Development of a Multidimensional Measure of Health Care Access Among LGBTQ Older Adults

Background and Purpose: Extant research has identified LGBTQ older adults as a health disparity population in need of improved access to care. Health care access is often seen as an isolated event of health care utilization, while in reality it is a complex process. Research and measurement considering the multidimensional factors influencing health care access among LGBTQ older adults remains limited. The current study combined theoretically cohesive indicators representative of multiple dimensions impacting health care access for LGBTQ individuals, including barriers to care, health literacy, patient-provider relationship quality, help-seeking beliefs, and health care discrimination to develop a comprehensive and reliable, yet parsimonious scale that can be utilized in future research.

Methods: Data from NHAS were used, including a total of 2450 participants from the 2015 wave of data collection. Twenty-four items were initially included in an assessment scale reliability using Stata 16. Confirmatory Factor Analysis (CFA) was subsequently applied using Mplus (v.8) to test the underlying factor structure of health care access. Retained items were standardized and a total score for health care access for each participant was calculated by averaging standardized items. Differences in mean scores were examined across gender, gender identity, and sexual orientation using Wald tests.

Results: Nineteen items remained in the final scale with a Cronbach’s alpha of 0.89 and an average inter-item correlation of 0.31. Each item was a moderate to strong contributor to the measure with item-rest correlation values ranging from 0.34-0.71. CFA was applied to the 19 items and the model displayed good fit. Majority of items showed strong loadings on its corresponding dimension. Data supported a three-factor structure of health care access: barriers to care, health literacy, patient-provider relationship quality. Results examining heterogeneity in health care access scores across gender, gender identity, and sexual orientation showed that women, participants who identified as “something else” (vs. men), transgender participants (vs. cisgender participants), and sexually diverse participants (vs. lesbian or gay participants) faced more difficulties when accessing care, each reporting significantly lower health care access scores.

Conclusions and Implications: The creation of this health care access scale creates several opportunities for use in future research. The combination of items provides a more concise, yet also multidimensional and reliable way to assess level of health care access among LGBTQ older adults. Due to the longitudinal nature of NHAS, future research could assess changes in access over the life-course, in relation to relevant demographic, economic, and social indicators, and as a predictor of health and utilization outcomes. An examination of the items dropped from the scale during the item reduction process provides the opportunity for scale refinement. Finally, it may be beneficial to examine potential emerging domains missing from the scale. For example, the use of digital technologies to access health information and care is rapidly expanding, especially among LGBTQ populations. However, the concept of electronic health literacy is new and not well understood. Integrating these questions into NHAS may help us begin to understand how this factor impacts health care access for LGBTQ older adults.