Cost efficient advertising to specialist audiences

How general principles can be applied to medical advertising

Kenneth E Clarke

This paper demonstrates how the lessons learned in tracking ads to consumers can be applied to specialist advertising targeted at doctors. The differences between awareness of advertising on TV and in print are highlighted. Advertising to the medical profession is almost entirely in the form of print media and the particular characteristics of this audience are considered. Their reactions to ads from both a professional and personal viewpoint are discussed. The medilink service can pre-test ads on impact, communication and potential wear-out.

ADVERTISERS and their agencies face the perpetual questions:
  • How can I be sure that my advertising is effective?
  • How can I make sure that my advertising is effective?
  • How can I make my advertising campaigns as cost-effective as possible?
These questions are of vital importance whether the category to be advertised is pharmaceuticals or four-wheel drive cars, computers or cornflakes. The main focus of this paper is on advertising to the medical profession, although we shall later refer to advertising to the general public, mainly, in that case, in the form of television advertising.

Medical advertising is different. It is a primary (although not the only) medium of communication between the pharmaceutical company and the potential prescriber. The doctor, in choosing between drugs, does not only employ rational judgment, but is influenced by general impressions, derived from experience or from relationships formed via communication.

THE ROLE FOR ADVERTISING IN PRESCRIBING

In deciding between drugs to prescribe, a doctor relies upon knowledge and rational judgment. However, our discursive interviewing with doctors, individually and in groups, shows that they are also influenced by impressions arising from experience, and from the network of influencing relationships which affect feelings about brands and companies. For doctors are human, and in making decisions they are subject to the same kinds of pressures and influences as other people. Of course, they have their expertise, and their need to maintain their professional reputation. But they also have moods and emotions, and mixed feelings towards the people with whom they are dealing. The pressures and stresses which arise in their relationships with patients, and in their practice, also contribute to the decision-making process.

Doctors wish to present themselves as rational, competent and worthy professionals. They are also obliged to fulfil their expected social role of being scientific and expert. It is required of them that they should also be financially responsible and careful, and yet at the same time caring, sympathetic and compassionate. In his relationships with the patient, the doctor may sometimes look for treatments which he perceives as the most gentle, the kindest, the strongest or the quickest-acting; at other times he may look for the most unpalatable cure for a difficult and frustrating patient.

The way advertising works amongst doctors can be seen as a process in which the doctor is stimulated to recall advertising memories by the patient, and the condition which he is treating. This is often, for the doctor himself, a time of stress when he is searching his memory rapidly for appropriate treatments.

ADVERTISING TO THE MEDICAL PROFESSION

Most medical advertising is seen as doctors are scanning through a variety of different magazines. These magazines are read often only superficially, and sometimes, it has to be said, begrudgingly. Magazines are often read out of a sense of duty and obligation. There is a professional ethos that the doctor should keep himself up-to-date, an ethos which is inculcated during medical training, and is later emphasised by his professional need to be aware of new developments and potential pitfalls in prescribing. Our research shows that magazines are usually read in what could loosely be called 'leisure time', often at home. The time spent on ads, and the attention which is paid to detail are both minimal. To be effective, ads have to compete with a process of selective attention and a pressure - often social and from other members of the family - to get through the magazine as quickly and efficiently as possible.

In the same way as other people read magazines, so too doctors have the medium under their own control. That is, on spotting an ad on the page they can stop and peruse it in some detail if they find it new, interesting, intriguing, or whatever. Alternatively, if it is one with which they are familiar, they will be tempted to say to themselves, 'seen it before', and quickly pass on to the next page. This is a common reaction which we find over and over again in research - not only among consumers generally, but also among specialist and professional audiences. For example, we find that, among general consumer audiences, ads tend to 'wear out' after three opportunities to see an ad. That is, it may take one or two 'opportunities-to-see' before real exposure to an ad takes place; it may also take one or two occasions to be exposed to an ad before someone registers the ad, stops and absorbs it. The corollary is highly important: if someone has not paid attention to an ad when they have seen it three times, it is highly unlikely that they ever will; and if they have paid it attention once already and absorbed it, they will not bother doing so again.

There comes a point, therefore, when providing more and more opportunities to see the same ad is a wasteful exercise. What is needed is a new 'twist' in execution and/or message to draw attention again.

The public stance of doctors is typically to deny an influence from advertising upon themselves. It would seem to be irrational or childish, and a confession of gullibility. Interviews with doctors often begin with the claim that ads have no effect. These same doctors, as they get more relaxed during an interview, then go on to produce associations and imagery based on advertising executions.

Just like other people, again, doctors tend to process ads at two levels.

The rational

An explicit examination as to what the ad is based upon, the details of any picture, headlines and copy about product characteristics. This is an analytical and critical function, during which the doctor is looking for meaning, relevance and credibility. At this level, the advertising functions in conveying knowledge and evidence - providing always that it is found to be believable.

The impressionistic

This involves the implicit assimilation of symbols, words and colours. The reader is responding, almost automatically, to the intuitive associations and values (caring, powerful, authoritative) and mood and feelings generated by the images on the page. At this level, the advertising is no less effective than at the rational level, and, indeed, is often more effective because it is not subject to scrutiny, censorship and rational evaluation. The function of the advertising is to build images and mental associations.

Ads do not just do things to doctors; doctors also do things with ads. Through advertising - and other communications as well - doctors:

  • make themselves familiar with the options available, and build up a landscape of drugs which they view as suitable for prescribing in specified conditions;
  • make sense out of new launches, and the distinctive claims and identities which are being attached to new brands;
  • attach character, meaning and associations to these brands - not only in terms of their medical and rational properties, but also in terms of their imagery and inner 'personality';
  • develop relationships with the brands in their repertoire of drugs which they find suitable.

REACTIONS TO ADVERTISING

Reactions to advertising depend on two aspects for the medical readers. First of all, there is their attitude towards their own role, and secondly the aspect of their own human characteristics.

Professional views

Sometimes ads are treated as an intrusion, and even subverting. Doctors want to reject the commercialism which is implied by advertising, and the attempt to influence their decision-making in other than clinical ways. This attitude is more typical of older and more traditional doctors, and may well be declining as younger GPs enter the profession having grown up in the commercial culture of the 1980s, when they developed ad literacy and an appreciation of advertising styles. On the other side of the scale is an acknowledgement that ads can have a role in keeping doctors informed, helping them to spot new drugs and modifications, reminding them of alternatives, and alerting them to suitability for patients with other conditions.

Personal appreciation

Under this heading, it is the individual's personality and outlook, which influences his or her appreciation of advertising, related in turn to particular styles of ads. On the negative side, ads can sometimes be found to be irritating. Sometimes ads are simply ignored if they are found to be dissatisfying. This is especially true of ads which are perceived as boring and unimaginative, over-complicated and confusing, with obscure connections between visual presentation and point of the ad (the creative bits being in parallel, rather than being directly connected, with the message and the brand). On the other hand ads can be found to be pleasing by doctors. Ads can brighten the chore of reading the magazines, and provide a more cheerful and amusing aspect to the task.

EVALUATING THE EFFECTIVENESS OF TV ADVERTISING TO CONSUMERS

Much advertising of OTS pharmaceuticals is conducted via television. It is in this area that decisions on the effectiveness of advertising are particularly important, because of the high cost of making and showing ads. It provides a useful starting-off point in understanding our approach to press advertising, to which we shall turn in the next section.

In an ideal world, the evaluation of the effectiveness of an ad or a campaign would be achieved by looking at the effect on sales. However, isolating the effect of advertising on sales is a complicated and time-consuming process, which can be carried out only after the advertising has been on-air for a good few weeks. This may be satisfactory if all we need is to plan budgets for re-showing an old ad, but not really attractive or even feasible for newly-developed ads and situations where we need to make a quick decision. An alternative is to use intermediate variables, which should give a faster and cleaner representation of effectiveness. Our experience over the last 20 years has indicated that advertising awareness is the best of all measures for this purpose. This is because it is very responsive to advertising and produces movements which can be measured easily and modelled. The Awareness Index measures the extra awareness generated per 100 GPs by a particular ad. The progress we are making in linking the Awareness Index to short-term sales movements has been reported elsewhere (1). We have also to take into account the extent to which the ad succeeds in communicating its intended messages (and perhaps others which were not intended), the extent to which it is relevant and credible, and the extent to which people who see the ad find it enjoyable and rewarding.

ADVERTISING VIA PRINT MEDIA

We have found that there is a significant difference between TV and print media. Television commercials tend to come at us without warning, and without giving us any opportunity to select which we wish to look at and which we wish to avoid. Some ads are simply more memorable than others - and that is the role of creativity. If an ad on television is interesting, involving, and enjoyable, then we tend to notice it over and over again, almost no matter how many times we might have seen it in the past. In contrast, the printed page is under the readers' control, and they have the opportunity to determine whether they wish to look at the ad or not after having once recognised it. Therefore, while the Awareness Index for TV ads tends to be constant, in press we are able to switch off with those damning words 'seen it - no interest'. In other words, the ad does actually wear out.

This was an effect which we had believed for some years to be occurring, but which we were able to prove once and for all with an exercise by Millward Brown in 1991 called 'Magtrak'. In this exercise, we monitored a whole series of ads from different product categories, including OTC pharmaceuticals, over a long period of time. The key measure we were looking at was that of claimed advertising awareness. However, when we came to produce the model, we found that this awareness index did not, like TV, remain constant, but fell off quite rapidly, and that repeated showings of the ad did not restore the efficiency of the ad to its original level.

The implications of this for advertisers are serious. What a declining awareness index shows is that an ad ceases to be noticed, and that the money which is spent on showing the ad again and again could well be being wasted.

A press ad does not have the kind of indefinite life that TV commercials often seem to have. (Bearing in mind that we are not suggesting that a TV commercial continues to have the same communication effectiveness for ever and ever, since while people may continue to notice the ad and enjoy the action which is being shown on their television screen, they may cease to take in the message which is being communicated.) For press ads the implication is that the life of the ad is necessarily short, and that a campaign needs to be regularly refreshed, so that there is a new creative hook which will draw the readers attention into the ad.

It is, therefore, essential that an advertising research programme should help the advertiser and the agency in the first place to develop creative ideas which will hook in readers, and lead them to read an ad, checking out whether it is likely to be interesting, informative, credible, and relevant. From the creative development stage, we need then to move on to some formal pre-testing, in order to ensure that the finished executions will achieve the objectives which have been set, and which have emerged from the initial creative development stage as being necessary. The final stage of tracking is designed to ensure that the advertising budget is in balance, and that ads do not continue to be shown long after they have ceased to draw in readers and have ceased to be noticed.

PRE-TESTING AND EVALUATION OF ADVERTISING OF PHARMACEUTICAL BRANDS

At this point, it is worth drawing together the main themes, and to point to the implications for styles of research, particularly drawing out the differences, as well as the similarities, between television advertising to consumers and print advertising for doctors.

TV advertising to consumers

The essential feature here is that most advertising to consumers, by definition almost, implies large audiences and therefore the use of expensive media, whether that be in the form of national television or national press. For television advertising, there is also the added cost of expensive production of the commercials themselves. The total cost, therefore, is a substantial element in a company's operating budget, and so comes under the close scrutiny of top management, especially in the financial departments.

In these circumstances, a substantial research budget can be justified, in order to ensure that the advertising budget is being spent as effectively and efficiently as possible. Most large advertisers these days commit themselves to long-running tracking studies. Millward Brown, who were the originators of the idea of continuous tracking, have many clients who actually began their tracking studies ten or more years ago. Today, we find that the large multi-national organisations are increasingly wanting comparable studies, conducted in a number of different countries at the same time and in a comparable format so as to provide international comparisons. For the top multinationals such as Unilever and IBM, we find ourselves operating tracking studies right around the world.

The role of tracking studies has remained much the same throughout the dozen years or more in which we have been running them. They provide a brand health monitor and, at the same time, an evaluation of the effectiveness of the advertising. Under this latter heading, the key question is, whether the advertising is succeeding in generating brand-linked memorability - the awareness index which has been mentioned earlier. Tracking also aims to measure the extent to which the advertising is succeeding in its communication objectives. Campaigns need to be examined in order to highlight the ads or executions which are working particularly well, and those which are less strong and may need to be replaced. It is also crucial to assess the extent to which people can relate to the ads themselves, displaying empathy and enjoyment. A tracking study will usually monitor not only the subscriber's own advertising, but also the advertising of all the major competitors in the market. In this way, a wider understanding of the dynamics of advertising in the market can be obtained in order to feed back into the creative cycle and the development of new advertising.

However, even the largest advertisers cannot easily afford to spend large sums of money on ineffective advertising. At best, such advertising may represent just a waste of money, but at worst the advertising may actually be actively disliked, and may only succeed in putting off potential buyers of the brand. Therefore, an increasing number of our clients in recent years have laid great importance on having available a reliable form of pre-testing, which will enable them to identify at an early stage any potential weaknesses in the executions, so that improvements can be made before the ad actually goes out on-air. We have gone a step further and, since 1989, have been able to provide our clients not only with a detailed diagnostic insight into the performance of their advertising, but also an accurate prediction of that crucial element on branded memorability - the awareness index again. The measure of our success in achieving this is illustrated in Exhibit 1.

Print advertising to doctors

The crucial difference here is that the media and production costs are very much less then those associated with TV advertising. Unfortunately, the costs of researching specialists audiences, such as doctors, tend to be somewhat higher than the costs associated with interviewing members of the public generally. This lays a particular onus on researchers to come up with cost-effective methods of research, which will nevertheless achieve all the objectives. With pre-testing, the objectives are much the same as with advertising to consumers on television. We need again to be able to identify executions which are unlikely to work in real life and, more particularly, to identify what it is about the ads which is a weakness and which needs to be rectified.

When it comes to tracking, one of the key considerations is again cost. Can advertisers of print advertising to doctors afford long-running, continuous tracking of advertising, employing long questionnaires which go into great detail about communication, empathy, stand-out and so on? The answer is clearly not. But the issue of wasting money on advertising still faces the advertiser. In this instance, the considerations are slightly different, for with print advertising it is quite possible to have a highly effective ad, but to run it for so long that it ceases to be noticed by the target audience. For this reason, the role of tracking is somewhat different with print advertising to doctors, and needs to concentrate on the issue of when the advertising has really 'worn out'. The diagnostic elements need to be investigated at a time when we can do something about ads which are likely to have a relatively short life - namely at the pre-testing stage.

In summary then, pre-testing is all about diagnostics and ensuring that the advertising is right before it goes on-air. Tracking, in this particular context, is all about getting the project in balance and ensuring that we do not continue to spend money on ads when they have ceased to be effective. It is argued by some that wear-out is less relevant, since the objective of the advertising is simply to remind doctors of the brand's existence. But it is worth asking whether that is not an excessively limited strategy, and whether all that money can be justified purely on the grounds of generating awareness. Indeed, it begs the question: awareness about what? Surely not just a brand name, but the brand itself and all the associations and images which go with it and, indeed, make up the brand. More basically, though, the question is also begged, that if an ad is no longer being noticed, how can it be reminding anyone of anything?

TRACKING OF PRINT ADVERTISING TO DOCTORS

For all the reasons noted earlier, to do with cost and the function of advertising in this market and to this target audience, a long-run commitment to continuous tracking cannot easily be justified, unless the advertiser has a number of brands which are being advertised at different points throughout the year. There is no reason why one tracking study should not cover a number of different brands, even from within different product categories. For any one brand, the issue is of running the tracking long enough to be able to detect wear-out, as demonstrated by a decline in the awareness index for the ad. Depending upon the schedule of advertising and the number of opportunities-to-see which the schedule provides, it is likely that the tracking would need to cover a period of around six months.

Costs must be kept low, and therefore a short telephone interview is commensurate with needs and budgets. The questioning can be kept short, since the crucial questions which we want to cover at this stage are measures of brand awareness ('What brands come to mind when you think of prescribing for ..............(condition)?'). From there we move on to prompted brand awareness, and then advertising recall.

That forms the core of the questioning for the tracking study, and the interpretation via modelling in the way described earlier. In an ideal world, we would suggest that diagnostic questions on communication, credibility, relevance and empathy will already have been covered in pre-testing.

PRE-TESTING PRINT ADVERTISING

In developing the 'Link' ad pre-testing system, we recognised that we can never hope to replicate in the test situation the relaxed viewing of TV or casual reading of ads which occurs in the real world. Therefore, unlike most pre-tests which try to assess ads directly by using simplistic measures, our approach is to ask questions that people can truly answer - namely, how they feel about the ads that we show them. Much of the questioning is open-ended and designed to provide a wealth of diagnostic information which throws light on the way the ad is working.

In applying the learning of how ads work to pre-testing, we have also been able to draw on extensive experience in research for the development of pharmaceutical advertising, from initial concept stage through to finished ads. The form of this research has been largely qualitative and has had the added benefit of providing insights into how doctors use advertising directed to them in professional journals and magazines.

We decided, though, that it would not be enough simply to show that we had an impressive pedigree in advertising research generally. In any case, our pharmaceutical clients would want the confidence that, in interpreting the results of their pre-tests, we would be able to set the findings in the context of other tests, ie that we had 'benchmarks' which could act as normative standards for our new 'MEDILINK' service. Therefore, at the end of March 1994 we conducted our own series of tests.

General Practitioners were recruited by telephone. They were sent a folder containing seven ads and then re-contacted by 'phone a few days later for the actual interview. We have found a very high degree of co-operation at all stages of research from both GPs and hospital specialists. Interviewing was conducted from Millward Brown's telephone interviewing centre, at our Head Office in Warwick, among a total sample of 104 doctors.

We wanted to have ads from the same product category, otherwise the danger would be that differences would not reflect the performance of the advertising, but a confused amalgam of advertising and product-category differences. At the time, this research was being set up, the professional journals featured a variety of ads for anti-hypertensives. Five ads were selected, and each folder for respondents included four of them. All folders contained ads for Adizem XL, Carace and Celectol together with one ad for either Adalat LA 30 or Motens. In order that our respondents should not be alerted in advance of questioning that this was the category of interest to us, we also included in each folder some 'filler' ads for Feldene, Minocin and Zantac, none of which were the subject of any questioning.

Although this research was conducted by Millward Brown International at their own initiative and expense, and so the findings are the copyright property of MBI, we did not think the limited range of findings we could show in this article would make it fair to discuss the brands by name. We shall therefore refer to the brands only by code letter in this report. Fuller details can be obtained by contacting the author.

  • Different ads do vary in their ability to create interest among General Practitioners. This is illustrated in Exhibit 2. Ad D is very clearly much the less interesting of the two. The importance of a press ad's ability to grab the readers' attention has already been stressed. Ad D is shown to be at a distinct disadvantage, this time to Ad B (Exhibit 3).

    EXHIBIT 2. INTEREST

    AD CAD D
    Very interesting204
    Quite intersting5623
    Not very interesting1539
    Not at all interesting933
    Base: (104)