Measuring contraceptive agency in the community

Abstract

Objectives: This study aimed to evaluate the Contraceptive Agency Scale (CAS), developed as a clinic-based measure, within a community population and to assess how agency varied by demographic and reproductive characteristics.

Study design: We conducted a cross-sectional survey of 1917 participants aged 15-45 years living in Oregon in 2023. Participants responded to the 7-item CAS, comprised items relating to active decision-making, freedom from coercion, and nonjudgmental care during their last health care visit involving contraceptive counseling. We assessed the dimensionality of the CAS and fit data to a partial credit model to analyze its psychometric performance in our community-based sample. Differences in agency by characteristics were assessed with multivariable linear regression.

Results: The CAS showed adequate to good internal consistency reliability (Cronbach alpha: 0.78). The CAS items mostly loaded onto a single factor and demonstrated reasonable fit to a partial credit model (information-weighted fit statistics ranged from 0.73 to 1.01). While participants identifying as Black had lower CAS scores than White participants (β coefficient: -1.39 [-2.19, -0.59], p < 0.001), Asian/Pacific Islander, Latino/a, and multiracial participants had significantly higher levels of contraceptive agency than White participants. Not desiring pregnancy was associated with higher contraceptive agency (β coefficient: 1.27 [0.72, 1.82], p < 0.001) In contrast, lower education, some college or less vs college or above (β coefficient: -2.14 [-2.69, -1.60], p < 0.001) and nonbinary/transgender identity vs female gender identity (β coefficient: -1.32 [-2.15, -0.50], p < 0.01) were associated with lower contraceptive agency.

Conclusions: The CAS can be used in a community sample to evaluate patient centered contraceptive decision making as a standard of care.

Implications: Analysis of contraceptive agency among a community-based participant population offers valuable insights into experiences with contraceptive counseling.

Keywords: Contraception; Family planning; Psychometrics; Reproductive autonomy.