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1 SEXUAL MINORITY STRESS, COPING, AND PHYSICAL HEALTH INDICATORS By DELPHIA JOSSIE FLENAR A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGR EE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 201 3
2 201 3 Delphia J. Flenar
3 In memory of Margaret Phillips
4 ACKNOWLEDGMENTS I have many to thank for their contributions to this dissertation Foremost, I thank my chair, Dr. Carolyn M. Tucker, whose support and empowering guidance have led to the creation of this work I also wish to thank my committee members, Dr. Greg Neimeyer, Dr. Catherine Cottrell, Dr. Edil Torres, and Dr. Mary Fukuyama. Their knowledge and feedback significantly improved this paper and the conceptual premises It is also important to thank all of the individuals who he lped spread the word about the study and assisted with recruiting participants, particularly my colleagues in the Counseling Psychology P rogram at University of Florida and my colleagues at the Ball State University Counseling Center. Thanks to those who w ere there to provide support, advice, and encouragement when I had questions about doing research with an unfamiliar population. Finally, and perhaps most importantly, thanks to my family and friends, my own personal cheering section, for their love, suppo rt, encouragement and investment in my success
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 I NTRODUCTION ................................ ................................ ................................ .... 11 Nature of Problem ................................ ................................ ................................ ... 11 Theoretical Framework ................................ ................................ ........................... 13 Aims, Hypotheses, and Research Question ................................ ........................... 14 2 L ITERATURE REVIEW ................................ ................................ .......................... 17 Sexual Minority Stress ................................ ................................ ............................ 17 Sexual Minorit y Stress Processes ................................ ................................ .... 18 Experiencing prejudiced events ................................ ................................ 18 Expecting and anticipating the experience of rejection or discrimination ... 18 ................................ ............................. 19 Internalizing negative societal attitudes ................................ ..................... 20 Sexual Minority Stress, Mental Health, and Physical Health Indicators ............ 21 Coping as a Buffer against the Impact of Sexual Minority Stress ........................... 23 Problem focused Coping as a Mediator between Stress and Health ............... 23 Social Coping as a Mediator between Stress and Health ................................ 24 Experiences of Stress, Coping, and Health among Individuals with Multiple Minority Statuses ................................ ................................ ................................ 25 Study Overview ................................ ................................ ................................ ....... 27 3 METHOD ................................ ................................ ................................ ................ 28 Participants ................................ ................................ ................................ ............. 28 Measures ................................ ................................ ................................ ................ 29 Demograp hic and Health Information Questionnaire (DHIQ) ........................... 29 Measure of Gay Related Stressors (MOGS) ................................ .................... 30 Coping Questionnaire (COPE) ................................ ................................ ......... 31 Health Promoting Lifestyle Profile II (HPLP II) ................................ .................. 31 Procedure ................................ ................................ ................................ ............... 32 Sta tistical Analyses ................................ ................................ ................................ 34 Preliminary Analyses ................................ ................................ ........................ 34 Analysis to Test the Hypothesized Model ................................ ......................... 34 Analyses to Answer the Research Question ................................ .................... 35
6 4 RESULTS ................................ ................................ ................................ ............... 37 Preliminary Analyses ................................ ................................ .............................. 37 Results of Bootstrapped Path Analysis to Test Hypotheses 1 4 ............................. 38 Direct Effects ................................ ................................ ................................ .... 39 Indir ect Effects ................................ ................................ ................................ .. 39 Total Effects ................................ ................................ ................................ ..... 39 Results of ANOVAs and MANOVAs to Explore the Research Question ................. 40 Demographic Differences in Sexual Minority Stress ................................ ......... 41 Demographic Differences in Coping ................................ ................................ 41 Demo graphic Differences in Engagement in a Health Promoting Lifestyle ...... 41 Demographic Differences in Number of Physical Health Problems .................. 42 5 DISCUSSION ................................ ................................ ................................ ......... 45 Summary of Results ................................ ................................ ................................ 45 Relationships among Sexual Minority Stress, Coping Styles, and Physical Health Indic ators ................................ ................................ ........................... 45 Multiple Minority Statuses and Investigated Variables ................................ ..... 46 Implications of Results ................................ ................................ ............................ 46 Sample Health Characteristics ................................ ................................ ......... 46 Minority Stress Model ................................ ................................ ....................... 47 Sexual minority stress and health ................................ .............................. 47 Coping and the Minority Stress Model ................................ ....................... 48 Experiences of Sexual Minority Stress within Sexual Minority Sub groups ...... 49 Limitations and Future Directions ................................ ................................ ........... 52 Recruitment and Sample Issues ................................ ................................ ....... 52 Measurement Issues ................................ ................................ ........................ 53 Conclusions ................................ ................................ ................................ ............ 55 APPENDIX A M EASURES ................................ ................................ ................................ ............ 57 Demographic and Health Information Questionnaire ................................ .............. 57 Measure of Gay Related Stressors ................................ ................................ ......... 60 Coping Questionnaire (COPE) ................................ ................................ ................ 63 Health Promoting Lifestyle Profile II ................................ ................................ ........ 64 B RECRUITMENT SCRIPT ................................ ................................ ........................ 68 C INFORMED CONSENT FORM ................................ ................................ ............... 69 LIST OF REFERENCES ................................ ................................ ............................... 72 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 77
7 LIST OF TABL ES Table page 3 1 Reported Sexual Orientation ................................ ................... 36 4 1 Selected descriptive statistics for all investi gated variables ................................ 42 4 2 Direct, indirect and total effects in the path model ................................ .............. 43 4 3 Sex and SES Statistics for Investigated Varia bles ................................ .............. 44
8 LIST OF FIGURES Figure page 1 1 Study path model. ................................ ................................ ............................... 16 3 1 th conditions. ................................ ................................ ........... 36
9 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy SEXUAL MINOR ITY STRESS, COPING, AND PHYSICAL HEALTH INDICATORS By Delphia J. Flenar August 2013 Chair: Carolyn M. Tucker Major: Counseling Psychology Lesbian, gay, and bisexual individuals (hereafter referred to as sexual minorities) face unique oppressive barrier s that impact their health such as legal discrimination, lack of culturally competent health providers, and unsafe living environments. Research has shown that sexual minorities experience higher rates of several physical health problems when compared to t heir heterosexual counterparts. Stress Model may be helpful in understanding what factors may contribute to the health status of sexual minorities. The present study extends the Minority Stress Model to examine physical health rathe r than mental health. The present study tests four hypotheses The first two hypotheses suggest that sexual minority stress is predictive of two physical health indicators. The second two hypotheses suggest that problem focused and social coping will parti ally mediate the relationship between sexual minority stress and each physical health indicator Additionally, the following research question is explored: Are there differences in the study variables in association with a) sex, b) socioeconomic status, a nd c ) the interaction between sex and socioeconomic status? Study participants consisted of 250 adults who identified as a sexual minority
10 To test the hypotheses, a bootstrapped path analysis was conducted. The results sup ported the first two hypotheses As levels of sexual minority stress increased, engagement in a health promoting lifestyle significantly decreased and the number of physical health problems significantly increased. The second two hypotheses were not supported. Problem focused and social c oping did not mediate the relationships between sexual minority stress and the physical health indicators; however, as levels of problem focused and social coping increased, engagement in a health promoting lifestyle significantly increased. Analyses of V ariance or Mul tivariate Analyses of Variance were conducted to address the research question. The results suggested significant sex and socioeconomic status differences in levels of sexual minority stress. Male sexual minorities reported higher levels of s exual minority stress than female sexual minorities. Also, sexual minorities with a low household income reported higher levels of sexual minority stress than sexual minorities with a middle household income The implications of the findings from this stud y for addressing sexual minority stress and health concerns for sexual minorities are discussed.
11 CHAPTER 1 INTRODUCTION Nature of Problem The health of lesbian, gay, and bisexual individuals (hereafter referred to as sexual minorities) is increasingly b ecoming a major focus of health and health disparities research 1 One contributor to this research focus is the fact that Healthy People, a U.S. government organization, recently created health promotion initiatives based on previous scientific literature to address the health disparities that sexual minorities face (Healthy People, 2010). The Healthy People organization suggests that sexual minorities face unique oppressive barriers that impact their health such as legal discrimination, lack of culturally competent health providers, and unsafe living environments. Much existing research has attempted to understand such factors in relation to sexual health (e.g., HIV/AIDs) and mental health among sexual minorities; however, it is likely that these factors al so impact physical health indicators (i.e., number of physical health problems such as cancer, obesity, or cardiovascular disease and engagement in a health promoting lifestyle ) Unfortunately, little research has been done to understand physical health a s indicated by the above mentioned phy sical health indicators, among sexual minorities. The research that is available has shown that sexual minorities experience higher rates of several physical health problems when compared to heterosexual men and women. Conron, Mimiaga, & Landers (2010) found that sexual minorities were more likely to report smoking, drug use, asthma, and activity limitation (i.e., lack of exercise) when compared to heterosexual individuals. Additionally, bisexual men and women reported 1 While individuals who identify as transgender are also considered sexual minorities, only transgender individuals who also identify as gay, lesbian, or bisexual are includ ed in this study.
12 experiencing more barriers to health care and higher prevalence of cardiovascular disease than heterosexual individuals. Ungvarski and Grossman (1999) found that gay and bisexual men have an increased risk of heart disease and certain cancers. S tud ies by Yancey, Cochran, Corliss, and Mays (2003) ; Boehmer, Bowen, and Bauer (200 7 ); and Struble, Lindley, Montgomery, Hardin, and Burcin (2011) showed that lesbian and bisexual women were more likely to be overweight or obese than heterosexual women Other stud ie s by Valanis, Bowen Bassford, Whitlock, Charney, and Carter ( 2000) and Roberts, Dibble, Nussey, and Casey (2003) showed that lesbian and bisexual women were at higher risk for reproductive cancers and cardiovascular disease than heterosexual women. In a ddition to the health disparities associated with sexual orientation, sexual minorities also may face health disparities related to their race/ethnicity, sex, and socioeconomic status. R acial/ethnic minorities and individuals with low household incomes ex perience higher levels of stress and health problems as compared to European Americans and individuals with middle and high incomes, respectively Racial/ ethnic minorities experience health disparities in relation to cancer screening s and management, card iovascular disease, diabetes, HIV/AIDS, immunizations, hepatitis, syphilis, and tuberculosis (Office of Minority Health & Health Disparities, 2012). I ndividuals from low income groups are 50% more likely to be obese than other socioeconomic groups thus in creasing their risk of experiencing obesity related diseases such as cardiovascular disease and diabetes (National Heart, Lung and Blood Institute, 2009). Additionally, racial/ethnic minorities and individuals with low household incomes have lower access t o quality health care and lower insurance coverage (U.S. Department of Health and Human Services, 2011)
13 There are also sex related health disparities, but the prevalence of disease within each sex varies by the type of disease. Women face health dispariti es related to breast cancer, heart attack mortality, and mental illness. Men face health disparities related to diabetes, renal disease, HIV/AIDS, substance abuse and suicide (U.S. Department of Health and Human Services, 2011). It seems likely that the in fluences on the physical health problems and health promoting behaviors of sexual minorities who have multiple minority statuses (e.g ., being lesbian African American/Black, and female) are different for these sexual minorities compared to sexual minoriti es who do not have multiple minority statu s es. However, it is not known that this is the case. Theoretical Framework M odel s that have been helpful in understanding mental health disparities in sexual minorities may be useful in understandin g physical heal th disparities. One such model is the Minority Stress Model In the Minority Stress Model Meyer (2007) targets stress that is specifically associated with being a sexual minority (e.g., lesbian, gay, or bisexual) The entire Minority Stress Model contains several processes and concepts related to sexual identity, various sources of stress that are uniquely associated with being a sexual minority coping and social support mechanisms, and mental health. The model highlights that there are four specific stre ss processes that are uniquely associated with being a sexual minority (hereafter referred to as sexual minority stress) including (a) stress related to experiencing prejudiced events, (b) stress related to expecting and anticipating the experience of reje ction or discrimination, (c) stress related to disclosing attitudes.
14 An abundance of literature has shown that sexual minority stress results in negative mental health outcomes (Mays & Cochran, 2001; Meyer, 2003; Herek & Garnets, 2007; Frisell, Lichtenstein, Rahman, & Langstrom, 2010; Kuyper & Fokkema, 2011; Lehavot & Simoni, 2011 ). One potential buffer against sexual minority stress is the ability to cope with the stres s. In the Minority Stress Model, coping and social support mediate the relationship between sexual minority stress and mental health outcomes. Studies that have examined the role of coping using the Minority Stress Model show that specific types of coping are better buffers against minority stressors than others (Sandfort, Bakker, Schellevis, & Vanwesenbeeck, 2009; Szymanski & Owens, 2008). In the present study, problem focused and social coping were used to mediate the relationship between sexual minorit y stress and physical health indicators, including number of physical health problems and engaging in a health promoting lifestyle (see Figure 1 1 ). Problem problem directly and change the source of stress. An example of problem focused coping is the ability to break a problem down into smaller parts in order to address it. Problem minority stress. Social coping is thus may directly address the social nature of sexual minority stress. The ability to cope with stress may lessen the impact of sexual minority stress on physical health indicators Aims, Hypothes es, and Research Question The present study aims to examine whether sexual minority stress, problem focused coping and social coping predict physical health problems and engagement in
15 a health promoting lifestyle (i.e., physical health indicators) Usin g a cross sectional design, the following research hypotheses were investigated: 1. Sexual minority stress will negatively predict level of engagement in a health promoting lifestyle. That is, as the levels of sexual minority stress increase, the levels of e ngagement in a health promoting lifestyle will decrease. 2. Sexual minority stress will positively predict number of physical health problems (e.g., diabetes, cardiovascular disease). That is, as the levels of sexual minority stress increase, the number of ph ysical health problems will increase. 3. Problem focused and social coping will partially mediate the relationship between sexual minority stress and level of engagement in a health promoting lifestyle. That is, the influence of sexual minority stress will be weaker on the level of engagement in a health promoting lifestyle when there are higher levels of problem focused and social coping. 4. Problem focused and social coping will partially mediate the relationship between sexual minority stress and number of phy sical health problems. That is, the influence of sexual minority stress will be weaker on the number of physical health problems when there are higher levels of problem focused and social coping. See Figure 1 1 for a graphical depiction of the above hypoth eses. For this study, all participants are considered to have at least one minority status because they are sexual minorities. Therefore, h aving a multiple minority status in this study is operationalized as also being a racial/ethnic minority, being a ge ndered minority (e.g., female or transgender), or having a low socioeconomic status in addition to being a sexual minority. Because having multiple minority statuses may influence experiences of sexual minority stress, coping, and physical health indicator s, the following research question was addressed: Are there differences in the major study variables in association with a) sex, b) race/ethnicity, c) socioeconomic status, d) the interaction between sex and race/ethnicity, e) the interaction between race /ethnicity and socioeconomic status, and f ) the interaction between sex and socioeconomic status?
16 Figure 1 1 Study path model. Social Coping Engagement in Health Promoting Lifestyle Sexual Minority Stress Experi encing Prejudiced Events Anticipating Rejection Disclosing Sexual Identity Internalizing Negative Attitudes Physical Health Problems Problem focused Coping
17 CHAPTER 2 LITERATURE REVIEW Sexual Minority Stress Sexual minorities are varied in their backgrounds and experiences; however, they do share a common identity and are often faced with unique stressors related to that identity. Meyer (2007) summarizes the key issues related to such stress in the M inority S tress M odel. The entire Minority Stress Model contains several processes and concepts related to sexual identity, various sources of stress, coping and social support mechanisms, and mental health. A subset of this model is being used to understand physical health indicators in the present study There are thr ee assumptions in the Minority Stress Model : (a) minority stress is unique from general stressors and it has an effect above and beyond general stress, (b) minority stress is stable and long standing, and (c) minority stress is based in social processes ra ther than in individual processes. In a study that examined sources of sexual minority stress among lesbian, gay, and bisexual participants focus group participants reported experiencing stress related to heteronormative expectations (e.g., assuming ever y person has a heterosexual orientation ), anti (Hequembourg & Brallier, 2009). These focus group findings are explains that there are unique processes of sexual minority stress. Meyer describes four specific processes of sexual minority stress: (a) stress related to experiencing prejudiced events, (b) stress related to expecting and anticipating the experience of rejection or discrimination, (c) stress related to disclosi and (d) stress related to internalizing negative societal attitudes.
18 Sexual Minority Stress Processes Experiencing p rejudiced e vents Prejudiced events are described as instances of discrimination or violence directed toward gay violence and discrimination has been a stable source of stress for sexual minorities for decades. Meyer (2007) conceptualizes prejudiced events as distal sources of stress for the sexual minority because they occur outside of the individual. The prejudiced events manifest in many different ways including violent assaults, bullying, workplace discrimination, denial of legal rights, etc. One study found that sexual minorities were twice as likely to experience a prejudiced ev ent as heterosexual individuals (Mays & Cochran, 2001). Expecting and a nticipating the e xperience of r ejection or d iscrimination The expectation and anticipation of experiencing rejection or discrimination is related to societal stigmatization of sexual mi norities. Because sexual minorities are stigmatized in society, they experience different levels of threat in their everyday interactions. Branscombe et al. (1999) explains that there are four types of threat tied to stigmatization : categorization threat, distinctiveness threat, threat against the values of the minority group, and threat of acceptance C ategorization threat is the threat that an individual from a minority group will be categorized or labeled as a member of a specific group, particularly wh en group membership is irrelevant to the context of the situation (e.g., being labeled as a sexual minority in the workplace). Distinctiveness threat is the opposite of categorization threat and occurs when an individual from a minority group is denied his /her group membership when it is relevant or significant (e.g., saying someone is not bisexual because bisexuality is just a phase or he/she is confused about his/her sexual identity).
19 to question the (e.g., suggesting sexual minorities are immoral or cannot be religious). T he threat of acceptance involves fearing rejection or negative group (e.g., stereotypically feminine lesbians fearing rejection by other lesbians because of their feminine appearance). Each of these sources of threat feed s into the constant expectation and anticipation of rejection that sexual minorities may experience. Sexual minorities may, often correctly, fe el th at others do not accept them or that others hold negative attitudes towards them Anticipation of such negative reactions and threats from others results in sexual minorities becoming vigilant towards others reactions. Because vigilance is an interna l process, Meyer (2007) conceptualizes this process as a proximal source of stress. This process is especially taxing because it requires the individual to be on guard most, if not all, of the time. Disclosure of o s exual i dentity Sexual minorities are often an invisible minority, meaning that their minority status is not necessarily app arent upon first meeting. As invisible minorit ies sexual minorities often struggle with whether to disclose or conceal their sexual identity. The process of revealing s uch a stigmatized identity can be stressful. This process is also considered proximal because it is a struggle within the self (Meyer, 2007). Some sexual minorities may conceal their identity as a way of protecting themselves from harm (i.e., prejudiced e vents), but concealment may also be related to often requires the sexual minority to monitor their use of language, appearance, mannerisms, interests, or behaviors. Like w ith vigilance towards prejudiced events,
20 Additionally, concealment may cut off sexual minorities from social support including allies of sexual minorities and the gay commu nity (Meyer, 2007). The process of disclosure can be stressful because one is often unsure of how others will react and may be fearful of negative reactions. Sexual minorities may have to face the stressful process of disclosure repetitively throughout th e lifespan. In the focus group article by Hequembourg and Brallier (2009) on sources of sexual minority stress, one of the participant s described this process as follows: out process is not just one time every single time you meet (p. 282). Internalizing n egative s ocietal a ttitudes anti gay attitudes. According to Herek, Gillis, and Cogan (2009), internaliza tion of negative societal attitudes can occur in both heterosexual and sexual minority individuals. In heterosexual individuals, these internalized attitudes shape the ed the self him self /herself it is called internalized or self directed homophobia. Inte rnalized homophobia often results in devaluing the self and having a negative self perception. I nternalized homophobia is often seen in its strongest form in early stages of the coming out/disclosure process ; however, it can manifest in other stages o f sex ual identity development and therefore may occur throughout the lifespan (Meyer, 2007).
21 To illustrate the process of internaliz ing anti gay attitudes, consider the attitude that displays of affection between same sex couples is disgusting or inappropriate. If someone who is heterosexual has internalized this attitude, s/he may feel uncomfortable or show disgust when seeing a same sex couple display affection. If someone who is a sexual minority has internalized this attitude, s/he may show disgust when othe r same sex couples display affection, but may also feel insecure about or ashamed of him self /herself when showing affection towards a same sex partner. Sexual Minority Stress Mental Health and Physical Health Indicators Because the original Minority Str ess Model highlights the relationships between sexual minority stress processes and mental health, most of the literature has focused on these relationships. The sexual minority stress processes have been linked to higher levels of psychological distress a nd psychological disorders (Meyer, 2003) Szymanski and Owens (2008) showed that internalized homophobia was a significant predictor of psychological distress in sexual minority women. Mays and Cochran (2001) found that sexual minorities had higher levels of perceived discrimination than heterosexual individuals and that this perceived discrimination was linked to higher levels of psychological distress and higher prevalence of psychological disorders such as depression, anxiety disorders, and substance dep endence. Szymanski (2009) showed that sexual minority men experienced harassment, rejection, and discrimination targeting their sexual orientation and these experiences were significantly related to psychological distress. Frisell et al. (2010) found that high levels of perceived discrimination accounted for higher rates of depression, generalized anxiety disorder, eating disorders, alcohol dependence, and attention deficit hyperactivity disorder in sexual minorities.
22 Studies have also examined the entire Minority Stress Model in relation to mental health. Kuyper & Fokkema (2011) link ed sexual minority stress with mental health problems in a Dutch sample Lehavot and Simoni ( 2011) found links between sexual minority stress and mental health in sexual minori ty women In a review of mental health in sexual minorities, Herek and Garnets (2007) discuss the role of sexual minority stress in anxiety disorders, mood disorders, suicide risk, substance use, and other forms of psychological distress. S tress has conseq uences not only for mental health, but for physical health as well ( see Tosevski & Milovancevic, 2006 for a review of stress and physical health ; McEwen, 2002 ). Unfortunately, there is no known literature linking sexual minority stress to general physical health. There is, however, evidence that sexual minorities do experience higher rates of physical health problems and lower engagement in health promoting behaviors. Conron, Mimiaga, & Landers (2010) found that sexual minorities were more likely to report smoking, drug use, asthma, and activity limitation (i.e., lack of exercise) when compared to heterosexual individuals. Several studies have shown that sexual minorities have an increased risk of cardiovascular disease and certain cancers (Conron et al., 20 10; Ungvarski & Grossman, 1999; Valanis et al., 2000; Roberts, Dibble, Nussey, & Casey, 2003). Also, sexual minorit y women are more likely to be overweight and obese than heterosexual women (Yancey et al., 2003; Boehmer, Bowen, & Bauer, 2007; Struble et al ., 2011). The present study aims to extend the Minority Stress Model literature by examining the impact of sexual minority stress on physical health indicators (i.e., physical health problems and engagement in a health promoting lifestyle )
23 Coping as a Buf fer against the Impact of Sexual Minority Stress Utilizing adaptive forms of coping can buffer against the negative influence of stress on engagement in a health promoting lifestyle enhance quality of life, and promote well being. For example, in a review of literature on coping and diabetes, Fisher, Thorpe, DeVellis, and DeVellis (2007) found that coping plays an integral role in managing diabetes and the overall quality of life in diabetic patients. In the health literature coping has also been shown to impact health outcomes /beh a viors such as proper diabetes management and metabolic control, improved dietary behavior, treatment adherence in breast cancer patients, increased life satisfaction in patients with musculoskeletal disorders, and increa sed health related quality of life (Rao, 2009). In a health intervention study, it was found that participants who created coping plans had significantly more fruit and vegetable intake and marginally higher levels of physical activity than participants in the control group (Luszczynska & Haynes, 2009). In the Minority Stress Model coping and social support mediate the relationship between sexual minority stress and mental health outcomes. In the present study similar constructs (i.e., problem focused an d social coping) were used to mediate the relationship between sexual minority stress and physical health indicators Problem focused Coping as a Mediator between Stress and Health Problem focused coping is defined as a form of coping that utilizes stra tegies to address a problem directly or change the source of stress. Busko and Kulenovic (2003) showed that problem focused coping is particularly helpful for coping with low control stressors, which are stressors that are difficult for a person to change (Busko & Kulenovic, 2003). Because sexual minority stress is comprised of many low control stressors such as discrimination and stigmatization problem focused coping may be
24 particularly useful for managing sexual minority stress Problem focused coping ma y also mediate the relationship between stress and various forms of health Studies have shown that p roblem focused coping mediate s the relationship between stress and well being one aspect of health (Chao, 2011; Karlsen, Dybdahl, & Vitterso, 2006). Probl em focused coping has also been linked to engaging in health promoting behaviors. In a study with gay men, problem focused coping was negatively related to the number of types of drugs used as well as the number of sexual partners, thus problem focused cop ing may help reduce HIV risk (Barrett, Bolan, Joy, Counts, Doll, & Harrison, 1995). Problem focused coping also appear s to have implications for mental health. Chang et al. (2007) showed that problem focused coping predicted better psychological adjustment Only one known study has examined problem focused coping in the context of the Minority Stress Model Problem focused coping showed no moderating or mediating effect between internalized homophobia one of the processes of sexual minority stress, and p sychological distress among sexual minority women (Szymanski & Owens, 2008). Because this study only examined one component of sexual minority stress (i.e., internalized homophobia) i t is worthwhile to examine problem focused coping in the context of sexu al minority stress as a whole Additionally, it is worthwhile to examine whether problem focused coping mediates the relationship between sexual minority stress and physical health indicators Social Coping as a Mediator between Stress and Health Having so cial networks and utilizing the support from those networks can serve as a strong buffer against stress and have a positive impact on health. When sexual minorities have strong social support from the gay, lesbian, and bisexual community or
25 strong social s upport in general, this support buffers against stress and decreases their risk of negative health outcomes, such as alcohol use problems, depression, or HIV related complications ( Hequembourg and Brallier, 2009). Mansini and Barrett (2008) found that soci al support, particularly support from friends, predicted higher quality of life, and lower depression, anxiety, and internalized homophobia among older gay, lesbian, and bisexual individuals. The role of social support in the context of the Minority Stres s Model is unclear. In a study with sexual minority women, having social resources mediated the relationship between sexual minority stress and mental health, including substance abuse (Lehavot & Simoni, 2011). In a study using sexual minority men, social support did not mediate the relationship between experiencing heterosexist (prejudiced) events and psychological distress (Szymanski, 2009). It seems, however, that social support may be related to sexual minority stress as a whole The present study empha size s the use of social support (i.e., social coping) to cope with the impact of sexual minority stress as a whole. It also extend s the literature by examining the role of social coping within the interplay of sexual minority stress and physical health ind icators. Experiences of Stress, Coping, and Health among Individuals with Multiple Minority Statuses H aving multiple minority status es (e.g. being a female sexual minority of color) may alter the experiences of sexual minority stress, e and mental and physical health. Such individuals may have a higher risk of exposure to stigmatization and discrimination, which heightens their levels of stress. Stanley (2004) discusses the experiences of biracial s exual minorit y women and sugges ts that they experience unique sources of stress such as lacking a sense of belonging to any one In a focus
26 group with sexual minority females, Pendragon (2010) found that the foc us group participants often experienced isolation, lack of acceptance, harassment, and violence. Meyer and Frost (2008) found that individuals in multiple disadvantaged groups (i.e., sexual minorities and racial/ethnic minorities) experience higher levels of stress than individuals in only one disadvantaged group On the other hand, being able to integrate multiple identities can facilitate coping Garnets 2007). Sexual minority females reported using multi ple coping strategies such as redefining self concepts or values, engaging in activism, or utilizing supportive relationships in order to cope with their unique stress (Pendragon, 2010). S exual minority individuals with multiple minority identities do not necessarily have greater psychological distress than sexual minorities with no other minority identities ( Consolacion, Russell, & Sue, 2004). Despite the potential of hav ing more coping resources, individuals with multiple minority statuses are still at hi gher risk for physical health concerns. Having multiple minority statuses increases susceptibility to experiencing health disparities such as lower acce s s to proper health care, higher cardiovascular disease risk, sexual health disease risk, or diabe tes risk ( Jackson, 2005 ; Cummings & Jackson, 20 08 ). An especially salient health concern for sexual minority women is the risk of o verweight and obesity ( Yancey et al., 2003; Boehmer et al., 2007; Struble et al., 2011 ) Overweight and obesity are also heal th concern s for sexual minority women of color ( Wilson, 2009 ) Given these concerns, it is important to examine the association of multiple minority statuses with sexual minority stress, coping, and physical health indicators (i.e., number of physical heal th problems and engagement in a health promoting lifestyle )
27 Study Overview The present study explore s whether problem focused coping and social coping mediate the relationship between sexual minority stress and physical health indicators (i.e., physical h ealth problems and engagement in a health promoting lifestyle). Additionally, this study explore s whether there are differences in the major study variables (i.e., sexual minority stress, problem focused coping, social coping, engagement in a health promot ing lifestyle, and number of physical health problems) in association with the presence or absence of multiple minority status Specifically, it determines if there are differences in the major stud y variables in association with sex race /ethnicity socio economic status sex x race/ethnicity, race/ethnicity x socioeconomic status, and sex x socioeconomic status
28 CHAPTER 3 METHOD Participants Participant inclusion criteria were : (a) age 18 or older, (b) identifies as lesbian, gay, bisexual, or as some o ther sexual minority, and (c) communicates in written form in English. Participant exclusion criteria were : (a) identifies as heterosexual and (b) age 17 or younger. A total of 393 individuals consented to participate in the study; however, only a total o f 258 participants completed the entire online survey resulting in a 65.6% participation rate Two participants were removed because they were under the age of 18. Additionally, six participants were removed for having significant missing data (i.e., more than 15% missing) The final sample consisted of 250 participants. Participants varied in their sexual orientation (see Table 3 1 ); 240 (96%) P articipants ranged in age from 18 to 8 9 years old, with a mean age of 41 years old ( SD= 14.56 ). There were 146 ( 58.4 %) females, 86 ( 34.4 %) males, 1 2 ( 4.8 %) transgender individuals, and 6 (2.4%) participants who identified as (e.g., genderfluid, queer, two spirited) One hun dred eighty eight ( 75.2 %) participants self identified as non Hispanic Caucasian/White/European American 26 (10.4%) self identified as multi racial/multi ethnic, 17 (6.8%) self identified as Asian/Asian American, 11 (4.4%) self identified as Hispanic/Lati no(a), 3 (1.2%) self identified as Black/African American, 1 (0.4% ) self identified as American Indian/Alaska Native, and 4 (1.6%) self Middle Eastern, Texan). The majority of participants were highly educated. One hundred twen ty five (50%) had completed professional/graduate school, 66 (26.4%) had completed a 4 year college/university, 25 (10%) had completed a 2 year college/university or trade/technical
29 school, 33 (13.2%) had completed high school or the GED test and 1 (0.4%) had completed middle school. Annual h ousehold income was determined by dividing the shared household income by the number of individuals living in the household. The median household income was $30,000. Ninety five ( 38 %) participants reported an a nnual ho usehold income below $25 ,000, 118 (47.2 %) participants reported an annual household income between $2 5,000 and $10 0,000, 10 (4 %) participants reported an annual household income above $10 0,000 and 27 (10.8%) participants did not report an annual household income as excellent, 92 (36.8%) rated their health as very good, 89 (35.6%) rated their health as good, 36 (14.4%) rated their health as fair, and 9 (3.6%) rated thei r health as poor. Participants endorsed several health conditions (see Figure 3 1 ). In addition to the health conditions listed, participants listed several other health conditions such as hormonal conditions, joint pain/injury, migraines, internal organ c onditions (e.g., cirrhosis of the liver) etc. Measures 1 Demographic and Health Information Questionnaire (DHIQ) The DHIQ was created by the primary researcher and consist ed of questions to obtain the following information: race/ethnicity, sex, sexual ori entation, age, education level, annual household income and numbers of individuals in the household was used where participants rate their level of heterosexuality on a 5 point scale r anging from 1 ( not at all heterosexual ) to 5 ( very heterosexual ), and their level of homosexuality on a 5 point 1 All measures can be found in the Appendices.
30 scale ranging from 1 ( not at all homosexual ) to 5 ( very homosexual ). Additionally, participants were asked to rate their overall health and to c heck off any health conditions they have including overweight/obesity, high cholesterol, high blood pressure, type 2 diabetes, cardiovascular/ heart disease HIV/AIDS, sexually transmitted infection, respiratory problems, gastrointestinal problems, skin con ditions, and cancer P articipants had the option of list ing any health conditions they have that are not listed. A total count of health conditions was used as a criterion variable (i.e., number of physical problems ) Measure of Gay Related Stressors (MOG S) The MOGS (Lewis, Derlega, Berndt, Morris, & Rose, 2003) is a 70 item checklist that assesses the number of sexual minority stressors (i.e., stressors that sexual minorities are likely to face) that have occurred in the past year, such as experiences wit sexual orientation. Each of the processes within the Minority Stress Model is covered in the MOGS. There are ten subscales; however, only an overall score was used in the p resent study. The instruction on the MOGS is to check any event that you have experienced in the past year that was stressful sexual minority stress was calculated by summing the number of items endorsed ranging from 0 70. Higher scores indicate a greater degree of sexual minority stress. of .88 for the MOGS in an adolescent population.
31 Coping Questionnaire (C OPE ) The COPE (Carver, Scheier, & Weintraub, 1989) is a 60 item questionnaire that is of fifteen subsca les, two of which were used in the present study (consisting of eight total items) The subscale s used measure use of planning which is a form of problem focused coping, and use of instrumental social support. The instruction on the COPE i s to indicate how frequently you use particular coping styles when experiencing stressful events using a 4 point Likert type scale, ranging from 1 ( usually ) to 4 ( usually do this a lot ). S ample item s from th e s e subscale s are ask peo ple who have had si milar experiences what they did try to come up with a strategy about what to do. Scores are calculated by summing the ratings of the items in each individual subscale. There is no overall score. Higher scores indicate more freq uent utilization of each coping style. I n the scale development study (Carver et al., 1989) t alpha for the planning /problem focused coping subscale has been reported to be .80 and the alpha for the use of the instrumental social support subs cale has been reported to be .75 Health Promoting Lifestyle Profile II (HPLP II) The HPLP II (Walker & Hill Polerecky, 1996) is a 52 item self report inventory that measures level of engagement in an overall health promoting lifestyle. Six HP LP II subscales assess level of engagement in specific health promoting behaviors that constitute a health promoting lifestyle including: health responsibility, exercise, nutrition, spiritual growth, interpersonal relations, and stress management. Only an overall score was used in the present study The instruction on the HPLP II is to indicate how frequently you engage in specific health promoting behaviors using a 4 point Likert type
32 scale ranging from 1 ( never ) to 4 ( routinely ). A sample item on this pro by taking the mean of all of the items to obtain an overall score. Higher scores indicate a lifestyle with higher self reported health promoting beh aviors. Walker & Hill Polerecky Procedure The present study was approved by the Institutional Review Board (IRB) at the affiliated university. All components of the study were complet ed online. Participants were primarily recruited through yahoo groups oriented towards sexual minorities. The researcher used an IRB approved recruitment script to recruit participants. The moderators of 160 yahoo groups were contacted requesting permissio n to post the recruitment script to the respective yahoo group ; however, only 90 moderators responded to the request and posted the script to their group Additionally, the recruitment script was printed in two media outlets oriented towards sexual minorit ies E mails were also sent to known individuals with connections to sexual minority communities (e.g., individuals who have done research wi th sexual minority communities or individuals who are affiliated with organization s focused on sexual minority issue s) The researcher asked such individuals to forward the recruitment script via e mail to individuals who may fit the inclusion criteria or to listservs oriented towards sexual minorities. ( See Appendix E for the recruitment script. ) informed consent and an Assessment Battery (AB) of the was in cluded in the email /recruitment script The first webpage in the link contain ed all of the necessary informed consent information. The informed consent included information on th e purpose of the study, what participation in the study entail s
33 the risks and benefits of the study, issues around compensation and confidentiality, the voluntary nature of the study, and the right to withdraw. ( See Appendix F for the informed consent for m ) Participants gave option on the webpage. Participants who did not agree were not able to access the AB and were sent to a closing webpage thanking them for their time. After agreeing to terms in the informed c onsent form participants were directed to a webpage to complete the AB. The questionnaires in the AB were counter balanced with the exception of the DHIQ which was placed at the end of the AB so as not to bias s ponses Completion of t he A B took approximately 15 30 minutes. Only the Principle Investigator (PI) had No identifying information, including e mail addresses, were Additionally, the data was password protected. Alt hough participants did not receive compensation after 250 participants completed the AB $ 250 was donated to the Human Rights Campaign, a civil rights organization that works to achieve equality for lesbian, gay, bisexual, and transgender individuals. P ar ticipants also had the opportunity to receive the results of the study and implications for health promotion and counseling interventions If participants decide d to receive the results they provide d their e mail address on a separate webpage ; however, th eir contact information was kept separate from the rest of their data. Participants e mail addresses will be deleted once they have been notified of the Recruitment and data collection lasted approximately 3 months.
34 Statistical Analyses P reliminary Analyses Prior to conducting the main analyses, the demographic characteristics (e.g., age, sex, race/ethnicity, and socioeconomic status) and variables of interest (sexual minority stress, problem focused coping, social coping, physical health problems, and engagement in a health promoting lifestyle) were examined for accuracy of data entry, missing values, and fit between their distributions and the assumptions of the General Linear Model for the continuous variables The internal reliability o f each self report scale was alpha. Descriptive statistics were calculated for the demographic variables and variables of interest. Analysis to Test the Hypothesized Model Hypothes es 1 4 stated that sexual minority stress will negatively predict level of engagement in health promoting lifestyle and positively predict number of physical health problems; problem focused and social coping will partially mediate the relationship between sexual minority stress and a health promoting lifestyle as well as partially mediate the relationship between sexual minority stress and number of physical health problems. To test these hypothese s, a bootstrapped path analysis was conducted. The bootstr apping method produces thousands of resampled data sets (random sampling with replacement) from the original measured data set, each with the same sample size as the original sample. The direct and indirect effects are re estimated in each random resample. The standard deviation of these effects serves as the empirical standard error used to test the significance of the average direct and indirect effects.
35 The use of this empirical method ensures that the asymptotic assumption of normally distributed effec ts need not be met. Because such empirical standard error estimates can be opportunistically small (given that they are estimated from the same defined sample), bias correcting augments to the standard error were used ( Arbuckle, 2008 ) T his method can be u seful when testing mediation effects because it takes into account the skewed distribution of indirect effects (Shrout & Bolger, 2002; Preacher & Hayes, 2008). The path analysis test ed all total effects ; the direct effects of sexual minority stress proble m focused coping and social coping on a health promoting lifestyle and the number of physical health problems ; and the indirect effects of sexual minority stress on a health promoting lifestyle and the number of physical health problems through both coping styles (i.e., the mediation). The model was fully recursive. Analyses to Answer the Research Question T he research question set forth in the present study stated : Are there differences in the major study variables in association with sex, race/ethnici ty, socioeconomic status (SES) sex x race/ethnicity, race/ethnicity x SES and sex x SES ? Due to limited diversity in the sample, the principle investigator was unable to explore the full research question. Thus, the following research question was addres sed: Are there differences in the major study variables in association with sex, socioeconomic status (SES), and sex x SES ? Between subjects, 2 way Analyses of Variance (ANOVAs) or Multivariate Analyses of Variance (MANOVAs) were conducted to address the r esearch question The independent variab les for the research question analyses were sex and SES Dependent variables were grouped into MANOVAs based on conceptual relation (e.g., coping strategies, health related variables) and by utilizing p reliminary cor relations If variables were moderately correlated and were conceptually related, they were grouped
36 into a MANOVA. Variables not conceptually related or not moderately correlated were placed as dependent variables into separate ANOVAs. Table 3 1 Particip Reported Sexual Orientation Not at all Homosexual Somewhat Homosexual Very Homosexual Not at all Heterosexual 1 (0.4%) 0 (0.0%) 4 (1.6%) 11 (4.4%) 104 (41.6%) 0 (0.0%) 1 (0.4%) 4 (1.6%) 28 (11.2%) 32 (12.8%) Somewhat Heterosexual 0 (0. 0%) 0 (0.0%) 27 (10.8%) 8 (3.2%) 5 (2 .0 %) 0 (0.0%) 4 (1.6%) 6 (2.4%) 2 (0.8%) 0 (0.0%) Very Heterosexual 0 (0.0%) 0 (0.0%) 1 (0.4%) 2 (0.8%) 6 (2.4%) Note. Numbers presented are the N and corresponding percentage for each category. Four participants di d not report their sexual orientation. Figure 3 1
37 CHAPTER 4 RESULTS First, the results of the preliminary analyses to address the general characteristics of the data are presented. Second, the results of a bootstrapped path analysis to test Hypothese s 1 4 are reported. Finally the results of the Univariate and Multivariate Analyses of Variance conducted to address the research q uestion are presented. Preliminary Analyses Prior to conducting the analyses to address the hypotheses and exploratory research question, the demographic characteristics (e.g., age, sex, race/ethnicity, and socioeconomic status ) and variables of interest ( sexual minority stress, problem focused coping /planning social coping /use of i nstrumental social support engagement in a health promoting lifestyle, and number of physical health problems) were exam ined for accuracy of data entry and missing values The investigated variables were also examined for the fit between their distributio ns and the assumptio ns of the General Linear Model (GLM) The assumption of normality was met by verifying that skewness and kurt osis statistics were between 2 and 2 and by producing and inspecting histograms and normal probability plots. Because of thei r categorical nature, sex, race/ethnicity, and socioeconomic status were not normally distributed. All of the study variables were fairly normal. Linearity and homoscedasticity were verified by producing and inspecting bivariate scatterplots. In addition, inspection of the correlation matrix revealed no b ivariate correlations above 0.50 among the variables of interest, indicating that multicollinearity did not exist. After the assumptions of the GLM were met, descriptive statistics of all of the study varia bles were calculated (see Table 4 1).
38 The internal reliability of each self full scale of the Measure of Gay Related Stressors was .94 for this sample. The s for the subscales of the Coping Questionnaire for this sample were .85 for the Planning subscale and .86 for the Use of Instrumental Social Support subscale. th Promoting Lifestyle Profile II was .93 for this sample. Results of Bootstrapped Path Analysis to Test Hypo these s 1 4 A path model with bootstrapped estimates of standard error was conducted to test hypotheses 1 4, which are as follows: 1. Sexual minority stress will negatively predict level of engagement in a health promoting lifestyle. 2. Sexual minority stress will positively predict number of physical health problems (e.g., diabetes, cardiovascular disease). 3. Problem focused and social coping will partial ly mediate the relationship between sexual minority stress and level of engagement in a health promoting lifestyle. 4. Problem focused and social coping will partially mediate the relationship between sexual minority stress and the number of physical health problems. Significance tests were conducted using bootstrapped estimates of standard errors for direct, indirect, and total effects. To test Hypotheses 1 4 in the present research, 1000 bootstrapped subsamples were selected. Two statistical packages, AMO S 20.0 and SPSS 19 .0, were used to conduct the bootstrapped mediation. All calculations involved were based on standardized values. Table 4 2 shows the resulting standardized direct regression paths, indirect mediation paths, and total regression paths. Th e overall model accounted for 26 % of the variance in level of engagement in a
39 health promoting lifestyle and 5 % of the variance in number of physical health problems. Direct E ffects The significant direct effects highlight the signifi cant relationships in the model while controlling for the other relationships in the model Hypotheses 1 and 2 were supported. Results indicated that sexual minority stress had a significant negative direct effect on engagement in a health promoting lifestyle and a significant positive direct effect on number of physical health problems Results also indicated that problem focused and social coping had a significant positive direct effect on engagement in a health promoting lifestyle. All other direct effects were not significan t. See Table 4 2 for the selected statistics on all direct effects. Indirect E ffect s Hypotheses 3 and 4 were not supported. The test of the indirect effects (i.e., the meditational effects) revealed no significant indirect effects. Specifically, problem fo cused and social coping did not significantly mediate the relationship between sexual minority stress and engagement in a health promoting lifestyle, nor did either coping style significantly mediate the relationship between sexual minority stress and numb er of physical health problems ( s ee Table 4 2) Total E ffects The significant total effects highlight the significant relationships in the overall model without controlling for other relationships within the model Results indicated that sexual minority s tress had a significant negative total effect on engagement in a health promoting lifestyle and a significant positive total effect on number of physical health problems. Results also indicated that problem focused and social coping had a
40 significant posit ive total effect on engagement in a health promoting lifestyle. All other total effects were not significant. See Table 4 2 for the selected statistics on all total effects. Results of ANOVAs and MANOVAs to Explore the Research Question T he research questi on set forth in the present study stated : Are there differences in the major study variables in association with sex, race/ethnicity, socioeconomic status (SES) sex x race/ethnicity, race/ethnicity x SES and sex x SES ? Due to limited diversity in the sam ple, the principle investigator was unable to explore the full research question. Specifically, the sample was fairly homogenous in regards to race/ethnicity, with 75.2% of the sample identifying as Caucasian/non Hispanic White/European American so no rac e/ethnicity analyses were conducted Additionally, only 4% of the sample fit into the high income group ( report ing an annual household income above $100,000 ) so only individuals with low and middle incomes were compared. Finally, only female and male part icipants were compared due to small N s for participants who Between subjects, 2 way Analyses of Variance (ANOVAs) or Multivariate Analyses of Variance (MANOVAs) were conducted to address the research q uestion The independent variab les for the research question analyses were sex and SES Dependent variables were grouped into MANOVAs based on conceptual re lation (e.g., coping strategies or health related variables) and by utilizing p reliminary correlatio ns If variables were moderately correlated and were conceptually related, they were grouped into a MANOVA. Only problem focused and social coping were grouped as dependent variables in a MANOVA ( R = .29, p < .01). Sexual minority stress, engagement in a
41 h ealth promoting lifestyle, and number of physical health problems were entered as a dependent variable in separate ANOVAs. Demographic Differences in Sexual Minority Stress Results of the ANOVA using sexual minority stress as the dependent variable reveale d a significant main effect of sex on sexual minority stress, F (1, 195) = 13.49, p < .001. Men ( M = 21.88 SD = 1 3.47 ) reported significantly higher levels of sexual minority stress than wo men ( M = 17. 13 SD = 1 0.81 ) There was also a significant main effe ct of SES on sexual minority stress, F (1, 195) = 8.38, p < .01. Individual s with a low household income ( M = 22.65 SD = 1 1 6 8 ) reported significantly higher levels of sexual minority stress than individuals with a middle household income ( M = 1 7.25 SD = 1 2 82) The interaction between sex and SES was not significant F (1, 195) = 1.49, p = .22 See Table 4 3 for group means and standard deviations. Demographic Differences in Coping Results of the MANOVA using problem focused and social coping as dependent variables revealed no significant main sex ( F (2 19 4 ) = 2.91 p = .0 6 ) or SES ( F (2, 194 ) = 0.92 p = 40 ) effects. There were also no significant interaction effects, F (2, 194 ) = 0.87 p = 42 See Table 4 3 for group means and standard deviations. Demogra phic Differences in Engagement in a Health Promoting Lifestyle Results of the ANOVA using engagement in a health promoting lifestyle as the dependent variable revealed no significant main sex ( F (1, 195) = 3.78, p = .05) or SES ( F (1, 195) = 3.02, p = .08) e ffects There were also no significant interaction effects, F (1, 195) = 1.90, p = .17. See Table 4 3 for group means and standard deviations
42 Demographic Differences in Number of Physical Health Problems Results of the ANOVA using number of physical health problems as the dependent variable revealed no significant main sex ( F (1, 195) = 0.59 p = 44 ) or SES ( F (1, 195) = 0.96 p = 33 ) effects. There were also no significant interaction effects, F (1,195) = 0.60 p = 44 See Table 4 3 for group means and sta ndard deviations. Table 4 1. Selected descriptive statistics for all investigated variables Variable Sexual Minority Stress Planning Use of Social Support Health Promoting Lifestyle Number of Health Conditions M 19.26 13.48 11.52 2.58 1.79 Comparativ e M a 12.58 b 11.50 b 2.65 c SD 12.58 2.62 2.98 0.41 1.75 Compar a tive SD a 2.66 b 2.88 b 0.41 c Obtained Range 0 61 5 16 4 16 1.65 3.65 0 10 Possible Range 0 70 4 16 4 16 1 4 Obtained .94 .85 .86 .93 Scale .88 .80 .75 .94 a Unable to access a comparative M and SD for the total 70 item MOGS score. b The COPE comparative sample M s and SD s are adapted from Carver, Scheier, & Weintraub (1989). c The HPLP II comparative sample M s and S D s are adapted from McElligott, Capitulo, Morris, & Click (2010).
43 Table 4 2 Direct, indirect and total effects in the path model Predictors Sexual Minority Stress Social Coping Problem focused Coping Dependent Variable: Health Promoting Lifestyle Total 0.265 0.298 0.320 ** ( .053) ( .057) (.051 ) Direct 0. 225 0. 298 0.320 ** ( .0 49 ) ( .05 7 ) (.051) Indirect 0.040 (.030) Number of Physical Health Conditions Total 0. 187 0. 060 0.1 08 ( .0 77 ) ( .0 63 ) (.070) Direct 0. 197 ** 0. 060 0.108 ( .0 77 ) (.0 63 ) (.070) Indirect 0.011 (.011) p < .05, ** p < .01. Note Values represent standardized effect estimates for total, direct, and indirect effects of each predictor. The value s in parentheses represent standard errors, which were empirically estimated with 1,000 bootstrapped samples.
44 Table 4 3. Sex and SES Statistics for Investigated Variables Female M ( SD) ( n = 130) Male M (SD) ( n = 69) Low Income M (SD) ( n = 85) Mid Income M (SD) ( n = 114) Sexual Minority Stress 17.13 (1 0 81 ) 2 1.88 ( 13.47 ) 22. 6 5 (1 1 6 8) 1 7.25 ( 12.82 ) Problem focused Coping 13.66 ( 2.54 ) 13.19 ( 2.69 ) 13.11 ( 2.85 ) 13.69 ( 2.47 ) Social Coping 11.81 ( 2.95 ) 11.14 ( 2.98 ) 11.34 ( 2.82 ) 11.53 ( 3.02 ) Health Promoting Lifestyle 2.62 (0.4 2 ) 2.52 (0. 39 ) 2.49 ( 2.07 ) 2.6 4 (0. 41 ) Number of Health Problems 1.64 ( 1.57 ) 1.88 ( 1.81 ) 2.07 ( 2.04 ) 1.69 ( 1.51 ) Indicates significant demographic differences. Note The values in parentheses represent s tandard deviations
45 CHAPTER 5 DISCUSSION Summary of Results Relationships among Sexual Minority Stress, Coping Styles, and Physical Health Indicators Hypothes e s 1 4 addressed the relationships among sexual minority stress, coping styles (i.e., problem f ocused and social coping), and physical health indicators (i.e., engagement in a health promoting lifestyle and number of physical health problems). Hypotheses 1 and 2, which pertain to the relationship between sexual minority stress and the physical healt h indicators, were support ed Both the total and direct effects within the path model suggest that sexual minority stress had a significant negative effect on engagement in a health promoting lifestyle. In other words, as levels of sexual minority stress i ncreased, engagement in a health promoting lifestyle decreased. Additionally, both the total and direct effects within the bootstrapped path model suggest that sexual minority stress had a significant positive effect on number of physical health problems. In other words, as levels of sexual minority stress increased, the number of physical health problems also increased. Hypotheses 3 and 4, which pertain to the mediational effect of the coping styles between sexual minority stress and the physical health in dicators, were not supported. There were no significant indirect (i.e., mediational) effects within the path model. However, both problem focused and social coping had significant total and direct effects on engagement in a health promoting lifestyle. As l evels of problem focused and social coping increased, engagement in a health promoting lifestyle also increased.
46 Multiple Minority Statuses and Investigated Variables The research question was developed to explore whether having multiple minority statuses influenced levels of sexual minority stress, coping styles, and physical health indicators. Specifically, the research question addressed differences in the investigated variables in association with sex, socioeconomic status (SES), and the interaction of sex and SES. Largely, the results suggest that having multiple minority statuses was not necessarily related to differences in the investig ated variables; however, there were demographic differences in association with sexual minority stress. Male sexual m inorities reported higher levels of sexual minority stress than female sexual minorities. Also, sexual minorities with a low household income reported higher levels of sexual minority stress than sexual minorities with a middle household income. There were no significant demographic differences in coping or physical health indicators. Implications of Results Sample Health Characteristics This study adds to the literature on the state of physical health among sexual minorities. It is important to highlight t hat while 46.4% of participants rated their health as very good or excellent, the average participant endorsed having approximately 2 physical health problems. This is consistent with the existing literature that suggests sexual minorities experience high rates of several physical health conditions, particularly when compared to heterosexual individuals (Conron, Mimiaga, & Landers, 2010). Of particular note is the high rate of overweight and obesity in this sample (44.4% of the sample), both of which are l inked to a number of long term physical health conditions (National Heart, Lung and Blood Institute, 2009). This statistic parallels the research showing high rates of overweight and obesity among lesbian and bisexual women
47 (Yancey, Cochran, Corliss, & May s, 2003; Boehmer, Bowen, & Bauer, 2007; Struble, Lindley, Montgomery, Hardin, & Burcin, 2011) and may be a precursor to the high risk of cardiovascular disease for sexual minorities (Ungvarski & Grossman, 1999 ; Valanis, Bowen, Bassford, Whitlock, Charney, & Carter ; 2000; Roberts, Dibble, Nussey, & Casey, 2003). Minority Stress Model addresses several processes and concepts related to sexual identity, various sources of stress, coping and social support mechanisms, and me ntal health. The findings in this study serve two purposes informed by the Minority Stress Model literature. First, this study provides partial support for the existing literature on the Minority Stress Model. Second, this study extends the Minority Stress Model by examining the impact of sexual minority stress on physical health indicators, rather than mental health indicators. Sexual minority stress and health Broadly, the results from this study and the existing literature suggest a negative link betwee n sexual minority stress and health. Specifically, sexual minority stress has been linked with negative mental health outcomes such as psychological distress or psychological disorders (Frisell et al., 2010; Mays & Cochran, 2001; Meyer, 2003; Szymanski & O wens, 2008; Szymanski, 2009). The results from this study parallel the findings with sexual minority stress and mental health ; specifically s exual minority stress was shown to have a negative association with physical health indicators (i.e., decreased en gagement in a health promoting lifestyle and increased number of physical health problems).
48 Coping and the Minority Stress Model In the original Minority Stress Model, coping and social support mediate the relationship between sexual minority stress and me ntal health outcomes. This study was designed to examine a similar relationship between sexual minority stress and physical health indicators by utilizing problem focused and social coping as mediators; however, the mediating relationship was not supported Clearly, these findings were unexpected. While the results did show a link between both coping styles and engagement in a health promoting lifestyle, these coping styles did not seem to buffer agai nst the sexual minority stress. The coping literature has already demonstrated a link between coping and engagement in specific health promoting behaviors such as treatment adherence or dietary behaviors The link between both problem focused and social coping styles and engagement in a health promoting lifesty le in the present study confirms the relationship found by other researchers between coping and health promoting behaviors ( Luszczynska & Haynes, 2009; Rao, 2009). Problem focused coping may be an adequate coping style when dealing with general stress, bu t it may not be adequate in mediating the ef fect of sexual minority stress. For example, s tudies have shown that problem focused coping mediates the relationship between stress and well being, one aspect of health (Chao, 2011; Karlsen, Dybdahl, & Vitterso, 2006). However, the results of this study are consistent with the focused coping had no moderating or mediating effect on the relationship between internalized homophobia, one component of sexual minority stress, and psychological distress. It appears that problem focused coping may not be the best coping style for addressing
49 various forms of sexual minority stress. One possible explanation is that problem focused coping is an intrapersonal style of coping, whereas sexual minority stress is largely a social and interpersonal process. Meyer (2007) suggests that actual or perceived social support mediates the relationship between sexual minority stress and mental health outcomes in the Minorit y Stress Model There is existing evidence that social support buffers against general and sexual minority stress and results in positive psychological outcomes ( Hequembourg & Brallier, 2009; Lehavot & Simoni, 2011; Mansini & Barrett, 2008). The present st udy examined perceived social support from a coping perspective, given the relationship between various coping styles and physical health indicators ; however, it may be actual social support, instead of the ability to cope using social support that is eff ective when deali ng with sexual minority stress. Experiences of Sexual Minority Stress within Sexual Minority Sub groups This present study explored demographic differences (i.e., sex and SES) in sexual minority stress, coping styles, and physical health indicator s among sexual minorities utilizing a multiple minority status framework. While some of the literature suggests differences in each of these variables ( i.e., stress, coping, and physical health indicators) by level of minority status (e.g., havin g multiple minority statuses versus having a single minority status) the present study only found minority status differences in the experiences of sexual minority stress. It is not clear why there were no significant demographic differences in the invest igated coping styles and physical h ealth indicators. These results are contrary to existing research that suggest s having multiple minority statuses facilitates coping and psychological resilience (Herek & Garnets, 2007). One possible explanation is that h aving multiple minority statuses allows an
50 individual to use a variety of coping styles, rather than elevating the use of just one coping style. Pendragon (2010) showed that sexual minority females would use multiple coping strategies as a way to manage di scrimination related to their multiple identities. Given the health disparities research showing that low income groups are at a higher risk for health problems than higher income groups, it would seem that there would at least be SES differences in number of physical health problems ( National Heart, Lung and Blood Institute, 2009 ; Office of Minority Health & Health Disparities, 2012 ). However, the prevalence of health conditions is only one factor when considering the contributors to health disparities; th is study does not account for the other factors such as access to and quality of healthcare. It is clearer why there were no sex differences in the physical health indicators. Because physical health varies by sex based on the type of condition and the s pecific health promoting behavior, taking a broader view of physical health may mask any existing sex differences. For example, women are more prone to certain kinds of cancers and may be more focused on dietary behaviors whereas men are more prone to diab etes or hypertension and may be more focused on exercise ( U.S. Department of Health and Human Services, 2011 ) Although there were no demographic differences in coping styles and physical health indicators in association with sex or income there were signi ficant differences in sexual minority stress in association with these demographic variables The multiple minority status framework may be helpful in explaining the intersection of sexual identity and SES on experiences of sexual minority stress S exual m inorities with a low household income reported higher levels of sexual minority stress than sexual minorities with a middle household income. Literature has shown that minorities experience h igher
51 levels of stress than majority groups, particularly low SES groups (see review in Hatch & Dohrenwend, 2007). Meyer and Frost (2008) found that individuals in multiple disadvantaged groups experience higher levels of stress than individuals in only one disadvantaged group. Conversely, the multiple minority status framework does not apply to the intersection of sex and sexual identity for this study. If the multiple minority status framework held true, female sexual minorities in this study would have reported higher levels of sexual minority stress than male sexual minorities; however, the opposite was true. The intersection of sex and sexual identity is a complex one in regards to experiences of stress and discrimination. In some cases male sexual minorities may experience more discrimination than female sexual min orities. For example, one study found evidence of workplace discrimination, especially with wages, against gay men, but not against lesbian women (Elmslie & Tebaldi, 2007). A very likely explanation for the sex differences in sexual minority stress found i n this study is that sexual minority me n experience different types of stressors from sexual minority women. Hequembourg and Brallier (2009) suggest that sexual minority women may experience more sexualized discrimination, while sexual minority men experie nce more physically threatening discrimination. Sexual minority women may be eroticized and sexual minority men may be recipients of verbal and physical threats, particularly by heterosexual men. The Measure of Gay Related Stressors does capture physical a nd verbal violence, but it does not capture sexualized discrimination. Accounting for sexualized discrimination may narrow the gap between sex es o n sexual minority stress.
52 Limitations and Future Directions Recruitment and Sample Issues It is important to n ote that the majority of the sample consisted of women ( 58.4 %) and non Hispanic White participants ( 75.2 %) thus limiting the generalizability to other populations Despite efforts to recruit participants from diverse racial/ethnic backgrounds by specifica lly targeting several online groups for people of color, there was little representation from racial/ethnic minority groups. There was also limited representation from t ransgender individuals ( 4.8 %) Dist rust is likely a major factor contributing to the l ack of representation from these groups For example, many racial/ethnic minorities may not have participated because of fears associated with exploitation or conce rns about data being used only to benefit the careers of the researchers rather than to bene fit the community ( Yancey, Ortega, & Kumanyika, 2006). Yancey, Ortega, and Kumanyika suggest bridging the gap between research related goals and goals of the community by improving communication. Due to the online nature of the present study, it was diffic ult to express intent and goals when recruiting participants. When the researcher had direct communication with the leaders of the online group and intentions were clarified, participation seemed to be stronger from those groups. The direct communication h ighlights another important point; that is, when leaders within the group endorsed the study, participation was stronger. It seems important to have an in group ally to enhance trust from participants. As a white, female researcher, it was more difficult t o gain the trust from non female and non white individuals. Many online groups did not allow membership unless one met the demographic criteria.
53 Occasionally, group leaders of such groups would allow the researcher to post information about the study after having direct communication with the researcher The process of expressing intent was also relevant with transgender participants. The study was not designed to address the needs of transgender individuals, knowing that stressors and health issues may be different from the stressors and health issues associated with gay, le sbian, and bisexual individuals; however, this was not clearly expressed in the recruitment materials. Some transgender individuals reported feeling offended tha materials. More research needs to be done to capture the experiences with stress, coping, and physical health among transgender populations and particularly research that is sensitive to the needs of this popu lation F uture online research similar to the present study should clearly express the intentions of the research in recruitment materials and highlight the relevancy of the research to the minority community. It may also be helpful to offer a brief report of research findings and implications to the participants once the study is complete so the participants are aware of how their data is presented. For the present study, a report will be given to participants who provided consent to receive the report Mea surement Issues An important limitation of the present study is that the measures all involved self report responses. The self report responses may be somewhat biased and may more accurately capture perceived, rather than actual, levels of sexual minority stress, coping, engagement in a health promoting lifestyle, and physical health problems. Future studies similar to the present study should ideally include gathering objective health indicator data such as health behavior logs.
54 There were some limitations related to the coping measure used (i.e., COPE). Although the COPE is a reliable and validated measure, the P lanning and Use of Instrumental S ocial S upport subscales are comprised of only four items, which may not fully capture problem focused and social coping. Participants in the present study tend ed to endorse high levels of these copings styles, which may limit the variance and impact the findings from the coping data. For example, the mean score was 13.48 for the Planning subscale and 11.52 for the Us e of Instrumental Social Support subscale out of a possible range of 4 16. Finally, it is possible that the selected coping styles may not have been relevant for this specific population. Future research should attempt to identify what successfully buffers against sexual minority stress by exploring various cop ing styles as buffers of this stress. The primary limitation to the assessment of sexual minority stress in the present study pertains to level of distress associated with the sexual minority stresso rs P articipants were told to endorse an item on the Measure of Gay Related Stressors (MOGS) if they had experienced the event and the event was stressful. Thus, the experience of a stressful event may have impacted participants without causing distress ; y et, the present study does not capture those experiences. Future research should differentiate between experiences of sexual minority stressors and feelings of distress related to such stressors. While the overall assessment of sexual minority stress prov ided a helpful general picture of the relationship between sexual minority stress and physical health indicators, more detailed information is needed about the processes underlying sexual minority stress. As indicated in Chapter 2, sexual minority stress, as defined in the Minority Stress Model, consists of several stress processes: (a) stress related to experiencing
55 prejudiced events, (b) stress related to expecting and anticipating the experience of rejection or discrimination, (c) stress related to discl and (d) stress related to internalizing negative societal attitudes. Future research should examine these stress processes more closely and identify if certain ones may be more predictive of physical health indicators. F inally, as the Minority Stress Model states, sexual minority stress has an effect above and beyond general stress. Future research should confirm this assumption of the model. Conclusions The purpose of this study was to a) examine whether sexual minority stress, problem focused coping and social coping predict physical health problems and engagement in a health promoting lifestyle (i.e., physical health indicators) and b) explore the impact of multiple identities on sexual minority stress, coping, and ph ysical health indicators. Sexual minority stress was predictive of physical health indicators and coping was predictive of engagement in a health promoting lifestyle. There were higher levels of sexual minority stress among male sexual minorities and sexua l minorities with a low household income, than their respective counterparts. The present study provide s a greater understanding of the psychological factors influencing physical health indicators (i.e., number of physical health problems and engagement in a health promoting lifestyle) among sexual minorities. Furthermore, support is provide d for further research using the Minority Stress Model to study such psychological factors Th e results of the present study ha ve implications for health care provision Specifically, the results suggest the need for health care providers to be trained in how to assess sexual minority stress among their patients and in ways they as providers may help to reduce/eliminate this type of stress during provider patient interac tions.
56 Additionally, the study has implications for counseling psychologists who focus on health related issues. Such psychologists should strive to discuss the role of sexual minority stress in the lives of sexual minority clients, and explore ways in whi ch to reduce/eliminate this stress. Overall support is provided for training psychologists as well as health care providers about the influences of sexual minority stress on the occurrence of health problems and levels of engagement in health promoting l ifestyles among sexual minorities. Clearly, the results of the present study provide an impetus for delivering more culturally sensitive/ competent physical and mental health care for sexual minorities Such health care could ultimately help eliminate the h ealth disparities that sexual minorities face.
57 APPENDIX A MEASURES D emographic and H ealth I nformation Q uestionnaire Directions : Please answer all questions that apply to you. Your answers will be kept confidential. Do you consider yourself to be any of the following races or ethnicities ? ( Click all that apply) ( Note : Even if you consider yourself to be Hispanic/Latino and/or African American or Black, you may also consider yourself to be one or more of the following races ) O American Indian or Alaska Native O Asian or Asian American O Black or African American O Caucasian / White / European American O Hispanic or Latino O Native Hawaiian or other Pacific Islander O Other: _____________________________________________ ( Please write in your race if it is not listed ) What is the highest level of education that you have completed ? O elementary school O junior high/middle school O high school or GED O 2 year college O 4 year college/university O professional/graduate school O trade/technical s chool What is your age? _________ What is your sex? O Female O Male O Transsexual O Other: _____________________________________________ ( Please write in your sex if it is not listed )
58 Consider your physical and affectional preference. To what degree are y ou heterosexual (physically attracted to and affectionate with the opposite sex)? Not at all heterosexual Somewhat heterosexual Very heterosexual 1 2 3 4 5 O O O O O Consider your physical and affectional preference. To what deg ree are you homosexual (physically attracted to and affectionate with the same sex)? Not at all homosexual Somewhat homosexual Very homosexual 1 2 3 4 5 O O O O O What is your current relationship status? O I do not have a partner O I am living w ith my partner (s) O I am not living with my partner (s) How many people currently live in your household (including yourself)? O 1 O 4 O 7 O 2 O 5 O 8 O 3 O 6 O 9 or more What is your yearly household income (the total combined income that is made yearly by all working members of your household)? $______________________ In general, how would you describe your health? O Excellent O Very good O Good O Fair O Poor
59 Do you currently have any of the following health conditions? ( Please bubble in all that ap ply to you. ) O Overweight/obesity O High cholesterol O High blood pressure (hypertension) O Type 2 diabetes O Cardiovascular/ Heart disease O HIV/AIDS O Sexually Transmitted Infection (STI) O Respiratory problems (e.g., asthma, COPD) O Gastrointestinal prob lems (e.g., IBD, ulcer) O Skin conditions (e.g., eczema, psoriasis) O Can cer ( please write in what type of cancer ): ___________________________________________________ O Other ( please list any additional health conditions ): ________________________________ ______________________ O I do not have any of these health conditions
60 M easure of G ay R elated S tressors Directions : Below are some issues you may or may not have dealt with because of your sexual orientation. If you experienced the event in the past yea r AND it was stressful, please select YES. If you have not experienced the event in the past year, please select NO. Only select yes for an item if it occurred for you in the past year. ___ 1. Introducing a new partner to my family ___ 2. Having s traight friends know about my sexual orientation ___ 3. Dating someone openly gay ___ 4. Having people at work find out about my sexual orientation ___ 5. Being affectionate in public with my partner ___ 6. Mental health discrimination base d on my sexual orientation ___ 7. Housing discrimination because of my sexual orientation ___ 8. Lack of security at work because of my sexual orientation ___ 9. Hiding my sexual orientation from others ___ 10. Possible rejection when I tell someone about my sexual orientation ___ 11. Being in public with groups of gays/lesbians/bisexuals (in a bar, in church, at a rally) ___ 12. The expectation from friends and family members who do not know about my sexual orientation for me to date o r marry someone of the opposite sex ___ 13. Keeping my sexual orientation secret from some friends and family members ___ 14. Possible loss of my children in a custody case due to my sexual orientation ___ 15. Legal discrimination due to my sexual or ientation ___ 16. Lack of support from family members due to my sexual orientation ___ 17. Working in a homophobic environment ___ 18. Fact that my family ignores my sexual orientation ___ 19. Having my lover and family members in the same place at the same time ___ 20. Telling straight friends about my sexual orientation
61 ___ 21. Rumors about me at work due to my sexual orientation ___ 22. Talking with some of my relatives about my sexual orientation ___ 23. Loss of job due to sexual orienta tion ___ 24. Discrimination in social services due to my sexual orientation ___ 25. Inability to get some jobs due to my sexual orientation ___ 26. A feeling that I must always prove myself at work because of my sexual orientation ___ 27. Loss of c lose friends to AIDS ___ 28. Fear that I will be attacked because of my sexual orientation ___ 29. Limits I have placed on sexual activity due to AIDS ___ 30. Lack of constitutional guarantee of rights due to sexual orientation ___ 31. My family's over zealous interest in my sexual orientation ___ 32. The need to exercise caution when dating due to AIDS ___ 33. Fear that I may have exposed others to HIV ___ 34. The feeling that my family tolerates rather than accepts my sexual orientation ___ 35. Rejection by my children due to my sexual orientation ___ 36. My lover's family's inability to accept our relationship ___ 37. Rejection by my brothers and sisters ___ 38. Harassment at work due to my sexual orientation ___ 39. Potential job loss due to sexual orientation ___ 40. Fear that I might get HIV or AIDS ___ 41. Loss of friends due to my sexual orientation ___ 42. The extra care I must take to assure that my partner gets benefits (insurance, etc.) that a legal spouse would get a utomatically ___ 43. Rejection by family members due to my sexual orientation ___ 44. Distance between me and my family due to my sexual orientation ___ 45. "Being exposed" as a gay/lesbian/bisexual ___ 46. My family's lack of understanding about m y sexual orientation
62 ___ 47. Physical assault due to my sexual orientation ___ 48. Threat of violence due to my sexual orientation ___ 49. The constant need to be careful to avoid having anti gay/lesbian violence directed at me ___ 50. Mixed feelin gs about my sexual orientation because of society's attitudes toward gays/lesbians ___ 51. Possibility that there will be violence when I am out with a group of gays/lesbians/bisexuals ___ 52. Fact that I have HIV or AIDS ___ 53. Fear that my friend s may be at risk for HIV ___ 54. Inability to get close to people because of my sexual orientation ___ 55. Constantly having to think about "safe sex" ___ 56. Harassment due to sexual orientation ___ 57. Being called names due to my sexual orient ation ___ 58. Lack of acceptance of gays/lesbians in society ___ 59. Being left out of things due to my sexual orientation ___ 60. Some people's ignorance about gays/lesbians ___ 61. Difficulty meeting people because of concern over HIV ___ 62. Shame and guilt because of my sexual orientation ___ 63. Conflict between my self image and the image people have of gays/lesbians ___ 64. Difficulty finding someone to love ___ 65. The image of gays/lesbians created by some visible, vocal gays/lesbi ans ___ 66. Difficulty accepting my sexual orientation ___ 67. Unwillingness of my family to accept my partner ___ 68. Talking to others about AIDS ___ 69. Rejection by my church or religion due to sexual orientation ___ 70. Feeling that I am lef t out of certain rites of passage (proms, weddings, etc.) because of my sexual orientation
63 Coping Q uestionnaire ( COPE ) Directions : We are interested in how people respond when they confront difficult or stressful events in their lives. There are lots of ways to try to deal with stress. This questionnaire asks you to indicate what you generally do and feel when you experience stressful events. Obviously, different events bring out somewhat different responses, but think about what you usually do when yo u are under a lot of stress. Then respond to each of the following items by selecting how frequently you use that response. Please try to respond to each item separately in your mind from each other item. Choose your answers thoughtfully, and make your ans wers as true FOR YOU as you can. Please accurate answer for YOU what YOU usually do when YOU experience a stressful event. Indicate the frequency with which you engage in each behavior by clicking on the circle beneath the answer you choose. I usually this at all I usually do this a little bit I usually do this a medium amount I usually do this a lot 1. I tr y to come up with a strategy about what to do 2. I ask people who have had similar experiences what they did. 3. I make a plan of action 4. I try to get advice from someone about what to do. 5. I think hard about w hat steps to take. 6. I talk to someone to find out more about the situation. 7. I think about how I might best handle the problem. 8. I talk to someone who could do something concrete about the problem.
64 H ealth P ro moting L ifestyle P rofile II Directions : This questionnaire contains statements about your present way of life or personal habits. Please respond to each item as accurately as possible, and try not to skip any item. Indicate the frequency with which you en gage in each behavior by clicking on the circle beneath the answer you choose. Never Sometimes Often Routinely 1. Discuss my problems and concerns with people close to me. 2. Choose a diet low in fat, saturated fat, and cholesterol. 3. Report any unusual signs or symptoms to a physician or other health professional. 4. Follow a planned exercise program. 5. Get enough sleep. 6. Feel I am growing and changing in positive ways. 7. Praise other people easily for their achievements. 8. Limit use of sugars and food containing sugar (sweets). 9. Read or watch TV programs about improving health. 10. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber). 11. Take some time for relaxation each day. 12. Believe that my life has purpose.
65 13. Maintain meaningful and fulfilling relationships with others. 14. Eat 6 11 servings of bread, cereal, rice and pasta each day. 15. Question health professionals in order to understand their instructions. 16. Take pa rt in light to moderate physical activity (such as sustained walking 30 40 minutes 5 or more times a week). 17. Accept those things in my life which I cannot change. 18. Look forward to the future. 19. Spend time with close fr iends. 20. Eat 2 4 servings of fruit each day. 21. Get a second opinion when I question my 22. Take part in leisure time (recreational) physical activities (such as swimming, dancing, bicycling). 23. Concentrate on pleasant thoughts at bedtime. 24. Feel content and at peace with myself. 25. Find it easy to show concern, love and warmth to others. 26. Eat 3 5 servings of vegetables each day. 27. Dis cuss my health concerns with health professionals. 28. Do stretching exercises at least 3 times per week. 29. Use specific methods to control my stress.
66 30. Work toward long term goals in my life. 31. Touch and am to uched by people I care about. 32. Eat 2 3 servings of milk, yogurt or cheese each day. 33. Inspect my body at least monthly for physical changes/danger signs. 34. Get exercise during usual daily activities (such as walking dur ing lunch, using stairs instead of elevators, parking car away from destination and walking). 35. Balance time between work and play. 36. Find each day interesting and challenging. 37. Find ways to meet my needs for intimacy. 38. Eat only 2 3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day. 39. Ask for information from health professionals about how to take good care of myself. 40. Check my pulse rate when exercisi ng. 41. Practice relaxation or meditation for 15 20 minutes daily. 42. Am aware of what is important to me in life. 43. Get support from a network of caring people. 44. Read labels to identify nutrients, fats, and sod ium content in packaged food. 45. Attend educational programs on personal health care. 46. Reach my target heart rate when exercising.
67 47. Pace myself to prevent tiredness. 48. Feel connected with some force greater than myself. 49. Settle conflicts with others through discussion and compromise. 50. Eat breakfast. 51. Seek guidance or counseling when necessary. 52. Expose myself to new experiences and challenges.
68 APPE NDIX B RECRUITMENT SCRIPT Hello! My name is Delphia Flenar and I am a doctoral student in the Psychology Department at the University of Florida. I am currently conducting a study under the guidance of Dr. Carolyn M. Tucker. The study has been approve d by the Institutional Review Board at the University of Florida (UFIRB # 2012 U 539). The purpose of this study is to examine engagement in a health promoting lifestyle. Addi tionally, this study examines what coping styles may adequately address stress in sexual minority adults. It is our hope that this study can inform psychologists and healthcare providers about the influences of stress and coping in the lives of sexual mino rities in order to establish more culturally sensitive physical and mental healthcare initiatives for sexual minorities. Your participation is essential to achieving this goal, so we hope that you will take part in our study. In order to participate, you must identify as lesbian, gay, bisexual, or as some other sexual minority; be able to read English; and be 18 years of age or older. If you would like to participate in our study, please click on the link below and you will be directed to the online surve y: https://ufpsychology.qualtrics.com/SE/?SID=SV_e5xqj0XCPyQ5TiA Please note that Facebook, Yahoo groups, or other online servers may record and use your online acti vity for other purposes. Thank you very much in advance for your time! Please feel free to pass on this link to other people who might be eligible. If 250 individuals participate, $250 will be donated to the Human Rights Campaign, a civil rights organizat ion that works to achieve equality for lesbian, gay, bisexual, and transgender individuals. If you have any question about this study, please feel free to contact me at firstname.lastname@example.org. Sincerely, Delphia Flenar M.S. Carolyn M. Tucker, Ph.D. Counse ling Psychology, University of Florida
69 APPENDIX C INFORMED CONSENT FOR M Informed Consent to Participate in Research and Authorization for Collection, Use, and Disclosure of Information PLEASE READ THE INFORMATION BELOW AND BELOW IF YOU AGRE E TO THE TERMS You are being asked to take part in a research study. This webpage provides you with information about the study and seeks your permission for the collection, use, and disclosure of your information necessary for the study. Your participati on is entirely voluntary. Before you decide whether or not to take part, read the information below and ask questions about anything you do not understand. You can email your questions to email@example.com If you choos e not to participate in this study, you will not be penalized or lose any benefits that you would otherwise be entitled to. 1. Title of Research Study: Sexual Minority Stress, Coping, and Physical Health Indicators 2. Source of Funding or Other Material Suppor t: Dereck Chiu Counseling Psychology STAR Scholarship 3. Purpose of the research study: The purpose of this study is to examine affects physical health problems and engagement in a health promoting lifestyle. Addit ionally, this study examines what coping styles may adequately address stress in sexual minority adults. 4. What you will be asked to take part in the study: You will be asked to complete a set of questionnaires online Specifically, the questionnaires will ask you about what types of stress you experience, how often you use certain coping styles, how often you engage in specific health promoting behaviors, and basic demographic and health information. Completing the questionnaires will take approximately 15 30 minutes. 5. Possible risks and benefits: We do not expect any risk to you for participating in this study. Some questions may cause mild personal discomfort due to their sensitive nature; however, if a question is too discomforting, feel free to skip that question. There are no known risks to completing the questionnaires. We do not expect any benefits associated with participation in this research project; however, there may be long term benefits in regards to enhancing counseling and health interventions for sexual minority clients counseling and health interventions at the conclusion of the study.
70 6. Compensation: There is no compensation f or participating in this study; however, if at l east 250 individuals participate in the study $ 250 will be donated to the Human Rights Campaign, a civil rights organization that works to achieve equality for lesbian, gay, bisexual, and transgender individuals. 7. Confidentiality: Records identifying part icipants will be kept confidential to the extent permitted by applicable laws and regulations and will not be made publicly available. However, federal government regulatory agencies and the Institutional Review Board (a committee that reviews and approves human subject research studies) may inspect and/or copy your records for quality assurance and data analysis. These records may contain private information. To ensure confidentiality to the extent permitted by law, the following measures will be taken : only PI and the research team members will have access to the data and protected computer files. We will ask you to write down your email address if you are interested in receiv ing the results at the conclusion of the study; however, this information will be kept separate from the rest of your data Records identifying participants will be kept confidential and will not be made publicly available. After data c ollection has been c ompleted and participants have been notified of the results, your email address will be removed. 8. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. In addition you may stop compl eting the questionnaires if it makes you feel uncomfortable You may skip any question that you do not wish to answer or that makes you feel uncomfortable, without receiving any penalty. For the information to be useful to us, please complete as many items as you can. 9. Right to withdraw from the study: You have the right to withdraw from the study at any time without consequence. Whom to contact if you have questions about the study: Delphia Flenar M.S. Doctoral Candidate firstname.lastname@example.org (352) 284 183 Th is research is being done under the supervision of Dr. Carolyn M. Tucker (352) 273 2167
71 Whom to contact about your rights as a research participant in the study: University of Florida Institutional Review Board Office Box 112250 University of Florida G ainesville, FL 32611 (352) 392 0433 Agreement: I have read the procedure described above. I voluntarily agree to participate in the study ACCEPT ( Consent by agreeing to terms and continue to participation link) REJECT (Refuse consent and stop participat ion ; will not continue to participation link)
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77 BIOGRAPHICAL SKETCH Delphia Flenar was born in Denver, Colorado in 1986. At the a ge of 4, Delphia moved to the small Midwestern town of Dunkirk, Indiana and spent her childhood and adolescence with her large family in Indiana during the school year and Colorado during the summer. Delphia attended Butler University in Indianapolis, Indi ana and graduated c um Laude in 2008 with a Bachelor of Arts in Psychology and a minor in Gender Studies. Florida to pursue degrees in Counseling Psychology. She received her M aster of Science degree in 2010 and her Doctor of Philosophy degree in 2013 from the University of Florida Delphia plans to pursue a career as a staff psychologist within a university counseling center Her research interests include empowerment of margin alized groups, addressing health disparities, and multicultural issues in health.