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FNEAMPIAELREA CLAO NETD OALM.ACCEPTABILITY IN ZIMBABWE
FEMALE CONDOM UPTAKE AND
ACCEPTABILITY IN ZIMBABWE
Sue Napierala, Mi-Suk Kang, Tsungai Chipato, Nancy Padian,
and Ariane van der Straten
As the first phase of a two phase prospective cohort study to assess the acceptabi
lity
of the diaphragm as a potential HIV/STI prevention method, we conducted
a 2 month prospective study and examined the effect of a male and
female condom intervention on female condom (FC) use among 379 sexually active
women in Harare, Zimbabwe. Reported use of FC increased from 1.1% at
baseline to 70.6% at 2 month follow up. Predictors of FC uptake immediately
following the intervention included interest in using FC, liking FC better than
male condoms, and believing one could use them more consistently than male
condoms. Women reported 28.8% of sex acts protected by FC in the 2 weeks
prior to last study visit. Though FCmay not be the preferredmethod for the major
ity
of women, with access, proper education, and promotion they may be a
valuable option for some Zimbabwean women.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that more
than 33 million people are infected with HIV. Women are more vulnerable to HIV i
nfection
for both biological and cultural reasons (Susser & Stein, 2000). New survey
data released by UNAIDS shows that in sub Saharan Africa, women are disproportiona
tely
infected by HIV at a 3:2 ratio, on average. Zimbabwe is one of the countries
worst affected by the epidemic, with an HIV prevalence rate of 20.1% among
15-to-49-year-olds (UNAIDS, 2006).
Twenty years into the HIV epidemic, female condoms are the only currently
available female initiated method of HIV and sexually transmitted infection (STI)
prevention (Bull, Posner, Ortiz, & Evans, 2003; FHI Research Briefs). Female con
doms
became commercially available 13 years ago and are now marketed in over 90
developing countries (Hoffman, Mantell, Exner, & Stein, 2004). There have been
both successes and disappointments in the uptake of this method around the globe
.
However, continued promotion of this method is important, as currently it is the
only
121
AIDS Education and Prevention, 20(2), 121 134, 2008
2008 The Guilford Press
Sue Napierala, Mi Suk Kang, Nancy Padian, and Ariane van der Straten are with the
Women s Global
Health Imperative, Department of Obstetrics, Gynecology and Reproductive Science
s, University of California,
San Francisco, University of California, San Francisco. Tsungai Chipato is with
the UZ UCSF Collaborative
Research Program in Women s Health and the Department of Obstetrics and Gynecology
,
University of Zimbabwe, Harare, Zimbabwe.
The authors acknowledge the study staff and participants in Zimbabwe for their c
ontributions to this study.
Support for this study was provided byCONRADand the Centers for Disease Control
and Prevention Contract
CSA 99 269.
Address correspondence to Ariane van der Straten, PhD, MPH, RTI International, 1
14 Sansome Street,
Suite 500, San Francisco, CA 94104; E mail: ariane@rti.org.
barrier alternative to male condoms and can provide women with increased control
in
reproductive health decision making.
Incident pregnancy rate within the first year is approximately 5%for perfect use
,
as compared to 3% for the male condom, and 21% for typical use as compared to
15% for the male condom (Hatcher et al., 1998; Trussell&Kowal, 1998). There are
no studies to date that examine the effectiveness of the female condom in preven
ting
HIV acquisition in humans; however, the female condom is impermeable to HIV,
cytomegalovirus, hepatitis B virus, and herpes simplex virus (Drew, Blair, Miner
, &
Conant, 1990; Voeller, Coulter, & Mayhan, 1991). Studies examining effectiveness
against STIs are few. Three randomized controlled trials for STI prevention have
been
conducted: two were designed as effectiveness trials (Feldblum et al., 2001; Fon
tanet
et al. 1998) and one was a noninferiority trial to demonstrate effectiveness com
pared
to male condoms (French, Latka, Gollub, Rogers, Hoover, & Stein, 2003). All thre
e
showed no difference between arms. In addition, there is evidence that the avail
ability
of the female condom, in addition to male condoms, may contribute to an overall
higher proportion of protected sex acts (Fontanet et al., 1998).
Worldwide, acceptability of the female condom is variable with ranges from
37% to 96% depending on settings and populations (World Health Organization,
1997). Of the few studies that have examined female condom use over 6 months or
more, all but one showed an increase in proportion of protected sex acts overall
with
promotion and provision of female condoms. A study among STI clinic attendees in
Alabama, showed that over a 6 month period the rate of protected sex acts increase
d
from 40% to 50% of sex acts with introduction of the female condom (Artz et al.,
2000). Use of male condoms did not decrease, and most women who used the female
condom used male condoms as well. A study of female condom acceptability among
high risk couples in Zambia found that approximately 25% of all coital acts were
protected by the female condom over a 1 year period. Additionally results suggeste
d
that the number of protected acts overall increased with the introduction of the
female
condom (Musaba, Morrison, Sunkutu, Musonda, & Wong, 1998).
In the mid 1990s, an acceptability study done in Zimbabwe showed a high demand
for the female condom, and subsequently Zimbabwean women petitioned the
government to make female condoms widely available (Warren&Philpott, 2003). In
1996 the female condom was approved for use in Zimbabwe, and in 1997 Population
Services International (PSI) began a social marketing campaign in which female c
ondoms
were subsidized and distributed in urban areas (Warren & Philpott, 2003).
These condoms were marketed as a method of contraception to avoid the stigma of
STI prevention that male condoms had in Zimbabwe (Meekers & Richter, 2005;
Warren & Philpott, 2003). One study among people who purchased the female condom
at retail outlets in urban Zimbabwe demonstrated that factors associated with
use included perceived ease of use and affordability, as well as ever having use
d the
male condom (Meekers&Richter, 2005). In parallel, the Ministry of Health launche
d
a distribution program targeted toward rural areas. Distribution of the female c
ondom
escalated from approximately 300,000 condoms sold in 1998 to over 1.6 million
in 2002 (Warren & Philpott, 2003).
We previously reported on diaphragm acceptability and mixed-method use of
male condoms, female condoms, and the diaphragm, among a sample of sexually acti
ve
women who were inconsistent condom users following a 2 month condom intervention
study, in Harare, Zimbabwe (Posner et al., 2005; Buck et al., 2005; Kang et
al., 2006 Van der Straten, Kang, Posner, Kamba, Chipato,&Padian, 2005). Here we
122 NAPIERALA ET AL.
report the effect of a 2 month male and female condom intervention on female condo
m
acceptability and use among sexually active women who, at study entry, reported
using condoms inconsistently, in Harare, Zimbabwe. Results of this study
provide additional support that the female condom is acceptable to some at risk
women.
METHODS
STUDY DESIGN AND POPULATION
A two phase prospective cohort study to assess the acceptability of the diaphragm
as a potential HIV/STI prevention method (Van der Straten et al., 2005) was
conducted, and results of the first phase are reported here. The purpose of the
first
phase was to identify women who, after a brief intervention, could not use condo
ms
consistently so that they would then be enrolled in the diaphragm study (phase 2
). After
reviewing the data on FC acceptability and uptake in phase 1, it was deemed impo
rtant
for publication. Women were recruited from reproductive health and family
planning clinics in Harare, Zimbabwe, between December 2000 and December 2001.
To participate in the study, women had to be between 16 and 48 years old, health
y,
not pregnant, and not wanting to become pregnant for the next 8 months. They wer
e
required to be sexually active (at least 10 acts of sex in the past 2 months), h
ave no allergy
to latex, and report condom use less than 100% of the time. Women were recruited
irrespective of HIV serostatus; however, free HIV counseling and testing was
offered as a service. Eligible women provided written consent and were enrolled
into
the condom intervention study.
STUDY VISITS AND PROCEDURES
The condom intervention study consisted of three visits over a period of 2
months. The first (baseline) visit took place immediately following enrollment.
At the
first visit a detailed questionnaire was administered by a trained interviewer.
Following
the questionnaire, participants had a pelvic examination, urine collection for p
regnancy
testing, and STI syndromic diagnosis and treatment. Free HIV ELISA testing
and counseling by a trained provider was offered as a benefit of study participa
tion.
Women found to be HIV-positive were allowed to remain in the study and were also
referred for additional support services.
MALE AND FEMALE CONDOM INTERVENTION
Following the baseline interview, women participated in a 30 minute
one on one counseling program about HIV and safer sex conducted by a trained
counselor. Immediately after the intervention, participants received an educatio
nal
assessment interview, to document what they had learned from the intervention. A
hierarchical
counseling message was used, presenting the male condom as the most effective
method for prevention of HIV/STIs, followed by the female condom whose
effectiveness is less well known. The condom intervention was based on social cogn
itive
models of behavior change. It emphasized enhancing condom self efficacy and
negotiation skills and included education about HIV and STI transmission, HIV/ST
I
risk assessment, safer sex options, and demonstration and practice of proper use
of
male and female condoms. For the female condom, after demonstration by the staff
,
participants practiced opening the female condom packet and inserting it into a
pelvic
model until they were comfortable with the procedure. Problem solving around ind
ividually
identified relationship and practical barriers to use was conducted and partic-
FEMALE CONDOMACCEPTABILITY IN ZIMBABWE 123
ipants had opportunities to role-play condom negotiation with the counselor. Aft
er
the counseling session, participants practiced inserting the female condoms on t
hemselves,
aided by the study clinician. Participants were given a 1 month supply of both
male and female condoms and were encouraged to drop in any time if additional
condoms were needed.
FOLLOW UP VISITS
Participants had two monthly follow up visits. Participants were resupplied with
male and female condoms at each visit. At the 1-month follow up visit, they receiv
ed a
booster counseling session on condom use, with content similar to enrollment. At
the
2 month follow up visit, participants completed a pictorial self administered retrospe
ctive
coital calendar covering 2 weeks prior to the study visit, and received an inter
viewer
administered follow up interview. Participants then had a final pelvic
examination, urine collection for pregnancy testing, and STI syndromic diagnosis
and
treatment.
MEASURES
At baselinewomen were given an interview administered questionnaire. The questionn
aire
included questions about demographics, medical history, sexual history and
behavior, vaginal practices, opinions about contraceptive methods, drug use, and
domestic
violence. Women were also asked if they had used the female condom for pregnancy
prevention (yes/no) and for HIV/STI prevention (yes/no) (a) ever, (b) in the pas
t 2
months, and (c) now.We determined use for both pregnancy and HIV/STI prevention
by looking at the intersection of these two questions.Women were asked to identi
fy all
methods of contraception they currently used (defined as using now ) at baseline fr
om
an array of listed methods (tubal ligation, birth control pills, IUD, male condo
ms, female
condoms, spermicides, diaphragm, Norplant, Depo Provera, partner vasectomy,
rhythm, douching, withdrawal, traditional, other). From this, indicator variable
s were
created for those using both hormonal or permanent, and barrier methods, those u
sing
only a hormonal or permanent method, those using only a barrier method and those
not
using any of the above mentioned methods. Women were asked which method they
liked best (and least) for pregnancy prevention andHIV/STI prevention from those
they
had ever used. Baseline male partner variables were assessed, including whether
the
partnerworked, how often hewas under the influence of alcohol or drugs during se
x in
the past 6 months (four response categories: every time, about half the time,
occasionally, never), and if there was a history of domestic violence.
The educational assessment interview was administered immediately following
the initial condom promotion and counseling session and asked about perceived ef
fectiveness
of the female condom for pregnancy and HIV/STI prevention, how interested
women were in using the female condom (three response categories: not at all int
erested,
somewhat/moderately interested, very/extremely interested), which method between
the male and female condom they liked better, and which they thought they
could use more consistently. Women were also asked to assess the perceived effec
tiveness
of the female condom for pregnancy and HIV/STI prevention (three response catego
ries:
not at all effective, somewhat/moderately effective, very/extremely effective),
and these two questions were asked again at the end of the 2 month follow up,
during the final interview administered questionnaire.
At the end of the 2 month follow up period women were given a second interviewer
administered questionnaire. Again women were asked if they had used the female
condom for pregnancy prevention (yes/no) and for HIV/STI prevention (yes/no)
124 NAPIERALA ET AL.
(a) in the previous 2 months (since last questionnaire) and (2) whether they use
d it
now. Uptake of the female condom, was defined as current use (i.e., use now ).
Again, women were asked which method they liked best (and least) for pregnancy p
revention
and HIV/STI prevention from the listed methods they had used in the past 2
months.
The self administered questionnaire (SAQ) was in the form of a coital calendar.
Women put stickers on the calendar indicating which day(s) they had sex and what
methods, if any, were used in the previous 2 weeks. At the 2-month visit, we use
d this
SAQ to determine the proportion of sex acts protected by the female condom in th
e
previous two weeks, and to identify women reporting 100% female condom use in th
e
previous 2 weeks.
STATISTICAL METHODS AND DATA ANALYSIS
Preference and use data are presented for the women who completed the
2 month condom intervention study. Bivariate associations with reported female
condom use and preference were tested using Student s t, chi square, and Fisher s exac
t
tests. Exploratory analyses of the association between reported female condom
use at study exit, baseline demographics, behavioral and attitudinal factors wer
e
based on bivariate comparisons using chi square and Fisher s exact statistics to ass
ess
significance of observed associations. An alpha level of .05 was used to judge t
he statistical
significance of each effect. Because only a few factors were associated with the
outcomes and because these factors were highly correlated, logistic regression r
esults
are presented as adjusted odds ratios for individual factors controlling for age
(an a
priori decision was made to include age in all models). In bivariate and logisti
c models
the attitudes data included are from the post intervention assessment. We chose
to include
this because it more accurately reflected attitudes prior to use. Data were
analyzed using SAS software, Version 9.1.
RESULTS
We screened 842 women: 424 were eligible, and of those 405 (95%) were enrolled
into the condom intervention study. Three hundred seventy nine (94% of those enr
olled)
completed the 2 months of follow up and constitute the analytical sample for
this article.
As shown in Table 1, the average age of participants was 28 (range: 16 48),
97.4% were married, and 69.1% had one lifetime sexual partner. The mean number
of children was 2.5 (range: 0 10), and 51.7% had finished at least secondary educa
tion.
Of the 303 women who elected to take an HIV test at baseline, 75 were HIV positive
.
Most women were using hormonal contraception. Of the 41 who reported
barrier method use, all were using male condoms, and four were also using female
condoms.
Perceived effectiveness of the female condom in preventing pregnancy and
HIV/STIs was high at baseline and did not change postintervention. Preinterventi
on,
74.7% (n = 283) of women reported that the female condom was very/extremely effe
ctive
in preventing pregnancy, and 68.3% (n = 259) reported it was very/extremely
effective in preventing HIV/STIs. Postintervention, this changed to 72.0% and
70.1%, respectively (see Table 2). Interest in using the female condom for pregn
ancy
or HIV/STI prevention was high with 75.9% of women postintervention reporting
they were very/extremely interested and 35.6% thought they could use the female
condom more consistently than male condoms.
FEMALE CONDOMACCEPTABILITY IN ZIMBABWE 125
At baseline, as Table 2 shows, only 21 women (5.5%) had reported ever using a
female condom, and eight reported using them in the previous 2 months (one woman
reported using it for pregnancy prevention only, five women for prevention of
STI/HIV only, and two for both). At the 2 month visit, of the 337 women who report
ed
female condom use in the past 2 months, the large majority (89%, n = 300) report
ed
using it for both pregnancy and HIV/STI prevention. Reported current use of
FC (use now ) increased from 1.1% (n = 4) at baseline to 70.6% (n = 266) at the end
of the study.
As reported on the SAQ at study end, of the 373 women who had sex in the previou
s
2 weeks, 68.1% had used the female condom at least once, corresponding to
28.8% of recent sex acts having been protected by the female condom. Twenty
women (5.4%) reported using the female condom as their only barrier method in th
e
previous 2 weeks. Of the 240 women who reported 100% of sex acts protected by a
barrier method in the past 2 weeks, 67.5% used the FC for at least a portion of
their
sex acts and 8.3% reported using only the FC to protect all sex acts.
We examined associations with female condom uptake (defined as current use at
the 2-month 2 visit) using the following baseline predictors: sociodemographics; e
ver
having used the female condom; contraceptive use; and variables collected during
the
postcounseling educational assessment, including interest in using the female co
ndom,
preferring the female condom to the male condoms, thinking they could use the
female condom more consistently than male condoms, and perceived effectiveness o
f
female condoms. We also examined baseline partner factors, including whether the
partner worked, was under the influence of alcohol or drugs during sex, and whet
her
there was a history of domestic violence. Finally, we looked at HIV status at en
try into
the study. As shown in Table 3, in bivariate analysis as well as logistic regres
sion, in-
126 NAPIERALA ET AL.
TABLE 1. Baseline Characteristics of Participants
Characteristics N (379) %
Age group
16 24 157 41.3%
25 34 152 40.1%
34 48 70 18.5%
Married 369 97.4%
Lifetime partners
1 262 69.1%
>1 117 30.9%
Mean number of children (range) 2.5 (0 10)
Education
Less than secondary 183 48.3%
Completed secondary 196 51.7%
HIV test
Positive 75 19.8%
Negative 228 60.2%
Not tested 76 20.1%
Current contraceptive method
Barrier method only (Male or female condom) 10 2.6%
Barrier method and hormonal or permanent method 31 8.2%
Hormonal or permanent method only 319 84.2%
No barrier, hormonal or permanent method used 19 5.0%
History/fear of domestic violence 294 77.6%
Partner works 349 92.2%
Partner under the influence of alcohol or drugs during sex in past
6 months 220 58.0%
Used male condom in last 2 months 90 23.8%
127
TABLE 2. Female Condom Use and Acceptability at Baseline
(pre and post intervention) and at 2 Month Visit
Baseline Pre intervention Baseline Post intervention 2 month visit
Variable N = 379 % N = 379 % N = 379 %
Use variables on face to face interview
Ever use FC 21 5.5%
Used female condom for Pregnancy or HIV/STI prevention
in last two months 8 2.1% 337 88.9%
Used FC in past 2 months for pregnancy prevention 3 0.8% 302 79.7%
Used FC in past 2 months for HIV/STI prevention 7 1.8% 335 85.5%
Current use of FC (using now ) 4 1.1% 266 70.6%
Self reported for the past 2 weeks
Reported having sex in the past two weeks 373 98.4%
Used FC during sex in past 2 weeks 254* 68.1%
Used FC for 100% of sexual acts in past 2 weeks 20* 5.4%
Female condom attitudes
Very/extremely effective against HIV/STI 259 68.3% 265 70.1% 285 75.2%
Very/extremely effective against pregnancy 283 74.7% 272 72.0% 274 72.3%
Very/extremely effective against pregnancy or HIV/STI prevention 319 84.2% 300 7
9.4% 308 81.3%
Very interested in the female condom for HIV/STI prevention 248 65.6%
Very interested in the female condom for pregnancy prevention 250 66.1%
Very interested in the female condom for pregnancy or HIV prevention 287 75.9%
Prefer female to male condom 145 38.3%
Feel they can use female condom more consistently than male condom 135 35.6%
Preference for FC
Liked FC best for pregnancy prevention 0 0.0% 76 20.1%
Liked FC best for HIV/STI prevention 1 0.1% 96 25.3%
Note. 2 women used for both pregnancy and HIV/STI prevention. 300 women used for b
oth pregnancy and HIV/STI prevention. *Denominator is 373, women who had sex in
the past 2
weeks.
128
TABLE 3. Baseline Factors Associated with Female Condom Uptake at 2 months Follow up
(N = 379)
Female condom uptake: Current use of female condom at 2 months Odds ratios adjus
ted for age
Variable N % p Value AOR 95% CI
Age (modeled continuously) mean=27.8 sd = 6.8 0.48 1.00 .99 1.01
16 24 113 72.0%
25 34 108 71.1%
34 48 45 64.3%
Secondary education 139 70.9% 0.75 1.08 0.69 1.68
Less than secondary education 127 69.4%
Married 259 70.2% 1.00 1.01 0.26 3.97
Not married 7 70.0%
Number of children 0.31 0.89 0.78 1.03
0 1 86 75.4%
2 81 69.2%
3+ 99 66.9%
Contraceptive method at baseline 0.09
Barrier method only 6 60.0% 0.18 0.03 1.22
Barrier and hormonal/permanent method 18 58.1% 0.16 0.03 0.83
Hormonal/permanent method only 225 70.5% 0.28 0.06 1.2
No barrier, hormonal or permanent method 17 89.5%
Partner works 0.20
Yes 248 71.1% 1.64 0.76 3.53
No 18 60.0%
Partner under the influence of alcohol or drugs during
sex in past 6 months 0.22
Yes 149 67.7% 0.75 0.48 1.18
No 117 73.6%
History/fear of domestic violence
Yes 209 71.1% 0.47 1.21 0.72 2.03
No 57 67.1%
HIV Status at baseline 0.99
Positive 53 70.7% 1.02 0.58 1.81
Negative 160 70.2%
Not tested 53 69.7% 0.98 0.56 1.73
129
Ever used FC 0.39
Yes 13 61.9% 0.67 0.27 1.68
No 253 70.7%
Think FC is very/extremely effective for pregnancy/HIV
prevention 0.11
Yes 216 72.0% 1.52 0.90 2.57
No 49 62.8%
Very/extremely interested in FC for pregnancy/HIV prevention
0.00
Yes 212 73.9% 2.03 1.24 3.32
No 53 58.2%
Prefer female to male condom 0.00
Yes 116 80.0% 2.26 1.39 3.68
No 149 64.0%
Think can use FC more consistently than male condom 0.00
Yes 108 80.0% 2.20 1.34 3.62
No 157 64.6%
Note. Logistic regression analysis: Adjusted Odds Ratio (AOR) adjusted for age; C
onfidence Interval (CI). p Value derived from chi square and Fisher s exact tests, as
appropriate
terest in female condoms for pregnancy or disease prevention (adjusted odds rati
o
[AOR]: 2.03, confidence interval [CI]: 1.24 3.32), preference of the female condom
over male condoms (AOR: 2.26, CI: 1.39 3.68), and thinking the female condom can
be used more consistently than male condoms (AOR: 2.20, CI: 1.34 3.62) were signif
icantly
associated with female condom uptake. Perceived effectiveness against either
pregnancy or HIV/STIs was not significantly associated with female condom
uptake (AOR: 1.52, CI: 0.90 2.57). Sociodemographic factors, partner factors and
HIV status showed no association with the outcome variable.
Although the number ofwomen was small (n = 20),we analyzed factors associated
with reporting 100% female condom use in the past two weeks at 2-month. Liking f
emale
condoms better than male condoms (AOR: 16.4, CI: 3.7 71.8, p = 0.00), and
thinking they can use the female condom more consistently than male condoms (AOR
:
18.5, CI: 4.2 81.4, p = ..00) were associated with 100% use in logistic regressi
on.
Women were asked to select their preferred method for pregnancy and disease
prevention from among those they had ever used. At baseline, birth control pills
were
most often listed as the preferred method for pregnancy prevention (35%), and on
ly
one woman (0.1%) stated that the female condom was her preferred method. In cont
rast,
at the 2-month visit, male condoms were most often listed as their preferred
method for pregnancy prevention (47%). Furthermore, at the 2-month visit, 20%
(76) of women liked the female condom best for pregnancy prevention, 25% (96) fo
r
STI/HIV prevention, for a total of 27% (102) for either pregnancy or HIV prevent
ion.
Of those who liked the female condom best at 2 month follow up, 99% were using
the female condom in the past 2 weeks and 13% had used the female condom for
100% of sex acts in the past 2 weeks. Women were also asked to select from the
method they had used, the one they liked the least. Of the 234 women who selecte
d the
FC as their least liked method for disease prevention at the 2-month visit, the
two most
common responses were that it was uncomfortable (38.0% ) and that it was not depen
dable
(31.9%). These were the same two chief complaints given by the 194 women
who selected the FC as their least liked method for contraception.
We examined factors associated with liking the female condom best at Month 2
for either pregnancy or disease prevention (Table 4). Controlling for age, in lo
gistic regression,
belief in the effectiveness of female condoms (AOR: 3.00, C: 1.48 6.1), interest
in using female condoms (AOR: 2.43, C: 1.31 4.54), liking female condoms
better than male condoms (AOR: 5.97, CI: 3.63 9.82), and believing that they could
use them more consistently than male condoms (AOR: 4.41, CI: 2.73 7.15) were all
predictors of liking the female condom best for pregnancy or HIV/STI prevention.
DISCUSSION
Despite a social marketing campaign beginning in the mid 1990 s promoting the female
condom in Zimbabwe, uptake of this method has been relatively minimal.
Though records show a steady increase of the female condom sales from 1998 to
2002, in our study sample in Harare, Zimbabwe, only a small percentage of women
had ever used this method. However, prior to the intervention, perceived effecti
veness
of the female condom was high, and following education and counseling, reported
use
of the female condom greatly increased over a 2 month period. The best predictors
of
female condom uptake were measures taken after the counseling intervention, rath
er
than baseline measures. Furthermore, liking female condoms best for HIV/STI or
pregnancy prevention greatly increased over the 2 month follow up as well.
130 NAPIERALA ET AL.
FEMALE CONDOMACCEPTABILITY IN ZIMBABWE 131
TABLE 4. Baseline Factors Associated with Liking the Female Condom Best
at 2-Months Follow-Up (N = 379)
Listed FC as Method Liked Best
Odds Ratios Adjusted
For Age
Variable N = 266 % p Value AOR 95% CI
Age (modeled continuously) mean=28.1 sd=7.1 0.95 1.00 0.99 1.01
16 24 42 26.8%
25 34 42 27.6%
34 48 18 25.7%
Secondary education 56 28.6% 0.45 1.23 0.78 1.94
Less than secondary education 46 25.1%
Married 99 26.8% 0.73 0.85 0.22 3.36
Not married 3 30.0%
Number of children 0.26 0.85 0.72 1.00
0 1 37 32.5%
2 30 25.6%
3+ 35 23.7%
Contraceptive method at baseline 0.24
Barrier method only 2 20.0% 0.32 0.05 1.95
Barrier and hormonal/permanent method 5 16.1% 0.26 0.07 0.96
Hormonal/permanent method only 87 27.3% 0.50 0.20 1.30
No barrier, hormonal or permanent method 8 42.1%
Partner works
Yes 94 26.9% 0.97 1.03 0.44 2.39
No 8 26.7%
Partner under the influence of alcohol or drugs during sex in past 6 months
Yes 59 26.8% 0.96 1.01 0.63 1.60
No 43 27.0%
History/fear of domestic violence
Yes 83 28.2% 0.28 1.37 0.78 2.43
No 19 22.4%
HIV Status at baseline 0.78
Positive 18 24.0% 0.81 0.44 1.47
Negative 64 28.1%
Not tested 20 26.3% 0.92 0.51 1.65
Think FC is very/extremely effective for pregnancy/HIV prevention
Yes 92 30.7% 0.00 3.00 1.48 6.1
No 10 12.8%
Very/extremely interested in FC for pregnancy/HIV prevention
Yes 88 30.7% 0.01 2.43 1.31 4.54
No 14 15.4%
Like FC better than male condom
Yes 70 48.3% 0.00 5.97 3.63 9.82
No 32 13.7%
Think can use FC more consistently than male condom
Yes 62 45.9% 0.00 4.41 2.73 7.15
No 40 16.5%
Logistic regression analysis: Adjusted Odds Ratio (AOR) adjusted for age; Confide
nce Interval (CI). p Value derived
from chi square and fischer s exact tests, as appropriate.
Interest in the female condom, preference over male condoms and believing they
can be used more consistently than male condoms were significantly associated wi
th
female condom uptake at 2 month follow up. Perceived effectiveness of the female
condom did not change with the intervention, though it was associated with likin
g this
method best, and the large majority of women reported using the female condom fo
r
the dual purpose of pregnancy and disease prevention. A small percentage of wome
n
(5.4%) reported using the female condom exclusively at the 2-month follow up.
One limitation of this study is that we did not assess the long term use and accep
tability
of the female condom. Factors associated with initial uptake may be different
from those associated with long term use (Artz et al., 2000; Musaba et al.,1998).
Other studies have shown that although not all women will show a continued inter
est
in female condom use, for a percentage of women the female condom will be prefer
red,
thereby filling an important niche (Cecil, Perry, Seal,&Pinkerton, 1998; Hart
et al., 1999; Hoffman, Exner, Leu, Ehrhardt,&Stein, 2003; Ray et al. 1998; Yimin
et
al. 2002). Also noteworthy is that most women (>90%) when they entered the study
were already using hormonal contraception, so there may have been less incentive
to
use the female condom than for women who decide to use it as their primary contr
aceptive
method. Thus, findings from this study may not be generalizable to
noncontracepting women or to those who may decide to use female condoms as their
primary contraceptive method.
Few women were exclusive users of the female condoms, and many used mixed
methods. Those who were not 100% condom users continued into the second phase
of the study, looking at barrier method preferences among women and men in Zimba
bwe.
Among the three methods evaluated male condoms, female condoms, and the
diaphragm it was found that though female condoms were used least frequently, the
majority of women did use a mix of all three methods (Buck et al. 2005; Posner e
t al.
2005). This may indicate that increasing the number of available options/choice
for
these women may increase their ability to protect themselves. Furthermore, there
seems to be a small, although important, group of women who may want to use fema
le
condoms exclusively, for whom increased access maybe important.
In this analysis of female condom use, many women seem to have a favorable perce
ption
of female condom effectiveness at baseline, and with a brief intervention, attit
ude
and use was easily enhanced. We hypothesize that one of the major limitations to
female condom use in Zimbabwe is access and education on proper use, and for pro
gram
planners, if this is enhanced, use will increase. Additionally, almost all women
reported using the female condom for the dual purpose of pregnancy and HIV/STI
prevention. The female condom is currently promoted as a contraceptive method in
Zimbabwe. However, program planners should be aware of this and, as most women
in Zimbabwe perceive the FC as highly effective for pregnancy and HIV/STI preven
tion,
continue promotion of the female condom in Zimbabwe for dual purpose. This
also may limit the stigma associated with the promotion of female condoms as a d
isease
prophylactic alone. In addition, the majority of women when given the option
and proper counseling, choose to use mixed methods. Therefore this promotion can
include hormonal and barrier methods as well. Even if female condoms are not the
preferred method for the majority of women, they do fill a niche and provide an
additional
option for women and their partners. With appropriate education, promotion,
and availability, the female condom can be a valuable option for pregnancy and S
TI
prevention for Zimbabwean women.
132 NAPIERALA ET AL.
FEMALE CONDOMACCEPTABILITY IN ZIMBABWE 133
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