The $120,000 Cold - Health Literacy in Market Research

Mark Twain once remarked that the difference between the right word and the wrong word is the difference between lightning and a lightning bug. During the height of the Great Recession, I found out just how right he was. The wrong words cost me six figures.

After a massive layoff in January 2009 (my company downsized by 40%), I found myself without a job and without too many viable prospects. No matter where I turned, no one was hiring at my level. Most of the positions I saw listed were entry level ones; a few companies in my field were looking for individuals who had worked 1-3 years. My experience had become a detriment.

As if my own observations were not sufficient on how dire things had become, a friend’s story about how two different PhDs had answered her ad for a barely-above minimum wage office assistant job hammered the message home. Putting it mildly, things were bad. You can understand then why I was so ecstatic when finally, after a series of phone interviews, I was invited to an in-person meeting at a prestigious healthcare organization.

The opportunity was for a Director of Marketing position with a proposed $120,000 salary plus a generous bonus—a sizable step up from an Unemployment Compensation check. It came down to two candidates: one other and me. They were going to have us both come in on the same day for a series of "Stress Interviews," and they would make their selection based on those interviews.

Murphy's Law operating the way it does, however, found me battling a wretched cold. The meeting facilitator, a headhunter from an external recruitment agency, felt that my condition warranted postponing the meeting. "You'll need to be on your game for these interviews, not drowsy with cold medicine," she said. I thanked her and we agreed that I’d touch base with her the following week. Desperate as I was for a job, though, I began to grow paranoid. What if she didn't relay to the company how excited I was to meet with them? Would they think that I lacked a strong enough desire and fortitude if I let the sniffles prevent me from coming in? I decided to reach out directly and email the company. I told them that I was disappointed I wasn't able to meet with them this week, but that it had been recommended that I reschedule when I was healthier.

In hindsight, I should have trusted the headhunter and the interview process. I shouldn't have reached out directly to the hiring company at all. Failing to do that, I still would have done considerably less damage had I only left off the second half of my remark that it had been "recommended" that I reschedule later.

My email was forwarded to the headhunter. She took offense and responded by:

1. Informing me that it wasn't just her recommendation that I reschedule the interview; it was the hiring company’s preference that I come in healthy and operating at peak capacity, and
2. Closing the meeting window without my interview ever being rescheduled.

By default the other candidate won the position.

This was a costly but important reminder of a marketing fundamental: the success of a product, service, or even oneself is often impacted less by its actual value than by one's ability to use the right words to sell it.

The words we use matter, and the wrong ones will cost you. The wrong words cost us all. They cost patients positive health outcomes, and they cost the healthcare system; it’s estimated that their role in poor patient understanding, which contributes to noncompliance issues, costs the healthcare system billions annually. These are just two reasons why thinking about health literacy is so vital. It’s something all healthcare communicators should do. Shockingly, it is seldom thought about in market research for fundamental patient touch points such as medication labeling (instructions for use).

Why is so much patient material still being written with health literacy as an afterthought, retrofitted like so much duct tape holding the machinery of communication together? When these "quick fixes" are added post-market research without specific patient input on the tactics, it's a gamble whether or not those tactics help to enhance understanding.

The faulty reasoning is that clear communication will be achieved as long as a text's readability is at an ideal level (in the U.S. typically written at a 5th or 6th grade level). The problem with this theory is that while readability is a good first step when thinking about health literacy optimization, it alone does not always result in total audience comprehension, and that, after all, is our goal. 

Starting to think about health literacy only after market research has taken place, and solely relying on readability scores to optimize text, are poor communication approaches with unpredictable results. Sadly, there are countless organizations that don't even do that much but rather ignore health literacy entirely. As a member of PMRG’s Health Literacy Initiative, my company, Sommer Consulting, and I are working hard every day to change that. 

While some organizations are doing their due diligence and including health literacy in their market research, it is not nearly as wide spread as it should be. The effectiveness of different plain language and health literacy optimization approaches to enhance understanding should be routinely tested with patients. Since a given communication tactic may not work in a new context despite possibly having worked previously, testing should occur each time new patient material is developed. This is the only way to guarantee that comprehension has been achieved. Assumptions should not be relied upon. They should not drive procedure for something as important as our health.

Will you join me in making #HeLIMaR (Health Literacy in Market Research) a priority? Doing otherwise risks, as George Barnard Shaw said, the single biggest problem with communication—the assumption that it has taken place.

Rude Ravens, Giant Rats, and Incontinent Seagulls

Though previously unpublished, this blog was written in 1999 about my initial impressions of Australia circa 1997. Though accurate at the time, some of the content may no longer reflect current conditions.

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Animals with accents? I didn't believe it. That was something I expected to find in Looney Tunes (a la Pepe Le Pew) and Disney cartoons, not during my travels. There I was in Perth, Western Australia, however, and there they were, crows with Australian accents.

I was exhausted for the first two weeks after my arrival in Australia. This was partly due to my not being able to sleep, too excited at being in a new and exotic land. To a lesser degree it was the natural result of my having just completed a thirty hour journey (from Philadelphia, Pennsylvania to Perth, including short stopovers to refuel/change planes in Frankfurt, Germany and Singapore); I was still jet-lagged, and I was trying to adjust to a 13-hour time difference. The blame, however, primarily fell on the Australian crow.

There are actually several types of crow that live in Western Australia. However, only two species can be found in the south-western region, and of these two only the Australian Raven (Corvus coronoides) is common in Perth.

I didn't notice the raven at first. I arrived in the early evening and was so grateful for a bed in which to sleep that I collapsed almost immediately, confident that I would not awaken until mid-day. At 5:02 in the morning, however, I sat bolt upright, my heart thumping. I was confused. Dreams still clouded my thoughts as a wet sleep-film did my eyes. I had no idea why I was awake. Then I heard the sound—awful, pitiful. The noise reminded me of a crying infant. Some people have likened it to the call of lamb at the slaughterhouse, but that thought is too gruesome for my liking.

I cautiously crept over to the window and peered out from behind the blinds toward the trees across the way. Two shadowy bodies, even darker than the slate sky and black bark framing them, perched on the branches, singing their terrible duet. As my eyes adjusted to the gloom, the specters solidified and their figures took form. They were ravens, plain and simple. Yet what was this sound they made? Where was the soft "caw" that wouldn't disrupt my slumber?

In a subsequent conversation with a group of Australians I was amused to learn that they were just as bewildered as I upon encountering foreign crow calls. One Australian related her long-held theory that the 1994 Brandon Lee film, The Crow, was flawed and contained a sound byte of a seagull rather than an actual crow.  

Two weeks passed. Everything was starting to feel a bit more familiar. After all, on the surface Australia very closely resembles the United States—fast food restaurants such as McDonald's and KFC are plentiful, American movies fill the screens of the cinemas, and everyone speaks English, albeit slightly different than the one that I grew up speaking. Finally I was able to sleep past five A.M. I was just getting accustomed to the idea of animals with accents when I was introduced to a new concept: ravens with different regional dialects.

Just off the coast, twenty minutes by ferry, lies Rottnest Island. Besides its quaint coves, pristine beaches, and turquoise waters, the island is best known for its cutest inhabitants, quokkas (kwok-uhs).

These small, docile marsupials lent the island its name. The first Europeans to explore the region mistook the quokkas for giant rats, thus naming the island Rat's Nest. Later the name evolved into "Rottnest." It was here that I took a short camping trip, and here that I first heard the Rottnest ravens.

These birds, though the same species I had encountered on the mainland, had a slight variation to their call. Instead of sounding like crying babies, these crows made a noise more reminiscent of a four-letter expletive. "FAWK! FAWK!" I walked around with an amused grin on my face for the next two days.

While I viewed the Rottnest ravens to be a cruder variety than the crows to which I was accustomed in southeastern Pennsylvania, I found the people of Western Australia to be pleasant, friendly, and extremely relaxed. At one point I was reading a book on the beach when I heard a crash. A few meters behind me, on a paved walkway, someone had lost his grip and dropped a bottle of Emu Bitter, a popular local beer. Moments later a blonde-haired, barefoot "surfie" (Australian for surfer) started walking on the pathway, completely oblivious to the shards of broken glass. He walked right through the glittering pile before he could be stopped or warned.

"Sorry," said the clumsy beer drinker.

"She'll be right," the surfie said, which is the equivalent of saying "it's okay; no harm done." The surfie then glanced down at the broken glass and added good humoredly, "You can't hold your beer, mate," referring to both the drinker's apparent low tolerance and to his having literally dropped the bottle. With that they each smiled and the surfie continued down the path.

I was astonished. I couldn't imagine such a scene in Philadelphia. Putting aside the fact for the time being that no individuals in American cities would ever brave our concrete jungles without the protection of footwear, if they did happen to step on broken glass in Philly, they'd be distraught, in pain, and angry. They most likely would lash out, at least verbally, at the person responsible for the broken glass. But not here in Australia. Both parties remained friendly and, mostly, unconcerned. In fact, the surfie hardly seemed to be uncomfortable, let alone in pain. Indeed, there was no blood or any other evidence of cuts, and as the surfie walked away I saw why this was the case; the soles of his feet were thickly calloused. This is not unusual. Neither, I learned, was the surfie's reaction.

I was told that his calm, relaxed attitude was fostered, at least in part, by the country's beach culture mentality. The majority of Australians live along the coasts since the continent's interior is an unforgiving desert thought by many modern-day Australians to be too harsh to support large communities. This coastal living has contributed to Australia's "no worries" motto, as well as to a more casual mode of dress (at least in Western Australia).  Excluding restaurants and night clubs, there is not a "no shirt, no shoes, no service" policy in effect here. On the contrary, lack of footwear is an accepted norm (hence the surfie's callouses). While it is true that most people still elect to wear shoes in public, it is not uncommon to find some, usually adolescents and young adults between the ages of 14-24, walking on sidewalks, entering supermarkets, and even attending lectures at universities completely shoeless.

This less formal approach to life extends to all areas of social behavior. When I returned to the Australian mainland from Rottnest, I had the opportunity to attend a party thrown by university students and young professionals in their early to mid-twenties. I was excited at the prospect of participating in an authentic Aussie bash, but shortly after my arrival, my  eagerness turned to confusion. I was sitting on the couch talking with two female friends, the only people at the party with whom I was acquainted, when I noticed that there were no other men in the room. I looked around and spotted them all standing outside on the patio. Why weren't the genders mingling? The scene reminded me of those dreadful Junior High School dances with the boys leaning awkwardly against the wall on one side of the gymnasium, and the girls on the other side, neither daring to dance with the other. I asked my friends to explain. 

Apparently this isn't too unusual at parties where nearly everyone knows one another. Though it is not always the case, I was told that it's still fairly common at Australian parties for boyfriends and girlfriends to separate and break off into groups of men and women—their same gender friends. They stay segregated like this for most of the night, meeting only in the kitchen when each gets a drink. 

I couldn't help but wonder how well I'd fare dating if I was single when most of my friends were already paired up and, therefore, these were the type of parties I attended. I am not confident that I'd have too positive of a love life if my only opportunity to socialize with women at parties consisted of five minute chats in kitchens, but the Australians are surprisingly successful. Once again, it comes back to their approach in life—casual and upfront. They don't seem to bother with those mind games that are so prevalent in the United States. There is far less consideration as to the rules governing how long one should wait before calling a guy or a girl whose number has just been requested. Australians usually tell you what's on their minds. If they like you it is seldom left up to conjecture or speculation.

Perhaps the best example I saw of this straightforward attitude was found on a sign outside a popular fish 'n chips shop in the port city of Fremantle, Western Australia. The sign read: Please don't feed the seagulls, or they will S.O.Y. (i.e., S**t On You).

It was that sign that gave me the idea to write this post. I found it hilarious and mentioned it around my Australian friends. Their universal response surprised me. To paraphrase, I was told in a no nonsense fashion that that was good advice. Seagulls are dirty; they carry disease. Possibly true, but didn't my friends appreciate why that sign was funny? They did, but that was a secondary reaction. Once again I was reminded that Australians and Americans are not the same. I was reminded of another observation too; something that hadn't been articulated or taught to me, but a truth that I had nonetheless picked up from an ethnography course at Johns Hopkins: the native may see the forest, while the visitor sees the trees, but only together can they possibly hope to see the leaves.

All of us have blind spots. When it comes to aspects of our culture that are ingrained and second nature to us, we often lack the capacity to even recognize them as significant. A savvy visitor can often learn more from what a local tour guide doesn't say than what the guide deems worthy of mention. It's the equivalent of observing the local side-step a patch of quicksand without thought or a passing comment. The visitor could then ask about it, making the local pause to reflect on something that he or she had until that moment done by rote and taken completely for granted as just the way things are. In this way, both parties are enriched by the experience, seeing the land through the eyes of the other. I have experienced this firsthand. I most clearly see my home when I host friends visiting from overseas, answering questions of theirs that never would have occurred to me to ask.

For a long while now I have wanted to gather personal accounts from my friends, family, and acquaintances around the world about a day in their lives. Any random or interesting anecdote would do. To me it would be like a multitude of tour guides showing me around  their homes. I would be watching for those guides to sidestep the quicksand.

It is my hope that some of you reading this now may be brave enough to share a few of your own stories in the comments section, regardless of whether you're contributing the native forest or visitor trees to the discussion; perhaps together we can see some leaves.

Mightier than the Sword—the Power of Brand

It is President Clinton’s assertion that the main weapon being used by Hamas in the current conflict in Gaza is a branding campaign against Israel. Without getting into a geopolitical debate or assigning blame on one side or the other for this current conflict, this is fascinating from a branding perspective. In fact, nation-branding, specifically Israeli nation-branding, is a topic I wrote about in the branding blog, The Finch Post, on February 17, 2012 (http://www.thefinchpost.com/2012/02/-this-brand.html).

In a recent interview, Bill Clinton said “Hamas was perfectly well aware what would happen if they started raining rockets on Israel. They fired thousands of them, and they have a strategy designed to force Israel to kill their own [i.e., Palestinian] civilians so  that the rest of the world will condemn [Israel]…In the short to medium term, Hamas can inflict terrible public relations damage on Israel by forcing it to kill Palestinian civilians to counter Hamas.”

I ask that no one use this as a platform to launch into a diatribe against either or both parties involved in the current conflict. My interest is not in the former President’s assignment of blame, but on his assertion that branding is being employed as an active campaign. I am curious as to how the branding community perceives this strategy. Are there comparable examples in the corporate world? Has one company or brand taken market share away from a rival by negatively branding it? What impact, if any, does such a practice have on the entity wielding the negative-branding tool against its competitor?