5.4.1 Patient
For the purposes of this research, a patient is someone who consumes medicine. Patients may take their medicine for a number of reasons. Since a patient is a consumer in this sense it is reasonable to invoke wider consumption literature. Motivation, the ability to act and beliefs are also explored.
Two important questions are what consumers do and why they do it. Many authors define consumption as the integration of resources to create value for the consumer (for example Siltaloppi & Vargo 2014; Hibbert et al. 2012; Peters 2014). Resource integration is the process by which the consumer uses their capabilities in order to use the consumable with the purpose of creating value in use. These capabilities align with the patient’s ability to act, their beliefs, and their motivation. Patients bring these to adherence as resources in order to create value in use from the medicine.
The environment should provide other resources in support of the patient’s intention to be adherent. The process of resource integration, if consumption is to take place, requires that sufficient of the right resources are brought together. This is described as there being sufficient resource “density” for value in use to
be achieved (Michel et al. 2007; Normann & Ramírez 1993).
For example, taking medicine may require a tumbler and some water. These are provided by the environment occupied by the patient. If these resources are not available then the patient may not be able to be adherent on that occasion.
Motivation has been identified as an important factor in why patients are adherent. At a basic level, Bhaskar (1993) stated that “absence” is the root cause
of consumption. In the case of medicine consumption that absence relates to the patient’s lack of health. This absence may also be the required “stimulus” to
action (Janz & Becker 1984). The process of “absenting of absence [is] manifest in the satisfaction of desire” (Bhaskar 1993 p.43). Mingers (2011) identifies this
absence) between the desired state of the system and the actual state of the system”.
While the term “desire” is a potentially emotive word, for Bhaskar it had no moral
overtones. Similarly, Ilmonen (2011 p.57) simply equates desire with a “specific need” for an “object”. That object in this context is the medicine. He speaks of
“needs and wants” (ibid. p.45), discussing how “the condition of need” becomes
“a specific need, i.e. want” (ibid. p.48) through “identification [with] its object” (ibid.
p.49). There is therefore a four-step progression. (1) Absence (of health). (2) This awakens a need (for a medicine). (3) This leads to the three equivalent ideas of desire, want or specific need (for a particular medicine). (4) Finally this results in “absent[ing] the absence” (of health) through obtaining and consuming the
medicine, thus closing the loop in the system and restoring health.
A level of motivation – perhaps an increasing level – is required to move from one step to the next in this four-step progression. However, a lack of movement through these steps does not imply that motivation is not present. It is fundamental to Bhaskar’s philosophy of Critical Realism (Bhaskar 2008 p.36) that “countervailing causes” may cause “generative mechanisms” such as motivation,
which “endure even when not acting”, to remain “unrealized” in practice (ibid.
p.xxxi). This therefore recognises that the patient may not consume even when motivated if there are forces acting which prevent it. In our example this may be that a tumbler or water is not available, thus preventing the patient from moving from desire for health to the health expected as a result of the consumption of medicine. This is a potentially important consideration when considered against expectancy-value theories which assume readiness for action always leads to action.
However, there may be more to why patients take their medicine than just the fulfilment of their wish to regain health. Joy & Li (2012) observe that consumption decisions are “complex, often riddled with ambivalence, internal contradictions and even pathology”. This observation is potentially explained by the Dialogical
demonstrate the existence of “multiple narratives reflecting multiple selves” which
represent “multiple realities”. They go on to say that consumption is viewed
differently by each self, while a “meta-self maintains a more balanced perspective… as a synthesizing activity” overall.
Perhaps the Dialogical Self Model does help to explain Joy & Li's conclusions. It certainly indicates that there are potentially multiple purposes to consumption and that they may be in conflict. Three consumption purposes, or goals, have been defined (Barbopoulos & Johansson 2016) as gain (functional, utilitarian), hedonic and normative.
In overview, the utilitarian goal takes the rational, objective, functional utility- maximising viewpoint. This is the one assumed to be operating in adherence decisions.
The hedonic goal relates to emotions, either positive or negative, and was identified by Hirschman & Holbrook (1982) as a result of empirical research. In adherence this may be relevant if, for example, consumption is performed in the presence of an otherwise-absent loved one or in a hospital with unpleasant connotations. Hirschman & Holbrook (1982) make three propositions regarding hedonic consumption. (1) “In some instances, emotional desire dominates utilitarian motives in the choice of products”. (2) “[C]onsumers imbue a product with a subjective meaning that supplements the concrete attributes it possesses”.
(3) “[H]edonic consumption is tied to imaginative constructions of reality”. These
propositions suggest that rational adherence decisions can be overruled by influences such as the emotions aroused by a medicine, the intangible attributes of a medicine, and internal views of reality which may not match objective reality. Point three is especially relevant when considering expectancy-value theories.
Though hinted at originally in the Theory of Planned Behaviour, the normative goal was added to the first two by Barbopoulos & Johansson (2016) and is applicable to the consumer abiding by external restrictions. In the case of adherence this may be pertinent to the patient’s support being present or otherwise, and their wish to engage with support from the appropriate source. It
may be also that the patient discovers that support varies depending on the environment in which they find themselves or perceive themselves to be. In addition, it is argued that the patient’s perceived or actual environment will determine the nature of the norms they abide by.
Finally in this consideration is the importance of patient beliefs. Earlier analysis has indicated that these are seen to be of significant importance. Interestingly, in the conclusion to his paper on the Theory of Planned Behaviour Ajzen (1991) opined:
“…there is plenty of evidence for significant relations between behavioral beliefs and attitudes toward the behavior, between normative beliefs and subjective norms, and between control beliefs and perceptions of behavioral control”.
In this analysis he is referring to beliefs, norms and external controls. It may be more sensitive in this context to rename “controls” to “instructions”. Some might
also at times rename “beliefs” to “values”, for example in the list provided by
Hibbert et al. (2012) of “values, norms, and required patterns of behavior”, but
the intent is the same.
5.4.2 Environment
Within this research, the environment is the situation in which the patient consumes the medicine. It is the combination of all of the aspects of the particular consumption situation which contribute to or detract from consuming the medicine in order to achieve value in use.
Returning to the earlier example, the tumbler and the water are part of the patient’s environment. These are enablers of consumption.
Also as indicated above, another element of the environment is the support provided – or otherwise – by others. This includes the patient-doctor relationship. This viewpoint has been considered in the light of the Dialogical Self Model and is positioned here as being dependent on which environment the patient is in or
perceives that they are in. The norm rule, discussed above, relates directly to the environment.
This environment is usefully visualised by Easton (2010), who links it with the Critical Realist “contingent relationship”. This refers to relationships which are
“neither necessary nor impossible” to exist. This outlook implicitly recognises that
the environment can vary since the relationships between elements of the environment do not necessarily obtain over time. There are many variables, which may include the time of day, the location, the availability of required contextual elements, and even the patient’s capabilities at that time. This perspective suggests that even with all those specified elements place in the value creation environment the patient may still not take their medicine. This could be due, perhaps, to a lack of capability or a suddenly reduced desire, and shows how the patient must contribute their capabilities in order for them to create value. In this it is possible to see “contextual variety” (Ng & Briscoe 2012), which
affects the patient’s ability to realise value in use.
5.4.3 Medicine
At its simplest, a consumable is something which can be consumed. In these thoughts the consumable is the medicine. The medicine provides its resources into the consumption environment, where its resources are combined with the patient’s resources to create value in use. The medicine’s attributes may contribute to the patient being adherent or may detract from it. Features detracting from adherence may be, for example, that it is bitter or too large to swallow, or its formulation – tablet, injectable, etc – may be unacceptable to the patient.
The medicine’s instructions are another contribution of the medicine into the consumption environment. Without accurate and accurately remembered instructions it is likely that adherence will not occur.
5.4.4 Beliefs, norms and instructions
From the foregoing, and referencing Ajzen (1991), it is possible to see that there in fact three “rules” which contribute to determining whether adherence will be achieved by the patient: beliefs, norms and instructions. It is reasonable to assume that these are always operating concurrently in any particular consumption context, and that they may either be aligned or in conflict.