Table 4.

Method attributes (actual and perceived) of FCs influencing acceptability, uptake and/or continued use

Attribute	Positive perceptions/facilitators of use (countries where relevant evidence was identified)	Negative perceptions/barriers to use (countries where relevant evidence was identified)
Appearance	• General appearance (People’s Republic of China) • Large size (South Africa, Uganda, El Salvador, Nicaragua) • Smell (preferred to MC) (Burundi, El Salvador, Nicaragua) • Natural feel (El Salvador, Nicaragua, Nigeria)	• Generally unattractive size and shape (Brazil, Ghana, India, Kenya, South Africa, Uganda, Zimbabwe, El Salvador, Cambodia, People’s Republic of China, Dominican Republic, Thailand, Vietnam, Nigeria, Nicaragua) • Too thick (Ghana) • Too big/loose/long (India, Kenya, South Africa, Uganda, Bangladesh, Thailand, Nigeria) • Rings are confusing (South Africa) • Smell (South Africa)
Different than other methods Lubrication	• Novelty factor (India, Kenya, People’s Republic of China, CAR, Nigeria) • Well lubricated (better than MC) (Brazil, Ghana, India, Uganda, Burundi, El Salvador, Swaziland, Nicaragua)	• More complicated than other contraceptives (Vietnam, Zimbabwe, South Africa) • Overlubricated (Namibia, South Africa, Tanzania, Zimbabwe, People’s Republic of China, Dominican Republic, Thailand) • Fear of adverse effects of lubricant (Burundi)
Insertion/use	• Easy/comfortable to insert and use during sex/“natural feel” (compared to MC) (India, Kenya, Namibia, South Africa, Zimbabwe, Burundi, El Salvador, Mexico, Cameroon, Cambodia, Dominican Republic, Thailand, Vietnam, Nigeria) • Allows sex in any position without technical difficulties (Brazil) • Permitting use when penis is not erect (El Salvador, Nicaragua)	• Difficult to insert/remove (Brazil, Namibia, Nigeria, PNG, Zimbabwe, Burundi, El Salvador, Bangladesh, People’s Republic of China, Swaziland, Thailand, Nicaragua, CAR, Tunisia) • Takes too long to insert (Vietnam) • Need privacy to insert (India, Swaziland) • Noise (FC1 only) (Brazil, Ghana, Namibia, PNG, South Africa, Burundi, Cambodia, Dominican Republic, CAR, Malawi) • Messy (Kenya) • Technical difficulties during sex/method failure (Brazil, Ghana, Nigeria, Zimbabwe, Burundi, Cambodia) • Fear of potential technical difficulties (Burundi, People’s Republic of China, Nigeria, South Africa) • Female or male partner discomfort (Brazil, India, Nigeria, Zimbabwe, Burundi, El Salvador, Bangladesh, People’s Republic of China, Dominican Republic, Swaziland, Thailand, South Africa) • Concerns about potential discomfort (South Africa, Tanzania, Burundi, El Salvador, Nicaragua) • Problems/discomfort related to inner/outer ring (Ghana, India, South Africa, Zimbabwe, Burundi, Cameroon, Vietnam, El Salvador, Nicaragua, CAR) • Itching sensations (CAR) • Bleeding/burning/allergy (El Salvador, Nicaragua)
Timing of use	• Ability to insert before sex (prior to drinking alcohol, prior to man getting an erection) (Brazil, Ghana, South Africa, Zimbabwe, El Salvador, Cambodia, Swaziland, Nicaragua)	• Perception that FC must be inserted several hours before sex (South Africa) • Insertion interrupts the sex act (Zimbabwe)
Practice improves confidence	• Comfort and ease of use improves with practice (Brazil, Ghana, Namibia, South Africa, Zimbabwe, Cameroon, Cambodia, El Salvador, Swaziland, Thailand, Vietnam)	• Requires practice to use with confidence (Cambodia) • Discomfort persisted with repeated use (South Africa)
Safety and effectiveness	• Perceived strength (compared to MC) (Brazil, India, South Africa, Zimbabwe, El Salvador, Cambodia, People’s Republic of China, Dominican Republic, Swaziland, Nicaragua) • Perceived flexibility (compared to MC) (South Africa) • Perceived safety (compared to MC) (Brazil, Zimbabwe, Thailand, CAR, South Africa) • FC cannot get lost inside the body (Cambodia) • Perceived effectiveness in pregnancy/STI prevention (compared to MC) (India, South Africa, Uganda, Burundi, El Salvador, People’s Republic of China, Dominican Republic, Vietnam, Nicaragua) • Perceived effectiveness in pregnancy/STI prevention (Rwanda, South Africa, Nigeria) • Reduced slippage (El Salvador, Nicaragua) • Better protection from STIs (covers the outer part of the vagina and labia) (El Salvador, Nicaragua)	• Doubts about effectiveness (compared to MC) (Kenya, Zimbabwe) • Fear of losing FC in reproductive tract/abdomen (Ghana, Zimbabwe, People’s Republic of China, South Africa) • Lack of trust in effectiveness against HIV/STI risk among males (Nigeria) • Method failure resulting in pregnancy (Nigeria)
Dual protective properties	• Provides dual protection (Kenya, South Africa, Uganda, Zimbabwe, Burundi, People’s Republic of China, Dominican Republic, Swaziland, Nigeria)
Pleasure	• Enhanced sexual pleasure for woman or man (including by clitoral stimulation from the external ring), preferred over MC for sexual pleasure (Brazil, Ghana, India, Kenya, Zimbabwe, Burundi, Swaziland, CAR) • Does not affect sexual pleasure (Kenya, South Africa, Vietnam, CAR) • Couples can stay together for longer after ejaculation (Kenya, South Africa)	• Reduced sexual sensation/pleasure for woman or man (Ghana, India, Kenya, Nigeria, South Africa, Burundi, People’s Republic of China, Dominican Republic) • Perception that it would interfere with sexual pleasure (Uganda) • Outer ring makes genitalia inaccessible (Uganda, Zimbabwe)
Woman initiated	• Increases woman’s control and sexual agency (Brazil, Ghana, India, Kenya) (Namibia, South Africa, Uganda, Zimbabwe, Burundi, Mexico, Bangladesh, People’s Republic of China, Dominican Republic, Swaziland, Thailand, Vietnam, Nigeria)
Covert use	• Ability to use covertly (Brazil, Uganda, Cambodia, Dominican Republic, Swaziland, El Salvador, Nicaragua)	• Inability to use covertly (Uganda, Zimbabwe)
Other	• Ability to use during menstruation (Brazil, El Salvador, Nicaragua) • Offers an alternative to MC (for those who cannot/prefer not to use MCs or when MC is not available at the time of sex (Brazil, Ghana, Nigeria, Swaziland, El Salvador, Nicaragua, Nigeria, South Africa) • Offers alternative protection when nothing else is available (Zimbabwe) • Offer alternative to hormonal contraception (Swaziland, El Salvador) • Reuse possible (Burundi, India)	• Inconvenient/long-term use not feasible (Burundi, People’s Republic of China, Thailand) • Not suitable for some traditional sexual practices (Burundi)

Abbreviations: MC, male condom; CAR, Central African Republic; PNG, Papua New Guinea; FC, female condom; STI, sexually transmitted infection.