The purpose of the thesis was to attempt to answer the question, what is adherence from a process perspective? Based on this research there are potentially three answers.
17.3.1 Answer 1: the triad
This is the coming-together of patient and medicine in context to create value, controlled by the three rules of medicine instructions, contextual norms and patient beliefs. It might be visualised as in Figure 52.
Figure 52: Triad perspective of adherence
This answer in itself is a development of previous adherence research. So far, research has been focused on dyads such as patient and context or patient and medicine. The three parts of the triad, with the three controlling rules, have not been brought together in this way before. However, this is quite a simple definition.
17.3.2 Answer 2: the qualitative process of adherence
This is a significant further development of the first answer. It brings in details which cannot be shown in the triad perspective. Based on the depiction of Service-Dominant Logic, it positions the six factors of adherence into a view of the process in order to show how they dovetail. In addition, the use of a lens which encompasses the full adherence process from absence to post- consumption value assessment significantly extends the theories currently applied to adherence research.
It also shows some of the irreducible complexity innate in adherence when it is understood as a complex interaction of service systems. Through this depiction it can be understood just why adherence is so hard to pin down empirically and perhaps explains why there is so much inconclusive research. Using a view of the process like this can provide a basis for future empirical research since it can illuminate reasons for results. Its depiction is repeated here as Figure 53.
Figure 53: Qualitative process of adherence
This is the view of the process which provides the greatest insights into adherence. It has been developed through a range of theoretical and practical measures. This process is considered to be the most developed of the three presented here. It goes well beyond previous theories, which have here been built on to gain a theoretical understanding of the adherence process. Therefore
this theoretical view of the adherence process is proposed as the answer to the question, what is adherence from a process perspective?
17.3.3 Answer 3: the quantitative process of adherence
This is a deconstruction of the qualitative process. Although its first test had no success it may still provide a basis for future adherence research. It pictures a series of factors moderating the patient’s attempt at adherence. Each attempt is enabled or driven by beliefs, motivation and agency, and is potentially moderated by the medicine’s affordance, the context, and the norms arising from relevant service ecosystems. One attraction of this view of the process is its extensibility, since other factors can be introduced. However, as a simplified statistical model it cannot give the fine-grained insights of the qualitative view of the process. It is repeated here as Figure 54.
Figure 54: Quantitative process of adherence
17.4 Contributions to knowledge
This research has made the following seven contributions to knowledge. Firstly, it has extended existing partial theories to establish a theoretical view of the adherence process. This qualitative theoretical view describing the process of adherence is considered to be a significant step forward from the theories currently applied to adherence research. This qualitative process of adherence process could potentially inform future empirical research and so improve the effectiveness of interventions aimed at increasing adherence.
Secondly, it has delivered a new understanding of adherence as an individual opportunity to be adherent rather than as an average of all consumption opportunities over a course of treatment. This permits a closer focus on just what enables or hinders adherence at a point in time and this in turn allows the investigation to be at a point when as many as possible of the factors affecting adherence are as constant as possible. This encourages a qualitative approach to adherence research. It could potentially reduce the need for quantitative research, since that has been shown to be weak in determining actual causes and therefore in the selection of optimum interventions in various contexts.
Thirdly, it has enhanced the general understanding of adherence. It can now be seen as a complex interrelationship of factors involved from the initial recognition of absence that triggers motivation right through to the ex post assessment of value gained from being adherent. To enable this, it has visualised adherence as a complex interaction of service systems, and so has developed a theoretical view of the adherence process which goes beyond the expectancy-value theories and permits the point of adherence to be included theoretically for the first time.
Fourthly, it has developed a quantitative perspective for the adherence process. This view could potentially inform quantitative research into adherence.
Fifthly, it has contributed a pictorial representation of the flow of Service- Dominant Logic which has not been presented before. It has also incorporated and positioned service ecosystems and the Integrative Framework of Value within the flow. This representation was used as the basis for developing the qualitative theoretical view of the process of adherence.
Sixthly, although the interviewees were not intended to be representative samples of their populations, the qualitative interviews suggested that reasons for non-adherence are broadly the same – although not necessarily for the same reasons – across developed and developing worlds. This surprising finding may have implications for future medicine formulations, since assumptions on agency and context may be causing adherence issues in the developed world in the same ways as for the developing world.
Seventhly, but less importantly from a theoretical perspective, is the addition of 19 new causes to the existing 55 causes of non-adherence (ASA & ASCPF 2006).