by Mo Hamzeh
It was a typical Thursday morning in Medical, Legal, and Regulatory (MLR) review, and we were about to review a simple branded banner ad for a prostate cancer drug. The team has always been accustomed to allotting 15 to 30 minutes at most to review a tactic as simple as a banner ad, but this was certainly not the case that day. The banner ad was pulled up onscreen for review and within two seconds of it being displayed, the legal reviewer abruptly said one word: “Nope.” Everyone in the room and on the phone was confused, so naturally, the lead marketer asked if there was a problem. The legal reviewer explained that the first frame of the banner ad displayed an African American male representing a patient with prostate cancer, and then the reviewer followed up by indicating that the prominent use of an African American male misrepresented the brand.
Before diving into the rationale that this legal reviewer provided for this decision, let us briefly discuss the reality of the prostate cancer patient population. This year, an estimated 268,490 men in the United States will be diagnosed with prostate cancer. The number of new cases diagnosed in Black men is 73% higher than the number of new cases diagnosed in White men. Black men in the United States and the Caribbean have the highest incidence rates of prostate cancer around the globe.1 In addition to being more likely to be diagnosed with prostate cancer, African Americans have the world’s highest incidence of prostate cancer and a more than two-fold higher mortality rate compared with White men.2
Now back to the MLR review where the legal reviewer refused to review the banner ad due to the representation of the patient in the first frame. You could hear a pin drop in the room when this decision was made. There was an overwhelming sense of discomfort among the marketers, ad agency partners, and even certain MLR review team members, especially since this was at a point in time when we as a nation were at the height of sensitivity around racism and racial disparities, including health disparities. It was at a time when Diversity, Equity, and Inclusion (DE&I) was at the forefront of corporate culture across all industries in our nation. But let it be clear that this legal reviewer was not acting on or making a decision under any racial or prejudicial ideologies or ways of thinking. The legal reviewer stated that we were misrepresenting the brand because the clinical trial of the product we were promoting had less than 1% African American patients represented in the study population. Consequently, this reviewer deemed it as a substantial legal risk to prominently represent an African American male on a branded piece promoting the product. All other reviewers then followed suit and the decision was made to replace the Black patient with a White patient—all because it misrepresented the clinical study population when in reality, it was most representative of our national population fighting prostate cancer.
The intent here is not just to tell a story about an instance that occurred in one MLR review, but to use this story to set the stage on a topic that runs rampant in the pharmaceutical and healthcare marketing and advertising industries. The topic of patients being underrepresented or misrepresented in marketing efforts across various disease states is neither novel nor unique. It has been an issue plaguing the pharmaceutical and healthcare marketing industries for quite some time now. Although many companies are actively attempting to address this issue, especially with the recent uptick in DE&I efforts, we still have a way to go when it comes to matching our industry’s multicultural representation with the multicultural reality. Therefore, the intent here is to briefly highlight just a select few of the fairly recent and successful trends in our industry that are being used to combat this issue, with a focus on three specific points: (1) representative clinical trial recruitment, (2) representative patient inclusion within pharmaceutical advisory boards, and (3) the importance of effective multicultural marketing.
Representative Clinical Study Recruitment
Let us first address one of the main principles that will help shift the narrative of multicultural representation in the pharmaceutical industry, which is the corporate recognition that multicultural recruitment efforts for clinical trials need to be significantly better and truer to the epidemiology of each respective disease state’s population. Ensuring people from diverse backgrounds join clinical trials is key to advancing health equity.3 Participants in clinical trials should represent the patients who will use the medical products. Unfortunately, this is often not the case as people from racial and ethnic minorities and other diverse groups are underrepresented in clinical research. So, while it may seem obvious, one significant step researchers and medical product sponsors can take to confront healthcare disparities is to ensure clinical trials for medical products are more inclusive of multiple populations.
In fact, the US Food and Drug Administration (FDA) issued final guidance in late 2020 with the agency’s recommendations of designing and executing clinical trials of drugs and biologics that include people with different demographic characteristics (e.g., sex, race, ethnicity, age, location of residency) and nondemographic characteristics (e.g., patients with organ dysfunction, comorbid conditions, and disabilities; those at weight range extremes; and populations with diseases or conditions with low prevalence). This guidance provides the FDA’s current thinking on steps to broaden eligibility criteria in clinical trials through inclusive trial practices, trial designs, and methodological approaches. In turn, it aims to provide recommendations for how sponsors can increase enrollment of underrepresented populations within their clinical trials.4
Ultimately, this will allow medical product manufacturers to reach their respective patient populations more accurately and effectively through even more targeted marketing efforts. It will also help prevent any uncomfortable conversations around potential risk due to legal technicalities associated with clinical trial recruitment and promotion of the product at hand.
Representative Patient Inclusion Within Pharmaceutical Advisory Boards
It is exceedingly important to understand that now, more than ever, patients of all socioeconomic or demographic statuses have access to self-research medical information. DeepIntent fielded a study in which they found that while stuck at home during the pandemic, people saw more pharma ads than ever and it was not just on televisions, but on computers and mobile devices. The study also found that consumers watching ads and searching for health information online weighed almost equally when measured against their physician-provided knowledge.5
As patients take their health and future into their own hands with the help of digital health tools, they also should be treated as equal partners within hospital, pharmacy, and even pharmaceutical company settings. For this reason, pharmaceutical companies are increasingly employing patients who have experience with the given company’s products on their advisory boards, and better yet, accurately represent the most affected patient populations. This allows companies to capture detailed patient information to inform future strategies and effective targeting approaches.
As an example, Novo Nordisk is committed to incorporating the patient voice at all stages of their product development process. They believe it takes a multistakeholder approach to develop new treatments for patients living with chronic diseases, and Novo Nordisk is convinced that patient partnerships are the best starting point for all medical innovations. As a result, in 2020, Novo Nordisk established patient advisory boards called DEEP (Disease Experience Expert People), which is a framework for placing patients center stage and providing an environment for their input to affect the patients’ care delivery model, as well as future patient communication strategies for Novo Nordisk products.6
Importance of Effective Multicultural Marketing
Multicultural marketing is the process of representing diversity within a brand’s collateral, messaging, and content, as well as speaking directly to diverse cultures, races, and groups. The multicultural or cross-cultural segment constitutes the largest, fastest-growing consumer segment in the US market. This is due to the significant treatment gaps across therapeutic areas that not only represent potentially millions of new scripts but also represent the strong brand upside and a reputational boost from the opportunity for the pharmaceutical industry to improve patient outcomes on a national scale. The multicultural segment is also at the forefront of the consumer movement when it comes to digital, mobile, and social media use and when communicated in a way that is relevant and resonates, has a higher promotional response. To address this growing populace, the number of pharmaceutical companies investing in multicultural marketing teams has more than tripled within the last decade. The good news is that although the industry is a bit behind, the needle is certainly moving in the right direction as many pharmaceutical companies have also adopted multicultural or multiethnic corporate strategies.7
A key part of effective multicultural marketing is that to close some of the gaps, an incremental investment is needed to specifically target these audiences, as traditional efforts can prove less effective. Using Nielson media data, a direct example of this can be seen in a breakdown of primetime TV viewers. When the top 10 English language networks were compared to the top Spanish language networks, it was determined approximately 70% of US Hispanics (18 years or older) are exclusively tuning in to the Spanish-speaking Univision. The data clearly show that traditional investments in the English language TV space are underreaching this audience.7
It is also important to gain the necessary vocabulary and language for essential conversations around cross-cultural marketing and to hear directly from leaders in cross-cultural marketing on how to create a business case for the investment internally and how best to collaborate successfully externally. Consideration of necessary ways to apply existing tools and data sets to communicate with a diverse audience more effectively is what sets apart a truly successful multicultural campaign from the status quo. For example, social media marketing and the content shared on various platforms, should mirror the diverse audience it’s targeting and seek to engage them, which will undoubtedly prove far more successful than those brands choosing to employ a more blanketed approach, designed to appeal to a broader and more general audience. Now is the time for marketing teams to appropriately budget for a targeted multicultural, multichannel approach to adequately communicate health information directly to communities of color through the specific platforms where they most engage. The inevitable result? Better DE&I practices by marketers, better brand visibility and results, and more informed and engaged target audiences.
In conclusion, a key takeaway is that multicultural marketing is simply marketing. It should now be the standard across any marketing strategy throughout any industry. But when speaking directly to the pharmaceutical industry, the main point is that patients want to be heard and most importantly want to understand treatment options available for their conditions, and that especially goes for the most at-risk patients, which for the most part, happen to be ethnic minorities in low socioeconomic geographic areas. However, it will be difficult to notice a significant shift without effectively addressing at least the three trends that were just highlighted: (1) representative clinical study recruitment, (2) representative patient inclusion within pharmaceutical advisory boards, and (3) the importance of effective multicultural marketing. It is imperative that all three items feed into each other, and as such, strengthen each other when done properly. Lastly, it is critical for the pharmaceutical companies in collaboration with all their partner agencies to continue to fight for appropriate, accurate, and necessary representation of patient populations not only as they pertain to clinical studies, but as they are truly represented in those most affected, especially in the underserved ethnic minority communities. Because as many of the team members in that MLR room reviewing the banner ad that one Thursday morning can attest, they never want to have to sit through a conversation like that ever again.
- Cancer.Net®. Prostate Cancer: Statistics. Accessed July 20, 2022. https://www.cancer.net/cancer-types/prostate-cancer/statistics
- Hoffman RM, Gilliland FD, Eley JW, et al. Racial and ethnic differences in advanced-stage prostate cancer: the Prostate Cancer Outcomes Study. J Natl Cancer Inst. 2001;93(5):388-395. doi:10.1093/jnci/93.5.388
- Clinical Trial Diversity. US Food & Drug Administration. Accessed July 20, 2022. https://www.fda.gov/consumers/minority-health-and-health-equity/clinical-trial-diversity
- FDA Offers Guidance to Enhance Diversity in Clinical Trials, Encourage Inclusivity in Medical Product Development. US Food & Drug Administration. Accessed July 20, 2022. https://www.fda.gov/news-events/press-announcements/fda-offers-guidance-enhance-diversity-clinical-trials-encourage-inclusivity-medical-product
- The Patient Perspective: Paving the Path to Awareness, Ad Relevance and Empowerment. DeepIntent+®. Accessed July 20, 2022. https://www.deepintent.com/the-patient-perspective-paving-the-path-to-awareness-ad-relevance-and-empowerment/
- Coquerel C, Kuruvilla S, Eichmann L. Inside Novo Nordisk’s Patient Advisory Board Meetings. Accessed July 20, 2022. https://www.clinicalleader.com/doc/inside-novo-nordisk-s-patient-advisory-board-meetings-0001
- Nielsen. The Multicultural Edge: Rising Super Consumers. Accessed July 20, 2022. https://www.nielsen.com/wp-content/uploads/sites/3/2019/04/the-multicultural-edge-rising-super-consumers-march-2015.pdf