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.”

Retail Behavioral Economics

Agencies have been applying behavioral economics, sometimes knowingly, sometimes not, for years. But as a formalized discipline, behavioral economics is a relatively new school of thought at the intersection of economics and psychology (when compared against economics as a whole).  At its core is a simple principle: human beings are predictably irrational. The discipline has been used to shed light on all sorts of entrenched patterns of behavior, such as why gamblers are willing to keep betting even while expecting to lose, or why people who want to save for retirement, or to eat better, or start exercising and quit smoking, end up doing no such things. Long before behavioral economics had a name, agencies and marketers have been using it using it. “Three for the price of two” offers and extended-payment layaway plans became widespread because they worked, not because agencies had run scientific studies showing that people prefer a supposedly free incentive to an equivalent price discount. In essence, it’s about targeting behavior humans are hardwired for.

There’s nothing new in finding the psycho-social hook that triggers a reaction. What is new is an interest in systematizing behavioral thinking and using the discipline more conspicuously to shed insight on the challenges advertisers face. Advertising is a business that tries to shape how people think about their choices – it taps into the underlying triggers that drive our beliefs, actions, and passions. Neoclassical economics can explain ads only as providing information. But if the seller can invest in advertising that frames the choice, that frame will skew the buyer’s decision. In other words, a more systematic approach can unlock significant value and increase share of culture by targeting actions to match practices, beliefs, and the reptilian brain.

A shot before bedtime: Take a product’s cost less painful. In almost every purchasing decision, consumers have the option to do nothing: they can always save their money for another day. That’s why the marketer’s task is not just to beat competitors but also to persuade shoppers to part with their money in the first place. According to economic principle, the pain of payment should be identical for every dollar we spend. In marketing practice, however, many factors influence the way consumers value a dollar and how much pain they feel upon spending it.

Retailers know that allowing consumers to delay payment can dramatically increase their willingness to buy. One reason delayed payments work is perfectly logical: the time value of money makes future payments less costly than immediate ones. But there is a second, less rational basis for this phenomenon. Payments, like all losses, are viscerally unpleasant. But emotions experienced in the present—now—are especially important. Even small delays in payment can soften the immediate sting of parting with your money and remove an important barrier to purchase.

Another way to minimize the pain of payment is to understand the ways “mental accounting” affects decision making. Consumers use different mental accounts for money they obtain from different sources rather than treating every dollar they own equally, as economists believe they do, or should. Commonly observed mental accounts include windfall gains, pocket money, income, and savings. Windfall gains and pocket money are usually the easiest for consumers to spend. Income is less easy to relinquish, and savings the most difficult of all.

Technology creates new frontiers for harnessing mental accounting to benefit both consumers and marketers. A credit card marketer, for instance, could offer a Web-based or mobile-device application that gives consumers real-time feedback on spending against predefined budget and revenue categories—green, say, for below budget, red for above budget, and so on. The budget-conscious consumer is likely to find value in such accounts (although they are not strictly rational) and to concentrate spending on a card that makes use of them. This would not only increase the issuer’s interchange fees and financing income but also improve the issuer’s view of its customers’ overall financial situation. Finally, of course, such an application would make a genuine contribution to these consumers’ desire to live within their means.

Become the icon: Harness the power of a default option. The evidence is overwhelming that presenting one option as a default increases the chance it will be chosen. Defaults (what you get if you don’t actively make a choice) work by instilling a perception of ownership before any purchase takes place, because the pleasure we derive from gains is less intense than the pain from equivalent losses. When we’re “given” something by default, it becomes more valued than it would have been otherwise. And we are more loath to part with it.

Savvy marketers can harness these principles. An Italian telecom company, for example, increased the acceptance rate of an offer made to customers when they called to cancel their service. Originally, a script informed them that they would receive 100 free calls if they kept their plan. The script was reworded to say, “We have already credited your account with 100 calls, how could you use those?” Many customers did not want to give up free talk time they felt they already owned.

Defaults work best when decision makers are too indifferent, confused, or conflicted to consider their options. That principle is particularly relevant in a world that’s increasingly awash with choice. A default eliminates the need to make a decision. The default, however, must also be a good choice for most people. Attempting to mislead customers will ultimately backfire by breeding distrust.

Limit the options: Don’t overwhelm consumers with choice. When a default option isn’t possible, marketers must be wary of generating “choice overload,” which makes consumers less likely to purchase. In a classic field experiment, some grocery store shoppers were offered the chance to taste a selection of 24 jams, while others were offered only 6. The greater variety drew more shoppers to sample the jams, but few made a purchase. By contrast, although fewer consumers stopped to taste the 6 jams on offer, sales from this group were more than five times higher. Large in-store assortments work against marketers in at least two ways. First, these choices make consumers work harder to find their preferred option, a potential barrier to purchase. Second, large assortments increase the likelihood that each choice will become imbued with a “negative halo”—a heightened awareness that every option requires you to forgo desirable features available in some other product. Reducing the number of options makes people likelier not only to reach a decision but also to feel more satisfied with their choice.

Brand matters: Position your preferred option carefully. Economists assume that everything has a price: your willingness to pay may be higher than mine, but each of us has a maximum price we’d be willing to pay. How marketers position a product, though, can change the equation. Consider the experience of the jewelry store owner whose consignment of turquoise jewelry wasn’t selling. Displaying it more prominently didn’t achieve anything, nor did increased efforts by her sales staff. Exasperated, she gave her sales manager instructions to mark the lot down “x½” and departed on a buying trip. On her return, she found that the manager misread the note and had mistakenly doubled the price of the items.  In this case, shoppers almost certainly didn’t base their purchases on an absolute maximum price. Instead, they made inferences from the price about the jewelry’s quality, which generated a context-specific willingness to pay.

The power of this kind of relative positioning explains why marketers sometimes benefit from offering a few clearly inferior options. Even if they don’t sell, they may increase sales of slightly better products the store really wants to move. Similarly, many restaurants find that the second-most-expensive bottle of wine is very popular. So is the second-cheapest. Customers who buy the former feel they are getting something special but not going over the top. Those who buy the latter feel they are getting a bargain but not being cheap. Sony found the same thing with headphones: consumers buy them at a given price if there is a more expensive option, but not if they are the most expensive option on offer.

Another way to position choices relates not to the products a company offers but to the way it displays them. For instance, that ice cream shoppers in grocery stores look at the brand first, flavor second, and price last. Organizing supermarket aisles according to way consumers prefer to buy specific products makes customers both happier and less likely to base their purchase decisions on price, allowing retailers to sell higher-priced, higher-margin products. For thermostats, by contrast, people generally start with price, then function, and finally brand. The merchandise layout should therefore be quite different.

Marketers have been aware that irrationality helps shape consumer behavior for a long time. Behavioral economics can make that irrationality a bit more predictable. Understanding exactly how small changes to the details of an offer can influence the way people react to it is crucial to unlocking significant value.

Brand Affinity, Culture, and a Pickup Truck

Brand affinity is the most enduring and valuable level of customer relationship and is based on the mutual belief that the customer and the company share common values. It breeds unshakable trust in the relationship the brand and the consumer share. It is at its strongest level when a customer believes that your brand champions the values they both share. Consumers who demonstrate affinity for a brand buy more, buy more often, and complain less than all other types of consumers. And the surest way to build brand affinity is to tap into the deep, culture truths your consumers hold. As an example, let’s talk about that most iconic of American driving, the pickup truck.

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The pickup truck has become an essential part of Western culture. Trucks are the symbolic embodiment of the hard-working American spirit. Even though trucks are needed and valued for their usefulness in farming, ranching and blue collar occupations, many, if not most, truck owners do precious little in the way of physical labor – spend a few hours driving through the pricier suburbs of Houston or Denver and it becomes abundantly clear that the truck is as much a cultural statement as it is a tool. According to a study conducted by Hedges & Company, truck owners spend a considerable amount of money on customizing their trucks, with 45 percent spending at least $1,000 and 17 percent spending at least $3,000 making alterations and refinements. The most common components customized are wheels and tires (36 percent), audio and video (29 percent), exterior trim (29 percent) and exhaust systems (19 percent). The high value that pickup truck owners place on their trucks and the amount of money that they spend in aftermarket products makes sense when you consider the fact that 64 percent consider their truck as an extension of their personalities.

Seems like a pretty straightforward discussion so far, but pause for a moment and try to picture the typical pickup owner. Visions of a guy in his 20s or 30s immediately come to mind. And while that’s clearly the target audience, it also represents a marketing plateau – there’s simply a cap on how many of these people exist. So where might other opportunities lie? What potential market is being overlooked. Well, let’s try women. When I was doing fieldwork with women who owned trucks, only one of the 30 participants owned a truck as a function of her occupation. Several used it as a means of establishing a sense of identity that said to the world, “I’m not a girlie girl.” Still more used it as a way of asserting a sense of strength on the highway. Some used it as a way of maintaining a connection with their past rural (or semi-rural) lives. The point is that the truck became an extension of themselves and utility played a minor role in the underlying reasons they chose it over a car or an SUV. And interestingly, the brands they chose most often were Toyota and Ford. They were seen as either more accepting of diversity because they weren’t part of the traditional American pickup market (Toyota) or because they harkened back to a simpler time (Ford). Dodge, on the other hand, was seen as embodying masculinity to the point of misogyny and Chevy, as one consumer put it, was “a truck for boys”. Toyota and Ford pickups fit easily into their cultural identity, Dodge and Chevy did not. The result is that the women who own Toyota and Ford pickups express extreme loyalty to the brands and say they are significantly more inclined to advocate for them. Considering the economic power of women, that’s a great place to be in.

So why does it matter? It matters because it speaks to the fact that the products we own and use, whether they are thought of by their manufacturers and retailers as utilitarian or extravagances, are reinterpreted and redefined by their owners and that is a huge opportunity for marketers. The truck is a fashion piece. It’s a toy. It is a way of stating you’re part of a tribe. And just as trucks have a range of unexpected meanings, so to do laptops, beer brands, eye glasses, etc. Regardless of your product or service, understanding the cultural elements of a brand gives build stronger connection to your consumers.