Sexual Health Services Questionnaire

Abstract

The Sexual Health Services Questionnaire (SHSQ) is an empirically validated, theoretically driven organizational assessment instrument developed by Scott M. Butler, David R. Black, George H. Avery, Janice Kelly, and Daniel C. Coster in 2008. Designed to evaluate the institutional landscape, clinical capacity, and scope of sexual health programming within postsecondary education, the instrument comprehensively operationalizes the adoption and delivery of sexuality-related services across college and university health centers, student health services, and community-based sexual health clinics. Grounded in Everett M. Rogers’s Diffusion of Innovations Theory (DIT), the SHSQ measures organizational innovativeness through the structural dimensions of institutional complexity, specialized workforce composition, and structural size.

Comprising 100 items distributed across 13 distinct sections, the questionnaire captures clinical staffing models (24 items), the integration and roles of peer education advocates (9 items), safer-sex supply distributions (8 items), barrier distribution mechanics and volumetric output (7 items), contraceptive service provision spanning barrier, hormonal, and emergency modalities (13 items), diagnostic screening technologies for sexually transmitted infections (STIs; 11 items), immunizations against oncogenic and viral pathogens (2 items), gynecological diagnostic and preventive examinations (4 items), specialized clinical examinations including forensic post-sexual assault care (1 item) and testicular evaluations (1 item), sexuality-related mental health and counseling modalities (6 items), regulatory clinical laboratory oversight (1 item), and detailed institutional and administrator demographics (14 items). Most items utilize a dichotomous behavioral-checklist response architecture (present/absent), supplemented by categorical write-in options and continuous volumetric reporting.

Psychometric evaluations from a geographically representative nationwide sample of 358 higher education health centers demonstrated robust internal consistency, yielding section-level Cronbach’s alpha coefficients ranging from .62 to .93 and an overall instrument alpha of .94. Test-retest reliability across a temporal stability sub-sample demonstrated an 87.37% concordance rate across service-related domains. Content and face validity were established through systematic literature synthesis and iterative evaluations by multidisciplinary panels of public health researchers, clinical psychologists, and health center directors. The SHSQ provides a standardized psychometric benchmark for campus health audits, epidemiological surveillance, public health policy formulation, and structural innovation research.

Keywords

Sexual Health Services Questionnaire, Diffusion of Innovations Theory, College Health Centers, Organizational Innovativeness, Institutional Complexity, Sexual Health Programming, STI Screening, Contraceptive Services, Peer Health Education, Health Center Administration

Authors

The Sexual Health Services Questionnaire was conceptualized, psychometrically developed, and validated by a multidisciplinary team of public health researchers, behavioral scientists, and statisticians:

• Scott M. Butler, PhD — Department of Kinesiology, Georgia College & State University, Campus Box 065, Milledgeville, GA 31061 (Email: [email protected]).
• David R. Black, PhD — Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana.
• George H. Avery, PhD — Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana.
• Janice Kelly, PhD — Department of Psychological Sciences, Purdue University, West Lafayette, Indiana.
• Daniel C. Coster, PhD — Department of Mathematics and Statistics, Utah State University, Logan, Utah.

Purpose

The primary purpose of the Sexual Health Services Questionnaire (SHSQ) is to provide a standardized, theoretically grounded psychometric framework for auditing, measuring, and analyzing the availability, diversity, and technological breadth of sexuality-related clinical and preventive services within institutional settings. Although engineered primarily for postsecondary student health services, its diagnostic taxonomy applies directly to outpatient clinics, municipal health departments, youth-focused community health centers, and managed-care ambulatory environments. Emerging adults within college settings experience disproportionate rates of unintended pregnancies and sexually transmitted infections (STIs), such as human papillomavirus (HPV), chlamydia, and gonorrhea, making campus health infrastructures central to contemporary public health intervention.

From a clinical and administrative perspective, the SHSQ resolves the critical problem of non-standardized institutional self-reporting. Historically, institutional inventories of reproductive health relied on disparate, non-validated questionnaires that failed to distinguish between specialized primary providers and non-specialized general clinicians, or between the mere presence of a product and the clinical modalities required to dispense it. The SHSQ systematically categorizes professional staffing tiers, peer-led preventive infrastructures, clinical diagnostic capacities, therapeutic contraceptive arrays, and post-trauma intervention services. Health center directors, campus administrators, and accreditation bodies utilize the instrument to conduct baseline institutional audits, pinpoint clinical service deficits, evaluate institutional compliance with national clinical standards, allocate capital and human resources, and benchmark institutional offerings against national and regional peer institutions.

From a research and psychometric perspective, the SHSQ provides operational tools to test sociological and organizational behavior models—most notably Everett M. Rogers’s Diffusion of Innovations Theory (DIT). Rather than treating health centers as monolithic delivery entities, the SHSQ allows researchers to evaluate how structural and social characteristics (such as professional staffing complexity, workforce training breadth, peer health advocate integration, and student population volume) predict an organization’s propensity to adopt cutting-edge biomedical and psychosocial innovations. These innovations include rapid point-of-care STI diagnostics, emergency contraception access points, pre-exposure immunizations, and specialized survivor services for sexual assault trauma. The instrument bridges the gap between individual health behavior theories and macroscopic organizational systems science.

Psychological Construct

The SHSQ captures organizational-level behavioral and structural constructs rather than individual psychological states. In the psychometric tradition of organizational assessment, the institutional unit of analysis exhibits behavioral tendencies, structural capabilities, and innovation-adoption characteristics analogous to individual personality profiles. The SHSQ operationalizes three primary psychological and organizational dimensions: Organizational Complexity, Organizational Innovativeness, and Organizational Size and Capacity.

1. Organizational Complexity

Drawing on structural organizational theory, complexity represents the degree to which an institution’s human capital possesses specialized expertise, differentiated knowledge bases, and advanced professional credentials. Within the SHSQ framework, complexity is not operationalized merely as total staffing volume; instead, it captures professional heterogeneity and structural differentiation. The construct evaluates the presence of specialized professionals whose primary, formal job description is dedicated to sexual and reproductive health (such as dedicated Sexuality Program Coordinators, Sexual Health Educators, and Sexual Assault Nurse Examiners [SANE]), contrasted against clinical personnel who provide sexual health services on an ad-hoc or secondary basis (such as general internists, nurse practitioners, physician assistants, clinical psychologists, psychiatrists, and clinical social workers). Furthermore, complexity incorporates structural role differentiation via peer-education auxiliary systems. When an organization utilizes paraprofessional student peer educators across diverse functional spheres—ranging from clinical outreach and relationship counseling to STI pre-test counseling and condom distribution—it reflects high operational complexity and decentralized health education networks.

2. Organizational Innovativeness

Organizational innovativeness reflects an institution’s readiness, speed, and comprehensive capacity to adopt new technologies, evidence-based practices, biomedical prevention tools, and psychosocial counseling interventions. In the SHSQ, this construct manifests through multi-tiered operational domains:

• Barrier Product Heterogeneity and Distribution Innovation: Moving beyond traditional male latex condoms to include female (internal) condoms, non-latex polyurethane barriers, dental dams, specialized lubricants, and sized products, alongside decentralized non-clinical distribution channels (e.g., residence halls, campus bars, and after-hours pickup).
• Contraceptive Technological Breadth: The institutional adoption curve of hormonal and mechanical contraceptives, evaluating whether clinics offer contemporary long-acting reversible contraceptives (LARCs, such as hormonal and copper intrauterine devices [IUDs] and sub-dermal implants), combined and progestin-only oral formulations, transdermal patches, vaginal rings, barrier diaphragms/caps, behavioral fertility awareness training, and both prescription and over-the-counter emergency contraception.
• Biomedical Diagnostic and Screening Sophistication: The operationalization of state-of-the-art diagnostic screening, ranging from traditional serological tests to rapid point-of-care capillary or oral-fluid HIV testing, nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae, HPV DNA molecular assays for cervical screening, and diagnostic colposcopy.
• Preventive Immunization Capacity: Proactive clinical integration of prophylactic vaccines against sexually transmissible oncogenic viruses, specifically the multi-valent Human Papillomavirus (HPV) vaccine and the Hepatitis B virus vaccine series.
• Psychosocial and Trauma-Informed Clinical Intervention: The provision of multi-modal, comprehensive psychological counseling encompassing individual and group psychotherapy, relational conflict resolution, sexual orientation and gender identity exploration, and trauma-informed clinical care for survivors of sexual assault and interpersonal violence.

3. Organizational Size and Structural Context

Consistent with structural contingency models, institutional capacity is moderated by institutional size and administrative architecture. The SHSQ measures this construct through quantitative indicators, including total campus enrollment, full-time equivalent health center staffing, residential versus commuter student proportions, institutional classification (public, private, faith-based, Historically Black Colleges and Universities [HBCUs]), and regulatory clinical capabilities, operationalized via the presence of a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver or compliance.

Theoretical Framework

The theoretical bedrock of the Sexual Health Services Questionnaire is Everett M. Rogers’s Diffusion of Innovations Theory (DIT; Rogers, 1962, 1995, 2003). Rogers conceptualized diffusion as the process through which an innovation—defined as an idea, practice, or object perceived as new by an individual or other unit of adoption—is communicated through specific channels over time among the members of a social system. When applied to health administration, DIT shifts focus away from individual patient compliance toward the structural, technological, and behavioral dynamics of the service-delivery organization.

The Complexity–Innovativeness Paradigm

Rogers (2003) defined organizational complexity as “the degree to which an organization’s members possess a relatively high level of knowledge and expertise, usually measured by the members’ range of occupational specialties and their degree of professionalism (expressed by formal training)” (p. 412). Classical DIT asserts that organizational complexity has a potent, positive correlation with organizational innovativeness. A health center staffed by a multidisciplinary team spanning board-certified physicians, advanced practice registered nurses, licensed clinical social workers, doctoral-level health psychologists, and specialized health educators possesses diverse professional viewpoints and external knowledge links.

These diverse networks accelerate an organization’s recognition of emerging clinical technologies (such as rapid oral HIV assays or hormonal IUD insertion protocols). Conversely, organizations characterized by low complexity—such as an under-resourced clinic staffed exclusively by a single general practice nurse—tend to exhibit limited external information seeking, which delays the adoption of novel clinical guidelines and contemporary harm-reduction protocols.

Structural Determinants and Institutional Size

DIT posits that institutional size serves as a fundamental facilitator of organizational innovativeness. Large organizations typically possess uncommitted resources (“organizational slack”), dedicated physical space, diverse patient volumes, and administrative capacity. Within the SHSQ framework, institutional size is operationalized through overall campus student enrollment and total clinical staff headcount. Larger postsecondary institutions can absorb the initial capital investments and supply-chain logistics required to maintain complex clinical inventories, such as refrigerated HPV vaccines, liquid nitrogen for cryotherapy, on-site CLIA-certified moderate-complexity diagnostic laboratories, and after-hours sexual assault forensic exam suites.

Decentralization and Paraprofessional Integration

Rogers emphasized that decentralized organizational systems, where decision-making and operational execution are distributed across peripheral networks, foster rapid spread of behavioral innovations. The SHSQ explicitly applies this through Section 2 (Human Sexuality Peer Helpers). Paraprofessional peer educators possess homophily with the broader student population, sharing social terminology, cultural scripts, and physical environments (such as residence halls, fraternity and sorority houses, and campus entertainment venues). By measuring peer integration, the SHSQ captures an organization’s capacity to bypass clinical barriers and extend preventive education, free barrier products, and pre-test counseling directly into the student social ecosystem.

Validity

The psychometric validation of the Sexual Health Services Questionnaire involved an iterative, multi-phase developmental design to ensure face, content, and construct validity across complex clinical and administrative domains.

Face and Content Validity

Initial item generation began with a systematic review of the clinical, epidemiological, and health administration literature regarding collegiate reproductive health, national clinical guidelines from the Centers for Disease Control and Prevention (CDC), and recommendations from the American College Health Association (ACHA). Draft items were refined to mirror the scope of contemporary contraceptive technologies, STI testing algorithms, gynecological examinations, and psychosocial counseling modalities available in ambulatory settings.

To establish rigorous content and face validity, the initial draft was submitted to an independent expert evaluation panel consisting of six specialists with doctoral or master’s-level credentials in college health leadership, behavioral psychology, and health promotion:

• A doctoral-level health promotion specialist with executive experience directing multiple university student health centers.
• A doctoral-level clinical psychologist recognized for leadership and curriculum design in collegiate peer-education and counseling networks.
• A doctoral candidate in health behavior specializing in collegiate sexual health, peer education coordination, and barrier distribution dynamics.
• A doctoral-level clinical psychologist serving as the executive director of a comprehensive ambulatory health center within a major public research university.
• A doctoral-level health educator with extensive teaching and administrative leadership experience in university health promotion programs.
• A master’s-level health promotion specialist serving as an active campus coordinator for human sexuality education.

Panelists conducted structural qualitative appraisals and cognitive interviews regarding item clarity, terminology, and operational comprehensiveness. Items that demonstrated ambiguity, lacked clinical specificity, or omitted critical contemporary practice areas (such as post-exposure prophylaxis or specialized barrier items) were revised, resulting in the final 100-item inventory.

Construct and Predictive Validity

Construct validity was evaluated by examining theoretical associations hypothesized by Rogers’s Diffusion of Innovations Theory. As predicted by DIT, statistical analyses conducted on national survey data (N = 358) supported the positive association between structural complexity (the aggregated staffing complexity index derived from Section 1, supplemented by peer-helper integration from Section 2) and overall organizational innovativeness (summed scores across clinical sections 3 through 11). Furthermore, health center staffing size and institutional campus enrollment correlated positively with the innovativeness index, confirming the hypothesized link between structural scale, organizational capacity, and technological service adoption.

Response Bias and Clarity Evaluation

To assess potential response bias and questionnaire interpretability, respondents who completed the instrument during the test-retest phase participated in a structured evaluative protocol based on Gunning’s clear-writing principles (Gunning, 1952). The results demonstrated high participant consensus:

• 91% of respondents confirmed that items were formulated in a clear, unambiguous, and easily interpretable manner.
• 64% affirmed that the 13 questionnaire sections provided exhaustive and adequate coverage of institutional reproductive health functioning.
• 98% stated their professional belief that health center directors and administrative respondents would complete the inventory honestly, minimizing concerns regarding social desirability bias in institutional reporting.

Reliability

The reliability of the Sexual Health Services Questionnaire was established using both internal consistency and temporal stability paradigms across a nationally representative sample of postsecondary health centers in the United States.

Internal Consistency

From an initial sampling frame of 1,200 postsecondary institutions housing an identifiable student health center, 358 institutions completed and returned the questionnaire, representing an initial response rate of 29.83%. Internal consistency reliability was computed using Cronbach’s alpha across the individual functional sections of the instrument. To ensure clinical coherence and statistical power, Sections 6 and 7 (STI testing and vaccinations) were merged for reliability analyses, as were Sections 8, 9, and 10 (gynecological examinations, post-sexual assault forensic exams, and testicular examinations). Section 12 (CLIA certification status) was excluded from alpha calculations due to its single-item administrative nature.

The resulting internal consistency coefficients revealed moderate-to-exceptional homogeneity across sub-domains:

• Sub-domain Cronbach’s alpha values ranged from .62 to .93 across the functional service clusters.
• The composite internal consistency coefficient for the overall questionnaire reached .94, demonstrating high measurement reliability across the broader construct of collegiate sexual health service availability.

Temporal Stability (Test-Retest Reliability)

To evaluate temporal stability, a randomly selected sub-sample of 50 health center directors from the initial respondent pool was invited to complete the SHSQ a second time, following an established temporal buffer. A total of 28 directors returned completed re-test protocols, yielding a re-test response rate of 56.0%. Demographic analysis confirmed that key institutional variables (institutional type, campus setting, student population volume, and regional distribution) were represented in the test-retest sub-sample. Item-by-item concordance analysis across all service-related indicators yielded an overall temporal consistency rate of 87.37%, indicating that the SHSQ serves as a stable, replicable instrument for cross-sectional and longitudinal institutional assessments.

Factor Analysis

The psychometric architecture of the SHSQ is rooted in index and composite measurement models rather than classic reflective factor models. In clinical and health administration questionnaires, service checklist items function primarily as formative or causal indicators rather than purely reflective manifestations of a single latent trait. For example, offering oral contraceptive pills does not statistically “cause” an institution to offer copper IUDs; rather, the presence of each independent clinical service incrementally constructs the overarching composite index of Organizational Innovativeness.

Formative vs. Reflective Measurement Models

In psychometric modeling, reflective latent variables assume that item responses are driven by an underlying latent condition, implying high inter-item correlations. In contrast, organizational capacity inventories like the SHSQ represent formative indices where individual items define the boundaries of the construct. The developers grouped items into 13 discrete, clinically validated domains based on health-systems workflows, allowing individual section sums to operate as distinct sub-indices.

Structural Dimensionality and Index Construction

Rather than relying on unrestricted exploratory factor analysis (EFA), which can produce fractured dimensions in broad binary checklists, structural validity was confirmed by mapping items onto the two major conceptual dimensions derived from Rogers’s Diffusion of Innovations Theory:

• Complexity Index: Created by summing all dichotomous items from Section 1 (health center personnel with primary and secondary sexual health responsibilities), supplemented by a binary indicator from Section 2 representing the utilization of peer helpers (scored as 1 if peer educators are used in one or more capacities, and 0 if not utilized). Restricting peer utilization to a single categorical point prevents over-weighting peer-led initiatives relative to licensed clinical staff.
• Organizational Innovativeness Index: Created by summing the dichotomous items across Sections 3 through 11 (encompassing barrier supplies, distribution strategies, hormonal/barrier contraceptives, STI diagnostic modalities, viral vaccines, gynecological exams, specialized examinations, and psychological counseling). This produces an overall innovativeness metric capable of serving as a continuous dependent or independent variable in advanced linear models, path analyses, or structural equation modeling (SEM).

Instrument / Measurement Tool

The complete structural, administrative, and scoring parameters of the Sexual Health Services Questionnaire are outlined below:

• Instrument Name: Sexual Health Services Questionnaire (SHSQ)
• Primary Author: Scott M. Butler, PhD (with David R. Black, George H. Avery, Janice Kelly, and Daniel C. Coster)
• Year of Copyright/Publication: 2008
• Instrument Type: Organizational-level health service audit; clinical capacity checklist and administrative questionnaire.
• Target Respondent: Student Health Center Directors, Medical Directors, Directors of Health Promotion, or designated administrative representatives.
• Administration Format: Self-administered paper-and-pencil inventory or secure digital questionnaire.
• Estimated Completion Time: Approximately 15 minutes.
• Total Item Count: 100 items distributed across 13 functional sections:
• Section 1: Clinical and Educational Personnel (24 items: 12 primary responsibility roles, 12 secondary responsibility roles).
• Section 2: Human Sexuality Peer Helpers (9 items).
• Section 3: Safer-Sex Products Distributed (8 items).
• Section 4: Condom Distribution Procedures (7 items: 6 categorical methods + 1 volumetric continuous ratio item).
• Section 5: Hormonal and Barrier Contraceptive Methods Available (13 items).
• Section 6: Sexually Transmitted Infection (STI) Testing Methods (11 items).
• Section 7: Prophylactic Vaccinations (2 items: HPV and Hepatitis B).
• Section 8: Gynecological Services (4 items).
• Section 9: Specialized Clinical Exam: Post-Sexual Assault (1 item).
• Section 10: Specialized Clinical Exam: Testicular Examination (1 item).
• Section 11: Sexuality-Related Counseling and Mental Health Services (6 items).
• Section 12: Regulatory Clinical Laboratory Status (1 item: CLIA Certificate).
• Section 13: Administrator and Institutional Demographics (14 items: respondent age, race/ethnicity, gender, administrative tenure, education, total health center employees, total student enrollment, state, institutional type, setting, residential profile, degrees awarded, medical school affiliation, and specialized institutional identity).
• Response Modes:
• Dichotomous Checklist: Marking an “X” indicates the presence of a service/staff role (scored as 1); leaving the field blank indicates absence (scored as 0).
• Open Write-in / Other: Provided in Sections 1, 2, and 13 to record unlisted specialized roles, degrees, or programs.
• Ratio/Continuous Reporting: Section 4 requests the numerical estimate of condoms distributed per year (coded as 0 for non-distribution, and 999 for unknown volume).
• Scoring and Index Synthesis Rules:
• Sub-scale Sums: Individual sections can be scored by summing binary affirmative marks (0 to k) to reflect clinical capability within specific clinical areas.
• Complexity Scale Score: Sum of affirmative responses across Section 1 (staffing roles) + [1 point if any peer-helper duty in Section 2 is marked “X”, or 0 points if no peer duties are endorsed].
• Innovativeness Scale Score: Direct sum of all binary affirmative responses across Sections 3 through 11 (range: 0 to 52).

Permissions & Fee and Test Year

The Sexual Health Services Questionnaire was published in 2008 and holds formal copyright (© 2008) by the developer group: Scott M. Butler, David R. Black, George H. Avery, Janice Kelly, and Daniel C. Coster. The tool was developed for public health research, epidemiological surveillance, and institutional benchmarking.

Licensing and Access Conditions: The SHSQ is available for non-commercial academic, institutional research, and clinical self-evaluation purposes. Although freely reproducible for academic research, health center directors and researchers seeking to use the scale for administrative audits, statewide surveys, or research publications should contact the primary author to obtain formal permission and maintain scoring consistency:

• Primary Contact: Scott M. Butler, PhD, Department of Kinesiology, Georgia College & State University, Campus Box 065, Milledgeville, GA 31061 (Email: [email protected]).
• Commercial Usage: Any commercial deployment, proprietary software integration, or profit-generating administrative audit by third-party healthcare consulting firms requires written authorization and licensing agreements from the copyright holders.

References

The theoretical, psychometric, and clinical foundations of the SHSQ are grounded in the following academic literature:

• American College Health Association. (2008). American College Health Association-National College Health Assessment: Reference group data report. American College Health Association. https://www.acha.org
• Butler, S. M., Black, D. R., Avery, G. H., Kelly, J., & Coster, D. C. (2008). Sexual Health Services Questionnaire. In Measurement Tools in Patient Education and Health Promotion. Georgia College & State University / Purdue University.
• Centers for Disease Control and Prevention. (2006). Sexually transmitted diseases treatment guidelines, 2006. Morbidity and Mortality Weekly Report: Recommendations and Reports, 55(RR-11), 1–94. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
• Gunning, R. (1952). The technique of clear writing. McGraw-Hill.
• Markman, L. M., & Black, D. R. (2001). Peer education: A broad perspective on collegiate peer helper interventions. Journal of American College Health, 50(2), 79–84. https://doi.org/10.1080/07448480109595708
• Rogers, E. M. (1962). Diffusion of innovations (1st ed.). Free Press of Glencoe.
• Rogers, E. M. (1995). Diffusion of innovations (4th ed.). Free Press.
• Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.
• Weisman, C. S., Nathanson, C. A., Ensminger, M., Teitelbaum, M. A., Robinson, J. C., & Plichta, S. (1995). Contraceptive services in college health centers: A national survey. Journal of American College Health, 43(6), 245–251. https://doi.org/10.1080/07448481.1995.9940484

Items of the Scale