I: Hello, my name is (Name) from Busara Centre for Behavioral Economics. You are being invited to participate in the study, but before you decide to participate, it is important that you understand why the research is being done and what it will involve.
This is the consent form that I am reading for you so that you can understand, and you can know what we are doing.
(Name)?
R: It is okay, I can hear you.
We want to understand the health behaviors of women and men in Kenya (including those who are a similar age and lifestyle as you). This will help us understand how women make decisions and to investigate what might prevent or motivate them to use HIV prevention methods.
We are doing this research amongst men and women of a similar age to you who live in this area, where getting HIV is common, as well as another area in Kenya and four other countries in Sub-Saharan Africa, in order to understand the differences and similarities in the behaviors of women and men.
If you decide to participate, we will ask you a series of questions. The interview will be carried out over the phone and will last approximately 1 hour, and I will be recording our conversation. You do not have to answer any question that makes you feel uncomfortable, and any information you provide will be kept confidential. Your responses will be recorded. The types of questions I will ask you include:
(1)Socio-demographic aspects – In this section, we get to know a bit more about you, e.g., your age, education, religion, and occupation.
(2)Communication channels – Where we ask you questions about who you usually talk to for advice on your health.
(3)Relationships dynamics – Where we ask you questions about any relationships you are in, what that relationship looks like, your sexual behaviors in that relationship, including condom and family planning usage.
(4)HIV prevention – We ask you questions on which HIV prevention methods you are aware of, what the concerns of your friends are and your opinions on a new anti-HIV device.
(5)Decision-making processes – We ask you questions about how you and your friends usually make decisions e.g., do you make them by yourself or after talking to others.
(6)Clinic experiences – We ask you questions about any experiences you have had visiting your local clinic for any health-related check-ups, e.g., how far is your clinic, does it cost you money to go there, how do people usually treat you in the clinic.
There are no direct benefits to you for participating in this study, but your participation with many others will help to better understand the profiles and behaviors of women in Sub-Saharan and how best to provide HIV prevention methods to them. There are no foreseeable risks for you if you choose to participate in this study. You may find some questions in our questionnaires intrusive. However, you do not have to answer any question that makes you feel uncomfortable, and any information you provide will be kept very confidential.
Every participant will be paid the same fixed incentive of KES.500 upon completion of the survey as a token of gratitude for your time and participation in the study.
The investigator may, without notice, withdraw you from participating in this research if circumstances arise that warrant doing so. Such circumstances include but are not limited to unexpected loss of funding etc.
We will not tell other people that you took part in this research, and we won’t share information about you to anyone who does not work in this research study. Everything you say in the discussion will remain completely confidential and will not be told to anyone else in your community, e.g., your partner, family members, neighbors, or friends. Any reports about this research will not contain any information like your name that could be used to identify you. However, we would like to use anonymous quotes from the interview in some of our reporting, which may be made public.
Your participation in this study will remain confidential, and your identity will not be stored with your data. Your responses will be assigned a code number, and the list connecting your name with this number will be kept in a locked room and will be destroyed once all data have been collected and analyzed. When the results of the research are published or discussed in conferences, no information will be included that would reveal your identity. The confidentiality of your data will be maintained to the extent allowed by law. The only people who will have access to your information are members of the research team and regulators such as Strathmore University Institutional Ethics Review Committee (SU-IERC). No information about you, or provided by you during the research will be disclosed to unauthorized people without your written permission, except if necessary to protect your rights or welfare, or if required by law.
Your participation in this research is completely voluntary. If you choose to participate, you may also subsequently withdraw from the study at any time without penalty or consequences of any kind. If you choose not to participate, you will not be penalized in any way or incur any losses.
I would like you to tell me if you understand all the information I have read out to you?
R: I understand.
I: Do you have any questions up to that point?
R: No.
I: So we can start the survey? (silence) Hello, (Name)?
R: Yes, I can hear you.
I: What is your name?
R: (Name)
I: Age?
R : 25 years.
I : Gender?
R : Female.
I : Occupation?
R : Supermarket attendant.
I : Level of education?
R : Form four.
I : Relationship status?
R : Single.
I : Before we get started, can you please tell me what you remember about the DPV ring? And if you don’t remember anything, that’s fine, am not here to test you or judge you.
R : About what?
I : DPV ring. In the last survey we conducted, you were asked questions about a new HIV prevention method and it’s inserted in a woman’s vagina. Can you remember anything about that device called DPV ring?
R : Yes.
I : What can you remember?
R : I remember we were told how it looks like, it’s round in shape.
I : What else can you remember?
R : We were also told that there is no effect when using this ring, even when you are having sex.
I : Let me remind you a bit about it. DPV ring is a device that looks like a ring and is inserted in woman’s vagina and it is used to prevent against HIV with 30-45% efficacy. From the research we conduct a lot of women did not like the ring due to its low efficacy. From what we described earlier, the ring’s efficacy is between 30-45%. Some women similar to you reported some concern over using the ring because of this level of protection.
What does efficacy mean to you?
R : I think it is fine.
I : How would you describe it to your friend who is similar to you?
R : I can explain to her that this device prevents HIV, that it is somehow protective and that when you are having sex it doesn’t disturb you.
I : What concerns, if any, do you have about the ring’s efficacy?
R : The concerns can be due to the fact that it’s inserted in the vagina you can’t even feel it.
I : Okay, but would you have any concerns?
R : I wouldn’t have any concerns.
I : Why do you think a close friend might have concerns about the level of protection?
R : The problem is understanding it. I also did not understand it from the start but when it was explained to me, I like it.
I : So a close friend can also have such a concern of not understanding it well?
R : Yes.
I : Do you think it has anything to do with the ring being used only for women?
R : No.
I : Why do you think that?
R : I have not understood that question well.
I : You said your friend may have concerns of not understanding about the ring well. My question is, does that concern has anything to do with the ring being used only for women?
R : Yes.
I : Why?
R : Because it is like a secret for women.
I : Is that the reason why it can be a concern?
R : Yes.
I : What level of protection would make you comfortable using the ring, knowing that there is no product that is 100% effective?
R : That question is a bit difficult.
I : Am asking, that level of protection from HIV that would make you comfortable using the ring, what percentage level would you prefer having in mind that there is no product that is 100% effective? I would like you to tell me what percentage would you prefer for DPV ring because it is between 30-45%. Have you understood the question now?
R : Yes.
I : Tell me what percentage would you like?
R : 50%.
I : Given the description on the efficacy of the ring above, how would you interpret it in terms of the level of protection it gives you?
R : Please repeat.
I : As I have explained to you it is between 30-45%, in the level of protection it provides to you, how would you interpret it? Would you say it is fine, or is it low or how would you interpret it?
R : I think it is okay.
I : Some women similar to you reported that the ring is less effective than a condom. Why do you think this is the case?
R : Some ask if this device protects at 30-45%, I ask myself where do the rest go?
I : Is that why it is less effective than a condom because of that percentage?
R : It is effective to some and not to others.
I : What characteristics do you think make certain HIV prevention products more effective?
R : Like the natural condom it’s level of protection is 75% and this one is 35% I wonder what happens to the rest of the percentage.
I : That is the quality of how it is made. Does this mean that a condom is more effective than DPV?
R : It is not because it is also not 100% effective.
I : Is it more effective?
R : It is effective but not more.
I : Describe an HIV prevention method you use and why.
R : One that I use?
I : Yes.
R : For HIV prevention?
I : Yes.
R : I use condoms.
I : Can you tell me why?
R : Because I don’t want to get pregnant now, I also don’t want to get infected with STDs or HIV.
I : Do you think women such as yourself are likely to use the ring with a condom?
R : Yes.
I : Why?
R : They can use them together because I don’t remember being told DPV prevents pregnancy.
I : Do you think women such as yourself are less likely to use the ring together with a condom?
R : Some, not all of them.
I : Why?
R : This is an individual’s choice you cannot force someone to use it.
I : Would you be concerned about the ring’s efficacy if you were to use the condom more frequently?
R : I wouldn’t have any concerns.
I : Why?
R : I just wouldn’t.
I : At least you would have a reason as to why you wouldn’t have any concerns.
R : Because there is no effect. Any product with an effect is the one that would make me have concerns.
I : Some women such as yourself use other methods to protect themselves from HIV such as PrEP and PEP. Have you heard of these methods before?
R : I have never thought of using them before since these are pills and I don’t like taking pills.
I : How did you learn about them?
R : We were taught when I went to the clinic to test for HIV, we were three of us so we were taught about PrEP.
I : So you understand that PrEP is a daily pill for prevention of HIV and PEP is the one taken after you are exposed to the risk of contracting HIV and is taken for a month?
R : Yes.
I : Have you ever used any of these two products?
R : No.
I : Why not?
R : Am afraid of medicines so what would make me use them is what am preventing myself from, HIV.
I : We are on another section on inserting and removal process. As described above, women get to insert the ring either by themselves or with the help of a medical professional. The ring needs to be inserted and removed every month and replaced with another ring. Some of the women we talked to such as yourself shared that they did not like the ring because of the need to insert and remove it.
Why do you think some of these women are concerned about inserting the ring?
R : (incomprehensible)
I : Kindly speak up.
R : Am saying, maybe this month has passed and you forgot that it should be removed, that could be the reason.
I : You’ve said it’s due to forgetting?
R : Yes.
I : Do you have similar concerns with the process?
R : No.
I : What are you worried about?
R : I have no worries.
I : What would make you feel more comfortable with ring insertion and removal?
R : It’s not painful while inserting or removing it.
I : Would you say you are more worried about inserting the ring than removing the ring?
R : The only worry would be if the person who inserted did not insert properly and you had sex with your partner who has a huge penis and he pushes it farther inside so you would put your hand far inside to remove it.
I : Are you worried about the ring having some repercussions if not inserted or removed properly?
R : Yes.
I : What would you be worried about.
R : It’s what I’ve told you about.
I : Is there any other worry apart from that one?
R : No.
I : Where do you think is an appropriate place to insert the ring?
R : At the hospital.
I : Do you have access to such a place?
R : Yes.
I : How does privacy factor in your decision about where to insert?
R : The doctors know where they are supposed to insert and there’s a difference if inserted by a different person.
I : A medical professional would be able to help with the insertion and removal of the ring. Which type of medical professional would you want to support you with the insertion?
R : Doctor.
I : What is their medical specialty or position?
R : Professional.
I : What kind of professional is this? There are different kinds like nurses, pediatrician, family planning doctor, gynecologist, etc. which one would you prefer?
R : The one who deals with the DPV.
I : For family planning or a nurse or gynecologist?
R : Family planning doctor.
I : Preference for male or female?
R : Any can do.
I : Where would you like him to do this?
R : In a private room at the hospital.
I : Some women were still uncomfortable with inserting and removing the ring, even after they were shown by a medical professional. Do you think you would share this concern as well?
R : No.
I : Why do you think such women would still be uncomfortable with this?
R : It could be maybe they have not been shown how to do it but if shown they wouldn’t have any concerns.
I : Some have concerns even after being shown how to insert and remove.
R : It all depends on a person’s level of understanding.
I : I would like to ask about risks of HIV contraction. From the women we talked to such as yourself, we were able to observe that a lot of women think they are at a low risk of contracting HIV. However, these same women are not as keen on using a condom, knowing their HIV status and that of their partner or even getting tested.
Do you think you are at a low risk of contracting HIV?
R : How? When you are using this ring?
I : Not necessarily but generally do you think you are at low risk of contracting HIV?
R : Yes.
I : Why?
R : Because am using these protective things.
I : What type of protection?
R : Condoms.
I : What do you think makes a person at risk of contracting HIV?
R : Maybe a condom may burst.
I : Would you want to use the ring given that you are at a low risk of contracting HIV?
R : Yes.
I : Why would you like to use the ring?
R : I would like to use both.
I : Why?
R : Because they are both protective and they have no effect, and even if you use two condoms at a go there is no effect.
I : Why do you think some women such as yourself are not taking any measures to protect themselves yet think they are at a low risk of contracting HIV?
R : That depends with a person.
I : Depends with a person how?
R : If one is not using protection how will their risk remain low?
I : That brings us back to my question why do you think such women or someone thinks they are at a low risk of contracting HIV but they still don’t want to use protective measures. Why do you think such women don’t want to take these measures to protect themselves?
R : Maybe they trust their partners.
I : Some women mentioned that they are at a high risk of contracting HIV but are not as keen on taking up the ring if it was offered to them. Why do you think they are not interested in the ring?
R : Because they don’t understand it.
I : If they understand more about it that is when they’ll use it?
R : Yes.
I : We are going on well. We are now on perceived stigma section. From the women we talked to such as yourself, a majority were really interested in using the ring. However, some women felt uncomfortable sharing that they are using the ring with others such as their partner and friends. Some of these women felt that these people might think negatively of them out of them using the ring.
Whose opinion about your ring use matters to you?
R : My own opinions.
I : What are some of the positive attitudes or perceptions that can come from other people knowing you are using the ring?
(Long silence)
Opinions are what people would think and about you. What are the good thoughts people would think knowing you are using the ring?
R : That am protecting myself.
I : Is there anything else?
R : No.
I : Who do you think would have these positive perceptions of you?
R : My friends.
I : What negative attitudes or perceptions do you think women such as yourself would experience from using the ring? We have talked about the good thoughts from people, how about the bad thoughts people would think knowing you are using DPV ring?
R : I don’t know what they would think.
I : You can say anything you think they would say, just as you said how they would think positively. What negative thing do you think people can say?
R : People have to talk.
I : What do you think they would say?
R : (Incomprehensible)
I : Please speak up.
R : Maybe they would say that thing/device is not good.
I : Is there anything else they might say?
R : No.
I : Why do you think you and other women might experience these negative attitudes/perceptions?
R : Because they don’t know it.
I : Is this the same case when you use other HIV prevention products? Like how you said you use condoms, is it the same case?
R : It can be the same as when you are using a condom.
I : As in people’s opinions can they be same as when you use a condom?
R : No, it can’t be same.
I : Why not?
R : A condom protects up to 75% and this is 35% so there is a big difference.
I : Is this the reason why they would give the negative opinions?
R : Yes.
I : Do you think any of these negative perceptions of people about you using the ring make you want to change anything about your life?
R : No.
I : Why not?
R : I wouldn’t want to change my life because of other people. My life is my own and theirs is their own.
I : A lot of women specifically mentioned that others would think they were promiscuous if they knew they were using the ring. Is this a concern for you?
R : That is none of my concerns.
I : Whose opinion about your rings really matter to you?
R : My own not anyone else’s.
I : What type of people in your community would generally hold this view?
R : Whoever likes can support me.
I : So you do not know whether it’s friends or family, whoever wants can support you?
R : Yes. Those who wants can support me and those who don’t can stay.
I : How would you tell others that you are using the ring?
R : I would tell them it’s benefits.
I : Is there anything else that you can tell them?
I : I can as well tell them that you do not have to be promiscuous to use it.
I : How would you tell your friend? Would you tell them over the phone, would you send someone to tell them or talk to them face to face?
R : Face to face.
I : Do you your friends are more likely to tell others about the ring?
R : Yes.
I : Why?
R : They can tell them because some don’t know about it, others don’t understand it well and others would like to see how it looks like.
I : How would you tell your partner?
R : I would tell him it doesn’t have any effects, as much as it is inserted it is safe.
I : Do you think your partner is more likely to tell others about the ring?
R : If he finds it is good he can tell others.
I : How does a typical conversation go when you want to use a condom with your partner?
R : It goes fine but sometimes we argue.
I : Can you please tell me how the conversation goes?
R : Sometimes he doesn’t want to use but I want to use.
I : If your partner disagrees, how do you respond?
R : I try to convince him.
I : How do you convince him?
R : I would tell him that it is not necessary for a person to be promiscuous to get infected, you can get it even in other ways like rape.
I : Is there anything else?
R : No.
I : Are you likely to share with your partner that you are interested in using the ring?
R : Yes.
I : What makes you comfortable or confident to do this?
R : I can be confident because it won’t hurt either of us.
I : How would you feel if your partner asked you to use the ring?
R : I would feel very good.
I : Why?
R : Because he minds about my life.
I : How would you introduce or tell your partner about the ring for the first time?
R : The first time I will have to have it in my hand so I can better explain about it.
I : How would women feel and act if they were more aware that the ring cannot be detected by their partner?
R : I would be okay with it.
I : How would you feel if your partner found out you were using the ring?
(Silence)
If you have not told him that you are using DPV ring and then he finds out you are using it, how would you feel?
(Silence)
Hello?
R : I wouldn’t feel anything because there’s nothing I can do if he finds out.
I : How might you expect him to react?
R : I expect him to accept.
I : What if he doesn’t accept?
I : That is up to him.
I : Would you have anywhere to store or dispose of the ring to avoid your partner knowing you are using the ring?
R : I have not understood that question.
I : Where would you dispose so that he doesn’t find out, or if you have an extra one for the following month, where would you store it so he doesn’t find out.
R : A place that only me knows and has access.
I : Like where?
R : In my bag and after I use I dispose it in the toilet.
I : Do you think other women have experienced some form of violence from their partner?
R : Maybe.
I : What type of violence is this?
R : I wouldn’t know.
I : How about physical or emotional violence?
R : Maybe physical.
I : Have you experienced any of these types of violence with your partner?
R : (chuckles) yes I have ever experienced it.
I : Has he ever beaten you up?
R : Not beating me, but we seriously quarreled.
I : Of the times you have experienced this, what led to it?
R : It was a misunderstanding.
I : Did you take any action after experiencing this?
R : No.
I : Do you think by using the ring, you are more likely to experience any form of violence from your partner?
R : There is a possibility.
I : Why?
R : He may think that by using the ring it could be an avenue to become promiscuous , which would lead to an argument.
I : We are on our last question. Some women are certain that their partner is unfaithful. Why do you think many may feel this certainty?
R : To me, you can’t trust a person you are not with 24/7. You can’t know how or where he is going.
I : Is this the reason why you may be certain he is not faithful?
R : Yes.
I : Thank you for your time today, I just have one final question. Is there any advice that you would give us around information or messaging about the DPV ring?
R : I am grateful for bringing us a device that is good.
I : Thank you again, it has been very helpful for us. The project has learnt a lot about how we can design and develop a communication strategy that will suit end-users like yourself and your feedback will go a long way towards achieving that. Do you have any questions for us?
R : Yes.
I : Please ask.
R : Are they available?
I : They are not yet available here in Kenya, that is why we are conducting this research in order to know whether many women would like it or not. If we find out a big number will like to use it, it will be delivered and be made available.
R : Okay.
I : Is there any other question?
R : No.
I : Okay, have a good day!
R : You too.
I : Thank you.