Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure

Abstract

Background Patient agency in contraceptive decision-making is an essential component of reproductive autonomy. Objective We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist. Design For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory–based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale. Participants A racially/ethnically diverse sample of 338 individuals, aged 15–34 years, receiving contraceptive care across nine California clinics in 2019–2020. Main Measures Contraceptive Agency Scale (CAS) of patient agency in preventive care. Key Results Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach’s α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more). Conclusions The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale

“…We tested the 55 items among patients seeking reproductive care from nine reproductive and primary care health facilities in the San Francisco Bay area between June 13, 2019 and February 26, 2020 (Harper et al, 2022 ). Study facilities were primarily Department of Health and non-profit community clinics, including Federally Qualified Health Centers, School-based Health Centers, reproductive health clinics, and an outpatient public hospital obstetrics and gynecology clinic.…”

“She should support me, she's my doctor:” Patient perceptions of agency in contraceptive decision‐making in the clinical encounter in Northern California

“…In 2017-2019, we conducted this qualitative study, including both focus group discussions and in-depth interviews, as the formative research for the development of a psychometric measure of contraceptive agency. 28 We conducted focus group discussions to capture perspectives and viewpoints that might uniquely emerge from interpersonal exchange. We then conducted interviews to ensure confidentiality and capture depth of experiences in a one-on-one setting.…”

“…Active decision‐making with the provider is important in contraceptive care, especially when patients are considering new or unfamiliar contraceptives 27 . This study explores how patient agency, and conversely provider bias or coercion, manifest during a clinical encounter, and how contraceptive agency increases or diminishes, with the goal of informing the development of a psychometric scale to measure patient contraceptive agency 28 . Describing agency from the patient perspective and having a robust scale can help us to move beyond a focus on contraceptive uptake and continuation, measures that fall short of capturing whether patients are not being coerced and are making their own contraceptive decisions.…”

Conceptualizing Contraceptive Agency: A Critical Step to Enable Human Rights-Based Family Planning Programs and Measurement

“…12 In 2023, Harper and colleagues published a new measure of decision-making agency in the contraception clinical encounter; the measure was developed and validated in the U.S. context. 16 The authors' review of the empowerment and patient-centered care literature led them to define 3 domains to guide item generation for this new measure: freedom from coercion, nonjudgmental care, and active decision-making. The resulting scale is unidimensional and composed of 7 items that capture agency in the clinical encounter.…”

“…A focus on agency aligns with other recent global efforts calling attention to the oftenoverlooked importance of focusing on an individual's capacity to make and carry out decisions related to their health and well-being-regardless of what they decide. [14][15][16] In this commentary, we delineate specific conceptual gaps we seek to fill before presenting a detailed framework for the construct of contraceptive agency. Consistent with Donald et al's multidisciplinary definition of agency as the ability to define one's goals and act on them 17 and Sato et al's definition of agency as an individual's ability to produce an effect in pursuit of goals and values, 18 we define contraceptive agency as the ability of an individual to make and act on decisions related to whether to do something to avoid or delay pregnancy and what, if anything, to do when they are not actively trying to become pregnant.…”