Abstract

Introduction: The Lesbian/Gay/Bisexual/Transgender (LGBT) community has a higher rate of mental illnesses, substance abuse, and sexually transmitted diseases. Despite high health needs, few availed to government health services due to fear of being stigmatized and discriminated. Healthcare workers should have good knowledge and attitudes toward the LGBT to reduce stigma and discrimination.

Objective: This study aimed to assess knowledge and attitudes toward LGBT patients among nurses in selected hospitals in Ampara district.

Methods: A descriptive cross-sectional study was conducted. A Self-administered questionnaire was used to collect data from 352 nurses. Data were analyzed using non-parametric tests.

Results: Majority (58.24%) had satisfactory knowledge of LGBT community, though a considerable number of nurses exhibited poor knowledge (32.67%). The percentage of correct answers to knowledge questions varies from 14.2% to 92.6%. Mean value for attitudes was 3.21. Majority (66.4%) of nurses had positive attitudes toward providing healthcare to LGBT, while only 36.8% of nurses had positive attitudes toward acceptance of LGBT. Gender (p=0.016), geographical location (p=0.000), and education (p=0.038) were significantly associated with the knowledge of nurses. Attitudes were significantly associated with education (p=0.021).

Conclusions: The mean value of nurses’ knowledge and attitudes regarding LGBT patients was just above the neutral level. Nevertheless, there was gross inadequacy of knowledge exhibited in some areas. Though the majority had positive attitudes toward providing health care, LGBT patients may be stigmatized due to poor acceptance by nurses. Therefore, improving nurses’ knowledge and attitudes toward LGBT patients is necessary to improve care for them in healthcare institutions.

Keywords: LGBT; Nurses; Knowledge; Attitudes; Lesbian/Gay/Bisexual/Transgender.

Citation: Ranawaka N, Nanayakkara R, Abeysekara CM, Welikumbura NH, Chathurika HLS. Knowledge and Attitudes Towards Lesbian/Gay/Bisexual/Transgender Patients among Nursing Officers in Selected Hospitals in Ampara district, Srilanka. SciBase Epidemiol Public Health. 2023; 1(3): 1011.

Introduction

Sexual orientation and gender identity are two important concepts that need to understand before defining the Lesbian, Gay, Bisexual, and Transgender (LGBT) community. Sexual orientation is defined as “how a person characterizes their sexual and emotional attraction to others” [1]. According to sexual orientation, people can be classified as heterosexual, bisexual, and homosexual (lesbian and gay).

A Lesbian is defined as “A woman who self-identifies as having an emotional, sexual, and/or relational attraction to other women” [2]. A Gay is defined as “A man who self-identifies as having an emotional, sexual, and/or relational attraction to other men” [2]. A Bisexual is defined as “A person who selfidentifies as having an emotional, sexual, and/or relational attraction to men and women” [2]. Gender identity is a “person’s internal sense of being a man/male, woman/female, both, neither, or another gender” [1]. Most of the time, gender identity corresponds with assigned sex at birth. If gender identity and assigned sex do not match each other, they are called transgenders.

LGBT community faces many discriminations and barriers to accessing quality health care, leading to health disparity [3]. They have a higher rate of mental illness (such as anxiety, and depression), substance abuse, Human Immunodeficiency Virus (HIV), and other sexually transmitted diseases (STD). Moreover, they were more victimized by violence [1]. Therefore, they need more support from health care services. According to researchers, a few of them get the benefits of the government health services despite having high health needs [4,5]. For example, in Ethiopia, LGBT population does not seek health care due to fear of homophobic reaction, stigmatization, and discrimination [5]. Therefore, the healthcare workers must have good knowledge and friendly attitude toward the LGBT population to minimize discrimination and stigmatization.

Further, many researchers highlighted the need of improving the knowledge and attitude of the healthcare workers towards LGBT population [6,7]. Therefore, it is essential to assess the level of knowledge and attitudes of healthcare workers to identify the gaps which need to be bridged by necessary interventions. No research was conducted in Sri Lanka to assess the knowledge and attitudes toward the LGBT community among healthcare workers. Nursing officers are the healthcare workers who first meet patients in Sri Lanka hospital settings. They spend more time with patients for nursing care compared to other health categories. Therefore, this research aimed to assess knowledge and attitudes of Nursing officers’ towards LGBT patients in selected hospitals in Ampara district. This research would help identify and correct the knowledge and attitudes gaps among Nursing officers and thereby will reduce the stigma and discrimination towards the LGBT population. Improved health seeking behavior of the LGBT population, will ultimately reduce the rate of mental illnesses, suicidal attempts, substance abuse and spread of HIV and STD.

Ampara district is situated in the Eastern province of Sri Lanka. The total population of Ampara district is 719,462. There are three leading hospitals in Ampara, District General Hospital (DGH) Ampara, Base Hospital Mahaoya, and Base Hospital Dehiattakandiya. DGH Ampara is the district’s largest tertiary health care provider [8]. Therefore, DGH Ampara was selected for the study. Base Hospital Mahaoya was selected from the other two Base Hospitals due to its high feasibility.

Literature review: Sri Lanka is a South Asian country with 21 million inhabitants and LGBT rights have been neglected since the colonial era [9].

Earlier, homosexuality was considered as a mental disorder worldwide, later, it was excluded from mental disorders category [10]. But according to the penal code 365 (A) in Sri Lanka, homosexuality is still considered as a crime. In 2017 Sri Lankan government considered some legislative changes toward the LGBT population, though the project was eventually abandoned [11]. Ministry of Health, Sri Lanka started to issue gender identity certificates for the transgender community since 2016. The process of obtaining a gender identity certificate was mentioned in General circular 01-34/2016. It was a huge victory for the transgender population in Sri Lanka.

According to a recent mapping study done in Sri Lanka, there were 9% lesbian, 32% gay, 38% bisexual, and 21% transgender in the Colombo district [12]. Rapid situation assessment done in Sri Lanka on transgenders has revealed that they were treated satisfactorily in healthcare settings/hospitals. However, some have faced verbal and nonverbal harassment in healthcare settings. Further, the same assessment found that transgenders’ psychological stress was very high due to the stigma, discrimination, and violence [13]. It is difficult to find literature on healthcare providers’ attitudes and knowledge toward the LGBT population in Sri Lanka hospital settings. H.U.S. Samaraweera mentioned in her research paper that Sri Lankans have more negative attitudes toward homosexuality, especially lesbianism [14]. Sri Lankan cultural and legal background may be the reason for the lack of research on to LGBT population.

Many types of research have proven the significant association and higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self-harm in LGBT people than in heterosexual people [15].

Many types of research have been conducted to assess nurses’ and medical officers’ knowledge and attitudes toward the LGBT population in other countries. A survey on healthcare providers’ attitudes and knowledge towards LGBT community suggested the need of additional education and training regarding LGBT to healthcare providers [6]. Another research found that Implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual healthcare providers [16]. A survey done in the United States on nursing students’ knowledge and attitudes toward LGBT healthcare concerns indicated a significant knowledge deficit [17]. Further, an observational study in Italy also discovered that nurses have moderately positive attitudes toward the LGBT population [7].

Methodology

A descriptive cross-sectional study was conducted in DGH Ampara and Base Hospital Mahaoya in Ampara district from August 2021 to January 2022. Data were collected from all permanent staff Nursing officers in both hospitals using self-administered questionnaire. The questionnaire consisted of three components.

Part A – Assess the Socio-demographic characteristics of nursing officers.

Part B – Assess the knowledge on LGBT population. This section was consisted of 15 questions.

Part C – Assess the attitudes on LGBT population. This section was consisted of 18 questions.

The questionnaire was prepared using Attitudes toward Lesbians and Gay Men (ATLG) scale, Attitudes toward Lesbian, Gay, Bisexual and Transgender Patients (ATLGBTP) scale and Knowledge of Lesbian, Gay, Bisexual, and Transgender People KLGBT questionnaires.

Knowledge questionnaire consisted of three choices with one correct answer. Attitudes questionnaires consisted of 18 questions, scored on a 5-point Likert scale.

Data collection was started after ethical approval and administrative clearance from the relevant authorities. The name list of nursing officers was obtained from the matron offices in both hospitals. The questionnaire was distributed to nurses and collected after specified time period. Written informed consent was taken before handing over the questionnaire and relevant research information was given to nurses.

Data was entered to excel sheet and then transferred to SPSS. Data entry and analysis was done by the research team.

Results

The main objective of this section of the document is to provide insight into the data that were extracted from the structured questionnaire. Charts and tables were used to present the data in an organized manner along with the interpretation. Under the descriptive data analysis, the mean and the median of the continuous variables were presented and frequency tables were used to present the categorical variables. Descriptive data analysis would provide a guide about the variables. Apart from the demographic variables such as age, gender, education, location, etc, two other variables, the knowledge and attitude were also measured using a series of indicator questions which were assessed by Likert Scale. Some of those questions were presented in positive as well as in negative directions. Before constructing the two composite variables from those different indicator variables, all the questions were re-directed to the positive direction using recodes. In order to assess whether those indicator questions represent the set composite variables (knowledge, attitude), internal reliability was calculated using the Cronbach’s Alpha test statistic. The two composite variables were constructed by calculating the mean value of the feedback given to each indicator question by each respondent.

Once the composite variables were constructed, the normality assumptions were assessed for the composite variables and found that both do not follow the normal distribution. That forced the researchers to use the non-parametric tests, Spearman correlation for continuous variables, the Mann-Whitney test for categorical variables with two levels, and the Kruk-Wall test for categorical variables with more than two levels under the inference data analysis part. The statistical significance was assessed against a 95% significant level.

The sub-objective of this section was to assess the level of knowledge (% of the respondent who correctly answered the questions in the field) and attitude (level of attitude under 1 to 5 Liker scale) towards the strength of the respondents, to assess the correlation between Knowledge and attitude with those demographic variables, and to test the significance of such association.

Socio-demographic characteristics of nursing officers: It was observed that the average age of the sampled respondents was 32.33 years, while the median was 29 years. The youngest respondent was 25 years and the oldest respondent was 54 years (Table 1). The average experience of the sampled respondents was five and half years with the median of 3 years. The reported lowest experience was one year and the highest experienced respondent had 21 years of experience (Table 1).

The study sample consisted of 89% females and 11% males. Out of the 352 total sample, 81% of the respondents were married. The majority (71.6%) was diploma holders and 28.4% were degree holders. 60.8% of the respondents were from the Ampara district and 39.2% were residing outside the Ampara district (Table 2).

Assessment of level of knowledge on LGBT patients: The knowledge was measured using fifteen questions with true or false responses. The percentages of correct answers were illustrated in Table 3. According to Table 6, it was found that more than half (56.4%) of the respondents were correct on their feedback. The median was 0.60 and the accuracy of the respondents varied from 27% to 87%. The coefficients of variance of knowledge and attitude were 0.25 and 0.05 respectively, and indicated a very low variance (Table 6).

Distribution of nursing officers according to the level of knowledge: One mark was given to a correct answer and zero mark was given to a wrong answer. Finaly, total marks out of 15 marks, converted to the percentage scale. Nurses who obtain ≥75 marks were categorized as nurses with “good” knowledge while those who obtained 50 to 75 marks were categorized as satisfactory knowledge. Those who obtained less than 50 marks were categorized as poor knowledge. According to the results, only 9.09% of nurses had good knowledge. A significant proportion of nurses (32.67%) had poor knowledge (Table 4).

Assessment of level of attitudes on LGBT patients: In assessing the attitude of the respondents towards the LGBT patients, they were divided broadly into two directions, namely positive direction and negative direction. In constructing the attitude composite variable, all the indicator questions towards negative direction were recorded in a positive direction (Table 5). The average value for attitudes was 3.206 on the 1 to 5 Likert scale and varied from 2.67 to 3.55 (Table 6).

Correlation analysis between continuous variable and knowledge and attitude: According to Table 7, both normality tests suggested that the two composite variables (knowledge and attitude) did not follow the normal distribution as the corresponding probability values were less than 0.05. Further, the Cronbach’s Alpha value of attitude was 0.766 and indicated that the selected fifteen indicator question can be used to construct the attitude composite (Table 8).

The graphical representation (Figure 1) of the correlation between age and knowledge suggested that there was a negative relationship between two variables while there was a positive relationship between age and attitude (Figure 2)

As per Table 8, age was having statistically significant negative correlation as corresponding probability value was less than 0.05. The magnitude of the correlation was weak as it was just below 0.500. The correlation between age and attitude was positive and also statistically significant (p=0.315).

Experience also had a negative weak correlation (-0.137) with knowledge, and it was statistically significant as corresponding probability was less than 0.05 (Table 8). On the other hand, experience and attitude had a positive significant correlation but the magnitude of the correlation was weak.

Correlation analysis between categorical variables and knowledge/attitude: Since the distribution of the Knowledge and attitude was not following normal distribution, the nonparametric test of Mann-Whitney was used to access the association.

Table 9 illustrates the levels of association between knowledge and other demographic variables. The average knowledge of the male was 50.7% and female was 57.1%. The difference was statistically significant as the corresponding probability value was less than 0.05(0.016). Therefore, it can conclude that females tend to have higher knowledge than males. The average knowledge of the married respondent was 56.6%, and unmarried respondents were 55.7%. But this difference was not significant as the probability value was 0.891. Hence it can conclude that marital status did not have any association with knowledge at 95% significance level. The respondents who were from Ampara district had only 51.4% of knowledge while respondents residing outside the Ampara district had 64.2% of knowledge. The statistical test suggested that this was a significant difference as the corresponding probability was less than 0.05. The average knowledge of diploma holders was 55.5% and degree holders were 58.9%. The none-parametric test revealed that it was a significant difference as the probability value was less than 0.05. Hence it can conclude that the higher the education, the higher the knowledge (Table 9).

Table 10 illustrates the association of the attitude with the rest of the demographic variables. Males had a better attitude than females (3.216 vs. 3.544), but the probability value of the test statistic was 0.056, which was not significant (less than 0.05). But there was a significant association of attitude and gender at a 90% significant level as the probability value was less than 0.10. The statistical test revealed that marital status and hometown did not have an association with attitude. The respondents who are having diploma had a better attitude (3.154) than respondents who had a degree (3.116). The statistical test suggested that this difference was statistically significant at a 95% significant level.

Table 1: Age and experience of nurses.

Table 2: Socio-demographic characteristics of nurses (categori- cal variables).

Table 3: Frequency table of knowledge.

Table 4: Distribution of nursing officers according to the obtain marks for knowledge.

Table 5: Frequency table of attitude.

Table 6: Descriptive statistics of composite variables.

Table 7: Normality test.

Table 8: Spearman correlation matrix.

Table 9: Mann-Whitney test results with knowledge.

Table 10: Mann-Whitney test results with attitude.

Discussions

This study was aimed to identify the knowledge and attitudes of nurses in Ampara district towards the LGBT population. Further, this research assessed the association between nursing officers’ socio-demographic characteristics with knowledge and attitudes.

Socio-demographic characteristics of nursing officers’ in selected hospitals in Ampara district: There were total of 413 nurses in both hospitals. Among them, 23 nurses who were working on a temporary basis were excluded from the study. 18 Nurses were on maternity leave. A total of 372 nurses were eligible for the study. Among them, 352 responded to the study. The non-responded rate was 5.68%.

2%) (Table 2). The male-to-female ratio was 1:9. The male-to female ratio of nurses was similar to other countries [18]. Most nurses (n=252, 71.6%) (Table 2) had only a diploma in nursing while the rest had a degree in nursing. Until recent years, there were only diploma courses in nursing in Sri Lanka. This could be the reason for the high number of diploma holders in the study population. A significant proportion of nurses were not from Ampara district (n=138, 39.2%). The mean age of nurses in Ampara district was 32.33 years, and the median was 29. There were no national-level data on nurses in Sri Lanka to compare the age distribution of nurses in Ampara district vs. National level. According to the 2020 national nursing workforce survey in the United States, the median age of nurses was 52 years. It revealed that nurses working in Ampara district were comparatively younger than in other countries [19]. As there was a younger population working in the Ampara district, their mean and median working experience was also low.

Knowledge of nursing officers towards LGBT patients: In this study, knowledge was assessed using 15 questions. Each question had three choices, yes, no, and not sure. Only one choice was considered as the correct answer. Lack of education and knowledge on LGBT community was a factor associated with inadequate care for LGBT patients [20]. The highest percentage (92.6%) of the correct answers was given to the question “Sex and gender have the same meaning”. The lowest percentage (14.20%) of correct answers was given to the question “Ministry of Health, Nutrition and Indigenous Medicine in Sri Lanka is issuing Gender Recognition Certificate for Transgender Community”. Ministry of Health Sri Lanka started to issue gender recognition certificates to the transgender community since 2016. The Ministry of Health issued a circular (circular number 01-34/2016) on issuing gender recognition certification and guidelines on applying for the certificate. Unfortunately, most nurses were unaware of the gender recognition certificate for the transgender community in Sri Lanka. The mean score nurses recorded was 56.42%. The median value was 60%. According to the result, 9.09% of nurses had good knowledge, 58.24% had satisfactory knowledge, and 32.67% had poor knowledge. Though most nurses have satisfactory knowledge, still a considerable number of nurses (32.67%) had poor knowledge. Most of the researchers around the world revealed the same result on knowledge level of nurses or health care providers regarding LGBT population [6,7,20]. It was hard to find any research which revealed the majority of nurses had a good knowledge of the LGBT population. Some universities integrated LGBT health guild into nurses’ curricula to fill deficiencies in knowledge gap [21].

Nursing officers’ attitude toward LGBT patients: Attitudes of nurses toward LGBT population assessed using 5-point Likert scale. The attitude varies from 2.67 to 3.55. The mean value of attitudes was 3.206, which was just above the middle value of the Likert scale. 92.6% of nurses disagreed with the indicator “I would prefer not to treat LGBT patients” and 89.2% agreed with the indicator “LGBT patients deserve the same level of quality care from medical institutions as cisgender patients”. It was revealed that nurses did not ready to compromise care for the patients just because they belong to LGBT category. Though, most of the nurses exposed negative attitudes towards indicators such as “I would feel comfortable working closely with a LGBT individual”, “I would feel comfortable if I knew that my best friend was a LGBT individual”, “I would feel comfortable if a close family member is a LGBT individual”, “Transgender individuals should be allowed to dress to reflect their gender identity in public”, and “Celebrations such as “Gay Pride Day” are ridiculous because they assume that an individual’s sexual orientation should constitute a source of pride”, It was apparent that nurses were unwilling to make friendships or relationships with the LGBT community and did not like expressing LGBTs’ gender identity in public. Therefore, it can be concluded that, as health care workers, nurses do their service provision without discrimination, but generally have a negative attitude toward LGBT community, especially on acceptance of the LGBT community. Attitudes towards LGBT population differed from population to population. Research done in Sweden early as 2004 revealed positive attitudes of nurses towards the gay and lesbian population [22], while a study done in Taiwan, showed negative attitudes toward the LGBT population by nurses [23].

Association of socio-demographic characteristics with knowledge and attitudes of nursing officers toward Lesbian/ Gay/Bisexual/Transgender patients: The result of this study revealed that there were significant associations between knowledge of nursing officers and sex (p=0.016), geographical location (0.000), and level of education (0.038). Female nurses, Nurses from outside Ampara district, and nurses with nursing degrees had significantly higher knowledge about the LGBT population (Table 10). According to the scatter plot diagram (Figure 5), there was a significant negative correlation between knowledge and age; older nurses showed more negative attitudes. Social media like Facebook, Instagram, and YouTube have more open discussions on LGBT. The younger generation is using these Medias more frequently. This exposure may be the reason for a negative correlation between knowledge and age. It needs more studies to confirm social media’s influence on knowledge and attitudes towards LGBT.

According to the result, only the education level had a significant association with nurses’ attitudes towards the LGBT population (p=0.021) (Table 11). The statistical test concluded that nurses with lower education tend to have a better attitude. Regarding gender, even though there was no statistically significant association, the result revealed that males had a better attitude than females (3.216 vs. 3.544). Nurses’ attitudes displayed a significant positive relationship with age, which means nurses’ attitudes towards LGBT increased with age. Many researchers found positive attitudes towards LGBT community with higher education levels [24,25]. However, our study found an inverse relationship between attitudes and education level. There is a concept called “Educationism and the irony of meritocracy” developed by a social psychologist, which means negative attitudes of higher educated people toward the less educated [26]. Likewise, nurses with higher education levels exhibited more negative attitudes towards LGBT community. Differences in curriculum, tutors, and teaching patterns can cause attitudinal differences between degree holders and diploma holders.

It was revealed that increasing knowledge would not change attitudes.

Conclusion

Conclusion

Nurses’ mean value of knowledge and attitudes regarding LGBT patients were just above the average. Nevertheless, there was a gross inadequacy of knowledge exhibited in some areas. Attitudes towards health care provision to LGBT patients were satisfactory though acceptance of LGBT patients as ordinary/ normal people was not adequate. Education level showed an inverse association with attitudes towards LGBT people. Therefore, increasing the educational level is not always able to change attitudes.

Nursing officers’ gender (p=0.016), geographical location (0.000), and education level (0.038) had a direct impact on knowledge, and educational level had a direct impact on attitudes toward LGBT patients.

Recommendations: It is necessary to improve knowledge and attitude of nurses toward LGBT patients. Hospital managers can arrange educational and training programs for the nurses who are already in the service to improve knowledge and attitude toward LGBT. As the level of education does not correlate with the attitude, special attention should be given to enhancing nurses’ attitudes in more practical ways. Lessons on LGBT community should be included in the nursing curriculum. The idea that “LGBT people are normal human beings” should be embedded in the health care workers’ minds, especially for nurses.

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