We demonstrated the efficacy of skills training in improving female condom knowledge, attitudes, and use among U.S. women attending family planning clinics. When compared to women who received brief instructions on female condom use as part of a behavioral intervention aimed at promoting women's general health, women who participated in intense skills training sessions that exclusively focused on the female condom became more knowledgeable about the female condom, had more favorable attitudes toward the device, and were more likely to use it. The same treatment dosage for both experimental and comparison groups allowed to control for Hawthorne effects and, in turn, reduced the likelihood that the efficacy of female condom skills training can be attributed to nonspecific factors, including group interaction and individual attention. The study design also ruled out the possibility that the differences in use were due to access to the female condom, as both groups were given identical access.
We found that the absolute difference in percentage points in using the female condom at least once between the experimental and the comparison group was 26.2% at the 3-month and 23.15% at the 6-month follow-ups. These results were comparable or greater than those reported in other female condom intervention trials (i.e., 13.89% and 24.1% at 3-month).10, 11
Moreover, whereas previous studies showed only a short-term intervention effect on female condom use (i.e., 3 months or less),9-13
our study found a significant longer-term (i.e., 6 months) effect. Also, the treatment effect achieved for female-condom-protected sex acts at 3 months did not diminish at 6 months. In fact, the mean percentage of sex acts protected by female condoms rose from 11.57% at 3 months to 18.87% at 6 months.
The greater magnitude of treatment effects, as well as the longer-term effects found in our study, may be due to the unique characteristics of our intervention that focused exclusively on the female condom, included self-insertion practice and feedback, and provided monthly condom supplies; other interventions did not include these features.9-13
A six-session group HIV/STI prevention intervention developed by van Devanter and colleagues,10
for example, devoted only one session to the female condom, used a pelvic model for condom demonstration and practice, and supplied female condoms upon request. Hoffman and colleagues9
covered the female condom in more than one session in their four- or eight-session HIV risk reduction intervention, but limited condom use practice to a pelvic model and provided female condoms only upon request after giving two samples to try at home. Our intervention is also distinguished from prior interventions in that we used both individual and group counseling to promote the female condom. This approach might have made our intervention more powerful by addressing issues unique to each woman during individual counseling sessions and thereby causing additional behavioral changes in an “individual” effect that group counseling alone might not have produced.
In addition to increasing female condom use, our female condom skills training increased the proportion of protected sex acts. We also found no reduction in male condom use among women in both experimental and comparison groups during the study. These findings were consistent with several studies that made both male and female condoms available to women7, 20-24
and indicated that female condom use supplemented male condom use to contribute to an increase in overall protection against HIV among women.
Our female condom skills training included activities aimed at improving women's self-efficacy related to female condom use. Women were taught, for example, how to introduce the female condom to their sexual partners and how to negotiate its use. However, we found no group differences in female condom self-efficacy at 3 and 6 months. One possible explanation for these findings is that we might have sampled women who were already highly confident in their ability to assert female condom use, and thus our intervention activities failed to produce a treatment effect. Our baseline data showed that mean scores on three measures of female condom self-efficacy ranged from 3.50 to 3.61 of a possible maximum of 4, indicating high levels of self-efficacy at baseline. Another finding of note is a reduction in women's perceived ability to discuss female condom use with sexual partners and resist partner objections to its use in the experimental group. It is possible that at baseline these women tended to overestimate their negotiation skills and later made more accurate assessments of their ability after participating in a role-play exercise or after actual experience trying to negotiate use with their partners.
Three study limitations should be noted. First, the findings of this study may be generalizable only to women attending family planning clinics. Second, because we advertised our clinical trial as a study to promote women's general health including sexual health and the female condom, we might have oversampled women who are interested in female-initiated barrier methods. Third, the accuracy of our data might have been compromised due to reliance on self-reports. However, any self-report bias is less likely to influence the differences observed between the intervention groups as it is expected to operate in both groups.
Our female condom skills training was successful not only in increasing female condom use, but also in increasing protected sex among U.S. women attending family planning clinics. We also found that the female condom contributed to increasing safer sex practices among these women without affecting their use of the male condom. These results suggest that our intervention has the potential to reduce HIV risk among women and can be an effective supplement to other HIV prevention strategies currently available for women and their sex partners.