
The PSQ-18, although brief, is a comprehensive and effective instrument. According to
Thayaparan and Mahdi (2013), the PSQ-18 is a “concise, validated tool that may be applied to
various settings, as well as comparing interventions” (p. 1). Although derived and abridged from
much larger questionnaires, the PSQ-18 was developed through rigorous research, preserving
internal consistency and reliability (Thayaparan & Mahdi, 2013). According to RAND Health
Care (n.d.), its sub-scale scores are markedly associated with their full-scale counterparts,
illustrating acceptable internal consistency reliability. “Moreover, both the magnitude of the
correlation coefficients and the overall pattern of correlations among PSQ-18 sub-scales are
highly similar to those observed for the PSQ-III” (RAND Health Care, n.d.). Because the PSQ18 was validated in its entirety, the questionnaire was utilized as specified by the survey
developer, RAND Health Care.
Data Collection
Sociodemographic data and primary data were collected from 56 study participants
(n=56). Basic sociodemographic data such as sexual orientation, gender identity, age, race and
ethnicity, education level, employment status, income level, and insurance status was collected at
the completion of the PSQ-18 questionnaire. Study participants were also asked whether or not

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they self-described or self-identified as LGBTQIA+. This was designed as a logic question. If
the study participant answered yes, the survey advanced to the next question to ascertain the
respondent’s sexual orientation. If the respondent answered no, the sexual orientation question
was skipped. To maintain privacy and confidentiality, direct identifiers were not collected from
study participants, and anonymity was maintained. In addition to ascertaining basic
sociodemographic data, one researcher-generated question was used to determine whether study
participants receive healthcare from LGBTQIA+ inclusion clinics or from traditional clinics. To
organize and secure data, collected demographic data was coded and electronically exported into
an IBM SPSS Statistics Version 28 data sheet, stored there, and later used for data analysis.
The data collection procedure was conducted over a three-week period. Primary data
was collected using an electronic version of the PSQ-18 to evaluate the difference in patient
satisfaction scores between LGBTQIA+ individuals who receive healthcare from LGBTQIA+
inclusion health clinics and LGBTQIA+ individuals who receive healthcare from traditional
health clinics. This instrument was selected because it is a valid and reliable measure. The
PSQ-18 was used to measure overall satisfaction with medical care, as well as satisfaction with
seven aspects of care: overall satisfaction, technical quality, interpersonal manner,
communication, financial aspects of care, time spent with doctor, and accessibility of care. The
instrument is comprised of 18 questions using a 5-point Likert-type scale where 1 is strongly
agree and 5 is strongly disagree.
Primary data was collected electronically from enrolled study participants through
Qualtrics, a web-based survey tool, sent by way of a survey link to LGBTQIA+ community
organizations and on-line communities for dissemination to their respective members. Again,
to maintain privacy and confidentiality, direct identifiers were not collected from study

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53

participants, and anonymity was maintained. Survey administration, sampling, and scoring
guidelines provided by the survey developer, RAND Health Care, were followed. To
organize and secure data, the PSQ-18 data was coded and electronically exported into an IBM
SPSS Statistics Version 28 data sheet, stored there, and later used for data analysis.
Study Timeline
This study was completed over a three-week data collection period.
Summary of Methodology
This chapter outlined the methods and procedures that were used to answer whether
LGBTQIA+ individuals who receive healthcare from LGBTQIA+ inclusion clinics feel more
satisfied with their healthcare than those who do not receive healthcare from inclusion clinics.
The following chapter discusses this study’s data analysis procedure, results, and limitations.
Chapter 4
Results and Discussion
Given the paucity of research on whether the healthcare provided by LGBTQIA+
inclusion clinics results in improved patient satisfaction, this study sought to measure differences
in overall patient satisfaction between those who receive healthcare from LGBTQIA+ inclusion
clinics and those who receive healthcare from traditional clinics. The study results will be
discussed in this chapter.
Data Analysis
The data analysis employed both descriptive and inferential statistics. Sociodemographic
data was summarized and reported using descriptive statistics and frequencies. Descriptive
statistics were also used for patient satisfaction to test against assumptions for inferential
procedures. To test for differences in patient satisfaction amongst LGBTQIA+ respondents who

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54

receive healthcare from LGBTQIA+ inclusion health clinics and LGBTQIA+ respondents who
receive healthcare from traditional health clinics, the independent samples t-test was
conducted on each sub-scale and overall scale of patient satisfaction. In cases of assumption
violations, the nonparametric independent samples Mann-Whitney U test was completed instead
of the parametric independent samples t-test. To determine the relationship between high- and
lower-income earners and patient satisfaction, a point-biserial correlation was conducted. IBM
SPSS Statistics Version 28 statistical software was used to perform the statistical analysis. The
study used a two-tailed alpha level of .05 for all significance tests.
Missing Data
Fifty-six (n=56) of 60 total survey respondents completed the on-line survey in its
entirety for a response rate of 93%. Because sociodemographic information was not collected
from 4 respondents, their characteristics could not be described. With the exception of clicking
yes on the consent form and consenting to complete the survey, 4 observations were completely
missing. Therefore, these 4 respondents were removed from the dataset, as they did not
complete any section of the on-line survey.
Discussion of Results
Fifty-six study subjects (n=56) participated in this research study. Thirty-seven of the
fifty-six survey respondents (66.1%) indicated that they did not seek healthcare from
LGBTQIA+ inclusion clinics, whereas 25% of the fifty-six survey respondents indicated they did
seek healthcare from LGBTQIA+ inclusion clinics, or they were unsure (8.9%). This resulted in
an unbalanced design for the independent samples t-test. To determine if there is a statistically
significant difference in mean values between these two groups, the independent samples ttest was conducted on each sub-scale and overall scale of patient satisfaction. None of the

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55

sub-scale or overall scale comparisons tested were statistically significant using a two-tailed test
at α=.05. Study results indicated that there was too small a sample size to detect differences in
the population. For the Communications sub-scale, respondents who went to inclusion clinics
had significantly higher communication satisfaction than those who did not go to inclusion
clinics as illustrated by the nonparametric independent samples Mann-Whitney U test. The
distributions in the two groups significantly differed and had a small effect size. To determine
the relationship between high- and lower-income earners and patient satisfaction, a point-biserial
correlation was conducted. It was concluded that there was not a relationship between the two
variables, as there was a non-significant positive correlation between income and patient
satisfaction.
Sociodemographic Characteristics
As part of the on-line survey, basic sociodemographic data such as sexual orientation,
gender identity, age, race and ethnicity, education level, employment status, income level, and
insurance status was collected from 56 study participants (n=56). The sample that was collected
was primarily white 85.7% (n=48), highly educated, with high salaries. Fifty percent (n=28) of
the respondents reported having a Bachelor’s degree, 28.5% (n=16) of the respondents reported
having a Master’s degree, and 55.3% (n=31) earned salaries greater than $100,000 annually. In
the overall population, the majority of respondents 87.5% (n=49) identified as cisgender. None
of the survey respondents identified as transgender. One hundred percent (n=56) of the
respondents had health insurance. To describe demographic characteristics more effectively,
frequency distribution tables of demographic variables by clinic type with correlating graphs
for visualization are illustrated below in Tables 1 through 8 and Charts 1 through 8.

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 1
Frequency Distribution of Sexual Orientation of Survey Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+
inclusion health clinic?
Yes

Frequency

Percent

1

7.1

11

78.6

2

14.3

14

100.0

1

2.7

Asexual

1

2.7

Bisexual

3

8.1

Gay

12

32.4

Lesbian

19

51.4

1

2.7

37

100.0

Asexual

1

20.0

Gay

2

40.0

Lesbian
Total

2
5

40.0
100.0

Bisexual
Gay
Lesbian
Total

No

Pansexual
Total
Unsure

Chart 1
Sexual Orientation of Survey Respondents by Clinic Type (n=56)

56

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 2
Frequency Distribution of Gender Orientation of Survey Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+
inclusion health clinic?
Yes

5

35.7

Cisgender Male

9

64.3

14

100.0

Missing

3

8.1

Bigender

1

2.7

Cisgender Female

20

54.1

Cisgender Male

11

29.7

Genderqueer

1

2.7

Non-binary

1

2.7

37

100.0

Missing

1

20.0

Cisgender Female

2

40.0

Cisgender Male

2

40.0

Total

5

100.0

Total
Unsure

Percent

Cisgender Female

Total
No

Frequency

Chart 2
Gender Orientation of Survey Respondents by Clinic Type (n=56)

57

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 3
Frequency Distribution of Race/Ethnicity of Survey Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+ inclusion
health clinic?
Yes

No

Unsure

Frequency

Percent

Asian or Pacific Islander

1

7.1

Hispanic or Latino

1

7.1

White or Caucasian

12

85.7

Total

14

100.0

Asian or Pacific Islander

2

5.4

Hispanic or Latino

1

2.7

Multiracial or Biracial

2

5.4

Native American or Alaskan Native

1

2.7

White or Caucasian

31

83.8

Total

37

100.0

5

100.0

White or Caucasian

Chart 3
Race/Ethnicity of Survey Respondents by Clinic Type (n=56)

58

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 4
Frequency Distribution of Age of Survey Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+
inclusion health clinic?
Yes

Frequency

25-34 years old

3

21.4

35-44 years old

2

14.3

45-54 years old

6

42.9

55 or older

3

21.4

14

100.0

18-24 years old

1

2.7

25-34 years old

2

5.4

35-44 years old

8

21.6

45-54 years old

8

21.6

55 or older

18

48.6

Total

37

100.0

25-34 years old

1

20.0

35-44 years old

2

40.0

45-54 years old

1

20.0

55 or older

1

20.0

Total

5

100.0

Total
No

Unsure

Percent

Chart 4
Age of Survey Respondents by Clinic Type (n=56)

59

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60

Table 5
Frequency Distribution of Education Level of Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+ inclusion health
clinic?
Yes

Frequency
Some college, no degree

1

7.1

Bachelor’s degree (e.g. BA, BS)

8

57.1

Master’s degree (e.g. MA, MS, MEd)

5

35.7

14

100.0

Some college, no degree

3

8.1

Associate degree (e.g. AA, AS)

3

8.1

Bachelor’s degree (e.g. BA, BS)

19

51.4

Master’s degree (e.g. MA, MS, MEd)

10

27.0

2

5.4

37

100.0

Some college, no degree

1

20.0

Bachelor’s degree (e.g. BA, BS)

1

20.0

Master’s degree (e.g. MA, MS, MEd)

1

20.0

Professional degree (e.g. MD, DDS, DVM)

1

20.0

Doctorate (e.g. PhD, EdD)

1

20.0

Total

5

100.0

Total
No

Doctorate (e.g. PhD, EdD)
Total
Unsure

Percent

Chart 5
Education Level of Respondents by Clinic Type (n=56)

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 6
Frequency Distribution of Health Insurance Status of Survey Respondents by Clinic Type
(n=56)
Do you seek healthcare from a LGBTQIA+
inclusion health clinic?

Insured

Frequency

Percent

Yes

Yes

14

100.0

No

Yes

37

100.0

Unsure

Yes

5

100.0

Chart 6
Health Insurance Status of Survey Respondents by Clinic Type (n=56)

Table 7
Frequency Distribution of Employment Status of Survey Respondents by Clinic Type (n=56)

61

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

62

Do you seek healthcare from a LGBTQIA+ inclusion health
clinic
Yes

No

Frequency
Employed full time (40 or more hours per week)

Percent

11

78.6

Employed part time (up to 39 hours per week

1

7.1

Homemaker

1

7.1

Self-employed

1

7.1

Total

14

100.0

Employed full time (40 or more hours per week)

24

64.9

Employed part time (up to 39 hours per week

3

8.1

Retired

5

13.5

Self-employed

3

8.1

Student and Employed full time (40 or more

1

2.7

1

2.7

37

100.0

Employed full time (40 or more hours per week)

4

80.0

Unemployed and currently looking for work

1

20.0

Total

5

100.0

hours per week)
Unable to work
Total
Unsure

Chart 7
Employment Status of Survey Respondents by Clinic Type (n=56)

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Table 8
Frequency Distribution of Income Level of Survey Respondents by Clinic Type (n=56)
Do you seek healthcare from a LGBTQIA+
inclusion health clinic?
Yes

No

Percent

$20,000 to $34,999

1

7.1

$35,000 to $49,999

2

14.3

$50,000 to $74,999

1

7.1

Over $100,000

10

71.4

Total

14

100.0

Less than $20,000

1

2.7

$20,000 to $34,999

1

2.7

$35,000 to $49,999

2

5.4

$50,000 to $74,999

3

8.1

$75,000 to $99,999

7

18.9

Over $100,000

21

56.8

Total

35

94.6

2

5.4

37

100.0

$35,000 to $49,999

1

20.0

$50,000 to $74,999

1

20.0

Over $100,000

3

60.0

Total

5

100.0

Missing
Total
Unsure

Frequency

Chart 8
Income Level of Survey Respondents by Clinic Type (n=56)

63

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

64

Comparing Survey Respondents by Clinic Type
The PSQ-18 questionnaire was used to measure respondents’ overall level of satisfaction
with their healthcare using a 5-point Likert-type scale where 1 is strongly agree and 5 is strongly
disagree. The PSQ-18 measures seven aspects of satisfaction with medical care: general
satisfaction, technical quality, interpersonal manner, communication, financial aspects, time
spent with doctor, and accessibility and convenience (RAND Health Care, n.d.). Respondents
were asked whether they “seek healthcare from a LGBTQIA+ inclusion clinic”. Fourteen of the
56 respondents (n=56) indicated that they did seek care at a LGBTQIA+ inclusion clinic, and 37
of the 56 respondents (n=56) indicated that they did not seek care at a LGBTQIA+ inclusion
clinic. The remaining 5 respondents were unsure whether they sought care at a LGBTQIA+
inclusion clinic. Because 66.1% of respondents did not seek care at a LGBTQIA+ inclusion
clinic, this resulted in an unbalanced design for the independent samples t-test. This imbalance
is congruent with what is elucidated in the current literature. In a study conducted by Martos et
al. (2019), only 13% of LGBTQIA+ individuals surveyed reported utilizing LGBTQIA+
inclusion clinics in the past five years.
Assumption Check
The assumptions for the independent samples t-test were reasonably well met for most of
the comparisons. The normality assumption was met for all sub-scales and overall scale except
the Communication and Financial Aspects sub-scales. Communication and Financial Aspects
sub-scales as shown in Chart 9 had a negatively skewed distribution, thus leaning to the higher
end. The Levene’s test for equality of variances (see Table 9) was rejected for the Financial
Aspects sub-scale, therefore equal variances could not be assumed for this sub-scale.

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Chart 9
Normality Assumption of Scales
General Satisfaction Sub-scale

Technical Quality Sub-scale

Interpersonal Manner Sub-scale

Communication Sub-scale

Financial Aspects Sub-scale

Time Spent with Doctor Sub-scale

Accessibility and Convenience Sub-scale

Overall Scale

65

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

66

Table 9
Levene’s Test for Equality of Variances
Scale

Levene’s Statistic (F)

p value

General Satisfaction Sub-scale

.007

.935

Technical Quality Sub-scale

.008

.929

Interpersonal Manner Sub-scale

.261

.612

Communication Sub-scale

.058

.811

Financial Aspects Sub-scale

4.337

.043

Time Spent with Doctor Sub-scale

1.463

.232

Accessibility and Convenience Sub-scale

.004

.952

Overall Scale

.151

.699

Due to assumption violations, the Communication and Financial Aspects sub-scales were
tested using the nonparametric independent samples Mann-Whitney U test instead of the
parametric independent samples t-test. The Mann-Whitney U test is a nonparametric test that
has very few assumptions about the data. The test compares the difference between two
independent groups when the dependent variable is ordinal or continuous, but not normally

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

67

distributed. The test does not have an assumption for equality of variance, which makes this test
a good substitution for the Communication and Financial Aspects sub-scales. However, because
this is a nonparametric test, inferences cannot be drawn about the overall population of
LGBTQIA+ individuals that seek care at both inclusive clinics and traditional clinics. For these
sub-scales, the sample data can only be looked at and checked for differences at the sample level.
Due to this, caution must be exercised when interpreting the results of the nonparametric tests.
Parametric Independent Samples t-test
To test for differences in patient satisfaction between LGBTQIA+ respondents who
receive healthcare from LGBTQIA+ inclusion clinics and those who do not, the independent
samples t-test was conducted on each sub-scale and overall scale of patient satisfaction to
determine if there is a statistically significant difference in mean values between these two
groups. None of the sub-scale or overall scale comparisons tested were statistically significant
using a two-tailed test at α=.05 as shown in Table 10. Effect sizes were medium for General
Satisfaction, Interpersonal Manner, and Accessibility and Convenience sub-scales, as well as the
Overall scale. This indicated that there was too small a sample size to detect differences in the
population. To test this theory, achieved power was calculated using G*Power. The probability
to correctly reject the null hypothesis with this sample size is quite low. Four of the six scales
tested had between 34.22% and 37.52% chance of correctly rejecting the null hypothesis. The
Time Spent with Doctor sub-scale only had a 7.43% chance of correctly rejecting the null
hypothesis. The Technical Quality sub-scale also had a small chance at 9.83%. Even if there is
a difference in the population, given the small sample size, it is unlikely the difference would be
detected. More research is needed with larger sample sizes to investigate whether there is a

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

68

difference in patient satisfaction between those who seek healthcare at LGBTQIA+ inclusion
clinics and those who do not.
Table 10
Parametric Independent Samples t-test Findings
Scale

tstatistic

df

p
value

Mean
Difference

Achieved
Power

.40637
.14913
.39382
.15637
.35618

Effect Size
(Cohen’s
d)
.5068
.2053
.4970
.1464
.5151

General Satisfaction Sub-scale
Technical Quality Sub-scale
Interpersonal Manner Sub-scale
Time Spent with Doctor Sub-scale
Accessibility and Convenience Subscale
Overall Scale

1.674
.664
1.593
.494
1.683

49
49
49
49
49

.101
.510
.118
.312
.099

1.722

48

.092

.34026

.5400

.3752

.3535
.0983
.3422
.0743
.3631

Nonparametric Tests
Mann-Whitney U. An independent samples Mann-Whitney U test as shown in Table 11
was conducted for the Communication and Financial Aspects sub-scales to determine if the
differences in the inclusion clinic and non-inclusion clinic distributions were significantly
different from each other. This is only for this particular sample, as the assumptions for these
sub-scales were not met.
For the Financial Aspects sub-scale, the mean for LGBTQIA+ inclusion clinic
respondents is 3.75 (SD=.546), and the mean for non-inclusion clinic respondents is 3.42
(SD=.901) as shown in Table 13. The distributions in the two groups did not differ significantly
(Mann–Whitney U = 215.5, n= 51, p=.332).
For the Communications sub-scale, the mean for LGBTQIA+ inclusion clinic
respondents is 4.15 (SD=.851), and the mean for non-inclusion clinic respondents is 3.69
(SD=.853) as shown in Table 13. The distributions in the two groups significantly differed and

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
had a small effect size (Mann–Whitney U = 147, n=50, p=.030,

𝑍
√𝑛

69

=.3067). In this sample,

respondents who went to LGBTQIA+ inclusion clinics had significantly higher communication
satisfaction than those who did not go to inclusion clinics.
Table 11
Mann-Whitney U Test Findings for Communication and Financial Aspects Sub-scales
Scale
Communication Subscale
Financial Aspects Subscale

Mann-Whitney
U
147

n
50

pvalue
.030

Effect
Size
.3067

Achieved
Power
.3665

215.5

51

.332

.1358

.2732

Point-Biserial Correlation. A point-biserial correlation was conducted to determine the
relationship between high- and lower-income earners (high income = $100,000 or higher; lower
income = 99,999 or below) and patient satisfaction. As shown in Chart 10, there was a nonsignificant positive correlation between income level and patient satisfaction, (rpb =.232, n = 53,
p = .095). This finding further supports the need for a more diverse and representative sample of
the overall LGBTQIA+ population. Correlations are illustrated in Table 12.
Chart 10
Point-Biserial Correlation Between High- and Lower-Income Earners and Patient Satisfaction

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

70

Table 12
Correlations Between High- and Lower-Income Level and Overall Satisfaction

Income over

Pearson Correlation

100,000

Sig. (2-tailed)

Income over

Overall

100,000

Satisfaction

N

1

.095
54

53
1

Overall

Pearson Correlation

.232

Satisfaction

Sig. (2-tailed)

.095

N

.232

53

55

Descriptive Statistics of Scales of Satisfaction
The mean, standard deviation, and variance for each of the sub-scales and the overall
scale are illustrated below in Tables 13 and 14. Descriptive statistics for each of the scales in
Table 13 are organized by clinic type.
Table 13
Descriptive Statistics of Sub-scales and Overall Scale of Satisfaction by Clinic Type
Do you seek healthcare from an LGBTQIA+ inclusion
health clinic?
Yes

No

N

Minimum

Maximum

Mean

Std. Deviation

Variance

General Satisfaction Sub-scale

14

2.00

5.00

3.8929

.85886

.738

Technical Quality Sub-scale

14

2.25

4.75

3.6964

.74794

.559

Interpersonal Manner Sub-scale

14

2.50

5.00

4.2857

.80178

.643

Communication Sub-scale

13

2.00

5.00

4.1538

.85109

.724

Financial Aspects Sub-scale

14

3.00

4.50

3.7500

.54596

.298

Time Spent with Doctor Sub-scale

14

1.50

5.00

3.6429

1.18368

1.401

Accessibility and Convenience Sub-scale

14

1.75

4.50

3.7143

.72627

.527

Overall Scale

13

2.22

4.50

3.8718

.66333

.440

General Satisfaction Sub-scale

37

1.50

5.00

3.4865

.74056

.548

Technical Quality Sub-scale

37

1.75

4.50

3.5473

.70425

.496

Interpersonal Manner Sub-scale

37

1.50

5.00

3.8919

.78294

.613

Communication Sub-scale

37

1.50

5.00

3.6892

.85270

.727

Financial Aspects Sub-scale

37

1.50

4.50

3.4189

.90149

.813

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

Unsure

71

Time Spent with Doctor Sub-scale

37

1.50

5.00

3.4865

.93902

.882

Accessibility and Convenience Sub-scale

37

2.00

4.50

3.3581

.65495

.429

Overall Scale

37

1.89

4.28

3.5315

.59512

.354

General Satisfaction Sub-scale

5

2.50

4.50

3.7000

.75829

.575

Technical Quality Sub-scale

5

2.50

4.50

3.8000

.75829

.575

Interpersonal Manner Sub-scale

5

3.00

5.00

3.9000

.74162

.550

Communication Sub-scale

5

2.50

4.50

3.9000

.82158

.675

Financial Aspects Sub-scale

5

3.00

4.00

3.3000

.44721

.200

Time Spent with Doctor Sub-scale

5

3.00

5.00

3.8000

.75829

.575

Accessibility and Convenience Sub-scale

5

2.50

4.00

3.5000

.61237

.375

Overall Scale

5

2.67

4.39

3.6889

.63294

.401

Std. Deviation

Variance

Table 14
Descriptive Statistics of Sub-scales and Overall Scale of Satisfaction
N

Minimum

Maximum

Mean

General Satisfaction Sub-scale

56

1.50

5.00

3.6071

.77878

.606

Technical Quality Sub-scale

56

1.75

4.75

3.6071

.71168

.506

Interpersonal Manner Sub-scale

56

1.50

5.00

3.9911

.78908

.623

Communication Sub-scale

55

1.50

5.00

3.8182

.85723

.735

Financial Aspects Sub-scale

56

1.50

4.50

3.4911

.80052

.641

Time Spent with Doctor Sub-scale

56

1.50

5.00

3.5536

.98016

.961

Accessibility and Convenience Sub-scale

56

1.75

4.50

3.4598

.67551

.456

Overall Scale

55

1.89

4.50

3.6263

.62016

.385

Study Limitations
Several imitations were identified within this study. One potential limitation of this
study was utilizing a nonrandom convenience sampling recruitment method. A primary
weakness of utilizing a nonrandom convenience sampling recruitment method is that the
sample selected may not be entirely representative of the overall population (Terry, 2015).
Because study subjects were recruited using a nonrandom convenience sampling recruitment
method, subjects self-selected themselves. As a result, a very homogenous sample was

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72

obtained. The sample obtained was not a good diversity sample and was mainly white or
Caucasian, cisgender, and highly educated with high salaries. Most study subjects were
employed full-time, and all study subjects had health insurance. It is assumed that
underserved and disadvantaged LGBTQIA+ subjects were under sampled in this study. Thus,
this sample is not completely representative of the overall LGBTQIA+ population and
findings of this study cannot be generalized to this population.
Another limitation of this study was a small sample size and the lack of observations
collected. If more observations had been collected, the study would have had more statistical
power to answer this study’s PICO question under investigation and to find a statistically
significant difference between comparison groups. A larger sample size may have been more
representative of the overall LGBTQIA+ population as well, as the larger the sample size, the
more representative it will be of the greater population (Terry, 2015). Because random
sampling may have selected a sample more representative of the LGBTQIA+ population’s
characteristics over nonrandom sampling (Terry, 2015), the random sampling recruitment
method should be considered in future research.
An additional limiting factor identified in this study was an imbalance between
comparison groups, as two-thirds of the survey respondents indicated that they did not seek
healthcare from LGBTQIA+ inclusion clinics, leaving a third of the respondents that did or
were unsure. It is usually best for the independent samples t-test to have balanced groups. This
can make it easier to find statistical significance, as fewer degrees of freedom (df) would need to
be taken. Additionally, this unbalanced design for the independent samples t-test made it harder
to reject the null hypothesis that the patient satisfaction is the same regardless of clinic type.

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73

Last, poor outreach may have been a study limitation as well. Poor responses were
received from LGBTQIA+ community organizations and on-line communities regarding their
willingness to participate in this on-line questionnaire study. Had there been a higher
response rate from LGBTQIA+ community organizations and on-line communities,
presumably, the study sample may have been larger, more diverse, and more well-balanced.
Summary
This chapter discussed the results of the study using both descriptive and inferential
statistics. Study limitations were also described. The following chapter will discuss the study
summary of findings, implications for nursing practice, and recommendations for further
research on this study topic.
Chapter 5
Summary, Conclusions, and Recommendations
Summary of Findings
In spite of extensive efforts to gain equal rights for LGBTQIA+ individuals, they remain
confronted with widespread health-related disparities and inequities due to stigma,
discrimination, exclusion, and oppression because of their sexual orientation and gender identity.
These persistent disparities and inequities are major obstacles to high-quality healthcare for
LGBTQIA+ individuals and detrimentally affects their health and well-being. To redress these
disparities and inequities and to afford LGBTQIA+ individuals an opportunity to receive highquality healthcare, safe and inclusive clinical spaces free of stigma and discrimination must be
created.
To explore this area of research further and to guide this study, the following PICO
question was developed: Do LGBTQIA+ individuals who receive healthcare from LGBTQIA+

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74

inclusion clinics feel more satisfied with their healthcare than those LGBTQIA+ individuals who
receive healthcare from traditional clinics? To answer this question, a nonexperimental,
nonrandom, cross-sectional study adhering to a quantitative methodology was conducted. The
nonrandom convenience sampling recruitment method was utilized, and fifty-six subjects (n=56)
participated in this on-line questionnaire study. The PSQ-18 questionnaire was administered to
evaluate study subjects’ overall satisfaction with their healthcare. To test whether the null
hypothesis could be rejected, the independent samples t-test statistical method was utilized. The
null hypothesis that was tested was that (H0) LGBTQIA+ individuals receiving healthcare from
LGBTQIA+ inclusion clinics will not have greater satisfaction with their healthcare compared
to LGBTQIA+ individuals receiving healthcare from traditional clinics.
The findings of this study revealed that the sample size was too small to detect
differences in the population, and the probability of rejecting the null hypothesis was quite low
with this small sample size. However, for the Communications sub-scale, respondents who
received healthcare from LGBTQIA+ inclusion clinics had significantly higher communication
satisfaction than those who did not receive healthcare from inclusion clinics, as the distributions
in the two groups significantly differed.
Implications for Nursing Practice
This study concludes with implications for future nursing practice to transform
healthcare for LGBTQIA+ individuals. Offering LGBTQIA+ patients culturally congruent
care will require nursing professionals to become more aware of their own attitudes, beliefs,
and prejudices toward working with the LGBTQIA+ community. Integrating an unbiased,
science- and justice-based approach, such as the Health Equity Framework into their respective
nursing practices, will allow them to become more mindful of their personal attitudes, beliefs,

LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL

75

and prejudices. This can reshape the delivery of LGBTQIA+ specific healthcare and translate to
greater health equity and improved satisfaction and health outcomes for this community. “In so
doing, nurses have transformative potential to override their bias, render LGBTQ+ visible, and
align their practices with their professional mandate of providing equitable and ethically
sensitive care to all” (Goldberg et al., 2019, p. 270).
Nursing professionals have an ethical and professional responsibility to foster a safe,
inclusive, and culturally sensitive and competent environment for LGBTQIA+ individuals;
however, when it comes to meeting the unique healthcare needs of LGBTQIA+ individuals, they
lack fundamental knowledge, education, and training on LGBTQIA+ health-related issues. To
make certain these unique healthcare needs are met for the LGBTQIA+ community, nurses and
advanced practice nurses have a professional obligation to close this knowledge gap. To ensure
their preparedness and readiness in caring for this vulnerable population, it will be imperative
that they receive adequate cultural competency and sensitivity education and training. This
education and training will also help alleviate any insecurities that nursing professionals may
harbor regarding their scarcity of knowledge in delivering proper care to LGBTQIA+
individuals. Furthermore, because nurses and advanced practice nurses are dutybound to
advance the profession of nursing through knowledge dissemination (ANA, 2015), it will be
equally imperative that they not only apply this knowledge to their own practices, but to
disseminate this knowledge to their fellow nursing colleagues, as well as to other
interprofessional team members.
Nurses and advanced practice nurses play a pivotal role in advancing the discipline and
profession of nursing through scholarly inquiry and research (ANA, 2015). According to
(Bonvicini, 2017), compared to other healthcare professionals, the nursing profession has lagged

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76

behind in conducting research to address health needs of the LGBTQIA+ community. To
advance the discipline and profession of nursing, nurse researchers must contribute to the nursing
body of knowledge by translating research into evidence-based nursing practice (ANA, 2015).
This research study provides direction for nursing researchers to further investigate whether the
healthcare provided by LGBTQIA+ inclusion clinics results in improved patient satisfaction for
the LGBTQIA+ community.
In spite of heightened awareness concerning LGBTQIA+ health disparities and their
associated causes, they still widely exist (Jennings et al, 2019). Consequently, to achieve health
equity for the LGBTQIA+ community, significant improvements within healthcare organizations
are essential to mitigate these health disparities respectively (Jennings et al., 2019). Nursing
professionals, regardless of their role or practice setting, are integral in removing institutional
barriers to high-quality healthcare for LGBTQIA+ individuals, and they have the capacity to
positively influence change against stigma and discriminatory practices within their respective
practice settings. Nurses and advanced practice nurses spend a considerable amount of time with
patients, leaving them in the perfect position to take on the role of a champion, advocate for
organizational change, and lead healthcare organizations to improvements in the delivery of
LGBTQIA+ healthcare (Margolies & Brown, 2019).
Recommendations for Further Research
Based on this scholarly work, further research with larger sample sizes to investigate
whether there is a difference in patient satisfaction between those who receive healthcare from
LGBTQIA+ inclusion clinics and those who receive healthcare from traditional clinics is
recommended. The results of this study suggested the sample size was too small to detect
differences in patient satisfaction between those respondents who received healthcare from

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77

inclusion clinics and those who did not. Had the sample size been larger, more statistically
significant results may have been observed. Therefore, a larger sample size is recommended to
give future research studies more statistical power to detect differences in patient satisfaction
between comparison groups. If differences were to be detected, it is recommended that
researchers further investigate strategies and best practices in the healthcare setting that have
been linked to improved patient satisfaction for the LGBTQIA+ community.
Whether the healthcare provided by LGBTQIA+ inclusion clinics results in improved
patient satisfaction has not been well established in the current literature. Therefore, further
research is needed to understand the relationship between receiving healthcare from LGBTQIA+
inclusion clinics and improved patient satisfaction. Future research studies may evaluate the
utilization of LGBTQIA+ inclusion clinics and their association with not only improving patient
satisfaction, but also with mitigating health disparities and achieving greater health equity for
this vulnerable and marginalized population.
Because underserved and disadvantaged LGBTQIA+ individuals were not well sampled
in this study, it is recommended that future researchers make a concerted effort to collect data
from these historically under sampled populations. Had the sample been more diverse and
representative of underserved and disadvantaged individuals, point-biserial correlation tests to
determine the relationship between socioeconomically advantaged and disadvantaged
LGBTQIA+ individuals and patient satisfaction may have resulted in a significantly positive
correlation between well-served and underserved individuals and patient satisfaction.
To obtain a larger sample size and a less homogenous sample, future researchers may
wish to consider a simple random sampling recruitment method rather than a nonrandom
convenience sampling recruitment method and target communities with a higher density of

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LGBTQIA+ individuals. A simple random sampling recruitment method may lead to a more
representative well-balanced and heterogenous sample, with more observations.
Earlier research suggests that effective communication skills exhibited by healthcare
providers can positively influence patients’ satisfaction with their healthcare encounters and
appreciably contribute to their health outcomes (Berman & Chutka, 2016). In this study sample,
respondents who received healthcare from LGBTQIA+ inclusion clinics had significantly higher
communication satisfaction than those who did not receive healthcare from inclusion clinics.
Although this finding may presumably be true for different groups, without further research, it
should not be generalized beyond this study sample. However, in the context of existing
literature, to better serve the unique healthcare needs of LGBTQIA+ individuals, open
communication behaviors toward these individuals is necessitated.
Forming the foundation for a more positive patient-provider relationship, effective
communication skills result in increased patient satisfaction and warrants further research
(Berman & Chutka, 2016). According to Banerjee et al. (2018), how healthcare providers
communicate with LGBTQIA+ individuals is integral to the provision of culturally competent
care. Behaviors and beliefs needed to provide inclusive, culturally competent care can be
measured through the comfort level of the healthcare provider with effective communication, as
well as through patient satisfaction (Keuroghlian et al. (2017).
Prior studies have discovered that training on LGBTQIA+ health topics in healthcare
settings is fairly limited, and the extent to which LGBTQIA+ cultural and sensitivity
competencies have been implemented by healthcare organizations is unknown (Goldhammer et
al., 2018). Additionally, there is a paucity of research on the training needs of healthcare
professionals with regard to LGBTQIA+-related healthcare. Given this paucity of research and

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enduring knowledge gaps in LGBTQIA+ health awareness and readiness amongst healthcare
professionals, further research is recommended to evaluate their educational and training needs.
Resolving the gaps in LGBTQIA+ health preparedness can better equip healthcare professionals
to deliver culturally competent care to patients who self-identify as LGBTQIA+.
Conclusion
Although the findings of this research study did not demonstrate statistically
significant differences in patient satisfaction between LGBTQIA+ respondents who receive
healthcare from LGBTQIA+ inclusion clinics and those who do not, based on a comprehensive
examination of relevant research it was concluded that LGBTQIA+ inclusion health plays a
critical role in improving patient satisfaction and the health and well-being of LGBTQIA+
individuals. Remaining an insufficiently researched area of healthcare utilization, further
research on understanding the role of LGBTQIA+ inclusion clinics and their influence on
improving patient satisfaction is warranted (Martos et al., 2019).
Hence, priorities for future research include assessing the impact LGBTQIA+
inclusion health utilization has on addressing the complex health issues and unmet healthcare
needs of LGBTQIA+ individuals, as well as assessing the impact LGBTQIA+ inclusion health
utilization has on redressing health disparities and inequities amongst this community. Further,
because study results revealed individuals who went to LGBTQIA+ inclusion clinics had
significantly higher communication satisfaction than those who did not go to inclusion clinics,
investigating the impact of culturally competent communication on improved patient satisfaction
should also be a priority for future research.
Lack of access to safe, culturally competent and sensitive, and inclusive healthcare
will further perpetuate the widespread health disparities and inequities suffered by

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80

LGBTQIA+ individuals (Kuzma et al. 2019). To advance the health of LGBTQIA+
individuals and achieve health equity, safe, affirming, and inclusive healthcare environments
must be created for these individuals.
Disclosure Statement
With respect to the research and authorship of this study, the study author does not have
any conflicts of interest to disclose.
Funding
The author of this study did not receive any external funding or financial support to
conduct this study.

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Appendices
Appendix A
Theoretical Framework – The Health Equity Framework

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LGBTQIA+ INCLUSIVE HEALTHCARE VERSUS TRADITIONAL
Appendix B
Edinboro University’s IRB Approval of Human Subjects Protocol

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Appendix C
Informed Consent Form

Edinboro University of Pennsylvania
CONSENT TO PARTICIPATE IN RESEARCH STUDY
Title of Study: LGBTQIA+ Inclusive Healthcare Versus Traditional: Comparing Patient Satisfaction
Principal Investigator: Dr. Jill Rodgers, DNP, FNP-BC, PMHNP-BC, Edinboro University Faculty
Co-Investigator(s): Gayle Kempinski, DNP(c), MSN, APNP, ANP-BC, OCN, Clarion and Edinboro University
Doctor of Nursing Practice Student
KEY INFORMATION
You are being asked by Dr. Jill Rodgers and Gayle Kempinski, DNP(c) to participate in a non-location, online questionnaire research study. Taking part in the study is voluntary, and you may stop at any time.
The purpose of the study is to evaluate the difference in patient satisfaction scores between lesbian, gay, bisexual,
transgender, questioning or queer, intersex, and asexual (LGBTQIA+) individuals who receive healthcare from
LGBTQIA+ inclusion clinics and LGBTQIA+ individuals who receive healthcare from traditional clinics.
In the study, you will be asked to complete an on-line patient satisfaction survey. It will take you
approximately 5 minutes to complete the survey.
There are no potential risks to participate in the study, and there are no direct benefits to participants from the
research. However, the study will help raise awareness around the need for LGBTQIA+ inclusion health
clinics to meet the unique health needs of LGBTQIA+ individuals. The study will also help the researchers
better understand how this research relates to their profession of nursing practice.
The information that you give in the study is anonymous. Your name and other information that could be used to
identify you will not be collected or linked to the data.
Remember, taking part in the study is voluntary. If at any time during the study you feel uncomfortable
or no longer want to participate, you may stop being a part of the study with no consequences.
You should know that information collected as part of this research will be kept as confidential as possible,
within local, state, and federal laws. This consent may be reviewed by the Edinboro University
Institutional Review Board (IRB). The results of the study may be shared in aggregate form at a meeting
or in a journal, but your personal information will not be revealed. Records from the study will be kept by
the Principal Investigator, Dr. Jill Rodgers, for a minimum of three (3) years after the study is complete.
Information that is collected as part of this research will not be used or distributed for future research
studies.
If you have questions about the study, you can contact Gayle Kempinski, Co-Investigator, at
gayle_kempinski@outlook.com. If you have a question about your rights as a research participant that you
need to discuss with someone, you can contact the Edinboro University Institutional Review Board at
irb.Edinboro@edinboro.edu. If you would like a copy of this informed consent, please contact Gayle
Kempinski, Co-Investigator, at gayle_kempinski@outlook.com.
SUBJECT’S STATEMENT

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If I have questions prior to completing the non-location, on-line questionnaire study, I will contact Gayle
Kempinski, Co-Investigator, at gayle_kempinski@outlook.com.
I understand that my participation is completely voluntary, and I may quit the study at any time without
penalty. I am at least 18 years of age. I have read the consent form. Prior to entering the survey, you will be
asked whether you consent to completing the survey. If you answer yes, you will enter the survey. If you
answer no, the survey will be discontinued.

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Appendix D
PSQ-18 Cover Letter and Instructions

LGBTQIA+ Inclusive Healthcare & Patient Satisfaction Survey
Survey Participants,
Thank you for participating in this on-line survey. In fulfilment of my Doctor of Nursing
Practice degree requirements, I am conducting a study to evaluate the difference in patient
satisfaction scores between LGBTQIA+ individuals who receive healthcare from LGBTQIA+
inclusion clinics and LGBTQIA+ individuals who receive healthcare from traditional clinics.
Prior to entering the survey, you will be asked whether you consent to completing the survey.
The survey is completely anonymous. The survey will take you approximately 5 minutes to
complete. Please complete it in its entirety.
Please forward the survey link to other potential participants within the LGBTQIA+ community.
Please click the survey link below to begin.
https://milwaukee.qualtrics.com/jfe/form/SV_ebqvym8f0KCQSfs

Thank you,

Gayle Kempinski, MSN, APNP, ANP-BC, OCN
Doctor of Nursing Practice Candidate
gayle_kempinski@outlook.com

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Appendix E
Instrument: Short-Form Patient Satisfaction Questionnaire (PSQ-18)

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