Symbolic ableism in health professions education: development and initial psychometric evaluation of the German symbolic ableism scale

Background Ableist attitudes may undermine equity, quality, and safety of care and may also shape the inclusion of learners and professionals with disabilities. Brief, context-sensitive instruments for health professions education are lacking. This study aimed to develop the German-language Symbolic Ableism Scale (SAS-G) and obtain initial exploratory psychometric evidence among medical and dental students. Methods A three-phase instrument-development study was conducted between 2022 and 2024. From the outset, people with disabilities participated directly as experts by experience in construct interpretation, item generation, and content review alongside disability-studies and clinical experts. In Phase 1, the original Symbolic Ableism Scale underwent forward-backward translation and was complemented by de novo items generated through this participatory process. Qualitative content analysis and content-validity ratios informed item refinement. In Phase 2, a general-population pilot sample ( N = 210) completed a 25-item pool; item-level findings guided conceptual and linguistic redevelopment into a 21-item pre-final student version. In Phase 3, 173 medical and dental students completed this version. Factor retention was guided by parallel analysis using Pearson and polychoric correlations and Velicer’s minimum average partial criterion. A primary maximum-likelihood EFA with oblimin rotation was supplemented by an ordinal-data sensitivity analysis using polychoric correlations and MINRES extraction. Internal consistency and hypothesis-generating regressions were examined. Results Ten items were retained in two factors: Denial of Rights and Structural Barriers (6 items; Cronbach’s alpha = 0.81; McDonald’s omega = 0.83) and Interpersonal Comfort (4 items; alpha = 0.70; omega = 0.74). The unrotated maximum-likelihood extraction accounted for 44.3% of total item variance, and the ordinal-data sensitivity analysis reproduced all primary item-to-factor assignments. In exploratory regressions, lower Denial of Rights and Structural Barriers scores were associated with female gender, medical study, and friendship with a person with disabilities; lower Interpersonal Comfort scores were associated with medical study and such friendship. Conclusions The SAS-G is a brief, participatively developed measure of two complementary dimensions of symbolic ableism in health professions education. Findings provide initial exploratory support for its structure and internal consistency in a single-site student sample; independent multisite confirmation and evidence of temporal stability, responsiveness, and measurement invariance are required before the scale is used to evaluate interventions or compare groups or countries.