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Schuyler, T. Masvawure, J. Smit, M. Beksinska, Z. Mabude, C. Ngoloyi, J. Partner negotiation and insertion difficulties are key barriers to female condom FC use in sub-Saharan Africa. Few FC interventions have provided comprehensive training in both negotiation and insertion skills, or focused on university students. Both groups received FCs. Two-thirds of women reported FC use. Women reported that FC insertion practice increased their confidence. FC educational and skills training can help facilitate use, improve attitudes toward the device and help women to successfully negotiate safer sex with partners.

Innovative strategies and tailored interventions are needed to increase widespread FC adoption. In its more than 30 years of existence, the female condom FC has been recognized as a safe and effective method for preventing human immunodeficiency virus HIVother sexually transmitted infection STIs and unintended pregnancy among diverse types of women in both high- and low-resource countries [ 1—11 ]. When compared to the MC, the FC is believed to offer a similar or greater amount of protection if used correctly and consistently [ 1516 ].

On a population level, research has suggested that access to FCs can decrease the of condom-unprotected sex acts, often through a combination of increased MC and FC usage [ 18—21 ]. However, proper insertion of the FC is crucial, and some women experience discomfort during sex if the FC is not positioned correctly [ 22—24 ].

In South Africa, a country where youth 15—24 years have high rates of HIV [ 25 ] and unplanned pregnancy [ 26 ], use of the FC remains low. In a population-based household survey of young people aged 18—24 years in four provinces, among women who reported to be currently using contraception, 5. In addition, the HSRC survey found that overall condom use declined from These data are a cause for concern, given the disproportionate risk of HIV among young women compared with that of young men in South Africa.

InHIV prevalence among to year-old women was Partner resistance often stems from lack of information or familiarity with the device, dislike of its physical features such as size, peer norms, perceived risk and self-efficacy [ 4Looking for casual sex Montgomery african women25—27 ].

In some parts of sub-Saharan Africa, women need to obtain permission from male partners to use an FC [ 2 ], and sexual communication with partners may be problematic [ 2930 ]. In South Africa, difficulty in negotiating use of prevention methods with male partners often reflects gendered power inequities within sexual relationships.

Imbalances related to sexual decision-making are believed to be a primary driver of unsafe sexual practices, rather than a lack of knowledge about disease risk or safer sexual behaviors [ 3132 ]. In sub-Saharan Africa, women frequently have less power than men due to prevailing gender norms and other gendered aspects of society, and thus may be unable to communicate with partners about sex or control their use of protective methods, and may be subjected to sexual violence and coercion [ 2293033—38 ].

This may be especially true for younger women, who are often in sexual relationships with older men and thus at increased risk of acquiring HIV [ 39—42 ]. In long-term sexual relationships, suggesting condom use may indicate lack of trust or infidelity by the partner making the request [ 3233364344 ].

ly, among sexually active youth in South Africa, about a third of those whose most recent sexual experience was with their main partner reported always using condoms, compared with more than half of those whose most recent partner was casual [ 4344 ]. In addition, youth in longer-term relationships may feel less concerned about disease prevention than pregnancy prevention, and rely on other forms of contraception than condoms [ 45 ].

It was also suggested that condom use may be perceived as a threat to emotional and physical closeness with partners. Thus, relationship dynamics within the broader gendered social environment can play an important role in FC use among women in South Africa. Difficulties with insertion have also been described as a major barrier to consistent and satisfactory FC use. Women have cited several common problems related to insertion, while also recognizing insertion-related benefits such as the ability to insert the FC long before sexual activity [ 51 ].

Insertion problems are found to decrease with practice [ 5052 ], but without supportive instruction may cause women to discontinue use. In addition, certain individual-level factors—including ambivalence toward FC benefits, having casual sexual partners, and having long fingernails—have been associated with FC insertion difficulties [ 50 ]. While the relationship between insertion difficulties and casual sexual partners is not fully understood, it may be due to increased pressure for sexual spontaneity and lack of partner support, whereas women with regular sexual partners may be more likely to plan for sex and discuss condom use with their partner [ 45 ].

The majority of national and international FC studies have employed quantitative methods. However, the complexities of sexual negotiation between couples and of FC insertion, as well as other contextual and structural factors associated with FC use, warrant a more in-depth understanding than can be achieved with quantitative measurement alone [ 105433—35 ].

Findings presented here are from the qualitative component of a larger study examining experiences with FC use among female university students following participation in an educational intervention, and specifically describe those related to partner negotiation and FC insertion.

We first describe the FC intervention trial and outcomes to provide a context for the qualitative study. The study was conducted between March and October with full-time female university students. Women were recruited by study team members who approached students on campus and informed them about the study. Those who were interested in participating were screened for eligibility. Eligibility criteria included aged 18 years or older; self-reported HIV-negative status; not being pregnant or not wanting to become pregnant in the next 9 months; self-reported condom-unprotected vaginal intercourse in the 2 months; capacity to complete informed consent and be interviewed; and willing to have the assessment and interventions audio-recorded.

Thus, university women considered to be high-risk were recruited into the intervention trial. First-year students were excluded due to high drop-out rates. Women deemed eligible to participate completed an informed consent and were scheduled for a baseline interview. It also incorporated a brief review of the female reproductive system and a demonstration of FC insertion on a pelvic model though participants did not practice on the model.

Both groups also addressed the potential for partner abuse and provided referral information, and all participants received FCs to practice and use with male partners. The efficacy of the two interventions in reducing the frequency of condom-unprotected intercourse among university students have been described elsewhere [ 55 ]. There were no ificant differences between intervention conditions—both groups reported ificant reductions in Looking for casual sex Montgomery african women condom-unprotected vaginal intercourse occasions, increased of FCs used, and increased odds of vaginal intercourse occasions protected by either a female or an MC from baseline to the 2.

Among the female students in the intervention, the average age was 20 years old and all participants were Black African. Participants reported some exposure to HIV risk. Women had an average of 2. Following participation in the intervention, 39 female participants 21 from MI group, 18 from EI group were randomly selected for in-depth interviews at 5 months post-intervention.

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In-depth interviews were also conducted with the primary male partner of each randomly selected participant, and were analysed in a companion study [ 56 ]. Interviews were held in a private room located on the university campus, and conducted by two Black African female nurses with clinical experience working with young people.

Coding and analyses of interviews were conducted using NVivo 9 by two researchers who employed the constant comparison method [ 57 ] to identify recurrent ideas or themes in the data. Inductive and deductive strategies were employed to compose a finalized codebook of 25 unique themes. This codebook was used to code all interview transcripts.

The current analysis is based on data that emerged from 11 codes which most pertained to FC use, partner negotiation and experiences with insertion. Following the coding of interview transcripts, a coding report for each theme was generated. Data regarding negotiation and insertion are examined here among women from both EI and MI groups collectively, as the two interventions were ly found to be similarly effective in increasing FC use among women and reducing condom-unprotected sex acts with partners [ 55 ].

It was also approved by Research Ethics Committees of two South African universities, including the site where the study was conducted. The 39 female university students who participated in in-depth interviews were representative of the intervention sample with regard to age and race—all women were Black African full-time students, with a mean age of 20 years.

The interview data from one participant were largely incomplete due to a recording error, and therefore excluded from the remainder of the analyses. Women initiated discussions with partners about using the FC at different time periods following participation Looking for casual sex Montgomery african women the intervention, ranging from 2 days to 3 months. Most women, however, reported initiating the discussion within one month of completing the intervention.

Many initiated the conversation by telling their partner about the intervention, or showing partners the FCs they received during the study. We were just talking and then I said, hey today I went to this workshop and they told us about the female condom…they want us to try it. Well I just placed Looking for casual sex Montgomery african women female condom on the table…and I just told him [what] we learned in the workshop. Only a few women, regardless of whether or not they used the FC with a sexual partner, reported that their partners were interested in and open to trying the FC following the initial discussion.

Others reported that partners were concerned about the presence and fit of the inner and outer rings, or were confused about the shape of the FC, or that their partners saw no need for the FC when the MC was available. According to the women, a few men were immediately and persistently reluctant. One woman described her partner as having decided against FC use before attempting to negotiate: He is not okay with it…he was talking about why they introduced the female condom because there is a male condom. He wasn't interested…because he didn't have the knowledge about it…he was asking me that what if it comes out and all that stuff.

Then, in that way he agreed to do it. I even taught him how to use [the FC] and everything…I showed him all the steps that we were showed in the workshop. I explained this is the female condom, it is used like this. You can put it in, take it out and hold [it], as I did. I knew what I was doing…cause we were told how to insert it…and we were shown but…I needed more practice. I was confident because we did it in the workshop and then the facilitator practice showed us so I was confident because I saw…when we practiced to do it.

When prompted by the interviewer, most women were able to correctly describe the FC insertion process step-by-step. Often this included difficulty correctly twisting the inner ring of the FC as is necessary to successfully insert the devicedue to its lubrication. Others noted difficulties related to pain or discomfort from the inner or outer ring, and problems getting the FC inserted fully.

It slips through the fingers, but I did practice it when we were trying and it come out okay.

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Usually, when we practiced, it was hard to hold on, [to] touch the ring…but then once you get that right, then it's just easy. They [the instructions] were [helpful] but not as helpful as the study…we saw exactly [how] everything [is] done. Some, however, reported using the instructions that came with the FC to help with insertion, sometimes reviewing them with a partner.

Additionally, a few women reported that their partners helped them during the insertion process e.

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Some women stated that it felt as if there was no condom at all. Several also noted that insertion of the FC was easier prior to sex, due to ly practicing insertion alone. This is one of the first studies of FC use among female university students in sub-Saharan Africa.

The majority of FC research and interventions in sub-Saharan Africa have been aimed at high-risk adult women [ 10 ].

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One study of male and female students at the University of Port Harcourt in Nigeria found that among sexually active students, most Our indicate that targeted training in FC use, which includes a focus on the development of skills related to partner negotiation and insertion, can facilitate usage among female university students and their partners. The study sample—young, Black African, university women with self-reported sexual risk—represents a population that could greatly benefit from enhanced use of the FC as a form of disease and pregnancy prevention.

Most women participating in our study were able to apply and transfer knowledge learned in the interventions to negotiate FC use successfully with their partners. Our study indicates that providing South African university women with tailored, one-on-one knowledge and skills development regarding use of a female-initiated HIV prevention tool can positively influence their ability to negotiate its use with sexual partners.

Women in our study reported feeling confident in their abilities to negotiate FC use with sexual partners following participation in the interventions, and many were able to overcome partner resistance and objections. Men in sub-Saharan Africa often hold more influence over sexual decision-making than women, and such gendered imbalances directly contribute to low condom use and lack of negotiation [ 33 ].

Many studies report that use of the FC may give women a greater sense of control and self-reliance in the protection of their bodies from disease and pregnancy, as well as more opportunities to negotiate and practice safer sex with a partner, leading to increased condom use [ 356810355960 ].

Our also emphasize the importance of guided and repeated practice in using the FC. The majority of women reported practicing FC insertion prior to use with a sexual partner, and many practiced multiple times before achieving success.

This has been ly noted in FC studies, which report that few women are able to master proper FC insertion techniques immediately, and that repeated practice following guided instruction can lead to decreased insertion difficulties and thus increased use [ 3435052 ]. Future FC programs should emphasize detailed, guided insertion instruction as a method of encouraging young women to practice using the device, as well as target gender equity and self-efficacy as the primary mechanisms by which behavioral change can successfully occur [ 31 ]. This can substantially contribute to the demystification of the FC which, in our study, occurred as a result of increased knowledge and self-efficacy.

For example, several young women used insertion of the FC as a method of negotiating use with partners. Women reported demonstrating or describing the process of insertion for their partner, in an attempt to quell any hesitation or concern regarding how the FC is used. Although this practice was not specifically described as a negotiation strategy during the interventions, it demonstrates that providing university-trained young women with education and training in FC use and negotiation can empower them to share knowledge with partners and apply their skills; this highlights the Looking for casual sex Montgomery african women as an acceptable and reliable prevention option.

Sexual behavior among youth can be influenced by a range of factors at the individual-level, as well as at the interpersonal- and environmental-levels [ 61 ]. Sexual risk behavior among youth in South Africa has been linked with poverty, unemployment, living in rural areas, and low levels of education [ 28616364 ]. Women in our study represent a well-educated population, and as per eligibility criteria, all reported condom-unprotected sex in the two months prior to the interventions.

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Most had a regular, main partner who was often older; the inherent risk in these relationship dynamics, including a lower propensity for condom use and a higher risk for HIV, may act against the protective benefit of being highly educated. In addition, some young men may perceive the FC as a threat to their sense of masculinity or as an indicator of infidelity [ 55 ], which could prevent young women from engaging in FC negotiation or use.

Thus, relationship and other socio-cultural factors likely play an important role in the potential for behavior change among this population, and future research should work to specifically assess these factors in relation to FC utilization.

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A few young women in our study noted that their partners assisted them during the FC insertion process, consistent with research in KwaZulu-Natal [ 67 ], and demonstrating the potential for young men to become involved in learning about and adopting the FC for regular use. In a companion analysis among the male partners of young women in this study, young men were open to sharing the responsibility for using condoms with their partners, and several reported greater comfort, feelings of safety, and sexual pleasure when using the FC [ 55 ].

However, the important role that young men can and will play in the sustained use of female-initiated methods of prevention requires their active engagement and integration into each step of the prevention pathway [ 122668 ].

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Our study is not without limitations. The qualitative data collected were based on self-reported attitudes and behaviors, and therefore may be subject to social desirability bias.

Looking for casual sex Montgomery african women

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Psychosocial Correlates of Unprotected Sex Without Disclosure of HIV-Positivity among African-American, Latino, and White Men Who Have Sex with Men and Women