Maximizing respondent-driven sampling field procedures in the recruitment of sexual minorities for health research

Exploring Social-Ecological Pathways From Sexual Identity to Sleep Among Chinese Women: Structural Equation Modeling Analysis

Background

Women and sexual minority individuals have been found to be at higher risk for experiencing poor sleep health compared to their counterparts. However, research on the sleep health of sexual minority women (SMW) is lacking in China.

Objective

This study aimed to examine sleep quality and social support for Chinese women with varied sexual identities, and then investigate the in-depth relationships between sexual identity and sleep.

Methods

This was a cross-sectional web-based survey. All participants completed a structured questionnaire containing a set of sociodemographic items referring to the social-ecological model of sleep health, the Pittsburgh Sleep Quality Index, the Social Support Rating Scale, and social relationships and environment domains of the World Health Organization Quality of Life-abbreviated short version. Pearson correlation coefficients were used to examine the relationship between sleep quality and social support as well as the two domains of quality of life. Structural equation modeling analysis was used to explore the social-ecological relationships.

Results

A total of 250 cisgender heterosexual women (CHW) and 259 SMW were recruited from July to September 2021. A total of 241 (47.3%) women experienced poor sleep quality and the rate was significantly higher in SMW than in CHW (55.2% vs 39.2%, P<.001). Around one-fifth of SMW reported low levels of social support, which was significantly higher than that of CHW (21.6% vs 5.6%, P<.001). Pearson correlations showed that overall sleep quality was significantly negatively associated with social support with weak correlations (r=-0.26, P<.001). The final structural equation modeling analysis with satisfactory fit indices identified 6 social-ecological pathways, showing that alcohol use, objective support, utilization of support, and perceived social relationship and environment quality of life played important roles in the sleep quality of individuals from their sexual identity.

Conclusions

SMW experienced poorer sleep quality compared to CHW. Further research is recommended to address the modifiable factors affecting sleep and then implement tailored sleep improvement programs.

Validation of the adapted female sexual function index among Chinese cisgender heterosexual women and sexual and gender minority women

BACKGROUND

The Female Sexual Function Index (FSFI) remains the most widely used scale for assessing female sexual function. However, while an adapted version of the FSFI has been proven to be suitable for Western sexual minority women, it has yet to be used in China.

AIM

This study aimed to validate the Mandarin Chinese version of the adapted FSFI among Chinese cisgender heterosexual women and sexual and gender minority women, and evaluate its psychometric properties.

METHODS

A cross-sectional online survey was conducted. The modified scoring method related to zero responses was examined, and structural validity, internal consistency, internal reliability, convergent validity, and known-group validity were evaluated.

OUTCOMES

The primary measure was the adapted FSFI, and the Positive Sexuality Scale and the New Sexual Satisfaction Scale-Short Form were used to test convergent validity.

RESULTS

A total of 431 Chinese adult women were recruited, including 193 cisgender heterosexual women and 238 sexual and gender minority women. Confirmatory factor analysis using the original scores supported the original 6-factor model. Using both Cronbach's α and McDonald's ω, the results showed that the values of the total scale and 6 subscales were in the 0.76 to 0.98 and 0.83 to 0.98 ranges, respectively, indicating satisfactory reliability. Moderate-to-strong correlations among the total FSFI scores and positive sexuality and sexual satisfaction were found (r = 0.32-0.71), supporting good convergent validity.

CLINICAL IMPLICATIONS

The adapted FSFI facilitates the use of more inclusive language in the clinical setting, allowing for a more comprehensive and unbiased assessment of sexual function in all women.

STRENGTHS AND LIMITATIONS

This study recruited both cisgender women of varied sexual orientations and gender minorities who were assigned female at birth, demonstrating that the adapted FSFI could be suitably applied to sexual minority populations. However, from a fully inclusive perspective of sex and gender, there is no research on how to accurately evaluate transgender women with female external genitalia or appropriately assess those with a female reproductive system but who do not self-identify as female. Therefore, more in-depth research is needed to further revise the FSFI for better use in the wider female population.

CONCLUSION

This Chinese version of the adapted FSFI has good psychometric properties and is a reliable and valid instrument to assess female sexual function. Furthermore, the modified scoring method could be an effective alternative among samples of sexually inactive women.

Quality of Life and Mental Health of Chinese Sexual and Gender Minority Women and Cisgender Heterosexual Women: Cross-sectional Survey and Mediation Analysis

BACKGROUND

Health-related research on sexual minority populations in China is lacking, and research on sexual and gender minority women (SGMW, including transgender women and persons of other gender identities assigned female at birth of all sexual orientations, and cisgender women with nonheterosexual orientations) is even less. Currently, there are limited surveys related to mental health in Chinese SGMW, but there are no studies on their quality of life (QOL), no studies comparing the QOL of SGMW with that of cisgender heterosexual women (CHW), and no studies on the relationship between sexual identity and the QOL as well as associated mental health variables.

OBJECTIVE

This study aims to evaluate the QOL and mental health in a diverse sample of Chinese women and make comparisons between SGMW and CHW and then investigate the relationship between sexual identity and the QOL through the role of mental health.

METHODS

A cross-sectional online survey was conducted from July to September 2021. All participants completed a structured questionnaire containing the World Health Organization Quality of Life-abbreviated short version (WHOQOL-BREF), the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

In total, 509 women aged 18-56 years were recruited, including 250 (49.1%) CHW and 259 (50.9%) SGMW. Independent t tests showed that the SGMW reported significantly lower levels of QOL, higher levels of depression and anxiety symptoms, and lower self-esteem than the CHW. Pearson correlations showed that every domain and the overall QOL were positively associated with mental health variables, with moderate-to-strong correlations (r range 0.42-0.75, P<.001). Multiple linear regressions found that participants belonging to the SGMW group, current smokers, and women with no steady partner were associated with a worse overall QOL. The mediation analysis found that depression, anxiety, and self-esteem significantly completely mediated the relationship between sexual identity and physical, social, and environment domains of the QOL, while the relationship between sexual identity and the overall QOL and psychological QOL was partially mediated by depression and self-esteem.

CONCLUSIONS

The SGMW had poorer levels of QOL and a worse mental health status than the CHW. The study findings affirm the importance of assessing mental health and highlight the need to design targeted health improvement programs for the SGMW population, who may be at higher risk of a poor QOL and mental health.

Family Planning Research in African Immigrant and Refugee Women: A Scoping Review

INTRODUCTION

African immigrants are a vulnerable population who are seldom seen in the literature, however, the scant research available reports that they experience increased challenges when making family planning decisions. A robust understanding of their specific family planning practices is imperative to providing appropriate, culturally congruent care. Considering this disparity, a scoping review was conducted to synthesize empirical knowledge and identify gaps in the literature around family planning in African immigrant populations in the United States.

METHODS

Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework, EMBASE, Global Health Database, PsycINFO, CINAHL, and PubMed were searched for literature regarding family planning topics such as decision-making and health care access among African immigrant women in the United States in June 2020.

RESULTS

The small number of retrieved studies for the literature review clearly highlights a dearth of research. Available evidence indicates stark disparities in health care access, unmet individual needs, and unacknowledged preferences.

DISCUSSION

Ignoring cultural considerations for the growing African immigrant population perpetuates the divide in family planning practices.

Challenges of virtual RDS for recruitment of sexual minority women for a behavioral health study

Respondent driven sampling (RDS) is an approach commonly used to recruit nonprobability samples of rare and hard-to-find populations. The purpose of this study was to explore the utility of phone and web-based RDS methodology to sample sexual minority women (SMW) for participation in a telephone survey. Key features included 1) utilizing a national probability survey sample to select seeds; 2) web-based recruitment with emailed coupons; and 3) virtual processes for orienting, screening and scheduling potential participants for computer-assisted telephone interviews. Rather than resulting in a large diverse sample of SMW, only a small group of randomly selected women completed the survey and agreed to recruit their peers, and very few women recruited even one participant. Only seeds from the most recent of two waves of the probability study generated new SMW recruits. Three RDS attempts to recruit SMW over several years and findings from brief qualitative interviews revealed four key challenges to successful phone and web-based RDS with this population. First, population-based sampling precludes sampling based on participant characteristics that are often used in RDS. Second, methods that distance prospective participants from the research team may impede development of relationships, investment in the study, and motivation to participate. Third, recruitment for telephone surveys may be impeded by multiple burdens on seeds and recruits (e.g., survey length, understanding the study and RDS process). Finally, many seeds from a population-based sample may be needed, which is not generally feasible when working with a limited pool of potential seeds. This method may yield short recruitment chains, which would not meet key RDS assumptions for approximation of a probability sample. In conclusion, potential challenges to using RDS in studies with SMW, particularly those using virtual approaches, should be considered.

Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Social and structural factors associated with depression and suicidality among men who have sex with men and transgender women in Nepal

INTRODUCTION

The prevalence of depression and suicidality is high among men who have sex with men (MSM) and transgender women (TGW) worldwide. Stigma and discrimination are likely contributing factors. More research is needed in low-income, non-English speaking countries to assess the effects of social and structural factors on depression and suicidality among MSM and TGW.

METHODS

Nepalese MSM and TGW (n = 340) were recruited using a respondent-driven sampling design and filled out a survey questionnaire. The outcomes were depression and suicidality. Data was analyzed using bivariate and multivariable logistic regression.

RESULTS

More than half of the participants (59%) suffered from depression. Severe depression was more common among TGW compared to MSM (41 and 20%, respectively). When it comes to suicidality, TGW had higher lifetime prevalence of suicidal thoughts compared to MSM (32 and 5%, respectively). Depression was positively associated with sex work both for MSM (AOR: 7.9; 95% CI 3.4-18.2) and TGW (AOR: 6.5; 95% CI: 2.3-18.2). MSM who were evicted by family had high odds of suicidal thoughts (AOR: 6.2; 95% CI: 1.3-28.8). For TGW, suicidality was associated with being cheated and threatened (AOR: 3.9; 95% CI: 1.2-12.5) and having forced to marry a female (AOR: 2.2; 95% CI 1.1-5.1).

CONCLUSIONS

Nepalese MSM and TGW suffer from a high degree of mental and psychosocial health issues. Future studies should focus on intervention research and on collecting data from a larger variety of gender and sexual minorities.

Alcohol use among sexual minority women: Methods used and lessons learned in the 20-Year Chicago Health and Life Experiences of Women Study

Background

Two decades ago, there was almost no research on alcohol use among sexual minority women (SMW, e.g., lesbian, bisexual). Since then, a growing body of scientific literature documents substantial sexual orientation-related disparities in alcohol use and alcohol-related problems. Research has identified multiple risk factors associated with high-risk/hazardous drinking among SMW. However, this research has almost exclusively used cross-sectional designs, limiting the ability to draw conclusions about processes through which sexual minority status affects alcohol use. Longitudinal designs, although very rare in research on alcohol use among SMW, are important for testing mediational mechanisms and necessary to understanding how changes in social determinants impact alcohol use.

Aim

To describe the processes and lessons learned in conducting a 20-year longitudinal study focused on alcohol use among SMW.

Methods

The Chicago Health and Life Experiences of Women (CHLEW) study includes five waves of data collection (2000-present) with an age and racially/ethnically diverse sample of 815 SMW (ages 18-83) originally recruited in the Chicago Metropolitan Area in Illinois, a midwestern state in the United States (U.S.). Measures and focus have evolved over the course of the study.

Results

The CHLEW study is the longest-running and most comprehensive study of SMW's drinking in the U.S. or elsewhere. Findings reported in more than 50 published manuscripts have contributed to understanding variations in SMW's risk for hazardous/harmful drinking based on sexual identity, age, race/ethnicity, sex/gender of partner, and many other factors.

Conclusions

By describing the process used in conducting this long-term study, its major findings, and the lessons learned, we hope to encourage and support other researchers in conducting longitudinal research focused on SMW's health. Such research is critically important in understanding and ultimately eliminating sexual orientation-related health disparities.