Adherence: Framing Compliance

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In today's volatile and competitive marketplace, the issues of compliance and adherence have never been more critical for pharmaceutical brands. To succeed in this marketplace, 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 their therapeutic category, and the roles their brand and medication play in impacting—and improving—people's lives.

The path to greater brand resonance requires marketers to develop a deeper and more comprehensive understanding of consumers with the relevant symptoms' “lens on life”—how they are living with a condition or disease state, whether they're already using your brand or not. 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.

Understanding all of the ways in which the disease state touches their lives, or having a 360° view, enables more innovative solutions for the brand by providing answers to critical questions such as: How can your brand help their lives in a way they can't live without? How can your brand's value proposition be best recognized or integrated into their daily routines or rituals? Once they are using a medication in your category, how do you get them to keep or start using your brand? How are economic conditions impacting the filling and refilling of prescriptions? What tradeoffs are they making to cope?

While context is the essence of ethnographic research as a whole, this article advocates a much broader context than that explored by more traditional pharmaceutical marketing or research plans—and a different, and more holistic research strategy is in order to tackle the complex issues of compliance and adherence.  The key is an authentic observational framework—an approach that goes beyond traditional research approaches using principles of cultural anthropology to understand a therapeutic category in new ways, and within the full context (a 360° view) of consumers' lives.  

Traditional Ethnography Isn't Enough
It is so important to have a deep, contextual knowledge of customers, but there are gaps in traditional research approaches as a whole, as well as limits to traditional ethnographic research (in-person observation) when it comes to achieving the type of insight being recommended. This is especially critical because traditional ethnographic approaches have recently been considered the panacea for any manner of marketing issues. While it is a powerful tool when used as part of a larger observational framework, traditional ethnography alone is not a magic bullet—especially for the complex issues of compliance and adherence.

Traditional ethnography can be a powerful tool to understand many types of consumer behavior. However, on its own, it often cannot deliver the kind of insights needed for the pharmaceutical industry because of some inherent challenges and limitations. The success of traditional ethnographic research alone does not neatly translate from the world of consumer packaged goods to pharmaceuticals for several reasons:
  • In any environment, an ethnographer's physical presence can be counterproductive by changing the very behaviors you are trying to observe.
  • Some conditions or products may have irregular or spontaneous usage patterns. Behaviors of interest may occur very frequently or infrequently, making it difficult to capture all use occasions, nuances, influences, etc.
  • Even the opposite extreme has the same problem, as there may be very habitual patterns/behaviors that occur “in secret” or in areas that would be particularly difficult for a researcher to observe as a visitor to an individual user's world.
  • The behavior of interest is frequently very personal in nature, and therefore hidden from an outsider's view either consciously or unconsciously.
  • Unlike consumer goods, matters related to health and lifestyle involve extremely complex, multi-faceted decision-processes.
Longitudinal Observation and Seeing the “Unseeable”
In addition to the above, the two most important limitations of traditional research approaches (including traditional ethnographic research in most cases) are also the most critical benefits to the proposed observational framework: the necessity of a more longitudinal view and the invisibility of some of the most critical aspects to be observed.

First, let's explore the challenges and opportunities related to the need for a longitudinal view. Pharmaceutical and health-related decisions involve complex, deeply personal decisions or occurrences that happen, or are developed, over long periods of time. 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. These more traditional research approaches can be employed with tremendous success when combined with a more comprehensive observational strategy. But, when used in isolation, they give us only one “snapshot” of the consumer's experience—and only the aspects of which they're currently aware. That is, 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. While it can be very helpful to “walk in their shoes,” even if for a little while, there is so much more to the overall puzzle than the individual pieces that can be seen in one day, or with the “day in the life” approach alone. And, even if this did provide a thorough picture, research budgets rarely allow for even one full day with each customer.

In contrast, the recommended longitudinal approach focuses on creating a process of self-discovery that goes well beyond what any moderator or 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 for recognizing, and then observing, the behaviors and attitudes that are most critical to the pharmaceutical brand and therapeutic category. Even more important, it provides a way to observe these nuances with the least amount of influence on the behavior itself and in a more cost-effective manner.

Now, let's explore the second, but closely related, key challenge and opportunity—the “invisibility” of the consumer's behaviors. Some of the most important aspects to be observed within the pharmaceutical and health-related arenas—especially those most critical to understanding the issues of adherence and compliance— are “invisible,” or not physically observable. Attitudes, perceptions, beliefs and many decision processes about diagnosis and treatment cannot be seen via traditional observation or uncovered with traditional research. As such, a longitudinal approach, described above, should be combined with an observational approach that yields a 360° view of the consumer's world, as this observational framework as a whole provides a more authentic and complete view of the consumer's reality—both the “seeable” and the “unseeable.”

Self-observation (consumers observing themselves) is an incredibly valuable technique here, especially when combined with a longitudinal approach. Both aspects can be adeptly observed with this technique. As such, it can be an extremely cost-effective approach and often more representative of real life, when compared to in-person observation alone. Self-observation has the most distinct benefit, though, in observing the deeply personal and “unseeable” aspects within the industry (such as perceptions, beliefs and decision processes). In self-observation, consumers explore and observe their own behaviors, attitudes and perceptions with the ethnographer's guidance. A trained and experienced ethnographer can use many tools to transform the consumer into the ethnographer's eyes and ears, and with limited impact on the behaviors themselves.

Within the construct of self-observation, one very successful approach for seeing the important “invisible” aspects 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 a therapeutic category—with the brand's marketing team along for the ride. In this journey, depending on the study's specific interests, they may explore and become aware of deeply personal self-perceptions, attitudes, habits, etc. they have developed over time, and about which they were previously unaware.

The “organic” nature of the assignments allows consumers to take their respective journeys in whatever direction makes sense for them, based on what they learn or recognize about themselves or their experiences along the way. At the same time, careful development of the assignment's overarching purpose ensures the fulfillment of the study's business and research objectives.

 In this way, 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. Very often, in this careful balance lies the precious, unexpected insight so coveted by the pharmaceutical brand manager—and so critical for innovative solutions.

Studies using such an observational framework to explore a 360° view of adherence and compliance wisely focus on the ways in which the symptoms and condition are experienced by each person within the greater context of their lives.

Applying the Framework to a Case Study
The following case study seeks to illustrate the ways in which the proposed observational framework can successfully address both the invisibility and the longitudinal aspects.

In a recent study regarding weight loss therapies, the pharmaceutical brand wanted to develop a holistic view of the consumers' decision pathways within the category: the avenues or treatments explored, how many times, in what order, and the emotional, physical and psychological toll of the entire behavioral cycle on their self-perceptions. This deeply introspective series of qualitative phases with one set of consumers was used to inform a large segment which would then be used to better position the company's specific brand and encourage trial and adherence. To this end, consumers were engaged for a three-phased study.
  • In Phase One, they participated in an in-person briefing (grouped by their stage of behavioral change in the category). This setting served to “prime the pump” for the critical observation work (Phase Two) by beginning the dialogue between the ethnographer and each consumer and within each consumer's own mind. Initial discussion sensitized them to the aspects of their experiences about which we were most interested, and facilitated the initial snapshot of their relationship with their weight (self-perceptions, habits, etc.).
  • Phase Two, then, continued the dialogue by asking them to complete a series of self-discovery assignments over the course of several weeks, including an experience map in which they plotted their weight loss successes and challenges along with key triggers and various therapeutic efforts.
  • By Phase Three, these consumers, now well-trained eyes and ears of their own experiences, poured out whole new levels of insight about themselves and their journey—including the inner demons, self-perceptions and misperceptions that so frequently hinder both trial and compliance.

Other benefits of this larger observational framework include:
  • Infinite flexibility: The approach provides an ability to customize the consumer's entire journey based on the therapeutic category and various aspects about the customer base (e.g., options range from paper journals to digital approaches involving blogging, “immediacy pulses” for real time reporting, etc.)
  • Cost-effectiveness: The fact that consumers are frequently unconscious of their actions makes ethnographic research a great fit—but traditional research would require days, weeks or months of observation to observe results—an expensive endeavor. And, more time “living among them” in traditional Margaret Mead fashion isn't necessarily the best use of budgets given the limitations. Instead, a longitudinal framework, often employing self-observation, yields a more deeply introspective view of their lives unattainable with a “one shot” visit at a fraction of the cost.
The limitations of traditional research serves not as a warning against its use, but rather to build upon it. Using the spirit of cultural anthropology, innovation can be applied to more traditional approaches to produce core insights in difficult-to-observe circumstances and see long-hidden aspects of customers' lives.

 This longitudinal approach provides a more holistic view of customers—a view that truly grapples with the barriers and opportunities related to adherence and compliance, in this case. This frame illuminates both the “seeable” and “unseeable” aspects of consumer reality and provides a foundation for developing a brand identity that resonates with the consumer as a whole person, not just as “product user” or “disease state.”

Laura Winn Johnson is a qualitative research manager at market research firm CMI, based in Atlanta

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