Last month, Jen and Jon discussed the rationale behind and the value in seeing the person within the patients. In the second part of the article, Jen and Jon review some research mechanisms and techniques which can prove successful in providing insights into the person behind the patient.
Jon Chandler 
Jennifer Squire 
16 Jun, 2009
From Monkey to man to Patient Part 2
The last decade has seen a resurgence of interest in ethnographic approaches in market research. Here a key driver has been the desire for a more accurate and authentic account of what goes on in the real lives of real people. Here, we will look at the use of video diaries as a ‘self drive’ variant of ethnography.
Recapturing past experience and its influence on the present is a major challenge when people do not carry this experience ‘top of mind’. Here we look at timelining as a set of techniques that enable people to retrieve and re-evaluate their own past experiences.
A broad raft of research techniques have been focused on exploring the depths of the human mind. Variously labelled as enabling, projective or creative techniques and so on, what unites nearly all of these is that they seek to push beyond the surface in some way or another. In what follows we will look very specifically at two particular techniques; creative drawing and emotional framing.
Video diaries
Getting inside the detail and drama of peoples everyday lives...
Ethnography is a label attached to research studies which endeavor in some
way to capture the authentic experience of the subject through intense observation.
Many of the pioneering studies in social anthropology were ethnographic; they
involved anthropologists living in the cultures they studied for extended periods
of time. In recent years this ‘living with’ approach to research has made a
small resurgence. In the healthcare arena this has included research amongst
patients. Fundamental here is the proposition that this type of approach comes
closest to capturing the real world of the patient.
Video diaries are one variant of the ethnographic approach. In effect Video
Diaries are self-drive ethnography and as such offer some unique benefits.
Like other ethnographic approaches they allow the patient to set the agenda,
and they allow us to hear the day-by-day authentic expression of everyday experience
and reality. Unlike other ethnographic approaches they are far less subject
to observer effects; results are uncontaminated by the presence of an ethnographic
intruder. Likewise they offer a better opportunity for capture of longitudinal
experience. Video diaries can be kept for weeks at relatively low per capita
cost, when ‘living with’ the subject is difficult to sustain or justify for
more than a few days.
Timespans for Video Diary projects can vary significantly according to needs,
as can the degree to which diary entries are directed or left open to the diarists
discretion. Typically each diarist is provided with a video camera and asked
to talk for 5 to 10 minutes each day about their condition, how they are feeling,
what impact their condition has had on their day, what it prevented them from
doing, its impact on others etc. Allowing the patients to talk openly, reflecting
their experiences over the course of a week or two, really gets into the hearts
and minds of the patient, and we get a first hand account of everyday life
living with their condition.
The video diary approach typically exposes real life issues, challenges and hopes over time and provides understanding of how these can be overcome.
After two years of going through the legal problems my condition has got worse whereby I can only walk very short distances with the aid of a stick. What effect does this have on me? Long self-staying, because I haven’t got my career anymore, friends I used to have don’t seem to get in touch or very few, so that means I have to make special efforts to keep in touch, which, because of my condition can be hard. People are very important in my life, some people don’t care, but others are very good... So, you learn a lot and you observe a lot when you are not well, but you do feel cut-off.
MS patient
I find the restrictions that I have got in my family life such as the inability to drive long distances anymore because of the discomfort you get when you are driving. My son wanted his bedroom painted... I have always looked after my own house, but for the last two years... forget it... If I am up and down on ladders, I get so uncomfortable that I have to pull back and say, this is as much as I can do for the time being.
Chronic back pain patient
Our everyday lives are subject to numerous influences, both internal and external, which shape who we are, how we live, impact on how we feel, how we communicate and how we interact. Our daily routines are altered by events which are both in and out of our control and changes to routine can have a significant impact, both negative and positive, on who we are as people.
Video diaries are a powerful tool, allowing us to gain insights into ‘real’ -and ‘current’ everyday things- both the significant and the more mundane that make us who we are. They provide us with a real time understanding of what shapes and influences our thoughts, our behaviour and our views of one’s self and allow us to see the impact a condition can have on all elements of life.
Timelining techniques
Understanding how time and experience have shaped the people that patients are...
A vast amount of our individual past experience is stored in our brains. Some
neuroscientists hold that absolutely everything is stored, nothing is forgotten
and that being unable to remember anything is a failure of access, not a failure
of memory storage. The point is that a vast amount of relevant patient experience
can potentially be recaptured from peoples’ memories. The challenge is to find
ways that will help people trigger those memories. To understand why a patient
behaves in the way they do with regards to their condition, we must try to
gain insight into their formative experiences as a person with a particular
condition. This is where timelining techniques can come into play.
The fundamental principles of timelining techniques are grounded in what we
know from neuroscience about the nature of the human brain and human memory.
What timelining seeks to do is provide people with mechanisms that allow them
to retrace and recapture key elements in the sweep of their own lives. Here
the proposition is that, given the right tools, time, encouragement and assistance,
people can remember and recapture a vast amount of their past experience. The
depth and breadth of this experience can give us new insight into many dimensions
of the patient world.
Timelining can take a variety of different forms. The key variation is around the time devoted to the exercise. At its simplest this can involve a simple 5-minute self completion task administered in either group or individual situations. Where timelining can become of far greater value is as the centre piece for an entire research project.
Here, for example, patients with chronic diseases can undertake extensive 1-2 hour pre-tasks in which the timelining principle is used. Given clear instructions, respondents recapture and build significant parts of their past experience:
- In erectile dysfunction; their experience of changing sexual function over time.
- In diabetes; their lifestyle and its interaction with their condition over the course of their life.
- In asthma; their very varied daily experience of living with the condition.
Using an A3 piece of paper, the patient ‘walks’ through their personal time line, from around the point of diagnosis of their condition to the present day. In conjunction with pre-task notes, the interviewer and patient ‘map out’ the key life events, experiences and memories which have occurred over this timeframe. As this ‘map’ evolves, the patient openly talks about each event, decisions that may have been made during this time and the impact these may have had. The timeline enables the patient to rediscover and express things that have positively or negatively shaped behaviours around their condition.
Any person typically produces a unique and very individual time line. However, within this common themes will start to appear. For instance, we can start to see how contact and communication with healthcare professionals impacted behaviour, understand the value of support systems, and see how attitudes were affected by certain life changing events. From the emergence of these common themes we can gain insights into how behaviours can be shifted positively.
Responses to and behaviours towards a condition are not static; they change and develop over time and are influenced by numerous internal and external factors. Timelining provides us with a vital mechanism that reflects this by looking at the long term picture, not just focussing on a snapshot in time.
Creative or psycho drawing
Identifying the underlying feelings and emotions that drive attitudes and behaviour...
A broad range of qualitative research techniques are designed to help push beyond surface accounts and rationalisations to get at underlying feelings and drivers: Obituaries, Personification, Guided Fantasy, Balloon Games, Laddering and the two approaches we will focus on here … Drawing and Emotional Framing.
‘Creative drawing’ or ‘psycho-drawing’ as it has been variously labelled has been used in market research for decades. As one of a variety of techniques that owe much to the psycho-therapeutic tradition, this is one of a number of qualitative approaches driven by a quest to ‘go deeper’ into the consumer psyche, to uncover more of what lies beneath the surface.
Creative drawing can be used in a variety of ways. Patients can visually express how they feel living with their condition, how they would ideally like to feel, how they feel about treatment or their relationships with their doctor.
Patients are given paper and a set of coloured pencils or crayons and encouraged
to express their feelings about particular situations, their condition, or
specific brands in a visual way. 
And they are not restricted by any pre-prepared
stimulus, they are in fact free to draw whatever they please.
Patients are openly encouraged to talk about their drawing, what it communicates
and represents, why they have chosen certain colours, and the associated words.
By talking through the illustrations, we not only uncover how a patient feels
but also what led to or impacted these feelings and how they have evolved.
Napoleon Bonaparte once said "Un bon croquis vaut mieux qu'un long discours," or "A good sketch is better than a long speech". Creative drawing can often provide greater understanding and more valuable content than just having a verbal discussion with a patient. The pictures produced do not need to be works of art, they all tell their own individual story. What we should be looking for is how the different elements of the picture interact and link together, what the colours represent and what the shapes are expressing. By visually conveying emotions or feelings we can often bring emotional needs to the surface which would otherwise remain untapped. This technique can therefore be very evocative and provide emotionally-based visual evidence that can be powerful when communicating patient feelings and needs to clients.
Emotional framing
Identifying the underlying feelings and emotions that drive attitudes and behaviour...
People rarely have ‘top of mind’ access to a comprehensive and coherent account
of their ‘needs’ in any particular instance. Although research in neuroscience
has demonstrated that ‘the emotional’ is dominant in human decision making,
people often have difficulties talking spontaneously about more ‘emotional’
needs. Emotional Framing is a research technique that can be effectively utilised
here to first of all identify emotional needs and then provide a route into
talking about what these mean, how, why and in what ways these are relevant.
In order to undertake this exercise the person is given a list of different
emotional states. Lists can be shorter or longer, but around 100 is generally
workable. These words are generally both positive and negative and cover a
broad spread of emotional states. The person is asked to select a number of
words [say between 7 and 10] that reflect how they feel about a particular
subject. To take our examples earlier this might be; ‘about being diabetic’
or ‘my asthma’ or ‘having erection problems’. The person is then invited to
talk about each of the emotions selected … typically, with some encouragement,
commentaries are immensely rich as people explain why a particular emotion
has been selected and illustrate this through recounting their own experiences.
This technique can be taken a step further to delve into patients ideal feelings and emotions….how would they ideally like to feel about their diabetes, their asthma etc and what would it mean to them if they could feel like this. We can then use these ideal feelings/emotions to understand where gaps/needs exist and how these could be fulfilled, for example by specific functional product features or by communication, support etc.
I chose mainly negative or neutral words to reflect how I feel about my condition. I am bored with it to be honest, it has been with me for so many years now that I am sick of thinking about it so push it to the back of my mind as much as possible. It is also frustrating, I cannot do all the things I want to do which gets to me. And I am dependant, on my medication, my family, my doctors, that is the one thing I can’t get used to, being dependant.
Asthma Sufferer
how do I feel, well guilty for one thing. And this is on a number of levels. Guillty that this is all my fault, I should have been more careful about what I ate and drank over the years. Also guilty that what I am not sticking to a diet, but it just seems impossible, it is so hard to change, even though I know I should. But that makes me angry, why should I have to change who I am. But in another way I feel thankful that it is not something more serious, it is just diabetes.
Diabetic Patient
Patients’ emotions or feelings towards a condition are often rooted deep in their subconscious and difficult to access. If we just ask the question “how do you feel...”, more often than not the responses we hear back from patients are limited, expected and tend to be feelings from the here and now. Although we should not dismiss such responses, we are far more likely to gain greater understanding about behaviours and attitudes if we look beyond the surface and uncover emotions which are not top of mind - for example: what led to diabetic patients’ non compliance or why asthma patients attitudes towards a new drug seem less enthusiastic than predicted. Emotional framing is a simple yet effective tool which helps gain easier access to the right hemisphere or ‘emotional side’ of the brain and dig deeper into emotional needs of patients.
These 4 techniques provide only a snapshop of the ways in which we can start to truly understand who the patient really is, what influences their behaviours, their beliefs and their emotions. By seeing the patient as more than just a condition or a set of symptoms we can understand how to start to engage patients in their condition, build more effective product development strategies and marketing strategies which ultimiately stengthen brands.
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