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Health Educ Res. 2016 April; 31(2): 260–272.
Published online 2016 March 8. doi:  10.1093/her/cyw001
PMCID: PMC5007577

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

Abstract

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.

Introduction

In its more than 30 years of existence, the female condom (FC) has been recognized as a safe and effective method for preventing human immunodeficiency virus (HIV), other sexually transmitted infection (STIs) and unintended pregnancy among diverse types of women in both high- and low-resource countries [1–11]. Other than the male condom (MC), it is the only female-initiated prevention option that protects against both HIV/STI and pregnancy, as microbicides and other female-initiated technologies are still undergoing development and preliminary evaluation [12–14]. When compared to the MC, the FC is believed to offer a similar or greater amount of protection if used correctly and consistently [15, 16]. Limited data exist on direct comparison of the male to FC in offering protection from HIV/STIs [17] and in a study of a STD clinic population, no significant difference was found between the two. On a population level, research has suggested that access to FCs can decrease the number of condom-unprotected sex acts, often through a combination of increased MC and FC usage [18–21]. However, proper insertion of the FC is crucial, and some women experience discomfort during sex if the FC is not positioned correctly [22–24]. Such problems can potentially limit use-effectiveness of the FC for HIV/STI prevention.

In South Africa, a country where youth (15–24 years) have high rates of HIV [25] and unplanned pregnancy [26], use of the FC remains low. In a Human Sciences Research Council (HSRC) nationally representative sample in 2008, among women who reported previous condom use, FC use prevalence was 7.2% [27]. In a population-based household survey of young people aged 18–24 years in four provinces, among women who reported to be currently using contraception, 5.8% reported FC use [28]. In addition, the HSRC survey found that overall condom use declined from 66.5% in 2008 to 49.8% in 2012, condom use at last sex for women ≥15 years was 33.6%, and 54.1% of women ≥15 years and 27.8% of youth aged 15–24 years reported never using a condom with their most recent sexual partner [25].

These data are a cause for concern, given the disproportionate risk of HIV among young women compared with that of young men in South Africa. In 2012, HIV prevalence among 15-to 24-year-old women was 11.4% compared with 2.9% among young men in the same age group [25], Similarly, HIV incidence rates demonstrate that approximately 113 000 new HIV infections occurred among young women in 2012 compared with 26 000 among young men [25]. The enhanced HIV/STI acquisition risk among young women in this country highlights the need for greater awareness and use of female-initiated prevention methods, including the FC.

Two common barriers to widespread use may explain women’s under-utilization of the FC—difficulties with partner negotiation and with FC insertion [5, 15]. Partner resistance often stems from lack of information or familiarity with the device, dislike of its physical features such as size, peer norms, perceived risk and self-efficacy [4, 10, 25–27]. In some parts of sub-Saharan Africa, women need to obtain permission from male partners to use an FC [2], and sexual communication with partners may be problematic [29, 30]. In South Africa, difficulty in negotiating use of prevention methods with male partners often reflects gendered power inequities within sexual relationships. Imbalances related to sexual decision-making are believed to be a primary driver of unsafe sexual practices, rather than a lack of knowledge about disease risk or safer sexual behaviors [31, 32]. In sub-Saharan Africa, women frequently have less power than men due to prevailing gender norms and other gendered aspects of society, and thus may be unable to communicate with partners about sex or control their use of protective methods, and may be subjected to sexual violence and coercion [2, 29, 30, 33–38]. This may be especially true for younger women, who are often in sexual relationships with older men and thus at increased risk of acquiring HIV [39–42]. Among South African youth, ~1–5% of men and 20–33% of women have reported sexual relationships with older partners [28, 42] and for young women, these partners are on average four years older than they are [43, 44].

Use of pregnancy and HIV/STI prevention is often dependent upon relationship context. In long-term sexual relationships, suggesting condom use may indicate lack of trust or infidelity by the partner making the request [32, 33, 36, 43, 44]. Previously, among sexually active youth in South Africa, about a third of those whose most recent sexual experience was with their main partner reported always using condoms, compared with more than half of those whose most recent partner was casual [43, 44]. In sub-Saharan Africa, young women who are married or in a stable, heterosexual relationship and who attempt to negotiate FC use may raise their partner’s suspicions about their sexual activity and also challenge his authority within the relationship, which could lead to violence and further hinder women from negotiating condom use [35, 37]. In addition, youth in longer-term relationships may feel less concerned about disease prevention than pregnancy prevention, and rely on other forms of contraception than condoms [45]. A recent mixed-methods study among largely female students at a rural South African university found relationship status to be a significant predictor of both intended and actual condom use, in that students who reported being in a relationship (defined as either exclusive or casual/non-exclusive) were less likely to use condoms than those who were single [46]. It was also suggested that condom use may be perceived as a threat to emotional and physical closeness with partners. Thus, relationship dynamics within the broader gendered social environment can play an important role in FC use among women in South Africa.

Difficulties with insertion have also been described as a major barrier to consistent and satisfactory FC use. Globally, the proportion of women who experience insertion difficulties ranges from 15% to 71% [47–51]. Women have cited several common problems related to insertion, while also recognizing insertion-related benefits such as the ability to insert the FC long before sexual activity [51]. Some report difficulty with the condom’s lubrication or with the positioning of the inner and outer rings during insertion [2, 51]; others may feel uncomfortable or embarrassed inserting the FC in front of a partner [2]. Insertion problems are found to decrease with practice [50, 52], but without supportive instruction may cause women to discontinue use. In addition, certain individual-level factors—including ambivalence toward FC benefits, having casual sexual partners, and having long fingernails—have been associated with FC insertion difficulties [50]. While the relationship between insertion difficulties and casual sexual partners is not fully understood, it may be due to increased pressure for sexual spontaneity and lack of partner support, whereas women with regular sexual partners may be more likely to plan for sex and discuss condom use with their partner [45].

Previous research has demonstrated that although youth are increasingly aware of HIV/AIDS and can easily access condoms, this knowledge does not necessarily translate into behavior change, and many youth continue to engage in risky sexual practices. The current study describes young women’s experiences with FC negotiation and insertion following an FC educational intervention targeted to female university students in KwaZulu-Natal Province, South Africa. A study in KwaZulu-Natal Province, a region with the highest HIV prevalence in the country [25], reported that 6.1% of university students overall and 8.7% of Black African students are living with HIV [53]. The majority of national and international FC studies have employed quantitative methods. However, the complexities of sexual negotiation between couples and of FC insertion, as well as other contextual and structural factors associated with FC use, warrant a more in-depth understanding than can be achieved with quantitative measurement alone [10, 54, 33–35]. Findings presented here are from the qualitative component of a larger study examining experiences with FC use among female university students following participation in an educational intervention, and specifically describe those related to partner negotiation and FC insertion. We first describe the FC intervention trial and outcomes to provide a context for the qualitative study.

Materials and methods

FC intervention trial

Procedures

The study was conducted between March 2008 and October 2009 with 296 full-time female university students. Women were recruited by study team members who approached students on campus and informed them about the study. Those who were interested in participating were screened for eligibility. Eligibility criteria included aged 18 years or older; self-reported HIV-negative status; not being pregnant or not wanting to become pregnant in the next 9 months; self-reported condom-unprotected vaginal intercourse in the previous 2 months; capacity to complete informed consent and be interviewed; and willing to have the assessment and interventions audio-recorded. Thus, university women considered to be high-risk were recruited into the intervention trial. First-year students were excluded due to high drop-out rates. Women deemed eligible to participate completed an informed consent and were scheduled for a baseline interview.

Following the baseline interview, women were randomized to either a two-session Enhanced Intervention (EI) group (n = 147) or one-session Minimal Intervention (MI) group (n = 149). Participants in the MI group received one didactic information-only introductory session on the FC, which included information on the FC’s preventive ability, how to use the FC, and differences between MCs and FCs, as well as HIV/STI and pregnancy risk and prevention education. It also incorporated a brief review of the female reproductive system and a demonstration of FC insertion on a pelvic model (though participants did not practice on the model). Those in the EI group received an enhanced two-session cognitive-behavioral intervention, which included the didactic information received in the MI group as well as information specific to negotiating FC use with a partner, FC insertion skills-building (including FC insertion practice on a pelvic model), and goal-setting to achieve HIV/STI and pregnancy prevention. Both groups also addressed the potential for partner abuse and provided referral information, and all participants received FCs to practice and use with male partners. The polyurethane FC (FC1) was used in the intervention as the synthetic latex FC (FC2) was not yet available in South Africa when the study was conducted [52]. The efficacy of the two interventions in reducing the frequency of condom-unprotected intercourse among university students have been described elsewhere [55]. There were no significant differences between intervention conditions—both groups reported significant reductions in number of condom-unprotected vaginal intercourse occasions, increased number of FCs used, and increased odds of vaginal intercourse occasions protected by either a female or an MC from baseline to the 2.5- and 5-month follow-up.

Characteristics of sample

Among the 296 female students in the intervention, the average age was 20 years old and all participants were Black African. The majority (95%) reported having a current main partner, who was on average 3.5 years older than the participant. Of these women, many (44%) believed that their partner was at risk for HIV/STI, and some (8%) reported that their partner had an STI in the past year. At baseline, <5% of women had ever used an FC, but the majority (98%) reported ever using an MC. Participants reported some exposure to HIV risk. Nearly 19% reported ever having an STI and viewed themselves to be at moderate risk of getting infected with HIV in the next six months (2.09, range = 1-4, with ‘1’ reflecting low risk perception and ‘4’ reflecting higher risk perception). Regarding partner risk, 8% indicated they had a partner with an STI in the last year, and 44% believed their main partner to be at risk for HIV or another STI. Women had an average of 2.4 (SD = 2.3; range = 1–20) lifetime sexual partners.

Post-intervention in-depth interviews

Following participation in the intervention, 39 female participants (21 from MI group, 18 from EI group) were randomly selected for in-depth interviews at 5 months post-intervention. In-depth interviews were also conducted with the primary male partner of each randomly selected participant, and were analysed in a companion study [56]. We explored women’s experiences in initiating and negotiating FC use with a partner, partner reactions to the FC, experiences with insertion and removal, knowledge and misconceptions about the FC and attitudes regarding future use. Interviews were held in a private room located on the university campus, and conducted by two Black African female nurses with clinical experience working with young people. Interviews were conducted in either English or in isiZulu, depending on the participant’s preference, lasted between 60 and 90 min, and were audio-recorded and transcribed.

Data analysis

Coding and analyses of interviews were conducted using NVivo 9 by two researchers who employed the constant comparison method [57] to identify recurrent ideas or themes in the data. Researchers first read a subset of transcripts, and recorded recurring themes regarding women’s experiences with the FC and the intervention. Inductive and deductive strategies were employed to compose a finalized codebook of 25 unique themes. This codebook was used to code all interview transcripts.

The current analysis is based on data that emerged from 11 codes which most pertained to FC use, partner negotiation and experiences with insertion. Examples of the codes used include ‘Conversations about the FC’; ‘Practice inserting an FC’; ‘FC use with a partner’; ‘Confidence inserting FC during practice’ and ‘FC negotiating strategies used’. Following the coding of interview transcripts, a coding report for each theme was generated. Researchers read each coding report to assess female university students’ experiences with using the FC after the interventions. Data regarding negotiation and insertion are examined here among women from both EI and MI groups collectively, as the two interventions were previously found to be similarly effective in increasing FC use among women and reducing condom-unprotected sex acts with partners [55].

Ethics

The study was approved by the Institutional Review Board (IRB) at the New York State Psychiatric Institute-Columbia University Department of Psychiatry. It was also approved by Research Ethics Committees of two South African universities, including the site where the study was conducted.

Results

Sample characteristics and FC use

The 39 female university students who participated in in-depth interviews were representative of the intervention sample with regard to age and race—all women were Black African full-time students, with a mean age of 20 years. The interview data from one participant were largely incomplete due to a recording error, and therefore excluded from the remainder of the analyses.

Two-thirds (n = 26) of the women reported having used the FC at least once with a sexual partner after participating in the study. Approximately one-third (n = 12) did not use the FC with a sexual partner and gave the following reasons: partner’s persistent objection (n = 3); partner’s lack of knowledge about the device (n = 1); partner’s dislike of FC size (n = 1); and difficulties with insertion (n = 1). Six women who did not use the device described their partner’s positive feedback about and/or agreement to use the FC following their discussions about it, but cited no specific reason for not using it.

Negotiation of FC use

Initiation of FC use

Women initiated discussions with partners about using the FC at different time periods following participation in the intervention, ranging from 2 days to 3 months. Most women, however, reported initiating the discussion within one month of completing the intervention. Many initiated the conversation by telling their partner about the intervention, or showing partners the FCs they received during the study.

We were just talking and then I said, hey today I went to this workshop and they told us about the female condom…they want us to try it.—Participant, MI group

Well I just placed the female condom on the table…and I just told him [what] we learned in the workshop.—Participant, EI group

Only a few women, regardless of whether or not they used the FC with a sexual partner, reported that their partners were interested in and open to trying the FC following the initial discussion. The majority indicated that their partners were initially hesitant to use the FC, primarily due to its size (n = 26) and lack of knowledge about its insertion (n = 12). Others reported that partners were concerned about the presence and fit of the inner and outer rings, or were confused about the shape of the FC, or that their partners saw no need for the FC when the MC was available. According to the women, a few men were immediately and persistently reluctant. One woman described her partner as having decided against FC use before attempting to negotiate:

He is not okay with it…he was talking about why they introduced the female condom because there is a male condom.—MI participant

He wasn't interested…because he didn't have the knowledge about it…he was asking me that what if it comes out and all that stuff.—EI participant

Negotiation tactics

The majority of women (n = 30) reported using what they learned in the interventions to negotiate FC use with their partners. Most of these women (n = 23) also reported using the FC with a partner. A number of women (n = 6) indicated they were persistent in their attempts despite initial partner resistance to FC use or their partner not taking the negotiation seriously.

He first laughed…and then truly no, I’m serious and then he said no, and then perhaps after a couple of days I told him I really I’m serious, he said, ok I’m fine, I’m really serious we gonna try it.—EI participant

At first he didn’t wanna agree to use [the FC], but I told him that they say it actually improves the sexual experience. Then, in that way he agreed to do it.—MI participant

The specific strategies or points of information most often used to negotiate FC use included: the FC is another method of STI/HIV and pregnancy prevention; the strength of the FC compared with the MC and the reduced likelihood of breakage during sex; and the FC as an alternative to the MC. Other points noted included the FC being the woman’s responsibility, rather than the man’s; enhanced sexual pleasure with an FC; and that known peers (e.g. friends or classmates) were using the FC. Several women (n = 12) described or demonstrated FC insertion as a method of negotiating use with a sexual partner.

I even taught him how to use [the FC] and everything…I showed him all the steps that we were showed in the workshop.—EI participant

I explained this is the female condom, it is used like this. You can put it in, take it out and hold [it], as I did.—MI participant

Some women (n = 8) did not use specific strategies or information learned in the workshops primarily because their partner was willing to try the FC, and thus they had no need to negotiate.

We didn’t negotiate, I just said let us do this and he was okay.—EI participant

In fact, we didn’t really negotiate…because I just told him and he was like ok, let’s just try it on.—MI participant

Experiences with FC insertion

The majority of women (n = 31) reported first practicing FC insertion on their own, including those who subsequently used the FC with a partner (n = 23) and those who did not (n = 8). Some women (n = 6) were able to successfully insert the FC on their first practice attempt; others reported an average of 2–3 practice attempts before successful insertion.

But I kept on trying like to insert it, it’s not difficult, you just try the first time, okay it doesn’t work…the second time, it’s much better.—EI participant

Among women who did not first practice insertion (n = 7), reasons were largely related to comfort with or self-confidence in their ability to insert the FC for sex. Of these women, a few subsequently used the FC with a partner (n = 3) and others did not (n = 4).

In general, several women (n = 12) felt confident, or that they ‘knew what they were doing’ about inserting the FC following the intervention though a few expressed the need for additional practice.

I knew what I was doing…cause we were told how to insert it…and we were shown but…I needed more practice.—EI participant

I was confident because we did it in the workshop and then the facilitator practice showed us so I was confident because I saw…when we practiced to do it.—MI participant

When prompted by the interviewer, most women were able to correctly describe the FC insertion process step-by-step. Among women who reported practicing insertion prior to sex, many (n = 24) described problems in their initial attempts. Often this included difficulty correctly twisting the inner ring of the FC (as is necessary to successfully insert the device), due to its lubrication. Despite this, the majority of these women (n = 18) reported subsequent use of the FC with a sexual partner. Others noted difficulties related to pain or discomfort from the inner or outer ring, and problems getting the FC inserted fully. Among women who did not use the FC during sex (n = 12), only two cited difficulties with insertion as a deterrent.

It slips through the fingers, but I did practice it when we were trying and it come out okay.—EI participant

Usually, when we practiced, it was hard to hold on, [to] touch the ring…but then once you get that right, then it's just easy.—EI participant

Almost all women felt that the insertion demonstrations and instructions provided in the interventions were ‘helpful’, ‘fun’ and ‘gave better understanding’, compared to the FC package instructions alone. A few women (n = 6) noted that they did not need to read the package instructions because they understood the process following participation in the workshops.

They [the instructions] were [helpful] but not as helpful as the study…we saw exactly [how] everything [is] done.—MI participant

They [the demonstrations] were excellent because…the way there were demonstrated you even saw that you not gonna get hurt or something, you not gonna get hurt, because the first thing that comes in your mind is that what happens to the ring that stays inside what happen to this and that…you showed us that ok fine after we have inserted it this is how it’s gonna sit you know, you gonna be fine, you gonna be perfect.—EI participant

Some, however, reported using the instructions that came with the FC to help with insertion, sometimes reviewing them with a partner. Additionally, a few women reported that their partners helped them during the insertion process (e.g. with the positioning of the FC’s outer ring).

Experiences with the FC during sex

Many women who reported using the FC with their partner during sex described a generally positive experience (n = 17)—stating that the FC fit well and was neither painful nor uncomfortable. Some women stated that it felt as if there was no condom at all. Several also noted that insertion of the FC was easier prior to sex, due to previously practicing insertion alone.

[During sex] you don’t feel much of the difference…the same as the male condom.—EI participant

Other women who used the FC with a sexual partner reported some discomfort with the fit and feel of the FC during intercourse (n = 7).

[The FC] feels normal, but it just that…there is something inside you.—MI participant

Discussion

This is one of the first studies of FC use among female university students in sub-Saharan Africa. The majority of FC research and interventions in sub-Saharan Africa have been aimed at high-risk adult women [10]. One study of male and female students at the University of Port Harcourt in Nigeria found that among 589 sexually active students, most (89.3%) had heard of the FC as a method to prevent HIV/STIs and unwanted pregnancies, but only 8.9% had used one [58].

Our results indicate that targeted training in FC use, which includes a focus on the development of skills related to partner negotiation and insertion, can facilitate usage among female university students and their partners. The study sample—young, Black African, university women with self-reported sexual risk—represents a population that could greatly benefit from enhanced use of the FC as a form of disease and pregnancy prevention. Prior to participation in the interventions, <5% of women in the larger study sample had ever used an FC. Most women participating in our study were able to apply and transfer knowledge learned in the interventions to negotiate FC use successfully with their partners. Even among those who did not use the FC with a partner, many reported ‘attempting’ to negotiate use based on knowledge gained in the interventions. Our study indicates that providing South African university women with tailored, one-on-one knowledge and skills development regarding use of a female-initiated HIV prevention tool can positively influence their ability to negotiate its use with sexual partners.

Women in our study reported feeling confident in their abilities to negotiate FC use with sexual partners following participation in the interventions, and many were able to overcome partner resistance and objections. Men in sub-Saharan Africa often hold more influence over sexual decision-making than women, and such gendered imbalances directly contribute to low condom use and lack of negotiation [33]. Improving women’s sexual autonomy and self-efficacy through training in and subsequent use of female-initiated contraceptive and HIV/STI prevention methods gives them greater control and bargaining power within their sexual relationships [3, 15, 59]. Many studies report that use of the FC may give women a greater sense of control and self-reliance in the protection of their bodies from disease and pregnancy, as well as more opportunities to negotiate and practice safer sex with a partner, leading to increased condom use [3, 5, 6, 8, 10, 35, 59, 60]. It is therefore imperative that HIV/STI and pregnancy prevention programming in sub-Saharan Africa promote female autonomy and gender equity within sexual relationships, as these are key to increasing safer sexual behavior among youth in this region.

Our results also emphasize the importance of guided and repeated practice in using the FC. The majority of women reported practicing FC insertion prior to use with a sexual partner, and many practiced multiple times before achieving success. This has been previously noted in FC studies, which report that few women are able to master proper FC insertion techniques immediately, and that repeated practice following guided instruction can lead to decreased insertion difficulties and thus increased use [3, 43, 50, 52]. Future FC programs should emphasize detailed, guided insertion instruction as a method of encouraging young women to practice using the device, as well as target gender equity and self-efficacy as the primary mechanisms by which behavioral change can successfully occur [31]. This can substantially contribute to the demystification of the FC which, in our study, occurred as a result of increased knowledge and self-efficacy. For example, several young women used insertion of the FC as a method of negotiating use with partners. Women reported demonstrating or describing the process of insertion for their partner, in an attempt to quell any hesitation or concern regarding how the FC is used. Although this practice was not specifically described as a negotiation strategy during the interventions, it demonstrates that providing university-trained young women with education and training in FC use and negotiation can empower them to share knowledge with partners and apply their skills; this highlights the FC as an acceptable and reliable prevention option.

Sexual behavior among youth can be influenced by a range of factors at the individual-level, as well as at the interpersonal- and environmental-levels [61]. Previous research has found that youth in South Africa and university students in particular, have high levels of awareness of HIV/AIDS yet may also have misconceptions or lack specific knowledge of how best to protect themselves, and continue to engage in risky sexual behavior such as unprotected sex or sex with multiple partners [31, 61, 62]. Sexual risk behavior among youth in South Africa has been linked with poverty, unemployment, living in rural areas, and low levels of education [28, 61, 63, 64]. Young women’s ability to engage in safe sexual behavior, including use of the FC, may be shaped by not only their knowledge of the FC and how to use it, but also by the levels of gender equity and sexual communication within their relationships, their socio-economic status, and their level of education [65, 66].

Women in our study represent a well-educated population, and as per eligibility criteria, all reported condom-unprotected sex in the two months prior to the interventions. Most had a regular, main partner who was often older; the inherent risk in these relationship dynamics, including a lower propensity for condom use and a higher risk for HIV, may act against the protective benefit of being highly educated. In addition, some young men may perceive the FC as a threat to their sense of masculinity or as an indicator of infidelity [55], which could prevent young women from engaging in FC negotiation or use. Thus, relationship and other socio-cultural factors likely play an important role in the potential for behavior change among this population, and future research should work to specifically assess these factors in relation to FC utilization.

It is also imperative to acknowledge the importance of incorporating young men into HIV/STI and pregnancy prevention interventions within the context of shifting gender norms and increased awareness to sexual power imbalances among youth in South Africa [38, 39]. A few young women in our study noted that their partners assisted them during the FC insertion process, consistent with previous research in KwaZulu-Natal [67], and demonstrating the potential for young men to become involved in learning about and adopting the FC for regular use. In a companion analysis among the male partners of young women in this study, young men were open to sharing the responsibility for using condoms with their partners, and several reported greater comfort, feelings of safety, and sexual pleasure when using the FC [55]. Thus, these features can be promoted to enhance men’s acceptance of FC use, and emphasized in FC programming and prevention strategies. However, the important role that young men can and will play in the sustained use of female-initiated methods of prevention requires their active engagement and integration into each step of the prevention pathway [12, 26, 68].

Our study is not without limitations. The qualitative data collected were based on self-reported attitudes and behaviors, and therefore may be subject to social desirability bias. While the goal of qualitative methodology is to elicit a range of responses from participants, not necessarily to attain generalizable data, the applicability of our findings to non-university populations and contexts is limited. By virtue of entry into a higher education institution and their younger age, female university students in our sample may be more motivated to use the FC and better able to negotiate FC use with male partners. In addition, the study did not explicitly evaluate other socio-cultural and economic factors which may directly influence FC use among university-aged women in South Africa. Notwithstanding these limitations, our study demonstrates that tailored, skills-based education about FC insertion and partner negotiation can enhance its use among young, higher-risk university women. While these findings may not be generalizable to other young women in South Africa, or to women in other age groups, they do demonstrate the potential for using the FC as a means of facilitating sexual communication and gender equity within relationships. Finally, our use of the FC1 model, which has been replaced by the FC2 [52], may limit the applicability of our results to current experiences with the FC2.

Conclusions and lessons learned

South Africa’s current National Strategic Plan on HIV, STIs and TB calls for targeted, evidence-based combination prevention interventions focused on high-risk populations in vulnerable areas, and highlights the importance of empowering women to negotiate condom use with sexual partners [69]. The country has had a national FC program since 1998, and utilizes both public-sector distribution strategies and social marketing campaigns to disseminate FCs across the country [70]. While the FC may not be the preferred HIV prevention option for all women with sexual risks in South Africa, it can protect those who prefer to use a female barrier method against unintended pregnancy, HIV and other STIs, while also supporting their sexual autonomy and promoting gender balance within sexual relationships [8, 12].

Our qualitative study demonstrates that after receiving tailored training in FC use, insertion and partner negotiation, high-risk, university-aged young women increased the likelihood of these women using the device with partners, leading to a greater number of condom-protected sexual acts [55]. Condoms have become increasingly accessible and favored among university students in South Africa, often even more so than other forms of contraception, and higher levels of education are known to predict use [25, 28, 43, 71]. At the same time, young women are increasingly gaining more decision-making power within their sexual relationships, and these relationships are becoming more equitable [43]. Recent studies in South Africa have indicated that gender roles are beginning to shift, as younger generations are becoming exposed to more balanced and gender-equitable perspectives toward sexual partnerships and decision-making [32, 37, 38], and demand for female-initiated methods of protection is increasing [29, 39, 66, 72]. Concurrently, there is resistance to these changes and maintenance of more traditional perceptions of gender roles and power relations, particularly with regard to sexual negotiation [37]. In addition, inconsistent condom use remains an important issue when considering the need for sustainable forms of HIV/STI and pregnancy prevention among youth in South Africa [56]. Thus, there is currently a unique and important window of opportunity to promote female-initiated methods, through educational and skill-building strategies, as catalysts for safer sex negotiation and balancing of power within relationships among young men and women in South Africa.

Future FC programming requires a tailored strategy to address the complex and gendered issues which exist among youth in South Africa [12, 36]. Effective FC programs must include accurate and comprehensive education focused on proper use, skill-building on insertion and negotiation, and follow-up strategies to ensure long-term usage [1, 5, 6, 73, 74]. Widespread adoption of the FC as a successful prevention method will require ‘proactive, well-planned strategies to integrate the FC into a country’s contraceptive method mix’ [15]. South Africa has begun to do this, reflected in the country’s most recent National Contraception Clinical Guidelines, which include parameters specific to the FC and highlight the importance of guided instruction and practice for correct and continued use of the device [75]. Results from the FC intervention trial described earlier, and from which the sub-sample of participants were drawn for this paper, indicated that both the MI and the extended EI demonstrated equivalent efficacy in reducing the number of condom-unprotected sex acts among female university students [55]. Both interventions promoted use of the FC as a method of initiating sexual communication within relationships, yet the brief MI may represent a more sustainable method of educating university women in FC use, as well as women more generally in clinic settings, in the future. Our study indicates that education and skill-building in FC use and negotiation may provide a suitable method for at-risk, university students in South Africa to facilitate safer sex practices with their partners. Lessons learned from FC programming can play a critical role in the introduction of vaginal pre-exposure prophylaxis (e.g. rings and film), an important female-initiated method with the potential to greatly enhance HIV prevention among women in sub-Saharan Africa if efficacy is demonstrated [76]. The complexities of gender and power within sexual negotiations require that HIV/STI and pregnancy prevention programs address gender roles, identities and inequalities within sexual relationships, while promoting women’s autonomy and self-efficacy in HIV/STI and pregnancy prevention [31, 38].

Acknowledgements

We are grateful to the students who participated in this study and the valuable contributions of the study’s Community Advisory Board. We also acknowledge the contributions of the officials at the higher education institution study site, who supported the study. None of the study authors report a conflict of interest.

Funding

This work was supported by a grant from the National Institute of Child Health and Human Development [grant number R01 HD046351; Joanne E. Mantell, MS, MSPH, PhD, Principal Investigator; Jennifer A. Smit, BPh, MSc, PhD, South Africa Site Principal Investigator]. The HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University is supported by a center grant from the National Institute of Mental Health [Grant number P30-MH43520; Principal Investigators: Anke A. Ehrhardt, PhD (1987-2013)/Robert H. Remien, PhD (2013-2018)]. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development, the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, MatCH Research (Maternal and Adolescent Child Health Research), and the University of Witwatersand, Faculty of Health Sciences, Department of Obstetrics and Gynaecology.

Conflict of interest statement

None declared.

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