Sexual outlook refers to individuals’ values and convictions toward sex, including systematic and consistent thoughts, emotions, views, patterns of behavior, and knowledge, often affected by the culture to which the individuals belong [1
]. Sexual outlook incorporates physical and mental satisfaction, the meaning of sex, the handling of sexual matters, the diversity of one’s sexual life, the use of resources such as sexual counseling and education, prejudice toward sex, knowledge about sex, openness to sex, and sexual responsibilities [2
]. In other words, people’s sexual outlooks reflect their education, environment, personal experience, and sociocultural elements. People express their sexual behaviors and thoughts based on their values and beliefs about sex. However, sexual and reproductive health are not discussed or are insufficiently discussed in many countries because issues of sexuality make people feel uncomfortable [6
Sexual activities positively affect physical and mental health [7
]. A positive and open outlook towards sex aligns with a higher sexual need, more knowledge about sex, and more sexual activities [8
]. As knowledge and outlooks toward sex closely relate, better sexual knowledge aligns with the formation of good sexual outlooks that enable adolescents, adults, and elders to maintain regular sexual activity [9
]. To remain satisfied in one’s sexual life, it is important to have positive and open outlooks toward sexual and reproductive health that can improve one’s quality of life, regardless of disabilities.
Sexual outlook researchers in Korea used modified instruments to consider current social or cultural situations [10
]. In using any instrument in a culture and environment outside the area in which the instrument was developed, a validity confirmation study must be performed [5
]; in Korea, the use of instruments is limited to previously developed instruments to measure sexual outlook that were not validated with research [3
]. A strong need exists to develop and validate a new universal instrument that briefly measures Korean people’s sexual outlooks, reflecting various population demographic characteristics.
The purpose of the present study was to develop the Sexual Outlook Questionnaire (SOQ) that can apply to a wide range of Korean people, including those with disabilities, and to validate the best set of possible items for the comprehensive use of research in improving clinical practice of sex education and developing sex-related intervention programs to protect the human rights of general adult populations.
2. Materials and Methods
2.1. Study Design
This was a methodological study to develop and evaluate the best set of SOQ items for Korean adults and to test its validity and reliability.
2.2. Study Participants
Participants in the present study were married or previously married adults of at least 19 years of age residing in the local society with no cognitive impairment. Participants who were disabled were outpatients or participating in health examinations whose disability had occurred at least one year before and who consented to participate in the present study. Those not eligible for the present study were people less than 19 years of age who were never married, with cognitive impairment, hospitalized for treatment, or whose disability had occurred within less than one year, and who did not consent to participate in the present study.
A convenient sampling was used in Seoul and the Gyeonggi-do area. The number of participants in the present study was 350 people with and without disabilities (130 with disabilities and 220 people without) residing in Seoul and the Gyeonggi-do regions. The number of participants was decided according to the argument that the ratio of cases and measurement variables should be more than 10:1 in an exploratory factor analysis [12
] and the appropriate number of participants is between 200 and 400 for researchers to construct a structural equation model for confirmatory factor analysis [13
]. We excluded data from 16 respondents who gave the same answer to all questions or who responded insincerely; thus, the data from a total of 334 respondents were used in the analysis.
2.4. Patient and Public Involvement
The SOQ for Korean adults used in the present study was developed and its validity was tested in two stages: the questionnaire-development stage and the questionnaire test stage. The literature related to sexual health was surveyed and in-depth interviews were conducted in the questionnaire development stage with those who were sexually active, including two people with myelopathy, one couple where one spouse had a stroke and the other had no disability, and three people without disabilities to determine the primary preliminary questionnaire. In the second step, we conducted a Delphi survey with seven experts, including physicians in rehabilitation medicine and gynecology and a clinical psychologist with more than five years of clinical practice, a Ph.D. in social welfare, a Ph.D. in nursing, a sex educator, and a Ph.D. in counseling to verify and revise the content validity of the primary preliminary questionnaire. A secondary Delphi survey was conducted with five experts in sex counseling to complete the secondary preliminary questionnaire. We conducted a preliminary survey using the secondary preliminary questionnaire with 10 people with disabilities and 10 without disabilities to check the appropriateness of the wording, the arrangement of the questions, and the applicability of the questions. After consulting with a scholar in Korean literature, we confirmed the final version of the questionnaire.
2.5. Questionnaire Development
Based on the literature review, we collected questions related to sexual outlook characteristics. In-depth interviews were conducted to extract meaningful statements about participants’ sexual lives. Interviews began with semi-structured questions such as, “What do you think about sex?” “How is your entire life affected by your sexual life?” “What is your wish for your sexual life in your future?” More detailed questions followed. We classified the questions extracted from the literature review and the interviews by similarity, segregated into five categories: values of sex (6 items), benefits of sex (9 items), meanings of sex (6 items), sexual assertiveness (6 items), and sexual responsibility (4 items). Therefore, the primary preliminary questionnaire consisted of 31 questions. Sexual outlook was measured on a 5-point Likert-type scale including the options of “strongly disagree”, “disagree”, “so-so”, “agree”, and “strongly agree”. A higher score indicated a positive sexual outlook.
The initial questionnaire included preliminary items of 29 questions measuring sexual outlooks with 10 questions about the participants’ general characteristics and the 10-point visual-analog scale to express the importance of sexual activity in one’s life. General characteristics included gender, age, education level, marriage status, employment, religion, disease history, presence of disability, type of disability, and time of disability occurrence.
2.6. Data Collection
The study proposal was approved by the Institutional Review Board of the National Rehabilitation Center (Approval No. NRC-2017-02-013). The data accrued from July to October 2017. Four research assistants who had research experience helped the data collection. They received about 30 min of education on the purpose of the study, the participants, and the method of collecting the questionnaires. Researchers explained the purposes and procedures of the study to participants and informed participants that their confidentiality would be secure, they could withdraw from the study any time during the survey, and their participation was voluntary. Participants completed the questionnaire on their own, but research assistants helped those who needed help due to a disability. The completed questionnaire was collected and sealed with a separate consent. A small gift was provided to each participant. The time taken by participants to complete the questionnaire was about 15 to 20 min.
2.7. Data Analysis
The SOQ’s validity and reliability were examined using IBM SPSS Statistic 22.0 and AMOS 22.0 software programs. The descriptive statistics and frequency analyses were performed with respect to the participants’ general characteristics and study variables. The content validity was tested by measuring the questions’ appropriateness on a 4-point scale. The content validity index (CVI) was calculated and questions having a CVI of 0.80 or higher were selected. To test construct validity, x Pearson’s correlation of the questions was analyzed and an exploratory factor analysis and confirmatory factor analyses were performed. We performed the Kaiser–Mayer–Olkin (KMO) test, Bartlett’s sphericity test, and the Measure of Sampling Adequacy (MSA) test to determine if the data were appropriate for the factor analysis. For the exploratory factor analysis, a principal component analysis (PCA) and a varimax rotation method were used to determine the number of factors with an eigenvalue of 1 or higher and which factor loadings were 0.5 or higher [12
]. After determining the number of factors, a confirmatory factor analysis was utilized to calculate model fitness. The fitness of the structural equation model was determined by considering the χ2
value, the degree of freedom (df), the root-mean-square residual (RMR), the root-mean-square error of approximation (RMSEA), the goodness-of-fit index (GFI), the comparative fit index (CFI), and the Tucker–Lewis Index (TLI) [14
]. A multi-trait/-item matrix analysis was performed to test convergent and predictive validity, and Cronbach’s α coefficient evaluated the reliability of the developed questionnaire.
Sexual outlook reflects a person’s psychological state [16
] and is expressed differently depending on the individual’s convictions and values, which sociocultural influences affect [17
]. The developed questionnaire that has well-validated and reliable items considers South Korea’s cultural characteristics, which are applicable to the general population including people with or without disabilities. We identified the SOQ’s three constructs (personal benefit, relational value, and sexual endeavor) by reviewing previous studies conducted on people with and without disabilities, quantitative and qualitatively.
Most previous studies that conducted research on sexual outlooks in Korea and other countries focused on specific populations such as nurses [18
], college students [20
], and elders [5
]. However, the questionnaire developed in the present study comprehensively embraced a wide range of age groups to measure the general traits of sexual outlooks in adult populations. As sexual outlook is an individual psychological factor [18
], it should not be ignored for those with differences such as physical disabilities [22
Hendrick et al. [4
] classified their scale items with four categories: “Permissiveness”, “Birth Control”, “Communion”, and “Instrumentality”. Similar to Hendrick et al., the SOQ developed in the present study has three factors: “personal benefit of sex”, “relational value of sex”, and “sexual endeavor”.
Factor 1 (“personal benefit”) addressed how sex impacted participants’ lives and included three questions about the health-promoting effects of sex in those with and without disabilities who were asked to respond about their recognition of healthiness, youth, and vitality as the benefits of their sex life. Factor 2 (“relational value”) included four questions about sex as an expression of love and a means of communication, the effect on the improvement of the relationship with the spouse (partner), and the willingness to solve sex-related problems. Factor 3 (“sexual endeavor”) included questions about the handling of sex-related problems, consulting with an expert, and sex education. The questionnaire developed in the present study is more convenient than conventional ones and contains essential questions that can induce a positive change in a person’s future sexual life. Therefore, the questionnaire may raise positive sexual interests and considerations among not only the adults who are or were married, but also among elders and people with disabilities who have been neglected and disadvantaged in their sexual lives.
Kedde et al. [23
] reported that about 50% of patients who have a disability or chronic disease need professional help in finding sexual partners and adapting to a sex life because of their health issues, and 40% of them need professional help with regard to sexual relations, practical sex-related problems, and sexual impairment. Kedde et al. also reported that two-thirds of participants in their study considered visiting an expert, but only 35% actually visited a medical expert. In addition, only one-third of those who had actually visited an expert responded that they had been positively affected by counseling with the expert. The survey in the present study showed that 35.2% of subjects currently have a sexual disability and the causes of the sexual disabilities were on the order of paralysis (27.8%), decreased sexual desire (25.2%), decreased sexual function (20.9%), and pain during sexual intercourse (13.9%). These results showed the sex-related problems of people with disabilities and suggested that various studies may need to be conducted on participants’ sexual outlooks according to gender, age, and types of disability using a verified scale.
The present study has the following limitations. First, the number of participants with a disability was not sufficiently large; thus, the validity of the questionnaire was not tested as a questionnaire of only people with disabilities. Therefore, a validity test must be conducted with respect to people with disabilities only, after securing a sufficiently large number of samples. Second, because participants in the present study were those residing in Seoul and Gyeonggi-do, the results of the present study may not be generalized to other regions of Korea.
Despite these limitations, the questionnaire developed in the present study was found to be sufficiently reliable. As participants in the present study included men, women, and people with and without disabilities in appropriate ratios, the questionnaire may generally apply to any group of adults, regardless of age and the presence of disabilities in the area of Seoul and Gyeonggi-do. However, the measurement assessed by the SOQ developed in the present study may be applied to capture the current problems of one’s sexual life and sexual outlook so healthcare professionals and heath service researchers could design and employ various sex-related programs to improve their knowledge and quality of life involving sexual health, and resolve current problems through various types of practical studies on sex education.