Lessons from a Female Condom Community Intervention Trial in Rural Kenya

The brief looks at what impact will a general distribution of the female condom have on Sexual Transmitted Infection (STI) rates in a rural area? The Familuy Health International conducted a community intervention trial and follow-up service delivery assessment in rural Kenya, collaborating with the University of Nairobi, Department of Medical Microbiology, and the Family Planning Association of Kenya.

The community intervention trial was conducted in six matched pairs of tea, coffee and flower plantations, each served by at least one primary health care clinic. Each matched pair comprised an intervention and a control area.

The study followed about 1,600 women, testing and treating them at baseline, six months and 12 months for three infections -- gonorrhea, chlamydia and trichomoniasis. "At both control and intervention plantations, about 24 percent of the women tested and treated had one or more of the three STIs at the beginning of the study. After 12 months, STI rates had declined to about 18 percent at both the intervention and control sites."

These results indicate that:

• Adding the female condom to the male condom distribution system did not contribute to any additional reductions in disease prevalence.
• At the same time, intensive male condom promotion and distribution were not sufficient to have an important impact on disease rates either.
• Reported female condom use was not sufficiently frequent to make a substantial difference in the overall number of protected sex acts in the intervention sites.

Also, providing female condoms did not result in more overall condoms distributed in intervention sites.

• At the end of the study, 58 percent of study participants in intervention sites reported that they had not used the female condom at all during the previous six months.

To assess why so few women used the female condom, researchers visited 16 of the 23 sites participating in the community trial, including a balance of high- and low-performing intervention and control sites. At each site, surveys were conducted with all available clinicians, outreach workers, recent family planning clients, and community key informants. Researchers also observed all family planning service delivery encounters in the clinic on the day of the visit.

A gap existed between clinicians' reported condom promotion activities and their observed behaviors. In 42 observed family planning visits, the woman in every case chose a hormonal method, but only once did a provider suggest a condom as a supplemental method for STI protection.

Despite this finding, 91 percent of providers interviewed said they had a major influence on whether clients used condoms. Many clinicians viewed the female condom as a feasible method only for single women and sex workers, not for women in stable unions. This provider opinion regarding appropriate female condom users may have contributed to inadequate interest on the part of clients.

Only one of 10 intervention site clinics distributed female condoms all 12 months of the trial as called for by the protocol. Despite the provider behaviors, outreach workers reported that clients viewed the female condom as an acceptable method, credited for being warmer, roomier, and stronger than the male condom.

Some women felt safer with the female condom because it was perceived as being less prone than the male condom to break. Further, women appreciated being able to insert the female condom themselves, avoiding the risk of men tampering with the device as was suspected with the male condom. At the same time, social norms and personal preferences appeared to limit true acceptability of the female condom and impede its introduction into sexual relationships.

"Community members expressed concern that the female condom may allow women too much freedom, enabling them to "move around" on their husbands. Some feared that intensified condom distribution might lead to increased prostitution."

With limited understanding of female anatomy, some users expressed fears that the female condom could "slip into the stomach," or get "lost inside the womb" or "stuck in the vagina." Others rumored it was laced with HIV or that the lubricant could cause infertility or produce infections. Some men worried that a woman could take semen captured in the female condom to a witch doctor and put a hex on the partner

The researchers concluded that:

• The availability of the female condom did not reduce STI rates, compared to the reductions achieved by distribution of the male condom alone.
• Female condom users generally liked the device, recognized its dual protection properties and appreciated its advantages over the male condom.
• Provider preconceptions may have resulted in limited opportunities for women to use the device.

Source: Family Health International website