A deeper examination

Editor’s note: Joel Goldberg has a private practice in behavioral science marketing research and is a member of the advisory board of Segmedica, Inc., a Lewiston , N.Y. , health care marketing research company.

This article provides an overview of behavioral science research techniques that are being applied to medical marketing research. These techniques enhance existing qualitative and quantitative methodologies in a number of different ways:

  • By developing a simple behavioral profile of each respondent, researchers can interpret their responses much more meaningfully.
  • Through an understanding of the mental processes of health care providers, research instruments can be designed to work more effectively.
  • By using behavioral measures as screening criteria for recruiting and panel-building, it is possible to create samples that are either behaviorally representative of the target universe or which are skewed to suit the objectives of the survey.
  • Respondents’ fundamental beliefs and ingrained mental processes are a strong and projectable guide to their likely future behaviors, whereas the attitudinal data typically gathered by conventional research are not.

These four advantages can best be understood by giving an example of each.

Improved interpretation of responses

Everybody has an optimum mode of assimilating information - a reliance on one of the five senses. For practical purposes, the four major assimilation modalities are reading, seeing (ranges from preferring graphics to the written word through to observing the actions of others), hearing and doing.

If the objective of a survey is to test various advertising concepts we might typically ask questions concerning the graphics, the headlines, the copy, the call to action and so on. We then summate the responses and report. Suppose that in this case the target universe is primary care physicians (PCPs). This group is particularly auditory. In fact, we have found in research that 80 percent of PCPs best assimilate information through hearing, rather than seeing or reading. We have also found that about 80 percent of PCPs are “big picture” people. Big-picture types are most comfortable with large pieces of information. For a limited period of time they can work well with details but will quickly return to the big picture. They see a whole issue at once. The big-picture type communicates and receives information in random order and in simple sentences with few modifiers. They poorly absorb details, sequences, modifiers and proper nouns. Understanding this about the universe and knowing exactly which respondents have these behavioral characteristics will completely alter the interpretation of the data gathered through a standard ad concept survey. We start the interpretation by knowing that an advertisement is not the optimum media for the information assimilation modality of the audience, and that the audience will best respond to a big-picture presentation of information. Just as important, we know which respondents fit the profile and which are the exception respondents, so that we are not confused by varying responses.

Improved research design

It is an axiom of market research that we “start with the general and move to the particular.” However, a vital and unconscious process in reasoning is the way in which an individual moves from the general to the particular and back again - connecting the big picture with the detail. The creative type (the kind of person who designs marketing communications for example!) moves from the general to the particular while the scientific type typically starts with the particular and generalizes to the big picture. We have found by simple experimentation that redesigning an interview questionnaire to lead physicians with a strong scientific process to generalize from particular examples leads to a much better interview result than the traditional method. The key here is that not all physicians have a strong scientific process - many actually have a stronger affinity with philosophical or emotional processes of decision-making, so that alternative questionnaires may be employed for different types of respondent. Advanced screening of physicians to determine their basic thought process (a very simple and short question sequence) tells the researcher which questionnaire to use.

Creating custom sample

In conventional market research, we generally rely on the random recruiting of large samples to provide a representative and projectable sample. By screening a sample behaviorally as well as demographically, it is possible to create small, representative samples; even as small as a single focus group.

If, in this case, the target universe is patients suffering from a certain disease, those so qualified can be screened using a small number of behavioral metrics. Those metrics might include information assimilation modalities, introversion vs. extroversion, and locus of control (degree of deference to authority figures such as physicians). The selection of the metrics would depend upon the objective of the study. As the proportion of each type in the general population is already known, these criteria reduce the recruitment to acquiring appropriate quotas of behavioral types already existing in the universe in known proportions.

By basing the sample design on known criteria the dependence of randomness is broken and the sample can be certified as representative of the fundamental behavioral profile of the universe.

Attitudes vs. beliefs

First, we have to get past the point that most people use the terms attitudes, beliefs and values interchangeably, so that the attitudinal questions in a typical survey may address both surface attitudes and fundamental beliefs. The advantage of thinking in behavioral science terms is that we understand which is which and can incorporate that understanding into survey design.

There is a well-established hierarchy of human behavior:

  • Attitudes

- conscious

- transient

- most recently formed of behavioral constructs

- There is not much we can do to influence behavior based on them

  • Beliefs

- in some cases, can be modified if fully understood

- must be directly addressed by sales and marketing tactics

  • Closely-held values

- elements of personality, not available for modification but must be directly addressed by sales and marketing tactics for those tactics to be fully successful

  • Behavioral filters

- unconscious processes used in information assimilation and decision-making

- consistent, generally predictable in multiple contexts

An example of a truly attitudinal question is to ask a respondent to rate the following statement for applicability to them on a Likert scale: “I generally do not prescribe drugs that have not been on the market for at least six months.”

This surface attitude may or may not be based upon deeply-held beliefs about the ethics of medical practice and attitude to risk. It is a gross simplification of a decision-making process that we have found involves many factors, including:

1. Underlying attitude to risks to patients.

2. The physician’s natural tendency to move towards positive outcomes or to seek to move away from negative results.

3. The locus of control, which, if external could mean that the physician’s attitude would be quickly modified by, say, thought-leader opinion.

4. The physician’s natural tendency to be a late or early adopter.

Our research shows that, in a general sense, about 50 percent of PCPs are very risk-averse in the management of their practices. For these respondents, avoidance of risk rates very highly in their hierarchy of decision criteria. This tendency is not homogenous, however. White/Caucasian physicians are much less risk-averse than other ethnic groups and physicians whose primary motivation to practice medicine is the maximization of personal income are more likely to be risk-averse than those with an emotional calling to serve the sick.

In all cases, the general behavioral tendencies of respondents need to be re-examined in the exact context of the disease state or health care process being studied. Some of the most interesting results from this type of research arise from discovering that physicians or patients are acting “out of character” in certain circumstances. For example, groups of physicians who normally interact with their patients on a 50:50 basis, allowing discussion between doctor and patient to create a consensus on how to move forward with the case, may in certain circumstances become much more forceful and authoritarian. In one example, we discovered this process at work in a market where efforts were being made to use DTC-driven “patient push” tactics to drive the adoption of a treatment regime. The discovery that this dynamic was at work highlighted that this precisely defined market was not a good environment for “patient push” and that traditional professional marketing would be a better use of marketing funds.

Fundamentally different

Behaviorally-based marketing research differs fundamentally from conventional research in a number of ways. Conventional research is based upon eliciting opinions and data (content) and then summating it into report form. Behavioral research elicits hidden motivators (context), which respondents are generally not able to reveal voluntarily as they are not in their consciousness, and then interpreting the output into actionable sales, marketing and communications strategies.

Carrying out this type of research involves two new processes. The first is the modification of a researcher’s skills. For example, in conventional research questions are sharpened to ensure that exactly the right content is forthcoming. In behavioral research questions are often generalized because it is the content chosen by the respondents and the language they use that provides the basis for interpretation. The second is the use of psycholinguistic analysis as one of the means by which the responses are interpreted.

When people speak there is actually a second level of information available that reveals much richer data and allows for a deeper understanding of their subconscious motivations. These subconscious motivations are very real and well documented - they speak to the heart of human behavior and decision-making. Very often the use of psycholinguistics leads to insights and uncovers practical channels of action that basic market research does not.

The answer to marketing questions does not always lie in what respondents say (content), but in how they say it (context), which can often override the stated answer to completely alter the meaning of the recorded response. Building behavioral techniques into market research provides important insights into human communication and decision-making that are often overlooked.

Individuals generally do not understand the deepest motivations, needs and desires that lead to their health care decisions. The most deeply-held values have the greatest power to influence and are also the most ingrained in beliefs, behavior and habits. For this reason they are most often not in the consciousness. However, these deeply-held values and criteria are available by listening to the language patterns used when describing experiences with a drug, device or instrument and using psycholinguistic analysis to reveal the respondents’ unstated motivations.

Growing use

While in its infancy in the health care industry, these techniques are based on very well-established science from both investigational and clinical psychology, and have been in use in other industries (such as packaged goods and financial services). Their growing use in health care will fundamentally change the techniques used and the impact of marketing research results upon sales training, marketing communications and marketing strategy.