We aimed to examine differences in microbicide acceptability between young women in different contexts: the USA and Puerto Rico. We considered several factors shown to influence microbicide acceptability: vaginal product use, reaction to gel use, sexual pleasure, partner reaction, and HIV risk perception.
Puerto Rican women’s experiences with douching may have positively affected their acceptability of the microbicide due to familiarity with the feeling of inserting a product and having it come out of the vagina and a positive association of intravaginal products with a clean and fresh feeling. In fact, research has suggested that microbicides are acceptable in places where women practice intravaginal cleansing (Montgomery et al. 2010
). Women in South Africa testing a microbicide associated the sensation of leakage and increased discharge with the efficacy of the gel in cleansing their vaginas, similar to other vaginal cleansing practices (Stadler and Saethre 2011
). Furthermore, our findings are supported by another study in which most Puerto Rican women reported that douching made them feel ‘clean’ and ‘good’ (Mason et al. 2003
) and they were more likely than women in the USA to say they would use a microbicide (Hammett, Mason, et al. 2000
). In addition, a study of vaginal douching practices among Latinas in the USA (primarily of Puerto Rican and Dominican descent) found that women douched both to feel clean and to prevent infections (McKee et al. 2009
). Thus, women who douche may associate the act of vaginally inserting a product and allowing it to leak out with being not only clean, but also infection free. Although douching has been shown to alter the vaginal flora and to increase women’s risk of bacterial vaginosis and sexually transmitted infections (Cottrell 2010
), positive associations of gel use with douching could influence acceptability of the gel by women who douche and facilitate campaigns to promote a successful microbicide candidate (Scorgie et al 2011
Another potential explanation for women’s differing perceptions of the gel in the USA and Puerto Rico may be related to the negative association with menstruation expressed by many US women. The scientific literature indicates that young women in the USA, particularly young white women, often describe menstruation as shameful and even stigmatizing (Johnston-Robledo et al. 2003
). In our US sample of mostly young, white women, discomfort related to menstruation may have influenced attitudes towards microbicide use, since participants found similarities between menstruation and gel leakage. In addition, research has demonstrated that in the USA, white women are more likely find suppressing menstruation via continuous contraceptive use acceptable than are women of other ethnicities (Edelman et al. 2007
). Hence, the US sample may have more negative associations with sensations similar to menstruation when compared to the Puerto Rican sample. Interestingly, though many Puerto Rican women stated they douched for cleanliness after menstruation, they did not negatively associate gel leakage with feeling dirty during menstruation.
In addition, US women’s perception of the gel as messy also translated into reduced sexual pleasure while using the gel. Though some studies of women in the USA have indicated lubrication preferences that would favour microbicide use during vaginal sex (Braunstein and Van de Wijgert 2005
; Tanner et al. 2009
), in our study we found that US women did not like the consistency of the gel during sex. In contrast, Puerto Rican participants reported fewer negative effects on sexual pleasure, and some found the increased lubrication from the gel to be pleasurable.
Also, participants in Puerto Rico rated their partners’ reaction as more favourable than participants in USA. Our results differ from other findings in which men in San Juan, Puerto Rico had negative reactions to microbicides (Hammett, Mason, et al. 2000
). However, participants’ reports of their main partners’ reactions generally paralleled their own perceptions of the gel. Therefore, it is difficult to distinguish whether participants were influenced by their partners’ reactions to the gel, or whether they interpreted their partners’ reactions to mimic their own. Young women’s perceptions of their partners’ assessments of a microbicide have been shown to influence their own acceptability and adherence to a product (Tanner et al. 2010
; Greene et al. 2010
), so it may be that our participants were influenced by their partners’ reactions. Almost all of our participants informed their partners of microbicide use, and women from all sites indicated that partner support was an important factor for continued use of the product. Hence, the importance of the partner’s reaction to the gel cannot be underestimated, particularly for women with steady partnerships who choose to inform their partners of gel use.
In addition, our qualitative data support the idea that risk perception is higher among our Puerto Rican sample. In fact, the risk contexts in which these young women live are quite different. The overall HIV incidence rate in Puerto Rico is 45.0/100,000, which is twice the estimated US rate of 22.8/100,000 (CDC 2009
). Among women in Puerto Rico and the USA, the differences are even more striking, as the HIV incidence rate is 2.5 times higher for women in Puerto Rico (29.8/100,000) than for women in the USA (11.9/100,000) (CDC 2009
). Furthermore, HIV incidence rates among white, non-Hispanic women in the USA (majority of our US sample) are even lower (3.8/100,000) than the total rates for women in the USA (CDC 2008
). These differing rates may contribute to diverse risk perceptions. Prior research has demonstrated that women who are concerned about HIV infection are more likely to say they would use a microbicide than those who do not prioritize HIV prevention (Hammett, Norton, et al. 2000
), which is closely related to risk perception. Therefore, Puerto Rican women may state that they would be more likely to use the microbicide than US women because the risk of contracting HIV is greater where they live. In our sample, women in Puerto Rico tended to focus on societal risk, while those in the USA focused on individual risk. Hence, the difference in risk perception may also be a function of these divergent assessments; nevertheless, in the context of microbicide acceptability it is interesting that respondents in Puerto Rico spontaneously chose to consider societal risk while women in the USA did not.
Our study had some limitations. First, since the study was carried out in locations with different native languages, the behavioural assessments were administered exclusively in English at the US sites and exclusively in Spanish at the Puerto Rico site. Anchors of response scales, such as Extremely Likely or Very Likely, may bring to mind different concepts in different languages. Nevertheless, qualitative data corroborate Puerto Rican participants’ more favourable ratings and increased likelihood of using the product. Another limitation of our study is that we had a relatively small convenience sample; hence our findings may not be representative of actual contextual differences, but rather of issues specific to our participants. Furthermore, although our US sample included a few Hispanic/Latino participants, we neither had data on their national background (Puerto Rico vs. other Latin American countries) nor a large enough sample to compare Puerto Rican participants in the USA to those in Puerto Rico in order to explore the influence of local context on participants with similar cultural backgrounds. Finally, participants in our study used the study gel twice daily for a two-week period; they may have had different reactions to gel use had they used it less frequently, over a longer period of time, or only before sex.
Our findings confirm that several important contextual factors impact young women’s microbicide acceptability. Women’s ideas of vaginal cleanliness, including negative associations of leakage with menstruation or positive associations with vaginal douches, may affect their perceptions of the gel’s physical qualities during and after use. In addition, women who live in places with higher HIV rates may have an increased perception of HIV risk and a greater likelihood of using a microbicide, even if they are in monogamous relationships. Finally, women’s perceptions of their primary partner’s support for microbicide use may influence product acceptability.
Future research should focus on evaluating, by design, potential differences in acceptability ratings by site in order to determine more precisely the ways in which factors affecting microbicide acceptability vary according to local or cultural context. This requires increased attention to theory in order to guide selection of sites and participant groups. Also, an emic approach to data collection which seeks to obtain acceptability data based on women’s experiences using a product within their local and cultural contexts, including how the product fits in with and influences existing socio-cultural practices, will help to ensure that these factors are taken into account (Montgomery 2010). In addition, partner acceptability data should also be collected whenever possible. Ultimately, a careful analysis of site differences will allow for successful development and marketing of microbicide products in various contexts and among diverse populations.