Category Archives: Research

All by Myself: the Lady Business vending system

All By Myself: The Lady Business Vending System

“All by Myself” is the final poster for my graduate thesis presentation.

Women loathe the invasion of privacy, long waits and bureaucracy that come with conventional health care delivery. Lady Business is a public restroom vending machine that allows a woman to take care of her female health care needs without requiring face-to-face interactions.

She’s the Boss

First I address the challenges women face in obtaining health care, uncovered through interviews and research with 17 women and 6 medical professionals.

Challenge: access

Getting your hands on female health care products can require jumping some hurdles. The Lady Business vending machine puts many self-care tools within women’s reach. Women don’t always have a caring doctor on speed dial, and see making appointments as a burden. Gaps in health insurance coverage also keep women away from clinics and pharmacies for fear of high prices. Women are interested in affordable self-tests and self-treatment so that they can avoid the hassle of dealing with the medical world. Women are also interested in self-care on the go, and asked for mundane products such as underwear and deodorant.

Women say, “Don’t make me go to the doctor” 

“I hate having to go somewhere every month to get birth control. Because that’s what prevents me from doing it.”

“I don’t want to go to the doctor to find out or have to ask ten people, do I have a yeast infection?”

“I don’t want to go to the doctor if I just have a “feeling” something is wrong.”

“I chose antibiotics and urine test strips because I get UTIs sometimes and I don’t want to go to the doctor every time.”

Challenge: time

Using a vending machine simply saves time. Public restrooms at school or work are always open and don’t require a long journey or an appointment. Making phone calls, setting appointments, waiting for exams and prescriptions, driving from place to place are all time-consuming parts of the process that offer the woman little value. Women would rather spend their time getting results and information about their health.

Women say, “I need it right away”

“I want a little shot of water to take the pills, so everything’s in the stall.”

“I’d want to buy emergency contraception and take it right now.

“UTI and yeast infection tests will help me figure out rather than speculate.

“More directions and explaining things better. Simple language. Less medical terms.”

Challenge:  shame 

Women want to take care of themselves without the judgement of others. Stigmas and taboos around female sexuality make many health care transactions so embarrassing, women area them or avoid them all together. Health care providers can’t assist women who don’t come in, and women end up with unplanned pregnancies, untreated infections, or just preventable problems. The vending system is designed to be used without forcing women to face anyone else – no asking, no permission, no shame.

Women say, “Help me hide”

“The bathrooms is private. It’s a good place to pull yourself together and contemplate.”

“I’m to embarrassed to pick up condoms, pregnancy tests or Plan B at a pharmacy”

“Maybe I’m a prude, but I don’t like the sales person knowing my sex life.”

“The self-care kit has to be hideable.”

“I need the packaging to stick in the waistband of my clothes. What if I ran into my boss?”

Why should the vending machine include free products?

Women say, “Free means somebody cares”

“It makes you feel supported to have feminine products available for free”

“Maybe free every once in a while? I always feel such goodwill when they are free on campus.”

“Condoms should be free on campus already, like Free Condom Friday!”

Yes She Can

Vending machine:

Women do not want to be seen buying products, so the vending machine is designed to be used quickly and to keep others from knowing what she buys. The machine is triangle-shaped to fit in the corner of a public restroom, instead of hanging on a flat wall. The woman naturally blocks the narrow front of the vending machine with her body while she’s using it, protecting her transaction from curious eyes. She selects products from a dedicated keypad, instead of pushing buttons close to the products, so it’s less easy to identify what she buys from her gestures. The waist-high dispenser means she can easily slip the product into a pocket or purse without having it be exposed. Swiping a credit card or university ID for payment is less fussy than inserting bills and coins, and allows women to buy higher priced items without worrying about correct change.

Product selection:

Women identified several types of products they’d like to buy from vending machines in public restrooms. Top concerns include treating diagnosing and treating common infections, using contraception, caring for periods, keeping clean and pain relief. Women asked for a mix of medical and convenience items. While most items are available at pharmacies or convenience stores, the process of purchasing them involves a special trip to the store and a face-to-face interaction with a cashier. Women were more interested in products that cater to urgent situations (feeling ill, getting a period, preparing for sex) than long-term use products (pack of birth control pills, antibiotics).

Package design:

Women don’t want to be seen using the products they buy. Lady Business purchases are designed to be used in the restroom stall. Women even admitted they’d rather swallow pills without water while in a stall than go stand at the sink with the package. They don’t want anyone to see the package on the floor, so packages are small enough to be unfolded and used in the lap. Products are adhered to the package with glue so nothing falls out when you open it. Packages designed to be mailed away for lab tests turn inside out to become an overnight envelope.

Self-care kits:

Many health situations women face involve a lot of time wasted spent waiting on others to provide a service. Ironically, the technology used to diagnose and treat many infections is simple enough for a woman to do it herself. In research sessions, women expressed interest in kits to help them deal with urinary tract infections, yeast infections, sex, pregnancy and periods. Believe it or not, women can take urine, saliva, and even blood samples, swallow pills, and apply creams with the best of them.

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Lady Business self-care kits + vending machine

Titles like "Yeast Beast" and "Piss Off" makes ladies smile when they're dealing with annoying health problems.

Just Testing: HPV, HIV, Syphilis, Gonorrhea, Chlamydia test kits for me and you

Piss Off: urinary tract infection test and urinary pain relief

Don't Panic: Emergency Contraception and Pregnancy Test

Yeast Beast: yeast infection test and antifungal cream and pill

Aunt Flow: tampon, pad, pain relief and chocolate

Date Night: condom, personal lubricant, wipes, panties

Self-care kits are designed to be small enough to use in the bathroom stall. The flat interior is perfect for brief instructions like, "eat yogurt. wear skirts. lay around."

The Lady Business vending machine is designed to help women cope with urgent situations - sudden symptoms, unexpected periods, and safe sex.

The box is designed to be flat and easy to hide.

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Full-size cardboard prototypes

I’ve been making quick cardboard prototypes from the small-scale versions I made last week. I’m testing them for ease of use and privacy. I tacked two up in the hallway and invited students to walk up and give them a try.

Medicine-cabinet style design

Cabinet-style vending machine, door closed. The machine remains unobtrusive while not in use.

Cabinet-style prototype, door open. Users would create privacy by opening the door and blocking the interface with their body.

Walk up to the machine, door closed.

Open the front panel to view the products on display.

This prototype blocks the view from one side, but not the other.

Side privacy panel design

Another prototype design, with privacy side panels (inspired by a urinal design)

Quickly buy something and slip it into a pocket.

From the side, people walking into the bathroom can't see what she's buying.

 

A triangular machine fits into a corner to help create a private zone for purchases.

The triangular shape would restrict where the vending machine is placed in the restroom. Ideally, it would be a corner furthest away from the entrance.

 

If you could have a vending machine…

…what would you put inside?

I asked several women to design their own vending machines for public bathrooms during user research sessions last week. Women were asked to imagine there was a female health vending machine in the bathroom at their job or school. I gave the women an empty vending machine template and several products to choose from.

Small group sessions invited women to suggest products for a female vending machine

vending machine template

Blank vending machine template. Women chose eight products for their ideal machine.

The vending machine template is based off the traditional sanitary napkin/tampon design found in most restrooms. I added space for about nine products, a checkout screen, and payment options for cash or credit cards. Many women requested a place to swipe a student ID so they would be able to charge their student health fee and not have a line item appear on their credit card.

A woman selects a pregnancy test and painkillers for her vending machine template.

What are my choices?

The choices of  products ranged from things one can buy at the drug store (testing kits, menstrual supplies) to prescription-only medicines (antibiotics and birth control pills). The range of services (phone support, smartphone app, website) were provided for the second part of the session, designing a self-care kit.

Samples of the products were available to examine. Many women had never heard of UTI test strips, menstrual cups, or the birth control patch.

Their choices surprised me. I had supposed that women would want to get more contraceptive products, like birth control pills, from machines, but interest there was very low. More appealing to women were self-diagnostic tools and treatments.

Products available to stock the "vending machine"

Example of a completed vending machine collage with explanations

What women want

Ten women created vending machine collages. The most popular products were for immediate use — I’m in pain and I want an Advil; I think I have a UTI and I want to know if I’m right; I’ve had unprotected sex and I want to act fast to prevent pregnancy.

Here is the total number of times products were selected:

  • Painkillers: 8
  • Urine test strips: 8
  • Emergency contraception: 8
  • Condom: 7
  • Pregnancy test: 5
  • Personal lubricant: 5
  • Maxi pad: 5
  • Tampon: 5
  • Yeast infection test: 4
  • Yeast infection cream: 4
  • Antibiotics: 4
  • Birth control pills: 3
  • Menstrual cup: 1
  • Wipes: 1

Women added their own products to the vending machine, like underwear, chocolate, female condoms and urinary pain relief tablets.

Anything else?

A blank card called “Anything else?” was popular for adding in other ideas…some of those suggestions (as written):

  • Different sizes of sanitary napkins
  • Tweezers or razor
  • Urinary pain relief tablets
  • Underwear and baggy for dirty underwear
  • Deodorant
  • Perfume samples
  • Advil is what I use
  • Hotline to a doc? (for EC or pregnancy test)
  • Female condom (during sex)
  • Something to induce vomiting (for a club or bar)
  • Gatorade, squirtpack (dehydrated) (for a club or bar)
  • Info about contacting/where/how to contact a medical provider
  • Underwear sounds like a good idea
  • Add a piece of chocolate in the package
  • HIV test
  • Panties

Seems like fresh underwear and information on contacting medical providers were common requests. Perfume and chocolate showed up as mood-lifters to help a woman get through a tough situation. Other random beauty items sprinkled into the mix would be great for convenience but might also have an unexpected benefit: camouflage for customers who may be buying an embarrassing product. If the machine has chocolate, deodorant and emergency contraception, other bathroom users are less likely to assume a purchaser is buying something “embarrassing.”

Women explained why they chose some products and didn't choose others.

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Interviews with women

I’ve interviewed 17 women over the last few weeks. I spoke with each woman face-to-face in the cafe of her choice or via Skype. My notes filled 400 index cards with their stories and observations on topics ranging from health care and contraception to relationships and family. Each woman was unique in her experiences. I am very grateful to these volunteers for sharing their stories and time with me.

400 notecards from 17 interviews

I mixed the notes and sorted across topics we discussed

Major themes emerged, and some surprises

Here are the topics we discussed most often:

  • Pharmacy experiences
  • Health insurance and payment options
  • Prescription vs. over-the-counter drugs
  • Gynecologist visits and pap smears
  • Barrier method contraception (condoms, vaginal contraceptive film)
  • Hormonal method contraception (birth control pills, ring, patch, Depo)
  • Behavioral method contraception (withdrawal, fertility monitoring)
  • Long-term method contraception (IUD, implant)
  • Permanent contraception (sterilization)
  • Emergency contraception and abortion
  • Relationships with partners
  • Talking to Mom and other confidants
  • Public restrooms and vending machines
  • Pregnancy and babies
  • Health issues with breasts, cysts and skin
  • Urinary tract infections
  • Yeast infections
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The dog ate my pill, twice!

What other shapes could birth control packaging come in?

One of the problems with birth control packaging is that you have a one-pill-a-day ration. This is helpful because you have a visual feedback channel to tell you if you’ve taken that day’s pill or not. The blister is either empty or full. But one problem that was identified during my user interviews is that the limited quantity of pills means that if one gets lost, it’s irreplaceable. It also means that the end of the month is a stressful time. As you come closer to the end of your pack, you have to make sure you can get the next pack: a recipe that includes having a current prescription, valid health insurance, and a stocked pharmacy, or on-time mail order service.

Could packaging continue to offer the feedback benefit but avoid the feeling that they are “running out of pills?” One design concept I sketched above is a refill-at-will bracelet. If a vending system or pharmacy could dispense single pills, a woman could fill her 28-day bracelet at her convenience. She’s less likely to start her new regimen late, and she can get replacement pills if her daily dose gets lost or eaten by her dog (true story from an interview).

 

“The technology exists”

I interviewed a physician this weekend to get another perspective on my project research. This doctor is a surgeon with a foundation in family practice. To protect privacy I will not reveal his name, but wanted to make a note of his insights to help strengthen my own understanding of women’s health.

Common complaints

According to the doctor, some common reasons women come into the doctors office are to seek contraception, get treated for sexually transmitted infections (STIs). Younger women have a range of issues around menstrual periods, such as cramping and heavy periods. More mature women seek care for issues related to their children’s health and breastfeeding. Blood pressure is also a concern. Women who are planning a pregnancy also need guidance, such as recommendations against drinking.

The doctor said that studies have shown that pregnant student struggle with grades, and that universities are “not giving women a fair go” by meeting their needs as mothers. One university, Duke, has childcare and a support system for graduate students with kids. He opines that other universities should be embarrased by comparison and should increase their facilities and resources for child family care.

Preventable problems

Access to contraception is a real problem in preventing unwanted pregnancy, according to the doctor. “We have the highest teen pregnancy rates in the developed world. Other countries have worked out that you can make it available and kids will use it,” he said. It’s “crazy” and a “catastrophe” that contraception is not more widely available.

He referenced a study done by “Wash U” where IUDs were offered, along with a range of other options, for free, to 10,000 women and let them choose. They gave them information on each method, and 50% chose the IUD, which has a lower rate of pregnancy than other common methods, like pills and condoms. IUDs last for 5 years, he said, you don’t have to remember to take it every day. “Our system is not educating women about their choices.”

Unintended pregnancy has a high social impact for women, he said. “Pregnancy leads to challenges.” High school and high school grads who get pregnant have a change in their social trajectory, which impacts the next generation as well.

Barriers to birth control include social opinions against public health and women’s rights. Consequences to society are the institutionalization of poverty and a lack of mobility in society resulting from making contraception difficult to get.

On college campuses, smoking cessation and weight gain are also concerns for women. Women aged 20-35 who smoke or gain a lot of weight are at risk for developing diabetes.The tobacco industry is experimenting with promoting smoking on college campuses, he said. “The industry was chased out of marketing to 5-15 year olds, so they changed their focus to 18 and up.”

Student health should “flood the campus with strategies” to help student deal with reproductive issues, smoking cessation, and weight management. Focus on these issues is being neglected, he said.

Self-treated health issues

The doctor mentioned he’d ever heard of “take your own pap smear” tests, which could be useful in parts of world with fewer resources. He said that a self-Pap kit might be “a way to get preventive service to women.” Some STI issues may be moving towards more self-treatment,” he said. Not needing to go through a provider for health care is becoming more common, with treatments for yeast infections and the trends in women opting for home birth. In Mexico and other countries, birth control pills are over the counter.

The doctor said he doesn’t know about any STI equivalent of dipstick test for self-diagnosis you can buy. “The technology is there to be able to do it, but it’s just not in the market,” he said. “You can’t do HIV/AIDS test here but technology is there,” to do the test yourself, he said.

How much instruction does it take for a patient to self-treat a medical problem?

When women go to the doctor for a diagnosis, they usually end up administering the medication themselves, be it a birth control pill, an antibiotic, or a cream. What level of instruction does it take to get the patient to self treat? I asked the doctor.

“We give too much information and not clear enough set of instructions,” he said. “Adherence to medication and treatment strategies is not great. The providers giving instructions are often giving complicated messages when the bottom line is two tablets a day. Don’t go into all the other stuff.”

When instructions look complicated, they’re probably not being followed. The strategy needs to be to “get it down to self-diagnosis and self management. Get more appropriate use of treatments,” he said. For example, with blood pressure, one of the challenges of treating is people not taking their medication. It’s “a lot of work to look at ways to simplify” the instructions. But with the right skills, you could be pushing providers to bring messages down to a simpler level. “These are the three things you have to do.” In the worst cases, like diabetes, instructions can be so difficult to follow, “people give up and don’t do anything.”

Women taking birth control pills

Challenges for women taking birth control pills include forgetfulness and cost, the doctor said. “They know it, they just forget.”

Besides this, problems related to birth control have more to do with timing, which isn’t really related to requiring the pill to be available by prescription. “You don’t need to see a gynecologist to learn how to take a pill every day. The real challenge is can you afford to renew the prescription?”

The costs associated with staying on the pill long term, including health insurance and exams can get in the way of actually continuing month to month. “We’ve made it hard for women, particularly in lower income settings, or those with less insurance” to stay on the pill, he said.

To this effect, I wonder, why can’t women get a lifetime prescription for birth control? Or a 20 year prescription? Why are prescriptions written for 12 months (or less)? Many women stay on their method of birth control for years at a time, even decades. Why insist on regular visits just to continue the method they are using?

Dangers of misuse?

Are there dangers of misuse associated with taking the pill? I ask this because of the way the pill seems to be so tightly controlled. One can usually only get a 30 day supply from the pharmacist. 90 days max. Why is it treated like a controlled substance?

The doctor explains that birth control pill can have risks for certain women, like those who smoke and are over 35 years old. But it doesn’t seem to explain why birth control pills are only available by prescription, since warning labels could be clear on the packaging if it were over the counter.

“If you’re between 35-45, the risk of breast cancer goes up, in part because of age, but the risk is low at 25, no one worries about it,” he said. “I don’t think providers really question birth control use after the age of 35,” so the restrictions are “not meeting a need.”

Why is the pill only available by prescription?

My biggest issue with hormonal birth control methods are that they are only available by prescription, which makes them harder to get and harder to stay on. After all, unlike implants, IUDs and sterilization, hormonal methods are self-administered: take a pill, put on a patch, or insert a ring. The doctor’s answer surprised me.

“It’s a paternalistic, medical view that the provider knows best and can mysteriously be on the lookout for complications, when I don’t think they are.” “It’s part of keeping an income stream going,” he said. Women must see them, call them, and get a Rx. There’s a “Toll along the way for each trip.”

What about pharmaceutical companies? Wouldn’t they be motivated by profit to put birth control pills on the shelves of pharmacies and grocery stores where women can buy as much as they want?

“If birth control was available over-the-counter,” he said, “drug companies wouldn’t be making as much money. So, it’s not in their interest” to push for making available OTC. Once a drug is “over the counter, the price goes down,” he said. Like popular antacid medications that went down in price once they transition from being prescription to OTC, “contraceptions would be in the same boat.”

In his opinion, at the “political level, lobbyists from pharmaceutical companies work opposing over-the-counter availability, since they make more money having a prescription.”

“Compare this to other countries, where you can have contraception over the counter,” he said.

When should a woman come into the doctor and not 

Since my thesis focuses on self-care, I wanted to make sure that I understood the limits of when a woman should be able to handle things herself and when she should really go to the doctor. I asked the doctor when should a woman go for a consultation?

“Pregnancy,” he said. Also in cases where a patient is bleeding, it’s best to see the doctor.

In general, if a woman tries to self-treat a condition and doesn’t see improvement in 3-5 days, then you go see a provider. In younger age group, you’re more likely to be safe going the self-treat route.”

Long term birth control at student health

Implanon - under the skin hormonal contraception

model IUD - rubber simulates the hormones on the main stem

Nuva Ring model - the real thing is translucent

I visited Carnegie Mellon’s Student Health Center and saw some medical models of birth control methods that are less familiar to me: the Ring, the Implant and the IUD. All are available at Student Health. In my interviews of 17 women, I’ve only met one or two who have used the Ring. One woman mentioned she had a friend who took the ring out before sex so her partner couldn’t feel it. (Is this a bad idea?) Another said that she’d had sex with the ring and when her partner came out, the ring was around his penis! She said they’d joke, “it’s a hole in one!”

More effective birth control harder to get

I read the FDA’s guide to birth control for women where various methods of birth control are compared by effectiveness, availability, and use.

The FDA's stunning guide to birth control for women

They grouped birth control methods into categories:

  • Barrier methods (condoms, spermicides),
  • hormonal methods (pills, rings, patches),
  • emergency contraception (the morning after pill),
  • implanted devices (IUD, implanon) and
  • permanent methods (tubile ligation, vasectomy).

What is interesting is that only the some of the barrier methods are available over the counter, with the exception of the morning after pill. All the rest must be administered by a healthcare professional. So, the majority of methods are out of the reach of regular people unless they have access to health care.

Another interesting point was that the change of getting pregnant was much higher with the barrier methods than with the other methods. So prescription-only methods are more effective, and harder to get.

The FDA has a nice little chart comparing effectiveness of methods. They are missing a column, though. Accessibility is missing from the diagram. You can practically draw a line between over the counter and prescription methods and see the jump in effectiveness. Is it ethical that these methods are harder to obtain?

Compare effectiveness, but not accessibility

A quick breakdown of availability and efficiency:

Barrier methods

Male condom, over the counter, 11-16% chance of pregnancy
Female condom, over the counter, 20% chance of pregnancy
Diaphragm with spermicide, prescription, 15% chance of pregnancy
Sponge with spermicide, over the counter, 16-32% chance of pregnancy
Cervical cap with spermicide, prescription, 17-23% chance of pregnancy
Spermicide alone, over the counter, 30% chance of pregnancy

Hormonal methods

Oral contraceptive, prescription, 5% chance of pregnancy
Patch, prescription, 5% chance of pregnancy
Vaginal contraceptive ring, prescription, 5% chance of pregnancy
Shot/injection, prescription, <1% chance of pregnancy
Emergency contraception, over the counter if over 18, 15% chance of pregnancy

Implanted devices

Copper IUD, inserted by doctor, <1% chance of pregnancy
IUD with Progestin, inserted by doctor, <1% chance of pregnancy
Implantable rod, inserted by doctor, <1% chance of pregnancy

So the more available, over the counter methods are much less effective than prescription only methods. Now, for things that need to be injected or implanted, I can see why a trip to the doctor’s office is needed. But for patches, pills and rings, these are dispensed by prescription but actually administered by the patient herself. So the service the doctor is supposedly doing for the patient is screening them for risks and controlling the supply.

Could a women self-screen for risks? The questionnaire for birth control seems pretty straightforward…do you smoke, do you have a history of stroke or blood clots? High blood pressure an uncommon risk, heart disease and stroke are rare.

What isn’t clear is if the women who smoke or have a history of heart disease should avoid the pill completely or if they can still use it but need to keep an eye out for certain symptoms. It seems this information could be made available to patients through a brochure, or a website, like everything else.

The women’s room as a use environment

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I presented a short talk about my thesis project to my Service Design class and looked at the three dimensions of service design according to Gupta and Vajic in “Contextual and Dialectical Nature of Experiences.” The service experience is created by designing three phenomenon: the use environment, the customer participation and the social interaction.

For a self-service design experience, I assumed that social interaction wouldn’t be important, but my professor, Miso Kim, said that for her, as a college student, going to the women’s room was a more social experience. In a meeting today with my thesis advisor, Suguru Ishizaki, he suggested that a social dimension could be important to this project, perhaps as data is collected and shared by users in a website or online forum.

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