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RESEARCH UPDATE |
January 2001
Promoting Dual Protection Within Family Planning Services in Nigeria
In much of sub-Saharan Africa, AIDS is greatly reducing the economic, health, and social improvements of the last 50 years. In some regions, HIV prevalence among adults is more than 30 percent. Young women are often hit hardest by HIV/AIDS—the same women seen in family planning clinics. Given rising rates of HIV infection, what role can family planning providers play in helping a woman determine if she is at risk for HIV and how she can protect herself?
Getting FP service providers to talk with clients about dual protection (DP)—the simultaneous protection of a woman from unwanted pregnancy and from HIV and other STIs—is not an easy task. Many family planning providers do not see disease prevention as their job. In addition, they often perceive the condom as an ineffective contraceptive and do not promote it to clients. Finally, many are uncomfortable discussing sexual matters with their clients, including whether clients’ partners have extramarital sexual relations.
In response to these challenges, the Association for Reproductive and Family Health (ARFH) is conducting operations research to test clinic- and community-based strategies to increase the adoption of behaviors that protect against unwanted pregnancy and HIV/STIs among female family planning clients and their partners in Ibadan, Nigeria.
Intervention Components
The study is taking place in six family planning clinics (three government- and three NGO-sponsored) that have a total of 15,000 client visits a year. As part of project activities, all service providers participated in 10 days of training in DP education and counseling. The training emphasized that DP can be achieved in three ways: 1) by using a male or female condom alone, 2) by using two methods—a condom and another non-barrier contraceptive, or 3) by using an effective contraceptive while practicing mutual monogamy. The training also covered HIV/STI information, counseling and communication skills, how to use male and female condoms, and condom negotiation strategies. Trainers used role modeling, behavioral rehearsal and corrective feedback extensively. All providers received male and female condoms to try and were later asked to discuss their experiences. Providers participated in a two-day field practicum to practice their newly acquired skills in real-life clinical settings.
Providers also assisted in the development of a flip chart, posters, brochures, and other IEC materials. The flip chart includes counseling guidelines to help providers explain and promote DP to clients. The guidelines cover risk assessment, the signs and symptoms of STIs, and what clients can do to prevent them. The guidelines also include how to use male and female condoms and negotiate their use with a partner, and how to assist clients in choosing a contraceptive (or two) that satisfies both their contraceptive and disease prevention needs.
The clinics initially provided up to three free female condoms per client. Additional female condoms sold for U.S. 10 cents, in line with the low prices charged for all other contraceptives, including male condoms. As of October 2000, the policy of offering free female condoms ended.
In Phase 1, completed at the end of December 2000, DP promotion efforts focused only on the female clients within the clinic setting. In Phase 2, launched in January 2001, a range of clinic and community-based strategies are being implemented to involve the male partners of clients in the practice of DP.
Study Methods
The results of Phase 1 and Phase 2 will be compared to each other as well as to baseline data collected before the DP intervention began. The operations research focuses on two areas: (1) system-level changes in the integration of HIV/STI prevention within family planning services, and (2) client-level behavioral change leading to the successful practice of DP.
The researchers are using qualitative methodologies, including clinic site management assessments, focus group discussions, FP client in-depth interviews, and monthly on-site monitoring, to understand and address the implementation problems. In addition, a DP service statistics system measures changes in clients’ barrier contraceptive choices, including the simultaneous use of a condom with other methods. Structured observations of provider-client interactions and client exit interviews assess changes in provider behavior and whether the DP intervention is proceeding as planned. Six-month follow-up interviews with DP acceptors and a comparison sample of non-DP new clients will occur during each phase to assess the short-term effects of the DP intervention.
Key Findings
- Clinic clients are primarily married (96 percent), often polygamously (22 percent), and mainly use the IUCD and hormonal contraceptives. Continuing clients made up more than 75 percent of visits.
- From January to December 2000, clients took or bought condoms in 14 percent of visits; three-quarters of these visits were for female condoms (Table 1). Clients procured a male or female condom in addition to another contraceptive in more than half of the cases. New clients were three times as likely as continuing clients to take a condom. Although half of clients reported in exit interviews using a male condom some time in the past, less than 2 percent of client visits in 1999 were for male condoms. This figure rose to 3 percent of client visits in 2000.
| Table 1. Condom visits: January–December 2000 | ||
| Total FP visits | 15,023 | |
| Condom visits | 2,116 | 14% (of total FP visits) |
| Female condoms | 1,672 | 11% (of condom visits) |
| Male condoms | 444 | 3% (of condom visits) |
| Single method | 964 | 46% (of condom visits) |
| Double method | 1,152 | 54% (of condom visits) |
| New clients | 948 | 25% (of new clients) |
| Continuing clients | 1,168 | 8% (of continuing clients) |
- Although services providers have greatly increased their discussion of certain aspects of DP with clients, less than a third discussed condom negotiation with clients (Table 2).
- The demonstration of male condoms to clients is dramatically lower than that of female condoms (Table 2). Given the primarily married clientele, providers may sense that women would feel more comfortable bringing home a female condom than a male condom.
Table 2. Observations of provider interactions with new clients: Baseline and Phase 1 | ||
Provider | Baseline | Phase 1 |
Discussed HIV/AIDS | 7 | 74 |
Discussed whether clients preferred FP method provides HIV/STI protection | 2 | 49 |
Used the DP flip chart | — | 47 |
Discussed condom negotiation | 3 | 29 |
Discussed sexual behavior of client's partner | 4 | 22 |
Showed client how to use male condom | 10 | 34 |
Showed client how to use female condom | — | 80 |
- Service providers deliver DP counseling less frequently to continuing clients than new clients (Table 3). Continuing clients often do not expect to spend much time at the clinic and providers are not accustomed to spending much time counseling them. Providers may need a separate protocol for providing DP counseling to continuing clients.
| Table 3. Observations of provider interactions with new and continuing clients: Phase 1 | ||
Provider discussed | New clients | Continuing |
Whether client might have an STI | 42 | 13 |
HIV/AIDS | 74 | 27 |
Female condom | 80 | 62 |
- While initial acceptance of the female condom was substantial—more than 20% of new clients initially took home a female condom—many were given out free.1 Many of these women may have been interested in experimenting with a new method. The level of use of female condoms is unknown, though planned follow-up interviews of DP clients should provide an answer.
- Male partners have been identified by both clients and service providers as the main barrier to DP practice. Most clients acknowledge that their husbands have other sexual partners or report that they are unsure, and are aware of the possibility of getting HIV or other STIs from their husbands. Because of strong male dominance in Yoruba culture, and fear of rejection and abuse by the husband, most women feel they cannot confront a partner about his sexual risk behavior. This indicates the need for providers to emphasize condom communication skills rather than simply providing DP information. It also highlights the need to involve men in DP educational and counseling efforts.
Conclusion
During the first year of implementation, the project demonstrated a modest increase in uptake of male condoms; significant interest in the female condom, particularly by new clients; and increased discussion with clients of DP themes by providers. Operationalizing the concept of DP in family planning clinics requires continuous monitoring, supervision, and in-service training of service providers. It also requires attention to male partners who act as significant barriers to women’s adoption of DP. The project’s Phase 2 male involvement activities will test whether, in the face of the AIDS epidemic, couples adopt behaviors that protect themselves against both unwanted pregnancy and HIV/AIDS.
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