• Exchanges

Method Choice – What’s Your Brain Got to Do with it?

Written by Guest Author Kate M. Guthrie, PhD, of the Alpert Medical School of Brown University and the Miriam Hospital in Providence, Rhode Island.

Ever meet a contraceptive method you didn’t like? Yep, me too. There are a lot of choices out there – some you’ve likely heard about, others you have to go digging to find information on. Even then, providers have their own faves and biases about which women will do best on which methods. This isn’t a criticism: they have lots of experience with this sort of thing.  Sometimes they’re right and other times… not so much.

Here’s the thing that gets my brain in a thought spiral about family planning methods. How does having choices help us consistently and effectively contracept?  Why is one method acceptable and another not? Here’s my bias: There’s a lot we do or want to do or need to do that our brain plays with in secret, but tells us little about. And I think this is true of contraceptive methods. Choice matters because how women (and sometimes their sexual partners) interface with their method matters—especially to their brains.

I’m sure most of you reading this could name the good things and not-so-good things about the current mix of family planning methods available to women.  Oral contraceptive pills? You need to set an alarm: everyday, day in and day out, but no-muss-no-fuss when it comes to sex. Spermicides? Remembering to apply them 15 minutes ahead of time is one thing… leakage and downright “ick” is another… but if you’re not into putting additional hormones into your body, they’re a reasonable option. The ring? I’ve heard way too many stories of the ring flinging through the air and across the room as women try to insert it, but eventually most get the hang of it. The diaphragm? Most young women don’t even learn about it as an option from their providers… and there’s the tedious start-up process with being sized… then there’s the remembering… The IUD? Once you get past the expense and the range of pain issues with insertion… well, it’s not bad. Some guys feel a pesky string, but all in all, very doable.

So, what am I driving at? The user’s experience. I would argue that while development of contraceptive agents that work is critical, the design of drug delivery systems that women can and will use is equally as critical, especially when you consider the ramifications of a poorly delivered contraceptive.

Imagine a world where contraceptive developers had an idea and before getting too far down the rabbit hole into determining its biophysical attributes, they sat down with a group of would-be users to hear about what physical/sensory attributes are important to them. Maybe they even show them a set of prototypes and ask them what they think of them. And then imagine after the meeting, the product developers refine their designs and make a set of prototypes that integrate what they learned and then ask the group if it is an improvement over the last.

Maybe, once they have it narrowed down to two or three designs, they create placebos that would behave as close as possible to the real thing from a physical/sensory perspective—and here’s the important part—ask those same would-be users to try them out. A plethora of questions could be answered long before getting too far down the pipeline (or rabbit hole).  This is what I mean by “iterative design.”

This particular step—of having would-be users actually use prototypes and evaluate them early enough to make a difference—is the piece that has been missing in contraceptive product development. Because actually experiencing it is way different than hypothesizing about it when you’re trying to get solid feedback. In not including this step in microbicide design, we learned the hard way that designing (or re-designing) an HIV prevention product with a belief in “if you build it, they will come” doesn’t work. Too many women with different needs and too many contexts in which they live.

One of the most fascinating parts of how we’ve developed iterative design strategies inclusive of user experience and behavior is that we get surprised all the time. I love surprises! Women are creative. If given the parameters, women can help design. And given what I’ve learned about bioengineers and chemists who formulate these products, they can build just about anything. Put the two in the same room and you have magic!

Spoiler Alert: What scientists and product developers know will work (or think will work) is not necessarily what would-be users are willing to opt in to.

Yes, efficacy is important. But so is effectiveness. And this means paying attention to other elements of the product and its use. The experience of using a contraceptive has to work for the user. We have to remember that we are living and breathing organisms first, thinking organisms sometime after that. Our bodies experience things before we are aware of those experiences. We sense things. We feel things. Both of those happen on a sensory level, a primitive and oftentimes unconscious level. Then and only then, does a user begin to make sense of that experience, to understand what, and how, and even why.  What our senses feel and what our brains think about what the senses feel… is what I call “perceptibility.”  A good product will be designed so that the sensations it elicits facilitate use. Maybe because it feels good. And likely because how it feels makes sense to the user… the kind of sense that’s consistent with use.

The contraceptive product development field’s current lack of attention to perceptibility undoubtedly contributes to the disconnect between the existence of highly effective methods and women not using them (correctly or at all) and risking unintended pregnancy.  I would argue that if we want to see a game-changer family planning method introduced in the next 20 years, we should place serious weight on conducting well-designed user experience (perceptibility) studies, as they may ultimately have the greatest impact on product acceptability and user uptake/continuation.