Elsevier

Women's Health Issues

Volume 14, Issue 3, May–June 2004, Pages 85-93
Women's Health Issues

Acceptability of an existing, female-controlled contraceptive method that could potentially protect against hiv: a comparison of diaphragm users and other method users

https://doi.org/10.1016/j.whi.2004.03.003Get rights and content

Abstract

Objective

The diaphragm, an internal barrier contraceptive device, is a candidate for a female-controlled method for preventing human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This study's objective was to examine how women who use the diaphragm differ from women using the pill and/or condoms with respect to factors hypothesized to influence the acceptability of contraceptive methods. Our goal was to increase understanding of who finds the diaphragm acceptable and why.

Methods

We conducted a cross-sectional telephone survey with selected female members of a managed care organization. For this analysis, we limited the sample to 585 women currently using the diaphragm (n = 196), pill (n = 200), condoms (n = 132), or pill and condoms (n = 57). We conducted bivariate analyses and multinomial logistic regression analyses to assess the associations between selected characteristics and diaphragm use.

Results

Diaphragm use was significantly associated with several variables. Of particular interest, placing less importance on hormonal method characteristics was significantly associated with diaphragm use (versus use of the pill, condoms, or both). Placing more importance on barrier method attributes was significantly associated with diaphragm use (versus pill use, alone or with condoms). In addition, lower condom use self-efficacy was significantly associated with diaphragm use (versus condom use, alone or with pill). Lack of motivation to avoid HIV/STIs was significantly associated with using the diaphragm versus condoms (only).

Conclusion

These results have important implications for future research, interventions, counseling strategies for providers, and product development. Our findings suggest that if the diaphragm protects against HIV, it could be a desirable option for some women.

Introduction

The diaphragm is an internal barrier device that provides physical protection of the cervix. It is one of the oldest contraceptive methods, and it is effective when used consistently and correctly (Trussell et al., 1993, Trussell and Vaughan, 1999). The diaphragm, however, is not a method that providers frequently recommend. Although research on providers' views of the diaphragm is lacking, it is generally believed that providers do not consider the diaphragm to be highly effective and that they are concerned about some women's ability to use the method correctly (Mantell, Hoffman, Exner, Stein, & Atkins, 2003). In addition, counseling and fitting women with a diaphragm probably takes more time than providing hormonal methods. As a result, currently few women ever hear about the diaphragm from providers (Mantell et al., 2003), and diaphragms are now used by only 2% of current contraceptive users (aged 15–44) in the United States (Piccinino & Mosher, 1998).

The diaphragm, however, is receiving new attention in the context of human immunodeficiency virus (HIV) prevention. Women need methods for protecting themselves from HIV and other sexually transmitted infections (STIs), and the diaphragm is a candidate for a female-controlled method that could reduce women's risk of acquiring HIV and other STIs (Cohen, 2002, 2002, Moench et al., 2001). Based on current knowledge regarding the pathways of HIV infection for women and evidence that the cervix is a site of particular susceptibility to HIV and STI acquisition, scientists have bolstered the case for internal barrier devices that cover the cervix. More specifically, evidence suggests that the cervix is vulnerable because, compared to the vagina, the cervical epithelium is relatively fragile and easily compromised (Anderson, 2002, Levy, 2002, Moench et al., 2001). In addition, the cervix is where many of the receptors which take in HIV particles are primarily located and is the entry to the upper genital tract (Anderson, 2002, Moench et al., 2001). Researchers have also pointed out, however, that the cervix produces immunologic substances that may help protect against disease, and thus a cervical barrier device could interfere with natural protection (Ellertson & Burns, 2003).

Three studies are examining the diaphragm's effectiveness in protecting women against STIs, including HIV (Ellertson & Burns, 2003). The first two studies are evaluating the diaphragm's protective effects against chlamydia and gonorrhea. The third is a randomized controlled trial among 4,500 women in Zimbabwe and South Africa that will test the safety and efficacy of the diaphragm for protection against HIV. Findings from these studies will undoubtedly influence the direction of research on the diaphragm and diaphragm-like products. Because efficacy influences acceptability, findings will also shape women's and provider's interest in and attitudes about the diaphragm.

A major research initiative to develop chemical barrier methods (i.e., microbicides) and mechanical barrier methods that women can use to protect themselves from HIV and other STIs is also in progress (Schwartz & Gabelnick, 2002). Because it may be years before microbicides and other new methods being developed are available for use (Cohen, 2002, Gollub, 1999), investigating the acceptability and efficacy of existing, female-controlled contraceptive methods that could potentially protect against HIV and other STIs is also essential (Stein, 1993, Stein, 1995, Stein and Susser, 1998).

The diaphragm has many advantages. It is safe, has limited side effects, and does not interfere with natural hormones. A woman can insert the diaphragm up to 6 hours before intercourse, and she can use it without her partner's knowledge (Stone, Timyan, & Thomas, 1999). In addition, because the diaphragm is worn completely inside the vagina, it is unlikely to interfere with intimacy and sexual pleasure. The diaphragm can be reused up to 3 years and, therefore, the cost of a diaphragm over time is low. Finally, the diaphragm could serve as a mechanical barrier device to hold microbicides (currently under development) and, thereby, provide dual protection against pregnancy and HIV/STIs.

For these reasons, improving understanding of women's acceptability of the diaphragm is essential. The present analyses are part of a multistudy project on the acceptability of the diaphragm among diverse samples of women in the United States. In this article, we compare women currently using the diaphragm with women using birth control pills, women using condoms, and women using the pill and condoms. We examined pill users because the pill is an effective contraceptive method, but not an effective disease prevention method. Women using condoms were examined because condoms are the cornerstone of HIV prevention, are a barrier method, and have the potential to provide dual protection if used correctly and consistently. Finally, we examined women using both the pill and condoms because these women are typically considered dual method users. Our objective was to examine how women who use the diaphragm differ from women using the pill and/or condoms with respect to factors hypothesized to influence the acceptability of contraceptive methods. The ultimate goal was to increase understanding of who finds the diaphragm acceptable and why. Such information is essential for understanding who might use the diaphragm as a disease prevention method, if it is found to be efficacious in preventing HIV.

Section snippets

Participants

As described elsewhere (Harvey et al., 2003, Maher, et al.), potential participants were selected from Kaiser Permanente Northwest (KPNW), a nonprofit health maintenance organization (HMO) that provides medical care to over 450,000 members in northwest Oregon and southwest Washington. Using existing administrative databases, we identified women aged 18–50 years old who were enrolled as KPNW members for at least 1 month in the previous 2.5 years. We used the KPNW database on pharmacy dispensings

Characteristics by current contraceptive method

As shown Table 1, the four contraceptive method groups differed significantly with respect to age, marital status, number of children, educational attainment, income, and sexual behavior. Perceived risk of HIV/STIs and motivation to avoid HIV/STIs were also significantly associated with current contraceptive method. The four contraceptive method groups also varied significantly in the importance placed on different contraceptive characteristics—specifically, attributes of hormonal methods,

Discussion

Research on the efficacy of the diaphragm for protecting women against HIV and other STIs is underway (Ellertson & Burns, 2003). The present study was part of a larger project to improve understanding of who finds the diaphragm acceptable and why. We examined the association between diaphragm use and factors hypothesized to influence acceptability of contraceptive methods among a sample of relatively low-risk women. Although we cannot extrapolate our findings to higher-risk women or draw

Acknowledgements

The authors thank the following individuals for their contributions to the study: Nancy Padian, PhD, Victor Stevens, PhD, Shannon Fulmer, MPH, Alan Bauck, Karen Riedlinger, MPH, Cheryl Johnson, EdM, Cherry Johnson, Andrea Brown, MA, Kennitha Burks, Amanda Petrik, Maile Thiesen, Eleanor Brown, Meredith Roberts Branch, MPH, and Katie Burns. We acknowledge Kaiser Permanente Center for Health Research for the development and maintenance of their data systems.

Dr. Bird's current research interests focus on the acceptability of HIV, STI, and pregnancy prevention methods and the role of relationship and sociocultural factors on sexual risk and protective behaviors.

References (22)

  • S.M Harvey et al.

    Who continues using the diaphragm and who doesn'tImplications for the acceptability of female-controlled HIV prevention methods

    Women's Health Issues

    (2003)
  • Anderson, D. (2002, September). The cervix: The Achilles heel of the female reproductive tract: HIV immunology. Paper...
  • L.J Beckman et al.

    Dimensions of the multidimensional contraceptive attributes questionnaire (CAQ)

    Psychology of Women Quarterly

    (1992)
  • L.J Brafford et al.

    Development and validation of a condom self-efficacy scale for college students

    Journal of American College Health

    (1991)
  • Branch M. R., Harvey S. M., Casillas A. Bird S. T. (2003, November). A new look at an old method: Exploring diaphragm...
  • Cohen, C. R. (2002, May). The diaphragm: A female controlled method to prevent HIV and other sexually transmitted...
  • Diaphragm Renaissance: The Role of Cervical Barriers. (2002, September). Meeting Sponsored by Ibis Reproductive Health,...
  • C Ellertson et al.

    Re-examining the role of cervical barrier devices

    Outlook

    (2003)
  • E.L Gollub

    Human rights is a US problem, tooThe case of women and HIV

    American Journal of Public Health

    (1999)
  • S.M Harvey et al.

    A new look at an old methodThe diaphragm

    Perspectives on Sexual and Reproductive Health

    (2003)
  • Levy, J. (2002, September). Keynote address: Overview of science. Paper presented at the Diaphragm Renaissance: The...
  • Cited by (17)

    • A phase I randomized safety study of a single-size silicone rubber diaphragm used with or without a lactic-acid-containing diaphragm gel

      2019, Contraception
      Citation Excerpt :

      However, it makes comparison of our findings to other studies of different designs among different populations difficult. Recent acceptability data indicate that the contraceptive diaphragm remains a desired method [41,42], particularly for women cannot use or chose to avoid hormonal regimens. The approval of an over-the-counter, single size, ergonomic, diaphragm eliminates the need for a pelvic examination to determine size and fitting, making it potentially more accessible, cost effective and desirable to women worldwide, including women living in HIV endemic regions [2,43–45].

    View all citing articles on Scopus

    Dr. Bird's current research interests focus on the acceptability of HIV, STI, and pregnancy prevention methods and the role of relationship and sociocultural factors on sexual risk and protective behaviors.

    Dr. Harvey's current research interests include the acceptability of reproductive technologies; the prevention of HIV/STIs and unintended pregnancies among high-risk women, men, and couples; and the influence of relationship factors on sexual risk-taking.

    Dr. Maher has an MS in Biostatistics and PhD in Epidemiology, and one of her areas of interest is HIV/STI prevention.

    Dr. Beckman conducts research on contraception, abortion, HIV/STI prevention and other women’s reproductive health issues.

    This research was supported by Grant Number 5R01 HD40137 from the National Institute of Child Health and Human Development to S.M. Harvey. Dr. Bird and Dr. Beckman were previously with the Center for the Study of Women in Society, University of Oregon, Eugene, Oregon. Dr. Maher was previously with the Kaiser Permanente Center for Health Research, Portland, Oregon.

    View full text