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Table 2 Second and Third order constructs

From: Motivations and barriers to uptake and use of female-initiated, biomedical HIV prevention products in sub-Saharan Africa: an adapted meta-ethnography

Third Order Labels Second Order Constructs Summary definition (translation) of the 1st and 2nd order constructs Sources
Sexual Satisfaction General Sexual Satisfaction The use of HIV prevention products like the microbicide gel can improve sexual satisfaction within the individual, partner, client, and couple combined. Gafos et al., 2010; Greene et al., 2010; Montgomery et al., 2010; van der Straten et al., 2012; Okal 2008
Sexual Performance and Play Product use can improve performance allowing the user or indiviudal to perform better, be hotter, for her partner, and partners or clients can last longer. There is also the added foreplay of initiating product use (ex. applying the gel). Guest et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010; Stadler et al., 2014; Gafos et al., 2010
Implications of enhanced satisfaction Enhanced sexual satisfaction increases trust among some couples, can promote security in the relationship if male partners find their main partners more attractive because of improved sex, and the sense of additional safety from the protection conferred adds to the sexual satisfaction. Montgomery et al., 2010; van der Straten, et al. 2014
Lubrication and traditional vaginal practices Previous intravaginal cleansing and insertion practices can be replaced by product use (ex microbicide), and can improve feeling of sex and feeling of vaginal, making sex more smooth. This more often improves sexual satisfaction, but added wetness can also imply promiscuity in some instances. Gafos et al., 2010; Greene et al., 2010; Guest 2008; Lees, 2015; Montgomery et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010; Sahin-Hodoglugil et al., 2011
Trust Trust or lack of trust in partner Product use could be motivated by fear of an unfaithful partner, where they had been and whether they would use a condom. General trust that a partner would use a condom properly was also often missing. In these cases, other HIV prevention products (gel, PrEP, or diaphragm) could confer added protection and peace of mind. Sahin-Hodoglugil et al., 2011; Kacenek et al., 2012; van der straten et al., 2014; Guest et al., 2008; Kacenek et al., 2010; Sahin-Hodoglugil et al., 2011; Mathenjwa et al., 2012; Lees 1015
Implications of product use for development and maintenance of trust Initimacy and creating and maintaining trust are important in relationships where other HIV prevention product use could reaffirm the relationship while condoms carried negative connotations of distrust, denoting infidelity. However, there was sometimes a worry that gels or oral PrEP could promote promiscuity, or at least suggest it. Okal et al., 2008; van der Straten et al., 2014
Communication and Enabling Environments Partner trust of a product was critical, because the trust in the product would translate to trust in a partner as well. Communication and disclosure of product use would improve use of the product, as well as overall communication in the relationship. If not discussed, or if the male partner did not trust the product, there was possibility for arguing and violence. Montgomery et al., 2008; Stadler & Saethre, 2011; Montgomery et al., 2010, Greene et al., 2010; Montgomery et al., 2012; Montgomery et al., 2014; Montgomery et al., 2008; Kacanek et al., 2012; van der straten et al., 2014; Magazi et al., 2014; Montgomery et al., 2015; Sahin-Hodoglugil et al., 2011; Stadler et al., 2014
Empowerment and Control Self-esteem and personal agency Product use had positive affects on personal agency and self-esteem leading women to feel empowered by the ability to decide to use a particular product and that there was something they could use without necessarily needing a male partner’s consent. However, in some cases the product could reduce the sense of personal power if it reminded the user of previous trauma. Sahin-Hodoglugil et al., 2011; Okal et al., 2008; van der Straten et al., 2012; Mathenjwa et al., 2012; Abrahams et al., 2010; van der Straten 2014; Lees 2015; Stadler & Saethre, 2011; Kacanek et al., 2012; Guest et al., 2008; Greene et al., 2010
Power positioning (Negotiation and control, Product use and engagement in services affects power dynamic) Male partners could react negatively to women having decision making power over product use, clinic attendance, or even knowledge that they did not possess. This could result in anger or violence in the household. Stadler et al., 2014; Montgomery et al., 2015; Montgomery et al., 2012
Personal Well-being Product use promotes health and well-being The use of HIV prevention products was seen as a deliberate action to promote one’s own health and sense of well-being. Products could strengthen the sense of self and empowerment, as well as prevent multiple diseases and improve health issues. The physical experience of side effects could also contribute to the sense of protection from the products. The engagement in health services in connection with HIV prevention product use was also a part of seeing onself as being healthy and promoting that image to others. Stadler & Saethre 2011: Montogomery et al., 2010; Magazi et al., 2014; van der straten et al., 2014
Quality of care as motivation for engaging in healthcare The quality of care could motivate or demotivate use of HIV prevention products, negative or positive attitudes from health worker staff would transfer to the individual and promote either their sense of good health or negative feelings towards health. Van der Straten 2014, Magazi 2014
Social Well-being Perceived implications of use (how I’m seen by others) People using products can fear what others will think of them as someone who uses HIV prevention products, largely because of an association with promiscuous sexual activity Okal et al., 2008; Gafos et al., 2010
Social construction of medication and product use The use of a medication can symbolise illness for some women and can challenge their understanding of what it means to be healthy. van der Straten et al., 2014; van der Straten et al., 2014; Montgomery et al., 2015
Conflation of ARVs for treatment and prevention Family members, partners or wider community members can mistake use of ART based PrEP, for ART used to treat HIV infection. This can lead to stigmatisation of people believed to be HIV positive van der Straten et al., 2014; Magazi et al., 2014; Montgomery et al., 2015
Interaction with normative vaginal practices and beliefs The use of vaginal microbicides in some settings compliments locally normative vaginal practices in helping to cleanse the vagina prior to, or after, sex. However, the converse was also observed and vaginal microbicides can be rendered less effectiveness by virtue of cultural norms relating to vaginal cleansing immediately after sex. Gafos et al., 2014; Greene et al., 2014; Behets et al., 2008, Stadler & Saethre, 2011
  The role of outsiders Many of the product trials or demonstration projects have been led and/or delivered by people perceived as ‘outsiders’, largely relating to a perception that the originate in the Nothern Hemisphere. van der Straten, 2014; Guest et al., 2010; Montgomery et al., 2010; Lees, 2015; Montgomery et al., 2014
Practical Considerations Accessing and storing medication Physically getting to the clinic to pick up medication or product refills could prove difficult and was an issue in terms of consistent access. Storing medications was sometimes problematic due to stigma within the household or among friends, where personal privacy was minimal. Greene et al., 2010; Magazi et al., 2014; Montgomery et al., 2010; van der Straten et al., 2014; Abrahams et al., 2010; Mathenjwa et al., 2012
Taking and adhering to medication Strategies for using products, such as gel within a certain time period or pills on a daily regimen, could be interrupted by changes in routines or boredom with use. Perceived or actual side effects were also barriers, as was the need to use multiple products such as condoms and gel when wanting to also prevent other STIs or pregnancy. If product use or associated clinic attendance got in the way of livelihood then product use was also demotivated. Guest et al., 2010, van der Straten et al., 2014; van der Straten et al., 2014; Montgomery et al., 2012,
Health service level issues The health service itself, including waiting times at the clinic, required frequency of visits in relation to livelihoods, and transport and ability to get to the clinic could also cause problems in consistent and continued product use. Magazi et al., 2014
Product attributes and acceptability The ease or difficulty in using a product would directly affect whether a product could be taken up and used. These included need for privacy or washing facilities, whether the product stayed where it was supposed to, ability to transport it inconspicuously, and flexibility around when sex occurred. Pain or irritation with use was also a demotivator. Ability to use covertly was positively regarded, even if rarely done. Okal et al., 2008; Sahin-Hodoglugil et al., 2011; Montgomery et al., 2012; Greene et al., 2010; Kacanek et al., 2012; van der Straten et al., 2014; Guest et al., 2010; Behets et al., 2008; Gafos et al., 2014; Stadler & Saethre 2011; Guest et al., 2008; Mathenjwa et al., 2012; van der Straten et al., 2012
Efficacy and Risk Reduction Efficacy for HIV prevention central concern Whether or not the product can effectively protect them from acquiring HIV was a key concern of women engaged with the products via trials or demonstration projects. A recognition that condoms are not always sufficient drives interest in their concern for new product efficacy. Lees, 2015; Greene et al., 2010; Stadler & Saethre 2011; 2014; van der Straten et al., 2014; Montgomery et al., 2010
Other (non-HIV) protective effects While not necessarily acurate in all instances, some female participants expressed beliefs that products could protect them from other STIs or from unwanted pregnancy. Montgomery et al., 2012; Okal et al., 2008; Mathenjwa et al., 2012; Guest et al., 2008; Behets et al., 2008
Perceptions around combination prevention While women may not always be using new technologies in isolation, sometimes a result of concerns for their effectiveness, they were comforted by a feeling that products could provide an additional layer of protection should their primary prevention mechanism (usually condoms) fail. Sahin-Hodoglugil et al., 2011; Okal, et al., 2008; Guest et al., 2008; Kacenek et al., 2012