Female Attitudes Toward the Morning-After Pill Scale (FAMPS, EAFPDS)

1. Abstract

The Escala de Atitudes Frente à Pílula do Dia Seguinte (EAFPDS), internationally designated in the psychometric literature as the Female Attitudes Toward the Morning-After Pill Scale (FAMPS), is a self-report psychometric instrument developed by Passos et al. (2023). The instrument was engineered to assess multidimensional cognitive and affective evaluative dispositions toward emergency hormonal contraception among cisgender women. Emergency contraception—predominantly administered in the form of levonorgestrel regimens—remains a cornerstone of reproductive healthcare, yet its utilization is frequently encumbered by psychosocial barriers, moral stigma, misinformation, and somatic apprehension. The FAMPS was constructed through an empirical psychometric pipeline commencing with an initial pool of 18 items generated from an extensive review of public health, reproductive medicine, and social psychological literature. Following content validation by an expert panel of psychometric and behavioral science judges, five items exhibiting poor content representation or semantic ambiguity were removed.

The refined 13-item experimental measure was administered to an empirical calibration sample of university-attending women in Brazil. An exploratory factor analysis (EFA) demonstrated an optimal, theoretically coherent two-factor latent architecture comprised of 7 final items. These dimensions capture two distinct psychological facets of contraceptive appraisal: Anxiety (4 items), representing emotional conflict, moral ambivalence, social shame, and anticipated guilt; and Safety (3 items), reflecting perceived somatic sequelae, menstrual cycle disruptions, and biological harm. Responses are captured along a five-point Likert-type response continuum ranging from 1 (“Never”) to 5 (“Always”). In initial validation studies, internal consistency reliability was documented at Cronbach’s α = 0.67 for the Anxiety subscale, α = 0.62 for the Safety subscale, and α = 0.66 for the global composite score, with average inter-item correlations (homogeneity) of 0.41 and 0.29, respectively. The FAMPS provides reproductive health researchers, clinical psychologists, and public policy analysts with a brief, empirically grounded diagnostic and evaluative tool to identify cognitive-affective deterrents to emergency contraceptive access.

2. Keywords

Anxiety, Emergency Contraception, Morning-After Pill, Reproductive Health, Contraceptive Attitudes, Female Sexuality, Psychometrics, Factor Analysis, Sexual Health, Health Belief Model

3. Authors

The Female Attitudes Toward the Morning-After Pill Scale was conceptualized, operationalized, and psychometrically validated by a collaborative team of Brazilian researchers specializing in social psychology, psychometrics, and human sexuality:

• Ádilo Lages Vieira Passos — Departamento de Psicologia, Universidade Federal do Ceará (UFC), Fortaleza, Ceará, Brazil.
• Ana Amábile Gabrielle Rodrigues Leite — Coordenação do Curso de Psicologia, Universidade Federal do Delta do Parnaíba (UFDPar), Parnaíba, Piauí, Brazil.
• Emerson Diógenes de Medeiros — Coordenação do Curso de Psicologia, Universidade Federal do Delta do Parnaíba (UFDPar), Parnaíba, Piauí, Brazil. (Corresponding Author: [email protected]).
• Ludgleydson Fernandes de Araújo — Programa de Pós-Graduação em Psicologia, Universidade Federal do Delta do Parnaíba (UFDPar), Parnaíba, Piauí, Brazil.
• Ricardo Neves Couto — Coordenação do Curso de Psicologia, Universidade Federal do Delta do Parnaíba (UFDPar), Parnaíba, Piauí, Brazil.
• Paulo Gregório Nascimento da Silva — Departamento de Psicologia, Universidade Federal da Paraíba (UFPB), João Pessoa, Paraíba, Brazil.

4. Purpose

The primary purpose of the Female Attitudes Toward the Morning-After Pill Scale (FAMPS / EAFPDS) is to assess the subjective cognitive, emotional, and normative appraisals held by women regarding the use and acquisition of the morning-after pill (emergency post-coital hormonal contraception). Despite global recommendations by the World Health Organization (WHO) designating emergency contraception as a safe, essential, and non-abortifacient method for preventing unintended pregnancy following unprotected sexual intercourse, contraceptive failure, or sexual assault, substantial psychological resistance persists across various populations. In Brazil and other socio-culturally conservative or predominantly Catholic societies, emergency contraception occupies a contested cultural space characterized by social taboo, moral sanction, medical misinformation, and conflation with induced abortion.

From an applied clinical perspective, understanding an individual’s explicit attitudes toward emergency contraception is critical for reproductive counseling, gynecological consultation, and adolescent medicine. Ambivalent or negative attitudes can lead to delayed administration, reducing efficacy because levonorgestrel regimens lose preventive effectiveness as the post-coital interval increases. Women harboring elevated anxiety, internalized shame, or anticipatory guilt may delay purchasing the medication or avoid pharmacies altogether due to perceived judgment by dispensing pharmacists or community members. The FAMPS allows clinicians and health service evaluators to identify patients who may avoid emergency contraception due to unfounded safety fears or moral distress, enabling tailored psychoeducation and therapeutic clarification.

From a public health and empirical research standpoint, the FAMPS serves as an operational instrument to evaluate educational interventions, reproductive health campaigns, and university sexual wellness initiatives. By segregating evaluative dispositions into somatic safety apprehensions and emotional-moral anxieties, researchers can assess which informational deficits require intervention. For example, high scores on the Safety dimension point to the need for scientific education regarding pharmacokinetics, side-effect profiles, and non-teratogenic mechanisms of action, while elevated scores on the Anxiety dimension highlight the necessity of dismantling stigma, moral conservatism, and social taboos surrounding female autonomy and post-coital prevention.

5. Psychological Construct

The psychological construct evaluated by the FAMPS is defined as an individual’s latent evaluative disposition—encompassing cognitive judgments, emotional appraisals, and behavioral intentions—directed toward emergency contraception. In accordance with classical attitude theory in social psychology, attitudes represent enduring mental organizations of beliefs, feelings, and behavioral predispositions toward a given psychological object. In the context of the morning-after pill, this construct manifests through two correlated, yet distinct, latent dimensions:

1. Contraceptive Anxiety (Affective-Normative Dimension)

The Anxiety dimension reflects the psychological distress, moral ambivalence, social shame, and anticipated guilt that women experience when contemplating or carrying out the purchase and ingestion of the morning-after pill. This factor captures the intersection between internalized socio-cultural values and immediate emotional reactions:

• Anticipated Guilt: Negative self-evaluative affect arising from the violation of internalized normative standards regarding sexual responsibility, prudence, or perceived maternal morality (e.g., feelings of personal failing or transgression).
• Social Stigma and Shame: Anticipated embarrassment and humiliation experienced during public retail acquisition (such as facing pharmacy staff), driven by fear of being judged as sexually reckless or promiscuous.
• Moral and Abortifacient Misconceptions: The cognitive categorization of emergency contraception as an abortive intervention rather than an anovulatory mechanism, triggering moral conflicts associated with religious or ethical prohibitions against abortion.
• Behavioral Avoidance: A generalized reluctance or refusal to employ emergency contraception even in high-risk post-coital situations, directly stemming from emotional discomfort (captured as an inverse behavioral disposition).

2. Perceived Safety (Cognitive-Somatic Dimension)

The Safety dimension captures cognitive risk assessments regarding the biological and physiological consequences of ingesting high-dose progestins. This factor encompasses subjective appraisals of medical hazard, endocrine disruption, and pharmacological safety:

• Perceived Somatic Toxicity: The belief that the morning-after pill is inherently harmful, intoxicating, or damaging to the female physiological system.
• Endocrine and Menstrual Apprehension: The conviction that taking emergency contraception will produce severe, irreversible, or chronic disruptions to the hypothalamic-pituitary-ovarian axis, leading to menstrual cycle irregularities.
• Cumulative Risk Perception: Apprehensions regarding the frequency of usage, operationalized through the belief that repeated administration causes long-term organ toxicity, permanent infertility, or adverse systemic outcomes.

6. Theoretical Framework

The development of the FAMPS is situated at the intersection of several established behavioral and social psychological frameworks, most notably the Theory of Planned Behavior, the Health Belief Model, and the Tripartite Model of Attitudes.

The Tripartite Model of Attitudes

According to the tripartite attitude model formulated by Rosenberg and Hovland (1960) and further developed by Alice Eagly and Shelly Chaiken, attitudes consist of three interrelated response classes: cognitive (beliefs, knowledge structures, thoughts), affective (emotions, feelings, physiological arousal), and conative/behavioral (behavioral intentions and observed actions). The FAMPS directly maps onto these components:

• The cognitive component is captured across items measuring explicit beliefs about the pill’s abortifacient nature, its endocrine impacts, and its perceived bodily harm.
• The affective component is measured through items capturing emotional states of guilt and shame.
• The behavioral component is indexed through behavioral endorsement or resistance regarding potential personal use.

The Health Belief Model (HBM)

The Health Belief Model (Rosenstock, 1974; Becker, 1974) posits that health-related decisions depend on subjective assessments of perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. Within the architecture of the FAMPS:

• The Safety subscale directly operationalizes perceived barriers related to somatic costs and biological hazards (e.g., menstrual disturbance, physiological damage).
• The Anxiety subscale reflects psychological and social barriers, where anticipated stigma, embarrassment in public interactions, and moral guilt function as costs that deter women from seeking post-coital intervention.

The Theory of Planned Behavior (TPB)

In Ajzen’s Theory of Planned Behavior (1991), human action is guided by behavioral beliefs (attitudes toward the behavior), normative beliefs (subjective norms), and control beliefs (perceived behavioral control). Subjective norms—the perceived social expectations of significant others—heavily influence decisions in domains governed by sexual morality. The FAMPS Anxiety factor incorporates social stigma (shame in pharmacy acquisition) and moral classifications (categorization of emergency contraception as abortion), reflecting how patriarchal norms and reproductive conservatism shape an individual’s behavioral intention to use the morning-after pill.

7. Validity

The psychometric validation of the FAMPS by Passos et al. (2023) established empirical evidence across several measurement parameters, centering on content validity and latent construct configuration:

Content Validity

The construct was operationalized through an initial generation of 18 items based on a comprehensive analysis of Brazilian and international literature addressing contraceptive practices, emergency contraception barriers, and reproductive decision-making. These preliminary items were submitted to a panel of expert judges specializing in psychometrics, social psychology, and reproductive healthcare. The judges evaluated each item for semantic clarity, psychological relevance, theoretical alignment, and target population suitability. Based on inter-rater consensus, 5 items demonstrating conceptual overlap, low discriminating power, or semantic ambiguity were discarded, yielding a 13-item instrument for empirical testing.

Construct and Structural Validity

Construct validity was evaluated by administering the 13-item version to a calibration sample of Brazilian female university students. Psychometric suitability of the data matrix was confirmed prior to factor extraction:

• The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity confirmed that the correlation matrix was appropriate for latent structure exploration.
• Exploratory factor analysis, combined with scree plot analysis, indicated a distinct two-factor solution.
• Items with weak factor loadings or substantial cross-loadings below the established cutoff of |≥ 0.37| were eliminated, leaving 7 structurally robust items distributed across the Anxiety and Safety factors.

Convergent and Discriminant Considerations

The emergent two-factor pattern demonstrated theoretical divergence between emotional-normative costs (Anxiety) and physiological-somatic risk perceptions (Safety). Item 12 (“I would use the morning-after pill”, reverse-scored) loaded cleanly onto the Anxiety factor, demonstrating that direct behavioral willingness is negatively tied to anticipated guilt, shame, and abortifacient beliefs rather than somatic safety perceptions alone.

8. Reliability

The internal consistency of the FAMPS was evaluated using classical test theory indices, specifically Cronbach’s alpha (α) and mean inter-item correlation (homogeneity index):

• Anxiety Subscale (4 items): Cronbach’s α = 0.67; average inter-item homogeneity = 0.41.
• Safety Subscale (3 items): Cronbach’s α = 0.62; average inter-item homogeneity = 0.29.
• Full Composite Scale (7 items): Cronbach’s α = 0.66.

In psychometrics, short scales (consisting of 3 to 4 items per factor) naturally yield lower alpha coefficients because Cronbach’s α is dependent on scale length. In such contexts, mean inter-item correlations between 0.20 and 0.40 indicate acceptable construct homogeneity without excessive item redundancy (Briggs & Cheek, 1986). The homogeneity values of 0.41 (Anxiety) and 0.29 (Safety) confirm that the items within each subscale measure unified conceptual dimensions.

9. Factor Analysis

The underlying dimensionality of the FAMPS was explored using Exploratory Factor Analysis (EFA). The analytical procedure and structural findings proceeded through several sequential phases:

Extraction Criteria and Item Retention

The extraction of factors was guided by empirical criteria, primarily Kaiser’s eigenvalue rule (> 1.0) and visual inspection of Cattell’s scree plot. The scree plot displayed a distinct break after the second factor, indicating a two-factor latent solution. A two-factor model was subsequently specified, and items were evaluated based on their primary factor loadings:

• A stringent retention threshold of |≥ 0.37| was applied. Items falling below this cutoff or displaying uninterpretable cross-loadings across both factors were systematically eliminated.
• This pruning reduced the scale from 13 experimental items to 7 psychometrically sound items.

Factor Matrix and Structural Composition

The resulting two-factor pattern revealed a clear structural distribution:

• Factor 1: Anxiety (Ansiedade) — Comprises 4 items (Original pool items 1, 13, 3, and 12). Items capture guilt (Item 1), abortifacient beliefs (Item 13), shame during purchase (Item 3), and personal willingness to use (Item 12, reversed).
• Factor 2: Safety (Segurança) — Comprises 3 items (Original pool items 5, 7, and 10). Items index perceived physical harm (Item 5), menstrual cycle dysregulation (Item 7), and negative cumulative effects from frequent use (Item 10).

10. Instrument / Measurement Tool

• Test Name: Female Attitudes Toward the Morning-After Pill Scale (FAMPS) / Escala de Atitudes Frente à Pílula do Dia Seguinte (EAFPDS)
• Authors: Ádilo Lages Vieira Passos, Ana Amábile Gabrielle Rodrigues Leite, Emerson Diógenes de Medeiros, Ludgleydson Fernandes de Araújo, Ricardo Neves Couto, and Paulo Gregório Nascimento da Silva
• Publication Year: 2023
• Test Type: Self-report psychometric inventory / attitudinal rating scale
• Administration Format: Electronic / digital questionnaire (suitable also for paper-and-pencil administration)
• Target Population: Adult cisgender women (tested on university students aged 18–64)
• Number of Items: 7 items
• Subscales / Dimensions:
  • Anxiety Subscale (Ansiedade): 4 items (Items 1, 3, 12, 13)
  • Safety Subscale (Segurança): 3 items (Items 5, 7, 10)
• Response Continuum: Five-point Likert-type scale:
  • 1 = Nunca (Never)
  • 2 = Raramente (Rarely)
  • 3 = Às vezes (Sometimes)
  • 4 = Frequentemente (Frequently)
  • 5 = Sempre (Always)
• Scoring and Directionality:
  • Reverse-Scored Item: Item 12 (“Eu usaria a pílula do dia seguinte”) must be reverse-scored prior to calculating scale scores: $1 \rightarrow 5$, $2 \rightarrow 4$, $3 \rightarrow 3$, $4 \rightarrow 2$, $5 \rightarrow 1$.
  • Subscale Calculation: Subscale scores are obtained by calculating either the arithmetic mean or the sum of items within each factor:
  • Anxiety Score: Sum or mean of Items 1, 3, 13, and reversed Item 12. Higher scores reflect greater negative affect, moral conflict, perceived social shame, and psychological resistance.
  • Safety Score: Sum or mean of Items 5, 7, and 10. Higher scores reflect greater perceived somatic harm, physiological distrust, and fear of endocrine disruption.
  • Composite Score: Higher overall scores represent more negative, apprehensive, and restrictive attitudes toward emergency contraception.

11. Permissions & Fee and Test Year

The Female Attitudes Toward the Morning-After Pill Scale (FAMPS / EAFPDS) was published in 2023 in the open-access journal Psicologia: Teoria e Pesquisa. The original research article and its associated measurement items are licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).

• Permissions: Free to use for non-commercial and commercial research, psychological training, clinical practice, and educational purposes, provided appropriate attribution is given to the original authors (Passos et al., 2023).
• Fee: None. The scale is freely accessible as a public-domain scientific instrument.
• Correspondence Contact: Emerson Diógenes de Medeiros (Universidade Federal do Delta do Parnaíba — UFDPar). Email: [email protected].

12. References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Becker, M. H. (1974). The Health Belief Model and personal health behavior. Health Education Monographs, 2(4), 324–473. https://doi.org/10.1177/109019817400200401
• Briggs, S. R., & Cheek, J. M. (1986). The role of factor analysis in the development and evaluation of personality scales. Journal of Personality, 54(1), 106–148. https://doi.org/10.1111/j.1467-6494.1986.tb00391.x
• Eagly, A. H., & Chaiken, S. (1993). The Psychology of Attitudes. Harcourt Brace Jovanovich College Publishers.
• Passos, Á. L. V., Leite, A. A. G. R., de Medeiros, E. D., de Araújo, L. F., Couto, R. N., & da Silva, P. G. N. (2023). Pílula do Dia Seguinte: Elaboração e Evidências Psicométricas de uma Medida [Morning-after pill: Psychometric preparation and evidence of a measure]. Psicologia: Teoria e Pesquisa, 39, Article e39505. https://doi.org/10.1590/0102.3772e39505.pt
• Rosenberg, M. J., & Hovland, C. I. (1960). Cognitive, affective, and behavioral components of attitudes. In C. I. Hovland & M. J. Rosenberg (Eds.), Attitude Organization and Change: An Analysis of Consistency Among Attitude Components (pp. 1–14). Yale University Press.
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403
• World Health Organization. (2018). Emergency contraception: Key facts. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/emergency-contraception

13. Items of the Scale