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Knowledge, attitudes, practices and behaviors associated with female condoms in developing countries: a scoping review

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Women in developing countries are at high risk of HIV, sexually transmitted infections, and unplanned pregnancy. The female condom (FC) is an effective dual protective method regarded as a tool for woman's empowerment, yet supply and uptake are limited. Numerous individual, socioeconomic, and cultural factors influence uptake of new contraceptive methods. We reviewed studies of FC knowledge, attitudes, practices, and behaviors across developing countries, as well as available country-level survey data, in order to identify overarching trends and themes. High acceptability was documented in studies conducted in diverse settings among male and female FC users, with FCs frequently compared favorably to male condoms. Furthermore, FC introduction has been shown to increase the proportion of "protected" sex acts in study populations, by offering couples additional choice. However, available national survey data showed low uptake with no strong association with method awareness, as well as inconsistent patterns of use between countries. We identified a large number of method attributes and contextual factors influencing FC use/nonuse, most of which were perceived both positively and negatively by different groups and between settings. Male partner objection was the most pervasive factor preventing initial and continued use. Importantly, most problems could be overcome with practice and adequate support. These findings demonstrate the importance of accounting for contextual factors impacting demand in FC programming at a local level. Ongoing access to counseling for initial FC users and adopters is likely to play a critical role in successful introduction.
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Open Access Full Text Article
http://dx.doi.org/10.2147/OAJC.S55041
Knowledge, attitudes, practices and behaviors
associated with female condoms in developing
countries: a scoping review
Lizzie Moore1
Mags Beksinska1,2
Alnecia Rumphs3
Mario Festin4
Erica L Gollub3
1MatCH Research (Maternal,
Adolescent and Child Health
Research), Department of Obstetrics
and Gynaecology, University of the
Witwatersrand, Westville, Durban,
South Africa; 2Faculty of Epidemiology
and Population Health, Lond on
Sch ool of Hy gie ne and Tropical
Medicine, London, UK; 3Florida
International University, Department
of Epidemiology, Stempel College of
Public Health and Social Work, Miami,
FL, USA; 4World Health Organization,
Special Program of Research,
Development and Research Training
in Human Reproduction, Department
of Reproductive Health and Research,
World Health Organization, Geneva,
Switzerland
Correspondence: Erica L Gollub
Florida International University,
Department of Epidemiology, Stempel
College of Public Health and Social
Work, 11200 SW 8th Street,
AHC 5-Rm 482, Miami, FL 33199, USA
Email elgollub@gmail.com
Abstract: Women in developing countries are at high risk of HIV, sexually transmitted infections,
and unplanned pregnancy. The female condom (FC) is an effective dual protective method
regarded as a tool for woman’s empowerment, yet supply and uptake are limited. Numerous
individual, socioeconomic, and cultural factors influence uptake of new contraceptive methods.
We reviewed studies of FC knowledge, attitudes, practices, and behaviors across develop-
ing countries, as well as available country-level survey data, in order to identify overarching
trends and themes. High acceptability was documented in studies conducted in diverse settings
among male and female FC users, with FCs frequently compared favorably to male condoms.
Furthermore, FC introduction has been shown to increase the proportion of “protected” sex
acts in study populations, by offering couples additional choice. However, available national
survey data showed low uptake with no strong association with method awareness, as well as
inconsistent patterns of use between countries. We identified a large number of method attri-
butes and contextual factors influencing FC use/nonuse, most of which were perceived both
positively and negatively by different groups and between settings. Male partner objection was
the most pervasive factor preventing initial and continued use. Importantly, most problems could
be overcome with practice and adequate support. These findings demonstrate the importance
of accounting for contextual factors impacting demand in FC programming at a local level.
Ongoing access to counseling for initial FC users and adopters is likely to play a critical role
in successful introduction.
Keywords: condoms, HIV prevention, contraception, female condom, developing countries,
behavior
Introduction
Women carry a disproportionate burden of HIV1 resulting from numerous physi-
ological, socioeconomic, cultural, and political factors, including unbalanced gender
norms impacting sexual negotiation.2–7 Furthermore, over one-third of pregnancies in
developing countries is unplanned,8 making unmet need for contraception a priority
policy area.9
The female condom (FC) is the only available woman-initiated method for pre-
venting HIV/sexually transmitted infections (STIs) and unintended pregnancy.10 It
has comparable dual protective efficacy to male condoms (MCs)11 and is frequently
cited as a tool for women’s empowerment.12–14 There are several FC models includ-
ing FC2, The Woman’s Condom, The Phoenurse, Cupid, Panty (Condon Femenino),
Velvet, and VA w.o.w (Condom Feminine); all have common components with unique
design features.15 Although the Female Health Company’s FC2 (Chicago, IL, USA)
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Moore et al
is the only current model approved by the United States
Food and Drug Administration (USFDA), Cupid has been
prequalified for distribution by United Nations (UN) agen-
cies16 and others have commenced or are planning UN and
USFDA applications.15
Over 20 years since its first USFDA approval, FC supply
and uptake remains inadequate.17 Few established national
programs exist,18–20 with low distribution21 often attributed to
a lack of policy and donor support11,17,22 and relatively high
procurement costs compared to MCs,11,23 despite long-term
cost effectiveness.14,24,25 As FC options increase, the method
may become more affordable, encouraging greater distribu-
tion and use.15
Increasing availability of new contraceptive methods
does not automatically broaden choice. Uptake depends on
the perceptions and experiences of potential users and the
socioeconomic context,23,26 with culture and gender relations
often having greater impact on acceptability than actual
attributes of the method.13,27 Health system capacity and
acceptance of new methods by service providers addition-
ally influence uptake and sustained use.26,28 Any FC program
evaluation must therefore consider acceptability in context,
by exploring knowledge, attitudes, practices, and behaviors
(KAPB) in a wide range of stakeholders. We conducted a
scoping review29 of FC KAPB across developing countries
to identify overarching themes linking contextual variables
with these outcomes.
Methods
The format of our review was a scoping study. The purpose
of a scoping review is to map a wide range of literature and
to identify the nature, range, and extent of the evidence.29,30
Scoping reviews differ from systematic reviews in their
broad approach to a topic, purposive sampling frame,
and identification of gaps in the literature. We searched
MEDLINE without date restrictions for material available
through January 2015, using the terms “female condom” or
“female-initiated”, to identify KAPB studies for male and
female users and nonusers. We also searched for studies
exploring perspectives of other stakeholders such as health
care providers, although this information falls beyond the
scope of this article. Countries in which research was identi-
fied are listed in Table 1. Titles or abstracts (where a decision
could not be made on title alone) were screened for studies
that discussed FC KAPB in developing nations. We included
English-, French-, and Spanish-language articles. We also
searched the Websites of major international organizations
involved in FC programming and the survey database of the
Reproductive Health Supplies Coalition31 using the same
inclusion criteria. We reviewed a compiled list of research
studies at the Female Health Company Website (http://www.
femalecondom.org/).32 All reference lists were reviewed;
where potentially relevant additional material was unavail-
able online, we contacted authors or publishers to obtain a
copy where possible. All sources were organized by country,
and data were extracted onto standardized data abstrac-
tion forms that stratified KAPB variables by distinct user
subpopulations. Data were then examined across countries
to identify emerging themes and trends. The purpose of a
scoping review is to map a wide range of literature and to
identify the nature and extent of the evidence;29 thus, for each
country, research articles for which there were available data
on potential or actual users or providers were then selected
for inclusion in this review.
Results
We identified 56 countries with national survey data (usu-
ally as Demographic and Health Surveys [DHS])33–41 and
34 countries with other types of material (peer-reviewed
articles, governmental or nongovernmental organizational
reports, or other gray literature). The frequency of articles
and the depth of information varied considerably across
countries. Table 1 shows the type of participants included in
the FC studies, by country. Most research focused on women,
particularly female sex workers (FSWs). Notably, only three
studies42–44 included men who have sex with men (MSM)
(none addressed FC use by women for anal sex); we therefore
include these data alongside those for female users, while
perspectives of heterosexual male partners are considered
separately. Sample sizes for quantitative reports ranged to
2,700, although most contained a few hundred participants.
Qualitative reports tended to be smaller, though most sample
sizes exceeded 100. Table 2 “maps” the number and variety of
peer-reviewed research compared with coverage by national
survey data, organized by country and continent. Most
countries listed provided DHS or other country-level survey
data, but peer-reviewed data were considerably less frequent.
The majority of peer-reviewed research emanated from
Africa, where both qualitative and quantitative studies were
available for several countries. By contrast, countries in the
Americas were less well represented by quantitative studies.
Single countries having the greatest number of peer-reviewed
articles were South Africa (18 articles), the People’s Republic
of China (nine articles), and Zimbabwe (eight articles) (data
not shown). Although most studies were conducted with
the discontinued FC1, several demonstrated comparable
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Female condoms in developing countries
acceptability between various brands.45–50 Reports on pro-
vider attitudes were limited; our search turned up only six
peer-reviewed articles. We made reference to these findings
where relevant and integrated with data from users.
Knowledge and awareness
National data on FC knowledge, primarily from DHS, were
available for 56 countries. These demonstrated widely vary-
ing between-country awareness (Table 3). The prevalence of
FC awareness within countries was consistently lower than
that of MCs; for example in the Democratic Republic of
the Congo, 43% and 82% of women had knowledge of FCs
and MCs, respectively.51 The proportion of women across
all countries having heard of FC (FC knowledge) was also
generally lower (47%) than for the oral contraceptive (OC)
(85%), injectables (80%), and the intrauterine device (IUD)
(55%) (data not shown).33 In general, men demonstrated
slightly higher FC awareness (54%) than women (47%), but
they exhibited lower levels of knowledge on other methods,
as compared with that of women: OC (76%); injectables
(67%); or the IUD (38%) (data not shown).33 FC knowledge
also varied within countries (where available);52 for example,
in India, 13% of urban women reported awareness compared
to 6% of rural women.41 Some studies supported the conten-
tion that greater awareness of and counseling on FC would
increase interest and possible use;53,54 nevertheless, it is clear
that FC awareness alone appears to be insufficient to stimulate
uptake.55 For example 91.4% of women interviewed in the
Table 1 Availability of female condom research by participant type and country
Country Women/ couples Men FSWs Providers Other
Bangladesh ■ ■
Botswana
Brazil ■ ■
Burundi
Cambodia
Cameroon
Central African Republic ■ ■
People’s Republic of China ■ ■
Dominican Republic ■ ■
El Salvador
Ghana ■ ■
India ■ ■
Indonesia
Ivory Coast ■ ■
Kenya ■ ■
Madagascar
Malawi ■ ■
Mexico ■ ■
Mozambique
Namibia ■ ■
Nicaragua
Nigeria ■ ■
Papua New Guinea
Rwanda ■ ■
South Africa
Swaziland
Tanzania ■ ■
Thailand ■ ■
Tunisia
Turkey
Uganda ■ ■
Vietnam ■ ■
Zambia ■ ■ ,
Zimbabwe ■ ■
Total 22 15 25 9 10
Notes: , Indicates that at least one piece of evidence identied for the specied country; , High-risk women; , high-risk men; , MSM; , government/NGO
stakeholders.
Abbreviations: FSWs, female sex workers; n, number; MSM, men who have sex with men; NGO, nongovernmental organization.
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Table 2 Comparison of national survey data and peer-reviewed research by type, country, and continent
Continent Country QuantitativeaQualitativeaMixedaAny peer review National survey
Africa Benin
Botswana ■ ■
Burkina Faso
Burundi
Cameroon ■ ■
CAR ■ ■
Chad
Comoros
Congo
DRC
Eritrea
Ethiopia
Gabon
Ghana
Guinea
Ivory Coast ■ ■
Kenya ■ ■
Lesotho
Liberia
Madagascar ■ ■
Malawi ■ ■
Mali
Mauritania
Mozambique
Namibia ■ ■
Niger
Nigeria ■ ■
Rwanda ■ ■
Senegal
Sierra Leone
South Africa ■ ■
STP
Swaziland ■ ■
Tanzania ■ ■
Tunisia ■ ■
Uganda ■ ■
Zambia ■ ■
Zimbabwe ■ ■
Americas Brazil ■ ■
Dominican Republic ■ ■
El Salvador ■ ■
Guatemala
Guyana
Haiti
Honduras
Mexico ■ ■
Nicaragua ■ ■
Paraguay
Peru
Asia Bangladesh ■ ■
Cambodia ■ ■
China ■ ■
India ■ ■
Jordan
Kazakhstan
Kyrgyz Republic
Philippines
(Continued)
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Female condoms in developing countries
most recent Swaziland DHS had heard of FCs, yet only 46%
knew where to source one.56
General perceptions and attitudes
High acceptability was documented across numerous and var-
ied settings where studies were undertaken among women,
men, and couples who tried the device.45,57–59 For example,
studies introducing FCs in South Africa and Kenya reported
that over 85% of male and female participants expressed
an intention to use FCs in the future, and even more would
recommend them to friends.60,61 A large number of studies
among FSWs suggest that FCs are consistently acceptable to
this population;62,63 for example, in Papua New Guinea, 90%
of female participants engaging in transactional sex reported
“liking” the FC.64 In India, 83% of MSM FC users said they
would continue to use the device.42
Numerous studies reported that FCs compared favorably
with MCs. For example, 80% of women in a South African
short-term crossover trial favored the FC1 and FC2 over
MCs;50 in a Nigerian study, many more participants accepted
and paid for FCs than MCs (8% versus 1%, respectively)
following a provider training intervention.65 Women and
MSM also gauged FC acceptability against the MC, based on
previous negative experiences or perceived superior safety,
strength, or effectiveness.42,43,66 Advantages over the MC were
frequently highlighted, such as comfort, lack of male respon-
sibility, enhanced sexual pleasure, and potential use during
menstruation.67–71 Contraceptive properties were highlighted
in El Salvador, Swaziland, and Zimbabwe.68–70
Several studies did not distinguish between factors
influencing initial uptake or continued use, but they reported
overall responses. The same method attributes of FCs were
perceived both positively and negatively by different groups
and between settings (Table 4). Similarly, environmental/
contextual factors both positively and negatively influenced
uptake in different settings (Table 5). Although few studies
commented on patterns of acceptability, several contradictory
trends existed between countries based on marital status, edu-
cation, and occupation,55,58,72–76 thus supporting the conclusion
of a 2006 systematic review that predictors of acceptability
are not generalizable across cultural contexts.77
Some studies reported that stigmatized notions of the
FC impeded initial use and were widely expressed by men,
women, and health care providers,52,54,73,78,79 linking the device
with infidelity and commercial sex work, even when marketed
as a contraceptive for stable couples.54,61,66,68,78–81 For example,
a quarter of female participants in a Kenyan study felt that
using or carrying an FC was synonymous with unfaithfulness.61
Researchers in Zimbabwe commented that “just like the male
condom, the [FC] was seen as a threat to intimacy and com-
mitment, in that requesting them would introduce an element
of distrust and suspicion of infidelity and promiscuity”.82
Cost was a frequently cited acceptability barrier. Although
both clients and providers often indicated that the FC should
be freely available,83–86 most conceded that they would be
willing to pay a highly subsidized price,67,87–90 usually equal
to that of MCs.66,91,92 FSWs in Malawi noted that free FCs
were only available in hospitals.84 By contrast, in Cameroon,
where intensive FC availability campaigns and a massive
decrease in price has recently occurred, a relatively high ever-
use rate among female high school students (8%) suggests
that price significantly influences acceptability.93
Lack of availability and access were the most frequently
cited contributing factors to FC non-use, discontinuation and
reuse, across diverse subpopulations, including students, FSWs
and women in the general population. For example, 43% of
Rwandan undergraduates agreed that they would use FC if
available;54 and only one-quarter of Chinese family planning
clients thought that FC was easy to obtain.95 Furthermore, lack
of access or availability were frequently cited by healthcare
providers as a reason not to counsel clients on FC use. 22% of
Zimbabwean health care workers indicated they would offer
FCs more frequently if availability was improved (note that the
terms availability and access were used variously by different
Table 2 (Continued)
Continent Country QuantitativeaQualitativeaMixedaAny peer review National survey
Tajikistan
Thailand ■ ■
Timor-Leste
Turkmenistan
Australia PNG
Europe Albania
Turkey ■ ■
Note: aIncludes only peer-reviewed research. Indicates that at least one piece of evidence of this type identied for the specied country.
Abbreviations: CAR, Central African Republic; DRC, Democratic Republic of the Congo; STP, Sao Tome and Principe; PNG, Papua New Guinea.
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Moore et al
authors with a great degree of overlap in meaning; we have
adhered to the original study terms where possible).94
Initial use
FC acceptance in a trial setting varied. In a large Brazilian
study, 90% of participants initially introduced to the device
had used the FC at least once at the 90-day follow-up visit
(hereafter, referred to as follow-up);58 whereas in a Kenyan
study, less than half of the participants recruited through HIV
counseling and testing centers were willing to use the FC.61
The most common reason for never-use was the fear of part-
ner reaction or partner refusal.60,61,78,96 Appearance59,61,81,92 and
lack of perceived need61 were also cited as initial barriers.
Triggers for initial FC use included novelty,43,61,67,71,96 dual
protective properties, partners’ or clients’ unwillingness to use
MCs,42,67,92 and the feeling that it was woman-initiated.43,61,67,97
Promotion and support were frequently-reported facilitators
of initial use.22,53,71,81,88,98–100 For example, counselor training
and peer support groups in Kenya helped women introduce
the FC into sexual relationships.98,101 In Zimbabwe, having
observed an FC demonstration in a hair salon more than
doubled a woman’s likelihood of having tried the device.22 In
Tanzania, a mass media campaign, which triggered commu-
nication about the FC between partners, increased women’s
intention to use the device.99
Table 3 Prevalence of female condom awareness and usea
by country (listed by prevalence of awareness) from national
survey data
Country Surveyb
date
AwarenesscEver
use
Current
use
Women Men
Namibia 2013 94.2% 92.5% 0.5%
2006 83.0% 82.3% 6.4% 0.3%
Swaziland 2006 91.3% 84.1% 3.3% 0.1%
2010
MICS
0.4%
Lesotho 2009 86.6% 77.9% 0.2%
Malawi 2010 86.0% 84.9% 1.2% 0.1%
Zimbabwe 2010 83.9% 87.4% 0.3%
Rwanda 2010 82.4% 79.9%
Gabon 2012 81.7% 78.2% 0.1%
Haiti 2012 81.5% ,0.1%
Ghana 2008 81.3% 86.3% 0.7% ,0.1%
Guyana 2009 78.4% 69.9% 1.5% ,0.1%
South Africa 2008
NHPIBCS
77.8%d72.1% 7.2%d
2003 53.2% 56.4% 2.6% 0.2%
Dominican
Republic
2013 74.8%
2007 52.2% 0.6%
Tanzania 2010 72.5% 73.4% ,0.1%
Uganda 2011 70.5% 81.4%
Cameroon 2011 70.4% 77.0% 0.1%
Sierra Leone 2013 69.5% 64.7% ,0.1%
Liberia 2013 69.3% 56.1%
Burundi 2010 69.1% 66.4% ,0.1%
Congo 2011 68.3% 85.0% ,0.1%
Zambia 2007 65.8% 65.5% 1.2% ,0.1%
Sao Tome and
Principe
2008 58.6% 61.1% 0.5%
Kenya 2008 57.6% 61.5% 0.6% ,0.1%
Comoros 2012 54.8% 60.8% ,0.1%
Ivory Coast 2012 54.4% 63.0% ,0.1%
Paraguay 2004 54.0%
Burkina Faso 2010 47.8% 52.5% ,0.1%
Mozambique 2011 45.3% 77.1% 0.1%
Peru 2011 44.7% 0.2%
Honduras 2011 44.6% 48.8% 0.4% ,0.1%
Democratic
Republic of the
Congo
2013 43.2% 52.8% 0.1%
Papua New Guinea 2006 40.1% 46.1% 0.6%
Senegal 2010 37.2% 44.0% ,0.1%
El Salvador 2008 36.8% 0.3%
Mali 2012 35.7% 38.7% ,0.1%
Benin 2012 34.9% 47.8% ,0.1%
Nicaragua 2001 32.9% 0.3%
Ethiopia 2011 31.9% 39.1% ,0.1%
Nigeria 2013 28.6% 32.8% ,0.1%
2008 14.7% 25.9% 0.2% ,0.1%
Guinea 2012 27.5% ,0.1%
Guatemala 2002 25.0%
Cambodia 2010 23.5% ,0.1%
Eritrea 2002 23.0% 0.1% ,0.1%
Philippines 2013 20.0%
(Continued)
Table 3 (Continued)
Country Surveyb
date
AwarenesscEver
use
Current
use
Women Men
Kyrgyz Republic 2012 19.5% 21.5%
Jordan 2012 18.7%
Madagascar 2008 18.5% 21.2% 0.1% ,0.1%
Kazakhstan 1999 17.9% 4.9% 0.1%
Albania 2008 15.2% 8.9% 0.3% ,0.1%
Niger 2012 15.2% 17.8% ,0.1%
Turkey 2003 13.5%e
13.4%f
Timor-Leste 2009 10.4% 10.4% ,0.1%
India 2006
NFHS
8.3% 16.8% ,0.1% ,0.1%
Tajikistan 2012 7.2%
Chad 2004 7.1% 27.3% ,0.1% ,0.1%
Turkmenistan 2000 6.3% ,0.1%
Mauritania 2000 5.3% 7.5% ,0.1%
Notes: aRefers to all women 15–49 years of age, unless otherwise indicated; brefers
to Demographic and Health Survey, unless otherwise indicated; cawareness of
female condoms as a contraceptive method (percentage of all respondents, currently
married respondents, and sexually active unmarried respondents ages 15–49 years
who know of any contraceptive method, by specic method); dsexually active women
over 15 years of age; eever-married women; fcurrently married women.
Abbreviations: MICS, Multiple Indicator Cluster Survey; NHPIBCS, National HIV
Prevalence, Incidence, Behavior and Communication Survey; NFHS, National Family
Health Survey.
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Female condoms in developing countries
Table 4 Method attributes (actual and perceived) of FCs inuencing acceptability, uptake and/or continued use
Attribute Positive perceptions/facilitators of use
(countries where relevant evidence was identied)
Negative perceptions/barriers to use
(countries where relevant evidence was identied)
Appearance General appearance
(People’s Republic of China)
Large size
(South Africa, Uganda, El Salvador, Nicaragua)
Smell (preferred to MC)
(Burundi, El Salvador, Nicaragua)
Natural feel
(El Salvador, Nicaragua, Nigeria)
Generally unattractive size and shape
(Brazil, Ghana, India, Kenya, South Africa, Uganda, Zimbabwe,
El Salvador, Cambodia, People’s Republic of China, Dominican
Republic, Thailand, Vietnam, Nigeria, Nicaragua)
Too thick
(Ghana)
Too big/loose/long
(India, Kenya, South Africa, Uganda, Bangladesh,
Thailand, Nigeria)
Rings are confusing
(South Africa)
Smell
(South Africa)
Different than
other methods
Novelty factor
(India, Kenya, People’s Republic of China, CAR, Nigeria)
More complicated than other contraceptives
(Vietnam, Zimbabwe, South Africa)
Lubrication Well lubricated (better than MC)
(Brazil, Ghana, India, Uganda, Burundi, El Salvador,
Swaziland, Nicaragua)
Overlubricated
(Namibia, South Africa, Tanzania, Zimbabwe, People’s
Republic of China, Dominican Republic, Thailand)
Fear of adverse effects of lubricant
(Burundi)
Insertion/use Easy/comfortable to insert and use during sex/“natural feel”
(compared to MC)
(India, Kenya, Namibia, South Africa,
Zimbabwe, Burundi, El Salvador, Mexico, Cameroon,
Cambodia, Dominican Republic, Thailand, Vietnam, Nigeria)
Allows sex in any position without technical difculties
(Brazil)
Permitting use when penis is not erect
(El Salvador, Nicaragua)
Difcult to insert/remove
(Brazil, Namibia, Nigeria, PNG, Zimbabwe, Burundi,
El Salvador, Bangladesh, People’s Republic of China,
Swaziland, Thailand, Nicaragua, CAR, Tunisia)
Takes too long to insert
(Vietnam)
Need privacy to insert
(India, Swaziland)
Noise (FC1 only)
(Brazil, Ghana, Namibia, PNG, South Africa, Burundi,
Cambodia, Dominican Republic, CAR, Malawi)
Messy
(Kenya)
Technical difculties during sex/method failure
(Brazil, Ghana, Nigeria, Zimbabwe, Burundi, Cambodia)
Fear of potential technical difculties
(Burundi, People’s Republic of China, Nigeria, South Africa)
Female or male partner discomfort
(Brazil, India, Nigeria, Zimbabwe, Burundi, El Salvador,
Bangladesh, People’s Republic of China, Dominican Republic,
Swaziland, Thailand, South Africa)
Concerns about potential discomfort
(South Africa, Tanzania, Burundi, El Salvador, Nicaragua)
Problems/discomfort related to inner/outer ring
(Ghana, India, South Africa, Zimbabwe, Burundi, Cameroon,
Vietnam, El Salvador, Nicaragua, CAR)
Itching sensations
(CAR)
Bleeding/burning/allergy
(El Salvador, Nicaragua)
Timing of use Ability to insert before sex (prior to drinking alcohol, prior
to man getting an erection)
(Brazil, Ghana, South Africa, Zimbabwe, El Salvador,
Cambodia, Swaziland, Nicaragua)
Perception that FC must be inserted several hours
before sex
(South Africa)
Insertion interrupts the sex act
(Zimbabwe)
(Continued)
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Moore et al
Table 4 (Continued)
Attribute Positive perceptions/facilitators of use
(countries where relevant evidence was identied)
Negative perceptions/barriers to use
(countries where relevant evidence was identied)
Practice
improves
condence
Comfort and ease of use improves with practice
(Brazil, Ghana, Namibia, South Africa, Zimbabwe, Cameroon,
Cambodia, El Salvador, Swaziland, Thailand, Vietnam)
Requires practice to use with condence
(Cambodia)
Discomfort persisted with repeated use
(South Africa)
Safety and
effectiveness
Perceived strength (compared to MC)
(Brazil, India, South Africa, Zimbabwe, El Salvador, Cambodia,
People’s Republic of China, Dominican Republic, Swaziland,
Nicaragua)
Perceived exibility (compared to MC)
(South Africa)
Perceived safety (compared to MC)
(Brazil, Zimbabwe, Thailand, CAR, South Africa)
FC cannot get lost inside the body
(Cambodia)
Perceived effectiveness in pregnancy/STI prevention
(compared to MC)
(India, South Africa, Uganda, Burundi, El Salvador, People’s
Republic of China, Dominican Republic, Vietnam, Nicaragua)
Perceived effectiveness in pregnancy/STI prevention
(Rwanda, South Africa, Nigeria)
Reduced slippage
(El Salvador, Nicaragua)
Better protection from STIs (covers the outer part of the
vagina and labia)
(El Salvador, Nicaragua)
Doubts about effectiveness (compared to MC)
(Kenya, Zimbabwe)
Fear of losing FC in reproductive tract/abdomen
(Ghana, Zimbabwe, People’s Republic of China, South Africa)
Lack of trust in effectiveness against HIV/STI risk among
males
(Nigeria)
Method failure resulting in pregnancy
(Nigeria)
Dual protective
properties
Provides dual protection
(Kenya, South Africa, Uganda, Zimbabwe, Burundi, People’s
Republic of China, Dominican Republic, Swaziland, Nigeria)
Pleasure Enhanced sexual pleasure for woman or man (including by
clitoral stimulation from the external ring), preferred over
MC for sexual pleasure
(Brazil, Ghana, India, Kenya, Zimbabwe, Burundi,
Swaziland, CAR)
Does not affect sexual pleasure
(Kenya, South Africa, Vietnam, CAR)
Couples can stay together for longer after ejaculation
(Kenya, South Africa)
Reduced sexual sensation/pleasure for woman or man
(Ghana, India, Kenya, Nigeria, South Africa, Burundi, People’s
Republic of China, Dominican Republic)
Perception that it would interfere with sexual pleasure
(Uganda)
Outer ring makes genitalia inaccessible
(Uganda, Zimbabwe)
Woman
initiated
Increases woman’s control and sexual agency
(Brazil, Ghana, India, Kenya) (Namibia, South Africa, Uganda,
Zimbabwe, Burundi, Mexico, Bangladesh, People’s Republic of
China, Dominican Republic, Swaziland, Thailand, Vietnam, Nigeria)
Covert use Ability to use covertly
(Brazil, Uganda, Cambodia, Dominican Republic, Swaziland,
El Salvador, Nicaragua)
Inability to use covertly
(Uganda, Zimbabwe)
Other Ability to use during menstruation
(Brazil, El Salvador, Nicaragua)
Offers an alternative to MC (for those who cannot/prefer not
to use MCs or when MC is not available at the time of sex
(Brazil, Ghana, Nigeria, Swaziland, El Salvador, Nicaragua,
Nigeria, South Africa)
Offers alternative protection when nothing else is available
(Zimbabwe)
Offer alternative to hormonal contraception
(Swaziland, El Salvador)
Reuse possible
(Burundi, India)
Inconvenient/long-term use not feasible
(Burundi, People’s Republic of China, Thailand)
Not suitable for some traditional sexual practices
(Burundi)
Abbreviations: MC, male condom; CAR, Central African Republic; PNG, Papua New Guinea; FC, female condom; STI, sexually transmitted infection.
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Female condoms in developing countries
Table 5 Contextual/environmental factors inuencing FC acceptability, uptake, and/or continued use (excluding availability)
Factor Facilitators
(countries where relevant evidence was identied)
Barriers
(countries where relevant evidence was identied)
Experience with
condoms
Familiarity with MC use
(Zambia, Bangladesh)
Lack of knowledge/experience with condoms
(Kenya)
Unfamiliarity with FC/lack of exposure
(South Africa, El Salvador, Swaziland)
Preference for MC
(Nigeria, Zambia, Thailand, South Africa)
Dislike of condoms in general
(Nigeria, Uganda)
Perceived
personal risk
Relationship or
gender dynamics
Perceived risk of STI/HIV infection
(Bangladesh, People’s Republic of China, Nigeria, Zimbabwe,
CAR, Tunisia, South Africa)
Lack of perceived need (for barrier contraceptive)
(Kenya, Nigeria, Burundi, Bangladesh)
Ability to discuss FC with a partner
(Tanzania, Zambia)
More comfortable using FC with (regular) paying client than
nonpaying partner
(Brazil, Ghana, El Salvador, Nicaragua)
Perception that clients would prefer FC
(Thailand)
Bargaining tool for protected sex
(Bangladesh, Cambodia, Swaziland, Thailand)
Share responsibility for condom use
(South Africa)
Partner acceptance of rst use predicted easier negotiation for
further uses
(Cote d’Ivoire)
Men would use if their partners initiate
(South Africa)
Potential for use during menstruation or breastfeeding protects
marriages
(Nigeria)
Can be used if client/partner does not like/refuses/cannot use MC
(Brazil, India, South Africa, Bangladesh, Dominican Republic,
Thailand, El Salvador, Nicaragua, Nigeria)
Better protection for women at risk of coerced sex
(Ghana)
Better protection for women whose husband is unfaithful
(Vietnam)
Limited ability to discuss FC with partner
(Ghana)
Desire for unprotected sex with a loving partner
(Nigeria, Uganda)
Male partner resistance/refusal
(Ghana, Namibia, Nigeria, PNG, South Africa, Zimbabwe,
Burundi, El Salvador, Bangladesh, Cambodia, Swaziland,
Thailand, CAR)
Fear of partner reaction/requirement for negotiation/
partner cooperation
(Kenya, Uganda, Burundi, El Salvador)
Male preference for being in control
(Zambia, Uganda)
Men’s fear that women reuse FC
(Uganda)
Difculty identifying strategies to negotiate FC use with
nonpaying partners
(El Salvador, Swaziland, Nicaragua)
Clients accept MC
(Thailand)
Cultural and
religious norms
Women unaccustomed, uncomfortable or embarrassed
to touch genitals/insert FC in front of a partner
(Brazil, South Africa, Cambodia, Dominican Republic)
Embarrassment/anxiety over FC appearance and use
(Vietnam)
Stigma/association with untrustworthiness/disease
(Ghana, Kenya, Nigeria, South Africa, Zimbabwe,
Burundi, El Salvador, Rwanda, Swaziland, Vietnam)
Condom use conicts with moral or religious beliefs
(Nigeria, Burundi, Bangladesh)
Promotion,
education, and
support
Provider or peer promotion/education/support/counseling
(Brazil, Kenya, Tanzania, People’s Republic of China, South Africa)
FC promoted as contraceptive rather than HIV prevention device
(Zimbabwe)
Lack of awareness of female anatomy causing fear of
losing FC in reproductive tract/abdomen
(Ghana, Zimbabwe, People’s Republic of China,
South Africa)
Lack of information about the device
(El Salvador, Nicaragua, Turkey, Tunisia)
Not fully aware on how to use
(Malawi, South Africa)
(Continued)
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Moore et al
Continued use
A large number of studies reported that continued use was
strongly influenced by experiences during the adoption
phase. These included reservations regarding appearance,
insertion or removal difficulties, discomfort caused by the
inner or outer ring, noise, technical difficulties during sex,
and partner resistance.60,66,71,92,96,102–106 However, study data
indicated that most users overcome initial difficulties with
practice, resulting in high acceptability62,70,81,102,107,108 and few
clinical failures.63,90,95,107,109 For example, FSWs in El Salvador
reported using FCs independently in up to ten sexual acts
before they formed an opinion of the device and felt skilled
enough to use it with a partner. Consequently, these women
recommended that providers offer in-depth training to poten-
tial users who are new to the FCs.92
Continued use was commonly associated with adequate
support during the adoption phase, through counseling or
peer education, in studies following women and couples
for 2–20 months.62,88,102,107,110 For example, in the People’s
Republic of China, education and demonstration sessions
significantly increased FSWs’ knowledge and acceptance
of FCs, and confidence that clients would accept its use.62,75
Brazilian women reported benefiting from FC demonstra-
tion, negotiation tips, hearing testimonials from others, and
discussing initial difficulties:
The meetings were good because she explained many
things, I could rehearse again how to insert it correctly in
a model resembling the vagina, I also talked about how to
introduce it to the partner.102
In the same Brazilian study, other important factors
influencing continued use were perceived safety (compared
with MCs), pleasure (stimulation from external ring), and
increased sense of power for safer sex negotiation.102
Conversely, some studies found that women were more
likely to report inconsistent use or discontinuation when their
initial difficulties were not overcome. Inconsistent use was
most commonly attributed to partner objection – as cited
by 30% of Kenyan women at 12-month follow-up111 and by
FSWs in Zimbabwe, who reported that their clients distrusted
unfamiliar methods.63 Other common reasons for discontinu-
ation were lack of perceived need for a barrier method, often
due to belief in a mutually faithful partnership,111 or desire
for unprotected sex with a loved one.48
Several studies found that discontinuation was frequently
attributed to partner resistance, objection, or dislike of the
device.60,66,112,113 Method attributes influencing discontinua-
tion included unattractive appearance, noise, reduced sensa-
tion, size, overlubrication, difficulty inserting, and discomfort
from the internal ring.58,60,66,84,105,113,114
Patterns of use
National survey data (Table 3) supported a handful of cross-
sectional studies52,54,66,115 that demonstrated low ever or cur-
rent use in the general population. FC use among FSWs was
more common,64,67,85,116,117 with ever-use prevalence ranging
from 5% in Malawi104 to 33% in Swaziland.117
Notably, trends in uptake based on demographic vari-
ables were inconsistent between countries, and no strong
association was apparent between awareness and ever use
for 22 countries where both national datasets were available
(Figure 1), although no formal statistical tests of associations
were undertaken. An analysis of South African national sur-
vey data identified significant associations only with older
Table 5 (Continued)
Factor Facilitators
(countries where relevant evidence was identied)
Barriers
(countries where relevant evidence was identied)
Infrastructure No need to attend clinic to access FCs
(Swaziland)
Difculty disposing of FC
(India)
Free FCs only at hospital
(Malawi)
Difculty of concealing the large package
(El Salvador, Nicaragua)
Poverty/nancial
resources
For FSWs, allows higher earnings when used covertly with clients
requesting no condom use
(El Salvador, Nicaragua)
For FSWs, allows higher earnings due to possibility of use during
menstruation
(El Salvador, Nicaragua)
Cost (if not free or heavily subsidized)
(Brazil, Ghana, India, Namibia, South Africa, Tanzania,
Zimbabwe, El Salvador, Mexico, Bangladesh, Nigeria,
Nicaragua, Malawi)
Loss of potential earnings from clients requesting sex
without a condom
(El Salvador, Nicaragua)
Abbreviations: MC, male condom; FC, female condom; STI, sexually transmitted infection; PNG, Papua New Guinea; CAR, Central African Republic; FSW, female sex worker.
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135
Female condoms in developing countries
age and living in a particular province. Interestingly, many
variables were associated with high knowledge prevalence
but low use, or vice versa.55
Dual protection was a commonly cited advantage in a
number of settings. For example, general population women
in South Africa and Ghana usually cited STI/HIV preven-
tion;66,88 Ugandan HIV-positive women cited prevention of
partner transmission;118 and Swazi FSWs cited prevention
of STIs, unintended pregnancy, and HIV reinfection.70
However, the most common partner type with whom FC
use was reported varied between settings. For example, in
Kenya, South Africa, and Zimbabwe, use was more com-
mon with a spouse/regular partner than a casual/commercial
partner,61,69,88 whereas in Uganda, use was more common in
high-risk sexual relationships.48 FSWs in Brazil and El Sal-
vador reported using FCs more often with regular clients than
with new/occasional clients or boyfriends.67,68 Conversely,
despite both sexes generally perceiving dual protection as an
advantage, women in Swaziland, Zimbabwe, Cote d’Ivoire,
and India reported discomfort discussing disease prevention
with long-term partners.69,70,119,120
Consistency of use and impact
on protected sex
The prevalence of consistent FC use varied between studies,
but it was often low. For instance, in Kenya, 11% of women
enrolled in an FC acceptability trial reported consistent use
at 6-month follow-up.111 Conversely, consistent use in a
general population sample ranged as high as 25%, as shown
in a recent cross-sectional study in a Zimbabwean hospital.121
Most evidence, however, suggested that couples interchange
MC and FC use to maintain or increase the proportion of
protected sex acts.69,70,88,122 In Zimbabwe, factors influencing
method choice included availability, partner preference, and the
woman’s menstrual cycle. Women were more likely to use FCs
consistently if they did not experience technical difficulties or
partner opposition, did not rely on other contraceptive methods,
and used FCs for contraception.69 Another Zimbabwean study
showed that factors influencing consistent use depended on
partner type: consistent use between spouses was negatively
associated with multiple partner behaviors, but for regular
nonmarital partners, it was positively associated with perceived
ease of use and effectiveness for STI prevention.123
A 2006 systematic review77 and three further studies in
Mexico, Kenya, and Madagascar85,122,124 concluded that FC
provision can increase consistent condom use in a population,
supporting other evidence that expanded choice improves
contraceptive uptake and health outcomes.18,19 The addition
of free FC provision into an existing peer education program
among FSWs in Kenya increased consistent MC or FC use
from 60% to 67%.124
Covert use
Despite being a commonly perceived advantage, studies that
investigated actual covert FC use suggest that this practice
is not widespread. Evidence from Brazil, South Africa,
8%
7%
6%
5%
4%
3%
2%
Mauritania
Chad
Turkmenistan Albania
India
Timor-Leste
Kazakhstan
Madagascar
Eritrea
Nicaragua Honduras
Peru
Sao Tome and Principe
Zambia
Ghana
Guyana
Malawi
Swaziland
South Africa
Kenya
Papua New Guinea
EI Salvador
1%
0%
0% 10% 20% 30% 40% 50%
Prevalence of FC knowledge (women)
Prevalence ever use
60% 70% 80% 90% 100%
Figure 1 Scatterplot showing the prevalence of FC knowledge in women and ever use for countries where national survey data were available.
Abbreviation: FC, female condom.
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Moore et al
India, and Uganda suggested that only a minority of women
practice covert use,43,60,67,125 although this may be higher for
FSWs.126,127 In South Africa, reduced partner awareness,
often when partners were drunk or high, was more important
to women than absolute covert use.80 Covert use may facilitate
higher sex work earnings from clients willing to pay more
for sex without a condom,68 whilst increasing a woman’s
chance of protection:
[I]f you have the female condom, you can go to the bath-
room and put it in and the client thinks they are not using a
condom. But because you are wearing it, there is no risk that
he can give you an infection (FSW, El Salvador).68
Reuse
Research in Zimbabwe, Uganda, Zambia, Mexico,
Bangladesh, and Swaziland suggested that a minority of
women reuse FCs.48,70,85,86,89,128 In India, 11% of MSM users
reported reuse of a single FC with multiple clients.42 In South
Africa, among 150 family planning clients and women at
high risk for STIs, 83% reported willingness to reuse the
FC, and those who trialed reuse up to seven times reported
that the recommended steps involved were easy to perform
and acceptable.91 In Swaziland, FSWs reported reuse without
removal or washing, citing reasons of limited availability and
lack of privacy needed for disposal and reinsertion.70
Heterosexual male partners
Studies involving heterosexual men were identified in
15 countries (Table 1); participants included single men,
FSW clients, regular or cohabiting partners, and husbands.
Men in several countries in Africa, Asia, and South America
welcomed the device.45,59,87,102,115,129 For example, over 80% of
men participating in an acceptability trial in India reported
willingness to buy both the FC2 and Reddy FC in the future.45
Men frequently perceived superior effectiveness of the FC
over the MC for HIV/STIs/pregnancy prevention and val-
ued its dual protective properties.45,89,115,118,130 High levels of
comfort and sensation were also reported, especially with
practice, resulting from loose fit and lubrication.48,89,131 Men
in Nigeria and Uganda liked the potential to insert before
sex, and not having to remove the FC immediately after
sex.48,89 Men in Brazil, South Africa, and China recognized
the advantages of a female-initiated method,59,87,102,115 namely
because it reduced male responsibility and increased female
sexual agency: “Women can decide independently whether
they would choose contraception or not. This is its greatest
strength” (College educated young man, Shanghai).87
Conversely, several studies identified major concerns
from men.48,59,79,82,130,132,133 Ugandan men complained that
the FC was more difficult to use than the MC,48 while South
African male students cited appearance, unfamiliarity, and
concerns about pleasure as barriers to initial use, but felt
that these might improve with experience.115 In another
South African study, male students with prior use of the
FC reported discomfort with their partners’ suggestion
of FC use, as well as female partners’ insertion prior to
negotiation.59 Other studies found that men felt threatened
by a woman taking control of her own sexuality and were
concerned that the FC might encourage promiscuity if
women no longer feel at risk.82,130,132,133 Ugandan and Indian
men feared that women would reuse FC without adequate
cleaning.45,118
Negative attitudes were sometimes fuelled by misconcep-
tions: men in Cameroon, Nigeria, and Zimbabwe reported
a refusal to use FCs with FSWs for fear of multiple use or
“sperm harvesting” for black magic.133 Some men in South
Africa believed that they might not be protected by a device
that is not worn by a man.115
Some studies found that women often reported
positive responses from male partners, despite initial
objection.63,88,102,134 For example, while some women in Zim-
babwe reported partner refusal for fear of women becoming
“casual about sex”, most said they were encouraged to get
more FCs.108 In South Africa, over 80% of women reported
partner approval, based on natural feel, sexual pleasure,
size, and strength. Conversely, attributes perceived as
“disliked” were overlubrication and large size.50 Notably,
these responses were mainly reported by women who had
successfully negotiated FC use.
Women’s empowerment
and negotiating use
The relationship between FC and women’s empowerment
was frequently commented on, yet inconsistently interpreted
by study authors. A few studies noted that by catalyzing pro-
cesses that challenge established gender norms, FCs had the
potential to transform gender relations. For example, univer-
sity students in Nigeria reported that a key reason for FC use
was the sense of empowerment that the method afforded.97
FC provision in Cambodia reinforced FSWs’ intentions
to share experiences and support each other to adopt new
methods.127 In Mozambique, nearly 5,000 women have met
in FC “empowerment groups” to discuss negotiation tactics
with partners and the correct use of FCs, including basic
education about women’s bodies.135 Conversely, most authors
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Female condoms in developing countries
characterized the FC as a protective tool for use within the
existing constraints of gendered power imbalances, usually
whereby women were empowered to protect themselves with
the FC when their partner refused MC use.43,50,67,68,105,112,126,128
Commentaries were similarly mixed on the question of
whether the FC truly “empowers”, or whether it can only
be used by already “empowered” women.12–14,125 In Tunisia,
the authors of a study on FSWs commented that FC accep-
tance would be slow due to women’s highly proscribed gen-
der roles and the fact that “customs imposed a real obstacle to
social innovations”.103 A number of other studies found that
FCs were of limited value to women, who were only able to
use them with full partner awareness and agreement.82,125,136
Indeed, in one Zimbabwean study, two-thirds of women said
that FC use depended on partner permission.82 Nonetheless,
studies conducted in over half the countries found that the
FC’s female-initiated nature was perceived as a major advan-
tage. In Zimbabwe, 35.6% of female inconsistent condom
users said they could use FCs more consistently than MCs,
simply because they did not have to rely on the man to wear
it.79,137 In Vietnam, women said that the FC offered more
control over unwanted pregnancy, even if desired by their
husbands, and it provided sexual security if they doubted
their husbands’ fidelity.81 Women in several settings preferred
the FC to the MC because they could guarantee that it had
not been deliberately damaged by men.70,126 FSWs often
valued the potential for FC use with drunk clients,43,68,127,138
and some women saw benefit in inserting the FC before
drinking themselves: “When I am going to date, and know
I am going to drink, then I put the female condom before,
because I think it is more safe, because I know that if I drink
I can forget to put it on” (28-year-old drug user, Brazil).102
The FC is also used as a bargaining tool to negotiate either
MC or FC use.127,128,138 For example, following an FC inter-
vention in Thailand, 60% of FSWs reported that more clients
agreed to use an MC after learning that the only alternative
was the FC.138 Other gender dynamics reported include men’s
involvement in FC use; for example, one South African study
found that 45% of women reported partner assistance with
FC insertion, stabilizing the device, or removal. In this study,
male involvement was most commonly reported by students
and least commonly by FSWs.139
Discussion and conclusion
FCs can be highly acceptable to women and men with
diverse risk profiles across a variety of settings, and as
a female-initiated method, the device can be used as an
additional tool to protect women within the context of
gendered power imbalances. Furthermore, FCs are often
used interchangeably with MCs, and thus their provision
can positively impact the proportion of protected sex acts
in a population, through uptake by women or couples for
whom other methods of contraception or HIV prevention
are inaccessible. The fact that most FC users employ the
method interchangeably with the MC means that consis-
tent FC use is less important than its role in increasing
consistent condom use overall. Despite clear advantages
at both an individual and population level, the national
prevalence of FC use remains extremely low, even in the
context of high awareness; these data suggest that models
of successful programming are still not being implemented
on a sufficiently wide scale. Current FC use was less than
1% (average: 0.04%) for all countries, compared with cur-
rent use of the IUD, pill, and injectables, which averaged
between 2%–6%, ranging up to 30% for the IUD (data not
shown).33,35,36,41 Ever use of FC was also less than 1% for
most countries notable exceptions were South Africa
(7.2%), Swaziland (3.3%), Guyana (1.5%), Malawi (1.2%),
and Zambia (1.2%) – compared with ever use of the IUD,
pill, and injectables, which averaged between 9%–21%,
ranging up to nearly 50% for the IUD (data not shown)
(Figure 1).33,36,41
Several important conclusions can be drawn from our
data. Since the same method attributes are perceived posi-
tively and negatively within and between localities, contex-
tual and environmental factors arguably play a greater role
in determining overall FC acceptability and uptake. This is
evidenced by the pervasive influence of stigma and male
partner responses in determining initial and continued use
of FCs. Indeed, even its female-initiated nature may limit
acceptability if men fear loss of control. The fact that most of
the physical and contextual factors negatively influencing use
can be overcome with practice and adequate support suggests
that demand creation is at least as important a component of
programming as adequate supply.
Currently, since most research has focused on FC accept-
ability in trial settings, little is known about the profile of
FC users and nonusers within the general population, and
systems and market research to identify effective promotion
and distribution mechanisms at a local level (ie, lower than
national) is lacking. The scarcity of studies addressing FC use
for anal sex by heterosexual couples and MSM in developing
countries is an additional research gap, which perhaps reflects
sociocultural taboo, as well as a general lack of attention to
male perspectives on FC use. Policymakers, international
donors, civil society groups, and programmers therefore
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Moore et al
have a responsibility not only to increase FC availability and
advocate the sexual rights of women, but also to identify
and implement local evidence-based strategies for effective
FC programming.
There was near-universal endorsement, across the stud-
ies and population groups reviewed here, that increasing
availability and access will contribute to increased FC use
and limit reuse, although reuse levels were found to be low
(current World Health Organization guidelines advise that a
new FC should be used with every sexual act; Family Plan-
ning Global Handbook, 2011).141 Integrating FCs into a wide
variety of services, programs, and nontraditional settings will
inevitably improve access, but it may also increase exposure
and normalize the device, thus contributing to the narrowing
of the observed gap between awareness and use. Adequate
programmatic support must also be available to ensure
implementation of strategies with proven efficacy, such as
FC demonstration, negotiation skills counseling, and user
support. Greater efforts are also required to target men in FC
programming and advocacy, by using male-specific branding
and addressing potential anxieties related to female-initiated
methods. One example is the recent branding as “inner
condoms” by the South Africa-based Population Services
International affiliate140 (see Figure 2). Promotional mes-
saging should draw on local evidence to increase FC accept-
ability in the general population, by promoting commonly
cited advantages such as sexual pleasure, while combating
stigma and taboo.
Limitations
This review used peer-reviewed literature, country surveys,
and other sources available via the Internet, and is thus subject
to these limitations. Papers and reports outside our language
scope would not be represented here. The fact that most
research to date has been conducted with the discontinued
FC1 suggests that some results may lack relevance to current
programming. Our study was not intended to be a systematic
review, and therefore did not include a complete count of
articles retrieved and rejected. Scoping studies represent a
broad approach to a topic, where the aim is to map a wide
range of literature and identify the nature, range, and extent
of the evidence. Some qualitative reports reviewed here were
based on small sample sizes, although most were based on
greater than 100 participants. Finally, the fact that our paper
selected developing countries as a focus should not be con-
strued to mean that the FC is not appropriate or acceptable
for women in developed countries, as considerable literature
has already shown.
Disclosure
The authors report no conflicts of interest in this work.
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... It has numerous benefits ranging from ease of use and access, as well as minimal untoward effects compared to other contraception method. Globally, the efforts to curb the spread of STIs and unplanned pregnancies have led to the introduction of female condoms (FC) to improve the sexual health of women by offering dual protection (3)(4)(5)(6)(7). More one out of three pregnancy in developing countries are unwanted/unwed/unplanned, thereby increasing attention of stakeholders to advocating contraception (8). ...
... The aftermath of some unplanned pregnancies include unsafe termination of pregnancy by quacks which pose major challenge to public health. The use and uptake of FC have been advocated as one of the major and safest means to prevention sex-related infections and to reduce the risk of unwanted pregnancies (1)(2)(3)(4)(5)(6)(7)(8). ...
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Background: The female condom is both a means of mechanical contraception and protection against sexually transmitted infections (STIs) and unwed pregnancies. The use and uptake of female condoms have been advocated as one of the safest ways to halt the risk of unplanned/unwanted pregnancies and STIs including HIV. Our study aimed to explore the knowledge, awareness, utilization, acceptance and accessibility of FC among female public health students in a Nigerian University. Methods: One hundred and ninety (190) female public health students took part in the study. A self-administered questionnaire was used to collect the data between August and December 2019. Data analysis was carried out using SPSS version 23. Results: Overall percentage awareness of female condoms usage in this study was 52.0%. Less than a quarter (22.4%) reported having seen a pack of female condoms, while the remaining 77.6% of the participants reported having never seen a pack of female condoms. In addition, the majority (87.4%) of the respondents did not know whether a female condom interferes with sexual pleasure/sensation. The majority of the respondents (77.4%) concurred that utilizing a female condom implies that "I don't trust my partner". Concerning accessibility of the female condom, only 1.8% agreed that FC is easily accessible while more than half (54.2%) are uncertain of the accessibility. Conclusion: Our study revealed a low level of knowledge and utilization of female condoms, and also limited access to the female condom as well as unsatisfactory acceptance and suboptimal awareness level which were suggested by the overall percentages in the study.
... Decades after the introduction of the FC, and despite concerted efforts by the global health community to promote uptake of the only available method for preventing STIs and unintended pregnancies, as initiated by the receiving partner, the FC only accounts for less than 2% of total condom distribution worldwide [17]. In nationally representative household surveys that looked at FC practices and behaviors, ever-use of FC among women of reproductive age was less than 1% in most developing countries, with the exception of Zambia, Malawi, Guyana, Swaziland, and South Africa, which ranged from 1-7% [35]. The results of our systematic review shed more light on the many facets of this underutilization challenge, and provide the basis for recommendations to improve acceptability and use of the FC for improved sexual and reproductive health in LMICs. ...
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Background: Sexually transmitted infections, including HIV, remain a significant public health challenge for low- and middle-income countries, and about 111 million unintended pregnancies occur in these countries annually. The female condom is the only commonly available method that affords women and girls more control in protecting themselves from sexually transmitted infections, as well as unintended pregnancies. Yet, the female condom only accounts for 1.6% of total condom distribution worldwide. Objectives: To help fill the gaps in an understanding of what works for improved acceptability and use of the female condom in low- and middle-income countries, we conducted a systematic review of the literature that focuses on acceptability of the FC, as examined in the specific settings of intervention programs or research in low- and middle-income countries. Methods: We conducted a preliminary search of two purposively selected databases (PubMed and POPLINE) for English language articles from 2009 to 2019 with the keyword "female condom." PubMed yielded 145 articles, while POPLINE yielded 164 articles. Included studies involve a purposive, interventional deployment of the female condom; have occurred in a low- or middle-income country, as defined by the World Bank; and have focused on acceptability of the female condom. Upon review of duplicates and abstracts, a total of 14 articles made the final selection. Findings: The included articles represent seven different countries: the Dominican Republic, El Salvador, China, Malaysia, Nicaragua, South Africa, and Uganda. We identified four key barriers to FC acceptability, including partner acceptability, functionality, aesthetics, and access. We identified four key facilitators to FC acceptability, including repeated use, supportive attitudes, protection confidence, and reproductive control. Conclusion: Effective promotion and uptake of the female condom in low- and middle-income countries can be realized if novel strategies and approaches are implemented to tackle persistent barriers to acceptability.
... The moderator will also encourage the participants to feel free and express their opinions. The moderator will open the discussion by making a statement and ask the respondents to comment [34][35][36][37][38][39]. ...
... They had fewer sexual partners and were less likely to use a condom during intercourse. There is extensive evidence that knowledge regarding condom use is low in some parts of Asia with a disparity in condom knowledge between the sexes (Lucea, Hindin, Gultiano, Kub, & Rose, 2013;Moore, Beksinska, Rumphs, Festin, & Gollub, 2015;Tangmunkongvorakul et al., 2017), and this study is consistent with these findings. A report by UNESCO on the sexual and reproductive health of young people in Asia and the Pacific found that less than half of young females (15-24 years old) in eight countries (Papua New Guinea, Nauru, Afghanistan, Bangladesh, India, Pakistan, Indonesia, and Timor-Leste) knew about the use of condoms for preventing HIV (Central Statistics Organisation (CSO) & UNICEF, 2012; UNFPA, UNESCO, & WHO, 2015). ...
Article
The presence of body dissatisfaction (BD) in non-Western countries is an important area of empirical enquiry. The results reflect collectivistic and individualistic cultures of Malaysians and Australians, respectively, whereby social approval, social acceptance, and cultural values are of high importance to Malaysians compared with the more liberal attitudes of Australians with respect to health behaviours. This study sought to compare: (1) Australian and Malaysian women on BD, thin ideal internalisation, sociocultural influences, problematic weight-related behaviours, and health behaviours; and (2) the degree to which BD is associated with health behaviours (smoking, alcohol consumption, drug use, and sexual behaviours) across the two cultures. Participants were 428 Australian females and 402 Malaysian females aged 18–25 years old. Australians had higher BD, thin ideal internalisation, family and media influences, restrained eating, and poorer health behaviours, while Malaysians had higher peer influence. There was no difference for bulimic behaviours across the two countries. BD was found to have an association with use of drugs, smoking, and sexual behaviours among Malaysian women, but not for Australian participants. The permeation of Western standards of the thin ideal due to increased industrialisation, Westernisation, and modernisation has brought about bulimic behaviours in Malaysian women, similar to that of Australian women.
... Currently, condoms are the only available MPT, yet male condoms are not within the control of a woman, and many women risk gender-based violence by merely suggesting condom use (19). The uptake of female condoms has been limited by cost, access, and acceptability issues (including the objections of male partners) (20,21). MPTs could help to overcome barriers to negotiating HIV prevention and adherence issues related to stigma and gender dynamics seen in trials of microbicides and oral pre-exposure prophylaxis (PrEP). ...
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Women of reproductive age need multipurpose prevention technology (MPT) products to address two overlapping health risks: unintended pregnancy and HIV. Currently, condoms are the only available MPT, however male condoms are not within the control of a woman, and the use of female condoms has been limited by low acceptability and cost. Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet uptake and adherence among women have been low to date. Women globally need more options for HIV and pregnancy prevention. Several MPTs for simultaneous HIV and pregnancy prevention are in various stages of development and clinical testing, although most are many years away from market launch. A dual prevention pill (DPP), a daily oral pill combining oral contraceptives and PrEP, both of which are licensed, approved products in many low- and middle-income countries (LMIC), is likely to be the fastest route to getting an MPT product into the hands of women. The DPP is one option that could enhance method choice, particularly for women who are already using oral contraceptives. By leveraging the oral contraceptive market and reaching women currently using condoms or with an unmet need for contraception, the DPP has the potential to increase the uptake of PrEP. The successful rollout of the DPP will require careful consideration of user-, provider-, and product-centered factors during product development and introduction. Early attention to these interrelated factors can help ensure that the DPP has the ideal characteristics for maximum product acceptability, that effective and quality services are designed and implemented, and that users can make informed choices, demand the product, and use it effectively. The proposed framework outlines key considerations for the effective development and introduction of the DPP, which could also facilitate integration models for future MPTs.
... Enhanced access to healthcare for young people has been documented to reduce risky behavior and improve health status, and serves as an indicator of equity [1]. Multiple studies in Africa have documented the challenges that young people encounter when accessing services for contraception, HIV testing, and other sexual and reproductive healthcare, and how limited access negatively affects their health status and outcomes [2][3][4][5][6][7][8][9][10]. The awareness of, and data highlighting gaps in health service access and outcomes among young African people are robust for HIV and sexual and reproductive health, but not as much for tuberculosis (TB) [11,12]. ...
Article
Objectives Tuberculosis (TB) is a leading infectious cause of death globally. Of the estimated 10 million people who developed active TB in 2019, 1.8 million (18%) were adolescents and young adults aged 15–24 years. Adolescents have poorer rates of TB screening, treatment initiation and completion compared to adults. Unfortunately, there is relatively less programme, research and policy focus on TB for adolescents aged 10–19 years. This article reviews the scope of health services and the relevant policy landscape for TB case notification and care/treatment, TB/HIV management, and latent TB infection for adolescents in Nigeria. Additionally, it discusses considerations for TB vaccines in this population. Content All Nigeria Federal Ministry of Health policy documents relevant to adolescent health services and TB, and published between 2000 and 2020 underwent narrative review. Findings were reported according to the service areas outlined in the Objectives. Summary and Outlook Nine policy documents were identified and reviewed. While multiple policies acknowledge the needs of adolescents in public health and specifically in TB programming, these needs are often not addressed in policy, nor in program integration and implementation. The lack of age-specific epidemiologic and clinical outcomes data for adolescents contributes to these policy gaps. Poor outcomes are driven by factors such as HIV co-infection, lack of youth-friendly health services, and stigma and discrimination. Policy guidelines and innovations should include adaptations tailored to adolescent needs. However, these adaptations cannot be developed without robust epidemiological data on adolescents at risk of, and living with TB. Gaps in TB care integration into primary reproductive, maternal-child health and nutrition services should be addressed across multiple policies, and mechanisms for supervision, and monitoring and evaluation of integration be developed to guide comprehensive implementation. Youth-friendly TB services are recommended to improve access to quality care delivered in a patient-centered approach.
... Previous studies in Malawi and Sub-Saharan African countries have found that men who believe that condoms decrease pleasure are less likely to use them [26][27][28]. Finally, access to female condoms for women in this study (and for women generally in Malawi) is limited, making condom use more challenging because male condoms require partner cooperation [29]. Therefore, we recommend improved access for women to condoms in all health facilities in Malawi. ...
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Background Although many countries have been promoting hormonal contraceptives to prevent unintended pregnancy and condom use to prevent HIV transmission, little is known about how women targeted by these messages have interpreted and internalized them. We describe HIV-positive and negative women’s understanding of the benefits of contraception and condoms and their motivations to use them. Methods This is a qualitative sub-study from a clinical trial evaluating the effects of progestin contraception on HIV-positive and negative women aged 18–45 years randomly assigned to depot medroxyprogesterone acetate (DMPA) injection or levonorgestrel (LNG) implant. We purposively recruited 41 women to participate in in-depth interviews (IDIs) and focus group discussions (FGDs) after randomization into the main study. We conducted a total of 30 IDIs and 6 FGDs comprised of 4–7 women (N = 32). All women were counselled about potential risks for HIV acquisition/transmission with progestin-only contraception, drug-drug interactions between the implant and efavirenz-based ART, and the need to use condoms with their assigned contraceptive to help prevent pregnancy and HIV acquisition and transmission. Results All women understood that HIV is transmitted through unprotected sex and that HIV transmission can be prevented through condom use but not DMPA injection or LNG implant use. Nearly all HIV-positive women knew or suspected that their partners were also HIV-positive and were most interested in using condoms to prevent infection with a drug-resistant HIV strain to keep their HIV viral load low. Almost all reported that their partners agreed to condom use, but few used them consistently. Most women believed that condoms were effective at preventing both HIV and pregnancy if used consistently. Nearly all women considered contraception and condom use as important in preventing unintended pregnancy and HIV because partner disclosure of HIV status is low. Conclusion Our results showed that both HIV-positive and negative women understood modes of HIV transmission and prevention and were aware that hormonal contraceptives are only effective for preventing pregnancy and not HIV. Although both HIV-negative and positive women were motivated to use condoms to prevent both HIV acquisition and infection with other HIV strains respectively, they all faced challenges from their partners in using condoms consistently.
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The existence and availability of evidence on its own does not guarantee that the evidence will be demanded and used by decision-makers or health policymakers for decision making and policy formulation. In addition to effective resource allocation, decision-makers, especially in low-income settings often confront ethical dilemmas about determining the best available evidence and its utilisation. This dilemma can be in the form of conflict of evidence, scientific and ethical equipoise and competing evidence or interests. In response to these challenges, we propose the use of “Value- and Evidence-Based Decision Making and Practice” (VEDMAP) framework developed under the Thanzi la Onse Project in Malawi. VEDMAP is a flexible and straightforward mixed-methods decision-making modelling framework that aims to assist policy and decision making to explicitly use optimal values and rationally navigate conflicting evidence.
Article
This study explored African-Jamaican women's lived experiences and meanings around the communication and negotiation of male condoms used in their relationships. A qualitative phenomenological research design was utilized. Semi-structured interviews were collected with a small sample of nine African-Jamaican women living in Saint Mary, Jamaica. Results indicate that women's power in relationships may be masked, despite being at a disadvantage when communicating/negotiating male condom use. Several facilitators and barriers for communicating/negotiating condom use were identified. Interventions developed to combat the HIV epidemic in Islington, Saint Mary, must take into consideration structural factors in curbing the spread of HIV/AIDS.
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Adolescents continue disproportionately face the impact of HIV and AIDs infections across the world generally and in Sub Saharan Africa in particular. One of these issues is the increasing rates of HIV prevalence and incidence rates over the years. This results from low uptake of HIV prevention services. Adolescents in high density urban areas are prone to several factors that hinder their access to HIV prevention services. Thus, the study sought to unearth factors that determine the accessibility of HIV prevention services among adolescents in Dzivarasekwa District. Qualitative and qualitative research methods were triangulated. A total of 500 questionnaires were administered to adolescents aged 15-19 years to collect quantitative data. The study also conducted 10 Focus group discussions and 20 Key informant interviews to solicit qualitative data. The findings showed that, a significant number of adolescents were engaging in sexual activities. Adolescents were aware of most of HIV prevention methods: however their knowledge was not being translated into utilization of these methods. This was influenced by a lot of factors at individual, interpersonal, organization, community and national levels. Low uptake of prevention services was mainly attributed to high cost, low awareness, lack of proper knowledge about the benefits of the services. Recommendations were also offered to service on how HIV prevention services uptake can be improved amongst adolescents.
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Millions of women worldwide lack the power to protect themselves from HIV; current prevention options require cooperation from the male partners. Limited prospects for an HIV vaccine and continued escalation of HIV make female-controlled HIV/STI prevention options like microbicides desirable. While socio-cultural factors could reduce acceptability of these options by vulnerable women, opinion leaders like health personnel and teachers could positively influence their acceptability. The aim of this study was to assess the acceptability of female-controlled HIV/STI prevention options among medical doctors, nurses, pharmacists and secondary school teachers in Dhaka, Bangladesh. A cross-sectional study was conducted using a self-administered semi-structured questionnaire among 375 professionals (nurses, doctors, pharmacists and teachers). The questionnaire assessed the respondents’ perception of HIV, and their attitudes towards female-controlled HIV/STI prevention options such as female condoms and vaginal microbicides. The study revealed that 98.4% of the respondents were of the opinion that women should determine their HIV/STI prevention options, while 89.3% agreed that options which empower women would be acceptable. It was also found that 18.4% would use the female condoms while 34.4% would use vaginal microbicides. Factors associated with willingness to use the female-controlled prevention options were HIV risk perception, marital status, profession, and duration in profession. There was no association between willingness to use female condoms and willingness to use the vaginal microbicides. While male condom use was positively associated with willingness to use female condom, there was no significant relationship between male condom use and willingness to use the vaginal microbicides. The study showed that professionals strongly supported HIV/STI prevention options that are female-controlled, with most preferring vaginal microbicides to the female condoms. Such support would inform the design of appropriate interventions to prepare the professionals for the eventual advent of an effective microbicide as a HIV/AIDS prevention option. South East Asia J Public Health | Jan-June 2012 | Vol 2 Issue 1 | 46-53 DOI: http://dx.doi.org/10.3329/seajph.v2i1.15265
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Background: Proper use of condom prevents Sexually Transmitted Infections (STIs) and unwanted pregnancies. Efforts have been made in Rwanda to raise the population awareness on the use of the Female Condom but little is known about the current status of its use among college students. Objectives: To assess the knowledge, attitudes and use of the female condom among undergraduates of Kigali Health Institute. Methods: A descriptive study was carried out between May and June 2010. The sample was randomly selected from the students of Kigali Health Institute. A questionnaire based study was conducted involving 429 students. It captured the sample characteristics, their knowledge, attitudes and use of the female condom. The data were entered and analysed in SPSS 16.0. Results: About 79% of the students were aware of the female condom, but only 24% knew how to use it. Most respondents believed that the female condom can prevent the unwanted pregnancies (78%), the STIs and HIV/AIDS (81%). About 8% had ever tried it and less than three percent cited it as their contraception method. Conclusion: Awareness of the female condom was high but few students knew how to use it. Overall, favourable attitudes were recorded though neutral ones were higher and use of female condom was very low. Key words: Knowledge, attitude, use, female condom
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Aim: The study was conducted to assess level of awareness and use of female condoms among young Nigerian women. Methods: A total of 435 young and single Nigerian women (comprising 261 female undergraduate students and 174 rural resident women) were recruited for this study. A structured questionnaire was administered to all participating subjects. Results. Awareness of the female condom was significantly higher among female undergraduate students (93.7%) than rural resident women (5.2%) (OR=280.73, 95%CI =121.15, 650.52; P=0.0001). No significant difference was observed in level of use of the female condom between female undergraduate students (1.9%) and rural resident women (0%) P = 0.1624.The media and friends were the most effective sources of information of female condom among female undergraduate students and rural resident women respectively. Preference for male condoms was given as reason for non use of the female condoms among both groups studied. Rural women's perception of the function of female condoms was largely on the premise of prevention of pregnancy. Conclusion: Female condom use among young and sexually active Nigerian women is poor. Strong grassroot intervention, interpersonal communication and elimination of inhibiting cultural and social beliefs are key to promoting increased female condom use in Nigeria.
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This empirical study on the knowledge and perceptions of the female condom was cast against the assumption that the female condom could potentially be a powerful contraceptive tool whose use women could initiate and use against sexually transmitted diseases, and in so doing, allow them to exercise control over their bodies and sexuality, more especially within the context of the high prevalence rates of HIV/AIDS in the country. Many African women in rural spaces are faced with the situation when the male condom cannot always be comfortably demanded due to gendered power imbalances. This is where the promoting of female condoms may come into play. Against this background, we embarked on a large scale study that included 1,290 women in the greater KwaZulu-Natal (KZN) province in South Africa. The findings revealed that a staggeringly high number of African women surveyed and interviewed, who are potentially the beneficiaries that stand the most to gain from female-initiated contraception, have very little exposure and knowledge of the female condom.
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Background Studies around the world have reported about the use of female condom (FC) for anal sex by men who have sex with men (MSM). No studies have been conducted in India about FC use for anal sex. This study was designed to know the reasons, perceived benefits, concerns and other issues around FC use in Andhra Pradesh where India HIV/AIDS Alliance implementing a HIV prevention program. Methods A qualitative study was carried out among MSM at three sites, selected using purposeful sampling method. Total eight Focus Group Discussions (FGDs) with 83 participants and 18 in-depth interviews (IDI) were conducted. IDI respondents were selected by purposeful sampling method from the self-reported FC users. A structured questionnaire was used for the study. Results In two sites, 18 out of 53 respondents (34%) reported using FC while none of the respondents at the third site had heard of using FC for anal sex. The practice is mainly due to peer influence within the local sexual networks. The decision to use FC is made by the recipient partner who is influenced by various factors like difficult partners/clients who don't like to wear male condom and in anticipation of having sex with more than one partner or group sex etc. A few MSM (11%) are using single condom with multiple clients. The perceived benefits with FC use include sense of security, having control, client satisfaction hence better income, and they can use a single condom for multiple encounters with multiple partners. Participants reported frequent problems with FC use, particularly rectal bleeding (100%), discomfort (72%) and slippage (28%). Despite bleeding from anus on first time use, majority (83%) of them said they will continue to use FC. One of the myths observed during the FGDs is the use of spit with mud as lubricant which was attributed to better satisfaction due to the presence of finer granules in the mud. Conclusions The study clearly shows that despite frequent problems with FC use, considerable number of MSM (83%) prefer to continue using FC. Therefore the need for modifying condom design, conducting training, and research on safety outcomes becomes absolutely imperative. IEC (Information, Education & Communication) materials need to be designed to spread the message on proper use and disposal of FC, and also to address the use of single condom with multiple partners. Using of mud with spit as lubricant needs to be explored further to better understand its consequences.
Article
AIDS, Sex, and Culture is a revealing examination of the impact the AIDS epidemic in Africa has had on women, based on the author's own extensive ethnographic research. based on the author's own story growing up in South Africa. looks at the impact of social conservatism in the US on AIDS prevention programs. discussion of the experiences of women in areas ranging from Durban in KwaZulu Natal to rural settlements in Namibia and Botswana. includes a chapter written by Sibongile Mkhize at the University of KwaZulu Natal who tells the story of her own family's struggle with AIDS.