Development and Psychometric Assessment of the Measure of the Barriers to Discussing Sexual Wellbeing Among Arab Australian with Chronic Disease

Development and Psychometric Assessment of the Measure of the Barriers to Discussing Sexual Wellbeing Among Arab Australian with Chronic Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Psychometric Assessment of the Measure of the Barriers to Discussing Sexual Wellbeing Among Arab Australian with Chronic Disease Ibrahim alananzeh, Albara Alomari, Heidi Lord, Ritin Fernandez This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3910182/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Addressing sexual health is an essential component of health care. However, patients are reluctant to broach this topic with their health care providers. Moreover, there is no instrument available to assess the barriers relating to discussing sexual issues among patients with chronic diseases. This article describes the development and psychometric assessment of an instrument intended to measure the barriers to discussing sexual wellbeing among Arab Australians with chronic disease. Through a comprehensive literature review and in consultation with key experts, barriers relating to discussing sexual issues were identified and the Information for Sexual Wellbeing Tool (IBaRIT) was developed and completed by 84 participants. Psychometric analysis supports the use of the IBaRIT as a valid and reliable instrument for understanding the barriers to discussing sexual wellbeing among Arab Australians with chronic disease and developing the needed interventions. Sexuality chronic disease Arab Psychometric Validation Introduction The global prevalence of chronic disease and multimorbidity is increasing not only due to the ageing population but also through the increase in obesity, which in turn leads to chronic illnesses such as diabetes and hypertension. emergence of higher levels of obesity creating chronic illnesses such as diabetes and hypertension [ 1 ]. Advancements in medicine and science have increased the life expectancy and longevity of people living with a chronic disease resulting in the focus shifting from purely survival to quality of life. Among people with a chronic disease, sexual health and wellbeing is often negatively affected and influenced by treatments, medications, and surgeries applied for chronic disease management.[ 2 ]. These management strategies can cause sexual dysfunction which adversely affects a person’s quality of life, which in turn can create depression and anxiety and cause relationship issues [ 1 , 3 ]. Sexual health, according to the World Health Organization (WHO), is defined as “…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity” (4) and further adding that sexual health and wellbeing “requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” [ 4 ]. Despite, people living with a chronic disease, sexual intimacy and wellbeing is still an important aspect of their lives, however, many people with a chronic disease experience sexual dysfunction and dissatisfaction and decreased sexual activity caused by adverse reactions to medications, altered body image, and physical constraints [ 2 , 5 ]. Sexual dysfunction for both males and females diagnosed with diabetes is a common complication that is growing in recognition. Diabetes is strongly associated with erectile dysfunction and is multifactorial, linked with vascular, hormonal, and neurological responses [ 6 ]. The global prevalence of erectile dysfunction caused by diabetes is reported as up to 73% and increases to up to 100% in men aged 70 years and above [ 7 ]. For women, there is a paucity of literature on the association between diabetes and sexual dysfunction, nevertheless when compared to women without diabetes significantly greater number of women with diabetes have sexual dysfunction [ 6 , 7 ]. Impaired sexual functioning among people with chronic pain is also common with up to 63% of people living with chronic pain experiencing sexual dysfunction. For sufferers of chronic pain, sexual dysfunction is reportedly caused by a myriad of problems including worsening pain, positioning for comfort, confidence, and psychological reasons such as depression and anxiety [ 8 , 9 ]. Sexual dysfunction has also been reported in approximately 88% of men following prostate surgery [ 10 ]. Perception of loss of femininity is one of the major influences of sexual dysfunction among women with breast cancer, requiring a psychosocial adjustment [ 11 ]. Sexual function is often altered for women with breast cancer depending on the type of treatments they receive. Chemotherapy can cause chemotherapy-induced menopause, while women who have a mastectomy lack sexual intimacy due to them losing ‘an independent sex organ [ 12 ]. Furthermore, a diagnosis of cancer and living with cancer can produce psychosocial issues such as grief, loss, fear, depression, and anxiety that influence a person’s capacity and ability to be sexually intimate with their partner. Sexual dysfunction among people with hypertension is often believed to be a natural progression of this chronic disease and has been described as a side effect of some anti-hypertensive medications. Commonly, more women than men with hypertension experience sexual dysfunction, with up to 50% of women with hypertension expressing sexual dysfunction [ 13 , 14 ]. Diminished sexual functioning among people with chronic kidney disease is commonly encountered and is often influenced by the social, physical, economic, and psychological factors that the person is facing [ 15 ]. Sexual dysfunction remains a cause for concern as it can cause frustration, hopelessness, reduced closeness with partners, insecurity, anxiety and depression [ 16 ]. Despite most people with a chronic disease experiencing some form of sexual dysfunction and sexual intimacy issues, only up to 22% convey the issue to a doctor [ 17 ]. The hesitation to discuss these problems with a health professional limit the potential for identifying approaches and appropriate strategies and resources to assist with their sexual wellbeing [ 18 ] and overcome sexual dysfunction [ 1 ]. Various barriers exist as to why people hesitate to consult with the doctor or a health professional about their sexual wellbeing have been reported in the literature. These include embarrassment, lack of privacy and time, fear of rejection and stigma and shame associated with cultural or religious beliefs [ 18 , 19 ]. The hesitation to discuss sexual wellbeing can also be provider focused as health professional are unwilling to raise the issue [ 19 ]. Notwithstanding the reported barriers that have been acknowledged in the literature, these vary among cultural groups and across countries. For example, for many migrant women in Sweden, sexual health and wellbeing is a taboo subject and not something that should be discussed, particularly in the presence of a male, this includes health professionals [ 20 ]. Whereas in the Western culture, there is often a social stigma surrounding discussion of sexual wellbeing, with women avoiding these conversations with a health professional [ 21 ]. Conversely, within many Muslim countries the barrier to sexual health wellbeing communication with health professionals is often hindered due to the sociocultural issues including providing sexual information to non-married people and religious prohibitions [ 22 ]. Establishing a valid and reliable instrument to assist in assessing the barriers to people living with a chronic disease in obtaining sexual health information is crucial. To the best of our knowledge, there is currently no instrument developed to assess the barriers to discussing, seeking and obtaining sexual health and wellbeing information among people with chronic disease. Therefore, the objectives of this study were to: (1) develop and investigate the content validity and psychometric properties of an instrument to assess the barriers to seeking help for sexual wellbeing; (2) investigate the relationship between participant demographics and the barriers to seeking help for sexual wellbeing among Arab people with a chronic disease. Methods Study Design: The first stage of the study included Instrument development assessment of content validity and pilot testing. The second stage included assessment of the instrument's psychometric properties and the final stage involved investigating the relationship between participant demographics and the barriers to seeking help for sexual wellbeing among Arab people with a chronic disease. Stage 1: Instrument development assessment of content validity and pilot testing The process used for the development of the instrument was guided by the research and development methodology that involves three steps. First, a comprehensive literature review was conducted to identify the barriers in discussing issues relating to sexual wellbeing with the health care provider. Secondly the items in the instrument and the response scoring were designed along with experienced academics, researchers, doctors, sexologists, and senior nurses from various backgrounds. The final step was to undertake the validity test of the instrument using Content Validity Index (CVI). Content validity refers to the extent to which the set of items comprehensively covers the different components of a given theoretical construct [ 23 ]. Participants for the validity testing included eight From Arabic community and Islamic leaders. Participants were asked to rate the relevance, clarity and appropriateness of each item in the instrument and make relevant modifications if necessary. Relevance and Clarity were rated as Yes, No, or partly. The final instrument was called the Identifying Barriers and Resistors to starting a conversation on sexual wellbeing information Tool (IBARIT) and was pilot tested with a sample of 10 people and no further modifications were required. The IBARIT consisted of 15items, each of which was rated on a 4-point Likert-scale, with scores ranging from strongly agree (1) to strongly disagree (5). The minimum score for the total scale was 15; the maximum was 60. Pilot testing was undertaken using a sample of 10 patients, and no changes were required to the wording of any items. Validation of the IBARIT Design: A prospective cross-sectional study design using convenience sampling was employed to participants for the study. Study setting and participants: The study was undertaken at the South Western Local Health District, New South Wales, Australia. Participants were included if they were: 1) of Arab heritage; 2) aged 18 years or older; 3) residing in NSW, Australia, and 4) identifying as having at least one chronic disease. People with known cognitive deficits were excluded from the study. Data Collection Arab people have strong social relationships with their community leaders hence the community leaders were invited to review the study procedures and materials and provide advice regarding recruitment strategies to ensure the study was sensitive to the Arab cultural and religious beliefs. Participants were recruited through advertisements in Australia-based Arab specific newspapers and radio, community leaders in known community organisations and during community events. Emails were sent to Arab specific organisations in South Western Sydney (Australia) to inform them of the research and to recruit participants. Participants were informed of the study by a bilingual health worker at the regular Arab community gatherings in Fairfield and Liverpool. short presentation outlining the sexual dysfunction among people with chronic disease and the importance of the study was given at the end of the presentation, the purpose of this study was explained by one of the research team (IA) and participants were encouraged to ask any questions. A paper-based self-administered survey was used to collect data. Information collected included demographics, medical history and, questions to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional. Demographic data collected included the year and country of birth, gender, employment status, religion, education level, main language spoken, and language generally used for reading. Ethical approval for the study was obtained from the University of Wollongong Human Research Ethics Committee, following the guidelines set forth by the Human Research Ethics Committee (HREC). Participants were informed that no identifiable information would be obtained, all responses were confidential, and that participation was voluntary. Completion of the survey was considered implied consent. Data Analysis All analyses were undertaken using SPSS© Version 25. The content validity of the instrument was assessed using the content validity index (CVI) and was computed using the Item-level -CVI (I-CVI) and the Scale-level-CVI (S-CVI). The I-CVI for individual items was calculated where the number of experts answering “YES” was divided by the total number of experts who participated. Those experts who answered partly were considered to be a NO. The S-CVI was computed using the S-CVI/Ave (averaging calculation method) S-CVI/Ave (based on proportional relevance) and S-CVI/ UA (based on the universal agreement method). The item was retained if the I-CVI was greater than 0.79 and items were considered to be appropriate but required revision if the I-CVI was between 0.70 and 0.78. Values of I-CVIs of 0.78 or higher and S-CVI/Ave of 0.9 and higher were considered to be excellent content validity, Items with less than 75% agreement were edited for clarity and precision. Best practices in exploratory factor analysis (EFA) using a multifactorial approach was undertaken [ 24 ]. The Bartlet Test of Sphericity was used to evaluate the suitability of the data set for factor analysis and the Kaiser-Meyer Olkin test (KMO) was used to measure sample adequacy [ 9 ]. The distribution of the responses was assessed using response-option frequency, mean, and standard deviations for each item. Next, confirmation of non-violation of the assumptions of normality, linearity, multicollinearity was undertaken. Finally, EFA using principal components analysis (PCA) was conducted using varimax rotation. Components were extracted based on visual inspection of the scree plot and established criteria [ 25 ]. Cronbach’s α-coefficient was used to assess the internal consistency reliability. Values greater than or equal to 0.9 were considered excellent, 0.8 to < 0.9 good, 0.7 to < 0.8 acceptable, 0.6 to < 0.7 questionable, 0.5 to < 0.6 poor, and < 0.5 unacceptable. The resulting factors were labelled according to reflect the underlying constructs. The normality of continuous data was ascertained by examining the skewness and kurtosis indices against accepted values. One-way ANOVA and t -tests were used to test differences between demographic variables and barriers to seeking help for sexual wellbeing. Pearson’s correlations were used to assess the relationships among continuous variables. Statistical significance was set at p < .05. Results Content validity results I-CVI Results (relevancy of individual items) All 15 items were identified as relevant and the I-CVIs ranged from 0.71 to 1.00. Six items had an I-CVI = 1.00, eight a score of 0.86, and one a score of 0.71 demonstrating excellent content validity. S-CVI Results (relevancy of the overall questionnaire) The S-CVI based on the ICVI was 0.90 and the S-CVI based on proportional relevance was 0.89 demonstrating high content validity. However, the S-CVI Universal approach method the content validity was 0.4 indicating poor agreement to all the items by the seven raters. Clarity of items: Three items ‘I feel that there is nothing that can be done about my sexual needs and intimacy’, ‘I feel that sexual needs and intimacy are not a health priority for me at the moment’, ‘I feel that discussing my sexual needs and intimacy are against my religion/beliefs’. had less than 75% agreement for clarity and were edited for clarity and precision. Participant demographics Of the 84 participants who completed the survey, the majority were male ( n = 63; 75%); and the mean age was 61.5 years (± 8.4 years). The majority (n = 59, 70.2%) were born in Iraq and the main language spoken at home was Arabic (n = 77, 91.7%). Approximately half the participants were Christians (n = 41, 48.8%) and more than a third had a bachelor’s degree or greater (n = 33, 39.3%). More than three-quarters of the participants were married or living with a partner (n = 66, 78.6%). The chronic conditions included high blood pressure, diabetes, cancer, heart disease, arthritis, kidney disease, high cholesterol, depression, anxiety, and respiratory disease. (Table 1 ) Table 1 Frequency Percent Gender Male 63 75 Female 21 25 Country of birth Lebanon 5 6 Iraq 59 70.2 Syria 14 16.7 Other 6 7.1 Religion Islam 20 23.8 Christian 41 48.8 Other 23 27.4 Language spoken at home English 1 1.2 Arabic 77 91.7 Other 3 3.6 Employment status Retired 20 23.8 Employed 17 20.2 Unemployed 46 54.8 Highest level of education Less than Bachelor’s degree 48 57.1 Bachelors degree or higher 33 39.3 Marital status Married/de facto 66 78.6 Separated/Divorced 12 14.3 Widowed 5 6 Smokers Yes 20 23.8 Children Yes 78 92.9 Medical history High blood pressure 45 53.6 Diabetes 29 34.5 Cancer 5 6.0 Heart disease 13 15.5 Arthritis 33 39.3 Kidney disease 1 1.2 High cholesterol 32 38.1 Depression 15 17.9 Anxiety 16 19.0 Respiratory disease, eg. Asthma, COPD, etc 7 8.3 Other 7 8.3 Validation of the IBARIT The total IBARIT score was 39.5 (SD = 9.1). The lowest score was for the barrier item “I feel that discussing my sexual needs and intimacy are against my culture” (M = 2.39, SD = 0.86); the highest barrier was for the item “I feel that sexual needs and intimacy are a private and personal issue” (M = 3.03, SD = 0.83). (See Supplementary Content 2.) Factor Extraction, Exploratory Factor Analysis, Internal Consistency The data were determined to be suitable for factor analysis as the KMO value was .882 and Bartlett’s test of sphericity reached statistical significance with its Chi-squared value of, 853.62, p 1, accounting for 71.8% of the total variance. This factor solution was also confirmed by visual inspection of the scree plot. All items had factor loadings > 0.4 and there were no cross-loadings. The factors were descriptively labelled ‘Personal importance’ (five items), ‘Communication with a health care professional’ (five items), and ‘Socio-cultural’ (five items). The reliability for the total IBARIT was α = 0.928. Cronbach’s alphas for the three subscales personal importance, communication with a health care professional, and sociocultural were .86, .88 and .87 respectively. The mean total score for the IBARIT was 39.5 (SD = 9.1). The mean scores for the sub-scales personal importance, communication with a health care professional, and sociocultural were 13.5 (SD = 3.4), 13.9 (SD = 3.7), and 12.1(SD = 3.4), respectively. The factor loading distribution for barriers items in the IBARIT is shown in Table 2 . Table 2 Descriptive statistics and factor loadings for the 15 items of the IBARIT Personal importance communication with a health care professional Socio-cultural Mean SD 3. I feel I am unwell to discuss my sexual needs and intimacy matters 0.745 0.369 0.403 2.56 0.79 2. I feel that sexual needs and intimacy are a private and personal issue 0.724 -0.015 -0.008 3.03 0.83 4. I feel that there is nothing that can be done about my sexual needs and intimacy 0.688 0.242 0.428 2.48 0.87 1. I feel ashamed to talk about my sexual needs and intimacy 0.686 0.275 0.322 2.80 0.93 5. I feel that sexual needs and intimacy are not a health priority for me at the moment 0.642 0.297 0.303 2.69 0.87 12. I feel uncomfortable to talk about my sexual health issues with a health care professional who is young 0.322 0.805 0.151 2.70 0.86 13. I feel uncomfortable to talk about my sexual health issues with a health care professional when my partner is with me 0.1 0.805 0.295 2.79 0.90 14.I feel uncomfortable to talk about my sexual health issues with a health care professional when my family member/friend is with me -0.027 0.775 0.167 2.85 0.98 10. I feel that the health care professional should initiate the discussion about my sexual needs and intimacy 0.484 0.718 0.157 2.73 0.81 11. I feel uncomfortable to talk about my sexual health issues with a health care professional of the opposite gender 0.544 0.665 0.064 2.74 0.88 9. I feel that the health care professional is too busy to discuss my sexual needs and intimacy 0.227 0.393 0.748 2.46 0.75 15. I am afraid of the health care professional's reaction -0.112 0.464 0.747 2.41 0.88 6. I feel that discussing my sexual needs and intimacy are against my religion/beliefs 0.5 -0.037 0.718 2.45 0.88 7. I feel that discussing my sexual needs and intimacy are against my culture 0.562 0.116 0.706 2.39 0.86 8. I feel that it is inappropriate to discuss my sexual needs and intimacy with a health care professional 0.495 0.191 0.584 2.44 0.82 Association between Demographics and barriers to seeking help for sexual wellbeing Univariate analysis demonstrated no statistically significant association among age, gender, highest level of qualifications and the IBARIT subscales. However, those who were unemployed had significantly higher mean scores for the subscales ‘personal importance’ and ‘communication with a health care professional’ compared to those who were retired. (Table 3 ) Table 3 Association between Demographics and the IBARIT subscales Personal Importance Communication with HCP Socio-Cultural Mean SD p Mean SD p Mean SD p Gender Male (n = 62) 13.6 3.5 0.805 14.1 3.5 0.365 12.1 3.6 0.815 Female (n = 21) 13.4 3.1 13.3 3.9 12.3 3.0 Education level Lower than Bachelors (n = 47) 13.5 3.0 .719 13.8 3.7 0.830 12.1 3.4 .753 Bachelors and higher (n = 33) 13.3 3.9 13.98 3.87 11.9 3.6 Employment status Retired (n = 20) 12.2 3.4 F = .016 12.28 3.9 F = .021 10.89 3.6 F = .054 Employed (n = 17) 12.5 3.4 13.68 3.8 11.6 3.3 Unemployed (n = 45) 14.5 3.2 14.7 3.2 12.9 3.3 Marital status Married/de facto (n = 65) 13.9 3.67 F = .167 14.1 3.9 F = .699 12.3 3.7 F = .770 Separated/Divorced (n = 12) 12.1 1.6 13.2 1.6 11.7 2.1 Widowed (n = 5) 12.2 2.5 14.6 3.2 11.4 2.7 Discussion Understanding the barriers to starting a conversation about sexual needs and intimacy with a health care professional is important to ensure that people with chronic conditions can have optimal information to improve their sexual wellbeing. This study was undertaken to develop and investigate the structure and construct validity of the IBARIT designed to measure the barriers to information seeking relating to sexual wellbeing among Arab people with chronic conditions. This paper presents the indices for content validity of the IBARIT including it factor structure and construct validity. The overall content validity index of the instrument using I CVI approach was high but was low using the S-CVI/UA approach. This could be due to the fact that there were seven expert raters making consensus difficult. Understanding content validity is important when using an instrument to ensure that it is suitable for the suitable for the socio-cultural background of the population being studied. Further refinement and validation of the instrument among other populations is warranted. This study highlighted that the IBARIT tool is a unique, valid and reliable instrument to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional among Arabic people with chronic conditions. The Cronbach’s alpha coefficient confirmed the IBARIT reliability, with high internal consistency. Factor analysis identified a three factors structure namely (1) Personal importance, (2) communication with a health care professional, and (3) Socio-cultural as the main constructs of the instrument. The Cronbach's alpha values ranged for the three factors and the total scale were greater than .85 indicating that the IBARIT was a reliable instrument to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional. The results of the study confirmed that there was no statistically significant association among age, gender, highest level of qualifications and the IBARIT subscales, indicating that the barriers for gender remained the same. This is consistent with the literature that demonstrates no statistically significant association between participants’ age, gender or level of education with accessing the sexual health support services and information and perceived barriers [ 26 ]. These findings suggest that health professionals should be careful not to assume that younger male or female patients with a high level of education would experience less barriers to discussing sexual issues or vice versa [ 27 ]. However, these socio-demographic factors may be important to consider in discussing sexual health issues. To date, there has been little research examining interactions between Arab people with chronic conditions and HCPs about sex from the patient’s perspective [ 28 , 29 ]. Likewise, no literature to date have considered the culturally specific demographic factors and the barriers that exist in commencing a conversation about sexual needs and intimacy with a health care professional. While there may be some similarities in the barriers across other populations, it cannot be assumed to be the same. It is important to note however, that people who were unemployed had significantly higher mean scores for the subscales ‘personal importance’ and ‘communication with a health care professional’ compared to those who were retired. A large meta-analysis study found that being unemployed is linked to reduced psychosocial wellbeing and life satisfaction and increases the risk of affective disorders [ 30 , 31 ]. Unemployed people often choose not to access the health services, seek support, and therefore do not benefit from available services [ 31 ]. A considerable number of studies prove that unemployed persons are less healthy than employed, both from the physical and mental aspects of health [ 32 , 33 ]. These can be justified by the impact of their unemployment status on their poorer access to the health care system due to inadequate health care for the unemployed and loss of income; less use of the necessary remedies; neglect of preventive health effects due to loss of income or impaired mental state; delaying necessary medical procedures [ 31 , 34 , 35 ]. Given that discussion of sexual wellbeing is a challenging subject for both patients and the health care providers, the IBARIT can be used to minimise the barriers to starting a conversation relating to sexual well-being. Patients with chronic disease can be asked to complete the IBARIT prior to seeing their specialists which can minimise some of the Uncertainty regarding starting the conversation. The IBARIT can also be used to train health professionals in identifying and addressing the sexual needs of the patients. STRENGTHS AND LIMITATIONS Employing multi-modal methods, the IBARIT was developed and tested with Arabic people with chronic conditions. Well-established techniques were used for the development and validation of the IBARIT which is a major strength of the study. Expert nurse academics and sexologists with extensive clinical and research experience established the content validity of the IBARIT. In addition, further content validity was undertaken by pilot testing the instrument with 10 participants. Despite the rigour with which the study was conducted, some limitations must be acknowledged. First, the study was conducted using convenience sampling. the sample is comprised of Arab migrants so our preliminary tests of the IBARIT may not support wide generalizability until further studies are performed to assess its validity with larger sample size. This study has the limitations of studies that use self-report measures, such as socially desirable responses, although participants were informed carefully that their responses would be anonymous and that it was important to encourage them to answer honestly. CONCLUSION The IBARIT is the first instrument to measure barriers related to seeking help for sexual wellbeing among the Arab population. The IBARIT has demonstrated high content validity of individual items of the overall questionnaire. The results of this study provide empirical support for the IBARIT as a valid and reliable instrument to measure to assess the barriers to seeking help for sexual wellbeing. Further research needs to be conducted to assess the validity and reliability of the instrument in other populations Declarations Author Contribution I.A and R.A: Conceptualization and MethodologyI.A ; A.A and H.L: Data Collection and Data Entry, Original Draft Preparation. 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Informatively missing quality of life and unmet needs sex data for immigrant and Anglo-Australian cancer patients and survivors. Qual Life Res., 22 (10), 2757–2760. Butow, P. N., Bell, M. L., Aldridge, L., Sze, M., Eisenbruch, M., Jefford, M., … King, M. (2013). Unmet needs in immigrant cancer survivors: a cross-sectional population-based study. Support Care Cancer., 21 (9), 2509–2520. Paul, K. I., & Moser, K. (2009). Unemployment impairs mental health: Meta-analyses. J Vocat Behav., 74 (3), 264–282. Åhs, A., Burell, G., & Westerling, R. (2012). Care or not care—that is the question: predictors of healthcare utilisation in relation to employment status. Int J Behav Med., 19 (1), 29–38. Stauder, J. (2019). Unemployment, unemployment duration, and health: selection or causation? Eur J Health Econ., 20 (1), 59–73. Urbanos-Garrido, R. M., & Lopez-Valcarcel, B. G. (2015). The influence of the economic crisis on the association between unemployment and health: an empirical analysis for Spain. Eur J Health Econ., 16 (2), 175–184. Ilić, B., Ledinski Fičko, S., Hošnjak, A. M., Kovačević, I., Smrekar, M., & Sedić, B. (2019). Unemployment and Access to Health Care. Croat Nurs J., 3 (2), 183–192. Staiger, T., Waldmann, T., Rüsch, N., & Krumm, S. (2017). Barriers and facilitators of help-seeking among unemployed persons with mental health problems: a qualitative study. BMC Health Serv Res., 17 (1), 1–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3910182","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270573660,"identity":"6dcab82b-37f0-4c5a-8a22-ac6d1544dad3","order_by":0,"name":"Ibrahim alananzeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBAC+RkMDMwMBgwM/BA+M2EtbBJQLZINpGkBAoMDRGuR7n34uaBgm7zxjeRjEgwV1okN7GcM8GuROW4sPcPgtuG2G2lpEgxn0hMbeHIIaJFIY5DmMbjNuO1GjtkNxrbDiQ0MhLUw/wZqsd88A6TlH1AL/xuCWthAtiRukABpaQBqkSBki8wxNmugluQZZ56l/0g4lm7cJvGsAK8W+dltzLd5/ty27W9PPmzwocZatp8/eQNeLaggAWQvCepHwSgYBaNgFOAAAJrEQP/rdd4DAAAAAElFTkSuQmCC","orcid":"","institution":"University of Wollongong in Dubai","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"alananzeh","suffix":""},{"id":270573661,"identity":"e550fd69-16b1-43af-9807-926f6e18a143","order_by":1,"name":"Albara Alomari","email":"","orcid":"","institution":"University of Doha for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Albara","middleName":"","lastName":"Alomari","suffix":""},{"id":270573662,"identity":"be2e5b8d-d7dc-4680-9ea2-518845e36239","order_by":2,"name":"Heidi Lord","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Heidi","middleName":"","lastName":"Lord","suffix":""},{"id":270573663,"identity":"903d998f-9228-40e2-a7b2-03aedc396704","order_by":3,"name":"Ritin Fernandez","email":"","orcid":"","institution":"University of Newcastle Australia","correspondingAuthor":false,"prefix":"","firstName":"Ritin","middleName":"","lastName":"Fernandez","suffix":""}],"badges":[],"createdAt":"2024-01-30 09:44:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3910182/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3910182/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52344665,"identity":"cb684f85-85f3-4d4a-a9fd-5d1f552866f4","added_by":"auto","created_at":"2024-03-09 14:47:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":442163,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3910182/v1/942f7310-9cb2-49d9-9a1b-9f28a5243ac8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Psychometric Assessment of the Measure of the Barriers to Discussing Sexual Wellbeing Among Arab Australian with Chronic Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global prevalence of chronic disease and multimorbidity is increasing not only due to the ageing population but also through the increase in obesity, which in turn leads to chronic illnesses such as diabetes and hypertension. emergence of higher levels of obesity creating chronic illnesses such as diabetes and hypertension [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Advancements in medicine and science have increased the life expectancy and longevity of people living with a chronic disease resulting in the focus shifting from purely survival to quality of life. Among people with a chronic disease, sexual health and wellbeing is often negatively affected and influenced by treatments, medications, and surgeries applied for chronic disease management.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These management strategies can cause sexual dysfunction which adversely affects a person\u0026rsquo;s quality of life, which in turn can create depression and anxiety and cause relationship issues [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual health, according to the World Health Organization (WHO), is defined as \u003cem\u003e\u0026ldquo;\u0026hellip;a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity\u0026rdquo;\u003c/em\u003e (4) and further adding that sexual health and wellbeing \u003cem\u003e\u0026ldquo;requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.\u0026rdquo;\u003c/em\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite, people living with a chronic disease, sexual intimacy and wellbeing is still an important aspect of their lives, however, many people with a chronic disease experience sexual dysfunction and dissatisfaction and decreased sexual activity caused by adverse reactions to medications, altered body image, and physical constraints [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual dysfunction for both males and females diagnosed with diabetes is a common complication that is growing in recognition. Diabetes is strongly associated with erectile dysfunction and is multifactorial, linked with vascular, hormonal, and neurological responses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The global prevalence of erectile dysfunction caused by diabetes is reported as up to 73% and increases to up to 100% in men aged 70 years and above [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For women, there is a paucity of literature on the association between diabetes and sexual dysfunction, nevertheless when compared to women without diabetes significantly greater number of women with diabetes have sexual dysfunction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImpaired sexual functioning among people with chronic pain is also common with up to 63% of people living with chronic pain experiencing sexual dysfunction. For sufferers of chronic pain, sexual dysfunction is reportedly caused by a myriad of problems including worsening pain, positioning for comfort, confidence, and psychological reasons such as depression and anxiety [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Sexual dysfunction has also been reported in approximately 88% of men following prostate surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Perception of loss of femininity is one of the major influences of sexual dysfunction among women with breast cancer, requiring a psychosocial adjustment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Sexual function is often altered for women with breast cancer depending on the type of treatments they receive. Chemotherapy can cause chemotherapy-induced menopause, while women who have a mastectomy lack sexual intimacy due to them losing \u0026lsquo;an independent sex organ [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, a diagnosis of cancer and living with cancer can produce psychosocial issues such as grief, loss, fear, depression, and anxiety that influence a person\u0026rsquo;s capacity and ability to be sexually intimate with their partner.\u003c/p\u003e \u003cp\u003eSexual dysfunction among people with hypertension is often believed to be a natural progression of this chronic disease and has been described as a side effect of some anti-hypertensive medications. Commonly, more women than men with hypertension experience sexual dysfunction, with up to 50% of women with hypertension expressing sexual dysfunction [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Diminished sexual functioning among people with chronic kidney disease is commonly encountered and is often influenced by the social, physical, economic, and psychological factors that the person is facing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual dysfunction remains a cause for concern as it can cause frustration, hopelessness, reduced closeness with partners, insecurity, anxiety and depression [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Despite most people with a chronic disease experiencing some form of sexual dysfunction and sexual intimacy issues, only up to 22% convey the issue to a doctor [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The hesitation to discuss these problems with a health professional limit the potential for identifying approaches and appropriate strategies and resources to assist with their sexual wellbeing [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and overcome sexual dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious barriers exist as to why people hesitate to consult with the doctor or a health professional about their sexual wellbeing have been reported in the literature. These include embarrassment, lack of privacy and time, fear of rejection and stigma and shame associated with cultural or religious beliefs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The hesitation to discuss sexual wellbeing can also be provider focused as health professional are unwilling to raise the issue [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotwithstanding the reported barriers that have been acknowledged in the literature, these vary among cultural groups and across countries. For example, for many migrant women in Sweden, sexual health and wellbeing is a taboo subject and not something that should be discussed, particularly in the presence of a male, this includes health professionals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Whereas in the Western culture, there is often a social stigma surrounding discussion of sexual wellbeing, with women avoiding these conversations with a health professional [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Conversely, within many Muslim countries the barrier to sexual health wellbeing communication with health professionals is often hindered due to the sociocultural issues including providing sexual information to non-married people and religious prohibitions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEstablishing a valid and reliable instrument to assist in assessing the barriers to people living with a chronic disease in obtaining sexual health information is crucial. To the best of our knowledge, there is currently no instrument developed to assess the barriers to discussing, seeking and obtaining sexual health and wellbeing information among people with chronic disease. Therefore, the objectives of this study were to: (1) develop and investigate the content validity and psychometric properties of an instrument to assess the barriers to seeking help for sexual wellbeing; (2) investigate the relationship between participant demographics and the barriers to seeking help for sexual wellbeing among Arab people with a chronic disease.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy Design: The first stage of the study included Instrument development assessment of content validity and pilot testing. The second stage included assessment of the instrument's psychometric properties and the final stage involved investigating the relationship between participant demographics and the barriers to seeking help for sexual wellbeing among Arab people with a chronic disease.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStage 1: Instrument development assessment of content validity and pilot testing\u003c/h2\u003e \u003cp\u003eThe process used for the development of the instrument was guided by the research and development methodology that involves three steps. First, a comprehensive literature review was conducted to identify the barriers in discussing issues relating to sexual wellbeing with the health care provider. Secondly the items in the instrument and the response scoring were designed along with experienced academics, researchers, doctors, sexologists, and senior nurses from various backgrounds. The final step was to undertake the validity test of the instrument using Content Validity Index (CVI). Content validity refers to the extent to which the set of items comprehensively covers the different components of a given theoretical construct [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Participants for the validity testing included eight From Arabic community and Islamic leaders. Participants were asked to rate the relevance, clarity and appropriateness of each item in the instrument and make relevant modifications if necessary. Relevance and Clarity were rated as Yes, No, or partly.\u003c/p\u003e \u003cp\u003eThe final instrument was called the Identifying Barriers and Resistors to starting a conversation on sexual wellbeing information Tool (IBARIT) and was pilot tested with a sample of 10 people and no further modifications were required.\u003c/p\u003e \u003cp\u003eThe IBARIT consisted of 15items, each of which was rated on a 4-point Likert-scale, with scores ranging from strongly agree (1) to strongly disagree (5). The minimum score for the total scale was 15; the maximum was 60. Pilot testing was undertaken using a sample of 10 patients, and no changes were required to the wording of any items.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eValidation of the IBARIT\u003c/h2\u003e \u003cp\u003eDesign: A prospective cross-sectional study design using convenience sampling was employed to participants for the study. Study setting and participants: The study was undertaken at the South Western Local Health District, New South Wales, Australia. Participants were included if they were: 1) of Arab heritage; 2) aged 18 years or older; 3) residing in NSW, Australia, and 4) identifying as having at least one chronic disease. People with known cognitive deficits were excluded from the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eArab people have strong social relationships with their community leaders hence the community leaders were invited to review the study procedures and materials and provide advice regarding recruitment strategies to ensure the study was sensitive to the Arab cultural and religious beliefs. Participants were recruited through advertisements in Australia-based Arab specific newspapers and radio, community leaders in known community organisations and during community events. Emails were sent to Arab specific organisations in South Western Sydney (Australia) to inform them of the research and to recruit participants.\u003c/p\u003e \u003cp\u003eParticipants were informed of the study by a bilingual health worker at the regular Arab community gatherings in Fairfield and Liverpool. short presentation outlining the sexual dysfunction among people with chronic disease and the importance of the study was given at the end of the presentation, the purpose of this study was explained by one of the research team (IA) and participants were encouraged to ask any questions.\u003c/p\u003e \u003cp\u003eA paper-based self-administered survey was used to collect data. Information collected included demographics, medical history and, questions to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional. Demographic data collected included the year and country of birth, gender, employment status, religion, education level, main language spoken, and language generally used for reading.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e for the study was obtained from the University of Wollongong Human Research Ethics Committee, following the guidelines set forth by the Human Research Ethics Committee (HREC). Participants were informed that no identifiable information would be obtained, all responses were confidential, and that participation was voluntary. Completion of the survey was considered implied consent.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll analyses were undertaken using SPSS\u0026copy; Version 25. The content validity of the instrument was assessed using the content validity index (CVI) and was computed using the Item-level -CVI (I-CVI) and the Scale-level-CVI (S-CVI). The I-CVI for individual items was calculated where the number of experts answering \u0026ldquo;YES\u0026rdquo; was divided by the total number of experts who participated. Those experts who answered partly were considered to be a NO. The S-CVI was computed using the S-CVI/Ave (averaging calculation method) S-CVI/Ave (based on proportional relevance) and S-CVI/ UA (based on the universal agreement method). The item was retained if the I-CVI was greater than 0.79 and items were considered to be appropriate but required revision if the I-CVI was between 0.70 and 0.78. Values of I-CVIs of 0.78 or higher and S-CVI/Ave of 0.9 and higher were considered to be excellent content validity, Items with less than 75% agreement were edited for clarity and precision.\u003c/p\u003e \u003cp\u003eBest practices in exploratory factor analysis (EFA) using a multifactorial approach was undertaken [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The Bartlet Test of Sphericity was used to evaluate the suitability of the data set for factor analysis and the Kaiser-Meyer Olkin test (KMO) was used to measure sample adequacy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The distribution of the responses was assessed using response-option frequency, mean, and standard deviations for each item. Next, confirmation of non-violation of the assumptions of normality, linearity, multicollinearity was undertaken. Finally, EFA using principal components analysis (PCA) was conducted using varimax rotation. Components were extracted based on visual inspection of the scree plot and established criteria [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Cronbach\u0026rsquo;s α-coefficient was used to assess the internal consistency reliability. Values greater than or equal to 0.9 were considered excellent, 0.8 to \u0026lt;\u0026thinsp;0.9 good, 0.7 to \u0026lt;\u0026thinsp;0.8 acceptable, 0.6 to \u0026lt;\u0026thinsp;0.7 questionable, 0.5 to \u0026lt;\u0026thinsp;0.6 poor, and \u0026lt;\u0026thinsp;0.5 unacceptable. The resulting factors were labelled according to reflect the underlying constructs. The normality of continuous data was ascertained by examining the skewness and kurtosis indices against accepted values. One-way ANOVA and \u003cem\u003et\u003c/em\u003e-tests were used to test differences between demographic variables and barriers to seeking help for sexual wellbeing. Pearson\u0026rsquo;s correlations were used to assess the relationships among continuous variables. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eContent validity results\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eI-CVI Results (relevancy of individual items)\u003c/h2\u003e \u003cp\u003eAll 15 items were identified as relevant and the I-CVIs ranged from 0.71 to 1.00. \u003cem\u003eSix items\u003c/em\u003e had an I-CVI\u0026thinsp;=\u0026thinsp;1.00, eight a score of 0.86, and one a score of 0.71 demonstrating excellent content validity.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eS-CVI Results (relevancy of the overall questionnaire)\u003c/h2\u003e \u003cp\u003eThe S-CVI based on the ICVI was 0.90 and the S-CVI based on proportional relevance was 0.89 demonstrating high content validity. However, the S-CVI Universal approach method the content validity was 0.4 indicating poor agreement to all the items by the seven raters.\u003c/p\u003e \u003cp\u003eClarity of items: Three items \u0026lsquo;I feel that there is nothing that can be done about my sexual needs and intimacy\u0026rsquo;, \u0026lsquo;I feel that sexual needs and intimacy are not a health priority for me at the moment\u0026rsquo;, \u0026lsquo;I feel that discussing my sexual needs and intimacy are against my religion/beliefs\u0026rsquo;.\u003c/p\u003e \u003cp\u003ehad less than 75% agreement for clarity and were edited for clarity and precision.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant demographics\u003c/h2\u003e \u003cp\u003eOf the 84 participants who completed the survey, the majority were male (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;63; 75%); and the mean age was 61.5 years (\u0026plusmn;\u0026thinsp;8.4 years). The majority (n\u0026thinsp;=\u0026thinsp;59, 70.2%) were born in Iraq and the main language spoken at home was Arabic (n\u0026thinsp;=\u0026thinsp;77, 91.7%). Approximately half the participants were Christians (n\u0026thinsp;=\u0026thinsp;41, 48.8%) and more than a third had a bachelor\u0026rsquo;s degree or greater (n\u0026thinsp;=\u0026thinsp;33, 39.3%). More than three-quarters of the participants were married or living with a partner (n\u0026thinsp;=\u0026thinsp;66, 78.6%). The chronic conditions included high blood pressure, diabetes, cancer, heart disease, arthritis, kidney disease, high cholesterol, depression, anxiety, and respiratory disease. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCountry of birth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLebanon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLanguage spoken at home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArabic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest level of education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than Bachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelors degree or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/de facto\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmokers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh blood pressure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney\u0026nbsp;disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh cholesterol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory disease, eg. Asthma, COPD, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eValidation of the IBARIT\u003c/h2\u003e \u003cp\u003eThe total IBARIT score was 39.5 (SD\u0026thinsp;=\u0026thinsp;9.1). The lowest score was for the barrier item \u0026ldquo;I feel that discussing my sexual needs and intimacy are against my culture\u0026rdquo; (M\u0026thinsp;=\u0026thinsp;2.39, SD\u0026thinsp;=\u0026thinsp;0.86); the highest barrier was for the item \u0026ldquo;I feel that sexual needs and intimacy are a private and personal issue\u0026rdquo; (M\u0026thinsp;=\u0026thinsp;3.03, SD\u0026thinsp;=\u0026thinsp;0.83). (See Supplementary Content 2.)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFactor Extraction, Exploratory Factor Analysis, Internal Consistency\u003c/h2\u003e \u003cp\u003eThe data were determined to be suitable for factor analysis as the KMO value was .882 and Bartlett\u0026rsquo;s test of sphericity reached statistical significance with its Chi-squared value of, 853.62, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eSkewness of the responses was minimal ranging from \u0026minus;\u0026thinsp;0.47 to 0.31. Analysis of the responses revealed a three-factor solution with eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1, accounting for 71.8% of the total variance. This factor solution was also confirmed by visual inspection of the scree plot. All items had factor loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.4 and there were no cross-loadings. The factors were descriptively labelled \u0026lsquo;Personal importance\u0026rsquo; (five items), \u0026lsquo;Communication with a health care professional\u0026rsquo; (five items), and \u0026lsquo;Socio-cultural\u0026rsquo; (five items).\u003c/p\u003e \u003cp\u003eThe reliability for the total IBARIT was α\u0026thinsp;=\u0026thinsp;0.928. Cronbach\u0026rsquo;s alphas for the three subscales personal importance, communication with a health care professional, and sociocultural were .86, .88 and .87 respectively. The mean total score for the IBARIT was 39.5 (SD\u0026thinsp;=\u0026thinsp;9.1). The mean scores for the sub-scales personal importance, communication with a health care professional, and sociocultural were 13.5 (SD\u0026thinsp;=\u0026thinsp;3.4), 13.9 (SD\u0026thinsp;=\u0026thinsp;3.7), and 12.1(SD\u0026thinsp;=\u0026thinsp;3.4), respectively. The factor loading distribution for barriers items in the IBARIT is shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDescriptive statistics and factor loadings for the 15 items of the IBARIT\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePersonal importance\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ecommunication with a health care professional\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSocio-cultural\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3. I feel I am unwell to\u0026nbsp;discuss my sexual\u0026nbsp;needs and intimacy matters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.745\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2. I feel that sexual\u0026nbsp;needs and intimacy\u0026nbsp;are a private and personal issue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.724\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4. I feel\u0026nbsp;that there is nothing that can be\u0026nbsp;done about my sexual needs and intimacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.688\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1. I feel ashamed to talk about my sexual needs and intimacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.686\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5. I feel that sexual needs and intimacy\u0026nbsp;are not a health priority for me at the moment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.642\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12. I feel uncomfortable to talk about my sexual health issues with a health care professional\u0026nbsp;who is young\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.805\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13. I feel uncomfortable to talk about my sexual health issues with a health care professional when my partner\u0026nbsp;is with me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.805\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.I feel uncomfortable to talk about my sexual health issues with a health care professional when my \u0026nbsp;family member/friend is with me\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.775\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10. I feel that the health care professional should initiate the discussion about my sexual needs and intimacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.718\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11. I feel uncomfortable to talk about my sexual health issues with a health care professional of the opposite gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.665\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9. I feel that\u0026nbsp;the health care professional is too busy to discuss my sexual needs and intimacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.748\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.\u0026nbsp;I\u0026nbsp;am afraid of the\u0026nbsp;health care professional\u0026apos;s reaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.747\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6. I feel that discussing my sexual\u0026nbsp;needs and intimacy\u0026nbsp;are against my religion/beliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.718\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7. I feel that discussing my sexual\u0026nbsp;needs and intimacy\u0026nbsp;are against my culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.562\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.706\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8. I\u0026nbsp;feel that\u0026nbsp;it is inappropriate to\u0026nbsp;discuss\u0026nbsp;my sexual needs and intimacy with a health care\u0026nbsp;professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.584\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between Demographics and barriers to seeking help for sexual wellbeing\u003c/h2\u003e \u003cp\u003eUnivariate analysis demonstrated no statistically significant association among age, gender, highest level of qualifications and the IBARIT subscales. However, those who were unemployed had significantly higher mean scores for the subscales \u0026lsquo;personal importance\u0026rsquo; and \u0026lsquo;communication with a health care professional\u0026rsquo; compared to those who were retired. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between Demographics and the IBARIT subscales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePersonal Importance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eCommunication with HCP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eSocio-Cultural\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower than Bachelors (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.719\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e.753\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelors and higher (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed (n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/de facto (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eF\u0026thinsp;=\u0026thinsp;.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/Divorced (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Understanding the barriers to starting a conversation about sexual needs and intimacy with a health care professional is important to ensure that people with chronic conditions can have optimal information to improve their sexual wellbeing. This study was undertaken to develop and investigate the structure and construct validity of the IBARIT designed to measure the barriers to information seeking relating to sexual wellbeing among Arab people with chronic conditions.\u003c/p\u003e \u003cp\u003eThis paper presents the indices for content validity of the IBARIT including it factor structure and construct validity. The overall content validity index of the instrument using I CVI approach was high but was low using the S-CVI/UA approach. This could be due to the fact that there were seven expert raters making consensus difficult. Understanding content validity is important when using an instrument to ensure that it is suitable for the suitable for the socio-cultural background of the population being studied. Further refinement and validation of the instrument among other populations is warranted.\u003c/p\u003e \u003cp\u003e This study highlighted that the IBARIT tool is a unique, valid and reliable instrument to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional among Arabic people with chronic conditions. The Cronbach\u0026rsquo;s alpha coefficient confirmed the IBARIT reliability, with high internal consistency.\u003c/p\u003e \u003cp\u003eFactor analysis identified a three factors structure namely (1) Personal importance, (2) communication with a health care professional, and (3) Socio-cultural as the main constructs of the instrument. The Cronbach's alpha values ranged for the three factors and the total scale were greater than .85 indicating that the IBARIT was a reliable instrument to assess the barriers to starting a conversation about sexual needs and intimacy with a health care professional.\u003c/p\u003e \u003cp\u003eThe results of the study confirmed that there was no statistically significant association among age, gender, highest level of qualifications and the IBARIT subscales, indicating that the barriers for gender remained the same. This is consistent with the literature that demonstrates no statistically significant association between participants\u0026rsquo; age, gender or level of education with accessing the sexual health support services and information and perceived barriers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These findings suggest that health professionals should be careful not to assume that younger male or female patients with a high level of education would experience less barriers to discussing sexual issues or vice versa [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, these socio-demographic factors may be important to consider in discussing sexual health issues. To date, there has been little research examining interactions between Arab people with chronic conditions and HCPs about sex from the patient\u0026rsquo;s perspective [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Likewise, no literature to date have considered the culturally specific demographic factors and the barriers that exist in commencing a conversation about sexual needs and intimacy with a health care professional. While there may be some similarities in the barriers across other populations, it cannot be assumed to be the same.\u003c/p\u003e \u003cp\u003eIt is important to note however, that people who were unemployed had significantly higher mean scores for the subscales \u0026lsquo;personal importance\u0026rsquo; and \u0026lsquo;communication with a health care professional\u0026rsquo; compared to those who were retired. A large meta-analysis study found that being unemployed is linked to reduced psychosocial wellbeing and life satisfaction and increases the risk of affective disorders [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Unemployed people often choose not to access the health services, seek support, and therefore do not benefit from available services [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A considerable number of studies prove that unemployed persons are less healthy than employed, both from the physical and mental aspects of health [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These can be justified by the impact of their unemployment status on their poorer access to the health care system due to inadequate health care for the unemployed and loss of income; less use of the necessary remedies; neglect of preventive health effects due to loss of income or impaired mental state; delaying necessary medical procedures [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Given that discussion of sexual wellbeing is a challenging subject for both patients and the health care providers, the IBARIT can be used to minimise the barriers to starting a conversation relating to sexual well-being. Patients with chronic disease can be asked to complete the IBARIT prior to seeing their specialists which can minimise some of the Uncertainty regarding starting the conversation. The IBARIT can also be used to train health professionals in identifying and addressing the sexual needs of the patients.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSTRENGTHS AND LIMITATIONS\u003c/h2\u003e \u003cp\u003eEmploying multi-modal methods, the IBARIT was developed and tested with Arabic people with chronic conditions. Well-established techniques were used for the development and validation of the IBARIT which is a major strength of the study. Expert nurse academics and sexologists with extensive clinical and research experience established the content validity of the IBARIT. In addition, further content validity was undertaken by pilot testing the instrument with 10 participants.\u003c/p\u003e \u003cp\u003eDespite the rigour with which the study was conducted, some limitations must be acknowledged. First, the study was conducted using convenience sampling. the sample is comprised of Arab migrants so our preliminary tests of the IBARIT may not support wide generalizability until further studies are performed to assess its validity with larger sample size. This study has the limitations of studies that use self-report measures, such as socially desirable responses, although participants were informed carefully that their responses would be anonymous and that it was important to encourage them to answer honestly.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe IBARIT is the first instrument to measure barriers related to seeking help for sexual wellbeing among the Arab population. The IBARIT has demonstrated high content validity of individual items of the overall questionnaire. The results of this study provide empirical support for the IBARIT as a valid and reliable instrument to measure to assess the barriers to seeking help for sexual wellbeing. Further research needs to be conducted to assess the validity and reliability of the instrument in other populations\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eI.A and R.A: Conceptualization and MethodologyI.A ; A.A and H.L: Data Collection and Data Entry, Original Draft Preparation. I.A and R.A: Data Analysis, Finalizing the Manuscript, Reviewing, and Editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Connor, S. R., Connaghan, J., Maguire, R., Kotronoulas, G., Flannagan, C., Jain, S., \u0026hellip; Wells, M. (2019). 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BMC Health Serv Res., \u003cem\u003e17\u003c/em\u003e(1), 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sexuality, chronic disease, Arab, Psychometric Validation","lastPublishedDoi":"10.21203/rs.3.rs-3910182/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3910182/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAddressing sexual health is an essential component of health care. However, patients are reluctant to broach this topic with their health care providers. Moreover, there is no instrument available to assess the barriers relating to discussing sexual issues among patients with chronic diseases. This article describes the development and psychometric assessment of an instrument intended to measure the barriers to discussing sexual wellbeing among Arab Australians with chronic disease. Through a comprehensive literature review and in consultation with key experts, barriers relating to discussing sexual issues were identified and the Information for Sexual Wellbeing Tool (IBaRIT) was developed and completed by 84 participants. Psychometric analysis supports the use of the IBaRIT as a valid and reliable instrument for understanding the barriers to discussing sexual wellbeing among Arab Australians with chronic disease and developing the needed interventions.\u003c/p\u003e","manuscriptTitle":"Development and Psychometric Assessment of the Measure of the Barriers to Discussing Sexual Wellbeing Among Arab Australian with Chronic Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 19:14:04","doi":"10.21203/rs.3.rs-3910182/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bda5521b-1625-4d89-9fb9-a839e17e41b9","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-25T06:07:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-06 19:14:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3910182","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3910182","identity":"rs-3910182","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}