Table 5.

Contextual/environmental factors influencing FC acceptability, uptake, and/or continued use (excluding availability)

Factor	Facilitators (countries where relevant evidence was identified)	Barriers (countries where relevant evidence was identified)
Experience with condoms	• Familiarity with MC use (Zambia, Bangladesh)	• Lack of knowledge/experience with condoms (Kenya) • Unfamiliarity with FC/lack of exposure (South Africa, El Salvador, Swaziland) • Preference for MC (Nigeria, Zambia, Thailand, South Africa) • Dislike of condoms in general (Nigeria, Uganda)
Perceived personal risk Relationship or gender dynamics	• Perceived risk of STI/HIV infection (Bangladesh, People’s Republic of China, Nigeria, Zimbabwe, CAR, Tunisia, South Africa) • Ability to discuss FC with a partner (Tanzania, Zambia) • More comfortable using FC with (regular) paying client than nonpaying partner (Brazil, Ghana, El Salvador, Nicaragua) • Perception that clients would prefer FC (Thailand) • Bargaining tool for protected sex (Bangladesh, Cambodia, Swaziland, Thailand) • Share responsibility for condom use (South Africa) • Partner acceptance of first use predicted easier negotiation for further uses (Cote d’Ivoire) • Men would use if their partners initiate (South Africa) • Potential for use during menstruation or breastfeeding protects marriages (Nigeria) • Can be used if client/partner does not like/refuses/cannot use MC (Brazil, India, South Africa, Bangladesh, Dominican Republic, Thailand, El Salvador, Nicaragua, Nigeria) • Better protection for women at risk of coerced sex (Ghana) • Better protection for women whose husband is unfaithful (Vietnam)	• Lack of perceived need (for barrier contraceptive) (Kenya, Nigeria, Burundi, Bangladesh) • Limited ability to discuss FC with partner (Ghana) • Desire for unprotected sex with a loving partner (Nigeria, Uganda) • Male partner resistance/refusal (Ghana, Namibia, Nigeria, PNG, South Africa, Zimbabwe, Burundi, El Salvador, Bangladesh, Cambodia, Swaziland, Thailand, CAR) • Fear of partner reaction/requirement for negotiation/partner cooperation (Kenya, Uganda, Burundi, El Salvador) • Male preference for being in control (Zambia, Uganda) • Men’s fear that women reuse FC (Uganda) • Difficulty identifying strategies to negotiate FC use with nonpaying partners (El Salvador, Swaziland, Nicaragua) • Clients accept MC (Thailand)
Cultural and religious norms		• Women unaccustomed, uncomfortable or embarrassed to touch genitals/insert FC in front of a partner (Brazil, South Africa, Cambodia, Dominican Republic) • Embarrassment/anxiety over FC appearance and use (Vietnam) • Stigma/association with untrustworthiness/disease (Ghana, Kenya, Nigeria, South Africa, Zimbabwe, Burundi, El Salvador, Rwanda, Swaziland, Vietnam) • Condom use conflicts with moral or religious beliefs (Nigeria, Burundi, Bangladesh)
Promotion, education, and support	• Provider or peer promotion/education/support/counseling (Brazil, Kenya, Tanzania, People’s Republic of China, South Africa) • FC promoted as contraceptive rather than HIV prevention device (Zimbabwe)	• Lack of awareness of female anatomy causing fear of losing FC in reproductive tract/abdomen (Ghana, Zimbabwe, People’s Republic of China, South Africa) • Lack of information about the device (El Salvador, Nicaragua, Turkey, Tunisia) • Not fully aware on how to use (Malawi, South Africa)
Infrastructure	• No need to attend clinic to access FCs (Swaziland)	• Difficulty disposing of FC (India) • Free FCs only at hospital (Malawi) • Difficulty of concealing the large package (El Salvador, Nicaragua)
Poverty/financial resources	• For FSWs, allows higher earnings when used covertly with clients requesting no condom use (El Salvador, Nicaragua) • For FSWs, allows higher earnings due to possibility of use during menstruation (El Salvador, Nicaragua)	• Cost (if not free or heavily subsidized) (Brazil, Ghana, India, Namibia, South Africa, Tanzania, Zimbabwe, El Salvador, Mexico, Bangladesh, Nigeria, Nicaragua, Malawi) • Loss of potential earnings from clients requesting sex without a condom (El Salvador, Nicaragua)

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