How to obtain a 360-degree view of pharmaceutical usage

Abstract

By combining ethnographic and other research methods, pharmaceutical firms can get a fuller picture of how patients use - or don’t use - the medications prescribed to them.

Coherence for adherence

Editor’s note: Laura Winn Johnson is qualitative manager with Atlanta research firm CMI.

In today’s volatile and competitive marketplace, issues of compliance and adherence have never been more critical for pharmaceutical brands. To succeed, it’s essential for those in pharmaceutical brand leadership to go beyond the drug and its delivery system toward an understanding of the larger context of therapeutic category and the roles that brand and medication play in impacting and improving people’s lives.

In other words, how does the brand fit into the 360-degree context of the patient’s life? This lens-on-life perspective is most effectively and efficiently achieved through combined ethnographic methodologies that yield a deeper, more contextual knowledge of customers. Through combined methodologies, one can create an authentic observational framework that addresses issues directly linked to key strategic decision-making, such as:

Are your customers following their doctors’ orders about frequency, dosage or directions?
Are your customers refilling their prescriptions? How easy is it to get a refill? Will they refill with your brand or a generic?
Are your customers aware of how your product is helping them?
Are your resources dedicated to the right strategies and tactics?
Are you missing an opportunity to launch a behavioral modification program in conjunction with your drug?

Presents challenges

In the traditional academic sense, ethnography is defined as the physical observation of others in the context in which a particular action or behavior occurs. Ethnographic marketing research, while valid for many categories - laundry detergent, for example - presents challenges in more complex categories like financial services and pharmaceuticals where “invisible,” highly personal and nearly subconscious thoughts rule the decision-making process.

Ethnography is flexible, thereby allowing creativity and technology to immerse the observer in the environment, without living with the observed individuals for months on end or influencing them. In order to achieve this flexibility, though, one must go beyond traditional research approaches - even most traditional ethnographic research.

The overarching principles of cultural anthropology enable a more comprehensive ethnographic design that allows the researcher to “see the unseeable” - that is, things that are not physically observable, such as an attitude, decision process, perception and driving motivation. All of these things are critical to understanding issues like compliance and adherence.

More comprehensive understanding

The path to greater brand resonance requires marketers to develop a more comprehensive understanding of consumers. To that end, utilizing a lens-on-life approach is needed: How are they living with a condition or disease state, whether or not they’re already using your brand? To develop innovative solutions to the critical issues of compliance and adherence, a clear connection must be made between the product and ALL of the ways in which a particular condition or disease state affects the way users think about themselves and their experiences in life - hence the 360-degree reference (Figure 1). Understanding all of the ways in which the disease state touches a patient’s life enables a brand to employ more innovative solutions.

The principles of a 360-degree lens-on-life approach permeate every aspect of the ethnographic study, all the way down to the specifics of organically-developed assignments. The observational framework holds closely to the rigors of classical ethnography - being both clear about what is to be observed while remaining open to what one will find. In this careful balance lies the precious, unexpected insight so coveted by the pharmaceutical brand manager.

The design of an ethnographic study typically involves aspects of in-person observation as well as situations in which patients will observe themselves, with an ethnographer’s training and guidance. Self-observation assignments are customized for the therapeutic category and generally involve a scope that incorporates key aspects of the consumer’s life experience, including the ways in which a condition impacts their life.

Four research approaches

Four research approaches compose a 360-degree lens-on-life study. Together they bring researchers closer to seeing the “unseeable” aspects of adherence and compliance: self-observation, longitudinal observation, multimethod research and technology.

Approach 1: Self-observation

Self-observation (consumers observing themselves) is a valuable technique, especially when combined with a longitudinal approach. Both aspects (the seeable and the unseeable) can be examined with this technique. As such, it can be extremely cost-effective and often more representative of real life when compared to in-person observation alone. The most distinct benefit of self-observation is in shedding light on the deeply personal and unseeable aspects such as perceptions, beliefs and decision processes. With the ethnographer’s guidance, consumers explore and observe their own behaviors, attitudes and perceptions.

Within the construct of self-observation, one successful approach is the use of organically-developed themes or assignments within a longitudinal study. These assignments, when designed by an experienced ethnographer, enable the consumer to take a cathartic and revealing journey of self-discovery related to their lives and their condition - with the brand’s marketing team along for the ride. Participants may explore and become aware of deeply personal self-perceptions, attitudes, habits, etc., that they have developed over time and about which they were previously unaware.

Example: Efficacy of prescription nasal sprays

If patients do not quickly feel relief, they may start taking medicine as directed but fail to maintain the regimen.
Why self-observation works in this case:

Patients can report their actual adherence and reasons for not following the regimen.
Through the training of an experienced ethnographer, respondents’ self-observation enables researchers to see things that would be nearly impossible to see in person.
The researcher benefits from a deeper, more introspective view (themes and learnings over time) via a longitudinal approach.

Approach 2: Longitudinal observation

Pharmaceutical and health-related decisions involve complex, deeply personal decisions or occurrences that develop over long periods of time (Figure 2). While traditional research approaches such as in-depth interviews or focus groups can elicit wonderfully rich information for many types of research objectives, they frequently fall short when a larger, more authentic understanding of someone’s entire experience with a condition is essential. For most therapeutic conditions, time spent with consumers in their homes can give marketers a more up-close and personal understanding of their customers’ daily lives or routines. But there is so much more to the overall puzzle than what can be seen in one day.

In contrast, the recommended longitudinal approach focuses on creating a process of self-discovery that goes well beyond what any ethnographer - or the consumers themselves - could know or relate in any one sitting. Because of the level of self-revelation required to “crack the code” of compliance, more time is required. This approach provides the consumer with a process and a stimulus to recognize - and then observe - the behaviors and attitudes that are most critical to the pharmaceutical brand and therapeutic category. Even more important, a longitudinal approach that leverages technology provides a way to observe these nuances with the least amount of influence on the behavior itself and in a more cost-effective manner.

Example: Delivery of human growth hormone

Based on how complicated it is to administer the medicine, people may not always administer it correctly.
Why a longitudinal method works in this case:

Patients can report feelings and adherence through the experience of injecting (or eventually discontinuing) medication.
In-person observation is helpful, but to reveal a wider array of emotional associations, a longer-term view is required.

Over time one can view the overlap between considerations and how they act together to impact compliance and adherence. A 360-degree lens-on-life also reveals the impact of other family members, the emotions involved in administering a treatment to one’s self or others and the emotions associated with the method of delivery. Over time, one begins to understand the interplay of emotions at work every time a treatment is administered by witnessing the patients’ routine, facial expressions, impact on daily life, etc.

Approach 3: Multimethod research

Blending traditional and less traditional methods brings researchers closer to covering all the bases (Figure 3). The mix can be complementary, leveraging tactical strengths and finding multiple ways to gather insights, or it can meld the best parts of each method into one hybrid approach.

With many categories, people can say that they do one thing but actually do another - sometimes without even realizing it. Take the example of healthy eating choices. In one research instance, a patient described how she had started eating healthier - while eating a hamburger and a plate of french fries. This humorous example underscores the need for a more comprehensive ethnographic approach, one that combines in-person observation with more longitudinal aspects so that patients can really see their own patterns. From a research perspective, it’s not as easy as just listening to what someone says they do or will do.

Example: Diabetes medications

Diabetes is an especially interesting therapeutic category because those with the condition often have to manage their behaviors and medications according to a detailed regimen - often a series of monitoring, shots and pills. It requires changing one’s routine and can have a significant impact on daily life. The easier the prescription is to fill and follow, the greater the likelihood of adherence.

In the case of diabetes, a one-day, in-person observation could lead to an incomplete picture of what happens on the days the diabetic patient isn’t being observed. Thus, we see the importance of observing the behavior in a variety of ways in order to see the full picture and reduce the influence of the observation itself.

To really understand the many complicated impacts on adherence and compliance, a combination of ethnographic methods usually leads to the most robust results. This is particularly true of longitudinal observations in categories where patients may be reluctant or sensitive to admit - even to their own doctor - how well they follow the doctor’s instructions for taking a medication.

Why a mixed-method works in this case:

Just watching someone in-person can impact how they behave. If a patient knows someone is observing them for a day, they will likely adhere to every element of every prescription for that one day.
Just asking someone depends on how well they know their own experience and beliefs. Individuals may not be able to articulate all of their influencers, especially without time to fully consider it over the course of a few days.
Just communicating online doesn’t always bring out the entire picture. Anonymity can be great, but people may still over- or understate what they do and how often. In-person observation is often tremendously important to get the whole truth, especially in certain therapeutic categories.

Approach 4: Technology

Technology helps close the gap and facilitates a more robust 360-degree view, but it’s not a magic bullet. Technology expands the researcher’s ability to “walk in the customers’ shoes,” moving beyond in-person observation. And technology can enable longitudinal views, more immediate reactions, and more authentic insights.

Why technology works to facilitate these objectives:

Greater flexibility and convenience for participants to provide input leads to higher participation rates and often generates more thoughtful responses.
Ongoing access to and interaction with respondents - versus a single discussion - creates relationships with participants that often yield greater insight into nuanced behavior and attitudes.
It enables longitudinal data or the ability gather information over long periods of time. In other words, you’re not seeing if someone adheres to the regimen that day, but every day and over time, as well as how it changes over time and in reaction to various symptoms.
The relative anonymity makes participants more comfortable and willing to share more personal and truthful information, particularly in health categories that may be very personal or potentially embarrassing.
Digital data collection allows for the generation of “instant transcripts” and for the immediate capture of real-time thought and action rather than relying on participants’ recollections. People may “remember” greater adherence with a medical regimen than they actually followed.
Online data collection is typically more time- and cost-efficient than in-person or phone and allows for greater geographic diversity, larger samples and shorter periods of fieldwork.
Online platforms with multimedia capabilities can allow for richer stimulus in participant responses and more engaging presentations.

Example: Black-box label warnings and the impact on adherence

Black-box warning labels are the most extreme example of the potential impact of side effect and interactions. Patients and doctors must weigh the benefits of taking a medicine with side effects versus not taking the medicine and coping with the symptoms of the actual condition.

Black-box warnings on drugs to prevent heart attacks, treat diabetes, arthritis and eczema have led to a range of new considerations for doctors and patients. However, understanding how people cope with side effects and drug interactions isn’t a very good question for a focus group. Technology enables a feeling of anonymity when talking about sensitive medication concerns and side effects.

Weight-loss case study

To see how this approach might work, let’s look at a hypothetical weight-loss case study. A pharmaceutical brand wanted to develop a new, more useful segmentation based on a greater understanding of customers. The results would be used to better position the company’s specific brand and encourage trial and adherence.

Business objectives:

Identify and gain a deeper understanding of the primary target audiences to increase marketing efficiency and effectiveness for a weight-loss medication.
Determine segments that are really committed to losing weight but know that it would be hard to achieve through willpower and diet alone.

Research objectives:

Identify potential drivers of differentiation between consumer segments based on psychographic, attitudinal and behavioral elements.
Understand the pathways consumers take to try to lose weight.
Determine if there are consumer segments more likely to consider taking a medication to support weight loss and continue taking it as prescribed.
Identify tipping points that motivate people to advance to the next stage of change and take action to lose weight in the near term.
Compile information to create meaningful and detailed profiles of consumer segments following a quantitative segmentation.

Methodologies included a series of qualitative phases, including: workbooks and mini-groups among consumers in various stages of behavior change to lose weight; self-observation and journaling for a six-week period among consumers who plan to start a weight loss program within 30 days.

Phase one included an in-person briefing based on their stage of commitment to losing weight. This stage “primed the pump” for the critical observation work that took place in phase two. Initial discussions sensitized participants to the aspects of their experiences about which the brand was most interested. And the first phase provided the initial snapshot of participants’ relationship with their weight (self-perceptions, habits, etc.).

Phase two included a series of assignments for self-discovery over several weeks, including: a timeline of relationship with food; an experience map to plot successes and challenges, key triggers and various therapeutic efforts; reporting of self-perceptions and perceptions of weight and health and; a weight-loss journal.

Respondents’ reactions to this research process - the assignments themselves and the process of completing them - revealed a great deal about the emotions, barriers and opportunities involved in weight loss.

Phase three was about bringing it all together. By phase three, the better-trained participants were able to observe their own experiences. And they did so longitudinally, which told the whole story. At this point, they poured out a new level of insight about themselves and their journey. Participants tapped into the deeper, more “invisible” aspects of their journey that frequently hinder lifestyle and medical choices.

The result of this 360-degree approach was a vibrant segmentation that guided a subsequent quantitative study, new target-marketing and positioning and improved messaging and media strategy. Brand marketers were armed with learnings to differentiate their brand among the highest-priority segments through a greater understanding of:

authentic, textured and comprehensive snapshots of each segment that helped brand teams really get to know them - including characteristics such as demographics, attitudes and behaviors;
deeply-held weight-loss fears that informed innovative brand strategies and marketing;
underlying motivations people have to lose weight and the enormous impact they have on real dedication to the task;
messaging to target the real reasons people commit to losing weight, not the reasons they might claim (like health).

Worth far more

Combined research methodologies, when utilized appropriately, can be worth far more than the sum of their parts. Even in the most complex and emotionally-loaded situations, experienced ethnographers can help participants achieve a level of self-discovery and awareness that would never be possible through any single, stand-alone approach. This ability to observe participants as they explore deeply personal self-perceptions, attitudes and habits can provide the researcher - and thus the brand marketer - with the necessary foundation for understanding challenging issues like adherence and compliance.