Women who receive instruction in female condom use, along with opportunities to practice method-related skills on a pelvic model, have an increased likelihood of using the method, of using it correctly and of viewing it in a favorable light.1 The strongest predictors of female condom use that emerged in a randomized controlled trial of a multisite intervention aimed at reducing women's risk of HIV and other sexually transmitted diseases (STDs) were having had instruction and skills training, and intending to use the method.
The trial was conducted between May 1995 and August 1997 in Baltimore, New York City and Seattle; women were recruited at community-based programs, family planning clinics and STD clinics, as well as through advertisements, flyers and community presentations. To be eligible, women had to be HIV-negative and at least 17 years old, and they had to have had intercourse with a male partner during the past three months. In addition, during the past year, eligible women had to have received an STD diagnosis, had three or more sexual partners, or had sex with a man who engaged in risky behavior. A total of 604 women were enrolled and were randomly assigned to a six-week intervention or a control group.
Those assigned to the intervention attended six weekly group sessions in which they were given skills training in communication, goal setting and male condom use; received information and watched a video about the female condom; observed a demonstration of female condom insertion using a pelvic model; and were provided an opportunity to practice on the model. Clinicians encouraged participants to practice inserting the female condom before using it with a partner. Women in the control group attended a one-hour nutrition counseling session and received printed instructions on how to use male and female condoms. Free female condoms were available to all women interested in trying the method.
At study entry and three months after the intervention, the women completed interviews that addressed a range of attitudes toward the female condom. Researchers also asked the women to demonstrate proper female condom use on a pelvic model and rated their skills in using the method. The analyses are based on 442 women who participated in the three-month follow-up.
Overall, the women were predominantly black (58%) or Hispanic (18%) and never-married (73%); their average age was 28.5 years. Roughly eight in 10 were unemployed; only one-quarter had more than a high school education. Four in 10 had at least one dependent child.
At baseline, experience with and attitudes toward the female condom were essentially the same among women assigned to the intervention and those assigned to the control group: Nine percent of each group had ever used a female condom either with a partner or for practice, and 7% had used one with a partner; use in the previous three months was negligible. Asked to rate the female condom on a variety of characteristics, with possible responses ranging from one (poor) to four (very good), women in both groups gave it an average score of 1.3-1.5 at baseline. On average, they performed only 2.7-3.0 out of six method-related skills correctly. About one-quarter of women in each group disagreed that their partner would find the female condom acceptable, fewer than half agreed and the rest did not know.
Three months after the intervention, however, the groups differed sharply on all of these measures. Significantly higher proportions of those in the intervention group than of controls had ever used a female condom (60% vs. 22%) and had used one with a partner (36% vs. 12%). Among those who had used female condoms in the past three months, women who had received instruction had used an average of 1.5, whereas those in the control group had used 0.5. The intervention group gave the female condom a more positive average rating than the control group (3.2 vs. 2.1) and correctly performed a greater number of method-related skills (4.6 vs. 3.3).
In initial comparisons, a number of attitudes, skills and behaviors related to female and male condom use distinguished women who had ever used the method (regardless of whether they were in the intervention or control group) from those who had never done so. To determine which factors independently affected use, the investigators conducted logistic regression analyses, controlling for baseline and follow-up differences between ever-users and never-users.
Results of these calculations indicated that participation in the intervention was the strongest predictor of use (odds ratio, 5.5), followed by a stated intention at follow-up to use the female condom (4.5). Other factors associated with increased odds of use were having asked a partner to use a condom in the past 30 days (2.3), feeling confident at follow-up in one's ability to ask a partner to use a condom (1.9) and having had favorable attitudes toward the female condom at baseline (1.2). Women who reported having only casual partners at follow-up were significantly less likely than those who reported having a main partner (exclusively or in addition to casual partners) to use the female condom (0.2).
Noting the importance of factors related to negotiating male condom use in predicting female condom use, the researchers comment that while the female condom "is not strictly 'female-controlled,'...it may give women more control than the male condom." However, they add, it might not be an option for women who lack negotiation skills. Of paramount importance, they conclude, is counseling that offers both information and a chance for women to practice using the method.--D. Hollander
1. Van Devanter N et al., Effect of an STD-HIV behavioral intervention on women's use of the female condom, American Journal of Public Health, 2002, 92(1):109-115.