| FC is an important technology that can play a vital part in reproductive health programs and needs to be introduced strategically to provide the greatest public health impact. Based on experiences from all over the world, the following key lessons have been learned about integrating FC into programs:
Identify and prioritize the target audience: In Brazil, which has seen FC female condom incorporated as a mainstream component of its sexual and reproductive health program, an extensive research study was carried out prior to introducing FC on a national level to determine acceptability and demand and to prioritize who the target audience would be and how they would be reached.
Ensure that there is an on-going and consistent supply:Experience from the field indicates that when programs lack sustainability and there is a disruption of supply, users become disgruntled and frustrated. It is therefore important to target distribution to ensure that FC users have the opportunity for an on-going, consistent supply.
Implement a comprehensive introductory outreach program and distribution strategy: A comprehensive introductory outreach program and distribution strategy should be developed at the same time as plans for the procurement of FC are initiated. A factor common to those countries that have launched and maintained successful FC programs has been the priority given to community work and the strong emphasis on educational work in health units. A study in Tanzania of the effect of mass media on intentions to use FC indicated that although mass media can be a useful tool to increase awareness of FC, peer educators and service providers have a stronger impact on a particular individual's motivation to use FC. Research from Zimbabwe and Brazil showed that those most likely to use and continue to use FC were those with accesses to community outreach programs. Findings from an acceptability study in India in 2003 indicated that over 75% of respondents in Andrah Pradesh and Maharastra consulted the outreach worker with questions about insertion of FC. In a study amongst attendees at an STD clinic in Alabama, clients were given the opportunity to practice FC insertion under guidance of a nurse. Reported difficulties with insertion decreased from 25% to 3% after women practiced inserting FC. This signifies the importance of communication and educational support in promoting FC use. FC is not simply a product, but a program.
Address Service Provider bias: Service providers may have a bias against barrier methods and FC research from around the world emphasizes the importance of the health care delivery system and the role that service providers, clinicians and peer educators play in successful FC programs. Growing evidence points not only to the positive role that health care providers can play in promoting the use of FC but how their own biases against barrier methods can marginalize and undermine FC programs. It is crucial that providers receive training as well as information and support about FC, so that they in turn feel confident and comfortable in promoting it to their clients. This is an effective means of increasing correct and continued use.
Target and involve men as well as women: It is important to target and involve men as well as women in the introduction of FC. In many regions of the world, men still maintain the dominant role in sexual decision making, including those decisions relating to contraception and disease prevention. Women may not be in a position to insist their partner uses a condom even where they suspect him of infidelity. It is therefore imperative that men are included in FC programs as studies indicate that in most cases, FC use requires the communication and co-operation of a woman's partner. Attitudes of men are generally positive towards FC. Men's willingness to use FC may even enhance its acceptability to women. This was a finding from the recent "1 FC - 1 Euro" campaign run in pharmacies in France. Data suggests that women will not use FC if they think their partners won't or don't like the method.
If there is any indication that stigma is attached to FC use, it must be addressed. Commercial sex workers (CSWs) in Togo said that one of the misconceptions surrounding FC was that men thought that FC use by women was a sign of promiscuity or being HIV positive. SWAA Ghana (Society for Women and AIDS in Africa) attained a 40% male involvement in their FC promotion campaign and reported that men felt comfortable purchasing the female condom at advocacy meetings and training workshops. Indeed following the launch of FC in Ghana, men were purchasing more female condoms than women. Including NGO's and CBO's in designing and implementing programs helps to address and overcome issues of stigma and assist in gaining male involvement.
Practice makes perfect: There is a need to provide samples of the product and good education on correct use of FC. One of the important lessons drawn from FC programs around the world is that FC becomes easier to use with practice. It is recommended that women try FC up to 3 times before they make a decision to discontinue using it. Reports from Brazil, India, USA and Zimbabwe indicate that whilst some users may find FC problematic to use initially, with subsequent use, these problems decline. Again, it is important that users have access to educational materials as well as a service provider/ outreach worker who can address any problems that may arise in the initial periods of use. FC use is not complicated so it is important not to over complicate its introduction. Additionally, FC training should incorporate education on anatomy, which may be poor, as well as include strategies for negotiation of FC use.FC is a dual protection device. In Zimbabwe and Nigeria, FC Programs have positioned FC as a contraceptive rather than a disease prevention method for HIV/STIs. In Zimbabwe, FC is branded as "Care, the contraceptive sheath". This may potentially eliminate any stigma which can be attached to both male and female condoms. Additionally, women may not feel comfortable discussing disease prevention with their partners.
Integration into Existing Programs: Program managers should consider the broader reproductive health needs of potential users; the services and technologies currently available; the current capability of the health service delivery system; and the social, political and cultural environments. When developing FC promotion & distribution strategies it is essential that well planned strategies are developed to integrate FC female condom into a country's contraceptive method mix. Different strategies and approaches may be needed to integrate FC for both family planning and disease prevention programs. It is particularly useful to analyze how male condoms are distributed and promoted to the proposed target groups. Consider whether or not FC should be included in this existing system. UNAIDS strongly advocates the importance of integrating FC into existing male condom programs. This integration is cost-effective, practical and impactful.The following list includes examples of projects where FC can be integrated:
- Community based distribution of male condoms and contraceptives
- STI Clinic Services
- Family Planning Clinic Services
- HIV/AIDS/STI Prevention programs with vulnerable populations
- Adolescent reproductive health programs
- Social marketing
- Peer education programs
- Male motivation programs
Monitoring and Evaluation of Programs:In some countries, there is an initial interest in FC which may be the novelty demand associated with all new products. In other countries, acceptability and demand for FC is demonstrated by increased volumes of FC distribution over time. The Brazilian National AIDS Program now distributes nearly 4 million FCs per year. All FC programs should include a monitoring and evaluation component. This is essential to identify what factors contribute to successful FC programs as well as isolating reasons for low uptake. In Ghana, a misconception that FC was for educated women only was addressed by publishing IEC materials in a range of local languages. In Zimbabwe, the need for more interpersonal communications was identified at an early stage of FC programming. Monitoring and evaluation systems also can indicate the actual use of FC over time.
Partnership, co-ordination and collaboration:A broad range of stakeholders is critical to the sustainability of FC programs. Widespread promotion of FC ensures that the product is not stigmatized as a free hand out for those who engage in high risk behavior and normalizes the device as a potential contraceptive and disease prevention method for all sexually active women and men. The support of Governments and organizations from both the public and private sector is essential to develop and sustain large scale FC programs.
Cost Effectiveness of FC:The cost of FC is often cited as a major barrier to making it accessible to greater numbers of women. However, research studies have indicated that there are more protected sexual acts when FC is available, and that the introduction of FC is not only cost effective, but cost saving in averting treatment costs related to HIV and STDs.
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