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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Are vending machines the answer to female health?

Wow! Vending machines have really been in the news lately, with a special spotlight on Shippensberg University’s health care vending machine. When surveyed, 85% of students at Ship U. responded that they would be interested in a vending machine at their student health center. Students buy hundreds of doses of emergency contraception from the machine each year. Pregnancy tests are also available. According to their website, they’ll be adding condoms to the machine soon. The school released a statement on their website about the availability of Plan B to their student population, and why they chose the vending machine system.

Lady Business

It’s exciting to see this idea in action in the real world! Back here at CMU, I continue to work on my thesis project developing a female health care vending machine design. Over the past few months, I’ve nicknamed my self-service healthcare concept “Lady Business.” I recently presented the Lady Business project at the  TEDxCMU finalist auditions here on campus. I didn’t make the final cut, but it gave me the opportunity to share the project with a group of students from other majors, and I wanted to share it here online. The model in the images is Loretta Neal, a fellow design student.

The idea

The idea for Ladybusiness came to me last summer as I was hiding in a small room at work, making secret phone calls to my nurse practitioner back home. I was trying to convince her to refill my prescription for birth control pills. My prescription from last  year prescription had run out, I was in a new city doing a summer internship, I didn’t have a local doctor, my health insurance had just changed, and the pharmacy nearest to me closed early.

Current vending machines offer up tampons and pads, but what else could go in the machine?

Between all the phone calls and time spent on online with my health insurance company and doctor’s office, waiting for my insurance to go through, and getting to the pharmacy before it closed, it took me three weeks to get my hands on a pack of birth control pills. I thought, “My god, shouldn’t this be easier?”

Thesis research

So, I picked this as my thesis topic and started doing research this fall. I interviewed women to find out what experiences they were having with their health, and it turns out, I’m not alone. Women told me their stories of visits to the gynecologist, trips to the pharmacy, problems  with health insurance and their experiences with common infections like UTIs or yeast infections.

Digital prototypes of what a female health vending machine could look like

During these interviews, I heard over and over three major issues that women were facing in these situations:

400+ notecards written during over 20 interviews

Having to overcoming barriers to access care, ranging from problems with administrative bureaucracy, cost, having no insurance or being dependent on someone else, which compromised their privacy. Mom knows when a young women on her parents’ insurance goes to the gynecologist because the explanation of benefits gets mailed back home. Some women end up going to Planned Parenthood and paying in cash instead of using their own health insurance. So, they have insurance, but it compromises their privacy to use it. Some women don’t have insurance at all, and therefore don’t really have access to contraception bedsides what they can buy on the drugstore shelves, which are one-time use barrier methods, like condoms. They aren’t able to access more effective, long term methods because they require prescriptions.

One woman told of a day when she was getting a haircut and her hairdresser seemed unusually upset. The hairdresser eventually apologized and said she was suffering from a very bad UTI, but her doctor refused to give her a prescription for antibiotics until she came into the clinic for a urine test, despite having had UTIs in the past and knowing the symptoms were. The woman, unable to leave work, had to spend the day giving haircuts in extreme pain.

The burden of time, from having to take time off of work or school to make appointments, getting to a clinic, waiting in waiting rooms, exam rooms, pharmacies, or for the mail to hopefully arrive on time. Taking care of your health means going through a complex system in which you must rely on others to give you what you need, and that takes time.

One CMU student reported that she went to student health twice in an attempt to get birth control and eventually gave up, because they wanted her to make a third appointments for a full exam. Another woman says she feels like she’s playing Russian roulette every month when she receives her birth control pill in the mail, because if it arrives late and she misses a few days, she experiences pain. She’s one of 14% of birth control pill users who take it for therapeutic reasons.


Feelings of shame are felt by virtually every woman when she has to face another person to ask for what she needs. Women talked about fear of being judged at the cash register at the pharmacy to buy condoms, even tampons! Women feel ashamed when dealing with health care providers that they feel don’t listen to them, or when they feel their privacy isn’t being protected in a place like a pharmacy. One woman was horrified when she went to a pharmacy to buy, and the pharmacist went around to every other person working in the pharmacy to check and verify if it was okay for her to buy two boxes. She left with about four or five people knowing that she needed EC. Another married woman told me every time she buys condoms, she’s afraid that the cashier thinks she must be running around on her husband! Some women say that they’ve discovered that the self-checkout at the grocery store is the best way to buy female products to avoid the unpleasantness of a face to face interaction. Fear of facing a cashier makes taking care of your female health needs unpleasant for many women.

Attitudes, not science

The protective barriers put into place to prevent women from having access to medicine and contraception make it difficult for women who need it to obtain care. The paternalistic attitudes of healthcare community are not science-based. 

Doctors treat ladies like “damsels in distress” who need to be protected and monitored. This attitude creates a hindrance for women who want to decide for themselves. Some pharmacists think women can’t handle the drugs without their help and control. During interviews, they expressed Irrational fears such as people “gobbling down the entire pack of pills,” or “Someone will find out a UTI treatment has antibiotics and they’ll buy it and take it for the sniffles.” These silly fears are used to keep medications under lock and key. In Australia, birth control is available over the counter with a blood pressure check and medical history. In the US, often a pelvic exam is required.

A Customer Journey

Let’s look at a typical customer journey for a woman who wants oral contraception. She makes her decision, then begins the search for a provider. She’ll call a clinic or make an appointment online and hopefully schedule a visit a few days or weeks away. She’ll then drive down to the clinic, wait in a waiting room, have a pelvic and breast exam, pap smear, medical history discussion, and then the doctor will select a prescription for her and give her a piece of paper with the name of the pill, granting her permission to go get the pill.

She’ll then drive down to the pharmacy, where she’ll drop off her prescription, wait, and then pick up 28-day supply of pills. She’ll either pay with her insurance, which limits her supply to 1-3 packs at a time, or if she doesn’t have insurance or her insurance doesn’t cover birth control (as is the case with two women I interviewed), she’ll pay out of pocket, anywhere from $10-70/pack.

After a year, her prescription will run out and she’ll have to return to the clinic to have another exam and request a new prescription. The idea of this system is to screen women to prevent contra-indications, or negative side effects. But because the pill has been in use for so many years, and is taken by so many women, it is generally considered safe for healthy women under 35 who don’t smoke. Serious side effects are rare. So, the protections become a barrier for women who don’t have access to this kind of care, and it places a very high burden on the woman to keep up with this level of care in order to stay on the pill.

To put this in perspective, women have 30 child-bearing years, but most contraceptions are designed for one-time use like condoms, or supplied for one month at a time, like pills. To avoid an unplanned pregnancy, this means dozens to hundreds of trips to doctors and pharmacies. More effective birth control is harder to get, because hormonal methods are available by prescription only. What are the consequences of making birth control hard to get? 50% of pregnancies in the US are unplanned (CDC). 

So, in this journey to get an everyday contraception like birth control, the woman deals with several people she makes trips to several places and she takes time out of her day. This is not just about birth control, women have to go through the same routine for common infections, like urinary tract infections or sometimes yeast infections. There are many obstacles that make these journeys difficult  or impossible for women to get care. But I think it doesn’t have to be this way.

Vending machine solution 

Let’s take another look at these vending machines. First, they’re found in public bathrooms everywhere, at work, at school, in shops and restaurants…everywhere women already are. There’s no phone call to make, no driving around, no special hours, no appointments, permissions or conversations. To find one, you just have to go to the ladies’ room. So, the biggest advantages of these female product vending machines is that they already exist. It’s a place women can enter and leave at their convenience, it’s not a separate trip, it’s women-only and anonymous.

So, what is this vending machine all about? Well, we’re all familiar with the big, clunky vending machines we see in public bathrooms. They’re everywhere, especially in women’s restrooms, but if you’re like most people I’ve talked to, you rarely use them. My idea is to re-claim this small vending space and re-design it, to dispense a variety of women’s high quality healthcare products. I’m proposing a radical departure from the current healthcare system that requires women to make doctor’s appointments and go to pharmacies for needs as simple as birth control pills, treatments for urinary tract infections, some treatments for yeast infections, that are designed to facilitate self-diagnosis, self-treatment, contraceptions, as well as products for the period.

Customer journey with vending machine: Woman enters the restroom, she scans the range of products available. If she has an infection, she takes a free testing strip and can walk into a stall and test herself. If its a quick urine test, she may be able to see results in a few minutes, then proceed to follow the instructions in order to pick a treatment from the machine and take it on the spot. If its a test that must be cultured, she can put it into an envelope and mail it away for test result. She could them receive a response from the lab and instructions on what treatment to buy or if she needs to go see a doctor. If she’s buying contraception, she could read a brochure to self-screen for the best method, or just refill her usual brand. If she prefers a long-term method that requires insertion by a doctor, like an implant or IUD, she could purchase it from the machine and take it to the doctor at her convenience. Again, instructions could come from several places: there could be a phone number at the machine to call for guidance, there could be free instruction sheets to help guide purchase, or there could be a website 

Self-care for women 

Let’s make things clear. What I’m proposing is a radical departure from the current health care system in the US. My project proposes to make many prescription-only treatments over-the-counter in order to make them more accessible to women. You see, the problem with restricting things like birth control pills, antibiotics, and other prescription products, is it denies the women a chance to consider a range of options and make an informed choice. Instead, a medical provider is making the choice for her, with drugs that are unfamiliar to her and aren’t designed and packaged for consumer use. Therefore, women sometimes feel like they’re flying blind when it comes to selecting contraception because they can’t see the choices in front of them. Or they feel frustrated and helpless when they have a UTI or yeast infection and can’t get treated until they see a doctor, even if they know what they have.

Women aren’t able to buy antibiotic treatments over the counter for common infections like UTIs, yet often it only takes a series of questions to determine if a woman has one, and can be diagnosed over the phone with 90% accuracy. However, some doctors insist on women coming in for a lab test before prescribing treatment.

Now let’s talk about the concept of self-service. Once upon a time, you had to ask someone for help to make a phone call, pump gas, buy a plane ticket, or take a pregnancy test. While many services have been converted from a personal service to a self service, health care for women remains very dependent on permissions, gatekeepers and access to expensive insurance, and healthcare providers. By converting the most common female healthcare needs into a self-services, a woman saves time, encounters fewer barriers to care, and doesn’t have to face anyone to get the products she needs.

Packaging could make it easy to test, treat, and refill on women’s health care supplies. Packaging could be an educational tool to help guide women’s choices. Women in Mexico are more likely to use birth control pills since they’re available over the counter, but they’re less likely to be on the right type of hormone mix. This is an issue that needs to be address in the way medicine packaging is designed for the consumer. Women should be able to self-screen for contraindications. In fact, it seems a woman is more likely to be honest when asking herself questions versus being asked by a health care practitioner — avoiding what’s known as “courtesy bias,” or responding “no” to questions about health conditions that could be used as a barrier to receiving the desired treatment.

Instructions and packaging are an important part of the design, because women will need to know how to select the method that’s right for them. Instead of a health care provider picking it out, the woman herself selects the method based on her lifestyle, age and health history. Tools could be developed, such as questionnaires, to help guide the woman’s choice, and advise her on what to do if she’s unhappy with her method. Contraceptions that are not self-administered, such as implants or IUDs could also be sold, then brought to a health care provider for insertion. Having the choice in front of her makes a woman aware of the variety of methods and puts her in control of what she uses and when.

Women in India are less likely to use condoms because of shame of buying them from a pharmacist. (Guttmacher)

Women under 18 who get pregnant are less likely to finish high school, yet legislation prohibits them from using Plan B without a prescription. (news source?)

What could go inside? 

Lady business vending machines could stock a range of female products, designed to inform and educate a woman on doing what’s right for her body. Self-diagnosis and treatment kits could be created for common infections, STIs, using simple dipstick or swab tests. The technology for many of these tests is very low-fi, and could involve taking a test strip into a stall, using it, and seeing results in minutes, then following advice to purchase a particular treatment, right there out of the machine. Test strips could be free, so you only buy the meds you need.

Oral treatments for yeast infections (Diflucan) isn’t available over the counter in the US, but it is available over the counter in Italy. (source: personal experience)

Contraceptions such as birth control pills, patches, rings, condoms, female condoms and other self-administered barrier and hormonal methods could be sold from a vending machine. In many other countries, hormonal contraceptions like pills are already sold over the counter. An advanced care clinician at CMU’s student health clinic said that foreign students who come here are often surprised they have to come in for a medical exam and a prescription just to get birth control. They’re used to getting contraceptions over the counter.

Women with a range of free choices of contraception are more likely to pick IUDs over other methods, 50% opted for IUDs in a Wash U study.

Women with a larger supply of birth control pills at home are more likely to stay on their prescription over time. (Source: Obstetrics & Gynecology) Yet insurance companies limit how many packs they will pay for at once, usually a 30 to 90 day supply. Some women use birth control pills for years at a time. Some for decades at a time. 

Conclusion 

I am seeking to push change in attitudes about women’s health. The vending machine concept questions the wisdom of the current state of women’s health care. My project proposes a possible future where we shift to a low bureaucracy model of health care for everyday needs. It focus is on educating the woman herself, and putting her in control of her health care. The vending machine isn’t designed to conform to the restrictions and bureaucracy of the current model, but is a proposal to change the model of care.

***

Sources

Guttmacher Institute

ISIS

Planned Parenthood

Personal interviews with 17 women and 5 health care providers

FDA

Academic studies

Articles and related topics

New study shows over-the-counter birth control improves usage

Contraception: Unintended and Teen Pregnancy | CDC Reproductive Health

Do Patients Understand?

Infographic: A Picture of Women’s Health – Health – GOOD

Should the Pill Be Sold Over the Counter? – The Daily Beast

ScienceDirect – Obstetrics and Gynecology Clinics of North America : Family Planning American Style: Why It’s So Hard to Control Birth in the US

Academic Medical Centers: Ripe for Rapid-Learning Personalized Health Care

A Zero-Cost Way to Reduce Unintended Pregnancy : Ms Magazine Blog

Contraceptive Comeback: The Maligned IUD Gets a Second Chance | Magazine

For Women > Birth Control Guide

FDA Flags Concern on Birth-Control Pill – WSJ.com

Over-the-counter birth control ‘not imminent’ in D.C. | Leah Fabel | DC | Washington Examiner

The Birth Control Pill Should NOT Be OTC — 5 Reasons Why | The Stir

Gel Cuts Herpes Risk in Women, Study Finds – NYTimes.com

At Walgreen, Pharmacists Urged to Mix With Public – NYTimes.com

Physician Dispensing – InstyMeds / Outpatient Medication Dispenser

Longer supply may help women stick with the Pill

Photo credits
Photographs by Jessamyn Miller except where noted below.
Model: Loretta Neal

Dependency: http://www.flickr.com/photos/36011007@N04/3945435028/ 

Work: http://blog.bioethics.net/2011/10/skin-cancer-your-hairdresser-and-you/

Insurance: http://www.srortho.com/patientinfo/insurance.html

Waiting room: Copyright Carl R. Darnall Army Medical Center, http://www.flickr.com/photos/crdamc/6350013423/sizes/z/in/photostream/

Urinalysis: http://www.sanctuarywellness.com.au/diagnostic_tests/urinalysis.html

Vending machine: http://www.flickr.com/photos/specialkrb/3397007256/

Reception desk: http://www.mlive.com/news/kalamazoo/index.ssf/2009/06/open_house_at_planned_parentho.html

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Lady Business

Self-service healthcare in the women's restroom

On December 16, I presented my thesis poster, “Lady Business.” The poster reviews my research, design ideas, prototypes and approach. Responses varied from horrified to enthusiastic about the idea of putting women’s health care products into a vending machine.

Lady Business

Self-service healthcare in the women’s restroom

This could be easier

This project began after it took 3 weeks for me to obtain a pack of birth control pills this summer. My prescription had run out, my insurance changed, I was living in a new city, and I didn’t have a doctor to see. While hiding in the phone booth at work to call a nurse I thought, why is this so hard?

Dream machine

I started daydreaming that I could buy my birth control pills from a vending machine in the restroom. Soon, I became interested in using my thesis project as a piece of design rhetoric. By showing an easier way, I want to argue that the current system is too burdensome.

Research

OBSTACLE COURSE

Do I have to?

Getting care for your female needs is time consuming, can sometimes be embarrassing, and may require access to health insurance, a clinician or a pharmacy. No matter her situation, one of these issues will affect a woman’s care experience.

Weird looks

Women fear being judged when they walk up to a counter to buy virtually any female product.

FLYING BLIND

Information, please

Interviews reveal women often deal with their care in isolation from their peers, and rely on scraps of information from doctor’s visits, commercials and hearsay.

Low visibility

Because many contraceptions and treatments for common infections are available only by prescription, women don’t often see their full range of choices.

DAMSELS IN DISTRESS

On the loose

Doctors speak about women’s health in tones of fear, saying common contraceptions and treatments are “dangerous” and subject to “abuse” if made widely available. In reality, serious side effects are rare and the consequences of not having access to care are much more severe.

Too much faith

Some providers believe women aren’t educated enough to handle self-care. But women say, “Nobody knows my body better than me.”

Ideation

ENVIRONMENT

In the ladies’ room

So how can women get the care they need without the hassles of the current system? Well, the answer is hanging on the wall of a women’s restroom near you. Yes, the humble and archaic feminine product vending machine.

We have the technology

The women’s restroom offers several advantages. It is public and accessible to women as they go about their day. The space is inherently women-only and anonymous. Vending machines are ubiquitous but under-used.

On the spot

Buy what you need and use it right away, even if you’re away from home.

PRODUCTS AND PACKAGING

Self Diagnose and treat

A sample testing and treatment kit for urinary tract infections (UTIs).

What a pill

Refilling birth control pills is a pain. Refill‑at‑will packaging could be topped up when you’re running low.

Prototyping

What’s next

In a second round of user research, I plan to ask women to assemble their ideal self-care kits for treatments and contraceptions. After they assemble the kits, they’ll stock the vending machine prototype and place it in a bathroom mock up.

Futurism

“Proposals” not solutions

Roberto Verganti said, “We do not look at the market, we make proposals to people.” I am proposing a future scenario for women’s health. This design isn’t about designing a solution around every medical regulation that exists today.

False Evidence

This project aims to suspend disbelief and ask viewers to imagine women’s health care as a selfservice. My prototype is presented as a possible future, meant to convince the world that this is a problem that needs solving. Women and care providers don’t question the system, even though it isn’t ideal for many. Rhetoric is needed to push women out of their “This is just the way it is” mindset and towards new models of care.

Jessamyn Miller
MDes candidate 2012
Communication Planning & Information Design

Graduate Thesis
December 2011
Advisor: Suguru Ishizaki
Carnegie Mellon University

Presentation

I presented the poster formally to a group of three design faculty members, Nick Durrant, Bruce Hanington and Terry Irwin. Here are my talking points:

Lady Business: the self-service female health care vending machine

  • My motivations for starting this project.
  • This is design rhetoric, not simply a solution. I am seeking to push change in attitudes about women’s health.

Research findings

  • The biggest problems women face in getting care are time, access and shame.
  • The “fear of the cashier” is ubiquitous in any health care purchase.
  • Women have 30 years of fertility and are given contraception in 1-day to 28-day doses. This means dozens to hundreds of trips to doctors and pharmacies.
  • Making decisions alone. Women feel like they are “flying blind” in how they select and use female health care products.
  • The choices aren’t in front of me. How can I know my options unless a health care worker recommends something?
  • Doctors treat ladies like “damsels in distress” who need to be protected and monitored.
  • This attitude creates a hindrance for women who want to decide for themselves.
  • Pharmacists think women can’t handle the drugs without their help and control.
  • Irrational fears such as people “gobbling down pills” are used to keep medications under lock and key.

Ideation

  • The women’s restroom is a good spot to buy women’s health care products.
  • It’s a place women can enter and leave at their convenience, it’s not a separate trip, it’s women-only and anonymous.
  • Packaging could make it easy to test, treat, and refill on women’s health care supplies.
  • Packaging could be an educational tool to help guide women’s choices.

Prototyping

  • Next round of user research will be to have women participants assemble self-care kits and vending machines.

Futurism

  • This is a proposal, not a solution.
  • This represents a possible future.
  • The goal is to question the current state of women’s health care.
  • The project is not meant to create a perfect system for today.
  • Isn’t meant to conform to the restrictions and bureaucracy of the current model.
  • This is a proposal to change the model of care.

 

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Self-service female health

Vending machine

A page from my sketchbook with my idea of one-stop lady health shop! March yourself over to the nearest vending machine in the public restroom and buy anything from birth control to testing kits and prescriptions. Get clear instructions on how to test yourself for common infections and take the treatment on the spot. We’ve put a man on the moon, can’t we help a girl treat her UTI?

Buy what you need in an anonymous, women-only environment

Self diagnosis and treatment kit

Inspired by the simple packaging of Help medicine, I sketched what an ideal test kit could be: diagnosis and treatment in one. No running around from doctor to pharmacy to find out you had a UTI (duh) and getting your antibiotics. Let’s package them together with the test so you can have a kit on hand when an infection strikes.

I'd rather diagnose and treat myself in privacy than run from clinic to pharmacy with a burning bladder.

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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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First vending machine prototype

image

image

This is the first idea for my vending machine for self-service women’s heath care. The first side shows the typical vending machine of today. The second side shows the vending machine of the future.

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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).

 

Over-the-counter Diflucan…in Italy

Italian packaging of Diflucan. Two doses for 7 Euros.

One of the only over-the-counter (OTC) self-treament regimens available for American women is yeast infection treatment. Unfortunately, OTC yeast treatments are strictly topical, which means 1, 3, or 7 days of creams, suppositories and applicators. Several years ago, I was prescribed Diflucan for a yeast infection by my gynecologist, and I was surprised at the ease of use of this method compared to the discomfort of creams. Yeast infections are so common, it’s hard to believe this easy, oral treatment isn’t available over the counter. Once a woman gets a yeast infection for the first time, she generally knows what’s going on when it happens again. But if she wants the Diflucan, she’s got to make an appointment, have a pelvic exam, get a prescription and go to the pharmacy. Her other option is buying a topical treatment like Monistat or Vagisil.

Last year I had the experience of coming down with a yeast infection while traveling abroad. I went to a pharmacy in Venice and said the word “Candida” which is Latin-ish for “yeast.” To my delight, the pharmacist returned with a box of Diflucan. Hurray! No awkward applicators and messy creams to deal with on my vacation. The box had two doses, so I took one and saved the other. Using Diflucan instead of the topical treatment was easier and cheaper. I didn’t have to go back to my hotel room to take the treatment, I just took one pill and was on my way.

A year later, I felt a yeast infection coming on, and took the other dose right away. My symptoms were gone in a day. I thought, “I’m lucky I have this on hand.” How convenient it would be if things were the same in the U.S.

Too much packaging, not enough value

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Look at all the unhelpful packaging that comes with my birth control pills. Everything but the pack itself goes straight into the trash. The last time I picked up my prescription, I watched the pharmacist take it off a shelf, unwrap the pills from a foil pouch, put it a blue plastic “privacy pouch,” staple paper to it and put it in a paper bag, then into a plastic bag. She then hands it to me, asks me if I have any questions (after 10 years of being on the pill, I say no), and I pay $15. I see absolutely no value to me, the patient, in the exchange above.

In this vein, I have decided that CVS pharmacy will not profit from my monthly obligatory trips to the pharmacy to pick up birth control. Whereas I would usually wait my 15 minutes browsing the aisles and picking up unnecessary products, I have decided to pointedly boycott the absent-minded spending and just pay for the pills, and leave.

“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.”