Study characteristics

The search strategy yielded 5234 relevant records. Finally, 62 full texts were reviewed, of which 15 separate scales were identified (Fig.1).

PRISMA flow diagram of study process

Ambiguous scales that measured the components, dimensions, or subscales of women empowerment but did not fit in our framework and original search strategy were excluded to consistently adhere to our conceptual framework (n=46). Another full text aimed at the psychometric analysis of Reproductive Agency Scale 17 (RAS-17), composing pregnancy-specific and non-pregnancy-specific agency items among Qatari and non-Qatari women with a normal pregnancy [20], was excluded to achieve the maximum homogeneity of the results. Some scales such as the Survey-Based Womens Empowerment (SWPER) Index and Composite Womens Empowerment Index (CWEI) have been developed to measure women empowerment [21, 22]; however, they did not include in this review because they were not applicable in sexual or reproductive health.

A detailed description of the included scales is shown in Table 1. The results revealed that included articles did not represent diverse geographical areas. The majority of studies (8/15) were conducted in the United States [5,6,7,8, 23,24,25,26]. Two were done in Nepal [12, 27], one in Spain [28], and the rest of the studies (4/15) were carried out in African countries [13, 29,30,31]. The sample size varied from 235 to 4674 in primary studies and 111,368 in one study using the Demographic and Health Surveys (DHS). The age of participants ranged between 16 and 71. The items of each scale ranged from 8 to 23. The target population in studies were as following: three studies (3/15) included adolescents and young adults (1524years) [11, 29, 30], three (3/15) were carried out on young women aged 1629 [7, 8, 25]; one conducted in young women 2035years [12]; six studies (6/15) aimed to assess women in reproductive age defined as those aged 15 to 49years [5, 6, 13, 26, 27, 31]. Two studies extended the age group of participants beyond 45years; in one study, women at the ages of 15 to 60 [24]; and in another, women ages 18 to 71 were included [32].

The most common domains of women empowerment in reproductive health that had been measured were: freedom from coercion, decision-making, communication with the partner, choice, control, autonomy, and ability to negotiate. Kabeers framework of empowerment was applied as the empowerment framework in two studies (2/15) [11, 31]; The theory of gender and power developed by Connell in four studies (4/15) [6, 24, 29, 30]; and Sex scripts (gender-stereotypical expectations to engage in sexual behavior) was used in two studies (2/15) [7, 8]. Moreover, the Reproductive empowerment framework developed by Edmeades et al. (2018) and General conceptualization of assertiveness based on human rights to autonomy, each one was used in one study [12]. The World Banks Empowerment Framework and The sexual and health empowerment framework developed by the authors were used in a study conducted by Moreau et al. [13]; whereas the rest of the studies did not apply any specific empowerment framework.

Of the included studies, seven applied either literature review, or expert panels, or empirical method to develop the item pool (Table 2). Adequate internal consistency defined as the alpha>0.7 was reported in nine studies (9/15). However, in four studies, poor internal consistency (<0.70) was seen. Two studies also did not report internal consistency. Most of the studies but three lack reporting testretest reliability. Nine studies proved content validity. Six criteria were applied to score scales by which nine of fifteen articles were rated as medium quality, two rated as poor quality, and four rated as high quality (Table 3).

Sexual and Reproductive Empowerment Scale is a 23-item questionnaire developed and validated by Upadhyay et al. (2020) and aimed to assess the latent construct of sexual and reproductive empowerment among a national sample of American males and females adolescents and young adults (AYAs) aged 1524years. This scale contains the following domains: comfort talking with a partner (three questions); choice of partners, marriage, and children (three questions); parental support (4 questions); sexual safety (4 questions); self-love (4 questions); the sense of future (2 questions); and sexual pleasure (3 questions). The total score could range from 0 to 92. The items can be self-administered, and on average, AYAs could answer all items in less than 2min. The baseline results demonstrated that sexual and reproductive empowerment was associated with access to sexual and reproductive health services and information, and also at 3-month follow-up was moderately associated with the use of desired contraceptive methods. In contrast to most reproductive empowerment measures, this scale can also be used among men and boys [11].

As a multi-dimensional scale, Reproductive Autonomy Scale (RAS) was developed and validated in the USA to measure reproductive autonomy among women. This scale is comprised of 14 items and three subscales. Reproductive autonomy was defined as womens power to decide about and exercise control on issues related to using contraception, pregnancy, and childbearing. The participants were selected from the family planning and abortion facilities in the United States. Three subscales of the scales were freedom from coercion (five questions), communication (five questions), and decision-making (four questions). The study found a reverse association between freedom from coercion and communication subscales with unprotected sex [24].

Hinson et al. (2019) developed and validated the reproductive decision-making agency scale among Nepalese women aged 1549. The 17-item scale attempts to measure womens decision-making over reproductive behaviors in three domains, including womens agency in using family planning methods, agency in choosing the method of family planning, and agency in choosing the time of getting pregnant. In this study, women whose husbands or other relatives rather than themselves mainly made decisions on reproductive behaviors were considered the lowest agency. In contrast, women reporting sole or joint decision makingwere categorized as the medium and high agency, respectively. The scales scores varied between three and nine, the higher scores representing the higher agency. This scale can be applied to assess a range of reproductive outcomes, particularly those related to reproductive control.

WGE-SRH was developed by Moreau, Karp, et al. (2020) in three African countries, Ethiopia, Uganda, and Nigeria, to provide a cross-cultural scale. This 21-items scale attempts to assess the existence of choice and exercise of choice across the three domains related to sex, using contraception, and pregnancy. Participants agreement or disagreement with each item scored from 1 to 10. The results showed that women who indicated higher scores on the contraceptive choice subscale are more likely to use contraception. Moreover, higher scores on the sexual exercise scale were associated with a higher possibility of volitional sex [13].

This 5-item measure was derived from the Reproductive Coercion Scale (RCS) by McCauley et al. (2017). The scale was validated in two longitudinal randomized controlled trials conducted on young English- or Spanish-speaking women aged 1629 in the USA. These five questions constructed two subscales: pregnancy coercion (three items) and condom manipulation (two items). Items include dichotomous (yes/no) answers. The short form of scale was useful in recognizing women who endorse low levels of reproduction coercion. This scale is particularly sensitive to identifying women who experience less common forms and multiple forms of reproduction coercion. Furthermore, this scale would provide a rapid assessment of reproductive coercion in clinics.

SAS was developed to measure womens understanding over the three subscales of assertiveness regarding initiation of sex, refusal of sex, and prevention of sexually transmitted disease/pregnancy (STD-P) with a regular partner. It comprises 18 items rated on a 5-point response format with anchors of 0 (Never) and 4 (Always). The higher scores on the scale, the higher sexual assertiveness is predicted. The SAS was developed and validated in a sample of young American women ages 1629. After 6 and 12months intervals, testretest reliabilities were assessed [5].

Antos-Iglesias and Carlos Sierra (2010) adapted the Hurlbert Index of Sexual Assertiveness (Hurlbert, 1991) among the Spanish community. The psychometric analysis was conducted among 400 Spanish men and 453 women who had a partner for at least six months. The original scale was composed of 25 items, ranging from 1 (Never) to 5 (Always). The total scores were between 0 to 100. The higher scores represent the higher sexual assertiveness. The exploratory and confirmatory factor analyses identified a 19-item structure with two correlated factors (Initiation and No shyness/Refusal). Six items from the original version were eliminated. Finally, the Spanish version showed satisfactory psychometric characteristics [32].

SAQ was derived from the Sexual Assertiveness Scale (Morokoff and colleagues, 1997) by Loshek and Terrell (2014) to provide a scale that does not include the condom insistence. The underlying hypothesis was although the sexual assertiveness scale encompasses condom insistence, it might not be administered to women at all life stages or in various kinds of relationships. The final scale comprises 18 items and three subscales, including the ability to initiate and communicate across desired sex, the ability to refuse unwanted sex, and the ability to talk about sexual history and risk. Response choices included a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). The results demonstrate satisfactory psychometric properties [26].

This 19-items scale aimed to measure gender-stereotypical expectations engaging in sexual behaviors. This study hypothesized that sexual pressure is associated with HIV sexual risk behavior. Scale composed of five factors: Condom Fear, Sexual Coercion, Womens Sex Role, Men Expect Sex, and Show Trust. Higher sexual pressure was identified through a higher score. The SPS can be used to assess to what extent adherence to gender-stereotypical expectations may limit womens sexual choices and lead to adverse consequences, such as being less assertive in communicating their desire to reduce risk and being more likely to be engaged in sex with men who are at the higher risk of HIV [7].

Jones and Gulick (2009) revised the sexual pressure scale (Jones, 2006) to improve its reliability. The study was carried out on a sample of young adult urban women. The reliability and confirmatory factor analysis using structural equation modeling resulted in 18 items with higher reliability than the original scale. After eliminating the Condom Fear factor, a 4-factor model encompassing Show trust, Womens sex role, Men expect sex, and Sexual coercion was remained [8].

This measure was designed by Pulerwitz et al. (2000) to address interpersonal power in sexual decision-making. SRPS consists of 23 items and two subscales, Relationship Control (RC) and Decision-Making Dominance (DM). RC subscale encompasses fifteen,and DM is composed of eight questions. The totalscore was ranged from 8 to 24. Lower scores on SRPS were associated with higher physical violence and lower consistent use of a condom [6].

This scale was derived from the Relationship Control subscale of the SRPS and then validated among AGYW who were at the risk of HIV in Kenya. The original subscale consisted of 15 items. A modified scale was extracted after removing three items related to condom use, resulting in 12 items in total. Participants were asked to express to what extent they agree or disagree with each item on a 4-point Likert scale. The results showed that AGYW with higher relationship power were less likely to experience sexual violence and more likely to use a condom and have knowledge of partners HIV status [29].

SRP equity is a South African adaptation of the Sexual Relationship Power, originally developed by Pulerwitz et al. in 2000 [6]. Over the community-based cohorts, 235 young men and women aged 1624years completed this questionnaire. Follow-up study performed six months later. The original SRPS consists of 13 questions. Participants answered on a 4-point Likert scale for each item, ranging from (strongly agree to strongly disagree). Higher scores representing greater equity in sexual relationship power. Finally, a 8-item scale for women and a 9-item scale for men were constructed. SRP equity was associated with higher education and no recent partner violence [30].

This scale was developed by Bhandari et al. (2014) to provide a validated scale for measuring Nepalese womens autonomy as one of the predictors of using maternal health care services. The 23 items were answered on a 3-point scale anchored with zero (not necessary), one (useful not essential), and two (essential). Three subscales, including decision-making autonomy, financial autonomy, and freedom of movement, constitute the scale. The Autonomy Measurement Scale showed appropriate psychometric characteristics and introduced a valid and standard scale for assessing womens autonomy in developing countries [27].

Using Demographic and Health Surveys (DHS) from nineteen countries in four African regions, a scale composed of 26 indicators was developed to assess different dimensions of women empowerment, including economic, socio-cultural, education, and health. Access to healthcare composes distance, money, and permission. For instance, items such as: whether women have the access or financial constraints to make beneficial health choices were included. If women reported difficulties accessing healthcare services, they were assigned a 0 score; otherwise, women were scored 1. This scale provided region-specific indicators of women empowerment in Sub-Saharan Africa [31].

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