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Access to ambulatory healthcare services for LGBTQ populations
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Access to ambulatory healthcare services for LGBTQ populations
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Content
i
Access to Ambulatory Healthcare Services for LGBTQ Populations
By
Trenton Keith Mendenhall
Rossier School of Education
University of Southern California
A dissertation submitted to the
in partial fulfillment of the requirements for the degree
Doctor of Education
December 2022
ii
© Copyright by Trenton Keith Mendenhall 2022
All Rights Reserved
iii
The Committee for Trenton Keith Mendenhall certifies the approval of this Dissertation
Kimberly Ferrario
Tory Cox
Rufus Tony Span, Committee Chair
Rossier School of Education
University of Southern California
2022
vi
Abstract
LGBTQ individuals consistently experience barriers when accessing ambulatory healthcare
services in the United States. Research shows that LGBTQ individuals are 2.17 times more likely
to delay seeking healthcare when compared to their non-LGBTQ counterparts, demonstrating
that access to healthcare is a significant problem (Jennings, 2019). A primary cause of this delay
in healthcare access is that a majority of clinicians and healthcare staff have not been provided
the proper training to treat the specialized needs of the LGBTQ population (Khalili et al., 2015).
In addition to a lack of trained providers, other barriers to healthcare access for LGBTQ patients
include poor stigma, gaps in health insurance coverage, and a lack of nondiscrimination laws
ensuring their protection as patients (Kates et al., 2018). The problem of access to healthcare for
LGBTQ individuals residing in the United States is vital to address because patients who receive
consistent access to care have better overall health outcomes (Macinko et al., 2003). The purpose
of this study was to examine barriers to accessing ambulatory healthcare services for LGBTQ
individuals. A qualitative research design utilizing a semi-structured interview approach was
used to collect and analyze data from ambulatory care healthcare providers. The findings showed
that participants identified several behaviors, influences, and factors that aid in improving
healthcare access for LGBTQ patients. Future research should explore replicating this study in
various ambulatory healthcare settings within different regions of the United States to identify
further geographical influences on healthcare access for the LGBTQ community.
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Dedication
To the LGBTQ community and all vulnerable populations who have struggled to access
equitable healthcare services.
viii
Acknowledgments
Thank you to Dr. Rufus Tony Spann for guiding me through my dissertation journey
from beginning to end. I appreciate your continued support and guidance. To Dr. Tory Cox, I
will forever be thankful to have had you as a mentor during my entire doctoral experience. I
genuinely appreciate your support and friendship. Dr. Kimberly Ferrario, you were truly the best
start and end to my OCL journey. Having you as my framing professor truly laid the foundation
for my dissertation studies and overall success in this program.
I send my appreciation and thanks to my classmates; a special thanks to Christopher
Hartnett for being my support system, group project partner, and friend. A huge thank you to the
ambulatory care providers who took the time out of their busy schedules to let me interview
them. I acknowledge your time is both limited and valuable. Your contribution of experience and
passion will lead healthcare access for LGBTQ patients in the right direction.
A final acknowledgment to my partner, family, friends, and colleagues who extended
support to me throughout the entirety of my doctoral journey.
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Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
Table of Contents .......................................................................................................................... vii
List of Figures ................................................................................................................................. x
Chapter One: Introduction to the Study .......................................................................................... 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 2
Importance of the Study ...................................................................................................... 3
Overview of Theoretical Framework and Methodology .................................................... 4
Definitions........................................................................................................................... 5
Organization of the Dissertation ......................................................................................... 6
Chapter Two: Literature Review .................................................................................................... 8
Shortage of LGBTQ Clinics and LGBTQ-Trained Physicians .......................................... 9
LGBTQ Youth .................................................................................................................. 11
LGBTQ Older Adults ....................................................................................................... 13
Transgender Discrimination in Healthcare ....................................................................... 16
LGBTQ Nondiscrimination Laws and Policies in Healthcare .......................................... 17
Conceptual Framework ..................................................................................................... 20
Summary ........................................................................................................................... 27
Research Questions ........................................................................................................... 29
Overview of Design .......................................................................................................... 29
Research Setting................................................................................................................ 31
The Researcher.................................................................................................................. 32
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Validity and Reliability ..................................................................................................... 37
Ethics................................................................................................................................. 38
Chapter Four: Findings ................................................................................................................. 39
Participants ........................................................................................................................ 40
Research Question 1: What Is the Willingness of Healthcare Providers to
Demonstrate Welcoming Behaviors Toward LGBTQ Patients? ...................................... 41
Research Question 2: What Are the Influences, if Any, That Affect a Healthcare
Provider’s Self-Efficacy Regarding the Needs of LGBTQ Patients? ............................... 47
Research Question 3: What Are the Factors in the Healthcare Provider’s Life That
Influence Their Beliefs and Attitudes About Their LGBTQ Patients?............................. 53
Summary ........................................................................................................................... 56
Chapter Five: Discussion and Recommendations......................................................................... 58
Discussion of Findings ...................................................................................................... 58
Recommendations for Practice ......................................................................................... 61
Integrated Recommendations............................................................................................ 66
Limitations and Delimitations........................................................................................... 68
Recommendations for Future Research ............................................................................ 68
Conclusion ........................................................................................................................ 69
References ..................................................................................................................................... 71
Appendix A: Interview Protocol ................................................................................................... 84
Appendix B: Information Sheet for Exempt Research ................................................................. 90
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List of Tables
Table 1: Qualitative Data Collection Method Data Source 31
Table 2: Interview Participants Demographics 41
Table 3: Themes and Key Examples 57
Table 4: Conceptual Framework and Key Findings 59
Table 5: Application of Kotter’s 8 Step Change Model 67
xi
List of Figures
Figure 1: Conceptual Framework: Social Cognitive Theory Triadic Reciprocal Model 26
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Chapter One: Introduction to the Study
LGBTQ individuals experience multiple barriers when accessing healthcare in the United
States. Healthcare access is the ease with which individuals can access a service, provider, or
healthcare institution and receive the appropriate services based on their needs (Levesque et al.,
2013). One of the common barriers to healthcare, specifically for disadvantaged populations,
including LGBTQ patients, is discrimination (Rivenbark & Ichou, 2020). The American Journal
of Public Health estimates that 5.4% of American residents over eighteen identify as lesbian,
gay, bisexual, transgender, or queer (Gates, 2017). LGBTQ stands for “Lesbian, Gay, Bisexual,
Transgender, or Queer” and is an acronym “used to collectively refer to all sexual minority,
transgender, or gender non-conforming people” (Martos et al., 2017, p. 1). According to
Jennings (2019), LGBTQ individuals are 2.17 times more likely to delay seeking healthcare
when compared to their non-LGBTQ counterparts, demonstrating that access to healthcare is a
significant problem.
Research confirms that LGBTQ patients experience significantly worse physical health
outcomes than non-transgender and heterosexual patients (Ranji et al., 2018). Common medical
conditions in the LGBTQ population include higher rates of sexually transmitted diseases
(STDs), cancer, obesity, risk of substance abuse, depression, and suicide (Hafeez et al., 2017).
Further evidence shows that most clinicians and healthcare staff have not been provided with the
proper training to treat the specialized needs of the LGBTQ population (Khalili et al., 2015). In
addition to a lack of trained providers, other barriers to healthcare for LGBTQ individuals
include poor stigma, gaps in health insurance coverage, and poor treatment from healthcare
providers (Kates et al., 2018). The problem of access to healthcare for LGBTQ individuals
residing in the United States is vital to address because patients who receive consistent access to
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care have better overall health outcomes, including lower hospitalizations and premature
mortality (Macinko et al., 2003). The purpose of this study will be to identify the barriers to
accessing ambulatory healthcare services for LGBTQ individuals.
Context and Background of the Problem
The West Coast Hospital (WCH, a pseudonym) is one of the largest university-based
medical systems in the greater Los Angeles area. The purpose of this medical system is to
provide state-of-the-art healthcare to not only Los Angeles residents but to patients who live
domestically and abroad. The mission of WCH is to be the trusted leader in health care. WCH
aims to provide quality healthcare that is patient-centric, caring, and forward-thinking while also
emphasizing integrity, respect, collegiality, and continuity. Overall, this organization commits to
providing excellent clinical care. While WCH actively promotes its mission statement of
providing uncompromising healthcare, the medical system still fails to implement measures or
take the initiative to improve access to healthcare for LGBTQ patients. In recent years WCH has
attempted to conduct various pieces of training regarding LGBTQ patient health. However, none
have been comprehensive and analyzed staff competency or motivation to date. There is
currently no data showing that the past LGBTQ trainings have resulted in improved patient
access.
Purpose of the Project and Research Questions
This study aims to identify the barriers to accessing ambulatory healthcare services for
LGBTQ individuals. These barriers will be identified by investigating how willing WCH
providers currently are regarding modeling positive and welcoming behaviors toward LGBTQ
patients, their willingness to learn the clinical needs of LGBTQ patients, and their willingness to
integrate LGBTQ patient feedback into their everyday healthcare practices. The following
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questions, rooted in Albert Bandura’s social cognitive theory, are proposed to understand how
behavior, environment, and person influence a healthcare provider and how this influences
LGBTQ patient access to healthcare (Bandura, 20000).
Three research questions guided this study:
1. What is the willingness of healthcare providers to demonstrate welcoming behaviors
toward LGBTQ patients?
2. What are the influences, if any, that affect a health care provider’s self-efficacy
regarding the needs of LGBTQ patients?
3. What are the factors in the health providers’ life that influence their beliefs and
attitudes about their LGBTQ patients?
Importance of the Study
Identifying and addressing the barriers to access to healthcare for LGBTQ patients is
critical for multiple reasons. First, not having timely access to or delaying access to necessary
healthcare services often results in missed opportunities to address severe health conditions
(Smith et al., 2018). Delaying accessing healthcare services for LGBTQ patients is often due to
fear of discrimination from healthcare providers (Macapagal et al., 2016). Additionally, when
patients delay treatment, do not immediately address underlying medical conditions, and do not
have access to constant continuity to treat these severe health conditions, negative health
outcomes such as premature mortality can often occur (Pereira et al., 2018). Nationally, there is a
shortage of physicians trained on the needs of LGBTQ patients. Evidence shows that only 51.1%
of healthcare providers feel competent in providing adequate care for LGBTQ patients (Rowe et
al., 2017). To break down barriers to access, WCH must examine its healthcare provider’s
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competency and motivation to learn the clinical needs of LGBTQ patients seeking services in
this health system.
Overview of Theoretical Framework and Methodology
The theory providing the most appropriate lens to examine the problem of access to
healthcare for LGBTQ individuals who reside in the United States is social cognitive theory. The
social cognitive theory uses a triadic reciprocal model to explain the interactions between
behavior, people, and the environment (Bandura, 2000). Furthermore, the researcher will use the
self-efficacy motivational variable of social cognitive theory to address the problem of access to
healthcare for LGBTQ individuals who reside in the United States. Self-efficacy is rooted in the
idea that individuals will likely engage in activities if they feel competent in their abilities
(Bandura, 1997).
Social cognitive theory is the appropriate lens to examine this problem since this theory
enables the examination of the problem of access to healthcare for LGBTQ individuals who
reside in the United States because it provides an opportunity to investigate the influence of the
environment on individuals and their behaviors. The self-efficacy component of social cognitive
theory allows for the examination of clinician motivation regarding a patient’s ability to access
healthcare, the ability to develop treatment plans or options that provide comprehensive patient
care, the ability to learn and model welcoming behaviors, and the ability to speak out about the
LGBTQ patient experience.
The research design for this study will utilize qualitative research methods, specifically
qualitative interviews. A qualitative-methods research approach is appropriate for this study
because access to ambulatory healthcare services for LGBTQ patients is a complex problem that
can best be understood by qualitatively obtaining insights directly from WCH providers. The
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data source for this research study will be semi-structured interviews that aim to gain insight into
WCH healthcare providers’ behaviors, perceptions, and motivations to welcome and provide
healthcare services for LGBTQ patients. Specifically, these interviews will investigate WCH
healthcare providers’ willingness to model welcoming behavior toward LGBTQ patients, their
ability to improve their self-efficacy by attending trainings to learn the specific needs of this
community, and their ability to integrate LGBTQ patient feedback into their daily practices and
interactions in order to break down the barriers that result in lack of access to healthcare for
LGBTQ patients.
Definitions
This section includes the proper gender terminology and specific healthcare industry
vocabulary utilized throughout this study.
• Access in the context of healthcare is defined as the ease with which individuals can
access a service, provider, or healthcare institution and receive the appropriate
services based on their needs (Levesque et al., 2013).
• Ambulatory healthcare services are outpatient treatments, screenings, or consultations
that do not require an overnight stay in the hospital and include specialties such as
primary care, infectious diseases, and outpatient mental health, which provide
treatment for STDs, HIV, depression, and other common medical ailments
(Hollenbeck et al., 2015).
• Barriers in healthcare are the factors that can prevent an individual or community
from acquiring access to health services (Morris, 2012).
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• A caregiver is an assigned individual, often a family member, friend, or paid
professional, who helps a person in need of healthcare or unable to seek healthcare on
their own manage their physical care (Sullivan & Miller, 2015).
• Cisgender refers to individuals whose sex they were assigned at birth is the same as
their gender identity (Dubin et al., 2018).
• LGBTQ stands for “Lesbian, Gay, Bisexual, Transgender, or Queer” and is an
acronym “used to collectively refer to all sexual minority, transgender, or gender non-
conforming people” (Martos et al., 2017, p. 1).
• LGBTQ older adults are individuals who identify as LGBTQ and are age 65 or older
(Tkatch, 2016.)
• LGBTQ youth are adolescents who identify as LGBTQ and are aged 13 to17 (Conron,
2020).
• Transgender refers to individuals whose gender identity differs from the sex they
were assigned at birth (Meerwijk & Sevelius, 2017).
Organization of the Dissertation
This study is organized into five chapters. The first chapter provides the reader with an
overview of the problem of practice and the importance of the study, as well as the context of the
organization of the study and critical healthcare terminology and vocabulary definitions. Chapter
Two provides an in-depth review of the current literature relevant to this study. Topics in this
chapter include a shortage of LGBTQ clinics, and LGBTQ-trained physicians, barriers to access
for LGBTQ youth and older adults, transgender discrimination in healthcare, and a review of
LGBTQ nondiscrimination laws and policies in healthcare. This chapter also illustrates the
conceptual framework that will be used in this study, specifically social cognitive theory, and its
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motivational variable self-efficacy. Chapter Three details the methodological approach to
complete this study, specifically the study design, research setting, data source, data collection,
and data analysis. Chapter Four analyzes and examines the qualitative data collected through
semi-structured interviews in this study. Finally, Chapter Five includes a discussion of this
study’s findings and recommendations for future practice and research.
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Chapter Two: Literature Review
This literature review will analyze multiple barriers to accessing ambulatory healthcare
services for LGBTQ individuals residing in the United States. Ambulatory healthcare services
are outpatient treatments, screenings, or consultations that do not require an overnight stay in the
hospital (Hollenbeck et al., 2015). Ambulatory care services include specialties such as primary
care, infectious diseases, and outpatient mental health, which provide treatment for STDs, HIV,
depression, and other medical ailments common within the LGBTQ community (Furness et al.,
2020). The review begins by providing an in-depth analysis of how the shortage of LGBTQ
ambulatory care clinics and the limited number of LGBTQ-trained physicians in the United
States impacts LGBTQ patient access to care. The chapter continues with a review of the
literature on how LGBTQ youth cannot access comprehensive ambulatory services, such as
mental and sexual healthcare services, resulting in increased rates of sexually transmitted
diseases, homelessness, and suicide. The literature then reviews how LGBTQ older adults
experience discrimination, elder abuse, and neglect when needing ambulatory healthcare
services. This review will then examine research on how transgender patients delay accessing
care because they face even more exacerbated discrimination when seeking treatment when
compared to their cisgender lesbian, gay, and bisexual counterparts. This chapter then reviews
the literature investigating the shortcomings of current healthcare nondiscrimination laws in the
United States for LGBTQ individuals. Although the literature here can be applied to various
healthcare problems, this review focuses primarily on the literature’s application to the problem
of access to ambulatory care services for LGBTQ populations. The chapter ends with an analysis
of Bandura’s (2000) social cognitive theory, which this study used for ambulatory care
clinicians’ interactions between behavior, people, and the environment and its impact on LGBTQ
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patient access to ambulatory healthcare services. This analysis also examines how self-efficacy,
the motivational variable of social cognitive theory, allows for examining clinician motivation
regarding an LGBTQ patient’s ability to access ambulatory healthcare services.
Shortage of LGBTQ Clinics and LGBTQ-Trained Physicians
The limited number of ambulatory clinics offering LGBTQ services in the United States
is one of the critical barriers LGBTQ patients face when accessing healthcare. Evidence shows
that most LGTBQ clinics are located in urban locations (Whitehead et al., 2016). Currently, only
thirty-seven states have operating community LGBTQ health centers, and within these states,
many patients do not live within a 60-mile radius of these medical establishments (Martos et al.,
2017). In the greater Los Angeles area, there are approximately 365,000 LGBTQ adults and only
a handful of LGBTQ-designated health clinics (Los Angeles Almanac, 2019). Although many
established clinics in urban settings will see transgender patients, they often lack the training,
infrastructure, and resources to meet the need for trans-specific care (Martos et al., 2017).
LGBTQ patients who reside in rural areas of the United States that are not near LGBTQ health
centers report lower rates of utilization of healthcare services and lower rates of disclosure of
their sexual identity to their providers due to fear of stigma (Whitehead et al., 2016).
Additionally, the rural areas that lack clinics offering LGBTQ patients services are often found
in the Southern United States, where there is a higher volume of conservative voters (White
Hughto et al., 2026). Not only is there a minimal number of ambulatory clinics in both urban and
rural settings providing LGBTQ services, but there is also a shortage of trained physicians who
can address the needs of these patients.
The deficit of physicians trained in the needs of LGBTQ patients is a significant
impediment to healthcare access for this community. Research shows that only 51.1% of
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providers feel competent in providing LGBTQ care (Rowe et al., 2017). The lack of training for
providers, specifically physicians, to learn the needs of this vulnerable population can be
attributed to their medical school curriculum. Only 16% of U.S. medical institutions offer a
comprehensive LGBTQ training course (Khalili et al., 2015). The low rates of inadequately
prepared physicians are even higher regarding transgender-specific care. Approximately 20% of
transgender patients report having to educate their primary care physician about their health care
needs (Bradford et al., 2013). Not only is there a shortage of LGBTQ competent providers and
clinics there is a shortage of healthcare institutions that can connect their LGBTQ patients to
LGBTQ competent providers. Specifically, only 9% of U.S. academic medical centers have
processes for connecting patients to LGBTQ competent physicians (Khalili, 2015). The lack of
providers and clinics results in significant appointment wait times and barriers to access for
LGBTQ patients.
When LGBTQ patients can finally access an ambulatory care clinic, they experience long
wait times and short appointments (Thompson, 2016). Longer wait times to be seen by a
provider frequently result in vulnerable populations not seeking healthcare services (Ray et al.,
2015). Not seeking timely healthcare can result in missed opportunities to address serious health
conditions (Smith et al., 2018). Shorter appointment times are also problematic because the less
time allocated for the provider to be with the patient, the less time the provider has to address
their patients’ needs (Trentalange et al., 2016). Overall, improving access to more LGBTQ
ambulatory clinics and the volume of physicians with comprehensive LGBTQ training is vital
for the health and well-being of this vulnerable population. A subset of the LGTBQ community
who are significantly impacted by barriers to access is LGBTQ youth. LGBTQ youth are
adolescents ages 13–17 and represent 9.5% of the youth population in the United States (Conron,
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2020). Given that LGBTQ youth comprise a substantial percentage of the youth population
within the United States, the multiple barriers that impact LGBTQ youth’s access to ambulatory
healthcare services need to be explored.
LGBTQ Youth
LGBTQ youth have less access to care, resulting in higher rates of contracting sexually
transmitted diseases (STDs), becoming homeless, and committing suicide compared to LGBTQ
adults (Fraser et al., 2019). This lack of access stems from fear of disclosing sexual identity to
clinicians, being unwelcomed in their family homes, and not having adequate access to mental
health or preventative healthcare services (Hafeez et al., 2017). Furthermore, LGBTQ youth are
more likely to engage in unsafe sexual behavior, such as irregular STD testing, if getting tested,
which often results in untreated sexually transmitted diseases. LGBTQ youth avoid getting tested
for STDs due to fear of discrimination associated with disclosing sexual orientation to a
healthcare provider (Hafeez et al., 2017). It is estimated that one in four LGBTQ youth has had
an STD or other medical ailment that requires screening or seeing an ambulatory healthcare
provider for treatment (Shannon & Klausner, 2018). Without frequent testing and treatment,
these high STD rates will continue to burden the LGBTQ youth population (Shannon &
Klausner, 2018). Overall, the culmination of these disparities results in poor health outcomes for
LGBTQ youth; however, the fear of accessing healthcare services often serves as the catalyst for
the struggles of many LGBTQ youths.
LGBTQ youth do not have patient-protected access to sexual health prevention,
screening, or treatment. Evidence highlights that LGBTQ youth fear their patient privacy being
breached, resulting in these patients not accessing the sexual health screenings and treatments
they need (Knight et al., 2013). This fear of patient privacy being breached stems from LGBTQ
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youth fearing being discriminated against by their healthcare providers due to disclosing their
sexual orientation and fear that their provider will also disclose this information to their parents
(Hadland et al., 2017). Providers disclosing a patient’s sexual identity to the parents can be
incredibly problematic since one of the primary pathways that result in LGTBQ youth
homelessness is when sexual identity is disclosed to the family and then forced to leave one’s
home (Castellanos, 2017). Patient privacy between LGBTQ youth and their healthcare providers
needs to be prioritized, especially if a potential outcome of a provider disclosing confidential
information to a parent can result in discrimination and possibly homelessness.
A disproportionate amount of LGBTQ youth in the United States experience
homelessness. Approximately 40% of homeless youth identify as LGBTQ, and many of these
youth cannot afford healthcare (Ranji et al., 2015). Not being able to afford healthcare causes
homeless LGBTQ youth to utilize the emergency department, instead of ambulatory clinics, as
their only source of care (Lebun-Harris et al., 2009). When individuals use the emergency
department as their only source of care, they often only receive specific treatment that day. This
is problematic because these patients are not provided with opportunities for follow-up or
ongoing treatment (Canham et al., 2017). Not having ongoing access to treatment can be very
detrimental to homeless LGBTQ youth’s health outcomes, especially if their healthcare requires
ongoing mental health services.
Adolescence is a critical time for LGBTQ youth’s mental health and well-being. During
this stage of development, many mental health disorders will arise, which is especially
problematic for LGBTQ youth due to their high risk for compromised mental health (Russel &
Fish, 2016). Research shows that approximately one-third of LGBTQ youth meet the criteria for
having a mental health disorder (Mustanski et al.,2010). Further research shows that ub the
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United States approximately 1.8 million LGBTQ youth ages 13–24 consider suicide each year,
demonstrating that LGBTQ youth may not have access to proper mental health services (Green
et al., 2019). LGBTQ youth often do not seek mental health services because they are concerned
that the mental health staff is not adequately trained or sensitive to the needs of LGBTQ patients
(Higgins et al., 2020). Mental health services are not the only sector of healthcare where LGBTQ
youth feel uncomfortable accessing care.
Multiple healthcare specialties fall under the umbrella of ambulatory care, and often
LGBTQ youth cannot access any of these outpatient clinics; therefore, their healthcare needs are
unmet. For the minority of LGBTQ youth who can receive care, 68% report not feeling
comfortable sharing their sexual orientation with their provider resulting in having accessed
uncomprehensive treatment (Hafeez et al., 2017). The combination of high sexually transmitted
disease and suicide rates with 9.6% of the youth population identifying as LGBTQ demonstrates
that it is vital that access to LGBTQ youth healthcare services is improved (Green et al., 2019).
Although many LGBTQ youths encounter significant healthcare access challenges, LGBTQ
older adults also experience multiple obstacles when accessing healthcare.
LGBTQ Older Adults
LGBTQ older adults have experienced a long and discriminatory journey accessing
healthcare throughout their lifetimes. LGBTQ older adults are individuals who identify as
LGBTQ and are age 65 or older (Tkatch, 2016.) Vulnerability and openness to healthcare
providers about one’s identity are not shared amongst LGTBQ older adults. Many of today’s
LGBTQ older adults are still fearful of disclosing their identity to healthcare providers. Research
shows that nearly 25% of LGBTQ older adults have not revealed their sexual orientation or
gender identity to their primary care physician (Foglia & Fredrisken-Goldsen, 2014). The
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hesitancy to disclose their LGTBQ identity stems from a long history of discrimination from
living in a time when the marginalization of LGBTQ individuals was even more prevalent than it
is today (Redcay et al., 2019). Laws decriminalizing homosexuality were not present in the
United States until the late 1960s, during peak adolescence, and into adulthood for current
LGBTQ older adults (Weinmeyer, 2014).
Furthermore, homosexuality was not removed as a mental illness by the American
Psychological Association until 1973 (Fetner, 2016). The fear of marginalization still results in
LGBTQ older adults not disclosing their identity. Failure of LGBTQ older adults to inform their
identity to their healthcare providers can have detrimental health outcomes for this vulnerable
population (Foglia & Fredrisken-Goldsen, 2014). This population is especially at risk of not
being able to make the most informed medical decisions due to mild cognitive impairments that
can occur in old age (Han et al., 2016). When LGBTQ older adults get to this cognitively
decreased state, they usually have to rely on the assistance of others, especially when accessing
healthcare.
When LGBTQ older adults struggle to access healthcare themselves, they often have to
seek support from a caregiver. A caregiver is an assigned individual, often a family member,
friend, or paid professional, who helps a person in need manage their physical care (Sullivan &
Miller, 2015). LGBTQ older adults are often subject to elder abuse or neglect due to their
identity when receiving healthcare. Evidence shows that 22.1% of LGBTQ adults over the age of
60 report they have been abused or neglected by a caregiver (Bloemen et al., 2019). Wallace and
Bonnie (2003) define elder abuse as:
intentional actions that cause harm or create a serious risk of harm (whether or not harm
is intended) to a vulnerable elder by a caregiver or other person who stands in a trust
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relationship, or failure by a caregiver to satisfy the elder’s basic needs or to protect the
elder from harm. (p. 2)
The failure of a caregiver to meet the needs of or protect their dependent older adult from harm is
considered neglect (Pillemer et al., 2016). Overall, discrimination in the forms of abuse and
neglect is not optimal for older adults who often experience poor health outcomes. One of the
poor health outcomes expected for older adults is decreased cognitive ability, which can result in
impaired decision-making (Harada et al., 2013). As an LGBTQ older adult’s cognitive ability
decreases to no longer being able to make their own decisions, their medical choices may need to
be made legally by someone else.
It is not uncommon for LGBTQ older adults to get to the physical state cognitively,
where they can no longer make their own healthcare decisions. If an LGBTQ older adult gets to
this stage, future healthcare-related decision-making is often legally transferred to a healthcare
proxy (HCP). An HCP is a legal document in which a patient has appointed another party to
make medical decisions (Moye et al., 2013). Many LGBTQ older adults no longer are connected
to or speak to their biological family members. Instead, they rely on their “chosen family” for
support. If an LGBTQ older adult has not been assigned a proxy to make their medical decisions,
many states would not legally recognize a partner or friend who has not been legally assigned as
the patient’s HCP (Castillo et al., 2011). This could result in medical decision choices being
made estranged family member or another individual who is inappropriate to make medical
decisions (Moye et al., 2013). This is problematic because only 34% of older LGBTQ adults
have a designated HCP (American Geriatrics Society Ethics Committee, 2015). Transgender
individuals more frequently are rejected or estranged from family members and thus may not
have an appropriate individual to make healthcare decisions if they have not selected an HCP
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(White Hughto et al., 2015). Additionally, transgender patients experience even worse
discrimination when accessing ambulatory healthcare services.
Transgender Discrimination in Healthcare
Transgender individuals frequently delay accessing medical treatment. The term
transgender refers to an individual whose gender identity differs from the sex they were assigned
at birth (Meerwijk & Sevelius, 2017). Conversely, cisgender refers to individuals whose sex they
were assigned at birth is the same as their gender identity (Dubin et al., 2018). Often transgender
individuals delay medical care because of discrimination they have faced from clinicians and
administrative staff in healthcare settings. Evidence shows that 26.9% of transgender individuals
have been discriminated against at healthcare practices (Bradford et al., 2013). This is
significantly higher than 15% of cisgender LGB individuals who have reported discrimination
while receiving care (Macapagal et al., 2016). Further research shows that 19% of transgender
patients were refused care upon disclosing their gender identity (Seelman et al., 2017). Overall,
transgender patients experience various discrimination methods when accessing or attempting to
access healthcare.
Multiple discrimination methods, including verbal harassment and written discrimination
against transgender patients, often occur in healthcare settings. Verbal harassment is quite
prevalent in healthcare settings given that 28% of transgender patients report being subjected to
verbal harassment during their clinical visits (Seelman et al., 2017). Written discrimination exists
in healthcare settings in the form of outdated and unmodified electronic health records that do
not allow transgender patients to select their identified gender. Transgender patients are then
either forced to identify as the sex they were assigned at birth or be forced to delay care (Malina
et al., 2020). Overall, transgender individuals are 23.8% more likely to delay accessing care due
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to identity-based discrimination (Macapagal et al., 2016). While transgender patients often face
discrimination when receiving healthcare, many transgender individuals cannot access healthcare
due to inadequate or limited coverage of trans-specific care.
The difficulty in accessing healthcare is exacerbated for transgender individuals because
of increased discrimination, discriminatory policies, and limited coverage. Transgender patients
have difficulty accessing treatment because many Medicare, Medicaid, and private insurance
companies deny coverage for trans-specific care (Winter, 2012). This lack of coverage results in
transgender individuals being unable to access a physician’s office and self-administer hormone
therapies in unsafe settings (Spicer, 2010).
It is estimated that there are currently one million transgender individuals residing in the
United States, which demonstrates that delaying access to care due to discrimination is a
significant problem (Meerwijk & Sevelius, 2017). Transgender patients are not the only
subpopulation of the LGBTQ community directly impacted by a lack of fully inclusive
healthcare nondiscrimination laws and policies.
LGBTQ Nondiscrimination Laws and Policies in Healthcare
In the United States, a significant factor in the inequity in access to ambulatory healthcare
services for LGBTQ patients is due to current healthcare laws not providing the same benefits
and protections for LGBTQ patients as heterosexual patients. These laws include insurance
coverage and enrollment, hospital visitation rights for same-sex partners, and insufficient legal
protections from discrimination within ambulatory healthcare settings. Insurance Coverage with
same-sex partners varies from state to state; however, in many states, coverage and benefits are
not as comprehensive as that of heterosexual couples (Buchmueller & Carpenter, 2010). A
primary example of this coverage inequality is that employer-sponsored insurance is not legally
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required to be extended to same-sex couples in all states, meaning many LGBTQ individuals
cannot enroll their spouses in their employer-sponsored health insurance (Gonzales & Blewett,
2014). Not being enrolled in their spouse’s health insurance can result in someone having to pay
high out-of-pocket costs for insurance or choosing to be uninsured; choosing not to be insured
can result in drastically higher preventable diseases cost or premature mortality (Ponce et al.,
2010). Transgender individuals also face health insurance inequities in that many insurances still
do not provide coverage for gender-reaffirming care at ambulatory health centers (Strousma et
al., 2020). It is estimated that 20.8% of the transgender population with insurance are still denied
coverage for their necessary gender-affirming hormones (Strousma et al., 2020). Not having
insurance that provides access and coverage to ambulatory healthcare treatments can negatively
impact one’s overall health outcomes (Ponce et al., 2010). When LGBTQ patients can find
healthcare services covered by their insurance, they still often experience legal barriers to
including their partners and family in their healthcare decisions.
Many healthcare settings do not have the same rights for same-sex partners as for
heterosexual relationships. Since same-sex marriage was not legal in all states until June 2015,
many same-sex couples are not legally married (Palfrey, 2015). Not being legally married is
problematic for same-sex couples because only seven states recognize an unmarried partner as a
close family, allowing them to be included in medical visits and the healthcare decision-making
process (Demartino et al., 2017). Not being included in the healthcare decisions making process
can be incredibly problematic, especially in cases of accidents or decisions regarding end-of-life
care (Tejwani et al., 2013). As previously noted, not having an assigned healthcare proxy, in this
case, one’s partner if unmarried, can have detrimental health outcomes for the LGBTQ
individual in need of ambulatory care (Moye et al., 2013). The lack of rights for same-sex
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partners directly affects access to equitable ambulatory services and, thus, overall health
outcomes for LGBTQ individuals. The drastic difference in rights between heterosexual and
LGBTQ individuals is predominantly due to the lack of nondiscrimination laws in the United
States.
Legal protections from discrimination within the healthcare setting do not exist within all
geographic areas of the United States. Only 23 states have mandated and enforced laws
protecting LGTBQ individuals from discrimination (Riggle, 2017). Baily (2010) reports that
93% of the 200 largest hospitals in the United States do not have fully inclusive
nondiscrimination policies for LGBTQ individuals. Discrimination is a significant deterrent for
LGBTQ patients seeking ambulatory healthcare services; not having legal protections will
further impact LGBTQ patient access, thus negatively impacting this vulnerable population’s
overall health outcomes (Pomeranz, 2018). Not only do many states not have nondiscrimination
policies, but many states also have policies that explicitly prevent passing laws that would
enforce nondiscrimination in healthcare (Hswen et al., 2020). Due to nondiscrimination laws not
being enforced at all ambulatory clinics nationally, many healthcare institutions, often faith-
based treatment centers, allow providers to refuse care to LGBTQ patients due to their religious
views (Fadus et al., 2020). Additionally, it is predominately conservative geographic areas that
tend to lack policies and laws that would protect LGBTQ patients from healthcare discrimination
(White Hughto et al., 2016). Overall, inequalities in laws and policies regarding healthcare for
LGBTQ patients constitute a significant barrier to healthcare access for this population.
The literature reviewed in this study strongly supports the need to improve access to
ambulatory healthcare services for LGBTQ patients. The shortage of clinics and providers
equipped to meet the needs of the LGTBQ population poses a serious threat to the overall health
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outcomes of this vulnerable population. LGBTQ youth and their fear of accessing healthcare
services due to discrimination and lack of trust in healthcare providers are resulting in
homelessness, untreated ongoing medical conditions, and serious mental health complications.
LGBTQ older adults frequently experience discrimination, elder abuse, or neglect when seeking
ambulatory healthcare services. Transgender patients face significant discrimination prior to
even accessing healthcare services. Finally, the LGBTQ community at large is met with a lack of
inclusive, nondiscriminatory legal protections that impact access coverage to ambulatory
healthcare services. In order to further explore and understand the shortcomings of healthcare
access, there needs to be an examination of the interactions between behavior, people, and the
environment and how this triadic relationship impacts LGBTQ individuals; ability to access
healthcare.
Conceptual Framework
Social cognitive theory is the theory providing the most appropriate lens to examine the
problem of access to ambulatory healthcare services for LGBTQ individuals who reside in the
United States. The social cognitive theory uses a triadic reciprocal model to explain the
interactions between behavior, people, and the environment (Bandura, 2000). The motivational
self-efficacy variable of social cognitive theory will allow further exploration and understanding
of the problem of access to healthcare for LGBTQ individuals. The previously noted literature
supports that access to ambulatory healthcare is an issue for LGBTQ individuals. Examining the
three components of social cognitive theory’s triadic relationship explains how ambulatory care
providers acquire and display certain behaviors that impact access to healthcare for this
vulnerable population.
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With social cognitive theory as the overarching foundation, this study can examine
ambulatory care clinician interactions regarding behavior, person, and environment within the
healthcare system and learn how these interactions impact the ability to provide access to
healthcare for LGBTQ patients (Bandura, 2000). This theory allows researchers to analyze the
key concepts from the literature regarding access to healthcare for LGBTQ patients by analyzing
the barriers resulting in poor access within each of the three components of this model.
The first component of social cognitive theory is behavior. According to Bandura (1997),
behavior is anything that one does where one can either be rewarded or punished. Behavior
occurs as a result of an individual responding to an observed stimulus (Bandura, 1997). Personal
and environmental factors influence the outcome of one’s behavior. Therefore, the reciprocal
relationship proclaims that one’s behavior can only be changed if their personal and
environmental factors change (Thojampa & Mawn, 2016). In the context of behavior regarding
LGBTQ patients, from a healthcare perspective, two primary behaviors need to be analyzed
when examining access to healthcare for this population. First, what is the frequency ambulatory
care providers choose to engage with LGBTQ individuals accessing or attempting healthcare
services actively? Second, how often are ambulatory care providers displaying help-seeking
behaviors toward LGBTQ patients? In this triadic relationship, behaviors are essential; however,
their relationship to environmental factors is also necessary to examine when attempting to
understand the barriers to ambulatory care services for LGBTQ individuals.
Environment is the second component of social cognitive theories’ triadic model.
Environment refers to the external factors or context that can impact a person’s behavior, and
these environments can be either social or physical (Carillo, 2010). According to Yuket (2019),
social environments consist of people such as friends or coworkers, and physical environments
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are inanimate. They can be the lighting in a room or the location of an office. As humans, we
analyze the environments in which we are, and the assessment and perception of our
environments hinder or facilitate our behavior and likelihood to act (Bergman et al., 2019).
Overall, one’s social and physical environment can strongly influence the frequency and
intensity of an individual’s behavior (Sarin & Lunsford, 2017). In healthcare, social
environments are the employees, clinicians, and staff, and physical environments are the office
spaces and clinic locations. When examining access to healthcare for LGBTQ patients through
this component of the model, attention needs to focus on how the health system creates a
welcoming environment for LGBTQ patients and how the health system provides both
workplace support for helping LGBTQ patients access healthcare and professional support for
ambulatory care providers to be able to learn how to assist these patients. Developing an
inclusive and welcoming environment for LGBTQ patients can help the environment of the
health system evolve by helping shape the personal factors of the clinicians.
The final component of the triadic model is person. Person refers to the cognitive and
personality factors which characterize an individual (Carillo, 2010). Bandura (1986) refers to
cognitive processes as one’s previously learned characteristics or personal factors, which include
expectations, personality characteristics, and beliefs. It is one’s personal factors, such as beliefs,
that will ultimately influence which behaviors one chooses to imitate or engage in. Furthermore,
one's past experiences, based on success or failure, can influence one’s choice to repeat certain
behaviors. Specifically, if an individual completes a task, they will feel more confident in
completing the same task in the future (Bandura, 1997). Ultimately, individuals’ beliefs, feelings,
and thoughts will shape their behavior (Bandura,1989). Through analyzing a physician’s
cognitive and personality factors, a better understanding of their willingness to learn the nuanced
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needs of LGBTQ patients can be developed, and their view of their ability to treat these patients.
Self-efficacy is a primary tenet of the person component of social cognitive theory’s triadic
model.
Self-efficacy is rooted in the idea that individuals will likely engage in activities if they
feel competent in their abilities (Bandura, 1997). This motivational variable proclaims that
individuals obtain information to evaluate efficacy from four sources: performance outcomes,
verbal persuasion, physiological feedback, and vicarious experiences (Artino, 2012). Each of
these four components of self-efficacy can impact access to ambulatory healthcare services for
LGBTQ individuals. The frequency in which ambulatory care clinicians have experiences with
LGBTQ patients directly impacts their ability to provide future healthcare services successfully.
Performance outcomes are the successful past experiences that gradually build upon each
success and result in an individual feeling confident that they can be successful in completing the
task at hand. Thus, self-efficacy raises (Bandura, 1997). In the healthcare setting, the more
frequently providers have successful experiences modeling welcoming behaviors and treating
LGBTQ patients, the more likely they will be confident they will succeed in future LGBTQ
patient interactions. Furthermore, as healthcare providers have more successful patient
interactions, their beliefs about their ability to perform certain services will also improve; thus,
their self-efficacy as a provider will increase (Schwarzer & Luszczynska, 2000). Interactions
with patients directly impact provider self-efficacy; however, individuals with influence over
these providers can also impact self-efficacy through verbal persuasion.
The second source for building self-efficacy is verbal persuasion. In this self-efficacy
component, an individual receives persuasive verbal measures, such as words of encouragement
regarding one’s ability, from someone they consider influential in convincing them of their
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ability to perform specific tasks or behaviors (Bandura, 1997). Individuals of influence can be
supervisors, colleagues, or someone well respected within the organization. In the healthcare
setting, encouraging verbal persuasion for positive performances with LGBTQ patients can
instill confidence in a provider’s ability to treat patients, positively impacting their self-efficacy.
Often healthcare providers have small failures that can potentially impact self-efficacy; however,
verbal persuasion from a colleague or supervisor can reinforce oneself efficacy in the event of a
failure or mistake (Adefolalu, 2018). Verbal persuasion is a powerful tool to bolster self-
efficacy; however, non-verbal cues, specifically physiological feedback, can often directly
impact one’s self-efficacy.
When performing tasks, our bodies have multiple physiological responses. Bandura
(1997) defines physiological feedback as the level of physical arousal an individual experiences
when conducting specific tasks. Anxiety and fear are common physical responses when
performing tasks and can impact performance. Typically, task success is more common if
individuals are not overcome by these stress-induced physiological reactions (Artino, 2012).
Anxiety often occurs when treating LGBTQ patients if a provider is not confident in their ability
to provide treatment or model welcoming behaviors. Evidence shows that healthcare workers
with high anxiety levels perceive themselves as ineffective when providing treatment and thus
exhibit lower self-efficacy (Munoz et al., 2018). Individuals often learn from their physiological
responses to tasks; however, they can also learn by observing others.
The final source of self-efficacy is the vicarious experiences one encounters. Bandura
(1997) states that vicarious experiences occur when individuals learn by observing others.
Through this observation process, individuals generate efficacy beliefs that they, too, can
successfully accomplish the observed task. Suppose a provider observes a colleague either
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modeling welcoming behaviors or treating an LGBTQ patient properly. In that case, the
provider’s self-efficacy can increase if they feel they can successfully execute what they observe.
Evidence highlights that vicarious experiences within a clinical setting can reduce task anxiety
and improve one’s self-efficacy (Parent & Fortin, 2000). Overall, these four sources of self-
efficacy can positively impact ambulatory care providers as they continue to work with LGBTQ
patients.
The self-efficacy component of social cognitive theory allows for the development of an
understanding of how ambulatory care providers have the potential to improve their self-efficacy
as a result of successful patient interactions (performance outcomes), develop confidence in their
abilities after receiving verbal input from supervisors (verbal persuasion), learn to respond how
their body is reacting when conducting task (physiological feedback), and improve their self-
efficacy by observing peers (vicarious experiences). Furthermore, when analyzing self-efficacy
and its connection to social cognitive theory, research goes one step further by allowing for the
examination of how engaging with LGBTQ patients (behavior) and creating an inclusive space
for LGBTQ patients (environment) influences provider ability and willingness to treat LGBTQ
patients (person); which directly impacts their self-efficacy as an ambulatory care employee. The
model in black on the left represents the components of self-efficacy. The red arrow connects
self-efficacy to the person component of the social cognitive theory triadic reciprocal model. The
model in gray on the right visually represents the three levels of the triadic reciprocal model:
behavior, person, and environment. See Figure 1.
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Figure 1
Conceptual Framework: Social Cognitive Theory Triadic Reciprocal Model
Self-
Efficacy
PERFORMANCE
OUTCOMES
Past experiences
with LGBTQ
patients
VERBAL
PERSUASION
Encouragement
or
discouragement
based off
performance with
treating LGBTQ
patients
PHYSIOLOGICAL
FEEDBACK
Enthusiasm
and/or anxiety
experienced
when treating
LGBTQ patients
VICARIOUS
EXPERIENCES
Experiences
viewing peers
treat LGBTQ
patients; peer
modeling
BEHAVIOR
• Frequency of
actively engaging
with LGBTQ
patients
• Displaying Help-
Seeking behaviors
towards LGBTQ
patients
ENVIRONMENT
• Health-system
behaviors towards
LGBTQ patients
• Workplace Support
Available for
Assisting LGBTQ
Patients
Workplace LGBTQ
Patient Training
Availability
PERSON
• Self-Efficacy for
treating and
assisting LGBTQ
patients.
• Willingness to
learn nuances of
LGBTQ patient
healthcare
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Summary
This literature review has provided significant empirical support that access to
ambulatory healthcare services for LGBTQ patients has five key areas of focus that the
healthcare industry must prioritize to minimize the current health disparities plaguing this
vulnerable community. First, the literature provides evidence of the shortage of LGBTQ clinics
and LGBTQ-trained physicians in the United States. This shortage prevents LGBTQ patients
from having timely access to comprehensive healthcare from LGTBQ competent providers.
Second, the literature outlines that LGBTQ youth have limited access to confidential mental and
sexual health resources. Furthermore, many LGBTQ has become homeless and forced to go to
the emergency room because they cannot financially afford treatment in an ambulatory
healthcare setting. Next, the literature informs that LGBTQ older adults need access to
ambulatory healthcare services free of discrimination, elder abuse, and neglect from healthcare
providers and caregivers.
Additionally, the literature provides the foundation that transgender individuals face
exacerbated discrimination when accessing care and other struggles to access competent trans-
specific ambulatory healthcare services. Finally, the literature provides substantial evidence that
nondiscriminatory healthcare laws and policies are not fully comprehensive and inclusive, nor
are they enforced in all healthcare settings. Analyzing these primary barriers to access to
ambulatory healthcare services through the lens of social cognitive theory will assist in
understanding how to improve overall health outcomes for the LGBTQ community.
The study design has been informed by an in-depth literature review that has allowed for
a comprehensive overview of the multiple barriers and challenges faced by members of the
LGBTQ community when accessing healthcare. This review highlights characteristics associated
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with a lack of access to healthcare for LGBTQ patients. It is the concepts presented in this
literature that qualify Bandura’s social cognitive theory and its self-efficacy variable to be used
to examine ambulatory care providers’ interactions and how the interactions between behavior,
person, and environment within the healthcare system influence their ability to provide access to
ambulatory healthcare services for LGBTQ patients (Bandura, 2000). Chapter Three will outline
the methodological approach taken to support the social cognitive theory and self-efficacy’s
conceptual framework of examining access to ambulatory healthcare services for LGBTQ
individuals seeking outpatient services at the West Coast Hospital.
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Chapter Three: Methodology
This study aims to explore WCH healthcare providers’ ability to provide access to
ambulatory care services for LGBTQ patients. Specifically, this study will investigate WCH
healthcare provider’s willingness to demonstrate welcoming behavior toward LGBTQ patients,
their ability to improve their self-efficacy for providing care for this vulnerable community and
understand what influences impact a provider’s belief system to break down the barriers that
result in lack of access to, delayed access to, or inequitable access to healthcare for this
vulnerable population. This chapter begins with an overview of the research questions, a
description of the research design, and a detailed synopsis of the research setting and researcher.
Next, the methods section of this study describes the participants, instrumentation, data
collection procedures, and data analysis for this study. The chapter concludes with a discussion
on validity, reliability, and ethics.
Research Questions
There are three research questions that will be used to frame this qualitative study:
1. What is the willingness of healthcare providers to demonstrate welcoming behaviors
toward LGBTQ patients?
2. What are the influences, if any, that affect a health care provider’s self-efficacy
regarding the needs of LGBTQ patients?
3. What are the factors in the health providers’ life that influence their beliefs and
attitudes about their LGBTQ patients?
Overview of Design
The research design for this study will take the approach of utilizing qualitative research
methods. Merriam and Tisdell (2016) define qualitative research as “an effort to understand
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situations in their uniqueness as part of a particular context and their interactions there,” where
the research goal is to investigate and understand the perspective of the individuals that are being
studied (p. 10). Thus, a qualitative methodology will allow me the as the researcher to explore
the perceptions and perspectives of interviewees through the lens of their lived experience within
the healthcare field. A qualitative-methods research design aligns closely with the purpose of this
study because access to ambulatory healthcare services for LGBTQ patients is a very complex
problem that can best be understood by qualitatively obtaining insights from multiple WCH
ambulatory healthcare providers.
The data source for this qualitative research will consist of semi-structured qualitative
interviews designed to examine WCH healthcare providers’ behaviors, perceptions, and
motivations to welcome and provide care for LGBTQ patients. Semi-structured interviews will
allow for further exploration of participant responses because it allows for both probing and
follow-up (Merriam & Tisdell, 2016). Furthermore, a phenomenological methodology will
incorporate narratives that capture all interviewees’ perspectives. Phenomenological
methodology is a qualitative research strategy where I, as the researcher, will aim to describe the
lived experience of the interviewee regarding a particular phenomenon (Creswell & Creswell,
2018). In this study, the phenomenon is access to ambulatory healthcare services at WCH for
LGBTQ individuals. Table 1 displays the data collection method that will be used for each
research question.
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Table 1
Qualitative Data Collection Method Data Source
Research questions Interview
RQ1: What is the willingness of healthcare providers to demonstrate welcoming
behaviors toward LGBTQ patients?
X
RQ2: What are the influences, if any, that affect a health care provider’s self-
efficacy regarding the needs of LGBTQ patients?
X
RQ3: What are the factors in the health provider’s life that influence their beliefs
and attitudes about their LGBTQ patients?
X
Research Setting
This research will take place within the ambulatory sector of WCH. The research serves
the interest of LGBTQ individuals who currently reside near WCH and seek access to
ambulatory healthcare services. The primary goal of this research study is to identify the barriers
resulting in lack of access to, delayed access to, or inequitable access to healthcare at WCH for
the LGBTQ population. WCH ambulatory providers will also benefit from this research as a
result of understanding and reflecting on their self-efficacy and behaviors toward treating and
assisting LGBTQ patients. Participants of this study are ambulatory care providers, and although
harm is unlikely, they will have the opportunity to leave the study at any time. Furthermore, if
participants feel harassed or harmed during this study, they may report it to the Chief
Ambulatory Officer of WCH. The above questions are answered from the researcher’s
perspective, trying to bring about improved access to healthcare within this organization’s
setting. The researcher has designed the questions and framed the scope for this study; however,
the researcher has also included members from the WCH patient experience team, the health
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consumer access team, and the clinical operations team throughout the planning process for this
research. The results will be disseminated electronically to all participants and WCH
organizational leadership.
The Researcher
This study focuses on access to healthcare for LGBTQ patients. As someone who
identifies as LGBTQ and has faced discrimination when seeking healthcare and works in
healthcare, specifically the healthcare organization where this study is taking place, I need to
remain a neutral researcher rather than a frustrated patient or employee. To reduce the potential
of biases in my research, I need to acknowledge my positionality as an LGBTQ healthcare
administrator who has had issues accessing ambulatory services and reflect on how this may
influence how I interpret data, and then take measures to ensure I remain objective. This will be
especially important when interviewing my research participants and collecting data. By
practicing reflexivity, I will mitigate the potential for making assumptions and developing biases
throughout my research. Creswell and Creswell (2018) define reflexivity as the process in which
researchers reflect on how their role in a study and their background or identity can help identify
areas where there could be biases. I will frequently reflect on my positionality to ensure I am not
allowing any biases or assumptions to impact the data. Furthermore, I will consult my peers to
debrief on my research to uncover any biases or errors in the study. As the researcher for this
study, there will be no imbalances of power occurring in my study. I do not supervise anyone I
would be interviewing, and no one in my target sample population reports to any of my
supervisors.
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Data Source
For this study, the data source will be interviews developed using qualitative research
methods. For this data source, a description of the participants, instrumentation, data collection
procedures, and plan for data analysis is detailed. Merriam and Tisdell (2016) state that most of
the data is collected through interviews in qualitative research. These interviews will follow a
semi-structured approach, allowing the interviewer to explore healthcare provider perception of
the multiple components of LGBTQ patient access by asking healthcare providers to share their
professional experiences in their own words. Furthermore, the semi-structured approach will
allow the interviewer to ask probing and follow-up questions during the interview (Merriam &
Tisdell, 2016).
Interviews
The data collection phase for this research study will consist of semi-structured
interviews. The participants will be WCH ambulatory providers. The instrument (Appendix A)
used to collect data will be a qualitative interview protocol composed of questions that allow
participants to answer in their own words based on their professional experiences (Merriam &
Tisdale, 2016). Burkholder et al. (2019) suggest that interviews should take place in a quiet place
to avoid distractions and disturbances that could interrupt or derail the interview, which could
either distract the interviewee or cause the interview to run over the allocated time. I will conduct
interviews in a quiet room free of disturbances which should avoid any disturbances or run over
the scheduled time for each interview. Upon completion of the interviews, each of the recordings
will be sent to a professional transcription service, followed by coding and thematic grouping.
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Participants
The target population for this research study is ambulatory healthcare providers who
work at WCH, specifically doctors, physician assistants, and registered nurses. This population is
appropriate because they are the patient-facing sector and care providers of the ambulatory
health sector of WCH. These providers are the individuals that treat patients, receive patient
feedback, and often provide follow-up care or communication. The participants will be selected
by using purposeful sampling. Purposeful sampling is used when a researcher aims to understand
a particular problem and purposefully selects a sample where the most information and insight
can be obtained (Merriam & Tisdale, 2016). Purposeful sampling was chosen as the participant
selection method because WCH providers are the most knowledgeable about interactions with
WCH LGBTQ patients. The target sample size is interviewing 10–15 providers or clinical staff.
This number is based on the consideration that no new information will be forthcoming from
additional interviews; this will ensure that this study will not reach a point of saturation or
redundancy. Merriam and Tisdale (2016) define redundancy as the phenomenon that occurs
when you conduct enough interviews to the extent that no new responses are being heard and no
new insights are developed. Therefore, I will conduct between 10–15 qualitative interviews for
this study.
Instrumentation
The instrument used in this study with be a qualitative interview protocol composed of
questions administered through a semi-structured interview (Appendix A). Semi-structured
interviews are an approach that allows researchers to ask questions in a more flexible and less
structured format (Merriam & Tisdale, 2016). This approach is the most appropriate because the
flexibility will allow the researcher to ask providers how to describe their understanding of the
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various components that impact access to healthcare for LGBTQ patients. I have developed
sixteen questions for this interview, six asking for specific information. The remaining ten are
open-ended and allow for probing and further exploration into the problem of practice. The six
structured questions that ask specific information will help address the research questions that
aim to investigate how often health system staff model welcoming behaviors toward LGBTQ
patients, how often they are provided LGBTQ-related training, and how often they receive
feedback from LGBTQ patients. The open-ended questions allow for exploration through the
lens of social cognitive theory by asking how providers describe and understand how their
behavior, environment, and personal factors impact access to healthcare for LGBTQ individuals.
Self-efficacy will be addressed through these open-ended research questions by asking
interviewees to describe how attending LGBTQ training or receiving patients’ feedback from
LGBTQ patients has impacted their abilities to provide healthcare services.
Data Collection Procedures
Burkholder et al. (2019) recommend that interviews take place in a quiet room that
provides privacy and is free of distractions. Also, it is set up well for audio/video recording to
avoid disturbances that could cause the interview to run over the allocated time, as well as to
ensure the researcher accurately captures all information through real video or audio recording
that can later be transcribed. I will conduct interviews in a quiet clinic room conference room
with audio and video recording free of disturbances. This should allow for my interviews to be
completed within the scheduled timeframe and for accurate video recording that will later be
transcribed. The geographical location and the scheduled timing of these interviews will be based
on convenience for the interviewees. The tenets laid out by Burkholder et al. (2019) as to where
to conduct an interview, specifically in a quiet room free of disturbances and interruptions, led to
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the strategy of conducting these interviews via Microsoft Teams to ensure ease of recording and
flexibility of timing for healthcare providers. In order to ensure privacy and no distractions, the
researcher will work with the scheduling coordinator for each clinic site to ensure the respective
provider at each location has a reserved, quiet, and private space. Since these interviews will take
place during working hours Chief Operating Officer and Chief Medical Officer’s approval will
be obtained to conduct these interviews during operating hours. The length of these interviews
will be between 45–60 minutes. The rationale for the interview duration is that the researcher
does not want to encounter interview fatigue and wants to be respectful of the time taken away
from ambulatory care providers’ working hours. In order to ensure trustworthy data collection,
each interview will be recorded, and a professional transcription service will transcribe each
recording. The rationale for using a transcription service stems from Creswell and Creswell
(2018) that by utilizing a transcription service, the researcher will be able to spend more time
analyzing the data instead spending time transcribing it.
Data Analysis
The purpose of data analysis for this study is to interpret the qualitative data; in this
research study, the data is the participant responses collected throughout the interviews (Merriam
& Tisdell, 2016). The first step in the data analysis process will be to have all the interviews
transcribed by a professional transcription service (Creswell & Creswell, 2018). The qualitative
data for this study will then be analyzed by using grounded theory of the data to identify codes
and themes that will help answer each research question (Merriam & Tisdell, 2016). Merriam
and Tisdell (2016) breakdown grounded theory into three steps that assist in identifying themes.
The three steps are open coding, axial coding, and selective coding. At each level data is
reviewed and aggregated resulting in theme development. In this study the data will be coded at
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each of the three levels of grounded theory and then grouped thematically, a qualitative narrative
will be used to detail and describe the themes discovered during the data analysis process. This
qualitative narrative will be used to understand the participants’ perspectives (Creswell &
Creswell, 2018). For this study, it will be necessary for the researcher to analyze and code the
collected responses and identify the themes that reflect WCHs ambulatory healthcare provider’s
ability to provide access to care for LGBTQ patients.
Validity and Reliability
In a qualitative study, validity and reliability depend on credibility and trustworthiness to
determine the overall quality of a study (Merriam & Tisdale, 2016). This qualitative study will
use three specific strategies to ensure credibility and trustworthiness. First, the researcher will
clarify any bias brought to the study through clarification and reflexivity. Merriam and Tisdell
(2016) state that by clarifying how the researcher’s background impacts their interpretations of
the findings, they will be able to create an open and honest narrative for their qualitative
research. Ravitch and Carl (2019) define reflexivity as the process in which the researcher
recognizes their role in the study, which allows them to be aware of any biases that could
potentially influence the study’s outcome. The second strategy will be peer debriefing to uncover
any biases or errors within the study. Merriam and Tisdell (2016) state that qualitative research
will have improved credibility because the peer debriefing process will help ensure that the
research resonates with other individuals, not just the researcher. The final strategy will be to use
mechanically recorded data via the Microsoft Teams video software. Mechanically recorded data
uses technology to directly capture quotes from participants, thus limiting any threats to validity
(Coleman, 2021). The culmination of these three strategies will ensure the credibility and
trustworthiness of the findings from this qualitative study.
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Ethics
In order to avoid any issues related to consent, this study will obtain informed consent
from participants before the start of each interview by having participants explicitly acknowledge
their willingness to consent to the research and be recorded in the interview. Since a critical tenet
of research is to protect subjects from harm and provide them the right to privacy, all
participant’s interviews will be kept confidential in the reporting, and none of the information
they provide will be associated with their name or role in the organization (Merriam & Tisdell,
2016). Additionally, participants will be informed that they can end their involvement in the
study at any time they do not feel comfortable participating. Due to the researcher’s junior rank
in the organization and having no direct reports, there should be no issues regarding power
dynamics or coercion. If, for some reason, these dynamic shifts, the researcher will find a proxy
to conduct the interviews. In order to ensure compliance with all university research regulations
and that no participants will be at risk for their participation, the study proposal will go through
the University of Southern California IRB process (Creswell & Creswell, 2018).
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Chapter Four: Findings
This chapter presents the qualitative data that was collected in this study. Interviews were
conducted for this qualitative study to explore and identify the barriers to accessing ambulatory
healthcare services for LGBTQ individuals. This study focused primarily on ambulatory
healthcare providers’ behaviors, self-efficacy, and influences when providing care for LGBTQ
patients. Findings were identified and further explored in each of the interviews.
Three research questions guided this study:
1. What is the willingness of healthcare providers to demonstrate welcoming behaviors
toward LGBTQ patients?
2. What are the influences, if any, that affect a health care provider’s self-efficacy
regarding the needs of LGBTQ patients?
3. What are the factors in the health providers’ life that influence their beliefs and
attitudes about their LGBTQ patients?
This study sought to obtain experience and insights from ambulatory care providers on the
barriers that impact access to healthcare for LGBTQ patients. The primary goal of the research
questions was to elicit responses around provider’s willingness to demonstrate welcoming
behavior toward LGBTQ patients, their ability to improve their self-efficacy for providing care,
and well as an understanding of influences on provider belief systems to break down the barriers
that result in lack of access to, delayed access to, or inequitable access to healthcare for this
vulnerable population. The theoretical framework centered around social cognitive theory and
how ambulatory care clinician interactions regarding behavior, person, and environment within
the healthcare system can impact the ability to provide access to healthcare for LGBTQ patients.
The description of the sample for this study is provided in the next section. Following the sample
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description, the remainder of the chapter is organized according to the three research questions.
Three subsections are provided to describe the three research questions’ findings, and various
emerging themes are explored within these sections. The chapter concludes with a summary.
Participants
The study sample consisted of 10 ambulatory healthcare providers who work at WCH,
specifically doctors, physician assistants, and registered nurses. All participants met the criteria
of being WCH providers who providetreatment for patients. Participants were purposefully
sampled from the WHC ambulatory care provider population. This population was purposely
sampled because WCH ambulatory care providers are highly knowledgeable about interacting
with WCH LGBTQ patients.
The 10 interviews were all conducted via Microsoft Team’s video conferencing software
and audio-recorded with participant permission. To ensure confidentiality for this study, the
interviewee designator, IP (interview participant), was assigned to each of the ten interview
participants. For example, IP1 corresponds with interview participant 1. Each audio file was
transcribed using Rev.com services and coded using NVivo software for further analysis. In this
study grounded theory allowed for theme development after data collection. Specifically, all of
the collected data went through the steps of grounded theory; open coding, axial coding, and
selective coding, ultimately allowing for the identification of ten emerging themes. No preset
themes were developed for this study. Table 2 depicts the designator (IP) used for each
participant, the participant’s area of clinical specialty, clinical licensure, and years of experience
within the ambulatory healthcare setting. Within this sample, six clinical specialties were
interviewed, and the average years of experience were 11, with a median of 10. No other
demographic data is reported in this study.
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Table 2
Interview Participant (IP) Demographics
Designator Clinical area of specialty Clinical licensure Experience (in years)
IP1 Ambulatory nursing RN 25
IP2 Infectious disease MD 3
IP3 Endocrinology MD 10
IP4 Family medicine MD 4
IP5 Primary care MD 10
IP6 Family medicine DO 9
IP7 Infectious disease MD 11
IP8 Primary care MD 2
IP9 Dermatology MD 12
IP10 Dermatology MD 24
Research Question 1: What Is the Willingness of Healthcare Providers to Demonstrate
Welcoming Behaviors Toward LGBTQ Patients?
Qualitative semi-structured interviews were the data collection method used to explore
this first research question. This research question asked participants, “What is the willingness of
healthcare providers to demonstrate welcoming behaviors toward LGBTQ patients?”. This
research question aimed to understand how healthcare providers demonstrate welcoming
behaviors toward LGBTQ patients. This question also aimed to explore if such behaviors can
potentially impact ambulatory healthcare access for this vulnerable population. Throughout these
interviews, four themes focused on welcoming behaviors emerged:
1. Theme 1focuses understanding welcoming behaviors.
2. Theme 2 focuses on operationalizing welcoming behaviors.
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3. Theme 3 focuses ongoing learning of welcoming behaviors.
4. Theme 4 focuses on commitment to ensuring welcoming behaviors.
Theme 1: Understanding Welcoming Behaviors
The first theme that emerged from the research questions was that eight participants had
similar understandings of what constitutes welcoming behaviors that would encourage LGBTQ
patients to access ambulatory healthcare services in a specific health system. Additionally, four
participants recognized significant opportunities to ensure inclusivity and make the LGBTQ
community feel welcomed into the healthcare setting. Each participant emphasized the
importance of welcoming behaviors for LGBTQ patients to feel comfortable when seeking
ambulatory care services.
Before even arriving at the clinic, IP2 relayed how impactful it is “being forward about
advertising, that patients know the institution, the clinic, the system is welcoming and wants to
take care of LGBTQ patients.” IP10 supported this notion of advertising by explaining that the
health system should let the community know through marketing initiatives “that we are open to
caring for that population.” Upon arrival at the clinic, IP4 shared that it needs to “signal that it’s
a safe space” by having “nonverbal cues in the waiting areas.” IP4 further develops a safe space
in their clinic by wearing “a little rainbow badge. I’ve always had a rainbow wristwatch or
something to signal a safe space”. IP5 also stated the importance of establishing a welcoming
environment by focusing on “the literature on the pictures that are around, you know you have
them on the walls and having that be more inclusive as well. I think it is important as well in
terms of who is represented on those”.
A common welcoming behavior indicated by participants was how patients are greeted
impacts how welcome they feel within the clinical setting. To start, IP6 stated that when patients
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enter the clinic and approach staff, they should be greeted with “nonverbal cues of being
nonjudgmental, so just kind of smiling and nodding.” According to IP8, when patients are first
handed paperwork to complete, “the things we are having patients fill out need to be more
inclusive.” IP3 further explained the importance of “making intake forms inclusive in terms of
gender identity and making space in forms for people to check off boxes that say I prefer not to
say so, that people always feel like they have a choice.”
From the social cognitive theory environment component perspective, developing a
welcoming environment both socially and physically can strongly influence the frequency in
which welcoming behaviors are exhibited. All participants understood that emphasizing
welcoming behaviors through verbal interactions or nonverbal cues in waiting areas early on
with patients is key to establishing a welcoming environment. It is a welcoming environment that
LGBTQ patients would feel comfortable accessing for their healthcare; however, these inclusive
behaviors need to be carried on and operationalized throughout the entire patient journey to
ensure ongoing access to truly inclusive healthcare services.
Theme 2: Operationalizing Welcoming Behaviors
Operationalizing welcoming behaviors within the patient process was a key emerging theme
throughout this study, especially regarding being aware of documenting and using chosen names
and patient pronouns throughout each stage of the patient journey. IP5 claims that one of the
more recent enlightenments of using pronouns during the LGBTQ patient experience is “how
much it can affect the actual flow of a patient encounter, I feel like we’re only just starting to
catch up to the importance of this particular population with regards to how we could improve
our approach.” According to IP1 “consistency in how we approach patients and being respectful
of what that person wants to be called and what kind of pronouns needs to be used.”
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Furthermore, IP3 makes “a very concerted effort to look at the chart, and I see that if the
pronouns are documented, you know, I sort of take that to heart, and their preferred pronouns are
there for a reason.” To develop a safe space for patients to share pronouns IP4 suggests that
providers “introduce themselves to their patients with their name, pronoun, and title as a way to
open up that channel of communication.”
Not only should there be an effort by the provider to review a patient’s chosen name and
pronouns when meeting directly with the patient, but IP3 also shared that “I think that we have a
lot of room to improve in terms of making sure that that we have those things documented in a
way that’s confidential or recorded.” IP8 also shared similar thinking that capturing pronoun
information within the electronic health records is necessary; however, not all staff are “asking
everyone because I don’t see it on all patients’ charts.” Furthermore, IP8 states the pronouns not
being updated will result in:
Sometimes people will complete everything online, and it won’t sync into the chart, and
they’ll be like, why are you asking me all of this? Like if somebody has noted something and
it’s kind of like, OK, they’ve already shared some information, and now it’s like I’m the third
person confirming that once again. Sometimes I don’t even know if it’s really been
confirmed or just auto-populated. Generally speaking, the chart doesn’t make it that easy for
us.
Overall, all participants agreed that consistently capturing and documenting patient
demographics is a vital step in ensuring that patients LGTBQ feel welcome when accessing a
health system.
Through the lens of the behavior component of social cognitive theory, the participants
focused on the fact that ambulatory care providers must display help-seeking behaviors toward
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LGBTQ patients by trying to identify, recognize, and utilize patients’ preferred pronouns within
each patient interaction. The participants placed heavy emphasis on the notion that capturing
accurate identifying information early on in the patient experience should be a priority.
Theme 3: Ongoing Learning of Welcoming Behaviors
Seven participants stated that welcoming behaviors toward LGBTQ patients within a
healthcare system are relatively recent developments to standard clinical practices. With
welcoming behaviors being somewhat novel, participants believe there is a constant evolution
and updating to these practices and, therefore, a need for ongoing learning from providers. Due
to the more recently identified and utilized terminology and best practices associated with this
community, IP7 feels it “important for all that to have some sort of CME and have training
specifically” regarding the LGBTQ patient population. IP3 strongly believes that they have “a
responsibility as a provider to stay on top of the literature” to ensure that LGBTQ patients feel
like they have a safe space to access healthcare. To stay up to date on how to be a better provider
to their patients, IP3 suggests that there should be training “maybe it doesn’t need to be super
frequent, but you know once a year or something like that where you sort of reminding people
like, hey, these are things that are important to you know for this population.” All participants
agreed that the need for ongoing education is necessary. Still, more importantly, providers must
be willing to continue to learn the needs of the LGBTQ to ensure consistent healthcare access.
Amongst the participants, there was a shared willingness to continue to learn about the
needs of LGBTQ patients. IP 1 stated they “absolutely want to learn more,” while IP4 said “very
willing.” IP6 also mentioned high levels of willingness for continued learning:
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Oh yeah, very willing. You know, I’m already trying to plan when because things are
always changing. We’re always learning more, and I think always honing and sharpening
those skills is important. And I think it’s like; obviously, we’re talking about
like a specific population, but I think it carries over for everyone. It’s just like being kind
and welcoming to everyone.
Given the emerging needs and evolving demographics of the LGBTQ community, participants
agreed that providers should require frequent, ideally annual, training to best support and treat
these patients.
From the social cognitive theory perspective, specifically the person component, the
participants heavily emphasized that a provider’s willingness to learn the nuanced needs of
LGBTQ patients should be prioritized as it directly impacts LGBTQ patients feeling welcomed
when accessing health services. Participants not only explained their willingness to learn
welcoming behaviors they discussed their commitment to ensure that these behaviors exist
within their clinical settings.
Theme 4: Commitment to Ensuring Welcoming Behaviors
All ten participants expressed interest in ensuring commitment to welcoming
behaviors by holding fellow health system employees accountable for adhering to all
nondiscrimination policies toward LGBTQ patients accessing services at WCH. IP1 shared that
“when you’re working in a community setting or with an organization that has you have to align
to the organization’s values,” while IP5 shared, “it makes 100% sense to me to be non-
discriminatory.” IP6 shared “Absolutely, I feel like that’s a like kind of an informed consent of
when you go to work somewhere that’s like you’re going to abide by their policies”.
IP9 share the sentiment that:
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Part of our job is to make everyone welcome, and you know our job as doctors are to
supervise and care for people, and I think we can’t let our own bias, belief, or religion get
in the way of providing care to people.
IP9 shared an example of a time when they a changed a nurse’s assignment to a patient because
“patient heard the nurses talking about her” in a discriminatory and jocular way, however, the
health system at the time did not discipline such behaviors. IP1 shared a similar experience of
frustrations with colleagues when their coworkers “were making fun of and laughing about a
transgender patient” and were not disciplined.
Utilizing the social cognitive theory framework, specifically the behavior component, where
anything one does can either be rewarded or punished, personal and environmental factors can
influence one’s behavior. For this reason, the reciprocal relationship between one’s behavior can
only be changed if their personal and environmental factors change. Participants enforcing
nondiscrimination policies that not only encourage the use of welcoming behaviors but ensure
staff adherence to such policies can directly affect the environment and, therefore, behavior, thus
impacting LGBTQ patient access. In summary, all participants in this study ensured commitment
to enforcing nondiscrimination policies at WCH.
Research Question 2: What Are the Influences, if Any, That Affect a Healthcare Provider ’s
Self-Efficacy Regarding the Needs of LGBTQ Patients?
The second research question, also explored using semi-structured interview
methodology, asked, “What are the influences, if any, that affect a health care provider’s self-
efficacy regarding the needs of LGBTQ patients?” This second research question aimed to
identify what factors can positively impact or inhibit a provider’s motivation to provide care for
LGBTQ patients. An additional four themes emerged from the interviews:
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1. Theme 5 focuses on impact of successful patient interactions.
2. Theme 6 focuses on verbal persuasions impact on provider performance.
3. Theme 7 focuses on factors facilitating provider confidence
4. Theme 8 focuses on outcomes of peer observations.
Theme 5: Impact of Successful Patient Interactions
Three of the participants of this study had successful interactions with LGTBQ patients
that impacted their ability and ongoing use of welcoming behaviors within the clinical setting.
IP3 shared, “I can think of one patient who just said like I just appreciate being able to come here
and that you just listen right.” IP1 provided an example of what they learned through a
successful interaction, and it is now their best approach when meeting with not just LGBTQ
patients but all patients:
And so that’s something I’ve shared with other patients about how powerful listening is.
And sometimes we don’t let people talk, and we don’t hear them out, or we don’t want to
hear and accept what they have to say. So, we just don’t. We cut them off, but how
important listening is and understanding and learning, for sure.
Another prominent example of an interaction that impacted all future patients’
interactions was from IP3:
I was a fellow at UCLA, and I went to see a patient in the ER who was being admitted
who was living with HIV that was not controlled. He had a lot of advanced
manifestations. When you meet those patients, you really have to go kind of head to toe
with symptoms because there are so many different things that can be going on with them
at the same time. And he was kind of hesitant to answer questions. And so, we went very
slowly. And the reason that I remember that encounter is because I received feedback
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afterward from the patient that it went well, which is one of the reasons that I remember
it.
Overall, these successful interactions with LGBTQ patients improved participants’ self-efficacy
as healthcare providers.
Applying the performance outcome component of the self-efficacy lens, the participant’s
ability to have successful experiences in demonstrating welcoming behaviors and treating
LGBTQ patients allowed them to be more confident that they will be successful in future
LGBTQ patient interactions. Thus, as explained by these healthcare providers, their successful
patient interactions have improved their self-efficacy as providers. In summary, successful
patient interactions have a direct impact on provider self-efficacy.
Theme 6: Verbal Persuasions Impact on Provider Performance
Five participants recognized the impact verbal persuasive measures, such as words of
encouragement regarding one’s ability to treat LGBTQ patients, had on their performance as a
healthcare provider. A common method in which persuasive verbal methods were received from
providers about their performance was in the form of direct positive feedback from their LGBTQ
patients. IP10 shared, “To hear that somebody felt that the staff treated them well. I mean. It’s
humbling, and it just makes you feel.”
Not only was verbal persuasion, in the form of verbal feedback, recognized by providers
as a mechanism that improved their skills, but it was also identified as the preferred method for
receiving ongoing patient feedback. IP2 shared, “it’s helpful when it’s very specific and comes
directly from a person.” IP1 explained their common practice for ensuring patients can give
direct verbal feedback: they “prefer a phone call, and I give patients my personal cell phone
number.” IP8 also agreed that receiving feedback “ideally would be like in person, like in the
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moment.” IP4 shared that they “feel confident integrating feedback from peers into their daily
practices”.
Based on the insights from the participants, the verbal persuasion component of self-
efficacy can impact provider performance. In the healthcare setting, when providers receive
encouraging verbal persuasion for positive performances with LGBTQ patients’ confidence is
instilled in their ability to treat patients, positively impacting their self-efficacy. This positive
impact on self-efficacy results in significantly improved healthcare experiences for patients
LGBTQ patients.
Theme 7: Factors Facilitating Provider Confidence
All participants were asked to share their confidence in providing healthcare services for
LGBTQ patients. All participants felt reasonably confident in their abilities; however, four
participants recognized that there are factors that influence their confidence, such as
physiological feedback, as well as many potential opportunities to build confidence further. IP1
explained that their fear and anxiety about providing care for these patients have been assuaged
because they “personally have had a lot of education.” IP3 recognized that by just trying to be an
understanding person, the fear of treating LGBTQ patients diminished. They specifically shared:
I feel reasonably comfortable, and I think a lot of it is about just being a good person,
right? And just understanding where people are coming from, and I’d like to think that I
am. I certainly have a lot more to learn in terms of, you know, maybe things I’m doing
that that people don’t like, or that I’m offending people by doing it. I’m certainly open to
change.
IP6 shared that although they are confident in their abilities, they are
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Always very self-conscious about if [they] make any missteps. Overall, I want someone
to feel comfortable and feel good by the end of the deployment. So, you know,
sometimes I’ve even said, potentially leading questions assuming things. And then I have
to catch myself. Oh, I’m sorry. I didn’t mean to do that. And sometimes we just, I think,
get in our heads about patterns and everything.
IP9 numerically ranked their confidence in treating LGBTQ patients and gave a rationale
this ranking by stating:
If I was going to give you, like, a one to ten scale of ten, being as confident as I could
imagine, probably an eight or a nine, I feel like most people are not perfect if you ask
them about any of their behaviors, and I feel like we all can learn more, but I make a
conscious effort to be as welcoming as possible to any group, including anyone from the
LGBTQ+ community. I think it also comes with practice.
As captured through the participant’s experiences, physiological feedback impacts provider
confidence.
Confidence can be examined through the lens of the physiological feedback component
of self-efficacy. Participants in this study shared that when performing clinical procedures or
trying to ensure welcoming behaviors when interacting with LGBTQ patients, they experienced
multiple physiological responses. Common physiological responses experienced by participants
were, anxiety and fear. Anxiety and fear often occurred while treating LGBTQ patients when a
provider was not confident in their ability to provide treatment or model welcoming behaviors.
Ultimately, through increasing exposure, ongoing education, and the development of standard
practices, these providers improved their self-efficacy in treating LGBTQ patients.
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Theme 8: Outcomes of Peer Observations
The final theme that emerged from this research question was that three of the
participant’s ability to demonstrate welcoming behaviors and provide care for LGBTQ patients
had been influenced by observing their peers’ interactions. Through peer observations, multiple
participants learned how not to treat LGBTQ patients. IP9 shared an experience with peers that
influenced the environment they create:
When I was a medical student, and I was on a surgery rotation, I was around an attending
provider who was making fun of patients in front of me, and I was really uncomfortable. I
have been in various places occasionally where not necessarily a doctor, but maybe a
staff member, a nurse, or someone at the front desk would make a joke. So, I am just
being really sure to promote a culture in the workplace where we’re not making jokes
about people based on any demographic feature.
Another negative encounter by observing peers was experienced by IP1, and they shared how
this experience was the turning point for them knowing they wanted to differentiate their career
to be more welcoming. IP1 shared:
There were three nurses, making fun of somebody that looks very masculine with the
name of Cindy. Somebody that’s, you know, wanting to be very feminine. To any lay
eyes would 99% tell you that he’s a male, but he did not identify as a male; they
identified as female, and the nurses actually thought he was joking. They thought it was a
joke until I went and spent some time with him. And that’s where I, you know, I began
differentiating myself in my career.
The culmination of the negative observations experienced by a healthcare provider in this study
led to the development of this theme.
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Another source of self-efficacy is the vicarious experiences one encounters that allow one
to learn by observing others. Although vicarious experiences often improve self-efficacy through
positive observations, in this study, many participants shared that when they watched a
colleague, often not modeling welcoming behaviors or properly treating an LGBTQ patient, they
learned from their colleague’s inappropriate behavior and developed their methods and practices
for interaction with LGBTQ patients.
Research Question 3: What Are the Factors in the Healthcare Provider ’s Life That
Influence Their Beliefs and Attitudes About Their LGBTQ Patients?
Research question three detailed “What are the factors in the health provider’s life that
influence their beliefs and attitudes about their LGBTQ patients?”. This question was intended to
understand if providers have a duty to provide healthcare services to the LGBTQ community
regardless of their worldview and religious beliefs, as well as investigate what circumstances,
influences, or interactions can change these views and belief systems. The leading themes for
this research question were duty to provide care and influences on belief systems and
worldviews.
Theme 9: Duty to Provide Care
All 10 participants recognized that healthcare providers hold various views, beliefs, and
religions; however, all participants agreed that none of these factors should allow a healthcare
provider to choose who to provide or not to care for. IP3 shared that the provider’s own beliefs
should not be a part of the treatment plan process:
So, you said personal and religious beliefs. I don’t think either one of those should really
be entering a provider’s thought process when they’re deciding on a treatment plan unless
the treatment plan would somehow interfere with the patient’s personal or religious
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beliefs. Right. But certainly, my beliefs should have nothing to do with how I treat the
person that I’m seeing.
IP7 believes that providers not only have a duty to provide care regardless of views but should
create an environment that is inclusive and welcoming by removing the stigma from sexual
history questions. Specifically, IP7 uses the following method when meeting with patients:
To me, it’s actually this is kind of an interesting topic because it’s not really something I
specifically include in my social history. So, I generally, you know, ask folks if they are
currently sexually active and if they would like routine screening kind of regardless of
age, sexual orientation, marital status really you know really anything to kind of
normalize just getting those kinds of testing.
Regardless of a provider’s views, beliefs, or religion, participants agreed that the care of LGBTQ
patients should be of the highest quality.
Participants 1, 4, and 6 referenced that a high-level quality of care should always be
provided to the LGBTQ population. IP2 stated, “As providers, we’re not just obligated to
provide care, but I think we’re obligated to provide really excellent care to patient groups that are
often ignored or marginalized.” IP9 agreed with this view and shared that “I have sort of a very
global answer to this, which is that I think it is our duty as healthcare providers to provide the
best care we can to every person, no matter what their background is.” Similarly, IP4 shared,
“We definitely should be writing appropriate care to all patients, regardless of our beliefs and
regardless of their beliefs, we should be able to separate that out and then just give patients good
care regardless.”
Overall, each participant agreed that providers have a duty to provide care for LGBTQ
patients regardless of their views. Participants’ responses can be analyzed through the lens of the
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person component of Bandura’s social cognitive theory (1986). This component investigates
one’s previously learned beliefs and can provide insight into what influences a provider’s choice
of who to provide care for. By analyzing physicians’ cognitive and personality factors, a better
understanding of their willingness to treat LGBTQ patients can be developed.
Theme 10: Influences on Belief Systems and Worldviews
The final theme that emerged from this research question was that there are, in fact,
influences that can change a provider’s belief system and worldview on who to provide care for.
What was discovered from three participants was that one’s own identity or that of a relative or
friend identifying as LGBTQ could impact a provider’s views. IP1 shared a very personal
experience detailing the impact their childing identifying as transgender had on their personal
and professional life:
Learning started with my own daughter at the age of 15. She’s gay, and I was not open to
that. I didn’t see that as something for her. But I said we are not going to lose our
daughter, so I learned a lot through her. I’ve also been at the bedside with her when she
was very masculine looking. She ended up having a ruptured ovarian cyst and, you know,
she identified as Oliver. She decided that she was no longer gay and that she was actually
wanted to be male, and we went through this time of her life where she was Oliver and so
that’s why I’m kind of sharing that story with you because it was my daughter that had a
ruptured cyst being admitted to the hospital looking like a male.
Having a child identifying as LGBTQ was not the only personal factor influencing a participant’s
belief systems of who to provide care for and how to provide it.
IP4 went into detail about their experience seeking out healthcare services and how the
fear they had due to their own identity as LGBTQ made them hesitant to seek out healthcare
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services but nonetheless served as a catalyst for providing a safe and welcoming clinical
atmosphere in their own place of work. They shared, “as a gay man myself, it’s always scary to
go into a clinical setting. Can I be myself? So, the things that I can do as a, as a doctor is to let
them know they can relax here.” IP2 provided insight on how their own gender identity changed
their methodology for providing treatment by listening to others. Specifically, that they are
“treated differently because of [their] gender sometimes. So, [they] learned a lot about how
people interact with bigger systems from just listening to them talk about their experiences.”
Influences on one’s belief systems and worldview can be examined through the
environment lens of social cognitive theory, specifically the social environments in one’s life.
The participants of this study shared that it was through their social environments, which consist
of people such as family, friends, or own identity, that can have an impact on their beliefs and
who they provide care for.
Summary
The themes and examples in this study surfaced from qualitative data analysis through
the lens of the social cognitive theory framework, emphasizing the motivational variable of this
theory, self-efficacy. This framework created a foundation for understanding the barriers to
healthcare access for LGBTQ individuals. The first research questions addressed how healthcare
providers demonstrate welcoming behaviors toward LGBTQ patients. The second research
question outlined factors influencing a provider’s self-efficacy in treating LGBTQ patients. The
third research question examined how a provider’s worldview and beliefs are developed and
explored what influence or interactions can change these views. Utilizing the perspective and
experiences of ambulatory healthcare providers at WCH is essential in the journey to understand
healthcare access, given their role as an integral part of the healthcare system. The impact of
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behavior, environment, and person on a healthcare provider and how this influence impacts
LGBTQ patient access to healthcare is critical to developing recommendations to improve
LGBTQ patient access. A summary of each theme and critical examples are shown in Table 3.
Table 3
Themes and Key Examples
Theme Key examples from data
Theme 1: Understanding of
welcoming behaviors
“Being forward about advertising, that patients know the
institution, the clinic, the system is welcoming and wants
to take care of LGBTQ patients.”
Theme 2: Operationalizing
welcoming behaviors
“Consistency in how we approach patients and being
respectful of what that person wants to be called and what
kind of pronouns needs to be used.”
Theme 3: Ongoing learning of
welcoming behaviors
“Maybe it doesn’t need to be super frequent, but you know,
once a year or something like that where you sort of
reminding people like, hey, these are things that are
important too, you know, for this population.”
Theme 4: Commitment to
ensuring welcoming
behaviors
“Part of our job is to make everyone welcome, and our job as
doctors are to supervise and care for people, and we can’t
let our own personal bias belief or religion get in the way.”
Theme 5: Impact of
successful patient
interactions
“I can think of one patient who just said like I just appreciate
being able to come here and that you just listen right.”
Theme 6: Verbal persuasions
impact on provider
performance
“To hear that somebody felt that the staff treated them well. I
mean. It’s humbling, and it just makes you feel.”
Theme 7: Factors facilitating
provider confidence
“Personally, I have had a lot of education.”
Theme 8: Outcomes of peer
observations
“So, I am just being really sure to promote a culture in the
workplace where we’re not making jokes about people
based on any demographic feature.”
Theme 9: Duty to provide
care
“I have a very global answer to this, which is that I think it is
our duty as healthcare providers to provide the best care we
can to every person, no matter what their background is”
Theme 10: Influences on
belief systems and
worldviews
“Learning started with my own daughter at the age of 15.
She’s gay, and I was not open to that. I didn't see that as
something for her. But I said we are not going to lose our
daughter, so I learned a lot through her.”
58
Chapter Five: Discussion and Recommendations
The purpose of this study was to solicit ambulatory care provider narratives that explore
and identify the barriers to accessing ambulatory healthcare services for LGBTQ individuals.
The barriers explored in this study present significant evidence of an imbalanced healthcare
access equality for this vulnerable population. Information gathered from the study may assist
ambulatory care providers and the WCH health system in finding reasonable accommodations to
reduce barriers to care encountered by LGBTQ patients. Based on the results of this study, three
recommendations surfaced to address access to ambulatory healthcare services for LGBTQ
patients. Recommendations include developing a provider directory, enhancing the current EHR
system, and building an LGBTQ multispecialty care clinic. This chapter discusses the findings,
recommendations for practice, limitations and delimitations, and suggestions for future research.
Discussion of Findings
This study aimed to understand the barriers that result in poor healthcare access for
LGBTQ individuals. The conceptual framework of this study, rooted in social cognitive theory,
demonstrated a reciprocal causative relationship between environment, behavior, and person-
related factors regarding healthcare access. Additionally, the self-efficacy component of social
cognitive theory allowed for the development of an understanding of how ambulatory care
providers can improve their self-efficacy through various motivational factors. Table 4
summarizes the findings presented in Chapter Four that align with this study’s conceptual
framework and literature review.
59
Table 4
Conceptual Framework and Key Findings
Participants reported that a key component to ensuring healthcare access for LGBTQ
patients is by establishing a welcoming environment. Specifically, participants discussed that a
welcoming environment not only has staff and providers constantly demonstrating both
welcoming and competent behaviors but also has nonvisual cues that exhibit inclusivity and
acceptance. Furthermore, having an LGBTQ-focused clinic increases LGBTQ patient access
since patients now have a clinical location where they can feel free from discrimination when
seeking care. This finding aligns with the study’s literature that a minimal number of ambulatory
clinics in urban settings provide comprehensive LGBTQ services and that this needs to be
addressed to ensure equitable access to care for this vulnerable population. With only 9% of U.S.
Component of conceptual
framework
Key finding
Environment Establishing LGBTQ-focused clinical environments is
a key driver to improving healthcare access.
Behavior The frequency in which ambulatory care providers
display welcoming and help-seeking behaviors
toward LGBTQ patients impacts healthcare access.
Person A provider’s commitment and willingness to provide
care for LGBTQ patients are influenced by their
beliefs and personal relationships.
Self-efficacy Self-efficacy for ambulatory care providers is increased
through positive reinforcements, including verbal
persuasion, physiological outcomes, performance
outcomes, and vicarious experiences.
60
academic medical centers having a process for connecting patients to LGBTQ competent
physicians (Khalili, 2015), it is vital that WCH actively work to improve their clinical
environment.
When ambulatory care providers choose to engage in demonstrating welcoming and help-
seeking behaviors toward LGBTQ patients’ healthcare access is improved. Participants of this
study discussed how operationalizing welcoming behaviors by placing heavy emphasis on
capturing accurate identifying information early on in the patient journey could directly impact
patient access because LGBTQ patients will not be deterred from seeking out services at this
location. This study’s literature review found that a common barrier to access was transgender
patients being forced to identify as the sex they were assigned at birth which often delayed their
ability to receive care if they did not comply (Malina et al., 2020). Ultimately, this study found
that standardizing welcoming behaviors amongst providers will improve LGBTQ patient access.
An influential factor in a provider’s commitment and willingness to provide care stems
from their belief systems and personal relationships with LGBTQ patients. Participants in this
study shared how their experiences with close family members and friends have influenced their
views on whom to provide care for and ensure this care is welcoming and equitable. In this
study, participants agreed that all health system employees should be held accountable for
adhering to nondiscrimination policies regardless of their beliefs, religion, or other world views.
This was an important finding that aligned with the literature review. There need to be more
nondiscrimination protections for LGBTQ patients seeking healthcare services, given that there
is still a high volume of discriminatory laws impacting this population.
The last key finding was that participants identified positive reinforcements’ impact on
their self-efficacy when demonstrating welcoming behaviors and providing care for LGBTQ
61
patients. The positive reinforcements identified in this study include verbal persuasion,
physiological outcomes, performance outcomes, and vicarious experiences. Participants shared
how their performance outcomes through successful patient interactions improved their
confidence in providing care for this population. Furthermore, participants shared that
physiological outcomes such as anxiety and fear were overcome due to increased exposure and
practice. The literature reviewed in this study shared that only 51.1% of providers feel competent
in their ability to provide LGBTQ care (Rowe et al., 2017). The findings of this study support the
notion that provider competence and self-efficacy can be improved through positive
reinforcement of operationalized behaviors and increased exposure.
Recommendations for Practice
The following sections describe the three recommendations that were developed from
this research. Specifically, the ten themes developed from the research serve as the foundation
for the development of the recommendations. The first is the development of an enhanced
provider directory. The second is to develop an inclusive referral form within an enhanced EHR
system. The third is to build an LGBTQ-Specific multispecialty care clinic.
Recommendation 1: Enhanced Provider Directory
Only 9% of U.S. academic medical centers have processes for connecting patients to
LGBTQ competent physicians (Khalili, 2015). WCH’s online provider directory currently allows
consumers to search for a provider by condition, specialty, and department; however, there is no
designation within this search feature for providers with expertise in treating LGBTQ patients.
Therefore, when consumers, in this situation LGBTQ patients, seek a provider at WCH, they
may choose not to pursue receiving healthcare services at WCH since they are unsure if the
providers will exhibit welcoming and accepting behaviors or can meet their clinical needs as
62
LGBTQ patients. This could result in LGBTQ patients seeking treatment from a local competitor
who has integrated “LGBTQ Champions,” providers with expertise in various aspects of care for
the LGBTQ community, into their search function within their provider directory.
In order to prevent the costly impact of losing patients to competitors, also known as
leakage, WCH must develop a rubric that measures and identifies specific variables that will
allow a provider to be classified as an LGBTQ champion. This rubric will measure past
education, training, and commitment to ongoing education in treating and caring for the LGBTQ
community. Identifying providers that meet this criterion should be obtainable since ongoing
commitment and willingness to continue to learn the needs of LGBTQ was a predominant
finding amongst the participants of this study. Upon assessing which providers meet the criteria
to be classified as LGBTQ champions, their “specializes in” section will be updated to display
the LGBTQ Champion designation. A project team will need to be assembled monthly to assess
rubrics and designate providers as LGBTQ Champions.
The reciprocal causative relationship within social cognitive theory is evident in this
recommendation. The three components of the social cognitive theory framework that can be
examined through this recommendation are that participants are willing to commit to ongoing
education, the person component; that participants emphasize the importance of establishing a
welcoming physical space via advertising and non-verbal physical cues, the environment
component; and that increased engagement with LGBTQ patients is a health system priority, the
behavior component. The causal relationship between these three factors can aid in creating
streamlined access to ambulatory healthcare services for LBGTQ individuals.
The goal of having a provider directory that designates which clinicians have expertise in
treating LGBTQ patients will reduce the amount of time it takes patients to find a provider,
63
prevent patients from seeking services elsewhere that would result in leakage, and ultimately
increase business by streamlining ease in requesting an appointment with a specific provider.
Recommendation 2: Inclusive Referral Form Within an Enhanced EHR System
As previously reviewed in the literature, discrimination exists in healthcare settings in the
form of outdated and unmodified electronic health records that do not allow patients to select
their identified gender. Thus, patients are then either forced to identify as the sex they were
assigned at birth or be forced to delay care (Malina et al., 2020). This identity-based
discrimination causes 23.8% of LGBTQ patients to be more likely to delay accessing care
(Macapagal et al., 2016). Participants in this study supported the idea that capturing accurate
identifying information early on in the patient journey should be a priority of a health system.
Currently, at WCH, there is no standardized patient referral form or process that inputs
patient information directly into the EHR system. Most clinics often use outdated paper referral
forms and lack inclusive terminology. This is especially common when it comes to transgender
patients and those individuals seeking gender-affirming care. With each clinic developing and
distributing various referral forms, there is no oversite to ensure that each specialty within
WCH’s ambulatory care setting uses the most inclusive and accurate terminology when asking
sensitive demographic questions. This results in many clinics not having accurate patient
preferred pronouns and other demographic information upon patient arrival. Not only are the
current paper forms unreliable and outdated the processing is delayed to most forms being
incomplete. This incompleteness results in significantly delayed processing and scheduling.
Recommendation 2 is moving away from each clinic being able to have their ownership
of developing and distributing forms; instead, a standardized digital form with required fields
such as chosen name, name on insurance card, date of birth, pronouns, etc. An enhanced referral
64
management workflow will be developed by an internal project team consisting of providers,
operational leaders, and EHR account executives. Upon development, this form will be digitally
distributed to community clinics and published on the health system website. Furthermore, it will
be reviewed by multiple stakeholders to ensure LGBTQ inclusivity and accuracy and buy-in
from operational leaders. In order to ensure that all clinics receive this updated form, the EHR
system used at WCH will develop a centralized repository for form collection, assigning work
queues to each clinical specialty for processing. This digital work queue will allow for the
tracking and processing of referrals and will aim to increase the completeness rate due to their
now-required fields for submission. The EHR and integrated systems at WCH will be updated to
align and capture patient data from a terminology-inclusive form. A centralized digital repository
will ensure that patients and referring providers can accurately enter patients’ demographic
details and that form is received. The project team will develop a strategic implementation
roadmap, draft communications for enterprise and community awareness, and develop and
provide training to all clinic staff on accessing these work queues and process referral forms
accordingly.
Developing a standardized and inclusive patient intake system would allow learning
experiences and interactions to improve provider self-efficacy. This system would ensure
providers are using correct terminology with patients resulting in positive performance
outcomes. Additionally, this system would ensure positive reinforcement through continued
exposure to positive interactions and welcoming operationalized behaviors. Next, it would
reduce any use of the wrong terminology that could result in negative physiological feedback,
such as fear or anxiety. The goal of implementing a standardized and streamlined referral form
process is to ensure that the health system accurately captures and obtains patient demographics
65
so that all patients, especially those identifying as LGBTQ, can receive welcoming and
appropriate care promptly. Additionally, this solution will help further reduce patient leakage by
ensuring capturing and processing of these forms within a shorter timeframe.
Recommendation 3: LGBTQ-Specific Multispecialty Care Clinic
A primary barrier LGBTQ patients face when accessing healthcare is the limited number
of ambulatory clinics offering LGBTQ services in the United States. WCH ambulatory care
services have over 80 clinic locations. Currently, none of these clinics are designated as LGBTQ-
specific treatment centers. When LGBTQ patients come to WCH to seek care, they are sent back
and forth between multiple departments, such as family medicine, endocrinology, gender-
affirming care, etc., managed by various staff. This back-and-forth results in significant waits for
patients to be scheduled and seen by providers within each of these specialties. There is a
massive opportunity for growth by establishing a multispecialty clinic LGBTQ clinic where
patients can access all the needed services in one location. By establishing such a clinic, WCH
could keep all LGBTQ primary care and specialty care in-house with reduced appointment wait
times and create a safe and welcoming environment for LGBTQ patients. Interest in establishing
a welcoming environment for LGBTQ patients was a predominant finding in this study.
Additionally, this interest signaled a motivation, and this increased self-efficacy, for participants
to improve their abilities when providing care for LGBTQ patients.
Recommendation 3 is repurposing an existing consult space and WCH’s first LGBTQ
Multispecialty Clinic. This clinic will consist of providers that have been designated as LGBTQ
champions. Additionally, the staff here will be required to be knowledgeable about this specific
population’s current needs and nuances. By establishing this site, current and new LGBTQ
patients will be able to quickly identify a location that can serve as their source of quality
66
ongoing care that they know to be accepting, inclusive, and welcoming. At this site, staff will be
able to ensure their patient’s information are accurate and updated within the electronic health
record patient database system. Furthermore, due to the multispecialty nature of this clinic, the
patient will be able to be referred to a specialist within the same clinical setting, which is one
they will be already familiar with.
The goal of Recommendation 3 is to expand LGBTQ patient access to care with reduced
patient wait times by establishing an LGBTQ multispecialty care clinic at WCH Ambulatory
Services. This clinic will be open to existing patients at WCH and all other LGBTQ individuals
who reside in the area and seek healthcare services. Establishing this LGBTQ multispecialty care
clinic will hopefully serve as a catalyst and framework for other academic medical centers to
open similar facilities.
Integrated Recommendations
In order to ensure successful development of the three recommendations from this study,
each recommendation will be implemented and evaluated using Kotter’s 8 step change model.
This organizational change model is appropriate for this study because it will provide a clear and
comprehensible roadmap to key stakeholders at each stage of the recommendation
implementation process (Kotter, 1996). The first step of this model is urgency, meaning that all
stakeholders of the organization need to ensure there is a clear understanding for urgent change.
Step two is creating a coalition of change, meaning that all the key participants are involved in
the change management process. Next, is developing a clear project vision. The fourth step is for
leadership to communicate the project vision for change to the organization. After
communicating the vision, the next step is to remove any barriers or obstacles. The sixth step is
to develop quick wins to help motivate the organization. The seventh step is to continue to build
67
on the change that was achieved during the first six stages. The eighth and final step is to fully
embed these changes into the organizations culture. The eight steps of this model and the
associated application of each step for the recommendations from this study are outlined in table
5.
Table 5
Application of Kotter’s 8 Step Change Model
Step Application of step
Step 1: Create
urgency.
Provide widespread awareness of the health inequalities experienced by
the LGBTQ Community by launching multiple campaigns and learning
events.
Step 2: Build a
coalition.
Develop a governance composed of Providers, Senior Leadership, Front-
Line Staff, Access Representatives, and LGBTQ advocates to oversee
the implementation of the recommendations, project planning, and
resourcing.
Step 3: Create a
vision.
Set a clear project vision that both aligns with the mission of West Coast
Hospital and prioritizes how access to ambulatory services for LGBTQ
Patients will be prioritized via implementation of these
recommendations.
Step 4:
Communicate
the vision.
Communicate the vision and recommendations to all members of the
WCH community via all communication channels, encourage feedback
from employees regarding fears, concerns, or proposed changes.
Step 5: Remove
barriers and
obstacles.
Identify the processes, systems, employees, and policies that are causing
a barrier to implementation of the recommendations. Refine, update, or
remove all barriers.
Step 6: Create
quick wins.
Given the low cost, oversite, and easy project lift implement
recommendation one (enhanced provider directory) while also
acknowledging achievements of overall project milestones
Step 7: Build on
the change.
Sustain WCH changes focused on LGBTQ access to ambulatory services
by identifying all successes and shortcomings, continuation of
removing barriers, and ongoing communication of upcoming project
plans.
Step 8: Embed the
change.
Align project goals to WCH values and mission and reinforce through
rewards, hiring new talent, and continual education. Annually conduct
a culture survey to ensure implemented recommendations have
sustained.
68
Limitations and Delimitations
The results of a study should be interpreted while knowing the associated limitation and
delimitations. Researchers must present a complete list of limitations associated with the study
(Ross & Zaidi, 2019). Limitations can be defined as shortcomings or weaknesses of a study that
have the potential to impact the outcomes and findings (Ross & Zaidi, 2019). One potential
limitation to this study includes truthfulness regarding participant response. Given the sensitive
nature of this research topic, it is possible that participants were not entirely truthful in all of their
responses. Another limitation of this study was using video conferencing software, Microsoft
Teams, instead of in-person interviews. Interviews that do not take place in-person do not always
allow for the opportunity to build rapport with participants and also potentially result in
responses being cut short due to not being able to assess body language (Roller & Lavrakras,
2015).
Theofanidis and Fountouki (2019) define delimitations as the choices made by the
researcher to set boundaries regarding the study’s scope, aims, and objectives. A potential
delimitation to this study is participant criteria. Specifically, this study seeks to interview only
ambulatory care providers, not inpatient physicians. Another delimitation of this study is that
although the literature review was extensive, it is possible that some existing barriers to access to
ambulatory healthcare services were not identified.
Recommendations for Future Research
This section will provide three recommendations for future research based on the findings
of this study. First, this study should be replicated using a larger sample size. A larger sample
size would aid in verifying the consistency of these findings. The second recommendation is that
future research includes gathering LGBTQ patient experiences in accessing healthcare services
69
and their perspective on receiving welcoming behaviors and proper healthcare treatment.
Additionally, this research should target front-line non-clinical staff who often serve as patients’
first source of interaction. By soliciting both groups, a more comprehensive understanding of
LGBTQ patient access to ambulatory healthcare services can be developed.
The final recommendation for future research is that research should be continued after
implementing the recommendations of this study and determining their impact. The findings of
this study allow health systems to begin identifying the barriers to access to healthcare for
LGBTQ patients; however, the true effectiveness of these recommendations needs to be further
examined. Understanding the effectiveness of these recommendations would open the ability to
generalize these recommendations and implement them throughout other health systems.
Conclusion
The purpose of this study was to identify the barriers to accessing ambulatory healthcare
services for LGBTQ individuals. Through the lens of social cognitive theory, this study
discussed the relationship between a provider’s behavior, environment, and person to understand
the impact a provider’s self-efficacy has on supporting the needs of LGBTQ patients. Further,
the study presented recommendations for improving LGBTQ patient access, including an
enhanced provider directory, an inclusive patient referral and intake system, and building an
LGBTQ-Specific multispecialty care clinic.
Access to healthcare for LGBTQ individuals is a complex subject that requires
collaborative efforts from all health workers, including providers and front-line staff, and health
systems who share a patient’s journey toward equitable healthcare access. LGBTQ communities
face significant healthcare access disparities at the federal, state, and local levels. Healthcare
access is one of the key drivers for LGBTQ patient health outcomes; therefore, supportive
70
interventions to streamline and ensure access are vital for positive health outcomes. Failing to
acknowledge the current inequity in healthcare for LGBTQ patients is naive. To mitigate these
barriers to care for LGBTQ patients, healthcare leaders must acknowledge the current
shortcoming of their health systems and hospital and focus on dismantling existing behaviors
that are ethically not right. Prioritizing changes that focus on developing welcoming
environments within a healthcare system will significantly impact LGBTQ patients’ ability to
access equitable ambulatory healthcare services.
71
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Appendix A: Interview Protocol
Each interview will begin by utilizing the same scripting. Following the introductory
scripting, additional questions organized into various categories will be asked to each participant.
The introduction scripting will be broken out into five phrases:
1. Thank you for agreeing to participate in my dissertation research. I truly appreciate
you taking the time out of your busy schedule meet with me. As I mentioned when
we last spoke, the interview should take about forty-five minutes to an hour, is that ok
with you?
2. Before we jump into the questions, I want to remind you about my study. I am a
doctoral candidate at Rossier School of Education of USC and am conducting a study
on primary barriers to healthcare access for LGBTQ individuals. I am interested in
understanding the willingness of ambulatory healthcare providers to demonstrate
welcoming behaviors toward LGBTQ patients, learn more about what influences
impact provider performance and ability to treat LGBTQ patients, and also to learn
how external factors influence beliefs and attitudes about LGBTQ patients. I am
talking to multiple ambulatory healthcare providers to learn more about this.
3. I want to assure you that the questions I ask today are strictly for research purposes.
My questions are meant to be evaluative, and I will not be making any judgments on
how you provide care as a health system employee.
4. This interview will be strictly confidential. Your name will not be shared with
anyone. I will not share your responses with other providers or clinical staff. The data
for this study will be compiled into my dissertation studies and none of this data will
be directly attributed to you. I will use a pseudonym to protect your confidentiality
85
and will de-identify any of the data I gather from you. I am happy to provide you with
a copy of my dissertation upon completion if you are interested.
5. Do you have any questions about the study before we get started? Also, I will be
recording today’s interview so that I can accurately capture and then transcribe what
you share with me. The recording is solely for my purposes to best capture your
perspectives and will only be shared with the transcription services company. Do I
have your consent to record and transcribe our conversation? Thank you, recording is
starting now.
The interview will continue by asking the participants questions about
professional background and experiences:
1. Can you tell me a little bit about yourself? Specifically, your background and what
field of healthcare you work in?
2. How long have you worked in healthcare?
3. In your multiple years of working in this industry how often do you interact with
LGBTQ patients?
4. Do you have professional relationships with LGBTQ patients? Describe.
5. Do you have personal relationships with LGBTQ individuals? Describe.
The interview will continue by asking the participants questions about
belief systems and worldviews:
6. Describe your view on if healthcare providers have a duty to provide care for LGBTQ
patients regardless of their personal and religious beliefs?
7. Describe any influences that you think may change a provider’s worldview on who to
provide care for?
86
8. Do you believe healthcare providers should adhere to nondiscrimination policies for
LGBTQ patients within the health system they work?
9. What if these policies do not align with a provider’s beliefs and worldviews?
The interview will continue by asking the participants questions about welcoming
behaviors toward patients:
10. Can you describe what kinds of behaviors that you think are welcoming toward
LGBTQ individuals?
11. Can you describe what behaviors you think are welcoming toward LGBTQ patients
within healthcare the setting?
12. Can you describe your approach for demonstrating welcoming behaviors toward
LGBTQ patients?
13. Can you describe how confident you are in your abilities to demonstrate welcoming
behaviors toward the LGBTQ patients you interact with?
14. Can you provide an example of a time when you felt you demonstrated welcoming
behavior toward an LGBTQ patient, if ever?
15. Did this success influence your confidence in future interactions with LGBTQ
patient, if at all?
16. Did this success make you feel any particular way?
17. Did anyone witness this interaction?
18. If yes, did they provide you feedback on or talk to you about this?
19. Can you describe a time you feel like you could have demonstrated more welcoming
behavior toward an LGBTQ patient, if ever at all?
20. If yes, when you think back on this do you feel any particular way?
87
21. Did anyone witness this interaction?
22. If yes, did they give you feedback on or talk to you about this interaction?
23. What platforms, interactions, and/or influences have allowed you to learn how to
demonstrate welcoming behaviors toward LGBTQ patients?
24. Did these occur at your organization and/or in your personal life? Describe.
The interview will continue by asking the participants questions about how the
participant has learned to support the needs of LGBTQ patients:
25. What platforms, interactions, and/or influences have allowed you to learn the needs of
LGBTQ patients, if any at all?
26. Did these occur at your organization and/or in your personal life? Describe.
27. Can you describe your willingness to continue to learn to the needs of LGBTQ
patients?
28. In what capacity/platform would you want to learn these needs? Describe.
The interview will continue by asking the participants questions about their experiences
with receiving patient feedback:
29. Do you ever receive patient feedback?
30. If yes, when was the last time you received feedback from an LGBTQ patient?
31. What method/platform (email, survey, SRM, directly from patient) do you value the
most to receive feedback from?
32. Can you provide an example of a time when you felt you successfully learned from
receiving LGBTQ patient feedback?
33. Did you integrate what your learned from this into your everyday practice?
34. Did this success impact your confidence in treating future LGBTQ patients, if at all?
88
The interview will end by asking the participants two questions about if they have any
additional input on the interview as well as thank them for their participation:
1. What other insight would you like to share about our conversation about LGBTQ
patient access today that I might not have covered, if any? Also, are there any
additional resources or support you might need in order to be better prepared to work
with LGBTQ patients?
2. Thank you so much for sharing your thoughts with me today! I really appreciate your
time and willingness to share. Everything that you have shared is really helpful for
my study. If I find myself with a follow-up question, can I contact you, and if so, is
email, ok? Again, thank you for participating in my study.
89
90
Appendix B: Information Sheet for Exempt Research
STUDY TITLE: Access to Ambulatory Healthcare Services for LGBTQ Populations in the
United States
PRINCIPAL INVESTIGATOR: Trenton Mendenhall
FACULTY ADVISOR: Rufus T. Spann, Ph.D., LPC, NCSP, NCC
You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.
PURPOSE
The purpose of this study is to understand healthcare provider perception toward LGBTQ
patients. Specifically, to investigate their willingness to demonstrate welcoming behavior toward
LGBTQ patients and their willingness to learn the specific clinical needs of this vulnerable
populations in order to break down the barriers that results in lack of access to, delayed access to,
or inequitable access to healthcare. We hope to learn what influences have impacted a provider’s
ability to demonstrate welcoming behaviors and learn the clinical needs of LGBTQ patients. You
are invited as a possible participant because you are a healthcare provider within an ambulatory
care setting.
PARTICIPANT INVOLVEMENT
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may withdraw your consent at any time and
discontinue participation without penalty. You are not waiving any legal claims, rights, or
remedies because of your participation in this research study. The investigator may withdraw you
from this research if circumstances arise which warrant doing so.
If you decide to take part, you will be asked to participate in an interview lasting approximately
45-60 minutes. The interview will take place via Microsoft Teams, will be video-recorded, and
later transcribed. Participants can decline to be recorded and continue with their participation.
CONFIDENTIALITY
The members of the research team, and the University of Southern California Institutional
Review Board (IRB) may access the data. The IRB reviews and monitors research studies to
protect the rights and welfare of research subjects.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
91
The data will be coded with a list of random codes, which will provide the only access to your
personal identity and will be accessible to one researcher (Trenton Mendenhall) only. These de-
identified data will be stored on a secure server and will be deleted upon completion of the
research project
Video recordings and transcripts will be stored on a secure server and will be deleted upon
completion of the research project. The one researcher (Trenton Mendenhall) and the transcribers
(rev.com) will be the only one’s able to access the recordings.
INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact:
Trenton Mendenhall
Trenton.Mendenhall@med.usc.edu
628-228-9684
or
Rufus T. Spann
Rtspann@usc.edu
IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.
Abstract (if available)
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Asset Metadata
Creator
Mendenhall, Trenton Keith
(author)
Core Title
Access to ambulatory healthcare services for LGBTQ populations
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Degree Conferral Date
2022-12
Publication Date
11/21/2022
Defense Date
09/27/2022
Publisher
University of Southern California
(original),
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(digital)
Tag
access,ambulatory healthcare services,Barriers,caregiver,cisgender,LGBTQ,LGBTQ older adults,LGBTQ youth,OAI-PMH Harvest,transgender
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theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Spann, Rufus Tony (
committee chair
), Cox, Tory (
committee member
), Ferrario, Kim (
committee member
)
Creator Email
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Tags
access
ambulatory healthcare services
caregiver
cisgender
LGBTQ
LGBTQ older adults
LGBTQ youth
transgender