Because use of the female condom can be initiated by women, the device provides a way for women to protect themselves from sexually transmitted infections ...
Factors Associated with Use of the Female Condom in Zimbabwe By Dominique Meekers and Kerry Richter
CONTEXT: Because women can initiate use of the female condom, the method is believed to make it easier for women to protect themselves against sexually transmitted infections (STIs), including HIV infection. Evidence is lacking about factors associated with trying the female condom and using it consistently. METHODS: A sample of 1,740 sexually active consumers visiting retail outlets in urban Zimbabwe that sell male or fe-
Dominique Meekers is professor and chair, Department of International Health and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA. Kerry Richter is deputy research director, Population Services International, Washington, DC.
male condoms were surveyed in 1998, one year after a social marketing campaign had begun. Logistic regression analyses were conducted to assess factors associated with ever-use of the female condom and consistent use (always or often) with marital and regular nonmarital partners. RESULTS: Perceived ease of use and affordability of the product and prior use of the male condom were associated with men’s and women’s ever-use. Consistent use with marital partners was negatively associated with reporting multiple partners in the past year (odds ratio, 0.3) and positively associated with using the device for pregnancy prevention (5.4) and previously using the male condom (8.0). Consistent use with regular nonmarital partners was associated with numerous variables, including perceived ease of use (1.9) and effectiveness for STI prevention (3.8), low HIV risk perception (2.4), and use for pregnancy (2.9) and STI (2.3) prevention. CONCLUSIONS: Perceived affordability and ease of use may encourage couples to try the female condom but may not lead to consistent use. Because the reasons for use can vary between marital and nonmarital relationships, the female condom may need to be positioned differently for different target populations. International Family Planning Perspectives, 2005, 31(1):30–37
Because use of the female condom can be initiated by women, the device provides a way for women to protect themselves from sexually transmitted infections (STIs), including HIV infection.1 When used correctly, the female condom is as effective as the male condom in reducing HIV transmission;2 in addition, it can be inserted hours before intercourse,3 and it is therefore less likely than the male condom to reduce sexual spontaneity. In Zimbabwe, where the prevalence of HIV infection is high and male promiscuity is common,4 there has been considerable interest in the female condom. More than 30,000 women petitioned the government in the mid-1990s to make female condoms widely available, to give women greater protection against STIs.5 In a context in which it is considered improper for a woman to refuse to have sex with her husband, the female condom may provide an acceptable solution.6 In initial acceptability studies in Zimbabwe, virtually all women liked the female condom, as did most males; most women and men preferred the female condom to the male condom.7 Men liked the product because it does not interrupt the sexual act and it reduces their responsibility for protection. The factors that affect use and consistency of use in the general population are unclear, however. Several studies suggest that the female condom is most likely to be popular among married women, because it allows them to ini-
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tiate protection.8 Nevertheless, some studies have shown that use is lowest with regular partners9 and that users of the female condom are likely to have already used male condoms.10 Thus, increased use of the female condom may not necessarily lead to increased levels of protection against HIV infection or other STIs. Reasons given in acceptability research for discontinuing female-condom use include partner disapproval, difficulty using the product and unplanned pregnancy.11 The device is considerably more expensive than the male condom (which is often available free of charge); thus, cost may be another reason for discontinuation.12 On the other hand, the female condom provides protection against both pregnancy and STIs, and women can initiate its use. Peer support and other social support appear to stimulate use.13 Positive promotion, publicity and support from health care workers are believed to improve correct use.14 Our analysis uses data from an exit survey of 1,753 randomly selected consumers at retail outlets in urban Zimbabwe to examine factors associated with the likelihood that men and women had ever used the female condom and factors associated with consistency of use with marital and regular nonmarital partners. At the time of our survey, a social marketing program promoting and distributing the female condom had been conducted in urban areas of Zimbabwe for a little more than a year.
International Family Planning Perspectives
THE SOCIAL MARKETING PROGRAM In 1997, Population Services International (PSI) started social marketing subsidized female condoms in urban areas of Zimbabwe. The social marketing program was conducted on behalf of the National AIDS Coordination Program and the Zimbabwe National Family Planning Council as part of a larger social marketing program promoting and distributing the male condom.15 The social marketing program is funded by the U.S. Agency for International Development and the British Department for International Development. Before the female condom was introduced in Zimbabwe, market research had been conducted to obtain information on consumer perceptions of the product. The device was marketed—under the brand name care—as a “contraceptive sheath” instead of a condom to avoid the stigma associated with STI prevention. The image of the product was supported by the slogans “the care contraceptive sheath is for caring couples” and “for women and men who care.”16 The product’s image was promoted through an extensive mass media campaign that included radio, magazine and newspaper advertisements. In addition, the communication campaign provided information on how to use the device through question-and-answer magazine columns, a weekly 15-minute radio call-in show that allowed consumers to ask questions about the product, and a detailed brochure that was available wherever the product was sold. Given that care was marketed as a contraceptive instead of a disease-prevention product, the campaign targeted women in long-term relationships. Initially, care was sold only through selected pharmacies and clinics. Distribution has since expanded to other outlets, including large supermarkets, convenience stores, private doctors’ offices and clinics. Care is sold at a retail price of US$0.24 (Z$3 each) for a box of two condoms. At the time of our survey, female condoms were also provided free of charge at government hospitals, family planning clinics and other public health institutions in two districts in each of the country’s 10 provinces.17 At the onset of the program, PSI forecast sales of 4,000 female condoms per month,18 yet during the first four months of the program, 95,000 condoms were sold.19 Although this novelty use has since decreased, sales remain higher than expected: From July 1997, when the program was launched, to December 1997, 120,720 care condoms were sold; 119,650 were sold in 1998, 165,769 in 1999, 187,049 in 2000, 455,566 in 2001, and 683,700 in 2002.20
for this oversampling. We excluded from our analysis 13 respondents who had not had vaginal intercourse in the year before the survey, which reduced our working sample to 1,740.
Sample Selection The survey covers Harare, Bulawayo, Chitungwiza, Gweru, KweKwe, Mutare, Masvingo and several small towns. The study was also conducted in rural areas; however, because female condoms were sold only in urban areas, we restricted our analysis to residents of urban areas. Sampling was conducted in two stages. In the first stage, the retail outlets were selected. Four outlet types were included: pharmacies, supermarkets, other traditional outlets (e.g., small stores) and nontraditional outlets. Outlets were selected systematically from a list of all outlets that sell Protector Plus male condoms or the care female condom. Outlets without any female-condom sales in the past three months were excluded. Fieldwork hours for each region (Harare, Bulawayo, other urban) and outlet type were allocated proportional to the sales volume of care and Protector Plus condoms (based on PSI—Zimbabwe 1998 sales records).21 The consumers (potential respondents) were selected during the second stage. A screening questionnaire was used to determine whether consumers had ever used the female condom and, for those who had not, whether they had used a male condom in the past year. All consumers who had ever used the female condom were selected for the femalecondom sample. Among the remaining persons screened, one in 10 male-condom users and one in 10 individuals who had never used either the female condom or the male condom were systematically selected for interviewing. After the target sample sizes for the male-condom user and the condom-nonuser groups were reached, recruiting of and interviewing with female-condom users continued. Same-sex interviewers conducted the interviews, using separate questionnaires for users of the female condom, users of the male condom and condom nonusers. Interviewers worked in pairs and kept a tally of the number of consumers who were not screened (i.e., persons exiting the retail outlet while an interview was in progress). The data are weighted to correct for the oversampling of femalecondom users and for the differential sampling probability across outlet types.*
Measures METHODS
Aim of the Survey This analysis uses data from a survey of 1,753 male and female consumers in urban Zimbabwe visiting retail outlets that sell male or female condoms. The sampling methods were designed to obtain a sample representative of the population of consumers (who constitute the target population for social marketing condoms). However, because use of the female condom is low, users of the female condom were oversampled. Our analyses are weighted to correct
Volume 31, Number 1, March 2005
We use three variables to examine female-condom use. Everuse of the female condom is measured by a dummy variable that equals one if the respondent reported having used the female condom at least once in the 12 months before the *The first weight equals 10 for consumers who used the male condom (but not the female condom) and for condom nonusers. For the femalecondom users, the corresponding weight equals 273/492, to account for the fact that 219 female-condom users were interviewed after the interviewing and screening of the other two groups had stopped. The second weight equals the ratio of the total number of consumers to the number of screened consumers.
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Factors Associated with Female-Condom Use in Zimbabwe
TABLE 1. Unweighted and weighted percentage distributions of sexually experienced consumers at retail outlets (N=1,740), according to selected characteristics, urban Zimbabwe, 1998 Characteristic
Unweighted
Weighted
Study subsample Male-condom users Female-condom users Nonusers
36.6 28.3 35.2
46.8 2.3 50.9
Age-group 15–19 20–24 25–29 30–34 35–39 40–49
6.4 29.7 28.0 16.7 10.8 8.5
7.3 31.6 27.9 14.9 10.3 8.0
Gender Female Male
45.1 54.9
47.8 52.2
Education
