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Emerging social media marketing strategy for pharmaceuticals Charles Scott Rader and Zahed Subhan Department of Entrepreneurship, Sales & Marketing, Hospitality & Tourism, Western Carolina University, Cullowhee, North Carolina, USA
Clinton D. Lanier Department of Marketing, Opus College of Business, University of St. Thomas, St. Paul, Minnesota, USA
193 Received 9 May 2013 Revised 26 August 2013 Accepted 14 October 2013
Roger Brooksbank Waikato Management School, University of Waikato, Hamilton, New Zealand, and
Sandra Yankah and Kristin Spears Department of Entrepreneurship, Sales & Marketing, Hospitality & Tourism, Western Carolina University, Cullowhee, North Carolina, USA
Abstract Purpose – The purpose of this paper is to assess the state of the art in social media and pharmaceutical marketing through empirical analysis of online consumer conversations. Proliferation of social media has significantly changed traditional one-way, marketing-controlled communications. Balance of power has shifted to consumers, who use social networking sites, blogs and forums to obtain extensive brand and product information, often from each other. This prompts companies towards more intimate, transparent and constant two-way consumer engagement. Pharmaceutical marketing and direct to consumer advertising (DTCA) are not immune to this pervasive, disruptive cultural/technological phenomenon, which poses particular challenges given regulatory, legal and ethical constraints on their marketing. Design/methodology/approach – This research uses “netnographic” data collection of online conversations occurring in social media and develops an explanatory framework using grounded theory analytical methods. Findings – This research shows that significantly impactful and pervasive bonding among consumers, bloggers and unofficial “experts” about pharmaceutical offerings is widespread, and occurs regardless (and perhaps in spite of) pharmaceutical companies’ involvement. Originality/value – Considering the structure and nature of online consumer bonding, a way forward is proposed for pharmaceutical companies to implement social media strategies as part of their pharmaceutical marketing and DTCA efforts through an intermediary and interactive online presence arising from disease and health care education. Keywords Social media, Online communities, Pharmaceutical marketing, Bonding, DTCA, Social listening Paper type Research paper
International Journal of Pharmaceutical and Healthcare Marketing Vol. 8 No. 2, 2014 pp. 193-225 © Emerald Group Publishing Limited 1750-6123 DOI 10.1108/IJPHM-05-2013-0027
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Introduction Marketing and advertising are experiencing a well-documented and revolutionary upheaval in both form and function in light of a rapidly changing communications technology landscape, particularly as it relates to the emergence of popular social media such as Facebook, Twitter, LinkedIn and YouTube (Edelman, 2010; Li and Bernoff, 2011; Scott, 2011). These radical changes are significantly impacting numerous industries, companies, brands, products and consumers (Davis, 2010; Hanna et al., 2011; PricewaterhouseCoopers, 2012), not the least of which includes the health (Keller and Thackeray, 2011; Neiger et al., 2012; Thackeray and Neiger, 2009; Thackeray et al., 2008, 2012) and pharmaceutical sectors (Bonk et al., 2012; Fox and Jones, 2009; Pesse et al., 2006). Due to a significant increase in consumer interest in obtaining health-related information online (Ye, 2011), coupled with social media being the most popular form of online activity (Qualman, 2011), this phenomenon is of particular concern to pharmaceutical companies, especially as it relates to their historic and continued efforts at marketing pharmaceuticals via direct-to-consumer advertising (DTCA). This paper sets out to assess, through an exploratory empirical study based in qualitative data, the current state of affairs regarding pharmaceutical marketing and related consumer activity within the realm of social media. Cast against the state-of-the-art social media marketing research and best practice, this paper pursues an in-depth investigation of consumer conversations related to pharmaceuticals and pharmaceutical brands as situated within the milieu of social media platforms. The resultant findings of these conversations are then presented, revealing emergent themes that indicate a preference for and prevalence of highly community-oriented bonding around visceral, and sometimes desperate, modes of interaction. A particular emphasis is placed on the difference between traditional models of DTCA and a normative model for moving forward through the lens of social media marketing strategy in other industries. In conclusion, recommendations are provided that integrate social media marketing best practice vis-a`-vis intermediary web presence that is focused on consumer education. This has the potential to acknowledge and respond to an inherent demand for engagement by consumers who form community around health concerns and corresponding pharmaceutical offerings, whilst still adhering to the present regulatory and legal constraints faced by the pharmaceutical industry. Literature review A revolution in marketing: emergence of social media It has been argued that a veritable revolution in marketing communications is occurring, instigated by the rapid rise in popularity of social media (Edelman, 2010; Li and Bernoff, 2011; Solis, 2012). Far and away, one of the most common forms of activity on the Internet (Madden and Zickuhr, 2011; Qualman, 2011), the notion of “social media” is somewhat amorphous and its definition is seemingly under constant revision as new communication technologies continue to appear on the scene. However, for the purposes of this paper, social media will be defined as the aggregate of networked, interactive, computer-mediated communication technologies including but not limited to blogs (e.g. WordPress, TypePad), microblogs (e.g. Twitter), tumblelogs (e.g. Pinterest, Instagram), social networking sites (e.g. Facebook, LinkedIn), forums/online communities/bulletin boards and user-generated content/media distribution sites (e.g. YouTube, Flickr, podcasts). The most consistent characteristic across this varied set of tools, and likely all
the technologies that are destined to replace them, is the participatory, two-way, decentralised accommodation of communication. Conceptually, our working definition of social media is in accord with prevailing current sources on the topic (Andreas and Michael, 2009; Kerpen, 2011; Khang et al., 2012). Impacting a wide cross-section of marketing activities, including research, strategy formulation, advertising, promotions and sales, it is proposed that social media is not as much an addition to the modern marketer’s toolkit as it is an endemic and ecological change (Davis, 2010; Hanna et al., 2011). This is largely due to the shift in control of communications from producers to consumers, who, in unprecedented fashion, have found social media as a platform for creating, distributing, evaluating, categorising and modifying information (i.e. UGC or “user-generated content”) largely through the venue of common conversations writ large within the process of a “consumer decision journey” (Edelman, 2010; Edwards, 2011). The subsequent impact on business and marketing strategy is significant. In sum, more than ever, consumers have a voice and they want to be heard and, moreover, are less and less susceptible to traditional marketing-controlled messages and media (Davis, 2010; Edelman, 2010; Hanna et al., 2011). Rather than passively awaiting product information as distributed by producers and marketers, which is often viewed with suspicion anyway (Hye-Jin et al., 2011; Jisu et al., 2005; Steyn et al., 2011), consumers instead are readily engaged in proactively soliciting companies and, more often, obtaining information from each other (Chatterjee, 2011; Fox and Jones, 2009; Hye-Jin et al., 2011; Li and Bernoff, 2011; Lipsman et al., 2012; Neiger et al., 2012; Vanden Bergh et al., 2011). In addition, a constant stream of influential bloggers, online forum/ community advocates and, often-anonymous, expert personalities increasingly weigh in on consumer decision-making (Greene and Herzberg, 2010; Jones, 2011; Scott, 2011). This dramatic paradigm shift can, in some respects, relegate companies, traditionally accustomed to controlling both the quality and quantity of communications about their offerings, to being “third in line” behind both other consumers as well as “armchair experts” in social media when it comes to exerting their desired influence on consumers. Indeed, it is appropriate to contrast this social media revolution with traditional advertising models. Most marketing managers who are still largely ensconced in the traditional paradigm of using one-way advertising view social media merely as additional available channels through which to distribute messages (Davis, 2010; Sacks, 2010; Stephen and Galak, 2009; Waters and Williams, 2011). Considering these new tools through such a traditional paradigm belies the significantly new opportunities for both marketing strategy and tactics. Pharmaceutical marketing, DTCA and the emergence of social media Of particular relevance to the present research, the traditional advertising paradigm has historically presented additional challenges to the pharmaceutical industry. As regards this industry sector, regulatory authorities (e.g. the Food and Drug Administration [FDA] in the USA) impose restrictions on companies’ marketing activities that effectively limit the use of traditional carte-blanche attributes-based messaging directed from companies to both customers (i.e. prescribers or other medical professionals) and consumers (i.e. patients) regarding pharmaceutical products. DTCA of prescription drugs, legal only in the USA and New Zealand, has generated a great deal of research in the pharmaceutical marketing literature (Greene and
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Herzberg, 2010; Silver et al., 2009). DTCA advertising has mushroomed from the few isolated and relatively sensational cases in the early 1980s to an omnipresent feature of American consumer society, powered by significant resources (in the form of promotional dollars expended by pharmaceutical companies). Proponents of DTCA argue that advertisements empower patients, whereas critics counter that they encourage wasteful prescribing (Mintzes et al., 2003). Whatever the merits and demerits of DTCA, it remains one of the most influential developments in pharmaceutical marketing and one of the most controversial modern business practices. DTCA in print and broadcast media is subject to scrutiny by the FDA that exerts control over drug labels and strives to ensure that promotional statements make claims about approved indications only and neither overstate the benefits of drug treatments and neither understate the risks. In print and broadcast media, the FDA provides detailed guidance for drug manufacturers which, following their publication in 1997 and 1999, fuelled the proliferation of DTCA in those countries where such advertising was permitted (the USA and New Zealand primarily). However, DTCA is evolving with emerging health care technologies such as use of the Internet, health care applications, social networking and the changing dynamics of the physician–patient relationship (Mackey et al., 2012). This has given rise to the emergence of online and interactive forms of “digital” DTCA through the use of websites and social media (Keller and Thackeray, 2011; Liang and Mackey, 2011; Thackeray and Neiger, 2009; Thackeray et al., 2008, 2012). With consumers becoming more active participants in the provision of their health care, they are increasingly using the Internet as a source for health care information (Applbaum, 2009; Mackey et al., 2012). Perhaps more significantly, with this shift in health care technology and communication adoption by consumers, DTCA is no longer confined within physical or geographical boundaries (Applbaum, 2009; Liang and Mackey, 2011). Similar to the ease of transmission of diseases through increased trade and travel, DTCA has globalised to markets outside of the USA and New Zealand via the Internet and other forms of cross-border promotion, resulting in a myriad of issues pertaining to regulation, adverse economic and patient safety consequences (Mackey et al., 2012). Relevant to the present study, the largest social media (i.e. Facebook and Twitter) collectively have ⬎1 billion users worldwide, and surveys “indicate that 60 per cent of Americans turn first to the social media when seeking health-related information” (Fox and Jones, 2009). It is, therefore, surprising that the pharmaceutical and medical device industries have been slow to establish a social media presence. The drug industry allocated ⬍4 per cent of the ⬎$4 billion it spent on DTCA to Internet outlets in recent years, and only a tiny fraction of this was spent for social networking sites (Arnst, 2009; Greene and Kesselheim, 2010). Additional important considerations regarding social media relate to their unique “conversational” qualities and attributes compared to the unidirectional messaging approach afforded by traditional DTCA or even emergent forms of digital or “eDTCA”. Thus, on the one hand, pharmaceutical companies may seek to immerse themselves in social media – including blogs, social networking sites and forums/online communities/ bulletin boards and, of course, post their own company websites (subject to any prevailing and enforceable regulations that might seek to limit the use of these). In this way, pharmaceutical companies can hope to “control” promotional messaging and conversations relating to their products and the disease conditions treated by these.
However, the ubiquitous, participatory, two-way and decentralised nature of social media, by nature, militates against “control” by any (one) party. In fact, and as recent attempts to block participation on pharmaceutical company controlled social media attest to (Moorhead et al., 2013), participants in various web-based social media react negatively to attempts by (social media) “owners” to interrupt or commandeer the two-way discourse. Finally, it is worth noting that even with their own media, pharmaceutical companies risk losing control over the content of the promotional message. Companies may intend to draw a line dividing their own media (such as a company website or a company-initiated chat area) from other online discussions of their products. However, the proposed distinction may no longer be technically possible, as entrepreneurs have effectively blurred the line between company-controlled websites and the general blogosphere (Greene and Kesselheim, 2010). Understanding the nature of this new era of decentralised, multi-directional and increasingly popular online discourse portends a “thick, rich” (Geertz, 1973) exploration of consumer engagement in social media, towards which our attention now turns. Research questions To assess consumer conversations and concomitant interaction with brands, or lack thereof, related to the pharmaceutical industry within the context of the previously described social media marketing revolution, our study seeks to address a broad-based and exploratory research agenda. Note that as opposed to traditional hypothetico-deductive research paradigms, which assume a priori knowledge about a phenomenon (i.e. what consumers, customers or pharmaceutical companies should be engaged in via social media) and then set about to deductively validate the existence of that assumption (i.e. actively attempting to surface evidence matching a pre-existing supposition of engagement), our approach leveraged initial research questions that served merely to circumscribe the general boundaries of the phenomenon (Glaser and Strauss, 1967) of consumer conversations about pharmaceutical products and brands. To this end, prior speculation as to the quality and extent of these conversations was held in abeyance, with a preference instead for iterative, exploratory and emergent theory building. To be sure, an initial scope of inquiry that is too myopic could cause important areas that emerge during the course of exploratory research to be overlooked, hence limiting the power and breadth of theory development and violating tenets of inductive, qualitative methodologies. Maxwell (1996, p. 49) suggests that inductive research questions “should be sensitive and adaptable” to discoveries as the research progresses, also noting that sometimes it is necessary to begin the research process before fully understanding what questions should be answered. Similarly, in the tradition of classical (“Glaserian”) grounded theory, the methodological framework used in this study, it is indicated that research questions regarding nascent, under-researched social–psychological phenomena be allowed to emerge as the investigation transpires (Glaser, 1978, 1992, 1998; Glaser and Strauss, 1967). As such, while the following research questions provided a general set of guiding inquiries for the study, they were subject to revision as the research progressed: • What is currently happening amongst consumers and within conversations in social media as regards pharmaceutical products and brands?
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• Where are consumers “virtually” congregating if conversations are occurring? • What is the nature and extent of their interactions? • What does this ongoing interaction mean for consumers? Using these questions as a broad-based preliminary boundary, a netnographic exploration of consumer conversations was pursued and is discussed in next section. Methodology To understand the current and prospective state of affairs pertaining to pharmaceutical social media marketing, empirical evidence was sought to indicate the quality of online conversations among consumers as well as other potential constituents (e.g. medical practitioners, other health care professionals and agents of pharmaceutical companies). Given that social media serves as an outlet for social communication, we purposefully decided to pursue a “consumer’s eye view” of these communications. In assuming this deeply grounded, highly empirical priority for in vivo consumer conversation, we were specifically interested in discovering what, if any, two-way conversations were occurring in open, publicly accessible social media venues as they related to consumers and pharmaceutical products and brands. As supported by numerous authors and significant research across several business and social science disciplines, when little is known about a phenomenon and, subsequently, few studies have adequately addressed it, qualitative methodologies are the only meaningful way forward in establishing knowledge (Bonoma, 1985, p. 201; Creswell, 2003, p. 22; Lincoln and Guba, 1985; Strauss and Corbin, 1998, p. 11). Given the nascent nature of both the communication technologies themselves as well as the glaring state of immaturity in terms of academic theorisation as well as practitioner activities (i.e. deployment of digital marketing tactics), our methodological approach necessarily followed an open-ended, exploratory combination of ethnographic data collection via netnography (Kozinets, 2006; 2010; Kozinets et al., 2010), which will be described further below, coupled with systematic qualitative data analysis in the tradition of grounded theory (Glaser, 1998; Glaser and Strauss, 1967; Glaser, 1978). Data collection: netnography Clearly, given the context of publicly accessible, interactive digital venues and consumer-generated online content within those venues, our approach to data collection was to engage in “netnography”, a contemporary, best-practice, technology-oriented instantiation of more traditional qualitative, field-based, immersive inquiry paradigms (Deshpande, 1983; Hirschman, 1986; Thompson et al., 1989). Netnography is a modern variant of the long-standing research tradition and corresponding methodologies of ethnography. Whereas ethnography traditionally attends to observation and analysis of a particular offline culture or set of individuals’ routines, conversations, interactions and artefactual outputs over a period and within a particular setting (Arnould and Wallendorf, 1994; Berner, 2006; Fetterman, 1998; Schouten and McAlexander, 1995), netnography leverages similar processes alternately applied to an online culture that emerges as and is typically archived online in perpetuity (Felix, 2012). In the case of the current research, online culture manifested as dynamic conversations occurring within and across various social media platforms such as forums, social networking sites, blogs and microblogs. Six investigators set about to gather and analyze the data, including
four academicians, one of whom has considerable pharmaceutical industry experience and three of whom have extensive experience in qualitative methods, along with two research assistants. Data collection involved a multi-phase, iterative search process. The unit of analysis consisted of idiosyncratic conversational stimuli, typically in the form of individual consumer questions or comments on forums, blogs and microblogs (i.e. “tweets”). These conversational stimuli ranged in quality and length, and could consist of something as simple as an affirmation (e.g. “I agree with you about that”) to a considerably longer – and sometimes paragraphs long – elaboration about something of concern to consumers in the community. These widely varying data were discovered and collected based on ongoing key word searches initially through the Google search engine and later evolving to deeper searches within social media venues themselves. Searches typically started with a combination of key words/phrases that included the likes of major pharmaceutical company names (e.g. GlaxoSmithKline, Pfizer, Johnson & Johnson, Merck, Sanofi-Aventis), brand names of their major drugs (e.g. Avandia®, Viagra®, Concert®, Fosamax® and Ambien®), and the associated diseases or therapeutic areas (e.g. diabetes, erectile dysfunction, attention deficit hyperactive disorder, osteoporosis and sleep disorders). These key word combinations were considered and refined over time based on the discoveries they led to, as explained in the data analysis section below. Data analysis: grounded theory To establish a substantive, explanatory framework that emerges from and is empirically rooted in consumer words and experiences discovered via netnography, grounded theory was chosen as the most appropriate methodology for data analysis. Grounded theory offers a rigorous research paradigm focusing on systematic inductive discovery dynamically paired with deductive confirmation of theory. This process unfolds through careful analysis of personal experiences as gathered via open-ended inquiry along with directed sampling via diverse information sources (Glaser and Strauss, 1967), which included in this case aforementioned netnographic data. Grounded theory is most frequently used to understand problematic, dynamic and newly emerging social processes (Glaser, 1978, 1998; Glaser and Strauss, 1967). The origins of the methodology are in health care and nursing (Glaser and Strauss, 1970; 1974) and continued with ongoing extensive use in medical and health care fields (Biernacki, 1986; Charmaz, 1987; Corbin and Strauss, 1991; Fagerhaugh and Strauss, 1977; Fagerhaugh et al., 1987; Rosenbaum, 1981; Strauss et al., 1985), inclusive of pharmaceutical research (Black and Tagg, 2007; West, 2012). Coupled with this history of health care-oriented applications, grounded theory also has a substantiated track record and increasingly popular reputation of being a rigorous and viable methodology for generating theory “from the ground up” in marketing and consumer behaviour research (Anitsal and Flint, 2005; Corsi and Martin, 1982; Elliott and Yannopoulou, 2007; Flint et al., 2002; Goulding, 1999; 2002; Holt, 1995; Lynda and Maree, 2008; Rosenbaum, 2006; Schouten, 1991; Simpson and Licata, 2007; Ulaga, 2003; Valor, 2007). As data collection ensued via the aforementioned netnographic process, the resulting waves of conversation stimuli (known as data “indicators” in the vernacular of grounded theory) led to ongoing collaboration among the investigators whereby, following the methodological tenets of grounded theory (Glaser, 1978, 1998), substantive codes (i.e. “low-level”, typically in vivo/emic
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Figure 1. Grounded theory’s iterative data collection, analysis and sampling process
indicators) were discovered, explored, refined, rejected and ultimately aggregated such that conceptual codes (i.e. “high-level”, typically abstract/etic descriptors) began to emerge. Thousands of data indicators, spanning dozens of forums, online communities, blogs and social networking sites, were collected over a period of four months and deposited in EverNote, a cloud-based collaborative database, and systematically reviewed for conceptualisation. The use of EverNote facilitated organization, running commentary, as well as ongoing, dynamic categorization and thematisation of substantive codes (i.e. actual excerpts and bits from the data) up to higher-order conceptual codes (vis-a`-vis “theoretical sampling” in grounded theory vernacular; Figure 1) among the investigators. Particularly, EverNote assisted in streamlining the task of “constant comparison”, (Figure 2), an iterative process of theoretical coding and sampling that is a core mechanic in grounded theory methodology (Glaser, 1978). In constant comparison, new data indicators (indicated in Figure 2 as “I”) were constantly compared to prior data indicators and resulting substantive codes were eventually collapsed into broader, explanatory categories. To this end, ⬎1,000 substantive codes (comprising individual indicators from the data) were iteratively collapsed into 18 conceptual codes (Table I) that were then eventually explained and subsumed, as discussed in the Findings section of this paper, by one major consumer process (“core category” in grounded theory vernacular) that exhibited two main properties. During initial data collection and analysis, it was discovered that most social media conversations concerning pharmaceutical-related happened on web-based, topic-oriented forums (i.e. “bulletin boards”) more so than popular social networking sites (e.g. Facebook, Twitter). Additionally, the topics of conversation primarily revolved around opposing ends of the therapeutic spectrum, namely, debilitating
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Figure 2. Grounded theory’s Concept-Indicator Model
Conceptual code
Correspondence to category
Adverse effects Ambiguity of effects Blog interaction Bonding Brand names Concerns about main effects Concerns about side effects Drug regimens Facebook interaction Forum/BB interaction Generic names Home remedies Illicit acquisition Illicit use Interaction with health-care professionals Prolonged use effects Recalls Symptoms
Efficacy Efficacy Bonding Bonding Efficacy; Bonding Efficacy; Bonding Efficacy; Bonding Efficacy Bonding Bonding Efficacy Efficacy Illicit Use Illicit Use Bonding Efficacy; Bonding Efficacy Efficacy; Bonding
chronic diseases (e.g. cancers and arthritis) and their treatments, and what may be termed as “lifestyle” diseases (e.g. erectile dysfunction, anxiety, obesity and sleep disorders) and their treatments. This discovery ultimately dictated a more directed and purposive approach to data collection and analysis where, in line with the grounded theory process of “theoretical sampling” (Glaser, 1978; Glaser and Strauss, 1967) guided
Table I. Eighteen emergent conceptual codes and correspondence to categories
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by emergent concepts (Figure 1), selective coding commenced around refined key words and phrases. Using this rich cache of data for ongoing thematic analysis resulted in convergence of mid-level conceptual categories around the core category that captured the majority of experiences in extant social media conversations. This core category and its major properties are explored in the next section. In keeping with traditions in qualitative methodologies associated with reporting findings (Fortner and Christians, 1989; Lincoln and Guba, 1985), we provide exemplar indicators in the form of representative excerpts from the data. These excerpts are intended to generalise not to a broader, statistically inferred population of individuals, but rather to the essence of the phenomenon under study. They provide the reader with a representative demonstration of the quality of a particular category as empirically grounded within the data. Findings As a result of extensive analysis of social media conversations, the major process that emerged to explain the majority of social–psychological variance in the phenomenon was that of consumer Bonding. In an integrative fashion, bonding at the same time broadly characterises as well as subsumes specificities of substantive consumer conversations occurring across social media platforms, keeping line with the nature of a “core category” in grounded theory (Glaser and Strauss, 1967). While by no means meant to represent an exhaustive descriptive portrayal of all conversations about pharmaceutical brands and offerings at the time of the research, bonding captures the preponderance of prominent and meaningful concerns occurring within the fabric of conversations from the consumers analysed. What follows is an introduction and subsequent depth discussion of the core category of bonding, along with two of its prominent conceptual properties. In brief, bonding represents an explicit cohesion and community among consumers who typically appear to exhibit similar symptoms, suffer from a common condition and, moreover, consume a particular drug or treatment regimen. Bonding here appears to manifest among consumers as a result of their “personal ties or linkages forged during interpersonal interaction” including “mutual interaction, communication, support, empathy and responsiveness” (Liang et al., 2008, p. 772). Part and parcel to bonding are two conceptual properties: efficacy and illicit use. Efficacy appeared as a thematic substrate of consumer bonding that largely pertained to less engrossing symptoms and conditions. In other words, whereas the broader process of bonding appeared to be instigated by highly impactful diseases, unfolding as a longitudinal process of consumer participation and acculturation over time, consumer discussions regarding efficacy often occurred on a relatively smaller scale and for a shorter period, and sometimes only once. Conversations about efficacy generally focused on the main and side effects of drugs, involved confirmation of findings or mitigation of concerns and sometimes occurred in a more abbreviated fashion than bonding, although these were part and parcel to its nature. The second property, illicit use, describes conversations centred on the discussion, distribution and procurement of prescription drugs typically used, or intended to be used, without prescription, off-label and/or recreationally. While nearly always occurring anonymously, participants in these conversations clearly leveraged the anonymity provided by being online and instigated a sub-community, as it were, albeit
make-shift and ephemeral. Although this category of conversations seemingly provides a less tractable phenomenon of consideration to pharmaceutical companies and pharmaceutical marketers than bonding at large, and its first property of efficacy, it is nonetheless presented here due to its prominence and correlation with search terms originating from pharmaceutical brand and/or generic names. The core category of bonding and its two conceptual properties will now be examined in more detail. They are explored via an accompaniment of representative excerpts from indicators in the data. Where necessary, identifiers such as what appeared to be actual names, email addresses, websites or unique nickname/handles were suppressed and replaced with random initials used to identify the data within investigators’ internal databases. Suppression of pharmaceutical companies’ names and products was also conducted. Save for these adjustments, to maintain authenticity of consumers’ experience, excerpts from data are presented verbatim, inclusive of typographical errors and expletives.
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Empirical indicators of bonding The process of bonding clearly emerged as the predominant theme across the data of participant conversations in social media. This is not surprising considering that the open, engagement-oriented, user-controlled nature of social media is, by nature, conducive to the congregation and interaction of individuals with similar interests and experiences (Felix, 2012; Matzler et al., 2011; O’Sullivan et al., 2011; Plangger, 2012; Yeh and Choi, 2011). Specifically, web-based forums were the most common venue where bonding occurred, with participants gathering together in online communities typically dedicated to specific diseases and conditions (Table II), and their corresponding drugs and treatments. For those terminal diseases that result in sufferers perhaps enduring a constant battle for survival, the forums become an ostensible lifeline, where through public threads or private messages to one another, participants extend support that is clearly more systemic and influential than that provided by health care practitioners, family members and pharmaceutical companies. It should be noted that forums are publicly available to curious onlookers, existing and prospective patients and, potentially, to pharmaceutical companies.
Disease/condition Cancer HIV/AIDS Psychiatric conditions (e.g., schizophrenia, bipolar disorder, anxiety disorder) Migraine and other headaches Insomnia and sleep disorders Allergies Chronic pain Autoimmune and inflammatory conditions (e.g., Crohn’s disease) Smoking (cessation) Sexually transmitted diseases (e.g., herpes but excluding HIV/AIDS)
Number of data indicators 235 186 142 135 112 104 96 88 71 45
Table II. Top lifestyle diseases/ conditions instigating conversation in social media
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In particular, data indicated that core social processes of bonding involved researching and obtaining information about diseases and treatments from others, widely sharing experiences and concerns with such and soliciting and conveying encouragement and validation among participants in the venues. Of these activities, data indicated that the latter was the most pervasive and intensive topic, wherein interaction revolved around empathy and understanding for and by other individuals in the community. Discourse in social media conversations resonated with encouragement and collegiality and support, as the following indicator demonstrates: [After lengthy series of public and private exchanges]: Thank you to all those that have sent helpful and supportive posts and e-mails. I do realize that many people while not necessarily closeted about their status [HIV/AIDS] and treatment experience, do not exactly live out loud about it either. I greatly appreciate all those who have contacted me […] (P.Z.)
As a rule, the extent of participants’ experience in the forum and the longevity of participation commanded unique authority, ultimately establishing a greater semblance of trust and, subsequently, creating bonds among participants. In particular, this extended to conversations and advice about pharmaceuticals. In the following exchange, the first participant has accrued influence among/over others in the forum due to their long-term dedication to detailed tracking of experience with the drug being discussed: [After a lengthy series of posts logging experience with an anti-smoking drug]: That all I have for now, I intent to keep this updated for others in the future. Please feel free to ask any questions- I’ll do my best to answer. Wish me luck everybody! :-) (N.T.)
In response, another participant contemplating the same drug: I think you are taking the right path by being knowledgeable and watching for possible side effects. I am very interested in keeping track of your journal-it really struck a chord with me for personal reasons. Keep me posted ok? Best of luck! (D.K.)
To this end, and indicated by these representative excerpts, two broad types of participants emerged from the analysis of conversations: (1) participants who are experienced with not only a given disease or condition but also with the drugs used to treat them; and (2) participants exhibiting a new diagnosis and/or considering a change in their medications. The following indicator provides insight into both of these types of participants: Hi! and welcome to the forum!! What your talking about [USE OF PARTICULAR DRUG] has its own thread and you’ll find [NAME OF EXPERIENCED PARTICIPANT] over there who’s one of the leading experts. (H.H.)
This type of welcome and referral was found to be replete across social media, where active participants assisted in directing new users to appropriate resources and, in this case, appropriate people. In the example of this exchange, the less experienced person is recognised and assisted by a more experienced participant who, in turn, refers the newcomer to yet another experienced participant and apparently one who has made quite a reputation for himself. In the data, experienced participants typically served the
role of facilitator, advisor and sometimes mentor to the second type of participant, who were “newbies” (i.e. newcomers) of sorts. Experienced participants, as alluded to in the above indicator, also went so far as to serve as confidants, companions and “surrogate pharmacists” through the conversations unfolding in social media. Although these two types of participants (novice and veteran) exhibit distinct characteristics, their commonality of interests and circumstances served as the primary impetus for discussion and provided the foundation for mutually beneficial relationships, a reciprocity without which would result in the community simply not existing. The dynamics of these relationships are predominantly friendly and supportive in nature. In sum, forums provide free and fast methods of collecting up-to-date, albeit informal and questionably accurate, information about drugs through seemingly honest reviews and experiences from other participants. Importantly, the data indicated that experienced participants of social media fill a space that the physician, pharmaceutical company and even friends and family seemingly cannot. Because they are not viewed as (apparently) having any vested interests, such participants can be seen as exerting more influence and power than physicians or pharmaceutical companies, more likely instigating a feeling of trust among less experienced participants. They relay information and answer questions about possible side effects, interactions and various methods of treatment, both pharmacological and alternative. These individuals serve as respected allies in the ongoing battle of illness and well-being that plays out in social media. Perhaps most importantly, these “experts” celebrate the highs experienced by sufferers and offer encouragement and understanding during low points, as the following exchange addressing a question about efficacy of a drug treatment for depression demonstrates: Thanks […] for your help. I have no one to talk to in real life about these feelings. Cant afford therapy. (E.M.)
In response: The main thing is for you to start feeling better again […] I’m so sorry you are having these feelings and I hope so much you can find a better medication - or combination of meds - and also that you find all the support you need to get through this. Thinking of you and wishing you all the very best. (J.R.)
Ultimately, whether truly having access to or being able to afford “real life” support, the ability to communicate online was seen as providing a less vulnerable experience for participants dealing with sensitive situations that can arise from being afflicted with diseases and conditions. Communicating with someone who is not perceived as being in an “official” health care capacity was seen as valuable because it is less intrusive than traditional forms of interaction. Here, the refuge of social media also appears to fill a gap that has emerged, at least in the USA, of compressed patient face-time with physicians and health care providers (Lewis, 2011; PricewaterhouseCoopers, 2012). Whereas certainly all doctors would hopefully provide a perfunctory explanation of drugs, their effects, and possible alternative treatments, the informal nature, openness and asynchronous/self-paced structure of social media benefits participants who might be experiencing difficulties understanding certain aspects of their diagnosis or prescriptions. Not to mention social media provides a wealth of resources for participants who otherwise could not afford appropriate treatment or health care.
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Empirical indicators of efficacy (property of bonding) While bonding emerged as the core category and was the most outstanding and explanatory characteristic of conversations across the data, participants also generally inquired about, broadcast, and explored the efficacy of pharmaceutical offerings. Although efficacy was a topic that was clearly prevalent in bonding conversations and processes, it is discussed separately here as a phenomenon that involved participants who experienced more fleeting, arguably less severe and, thus, less impactful concerns than those that warranted a longer-term process of bonding. To be sure, conversations about efficacy occurred notwithstanding the social and emotional support associated with bonding through a long-standing community. Most conversations about efficacy occurred in forums, followed by blogs. Topics ranged from relatively bizarre and exceptional events to concerns from frightened and apprehensive individuals. Ultimately, two sub-categories of conversations about efficacy were found to emerge from the data. The first category involved general inquires about common side effects experienced by a prevailing number of individuals. These usually pertained to documented side effects that have been confirmed during clinical trials and, subsequently, relayed to consumers by producing pharmaceutical companies. Although rote, factual information about such side effects is readily available via producer-controlled sources as well as official health care practitioners, participants exhibited the desire to have others confirm and allay their concerns and fears. As such, participants engaged other consumers via social media to ask questions about specificities, variations, duration and personal experience of side effects. As with bonding, participants sought explanation and validation from other users, although often doing so in a “fire-and-forget” fashion that varied somewhat from the longer-term support network and engagement seen with bonding. The following indicator provides is representative of many such interactions: I have been on [DRUG NAME] for three years and mine is a high dose for RA [RHEUMATOID ARTHRITIS]. I have been through a lot of side effects. I know just what you mean - like you have been kicked in the abdomen. And I have been through the hair loss and lots of other boloney. Don’t give up too soon on this important med. It’s one of the best meds there is right now for RA. Are you on folic acid? How much? My dr. had to double mine to 2 mg. Folic acid prevents most side effects. Also, if you can ‘push through’ this, the side effects tend to subside and be gone for a long time. Then, they sometimes come back for a while, but they are NOTHING compared to RA!! (G.K.)
The second type of conversation about efficacy revolved around the pay-off of the main effect of a drug compared to the nature of side effects, including their prevalence and severity. In essence, this amounts to a consumer cost-benefit analysis played out in an online, public venue. Many individuals even consulted others in forums or websites before they notified doctors or other medical professionals about side effects. These individuals usually appeared curious about whether what they were experiencing was relatively common compared to the general population, or whether they were experiencing something abnormal. These community members relayed their own experiences with particular drugs, to include the side effects they experienced, along with details of side effects they have learned about through their own searches and/or
visiting forums and websites. The following indicator provides an example of this second type of efficacy inquiry: [DRUG NAME] was prescribed to me by my [OB/]GYN for bone loss. After taking it for 3 weeks, I started to experience severe pain in my (left) hip and in the muscle down the outside of my leg to my knee. I stopped taking it after 4-5 weeks because the pain got so bad I could not sit. After seeing an MD, a chiropractor, a neurologist, I had numerous tests, took pain medication, used pain patches and had xrays, not one doctor could discover why I was in pain. I am still, one year later experiencing the pain off and on. I believe it is directly related to the [DRUG NAME]. I believe it caused some permanent damage to the nerves. Sorry I ever took the medication. (F.D.)
This account, indicative of many others like it, is clearly visible to other consumers in the open forum and likely gives those participants pause to consider whether to move forward with taking a particular drug or engaging in a particular treatment. It can also serve as a condition for the greater process of bonding. Despite formal DTCA occurring in either traditional or digital channels of communication, it is reasonable to assume that real life, unsolicited accounts from current users provides considerable information to curious prospective consumers. Empirical indicators of illicit use (property of bonding) Another function of bonding, although a relatively idiosyncratic one, was illustrated through social media conversations about acquisition, distribution and use of pharmaceuticals in an illicit context, labelled here as simply “illicit use”. This appeared to be most popular with drugs that have a high level of dependency and a history of being used recreationally. Examples include controlled drugs intended for pain relief, sleep disorders and sedatives typically prescribed for the treatment of anxiety. Forums that focus specifically on the discussion of prescription drugs provide an anonymous and potentially misrepresentative outlet for illicit behaviour. In terms of discussion about illicit use of pharmaceuticals, participants were found to detail effects and “proper” dosage of pharmaceuticals to achieve a desired recreational outcome. As examples: Im sooooooooooo relaxed right about now :) (J.D.) Thank you [DRUG NAME] for knocking me out and putting me to sleep. (J.S.) Thank you so much for that “warm blanket” feeling! (M.)
To this end, “experts” and long-term participants, akin to those found to be involved in more legitimate conversations (discussed above in bonding, for instance), were prevalent in contexts of illicit use as well. Hey [NAME OF PARTICIPANT], so how many should I pop to be on a good one [i.e. HIGH]? (C.V.)
Participants of this sort would acknowledge, in some cases, having addictions and often acknowledged that aspect of their use, voicing concerns and need for help with the rest of the community. Other participants relayed positive recreational experiences and attempted to connect with other users who have similar experiences. In such cases, attempts were made to normalise such behaviour and curtail accusations of dependency.
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Conversations about illicit acquisition were routinely met with solutions in the form of illicit distribution. Participants who were engaged in these conversations were seldom timid or coy about their intentions, overtly discussing and making arrangements for the exchange of drugs and money. The following indicators provide examples of these interactions: Is this stuff really legal to by off the internet, luv to have some. (K.W.P.) I have a script of 90 mg [DRUG NAME] im looking to get rid of […] i cant take them anymore […] let me know. (J.S.) [In response to a solicitation]: Your always welcome bro . . ! you just tell me which product you want […] ! Also you can contact me at -------@---------[PERSONAL EMAIL] and my website is www.------------.com. (M.S.)
Although most forums appeared to originate from within the USA that did not prevent international participants from contributing to conversations about acquisition: Somebody from USA post some to me please, really wanna try em. (A.C.)
This introduces an important consideration in that while provisions for DTCA are officially applicable only in the USA and New Zealand, the Internet and, concomitantly, social media know no boundaries and, unless routinely and exhaustively firewalled by other countries, allow global access to information that might otherwise not be available through traditional channels in most countries. Although the assumption may be that the majority of participants engaged in illicit use in social media are simply attempting to obtain the drugs for wonton, recreational use, some participants claimed to be in possession of a legitimate prescription and were seeking the same medications at either a reduced price or in lieu of access to their physician. Such participants are enticed by a seemingly endless supply of vendors that openly advertise private and public sale of prescription drugs. The following are examples of such interactions: [PARTICIPANT NAME], would u plz give me ur email or I can provide mine. Would like to know of a legit hookup I too suffer from nerve pain in my back looking for relief I am also not a Junkie. (G.7.) Yeah I hate to admit it but I got scammed for $260.00 over at the [DRUG NAME] forum looked pretty legit. Ordered from a [PREVALENT PARTICIPANT] there. I need a legit supplier my goal is not to be wasted on pain killers but to get some relief from my nerve pain. The clinic I go to my doctor is a joke either does not belive or does not care. (M.D.)
Here, any semblance of community is leveraged/exhorted to circumvent constraints that are either related to legitimacy (i.e. whether or not the person seeking a pharmaceutical has a prescription) or availability (i.e. the person lives in a market where the product is not available). Discussion The core category of bonding is clearly manifest in the data indicators of this study, and most prominently explains the phenomenon of social media conversations among consumers of pharmaceuticals. As a broader phenomenon of consumer behaviour,
marketing academics and practitioners for several decades have been interested in actual and virtual congregation of both current and prospective customers around their particular firms (Price and Arnould, 1999; Schouten and McAlexander, 1995), brands (Johnson and Thomson, 2003; Thomson and Johnson, 2006; Matzler et al., 2011; McAlexander et al., 2002) and products (Schultz et al., 1989; Wallendorf and Arnould, 1988; O’Sullivan et al., 2011; Schau et al., 2009; Muniz and Schau, 2005). Recently, the general notion of bonding via Internet and social media venues is starting to be explored (Hsu-Hsien, 2011; Marchi et al., 2011; Yeh and Choi, 2011). Ultimately, formalisations of the concept are generally resolved to the consensus that bonding is a multi-dimensional construct representing a degree of connection, or attachment, between an individual and object (e.g. brand, product and service) that comprises facets such as strength, valence, social structure, individuation and temporal orientation (Ball and Tasaki, 1992). This arc of theoretical conceptualisation and empirical studies has also cast bonding in the more sophisticated and involved process of ongoing consumer–firm relationships (Arantola, 2002; Walls, 2003; Wilson and Mummalaneni, 1986; Ahmad and Buttle, 2001; Buttle et al., 2002; Mende et al., 2013). In particular, social bonding, where firms carry out functions that give rise to long-term relationships through a focus on community, is seen as a key antecedent to successful consumer–firm relationships (Ruixue et al., 2009; Liang et al., 2008). Notably, to date, there is little to no literature that extends this research stream to the pharmaceutical industry and its consumers. As such, and certainly germane to the current study, the stage has been set for an empirical exploration of the instantiation of such consumer–firm engagement couched within the dynamic online ecosphere of pharmaceutical firms, brands and products. Uniquely, however, is the prospect (and initial evidence in this research) of a more evolved type and intensity of bonding, particularly in light of the pervasive and often severe impact of both non-life threatening and terminal diseases on consumers’ daily lives. Put simply, the nature of these diseases, and the products that are meant to ameliorate them, can understandably be far more epic and central to consumers’ lives than perhaps their Harley Davidson motorcycles (Schouten and McAlexander, 1995) or erstwhile Apple electronic gadgets (Muniz and Schau, 2005). To this end, the experience that consumers simultaneously convey and absorb in bonding around this product category is potentially far more intense, relevant and intimate than other products and services they might consume. This portends a form of hyper-bonding, as there are arguably fewer concerns more important to consumers than the state of their health, especially in the face of potentially terminal diseases. Bonding and social media In this study, the core consumer process of bonding is conveniently facilitated via social media communication technologies. Notably, bonding occurs not only around a community of consumers with like interests, as has always been possible even in lieu of technology, but now, thanks to increasingly mobile and easy-to-use technologies, unfolds instantaneously, all the time, and everywhere. The intensified and ubiquitous bonding that occurs among consumers of pharmaceutical offerings could readily be attributed to, and is certainly exacerbated by, the ease of accessing and maintaining interactions through ever-present communication technologies like social media. Additionally, social media exhibits properties that might otherwise be absent or suppressed in “real world” or “offline” consumer communities, namely, anonymity, that
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can be seen as furthering a motivation to bond. Within the context of health concerns in general and lifestyle/terminal diseases in particular, the relative anonymity that social media affords to consumers, coupled with the provision of convenient group venues where consumers can meet others with similar interests and values, eases interaction and knowledge-seeking around topics and experiences that are otherwise sensitive and potentially embarrassing. Our research, thus, supports the proposition that the relative anonymity of the Internet, which extends to social media in particular, contributes to such close relationship formation perhaps by reducing the risks inherent in self-disclosure (Bargh and McKenna, 2004). Previous researchers have studied the provision and seeking of social support online by those with grave illnesses (Davison et al., 2000). These studies found that people used early Internet support groups particularly for embarrassing, stigmatised illnesses such as AIDS and prostate cancer. Interestingly, McKay et al. (2002) found that diabetes self-management and peer support over the Internet led to just as much improvement in physiological, behavioural and mental health – especially in dietary control – as did conventional diabetes management. Thus, the beneficial effects of patients’ interactions over the Internet regarding their illnesses likely cannot be overstated and is an area justifying much further research. However, and commensurate with the findings from the present research, a wide variety of illnesses, terminal or otherwise, are also reflected in the new social media venues, seemingly due to the increased user-friendliness and widespread social acceptance of such tools, which are effectively replacing their predecessors (i.e. basic Internet forums). From the perspective of pharmaceutical companies, the ability to participate in and/or input to these discussions via social media presents a valuable lens into patients’ lives, as it relates to the management and pharmacological treatment of their illnesses. The role of pharmaceutical companies in cultivating and nurturing psychological health The findings that emerged from this research ultimately provide support for a growing sentiment that fundamental change is occurring in marketing, requiring new modes of thought and action in terms of the overall strategic paradigm of communication products, not the least of which include health care and pharmaceuticals, especially in light of tools that enable consumer empowerment (Coddington et al., 2001; Pesse et al., 2006). The indications of the therapeutic potential of bonding (albeit non-professional) through social media communities provide a glaring indication of how important these cutting-edge and seemingly volatile communications technologies are in terms of impact on the perception and interaction with pharmaceutical offerings. At issue here is not only the well-being of consumers in terms of their diseases and conditions corresponding with potential mitigating properties of pharmaceutical offerings but also the psychological health of consumers as they participate in the regimen of treatment, and all of the trials and tribulations that accompany that part of their lives. Our research corroborates very recent findings that indicate consumers are 24 times more likely to seek or share health care information via social media such as community websites than corporate websites, predominantly because social media is found to be more accessible (PricewaterhouseCoopers, 2012). As has been demonstrated in our data analysis, consumers readily leverage social media to communicate and, more precisely, share stories and narratives amongst themselves about everyday life experiences
(Gentle, 2009; Kozinets et al., 2010; Pulizzi, 2012; Quish, 2010; Segbers, 2010; Shu-Chuan and Yoojung, 2011), not the least of which include diseases, conditions and treatments thereof (Leimeister et al., 2008; Thackeray et al., 2008; Thackeray and Neiger, 2009). Importantly, both a determinant and outcome of these social media narratives includes evaluation of health care provision and perception of efficacy (Hackworth and Kunz, 2011; Segbers, 2010; Weiss, 2010). In the end, the more endemic, pervasive and generally life-impacting a condition is, the more conversations exist around its nature and, correspondingly, the higher likelihood a community will emerge to address its concerns. Discovering where these communities exist, understanding the nature and extent of their purview, identifying influential issues and participants and becoming part of the ongoing discourse and culture over the long term have all been found to be important tactics comprising a successful social media marketing strategy, ultimately shoring up product knowledge, sales and brand loyalty (Armelini and Villanueva, 2011; Chatterjee, 2011; Plangger, 2012; Stephen and Galak, 2009). However, to date, pharmaceutical marketing via Internet and social media (if utilised at all) has primarily involved replication of traditional “one-way” strategic and tactical frameworks of DTCA (Bonk et al., 2012; Greene and Herzberg, 2010; Jambulingam and Sharma, 2010; Liang and Mackey, 2011; Greene and Kesselheim, 2010). In short, while new communication technologies like social media have been demonstrated to engender a wholesale and unprecedented shift towards consumer empowerment via intimate, two-way engagement, pharmaceutical companies are still operating in a mode that essentially leverages these new tools as simply incrementally new channels by which to distribute traditional advertising messages. In effect, little to no two-way engagement by pharmaceutical companies is occurring in tools that, by nature, dictate such engagement. Further, if organisations are to follow the tact taken by consumers, which is an investment in community that transpires and gains value over time, a longitudinal strategy is warranted. To wit, in the broader marketing practice of successful bonding via consumer–firm interactions, Walls (2003, pp. 75-76) has suggested that, in contrast to a “fire-and-forget” mentality conducive to advertising, “a healthy relationship will continually revise its bond strength to reflect its ongoing experience” because “the bond is dynamic in nature and is a renewal process”. Managerial implications Considering the nature and structure of online conversations discovered in this empirical study, we offer a reflection on this new paradigm of communication and propose a way forward for pharmaceutical companies that are either contemplating or attempting to implement social media strategies and tactics as part of their pharmaceutical marketing and DTCA efforts. Essentially, to understand how pharmaceutical offerings weave into the fabric of consumers’ everyday lives, marketers must first find where consumers are bonding, then begin a longitudinal process of ascertaining what their interactions are about, as they pertain to related brands, products and diseases. To provide guidance towards this end, we first present a tailored structure for proceeding with the fundamental tactic of “social listening” that facilitates an intimate understanding of bonding. Second, we introduce an emergent strategic framework for pharmaceutical social media marketing efforts that respects and leverages the bonding process whilst accommodating concerns that are particularistic to the pharmaceutical industry.
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Social listening: considerations for the pharmaceutical industry Social media marketing best practice has been recognised as proceeding first and foremost with its own flavour of market research (Davis, 2010; Kerpen, 2011; Li, 2009; Li and Bernoff, 2011; Rappaport, 2010). Namely, as the research here has prompted, firms must survey the landscape of conversations, narratives and, ultimately, consumer bonding through a process commonly referred to as “social listening” or “social media monitoring” by both academics (Birch and Karma, 2011; Bennett, 2012; Berkman, 2008; Crawford, 2009; Rappaport, 2010) and practitioners (Radian6, 2009a,b, 2011; Strategic Communication Management, 2007). Social listening involves a systematic and persistent monitoring of social media platforms, typically conducted by proactive and/ or automated online searches using a continuously updated list of key words/phrases that are relevant to the focal industry, company, brand(s), product(s) and, of course, consumer experiences (Radian6, 2009b, 2011; Rappaport, 2010). Social listening is the first step towards engaging consumers on their own turf, on their own terms and in their own voice (Kerpen, 2011; Porter et al., 2011; Radian6, 2011; Rubinson, 2009; Sosnow, 2011). As per Figure 3, this process involves three basic steps: (1) developing and managing key words thought to be relevant to a focal firm’s industry, brands, products, services and consumer concerns; (2) using these key words to seed ongoing searches of social media for related consumer conversations, which, in turn, also leads to refinement of key words; and (3) capturing, categorising and routing search results. Next, each of these three steps will be addressed in detail. The first step, development of effective key words, is paramount to the success of a social listening strategy. Note that key “words” can and likely should actually entail entire phrases (e.g. “migraine headache relief”). Development of these phrases requires careful consideration of what words might be part and parcel of consumer-driven conversations about pharmaceutical products – the raw, typically unfiltered data that are indicative of the bonding process. For example, although pharmaceutical companies might often refer to the chemical or generic names for drugs (e.g. diazepam, fluoxetine, zolpidem), consumer conversations in social media predominantly focus on brand names, despite the fact that the drug may have been available in a generic version, perhaps for several years (e.g. Valium®, Prozac®, Ambien®). Pharmaceutical executives and marketers may also have a tendency to describe their products in terms of the “therapeutic areas” that that they fall into (e.g. central nervous system, cardiovascular
Figure 3. Social listening process
or inflammation), whereas in bonding, patients adopt language specific to the disease or condition that concerns them (e.g. depression, high blood pressure or arthritis). Furthermore, through bonding, consumers might focus primarily on discussions about symptoms (i.e. a property of bonding-labelled efficacy, as found in the current research), using common or even slang vernacular, as opposed to formalised medical terminology associated with particular diseases and conditions. This deference to “consumer speak” over “corporate speak” is recognised as an important tactic for social listening (Scott, 2011, pp. 182-187). Refinement of key words through trial and error should lead to better search results and hence more effective isolation of social media conversations. Ultimately, a collective, cross-functional effort inside the firm should be applied to key word cultivation and maintenance over time. In the second step, the aforementioned key words are used to seed ongoing searches of social media. From a procedural standpoint, these searches can occur at the broadest level via the Google search engine. A useful tool to automate the search process is Google Alerts. Google Alerts allow lists of key words to be entered and managed and when corresponding search results are found for those key words, an email is generated with a digest of the results. This effectively results in a “push” versus “pull” search strategy. While Google provides search results for most of the Internet, including blogs, forums and bulletin boards, specific social media platforms such as Facebook and Twitter should be searched separately to ensure real-time results. As discovered in the current research, it is important to note that consumer conversations and engagement with brands and products can emerge not only from “buzz”-worthy social media (e.g. Facebook and Twitter) but also from lesser known sources, such as forums and bulletin boards (as discovered in the current research), image (e.g. Flickr, Photobucket) databases and video repositories (e.g. YouTube). As the social listening process unfolds over time, an inductive process of trial and error will allow the most relevant key words as well as focal social media platforms, and consumer bonding within them, to emerge, thus refining the search process on an ongoing basis. The third step involves capturing, categorising and routing search results. Search results can be reduced down to the most pertinent snippets or excerpts of consumer conversations, catalogued in a spreadsheet or database and retained for analysis over time. This potential abundance of data should give rise to categorisation of bonding processes according to topic (e.g. pharmaceutical companies, brands, products, diseases, conditions, symptoms and efficacy), conversation type (e.g. expressed needs, competitor mentions, influential comments) and valence (e.g. complements, complaints). Depending on the nature of the business unit or organization, workflow routing could occur, directing particular conversations or conversation threads to relevant parties within the business. Ultimately, like the ongoing cultivation of key words themselves, the inductive development and maintenance of categories and workflow routing rules should be a persistent, cross-functional organisational effort. Emergent social media strategy framework: education as intermediation Through social listening, identifying the locations for bonding, corresponding key participants and nature and type of conversations presents companies with the opportunity for consumer engagement. The ultimate pay-off from this engagement comes in the form of better product knowledge, long-term relationship development, new product development, testing and introduction, financial performance (Li, 2009;
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Figure 4. Dissemination model
Muntinga et al., 2011; Nail, 2009; Pooja et al., 2012) and, in the case of pharmaceuticals, potential new indications. However, owing to regulatory and legal constraints, pharmaceutical companies must tread cautiously with such consumer interaction – a barrier that marketing counterparts in non-regulated industries do not face (Ofek and Wagonfeld, 2011; Schneller and Marshall, 2007; Stephen, 2010). In light of such constraints, pharmaceutical firms’ web presence to date has been relegated to a largely one-way, traditional advertising model that essentially replicates elements of print and broadcast advertisements, but in the digital domain. Contrast this with the nature and potential of social media. By default, social media are tools that serve as outlets for social communication (Blanchard, 2011; Solis, 2012). Whereas, what has passed historically as “communication” by marketers (e.g. advertisements, promotions and controlled messages) can perhaps more appropriately be classified as “dissemination”, lacking, as it typically does, a two-way collaboration between sender and receiver (i.e. a face-to-face conversation or telephone call) and relying instead on largely unidirectional distribution of messages (i.e. television, radio, print, email blasts) (Edelman, 2010; Li and Bernoff, 2011; Solis, 2012). This applies to drug information websites that typically achieve little more than providing access to rote product information, subject to the same regulatory oversights as “marketing” or “promotional” information delivered via the traditional media. This status quo is depicted as the “Dissemination Model” in Figure 4. Although marketers have historically found themselves primarily involved in this business of dissemination, the tide is clearly turning towards a new model of consumer empowerment and interactive engagement (Castronovo and Lei, 2012; Diffley et al., 2011; Kunz and Hackworth, 2011; Reynolds, 2010; Wright et al., 2010). As per the aforementioned marketing revolution that is occurring as a result of the advent and increasing use of social media, and corresponding with the findings in this research, through bonding, consumers are much more often inclined to obtain information about products and brands from each other and as a result can exhibit aversion to what is perceived to be outright advertising proffered by corporations. As such, a perhaps less overt “Education Model”, as shown in Figure 5, has recently started to emerge as a new tactic in the repertoire of pharmaceutical marketing communications, wherein disease awareness websites, consumer advocacy group websites and even popular medical advice forums have begun to serve as an intermediary between established pharmaceutical corporate web portals and their corresponding drug information websites (e.g. Pfizer Inc.’s “Campaign Against Migraine” website). This approach is akin to the increasingly popular notion of “content marketing” (Handley and Chapman, 2011; Lieb, 2011; Pulizzi and Barrett, 2009; Rose et al., 2011; Wuebben, 2012), providing utilitarian benefits to consumers in the form of seemingly unbiased and helpful information about causes, symptoms, diseases and treatments.
In the case of pharmaceutical marketing, these portals or intermediary sites also have the potential to offer consumers tacit or implied third-party endorsement of certain diseases (that a particular company offers drug products for), or treatment approaches that may be synergistic or complimentary to the pharmaceutical company’s drug marketed or approved treatments. It should be noted that pharmaceutical companies using this model clearly remain beholden to regulatory constraints (typically by way of a pop-up disclaimer) when passing consumers from rather generic disease education information (i.e. websites) to more specific drug information. However, disease education sites and the corresponding “Education Model” advanced here provide pharmaceutical companies with a rare opportunity to establish rapport with their ultimate consumers and, while eventually leading to a transmission of product information, advances a semblance of goodwill and contribution to public knowledge, product sales notwithstanding. Importantly, these sites and the corresponding “Education Model” begin to provide accessible, useful content to consumers as opposed to pure-play advertising and as such serve as a potential gateway for integration into the consumer bonding process. Thus, naturally extending the “Education Model” gives rise to an emergent social media strategy framework, shown in Figure 6 as the “Interaction Model”. This model portends the opportunity to link extant web-related marketing efforts in the form of disease education to the highly active and increasingly popular social media platforms where consumer bonding occurs. Whereas the overt promotion of drugs in forums, bulletin boards and blogs is rife with concerns (Greene and Kesselheim, 2010), not the least of which is likely negative consumer reaction, disease education websites could be expanded to include integration with specific social media platforms (and thus influencers) discovered by pharmaceutical companies during the aforementioned social listening process. To illustrate this proposed stepwise integration into the consumer bonding process, as indicated in Figure 6, a “constellation” of relevant and specific social media outlets
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Figure 5. Education model
Figure 6. Interaction model
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could be linked to and from the company-sponsored disease education websites. For example, if the disease education website concerns the nature and causes of migraine headaches, featured elements within the site could link outward to extant social media such as popular forums and blogs that feature consumer bonding around migraines. As has been demonstrated, as platforms for bonding, these forums are seen as clearly providing value to consumers, and by linking directly to them, pharmaceutical companies could be seen as, at minimum, acknowledging that the communities exist. Conversely, agents of pharmaceutical companies, while restricted in their direct interactions with consumers in social media, could identify through social listening when and where consumers rally around the trials and tribulations of diseases, their drug treatments and other disease management strategies and, to the extent that it is permitted by prevailing regulations, respond directly to comments posted and discussions by referring protagonists to the sponsored disease education websites. Further, pharmaceutical companies may take advantage of the opportunity to reframe content of said disease education websites to better address the concerns reflected in consumer commentary and discourse occurring in various social media. This “quasi-dialogue” holds the potential to enable pharmaceutical companies to begin the process of acknowledging and participating in the process of consumer bonding, which, in most cases, has been occurring for some time and without their involvement. Conclusion Opportunities abound for companies that are willing to eschew the temptation to use social media as just another set of tools for distributing advertising messages and instead approach consumer research and interaction at a more intimate and organic level. For pharmaceutical companies, in particular, the time is ripe to be the “first to market” in leveraging the new social media as an essential means of carefully listening to and engaging with consumers, on consumers’ own terms and in their own venues, thus extending companies’ touch points beyond mere dissemination of advertising messages. The extent to which a significant part of the fabric of consumers’ everyday lives can centre on symptoms, conditions and drugs all while occurring online, anonymously and ubiquitously is an urgent consideration for pharmaceutical companies. To be sure, this new era of consumer behaviour requires not only new tools and techniques, outlined herein, but an altogether new way of strategic thinking as well. With the increasing proliferation of mobile-enabled access to social media, it is reasonable to assume that consumer bonding around terminal, non-life-threatening and lifestyle diseases will continue to exacerbate. While admittedly somewhat constrained by regulations that are normally not a hindrance to marketers in other industry sectors, in the broader sense, a framework such as the proposed Interaction Model paves the way for this idiosyncratic industry to move forward in terms of operationalising social media not just as an outlet for promotions but also as an endemic part of fundamental ways of re-considering pharmaceutical business strategy. While engagement with consumers in social media is not without risks (Cawley, 2011; Sosnow, 2011; Steinman and Hawkins, 2010), perhaps the greatest risk in this new era of communication is not being engaged at all (Parent et al., 2011; Stuth and Mancuso, 2010).
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for the Grounded Theory Institute, Mill Valley, California. Charles Scott Rader is the corresponding author and can be contacted at:
[email protected] Zahed Subhan is an Assistant Professor in the Department of Entrepreneurship, Sales and Marketing at the Western Carolina University, USA. Previous positions held include Chief Executive Officer, Vice President Marketing, Chief Business Officer and Head of Sales and Marketing in the Pharmaceutical and Biotechnology industries. His primary research interests are in the fields of strategic marketing, new product development and innovation management in emerging market firms. He is published in journals including the Journal of Selling and Academy of Marketing Studies Journal. Clinton D. Lanier is an Assistant Professor of marketing at the University of St. Thomas. His research interests include experiential marketing, consumer experience and fans and fandom. He has published in the Journal of Marketing Management, the Academy of Marketing Science Review, Memorable Customer Experiences and Research in Consumer Behavior: Consumer Culture Theory. Roger Brooksbank is an Associate Professor of Marketing at the University of Waikato, New Zealand. Roger has previous experience as a Sales Executive, Sales Manager and Marketing Director in the UK. His research interests are in the areas of business competitiveness and strategic marketing, with publication in journals including Marketing Intelligence and Planning, Innovative Marketing, Journal of Global Marketing, and Asia Pacific Journal of Marketing and Logistics. Sandra Yankah is a student of sociology and marketing at the Western Carolina University. Kristin Spears is a student of marketing at the Western Carolina University.
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