Recycling Gone Wrong: Condom Re-use as a Design for Equity Problem
By: Annie Hardy
Tags: Health, Design For Good, Design, Health Equity, Birth Control

This topic is exceptionally controversial and decidedly gross. The CDC issued a tweet in July of 2018 about a shocking occurrence in America.

Some Americans are apparently washing and reusing condoms.

“We say it because people do it: Don’t wash or reuse #condoms! Use a fresh one for each #sex act. https://go.usa.gov/xU5vh”

The Tweet has been shared almost 1,500 times, and I’ve seen comments from the general public of shock and disgust. Myriad gifs have been dedicated to responses, which have reached 483 as of February 29th.

However, though this topic is untenable and unpalatable, it should still be taken seriously as a public health issue. Most of us — those who peruse LinkedIn for content and connections — are likely in a privileged place where we wouldn’t ever even contemplate recycling a condom.

But I surmise that action is a choice that people make when they have far harder choices that the majority of us. Food or medicine? Electricity or auto insurance? Clothing for their children or dental care?

Condom re-use isn’t just a public health issue. It’s an issue of designing for equity.

In that vein, this article is written to take us outside of our own discomfort into an intellectual effort to answer a key question:

Why, with the prevalence of free condom programs — some of which deliver condoms straight to your door — would anyone need to preserve one for future use?

Defining the landscape

First off — based on what I can read, neither the CDC tweet nor the associated news articles cite empirical studies that identify the reasons behind why someone would reuse a condom. I sent a follow-up inquiry to the CDC to get more details about the source of this revelation. Their response:

“The tweet was based off information from field staff and on the Do’s and Don’ts of condom use” — CDC Division of Sexually Transmitted Disease Prevention

And in their Condom Fact Sheet, they note that “the exact magnitude of protection has been difficult to quantify because of numerous methodological challenges inherent in studying private behaviors that cannot be directly observed or measured.”

Thus, lacking more empirical evidence of frequency and demographics, I have to make my own inferences based on my research and also my personal anecdotal experiences working in health with low-income populations.

The Demographic of Communities most at Risk for HIV and Disease

As you’re certainly aware, the availability of free condom distribution programs doesn’t mean use across all populations. Populations at risk include those who are uneducated in the efficacy (or lack thereof) of twice-used condoms. The link between low income and low education has been well established, and the prevalence of STDs in those communities as also well established.

“Factors such as poverty, large gaps between the rich and the poor, fewer jobs, and low education levels can make it more difficult for people to stay sexually healthy.” — CDC.gov on Economic Health Disparities

Based on this data, I’m going to focus this endeavor on condom use in socioeconomically disadvantaged populations.

Shadow Mapping: Capturing the Hidden User Experience

There are a variety of outcomes of generative research that explores how people engage with a product, service, process, or solution. Some common frameworks and outcomes used in research projects like this are below, with my own explanation of how I use them:

Personas — segmentation of your audience types that include pain points and measures of success

— segmentation of your audience types that include pain points and measures of success Journey Maps — a map of the journey of consideration or use of a product or service, often including emotional drivers that advance a user’s progress

— a map of the journey of consideration or use of a product or service, often including emotional drivers that advance a user’s progress Experience Maps — touchpoints or that a user experiences through interacting with a product or service during a specific process

— touchpoints or that a user experiences through with a product or service during a specific process Mental Models — tasks that a user is trying to accomplish through a process or journey of considering or using a product or service, and resources they have to meet those needs

— tasks that a user is trying to accomplish through a process or journey of considering or using a product or service, and resources they have to meet those needs Jobs To Be Done — a framework for crafting a deliverable based on micro-goals they have through the consideration or use of a product or service

— a framework for crafting a deliverable based on micro-goals they have through the consideration or use of a product or service Contextual Inquiry — observing a user in their native environment as they navigate a process or use a product or service

— observing a user in their native environment as they navigate a process or use a product or service Generative Research — primary qualitative research conducted by asking individuals many “how” and “why” questions related to the consideration or use of a product or service, designed to reveal processes and emotions

— primary qualitative research conducted by asking individuals many “how” and “why” questions related to the consideration or use of a product or service, designed to reveal processes and emotions Use Cases — stories of how a user interacts with a product or service created by product managers that help a development team prioritize and create features — typically shorter than any of the above scenarios and usually not necessarily linked to user personas

These have myriad applications and outcomes; It can get quite confusing about which to use, and when. Each outcome has strengths and weaknesses, and many can be combined to result in a more thorough deliverable. But for the purpose of this research, we’re going to create what I’m calling a Journey Map — but which is really a hybrid of several of these approaches or frameworks — for the specific use case of socioeconomically disadvantaged citizens in Austin accessing free condoms at clinics. This map will address the various tasks that need to be accomplished, the resources available, and the obstacles to getting the task accomplished.

Condom distribution today

From my research, it seems that the most common means of accessing condoms are community clinics (Federally Qualified Health Centers) and family planning clinics. Many of those organizations receive and give away free condoms through programs like Title X. Although there are some innovations happening in condom distribution that are seeing far more success — like pairing free condom programs with social media marketing campaigns that promote their use, or offering text-message-ordering for free condom kits to be delivered to your door — clinics still reign as the primary resource.

So let’s map out the expected objectives and resources available for socioeconomically disadvantaged populations who need to access a clinic to get free condoms. (Please consider this a high-level example):

Example of a Journey Map of someone trying to access free condoms at a clinic.

From this map, even just looking at the first column, “Find a clinic location,” you can see basic things a clinic needs to do. Clinics and their website links need to be listed on Google Maps. Clinics need to provide flyers at their clinic or other community clinics, promoting free condoms. Clinics need to create social awareness so communities share information with their friends and family.

And typically, this is a sufficient model for designers to understand their audience, and move forward to into design and development of the opportunities that this map reveals. But often, the research is biased based on the researcher’s experience and doesn’t accurately reflect the user’s true perspective. That’s where a shadow map comes in.

Revealing Hidden Obstacles through Shadow Mapping

The difference between a journey map and a shadow map is how deeply you go digging into the hidden obstacles to adoption or activation. For instance, in the case of condom re-use, user research could lead us to establish processes based on our own logical interpretation of our findings. We think and feel that condom use could be addressed by creating clearer messaging in clinics about the availability of free condoms, or creating social awareness campaigns. But we may not think of the complexities of the hidden journey that’s outside of our own experience.

These hidden factors that many researchers don’t often enough explore can — and should — be included in addition to the findings that populate a traditional journey map. And so although our journey map seems a logical reflection of reality, there are some crucial hidden factors not represented here.

In this article, I want to walk through the shadow map that might lead to reused condoms and encourage designers to ask deeper questions that reveal hidden obstacles within their use case.

Cultural Obstacles to Free Condom Access

In more than 3 years as a Community Health Worker, I recognized some key challenges with depending on clinics for distributing condoms. In that role, I spent hours upon hours in community clinics and I’d never seen condoms available outside an appointment.

I wanted to find out more about whether my observations could be anecdotally confirmed by a current community health educator, which is why I reached out to People’s Community Clinic. People’s is a non-profit clinic in East Austin that serves low-income residents with medical services. Upon reaching out to learn more, I spoke with Therin Geeslin, Peoples’ Health Education Supervisor, who validated my concerns with their measurable experience.

Ms. Geeslin and I discussed obstacles to access, some of which are reflected in the high-level example of a shadow map you can see below. Shadow mapping focuses more on those cultural obstacles than the user experience — which can be very far outside of a Designer’s experience and which may not be revealed in audience research.

Example of the Shadow Map of someone trying to access free condoms at a clinic.

As you can see, accessing free condoms at a clinic — again the most common form of access for socioeconomically disadvantaged populations through Title X free condom programs — it’s far more complicated than you might have imaged. The obstacles vary; It’s possible that clinics aren’t on the bus line (especially common in rural communities), getting free condoms requires an appointment…with a 3-week wait times, or they don’t have a car and their ride to the clinic all of a sudden cancels on them. And at any point at all, the entire process to access clinics can be derailed. Users can fail to finish the process. They can fail to use birth control, leading to STDs and unintended pregnancies.

And yes, it might force them to consider re-using condoms.

Key Obstacles

Based on my own accounts working with Medicaid populations, some of the crucial factors impeding free condom distribution include the following:

Requiring appointments — In most clinics, a patient is offered condoms during a doctor’s appointment — they must set up an appointment and show up to even get an offer of condoms. But because setting an appointment with a doctor can take weeks, actually getting in at a clinic appointment is a more challenging method of access than many realize.

When People’s Community Clinic put free condoms in the bathroom, they went from giving away 2 bags a month of condoms to 15 bags, representing an increase of over 600%. They attribute this to the fact that they — unlike other community clinics — no longer required an appointment for patients to access condoms.

Transportation to the clinic — Socioeconomically disadvantaged people are less likely to have transportation, requiring them to take the bus or get a ride to go anywhere. And if they take the bus, a bus ride can take over an hour. Additionally, People’s estimates that 40% of appointments in community clinics result in no-shows, showing that even if you schedule in advance, that doesn’t mean you’ll get there.

Clinic hours — Most clinics operate on the same schedule as other businesses, closing at 5 or 6. Some offer extended hours — but not all. And when you think about the cost of living — minimum wage employees are having to work more than 40 hours a week just to afford housing in many cities. That doesn’t leave much time to make it into a clinic.

Clinic wait time — getting a walk-in appointment in one of those clinics can require hours of waiting, untenable for people who just need condoms. And Ms. Geeslin estimates that setting an appointment at her clinic takes 3 weeks on average, severely impeding the pursuit of finding a quick birth control solution.

Unique challenges of teenagers — “Half of all childbearing outside marriage begins in the teenage years.” How do teenagers get access to birth control if their parents don’t know they’re having sex? Is there a possibility that they’re reusing condoms because they have trouble getting others?

Unstable housing situations — People who are economically disadvantaged can be more migratory that more affluent populations, so they may remain at one address for a longer period of time. Sometimes the reason is because of displacement, sometimes it is because of circumstance, and sometimes, the working poor cannot afford stable housing on their given income. They may move from apartment to apartment, or staying with family, or staying on couches. So even if this group had signed up for free condoms, what is the likelihood that they’ll still be in the same place for their monthly delivery? What is the likelihood that they’ll change their address in the free condom’s system?

But these obstacles are likely foreign to most of the readers of this article. Most of us — but not all — represent the typical demographic of the socioeconomically disadvantaged.

Which is — I believe — an important obstacle to our ability to empathize with condom recyclers.

Designers ≠ Condom Reusers

Not to put everyone in a bucket, but based on the demographics of Designers, it is highly unlikely that they’ll be compelled to re-use condoms.

Most Designers are middle or upper-middle class people. They’re largely white (73%) and educated (86% have at least a Bachelors, and 18% of those also hold a Masters).

But low-income Americans look very different. Only 12% of low-income citizens are white; 26% are Hispanic and 21% are black. And 63% of low-income Americans never received an education beyond high school.

Although we as Designers spend countless hours exploring and researching the experience of those different than us, designing for equity requires a slightly different skill set. More than designing digital apps or websites or B2B software, designing for equity requires generative research and contextual inquiry into a scenario and environment that is far different than ours.

And I acknowledge that it is very, very difficult to set aside our judgment and assumptions to be more empathetic with people who re-use condoms.

Judgment is a useless change agent.

Recycling condoms is gross. I get it. It is so outside of the experience of most of us, we cannot possibly conceive of a situation where anyone would be forced to wash and re-use a condom.

But after walking through cultural barriers to free condom access, do you think that immediate judgment is a little short-sided?

This kind of unbiased academic exploration of new environments isn’t just crucial in designing for equity; It’s important for Designers of all stripes, in all scenarios.

If Designers fail to think outside of our own experience, we will not be able to change the world through products, processes, and experiences designed for equity.

I challenge you to check yourself when you face untenable news, to consider the environment behind the story. Even — and especially — when you find yourself befuddled by why someone would take an action you didn’t expect.

And maybe — just maybe — you’ll be able to walk in a pair of shoes that totally doesn’t fit you, but that will let you travel to a foreign place with a new set of eyes.

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I would be remiss if I did not tout the important work that is done by organizations like Women’s Health and Family Planning of Texas in making sure that Title X funds are distributed to clinics that are reducing the number of unintended pregnancies.

And lastly, among the rest of my friends who submitted…colorful ideas for the title of this article, I want to thank Kelli Brookshire for inspiring the final winner, as well as thanking the other title concept finalists: One and Done (Joann Miller) and Condom Sense (Chris Putaansuu).