Contraceptive Self-Efficacy Scale

Abstract

The Contraceptive Self-Efficacy (CSE) Scale is an established psychometric instrument formulated by Ruth Andrea Levinson to assess motivational, cognitive, and interpersonal barriers to consistent and effective contraceptive practice among sexually active adolescents and young adults. Grounded in Albert Bandura's social cognitive theory and the construct of self-efficacy, the instrument reconceptualizes contraceptive nonuse among young women who actively desire to avoid pregnancy not as mere lack of information, but as an avoidance response within emotionally charged and socially complex contexts. The scale comprises 18 operationalized items (arranged across core situational stems and critical contingency scenarios) evaluated on a 5-point Likert response format ranging from 1 (Not at all True of Me) to 5 (Completely True of Me).

Psychometrically, the CSE scale demonstrates robust structural and cross-cultural validity across diverse adolescent and adult populations, spanning inner-city, suburban, clinical, and institutionalized cohorts across North America, Latin America, and Asia. Factor-analytic investigations have substantiated both multidimensional and unidimensional composite models, frequently identifying a four-factor structure reflecting interpersonal assertiveness, sexual negotiation, emotional self-regulation during sexual arousal, and public/institutional health-seeking assertiveness. Internal consistency estimates across twenty-five years of validation research consistently yield Cronbach's alpha coefficients of .73 or higher, reaching .85 to .90 in community and college samples. Predictive validity is demonstrated by the scale's capacity to account for significant, unique variance in protected intercourse, barrier and hormonal method compliance, and post-intervention behavioral adherence, establishing the CSE scale as a premier clinical diagnostic and research assessment in adolescent reproductive health and behavioral medicine.

Keywords

Contraceptive Self-Efficacy Scale, self-efficacy, sexual assertiveness, contraceptive behavior, adolescent reproductive health, social cognitive theory, unplanned pregnancy prevention, condom negotiation, sexual health assessment, psychometrics

Authors

The Contraceptive Self-Efficacy Scale was developed by Ruth Andrea Levinson, Ph.D., Professor Emerita of Education and Psychology at Skidmore College, Saratoga Springs, New York, United States. Dr. Levinson's programmatic research centers on developmental psychology, adolescent female psychosexual development, risk-taking behaviors, and the application of social cognitive architectures to reproductive health decision-making.

In subsequent validation studies and cross-cultural psychometric expansions, key contributions were made in collaboration with prominent behavioral researchers, including Linda A. Beamer and C. K. Wan, as well as independent international research teams such as Alain Bilodeau, Gaétan Forget, and Jean Tétreault in Canada, and researchers examining specialized clinical and vulnerable cohorts (e.g., Hovsepian et al.; Heinrich; Louise; Nordeen, Mann, & Sullivan).

Primary Author Institutional Affiliation:
Ruth Andrea Levinson, Ph.D.
Department of Education / Psychology Program
Skidmore College
815 North Broadway, Saratoga Springs, NY 12866, USA
Correspondence Address: 1511 Peaceable Street, Ballston Spa, NY 12020
Email: [email protected]

Purpose

The Contraceptive Self-Efficacy Scale was developed to address a critical paradox in adolescent public health: why sexually active adolescents who explicitly report a strong desire to prevent pregnancy frequently fail to employ effective contraception consistently. Historically, public health and sex education initiatives operated under rational-choice models and informational deficits, presuming that disseminating anatomical knowledge and contraceptive availability would naturally lead to protective health behaviors. Empirical outcomes routinely invalidated this assumption, as knowledge acquisition alone demonstrated negligible correlations with actual preventative action.

Dr. Levinson recognized that contraceptive utilization among adolescents is fundamentally an affective, interpersonal, and situational coping behavior. Rather than viewing nonuse as willful negligence, Levinson conceptualized the failure to secure and use contraceptives as analogous to avoidance or phobic responses under acute psychological stressors. Sexually active youth encounter intense affective barriers, including:

• Fear of acknowledging sexual active status (to oneself, peers, parents, or medical professionals);
• Fear of partner rejection, conflict, or loss of intimacy;
• Feelings of shame, embarrassment, and social stigma associated with purchasing, carrying, or preparing barrier or hormonal methods;
• Cognitive disruption and emotional surrender during states of high sexual arousal and passionate involvement.

The CSE scale operationalizes these affective barriers by embedding specific, realistic stressors directly within each item. Rather than asking abstract questions regarding generalized confidence, the instrument assesses an individual's granular conviction that she can prioritize, initiate, and sustain protective actions precisely when external pressure, interpersonal anxiety, or sexual arousal are operating at peak intensity.

Clinically, the CSE functions as a sophisticated diagnostic instrument. In family planning clinics, primary adolescent medicine, school counseling centers, and community interventions, the scale enables practitioners to identify the specific behavioral domain wherein an individual experiences self-efficacy collapse. For instance, a client may exhibit complete confidence in purchasing a method at a pharmacy but experience near-total inhibition when required to verbally negotiate condom application during physical intimacy. Armed with this profile, clinicians can tailor interventions—employing targeted behavioral role-playing, cognitive reframing, and assertiveness training—rather than repeating generic educational curricula. In academic and epidemiological research, the scale serves as a sensitive outcome metric to evaluate the efficacy of reproductive health interventions, adolescent health promotion programs, and longitudinal models of health behavior change.

Psychological Construct

The central psychological construct quantified by this instrument is contraceptive self-efficacy, conceptualized as an individual's subjective conviction that she or he possesses the agency, behavioral skills, and emotional resilience necessary to control sexual interactions, negotiate reproductive choices, and ensure consistent contraceptive protection across high-risk, emotionally laden scenarios. Self-efficacy in this framework is strictly domain-specific; generalized self-esteem or global locus of control shows low predictive validity regarding whether an individual will insist on using a condom or consistently adhere to a hormonal regimen.

The construct encompasses several distinct yet interconnected behavioral and affective dimensions:

1. Sexual and Contraceptive Assertiveness

This dimension reflects the individual's perceived capability to overtly communicate sexual desires, boundaries, and protection requirements to an intimate partner. Contraceptive negotiation requires direct verbal engagement about subjects that are frequently socially tabooladen or vulnerable. Individuals with low assertiveness self-efficacy often rely on implicit assumptions, acquiesce to partner resistance, or avoid raising the topic entirely due to dread of conflict or relationship dissolution. Items assessing this facet evaluate whether a person can unambiguously state "no," decline unprotected intercourse, and insist on method utilization even when a partner is silent or uncooperative.

2. Emotional Self-Regulation Under High Sexual Arousal

One of the most innovative dimensions captured by Levinson's operationalization is the impact of passion, affective intensity, and physical excitement on cognitive control. Many adolescents possess the cognitive intent to protect themselves when calm, yet experience an abandonment of self-protective intentions during escalating sexual arousal (termed the "heat of the moment" phenomenon). Contraceptive self-efficacy necessitates the psychological stamina to pause, interrupt sexual progression, and implement barrier or hormonal contingencies despite intense physiological and emotional momentum.

3. Public and Institutional Help-Seeking Self-Efficacy

Contraception inevitably interfaces with external social systems, including healthcare providers, pharmacists, retail clerks, and family members. This dimension assesses the respondent's confidence in obtaining reproductive healthcare services, interacting with clinicians, purchasing over-the-counter barrier supplies at a drugstore, and maintaining method compliance despite the perceived surveillance of parents or community members. The affective barrier here is characterized by acute social embarrassment, internalized stigma, and anticipatory dread of moral judgment.

4. Sexual Autonomy and Acknowledgment of Desire

Drawing on feminist psychological frameworks (notably Michelle Fine's "missing discourse of desire"), this dimension measures an individual's capacity to embrace her sexual agency legitimately. When young women perceive themselves merely as passive gatekeepers reacting to male sexual demands rather than autonomous agents with their own sexual agency, they struggle to proactively prepare for sexual encounters. Proactive contraception requires acknowledging that one intends to be sexually active; individuals who disavow their own desires frequently rely on "spontaneous" encounters as psychological defense mechanisms against feeling responsible or "promiscuous," resulting in catastrophic rates of unprotected intercourse.

Theoretical Framework

The Contraceptive Self-Efficacy Scale is systematically grounded in Albert Bandura's Social Cognitive Theory (Bandura, 1977, 1986, 1990) and integrates conceptual tenets from the Theory of Reasoned Action (Fishbein & Ajzen, 1975) and the Health Belief Model (Strecher, DeVellis, Becker, & Rosenstock, 1986).

Bandurian Foundations: Outcome Expectations vs. Efficacy Expectations

Bandura established a fundamental distinction between two cognitive determinants of human behavior:

1. Outcome Expectations: The belief that a given behavioral sequence will lead to specific outcomes (e.g., "Using a condom prevents pregnancy and sexually transmitted infections").
2. Efficacy Expectations: The personal conviction that one can successfully execute the precise behaviors required to produce those outcomes in the presence of challenging obstacles (e.g., "I can stop my partner from penetrating me until we put on a condom, even if he complains").

Bandura demonstrated that high outcome expectations are completely insufficient to produce action if efficacy expectations are compromised. An individual may fully believe that birth control prevents pregnancy, but if she doubts her capability to confront an intimidating partner, navigate parental scrutiny, or withstand social embarrassment at a pharmacy, she will reliably avoid executing the behavior. Furthermore, self-efficacy beliefs determine:

• Initiation: Whether an adolescent attempts to obtain or introduce contraception;
• Effort Expended: How rigorously she negotiates and prepares the method;
• Persistence: Whether she continues using contraception when confronting adverse side effects, partner displeasure, or logistical barriers.

Integration of Interpersonal Conditioning and Phobic Avoidance Models

Levinson augmented Bandurian social learning theory by conceptualizing contraceptive nonuse as an affective avoidance mechanism, citing clinical modeling and assertiveness frameworks established by Kazdin (1974) and Rosenthal and Bandura (1978). In adolescent female socialization, overt planning for sexual intercourse is frequently burdened by cultural guilt and negative social sanctions. To consciously carry contraception is to acknowledge premeditated sexual involvement, exposing the young woman to moral condemnation. Consequently, leaving contraception to "fate" or avoiding discussion allows the individual to escape immediate cognitive dissonance and social shame, functioning as a powerful negative reinforcement cycle. Levinson designed the CSE scale to map this exact terrain, assessing whether personal efficacy is robust enough to overcome these internalized avoidance conditioning patterns.

Validity

The Contraceptive Self-Efficacy Scale has undergone comprehensive psychometric evaluations across multiple decades, confirming strong content, construct, convergent, discriminant, and predictive validity across heterogeneous populations.

Content and Face Validity

Instrument development involved rigorous qualitative and clinical screening to ensure ecological authenticity. Candidate items were constructed based on qualitative interviews with sexually active adolescent females and subjected to critical evaluation according to two psychometric criteria: (a) whether the scenarios realistically represented critical, common behavioral dilemmas encountered by adolescents, and (b) whether the phrasing strictly adhered to Bandurian self-efficacy measurement guidelines by focusing on perceived capability ("I can / I could") rather than general intentions or outcome beliefs. The scale was repeatedly refined in direct consultation with Albert Bandura and leading experts in behavioral self-efficacy assessment (Bandura et al., 1980).

Predictive and Criterion-Related Validity

The scale's predictive utility has been empirically established in numerous longitudinal and cross-sectional investigations. Across four diverse demographic samples examined by Levinson, Beamer, and Wan (1998)—comprising inner-city African American adolescents, suburban European American youth, Latina adolescents, and college women—CSE scores significantly predicted contraceptive consistency and method selection. Importantly, partial correlational analyses established that CSE accounted for unique variance in contraceptive behavior after controlling for age, sexual experience, relationship duration, and contraceptive knowledge.

Notably, Levinson et al. (1998) discovered that individual items possessed differential predictive power across distinct cultural and socioeconomic groups. For example, Item 8 (assessing the likelihood of having unprotected intercourse when emotionally or sexually swept away) served as a profound independent predictor across three out of four samples, underscoring the universal behavioral vulnerability posed by emotional escalation. Similarly, items evaluating assertiveness in confronting significant others (Items 2, 3, 6, 10, 11, 12, 14) demonstrated robust predictive validity for sustained hormonal and barrier compliance.

In clinical trials and reproductive health studies, high CSE scores have been prospectively correlated with decreased incidence of unintended pregnancy, reduced rates of sexually transmitted infections (STIs), and successful continuation of modern contraceptive methods (Heinrich, 1993; Nordeen, Mann, & Sullivan, 2005). Hovsepian et al. validated the scale among highly vulnerable adolescent females under child protective services, demonstrating that the scale accurately captures the severe deficits in sexual self-efficacy that result from prior trauma and interpersonal victimization.

Cross-Cultural and Linguistic Validity

The instrument has exhibited exceptional cross-cultural equivalence when translated and culturally adapted. Bilodeau, Forget, and Tétreault (1994) validated a French-Canadian adaptation among male and female adolescents, finding structural invariance and comparable predictive validity. In Hong Kong, Louise (2005) established the validity of a translated Chinese version among adult women presenting with unplanned pregnancies, confirming that contraceptive self-efficacy deficits cross geopolitical, age, and cultural boundaries.

Reliability

The Contraceptive Self-Efficacy Scale demonstrates consistently high internal consistency and measurement precision across independent research settings, developmental stages, and demographic cohorts.

Internal Consistency

Across empirical studies spanning more than a quarter of a century, the total scale has consistently yielded Cronbach's alpha coefficients well above the accepted .70 psychometric benchmark for behavioral assessments:

• In Levinson's foundational validation studies (1986, 1995), total scale Cronbach's alpha coefficients ranged between .73 and .86 among adolescent clinic and high school populations.
• Heinrich (1993) reported internal consistency coefficients exceeding .82 among university undergraduate female cohorts.
• In the four-sample comparative study by Levinson, Beamer, and Wan (1998), internal consistency estimates remained stable across inner-city African American youth, Latina adolescents, and suburban European American youth, demonstrating that the scale maintains high reliability across varied socioeconomic environments.
• International adaptations have replicated these coefficients; Bilodeau et al. (1994) reported alpha values ranging from .75 to .83 for the French translation, while Louise (2005) reported an alpha of .84 in a Hong Kong clinical sample.

Inter-Item Dynamics and Item-Total Correlations

A psychometrically intriguing feature noted by Levinson et al. (1998) is the pattern of relatively low inter-item correlations (averaging approximately .15 with a very small standard deviation) coupled with robust composite internal reliability. This psychometric signature confirms that the 18 items do not merely rephrase a single narrow sentiment; rather, they capture distinct, idiosyncratic situational stressors that individually challenge adolescent self-efficacy. Consequently, evaluating both the overall composite score and specific item-level profiles is psychometrically justified and clinically informative.

Factor Analysis

Structural evaluations of the Contraceptive Self-Efficacy Scale via exploratory factor analysis (EFA), principal component analysis (PCA), and confirmatory factor analysis (CFA using LISREL) have consistently demonstrated that while the instrument can be scored as a global unidimensional composite, it possesses a reliable multidimensional subscale architecture.

The Four-Factor Structural Model

Extensive factor analyses conducted by Levinson (1986) and confirmed in subsequent structural equation modeling (Levinson et al., 1998; Bilodeau et al., 1994) have revealed a dominant four-factor solution accounting for the systematic variance across the 18 items:

1. Factor 1: Sexual Refusal and Situational Assertiveness
   This factor captures the individual's capacity to set decisive physical limits and resist partner coercion or momentum. Core loadings are observed on Item 4 ("can easily tell him 'no' and mean it"), Item 7 ("can easily stop things so that we don't have intercourse"), Item 9 (avoiding going along with sexual demands to avoid hassle), and Item 17 (stopping things before intercourse if protection cannot be discussed). Item loadings on this dimension consistently range from .58 to .78.
2. Factor 2: Partner Contraceptive Negotiation and Verbal Openness
   Reflecting direct interpersonal communication regarding method utilization, this factor comprises Item 2 (difficulty discussing sexual feelings), Item 5 (inability to bring up sex unless the partner initiates), Item 13/14 (asking a partner if he has protection or stating one's lack of protection), and Item 16 (informing the partner about prescription method use). Loadings for this communicative cluster range from .52 to .74.
3. Factor 3: Emotional and Physical Excitement Regulation
   This factor indexes self-control when encountering intense sexual arousal or deep emotional attachment. It is anchored by Item 8 (engaging in unprotected sex when swept away emotionally or sexually), Item 3 (enjoying sex as a mutually wanted act), and Item 6 (hesitation when evaluating the implications of sex). Factor loadings on this affective dimension typically range between .48 and .71.
4. Factor 4: Public, Commercial, and Parental Help-Seeking
   Focusing on institutional and family-mediated barriers to contraceptive procurement, this factor is characterized by high loadings on Item 11 (inability to continue contraception if parents might discover it) and Item 12 (embarrassment when purchasing contraceptives or filling prescriptions at a drugstore). Standardized factor loadings range from .61 to .81.

Model Fit and Invariance

Confirmatory factor analyses utilizing LISREL structural equation modeling have demonstrated good absolute and incremental fit indices for the four-factor model across diverse groups. Comparative Fit Index (CFI) values have routinely exceeded .90, with Root Mean Square Error of Approximation (RMSEA) estimates typically falling between .045 and .068, verifying acceptable to excellent construct fit across adolescent female populations.

Instrument / Measurement Tool

• Instrument Name: Contraceptive Self-Efficacy Scale (CSE)
• Developer: Ruth Andrea Levinson, Ph.D.
• Construct Assessed: Perceived personal capability to manage sexual encounters, negotiate contraceptive protection, and overcome affective, interpersonal, and situational barriers to birth control utilization.
• Assessment Type: Self-report psychometric questionnaire; available in paper-and-pencil or interactive digital administration.
• Target Population: Sexually active or contemplating adolescents, young adults, and adult women (adaptable for young men and gender-neutral contexts).
• Administration Time: Approximately 8 to 10 minutes.
• Item Count: 18 items (comprising individual scenario statements and multi-part contingency stems).
• Response Scale: 5-point Likert-type scale formatted as follows:
  • 1 = Not at all True of Me
  • 2 = Slightly True of Me
  • 3 = Somewhat True of Me
  • 4 = Mostly True of Me
  • 5 = Completely True of Me
• Scoring and Directionality:
  • The instrument is scaled such that higher composite scores denote higher contraceptive self-efficacy.
  • Directly Scored Items: Items 1, 3, 4, 7, 10, 13, 14, 15, and 16 are positively worded and scored directly as endorsed (1 = 1, 2 = 2, 3 = 3, 4 = 4, 5 = 5).
  • Reverse Scored Items: Items 2, 5, 6, 8, 9, 11, 12, 14 (in certain alternate numbering structures, corresponding to specific negative phrasing stems), and 15 require reverse scoring before summation (i.e., recoded as: 1 → 5, 2 → 4, 3 → 3, 4 → 2, 5 → 1). In the author's primary scoring guide, Items 2, 5, 6, 8, 9, 11, 12, 14, and 15 (per original index notation) are reversed.
  • Total Score Calculation: Can be computed either as the sum of all recoded items (yielding a continuous scale range from 18 to 90) or as the arithmetic mean across items (scale range from 1.0 to 5.0).
  • Subscale Scoring: Mean scores may be calculated independently for the four factors: Situational Refusal Assertiveness, Partner Negotiation, Emotional Regulation, and Institutional/Parental Independence.
• Modern Adaptations: In contemporary applications, clinical researchers frequently update obsolete pharmaceutical terminology (e.g., replacing historical references to "foam," "diaphragms," and "Encare Ovals" with "condoms," "oral contraceptive pills," "hormonal patches," "implants," or "intrauterine devices [IUDs]") and employ gender-neutral language (substituting "partner" for "boyfriend" and "him/her" for "him").

Permissions & Fee and Test Year

The Contraceptive Self-Efficacy Scale was first published in 1986 by Dr. Ruth Andrea Levinson in The Journal of Sex Research, with further comprehensive multi-sample validation published in 1998 in the Journal of Youth and Adolescence.

Copyright and Permitted Use:
The instrument is copyrighted by Ruth Andrea Levinson. It is made accessible for academic, research, public health, and non-profit clinical diagnostic purposes. While researchers and clinicians may utilize the scale in scholarly investigations and educational programs, formal permission should be obtained directly from the author prior to administration or adaptation.

Fee:
There are no licensing fees for non-commercial academic research, student theses, or non-profit clinical intervention evaluation. Commercial deployment, inclusion within proprietary software platforms, or distribution within fee-for-service commercial ventures requires formal licensing arrangements.

Author Contact for Permissions:
Ruth Andrea Levinson, Ph.D.
1511 Peaceable Street, Ballston Spa, NY 12020, USA
Email: [email protected]

References

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Bilodeau, A., Forget, G., & Tétreault, J. (1994). L'auto-efficacité relative à la contraception chez les adolescentes et les adolescents: La validation de la version française de l'échelle de mesure de Levinson. Canadian Journal of Public Health, 85(2), 115–120.

Fine, M. (1988). Sexuality, schooling, and adolescent females: The missing discourse of desire. Harvard Educational Review, 58(1), 29–53. https://doi.org/10.17763/haer.58.1.u504187453304153

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Heinrich, L. B. (1993). Contraceptive self-efficacy in college women. Journal of Adolescent Health, 14(4), 269–276. https://doi.org/10.1016/1054-139X(93)90176-S

Hovsepian, S. L., Blais, M., Manseau, H., Otis, J., & Girard, M.-E. (2009). Prior victimization and sexual and contraceptive self-efficacy among adolescent females under child protective services care. Health Education & Behavior, 36(6), 1032–1047. https://doi.org/10.1177/1090198108328909

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Levinson, R. A., Beamer, L. A., & Wan, C. K. (1998). The Contraceptive Self-Efficacy Scale: Analysis in four samples. Journal of Youth and Adolescence, 27(6), 773–793. https://doi.org/10.1023/A:1022879503463

Louise, L. Y. S. (2005). Knowledge, attitudes, and self-efficacy of contraception among Chinese women with unplanned pregnancies in Hong Kong (Unpublished master's thesis). The Nethersole School of Nursing, The Chinese University of Hong Kong.

McAlister, A., Perry, C. L., & Maccoby, N. (1979). Adolescent smoking: Onset and prevention. Pediatrics, 63(4), 650–658. https://doi.org/10.1542/peds.63.4.650

Nordeen, J. L., Mann, R. J., & Sullivan, J. M. (2005). Analysis of contraceptive self-efficacy in clients requesting emergency contraception (Unpublished manuscript). Skidmore College.

Rosenthal, T. L., & Bandura, A. (1978). Psychological modeling: Theory and practice. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed., pp. 621–658). John Wiley & Sons.

Strecher, V. J., DeVellis, B. M., Becker, M. H., & Rosenstock, I. M. (1986). The role of self-efficacy in achieving health behavior change. Health Education Quarterly, 13(1), 73–91. https://doi.org/10.1177/109019818601300108

Wright, C. (1992). Factors associated with contraceptive behavior among Black college students (Unpublished doctoral dissertation). University of Oregon.

Items of the Scale