Author(s): Precious Magumise and Elizabeth Kateta*
The advent of the female condom was hailed as an appropriate intervention measure against the spread of sexually transmitted infections and HIV. The female condom is an effective dual protective method viewed as a tool for woman’s empowerment, though the supply and uptake of this device are limited. This study determined and described the factors that have resulted in the low uptake of female condoms at Engela State Hospital among child- bearing age woman. A quantitative-descriptive research was used on the population of mothers utilizing health services at Engela clinic. Convenience sampling was used to select 52 respondents that participated in the study. Data was collected by means of questions and analysed by using Microsoft Excel 2016. The results showed that the factor leading to the low rate of female condom use was the absence of female condoms in hospitals and the community, rather than male condoms (80.8%) They are difficult to use (88.5%), married women are often powerless to request their partner to wear a condom (84.6%), women prefer the use of male condom than the female condom (88.5%), people are used to using male condom than the female condom (88.5%) and female condoms increase sexual pleasure (88.5%). It was concluded that in Engela State Hospital, a variety of factors influence the use of the Female Condom by women of reproductive age. Therefore, the Namibian government, through the Ministry of Health and Social Services, should implement intensive interventions such as the provision of Information Education and Communication materials and broad peer education. Moreover, The Namibian government, through the Ministry of Health, should study the findings of global research on the use of FCs and use these findings to build a strategic plan to guarantee that FCs are used effectively.
WHO, UNAIDS and UNICEF state that the mix of components tailored for different populations is the most effective approach to reduce HIV transmission and new data from biomedical studies have expanded the set of available prevention intervention, including preventing sexual transmission by promoting male and female condoms [1]. In developing countries, women are vulnerable to high incidents of HIV, sexually transmitted infections, and unplanned pregnancy. While the unplanned pregnancy can be prevented through the consistent use of contraceptives such as the pill, the same cannot be said for HIV and other sexually transmitted. The advent of the female condom was hailed as an appropriate intervention measure against the spread of sexually transmitted infections and HIV. The female condom is an effective dual protective method viewed as a tool for woman's empowerment, though the supply and uptake of this device are limited. According to WHO/UNFPA, the female condom has the potential to decrease STI statistics as the only female initiated dual protection device that is believed to be effective at preventing STIs and pregnancy [2]. However, the uptake of new contraceptive method is influenced by a nexus of cultural factors, socioeconomic and individual. Studies of knowledge, attitudes, practices, and behaviors on female condom across developing countries, have revealed that there is need to identify trends and themes on the usage of this device.
Low acceptability was noted in studies conducted in diverse settings among female condom users, though in instances where such condoms are preferred over the male condom. The introduction of the female condom has been shown to increase the proportion of protected sexual activities. The female conducts have also provided couples with additional choices of engaging in safe sexual acts. However, in Namibia it was observed that there is a low uptake of the female condoms. We identified a large number of method attributes and contextual factors influencing FC use/nonuse, most of which were perceived both positively and negatively by different groups and between settings. In a number of cases, the most pervasive factor preventing the initial and continued use of the female condom, has been the attitudesand objection of the male partners. In Namibia, such a situation is mostly acute among women of child bearing age and post-natal mothers. However, most problems surrounding the use of female condoms could be mitigated by practice and adequate support to women of child bearing age. The findings of various studies reveal that contextual factors can positively and negatively influence demand and use of female condoms at a local level. Crucially, access to counseling programs to the initial female users and adopters could play an important role in successful introduction and use of the female condoms especially in developing countries like Namibia.
The burden of HIV is usually borne by women resulting from various cultural, socioeconomic, physiological and political factors such as unequal gender norms which have an impact on sexual negotiation between men and women. Young women are especially vulnerable and they account for a disproportionately 64% of young people living with HIV globally [2]. In many developing countries such as Namibia, men play a dominant role in sexual acts with women fulfilling a subservient role. Over one-third of pregnancies in developing countries is unplanned thereby necessitating the need for contraception that put women in charge of their bodies [2]. It is priority that the female condoms seek to fulfill. However, the female condom is the most only available woman-initiated method for preventing HIV/sexually transmitted infections and unplanned pregnancy even through there are female condoms. Of importance is that the female condom has comparable dual protective efficacy to male condoms.
It is against this background that this incumbent study sought to investigate that factors contribute to low uptake of female condoms among women of child bearing age and post-natal mothers using the case of Engela State Hospital.
The government of Namibia provides condoms both male and female as one of the measures for reducing the spread of HIV, SITs and a family planning method to avoid unintended and unplanned pregnancies, but it seems that the use rate of female condoms by women of childbearing age is still lower than that of male condoms [3].
The research report stated that limited understanding of female condoms, lack of skills in use, and difficulty in obtaining female condoms have led to low use of the device [4]. In some of the tribes in Namibia, they believe that use of condom is considered as immoral and deviant. Women believe that the choice of condom use is for men and condom use is against their norms.
During the clinical internship at Engel State Hospital, the researcher observed that most patients took male condoms instead of female condoms. The female condom box was always full, and the male condom is always empty and always replaced, which indicates that the use rate of female condoms is very low. Despite the availability of female condoms at the hospital and health education being rendered by midwives on the effectiveness of the device, there is low use, thus, the need to determine factors that contribute to low uptake of female condoms among child- bearing woman at Engela State Hospital.
• What are the factors that contribute to low uptake of female condoms among post-natal mothers at Engela State Hospital?
To determine and describe the factors that have resulted in the low uptake of female condoms at Engela State Hospital among post-natal mothers.
• To identify factors that contribute to low uptake of female condoms among child-bearing woman at Engela State Hospital
• To identify ways that can improve on the uptake of female condoms.
According to Burns and Grove quantitative research is a formal, objective, systematic process in which numerical data are utilised to describe information about the phenomenon. Added to that, Polit et al state that quantitative measurement refers to the assignment of numerical values to objects to represent the kind or number of characteristics of those objects or events [5]. This research method is used to describe variables and determine the interactions between variables. Creswell states that quantitative research is “an enquiry into a social or human problem, based on testing a theory composed of variables, measured with numbers, and analyzed with statistical procedures, in order to determine whether the predictive generalizations of the theory hold true [6]. The study used a quantitative-descriptive research design. The use of the descriptive research design involved describing the behavior of the problem under study without influencing it in any way, and the use of quantitative research enabled gathering of observable data to answer a research question using statistical, computational, or mathematical techniques.
A population refers to the entire group of persons or objects that is of interest to the researcher, in other words, that meets the criteria that the researcher is interested in studying [7]. For the purposes of this study, the target population consisted of women of child bearing age attending health services at Engela clinic. According to the medical register between 20 to 30 women attained health services at the clinic. This implies that between 600-900 mothers utilize health services at Engela clinic. Thus, the population of the study
Researchers can often not study whole populations due to time and cost constraints. Thus, a portion or sample of that population is subjected to research. For the purpose of this study, the researcher will use convenience sampling to select respondents. According to, Brink, Van de Walt and Van Rensburg [8]. convenience sampling is also referred to accidental or availability sampling involves the choice of readily available participants. This is the best way of choosing a sample in this type of study because the researcher can choose to distribute the questionnaire to the women of the child bearing age that were available at the time of the study.
The inclusion criteria were only women of child bearing age aged 18 years and above utilizing medical services at Engela clinic. They were able to freely patriciate in the study
The exclusion create was any mother below 18yaers old and above 49 years old.
A sample is a part or fraction of a whole or a subset of a larger set, selected by the researcher to participate in a research study [6].
When dealing with people, it can be defined as a set of respondents (people) selected from a larger population for the purpose of a survey. In this study, the sample size of the respondents is calculated using Raosoft sample size online calculator
Considering margin of error 10%,
Total population of 600 female students
Confidence level of 90%,
Response distribution is 50%
The sample size = 61 respondents
According to Johnson and Keehn the research setting is the location where the research takes place. The study will be conducted at Engela clinic. The clinic offers diagnosis or treatment of patients on an outpatient basis. It also offers immunisation for under-five year old. The clinic has a section of family planning services such as the collection of condoms both male and female condoms. The researcher easily accessed this clinic and it had female condoms in stock.
Research instruments are tools that a researcher uses to collect needed data for the research [9]. They comprise of questionnaires, interview guidelines and proceedings. In the case of this study, the questionnaire will be used as the main research instrument. Questionnaires are basically an instrument comprising of a classification of questions for the determination of getting together material from respondents [6]. According to Thomas & Silverman,a questionnaire contains relevant and carefully formulated questions, which enables the investigator to carefully analyse and make good conclusions [9]. The questionnaire is usually printed and is answered by a group of people.
The questionnaire was developed in line with the reviewed literature. The questionnaire was developed by the researcher and had closed ended questions not to all filling of unnecessary information/data. The instrument is in English the official language. It has two sections; One on demographic data and another one on factors contributing to low uptake of female condoms at at Engela State Hospital
According to Creswell a collection of data involves bringing together information and measuring it on variables of interest to the researcher [6]. It allows the researcher to answer set research questions and assess the results by making conclusions and recommendations. Primary data was collected directly from the selected female students. Data collection was done after obtaining ethical clearance, from the WHTC research ethical committee, MoHSS and Engela State Hospital administration, the researcher introduced herself to selected respondents. The researcher used a private room at Engela State Hospital in data collection. The sampled respondents were asked to sign the consent form. Data collection was done by the researcher. The researcher distributed the questionnaire to respondents. They were able to fill it for between 8-15minutes Data collection process commenced in February 2022 for three days at Engela clinic.
Weisberg states that criterion determines the level of accuracy of the instrument employed to conduct measurement and the acceptability levels of the indicators on the concept it is based on. In this case, the measurements will be employed to establish what this study intends to measure, that is, identifying the reasons for the low uptake of female condoms among post-natal mothers. Thus, internal validity was established by focusing on measuring instruments that enabled the procurement of the appropriate data as contributing to factors found.
This was established by conducting a pilot study to find out if there was indeed a low uptake of female condoms among childbearing age mothers at the study setting.
Reliability refers to the ways in which employed research instruments engender exact results when same conditions are used by a different researcher. The research tested if the research instrument used in the study enabled the obtaining of the reliable and veritable data.
Babbie and Mouton posit that the plan for data analysis in quantitative research is "to organise the description of observations in such a way that it becomes manageable [10]. Descriptions are balanced by analysis and lead to interpretation. The data that was obtained from this research was analysed using the Microsoft Excel 2016. Results of the study were presented in tables, charts and graphs for easy understanding. The researcher used the data with an aim of presenting the research findings in respect to the study problem.
According to Polit and Hungler ethics can be defined as “a system of moral values concerned with the degree to which research procedures adhere to professional, legal and social obligations [5].” In addition, Burns and Grove contend that when human beings are used as subjects, researchers should ensure that participants’ rights are observed and respected [11]. Research participants should be obtained permission before to respondents can participate in any study. Ethical issues considered during this study will include obtaining permission from the relevant authorities and the prospective respondents, respectively to conduct the research, anonymity, respect for human dignity, confidentiality, beneficence and justice.
The informed consent consists of three elements namely, the type of information required from the participant, the degree of understanding that the participant must have in order to give consent and the clarity that the participant have the right to either give nor refuse to give consent [8]. The researcher obtained permission to conduct the study from the Research Committee of Welwitchia Health Training Centre and the relevant authorities from the Ministry of Health as well as from the hospital manager Engela State Hospital. Each respondent was informed about the purpose, significance and benefits of the study, and the time required to complete the questionnaire. Further to that each respondent received a covering letter together with a questionnaire for completion.
Anonymity relates to keeping subjects nameless in relation to their participation in the study. In this study, the questionnaires were distributed to the respondents at Engela State Hospital by the researcher on pre-arranged data-collection day. An explanatory
covering letter accompanied each questionnaire. The respondents were assured that their names would not be disclosed and all information that was obtained would be treated in the greatest confidentiality at all times. In this study, anonymity also ensured in that no participant will be linked to the information on any completed questionnaire.
The process of ensuring confidentiality refers to the researcher’s responsibility to prevent all the data gathered during the study from being linked to individual participant [8]. Neither the respondents were able to gain access to the raw data of the research. For instance, upon receipt of the completed questionnaires from the respondents, these questionnaires were placed into sealed boxes, which were handled by the researcher only.
According to Brink, Van de Walt and Van Rensburg participants are autonomous and have the right to self-determination and individuals with decreased autonomy requires additional protection [8]. In terms of this principle, human beings are seen as autonomous, that implies the respondents have the right to self-determination. The researcher upheld the principle of selfdetermination by ensuring that each respondent had the right to decide voluntarily whether or not to participate in the research.
According to Brink, Van de Walt and Van Rensburg the principle of beneficence refers to the act of doing good, promoting good or doing what is best for the patient or participants [8]. On the issue of the freedom from harm, the study caused no physical harm to the respondents who took part in the study. Psychological discomfort resulted from the nature of the questions were minimized in this study especially the anticipated unwillingness of the respondents to expose their sexual activities.
This principle refers to the participant’s right to fair selection and treatment. The principle of justice includes the right to fair treatment and the right to privacy. The completed questionnaires were only accessible to the researcher. The respondents were treated equally irrespective of the nature of their knowledge of contraceptive and the reproductive information they already had. It was also explained that the information could help improve contraceptive health services and policies for women.
The findings analysis for the data collected is presented in this chapter. The first section presents descriptive information on respondent’s demographic characteristics, followed by factors contributing to low condom uptake among females. This study purposely determined and described the factors that have resulted in the low uptake of female condoms at Engela State Hospital among post-natal mothers. The respondents were given 61 questionnaires, however only 52 were filled out completely and used for analysis. This means that an 85 percent response rate was reached, on which the conclusions and recommendations are based. The response rate for this study is shown in Figure 1.
Figure 1: Response rate
The demographic information comprises of age, marital status, highest education level, religion, and ethnicity. The mentioned information is presented in table 4.1 on the following page.
| Variables | Frequency (%) | |
|---|---|---|
| Age group (years) | ||
| 18-19 | 1 | 1.9 |
| 20-29 | 22 | 42.3 |
| 30-39 | 18 | 34.6 |
| 40-49 | 11 | 21.2 |
| Marital status | ||
| Single | 37 | 71.2 |
| Married | 9 | 17.3 |
| Widowed | 2 | 3.8 |
| Divorced/ separated | 4 | 7.7 |
| Highest education level | ||
| No formal education | 0 | 0.0 |
| Primary | 6 | 11.5 |
| Secondary | 33 | 63.5 |
| Tertiary | 13 | 25.0 |
| Religion | ||
| Christian | 51 | |
| Muslim | 1 | |
| Hindu | 0 | |
| Ethnicity | ||
| Oshiwambo | 42 | 80.8 |
| Damara/Nama | 3 | 5.8 |
| Coloured | 0 | 0.0 |
| Kavango | 1 | 1.9 |
| Kaprivi | 0 | 0.0 |
| Herero | 6 | 11.5 |
The results in Table 3.1 on the above show that the majority of the respondents are in the age group 20-29 years old, accounting for 42.3%, 34.6% for those aged 30-39, and 21.2% for those aged 40- 49, with only 1.9% in the age bracket 19-19 years. The bulk of the respondents (71.2%) were single, while 17.3 %, 3.8%, and 7.7% were married, widowed, or divorced or separated, respectively. The majority of them have a secondary education, accounting for 63.5% of the respondents. The majority of those who responded were Christians (98.1%). The bulk of responders were Oshiwambo (80.8%), with Herero accounting for 11.5% of the total respondents.
| Statement | Yes | No | I don’t know | |||
|---|---|---|---|---|---|---|
| Freq. | % | Freq. | % | Freq. | % | |
| Female condoms are not available at the hospital and in the community than male condoms |
42 | 80.8 | 8 | 15.4 | 2 | 3.8 |
| Female condom is difficult to use | 46 | 88.5 | 4 | 7.7 | 2 | 3.8 |
| Married women are often powerless to request their partner to wear a condom |
44 | 84.6 | 5 | 9.6 | 3 | 5.8 |
| There is no proper education on the use of female condoms |
37 | 71.2 | 14 | 26.9 | 1 | 1.9 |
| Women prefer the use of male condom than female condom |
46 | 88.5 | 3 | 5.8 | 3 | 5.8 |
| Women lack ability to convince sexual partner to use a female condom |
40 | 76.9 | 10 | 919.2 | 3 | 3.8 |
| Limited source of information about female condom use limit its uptake |
37 | 71.2 | 14 | 26.9 | 1 | 1.9 |
| People are used to using male condom than female condom |
46 | 88.5 | 3 | 5.8 | 3 | 5.8 |
| Use of female condoms implies lack of trust to partner/ spouse |
27 | 51.9 | 23 | 44.2 | 2 | 3.8 |
| The use of female condom is associated with prostitutes. |
29 | 55.8 | 19 | 36.5 | 4 | 7.7 |
| Female condoms are difficult to use. | 38 | 73.1 | 10 | 19.2 | 4 | 7.7 |
| Female condoms increase sexual pleasure | 46 | 88.5 | 4 | 7.7 | 2 | 3.8 |
| Female condoms are uncomfortable to use | 38 | 73.1 | 9 | 17.3 | 5 | 9.6 |
About 80.8% of the research respondents responded that female condoms (FCs) are not available at the hospital and in the community than male condoms, 15.4% responded that FC are available at the hospital and in the community than male condoms and 3.8 responded that they did not know whether FC are not available at the hospital and in the community than male condoms or not. Respondents with mentioned that FCs are difficult to use (88.5%), 84.6% indicated that married women are often powerless to request their partner to wear a condom and 71.2% mentioned that there is no proper education on the use of FCs that contribute to low uptake of FCs.
In addition to the above, women prefer the use of male condom than FCs (88.5%), they lack ability to convince sexual partner to use a female condom (76.9%) and there is lack of information about FCs which limit its uptake (71.2%). About 88.5% of the respondents said that people are used to using male condoms more than female condoms, and using female condoms means a lack of trust in their partner/spouse (51.9%). Respondents believed that the use of female condoms was related to prostitute clients (55.8%), 73.1% of respondents thought that FCs were difficult to use, 88.5% said that FCs increased sexual pleasure, and finally FCs were uncomfortable to use (73.1%).
This chapter presents the findings in tabular form and briefly explains each tab. Results indicate FC are not available at the hospital and in the community than male condoms (80.8%), FCs are difficult to use (88.5%), they increase sexual pleasure (88.5%), women prefer the use of male condom than FCs (88.5%) and people are used to using male condom than female condom (88.5). The next chapter presents a discussion of the results.
The previous chapter presented the results obtained from the questionnaires that were answered by 52 respondents. This chapter discusses the results and links them with the literature and background of this study
The demographic characteristics of respondents showed that respondents were aged 20-29 years old (42.3%), single (71.2%), had a secondary education level (63.5%), belonged to Christianity (98.1%), and were of Oshiwambo ethnicity (80.8%).
The present results of the study showed that FCs are not available at the hospital and in the community than male condoms (80.8%) that limit their use. FC are not always available in health facilities and the general population, according to a report by WHO, UNAIDS, and UNICEF (2011), which contributes to their low uptake. Similarly, it was discovered that FC is difficult to use with (88.5%). A cross tabulation of two factors, uptake of FC versus difficulty in using FC, found that 22/30 (73.3%) of participants who had used Female condoms said the FC was difficult to use (insertion of the FC was difficult.) and 8/30 (26.7%) said it was not difficult to use. Isah, Ogunbowale, and Alagbile (2013) report this experience in their literature review, stating that 46 percent of the participants agreed that the Female Condom is difficult to use. Regarding insertion, study participants reported that it was difficult to insert, that it required practice prior to usage, and that they did not appreciate the removal method [13].
In a study conducted in Delaware (USA), half of the respondents said that using the Female Condom reduced increase sexual pleasure. Leeper shares these sentiments, claiming that “too much lubrication made insertion difficult, dirty, and frustrating,” lowering sexual enjoyment [13]. It also disrupted lovemaking, wasnot spontaneous, and took preparation and planning, according to Leeper [13]. Female condoms were proven to boost sexual enjoyment in this study (88.5%). The similar experience is reported by the Population Council in its study on the Female Condom in Ghana. The similar experience was reported by the female undergraduate students of the University of Ibadan, Nigeria, in the study on Female condom awareness, use, and concerns among Nigerian female undergraduates by Okunlola et al. Despite the fact that all 30 participants who had previously used the Female Condom agreed that the FCs diminished sexual pleasure, it was discovered that this group had two motivational factors that led them to continue using the Female Condom despite its ability to reduce sexual pleasure.
The findings of this investigation were as follows: Female condoms are uncomfortable to use (73.1%). Mack et al. in their study of low-income African-American women accessing health facilities in El Salvador, describe this experience [13]. One of the barriers to the use of the female condom, according to his research, is its discomfort and inhibition during use. Women complained that the inner rings were uncomfortable to use, that the female condom was slippery and cumbersome, that it frustrated their love episode, and that the mechanics of the device were unacceptable to some study participants because it was too long, too large, or didn’t feel right, according to Leeper [11].
The present study found that women prefer the use of male condom than female condom (88.5%) and that people are used to using male condom than female condom (88.5%) [14]. These finding comply with a study by Thomsen (2016) which observed the same experience in a prospective research investigating the effects of introducing the female condom in a sex worker population in Mombasa, stating that there was a high degree of replacement of the female condom for male condoms. Thus, women preferred the use of male condom than female condom.
Other problems that have been identified as impeding the use of FCs include a lack of sufficient FC education, a lack of trust, the perception that FCs are linked with prostitutes, and women's inability to persuade their sexual partners to use a female condom. Mativo (2020) discovered that factors impacting accessibility and acceptability of the Female Condom among women in Kiambaa Division, Kiambu District, Kenya, were similar.
In Engela State Hospital, a variety of factors influence the use of the Female Condom by women of reproductive age. Women prefer to utilize the Male Condom over the Female Condom. Female condoms are less common in hospitals and communities than male condoms, and female condoms are more difficult to use. The study also found that married women are often powerless to ask their partners to use a condom, that women prefer male condoms over female condoms, that people are more accustomed to using male condoms than female condoms, and that female condoms boost sexual pleasure [15-31].
The Namibian government, through the Ministry of Health and Social Services, should implement intensive interventions such as the provision of Information Education and Communication (IEC) materials and broad peer education. This will ensure that the targeted demographic is well-equipped not only with proper product knowledge, but also with the skills to use it comfortably and effectively, and will aid in addressing the negative attitudes that discourage female condom use.
The MOHSS should allocate or source funds for the implementation of a long-term Female Condom promotion program that includes, among other things, the development of an innovative social marketing strategy that includes developing local branding and attractive packaging, collaborating with the media, and enlisting popular figures to serve as product “champions,” among other things. As a result, the Female Condom will be as popular as the Male Condom, allowing the two goods to compete effectively in the market. The government should recognize that short-term advertising of FCs is insufficient for generating and maintaining widespread client interest, and that long-term political and financial support for all aspects of product promotion is required.
The Namibian government, through the Ministry of Health, should study the findings of global research on the use of FCs and use these findings to build a strategic plan to guarantee that FCs are used effectively.
The government should use the MoHSS to identify and address flaws in the FCs’ supply chain. This is to avoid stockouts and ensure that FCs are always available in all areas, so that client interest and patronage may be maintained and perpetuated.
It is necessary to conduct a social behavioral study. Some operational research is required to inform the development of appropriate advocacy, distribution, and marketing strategies for the Female Condom. Factors influencing female condom demand and supply, methods for overcoming social-cultural barriers that currently discourage use of the Female Condom, debunking myths and misconceptions that currently discourage use of the Female Condom, and developing appropriate Information Education and Communication (IEC) materials are all topics that should be researched.
• All glory to God, who has led me this far
•I would like to express my gratitude to my research supervisor Ms. Elizabeth Kateta for her patience, unwavering support, encouragement, and unwavering dedication in offering advice and assistance during the preparation of this study report.
•My family has been a fantastic source of support during this journey.
•God bless my lovely mother, who stood with me, encouraged me, and believed in me despite all obstacles so that I could achieve my goal.
•May God richly bless all those who contributed to the accomplishment of this project.
