African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 7, Num. 3, 2003, pp. 101-116

African Journal of Reproductive Health, Vol. 7, No. 3, December, 2003, pp. 101-116

The Female Condom: Acceptability and Perception among Rural Women in Zimbabwe

Le condom féminin: acceptabilité et perception chez les femmes rurales au Zimbabwe

Monica Francis-Chizororo¹ and Neddy Rita Natshalaga^1,2

¹Research Fellows, Institute of Development Studies, University of Zimbabwe. ²Ph.D. student, Syracuse University
Correspondence: Monica Francis-Chizororo, Institute of Development Studies, University of Zimbabwe, P.O. Box MP 167, Mount Pleasant, Harare, Zimbabwe. Tel: 263-4333341/3 Fax: 263-4-333345 E-mail: jmchiz@africaonline.co.zw

Code Number: rh03044

Abstract

This study was conducted to generate data for developing an action plan for accessing the female condom through primary health care centres in Zimbabwe. It used both quantitative and qualitative methods to gather information from sexually active women and men on the perception and acceptability of the female condom among users in rural areas of Zimbabwe. The findings show that very few women had used the female condom prior to the survey. Several women (93%) liked the condom especially young women aged 20-39 years (83%), compared to older women aged 40 years and above (11%). Both women and men liked the dual role of contraception and protection against STIs including HIV/AIDS played by the female condom. Most women (98%) felt that it is important for women to have their own condom. However, both men and women pointed out that it will be difficult to introduce the female condom in married situations due to the stigma associated with condoms in general. Over 80% of women said they will have to seek permission from their partners to use the female condom. Women had problems with inserting the condom and were concerned with lubrication, size and appearance, and how to dispose of used condom. Regarding cost, 77% felt that the female condom is too expensive given that the male condom can be obtained free from health centres. The cost of the female condom could hinder its continued use and would encourage women, especially commercial sex workers, to re-use it. Respondents still require more information relating to side effects (45%), effectiveness in STIs prevention including HIV/AIDS (44%), proper use (43%) and cost (32%). (Afr J Reprod Health 2003; 7 [3]: 101-116 )

Résumé

Le condom féminin: acceptabilité et perception chez les femmes rurales au Zimbabwe. Cette étude a été mené pour produire des donnés en vue de développer un plan d'action qui permettra d'aborder le condom féminin à travers des centres de services médicaux primaires au Zimbabwé. Ile se servi des méthodes quantitatives et qualitatives pour recueillir les informations de la part des femmes et des hommes sexuellement actif sur la perception et l'acceptabilité du condom féminin chez les usagers dans les régions rurales du Zimbabwe. Les résultats ont montré que très peu de femmes avaient utilisé le condom féminin avant l'enqûete. Beaucoup de femmes (93%), sourtout les jeunes femmes (âgé de 29-39 ans (83%) ont beaucoup aimé le condom, par rapport à des femmes âgés de 40 ans et plus (11%). Et les femmes et les hommes ont aimé le double rôle de la contraception et de protection contre les MSTs y compris le VIH/SIDA joué par le condom féminin. La plupart des femmes (98%) estiment qu'il est nécessaire que les femmes possèdent leur propre condom. Pourtant, et les hommes et les femmes ont affirmé qu'il sera difficile d'introduire le condom féminin dans des situations de mariage à cause du stigmate lié aux condoms en général. Plus de 80% des femmes ont déclaré qu'elles demanderaient la permission de leurs conjoints pour utiliser le condom féminin. Les jeunes avaient des difficultés à inserrer le condom et elle se préoccupaient de la lubrication, de la taille et de l'apparence et comment se débarrasser du condom utilisé. Pour ce qui du coût, 77% ont estimé que le condom féminin est trop cher étant donné qu'on peut obtenir gratuitement le condom masculin dans des centres médico-social. Le coût du condom féminin peut entraver son usage continu et encouragerait les femmes surtout les prostitutées, à le ré-uliliser. Les interviewé ont encore besoin de renseignements supplementaires concernant les effets secondaires (45%), l'efficacité de la prévention des MSTs y compris le VIH/SIDA (44%), l'usage (43%) et le coût (32%). (Rev Afr Santé Reprod 2003; 7[3]: 101-116)

Key Words: Women, female condom, acceptability, perception, control, sex, HIV/AIDS

Introduction

Condom use is one of the major strategies aimed at curbing the spread of HIV/AIDS. However, in Africa, attempts to promote condom use have been faced with resistance from Christian and Muslim religions as well traditionalists.¹ Despite their role in family planning and in preventing the spread of sexually transmitted infections (STIs) including HIV/AIDS, condom use is associated with immorality and infidelity among men and women. In many situations condom use is within certain sexual relationships, particularly among commercial sex workers. For married couples or steady relation-ships condom use is almost non-existent, as it indicates lack of trust and/or the fact that someone wants to use a condom because s/he is already infected.^2,3

However, due to increasing rates of HIV/AIDS infection women all over the world, including Zimbabwe, have put requests for a device that they can use themselves to prevent being infected with STIs and HIV/AIDS. In most developing countries more women than men are affected by HIV/AIDS. Six of every ten HIV/AIDS infections are among women.⁴ According to the National AIDS Coordination Programme (NACP), women aged 15-19 years are six times more affected by HIV/AIDS than their male counterparts.⁵ It is therefore important for women to have a protective device that they can initiate and control particularly in situations where the male partner refuses to use the male condom. However, the extent to which the women will be able to achieve this depends on the involvement and attitude of the men in negotiating safe sex.

Promoting condom use has been a problem in many African cultures and traditional societies where marital norms are influenced by a strong patriarchal system that confers decision-making power on men and older family members.⁶ Men play the dominant role in decisions concerning the number of children a woman will bear and her use of family planning methods.⁷ As a consequence, it is difficult for women to refuse sex or demand protective measures such as male or female condom use even if they suspect their partners of infidelity. A study in Zimbabwe found that majority of women do not have assertive powers to make decisions on the use of condoms with their partners. In this study, men argued that they paid lobola (bride price), thus they should get maximum satisfaction from sexual intercourse.³ The problems have been exacerbated by the fact that the use of male condom is dependent on the willingness of the men. In another study, women reiterated that as they are economically dependent on their husbands/partners, they cannot make decisions that are contrary to their wishes.⁷ Therefore, women are forced to risk "biological deaths" from HIV/AIDS to avoid the "social death" and poverty due to divorce and abandonment.⁸

Zimbabwe is one of the first countries in Africa where the female condom has been marketed on a large scale. This is the successful outcome of a petition signed by 30,000 women, in which the women demanded that the female condom be made accessible and available to them⁹ and after an earlier study had shown that women, both in urban and rural areas, liked the female condom.¹⁰ In this study, almost all the women liked the female condom (97-100% for commercial sex workers, 95% for urban women and 100% for rural women). In addition, majority of the women claimed that their male partners preferred the female condom to the male condom (81-91% for commercial sex workers, 66% for urban women and 100% for rural women). The main question that however remains is on the long-term acceptability of the female condom among couples in most developing countries.

Evidence available shows that little research has been conducted on the female condom in Zimbabwe, and Africa as a whole.^11-13 Although the few studies conducted have shown that both women and men like the female condom, much still remains to be known about the device. Such factors as potential side effects, accessibility in terms of distances travelled to procure the contraceptive and costs can deter potential users from adopting the family planning method. As Rwabukwali¹⁴ stated, the image and perception of a given contraceptive method are important in the decision to use such a method. Furthermore, understanding cultural norms of female submission and passivity in sexual negotiation is important for the sustainable use of female condoms in Zimbabwe as well as other African countries.

Method

Design

Data were obtained for this survey using quantitative (individual interviews) and qualitative (focus group discussion) methods. During the quantitative survey a questionnaire was administered to sexually active women to collect information on their perception of the female condom, preferred sources of information and education about the device, cost preferences, as well as current levels and knowledge gaps regarding the female condom. The quantitative survey was carried out in two sages. The first stage was an enrolment questionnaire that was administered to women attending clinics. The enrolment questionnaire was designed to gather data on socio-demographic characteristics, sexual behaviour and pre-exposure knowledge about the female condom from respondents. The enrolment questionnaire was accompanied by the distribution of condoms. Seven condoms were given to each woman to use over a month, the enrolment survey period. However, the women could also come to collect more condoms during the period of the survey. After one month the same women were requested to come forward and complete the evaluation questionnaire, which was designed to gather data on use, perceptions and attitudes, needs and cost analysis regarding the female condom.

Sampling and Sample Size

Sampling involved selection of districts and health centres as well as individual women from the eight provinces in the country. Zimbabwe has basic hierarchical administrative boundaries, namely, the province, district, ward development committee (WARDCO) and the village development committee (VIDCO). Each province is divided into districts, districts into wards and wards are subdivided into VIDCO/Eas. In this study, districts and rural health centres were randomly selected using a probability proportionate to size sampling (PPS) procedure since the provinces do not have equal numbers of districts and health centres. A total of thirty rural health centres were selected.

Systematic random sampling was then used to select the women as they sought various health services at the clinic. The trained enumerators recruited every tenth woman who registered at the outpatients department, before they had consulted a health provider. Registration of a patient involves giving one's name, the physical address as well as paying a user fee if need be. After registration, an outpatient number is given to the health user. In this study, the respondent's outpatient number became her identity number. This, and not her name, appeared on both the enrolment and evaluation questionnaires for anonymity. Only women seeking health services were interviewed; those who had accompanied sick relatives or children were not part of the survey. The enumerators explained the purpose of the study to the study participants. They were in addition shown how to use the female condom. The interview was carried out after obtaining verbal consent from the women. Interviews were arranged and carried out at periods that were convenient to the respondent and in privacy to avoid embarrassing them.

Sample Size

Each health centre was supposed to interview 30 women, depending on the availability of clients. A total of 900 women were recruited during the enrolment stage. However, some women did not return to complete the evaluation questionnaire due to lack of time or interest, or could have left the area during the follow-up period. As a result such questionnaires were discarded because they were considered incomplete. Despite this limitation researchers were able to follow up about 95% of the original sample. Therefore, the final sample size had 700 women. The quantitative data was analysed using SPSSPC⁺.

Focus Group Discussions (FGDs)

The quantitative data was supplemented with information from six FGDs held with separate groups of female and male users of the female condom, who had not participated in the quantitative study. Whereas the survey presented individual attitudes and behaviours, the focus groups explored group norms and expected behaviours. Males were included in focus groups because they are also users of the female condom and mainly due to their influence on reproductive decisions. Therefore, it was important to get their views and feelings about the female condom for its sustainability. However, it would have been useful if the men were also part of the national quantitative survey. Nevertheless, the results presented here are a fair presentation of the problem under investigation. A total of 11 focus groups were conducted. The focus group discussions were conducted in December 1997 and January 1998 after a preliminary analysis of the quantitative data. This enabled the researchers to determine missing gaps and areas that needed further exploration from the quantitative preliminary findings. All focus groups were tape-recorded, translated to English and transcribed. Dt Search was used to analyse the focus group data.

The findings presented here should be interpreted with caution for several reasons. Reporting whether the women liked the female condom is highly susceptible to politeness bias, given that the female condoms were distributed freely. Data was collected from women seeking health services at the clinics only. Those who rely on other forms of health services (traditional and spiritual) were not included in the study sample. The results will emphasise data from the focus group discussions since it highlights the perception and attitudes towards the female condom in greater detail than the quantitative survey. Furthermore, the qualitative data sought to find out the influence of male's views regarding use of the female condom by women.

Socio-Demographic Characteristics of Respondents

The socio-demographic characteristics of respon- dents from the quantitative survey are shown in Table 1. About 53% were aged 15-19 years. Very few (11%) were over 40 years. The mean age of respondents was 29 years; the modal age group was 20-29 years, indicating that the respondents were relatively young women.

About 99% of the respondents had attended school. However, this figure is generally higher than the national level of education (90%) for women interviewed in the Zimbabwe Demographic and Health Survey (ZDHS) 1994.¹⁵ This difference could be due to differences in the methods used, or it could suggest a general improvement in literacy level among women. However, the chi-square test indicated a significant relationship between level of education and age (p < 0.001). The younger respondents were more likely to be more educated (67% of the women aged 20-29 had secondary education) than the older ones (42% of women aged 40 years and above had secondary education).

The educational standards of husbands/partners as given by women respondents was 23% primary level, 70.3% secondary level, 4.9% higher education level, and the remainder had never attended school. The results correspond with the 1994 ZDHS; that men are much more likely to reach secondary school (52%) than women (40%).¹⁵ This is not surprising given that women suffered discrimination during the colonial period when families opted to educate the boy-child as he was traditionally considered the bread winner.¹⁶

The survey collected information from women regarding their current occupation. About thirty two per cent of the women were engaged in subsistence farming and very few (17%) had professional jobs. Employment in professional jobs was more common among women with higher levels of education (80%), compared to a majority of women who were general hands (50%) with lower education levels. As given by respondents, the husbands'/partners' occupations were 29% general hands, 39% professional, 21.1% skilled, 3.8% farming and 6.7% self-employed.

About three quarters of the women interviewed had between one and four children. The upper figure of four was just below the national total fertility rate (TFR) of 4.39. The fact that most women have small families could be partly a result of the relatively young average age of the women that were interviewed.

Contraceptive Use, Condom Knowledge and Current Use

This section found out if respondents were aware of different methods of family planning and whether or not they used any method. Ever-use of contraceptive methods was reported by 78.4% of respondents, while 79% stated that they discussed family planning with their husbands/partners. Of the women current contraceptive users, the pill was the most commonly used (46.4%), followed by injectable (27.3%), the male condom (17.8%), and others such as traditional and withdrawal (8.4%).

The study sought to find out if respondents had ever used condoms before and whether consistently or inconsistently. We felt that if a person had used condoms before, she was likely to use the female condom. About 76% of the women stated that they had ever used the condom prior to the study. Of these, an overwhelming majority (98.1%) used the male condom, 0.8% female condom and the remaining 1.1% used both. Over half (52.4%) of the women who had used condoms before were inconsistent users. Several reasons were given for using the condom inconsistently. Most women (53%) stated that it depended on the male partner. In circumstances that use of male condoms depended on the men, women felt powerless to negotiate condom use during sexual intercourse. The result concurs with other studies reporting low and highly inconsistent condom use, even if the concerned couples recognised the need.^17-20

Despite the non-use of female condom prior to the survey, majority of respondents (71.2%) were aware of the existence of the female condom. When asked what they had heard about the female condom, about two thirds mentioned HIV/AIDS prevention, 57% said it is a device used to protect oneself against sexually transmitted diseases, and less than half (40%) mentioned new contraceptive method for women (Figure 1). The almost non-use of female condom suggested that the condom was not yet accessible and available to most potential users. Studies have found out that lack of access to services and information about available methods, how they work and their side effects discourage women and men from starting to use contraception.²¹ Further-more, cultural norms like control over female sexuality can effect contraceptive initiation.

Acceptability^b of the Female Condom

As indicated in an earlier paragraph, respondents were allocated female condoms after which they completed an evaluation questionnaire. Respondents were asked if they liked or disliked the female

condom after having used it. An overwhelming majority (93%) said they liked it. Cross-tabulations showed that there were no significant differences between condom acceptability and background characteristics of respondents except for age. Young women aged 20-29 years (47%) liked the condom more than the older women aged 40 years and above (11%). These findings concur with recent findings among Zimbabwean women where over 90% said they liked the female condom.¹⁰ Studies carried out with small numbers of women and couples indicated that many women and men liked the female condom and they preferred it to the male condom.¹⁷

Respondents were asked to specify what they liked about the female condom and their responses were more linked to sexual satisfaction rather than protection against STIs/HIV/AIDS or con-traception (Figure 2). The fact that the female condom can be inserted before sexual intercourse was more appealing to women users in the questionnaire survey. Women in the focus group discussions reinforced these factors regarding the extent to which they like the female condom. The dual role played by the female condom was greatly appreciated by both women and men in the focus groups. The most common statement from women participants was:

I like the female condom because it can serve for two purposes, that is family planning and protection against STIs.

Commenting on why they like the female condom during a focus group discussion, a 24-year-old single mother stated:I like the female condom because some men do not want to use their own condom (male). They say to you, "I do not eat a sweet in its wrapper. If I use a condom it's as good as masturbating". Therefore, I really feel protected with this new device because I will decide when to use it.

Issues of choice, power and control were also major reasons mentioned by the women for liking the device, as highlighted in the following segments from different focus group discussions:

It's a good idea because if men are drunk and cannot wear their own condom, I am at least able to protect myself with the female condom. (commercial sex worker)

The female condom is good in that if the male partner does not want to put on the condom, you can use your own. This is because most men insist that they cannot use the condom if they are going to pay. If it happens that such men are infected, you end up being infected as well. (Female respondent, Birchenough Bridge)

It gives us choice. We feel empowered to have our own condom. (Primary school teacher)

The male focus group participants liked the female condom because of the sexual pleasure it offers, particularly because it is not too tight and due to the arousal offered by the rings. The most common statement was that:

… we like it. Unlike the male condom, this new device is not too tight.

For example, the female condom was said to provide warmth and, unlike the male condom, it does not require a certain degree of sexual preparedness (erect penis). Furthermore, male participants appreciated the dual role played by the female condom and the fact that they no longer worry since the woman can use her own condom if the man does not have. Below are some highlights from male participants on what they liked about the care contraceptive sheath:

I felt happy because there was no need for me to put the male condom … Sometimes you are forced to remove the condom during intercourse because it is too tight, and you end up contracting STIs.

For us males, the female condom serves two purposes: when you are with a girlfriend it's both a contraceptive measure and a preventive measure against STIs/HIV/AIDS. You can never trust girlfriends. They can fall pregnant when you least want them to do so.

Although male participants indicated that they liked the idea of shifting the responsibility to wear condom to the women, they felt threatened by the women's control over their own sexuality. The men were worried that availability of the female condom will encourage women to engage in promiscuous activities. The women participants also reiterated that men are caught in-between, they like the female condom but they fear their loss of power, as two women commented:

The men are not happy. The men like us to use the female condom. But they also have a strong desire to control us.

They (men) do not want us to have a chance to decide about when to use the condom. They feel that the female condom empowers us and gives too much control over our own sexuality. They (men) should give us a chance since we want to use the female condom and we like it. These men need to be educated on this. (Married woman with a husband involved in extra-marital affairs)

The Dilemma of Female Condom Usage among Women

Although males and females liked the female condom, about 67% of respondents stated that they have to seek permission from their husbands/partners before they can use it. Qualitative data reinforced this factor. Many study participants spoke of the difficulty women, especially married women, will have in trying to introduce the female condom in the home or in long-term relationships. One married woman remarked:

If you are married you have no choice. No wonder why we are dying from AIDS and commercial sex workers are going on and look healthy. The sex workers can enforce the use of the condom to protect themselves.

Another married woman from a different focus group offered the same opinion:

Just like the male condom, the new female care contraceptive sheath was seen as a threat to intimacy and commitment in that requesting them would introduce an element of distrust and suspicion of infidelity and promiscuity.

Men think that the women will use the female condom for prostitution. This is because men first use condoms with prostitutes before they use them with their wives. As a result they always associate condoms with prostitution. (Female, aged 33 years and unemployed)

The idea of women, especially the married women, buying condoms over the counter was considered to be unheard of, and this was said to be influenced by society, which associate condoms with men as shown in the following segment:

It's difficult for married women to get the female condom. In fact you realise that in our African society it is unacceptable to see a married woman asking or looking for condoms. The husband would never want to hear that. (Female participant)

… each time a married woman, or even us the singles, want to buy a condom you have to consider what the people will think or say if you are seen purchasing the condom.

As mentioned earlier, the fact that decisions are generally made by men render the women powerless to enforce the use of condom, as one married woman summarised:The men always have the final say. As women we can only recommend the use of the female condom. But we cannot enforce its use. Not when you are married.

Several men said they would suspect their wives if they tried to introduce the female condom into the home. Such women are considered to be of loose morals, as reflected in the following comments:

My wife cannot request me to use a condom with her. I would not allow her rights or democracy to go beyond this.

It is good for women to have their own condoms. But bringing it home is a different issue. I would want to know where she got it and why she wants to use it. A girl I want to marry cannot ask me to use condoms whether male or female condom. I will definitely leave her because she is of loose character.

The men, as shown in the preceding dialogue, seem to use or have used the female condoms with girlfriends and rarely with their married partners.

Commercial sex workers who participated in the study re-affirmed this statement. To some extent the sex workers said they have the power to refuse unprotected sex to safeguard themselves from infections. This indicates the growing view that condoms are a requirement as a result of the threat of HIV/AIDS. One sex worker stated that one needs courage to refuse unprotected sex.

If you are a woman, tell the men that, "Look you are in my house and you have to do what I want. If you do not want to use the condom get away". He has to listen to what I say or he goes with no sex.

One commercial sex worker concerned said they have a slogan that says "Condom forward and sex later". However, the sex workers acknowledged that poverty and financial problems could force them to have unprotected sex. Consider the following remark from a commercial sex worker who participated in the FGDs:

Most men complain that condom affects sex and as a result they offer high prices for sex without condom. They may say they want to feel the extra heat. They say to us "I want it flesh" to enhance their physical and sexual pleasure. With the current economic hardships, we have no option but to succumb to the men's needs.

However, several young men and some married women said there are certain times when the female condom can be used in married situations, that is when a woman delivers, is menstruating, or for family planning. A good approach by the woman and a certain level of education and understanding by the male partner was required to introduce the female condom into the home as illustrated in the response below:

In married situations it is best to talk about the condom before bringing it into the house. The approach is also important. But it also depends on the husband's level of understanding … A number of men use condoms with commercial sex workers or their girlfriends. As a result they associate condoms with prostitution and would not want to see their wives being associated with condoms.

I have no problems if my wife brings this (referring to the female condom). But it will depend on how the condom comes into the house. I will not accept it if she is not trustworthy … In most cases it is the husband who has the final say regarding the use of the female condom.

Perceived Strengths and Weaknesses of the Female Condom

There were aspects of the female condom that raised interest and concern among focus group participants. These are to do with appearance and size, lubrication and the rings (both inner and outer rings) as well as insertion and disposal.

Rings

The female condom consists of two flexible polyurethane rings. The inner ring is at the closed end with internal rings. On the other hand, the outer ring forms the external edge of the device and remains outside the vagina after insertion. Since the use of female condom was unfamiliar to most respondents, the majority of focus group participants made negative comments about the inner and outer rings. They were not well-informed about the function of the rings and as a result the majority had misconceptions about their use. They felt that the inner ring was a main source of discomfort during intercourse particularly on the cervix.

The inner ring was painful when it touched my cervix. I was really hurt and I started bleeding. (Married woman)

Some participants said they had problems with the ring when they tried to insert the female condom. As a result the study found that some respondents removed the inner rings during sex. Some women were not sure if this was due to improper insertion or the force with which the man pushed inside during sex. Two young unmarried women had this to say:

It appears like there is a design with the inner rings. It is the one that gives us more problems because it's really difficult to get in the right place.

I do not know whether it's because the men exert too much force or it's me who had incorrectly inserted the female condom.

On a positive note, some men and women participants observed that the inner ring facilitated insertion. For most men the inner ring was a source of sexual satisfaction, a factor also acknowledged by the women as illustrated in the following comment:

With all the men I have had sex with, none have complained about the ring. In fact, some men feel that the inner ring is a source of exciting sensation during sexual intercourse. (Commercial sex worker)

The outer ring was said to be too big and loose. As a result, men sometimes penetrated by the side of the female condom. Furthermore, both men and married women complained that the outer ring prevents the men from fondling their private parts, but most commercial sex workers were not worried about this issue, as indicated in the following statement:

For us, sex is not for enjoyment, but for money. Therefore, whether or not my partner fondles my private parts, I do not care.

Focus group participants, especially women, expressed mixed feelings about the lubrication of female condom. For some women the lubricating gel made insertion easier and reduced noise made during intercourse. On the other hand, some respondents felt that the sheath's lubrication makes it slippery during insertion, that it is too messy and spoils hands and sex. There was fear that the lubricant would have side effects especially cervical complications.

When I told my husband that I was to participate in this discussion he said to me, "Tell them to reduce the amount of lubricant".

Several men did not like the lubricant; they said:

It's too warm and too slippery.

This is not surprising, given that most men prefer dry sex.¹⁰

Appearance and Size

Very few male participants did not like the appearance of the female condom. They stated that the condom looked funny and at first were not sure how it can be used, as one participant said with laughter:

I never thought it would work the first time I saw it. It really looked funny.

Several men appreciated the big size of the sheath because, unlike the male condom, the female condom is not tight, as noted in the following remark from a male participant:

… What makes us get STIs is that we are forced to take off the male condom during intercourse because it is too tight. The size of the female condom is ideal …

Some female participants were concerned that its big size can put off the men who will eventually refuse sex. Both males and females wanted the size of the female condom to be reduced. One community health worker was not sure if the condom is appropriate for young women who are virgins.

The condom cannot be used by virgins because it needs a wider opening. Therefore, young girls will not be protected by the female condom at first sexual intercourse.

Inserting the Female Condom

Although the women in the quantitative study indicated that they were shown how to insert the female condom at the beginning of the survey, several women had problems with this. Almost all the women and men complained about the difficulty experienced with inserting the female condom. Other women felt embarrassed to insert the female condom in the presence of their male partners. As a result some women asked their partners to look away or they inserted it in the private of the bathroom. Sex workers who participated in the group discussions said their nature of work discourages the use of female condoms because of the time it takes to insert. An excerpt from two commercial sex workers in a focus group discussion illustrates:

I do not think the female condom will be convenient for us given the fact that most of our activities are done hurriedly while on the other hand the condom needs time to put on.

To add to what my colleague had said, it is better to put the condom before you go to the bar. If someone picks you up and you want to have quick sex, "you won't have time to put the female condom on".

Several participants wanted more information on how to insert the female condom so that it does not move out of place during sexual intercourse and to prevent the men from penetrating by the side.

Re-Using the Female Condom

The survey indicated that an overwhelming majority of the respondents (91.1%) had never considered re-using the condom. This may be due to the fact that the women were supplied with free condoms and they could get more if they needed it during the study period. Only 2.6% from the quantitative survey indicated possibilities of re-using the female condom. However, almost all focus group participants stated that it is possible to re-use the female condom, as noted in the following extract:

Ah! (With a frown on the face) It's not possible to re-use this female condom.

Several women counter-argued:

Ah! It's very possible! You can re-use it. The female condom can be used three or four times with different people. It's very strong. You can wash it with soap and water, rinse it in warm water to kill germs, and then you can lubricate it.

In some cases where we have several partners a night, it means we have to change the condom every now and then. However, if you are drunk, it's very easy to re-use the condom. You simply forget to remove it. (Commercial sex worker)

Male focus group participants were also aware of the possibilities of the women re-using the female condom.

It's possible for women to re-use the female condom. But it's not good because it is as good as having sex without a condom. (Male respondent)

They devised means to avoid contracting STIs through re-used female condoms by providing the condoms themselves, as illustrated in the following statements:

It is possible to wash the condom. I advise other men to carry their own female condoms. Or you should ask her to open a new pack in front of you.

She cannot re-use it with men because I will provide her with my own female condom.

The findings concur with results from a study among commercial sex workers in Chiredzi, where re-use of female condoms was common among CSWs.²² In this study CSWs re-used the female condom because they found it difficult to insert and it was time-consuming to change the condom after every sex act. As a consequence, this prompted males in the study area to bring their own female condoms to CSWs for fear of infections.

Disposing of the Female Condom

This qualitative study revealed various ways through which users dispose the female condom. The methods used vary from burning, throwing it away in pit and/or Blair latrines and rubbish bins or pits, and flushing it down the toilet (for those households with flush toilets). As reflected in the following extract, disposal of female condom still remains a problem area:

We wrap it in a tissue and flush it down the toilet.

We burn it, but it is embarrassing to be seen burning the condom everyday.

However, you can pretend you are burning paper. For some of us who are known to work with condoms, the people will just say: "She is burning her things." (Commercial sex worker)

We throw away the used female condoms in the rubbish bin or pits because they would cause blockages in the flush toilet system.

In a separate interview, one community health worker summed up when she stated that:

There is need to improve on the method of disposal for the female condom. In some cases you find children having taken off the outer ring and they used them as bracelets, even some adults have used the ring as bracelet. Some children use the condoms as balloons and they can get diseases from this.

Cost of the Female Condom

The cost of any family planning method will determine its continued use or non-use. The study sought to find out respondents' feeling about the current cost of the female condom. At the time of the study, it cost Z$7.50 to bring the female condom to Zimbabwe. About two fifths of the women were not aware of the cost of the female condom. Although the cost price of the female condom was subsidised at Z$3.00 for a packet of two, over three quarters (76.5%) felt that the female condom was too expensive given that the majority of women are unemployed or are employed in low paying jobs. Focus group participants revealed that the cost of the female condom could be a strong factor that has a potential to hinder its continued use. Almost all the focus group participants raised the following question:

Why is the female condom being sold for such a high price when the male condom is being distributed free?

In spite of the high cost, about 69% of respondents and their male partners stated that they were willing to pay for the female condom. Of these, about half felt that it should cost less than Z$1.00 or its equivalent of the market price of the male condom. In addition, respondents were asked whether or not their male partners were willing to pay for the female condom. Approximately 40% of respondents' partners had not asked about their partner's willingness to pay. Of those that asked, very few (14%) of the respondents' male partners were not willing to buy the female condom. On the contrary, sex workers stated that it is very rare for men to provide the condoms because they (men) don't want to use the condoms. The commercial sex workers said the female condom is too expensive for their kind of business, as they will not be able to realise enough profits.

The female condom is expensive and these men don't want to provide us. For example, if the men pay $10 to have sex, it means that I get $7.00 after deducting $3.00, the cost of the female condom. My income actually falls.

Obtaining the Female Condom

One of the factors that will determine the sustain- ability of the female condom is its availability. In Zimbabwe, procurement and distribution of condoms is through the Zimbabwe National Family Planning Council (ZNFPC). Generally, condoms are available from places such as beer halls, clinics, private doctors, pharmacies and community-based distributors (CBD). The socially marketed condoms are obtained from retail shops and pharmacies. The later are usually beyond the reach of most potential users especially the unemployed. Respondents were asked where they think the female condom should be available. As Figure 3 shows, an overwhelming majority (82%) preferred to get the female condoms from the health centres, followed by ZNFPC clinics (38%). The health centres were most preferred because of the confidentiality and easy access associated with them and the fact that they would get the female condoms free. Related to this, most respondents (87%) preferred the nurse to provide information on family planning matters including the use of female condoms. But the long distances to clinics in rural areas have the potential to deter women from seeking the female condom. Some women, therefore, suggested that female condoms be made available to community health workers, as one married woman suggested:

The village worker has to be a decent married woman who is trusted and respected by the community.

Discussion and Conclusion

The findings of this study revealed that both women and men liked the female condom. Preference of the female condom was almost homogenous except for age. The younger women liked the female condom more than the older women. Studies have shown that young women who are sexually active use condoms to prevent pregnancy and STIs/HIV/AIDS.²³ Given the changing traditional beliefs regarding sexuality as a result of modernisation, if young women are empowered they will be able to negotiate safe sex through the use of female condoms. There is need for reproductive health programmes that target these young women to encourage sustainable use of the female condom. This will enable educated young women to plan their productive and reproductive goals without fear of having unplanned pregnancy and HIV/AIDS. However, the women and their male partners need to be educated on the importance of using the female condom consistently for greater effectiveness in curbing the spread of HIV/AIDS.

Both men and women expressed great concern over the structure of the female condom. They did not like its size and shape. Women were worried that the female condom is too long and will put off their male partners during intercourse. In addition, other men complained that they could not touch the women's private parts during foreplay. Unlike the male condom, the inner ring was regarded as the main source of pain and discomfort during sexual intercourse by most women. The women did not like the lubricating gel and were worried that it could cause cervical cancer. Furthermore, the female condom has problems that have to do with its mechanical device. For example, most women complained about not being able to insert it within a short time. In some cases men penetrated by the side of the condom, causing great pain to the woman. Potential users need to be equipped with skills on insertion and proper use. Although respondents liked the female condom, data from this study show that more information is needed regarding it. This is related to side effects of the lubricating gel, effectiveness in preventing STIs/HIV/AIDS, proper use, costs and methods of disposal, and re-use of the female condom. Therefore, reproductive health programmes need to provide more information about the female condom with its negative and positive aspects through information education and communication (IEC) channels.

The idea that women can now control condom use worried men who were suspicious that women can re-use one female condom with several male partners. Although a negligible percentage had re-used the female condom, both men and women were aware that it is possible to re-use it. Commercial sex workers stated clearly that the cost of the female condom is high and this would encourage them to use the condom several times by washing it and putting lubricating gel obtained from shops. In addition, the time taken to insert it is too long for commercial sex workers' kind of business especially when they have several partners at night. As a result, the males in this study encouraged each other to buy their own female condom, which the woman will open and insert in their presence if they have to engage in sex with the commercial sex worker. The preceding discussion clearly shows that women have the potential to re-use the female condom because of its high cost. Further research is required to determine the effect on the device if it is re-used through washing, and how effective it will be in preventing pregnancy and HIV/AIDS.

The study revealed that female condoms are extremely expensive and this has the potential to prevent their widespread use. At the time of the survey the female condom cost approximately three times the price of the male condom despite the fact that the two are already heavily subsidised. Given a situation where male condoms are available free at health centres, the women find it unfair to buy the female condom at such a high price, considering the fact that they are unemployed and have been economically disadvantaged in many ways. The Family Heath International²⁴ has also raised the same concern regarding affordability of female condoms especially among couples in developing countries. Further research is required in this area to find out whether or not it is cost-effective to subsidise the male or female condom.

The female condom gives women control over their sexuality. As discussed in a preceding paragraph, the need for family planning methods that women can control has become urgent in view of the spread of HIV/AIDS.^25-27 For most women the female condom has a dual purpose, protection against STIs and HIV/AIDS, and unwanted pregnancy. Although the women recognised the dual protection offered by the female condom, the fact that they liked it is linked to sexual satisfaction. They said it can be inserted before foreplay, a factor also stated by males during the focus group discussions.

Of major concern from the study was whether or not the female condom would be used by women in married situations, given the social stigma associated with condoms in general. Women, health workers and the men during focus groups clearly stated that it would be difficult for a married woman to introduce the female condom into the household. In addition, use of condoms in married situations implies extramarital relationships. Moreover, the low economic situation of most parts of Africa renders women powerless in negotiating safe sex. Focus group participants revealed that even if the female condom is made available, most women, particularly married women, will have to seek permission from the men before they use the condom. Ulin et al²⁸ reported that women in developing countries do not have the right to refuse sex without condoms and that men will always determine whether the married women will use the female condom or not. In this study, refusing sex without condom provoked anger or violence. This is consistent with other studies that have revealed that women's ability to negotiate safe sex may be limited by socio-cultural and economic factors relating to gender, class and power relations. Kisekka,²⁹ in a study of Baganda and Hausa people, observed that women had little or no bargaining power in sexuality issues because they were poor, ill-educated and economically dependent on their male sexual partners. Therefore, the role played by men in influencing decisions on reproduction cannot be ignored.^30,31 The challenge is therefore to educate couples, especially men, to accept the female condom and that it is just like any other family planning method. Involving men would encourage partners to talk to each other about sex. Further marketing of the female condom needs to emphasise the importance of the device as a contraceptive rather than protection against STIs including HIV/AIDS. This is likely to encourage men to accept the use of the female condom with their partners.

Acknowledgements

This study was funded by the National AIDS Control Program (NACP) through a grant provided by SIDA and UNAIDS. We are grateful to Ms Gotora and Cornelius Chikwama for assisting with focus groups. The views expressed here do not reflect those of NACP.

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^aThe results are part of a national study that was carried out in both urban and rural areas entitled "Piloting the Female Condom in Zimbabwe". The national sample comprised 1391 women drawn from 69 health centres.

^b Acceptability as used in reproductive health refers to an action whereby an individual consciously decides to initiate use of a particular contraceptive method, either by attending clinic, seeing a physician or obtaining the necessary supplies from existing sources (Mundigo A. Acceptability of Fertility Regulation Methods): Concepts and Research Needs. A division paper prepared for the Tanzania workshop on condom acceptability, Arusha, Tanzania, 27-30 October 1987.

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