Ten-item questionnaire validated to assess athletes’ and coaches’ hormonal contraception knowledge

Researchers in Germany and Sweden have developed and validated a ten-item questionnaire designed to measure how much female athletes and their coaches actually know about hormonal contraception. The tool, called the Hormonal Contraception Knowledge Questionnaire (HCKQ), was created by Katharina Fischer of Leipzig University and the Institute for Applied Training Science, together with colleagues from Humboldt-Universität zu Berlin, Macromedia University of Applied Science and Mid Sweden University. Writing in Frontiers in Sports and Active Living, the team describes a nine-step development and validation process that moved from item generation through expert review to large-scale testing with 562 elite female athletes and 170 coaches, producing initial evidence of content validity, known-groups validity and moderate reliability.

The rationale is grounded in the realities of elite sport: female athletes train and compete under the influence of fluctuating reproductive or synthetic hormones, whether from their menstrual cycles or from hormonal contraceptive use. Yet previous research suggests that knowledge within athlete and coach populations appears limited regarding the different types of hormonal contraceptives available, their mechanisms, and their implications for health and performance. The authors argue that foundational knowledge may support athletes and coaches in asking informed questions, recognizing their own knowledge gaps, and engaging in shared decision-making with qualified healthcare professionals. Elite sport in Germany is organized around a federal, federation-based support system that includes Olympic training centers, but current analyses indicate heterogeneous quality and implementation of existing support structures, which may influence how easily athletes and coaches can access specific information on female health in sport.

Hormonal contraceptives primarily contain synthetic progestins and/or estrogens, which modify the body’s natural hormonal milieu by inhibiting endogenous hormone production. Combined progestin-estrogen methods mainly suppress the secretion of luteinizing hormone and follicle-stimulating hormone, thereby inhibiting ovulation. Progestin-only methods vary in their effects on ovulation: some formulations may not consistently inhibit it, acting instead largely by thickening the cervical mucus to block sperm penetration. Many contraceptives also reduce fallopian tube motility and limit endometrial development, making implantation less likely. Specific effects differ depending on the formulation, the route of application—oral, intrauterine, or implant—and the product brand.

The prevalence of hormonal contraceptive use among female athletes ranges widely, from approximately 30% to 68%, depending on individual characteristics, sport type, and personal motives, and use appears more common among athletes who are older and in a relationship. Recent public health data from Germany suggest a potential generational shift in contraceptive behavior, with declining use of oral contraceptive pills among people aged 16 to 25 years, possibly linked to increasingly critical attitudes toward hormonal contraceptives and concerns about side effects such as headaches, weight gain, mood changes and reduced libido. Athletes also use these methods for non-contraceptive reasons, including managing menstrual symptoms, regulating bleeding to align with training and competition schedules, and improving skin quality. Regarding perceived performance effects, earlier work reported that 31.5% of 181 Swiss female elite athletes perceived no noticeable impact, 43.6% were unsure, and minorities reported benefits such as more consistent performance (14.4%) or feeling more powerful (7.7%).

Only two earlier studies had examined oral contraceptive pill knowledge among female athletes and coaches, each using its own instrument. Mean knowledge scores were 36% for female athletes, 40% for female coaches, and 28% for male coaches, with a significant difference between female and male coaches, and female athletes who used hormonal contraceptives demonstrated significantly better understanding than non-users. Both studies focused only on oral pills, and the instruments had methodological shortcomings: one did not report item-level psychometric indicators such as item difficulty or discrimination, while the other used mixed answer formats, including open-ended items, complicating scoring and comparability. Previous tools typically targeted either athletes or coaches, and none had included items on intrauterine systems, a method used as frequently as oral pills among elite female athletes in Germany. The new questionnaire was designed with gynecological expert input to address these gaps, using a single-choice format with a do-not-know option to reduce guessing.

Development proceeded in three phases. A structured literature review of scientific and non-scientific educational materials defined hormonal contraception knowledge and identified four content domains: safety of use, functions and effects of different methods, risk factors and side effects, and the fertile window within the menstrual cycle. Three gynecologists with three to seventeen years of professional experience suggested 39 potential items, of which 11 were excluded, mainly on intake protocols or comparisons with other methods, and the remaining 28 were consolidated by merging 13 overlapping items into 15 item groups. A further 32 items were drawn from existing questionnaires, 14 were excluded, and the remaining 18 were integrated into those groups, producing a 17-item preliminary version covering safety (three items), mechanisms and effects (eight), risk factors and side effects (three), and the fertile window (three).

This preliminary questionnaire was piloted with 325 recreational female athletes, mean age 25.5 years, and 46 coaches recruited between May and July 2021. Item analysis removed seven questions: one answered correctly by 90% of respondents, which sat at the upper boundary of the predefined difficulty range and offered little discrimination; four with item-total correlations below the preferred criterion of r = .30, although several statistically weaker items were retained on expert judgment because they addressed concepts essential to content validity; and two items using an all-of-the-above format judged likely to encourage guessing. The resulting ten-item scale was then rated by an expert panel of 18 specialists—seven gynecologists, five biologists, four sports physicians and two sports scientists—who scored relevance and clarity on six-point scales, giving mean ratings of 5.5 for both. The item-level content validity index ranged from .89 to 1.00 and the scale-level index reached 97%, and a video conference with five panel members refined item wording.

The final evaluation enrolled 562 German elite female athletes, mean age 21.0 years, training on average 17.6 hours per week, of whom 72.6% competed at international level, and 170 coaches, 55 female and 114 male, recruited through national sports federations, athletes’ organizations and coach academies between August 2022 and February 2023. The mean item difficulty index was 46%, but individual items spanned an enormous range: 88% answered correctly a question identifying the season of the year as a factor that does not generally influence pill effectiveness, while only 8% correctly identified which hormones are contained in a hormonal intrauterine system, making it the most difficult item. The mean item-total correlation was r = .29, with values ranging from .14 to .46.

Construct validity was supported by significant group differences. Knowledge scores differed between female athletes, female coaches and male coaches (F(2,728) = 6.51, p = .002), with female coaches scoring highest at a mean of 5.45 points, significantly above both male coaches at 4.27 and female athletes at 4.58, while male coaches and female athletes did not differ significantly. Female athletes using hormonal contraceptives also scored significantly higher than non-users, 5.02 versus 4.51. The authors suggest the coach difference may reflect greater personal and professional exposure to reproductive health topics among female coaches, noting that female athletes often report feeling more comfortable discussing menstrual-cycle-related issues with female coaches, whereas such topics are often perceived as private or sensitive in conversations with male coaches. Higher scores among users may reflect exposure to information through personal use, medical counseling or information seeking. The effect sizes were small, however, and the authors caution that group membership explained only limited differences in knowledge.

Reliability estimates were modest but interpreted as acceptable for a newly developed instrument at an early validation stage. Cronbach’s alpha reached .61, with McDonald’s omega at .62 and Guttman’s lambda2 at .63, values the researchers attribute partly to the diversity of topics covered by only ten items and to the retention of statistically weaker items judged essential for content validity. For comparison, an earlier twelve-item oral pill questionnaire achieved an alpha of .84, and a recent 46-item menstrual cycle and contraception questionnaire reported .93, implying different applications for the shorter tool. Test-retest reliability was examined in a separate mixed-sex cohort of 64 sport science students who completed the questionnaire twice, one week apart, in April 2025. Scores were stable, with a strong Spearman correlation of .75 and an intraclass correlation coefficient of .74, and Bland-Altman analysis showed no systematic bias, only a minor mean increase of .23 points between administrations, with 70% of participants reporting no additional exposure to contraception information during the interval.

The authors acknowledge several limitations. Athletes and coaches were pooled for item analyses, so item selection may have been biased toward female athletes’ knowledge profiles; some subgroup comparisons were slightly underpowered relative to the planned sample sizes, with 162 hormonal contraceptive users instead of the calculated 196 and 55 female coaches instead of 59; and the small effect sizes warrant cautious interpretation. The questionnaire was validated in German, with the English version prepared solely for publication and not yet independently validated, and test-retest reliability was assessed in students rather than athletes or coaches. The team notes that the difficult intrauterine system item may need rewording in future revisions, and proposes that the HCKQ could serve as a research instrument exploring links between contraceptive knowledge and demographic or physiological factors, and as a screening tool to identify knowledge gaps and evaluate educational programs before and after interventions. The authors stress it should not be used as a stand-alone decision-making tool, since individualized contraceptive choices require consideration of medical history, personal preferences, symptoms, training demands and performance goals in consultation with qualified healthcare professionals, and they call for translation and validation in other languages and cultural contexts.

Subject of Research: Development and validation of a questionnaire assessing hormonal contraception knowledge in female athletes and coaches

Article Title: The development and validation of a questionnaire to assess female athletes’ and coaches’ knowledge about hormonal contraception

Article References: Fischer, K., Kirschbaum, E. M., Nikoleizig, L., Elbe, A.-M., & McGawley, K. (2026). The development and validation of a questionnaire to assess female athletes’ and coaches’ knowledge about hormonal contraception. Frontiers in Sports and Active Living, 8, Article 1921305. https://doi.org/10.3389/fspor.2026.1921305

Image Credits: AI Generated

DOI: 10.3389/fspor.2026.1921305

Keywords: hormonal contraception, female athletes, coaches, questionnaire validation, menstrual health, oral contraceptives, intrauterine system, psychometrics, elite sport, reproductive health, women in sport, instrument development