Ethnography – It’s Broader Than You ThinkPeter SimpsonDonna SimpsonSegmedica, Inc.

Presentation Contents

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An Expanded View of Ethnography

The Impact of Technology

Mini-Case Studies

Advanced Linguistics

Analysis and Presentation

Summing Up

• Technology advances have given us a range of new ways to conduct Observational Research

• Today we want to talk about the full range of observational techniques, their strengths and weaknesses and how they can be integrated with interrogational research

• Also talk about the link to two other types of research:

– Interactional– Simulation and role play

Ethnography Expanded View

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The Full Spectrum of Research OptionsPure

Ethnographic

Interrogational

StimulationSimulation

Interactional

The Technology Effect• Technology is rapidly making tools

that are smaller, less costly and easier to use

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$$$

A New Range of PossibilitiesWhat We Want to Do How We Can Do It

Observe how patients manage at home In person video ethnographyWebcamsWebcam diariesActivity sensors

Observe how HCPs and patients interact In office video ethnographyIn office audio recordingsActor based role play

Observe unguarded thoughts Social media and blog monitoring

Track how HCPs are projecting product information to patients

In office audio recordings

Gather unpolluted language for linguistic analysis and messaging development

Social media and blog monitoringWebcam diariesSelf Moderating Research

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Integrating Observational Research

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• We see Observational Research as largely an adjunctive data gathering technique

• We seldom use it alone or in large amounts

• In most cases you do not need $$$ “ethnography projects”!

• It combines well with all other types of research, for example for a patient journey:

– In-home video ethnography– In office Audio ethnography– HCP IDIs and TDIs

In Office Audio Actor Driven Physician Role Play

In-office HCP Appointment Recordings In-facility simulated physician-patientinteractions

Real Physician Patient Interaction Simulated interaction with a real physician and an actor “patient”

Physician is fully prepared in advance forthe interactions

Physician has no warning of the interaction

Physician and patient may both “play” to the microphone

Physicians tend to act as they normally would

Little ability to influence the encounter or repeat an effect

Complete control over the actor and the clinical case study

Body language, facial and physicalgestures not observable

All body language observable

An Example of Complimentary Techniques

Case Studies

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The Waiting Room TV Case

The Inactive Patients Case

The Obesity Conversation Case

The International Adherence Case

The Teenage Genetic Disease Case

The International Social Media Monitoring Case

All respondents in these cases signed appropriate video/audio release forms and waivers to permit these videos to be shown at research events. Segmedica is a HIPAA certified organization. All incoming data is screen for

Patient Healthcare Information (PHI) which is removed before material is analyzed or used in any way.

The Waiting Room TV Case

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Objective: To determine the value of sponsorship of a specialty medical channel broadcasting to physician's waiting rooms

Methodology:

• In-office audio recordings plus follow up TDIs with patients• To see if/how the TV channel was influencing HCP/Patient conversations

• Ethnographic Simulation Research• Rented physician's offices on the weekend• Brought in patients for interview• Set concealed webcams in the waiting room (patients signed video releases before

entry)• Placed a staff anthropologist in the waiting room • Placed product brochures in the waiting room• As the patients cycled through, we recorded their observations of the TV, reading

of brochures, etc.• They were interviewed in an exam room about sources of product information,

etc.

In the Waiting Room: ESR™

Elapsed Time = 5:30Patient watches TV for a couple of minutes, then reads a magazine and looks up when the sound is on

Elapsed Time = 3:37Patient distractedly watched TV for about 2 minutes, then gets something to read

These clips show how frequently/how long patients focused on the TV (cont’d)

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Study OutcomeIdentified a need to re-edit the television

input with respect to:

Use of sound

Length of presentation

to match patient

attention span and waiting

room “dwell time”

Need for follow up

materials to support and reinforce the TV message

Suggestion for take

away DVD to enable

patients to watch in full at home and

with caregivers

Suggestion for parallel

web program

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The Inactive Patient Case

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Objectives: Understand how physically active a cohort of patients was in their home and other life activities

Methodology:

• Patients were recruited and equipped with a BlueTooth® enabled accelerometer and a base station and internet connected notebook computer were set up in their homes

• The accelerometer recorded activity and sleep patterns and the data was batched by the base station and transmitted to our offices

• A staff anthropologist visited each home for half a day

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Brand building opportunities:

Developed a program for patients to optimize physical activity

Opportunity to forge alliances with

insurance companies to

promote wellness programs adapted and marketed to appeal to people with the target

disease

Powered a website which informed

patients and caregivers on how to optimally configure

their homes to meet the long term needs

of patients• These needs were not

being addressed by physicians

Unexpected benefit – close cooperation

with an advocacy group to help

enhance public support

Study Outcome

The Obesity Conversation Case

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Objectives: To understand and improve HCP/patient dialogue on Obesity

Methodology:

• In office audio recordings• Interactional research combined with self-moderating research• 4 PCPs would observe 4 obese patients talking about what it is like to discuss

obesity with their physicians• The patients observed the physicians having the same discussion• Then the groups were put together with the remit of developing an ideal

format of HCP/Patient discussion• (All respondents were made aware that they were being observed by the other

group)

Study Outcome

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Helped promote alliance with larger pharma company

Patients need to feel:• The Doctor is “with them”• Practices what they preach• Understands the whole problem• Will forgive them their failures

• Positioning• Messaging• Physician – patient programs• Web site development

Multi-faceted

The International Adherence Case

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Objective: to understand the motives for non-compliance and non-persistence with a drug and how compliance could be improved

Methodology:

• Specialists were recruited for IDIs• During the IDI, a detailed clinical and socio-economic case study

was presented• Without prior warning, an actor was introduced and the physician

told to imagine they were a patient and to explain their options• Patient IDIs took place in which the actor played the role of the

spouse of someone recently diagnosed with the disease and who was non-adherent. The respondent was asked for advice

Study Outcome

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• Understanding that Adherence issues were universal with local detailed differences

• Development of programs and messages designed to promote adherence

• Understanding that the physician was often a part of the problem- Their “fair balance” amounted to negative spin

• Physician education program in encouraging and sustaining compliance

The Teenage Genetic Disease Case

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Objective: To understand the tween and teen population issues with a rare genetic disease (universe = 1,500 in the US)

Methodology:

- Webcam diaries- Webcam face to face IDIs- Webcam based focus groups • The diaries gave key insights as to the tweens and teens daily

activities and the impact of their disease on those activities

Study Outcome

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• Develop of programs designed to foster intimacy between the client and the target patient community

• Acquisition of language and concepts for communications, especially with teen patients and caregivers

• Web site development

Applying Advanced Linguistic Analysis to Observational Results

A Real ExamplePHYSICIAN: “Well, I mean, for a medication option standpoint, there’s pretty much just one other medicine that’s available that’s called Product X. I think we might have talked about it before, but it’s only available through a specialty pharmacy. It, sort of, comes in the mail.”PATIENT: “Yes, I think you’ve said something.”PHYSICIAN: “Yes. And the main issue with it is that you have to have your blood checked on a regular basis, because it can sometimes cause severe side effects.”

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A Real ExamplePHYSICIAN: “Well, I mean, for a medication option standpoint, there’s pretty much just one other medicine that’s available that’s called Product X. I think we might have talked about it before, but it’s only available through a specialty pharmacy. It, sort of, comes in the mail.”PATIENT: “Yes, I think you’ve said something.”PHYSICIAN: “Yes. And the main issue with it is that you have to have your blood checked on a regular basis, because it can sometimes cause severe side effects.”

This physician, speaking to a real patient, is:• Prevaricating• Stalling• Framing this as a bad choiceHis interview results said• I always explain Product X as an optionThe chart said• Explained Product X to the patient as an option

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What is new is that this analysis enables us to carry out analysis on lots of language –the more the better!

Computer processing identifies language patterns across respondents

A major new tool in research analysis

• Adjunctive analysis carried out on unpolluted language to deliver additional actionable insights

• Sources include online communities, self-moderated research, video diaries, and all forms open-ended questioning

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The process is based on semantics, the branch of linguistics which deals with meaning of words in context

Words change their meaning according to context, usage and inflexion and body language

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The process is based on semantics, the branch of linguistics which deals with meaning of words in context

Words change their meaning according to context, usage and inflexion and body language

Yeah means yes

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The process is based on semantics, the branch of linguistics which deals with meaning of words in context

Words change their meaning according to context, usage and inflexion and body language

Yeah means yesRight means correct

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The process is based on semantics, the branch of linguistics which deals with meaning of words in context

Words change their meaning according to context, usage and inflexion and body language

Yeah means yesRight means correctYeah Right! Means no and incorrect

• We must be able to set words into context to understand their true meaning

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Themes and Concepts – The

Building Blocks of Linguistic

Analysis and Application

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Themes and Concepts

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Insights, Recommendations

Analysis (combo of hard data and interpretation)

Discovering common themes and concepts is the first step

Words, phrases, sentences, etc.. are unstructured data

• As we peer into the meaning of the language, themes emerge• Identify concepts that are relevant and analyze those in context• What results is a much deeper understanding • More important is how they are interpreted

– Key words or phrases that will resonate best

Getting to the roots of the Language

A Case Study about Ulcerative ColitisUsing Social Media Monitoring

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Natural Language Processing (NLP) – The first step

NLP defines themes and concepts by using a combination of analysis algorithms to analyze strings of language

• Both frequency and co-occurrence play a big role

• Provides the building blocks for analysis

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Concept Paths

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Concept Paths

Concepts emerge that are associated with each theme

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0 20 40 60 80 100 120

healthtimeyearblogtake

colonbowelgluten

symptomsinside

digestivepain

medicalsystemdoctortakingcancer

chronicsuffering

surgerysupport

research

Relevance percentage

Concept Cloud

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Theme: Disease

• Comparison of ulcerative colitis to Crohn’s disease is a commonly discussed topic in social media

• Belief that similar treatments can be used in both UC and Crohn’s disease.

• Numerous posts hoping to help

• Numerous posts hoping to help people become more aware of UC and the toll it takes on themselves and their families/caregivers

Theme: Disease

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Theme: Disease

• Proper nutrition can be beneficial to UC sufferers

• Probiotics and herbal supplements are also discussed

• Social media posts stress finding a good doctor or nutritional expert

Theme: Health & Diet

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Theme: Disease Conversations about the colon • Conversations about the colon

were mostly associated with colonoscopies

• Colon cancer was of great concern to UC patients

• Colon cleansing was also frequently discussed

Theme: Colon

Bringing it all together

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• In the examples from the previous slides, we studied social media from all the major websites gathering comments and conversations on Ulcerative Colitis

Concepts Key Concept

Inflammation Pain

Health

Body

Colon Disease

Lifestyle

Themes

Lifestyle in the context of pain management, inflammation control, and overall management of health

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Resonating Language –Patients

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• Suffering is a word that is often used in connection with UC.

Patients often describe themselves • Patients often describe themselves as “suffering with UC” instead of “having UC” or something similar.

• Patients choose the word suffering because of its negative connotation.

Theme: Pain & Suffering

It connects to their emotional • It connects to their emotional feelings of worry and hopelessness, as well as the physical pain.

“Uncontrolled Ulcerative Colitis and Celiac Sprue: I have been suffering from diarrhea since my birth.”tweet

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• Everyday life is a concept that is frequently associated with UC.

This is primarily because of the • This is primarily because of the negative impact it can have on so many areas of a persons life.

• Patients who suffer on a regular basis feel frustrated with not being able to comfortably do things such as go to work, go to restaurants, etc.

Key Concept: Lifestyle

“The world large web has introduced with it a new wave of technological innovation that enables individuals to do just about everything from the comfort of their home. Today it is not necessary to reside a existence that is made up of suffering and that there are definite ways to adjust your everyday life from a person that contains suffering to 1 in which you are satisfied peaceful and struggling free all the time.” tweet

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Resonating Language –Physicians

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“He was having a regular checkup (colonoscopy) and the Dr. noticed a slight degree of inflammation. His doctor decided to switch his medication.” tweet

Theme: Inflammation

• There are a number of conditions associated with inflammation and symptoms that may be similar to other diseases.

• Inflammation was seen as an indicator that the patient is uncontrolled and might need a change in treatment. This is controversial and does not come out strongly in physician interviews

Reducing inflammation was seen as the key to solving the • Reducing inflammation was seen as the key to solving the majority of the symptoms that patients complain of, such as pain. This is controversial and does not come out strongly in physician interviews

“In my previous articles I have discussed the issue of leaky gut what happens to make the gut leaky and what problems it can cause such as inflammation and over active immune response.” blog post

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“Technology allows us some great tools to help track our symptoms using our smartphone ipod touch or ipad. In this video I demonstrate a downloaded app called GI Monitor which tracks symptoms, meals and pain/stress levels.” you tube

• Physicians considerate it a challenge to find pain relief that best suits the UC patient without causing debilitating side effects.

• There are many tools out there to track research and the success of new medications to relieve pain.

Theme: Pain

• Pain management without the fear of failure or addiction can be can also be a challenge to physicians.

“Patients with Ulcerative Colitiis may complain of abdominal pain fatigue loss of weight.” facebook user

How Linguistic Analysis Benefits Market Research

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Discovers hidden concepts inside the language

Develops lexicons or suggested key phrases that resonate with the targets

Reveals much more about what is being said, why it is being said and most importantly how it can be used

Sources of Language

• Previous or archived research• Online communities or bulletin boards• Self-moderated groups• IDIs and Focus groups • Ethnography• Simulated research

Presentation

Analysis• Observational Research produces a lot of output:

– Video– Audio– Stills– Transcripts– Notes– Artifacts

• This has to be cost effectively integrated together with the output of other modalities

• Semantic Clustering is a useful tool for this– Language analysis models which seek patterns in

unstructured data• Web based softwares enable the management of

different media in one database• HCP-patient dialogue can also be analyzed using variants

of the Roter system

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Often You Come Homewith Pure Gold

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Classic Video Ethnography is Vivid

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Life as it Really is

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Presentation Options• Ethnography generates very rich data• Video is most impactful• Gather video clips onto a chapterized DVD

and use it drive an immersion workshop• Video and audio clips come from different

observational and well as interrogational modalities and complement one another

• We sometimes bring a patient and/or physician into the presentation

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Benefits of Observational Research

Applications• Observational Research is the gift that keeps

on giving:– It can be brought into general insight work,

segmentation, positioning and messaging– It can be used for observing physician-sales rep

interactions– Semantic Clustering can be used to analyze

“hot line” recordings– It can be used in independent pharmacies for

pharmacy/patient interactions

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Benefits ofObservational Research

• Can account for the complexity of group behaviors• Reveal interrelationships among multifaceted

dimensions of group interactions, and provide context for behaviors

• Can reveal qualities of personal experience in a way that other research methods cannot

• Can help determine future questions and types of follow-up research

• Helps to understand why behaviors occur, rather than just noting the occurrence

• Very impactful for Brand Teams• Connects well to conventional interrogational

research• By combining with conventional research you are

able to use exotic and costly techniques in smaller amounts

• Sometimes it completely overturns conclusions from interrogational research

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Summary• Observation in all its forms, combined

with linguistic analysis and often complimented with market research modalities, is a very powerful tool

• When properly matched to objectives, and used only when needed, observational research can be used in combination with other modalities

Things to Think AboutExample Challenges Combos Ethnographic Techniques to Consider

Patient Journey In-home video, in-office recordings, physician/actor role play

Patient Profiles In-home video, webcam diaries

Segmentation In-home video, webcam diaries, advanced linguistics analysis

Adherence Physician/Actor role play, in-office recordings with f/u interviews, webcam diaries, advanced linguistics analysis

Use and usability In-life use of products and packaging (in-home, in-office, in-hospital, etc.)

When considering direct observation – what will be going on? Is there something to see and observe?

(Physical constraints, dietary and activities issues, interpersonal relationships)Do you need a longitudinal element? (web cam diaries)

How much ethnography do you need to achieve the level of insight, richness and impact that you need?