In the month after they were randomly assigned to an intervention that included the female condom in an array of strategies aimed at preventing unprotected intercourse, participants perceived the method to be more effective than nonparticipants did, were more likely to talk to their partners about it and were more likely to try it. However, data gathered during a trial of the intervention show that over the next several months, most differences disappeared, and most women who tried the female condom did not continue using it. The odds of continued use were increased if women felt sure of their ability to use the method, if they or their partners were satisfied with it, if they had negative or neutral feelings about male condoms, and if they had ever used the diaphragm.1
The 360 study participants were recruited from a family planning clinic in New York City in 1994-1997; after completing baseline interviews, they were randomly assigned to an eight-session intervention group, a four-session group or a control group. Women in both intervention groups were taught skills for negotiating with partners about male and female condoms; they also received information about the female condom, practiced inserting it into a pelvic model, received female condoms and strong encouragement to use them, and talked with other participants about their experiences in using the method. At baseline and in three follow-up interviews (at one, six and 12 months), women provided information about their sexual behavior, method use, communication with their partner about safer sex, perceptions of male and female condom effectiveness, overall impressions of these two methods and perceptions of their ability to use the female condom.
Participants were predominantly black (72%) and never-married (90%); their average age was 22 years. Before enrolling in the study, 58% had ever had a sexually transmitted disease (STD). Although 75% had used a male condom at some point in the previous three months, only 25% reported consistent use. Fourteen women had ever used a female condom. The majority of participants (76%) had had only one male partner in the past three months, but a substantial minority (41%) knew or suspected that their partner was not monogamous, and 18% said that he had recently had STD symptoms.
During follow-up, 109 women reported having used a female condom for the first time; most of them (76) had done so before the one-month interview. The main reasons women cited for first-time use were that they wished to try something new (47%) and they had attended the intervention (43%). Fifty-nine percent of first-time users were somewhat or very satisfied with the method, and 50% reported that their partners were at least somewhat satisfied with it. Half of those who tried the method considered it easy to use; most of those who found it difficult to use reported problems inserting the device. Of the 93 women who reported first use at the one- or six-month interview, only 21 also reported use at a subsequent interview.
At the one-month follow-up, intervention participants and controls reported significantly different attitudes and behaviors related to the female condom. Women in both the four- and the eight-session intervention groups gave the method higher effectiveness ratings than did those in the control group; women in the eight-session group also had significantly more positive views of it than did controls. Intervention participants had significantly elevated odds of having negotiated female condom use with their partner (odds ratios from logistic regression analysis, 10.3 for the eight-session group and 3.9 for the four-session group) and of having tried the method for the first time (9.5 and 4.4, respectively). Among first-time users, significantly higher proportions of women from the intervention groups than of controls were very or somewhat satisfied with the method (69-70% vs. 33%).
Far fewer differences were observed between intervention participants and controls later in the follow-up period. At six months, women in the eight-session group had significantly elevated odds of saying that they had talked with their partner about the female condom since the previous interview (odds ratio, 2.4); women in both intervention groups were likelier than controls to give this response at 12 months (3.6-3.7). Also at 12 months, women in the four-session group rated the female condom as more effective than did controls. Participation in the intervention was not associated with first-time use of the female condom at six or 12 months.
The researchers used logistic regression to examine the predictors of first-time and continued use of the female condom. Results indicated that the likelihood of first-time use was elevated among women who participated in the intervention (odds ratios, 5.4 for the eight-session group and 3.0 for the four-session) and those who had negotiated safer sexual behavior with their partner before enrolling in the study (1.8); it was lower among white women and those of other races than among blacks (0.2). Among the factors associated with continued use, several were related to the method itself: Women had increased odds of using the female condom more than once if they considered themselves able to use it (1.9), if they had an overall positive impression of it (3.5), if they were satisfied with it (2.3) or if their partner was (4.3). Other significant predictors of continued use were ever having used the diaphragm before entering the study (5.4), having negative or neutral feelings about the male condom at study entry (2.9), and having talked with a partner about the female condom between baseline and the one-month interview (5.3).
The researchers conclude that the female condom is "difficult for women to adopt without...extensive training in its use," including the opportunity to practice inserting the device. Additionally, they observe that although the method has been promoted as a feasible one to use in the absence of partner support, the finding that partner satisfaction predicted continued use suggests a need to make the female condom acceptable to men. They call for both individual-level interventions and policy changes such as increased promotion to help ensure that the method's potential to contribute to STD prevention is realized.
—D. Hollander
1. Hoffman S et al., Female-condom use in a gender-specific family planning clinic trial, American Journal of Public Health, 2003, 93(11):1897-1903.