Fieldwork Part 2: Hemophilia

Coming out of the field, two themes emerged again and again from our research: the idea of rite of passage and the importance of control.

Rites of passage in adulthood serve as a symbolic transition into a new state of being, with certain responsibilities, actions, benefits, and social roles. In the case of non-compliant sufferers of hemophilia, that transition was almost always lacking. There is no ritual of separation as parents continue to call several times a day. There is no statement by either the person with the disease or the people who care for them acknowledging that they are now responsible for their own life – not just figuratively, but literally. And so, our participants created it for themselves.

This process was entirely personal, and these young men found themselves in an extended transitional state, searching for a sort of resolution. Until that resolution was found, the medication became a target for asserting a sense of growing personal control. The medication and the needle became the symbol on which to hang a new sense of control and identity.

Control over the physical, psychological, and cultural state that had dominated every element of their lives was central to our participants’ move to a new identity. There is no cure for hemophilia, but, in gaining control over their identity and establishing themselves as something “beyond the disease”, they are reborn as someone “with hemophilia” rather than a ”hemophiliac”. They become a fully realized person, rather than being an extension of the disease.

Having finally identified our two major conceptual themes, we developed a new campaign centered on the passage into adulthood. Working with our creative team, we changed the conversation from one of vague rebellion to one of control. Taking control of your regimen is a symbolic rebirth. Taking control of infusion means leaving your past behind, not just following the same old pattern. The focus was on defining your future through medication and redefining being a “hemophiliac”. Treatment would be synonymous with stripping the disease of its power and ushering in a whole new world of possibilities defined by the person with the condition.

We also knew that a traditional campaign wouldn’t have legs if it didn’t have a digital extension, so we developed an entirely new web presence: a new, secure website focused on the aspects of transition to living away from home. We developed a private community with a focus on tips, not support. The term support conjured images of the meddling they were trying to escape. “Tips” conveyed shared knowledge and the sense of fostering a community from a group with similar experiences others can’t quite grasp. The community is closed to anyone who doesn’t have the condition or who hasn’t been invited into the conversation by someone with hemophilia. Control is exclusive to people with hemophilia, they have the power to limit or extend their world as they see fit.

At a more concrete level, users gain control over payment, appointments, and doctors. They gradually transition into managing their own care over time, with a series of guideposts, acknowledgements and reminders.  This led to developing a model that allowed content to be restructured to reflect where users were on the transitional/post-transitional continuum. Content could be assigned based on how long they had been out of their parent’s home, whether or not they were living alone, and whether or not they were working regularly with a medical team to address the disease. All of this provided tools to manage the transition to independence.

This website also provided these young men with an outlet for sharing their experiences and stories, moving them from a sense of isolation – it’s decidedly uncommon to find someone else with hemophilia in your circle of friends and acquaintances – to one of community. The upside of this was increased support, a sense of belonging, shared advice, and more sustained, expansive interaction. Not only did it help increase compliance, it also helped broaden the conversation to other young men with hemophilia who were using another medication to regulate the disease. Jacob, a 19-year-old electrician expressed it by saying, “There aren’t that many of us, so when we’re talking with each other it’s believable, it’s real. It keeps you honest.”  In other words, it built awareness of and consideration for our client’s medication. And it helped these young men feel like they were more than their disease.

The pharmaceutical industry is extremely conservative and generally fixated on data. While the industry does hire people to do more exploratory work, numbers rule the marketing landscape. For this reason, and the fact that this was the first time they had ever funded this type of research, we chose to set the stage by telling a story.

The response? In addition to giving the green light to all of our proposals, the client asked that we share the work throughout the company as a demonstration of the power of qualitative research.

In the end, getting our heads out of the data, rethinking the questions, and getting into the lives of these young men made all the difference to the brand, and, I’d like to think, the people coping with the disease day to day.

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Fieldwork Part 1: Hemophilia

David has hemophilia. Three days a week, he wakes up, showers, dresses, and sticks a needle into a vein. He’s been doing this since he was a child. He does this three days a week, for fifteen minutes each time, because if he doesn’t, a fall or scrape can land him in the hospital – or a coffin. This needle is a reality he’s lived with all 22 years of his life and one he will carry to the grave. It is, and always has been, a symbol of who he is. It has defined his life.

It would seem on the surface that medication compliance would be a non-issue. But for the makers of blood clotting drugs used to treat the disease, it turns out that managing this very necessary element to living with hemophilia is not as simple as it seems. Quite simply, young men (women very rarely suffer from hemophilia) are not particularly good about taking medication, even when that medication is essential to living a healthy life.

From the time they are children these individuals have limitations imposed upon them. Playing with others is often curtailed, parents hover, and they grow up constantly under a watchful eye. As one of our participants, John, explained as we sat in the Seattle apartment he shares with a couple of fellow college students:

“My mom and dad were everywhere, all the time. I get it, but it fucked with me, too. I couldn’t play sports until I was in high school. My mom controlled my infusion schedule and always checked to make sure I’d done it. So, when I went to college, yeah, I kind of slacked off. I don’t think it was some sort of rebellion, I mean, I wasn’t angry. But there’s a kind of freedom I’d never had before, and you take advantage of that, I guess. People can’t imagine what it’s like to shove a needle into their body twice a week, every week, and spend 15 minutes slowly pumping yourself full of your medicine.”

The transition from adolescence into adulthood can be difficult, but when chronic illness is a central marker of identity, that transition becomes harder for young men who have lived in a framework of dependence. Taking care to infuse means being able to engage in every activity they choose with the people around them, but there are a host of reasons to let treatment slide; some functional, such as time management, and some symbolic, like telling the disease to fuck off. 

The fieldwork noted that the role of shared space vs. private living space – often very limited – had an enormous impact on compliance. The first evidence of this point was the role of the refrigerator. Because the medication needs to be kept cold until use, it has to be stored in the refrigerator. Having the medication on public display was embarrassing and inevitably led to questions by both roommates and visitors. That meant that he and his medical condition were suddenly thrust into the spotlight, focusing attention not on the person, but the person as his illness. The second shared space vs. private space problem was finding a place to infuse. The process takes about 15 minutes and while it wasn’t hard to find time to do it, the patient needed to avoid interruptions, excuse himself and ensure some degree of privacy. Because this could be difficult or embarrassing, he might simply forego treatment.

House hygiene was another issue, especially in a shared environment. When we entered one apartment, as might be expected, I had to search to find a space that was free of pizza boxes, clothes, or textbooks. Keeping infusion equipment clean, keeping the bathroom clean, keeping the refrigerator clean, etc. was often a point of contention. Because the person with hemophilia is dependent on others to help keep a clean environment, it was often simply easier to skip infusion than to confront or manage the living situation with roommates.

But the environment is only one of the issues impacting these men; social and psychological changes are another. After moving away from home, young men with hemophilia encounter a degree of personal freedom that they have never experienced before. The wide range of limitations placed on these young men growing up are suddenly gone and learning how to handle it is the problem. There is a significant resistance to personal and social childhood limitations, the result being that finally getting involved in intramural football isn’t enough. As one participant, Brent, told us, “Hell yes, I did stupid things. I had someone watching everything I’ve done for my whole life. So you go a little bat-shit when you’re on your own.”

Resistance might mean drunken Twister, midnight wrestling, or skateboarding without a helmet. In one instance, I had the dubious honor of “officiating” an arm-wrestling contest that was fueled by shots of Fireball – not something you drink when planning an evening of rich conversation. I watched as our participant had his hand driven into the table by a friend who was considerably larger. Under normal circumstances this would have hurt, in this instance, had the participant not been infusing, it could have been life-threatening. 

Chronic illnesses can shape a life-long sense of self, and adulthood is the first time these young men have control over how the world sees them. Social bonding becomes more important than managing the disease because for the first time, they can simply be “Steve”, not “Steve the hemophiliac”. This sometimes leads to a more exaggerated expression than you see with the typical 18-year-old man. And it often leads to less compliance as the young man finds himself expressing his identity in opposition to the illness.

Not taking the medication is dangerous, but it’s also empowering. One participant, Jason, lived with two other young men in a small apartment, strewn with the standard debris of college life. For him, this wasn’t just a matter of letting the housekeeping slide a bit, it was a way of demonstrating his sense of independence. And while his infusion tools were kept clean and away from the chaos of the apartment, there was a haphazard element to their storage that fit the overarching theme of making a break with the past. “I know it’s stupid, but at least I’m in control. Not my mom. Not the disease.”

Yellowstone’s Wolves and Reintroducing a Brand

Two decades ago, Yellowstone National Park was suffering. It was the victim of defoliation, erosion, and an unbalanced ecosystem. But in 1995, everything changed. That was the year wolves were reintroduced to the park.

Prior to the return of wolves, deer, elk, and bison populations had increased substantially, resulting in overgrazing, particularly of willows and other vegetation important to soil and riverbank structure. This left the landscape vulnerable to erosion. Without wolves, the entire ecosystem of the park suffered.

When wolves were brought back to the park, they changed their prey’s behavior patterns. The herbivores started to avoid areas like valleys and gorges where they could be easily hunted by predators. And those areas began to regenerate. Species such as birds, beavers, mice, and bears returned. Plant life once again thrived along the riverbanks and erosion decreased significantly. Perhaps most remarkable, the stabilization of the riverbanks actually made the rivers and streams change course. The entire landscape of the park transformed.

Brands aren’t that dissimilar. They exist as part of a broader ecosystem and when they are removed, that ecosystem changes. Now, to be fair, “ecosystem” is admittedly an industry buzz word that’s been around for years, including the branding world. Most focus on the integration of social media, digital marketing, and consumer data. And they usually employ traditional means of brand communication. Every brand is part of a larger, interconnected cultural system. Not just the culture of the people inside the company, but its partners, customers, non-customers, and even competitors. It has history, mythology, functions, and forms. Every action results in a reaction.  

So, when a brand is reintroduced or reinvented, it does so in the context of a deeply interconnected set of variables. When ta brand is reintroduced or reinvented, it change the system. The burden of a brand revivalist, then, is to rewrite and reshape not only the brand itself, but the ecosystem in which it operates. No matter what the reason is for your brand relaunch, this means it needs to be specific and backed up by a concrete plan. The first step in the process is understanding where it fits in the ecosystem, what role it plays, and then deciding which aspects of the brand need to be retooled.  This, of course, requires a thorough evaluation of the core brand identity across all of its various components.

The second and perhaps more important step is to fully understand how the brand shapes the broader cultural patterns that impact its consumers/customer/users. Most situations involving a brand relaunch are going to be long-term affairs, and the planning stages need to be informed not only so the reintroduction itself will have maximum impact, but also so that it positively effects the system of which it is part, both sort and long-term.

ROI and the Intersection of Exploration

When chemists at Oregon State University discovered a brilliant new blue pigment serendipitously, they were not thinking about creating art. But in a true art meets science moment, an applied visual arts major began using the blue pigments in her artwork as part of an internship in Subramanian’s laboratory. This was also her first foray into the world of chemistry. Human history is filled with examples of innovation that occurred at the juncture of art and science, whether it’s as profound as Leonardo da Vinci’s explorations of anatomy or as mundane as liquid nitrogen ice cream. The point is simple – creative inspiration, whether in product development, advertising, or any other activity, is a matter of rethinking how we look at a problem.

Driven by CEOs that want to see ROI and engagement for every cent spent versus the equally valuable but often nebulous idea of “brand impact,” campaign and branding initiatives can be particularly challenging for CMOs today. Seemingly competing world views clash in large part because we take a binary position – it’s an either/or mentality where art and science are somehow in conflict. But is that fair or is it a modern construct? Are art and science so divergent or have we slipped into a lazy pattern of thinking.

Brands that want to take advantage of the intersection of art and science can start by simply acknowledging the fact that creative and metrics are not mutually exclusive concepts. By blending these two components of the creative process (and yes, science is a creative enterprise) and giving them a common goal to work towards, we see focused innovation. We see new expressions of a common undercurrent.

Blending art and science is about collaborating in ideas generation: the inter-relationship is critical, you can’t have one thing without the other. A bunch of code or data is just a bunch of numbers without the art. A visual masterpiece that produces no action is inspired but not inspiring. Science enables us to be more creative, and creativity allows us to get the most out of our data. But consider “the multiplier effect”. If either the data or creative are bad, the idea will fail. Or worse yet, if they work alone, without the cross-pollination that happens when different ways of experiencing the world come together, then the result can be flat out detrimental. It’s not one or the other that we need, it’s both. It’s not science plus art equals results, it’s more science times art, so a zero for either means failure.

That is where the interesting ideas are – at the intersection of exploration. The future is all about ideas connecting. Those who can bridge art and science will be in demand, will be powerful. If our ideas are going to change hearts and minds, then we need to find expression that can move freely between the boundaries of art and science.

Brands and Self-Creation

The old brand model advocated the creation of an external brand image to influence consumers. It talked about benefits, it talked about the company, it promised to give you sex appeal. Those times are long past. This is partly due to the sheer number of channels in which people interact, but I believe there is a deeper reason. And that deeper reason is that successful brands reflect culture, not targets or widgets. In other words, talking about what you do is no longer enough.

Consumers will no longer buy the external brand image we create, but will take it upon themselves to define what a brand really stands for by probing for their own truth. Today we’re seeing that certain issues which could be considered secondary to a brand are suddenly primary. People are not just choosing the best, the sexiest, or the cheapest. They’re choosing brands that have meaning. Their concept of nature, of self, of society takes center stage. Particularly in such a media-rich, postmodern, global environment, a sense of culture has become increasingly complex. That 35-year-old, American woman, might identify more closely as a post-punk-artist-suburban-engineer. In other words, she isn’t defined so much by her demographic makeup or media habits as she is by the choices she makes in shaping our own worldview and sense of self. And this is where brands taking on a new and intriguing role.

So, what role does brand play in this landscape of self-creation? Brands become symbols and metaphors for crafting identity. They introduce, reflect, and influence meaning. The most resonant brands are creating value not just by the products or services they represent, but by the symbolic power they impart. Indeed, meaning has become the most important product a brand creates.

Perhaps the most relevant is that “culture” is a transmitted pattern of meanings embodied in symbols by which people communicate, perpetuate, and develop their knowledge about and attitudes toward the world. We’ve all heard it. A brand must stand for something and drive people to participate in it, become part of it. Wonderful, but how do you begin to determine where your brand fits into a cultural matrix? I believe it starts with eight simple questions:

  1. Does it have a higher purpose?
  2. Does it have norms?
  3. Does it have specific values?
  4. Does it have special language?
  5. Does it use specific metaphors and symbols?
  6. Does it have myths, legends, and storytelling?
  7. Does it have rituals?
  8. How broad is its social presence?

Why this particular approach? Because, when people make a purchase, whether it be a mobile phone, a bag of dog food, or a bottle of milk, they are actually using that product or service to add meaning to their lives. The meaning that has been created in the goods and services that everybody buys is not intrinsic to those goods and services. It’s our culture that determines this. If you come to marketing from that point of view, it suggests that the choices we make are actually very important to us, even if those choices seem rather functional. From that perspective, the marketer has a responsibility to craft strategies and messages that reflect these cultural perspectives.

Culture and Marketing

Change in Media, Change in Targets

It’s time to update the idiom. There are three things certain in life: death, taxes, and…branding. People are exposed to thousands of commercials in various mediums every day, including radio, television, social media and print. This adds up and evolves, resulting in the average individual adult or child being exposed to countless varied ad instances every year. But quantity is not the only thing that is changing. In the past, advertising was largely a one-way communication. Now, customers are taking control of the products, services, and the way they interface with them. In other words, audiences can volley back and participate in the millions of advertising interactions they experience every day. “It is shared communication, not only between the firm and customers but between actors in the marketplace.”

This dynamic personalization has advanced the industry beyond just marketing to personas, segments, and averages. We can be more specific in our design – we have the technology – and that has upped the bar. Today’s marketer should be able to 1) recognize every customer as an individual, delivering 1-1 experiences that feel one-of-a-kind in the hearts and minds of consumers, 2) know the discrete intention of every engagement, and 3) own every moment. Thus, the future of marketing lies in the battle for these micro-moments, shared in the space between the brand itself and the consumer’s response. Creating trust in this space, between brand and audience, is then vital. And the internet is influencing this interaction.

It is easy to see, then, that the moving target that is impactful advertising is only moving more quickly as the nature of advertising continues to evolve. Mass marketing isn’t dying, but it is definitely going through some natural selection. This denotes a change in what has long defined the consumer marketplace as fragmentation and niche groups come to define cultural patterns and, as such, hyper-targeted audiences. Increasingly sophisticated technology has enabled consumers to skip over these mass-market models, allowing people to quickly and easily search out specific products that speak to them. And data shows that this new self-curated buyer journey leads to consumers committing their dollars to brands that, across digital channels, give them content they care about1. In other words, people are choosing brands that help them define their individual identities and build their tribes over brands lacking a certain cultural trust or significance.

In this cultural resonance we find a huge opportunity for brands: people don’t hate advertising as much as they may claim. Now more than ever, brands are part of culture and identity – i.e. things consumers want to cultivate. 83% of people agree with the statement “Not all ads are bad, but I want to filter out the really obnoxious ones.”3  Translation: consumers don’t hate ads so much as they hate irrelevant ads, meaning ads that don’t speak to them functionally or emotionally. To endure now, successful brands must adopt a process that gives consumers a more relevant experience wherever and however they shop4. The experience will need to continuously optimize based on cues from the market and the target audiences2. This strategy will improve conversion rates, foster communities, and drive advocacy. Ultimately, brands with staying power will create a steady reciprocal relationship with their consumers, turning them into powerful ambassadors and fanatics.

So what do I mean by culture here? Culture is the sum total of shared values, ideas, beliefs, behaviors, and ideology of a group of people. You might say it is the glue that holds groups of people together and shapes their identity. Drawing on our extensive experience working in cultural influence, we tend to agree. When developing a campaign or marketing plan, other people tend to focus on benefits, features, and superficial aspects of the target audience. But, when we talk about a focus on “culture” we are talking about the deeper emotions, motivations, and associations people have with an activity, product, or service, many of which are subconscious. Culture is not a trend, though trends may impact it. Rather, culture is comprised of cognitive, social, and conceptual “frames” that people build upon. Think “pants”. Stylistically they change over time and if you make them, you better stay on top of the trends. But at a deeper cultural level we have an understanding of what pants are regardless of time. Understanding the deeper concept – what signals pants versus what makes bell-bottoms – and how it’s constructed gives you an incredible amount of power.

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Perhaps the most important piece to remember is that culture is a process. Culture is shared interactions, which means it is fluid. The reification of culture (regarding culture as a thing) leads to a notion that “it” is a thing that can act almost independently of human agency. But culture does not. Culture is subject to change and change can be controlled, or at least influenced, in any number of ways, including how we insert a brand into a person’s life. There are undercurrents and motifs that remain focal points through time, but they are always subject to restructuring. We are able to harness this cultural restructuring into a step-by-step analysis to approach, influence, and react to audiences.

First, cultural change is a selective process. Whenever cultures are presented with new ideas, they do not accept everything indiscriminately2. A marketing message or innovation is most likely to be diffused into a recipient culture if: (1) it is seen to be superior to what already exists; (2) it is consistent with existing cultural patterns; (3) it is easily understood in the context of their symbolic and functional constructs; (4) it is able to be tested on an experimental basis; and (5) its benefits are clearly visible.

Second, new ideas, objects, or techniques are usually reinterpreted and reworked so that they can be integrated more effectively into the total configuration of the recipient culture. In other words, people don’t simply consume marketing, they interpret and reinvent it.

Third, some cultural traits are more easily accepted than others. By and large, technological innovations are more likely to be borrowed than are social patterns or belief systems, largely because the usefulness of a particular technological trait can be recognized quickly. But technological advancement can only get you so far. For instance, by any reasonable measure, the US should have adopted the metric system by now. The thing preventing it is a lack of cultural connection. The same process holds true for brands.

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This cultural function means that the brand someone selects, that she is loyal to, is driven more by the deep emotional and cultural needs than by features and benefits. The sustainable brand, the brand that draws people to it again and again, reflects cultural truths. When you identify those deeper truths, you build a much deeper, more authentic connection both to that individual and to their “tribe”. From a strategic perspective, it provides you with more nuanced and adaptive creative, the ability to identify the right channels and platforms in which to market, and a long-term roadmap to evolve your communication as the brand grows. At a practical level, it means sustainable ROI and target audience ownership.

We believe that to be relevant and long-lasting a brand – one that sees return on innovation and investment – must operate like a member of culture alongside its consumers. A company must share out its core values and articulate WHY it exists. A brand must stand for something and drive people to participate in it, become part of it. People want to belong to something bigger than themselves.

 So, we know we must tap into a brand’s cultural depth with its audience. We need to build and recognize trust and grab a piece of it. And that’s how you get a share of culture. If we were to define it for a textbook, we’d say Share of Culture is the positive feelings, attitudes and beliefs shared between a brand and its audience. We believe the key to creating marketing campaigns that resonate today is to leverage your audience’s culture, seeing the bigger picture and building a reciprocal space. And, in the end, placing your audience’s culture at the center of marketing strategies creates sustainable ROI because culture has the power to nurture stronger, longer lasting and more engaged relationships with your audiences.

To be relevant and long-lasting, a brand must operate like a member of a culture – an equal participant. At the same time, it must own a piece of it. To rephrase, a company must share out its core values and articulate WHY it exists. And because people want to belong to something bigger than themselves9., when they make a purchase – whether it be a home, a new gaming system, or vacation package – they are actually using that product or service to add meaning to their lives. The meaning that has been created in the goods and services is not intrinsic to those goods and services. The meaning is created as the brand interacts with culture. It’s actually our culture that says a diamond has more value than a ruby, and gold has more value than silver, an Apple mobile device has more value than a Nokia, etc. If you come to marketing from the vantage point of added meaning, it suggests that choices consumers make have great symbolic connotations, both within their life and without. From that perspective, the marketer has a responsibility to do the right thing by those consumers – the brand’s peers within their share of culture – who are choosing a certain product in order to craft their identity. The trust and respect between brand and buyer has been established. The result of building this sort of reciprocal bond is that you move customers from being loyalists to being advocates by establishing a very strong sense of brand affinity through meaning.