The PRIDE Scale included 39 new test items examining LGBTQI+ health care knowledge, awareness, attitudes, skills, and the work environment,. Development of these items was iterative and generated through literature reviews, expert consultation, and adaptation from existing scales. The Delphi method was used to select the most relevant items via iterative rounds of feedback from an expert panel. The first step was to identify and recruit a diverse group of international experts with relevant experience in LGBTQI+ health care, psychometric scale development, and clinical competence. These experts included health professionals (mostly physicians and psychologists), LGBTQI+ health advocates, clinicians, researchers, public health professionals with expertise in biostatistics and epidemiology, and educators. In total, the panel was comprised of 12 members. There were 3 Delphi rounds. In the first round of item generation, experts on the study team developed a broad number of items (100) both from the existing literature and newly formed items, which were then randomly listed and presented to the expert panel. Experts were asked to evaluate each item based on its relevance, clarity, and its potential importance for measuring LGBTQI+ related competencies among health care professionals. Experts could also comment on each item and suggest new or adapted items. After the first round, responses were scored for relevance and ordered accordingly. Quantitative consensus was defined a priori as a threshold of ≥75% and a median rating of ≥4 on a 5-point scale indicating an item as important or very important. These thresholds align with accepted Delphi standards and ensure that retained items reflect high agreement and rating stability. Based on the scoring (1-100), 39 items that showed strong consensus for inclusion were retained. These items are measured on a 5-point Likert-style scale that ranges from 1 (strongly disagree) to 5 (strongly agree).

In designing the scale, the team made several decisions to ensure applicability and interpretability. We drew upon existing implicit bias scales. While the scale is aimed toward those who provide clinical care, we ensured that the questions had a broad reach by using “clients or patients” instead of “patients” alone. We also avoided questions that were overly technical or related to specific specializations. While we believe it is important to address the needs of specific sexual and gender minority groups, we restricted these to a few questions rather than repeating questions by group. We elected to phrase questions in a way that addresses perceptions of one’s specific institution rather than perception of self. Finally, we avoided some questions over concerns about long-term relevance (eg, specifying pronouns when working with colleagues or clients, as this may become more normalized over time).

In addition to the 100 test items, to enable convergent construct validity testing and criterion and concurrent validity testing of the PRIDE scale, 2 further scales were used forming part of the main survey; these included the LGBT-DOCSS [22]; and the LGBTCI [24,28]. The LGBT-DOCSS is an internationally established, interdisciplinary self-assessment for health and mental health professionals working with LGBT clients [21]. The scale is comprised of 18-items and 3 subscales (clinical preparedness, attitudes, and knowledge). Items are rated on a 7-point Likert scale (1 strongly disagree to 7 strongly agree), with 8 items reverse-scored. For our purposes, we adjusted this to a 5-point scale, as we felt it would reduce cognitive load and potentially improve response rates. The loss of granularity would have minimal to no loss of psychometric information. From these items, a total mean score and 3 subscale scores (clinical preparedness, attitudes, and knowledge) can be computed. Higher scores thus reflect greater levels of LGBT cultural competence. The LGBT-DOCSS has demonstrated strong reliability and construct validity [22]. The LGBTCI is a well-used and researched assessment of LGBT workplace support and overall climate [24,28]. For this survey, we used only the 12-item Workplace Support subscale, in which items are rated on a 4-point Likert scale from 1 (doesn’t describe at all) to 4 (describes extremely well).

Additionally to the above, the main survey also included screening items (namely, consent, previous participation check, and age) and demographics (current employment, clinical and practice specialization, health and social care facility type, gender identity, sexual orientation, network diversity, ethnicity, and political ideology). The exact items and their phrasing were adjusted between the United States and European versions of the surveys to ensure cultural relevance.

A cross-sectional multicenter, multicountry scale validation study. Participants were recruited from October 2024 to December 2025. Study sites were located in Boston (United States), Washington, DC (United States), New York (United States), Brighton (United Kingdom), and Verona (Italy).

The study population consisted of health professionals, including students or health professionals-in-training, such as physicians, nurses, and other allied health professionals (eg, podiatrists, occupational therapists, physiotherapists, and mental health professionals) working in Italy, the United Kingdom, and the United States, with respondents able to complete the survey in English or Italian, depending on the country. The goal was to have a norming sample of international health care professionals including those in-training.

Sample size was calculated considering the 2 main statistical techniques to be used in the analysis: exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Based on the literature, as a rule of thumb (item-to-participant ratio), 5 to 10 participants per item are required [29-32]. For the 39-item PRIDE scale, this would translate to a minimum of 195 participants (5 participants per item) and a preferred sample size of 390 participants (10 participants per item). However, as we are planning an EFA and CFA, a total of approximately 700 participants is planned. For test-retest reliability, based on Walter et al [33], and assuming a null intraclass correlation coefficient of 0.40, an expected intraclass correlation coefficient of 0.70, 2 administrations of the scale, a significance level (α) of 0.05, and a power (1–β) of 0.80, a sample size of 62 is required.

Eligible participants needed to be aged 18 years or older and be a health care professional or health care educator in a health and/or social care setting in Italy, the United Kingdom, or the United States (eg, physician, psychiatrist, psychologist, counselor, social worker, occupational therapist, university lecturer, paramedic, nongovernmental organization practitioner, nurse, etc) or currently training for a profession involving health and/or social care (eg, student nurse, medical student, mental health therapist-in-training); and be able to provide informed consent (online) to participate in the survey. Exclusion criteria were those aged under 18 years, and not a health care professional (or educator) or health care professional (or educator) in-training.

The final PRIDE survey comprised three main sections as follows (Figure 1): (1) participant screening; (2) demographics; and (3) 39 test items, together with the LGBT-DOCSS [22] and 12 items from the LGBTCI scale [24]. The questionnaire items were translated and back translated for the Italian version. A copy of the final English version of the questionnaire is available as Multimedia Appendix 1. The protocol was developed and completed using the SPIROS (Standardized Protocol Items Recommendations for Observational Studies) guidelines (Checklist 1) [34].

The following institutional review boards approved this study: University of Brighton Cross School Research Ethics Committee B (2025‐15162-Sherriff International LGBTQI+ competency scale); Verona University Hospital (PRIDE - Prog. 491CET); George Washington University (NCR246211, Pratt-Chapman Updating measurement for LGBTQI-Affirming Care); Boston University Medical Center (H-43531, Zumwalt Assessment of educator knowledge and attitudes about sexual and gender minority topics); City University of New York (2024‐0850-Hunter, Bidell Developing a New LGBTQI+ Clinical Competency Assessment Scale for Health and Mental Health Providers). Participants provided informed consent to participate, including an understanding involvement was voluntary, could be withdrawn at any time without justification, and that all information would be handled confidentially.

The development and validation of the new PRIDE scale will represent a significant advancement toward improved cultural competence among health care professionals in Europe and the United States. Validating the scale in English- and Italian-speaking populations will support the development of international interventions and, ultimately, treatment outcomes for LGBTQI+ people globally.

The PRIDE Scale is anticipated to make several distinct contributions to the field of LGBTQI+ health and to the broader science of clinical competency assessment. First, it will provide a contemporary, psychometrically robust instrument that reflects current language, conceptual nuance, and lived realities of LGBTQI+ communities, addressing well-documented limitations of existing tools. Currently, the most frequently used measure of health care professionals’ knowledge and attitudes toward LGBTQI+ individuals is the LGBT-DOCSS, developed nearly a decade ago [21,22], which no longer fully reflects contemporary language, concepts, or understandings of LGBTQI+ identities. Due to evolving cultural norms, some of the LGBT-DOCSS terminology is now perceived as outdated and, in some cases, offensive by survey-takers. The PRIDE Scale will enable researchers to build on the contributions of the LGBT-DOCSS while modernizing the language and explicitly incorporating perceptions of workplace climate, which has been shown to shape patient outcomes [55]. Second, by being developed and validated simultaneously across 3 countries and 2 languages, the PRIDE Scale is positioned as one of the few internationally validated LGBTQI+ competency measures, with formal measurement invariance testing supporting cross-cultural comparability. Third, by integrating individual-level competence (knowledge, attitudes, awareness, and skills) with organizational climate, the scale operationalizes a more ecological understanding of clinical care, consistent with growing evidence that workplace context shapes health care professional behavior and patient experience [25-27]. Fourth, the instrument is expected to function both as a research outcome measure (eg, for educational and organizational interventions) and as a practical self-assessment and quality-improvement tool in clinical and training settings.

Despite challenging political climates, health care professionals remain ethically bound to provide competent and compassionate care to all patients, including LGBTQI+ people. Yet, as social and cultural norms continue to shift, health care professionals are exposed to a wide range of messages about LGBTQI+ communities, starting in their youth, through their specific training experiences, and beyond during their practice as clinicians. These influences create and shape explicit and implicit biases among health care professionals which can negatively impact clinical competence and services for LGBTQI+ people [22]. Although efforts have been made to address such biases, including increasing the number of training hours devoted to LGBTQI+ health, accurately assessing health care professionals’ competence requires reliable and valid self-assessment tools [12,56].

Several limitations should be acknowledged. First, the convenience sampling approach, supplemented by snowball recruitment through professional mailing lists, LGBTQI+ associations, conferences, and institutional teaching sessions, limits the generalizability of the findings to the broader health care workforce in Italy, the United Kingdom, and the United States. To partially mitigate this, the sample demographics will be benchmarked against national statistics. Relatedly, the recruitment strategy is susceptible to network bias: health care professionals with preexisting interest in LGBTQI+ health may be overrepresented, while less engaged or less supportive professionals may be underrepresented, potentially attenuating variability in key constructs and inflating estimates of health care professional readiness and of an inclusive climate. The reliance on self-report measures further introduces social desirability bias, as participants may respond in ways that align with professional norms rather than their actual beliefs, knowledge, or behaviors; anonymous administration reduces but does not eliminate this concern.

Second, although the instrument was developed and administered in multiple languages across 3 national contexts, translation and cross-cultural adaptation processes inevitably introduce subtle semantic and conceptual differences across versions. While measurement invariance testing and Differential Item Functioning analyses will identify items that function differently across linguistic, cultural, or demographic groups, some degree of construct nonequivalence may persist, particularly given the heterogeneous legal, cultural, and clinical frameworks governing LGBTQI+ health across the participating countries.

Third, the Delphi expert panel, while interdisciplinary and international, comprised 12 members, and consensus-based item generation is inherently shaped by the perspectives, disciplinary backgrounds, and sociocultural positioning of the panelists. Although the 75 percent consensus threshold and 3-round structure were designed to enhance rigor, alternative panel compositions might have yielded different item pools, particularly regarding emerging or contested constructs within LGBTQI+ health.

Finally, the PRIDE Scale captures health care professional–reported competence and perceived workplace climate but does not incorporate patient-reported experiences or objective behavioral indicators of inclusive care. Triangulation with patient outcomes, simulated clinical encounters, or organizational audit data will be necessary in future work to fully establish the criterion validity and real-world utility of the instrument. Future longitudinal work will be required to establish these properties and to assess the scale’s responsiveness to educational or organizational interventions.

The development and validation of the new PRIDE scale will represent a significant advancement toward improved cultural competence among health care professionals. Validating the scale in English and Italian-speaking populations will support the development of international interventions and ultimately improve treatment outcomes for LGBTQI+ individuals. Just as the 2017 LGBT-DOCSS has been used to assess medical students [57], residents [58], social workers [59], and interprofessional teams in oncology centers [60], the PRIDE Scale is expected to be used in a myriad of clinical and public health settings. Consequently, the PRIDE Scale has the potential to have a far-reaching impact on the provision of clinical care and public health services across the globe.