Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)


Community Health and Social Sciences


Diana Romero

Committee Members

Heidi Jones

Laurie J. Bauman

Subject Categories

Public Health | Social and Behavioral Sciences


Multipurpose Prevention Technologies, vaginal ring, pregnancy prevention, HIV prevention, grounded theory, qualitative methods


Heterosexual vaginal sex can simultaneously put women at risk for unintended pregnancy and sexually transmitted infections, such as HIV, disproportionately impacting poor women around the world. Both unintended pregnancy and HIV are persistent public health concerns associated with negative outcomes for mothers, families and communities. The current mix of prevention tools available to women to protect against unintended pregnancy and HIV is limited. Multipurpose Prevention Technologies (MPTs) are innovative products that simultaneously offer protection against pregnancy and HIV. However, MPTs will only be effective in reducing unintended pregnancy and incident HIV if women are willing to use them. With an understanding that product use relies on some level of product acceptability, I designed my dissertation study to produce a conceptual model of women’s acceptability of an MPT intravaginal ring (IVR).

Toward this end, I used grounded theory methodology and multiple qualitative methods (in-depth interviews, focus group discussions and card sort data) with 18-45 year old women in the US, in the context of a Phase 1 trial of an antiretroviral IVR, to explore acceptability of an MPT in vaginal ring form. Concurrent to the conceptual analysis necessary for model development, I conducted a methodological assessment of the three forms of data to increase overall validity and complexity of findings in the new model. I integrated conceptual findings generated from the interviews, card sorts and focus groups with insights generated from evaluation of features inherent to each method.

The emergent model “Dynamic Considerations for Acceptability and Likely Use of an MPT Ring” identified a narrative of acceptability and use that includes three main constructs. The first construct related to product acceptability was “Episodic Factors”, which includes MPT product, use, and sexual encounter attributes that women consider per life episode (e.g. a sexual encounter). A second construct is “The Priority Triad”, which is a core process within the model that drives both women’s acceptability and commitment to use an IVR MPT. This triad describes how women (re)prioritize, (re)shift and (re)balance their acceptability of an IVR MPT based on the dynamic needs of relationships, partners and the self. A third construct describes the “Rationale for Need” of an MPT, based on women’s perceived risk of HIV and/or fertility desires. Women who determine there is no rationale for needing an MPT will be unlikely to use one, regardless of triadic priorities or episodic considerations. The conceptual components of this newly developed model were generally comparable across all three data collection methods, and data triangulation efforts demonstrated strong complementary results.

The new model elucidates the complexity of women’s acceptability and expected use of a vaginal ring for simultaneous prevention of HIV and pregnancy. The integration of multiple qualitative methods adds validity, depth and further insight into this model. Results from this study can inform clinicians and clinical guidelines for improving decision-making about prevention methods that is woman-centered but also partner- and relationship-aware. Product developers should not develop a ‘best’ product, but rather a suite of MPTs that can fit a woman’s needs at different moments in her life. New MPT study designs should consider involvement of both partners; assessment of use during menstruation and sex; and should include women in different types of relationships, with varied perceptions of HIV risk and fertility desires. Study designs that incorporate multiple or mixed methods should embrace the inherent benefits of the respective data collection methods for deeper contextualization and meaning-making of conceptual findings. Future research efforts should test, augment and clarify this new model conceptually, as more MPTs are developed and evaluated and in different populations.



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.