Cognitive Interviews Demographics (N=30)
As seen in Table 1, participants ranged in age from 20 to 40 years (mean=29.1, standard deviation [SD]= 5.3), and half (n=15, 50.0%) of participants identified as gay/homosexual. Most participants (n=19, 63.3%) reported their relationship status as single and more than three-fourths (n=23, 76.7%) had a university education or higher.
Table 1: Sociodemographic characteristics of Cognitive Interview participants (N=30)
Demographics
|
|
|
Mean (SD); N (%)
|
Age (in years)
|
29.1 (5.3)
|
Current Sexual Orientation
|
|
Gay/Homosexual
|
15 (50.0%)
|
Bisexual
|
15 (50.0%)
|
Current Relationship Status
|
|
Single, never been married
|
19 (63.3%)
|
Long-term relationship with a man
|
7 (23.3%)
|
Long-term relationship with a man
|
3 (10.0%)
|
Separated
|
1 (3.3%)
|
Current Housing Status
|
|
Stable Housing
|
29 (96.7%)
|
Unstable Housing
|
1 (3.3%)
|
Educational Attainment
|
|
Senior Secondary School (SSS) or lower
|
7 (23.3%)
|
Some University/Vocation Education
|
15 (50.0%)
|
University Degree
|
8 (26.7%)
|
Current Employment Status
|
|
Employed
|
16 (53.3%)
|
Unemployed
|
14 (46.7%)
|
Cognitive Interview Findings
Of the 20 statements contained in the CESD-R scale, 8 were modified (Table 3). A majority of the modifications constituted changing a few words to make the phrase more understandable (for example, we changed “I had trouble keeping my mind of what I was doing” to “I had trouble concentrating on what I was doing”). Only one of the statements was completely modified (“I could not get going” to “I lacked motivation”).
Of the 12 statements contained in the MSPSS, 8 were modified (Table 3). In the significant other subscale, “special person” was replaced with “significant other”. The rest of the changes were minor word substitutions such as changing “I can talk about my problems with my family” to “I can share my problems with my family”
Of the combined 16 statements contained in the 5 subscales of the LGBT Minority Stress Measure, 11 were modified (Table 3). A majority of the modifications constituted changing a few words to make the phrase more understandable (for example, we changed “I feel like I am a part of the LGBT community” to “I feel like I am a member of the LGBT community”). A few statements were completely changed (for example, we changed “If I was offered the chance to be someone who is not LGBT I would accept the opportunity” to “If I could change from being LGBT to be straight, I would.”
Quantitative Sample Demographics (N=406)
As seen in Table 2, participants ranged in age from 18 to 60 years (mean=29.2, SD=5.8), the majority (n=238, 58.6%) identified as bisexual, and 61.6% were single. We had an ethnically diverse sample (20.3% were Igbo, 17.8% were Hausa, 17.7% were Yoruba, 15.7% were Urhobo, and many more ethnic groups were represented) Most (n=238, 61.8%) participants reported experiencing high financial hardship and 22.3% reported a history of incarceration (n=86). One-fourth (n=99, 24.8%) of participants reported living with HIV and one third (n=124, 32.3%) reported a sexually transmitted infection diagnosis in the previous year.
Table 2: Sociodemographic characteristics of Quantitative Assessment participants (N=406)
Demographics
|
|
|
Mean (SD); N (%)
|
Age (in years)
|
29.2 (5.8)
|
Current Sexual Orientation
|
|
Gay/Homosexual
|
160 (39.4%)
|
Bisexual
|
238 (58.6%)
|
Current Relationship Status
|
|
Single
|
250 (61.6%)
|
Not Single
|
150 (36.9%)
|
Religious Affiliation
|
|
Christian
|
253 (62.3%)
|
Muslim
|
116 (28.6%)
|
Other
|
30 (7.4%)
|
Monthly income (in Naira)
|
|
0-10,000
|
105 (25.9%)
|
10,000-30,000
|
106 (26.1%)
|
30,000-50,000
|
81 (20.0%)
|
50,000-100,000
|
54 (13.3%)
|
100,000+
|
49 (12.1%)
|
Employment Status
|
|
Employed
|
319 (78.6%)
|
Unemployed
|
81 (20.0%)
|
Table 3: Original and modified measurement scale items
Scale
|
Original Item
|
Modified Item
|
CESD-R
|
My appetite was poor
|
I didn’t have an appetite
|
I could not shake off the blues
|
I could not change my bad mood (final item)
I could not think straight (other suggested item)
I could not think properly (other suggested item)
|
I had trouble keeping my mind of what I was doing
|
I had trouble concentrating on what I was doing
|
I could not get going
|
I lacked motivation
|
I lost interest in my usual activities
|
I lost interest in my daily activities
|
I felt fidgety
|
I felt nervous
|
I wanted to hurt myself
|
I wanted to harm myself
|
I had a lot of trouble getting to sleep
|
I had trouble sleeping
|
MSPSS
|
There is a special person who is around when I am in need
|
There is a significant other I can lean on
|
There is a special person with whom I can share my joys and sorrows
|
There is a significant other who I can share my joys and sorrows with
|
I get the emotional help and support I need from my family
|
I get the love and support I need from my family
|
I have a special person who is a real source of comfort to me
|
I have a significant other who is a real source of comfort to me
|
My friends really try to help me
|
My friends are there for me
|
I can talk about my problems with my family
|
I can share my problems with my family
|
I have friends with whom I can share my joys and sorrows
|
I have friends who I can share my joys and sorrows with
|
There is a special person in my life who cares about my feelings
|
There is a significant other in my life who cares about my feelings
|
The LGBT Minority Stress Measure
|
|
|
Community Connectedness
|
I feel like I am a part of the GBMSM community
|
I feel like I am a member of the LGBT community
|
I feel that I could find information and pamphlets on GBMSM issues
|
I feel that I could find information, books, flyers on LGBT issues
|
I feel that I could find professional services for GBMSM issues if I needed to
|
I feel that I could find friendly services for LGBT issues if I needed to
|
I feel that I could find a public space that is supportive of GBMSM activities
|
I feel like there is a safe space where LGBT social activities can take place
|
Internalized Stigma
|
If I was offered the chance to be someone who is not GBMSM, I would accept the opportunity
|
If I could change from being LGBT to straight, I would
|
I envy people who are not GBMSM.
|
I am jealous of people who are not LGBT
|
Rejection Anticipation
|
I brace myself to be treated disrespectfully because I am GBMSM
|
I prepare myself to be treated disrespectfully because I am LGBT
|
Identity Concealment
|
I avoid telling people about certain things in my life that might imply I am GBMSM
|
I avoid telling people about certain things in my life that might make them think I am LGBT
|
I avoid talking about my romantic life because I do not want others to know I am GBMSM
|
I avoid talking about my love life because I do not want others to know I am LGBT
|
I do not bring a date to social events because I do not want others to know I am GBMSM
|
I do not bring a date to social gathering/ parties because I do not want others to know I am LGBT
|
Victimization Events
|
I have been verbally harassed or called names because I am GBMSM
|
I have been called names or insulted because I am LGBT
|
Confirmatory Factor Analysis Results (N=406)
CESD-R
All items significantly loaded onto the one-factor depression construct except item #9 (I slept much more than usual), (β=0.25) (Table 4). The fit indices for the one-factor model were acceptable (RMSEA=0.10; CFI=0.82; TLI=0.80). This provides evidence that the CESD-R is a reasonable instrument to ascertain depressive symptoms among Nigerian GBMSM.
Table 4: Standardized factor loadings from confirmatory factor analysis for the Center for Epidemiologic Studies Depression Scale (CESD-R).
Item
|
1 Factor
|
|
Depression (α=0.93)
|
- I could not change my bad mood*
|
0.665
|
|
0.710
|
|
0.656
|
|
0.709
|
- I lost interest in my daily activities*
|
0.710
|
- I didn’t have an appetite*
|
0.452
|
- I lost a lot of weight without trying to
|
0.617
|
|
0.679
|
- I slept much more than usual
|
0.246
|
|
0.646
|
- I had trouble concentrating on what I was doing
|
0.680
|
- I could not focus on the important things
|
0.762
|
|
0.668
|
|
0.651
|
|
0.649
|
|
0.684
|
- I felt like I was moving too slowly
|
0.659
|
|
0.743
|
|
0.595
|
|
0.466
|
*modified version of original question
MSPSS
All items significantly loaded onto their respective factors (Table 5). The three-factor model measures three distinct sources of perceived social support (family, friends, and significant other). The fit indices for the one-factor model were acceptable (RMSEA=0.09; CFI=0.92; TLI=0.90). The better fit statistics and multidimensional nature of social support leads us to conclude that the three-factor model is parsimonious.
Table 5: Standardized factor loadings from confirmatory factor analysis for Multidimensional Scale of Perceived Social Support (MSPSS).
Item
|
3 Factor
|
Significant Other (α=0.81)
|
Family (α=0.80)
|
Friends (α=0.82)
|
- There is a significant other I can lean on*
|
0.672
|
|
|
- There is a significant other who I can share my joys and sorrows with*
|
0.675
|
|
|
- I have a significant other who is a real source of comfort to me*
|
0.790
|
|
|
- There is a significant other in my life who cares about my feelings*
|
0.708
|
|
|
- My family really tries to help me
|
|
0.820
|
|
- I get the love and support I need from my family*
|
|
0.835
|
|
- I can share my problems with my family*
|
|
0.581
|
|
- My family is willing to help me make decisions
|
|
0.579
|
|
- My friends are there for me*
|
|
|
0.755
|
- I can count on my friends when things go wrong
|
|
|
0.821
|
- I have friends who I can share my joys and sorrows with*
|
|
|
0.674
|
- I can talk about my problems with my friends
|
|
|
0.673
|
*modified from original question
LGBT Minority Stress Scales
All items significantly loaded onto their respective factors (Table 6). The five-factor model measures five distinct experiences of minority stress (community connectedness, internalized stigma, rejection anticipation, identity concealment, and victimization events). The good fit statistics (RMSEA=0.08; CFI=0.91; TIL=0.90) and multidimensional nature of minority stress leads us to conclude that these measures accurately assessed various dimensions of experiences of minority stress among Nigerian GBMSM.
Table 6: Standardized factor loadings from confirmatory factor analysis for the LGBT Minority Stress Measure.
Item
|
5 Factor
|
Community Connectedness (α=0.86)
|
Internalized Stigma (α=0.80)
|
Rejection Anticipation (α=0.72)
|
Identity Concealment (α=0.86)
|
Victimization Events (α=0.92)
|
- I feel connected to other LGBT people
|
0.697
|
|
|
|
|
- I feel like I am a member of the LGBT community*
|
0.673
|
|
|
|
|
- I feel that I could find information, books, flyers on LGBT issues*
|
0.849
|
|
|
|
|
- I feel that I could find friendly services for LGBT issues if I needed to*
|
0.801
|
|
|
|
|
- I feel like there is a safe space where LGBT social activities can take place*
|
0.664
|
|
|
|
|
- If I could change from being LGBT to be straight, I would*
|
|
0.841
|
|
|
|
|
|
0.904
|
|
|
|
- I am jealous of people who are not LGBT*
|
|
0.554
|
|
|
|
- When I meet someone new, I worry that they secretly do not like me because I am LGBT
|
|
|
0.645
|
|
|
- I prepare myself to be treated disrespectfully because I am LGBT*
|
|
|
0.550
|
|
|
- I expect that others will not accept me because I am LGBT
|
|
|
0.764
|
|
|
- I worry about what will happen if people find out I am LGBT
|
|
|
0.593
|
|
|
- I avoid telling people about certain things in my life that might make them think I am LGBT*
|
|
|
|
0.865
|
|
- I avoid talking about my love life because I do not want others to know I am LGBT*
|
|
|
|
0.888
|
|
- I do not bring a date to social gathering/ parties because I do not want others to know I am LGBT*
|
|
|
|
0.693
|
|
- I limit what I share on social media, or who can see it, because I do not want others to know I am LGBT
|
|
|
|
0.591
|
|
- I have been called names or insulted because I am LGBT*
|
|
|
|
|
0.864
|
- Others have threatened to harm me because I am LGBT
|
|
|
|
|
0.905
|
- I have been bullied by others because I am LGBT
|
|
|
|
|
0.898
|
*modified from original question
Scale Properties (N=406)
Scores on the CESD-R (20 items) ranged from 0 to 55 (M=11.4, SD=12.2). Internal consistency was high (Cronbach’s α=0.93). Scores on the MSPSS (12 items) ranged from 12 to 84 (M=58.4, SD=12.6). Internal consistency was high (Cronbach’s α=0.86). Scores on the community connectedness subscale (5 items) ranged from 5 to 25 (M=19.8, SD=4.5). Internal consistency was high (Cronbach’s α=0.86). Scores on the internalized stigma subscale (3 items) ranged from 3 to 15 (M=8.0, SD=3.5). Internal consistency was high (Cronbach’s α=0.80). Scores on the rejection anticipation subscale (4 items) ranged from 4 to 20 (M=9.8, SD=4.0). Internal consistency was acceptable (Cronbach’s α=0.72). Scores on the identity concealment subscale (4 items) ranged from 4 to 20 (M=13.1, SD=4.8). Internal consistency was high (Cronbach’s α=0.86). Scores on the victimization events subscale (3 items) ranged from 3 to 15 (M=5.4, SD=3.2). Internal consistency was very high (Cronbach’s α=0.92).
Construct Validity Analysis
To evaluate the convergent validity (Table 7), correlations (Pearson’s coefficients) were conducted between the CESD-R, the MSPSS, the LGBT Minority Stress Measure, and the UCLA Loneliness Scale. We hypothesized that there will be a positive significant relationship between depressive symptoms, minority stress, and loneliness. We also hypothesized a significant inverse relationship between perceived social support and loneliness. Upon calculation of Pearson’s coefficient, the UCLA Loneliness Scale was found to be correlated, but not strongly, in the expected direction with CESD-R (r=0.38, p<0.01), perceived social support (family [r=-0.23, p<.01], friends [r=-0.26, p<0.01], and significant other [r=-0.20, p<0.01]) and all but one of the minority stress scales (community connectedness [r=-0.09, not significant], internalized stigma [r=0.10, p<0.05], rejection anticipation [r=0.23, p<0.01], identity concealment [r=0.14, p<0.01], and victimization events [r=0.19, p<0.01]), thereby demonstrating evidence for convergent validity. Additionally, the social support and minority stress subscales were highly correlated with each other (|r|=0.23-0.48), p<0.01), providing evidence for concurrent validity.
To evaluate discriminant validity (Table 7), correlations (Pearson’s coefficients) were conducted between CESD-R, MSPSS, LGBT Minority Stress Measure, and healthcare utilization. We hypothesized that there will be no statistically significant relationship between depressive symptoms, perceived social support, minority stress and healthcare utilization. Upon calculation of Pearson’s coefficient, healthcare utilization was found to be not strongly correlated with the CESD-R (r=0.02, not significant), perceived social support (family [r=-0.01, not significant], friends [r=-0.07, not significant], and significant other [r=-0.05, not significant]) and all the minority stress scales (community connectedness [r=0.09, not significant], internalized stigma [r=-0.03, not significant], rejection anticipation [r=0.06, not significant], identity concealment [r=-0.02, not significant], and victimization events [r=0.05, not significant]), thereby demonstrating strong evidence for discriminant validity.
Table 7: Correlation demonstrating convergent and divergent validity between scales and validity measures
Measure
|
1
|
2
|
3
|
4
|
5
|
6
|
7
|
8
|
9
|
10
|
11
|
|
1
|
-.26**
|
-.04
|
.15**
|
.37**
|
.17**
|
.24**
|
.23**
|
.27**
|
0.38**
|
0.02
|
|
|
1
|
.48**
|
0.53**
|
.23**
|
-0.18**
|
-0.17**
|
-0.48**
|
-0.28**
|
0.23**
|
-0.01
|
|
|
|
1
|
0.56**
|
.25**
|
-0.20**
|
-0.23**
|
-0.17**
|
-0.29**
|
0.26**
|
-0.07
|
- MSPSS (significant other)
|
|
|
|
1
|
0.19**
|
0.10
|
0.14
|
-0.19**
|
-0.24**
|
0.20**
|
-0.05
|
|
|
|
|
|
1
|
-0.29**
|
-0.27**
|
-0.25**
|
-0.38**
|
0.09
|
0.09
|
|
|
|
|
|
|
1
|
0.29**
|
0.25**
|
0.33**
|
0.10*
|
-0.03
|
|
|
|
|
|
|
|
1
|
0.27**
|
0.24**
|
0.23**
|
0.06
|
|
|
|
|
|
|
|
|
1
|
0.30**
|
0.14*
|
-0.02
|
|
|
|
|
|
|
|
|
|
1
|
0.19**
|
0.05
|
|
|
|
|
|
|
|
|
|
|
1
|
0.04
|
|
|
|
|
|
|
|
|
|
|
|
1
|
*P<.05, **P<.01