Adherence and Emotions


In a review of about 40 to 50 scientific, peer-reviewed articles involving adherence to long term therapy, we have found that adherence research and programs may be missing the point: emotions are rarely taken into account. 

Adherence is one of the key issues facing the industry. Hundreds, if not thousands of studies have been conducted to assess adherence issues, but the problem persists. The total annual cost of non-adherence in the United States is estimated at $300 billion. This is largely related to the cost of hospitalization and medical procedures for people suffering from cardiovascular disease and diabetes. The cost to the pharmaceutical industry is staggering given that average adherence on medications for chronic diseases is only around six months.

While the research is interesting, one thing seems to be missing: none of it focuses much attention on the underlying emotional factors that impact patient willingness or ability to adhere to a therapeutic regimen over the long term.

In the word cloud above, built by aggregating the text of 30 articles on compliance and adherence, the size of the words indicates their relative frequency. Two elements are noticeable: the size of the words “patient” or “patients” compared to “physician”. And the absence of the word “emotion”. The burden of adherence is placed on patients and yet nothing is done to truly understand their perspective.

According to many research studies, typical patient adherence programs have little success, especially for chronic disease. Most efforts are behavioral, working on ways to increase the physical actions of adherence (i.e., making sure the patient takes a pill). Few efforts focus on the fundamental issue of trust between patient and physician. How do you get the patient to believe that the physician’s treatment decisions are valid and the best for the patient’s health? How do you get the patient to overcome the anxiety and fear when facing a disease state?

New models are emerging to address adherence and improve outcomes. Accountable Care Organizations, Care Alliances, Integrated Systems, Nurse Navigators and others all try to improve practitioner/patient relationships by focusing on treating patients comprehensively. This includes, for some of these organizations, obtaining an understanding of the patient’s emotional state.

There is, on the other hand, a decent body of research assessing communication between physicians and patients. The findings are quite conclusive: physicians have difficulty communicating effectively with patients and this has a strong negative impact on adherence. Patients forget most information about disease and treatment that physicians communicate to them, and this happens almost before they leave the doctor’s office.

At Stone Arabia Consulting we are experienced in conducting research into emotional drivers of choice. We’ve worked with leading pharmaceutical companies as well as smaller firms, even one-person startups, to help determine strategies for improving patient or physician emotional engagement to therapy over time. This research can take the form of a fully comprehensive program of exploratory research on patient journey and flow, or it can work in a smaller online survey. We rely heavily, though not solely, on visual stimuli, often shared across patient and physician targets, to assess unconscious emotional factors determining treatment choice by doctors and patient response to those choices. We are available to answer all questions.


Employer sponsored health insurance was declining before healthcare reform:

Mulling over the ACA

I will write something about ACA (health reform) but I get images of the Matterhorn, Grand Canyon, surface of Jupiter in my head. Coming up!

First question I want to ask: Is there anything funny about healthcare reform? Like, ha ha, funny?

Google Survey Research: Promise, Threat or Hot Air?

BargamotRecently I received a coupon to use Google’s survey research capability. I would get $75 off the cost of a survey. For one question among 200 respondents, $75 off meant I would be paying $25. Who could argue with that? And I thought: time to get a new career!

Well, it’s not all clear cut. Google’s surveys only allow you to run one question, plus one overall screener, for each respondent. You can run multiple questions in the same project, but each question will be asked of a different set of respondents. You can’t crosstab results. You can’t find out, for example, if people on a given drug are more satisfied with their physician. I didn’t see the value in running more than one question if I was paying for it out of pocket – especially if I couldn’t crosstab it. For the questions I look to answer, I would have to run my own survey using more traditional methods. Frankly it won’t cost me all that much money anyway, maybe about $5,000 in operational expenses like patient sample and programming, and then my time writing the survey and analyzing it.

Google’s sampling is based on what they call a “surveywall”: respondents answer the screener and a single survey question in order to gain access to premium content on selected websites.

Well, I tested Google, and for $25 I got my 200 respondents as promised. I had thrown a wrench in the works by screening to see if I could get ‘doctors’. Over 6,500 people were screened, and 4.4% qualified themselves as doctors. This incidence translates into about eight million physicians in the general population: obviously a number of respondents are fibbing about their profession. This isn’t surprising since I didn’t ask for an ME number or other verifiable identifier.

Google uses “inferred demographics” to understand characteristics like age, gender, income. Inference is based on IP address and DoubleClick cookie information. These two sources are supposed to provide information on behavioral patterns to allow them to infer demographic characteristics. The inferred demographics don’t cut it for me –not a single respondent in my data makes more than $100k per year. If this is true, then very few, if any, of the respondents are doctors: that is, they are all lying about their profession. If it’s not true, then what good are the inferred demographics?

Setting aside sampling method and demographic inference, the Google consumer research format has a lot of structural limitations. For a researcher with knowledge of the field and training in research methods, it may be hard to accept them.

  • There are only 12 question types to choose from when writing a Google survey. Three of them are open end questions. Six involve respondents assessing a picture (logo, ad…). Three are scale questions and all of those allow only a 5-point scale. So if you like to use any other size scales…. Well, no luck here.
  • I’ve already mentioned the fact that respondents can be asked only one question each. This destroys any possibility of performing in-depth analyses. For a single punch question, only five responses will be shown to any respondent. When you have more than five responses in your list, five out of six answers are randomly shown to each respondent. The six responses are covered, but only by a partial sample.
  • Multi-punch questions can only have five responses total. If there are more than five drugs in your category and you want to see all of the ones people have been on in the past, well, you just can’t. Other specify’ is never an option, so you can’t understand what people think if they don’t think within the five responses you pre-programmed. If they select ‘other’, you won’t know what it means.

I am not an enemy of Google. I was Director for Advertising Research at DoubleClick, which is now a division of Google. I am a devoted user of many Google products, like their online music service, their photo storage service, Google documents/drive, and I own an Android phone and two Android tablets.

In a 2011 survey of corporate market researchers, Cambiar Consulting found that one in five thought Google could be the leading research company by 2020. I am not trying to bash Google here. But for now at least, Google has missed the boat on this research product. The people leading the Google research initiative are software engineers, not researchers. They got the engineering down, as usual, but they missed the behavioral science aspect of the model.

I can think of one possible use for this survey tool. Sometimes ad agencies approach me with a quick deadline, low budget need for a short survey to feed into a pitch to a new or existing client. This might be the perfect tool for that: for a couple hundred bucks you get your answers. However, when I ran my survey it took nearly two weeks for field to complete, so the quick aspect that agencies on deadline need isn’t necessarily covered.

If you’re looking to do some relatively quick turnaround research that gives you insightful feedback to a problem, is designed by serious professionals and can help impact your bottom line, there are a lot of companies out there to help you. Stone Arabia Consultants among them.

John Mitchell

Pharma Cliff-Hanger?

We have been wondering about the doomsday scenarios presented relating to the major pharmas and the patent cliff. Projections on revenue a couple of years back were pretty bleak for some of the majors, starting in 2011. The first chart was based on projections compiled by Bernstein analyst Tim Anderson in mid-2011. 

Below we compiled a chart of some of the leading pharmas with real revenue figures for the past four years. Numbers come from Google finance. Other than Pfizer, AZ and BMS, it’s not so horrific. Sanofi is actually slightly on the uptick in spite of the loss of Plavix, and Roche is holding its own.


In addition, if you look at stock prices over the past year, some of these companies are doing pretty well. Look at Lilly, up 39% in a year. And Pfizer, with post-Lipitor revenue dropping to the point that the company is just a notch above Novartis in sales, is up 29%.

Now, I’ve been joking lately that it’s time for the rats to take advantage of their opportunities as the Cretaceous-Paleogene extinction event in pharma occurs, but who knows, this may be just the beginning of the Jurassic.

Research Operation Costs Continue to Fall

The fall in research operations costs is astounding. If you’re not benefiting from it, you should be. Don’t be the sacrificial lamb. Efficiencies in operations enable cost reductions that should be passed on to the end consumer. Firms that are inefficient in the research market should get out of the way.

Most employers appear prepared to maintain healthcare coverage for employees

After ACA come full bloom in 2014, most employees appear prepared to maintain health insurance coverage for employees, according to a survey by published on Sunday, February 9. Thus, the rumors that employers would greedily prefer to jettison coverage, pay employees a $2000 cash lump sum and run for the hills while letting employees fend for themselves appear to be untrue, as is much of the discourse around the response to #HealthcareReform. Over 80% of survey respondents will maintain employee health plans. 

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