ACCEPTABILITY RESEARCH STUDY ON FEMALE CONDOMS
IN INDIA

KEY FINDINGS

 

The FC female condom is a strong, soft, transparent polyurethane sheath inserted in the vagina before sexual intercourse, providing protection against both pregnancy and STIs including HIV/AIDS. It forms a barrier between the penis and the vagina, cervix and external genitalia. It is stronger than latex, odourless, causes no allergic reactions, and, unlike latex, may be used with both oil-based and water-based lubricants. It can be inserted prior to intercourse, is not dependent on the male erection, and does not require immediate withdrawal after ejaculation. With correct and consistent use, the female condom is as effective as other barrier methods and has no known side effects or risks [1] [2]

Extensive research of FC female Condom has demonstrated high acceptability for the device amongst women and men.  Women have been hit particularly hard by the HIV/AIDS pandemic, male-to-female transmission is estimated to be twice as high as female-to-male. More alarmingly the infection rate data shows most sexually transmitted HIV infections in females occur either inside marriage or in relationships that women believe to be monogamous (UNAIDS).   The FC female condom is the only female initiated option currently available and the only new HIV prevention technology created since the advent of the HIV pandemic.

FHC, the sole manufacturer of the FC female condom and HLL has forged a partnership to bring this technology to India and to support current efforts to prevent HIV and address gender vulnerability in India. As an initial stage of this strategic plan an acceptability study was conducted in 3 states of India with high HIV prevalence rates -Andhra Pradesh, Kerala and Maharashtra amongst 3 sets of target groups -  Commercial Sex Workers (CSWs), Men-who-have-Sex-with-Men (MSMs) and married couples.

The objective of the study was to introduce the female condom as an additional option to the male condom that would contribute to increasing protection against STDs and HIV infection among women and adolescent girls. The research study was conducted to assess the acceptability and feasibility of the Female condom in India and to strategize future marketing plans for its distribution and integration into sexual and reproductive health programmes. The study also looked into the scope of using the Female Condom as a spacing method for married couples. India with 28 NGOs facilitating in the completion of the research and conducting training and education activities.

The study was implemented in collaboration with Blackstone Market Facts India Pvt. Ltd. with support from selected NGOs in three states. During the acceptability study, Female Condoms were issued to the target audience for three months. Over the three-month period, sexual behaviour and usage patterns of Female Condoms were studied amongst the enrolled target audience.

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1.         RESEARCH DESIGN

In order to meet the objectives of the study, a combination of quantitative and qualitative techniques were used.  The research took place over three months and usage and product attributes were recorded before, during and after the study period at fortnightly intervals.

Quantitative: For the quantitative component of the study pre coded structured schedules were used.  These were filled in after face-to-face interviews with the specified target respondents. The tools included usage monitoring tools and pre and post usage questionnaires.

Qualitative: Focus group discussions (FGDs) and in-depth interviews, coupled with key informant/community member interactions were the main qualitative modes of enquiry for the study. A total of 20 FGDs were conducted with each FGD consisting of 6 – 8 respondents. Around 15 in-depth interviews were conducted as well as 4 – 5 mini FGDs across the categories.

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2.         TARGET RESPONDENTS

 The following groups were the target respondents for the study

• Commercial sex workers (both brothel based as well as roamers): In Maharashtra, 97.9% of CSWs worked out of brothels, whereas in Kerala, 77.4% of CSWs were street based and 17% home based. In AP, 72% of the respondents belonged to brothels and around 22% were street based workers.

 
• Men who have sex with men (MSM), as well as men who solicit clients for monetary remuneration (Male Sex Workers, MSWs)

 
•  Married women from selected eligible couples : A majority of the respondents were in the age group of 26 – 35 years (mean age 31.4 years). In terms of their level of education, 25% of the eligible women had completed only high school levels of education. 85% of the couples were using either male condoms or traditional methods (24%) to prevent or defer pregnancy.

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3.         STUDY CENTRES

The study was carried out in selected districts in the states of Kerala, Andhra Pradesh, and Maharashtra.

 

 

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4.         SAMPLE SIZE

It was proposed to recruit 250 respondents from each of the states. The table below details the number of participants recruited for all three categories for all three states:

 

(Sample selected was not random but as per the rapport of the NGOs with the target audience)

More than 400 CSWs were contacted at each study site, 372 willingly agreed to use FC. Out of the total CSWs enrolled, 337 continued consistent usage of FC female condom.

 Out of 225 eligible couples, who willingly enrolled for the study, 201 (89.3%) eligible couples continued using Female Condom consistently over the study period.

 Of 170 MSM contacted, 144 willingly enrolled for the study and 136 continued using Female Condom consistently over the three month period.

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FINDINGS OF THE STUDY

 

1.            TYPICAL PROFILE OF FC USERS

Of the 337 commercial sex workers studied during the research period 55.2% were primarily operating from organised as well as isolated brothels. 57.3% fell within the age group of 21 to 30 years, although in Kerala the majority were above 35 years of age. 50.8% of the sex workers were illiterate.

Among the 144 MSM respondents, 58.3% fell within the younger age group of 21-25 years. In terms of educational achievement, more than two-thirds (68.1%) had passed middle school.

38.3% of the 201 eligible married women fell within the 26-30 age group. 75.1% of the women had middle school or higher level education. 73.1 percent% also had one or two children. Criteria for married women to be chosen for the study included being currently married, not-pregnant, non-sterilized and living with their husband.

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2.            AWARENESS ABOUT FC AMONG USERS

Only 23.7 percent of the CSWs reported having heard of a female condom prior to the study. The awareness levels of the female condom were highest among MSM, almost half of whom said they knew of female condoms. While a high proportion of MSM in Maharashtra (74.5 percent) and Kerala (55 percent) were aware of it, in Andhra Pradesh knowledge about female condom was found to uncommon with 18% having heard of the female condom.

Less than a fifth of the eligible women had heard about female condom, and the majority had no knowledge of it at all.

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3.            ATTRIBUTES

Attributes Liked in FC : 

The primary attributes liked by the CSWs in the female condom were:

• it could be used with clients who refused to use a male condom (69%) or with clients who were drunk (57%). The FC female condom was primarily a contingency device for using with men who would not use the male condom, thus achieving additional protection rather than substituted acts.  Over the study period 30 to 50% of CSWs said that they used the condom without their client’s knowledge.

 
• its good lubrication (50% of CSWs)

 
• pleasure during sex while using FC (25%)

 
• enjoyment by some clients who liked the lubrication of a female condom (40%).

Among the MSM, the major components liked were:

• good lubrication (81%)

 
• the reliability of the device during sex (79%), the major concern among them being the tearing of the male condom during sex.

 
• 42% felt that FC was giving better protection than male condoms with the larger size of the device affording additional coverage

 
• 40% felt that they could use it with their partners/clients who refused to use male condoms

 
• sexual acts were more pleasurable to them as well as to their partners (around a third of respondents).

 

Among Eligible women the major components liked were:

• it could be used when their husband refused to use a male condom (half of the women)

 
• its good lubrication (40%)

 
• pleasure during sex while using FC (35%)

 
• increased sensation due to the condom (a fourth).

Attributes Disliked in FC:

Factors disliked in a female condom included its physical attributes. More than half of the respondents said that they did not like the hardness of the inner ring, followed by size of the condom, and the time and privacy required for insertion, not always available to commercial sex workers.

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4.         TRIAL PERIOD

 Ø   Novelty or experimentation was the primary reason for trying the FC initially among the target
      categories (67.7% of CSWs, 90.4 % of ECs).

 Ø   The majority of Sex workers used a female condom for those clients who refused to use male
       condoms (65%). Disease prevention was more important than contraception among the
       commercial sex workers in terms of prompting trial, followed by the feeling that it was a female
       controlled device.

 Ø   The majority of Female Condom users had been relying on some method of family planning prior to
        trying the Female Condom, primarily the male condom.

 Ø   More than 80% of the women had been using male condoms before first trying the Female Condom.

 Ø   The main reasons for FC use among MSMs was non reliability of male condoms (35%) and
       a desire for more lubrication (37%)/p>

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5.         CHARACTERISTICS OF USE

5.1     Consistency of Use of FC

Usage of some barrier method was consistently high over the study period with very few CSWs reporting sexual contact without any barrier method.   All MSM reported using FC at the baseline and that proportion remained extremely high with  94.3 percent still consistently using the female condom at the end of the eighth week. Strikingly male condom use also rose for MSM during the study period, with more than a three fold drop in unsafe sex over the three month period, reflective of condom programming that increases overall condom use, both male and female, through intensive education and support.

Similarly usage levels were very high throughout the study for eligible couples remaining close to 90%.

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5.2     Comfort Levels with Insertion

While a majority of the female commercial sex workers (80 percent) reported that they found insertion of the device straightforward, 57% of MSM reported difficulties.   However, comfort levels with insertion increased consistently over the weeks. The percentage of CSWs saying insertion was difficult dropped from 36 percent at baseline to nil after 8 weeks of usage of FC. Difficulties reported with insertion were mainly due to a lack of privacy o insert the condom, and most CSWs (75%) inserted the condom after their client arrived. Such proportions also decreased substantially over the weeks for MSM (46 to 32 percent) and eligible couples (59 to 21 percent). Most of the respondents became comfortable with insertion after practicing 2-3 times. A large majority (more than 80 percent) also consulted the outreach worker in cases where they had difficulties using the female condom; this consultation helped them resolve the difficulty, highlighting the critical role of outreach workers in the success of female condom programmes.  

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5.3     Perception of FC Users Regarding Efficacy, Reliability, and Ease of Use
          of Female Condom

The majority of respondents across the categories perceived the female condom to be more effective, reliable and strong (more than half) as compared to a male condom. This was a major response among all three categories.

However, with regards to ease of use of the female condom, a majority of respondents found it to be problematic and cumbersome to use especially in the initial period. All respondents said they had some difficulty with using the condom; the condom’s large size (45 percent); slippery nature (around 15 percent); time and privacy required for insertion (a fourth) – all these factors were cited as major reasons for saying the female condom was not easy to use. Most participants found that ease of use increased considerably after two insertions.

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5.4     Usage of Female Condom and Male Condom

Usage of some barrier method was consistently high over the weeks, with very few sex workers having sexual contact without any protective method. Usage of male as well as female condoms was very high.  Data indicates a consistent upward trend of male and female condom usage, moving from 94.3 percent at baseline to 100 percent at the end of the 5th fortnight, with more of the respondents using female than male condoms in the previous fortnight.

Usage of the female condom was consistently high over the weeks among all the categories, although it dropped from 94.1 percent to 89.5 percent at the end of the study period amongst Eligible Couples. The use of male condoms decreased from 94 % to 84% among the MSM during the study period, while the use of female condom remained consistently high.

Table 6.1 Use of male and female condoms

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5.5      Client Negotiations & Ability to Discuss and Convince Partners

Three variables in the negotiation of FC use were studied over the duration of the research. These were:

1. the frequency of discussions with client/partner regarding usage of the device
2. the ability to convince him to use the device
3. the ability to use the device without informing him at all.

Discussions with partners/clients over use of the female condom increased steadily over the study period.  At the outset of the study 13.7% of CSWs discussed use of the device with their partners/clients.  This figure had risen to 45.8% at the end of the monitoring phase.

 An important indicator of the better acceptability of the device as well as the effectiveness of training and counselling during the study period was the ability of the sex worker to convince their client/partner to use a female condom. This could only come from the enhanced negotiation skills of the respondent. The chart below shows the proportion of those saying they were able to convince their partner to use a female condom increasing from 10.9% at baseline to 57.6% at the end of the monitoring phase. The proportion of sex workers who were never able to convince the clients to use the device decreased to nil over the study period, illustrating the success of the educational programme and enhanced communication skills of the sex workers.

The female condom takes more time and effort to insert before intercourse and it is difficult to use it without informing the client/partner. Very few commercial sex workers were able to use it without informing their clients.  The proportion of those saying they could use it without informing their clients remained very low throughout the study period.

Table 6.2: Negotiation of FC Use with Partner

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5.6     Willingness to Continue Use

Participants were asked if they would continue to use female condoms after the end of the trial if they were available:

• 94% of CSWs said that they would continue to use the condom in future and 37% of them would use it on all occasions

 
• 89% of CSWs liked it at the end of the study period

 
• 80% of MSM had an intention to use FC in the future with 57% wanting to use it in all sexual encounters

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5.7  Affordability and Willingness to Pay for FC

When asked about the maximum price they were willing to pay for a female condom, the majority of CSWs were only willing to pay upto Rs 5, although around a fifth were also ready to pay up to 10 rupees. Around 20% of the FC users in all the three categories said that they could not afford Female Condoms and wanted it distributed free of charge. Around 80% of the target audience agreed to pay upto Rs 2.00 per pc. and 47% were willing to pay upto Rs. 5.00.

Very few were willing to pay a higher amount. The majority of respondents also said it would be difficult to get the clients to pay for the device.

Some sex workers also mentioned being paid higher for using a female condom, primarily because the client had more pleasure using a female condom, and they did not like to use a male condom.

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5.8  Programmatic Strategies

A key finding was that usage and response varied across NGOs, target groups and states depending on the programmatic approach and attitudes of the providers and outreach workers. It was noted that usage increased and remained high where the product was presented in a positive way, supported by appropriate materials and potential problems with insertion were smoothed out by the outreach worker.

Another key finding was the significant support that outreach workers could offer to clients which resulted in increased condom use. Enabling clients to overcome insertion issues, using the educational materials to support usage and offering condoms in a non-judgemental environment helped increase condom use over the study period. The MSM group and CSWs both highlighted the importance of their interaction with the outreach workers and wanted to buy condoms from them in future.

The appropriateness and helpfulness of the educational materials was discussed. The CSWs said that the illustration of FC insertion was key and that they could share these diagrams with client. A pictorial representation of insertion was very important. The  MSM group, not surprisingly wanted appropriate and relevant educational materials for themselves and not representation of vaginal insertion. Additionally the EC group found the insertion pictures and the accompanying text to be useful.

Many participants mentioned the need for a private space to insert the condom and found that usage was more difficult in instances of unplanned sex.

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