A unique study explores the role of peer support in encouraging and sustaining female condom use and promoting better communication between women and men.
Ten women sat in a Nairobi office discussing something found in few Kenyan bedrooms -- the female condom. They laughed about its size and shape, about their partners' first reaction to it, and about the changes it had brought to their relationships. But amid the laughter one could hear concern -- and confidence.
"When I took it home for the first time, my husband quarreled with me, saying he would never eat a sweet with its wrapping on," Grace Nduta said.
As the others laughed, she explained that she had convinced her husband to try the device by telling him about the side effects she experienced with the coil and the pill. "He soon listened because he did not want any more children," she added. Now Nduta and her husband enjoy using the female condom.
Salome Kago said she didn't dare try the device with her boyfriend until the others in the group said their partners had agreed to it.
Most of the women said that using the female condom had given them courage to discuss sex with their husbands and boyfriends. But they are still wary about saying no to their partners when they don't feel like making love.
"I would not dare because he will be suspicious that I have been with another man," Nduta said.
"I think you have to say no in a nice way, otherwise he will always misuse you," advised a third woman, Grace Buhila.
These women were participants in a study of use of female condoms sponsored by the AIDS Control and Prevention (AIDSCAP) Project's Women's Initiative with support from the U.S. Agency for International Development (USAID) Mission in Kenya. Their conversation was the result of a unique study design that allows participants to help each other devise strategies for negotiating use of the female condom with their partners.
Unlike acceptability studies that have focused largely on the device itself, the AIDSCAP female condom study will identify reasons for continued use and non-use of the device. But the research is also designed to examine how the female condom affects women's ability to negotiate safer sex and to help them initiate and sustain use of the device through peer support.
Dr. E. Maxine Ankrah, associate director for AIDSCAP's Women's Initiative, incorporated group discussions into the study design because she was convinced that women work and think communally and that together they would come up with their own protective strategies against HIV/AIDS.
"I thought women would be more likely to use this controversial device, the female condom, if they enjoyed the support of other women," she explained.
Innovative Design
Almost half of the 7,500 people who become infected with HIV infections every day are women. Because many women's economic and social dependence on men makes it difficult for them to negotiate safer sex with their partners, the lack of an effective, affordable female-controlled method of HIV protection is one reason for the increasingly rapid spread of the virus among women.
The female condom, which has proved an effective barrier against HIV and other STDs in laboratory studies and offered 97 percent protection against the STD trichomoniasis to those who used it correctly in a clinical trial,1 is one method that can be controlled by women, albeit with the consent of a male partner. So far, however, its availability in the developing world has been limited by concerns about its acceptability and cost. Female condoms sell for about $2.50 each in the United States, but are available for 65 to 90 U.S. cents each to public sector organizations that distribute large quantities. In Kenya, female condoms are not available on the open market.
The AIDSCAP study, conducted at sites in Nairobi, Kenya, and São Paulo, Brazil, examined the influence of various social, cultural and economic factors on acceptability and the degree to which women feel use of a female-controlled method increases their power within a relationship. In Kenya, AIDSCAP worked with the principal investigators, USAID, the National AIDS/STD Control Programme (NASCOP) and a local advisory committee that included the deputy director of the NASCOP to develop a study protocol that expanded the scope of traditional acceptability studies.
Most acceptability studies of contraceptive methods look at couples' reactions to a new method. AIDSCAP's study recruited women, not couples. "The idea was to let the woman decide who the partner is and how she can negotiate," Dr. Ankrah said.
Peer support was built into the design by enabling women to meet in small groups to discuss their experiences during the four-month study.
"Through these processes, we have been trying to see whether women's support systems -- the women's groups which have assisted them in the past -- could become a vehicle for sustaining their protection from HIV and STD," said Dr. Wanjiku Kabira of the University of Nairobi, a gender training specialist and one of the study's principal investigators.
Women's Networks
Another innovative feature of the study was the recruitment, which was conducted through local women's organizations in both countries. In Kenya, the investigators met with 318 members of 21 organizations to explain the purpose of the study. At each meeting, co-principal investigator Dr. Joseph Ruminjo, an obstetrician-gynecologist, demonstrated how to use the female condom with an anatomical model. The women were given female condoms to try at home and asked to return for a second meeting if they were interested in participating in the study.
Most of the women were eager to learn more about the study once they heard that the female condom could protect against HIV/AIDS, according to Dr. Kabira. "Many have seen their neighbors, relatives or family members die of AIDS, and as we discussed it with them, we realized that the fear they harbored regarding the disease was immense."
One hundred forty-five women returned. Some women who did not meet the eligibility requirements because they were older than 40 or were widowed and not sexually active brought their younger sisters or daughters to participate.
The study protocol for both Kenya and Brazil call for a total of 96 participants, representing two age groups (18 to 25 and 26 to 40) and two socioeconomic levels (upper and lower, defined by possession of such household items as refrigerators and televisions as well as education, employment and income). The most difficult women to recruit were the younger, upper-income women who were pursuing individual careers and were not as likely to participate in women's groups. However, these women were still more accessible through women's organizations than workplaces or schools, according to Dr. Ankrah.
Each of the 96 participants was interviewed individually at the beginning and end of the study. In addition, the women who came to the second meeting but decided not to enroll in the study were interviewed to find out why they had declined to participate.
Participants were assigned to 10 groups of 8 to 13 women of the same age group and income level. Each group participated in a facilitated focus group discussion at the beginning and end of the four months to provide information for the study. In addition, each group met twice during the four months for unstructured peer discussions.
In their groups, the women discussed the female condom, the cultural inhibitions that affect their negotiation of the terms of their sexual encounters, and the power relations in their homes. It was clear that all, whether divorced, single, or married, felt vulnerable to the disease, Dr. Kabira observed.
"But the discussions also showed that married women were more disadvantaged and helpless since cultural inhibitions had more bearing on them," she added.
Men's Perspective
To get the male perspective on the female condom, the investigators asked the women to invite their partners to participate in a focus group discussion. A total of 55 male partners participated in six focus group discussions after the women had concluded their exit interviews.
At an April 24 focus group discussion in Nairobi, six men discussed their sexual lives, their wives and their girlfriends with ease. For the most part, they spoke approvingly of the female condom.
"You know, most men will always have another woman, so this device will help a great deal in not just protecting our wives but ourselves," Wilson Amazimbi said.
Richard Maina thought the condom looked strange when he first saw it, but found it very comfortable when he tried it with his wife. "The male condom is tight and uncomfortable, but with this one, one does not feel like there is a barrier," he said. "Moreover, it is the woman who will wear it, and I do not have to wear it or handle it after."
Another man who has two wives and 11 children made the others laugh when he said he wished he had known about the female condom earlier.
However, the men who were introduced to the condom by their wives could not help feeling suspicious. "We are used to using condoms with commercial sex workers, so I wondered what my wife was up to when she introduced it to me," one man said.
Another man noted that a friend almost beat his wife when she asked him to use it because he thought she wanted to use it with other men too. However, this response was unusual: only one of the 96 women reported that a partner had reacted violently when she suggested using a female condom.
That the men wanted more female condoms was indisputable. "If you maintain the supply, we are sure to be protected and to plan our families," the father of 11 said.
Positive Process
The response to the study among both women and men was far better than the investigators had expected. Men were willing to participate in focus group discussions, and no one dropped out of the study. Some of the women decided to continue meeting in their groups after the research concluded.
Data collection was finished at the Nairobi site in March 1996. The researchers are analyzing the data and will submit a report at the end of August. Results from Kenya and Brazil will be shared with women's organizations and policy makers once they become available.
But it is already clear to the Kenyan investigators that the group discussion have had positive results. Many participants reported that they found it easier to talk to their partners about sex -- something that rarely happens in most relationships, Dr. Kabira observed.
"The fact that a woman can wear a condom may be against tradition," she said, "but it provides an opportunity for the partners to talk about sex and their sexual lives."
The value the study placed on participation and contributions seemed to give the women more confidence, Dr. Kabira added. "Traditionally women are considered recipients of information and not disseminators. But in this case, they are the participants and disseminators and they own the process and contribute to it."
-- Jemimah Mwakisha
Jemimah Mwakisha is a journalist with Nation Newspapers Limited in Nairobi, Kenya.
References
- Soper, D.E., D. Shoupe, G.A. Dhangold, et al. 1993. Prevention of vaginal trichomoniasis by compliant use of the female condom. Sexually Transmitted Diseases 20:136-139.
