The qualitative/quantitative segue in health care marketing research

Editor's note: Dr. Murray Simon is president of DIRIS Health Care Consultants of Charlotte, North Carolina.

Pick up a major newspaper in this country on any given day and chances are you will find one or more feature articles dealing with the cost of health care. Few issues generate the ongoing emotions that this one does. During the past ten to fifteen years we have gone from an attitude of quality care at any price to an almost chaotic "battle of the special interest groups. " The public is demanding good care at a reasonable price; employers are trying to climb out from under the cost of medical coverage in the work place; physicians are being forced to negotiate their fees and no longer feel in control of their practices. Hovering over all is the federal government, trying to figure out how to bring its own special brand of absentee, deficit-ridden management into play in this area.

Somewhere in the midst of all this confusion stands the marketer of health related products and services, mandated with the charge of successfully selling new and existing products in this ever changing marketplace. It's not an easy job, but someone has to do it. Health care manufacturers are acutely aware of the need to stay current in the face of rapid change within the health care service sector. Cost containment . . . managed care . . . resource based/relative value scales . . . the FDA's recent hard-line on consumer product claims . . . prescription product advertising to the public are just a few of the issues that are currently impacting, not only on the provider and patient, but on the marketer of goods and services as well.

One of the ways the industry is meeting this challenge is, of course, through the use of marketing research, and in particular, through the expanded use of what we refer to as the Qualitative/ Quantitative Segue. A workable definition for the Q/Q Segue could be: the use of a qualitative marketing research study to help define appropriate language, issues and areas of sensitivity to be used in developing a subsequent quantitative study.

There are generally two major reasons for a company to consider using the Q/Q Segue:

1. The company is new to this particular product/service category and has to have a better understanding of the marketplace before developing appropriate marketing strategies.

2. The subject is complex and it is important to understand both how the product is used in the field and what language is correct in communicating with end users.

Some might suggest that a well designed quantitative study can provide all of the information necessary and that a qualitative precursor is just a waste of time and money. The arguable point in that statement is the phrase "a well designed quantitative study." As a former health care provider, I remember a number of questionnaires that wound up in the waste basket because a quick read classified them as prepared by someone who did not do his/her homework. If pre-study assumptions are made that are incorrect, if assumptions are overlooked, if regional variations are not recognized, if the language used is inaccurate or inappropriate, if small but influential sample segments are not identified, or even something as minor as telephone interviewers repeatedly mispronouncing a word or technical term; all of these factors and more can have a damaging influence on the outcome of a quantitative study; all of these factors and more can be minimized or avoided through the use of the Q/Q Segue. Let's take a look at the potential advantages in using a qualitative foundation for a quantitative study.

• Appropriate language. Health care professionals place a premium on their time and they easily become impatient with those whom they consider to be wasting it. If a questionnaire uses inaccurate or inappropriate language, one of three things will occur:
  
  1. The questionnaire winds up in the round file or the telephone interview is terminated.
  
  2. The provider will "toss off" answers with little forethought.
  
  3. A staff member will be asked to "fill this out and send it back."

Here are some examples of language variation that we have encountered in previous Q/Q Segue studies:

• Veterinarians do not use the term "heart attack" in referring to small animals (cats, dogs). They refer to them as "cardiovascular accidents."
• Oral surgeons, in dealing with problems related to the jaw joint, have recently adopted the universal term "Tempero-Mandibular Dysfunction" (TMD).
• Physicians are often concerned when a prescription drug becomes available in a reduced strength, over the counter version. They worry that their patients will bypass the office prescription and take a heavier than recommended dosage of the OTC. Physicians refer to it as "double dosing."

Certainly a questionnaire would not be inaccurate in using the terms "heart attack" with veterinarians or "jaw joint problems" with oral surgeons, but by using the more familiar terminology the study sends a subtle message that this is a well thought out questionnaire - that someone &d their homework before hand.

• Quality quantitative. There's an old saying: Don't send a boy to do a man's job. This seems particularly appropriate in a discussion of the Q/Q Segue. Doing a qualitative segment first better prepares you for doing the quantitative segment. Questions will be much more specific and better directed than they would have been without the qualitative input and this can have a positive impact on the results in a number of ways:
  
  1. Respondents want to know, "How long will this take?" Many of the exploratory questions are answered in the qualitative phase which can lead to a shorter quantitative questionnaire. Shorter questionnaires generally have better response rates than longer ones.
  
  2. The quality of what you get is directly related to how well you frame your questions. The qualitative portion of the Q/Q Segue gives you the opportunity to "test run" certain questions and pre-determine their potential relative effectiveness. If attributes lists are to be rated, these lists can be fine tuned and narrowed down to the important essentials.
  
  3. As a qualitative researcher I hesitate to bring this up, but in certain situations i.e., research on technical products with low incidence medical specialties(nuclear radiologists, pediatric ophthalmic surgeons, etc.), if you've done three or four focus groups around the country you already have the beginnings of a statistical consensus which, in combination with the analysis of the quantitative segment, can provide a pretty good reading on market potential.
  
  4. The Q/Q Segue gives everyone on the marketing team an opportunity to directly examine the parameters of the task at hand. We have seen it happen a number of times. When the viewing room contains brand managers, R&D people, directors of marketing and business development analysts there is a very strong "reality check" that carries forward into the quantitative study.
  
  5. Some of our clients regularly use the Q/Q Segue to evaluate the potential for certain products under development that are being considered for licensing and/or marketing. In these cases not only does the qualitative study give us the opportunity to test and modify concepts for use in the quantitative phase, but it frequently results in the elimination of some products because of strongly negative responses. It focuses the quantitative questionnaire directly on those products with potential .

• Incorrect assumptions. In one Q/Q Segue study within a particular medical specialty, the assumption was made that this group screens all of their adult patients over a certain age for a particular type of cancer. The qualitative segment of the study revealed that this was not the case. They screen all adult patients within a certain age range for specific diagnostic criteria, and those who test positive are then tested for cancer. This may seem like a basic problem of semantics, but to these specialists it represented a valid differentiation in diagnostic protocol. If the quantitative questionnaire had been developed without the qualitative input, the question "What percentage of your adult patients do you initially screen for cancer?" could have produced dangerously misleading results.

• Overlooked assumptions. While testing concepts for a new medical product, one of the respondents mentioned a marketing related factor that the client had considered unimportant prior to the study. The rest of the group strongly concurred with this respondent's assumption. This bit of information added a new dimension to the marketing strategy being developed and necessitated a significant change in the soon-to-follow quantitative study. But fortunately the client had the option of making this change before the fact, not after it. If this situation had gone unidentified, a large pothole on the long road to marketing success may have caused some serious damage.

• Regional variations. There are far fewer Caesarean sections performed in Bangor, Maine than in Portland, Maine even though the population and hospital demographics are similar. General dentists perform more periodontal surgery in the Boston area than do general dentists in the metropolitan Los Angeles area. While a well designed quantitative study will pull out these geographic variations, it is important to know that they exist and to recognize what type of input you will need to make your quantitative results more complete. It's a lot more effective to go hunting for bear with a rifle than with a fishing rod.

• Influential segments. Not too long ago we did a Q/Q Segue with specialists on the subject of diagnostic procedures. The research protocol called for four focus groups to be followed by a nationwide telephone survey. During the qualitative phase it became clear that there was a sub-segment, previously unidentified, that greatly influenced how these specialists did their diagnostic procedures. This sub-segment not only had a strong influence on the diagnostic products used, in many cases they dictated how the procedure was to be done. If a qualitative phase had not been involved, the quantitative instrument may have elicited this information but a follow-up study would have been necessary to expand on it.

• Market potential. Often, one of the most important questions to be answered by a quantitative study is, "Is there market potential for this product?" This may prove to be a big negative to some readers, but some of the Q/Q Segues that we have been involved with have ended at the qualitative stage because the market potential was painfully clear by the time we had completed the final focus group or one-on-one interview. These situations generally evolve in one of two ways:
  
  1. The research is early/primary and the client learns all they feel they need to know during the qualitative stage.
  
  2. The product or concept is a total bomb with no hope of redemption.

While this can result in the research firm losing out on a quantitative study, there is a positive side to it; it can lead to a satisfied customer with the potential for more work later on.

One of the most important factors in developing a successful Q/Q Segue is adequate preparation for the qualitative phase. Sometimes these studies represent uncharted waters for the client and a large, rapid learning curve is anticipated. If the qualitative researcher spends too much respondent/client time in moderator education, important factors can be missed or overlooked. This is especially true in projects having to do with relatively technical subjects. In these situations, it is incumbent on the researcher to familiarize himself/herself with the language beforehand and to develop at least a reasonable understanding of the practice modalities involved in the use of the product or service to be studied. Anything less could result in an incomplete or inaccurate study and this could easily be carried forward and compounded in the quantitative phase.

It is also critical to have as complete an understanding of the research objectives as possible. This needs assessment must go beyond the development of a good discussion guide or qualitative questionnaire. The following factors should also be weighed and considered:

• What decisions have to be made from this study?
• Have previous studies been done? What were the results?
• If prototypes or concepts are to be tested, what is the extent of the client's commitment to these products?
• Who is the actual client - marketing, R&D, business development, research?
• What are the parameters of the quantitative study?

These factors can have a very important impact on the direction that the qualitative segment should take.

Marketing research is experiencing a move towards alliances where two or more research firms capitalize on individual strengths to produce a research instrument that is unique or stronger than the sum of its parts. The Q/Q Segue is an ideal situation for the melding of talents between an experienced quantitative firm and a well seasoned, specialized focus group moderator. Our own experience in these "partnerships" has been very positive and we would encourage others to consider developing similar working relationships.