Lori Dixon

Marketing research firms have always done well at listening to the “voice of the customer.” Most survey methods allow consumer comments to be accurately captured and confidently measured.  The challenge is when the “voice” is not enough and the real need is to understand how the consumer behaves in their natural environment.  Sometimes, it is significantly more insightful to obtain a sneak peek into the “life of the customer.”

Officially, this type of research is called ethnographic research. Research that observes people in their natural environment.  We have used this type of observation method for years when we want to see how a child interacts with a product at their preschool for example.  However, when the goal is to learn how adults use products in their home, the challenge increases.  You need permission from a highly targeted group of people, but you don’t want to tip your hat by asking too many questions such that they adapt for the interview.

This case study demonstrates how ethnographic research created a new way to look at potential solutions for an age-old problem.

The Research Project
Pharmaceutical companies and package design firms have been studying prescription drug compliance for years.  What they know for sure is that every missed dose of a drug is lost revenue.  What they don’t know is how to break into the daily regime to increase compliance.   The assumption is that senior adults, the segment with typically the most complex mix of maintenance drugs, want to be more complaint but often forget to take their medication.  Therefore, their goal had been to learn as much about dosing routines as possible to identify opportunities for a compliance aid to increase adherence to the dosing instructions.

Note that the market is not without plenty of compliance aid options.  A quick Internet search generates about forty different product types that range from less than five dollars to just under one-thousand dollars.  Some are nothing more than plastic boxes with a letter to designate the day of the week.  Others can be wired to alert a caregiver if there is inactivity at a dosing time.  The challenge with many of these devices is that they require dexterity (to set alarms, install batteries, etc.) or are complex to fill.  Some compliance aids fit onto individual pill bottles or caps.  This is helpful for the patient who takes one medication or who is willing to allow the dosing requirements of one prescription to dictate the dosing requirements of all drugs.  The shortcomings of current gadgets are well documented.

However, the stimulus for inventing the perfect new compliance innovations is easy to understand.   Pharmaceutical industry research cites a range of staggering statistics that associate drug therapy non-compliance with deaths, increased admissions to hospitals and nursing care facilities and increased health care costs in the billions overall.

Compliance aids to remind seniors to take their medications or help them dose properly may be one solution or part of the solution.  However, maybe the answer is not a better mouse trap.

The Research Objective
The project started with a typical question:  how can we create a better compliance tool?  This seemed that it was an easy survey research question.  However, most senior adults are on complex drug therapies that include five or more prescription medications that are taken at various times of the day.  Add to this a variety of inhalers, creams, vitamins, supplements and over-the-counter drugs and then even the most flexible questionnaire is not going to capture the nuances of how seniors organise their medication routine.

The next thought was to try focus groups.  These discussions were helpful in understanding how medications are “supposed to be taken,” but lacked in true insight.  Most seniors able to attend a focus group are not in the category of being dangerously forgetful.  This group of focus group attendees, chosen because they take several medications, was aware that their quality of life depends on taking the medication.  As a result of this recognition, they have systems to help them comply.  They described their process in terms of how they use reminder boxes and place the reminder boxes in places that trigger their memory.  We should have known that traditional questions will yield traditional answers.

As we attempted to fine tune the research process, we asked respondents to bring in pictures of their reminder boxes and pill caddies, medicine cabinets and drawers, and other gadgets used as part of their drug therapy program.  This added some insight, but it became apparent that the pictures were capturing only part of the story.  They were “staged” to some extent and, just enough out of context that their value was slightly diminished.  Furthermore, as the conversation about the pictures unfolded, the real stories were told, “well, these are usually on the rack but the light was wrong for the picture … these are in the cupboard but I put them on the table so you could see the packages better, etc.”  Clearly, the respondents were trying to be helpful, but in their efforts to make the pictures clear they muddied the real story.

The learning from the central location interviews was that taking medications is a complex process that is influenced by the number of prescriptions taken, dosing cycles, life style, caregiver’s role, household structure and mental age. (We all know physical age is irrelevant among today’s seniors.)  Thus, to truly understand how one integrates a complex drug program into their daily routine, you really need to witness the “life of the customer” in their own environment.

The research process unfolded in two phases. The first phase was to identify seniors who take several maintenance drugs and live in an independent living situation (rather than a nursing care centre).  We also wanted to talk to seniors who take primary responsibility for managing their own compliance with their health care routine. However, we did not want to include only those seniors willing to help with research projects. Therefore, we started the recruitment process by finding adult children of seniors living in the area.  These adults helped us recruit their parents.  We said that we wanted to video the interview, but we did not explain the topic in much detail.  We said the study was to discuss health care issues and how they maintain their health.  Our goal was to be fair to the respondent but not to tip our hand too much.  In the past we have found that respondents tend to “tidy up” the areas that they think will be on camera and thus reduce the value of capturing a true lifestyle evaluation.

The in-home interviews were invaluable to understanding how dosing schedules, medication packages, and compliance aids fit into one’s lifestyle and personal priorities.  This research method allowed us to learn first hand how packages must slide into drawers, nest into cupboards and remain stable on small nightstands.  It revealed challenges that could have been lost in a typical focus group or interview because seeing the person move around the house, pointing out their medications, stimulated questions that may have been left unasked.  For example, one senior organised her medication in shot glasses on the windowsill above the sink.  Each Sunday evening, she drops the pills and vitamins into her morning, noon, afternoon and evening shot glasses.  The shot glasses remind her of the places she has been with her children, and that, by taking her medication, she will be healthy enough to continue going places with her grandchildren.  Had the city names on the glasses not been noted by the interviewer, the motivation behind using shot glasses, rather than a plastic reminder box, may have remained uncovered.  Most importantly, the underlying reason why compliance is important to her lifestyle may have been lost in the detail of how the shot glasses do not provide any UV or moisture protection for the medications.

This extra learning leads to significantly more insightful hypotheses.  For example, is the role of compliance packaging only to serve as a memory aid or should it help motivate a person to take their medication.

It was also vital to learn that a compliance aid or package that influenced compliance with only one medication would have little value for most senior adults who take multiple medications and create a “system” for their entire medication schedule.  They tend to work their medications into a daily schedule that matches how they arrange their home and accomplish their daily tasks.  For example, one senior puts her morning medication (the only one she takes before breakfast) in her kitchen cupboard.  Her response to a verbal question about where she stores her medication would have resulted in the generic code of “kitchen” or maybe kitchen cupboard.  However, when she pointed to the containers in the various cupboards, the story became clear.  The lone bottle next to the cat food in the cupboard evoked a telling of the way in which her memory aids have been created from a lifetime of habits.  She awakes to the purr of her cat.  Her first task of the day is to feed her kitty and her second task is to take her morning medication, which she sees next to the tins of cat food.  Her other morning medications are taken with breakfast and, therefore, are sitting in a plastic basket next to the coffee maker.  She always has coffee with breakfast.

Using this type of research yielded a whole new set of hypotheses that may have been left uncovered with traditional research methods.  For example, can compliance be enhanced with more packages that buzz or have calendars on them or by creating products that foster a more symbiotic relationship with the patient’s lifestyle?  When the research goal is to find information that will help build a better product, the results are undoubtedly focused on comments that help build a better mousetrap.  However, when the research question is how can we influence behaviors? The starting point needs to be a true commitment to learning behaviors.

The deliverables from ethnographic research are also unique in that the reports include pictures, video clips and quotes.  The videos can be shared with marketing and product development staff to give them a window into their customer’s daily life.

Lori Dixon is owner of Great Lakes Marketing in the USA