Because of shortcomings in the quantitative research, no conclusions could be drawn on the validity of any new or modified survey instruments. While future research may prove more fruitful, at this stage there will be no further discussion of these.
15.4 Summary
A logical step-by-step process was followed in an attempt to extract any significant relationships; none were found.
16 Quantitative Research Conclusions
16.1 Introduction
This chapter sums up and draws conclusions on the quantitative research. Its structure is as per Figure 50.
Figure 50: Chapter structure
16.2 Conclusions
This first step towards testing the qualitative process of adherence by means of the quantitative process was unsuccessful in identifying significant moderating effects. Issues arose at several points in the procedure.
Firstly, the overall purpose of the survey was blurred. While it was aimed at understanding the interrelationships between adherence factors, there was also a desire to capture much more detail on reasons for non-adherence than was necessary for this purpose alone.
Secondly, the pilot test results were not exploited. This meant that the survey contained too many questions for most people to be willing to complete. This should have been noticed and addressed, but since no statistical analysis was performed on the pilot results there was no basis for exclusion of any questions.
Thirdly, the methods used to invite participants did not reach far enough into the overall population to consider the selection process random. Instead, point solutions to boost participation were used, resulting in both convenience and snowball sampling. One reason for this was that most recruitment was performed online thus disenfranchising the section of the population which was unable to
receive such invitations. This meant that even if statistically significant results had been obtained it would still not have been possible to make broad claims for the general population.
Fourthly, the means of completing the survey was not generally accessible. An online survey may have encouraged the young to participate rather than the more mature, all things being equal. It also meant that in the developing world it enabled only the more relatively wealthy, who had smartphones, to participate; this therefore missed out the true Base-of-the-Pyramid residents who were much more fairly represented in the qualitative results.
Fifth and finally, there were too few respondents to achieve statistically valid results. The analysis process used was statistically sound but it did not yield any valid results.
16.3 Summary
This first attempt to test the quantitative process was unsuccessful. This was as a result of shortcomings at some points in the survey procedure from design to implementation. However, the appropriate statistical approach was taken in the analysis of the results.
The value and validity of the qualitative process of adherence is not negated by disappointing quantitative results. The quantitative process of adherence may yet be found to be relevant.
17 Conclusions
17.1 Introduction
In this final chapter the research threads are brought together, views of the qualitative and quantitative processes discussed, and some answers proposed for the question, what is adherence from a process perspective? Following this, managerial implications are raised, limitations discussed and recommendations for follow-on work suggested.
The structure of this chapter is as in Figure 51.
Figure 51: Chapter structure
17.2 Conclusions
17.2.1 Literature review
It became clear through the literature review that there has been little theoretical research into adherence. Most has had practical bent, and the relatively few which have employed theory as a basis have used an expectancy-value one such as the Theory of Planned Behaviour.
As a result of the literature review, six adherence factors were identified for taking forward: beliefs, motivation, agency, context, norms and affordance. These were applied to a process derived through the lens of Service-Dominant Logic. This led to the creation of an initial process of adherence. This was then examined for validity in the qualitative research.
17.2.2 Qualitative research
Qualitative Proposition 1 proposed that the interviews were satisfactorily comprehensive and could therefore be used as a basis for endorsing the soundness of the second proposition and therefore the process of adherence. This was approached in two ways. The first examined the interviews to establish whether interview responses adequately covered all of the six factors of adherence. The second used a bottom-up method to determine the number of causes from the list of 55 causes in the ASA & ASCPF (2006) report, Adult Meducation. Forty-five of the 55 causes were found, the other ten requiring either an undue level of personal exposure by the interviewees or the possibility of personal assessment and recording by the interviewer. In addition, 19 causes of adherence not mentioned in the list of 55 causes were identified from the interviews. The results of these validations were considered to be in good alignment with Proposition 1 and therefore Qualitative Proposition 2 was supported.
Proposition 2 proposed that the initial process was a useful way of understanding the process of adherence. Performing and analysing 30 qualitative interviews showed good alignment with the process, and as a result a refined version was proposed as the qualitative process of adherence. This was on the basis that the interviews did in fact comprehensively cover the ground, which was the subject of the first proposition.
One important facet of this research is the focus on adherence as an individual act rather than an average of all adherence events for a patient or even a cohort of patients. The viewpoint of Service-Dominant Logic inherently supports this perspective, which allows a focus on what factors and rules are uppermost in the patient’s mind at that point of adherence. While this is innately a qualitative approach, it may provide greater insights into causes of non-adherence in practice, and therefore guide adherence interventions more effectively than repeated quantitative approaches which often produce inconclusive results.
17.2.3 Quantitative research
This research was performed in order to operationalise the major factors of adherence. A quantitative process of adherence was created from the qualitative process which was suitable for statistical analysis. The research failed to provide support to validate that process.