Communication between partners is a key factor in achieving correct and consistent use of barrier methods. Yet, in many societies, few couples ever talk to each other about reproductive health issues.1
The couples who do not talk are at a greater risk for sexually transmitted disease and unintended pregnancy.2 Providers who counsel clients on how to negotiate with partners and how to talk openly about sexual fears, risks and concerns will help clients achieve better contraception and safer sex.
While many AIDS prevention programs have explored ways to improve couple communication in order to promote effective condom use, family planning clinics have focused less on this issue.
"Most family planning programs offer methods women can use without involving their partners -- such as pills and injectables," says Laurie Fox, who specializes in family planning and STD integration research at FHI. "The issue of correct and consistent barrier contraceptive use can be difficult because it requires something new -- teaching partner cooperation." Some family planning providers criticize barrier methods because they are less effective in typical use than many other contraceptive options. The effectiveness of barrier methods would probably improve, however, with greater emphasis on couple communication.
"If family planning programs can counsel which method is best and how to use it, why can't they counsel clients on how to talk to their partners?" says FHI's Carol Joanis, who conducts research on the acceptability of contraceptive methods. "Certainly, we have enough experience with AIDS to know that communication is needed. Why is it such a radical notion? You ask if your client feels comfortable talking to her partner about condoms. Very simple questions lead to talking."
Building confidence
Ultimately, the effectiveness of communication about sexual issues depends on a person's self-esteem and sense of self-worth, says Joanis. The more confidence a woman has, the more she will be able to communicate about her needs, about sex, and her feelings, even in cultures where such communication is considered taboo.
Strengthening a woman's confidence in being able to manage her own sexual relationship may improve condom use, according to FHI's Dr. Priscilla Ulin, who conducted focus groups on safe sex in Haiti. Discussion groups among women, or among women and men, can promote a dialogue about sex, barrier methods and sexual risks.
Some women prefer gently encouraging a man to wear a condom, while others think they should convince a man rationally and appeal to his sense of duty to protect the family from AIDS. If communication does not work, women sometimes withhold sex, although such a tactic can be risky.3 Counselors should consider asking clients what types of threats, reactions, and consequences they face.
In 1993 and 1994, the Washington-based International Center for Research on Women, an independent research group, organized 240 female factory workers into small discussion groups in Chiang Mai, Thailand, in collaboration with Chiang Mai University. After the sessions, the number of women who said they felt confident talking to a partner about STD risks increased from 60 percent to 90 percent. The portion of women who said they would not be embarrassed to give a partner a condom jumped from 36 percent before the sessions to 82 percent.4
Educational background may improve prospects for couple communication and contraceptive use, suggests a survey of 1,022 Nigerian men. The survey showed that among educated men who communicated about family planning with their partners, 60 percent used contraceptives. Among the educated men who did not discuss sexual matters with partners, only 10 percent used contraception. Among uneducated men in the survey, 27 percent who talked about family planning were using contraception, compared with only 4 percent who did not communicate with partners.5
Couple communication among adolescents should be encouraged. A University of Minnesota study looked at 550 adolescent women in the United States who used school and community-based clinics. Women who said they communicate openly with their partners had the lowest risks of pregnancy and sexually transmitted diseases (STDs). Nontalkers were five times more likely to have multiple partners and twice as likely to have sex with a partner infected with an STD.6
Among married couples, communication seems to improve contraceptive use. The U.S.-based Demographic and Health Surveys (DHS) analyzed reports from 7,150 married women in its 1988 Kenya survey, finding that 36 percent of couples who communicated frequently about sex used contraception, compared with only 12 percent of women who did not communicate with their spouses.7
Learning to talk
Teaching women to talk about STD risks with their partners may require approaches that are different from the interventions used with men.
An STD education campaign in the Dominican Republic in 1995 improved condom use among men, but failed to address the needs of women. When surveyed, women said they did not like the idea of discussing sexual issues with men present. Consequently, the Coordinadora de Animación Socio-Cultural (CASCO), a non-profit STD prevention organization in Santo Domingo, and FHI's AIDSCAP project, revised their approach. In female discussion groups, women felt more comfortable talking about the challenges of encouraging condom use.
"We needed to think of a new strategy exclusively for women," said Betaña Betances, a CASCO social psychologist. The Santo Domingo discussion groups involved 185 young women, ages 15 to 24. Women said they understood condoms would help protect them from HIV and other STDs, but they feared insisting on condom use. They thought condoms would make them look promiscuous. Women with multiple partners were more likely to use condoms, while those with monogamous relationships were less likely to do so.
When asked what type of sexual education they would most like to receive, the women were divided about whether they preferred talking to peers or experienced counselors. The women suggested having a resident female counselor in their communities with whom they could discuss sexual matters at any time.
In 1993, Brazil's family planning organization, Sociedade Civil Bem-Estar Familiar no Brasil (BEMFAM), began offering peer discussion groups to women attending BEMFAM clinics for routine medical services. By 1996, more than 2,500 women across the country had participated in the one-hour discussions, designed to teach communication skills about safe sex. Comic strip stories about HIV risk were used to open up the group conversations, and penis models were used to teach women how to use condoms.8
In 1994, International Planned Parenthood Federation (IPPF) helped train counselors at the Jamaican Family Planning Association on partner negotiation and how to prompt clients to think about partners' sexual habits and STD risk. Training included role plays in condom negotiation strategies with a reluctant partner. The role playing helped counselors appreciate the complexity of trying to convince a partner to do something in the middle of a sexual act, says IPPF's Julie Becker.
A project by AIDS Technical Support: Public Health Communication Component (AIDSCOM) in Brazil, Tanzania and Indonesia asked women to talk about the reactions or consequences they might encounter if they tried to talk to their partners about sexual risks, or insisted on condom use. In focus groups of 40 women in each country, women were asked to indicate the advantages and disadvantages of discussing safe sex.
Advantages included protection from AIDS and other STDs, protection from pregnancy, convincing a partner to have only one partner, and strengthening the relationship. But several disadvantages also were listed, including the potential for instilling distrust and suspicion.9
"It's a really tricky issue," says FHI's Donna Flanagan, who specializes in behavior change communication to help prevent AIDS. "You have to teach someone how to convince somebody else to do something, like wear a condom. That requires skills. Not only skills in communication, but it also requires self-confidence and assertiveness."
-- Sarah Keller
Footnotes
Nyblade L. Husband-wife communication: Mediating the relationship of household structure and polygyny to contraceptive knowledge, attitudes and use: A social network analysis of the 1989 Kenya Demographic and Health Survey. In International Population Conference, Montreal Aug. 24-Sept. 1, 1993, Volume I. Belgium: International Union for the Scientific Study of Population, 1993:109-20. Salway S. How attitudes toward family planning and discussion between wives and husbands affect contraceptive use in Ghana. Int Fam Plann Perspect 1994;20(2):44-47. Gage AJ. Women's socioeconomic position and contraceptive behavior in Togo. Stud Fam Plann 1995;26(5):264-77.
Edwards SR. The role of men in contraceptive decision-making: Current knowledge and future implications. Fam Plann Perspect 1994;26(2):77-82.
Ulin P, Cayemittes M, Metellus E. Haitian Women's Role in Sexual Decision-Making: The Gap Between AIDS Knowledge and Behavior Change. Durham: Family Health International, 1995.
Cash K. Experimental Educational Intervention for AIDS Prevention among Northern Thai Single Migratory Factory Workers. Women and AIDS Research Program, Research Report Series No. 9. Washington: International Center for Research on Women, 1995.
Oni G, McCarthy J. Family planning knowledge, attitudes and practices of males in Ilorin, Nigeria. Int Fam Plann Perspect 1991;17(2):50-54.
Edwards.
Nyblade.
Badiani R, de Oliveira MR, Pinto P, et al. Empowering Women to Negotiate Safe Sex: A Model from Brazil. XXII National Council for International Health, Washington D.C. June 1995. Unpublished paper.
Middlestadt S. Encouraging discussion with partners and building negotiation skills: HIV prevention strategies for women in relationships in Brazil, Tanzania and Indonesia. Adv Contracept 1993;20:297-302.
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