Measuring stigma among abortion providers: assessing the Abortion Provider Stigma Survey instrument.

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Measuring Stigma Among Abortion Providers: Assessing the Abortion Provider Stigma Survey Instrument a

b

Lisa A. Martin PhD , Michelle Debbink MD, PhD , Jane Hassinger c

d

e

MSW , Emily Youatt MPH , Meghan Eagen-Torkko CNM, MN & Lisa H. Harris MD, PhD

b

a

Women’s and Gender Studies, University of Michigan–Dearborn, Dearborn, Michigan, USA b

Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA c

Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan, USA d

Health Behavior & Health Education, University of Michigan, Ann Arbor, Michigan, USA e

School of Nursing, University of Michigan, Ann Arbor, Michigan, USA Accepted author version posted online: 25 Jul 2014.Published online: 25 Sep 2014.

To cite this article: Lisa A. Martin PhD, Michelle Debbink MD, PhD, Jane Hassinger MSW, Emily Youatt MPH, Meghan Eagen-Torkko CNM, MN & Lisa H. Harris MD, PhD (2014) Measuring Stigma Among Abortion Providers: Assessing the Abortion Provider Stigma Survey Instrument, Women & Health, 54:7, 641-661, DOI: 10.1080/03630242.2014.919981 To link to this article: http://dx.doi.org/10.1080/03630242.2014.919981

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Women & Health, 54:641–661, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.919981

Measuring Stigma Among Abortion Providers: Assessing the Abortion Provider Stigma Survey Instrument LISA A. MARTIN, PhD Women’s and Gender Studies, University of Michigan–Dearborn, Dearborn, Michigan, USA


MICHELLE DEBBINK, MD, PhD Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA

JANE HASSINGER, MSW Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan, USA

EMILY YOUATT, MPH Health Behavior & Health Education, University of Michigan, Ann Arbor, Michigan, USA

MEGHAN EAGEN-TORKKO, CNM, MN School of Nursing, University of Michigan, Ann Arbor, Michigan, USA

LISA H. HARRIS, MD, PhD Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA

We explored the psychometric properties of 15 survey questions that assessed abortion providers’ perceptions of stigma and its impact on providers’ professional and personal lives referred to as the Abortion Provider Stigma Survey (APSS). We administered the survey to a sample of abortion providers recruited for the Providers’ Share Workshop (N = 55). We then completed analyses using Stata SE/12.0. Exploratory factor analysis, which resulted in 13 retained items and identified three subscales: disclosure management, resistance and resilience, and discrimination. Stigma was salient in abortion provider’s lives: they identified difficulties surrounding disclosure (66%) and felt unappreciated by society

Received November 19, 2013; revised March 7, 2014; accepted March 26, 2014. Address correspondence to Lisa A. Martin, PhD, Women’s and Gender Studies and Health Policy Studies, College of Arts, Sciences, and Letters, University of Michigan, Dearborn, 4901 Evergreen Rd., Dearborn, MI 48128. E-mail: [email protected] 641

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(89%). Simultaneously, workers felt they made a positive contribution to society (92%) and took pride in their work (98%). Paired t-test analyses of the pre- and post-Workshop APSS scores showed no changes in the total score. However, the Disclosure Management subscale scores were significantly lower (indicating decreased stigma) for two subgroups of participants: those over the age of 30 and those with children. This analysis is a promising first step in the development of a quantitative tool for capturing abortion providers’ experiences of and responses to pervasive abortion stigma.


KEYWORDS

reproductive health, psychosocial, quality of life

Women in the U.S. increasingly depend upon a relatively small number of abortion providers for this frequent procedure: Estimates suggest that 1,793 to 7,500 doctors perform the 1.2 million abortions annually sought by U.S. women (Jones & Kooistra, 2011; Stulberg et al., 2011). Until recently, most efforts to address abortion workforce issues have focused on physician training. However, approximately half of the physicians who are trained to provide abortion ultimately do not do so (Freedman, 2010; Steinauer et al., 2008). The impact of abortion stigma on providers may contribute to this training-provision gap. Sociologists characterize abortion work as “dirty work”—tasks or occupations that are socially necessary, yet regarded as physically disgusting, socially degrading, or morally dubious (Hughes, 1951; Harris et al., 2011; Joffe, 1978; O’Donnell, Weitz, & Freedman, 2011). Dirty work depends on stigmatizing both the work and workers; this stigma is generated in multiple arenas, from public discourse and policy to interpersonal relationships (Harris et al., 2011; Kumar, Hessini, & Mitchell, 2009). Public discourse can marginalize and delegitimize providers and can promote harassment and violence (Garnets, Herek, & Levy, 2003; Herek, 1993). Stigma may also contribute to increased stress, burnout, and strain on collegial relationships (Freedman, 2010; Norris et al., 2011). Pervasive social stigma and harassment may, in turn, deter individuals from providing abortion care (Harris et al., 2011, 2013; Joffe, 2009). If stigma represents a human resource issue in abortion, then reducing its impact may improve access to abortion care. In previous qualitative work with abortion providers participating in the Providers Share Workshop, we found that stigma contributed to stress, isolation, and disconnection in multiple areas of providers’ lives (Harris et al., 2011). By providing a safe space for mutual support, the workshop appeared to ameliorate disconnection, suggesting it might serve as a stigma management tool (Harris et al., 2011). However, as it was a qualitative study, we were unable to assess the experience or salience of stigma among providers, or the ways in which


The Abortion Provider Stigma Survey Instrument

643

providers’ assessment of and response to stigma might have changed as a result of the workshop. While few tools specifically assess abortion stigma, stigma has been measured in a variety of other arenas, including mental illness (Corrigan et al., 2000, 2003; King et al., 2007; Link et al., 2004), HIV and AIDS (Abell et al., 2007; Kalichman et al., 2009; Sengupta et al., 2010), and sexuality and sexual orientation (Garnets, Herek, & Levy, 2003; Herek, 1993). Though these measures identify similar constructs across groups, the manifestation and perpetuation of stigma also depends on the relationship and context between the stigmatized and stigmatizers (Link & Phelan, 2001). Therefore, we felt it important to devise an instrument specifically for abortion providers that included adaptations of items that targeted universal aspects of stigma in each of its domains as well as items that measured circumstances specific to abortion care, including stigma related to professional work. Here, we report on the development of a 15-item Abortion Provider Stigma Survey instrument intended as a first step in evaluating providers’ experiences of stigma as a result of their work in abortion care. We describe the psychometric properties of the instrument and its utility in evaluating changes stigma following participation in the Providers Share Workshop. Our objectives were to increase our understanding of the extent to which abortion providers experience stigma; to monitor changes in stigma experiences over time; and to evaluate the importance of stigma as a human resources issue in abortion care.

METHODS We developed the Abortion Provider Stigma Survey instrument to take advantage of the opportunity afforded by the Providers Share Workshop to apply the instrument in a field setting. This allowed us to quantify baseline experiences with stigma as well as any changes that might have occurred over the course of the workshop.

Providers Share Workshop The Providers Share Workshop consisted of five sessions in which abortion providers met to discuss their work, including its stresses and burdens. The goal of the workshop was to provide a safe space for abortion workers to discuss all aspects of their work in the short term and, in the longer term, to strengthen worker resilience and abortion human resources (Harris et al., 2011). From a research perspective, it provided qualitative data for hypothesis generation regarding abortion workers’ responses to their work. An experienced facilitator (not employed at the clinic) led the sessions, each of which was organized around a theme: (1) What abortion work means to me; (2) Memorable stories; (3) Abortion and identity; (4) Abortion politics; and (5) Strategies for self-care. Sessions lasted one to

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two hours and were held over an 8- to 12-week period. Journaling exercises and collage-making—methods demonstrated to help people in stressful environments increase self-awareness and reduce anxiety—supplemented discussions (Oster et al., 2006; Pifalo, 2006).


Providers Share Workshop Recruitment and Survey Procedures The seven sites that participated in the workshops represented a diverse group in terms of geographic, demographic, and institutional contexts—East coast, West coast, Midwestern, and Southern clinics; private and non-profit clinics; public and private hospitals; and states with and without Medicaid abortion funding. Eligible sites needed a minimum of six participants, were able to accommodate the workshop schedule, and reported no administrative or leadership turnovers in the previous six months. Individual participants were recruited by the site liaison via email, flyers, and all-staff meetings. Any employee with direct abortion care responsibilities was eligible to participate. All workers who directly performed or assisted with abortion care were invited to participate, including any administrators, managers, or receptionists who felt they had direct contact with the provision of abortion services. Site-based liaisons recruited participants via emails, announcements at allstaff meetings, and flyers posted in staff-only areas. Based on estimates provided by the liaisons at each site, a total of 135 participants were identified across the sites, which resulted in a participation or uptake rate of 59% (79/135). On average, sites recruited 11 participants, with a range of 6–24 participants per site. The Abortion Provider Stigma Survey item pool was finalized after the initiation of the workshop study, which resulted in 55/79 respondents. Given the exploratory nature of this study, we planned to investigate changes at item/subscale/total score levels. Our initial power calculations used 135 participants as an estimate. A sample of that size would have resulted in sufficient power (at the 0.80 level or higher) to detect a onepoint change in any of the measures. Post-hoc power calculations indicated that 55 respondents provided sufficient power at the 0.80 level to detect a one-point pre-to-post change in individual items, and a two-and-a-half to three point change across administrations on subscales or total score on the Abortion Provider Stigma Survey. Surveys were administered using a secure website. Participants completed a pre-workshop survey after providing consent but prior to the first session. The post-workshop survey was completed within 3 weeks of the conclusion of the workshop, with an average time between survey administrations of 68 days. The survey consisted of 151 items that included demographic questions and: (1) Professional Quality of Life Scale (Stamm, 2005); (2) Ways of Coping (WAYSS) (Folkman et al., 1986); (3) Workgroup Characteristics Measure—Process Subset (Campion, Medsker, & Higgs, 1993; Campion, Papper, & Medsker, 1996; Carless & Paola, 2000); (4) People and Organizational Culture Profile (O’Reilly, Chatman, & Caldwell, 1991);


645

(5) 15-item Abortion Provider Stigma Survey; and (6) open-ended response questions evaluating the workshop. Surveys took approximately 45–60 minutes to complete per administration. The University of Michigan Institutional Review Board approved the study.


Development of the Abortion Provider Stigma Items Procedures for creating the Abortion Provider Stigma Survey items included: (1) literature review of existing stigma measures used in health care and in social science; (2) review of qualitative findings from the Providers Share Workshop pilot to identify salient themes not covered by existing measures; (3) modification of existing items and creation of new items; and (4) a review of the instrument by experts in family planning. We reviewed Van Brakel (2006) and concluded that, of the five elements they identified (discrimination, lay attitudes, perceived threat, internalized stigma and stigma resilience, and structural stigma), all but lay attitudes toward the stigmatized group were relevant to our proposed instrument because we planned to assess stigma only from the viewpoint of the targeted group. Because many aspects of stigma are similar across conditions, we conducted a literature search for validated stigma measures and handsearched bibliographies of relevant papers for additional measures with the plan of adapting an existing valid measure. We identified King et al.’s Stigma Scale (2007), which assesses the impact of stigma among people with a variety of psychiatric disorders, as the most comprehensive and thorough starting point for adaptation. Importantly, the Stigma Scale directly assesses the targeted group’s experiences with stigma and contains items reflecting the four relevant aspects of stigma identified by Van Brakel (2006). While constructing the measure, we felt constrained to limit the number of items due to the circumstances of the ongoing Providers Share Workshop study and therefore could not include a large item pool (40 to 50 items) at the outset, as would be required by traditional scale development methods. Two primary considerations drove this decision. First, because the workshop was a qualitative, explorative study we were concerned that a priming effect might arise; that is, if we had asked providers to think at length about their experiences with stigma, it might have influenced their discussions in ways that would have falsely inflated the salience of stigma. We did not want to introduce bias that would adversely affect future hypothesis generation or theoretical model development. At the same time, we felt an acute need to quantify providers’ baseline and post-intervention experiences regarding stigma. Second, the initial planned quantitative evaluation before the addition of the stigma items was already lengthy, 136 items from pre-existing instruments (see details above). Given the length of the existing survey, the introduction of dozens of additional potential items that would have been necessary for a traditional expanded item pool was deemed impractical and burdensome for the participants; ultimately, we decided that a


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shorter instrument offered a reasonable compromise as a starting point for developing a stigma measure for abortion providers. The resulting 15-item pool (see the appendix) contained six items that were modified from the King Stigma Scale (items 1, 2, 3, 11, 12, and 13) and nine items that reflected important findings from our previous qualitative work (items 4, 5, 6, 7, 8, 9, 10, 14, and 15). The modified items addressed discrimination, disclosure, and discriminatory media representation. The items derived from our qualitative work addressed fear of violence, pride and stigma resistance, being stigmatized or marginalized within the medical community, and being stigmatized by patients. We used a five-point response scale (all of the time, often, sometimes, rarely, never) and assigned each answer a point value ranging from 1 to 5, where higher values indicated greater perceived stigma. After the pool of items was assembled, we solicited seven individuals who represented a range of professional roles in abortion care to review the items regarding interpretability, readability, whether questions asked about abortion stigma, and whether anything was missing with regard to stigmatizing experiences. Colleagues reported that the items had face validity and readability. No reviewers suggested additional items, offered alternative wording for the existing items, or felt that significant aspects of stigma in abortion work had been omitted. In an earlier test-retest analysis, the Abortion Provider Stigma Survey ( APSS) demonstrated internal consistency (Cronbach’s alpha = 0.81) providing confidence that the items measured a single related construct and offered excellent test-retest reliability (Pearson’s r = 0.94), indicating the instrument was stable over a short period of time (Martin et al., 2011).

Analysis We performed exploratory factor analysis to examine the underlying structure of the items and to identify potential subscales. Examination of the eigenvalues and scree plot suggested a three-factor solution, which we rotated to obtain interpretable factors. We performed a Promax (oblique) rotation and determined the factors were not significantly correlated; thus, we used the default varimax (orthogonal) rotation. After rotation, factor loadings of less than 0.300 were excluded, as suggested by Costello and Osborne (2005). We retained items with multiple loadings on the highest loading factor when the difference between the primary and secondary loading values was large (typically 0.3 to 0.4). We further examined any items with weak or indiscriminate loadings for theoretical importance before deciding to discard or exclude them altogether (Matsunaga, 2010). We assessed internal consistency for the complete final set of items and subscales. We report descriptive analysis of the individual items, subscales, and total scale. Paired t-tests evaluated pre-to-post changes in the mean total score and subscale scores. We excluded responses missing data at Time 2 on


647

a per-item basis; that is, we included in subscale and total score analyses only responses with complete data for all items. Qualitative data suggested that experiences of and responses to stigma varied depending on the provider’s age, whether they had children, and job type, so these demographic characteristics were used to conduct sub-group pre-to-post analyses. We completed all analyses using Stata SE/12.0 (StataCorp, 2011).

RESULTS Providers Share Workshop Analysis


DEMOGRAPHIC CHARACTERISTICS A total of 55 respondents (all female), whose mean age was 34 years (range 23–59 years), completed the stigma measure at Time 1 (Table 1). The sample was racially/ethnically diverse, highly educated, included parents and non-parents, and reflected a broad array of providers. Because some clinics emphasize staff cross-training, participants were permitted to select multiple job types; 20% of the sample did select more than one job type. DESCRIPTIVE STATISTICS

FOR THE

15 SURVEY ITEMS

Abortion stigma was salient in provider’s lives: 62% of the sample reported that they felt unappreciated by society “often” or “almost all of the time,” and 71% felt that the media “rarely” or “never” takes a balanced view of abortion (Table 2). In addition to feeling marginalized in society, 54% also reported marginalization within healthcare at least “some of the time.” Despite their perceived devaluation in society, many of the providers also reported stigma resilience and resistance. Approximately half of the workers (54%) reported feeling proud to work in abortion care “all of the time,” and an additional 29% felt proud “often.” Participants also felt their work made a positive contribution to society—84% reported feeling this way “all of the time” or “often.” Worries over disclosure of abortion work were prominent: 66% of the sample reported that they worry about the consequences of disclosure of their abortion work and 67% reported avoiding disclosure at least “some of the time.” Further, 67% worried that if they disclosed their work in abortion it would become a defining characteristic, i.e., that they would only be seen as an abortion worker, rather than as a person who does abortion work. At the same time, 70% of the sample believed that it was important to disclose their abortion work at least “some of the time.” A total of 50% of the sample reported having experienced harassment—either verbal or physical violence. EXPLORATORY FACTOR ANALYSIS Factor analysis using the Time 1 responses showed that a three-factor solution explained 89% of the variance (Table 3). Consequently, 14 of the

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L. A. Martin et al. TABLE 1 Characteristics of the Providers Share Workshop Sample at Baseline


Characteristics Sex: Female Age (years) 23–29 30–39 40–49 50–59 Race/Ethnicity White Black Hispanic Asian Multi-Ethnic Other Not Reported Parenting Status Yes–-Adult Children Yes–-Minor Children No Not Reported Sexual Orientation Heterosexual Gay, Lesbian, Bisexual, Trans, or Queer Not Reported Education High School Some College Associate’s Degree Bachelor’s Degree Some Graduate/Professional School Graduate/Professional Degree Not Reported Job Type Counselor Nurse Physician Recovery Room Assistant Manager Surgical Assistant Prep/Cleanup Other Not Reported Reported Multiple Job Types Time Worked at Current Organization > 1 month 1–6 months 7–12 months 1–2 years 3–5 years 6–9 years 10+ years Not Reported

%

(N)

100

(55)

36 38 16 9

(20) (21) (9) (5)

56 15 19 4 4 2

(27) (7) (9) (2) (2) (1) (7)

10 29 61

(5) (14) (29) (7)

77 23

(37) (11) (7)

56 22 7 24 4 37

(3) (12) (4) (13) (2) (20) (1)

24 15 5 3 9 16 3 25

(18) (11) (4) (2) (7) (12) (2) (19) (1) (15)

20 3 9 7 14 31 19 17

(1) (4) (3) (6) (13) (8) (7) (13)

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The Abortion Provider Stigma Survey Instrument TABLE 2 Descriptive Statistics of the Abortion Provider Stigma Scale Items

1 2 3 4


5 6 7 8 9 10 11 12 13 14 15

a

All of Somethe time Often times Rarely Never (%) (%) (%) (%) (%) Mean (S.D.)

Median (1–5)

Items

N

People’s reactions make me keep to myself Been verbally or physically threateneda Media takes balanced view Marginalized in healthcare Emotional punching bag Proud to work in abortion care Connected to coworkers Unappreciated by societya Making a positive contribution Risk of being essentialized Worry about disclosure Bothers me if neighbors know Avoid disclosure Fear of violence if I disclose Important to disclose Total score

55

0.0

10.9

34.6

30.9

23.6

2.36 (0.963)

3

55

1.8

3.6

23.6

20.0

50.9

1.86 (1.0)

1

53

5.7

3.8

18.9

47.2

24.5

3.81 (1.039)

4

55

9.1

16.4

29.1

21.8

23.6

2.66 (1.265)

3

55

5.5

12.7

30.9

25.5

25.5

2.47 (1.168)

3

55

54.6

29.1

14.6

0.0

1.8

1.66 (0.865)

1

54

48.2

33.3

11.1

3.7

3.7

1.82 (1.029)

1

55

20.0

41.8

27.3

1.8

9.1

3.62 (1.1)

4

55

61.8

21.8

9.1

3.6

3.6

1.66 (1.040)

1

55

3.6

25.5

38.2

12.7

20.0

2.80 (1.145)

3

55

9.1

23.6

32.7

20.0

14.6

2.93 (1.184)

3

55

9.1

10.9

20.0

25.5

34.6

2.35 (1.308)

1

54 55

5.6 3.6

11.1 10.9

50.0 20.0

13.0 36.4

20.4 29.1

2.69 (1.096) 2.24 (1.105)

3 2

55

9.1

20.0

41.8

20.0

9.1

3.00 (1.071)

3

51

32.50 (6.0)

Indicates that item was not retained in the final subscale.

15 items loaded onto one of the three factors. Item 8 failed to load on any factor after rotation and was eliminated. Item 14, fear of violence resulting from disclosure, loaded strongly on Factor 1 (loading score 0.730), and weakly on Factor 3 (loading score 0.320); given the difference in loadings greater than 0.40, it was retained with Factor 1. Item 2, being verbally or physical threatened, loaded onto both Factor 1 (loading score 0.399) and Factor 2 (loading score 0.329). As the factor loading was above 0.3 in both factors, we relied upon further internal consistency analyses to determine whether the item should be dropped. The internal consistency of the Disclosure Management (Factor 1) and Discrimination (Factor 3) subscales was evaluated with and without item 2. Internal consistency for the Disclosure Management subscale was strong

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L. A. Martin et al.

TABLE 3 APSS Item Factor Loadings—Varimax Rotationa,b,c

Items 1 2 3 4 5 6


7 8 9 10 11 12 13 14 15

Keep to myself Been verbally or physically threatenedc Media takes balanced view Marginalized in healthcare Emotional punching bag Proud to work in abortion care Connected to coworkers Unappreciated by societyc Making a positive contribution Risk of being essentialized Worry about disclosure Bothers me if neighbors know Avoid disclosure Fear of violence if I disclose Important to disclose

Factor 1 Disclosure management

Factor 2 Resilience and resistance

.6554 (.3993)

Factor 3 Discrimination (.3292) −.6212

.3350 .6085 .7836 .8436 .7287 .3699 .9125 .8517 .8524 .7296

(.3189) .6472

a

Three-factor solution explains 89.22% of variance. N = 51. c Indicate that item was not retained in the final subscale. b

regardless of the inclusion of item 2, with an alpha of 0.86 when included and 0.85 when eliminated. The Discrimination subscale internal consistency was weak regardless of whether item 2 was present (alpha = 0.57) or absent (alpha = 0.60). As the presence or absence of item 2 did not improve the internal consistency of either subscale, it was dropped from further analyses. The Cronbach’s alpha for internal consistency of the Resilience and Resistance subscale (Factor 2) was 0.82. The final 24-item instrument demonstrated an internal consistency of 0.80. Disclosure Management explained 44% of the variance and contained seven items (1, 4, 10, 11, 12, 13, and 14) focused on issues of disclosure, including worries, consequences, and actions associated with disclosure. Resilience and Resistance explained an additional 25% of the variance and contained four items (6, 7, 9, and 15) that focused on the positive aspects of the work. Discrimination explained an additional 10% of the variance and consisted of two items (3 and 5) that captured the perceived consequences of abortion stigma.

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BASELINE SCORES SUBSCALES

OF THE

ABORTION PROVIDER STIGMA SURVEY

AND

The mean score for the 13-item scale at Time 1 was 32.5 (s.d. 6.0, range 21–46). The mean scores for each subscale were as follows: Disclosure Management—17.8 (s.d. 5.7, range 7–32); Resilience and Resistance—8.1 (s.d. 3.3, range 4–20); and Discrimination—6.3 (s.d. 1.9, range 2–10) (Table 4). We assessed potential differences in the baseline survey scores and subscale scores by the reported demographic characteristics. With one exception, no differences were observed in baseline total APSS scores by any demographic category, age (range 32.1–33.0), education level (range 29.3–38.0), race/ethnicity (range 26.6–36.0), sexual orientation (range 32.7–32.9), parenting status (range 31.0–33.8), or length of time worked in the organization (range 30.6–37.0). The exception was that surgical assistants had significantly lower stigma scores at baseline than workers in other job categories, 28.5, compared to the workers in all other job categories 33.4 (t = 2.203, p < .05). No significant baseline differences were observed between demographic groups and the APSS subscale scores. POST-INTERVENTION CHANGES

IN THE

APSS

Of the 55 participants who completed the survey at Time 1, 52 completed the survey at Time 2, which yielded a response rate of 94.5%. The analysis that compared Abortion Provider Stigma Survey scores before and after the workshop revealed no change in the overall score or subscale scores for the total sample (Table 4). Paired t-test analysis of changes in the APSS total and subscale scores by demographic categories revealed reduced stigma scores post-intervention. The overall stigma survey score dropped an average of 3.8 points (t = 2.6, p < .05) among participants with “some college” and participants who reported the job type “Other” (this group consisted primarily, though not entirely, of administrators and receptionists). We also observed statistically significant decreases in the Disclosure Management sub-scale score—indicating increasing comfort with disclosure—among participants over age 30 (compared to younger participants), who reported a 1.6 point reduction (t = 2.993, p < .01), and participants who had children (compared to those without), whose scores dropped 1.8 points (t = 2.551, p < .05). Participants who had “some college” education also demonstrated a significant decrease of 2.6 points (t = 4.5, p < .01) in the Disclosure Management sub-scale.

DISCUSSION In this study, we report on the development and psychometric properties of a new measure of abortion stigma for providers and its first use in the field as

652

No

33.8 (6.9)

19.0 (3.7)

16.2 (6.7)

31.0 (4.4)

21.5 (3.5) 20.0 (0.0)

36.0 (0.0)

Asian

17.4 (8.2)

13.9 (3.4)

19.2 (5.1)

17.9 (5.5)

36.0 (0.0)

33.7 (6.9)

Hispanic

Other Parenting Status Yes

26.6 (3.7)

Black

32.2 (6.4)

Race/Ethnicity White

Age (years) Under 30

32.1(5.6)

33.0 (6.7)

Total Sample

30 and older

17.8 (5.7)

32.5 (6.0)

Characteristics

17.6 (6.1)

Disclosure management

APSS total

8.2 (3.8)

8.1 (2.5)

7.0 (0.0)

8.5 (2.1)

9.4 (5.5)

7.1 (1.9)

7.9 (2.9)

7.8 (3.2)

8.8 (3.4)

8.1 (3.3)

Resistance and resilience

6.6 (1.6)

6.1 (2.0)

9.0 (0.0)

6.0 (1.4)

6.3 (2.3)

5.6 (1.7)

6.4 (1.5)

6.1 (2.0)

6.7 (1.6)

6.3 (1.9)

2.7 (−0.8–6.2) 0.2 (−1.8–2.2)

−0.2 (−2.2–1.9) 1.6 (−3.2–6.4) 3.2 (−3.4–10.0) 0.5 (−56.7–57.7) —

0.1 (−4.6–4.8) 1.5 (−0.3–3.3)

1.1 (−0.6–2.8)

0.1 (−0.8–0.8) 0.8 (−2.6–4.3) 0.4 (−4.0–4.8) 0.0 (0.0–0.0) — 0.7 (−0.5–1.9) 0.0 (0.0–0.0)

1.8∗ (0.3–3.4) −0.7 (−2.7–1.3)

0.8 (−1.1–2.7) 0.0 (−0.0–0.0)

0.3 (−0.5–1.1)


−0.15 (−1.6–1.3) 1.6 (−1.1–4.3) −0.14 (−6.9–6.6) 0.5 (−44.0–45.0) —

−2.6 (−6.2–0.9) 1.6∗∗ (0.5–2.7)

0.3 (−1.1–1.7)


−0.2 (−2.0–1.5) −0.3 (−0.9–0.3)

−0.5 (−1.1–0.2) −0.3 (−2.4–1.7) −0.7 (−3.3–1.8) 0.0 (0.0–0.0) —

−0.5 (−1.6–0.7) −0.2 (−1.1–0.8)

−0.3 (−1.0–0.5)

Discrimination

Pre-post differences time 1 mean—time 2 mean (95% confidence interval)

Discrimination APSS total

Mean baseline scores mean score (Std. deviation)

TABLE 4 Baseline and Pre-to-Post Differences in APSS Scores


653

Nurse

18.8 (4.0)

32.3 (6.0) 18.7 (3.9)

18.1 (5.8)

32.3 (5.9)

34.4 (5.7)

21.5 (3.5)

19.2 (5.5)

16.8 (9.8)

18.0 (1.0) 15.3 (5.0)

18.2 (4.1)

17.9 (6.3)


38.0 (2.8)

33.7 (6.6)

Bachelor’s Degree

Some Graduate/ Professional School Graduate/ Professional Degree Job Type Counselor

36.5 (4.7)

29.3 (2.1) 29.9 (5.6)

32.9 (6.6)

32.7 (6.2)

Associate’s Degree

Education High School Some College

Gay, Lesbian Bisexual, Trans, or Queer

Sexual Orientation Heterosexual

Characteristics

APSS total

9.4 (2.9)

7.1 (2.6)

7.5 (3.6)

10.5 (0.7)

7.8 (2.5)

12.2 (4.6)

7.0 (1.0) 7.7 (2.2)

7.9 (2.9)

8.3 (3.5)


5.6 (1.8)

6.6 (1.5)

6.2 (1.7)

6.0 (1.4)

6.8 (1.6)

6.4 (2.2)

4.3 (2.1) 6.7 (2.3)

6.8 (1.7)

6.2 (1.8)

1.2 (−0.2–2.7) −0.3 (−2.5–2.0) −0.3 (−2.5–1.9)

1.0 (−1.0–3.0) −0.7 (−4.0–2.7) −0.5 (−3.0–2.0)

— 2.6∗∗ (1.2–4.0) −4.0 (−30.3–22.2) −0.9 (−3.6–1.8) —

(−3.6–4.1)

(−4.7–5.3) — 3.8∗ (0.0–7.7) 5.0 (−83.9–93.9) −0.4 (−4.7–3.8) —

0.3 (−1.4–1.8) 0.29

1.3 (−0.6–3.2) 0.3


(Continued)

−0.6 (−1.4–0.1) −1.3 (−3.0–0.5)

0.0 (−0.7–0.7)

−0.2 (−1.4–1.1) −0.6 (−1.7–0.6) 0.6 (−0.3–1.5)

— −0.8 (−3.1–1.6) 0.5 (−6.7–7.7) −0.4 (−1.5–0.7) —

(−2.7–1.3)

−0.1 (−1.0–0.7) −0.7

Discrimination

— 1.4 (−1.6–4.4) 1.0 (−1.1–3.10) 0.0 (−1.6–1.6) —

(−1.1–2.5)

0.2 (−0.8–1.1) −0.7






654

15.3 (3.8)

28.5∗ (2.7)

Surgical Assistant

33.25 (6.8)

30.6 (7.5)

31.6 (4.1)

3–5 years

6–9 years

10+ years

15.7 (6.1)

16.7 (6.2)

18.3 (7.0)

16.0 (5.6)

20.3 (4.4)

12.0 (0.0) 17.5 (7.1)

∗∗

Indicates significant difference at p < 0.05 level. Indicates significant difference at p < .01 level. —Indicates too few observations to calculate differences.

∗

31.4 (6.7)

34.9 (5.2)

1–2 years

Time at Organization > 1 year

26.0 (0.0) 33.2 (7.1)

18.7 (6.7)

31.6 (5.4)

Recovery Room Assistant Manager

Prep/Cleanup Other

13.5 (2.1)

27.0 (1.4)

Physician

21.0 (2.0)

34.0 (1.8)

Characteristics


APSS total

8.9 (4.2)

7.3 (2.4)

8.7 (4.3)

8.2 (1.3)

8.2 (2.5)

7.5 (0.7) 7.9 (4.2)

7.0 (2.1)

6.1 (1.7)

6.0 (1.4)

7.3 (2.1)


7.0 (1.9)

6.7 (1.10)

5.9 (2.5)

7.2 (1.9)

6.3 (1.6)

6.5 (0.7) 6.7 (2.1)

6.1 (2.3)

6.7 (1.1)

7.5 (0.7)

5.8 (1.0)

−0.6 (−7.1–5.9) 1.3 (−2.5–5.1) −0.9 (−6.4–4.6) 0.7 (−2.1–3.5) 1.0 (−2.4–4.4)

0.4 (−1.9–2.7) 0.2 (−1.5–1.7) — 0.5 (−3.0–4.0)

−0.7 (−3.9–2.4) 0.9 (−4.2–5.9) — 3.8∗ (0.4–7.2) −1.0 (−13.4–11.3) 6.0 (−3.0–15.0) 0.5 (−2.8–3.8) 0.3 (−2.8–3.4) 2.8 (−7.6–13.1)

4.0 (−3.4–47.4) —

4.0 (−8.7–16.7) —


−0.6 (−4.2–3.0) 3.7 (−2.6–9.9) −0.8 (−3.1–1.4) −0.1 (−1.9–1.6) 0.8 (−0.8–2.4)

−0.7 (−2.7–1.3) 1.0 (−0.6–2.6) — 0.5 (−1.6–2.5)

0.0 (−12.7–12.7) —


−1.5 (−3.3–0.2) 1.0 (−1.5–3.5) −0.6 (−2.6–1.3) −0.3 (−1.4–0.9) 1.2 (−3.0–5.4)

−0.4 (−1.5–0.6) −0.6 (−2.4–1.2) — 0.4 (−1.6–2.3)

0.0 (0.0–0.0) —

Discrimination




TABLE 4 Baseline and Pre-to-Post Differences in APSS Scores (Continued)



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part of the evaluation of the Providers Share Workshop. To our knowledge, this is the only quantitative measure of abortion providers’ lived experience of stigma.


Developing the APSS and Its Subscales We developed our instrument with the intent of assessing providers’ exposure and responses to stigma in varying contexts, and our results suggest it offers a good starting point for this purpose. The factor analysis resulted in three subscales: Disclosure Management, Discrimination, and Resistance and Resilience, which roughly correspond to previously identified constructs in stigma survey research (Van Brakel, 2006). This indicates that our measure captures similar constructs to other validated instruments, which improves confidence in its validity. Factor analysis results revealed that the eliminated item regarding violence (item 2) was weakly and equally related to both discrimination and disclosure management. The item addressed both physical and verbal abuses, which likely are not experienced in the same way; this ambiguity may have contributed to its indiscriminate loading. Alternatively, the indiscriminate loading of this item may suggest that providers understand violence as a known risk associated with their work and accept the burden of managing that risk through their disclosure practices. This interpretation mirrors qualitative findings in which providers described feeling vulnerable to violence as a factor considered in their disclosure decisions (Harris et al., 2011). Though individual clinics often manage physical risk by implementing safety mechanisms (e.g., metal detectors, video surveillance), less attention has been paid to helping employees manage the emotional impact of coping with the potential for violence. In a way, providers’ willingness to self-manage this risk through their disclosure practices may permit prochoice political institutions to overlook the emotional challenges workers may face. It may also drive those individuals unwilling to manage it away from providing abortions.

Abortion Providers’ Reports of Stigma Abortion providers manage stigma, in part, through disclosure decisions. In our study, providers worried about disclosing their abortion work and avoided it “sometimes.” Some scholars have suggested that lack of disclosure is driven solely by internalized feelings of shame (Corrigan et al., 2003; Rüsch, Angermeyer, & Corrigan, 2005). However, we believe that providers’ consciousness of fluctuating circumstances and contexts leads them to choose disclosure or non-disclosure in a reasonable effort to avoid unnecessary unpleasant situations, discrimination, and threat.


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Previous research has suggested that “dirty workers” can experience their work as heroic or honorable in the face of stigmatization (Harris et al., 2011; Hughes, 1951; Joffe, 1987; O’Donnell, Weitz, & Freedman, 2011). In our study, providers reported high levels of pride and felt that their work made a positive contribution to society, yet simultaneously reported that they felt unappreciated by society and marginalized within the medical field. It appears that providers’ sense of pride and the meaning they find in their work may serve as a buffer against social devaluation. Notably, providers’ overall survey and subscale scores did not change after they participated in the Providers Share Workshop. The Abortion Provider Stigma Survey was designed to measure providers’ perceptions of, exposure to, and responses to stigma. But because abortion stigma is produced and enacted in multiple spheres of social life, most of which exist outside the influence of the workshop, the lack of change in scores after the workshop was not unexpected. Though one possible outcome of the workshop was reduction of the negative impact of abortion stigma on workers—and qualitative results from the pilot suggest this is the case (Harris et al., 2011)—the task of dismantling abortion stigma itself was outside the scope of the workshop. Accordingly, the subscale with the greatest potential for change following the workshop was Disclosure Management, which captured participants’ responses to stigma. Our results revealed changes in disclosure practices among subgroups of providers toward greater disclosure, suggesting that workshop participation may influence the stigma management strategies some groups of abortion providers use. Specifically, Disclosure Management scores for providers with children and providers over age 30 indicated increased comfort with disclosure after the workshop. These findings support previous qualitative research that suggests providers with children might be more cognizant of the potential costs that disclosure could have on their families (Harris et al., 2011; O’Donnell, Weitz, & Freedman, 2011). Though these groups likely overlap somewhat, it is also possible that older participants, regardless of parenting status, have greater professional ties and other constraints that lead them to disclose their work less frequently than younger participants. Following the workshop, they may have felt more inspired to reach out to others as a way to combat the isolation and interpersonal disconnections produced by abortion stigma (Harris et al., 2011).

LIMITATIONS While the current study provides new insights, it has several limitations. Perhaps most importantly, the study is limited by a small sample size, particularly for reliable exploratory factor analysis. The projected sample size of the national study would have provided sufficient power for this study by standard rules of thumb (5 to 20 participants per item) (Gorsuch, 1983).



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However, sample sizes can be relatively small when communalities are high (>0.6), as was the case with the majority (11 of 13) of factor loadings, and there are four or more items per factor, which was true for two of the three factors (MacCullum et al., 1999; Worthington & Whittaker, 2006). Lack of an expanded potential item pool for measure development also resulted in several limitations. First, it is likely that the weakness of the Discrimination subscale and the ambiguity of Item 2 were direct consequences of this constraint. New items addressing multiple forms of discrimination and violence could replace Item 2 in future iterations. Second, the instrument assessed the positive aspects of internalized stigma, namely, resilience and resistance, but it did not include shame and guilt, which are often components of other stigma measures. However, we believe that items that tested well in this field test likely constituted the core concepts of the instrument. Future study with an expanded item pool followed by exploratory factor analysis would help address these limitations. Several issues exist regarding generalizability. First, each site was responsible for conducting their own recruitment measures, resulting in lower than anticipated recruitment. As we do not have any comparable data on those providers who did not elect to participate in the workshops, it is possible that this self-selected group is biased. Second, our all-female sample likely reflects a gendered perspective of abortion stigma; men working in abortion care may have different experiences (Harris et al., 2011). Demographics for physician abortion providers indicate a current male predominance, but a trend toward feminization of the workforce. No data exist on the gender balance of the abortion workforce as a whole. However, because nursing, administrative, and counseling professions in general are predominantly female (HRSA, 2010; NASW Center for Workforce Studies, 2006), it is likely that the total population of abortion providers is largely female. Additionally, the workshop sample had a low rate of physician recruitment, especially as compared to the pilot. This may reflect logistical difficulties or a sense of detachment from other workers—physicians are often part-time workers at clinics and divide their time among many sites. Future studies should investigate physician- and gender-specific barriers related to participating in this or other similar workshops. For these reasons, these findings are not necessarily representative of all abortion providers. Despite these limitations, we are encouraged by the results of the first deployment of the Abortion Provider Stigma Survey as a starting point for measuring abortion provider stigma.

CONCLUSION This first use of the Abortion Provider Stigma Survey suggested that it may be a useful tool for quantifying and understanding provider perceptions of stigma. Future analysis with larger, more representative samples, additional


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items, and confirmatory factor analyses will allow us to fully validate the results and establish its usefulness in assessing abortion provider stigma. Following such studies, the survey could be used to explore the relationship between stigma and resilience and coping, professional satisfaction, and worker tenure; it could also be used to guide supportive interventions for strengthening the abortion workforce. The Abortion Provider Stigma Survey captured the experiences of, responses to, and outcomes of pervasive abortion stigma among diverse abortion workers. Workers do feel devalued and face difficult decisions around disclosure. However, the instrument also suggests abortion providers resist stigmatization and have high levels of pride that may help insulate them from negative effects of stigma. As we seek to encourage and sustain abortion providers, we must consider the impact of stigma. The Abortion Provider Stigma Survey may provide a useful tool to measure, evaluate, and understand abortion stigma and its influence on retention and recruitment in the abortion workforce.

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APPENDIX: THE ABORTION PROVIDER STIGMA SCALE ITEMS


Please consider your experiences as someone who works in abortion services. Indicate how often you have felt or experienced the following: All of the time [1], Often [2], Sometimes [3], Rarely [4], Never [5]. Disclosure Management 1 People’s reactions to my being an abortion worker make me keep to myself∗ 4 I feel marginalized by other health workers because of my decision to work in abortion care∗ 10 I feel like if I tell people about my work they will only see me as an abortion worker∗ 11 I worry about telling people I work in abortion care∗ 12 It bothers me if people in my neighborhood know that I work in abortion care∗ 13 I avoid telling people what I do for a living∗ 14 I am afraid that if I tell people I work in abortion care I could put myself or my loved ones at risk for violence∗ Resilience and Resistance 6 I am proud that I work in abortion care 7 I feel connected to others who do this work 9 By providing abortions I am making a positive contribution to society 15 I find it important to share with people that I work in abortion care Discrimination 3 Newspapers/television take a balanced view about abortion care 5 I feel that patients use me as an emotional punching bag∗ Items Dropped from Analyses Following Exploratory Factor Analysis 2 I have been physically or verbally threatened or attacked as a result of working in abortion care∗ 8 I feel that society does not appreciate the work I do in abortion care∗ ∗

Items are reverse coded, ensuring that higher values indicate greater stigma.

Commentary: abortion provider stigma and mainstream medicine.

Everything is not abortion stigma.

Commentary: imagine a world without abortion stigma.

Introduction: bringing abortion stigma into focus.

Abortion 'on the NHS': the National Health Service and abortion stigma.

HIV-Related Stigma Among Healthcare Providers in the Deep South.

Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya.

AIDS stigma and discrimination among migrant workers in Zhejiang, China.

Psychosocial factors and pre-abortion psychological health: The significance of stigma.

Assessing Stigma among African Americans Living with HIV.

Measuring HIV stigma at the family level: psychometric assessment of the Chinese Courtesy Stigma Scales (CCSSs).

ADHD stigma among college students.

Association between patient-provider communication and lung cancer stigma.

TRAP laws and the invisible labor of US abortion providers.

Development of a Conceptual Model and Survey Instrument to Measure Conscientious Objection to Abortion Provision.

Exploring stigma by association among front-line care providers serving sex workers.

Stigma creating stigma: a vicious circle.

Service provider perspectives on post-abortion contraception in Nepal.

Stigma and Self-Stigma in Addiction.

Measuring stigma after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Stigma item bank and short form.

Stigma among California's Medical Marijuana Patients.

Stigmatized by association: challenges for abortion service providers in Ghana.

Internalized stigma and stigma resistance among patients with mental illness in Han Chinese population.

Perceptions of misoprostol among providers and women seeking post-abortion care in Zimbabwe.