'Female condoms give women greater control': a qualitative assessment of the experiences of commercial sex workers in Swaziland

Barriers and Enablers Influencing Women's Adoption and Continuation of Vaginally Inserted Contraceptive Methods: A Literature Review

Most vaginally inserted methods have limited availability and use despite offering characteristics that align with many women's stated preferences (e.g., nonhormonal and/or on demand). The objective of this review was to identify enablers and barriers to women's adoption and continuation of vaginally inserted contraceptive methods in low- and middle-income countries (LMICs). We searched three databases (PubMed, Embase, and Web of Science) and 18 websites using keywords related to five vaginally inserted contraceptive methods (diaphragm, vaginal ring, female condom, copper intrauterine device [IUD], hormonal IUD) and terms associated with their adoption and continuation. Searches were limited to resources published between January 2010 and September 2020. Studies eligible for inclusion in our review presented results on women's use and perspectives on the enablers and barriers to adoption and continuation of the vaginally inserted contraceptive methods of interest in LMICs. Relevant studies among women's partners were also included, but not those of providers or other stakeholders. Data were coded, analyzed, and disaggregated according to a framework grounded in family planning (FP) literature and behavioral theories common to FP research and program implementation. Our initial search yielded 13,848 results, with 182 studies ultimately included in the analysis. Across methods, we found common enablers for method adoption, including quality contraceptive counseling as well as alignment between a woman's preferences and a method's duration of use and side effect profile. Common barriers included a lack of familiarity with the methods and product cost. Notably, vaginal insertion was not a major barrier to adoption in the literature reviewed. Vaginally inserted methods of contraception have the potential to fill a gap in method offerings and expand choice. Programmatic actions should address key barriers and enable voluntary use.

A systematic review exploring the contraception values and preferences of sex workers, transmasculine individuals, people who inject drugs, and those living in humanitarian contexts

Objective

We sought to systematically review the literature on values and preferences regarding contraception among individuals within selected key populations.

Study design

As part of a larger set of reviews on patients’ and providers’ values and preferences related to contraception globally, we searched ten electronic databases for articles from January 1, 2005 to July 27, 2020. No language restrictions were applied. Data was independently abstracted by two authors and study rigor was assessed using an 8-item measure developed by the Evidence Project for quantitative studies and an adapted CASP checklist for qualitative studies.

Results

We identified 12 studies that met our inclusion criteria examining selected key populations, including sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts. Seven key themes that spoke to values and preferences emerged related to: autonomy, perceived effectiveness and safety, birth spacing and family outcomes, impacts on sexual experience, hormonal effects (e.g. desire for non-hormonal method or perception that the method is more natural as compared to hormonal methods), physical attributes (e.g. appearance and/or ease of use), and stigma. Six studies were of high rigor, five were of moderate rigor, and one was of low rigor. One study described the values and preferences of two of the selected key populations. The research available on the values and preferences of sex workers regarding methods of contraception was limited to female condoms.

Conclusion

Consideration of the values and preferences of individuals within selected key populations can inform providers, programme managers and policy makers participating in the delivery of contraceptive care. Contraceptive research among sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts is quite limited; further research is needed to better understand the values and preferences of these populations.

Perceived male partner attitudes toward the female condom predict female university students' use of the female condom

Female and male condoms are the only methods that prevent both sexually transmitted infections (STIs), including HIV, and unintended pregnancy. Despite continuing high STI rates, few studies investigate factors predicting whether women initiating female condom (FC) use sustain use. Using data from a randomized trial, we examined predictors of sustained FC use at five-month follow-up (FU2) among female university students in South Africa who participated in either a one-session, information-only, group-delivered Minimal Intervention or a two-session, group-delivered Enhanced Intervention. In the final multiple logistic regression model, believing one's partner holds positive attitudes toward the FC (aOR = 1.40; p = 0.028), and greater FC use for vaginal sex at previous assessment (aOR) = 1.19; p = 0.008) were associated with greater odds of FC use at FU2. Excluding number of FC-protected occasions at FU1 from the analysis, discussing FC use with partner (aOR = 2.89; p = 0.071) and believing one's partner holds positive attitudes toward the FC (aOR = 1.63; p < 0.001) were associated with greater odds of use at FU2. The FC empowers women to protect themselves from both STIs and unintended pregnancy, but targeted interventions are needed to address men's negative attitudes toward the device. Engaging men as FC champions to support and promote FC use, along with marketing campaigns targeted to men, may expand FC coverage and enhance uptake.

Women's sexual experiences as a side effect of contraception in low- and middle-income countries: evidence from a systematic scoping review

Contraception is essential to preventing unintended pregnancy. While contraceptive use has increased significantly over the past decade, discontinuation and gaps in use remain common. Although women cite side effects as the reason for discontinuing or stopping methods, little is known about the specific ways in which contraception affects women's sexual experiences. This systematic scoping review aimed to understand how contraceptive-induced side effects relating to women's sexual experiences have been measured, classified, and explored in the literature, specifically in low- and middle-income countries (LMICs). Studies were eligible for inclusion if they were peer-reviewed, English-language articles published between 2003 and 2018 that examined women's sexual experiences related to their use of modern contraception, including sexual satisfaction, arousal, sexual dysfunction, discomfort, vaginal dryness, sexual frequency, and relationship or partner dynamics. Study populations were restricted to women of reproductive age in LMICs. Twenty-two studies were deemed eligible for inclusion, comprising a range of methods and geographies. Emergent sexual experience themes included: menstrual issues impacting sexual experience; libido; lubrication; sexual pleasure; dyspareunia; and female sexual function. Results highlight the variability in measures used, lack of a women-centred perspective, and void in research outside of high-income countries to study the influence of contraception on women's sexual experiences. Very few studies focused on women's sexual experiences as the primary outcome or predictor. Providers should adopt woman-centred contraceptive counselling that considers women's relationships. Further research is needed to disentangle the nuanced effects of contraception on women's sex lives, contraceptive decision-making, and method continuation.

Improving knowledge, acceptance, and utilization of female condoms among sex workers through a peer education: a mixed methods study in Surakarta Municipality, Central Java Province, Indonesia

Female sex workers (FSW) are high-risk for HIV infection. The authors conducted a quasi-experimental study by providing peer education on 110 FSWs, and routine HIV education on 120 controls, in Surakarta Indonesia. An additional qualitative study was performed to explain the contextual factors contributing to the effectiveness of peer education. The difference in difference approach showed that peer education improved knowledge, acceptance, and utilization of female condom. The improvements were related to the clients' perceptions, access, and available interactive communication with the peer educator. The peer education program should be enhanced to support the prevention of HIV/AIDS.

More Than a Physical Burden: Women's Mental and Emotional Work in Preventing Pregnancy

In the United States, responsibility for preventing pregnancy in heterosexual relationships disproportionately falls on women. While the biotechnological landscape of available methods may explain the assignment of the physical burden for contraception to women, this does not mean the concomitant time, attention, and stress that preventing pregnancy requires must also be primarily assumed by women. Building on work identifying health care providers as contributors to the construction of normative ideas about reproduction, this study analyzed 52 contraceptive counseling visits with women who reported they did not want future children for the construction of responsibility for the mental and emotional aspects of contraception. Offering a case of how gender inequality is (re)produced through clinical encounters, findings demonstrate that clinicians discursively constructed these responsibilities as women's and point to structural aspects of the visit itself that reify this unequal burden as normal. Results are consistent with research identifying the broader feminization of family health work in heterosexual relationships. To the extent that the distribution of the mental and emotional responsibilities of preventing pregnancy is both a product of and contributor to gender inequality, this analysis yields insight into the production-and possible deconstruction-of (reproductive) health care as a gendered social structure.

Effect of HIV self-testing on the number of sexual partners among female sex workers in Zambia

Objectives:

To assess the effect of two health system approaches to distribute HIV self-tests on the number of female sex workers’ client and nonclient sexual partners.

Design:

Cluster randomized controlled trial.

Methods:

Peer educators recruited 965 participants. Peer educator–participant groups were randomized 1 : 1 : 1 to one of three arms: delivery of HIV self-tests directly from a peer educator, free facility-based delivery of HIV self-tests in exchange for coupons, or referral to standard-of-care HIV testing. Participants in all three arms completed four peer educator intervention sessions, which included counseling and condom distribution. Participants were asked the average number of client partners they had per night at baseline, 1 and 4 months, and the number of nonclient partners they had in the past 12 months (at baseline) and in the past month (at 1 month and 4 months).

Results:

At 4 months, participants reported significantly fewer clients per night in the direct delivery arm (mean difference −0.78 clients, 95% CI −1.28 to −0.28, P = 0.002) and the coupon arm (−0.71, 95% CI −1.21 to −0.21, P = 0.005) compared with standard of care. Similarly, they reported fewer nonclient partners in the direct delivery arm (−3.19, 95% CI −5.18 to −1.21, P = 0.002) and in the coupon arm (−1.84, 95% CI −3.81 to 0.14, P = 0.07) arm compared with standard of care.

Conclusion:

Expansion of HIV self-testing may have positive behavioral effects enhancing other HIV prevention efforts among female sex workers in Zambia.

Trial Registration:

ClinicalTrials.gov NCT02827240.

Talking about male body-based contraceptives: The counseling visit and the feminization of contraception

In developed countries, women bear the primary, and sometimes exclusive, responsibility for preventing pregnancy in heterosexual sexual relations. This unequal burden is not an intrinsic fact; it is the consequence of broad social narratives and interpersonal negotiations. The contraceptive counseling visit is increasingly recognized as a site of the discursive production of normative ideas about reproduction, suggesting that clinicians themselves may contribute to the assignment of responsibility for contraceptive labor to women (i.e. the feminization of contraception). Scholars have not yet considered how providers talk to patients about methods that are male body-based (i.e. condoms, withdrawal, and vasectomy) and, as such, may disrupt the feminization of responsibility for contraception. Using transcripts of 101 contraceptive counseling visits recorded between 2009 and 2012 in the San Francisco Bay Area, I investigate how clinicians discuss male body-based methods with female patients. Drawing on a constructivist approach, I find that clinicians generally devalued male body-based methods in their counseling. They did so by, first, failing to discuss them as options for long-term contraception. Second, when they did discuss them, clinicians tended to emphasize aspects of the methods that were presumed "negative" (e.g. the lower efficacy of withdrawal and condoms) but not features that patients might view positively (e.g. the high efficacy of vasectomy or the lack of side effects with condoms and withdrawal). In aggregate, these discursive practices marginalize male body-based methods as contraceptive choices. As a practical effect, this may encourage women to choose a method that does not best meet their preferences. At a structural level, by devaluing methods that could undercut the unequal division of fertility work, these discursive patterns contribute to the feminization of responsibility for contraception and the retrenchment of the unequal gendered division of fertility work.

Motivations and barriers to uptake and use of female-initiated, biomedical HIV prevention products in sub-Saharan Africa: an adapted meta-ethnography

BACKGROUND

Women bear a disproportionate burden of HIV throughout the world prompting extensive research into HIV prevention products for women which has met with varied success. With an aim of informing future policy and programming, this review examines the barriers and motivations to the uptake and use of female initiated products in sub-Saharan countries.

METHODS

We conducted a systematic review as an adapted meta-ethnography of qualitative data focused on actual use of products. After deduplication, 10,581 and 3861 papers in the first and second round respectively were screened. Following the PRISMA guidance, 22 papers were selected and synthesized using Malpass's definitions of first, second, and third order constructs. First order constructs, consisting of participant data published in the selected papers, were extracted and categorised by second and third order constructs for analysis. A weight of evidence review was conducted to compare and assess quality across the papers.

RESULTS

The 22 papers selected span 11 studies in 13 countries. We derived 23 s order constructs that were translated into seven overarching third order constructs: Sexual Satisfaction, Trust, Empowerment and Control, Personal Well-being, Product use in the social-cultural environment, Practical Considerations, Risk Reduction, and Perceptions of Efficacy. Relationships and trust were seen to be as or more important for product use as efficacy. These constructs reveal an inherent inter-relationality where decision making around HIV prevention uptake and use cannot be binary or mono-faceted, but rather conducted on multiple levels. We developed a framework illustrating the central and proximal natures of constructs as they relate to the decision-making process surrounding the use of prevention products.

CONCLUSIONS

Health systems, structural, and individual level HIV prevention interventions for women should adopt a holistic approach. Interventions should attend to the ways in which HIV prevention products can serve to reduce the likelihood of HIV transmission, as well as help to protect partnerships, enhance sexual pleasure, and take into account woman's roles in the social environment. Stigma, as well as sexuality, is likely to continue to influence product uptake and use and should be prominently taken into account in large-scale interventions.

TRIAL REGISTRATION

Not applicable.

The Sexual Acceptability of Contraception: Reviewing the Literature and Building a New Concept

How contraceptives affect women's sexual well-being is critically understudied. Fortunately, a growing literature focuses on sexual aspects of contraception, especially hormonal contraception's associations with libido. However, a more holistic approach to contraceptive sexual acceptability is needed to capture the full range of women's sexual experiences. We conducted a narrative literature review of this topic, working with an original sample of 3,001 citations published from 2005 to 2015. In Part 1, we draw from a subset of this literature (264 citations) to build a new conceptual model of sexual acceptability. Aspects include macro factors (gender, social inequality, culture, and structure), relationship factors (dyadic influences and partner preferences), and individual factors (sexual functioning, sexual preferences, such as dis/inhibition, spontaneity, pleasure, the sexual aspects of side effects, such as bleeding, mood changes, sexual identity and sexual minority status, and pregnancy intentions). In Part 2, we review the empirical literature on the sexual acceptability of individual methods (103 citations), applying the model as much as possible. Results suggest contraceptives can affect women's sexuality in a wide variety of positive and negative ways that extend beyond sexual functioning alone. More attention to sexual acceptability could promote both women's sexual well-being and more widespread, user-friendly contraceptive practices.

Building young women's knowledge and skills in female condom use: lessons learned from a South African intervention

Partner negotiation and insertion difficulties are key barriers to female condom (FC) use in sub-Saharan Africa. Few FC interventions have provided comprehensive training in both negotiation and insertion skills, or focused on university students. In this study we explored whether training in FC insertion and partner negotiation influenced young women's FC use. 296 female students at a South African university were randomized to a one-session didactic information-only minimal intervention (n= 149) or a two-session cognitive-behavioral enhanced intervention (n= 147), which received additional information specific to partner negotiation and FC insertion. Both groups received FCs. We report the 'experiences of' 39 randomly selected female students who participated in post-intervention qualitative interviews. Two-thirds of women reported FC use. Most women (n= 30/39) applied information learned during the interventions to negotiate with partners. Women reported that FC insertion practice increased their confidence. Twelve women failed to convince male partners to use the FC, often due to its physical attributes or partners' lack of knowledge about insertion. FC educational and skills training can help facilitate use, improve attitudes toward the device and help women to successfully negotiate safer sex with partners. Innovative strategies and tailored interventions are needed to increase widespread FC adoption.

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

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.

Determinants of consistent condom use among female sex workers in Savannakhet, Lao PDR

Background

Female sex workers (FSWs) are a high-risk population for HIV. Correct and consistent use of condoms is the most effective measure for reducing transmission of HIV. Lao PDR is a low HIV-prevalence country, but FSWs have a relatively high HIV prevalence. To be able to make recommendations for condom promotion interventions in Lao PDR it is important to know more about the context specific situation. This study looked at reasons for and associated factors of consistent condom use among FSWs.

Methods

A cross-sectional survey among 258 FSWs in Kaysone Phomvihan district in Savannakhet province was performed.

Results

Almost all FSWs had enough condoms (94 %), condoms always available (100 %) and could always afford condoms (92 %). Consistent condom use was 97% with non-regular partners and 60% with regular partners. Almost all respondents (95 %) had received information about condoms from the drop-in centre. Stated reasons for consistent condom use were prevention of HIV (94 %), STIs (88 %) and pregnancy (87 %). Most reasons for inconsistent condom use were related to partners not wanting to use condoms because of reduced sexual pleasure. Some FSWs reported that they were physically abused and forced not to use condoms. Shorter time in sex work, higher education and FSW not having regular partners were significantly associated with consistent condom use.

Conclusions

Consistent condom use was very high with non-regular partners, but less frequent with regular partners. The main reason for inconsistent condom use was that the partner did not want to use a condom. Associated factors for consistent condom use were not having regular partners, higher education and shorter time in sex work. Condom promotion programs should include both FSWs and their partners and female condoms should be included in condom intervention efforts. Future studies should investigate the validity of self-reported sexual practices, partners’ reasons for inconsistent condom use, risk of violence in sex work and why shorter time in sex work is associated with consistent condom use.

Factors facilitating and inhibiting the use of female condoms among female university students in Durban, KwaZulu-Natal, South Africa

OBJECTIVES

The study aimed to explore the factors facilitating and inhibiting female condom use among female university students in South Africa.

METHODS

This qualitative study drew on 15 individual, in-depth interviews with female university students in Durban, South Africa.

RESULTS

The results of the study highlight several factors that facilitate and inhibit female condom use. Protection from sexually transmitted infections (including HIV/AIDS) and prevention of pregnancy facilitated use of the device among female students. In addition, students expressed positive attitudes towards the female condom and preferred it to hormonal contraceptives because it offered them dual protection. Absence of side effects and greater power and autonomy to initiate safer sex were other factors that facilitated use. Inadequate availability, partner objection, stigma, insertion difficulties and lack of awareness served as significant barriers to consistent female condom use.

CONCLUSIONS

Although the female condom can protect female students from infections and pregnancy, there are several barriers to its use. Interventions should aim to increase availability of the female condom, and male involvement should be increased to facilitate consistent use of the method.

Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland

Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR]  = 2.25, 95% confidence interval [CI]: 1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.

"It's a different condom, let's see how it works": young men's reactions to and experiences of female condom use during an intervention trial in South Africa

Although male partner cooperation is often essential for successful use of the female condom, only a few studies have directly assessed men's experiences of using the device. We examined barriers to and facilitators of female condom use via qualitative in-depth interviews with 38 young men (18 to 28 years) in South Africa whose partners, all university students, were enrolled in a female condom intervention trial. In all, 21 men used the female condom; the remaining 17 did not attempt use. The main facilitators to female condom use were convenience of use for men, curiosity to see how female condoms compared to male condoms, enhanced sexual sensation, and perceptions of better safety and comfort of the device compared to male condoms. The main barriers were men's limited familiarity with the device, insertion difficulties, and men's concerns about loss of control over sexual encounters. We recommend that human immunodeficiency virus (HIV) prevention and condom promotion programs around the world target men directly for education on female condoms and that they also work with couples jointly around issues of safer-sex communication and negotiation.