Original ResearchDevelopment and validation of the Barriers to Physical Activity and Sport Questionnaire for lesbian, gay, bisexual, transgender and queer/questioning persons
Introduction
Physical activity and sport (PAS) is nowadays a public health concern owing to its potential biological and psychosocial benefits.1,2 These positive outcomes can be especially relevant for populations at high risk of social exclusion because they generally have worse health than the general population.3,4 Lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+ [encompassing all spectrums of sexuality and gender]) people are a socially excluded group owing to the oppression and structural violence they suffer.5, 6, 7 Although a full spectrum of identities is grouped within this LGBTQ+ umbrella term, hierarchies, differences and nuances of oppression that can affect differently their PAS practice cannot be neglected to develop more accurate PAS policies.8 However, the majority of the literature regarding this topic emphasizes that, as a result of this violence, all subgroups present higher prevalence of mental disorders such as depression, anxiety, stress and suicide attempts, as well as a higher risk of developing psychosis or other severe mental illnesses, than the general population.9, 10, 11 PAS developed in a safe context could thus be particularly beneficial to LGBTQ+ people's health and well-being because different psychological benefits such as increased self-confidence and self-esteem have been demonstrated for this population.12,13
However, LGBTQ+ people's PAS engagement is usually lower than the general recommended levels for adults' health.14,15 This dominant trend is especially pronounced among lesbians and transgender women.7,16 Therefore, developing and implementing PAS promotion programs addressed to this population should be a priority of public health policies. For these programs to be effective, knowledge on the barriers preventing LGBTQ+ people from participating in PAS is crucial. Some studies emphasize that the identification of general population– and lesbian-specific barriers17 enables the development of interventions designed to help these women to overcome the main barriers they face and increase their physical activity.18 Research shows that sufficiently active lesbians and gays experience fewer barriers to PAS than insufficiently active peers.19,20
The international literature has identified several barriers to PAS experienced by LGBTQ+ people, with homophobia, biphobia and transphobia being the most pervasive ones.21,22 Particularly, a study developed with non-heterosexual participants from English-speaking countries reported that 54% of gay men and 48% of lesbian women personally suffered from homophobia in sports domains, while 60% of bisexual men and 29% of bisexual women faced it.22 In a recent European study developed among LGBTQ+ people, 82% of participants had witnessed homophobia/biphobia/transphobia, and non-binary transgender and non-identifying people witnessed the most usages of homophobic/biphobic/transphobic language.21,23
Perception of unsafety, discrimination, negative experiences and lack of confidence have been also found to hinder PAS participation in this population.11,14,21,22 The fear of being discriminated in this context stopped them from making their sexuality visible, and between 74% and 81% of LGBTQ+ respondents were completely or partially in the closet in their sports centres owing to this fear.11,21,22 Stereotypes and expectations of success are also deterrents for non-active lesbians to engage in sports, while conceptions about gays' weakness and non-athletic behaviour may lead them not to be involved in PAS.7,19 Sexism and gender binarism have also been identified as relevant barriers because dealing with ‘boys’ and ‘girls’ sports is often challenging for LGBTQ+ communities, especially for non-binary transgender people who find a limited range of sports available according to gender labelling.11 In this regard, strict legal requirements to participate in competitive sports and communal changing rooms and showers have been found especially discouraging for transgender persons as well.21,24, 25, 26, 27
However, although several barriers to PAS have been identified for the LGBTQ+ communities,20,28 there is a lack of studies addressing this topic from a multilevel approach in which the relations and interactions between these barriers are considered. Socio-ecological models could be especially relevant in this regard. Although several and slightly different socio-ecological models have been proposed in the field of health promotion,29, 30, 31 the main tenets defining all of them are as follows: (a) human behaviour results from the interaction between different factors emerging from different levels of influence, and (b) the levels of influence are expected to affect each other, so that changes in one level could cause a knock-on effect on the others. Socio-ecological models thus provide a proper framework to understand LGBTQ+ people's PAS behaviours because they go beyond individual-level theories by considering all the factors involved at other levels (e.g., social, environmental), as well as their interactions.27
Nevertheless, although socio-ecological models have been widely used in the field of health promotion in many different populations, few studies focusing on LGBTQ+ people's health have adopted this approach. One of them, focused on the lesbian population, has identified specific barriers to PAS in each level of influence, such as public disclosure, lack of others' acceptance and lack of fitness facilities, among others.17 However, to the best of our knowledge, no studies before have developed and validated an instrument capable of measuring barriers to PAS experienced by LGBTQ+ people across the different socio-ecological levels. Therefore, the aim of this work was twofold: (a) to elaborate a questionnaire on the barriers to PAS experienced by LGBTQ+ people using a socio-ecological model (Barriers to Physical Activity and Sport Questionnaire for LGBTQ+ persons [BPASQ-LGBTQ+]) and (b) to validate the BPASQ-LGBTQ+ through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).
Section snippets
Questionnaire development
Different procedures were carried out to achieve content validity of the questionnaire. First, an extensive literature review was conducted by four members of the study team to develop a bank of items reflecting on barriers to PAS that could be relevant for LGBTQ+ communities. It was early developed around the research on transgender people's PAS participation, area in which the team had some years of experience, and later completed with research on LGBTQ+ people's PAS participation. In both
Domain identification and scores
An EFA using principal axis factoring extraction and Promax rotation with Kaiser normalization was conducted. A preliminary EFA showed that two items (‘Fear of getting injured or harm your health while engaging in PAS’ and ‘Lack of free time’) did not fit these criteria and were thus excluded from subsequent analyses. After a second EFA, four factors accounting for 51.1% of the total item variance were extracted (see Table 2).
Although the questionnaire was theoretically based on three
Discussion
To the best of our knowledge, the present study is the first to develop and validate a questionnaire for measuring barriers to PAS in LGBTQ+ people using a socio-ecological approach. Having an instrument that is capable of capturing barriers within the different socio-ecological levels is of great relevance, given that people interact with their environments in complex ways when trying to be physically active. The study thus makes a relevant contribution to the field of LGBTQ+ people's health
Acknowledgements
The authors thank all participants and associations for their collaboration in this study.
Ethical approval
The participants gave their informed consent to participate in the study, and the Ethics Committee of the Universitat de València approved the materials and procedures used.
Funding
None.
Competing interests
The authors declare that they have no competing interests.
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