ISSN 0309-0566Volume 52 Number 11 2018

European Journalof Marketing

Endorsed by the

Marketing as an integrator in integrated health

Guest Editors: Debbie Isobel Keeling, Michael Rigby,

Ko de Ruyter, Liliana L. Bove and Philip J. Stern

SENIOR ADVISORY BOARDProfessor Kwaku Atuahene-GimaChina Europe International Business School,People’s Republic of China

Professor Rod BrodieAuckland University, New Zealand

Professor Stephen BrownUniversity of Ulster, Northern Ireland

Professor Dave CravensTexas Christian University, USA

Professor Peter DanaherMonash University, Australia

Professor Marnik DekimpeCatholic University of Tilburg/LeuvenUniversity, The Netherlands

Professor Adamantios DiamantopoulosUniversity of Vienna, Austria

Professor Evert GummessonStockholm University, Sweden

Professor Nigel PiercyWarwick University, UK

Professor Jaideep PrabhuUniversity of Cambridge, UK

Professor Lisa ScheerUniversity of Missouri, USA

Professor Leigh SparksStirling University, Scotland, UK

EDITORIAL REVIEW BOARDProfessor Nicholas AlexanderUniversity of Ulster, Northern Ireland

Dr Lynda AndrewsQueensland University of Technology,Australia

Dr Paolo AntonettiQueen Mary University of London, UK

Associate Professor Nicholas AshillVictoria University of Wellington,New Zealand

Professor Michael BakerWestburn Publishers Ltd

Associate Professor David BallantyneUniversity of Otago, New Zealand

Professor John BalmerUniversity of Brunel, UK

Associate Professor Syagnik BanerjeeUniversity of Michigan-Flint, USA

Professor Roger BennettLondon Metropolitan University, UK

Professor Xuemei BianNorthumbria University, UK

Professor Grete BirtwistleGlasgow Caledonian University, UK

Professor Björn BjerkeMalmö University, Sweden

Prof. Dr Manfred BruhnUniversity of Basel, Switzerland

Professor David J. CarsonUniversity of Ulster, UK

Dr Eugene Y. ChanMonash University, Australia

Professor Leslie de ChernatonyAston Business School, UK

Slyvie ChettyUniversity of Otago, New Zealand

Associate Professor Henry F.L. ChungMassey University, New Zealand

Professor Nicole CovielloWilfrid Laurier University, Canada

Professor Tevfik DalgicUniversity of Texas at Dallas, USA

Dr Kenneth R. DeansLa Rochelle Business School, France

Professor Anne Marie DohertyUniversity of Strathclyde, UK

Elena Delgado-BallesterUniversity of Murcia, Spain

Professor Bill DonaldsonThe Robert Gordon University, Aberdeen, UK

Professor John EganLondon South Bank University, London, UK

Professor Kim-Shyan FamVictoria University of Wellington,New Zealand

Professor Pervez GhauriKings College London, UK

Professor Audrey GilmoreUniversity of Ulster, UK

Professor Christina GouldingKeele University, UK

Professor Kjell GrønhaugNorges Handelshoyskole, Norway

Dr Chiquan GuoThe University of Texas – Pan American, USA

Professor Chris HackleyRoyal Holloway University of London, UK

Dr Rob HamlinUniversity of Otago, New Zealand

Dr Jennifer HarrisUniversity of New South Wales, Australia

Professor Lloyd HarrisCardiff Business School, UK

Phil HarrisUniversity of Chester, UK

Assistant Professor Teresa Pereira HeathNottingham University Business School,University of Nottingham, UK

Professor Graham J. HooleyAston Business School, UK

Professor Gábor HoványiPannónia UTCA, Hungary

Professor Claes HultmanÖrebro University, Sweden

Dr László KárpátiBudapest Business School, Hungary

Professor Erdener KaynakPennstate Harrisburg, Pennsylvania, USA

Professor David A. KirbyThe British University in Egypt, Cairo, Egypt

Professor Philip J. KitchenUniversity of Rennes, France

Associate Professor Mirella KleijnenVrije Universiteit Amsterdam, Netherlands

Professor Simon KnoxCranfield University, UK

Associate Professor Anjala KrishenUniversity of Nevada, Las Vegas, USA

Professor Raymond LaForgeUniversity of Louisville, USA

Dr Meredith LawleyUniversity of the Sunshine Coast, Australia

Professor Veronica LiljanderSwedish School of Economics and BusinessAdministration, FinlandProfessor Adam LindgreenCopenhagen Business School

Associate Professor Ian LingsQueensland University of Technology, Australia

Professor Andrew McAuleySouthern Cross University, Australia

Dr Rosalind McMullanThe Coves Consulting, UK

Professor Bill MerrileesGriffith University, Australia

Professor Morgan MilesThe University of Canterbury, Christchurch,New ZealandAssociate Professor Kobe MilletVrije Universiteit Amsterdam, Netherlands

Dr Erik MooiUniversity of Melbourne, Australia

Professor Luiz MoutinhoUniversity of Glasgow Business School, UK

Professor Patrick MurphyUniversity of Notre Dame, USA

Dr Elina NarvanenUniversity of Tampere, Finland

Professor Aron O’CassMacquaire University, Australia

Associate Professor Kelley A. O’ReillyWestern Michigan University, USA

Dr Tom O’TooleWaterford Institute of Technology, UK

Dr Harmen OppewalMonash University, Australia

Professor Adrian PalmerUniversity of Wales Swansea, UK

Dr Ravi PappuUniversity of Queensland, Australia

Professor Paul PattersonUniversity of New South Wales, Australia

Professor Michael PolonskyVictoria University, Melbourne, Australia

Professor Gerard PrendergastHong Kong Baptist University, Hong Kong

Dr James E. RichardVictoria University of Wellington, New Zealand

Professor Gregory RoseUniversity of Washington, USA

Dr Rajat RoyBond University, Singapore

Dr John M. RuddWarwick Business School, UK

Professor Jonathan E. SchroederRochester Institute of Technology, USA

Professor Piyush SharmaCurtin University, Australia

Professor Wai SiuHong Kong Baptist University, Hong Kong

Professor Goran SvenssonOlso School of Management, Norway

Professor Isabelle SzmiginBirmingham Business School, UK

Associate Professor Ramendra ThakurUniversity of Louisiana at Lafayette, USA

Professor Hans Mathias ThjømøeNorwegian School of Management, Norway

Professor Caroline TynanNottingham University Business School, UK

Dr Richard J. VareyUniversity of Waikato, New Zealand

Professor Cleopatra VeloutsouUniversity of Glasgow, Scotland, UK

Associate Professor Pavlos A. VlachosALBA Graduate Business School, Greece

Professor MartinWetzelsEindhoven University of Technology, The Netherlands

Professor Len TiuWrightDe Montfort University, UK

Professor MalcolmWrightUniversity of South Australia, Australia

Professor Judy ZolkiewskiAlliance Manchester Business School, UK

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Guest editorialMarketing as an Integrator in Integrated CareIntegrated care has been heralded as a primary health sector policy objective not only acrossEurope but also globally (WHO, 2015, 2016). The twomajor drivers are:

(1) the desire for more person-sensitive approaches to the delivery of health and socialcare services; and

(2) the spiralling and unsustainable rises in the cost of health care.

Integrated care is not disease or condition specific, instead it encompasses multiplechronic or acute diseases or complex single conditions and recognises the need tonavigate through a labyrinth of services, especially under conditions when the patienthas no or depleted resources through complications such as frailty, cognitive declineand social isolation. However, today’s reality with regard to service provision,especially for vulnerable groups living in the community (e.g. older people, those withchronic or mental health conditions and children with complex needs), is one offragmentation resulting in disjointed, inefficient and patchy care that is not patient-centred and raises problems associated with polypharmacy and professionaldisharmony. There is a desperate need for new conceptual and organisationalapproaches to care that link multiple stakeholders into a single integrated response.Achieving this goal is a recognised contemporary grand challenge, not least because ofthe diversity in perspectives of the multiple stakeholders involved and thefragmentation of health-care delivery systems.

Active projects across Europe have made valuable steps forward in integrated care.Pilot initiatives can be found in a number of countries including Denmark, Estonia, TheNetherlands, Sweden and the UK, and the concept of integrated care is being encouragedwidely as both a service and professional philosophy. The European Federation forMedical Informatics (EFMI) organised the “Village of the Future” (MIE2012) visioningthe integration of social and health care, followed by “The Caring Village of the Future”(Medinfo, 2013) and the Kurhaus Conference (PCSI 2015). The International Foundationfor Integrated Care, the principal NGO for Integrated Care, is active in promoting deliveryand organisational innovation globally, but has much less focus on applied informaticsinnovation. Other examples of contemporary projects are: Project INTEGRATE(projectintegrate.eu.com); SCIROCCO (scirocco-project.eu); SmartCare (pilotsmartcare.eu); INDEPENDENT (independent-project.eu); CommonWell (commonwell.eu);Health@Home; Beyond Silos; and CareWell. Projects analysing business/fundingmodels of providing health and social care e-solutions include: eCareBench; SALT;PSYCHE; and Older Person Services (Dublin, Ireland). Other projects are working onaccessibility, functional and infrastructure aspects, including interoperability betweenelectronic health record systems across Europe: MeAC (eaccessibility-progress.eu);epSOS (epsos.eu); Promoting Effective Homecare and Telemonitoring; and Palante(palante-project.eu). Finally, projects focussing on enhancing communications betweenstakeholders with supporting information structures include KITE and CancerStories(cancerstories.info).

Achieving integrated care is a multidisciplinary problem, yet with a few notableexceptions across disciplines, there is a lack of coordination efforts between disciplines toeffectively integrate knowledge and approaches. Also, much attention is focussed on the

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review and redesign of health processes for improved efficiencies, rather than focussingmore innovatively on how services present to users and drawing on other disciplineswith strengths in service-user centricity, such as, marketing. The main aim of thisspecial section is, thus, to provide a platform that explicitly coordinates and curatesmultidisciplinary research aimed at providing a shared understanding and knowledgebase that directly addresses the fragmentation in this field. Within the marketingdiscipline there is a strong and well-established theoretical knowledge base that canmake a significant contribution to realising integrated care. In particular, marketingcan perform the role of lynchpin between care disciplines, not least in providing freshunderstandings of patients as service users and their networks. A recent review thatspecifically integrates health care and services research demonstrates the promise ofsuch multidisciplinary thinking (McColl-Kennedy et al., 2017a), and in confirmation,most recently, the specific role of marketing in health care has been explored (Andersonet al., 2018). Notwithstanding, marketing is often the overlooked and misunderstoodpossible partner in major health and care projects at National and European levels,which has constrained its potential impact on this area. Thus, this special sectionshowcases how research in various domains of marketing can play a central integratorrole in drawing together multiple disciplines around integrated care in addressing thechallenges that consumers, practitioners and policymakers face. Moreover, weprovide insights into how research in integrated care can in turn inform and advancemarketing theory and the formation of multidisciplinary research networks to play aleading role in this important arena. We do so by identifying four big challenges inintegrated care to which we believe marketing can contribute and each of the articles,and accompanying commentaries, in this special section provides an example of thispotential contribution.

New thinking to address fragmentation in integrated careTackling the barriers to integrated care and hence facilitating its delivery would producesignificant positive impact, as health, social and other care systems struggle with this issue.A core problem from the health and care provider perspective is that the field is fragmentedwith no one agency having overall responsibility, thus hindering innovation in integratedcare, and the consumer perspective shares this lack of a single supplier point. The essentialvision of person-centred integrated care challenges established practices and care deliveryprocesses, necessitating changes in service policy, delivery and the development ofinnovative technology solutions, while also changing societal thinking about health-careprofessions and the role of patients and their advocates. What is clear is that integrated caremust progress beyond harmonisation of parallel services, to mutual understanding andcomplementarity in a person-specific, sensitive, inclusive and accountable way. Such anintegrated approach will optimise the co-production of health (Palumbo, 2016; Rycroft-Malone et al., 2016), whereby individuals take on appropriate responsibility for aspectsof their health maintenance and support, assisted (within their capacity and mutualpermissions) by family and close social contacts. Co-production implies thatindividuals exercise autonomy, which requires decision-making capacity. The mostvulnerable groups often experience impaired decision-making ability for many reasons(transient or enduring). Assisting such individuals to engage in decisions about care isa complex ethical, legal and human rights issue. Rather than taking a discipline-centredapproach, integrated care requires a challenges approach. To achieve true person-centric integrated care is complex and can only be achieved by integrating concepts,objectives and methods across a diverse array of disciplines; incorporating social

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sciences, health and care sciences, informatics, medical engineering, ethics, systemsand policy studies, to name just a few. Yet it should also be simple – meeting a person’swell-being needs in a sensitive joined up way.

The use of digital tools may play a key role in delivering integrated care, but raiseschallenges of acceptability, responsibility, accessibility, financing and ethics; yet debatescontinue to focus on the technical aspects of ICT development (Stroetmann et al., 2010).Instead, the European Science Foundation report on Developing a New Understanding ofEnabling Health andWellbeing in Europe (Rigby et al., 2013) and the OECD (2013) report onSmarter Health and Wellness Models emphasise the need for innovative social scienceresearch, alongside innovative ICT support. Marketing is an obvious but overlooked keysocial science player here.

The four big challenges to achieving integrated careWe identify four challenges that consumers, practitioners and policymakers face indeveloping and implementing integrated care and label these as: self; society; micro(person-level) systems; and macro (service level) systems. For each of these fourchallenges we present examples of past research activity that have emerged frommarketing in Table I. Whilst this is by no means an exhaustive list, it is an illustrativeinventory of the advances that can be made and the possible key value areas offered bymarketing to the study and realisation of integrated care. In the following section, weoutline how each of the papers in this special section contribute to forwarding the roleof marketing as an integrator of integrated care and formulate some challenge issuesthat accompany that role.

Challenge 1: selfCentral to integrated care must be self, referring to the person at the centre of care – thepatient or the consumer of care services. Self encompasses more than asking patientconsent and preferences at the point-of-care delivery, but includes meaningfulrecognition of voice, choice, autonomy and accommodation of gradual changes in self-expression ability. In relation to the self, there is a clear, acknowledged need foridentifying shared priorities for governance and safeguarding patients in an integratedsystem of care. Yet therein lies the danger of overlooking or misunderstanding thevalues and perspectives of both the person in need of care and diversity within thewider society. Innovations fail if they do not take adequate account of human and socialissues. Policymakers, politicians and developers often base their thinking on peoplethey know and interest with (usually an educated subset of the population). Such designby professionals and policymakers for “People Like Us” disadvantages thosevulnerable groups most in need of support, who are inadequately understood and thuscomparatively disenfranchised and disconnected (Showell and Turner 2013, Dietrichet al., 2017). Identifying values and designing systems of care aligned to a person’svalues, competencies and resources will act as a catalyst for more readily anduniversally accepted and adopted systems. Harnessing the potential of technology(especially mobile) for integrated care must fully consider the ethical issues raised bythe use of technology as a solution. For vulnerable persons technology can be daunting,hence the need to evaluate consumer-facing technologies for their applicability forintegrated care and their ability to promote social inclusion (Keeling et al., 2018).

Marketing scholars have been actively building a strong knowledge base aboutconsumers and health and social care and such works as these and many others in the fieldcan make a significant contribution to designing systems of care that align with person

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values, competencies and resources and aid in the acceptance, adoption and engagementwith such systems (Table I). One of the key challenges with regard to self is making theconsumer’s voice heard right at the conception of care and care design. This is emphasisedby one of our practitioner commentators, Dr Áine Carroll. Ferguson (this issue) gives avery personal account and demonstrates how reflexive introspection can be effectivelyused, beyond its therapeutic benefits, to bring a deeper understanding of the meaning ofillness and treatments from a patient’s perspective. This is not only in terms of thedistinct meaning separate to professional understandings, but also the transformationof meaning across the course of illness and treatment and its impact on a patient’sagency. As Carroll (this issue) comments, exploring the power of such methodologies is

Table I.Examples of researchactivity in themarketing disciplinewithin challengeareas

Challenge area Themes Authors

Self Co-creation and co-production Anderson et al. (2018)Essén et al. (2016)McColl-Kennedy et al. (2017b)Sweeney et al. (2015)

Empowerment and engagement Keeling et al. (2018)Ouschan et al. (2000,2006)Seiders et al. (2015)

Emotions Gallan et al. (2013)McColl-Kennedy et al. (2017c)

Search, decision-making andprevention

Larson and Bock 2016Zainuddin et al. (2013)

Technology and (self) health-management

Erdem and Harrison-Walker (2006)Nieroda et al. (2015)Schuster et al. (2013)Tian et al. (2014)

Journey Tax et al. (2013)Society Economics and societal benefits Chan et al. (2015)

Dagger and Sweeney (2006)Capacity building El-Manstrly and Rosenbaum (2018)

Keeling et al. (2015,2018)Restorative servicescapes Rosenbaum and Smallwood (2011, 2013)

Micro systems Co-creation in ecosystems Dahl et al. (2018)Dietrich et al. (2017)Elg et al. (2012)Frow et al. (2016)Osei-Frimpong et al. (2015)Spanjol et al. (2015)

Roles, structures and relationships Danaher et al. (2008)Keeling et al. (2018)

Physician prescribing behavioursand decision-making

Chan et al. (2013)Nair et al. (2010)Stern and Wright (2016)

Macro systems Health Service Quality Dagger et al. (2007)Faulkner et al. (2017)

Role of Pharma Manchanda and Honka (2005)Stros and Lee (2015)Wieringa et al. (2014)

Technologisation of Service andService Design

Green et al. 2016Rosenbaum and Wong (2012)Rosenbaum et al. (2017)

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likely to inform practice and service design, not just by offering a patient perspective,but also by helping to define the voice that is present at different stages of the patientjourney. Ferguson (this issue) emphasises the importance of the personal ontologies ofhealth that develop (and change) across a journey. Hence, we can more clearlyunderstand patient choices (and those that they do not want to make), the level ofengagement they desire (if any) and the challenges they are facing that compete fortheir resources in the face of major life decisions. From an integrated care perspectivesuch understandings provide us with an understanding of the fluidity of the patientvoice and the flexibility in the constellations of care required for a truly patient-sensitive approach. This is not only applicable to the patient, but also the other, oftenneglected voice, that of the informal carer.

Ferguson’s article and its accompanying commentary serve as one example of thecontribution to be made by marketing to the realisation of integrated care. While translatingthe challenge of self into other pertinent issues for integrated care, we identify three keydevelopment areas for further research. Patient and carer perspectives within integratedcare are difficult to study, as they require a longitudinal perspective over a period of years,but a thorough understanding of the following three areas would inform and facilitatedevelopment of more effective models of patient-centred care:

(1) Understanding of how consumers (patients and carers) utilise self-service withinhealth and social care and how this disrupts and/or contributes to formal careprovision (with reference to the systems layers identified later). This aligns withthe need to adopt and further develop the concepts of participation, engagementand co-creation as theoretical underpinnings for adopting responsibility for self-management of care.

(2) Integrated care will entail consumers (patients, carers etc.) interacting withtechnology in some form. An urgent issue is to utilise marketing frameworks to aidin the development of assisted decision-making for vulnerable individuals. Thisgoes beyond facilitating consumer acceptance/adoption of and engagement withtechnologies as a means of delivering integrated care, to understanding whatconsumers need from such technologies and how these needs (mis)align with theintentions of use within the care system.

(3) A fundamental principle of integrated care is that the patient is at the centre ofcare – not the disease. As such, we should continue recent efforts to developunderstandings of patient and carer journeys with the person as the point ofreference and not the formal system. This includes a focus on not only interactionswithin formal health systems, although those remain key to access of care, but alsowhat occurs outside of these, which supports or thwarts the patient’s recoveryprocess. This is especially important in the case of very vulnerable consumers andtheir carers, who often lack a voice in society.

Challenge 2: societySociety should not just reclaim some of the non-technical responsibility for supporting thosewith frailty or chronic conditions who could be supported in their own homes, but shouldincreasingly provide a major resource, if it can be appropriately coordinated, to ensure safeand reliable support. Society recognises the cost of care beyond the individual, especially ofineffective or neglectful care. Health care puts one person, the patient, at the centre ofdelivery, whereas social care recognises the importance of the family and community

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setting. Integrated care demands recognition of the needs, competencies, resources and othercommitments (including other caring) of patient, family and informal carers. Informalcarers’ needs are an important focus as this is perhaps the most neglected group in terms ofresearch. The wider societal costs of care include: multiway interactions betweenprofessionals and lay persons/families and how to bridge these effectively, including e- andhealth-literacy; identifying what new types of training for persons, families andprofessionals are required to enable effective co-production within virtual care teams.Society can also offer those aspects of life which are not directly related to health or socialcare, but which nevertheless are known to be essential to a healthy and fulfilling life,including restorative green spaces, social activities, hobbies and interests, spiritual supportand facilitated transport to access these activities and health services.

Marketing can contribute to these issues, particularly around building capacity andhence resilient supportive communities both off- and on-line (Table I). Underpinningsuch efforts, however, is the need for effective communication across stakeholdergroups, emphasised by one of our practitioner commentators, Sonja Müller (this issue).Effective communication can be viewed as the ‘lubricant’ of collaboration. Marketinghas a rich history and hence much to offer in this area. In a direct application of thisexpertise, Orazi and Newton (this issue) demonstrate how marketing communicationtheory can be used to effectively increase receptiveness to health messaging byfocussing on the source of the communications. In particular, their work demonstratesthat there is an appetite amongst consumers of health care for co-created messages.That is, those messages that combine professional credibility and competency withconsumer validation are viewed as more authentic and hence more positively received.As Müller (this issue) emphasises, this work provides a foundation for going on toexplore further challenges, especially around the core issue of facilitating effectivecollaborations. It is a given that marketing theory can aid the transformation ofstakeholder communications and collaboration within integrated care. Specific areas toadvance are:

� At the heart of enabling integrated care policy is collaboration, even co-creation,and the effective integration and application of resources amongst diversestakeholders; not limited to patient-professional dyad but extending out to thelocal community and society. There are many challenges to developingcommunications that encourage interaction and contribution rather than simplyplaying an educational role. There is an urgent need to identify and put intopractice marketing communications theories that can inform the facilitation anddevelopment of a collaborative culture, emphasising inclusiveness, team-working and person-centredness, rather than the (often) prevailing paternalisticculture.

� Marketing theories and practice can and do make a large contribution to addressingissues in society. Particular, areas to address within the field of integrated care arethe reduction of stigmatisation around comorbidities, heightening awareness ofneglect and how to address neglect and identifying and tackling disenfranchisementwithin care.

� Building health and social care capital to facilitate resilient societies willcontinue to increase in importance. Formal integrated care delivery has fuzzyboundaries – practitioners are not the owners of health and social care, nor arethey the sole providers. There is a continuing struggle to effectively identify andsupport the large numbers of informal carers (children and adults) and

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communities that provide intensive care but receive little support themselves.Important areas to pursue are the quality of interaction between carers and theirloved ones and between carers and care teams, involvement in shared decision-making and care pathways, carer training and empowerment and innovativecare support structures.

Challenge 3: micro (person-level) systemsDesigning and delivering integrated care is demanding at the frontline. We should notunderestimate the impact of new terms of service delivery and fundamental changes in rolesacross the service areas. Innovations in communications that integrate professional and layperson support require new constellations of collaborative working. Challenging issuesinclude: linking ‘other individuals’ to the patient care plan; linking carers through remotee-links; aggregation of one informal carer’s multiple caring roles; and the formation andcoordination of virtual care teams. From table I we can see that marketing has already madeadvances in identifying and defining the various roles and relationships and competingneeds amongst stakeholders.

Focussing on the frontline, Taiminen, Saraniemi and Parkinson (this issue) directlyexplore physician attitudes to computerised Cognitive Behavioural Therapy (cCBT), adigital self-help service available to mental health patients. Whilst digital self-services maybe one way of addressing service efficiencies, improving accessibility and presentingpatients with more empowering options; Taiminen, Saraniemi and Parkinson rightly pointout that physicians, who may ‘prescribe’ such services to patients, are also consumers ofsuch services. Their study highlights the potential ethical issues raised through introductionof these services such as blurring physician accountabilities and the need to responsiblydelineate what the active role of the patient really means and requires. One of ourpractitioner commentators, Dr Rachel Davies (this issue), confirms that these conflictsemerge in everyday mental health practices. Davies finds the notion of physician as a ‘valueself-creation supervisor’, proposed within the article, useful as it focusses on thefacilitative role of the health-care professional and mirrors some observable shifts in currentpractice. She also identifies the role of training in supporting the development of this role forfuture practitioners.

The frontline of health and social care is not limited to easily identifiable groups norare the roles of those involved sharply defined or equally understood between groups.Integrated care delivery brings further fuzziness to issues of accountability,responsibility and decision-making. The following three areas are suggested for futureresearch:

(1) The renegotiation of roles and responsibilities of health-care professionals,carers and patients and all of those involved in integrated care needs to bedocumented. This would help identify the practical, social and cultural barriersand facilitators to collaboration at the frontline, and enable negotiation in multi-stakeholder projects around integrated care. There may be obvious divisions tobridge, such as those between formal care centres and community services(informal and formal), or less obvious divisions such as virtual care delivery(e.g., through online communities, such as PatientsLikeMe, or self-managementthrough mobile and digital applications and wearable technologies).

(2) Innovative approaches are needed to help build sustainable health and social caresystems. One valuable direction may be the application of marketing expertise tothe recruitment and retention of informal carers. Another direction is the design,

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implementation and utilisation of online service delivery to reach out tovulnerable communities. Yet another direction is evaluating the outcomes ofcurrent innovations in service delivery, such as group consultations for chronicpatients, and how such practices can inform sustainable integrated care deliverywith improved quality of life outcomes for patients and their families.

(3) Future research is needed to examine how frontline technology can instigate andenable learning and information exchange between patients, carers and careprofessionals. Marinova et al. (2017) identify a number of instances of howtechnology may substitute dyadic or triadic interactions between the key actors,such as health monitoring and sharing by mobile devices. In addition, thecomplementary role of technologies is discussed. As an example, AI-poweredvirtual agents are increasingly playing a role in mental health care, alongsidehealth-care professionals, and can even assist with the informational andemotional needs of clients. However, as shown by the recent shelving of Nadia, thevirtual Chabot with emotional intelligence who was to help clients navigate anational disability insurance scheme, some governments have low tolerance forrisk (Probyn, 2017). Future research should extrapolate how technologies are bestpositioned to support integrated care functions, thereby presenting a clearevidence base for sound investment.

Challenge 4: macro (service-level) systemsThe Macro Systems are complex, involving health, social care, welfare, housing and othersocial systems, and information and informatics systems. Much of the current research andinnovation is focussed on system silos divorced from the people systems. Policy systems areincreasingly the trigger, and often the impediment, to truly innovative integration, giving aconcomitant need for policy to be evidence-based with a stable longer-term horizon.Applying an integrated research lens is essential to issues of how individual care, inpersonalised packages, can be made seamless and systematised to ensure effective delivery,harnessing heterogeneous resources. New approaches to understanding the setting of policyacross boundaries; shared ICT ‘ownership’; quality assurance; incentives, rewards andcontrols; governance; and equity, will be needed.

Cruz, Snuggs and Tsarenko (this issue) effectively demonstrate the fragility ofintegrating service systems. Focussing on the underlying social dynamics, they identify thatempowering consumers at one level of the system, that is, the individual level, can facilitatefragmentation at another level, that is, the service system level. The labyrinth metaphor thatthey advance helps stakeholders in integrated care to effectively identify and understand theinteractions and tensions that can lead to the fracturing of these services; thereby mitigatingthese in designing, delivering and being a part of integrated care services. Marilène Dols(this issue), one of our practitioner commentators, develops these ideas further by pointingout the additional complexities (and therefore opportunities for further fragmentation) thatare introduced when patients feel empowered to choose complementary and alternativecures (CAC) as part of their care pathway. Dols (this issue) emphasises the need forprofessionals to acknowledge such patient choices as an integral part of empoweringpatients in their care.

Strategic marketing management plays an important role in devising new models ofintegrated care that effectively combine informal and formal collectives and organisations.Fruitful directions include:

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� Exploring competition and co-opetition strategies in health and social care thatcould bring an innovative approach to integrated care design and delivery whencombined with learnings from marketing that inform ethical practice in integratedcare.

� Using stewardship to inform models of integrated care around issues ofaccountability, responsibility and sustainability of health and social care. As well asthe role that health marketing theory could play in resolving common issues withpolypharmacy at a professional, patient and carer level.

� Understanding smarter health as a means of delivering person-centred delivery,including issues around electronic health records, e-health and advances in AI.

ConclusionThis special section is a call for a deeper, more mature and reflective interactionbetween marketing researchers and health-care system researchers to actively seek outopportunities for multidisciplinary collaborations that work towards addressing thefour big challenges identified here. Mutual misconceptions may initially hinder this.Within health care, marketing may be seen as primarily associated with the revenuemaximisation activities of the pharmaceutical industry and private hospitals, togetherwith some recognition of social marketing for public service messages. Indeed, public-and insurance-funded services do not want to increase market share as they are alreadyover-loaded. Marketing scientists may hitherto not be fully aware of the consumer andtransactional issues so vital within integrated care delivery. But an opening of minds tomutual interests and opportunities, as envisaged by this issue, should be mutuallystimulating and beneficial, and hence contribute to developing effective integrated care.We believe that marketing as a discipline has great potential to play a pivotal role inmultidisciplinary teams working on this important issue. Integrated care is aboutpeople and their needs for multiple health and allied services, and should transitionaway from inflexible product delivery – a transformation where marketing has much tooffer. The articles and commentaries in this special section demonstrate how theoryand methods can contribute to solution development as well as stimulate debate andcreativity amongst professionals working in other disciplines. We know that there aremany challenges to working across disciplines, not least issues around diverseterminologies, methods and accepted practices. But we see these as catalysts, and byaddressing these differences across disciplines we directly work towards solutions thatare based on integrated rather than parallel care systems.

Thank youThis special section would not have come about without the efforts and support ofmany, to whom we extend very grateful thanks. To the authors, we appreciate yousubmitting your works and, more especially, for your efforts in branching out into newfields of multidisciplinary research that promise such high practical impact as well aspushing the boundaries of conceptualisation beyond specific disciplines. To thereviewers, we thank you for contributing to the development of the papers published inthis special section, and also for guiding the authors of those papers that did not make itthrough to publication, but showed great promise for the future. To the practitioners fortaking the time out of their busy schedules to consider the value of the academic workpublished here. We thank you for your conversations, both the commentaries published

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here, and also for those that extended beyond – it was particularly rewarding to learnabout the value that we from the marketing discipline can add to the pursuit ofintegrated care. We thank the Editorial and Publisher Teams for making spaceallowing us to open up a dialogue between disciplines and between academia andpractice – in line with the true spirit of the Integrated Care journey. Finally, to thereaders, we hope that you enjoy the special section articles and commentaries and thatthey inspire you to take up the challenges that we detail here to push knowledge andpractice in the multidisciplinary field of integrated care.

Debbie Isobel KeelingUniversity of Sussex Business School, University of Sussex, Brighton, UK

Michael RigbyKeele University, Keele, UK

Ko de RuyterKing’s College Business School, London UK and UNSW Australia Business School,

Kensington, AustraliaLiliana L. Bove

Department of Management and Marketing, University of Melbourne,Melbourne, Australia, and

Philip SternUniversity of Exeter Business School and Ehrenberg-Bass Institute for Marketing

Science, University of South Australia, AustraliaEmail p.stern@exeter.ac.uk

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Frow, P., McColl-Kennedy, J.R. and Payne, A. (2016), “Co-creation practices: Their role in shaping ahealth care ecosystem”, Industrial MarketingManagement, Vol. 56, pp. 24-39.

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Green, T., Hartley, N. and Gillespie, N. (2016), “Service provider’s experiences of service separation”,The Case of Telehealth”, Journal of Service Research, Vol. 19 No. 4, pp. 477-494.

Keeling, D.I., Laing, A. and de Ruyter, K. (2018), “Evolving roles and structures of triadic engagementin healthcare”, Journal of Service Management, Vol. 29 No. 3, pp. 352-377.

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World Health Organisation Regional Office for Europe (2016), “Strengthening people-centred healthsystems in the WHO european region: framework for action on integrated health servicesdelivery”, WHO, Copenhagen, available at: www.euro.who.int/__data/assets/pdf_file/0004/315787/66wd15e_FFA_IHSD_160535.pdf?ua=1

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Further readingFaulkner, M., Romanuik, J. and Stern, P. (2016), “New versus frequent donors: exploring the behaviour

of the most desirable donors”,AustralasianMarketing Journal, Vol. 24 No. 3, pp. 198-204.McColl-Kennedy, J.R., Vargo, S.L., Dagger, T.S., Sweeney, J.C. and Kasteren, Y.V. (2012), “Health care

customer value cocreation practice styles”, Journal of Service Research, Vol. 15 No. 4, pp. 370-389.

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“I just don’t feel like myselfanymore”: putting the patient’s

voice into integrated careShelagh Ferguson

University of Otago, Dunedin, New Zealand

AbstractPurpose – This paper aims to elucidate health-related transformations experienced by an individual.Building from personal experience offers an understanding of the relational dynamics at play within healthtransformations, which makes a contribution to realising and facilitating the agency of the patient in systemsof integrated care.Design/methodology/approach – Introspection can be used as a methodology to elucidate messy andpersonal affective experiences. The author’s introspection is an 18-month catalogue and analysis fromdiagnosis of breast cancer through significant stages of rehabilitation. Reflexive introspection has gainedtraction in health research due to its cathartic benefits, whilst this approach offers much; a key challengefor integrated care is translating deeply personal and subjective introspections into strategic-levelapplication.Findings – Using Turner’s (1969) concept of liminality, this research explicates key relational dynamics ofhealth-related transformations experienced by an individual. By recognising changes in affective being as apivotal point in rehabilitation, this work links embodied transformation as a critical antecedent to a patient’swillingness to engage his/her agency in their rehabilitation.Originality/value –Whilst recognising that integrated care is patient-centred and seeks to incorporate thepatient’s voice, this research gives insight into how the author, as a patient, engaged her agency in herrehabilitation through building her own transformed personal ontologies of health.

Keywords Transformation, Introspection, Breast cancer, Integrated care, Patient’s voice

Paper type Research paper

Whilst the integration of health care, social care and other related services hasbecome a universally accepted and pursued strategy in contemporary healthcaresystems, the realisation of such a goal has been problematic (World HealthOrganisation, 2016). At the heart of this strategic aim is patient-centred care (Osbornet al., 2014; World Health Organisation, 2015); however, focussing on the needs of thepatient does not necessarily give voice or attribute agency to the patient. Agency isthe capacity of individuals to act independently and make choices, constrained byfactors such as education, social class, religion, gender, ethnicity ability and/orcustoms (Barker, 2005, p. 448), and has been identified as conducive to patients’ self-management and effective rehabilitation (Hunter et al., 2015). Facilitating patientagency requires a focus on reflexive empowerment which is not necessarily presumedin models of patient-centred care.

The patient’s transformative experience of being ill can evade easy generalisation,articulation, description or representation. More recent WHO initiatives seek to engagepatients as stakeholders into such systems (Ferrer, 2015). This continues to be problematicas patients often lack expert knowledge and may not be willing or able to translate theirtransformative experience of illness into a contribution to their care. This research seeks to

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Received 29 December 2016Revised 11 July 2017

15 August 201721 August 201726 October 2017

Accepted 19 June 2018

European Journal of MarketingVol. 52 No. 11, 2018

pp. 2207-2213© EmeraldPublishingLimited

0309-0566DOI 10.1108/EJM-12-2016-0825

The current issue and full text archive of this journal is available on Emerald Insight at:www.emeraldinsight.com/0309-0566.htm

elucidate some key relational dynamics of health-related transformations experienced by theindividual through the lens of Turner’s (1969) sociology-based concept of liminality. Turner(1969, p. 95) defines liminality as the state of individuals who “are neither here nor there”;they are betwixt and between the positions assigned and arranged by law, custom,convention and ceremonial. Building from personal experience provides a particularperspective that makes a contribution to facilitating the agency of the patient in systems ofintegrated care.

Turner’s (1969) concept of liminality has been used in a wide range of disciplines includingnumerous applications within health research, yet none link a personal understanding ofpatient transformation as a contribution to improving integrated care. As a consumerresearcher, I am familiar with liminality as a theoretical lens to understand consumption-related phenomena exploring life transitions at an individual level (Hogg et al., 2003;McAlexander et al., 2014; Schouten, 1991). This body of research has theorised well theindividual processes of transformation and drawn conclusions that have implications at astrategic level. Thus, I draw upon it to focus on the processes of how I moved through a breastcancer transformation; what were the dynamics that enabled me to enact my agency; and whatare the essentialised implications for integrated care.

I found several aspects of Turner’s (1969) framework useful for structuring precipitoustransformations, his three-stage liminal process; separation, marginal and reaggregation,resonated to some degree. His emphasis upon the sudden foregrounding of agency (or lackthereof) and the sometimes dramatic tying together of thought and experience offered somelegitimisation in my post-diagnosis confusion. His emphasis upon a period of scrutiny forcentral values and axioms, where normal limits to thought, self-understanding and behaviourare undone, encouraged me towards approaches of introspection, as did his call for greatersubjectivity and reflexivity.

Research approach and methodologyWhen the epistemology of the phenomenon under investigation is messy, confused anddeeply personal, the research approach and methodology must capture and make sense ofsuch richness. Whilst investigating the patient’s lived experience is not common, medicalsociology has largely relied on anthropological approaches to address such researchtopics (Buch, 2015; Mol, 2008), particularly when the issues of patient autonomy, socialequality and power relations are considered in specific contexts of care or in entiremedical systems (Kaufman, 1988). Introspection is a well-accepted anthropological socialscience methodology used in health research (Liggins et al., 2013; Uotinen, 2011). As such,it is viewed as radically different from the dominant positivist paradigm of medicalresearch. As a methodology, it can be characterised by the explicit and reflexivepositioning of the author within the text, the use of biographical material as socialresearch data and a subjective, first-person tone in writing. Rigour is ensured bysystematic examination using a hermeneutic and iterative approach of all introspectionsthroughout the process and critical reflexive peer analysis with another cancer patientintrospector (Doane, 2008). Whilst integrating the patient’s voice into health research isimportant (Ellingson, 2006), the potential of this technique to add depth and insight topatient experience has largely lacked traction in some of the more positivist medicaljournals (Lorde, 1980, as an exception). A key challenge for integrated care is translatingdeeply personal and subjective introspections into strategic-level application; hence byfocussing on key relational dynamics framed by literature-based individual-leveltransformational process, I seek to make such a contribution.

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Health-based introspection can also have a significant cathartic impact, as Frank’s (1995)work on wounded storytellers powerfully argues. This was the starting point for myintrospection; by writing about my experience of being ill, I expected transformation but wasunsure of the form, type or duration. I hoped it would be cathartic and a means to manageand order my uncertainty and confusion. With Frank (1995) as my companion, I deliberatelytried to sensitise myself to alternative understandings. My reflexive account includes events,memories and understanding crafted to link my unique properties into an 18-month-longaccount commencing with diagnosis, an experience account from within (Pred, 2005). Whilstrecognising and retaining some of the existing sense-making categories of ill health, such as alinear path from diagnosis to recovery, I used introspection to re-examine such presumptions.Through this re-examination process, existing conceptualisations and details of life, that areseldom valued, quickly forgotten or that remain uncaptured altogether by traditionalresearch methods, can be re-presented (Lyotard, 2003). In summary, the following accountoffers insights gained frommy personal introspection made accessible for others, concludingwith practical applications to integrated care.

Reconfiguring liminality for integrated careI have known from the age of 11 (when my mother was diagnosed) that I was likely todevelop breast cancer so I was not surprised at my diagnosis. My initial response to a doublemastectomy and reconstruction subsequent to that diagnosis was I would move from onestate of health to another. For example, having breast cancer to not having breast cancer;having long-familiar breasts to having reconstructions that sometimes remind me ofdumplings in soup (floating very buoyantly on the front of my body); and from being veryclear about who I thought I was in terms of my feminine identity to reconciling previousculturally anchored attitudes related to “fake boobs”. My initial framing of cancer asdichotomous was useful in its simplicity during early stages of illness, and transferringbetween themwould be a liminal state as described by Turner (1967).

Many things in my transformation surprised me, not least the emotional reattachmentto my mother and cathartic reconciliation with my inherited genetic predisposition. In theintervening 35 years between my mother’s breast cancer diagnosis and my own, medicalresearch would appear to have redefined the experience, from pre-emptive screeningbased upon genetic predisposition to early diagnosis. However, my prevailing reflectionupon my inherited health is warmth towards my mother. I now know intimately muchmore about her journey and what it may have felt like for her. My mother was diagnosedwith breast cancer at the very young age of 37. I was 11 at the time, and my dominantmemory of my mother during my teenage years was watching the health servicesunsuccessfully chase cancer around her body as her world was increasingly limited bythe disease. From the perspective of a rather moody teenager, I felt anger, grief, loss andfear at her removal from my life and awareness that genetically I was stronglypredisposed to the same illness. I cannot recall her ever talking about what cancer feltlike. Never one for self-pity or introspection; she trained us all to cook and clean to anacceptable (her) level. The mortgage was paid off to ensure stability for the family andencouragement was unstintingly given to “get on with things”. At no point can I actuallyrecall any discussions of any affective elements of her experience.

I remember my mother as sharp as a tack, pragmatic, analytical and insightful. Iaspirationally hope that I have some of her qualities. I apparently look incredibly similar. Byher absence from my life, I am afforded the freedom to create narratives to fill variousemotional needs, but sharing the illness of breast cancer has a tangibility that thesecreations could never emulate. Irrespective of our differing subjective positions, I feel

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symmetry and affective closeness to her through our shared genetic weakness. Adding acertain poignancy and uniqueness to our bond, at present, I am the only family member tohave been diagnosed with breast cancer followingMum’s death.

Beyond this surprising outcome, my introspection centres upon the simplistic duality oftransformation morphed over time into a two-stage process defined by my will to exerciseagency. Thus, I have organised the remainder of this introspection into two distinct dynamicprocesses of normalisation negotiations based around positivistic data and embodyingtransformation (very much a form of Turner’s (1969) reaggregation).

Normalisation negotiationsThe medical necessity of surgery on cancer (and many other conditions) seems to meanthat the first step of health transitions requires a move from the known but most possiblyfatal to the unknowable and is driven by fear of dying and striving to live. Myintrospection records exactly that, a fast and largely fear-driven process of moving awayfrom having breast cancer, fundamentally removing most of my self-determination fromthe process. At this stage, I was certainly following established ontologies of health andillness at a visceral level. I did not know what they were or what I was doing, justfollowing the path in front of me designed by the hospital-based health modalities. Did Ifeel I had agency? I am not sure I even wanted agency at this stage. The researcher in merecognised that the ontological status of many aspects of medical knowledge is driven bypositivistic approaches and statistical results. Degrees of variance and significance areoften the parameters of illness and recovery. From a patient’s perspective at a time ofuncertainty, this was hugely reassuring; when diagnosed, I considered the statistic thatgiven my family history: I had a 50-70 per cent chance of the cancer returning if I had alumpectomy. This framed a very clear choice for my double mastectomy. I was relievedand reassured that such unambiguous statistics were available to me.

The process of normalisation negotiations, utilising medical data and statistics as abasis, is incredibly comforting during the pre-operative and fearful stages of transformation(diagnosis, operation/treatment and immediately post-operative were the times when Iactively wanted the reassurance of hard data). By surrendering my agency, I was able toaccept them as giving hope and confidence, which are pre-requisites to moving forward.However, ultimately using medical data and statistics became an inhibitor to movingbeyond fear. The bridge between the two processes was linked to affective experience forme. I became aware of this when trying to re-inhabit my body again during rehabilitation,even if that embodiment was negative or recognition of disassociation, such as “I feel reallyremoved from my body”. Recognising an affective sense of being was a pivotal point for me.By normalising against data, I was not exercising my agency and consequently could notinhabit the “transformed self” and progress rehabilitation.

Embodying transformationWhen creating my critical introspection, I noted the difference in my agency between beingin a surgical modality and a rehabilitative one. At my post-operative out patients dischargeabout a month after the mastectomy, I asked the surgeon if these fake boobs would be coldor make me feel cold. I am a passionate mountaineer and backcountry skier; hence,ascertaining if this skin and silicon combination would have a lower temperature above thesnowline was important to me. He assured me that there would not be a discernibledifference. I discovered this to be very untrue for me in a somewhat disconnected manner.My boobs are cold, in many situations, not just above the snowline, but at night, I wake upand they are cold to touch. Similarly, when dressing or undressing, the rest of my body is,

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well, body temperature, but the reconstructions are much colder. As the nerves have notregrown, they are often cold to touch, but I do not feel it specifically, which is a very strangesensation. They are part of my body but not connected to it by sensation, in the way aperson would notice if their fingers were immersed in cold water. Hence, I often feel chilly ina non-specific manner.

A similar unexpected consequence is dramatically altered buoyancy. Perhaps thisshould have been obvious, but it was not to me or my family and friends who watched mesink for a very long way before I struggled back to the surface after launching myselfjoyfully from a boat into the sea. The uncomfortable silence that followed was comical aseach of us wondered if it was inappropriate to laugh uproarious at a clearly farcicalsituation. I needed a life jacket to swim the 50 m to the beach. These may seem small,insignificant events after surviving the illness that was fatal for my mother. I find thatdespite the passage of time, inhabiting my transformed self is still all encompassing, andthe comfort I found in medical statistics to shape my choices is little more than a distantmemory. Whilst the first part of transformation was largely predictable, the second partwas surprising and unknowable at the start. Negotiating cold noobies (as they arefamiliarly known, an affectionate portmanteau of new boobies) occupies me significantlymore than rehabilitating my arms, back and chest post-operatively, precisely because it isunknowable. I am simply making it up as I go along, hence the absorption. This will mostlikely continue indefinitely for me. I find I am truly caught between the sublime – havingless than 2 per cent breast tissue and clear histology, I am extremely unlikely to havebreast cancer again and the ridiculous – would 3D nipple tattoos be better than nipplereconstructions or maybe nothing is best? I have no idea and I shall make it up as I go.There is no plan.

Conclusions and implications for integrated healthcareIn conclusion, my contribution relates to my willingness to exercise my agency in differentintegrated care modalities, theorised by Turner’s two-stage transformation process. Whilst Iam not the first patient or health researcher to conclude that rehabilitation is more effectivelyachieved when patients exercise their agency, my contribution is the connection between thetwo parts of the process based on becoming sensitised to affective elements. It was at thispoint that I started to grow my transformed personal ontologies of health. Mine involvedmountains, sinking and emotional connection with my mother. Others such as Hollenbeckand Patrick (2016) and Parsons et al. (2008) found new health ontologies based on mastery ofbeating cancer and resuming paid employment. Neither of these was significant for me,reiterating the personal nature of transformation. Therefore, the challenge for systems ofintegrated care is giving voice and space to patients to exercise their agency by supplyingempathetic and empowering provision attuned to affective awakenings in rehabilitatingpatients, including tools such as introspection and effective questioning techniques. I chargehealth-care providers to consider how rehabilitative modalities of integrated care can attendto the affective cues that I have detailed in my introspection. The relational dynamicsbetween affective cues and willingness to exercise agency are casually linked. Empoweredpatient agency is consequent to developing affective sensibilities; however, these maymanifest, thus illustrating the complexity and conflicts of what would constitute activepatient-centred care.

A final word relates to my ability to carry and reconcile contradictions going forward. Ifind it perfectly possible to have fake boobs that are of my body yet completely foreign andridiculous concurrently. To carry such a contradiction may seem destined to delay

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rehabilitative progress towards new identities, but I feel it every day until the memory of thereal fades away, replaced by the unreal.

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Corresponding authorShelagh Ferguson can be contacted at: shelagh.ferguson@otago.ac.nz

For instructions on how to order reprints of this article, please visit our website:www.emeraldgrouppublishing.com/licensing/reprints.htmOr contact us for further details: permissions@emeraldinsight.com

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PRACTITIONER COMMENTARY

“I just don’t feel like myselfanymore”: putting the patient’s

voice into integrated care

Integrated care has long been the holy grail of health and social care. Yet it is as elusive as themythical receptacle in terms of a universally accepted definition and delivery model. However,even though academics clinicians and managers may argue for their particular vision ofintegrated care, one thing is universally held true, that the realisation of integrated care mustresult in better outcomes and experience of health services for the individuals who use them. Itis also almost unanimously accepted that the design and delivery of services must have thevoice of the user at its core. Individuals using our health services should feel that they are seenas individuals and that the delivery of services recognises and strives to meet their needs, andis coordinated around them. But, dear readers, how best to give primacy to the voice of the userin integrated care service delivery and design – therein lies another elusive challenge. As aclinician with responsibility for the design of integrated care programmes, who has promised todo just that in the design of our integrated care programmes in Ireland, how best to do itremains as elusive to me as that legendary aforementioned vessel. We realise that we need touse multiple methods to capture the patient voice in a meaningful way and we have exploreddifferent quantitative and qualitative methods including surveys, narratives, stories andsensemaking technologies. So I read this paper with great interest and it has openedmy eyes toa whole new area of research, health-based introspection. I must confess that this was acompletely new field for me, and although I initially struggled with the terminology, after someremedial reading, I found myself immersed in a powerful scientific exploration of an incrediblypersonal journey. I was moved by the account and throughout found areas for improvement asa clinician, patient and for service design and delivery. I am grateful to the author forintroducing me to a new area of social science to which I have previously been blind. My eyeshave now been opened and I have a curiosity to understand more about this methodology, as Ican see it as a powerful tool that can contribute at macro, meso and micro levels. Whilst I knownot all patients will wish to or have the skills to perform this type of research, I have begun torealise the important role of qualitative social research methodologies in the pursuit ofintegrated care and its relevance and worth to a wide range of stakeholders and users ofresearch. Yet it is a new field to many involved in integrated care. The challenge for socialscientists and clinicians like me is how do we co-create relevant, worthwhile research thatcontributes to our shared goal of integrated care? I believe that integrating quantitative andqualitative research methods will lend depth and clarity to integrated care in a way that issynergistic andmost importantly, gives the voice of the people we serve primacy.

Aine CarrollUniversity College, Dublin, Ireland

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European Journal of MarketingVol. 52 No. 11, 2018p. 2214© Emerald PublishingLimited0309-0566DOI 10.1108/EJM-11-2018-895

Collaborative authenticityHow stakeholder-based source effects influence

message evaluations in integrated careDavide Christian Orazi and Fiona Joy Newton

Department of Marketing, Monash University, Melbourne, Australia

AbstractPurpose – Effective communication of information is central to integrated care systems (ICS), particularlybetween providers and care-consumers. Drawing on communication theory, this paper aims to investigatewhether andwhy source effects increase positive evaluations of health-relatedmessages among care-consumers.Design/methodology/approach – A preliminary online survey (N = 525) establishes the discriminantvalidity of the measures used in the main experimental study. The main study (N = 116) examines whetheridentical messages disclosed to be created by different sources (i.e. institutional, care-consumer, collaborative)lead to different message evaluations, and whether source credibility and similarity, and messageauthenticity, explain this process.Findings – In comparison to any other source, messages disclosed to be co-created are evaluated morepositively by care-consumers. This effect occurs through a parallel serial mediation carried over byperceptions of source credibility and source similarity (parallel, first serial-level mediators) and messageauthenticity (second serial-level mediator).Practical implications – The findings offer guidelines for leveraging source effects in ICScommunication strategies, signaling how collaborative message sources increase the favorableness of healthmessage evaluations.Originality/value – This research demonstrates the efficacy of drawing onmarketing communication theoryto build ICS communication capacity by showing how re-configuring the declared source of informationalcontent can increase positive evaluations of health-related messages. In so doing, this research extends existingliterature onmessage authenticity by demonstrating its key underlying role in affectingmessage evaluations.

Keywords Authenticity, User-generated content, Integrated care systems,Multicategorical parallel serial mediation, Source effects

Paper type Research paper

IntroductionThe increasing prevalence of individuals with comorbidities, an aging population, and theneed to maximize care efficiencies have combined to drive the implementation of integratedcare systems (ICS) within many developed countries (Desmedt et al., 2016; Morley et al.,2017; Shaw et al., 2011). Although definitions vary (Armitage et al., 2009), ICS are designedto “impose the patient perspective as the organizing principle of service delivery” (Lloyd andWait, 2005, p. 7) to increase care coordination and improve the care experience, outcomesand well-being of care-consumers (Martínez-González et al., 2014; Shaw et al., 2011; Valentijnet al., 2013).

Communication plays a pivotal role within ICS by ensuring care-consumers have theinformation needed to become involved and informed decision makers (Koh and Rudd, 2015;Mitchell et al., 2015; von Thiele Schwarz, 2016). This is critical, as feeling informed andinvolved in one’s treatment facilitates decision-making (Street et al., 2009). Moreover, theinformation communicated to care-consumers can influence their care experience and actualhealth behaviors (Hill and Sofra, 2018). For example, failure to adequately communicate the

Collaborativeauthenticity

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Received 31 October 2016Revised 16May 2017

16 August 201722 November 201714 December 2017

Accepted 19 June 2018

European Journal of MarketingVol. 52 No. 11, 2018

pp. 2215-2231© EmeraldPublishingLimited

0309-0566DOI 10.1108/EJM-10-2016-0610

The current issue and full text archive of this journal is available on Emerald Insight at:www.emeraldinsight.com/0309-0566.htm

risk of breast cancer reoccurrence can lead to a range of suboptimal health and behavioraloutcomes for women with this disease (Janz et al., 2017).

When communicating with care-consumers, however, providers tend to treat them asrational beings (Bekker et al., 2003; Fotaki, 2014), overlooking the power of heuristics insense-making and judgment formation (Brown et al., 2017; Gigerenzer and Gaissmaier, 2011;Payne et al., 1991). Indeed, care-consumers do not just rely on message content but ratherexamine the message source (Rains and Ruppel, 2016) to form attributions of credibility(Hovland and Weiss, 1951; Kelley, 1967; Petty et al., 1981) and similarity (Chaiken, 1987),which they use to inform their message evaluations (Martín-Santana et al., 2018;Pornpitakpan, 2004; Wilson and Sherrell, 1993). Positive message evaluations, in turn, arerelevant to ICS, as they lead to a higher likelihood of message receptivity, behavioralintentions and treatment compliance (MacKenzie et al., 1986; Martín-Santana et al., 2018;Mehta, 2000). Consequently, identifying ways to maximize the influence of source effects onmessage receptivity may encourage a better understanding and collaboration between care-consumers and ICS providers (Davis et al., 2005; Jordan et al., 2008). For instance, if thesource of a treatment compliance message resonates with care-consumers, then they may bemore willing to heed the message content and reap the benefits of being able to make betterinformed decisions.

Drawing on marketing communications theory, one potential strategy to achieve suchoutcomes is to convey the principle of consumer involvement at the message source level. Priorresearch on user-generated communications shows consumer evaluations of identical messagesdiffer based on whether the disclosed source is a corporate organization, a consumer or acollaboration between the two (Lawrence et al., 2013; Orazi et al., 2016; Thompson andMalaviya, 2013). As prior research has only performed binary comparisons in a commercialcontext, it is unclear whether or why one of the three source disclosure types (institution vscare-consumer vs collaborative) will lead tomore positive message evaluations.

This research thus investigates whether, and why, evaluations of an identical messagewill differ based on the disclosed source being:

� an institutional provider;� a care-consumer; or� a collaboration between the two.

We contend collaborative sources will lead to more positive message evaluations comparedto the alternatives, as they combine both institution-driven credibility and consumer-drivensimilarity. Credibility and similarity, in turn, are expected to enhance perceptions ofmessage authenticity, namely, the feeling that the message is realistic and genuine (Ertimurand Gilly, 2012; Stern, 1994). We test this contention in an experimental study in which wefind that collaborative sources lead to more positive message evaluations first throughattributions of source credibility and similarity, and second through attributions of messageauthenticity.

Our findings contribute to marketing and communication theory while also offeringnovel communication strategies for integrated care providers. From a theoreticalperspective, testing a full taxonomy of source disclosure allows us to extend the literature onsource effects and user-generated communications while also examining the underlyingprocesses (Orazi et al., 2016; Thompson and Malaviya, 2013). In demonstrating thatattributions of source credibility and similarity are distinct from, and positively correlatedto, attributions of message authenticity, we also add to the literature on messageauthenticity (Chalmers, 2007; Ertimur and Gilly, 2012). From an applied perspective,

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knowing which type of source disclosure will maximize favorable evaluations of messagecontent has utility for ICS seeking to influence both care-consumers’ receptivity towardhealth-related information and their acceptance of procedural changes to the provision ofintegrated care. Take, for example, the UK’s move to fully integrate health and social(community level) care by 2020 (Morse, 2017). Using collaborative sources to conveyinformation about progress toward this goal may help build receptiveness to the anticipatedbenefits and the challenges involved in achieving it.

Conceptual and hypotheses developmentStakeholder-based source effects: credibility and similarityWhen evaluating a message, receivers use the message source as a heuristic cue to informtheir evaluations (Gigerenzer and Gaissmaier, 2011; Payne et al., 1991; Rains and Ruppel,2016). The message source, in turn, should be reflective of the involvement of allstakeholders in the topical issue (Orazi et al., 2017). If we imagine an ICS context in which thekey stakeholders involved in the communication process are institutional providers andcare-consumers, the possible message sources (or combination thereof) are:

� institutional providers;� care-consumers; and� institutional providers collaborating with care-consumers.

Each of these sources will trigger corresponding source effects. Source effects are bestexplained through attribution theory, which posits people make sense of the world byascribing traits to, and establishing relationships between, the objects surrounding them(Fiske and Taylor, 1991; Kelley, 1967), particularly in provider-patient contexts (Bsharat andDrach-Zahavy, 2017). In evaluating a message, individuals typically draw on theirinferences about the source’s credibility and similarity (Wilson and Sherrell, 1993).

Perceptions of credibility refer to the assessment of the source’s perceived expertise andtrustworthiness (Hovland et al., 1953; Pornpitakpan, 2004). Expertise emanates fromexpectations that the source is knowledgeable and authoritative on the topic, whereastrustworthiness stems from perceptions of integrity and sincerity (Ohanian, 1990). In an erain which health information is commonly available viaWeb sources, individuals are attunedto assessing the credibility of information they receive (Sillence et al., 2007; Synnot et al.,2016; Wathen and Burkell, 2002). This propensity has direct relevance for ICS and providers,as research suggests perceptions of source credibility facilitate opinion and attitude change(McGinnies and Ward, 1980; Pornpitakpan, 2004) and enhance behavioral compliance in arange of health contexts (Byrne et al., 2012; Levine et al., 1978; Major and Coleman, 2013).Although some individual studies suggest laypeople can be perceived as being morecredible than professionals in certain situations (Kareklas et al., 2015), such as when layexperiences are sought (Hu and Sundar, 2010), a recent meta-analysis of health informationcredibility supports the notion that experts are typically perceived as more credible thanlaypersons (Yang and Beatty, 2016). This finding aligns with the notion that authority orreputational heuristics influence evaluations of health information (Flanagin and Metzger,2013). We thus contend institutional sources (i.e. public institutions or private accreditedorganizations), either in isolation or in collaboration with care-consumers, will be more likelyto be perceived as possessing topical expertise and willing to disclose truthful information tocare-consumers. That is:

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H1. Perceptions of credibility will be higher for messages disclosed to be created by (a)an institution only or (b) an institution and care-consumer collaboratively, incomparison to messages disclosed to be created solely by a care-consumer.

Individuals also use attributions of similarity with the message source to inform theirmessage evaluations (Andsager et al., 2006; Hilmert et al., 2006; Wilson and Sherrell, 1993).Attributions of similarity reflect the expectation that the source shares ideological oridentity characteristics with the message recipient, such as interests, beliefs and experiences(Ohanian, 1990; Turner, 1991). Accordingly, messages delivered by sources perceived to bemore (vs less) similar return more (vs less) positive message evaluations, as individuals aremore likely to identify with (and thus like) sources similar to themselves (Andsager et al.,2006; Thompson andMalaviya, 2013).

Denoting that a message has been developed by consumers may also enhanceperceptions of similarity (Thompson and Malaviya, 2013), as evidenced by the use ofconsumer-generated advertising within the commercial marketing sector (Ertimur andGilly, 2012; Lawrence et al., 2013; Thompson and Malaviya, 2013). Disclosing care-consumers as message sources represents a novel and germane messaging tactic within ICSand warrants further investigation to clarify prior conflicting findings including positive(Thompson and Malaviya, 2013), negative (Steyn et al., 2011) and non-significant effects(Lawrence et al., 2013). From an ICS perspective, source similarity taps into the theme ofpatient-centeredness (Lloyd andWait, 2005) and may help foster a sense of kinship betweenproviders and care-consumers. After all, a care-consumer source is likely to evokeperceptions of similarity by virtue of sharing not only a common health-related need for theservice but also care experiences and the assumption of a deeper understanding andsensitivity to the issues addressed by the message. Given identification increases when aportrayal mirrors one’s own experiences (Andsager et al., 2006), care-consumers are likely toidentify more with a source that includes a fellow care-consumer (either in isolation or incollaboration with an institution) than with an institutional entity alone. As such:

H2. Perceptions of similarity will be higher for messages disclosed to be created by (a) acare-consumer only or (b) an institution and care-consumer collaboratively, incomparison to messages disclosed to be created solely by an institution.

Stakeholder-based source effects: authenticityBeyond source credibility and source similarity, qualitative research suggests sourcedisclosure may also influence perceptions of message authenticity (Chalmers, 2007; Ertimurand Gilly, 2012). In general terms, authenticity defines the “illusion of the reality of ordinarylife in reference to a [. . .] situation” (Stern, 1994, p. 388). Although most marketing researchhas focused on perceptions of authenticity in reference to products and brands, and theirrelationship with their heritage and values (e.g. Trappist beers in Beverland et al., 2008),authenticity can also be used to describe how real or genuine something is (Grayson andMartinec, 2004). The few studies specifically examining the authenticity of message contenthave tended to use “authenticity and credibility almost interchangeably” (Ertimur and Gilly,2012, p. 126). This conflation is problematic when discussing the potential relationshipbetween these two constructs, as the extent to which a source is perceived to be expert andtrustworthy (i.e. credible) is different from the assessment that the overall object of thecommunication symbolizes a realistic and genuine scenario (i.e. is authentic).

Drawing on Grayson andMartinec (2004) and Stern (1994), we address this distinction byoperationalizing perceived message authenticity as the subjective assessment that the

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situations and issues depicted within an ICS message are realistic and genuine. Givenperceptions of message authenticity are predicated on subjective appraisals of realism andgenuineness (Chalmers, 2007; Ertimur and Gilly, 2012), some disclosed sources are likely toevoke authenticity more than others. For example, messages co-developed by a hospitaldietician and a diabetic patient emphasizing the centrality of healthy eating in themanagement of diabetes may beperceived more authentic than those developed solely by ahospital dietician or a care-consumer. We have already postulated that collaborative sourcesengender higher source credibility relative to care-consumer sources (H1), and higher sourcesimilarity relative to institutional sources (H2). In line with our contention that collaborativesources provide a richer set of cues for recipients to self-reference and draw upon whenevaluating a message, we expect that:

H3. Perceptions of message authenticity will be higher for collaborative sources thanfor both institutional and care-consumer sources.

Processes underpinning the effect of source disclosure on message evaluationsIn explicating the mechanisms underpinning the relationship between source disclosure andmessage evaluations, prior research indicates both source credibility and similarity canpositively influence message evaluations (Liao and Ma, 2009; Thompson and Malaviya, 2013;Wilson and Sherrell, 1993). We thus expect knowing a message has been collaborativelycreated by an integrated care provider and one or more fellow care-consumers will engendermore positive message evaluations by virtue of institutional-driven credibility and consumer-driven similarity. Furthermore, we posit that the effect of source disclosure on messageevaluations will be serially mediated by authenticity, as perceptions of source similarity andcredibility both contribute to develop the “illusion” of the reality of ordinary life, which isfoundational to the original operationalization of authenticity (Stern, 1994). After all, inferringthat a source is credible is likely to strengthen perceptions that the information conveyed by themessage is realistic and accurate. Equally, the heightened sense of similarity that arises when amessage recipient self-references the source can enhance the genuineness of the message(Ertimur and Gilly, 2012). We thus anticipate that collaborative sources will lead to morepositive message evaluations through a serial mediation passing first from credibility andsimilarity, and then from authenticity. In sum:

H4a. Messages disclosed to be collaboratively created by an institution and care-consumer will lead to more positive message evaluations in comparison tomessages disclosed as being created solely by an institution or care-consumer.

H4b. The effect of source disclosure on message evaluations will be serially mediatedby credibility and similarity (parallel, first serial-level mediators) and authenticity(second serial-level mediator).

MethodHealth context of data collection siteThe reported studies are based on US data. Although a systematic review of the US healthsystem is beyond the scope of this research, it is worthwhile noting that efforts to developICS in the US have not been without problems (McHugh et al., 2016; Wishner and Burton,2017). Continued uncertainty regarding the fate of the Affordable Care Act (Sommers et al.,2017), projected growth of national health expenditures predicted to exceed growth in thenational gross domestic product (Keehan et al., 2017) and concerns about the ongoing

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funding of the Medicaid program (Wishner and Burton, 2017) have posed significantchallenges. We acknowledge that these inherent features of the US systemmay have exertedan influence on the way respondents reacted to our source manipulations.

Preliminary studyWe first conduct a confirmatory factor analysis (CFA) on a separate sample to ensure thediscriminant validity of authenticity. Following this preliminary study, we design a single-factor (source: institution vs care-consumer vs collaborative) between-subject experiment toassess:

� whether collaborative sources lead to more positive message evaluations than thealternatives; and

� the mechanisms underlying this effect.

Participants, procedure and measures. To sample the general US population, 530 US adultswere recruited from MTurk in return for US$1 (Paolacci et al., 2010, for a review on thevalidity and reliability of MTurk samples). Five participants were removed from the samplefor failing an attention check, leaving 525 cases for analysis (Mage = 36.18, SD = 12.03; 57.5per cent male).

After reading the study explanatory statement, participants were assigned to a one-group post-test only design and exposed to a risk minimization health message. Themessage recommended individuals to reduce their food portion sizes as a means of lesseningthe deleterious health impacts associated with being or becoming obese. The messagefeatured a visual image of an obese person requiring a mobility scooter and a graphicrepresentation of the increasing portion sizes of a commonly consumed food (a hamburger)across time. The call to action was “Cut your portions. Cut your risk.” A statement in thebottom left hand corner disclosed the message was created collaborative by the Departmentof Health and a person impacted by obesity-related health conditions. Next, participantsreported whether they had seen the message before and completed the following measures:message evaluations; perceptions of source credibility, source similarity and messageauthenticity, as well as perceptions of the egoistic and altruistic motives of the source.

Given positive message evaluations can increase behavioral compliance (MacKenzieet al., 1986; Mehta, 2000), the primary dependent variable was message evaluations,which was assessed using a four-item, five-point semantic differential scale (Thompsonand Malaviya, 2013). Source credibility was measured as a second-order factorcomprising trustworthiness and expertise, using two five-item, five-point semanticdifferential scales (Ohanian, 1990). Source similarity was measured using a three-item,five-point semantic differential scale (Lawrence et al., 2013). Message authenticity wasassessed using a four-item, five-point Likert scale (Kovács et al., 2013). As consumers canexpress concern about the motives that drive other consumers to create message content(Ertimur and Gilly, 2012), perceived egoistic and altruistic motives were included ascontrols and measured using separate three-item, seven-point Likert scales (Cnaan andGoldberg-Glen, 1991; Daugherty et al., 2008). Socio-demographic (gender, age andeducation) and context-specific control factors (unhealthy food consumption frequency,attitudes toward fast-food, height and weight) were also included. The latter two wereused to calculate respondents’ body mass index (BMI), computed as the ratio betweenweight in kilograms and the squared height in meters (World Health Organization, 2014).Table I provides an overview of scale items, factor loadings and average varianceextracted for each latent construct.

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Results and discussion. Although 67 participants reported having seen the stimulus before,all were retained for analysis as there were no significant differences on any of the measuresbetween those reporting (vs not reporting) prior exposure. To conduct the CFA, we usedstructural equation modeling with maximum likelihood estimation (software package:AMOS 22). We included specific fit-indexes to evaluate incremental fit (CFI), absolute fit(AGFI) and parsimony (PNFI), as well as the RMSEA as a measure of both absolute fit andparsimony (Iacobucci, 2010). Convergent validity (Bagozzi and Phillips, 1991) wasdemonstrated as all items loaded over 0.70 on their respective factor and the averagevariance extracted (AVE) for each factor was greater than 0.50 (Table I). Discriminant

Table I.Items, standardizedfactor loadings andmeasures of validity

Scale and scale items b CR AVE

Source credibility – The source of the message is 0.939 0.885Trustworthiness 0.961 0.941 0.761Undependable – dependable 0.887Dishonest – honest 0.854Unreliable – reliable 0.918Insincere – sincere 0.789Untrustworthy – trustworthy 0.907Expertise 0.914 0.945 0.774Not an expert – expert 0.845Inexperienced – experienced 0.882Unknowledgeable – knowledgeable 0.880Unqualified – qualified 0.912Unskilled – skilled 0.879

Source similarity – The source of the message is 0.923 0.799Dissimilar from me – similar to me 0.926Distant from myself – close to myself 0.907Like me – not like me 0.847

Message authenticity 0.927 0.761The message looks authentic 0.888The message feels genuine 0.888The message feels real 0.905The scenario depicted is close to reality 0.807

Message evaluations 0.945 0.813Bad – good 0.878Unconvincing – convincing 0.839Unfavorable – favorable 0.943Dislike – like 0.942

Motives of source – To what extent the creator of the message wasmotivated by the following?Egoistic 0.883 0.715In exchange for a personal reward 0.865To gain a tangible profit 0.851Would have not participated if no reward was available 0.820

Altruistic 0.924 0.801To benefit society 0.883To make a contribution to the common good 0.904To help others 0.898

Notes: b = standardized factor loading; CR = composite reliability; AVE = average variance extracted;numbers in ital indicate beta of the second-order factor rather than single-item factor loadings

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validity was demonstrated as the AVE of each construct was greater than the sharedvariance between each pair of constructs (Fornell and Larcker, 1981). Table II reportscorrelations, shared variance and AVE for the measurement model. Notably, messageauthenticity discriminates well from source credibility and from all other variables includedin the measurement model. The measurement model also achieved a good fit (x 2/df =659.55/307 = 2.15; AGFI = 0.89; CFI = 0.97; RMSEA = 0.047; PNFI = 0.83). In summary, theconstructs to be used in the main experimental study displayed convergent anddiscriminant validity (see Supplementary Materials for more information on competingmodels).

Main experimental studyParticipants, procedure and measures. In line with the preliminary study, 120 US adults wererecruited from Amazon MTurk. After removing incomplete and failed attention checkresponses, 116 cases remained for analysis (Mage= 35.14, SD = 11.77; 62.1 per cent male). Thisstudy used a single-factor (source disclosure: institution vs care-consumer vs collaborative)between-subjects design, manipulating source disclosure by varying the source listed in thebottom left hand corner of the stimulus used in the preliminary study. Participants were eitherinformed that the message was created by the Department of Health (institutional source), by aperson impacted by obesity-related health conditions (care-consumer source), or by acollaboration between the two (collaborative source). Immediately after random assignment,participants completed the previously validated measures for message evaluations (a = 0.92),perceived authenticity of the message (a = 0.86), source credibility (a = 0.94) and sourcesimilarity (a = 0.84). Finally, participants provided their perceptions of the message source’segoistic (a = 0.89) and altruistic motives (a = 0.91) and completed the socio-demographic andcontext-specific controls used in the preliminary study.

ResultsPreliminary analyses. Tests for univariate normality and homogeneity of variancesreturned satisfactory results for all variables of interest except authenticity (Levene’s testp < 0.034). The three experimental conditions did not differ in terms of unhealthy foodconsumption frequency, attitudes towards fast-food, education, BMI, age and gender (allFs< 1).

Credibility. H1 predicts that credibility would be higher for institutional andcollaborative sources in comparison to care-consumer sources. An ANOVA using sourcedisclosure as the main factor indicated a significant effect on source credibility (F(2, 115) =13.22, p < 0.001). In full support of H1, planned contrasts indicated that care-consumer

Table II.Latent variablescorrelations anddiscriminant validity

EGO ALT CRED SIM AUTH MEV

EGO 0.715 0.336 0.126 0.051 0.107 0.090ALT �0.580 0.801 0.483 0.207 0.394 0.399CRED �0.356 0.695 0.885 0.350 0.588 0.654SIM �0.226 0.455 0.592 0.800 0.262 0.469AUTH �0.327 0.628 0.767 0.512 0.762 0.617MEV �0.301 0.632 0.809 0.685 0.786 0.813

Notes: r = below the diagonal; r2 = above the diagonal in italic; AVE = on the diagonal in bold. EGO =Egoistic motives; ALT = Altruistic motives; CRED = Source credibility; SIM = Source similarity; AUTH =Message authenticity; MEV =Message evaluation

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sources were perceived as less credible (M = 3.42, SD = 0.67) than institutional (M = 3.99,SD = 0.65; F(2, 115) = 14.32, p < 0.001) and collaborative sources (M = 4.13, SD = 0.68; F(2,115) = 22.37, p< 0.001).

Similarity. H2 contends similarity would be higher for care-consumer and collaborativesources in comparison to institutional sources. As the ANOVA results indicated nosignificant differences in ratings of source similarity across the three experimentalconditions (all Fs< 1),H2was not supported.

Authenticity. H3 predicts authenticity would be higher for collaborative sources incomparison to both institutional and care-consumer sources. Given the Levene’sstatistic indicated unequal variances, a test of robustness of equality of means wasconducted to ensure differences between the three experimental conditions werestatistically significant. Both the Welch (F(2, 68.34) = 5.40, p < 0.01) and the Brown–Forsythe tests (F(2, 82.61) = 3.61, p < 0.05) confirmed a significant effect of sourcedisclosure on authenticity. In full support for H3, planned contrasts indicatedcollaborative sources (M = 4.18, SD = 0.44) were perceived as being more authenticthan institutional (M = 3.88, SD = 0.78; F(2, 115) = 4.14, p < 0.05) and care-consumersources (M = 3.82, SD = 0.60; F(2, 115) = 6.63, p< 0.05).

Message evaluations. H4a contends that collaborative sources lead to more positivemessage evaluations in comparison to both institutional and care-consumer sources. TheANOVA indicated a significant effect of source disclosure on message evaluations (F(2, 115) =3.10, p < 0.05). In support of H4a, planned contrasts analysis indicated that disclosing acollaborative source led to message evaluations (M = 4.06 SD = 0.76) that were marginallysignificantly higher than institutional sources (M = 3.66, SD = 0.90; F(2, 115) = 3.66, p< 0.067)and significantly higher than care-consumer sources (M= 3.60, SD= 0.94; F(2, 115) = 6.09, p<0.05). Table III summarizes the results for the first four hypotheses.

Mediation analysis. Multicategorical mediation analysis using PROCESS (Model 6) with10,000 bootstrapped samples and bias-corrected confidence intervals (Hayes, 2013; Hayesand Preacher, 2014) was used to test H4b that the effect of source disclosure on messageevaluations is carried over through:

Table III.Mean differences andplanned contrasts for

source disclosure

Type of source effectSource effect Institution mean (SD) Care-consumer Mean (SD) Collaborative mean (SD)

Credibility 3.99 (0.65) 3.42 (0.67) 4.13 (0.68)Similarity 3.16 (0.99) 3.41 (0.98) 3.43 (0.80)Authenticity 3.88 (0.78) 3.82 (0.60) 4.18 (0.44)Message evaluation 3.66 (0.94) 3.60 (0.94) 4.06 (0.76)

Planned contrasts for significant differences (p-value)CredibilityCare-consumer *** 2 2Collaborative n.s. *** 2

AuthenticityCare-consumer n.s. 2 2Collaborative ** *** 2

Message evaluationCare-consumer n.s. 2 2Collaborative * ** 2

Notes: ***p< 0.01; **p< 0.05; *p< 0.10

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� source credibility and source similarity as parallel, first serial-level mediators; and� perceived authenticity as a second serial-level mediator.

As multicategorical mediation allows for the simultaneous testing of all direct, indirect andtotal effects, it offers a more rigorous test compared to alternatives such as splitting the dataset and conducting simple mediations, or replacing the multicategorical variable with acontinuous manipulation check scale (Hayes and Preacher, 2014).

The three source disclosure conditions were reduced to k – 1 parameter estimates (Cohenet al., 2003) and indicator coding was used to create the two indicator variablesD1 [1 = Care-consumer, 0 = Institution; Collaborative] and D2 [1 = Collaborative, 0 = Institution; Care-consumer]. That is, D1 codes the care-consumer condition, D2 the collaborative conditionand the institutional condition works as the reference group, receiving a code of 0 in both D1and D2 (Hayes and Preacher, 2014). Figure 1 presents the multicategorical parallel serialmediation analysis with source disclosure represented by the two indicator variables D1 andD2. Perceived source altruistic and egoistic motives were included in the model as covariates(for more details, see Supplementary materials).

The total indirect effect on message evaluations for D1 was non-significant (B = �0.12,SE = 0.18, CI [�0.48, 0.08]). The only significant relative indirect effects were:

� D1!Credibility!Authenticity!Message evaluations, CI [�0.35,�0.15]; and� D1!Similarity!Authenticity !Message evaluations, CI [0.01, 0.15].

These results suggest that, compared to institutional sources, care-consumer sources lead toless favorable message evaluations by reducing perceived credibility, with a smallcompensating positive effect through source similarity. In contrast, the total indirect effectofD2 (i.e. collaborative source) was significant (B = 0.30, SE = 0.16, CI [0.01, 0.61]), with onlythe relative indirect effect of D2!Authenticity!Message evaluations, CI [0.01, 0.38] being significant.These results suggest that, compared to institutional sources, collaborative sources increasepositive message evaluations by increasing the perceived authenticity of the message.Overall, these results provide partial support forH4b.

Figure 1.Multicategoricalserial mediation

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General discussionGrounded in ICS and marketing communication theory, this research compared the effectsof three types of ICS source disclosure on health message evaluations and sought toexplicate the source effects underpinning this relationship. Our findings demonstrate thatdisclosing a collaborative ICS source leads to more positive evaluations of a health messagein comparison to other sources. Specifically, collaborative sources are perceived to be ascredible as institutional sources, as similar as care-consumer and institutional ones, butmore authentic than either care-consumer or institutional sources. These results providerelevant theoretical contributions and are of pragmatic importance.

Theoretical contributionOur findings contribute to theory in three ways. First, we broaden extant literature onsource effects by being the first to compare a taxonomy of three key ICS stakeholder sources(institutional, care-consumer and collaborative). Prior research in the private and publicdomain either compared consumer vs corporate sources (Lawrence et al., 2013; Thompsonand Malaviya, 2013) or collaborative vs institutional sources (Orazi et al., 2016), but not allthree and not in a health-care context. By specifying and testing this taxonomy, we shedlight on the mechanisms underpinning how each message source influences messageevaluations and offer a potentially low-cost pathway to effect change that is well suited tothe fiscal constraints experienced by many ICS. However, care is needed when using thistaxonomy as not all sources are equal in terms of their effect on source attributions andmessage evaluations. For instance, if the goal is to bolster positive message evaluations,then providers would be advised to use collaborative sources over care-consumers inisolation. Conversely, prudence should be exercised when selecting a message sourceleveraging only attributions of source similarity as our results, in line with Lawrence et al.(2013), suggest this tactic may not augment positive message evaluations.

Second, by evidencing the discriminant validity of message authenticity, we bring intoquestion prior conceptualizations of authenticity and credibility as being aspects reflectiveof the same construct (Lawrence et al., 2013) and proffer a new perspective on the multiplemeanings of authenticity. Specifically, while prior marketing research has typicallyconsidered authenticity in reference to the attributes of an advertised product (Beverlandet al., 2008), we consider authenticity in terms of whether the message itself is perceived as arealistic and genuine representation of a real-life scenario (Stern, 1994).

Third, the findings demonstrate the efficacy of drawing on marketing communicationtheory to build ICS communication capacity by showing how the disclosed source ofinformational content can increase positive evaluations of health-related messages.Specifically, collaborative sources may help signal the integral and active role care-consumers have within health-care teams and encourage care-consumers to bring their ownskills, knowledge and insights into the treatment paradigm. The value of such activeinvolvement and co-creation is evidenced within the transformative services literature(McColl-Kennedy et al., 2012, 2017) and includes care-consumer compliance to medicaladvice (Seiders et al., 2015). That this type of value co-creation depends on informationsharing (Osei-Frimpong et al., 2018) underscores the utility of ICS drawing on marketingtheory and practice going forward.

Managerial implicationsBy demonstrating that re-configuring the declared source of informational content canincrease positive evaluations of health-related messages, our findings highlight theefficacy of drawing on marketing communication theory to build ICS communication

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capacity. The findings inform ICS communication strategies aimed at enhancingcompliance to message recommendations around the prevention or remediation of healthconditions. Given perceptions of message authenticity are predicated on the contentbeing a genuine representation of reality, a disclosed collaborative source may also helpconvey the centrality of care-consumers to the system, thus signaling the core philosophyof service delivery being built around the perspective of care-consumers (Lloyd and Wait,2005; Shaw et al., 2011). Given the rising need for multidisciplinary health care (vonThiele Schwarz, 2016), co-opting (and disclosing) these stakeholders in thecommunication process may further enhance message authenticity. Our findings alsosuggest the disclosure of collaborative message sources may have an oblique benefit toICS providers. As evaluative responses toward an advertisement can influence attitudestoward the depicted brand (Gardner, 1985; Mitchell and Olson, 1981), it is possible thatthe positive evaluations of an ICS health message could influence care-consumersattitudes toward the institution itself.

Limitations and future researchThis research has a number of limitations. First, we did not directly measure resultantbehaviors, although prior research has identified links between favorable messageevaluations and behavioral compliance (MacKenzie et al., 1986; Mehta, 2000). Second, aswe only examined one type of health message, future research is needed to explorewhether the effects hold for messages dealing with other wicked consumption behaviors(Koch and Orazi, 2017), or treatment compliance and proactive behaviors such asattending clinics for regular check-ups. Third, our model does not explain whyinstitutional sources are perceived as being similar to care-consumer and collaborativesources. It is possible that our written source disclosure provided too few cues forparticipants to draw upon when evaluating the degree of similarity between themselvesand the care-consumer source. Future research could explore whether the relationshipbetween disclosed source and perceptions of source similarity is moderated by theamount of information provided about care-consumer sources. Relatedly, ourmanipulation for the care-consumer and collaborative conditions disclosed theinvolvement of only one care-consumer. Disclosing the involvement of multiple care-consumers could engender higher perceptions of similarity by virtue of a strongerendorsement effect. Finally, issue-involvement may also act as an additional moderatorbetween source type and similarity, such that highly involved consumers will perceivecare-consumer sources to be more similar (Orazi et al., 2016).

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Corresponding authorDavide Christian Orazi can be contacted at: davide.orazi@monash.edu

For instructions on how to order reprints of this article, please visit our website:www.emeraldgrouppublishing.com/licensing/reprints.htmOr contact us for further details: permissions@emeraldinsight.com

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PRACTITIONER COMMENTARYCollaborative authenticity: how stakeholder-basedsource effects influencemessage evaluations

in integrated care

We know from many projects and studies that if a person’s health and well-being ismanaged holistically and they are involved in decisions about their care and support, theyhave a positive experience of care and their outcomes improve. Much has been achieved inthe past decade or so in that regard. Still, Europe seems to be some steps away from reallyand truly integrated health and care systems, and the majority of mainstreamed servicestend to be firmly located within one or other of either the social care or health-care domains.Thus, much remains to be done if we want to tap the full potential of integrated care forachieving the “quadruple aim” to improve patient experience, outcomes of care,effectiveness of health systems and provider experience; improvements in communicationbetween providers and care consumers based on a better understanding of communicationand source effects are an important step in that regard.

As a project coordinator of several EU-funded projects on integrated care programmedesign, piloting and evaluation, I learned in recent years how important communication andlanguage are, and how much can go wrong in that regard between the various stakeholdersinvolved in integrated care. Admittedly, my first and immediate thought when I started toread the paper was “What has marketing to do with integrated care?” Already after the firstparagraph, however, the paper triggered many ideas for my daily work in European projectsthat aim to better design and scale integrated care provision schemes across Europe. Ofcourse, many of the care programmes designed and evaluated in these projects deal withinformation and data sharing, as this is one of the key challenges (but also opportunities) ofintegrated care. However, they are too often about sharing information about rather thanwith the care consumer. And often, answers are provided on what and by what meansinformation is shared between the different stakeholders involved, but none of the schemes Iam aware of ever considered how, for instance, source effects impact the perception of amessage. There is much research about patient-centeredness and many (pilot) programmeshave been implemented which aim to put the patient at the centre of care, but effects ofcommunication seem not to be considered enough yet if at all, especially when it comes tomeasuring impacts of communication on care outcomes. Often, seemingly small changes ofcare pathways, undertaken based on research results like the ones in the paper, have astrong impact on health outcomes and the way a care consumer experiences their carejourney. A recent pilot study, for example, revealed that patients tend to perceive that a careprofessional has spent more time at their bedside when they sit rather than stand (Swaydenet al., 2012). Other studies established evidence of positive impacts of altering the geographyof consultation rooms – to the effect that patients and physicians sit next to each other ratherthan opposite each other – on patient–professional relationships.

As coordinator of many implementation projects, I welcome the relevance and practicalvalue of these research results for better shaping the practicalities of a collaborative culturethat emphasises team working and patient-centeredness. They can help increasecompliance, which is still a tremendous challenge and a complex issue, since human beings

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European Journal of MarketingVol. 52 No. 11, 2018pp. 2232-2233© Emerald PublishingLimited0309-0566DOI 10.1108/EJM-11-2018-897

do not act as homo economicus. Thus, resultant behaviour measurement and furtherinvestigation on how collaborative messaging could look in practical terms would be crucialto further improve integrated care programmes across Europe. In my view, it can provide acatalyst for action and real-world change, especially as little research has been done tomeasure the quality of integrated care from the care consumer perspective.

Sonja MüllerIndependent Researcher, Bonn, Germany

ReferenceSwayden, K.J., Anderson, K.K., Connelly, L.M., Moran, J.S., McMahon, J.K. and Arnold, P.M. (2012),

“Effect of sitting vs standing on perception of provider time at bedside: a pilot study”, PatientEducation and Counseling, Vol. 86 No. 2, pp. 166-171.

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Incorporating digital self-servicesinto integrated mental health care:

a physician’s perspectiveHeini Sisko Maarit Taiminen

School of Business and Economics, University of Jyväskylä, Jyväskylä, Finland

Saila SaraniemiDepartment of Marketing, Oulu Business School,

University of Oulu, Oulu, Finland, and

Joy ParkinsonSocial Marketing @ Griffith, Griffith Business School,

Griffith University, Brisbane, Australia

AbstractPurpose – This paper aims to enhance the current understanding of digital self-services (computerizedcognitive behavioral therapy [cCBT]) and how they could be better incorporated into integrated mental healthcare from the physician’s perspective. Service marketing and information systems literature are combined inthe context of mental health-care delivery.Design/methodology/approach – An online survey of 412 Finnish physicians was undertaken tounderstand physicians’ acceptance of cCBT. The study applies thematic analysis and structural equationmodeling to answer its research questions.Findings – Adopting a service marketing perspective helps understand how digital self-services can beincorporated in health-care delivery. The findings suggest that value creation within this context should beseen as an intertwined process where value co-creation and self-creation should occur seamlessly at differentstages. Furthermore, the usefulness of having a value self-creation supervisor was identified. These valuecreation logic changes should be understood and enabled to incorporate digital self-services into integratedmental health-care delivery.Research limitations/implications – Because health-care systems vary across countries, strengtheningunderstanding through exploring different contexts is crucial.Practical implications – Assistance should be provided to physicians to enable better understanding of theapplication and suitability of digital self-service as a treatment option (such as cCBT) within their profession.Additionally, supportive facilitatingconditionsshouldbecreated to incorporate themaspart of integratedcarechain.Social implications – Digital self-services have the potential to serve goals beyond routine activities in ahealth-care setting.Originality/value – This study demonstrates the relevance of service theories within the health-carecontext and improves understanding of value creation in digital self-services. It also offers a profounddepiction of the barriers to acceptance.

Keywords Integrated care, Service providers, Value creation, Self-service, Service separation,Computerized cognitive behavioural therapy

Paper type Research paper

This study is part of Redefining Digital Opportunities – ReDo research project funded by Tekes – theFinnish Funding Agency for Technology and Innovation, the Universities of Oulu, Jyväskylä, andTampere, VTT, and participating companies. The authors gratefully acknowledge the assistance of theHelsinki-Uudenmaa hospital district and The Finnish Medical Association in the data collection phase.

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Received 7March 2017Revised 28August 201720 November 201713 December 201715 December 2017Accepted 19 June 2018

European Journal of MarketingVol. 52 No. 11, 2018pp. 2234-2250© EmeraldPublishingLimited0309-0566DOI 10.1108/EJM-02-2017-0158

The current issue and full text archive of this journal is available on Emerald Insight at:www.emeraldinsight.com/0309-0566.htm

1. IntroductionThe treatment gap for mental disorders is a broad issue, even in well-developed countries(Patel et al., 2013; WHO/WONCA, 2008). For individuals, not getting help is mainly due toshortcomings in the accessibility of mental health services, which are often part of anoverburdened special health-care system, and accessed via primary care practitioners whodo not always possess the necessary resources to treat mild-to-moderate cases (OECD, 2014).Approaches addressing these challenges are commonly related to principles of integratedcare and provision of seamless, effective and efficient care throughout an individual’s lifein cooperation with the individual and their family. These principles call for an individual-centered approach, better access to health-care services, and better communication andcontinuity between different levels of health-care providers (Kodner, 2009).

New technologies have provided opportunities to better integrate care. The computerizedcognitive behavioral therapy (cCBT) approach is one option to promote more efficient caredelivery in the context of mental health. The cCBT approach makes it possible to integratedifferent levels of care in one setting and to provide flexible access to care, addressing thechallenge of providing cost-effective treatment options with decreasing public resources(Chatzimarkakis, 2010; Cummings et al., 2013; Du et al., 2013). The benefits of cCBT fit wellwith the integrated care philosophy (Kodner, 2009). Despite the potential of cCBT and thegenerally positive attitudes toward it, utilization among physicians is low in manycountries, including in the USA (Carper et al., 2013), Australia (Donovan et al., 2015) and theUK (Du et al., 2013; Stallard et al., 2010). In the EU, while the potential is known, cCBT hasnot yet been routinely incorporated into health-care delivery (Topooco et al., 2017; Vis et al.,2015).

To improve current understanding, this paper takes a multidisciplinary perspective bycombining service marketing and information systems literature in the mental health-carecontext. The study reflects the physicians’ perspective, because without their support suchservices will not become part of future health-care delivery. From a service marketingperspective, cCBT represents a form of digital self-service exemplifying the phenomenon ofservice separation. Accordingly, this paper first applies service marketing, and particularlyvalue creation literature, to strengthen the knowledge of cCBT as a service type. Second, amore consistent understanding of the barriers to acceptance will be established byexamining barriers identified in the mental health-care literature through informationsystem lenses. Then, these perspectives will be extended through empirical understandingand combined to understand how digital self-services can be incorporated to contribute tointegrated mental health care. To serve this aim, this study addresses the following researchquestions:

RQ1. How can value creation logic be extended to incorporate digital self-service (cCBT)into integrated mental health-care delivery?

RQ2. What are the barriers to digital self-service (cCBT) acceptance in mental health-care delivery and how can they be overcome?

The purpose of this paper is to enhance the current understanding of digital self-services inthe form of cCBT and how they can be incorporated to contribute to integrated mentalhealth care from the physician’s perspective. The current research makes three theoreticalcontributions to the literature that also translates into contributions to practice. First, thispaper extends the understanding of separated service delivery (Green et al., 2016; Keh andPang, 2010; Paluch and Blut, 2013) by providing a description of the value creation logic of

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digital self-services in a mental health-care context. From practical perspective, this opensnew avenues to understand the fundamental logic of these special types of services inhealth-care settings. Second, this paper contributes to the current discussion about cCBTacceptance (Lazuras and Dokou, 2016; Montero-Marin et al., 2015; Topooco et al., 2017),providing a more systematic way to understand the factors influencing acceptance. Thisprovides service managers a more comprehensive understanding of the issues hinderinguptake of these special types of services. Third, by utilizing and further developingunderstanding of the logic of value creation within the mental health context, this paperhelps understand how digital self-services could become integrators in integrated care. In sodoing, the study provides further evidence of the relevance of service theories within thehealth-care context (Hardyman et al., 2015; McColl-Kennedy et al., 2012; McDermott andPedersen, 2016).

2. Conceptual development2.1 Digital self-service (cCBT) from value creation logic perspectiveComputer-mediated technologies have increasingly separated consumers and serviceproviders, and health care as a context is no exception (Green et al., 2016; Hartley and Green,2017). Service separation refers to a spatial (Keh and Pang, 2010) and/or temporal separation(Green et al., 2016) between service production and consumption that challenges theessential element of the IHIP paradigm; services inseparability (Zeithaml et al., 1985).Separated services are effective for routine activities; however, to deliver value – includingcare and personal interaction – the unseparated mode is seen as more effective and desirable(Keh and Pang, 2010).

Green et al. (2016) suggest that there are different degrees of service separation thatdepend on the technology infused into the service. At one end of the spectrum, the serviceencounter is completely replaced with a digital form. These services can be classified asself-services where value is “produced by customers for themselves, independent of directservice employee involvement, using a technological infrastructure that is provided bythe service provider” (Schumann et al., 2012, p. 134). In this study, cCBT represents such atechnology-infused self-service where the value is created indirectly through a digitalencounter.

As a service type, cCBT contrasts with the traditional paternalistic model of medicinepractice, which views physicians as experts who assess, diagnose and deliver treatment(Mechanic, 2008). These new self-care practices transfer care from traditional clinicalsettings, controlled by a physician, to the domestic environment (Storni, 2014). The customeracts as an independent value creator, self-creating value independently of the serviceprovider (Zainuddin et al., 2016). Consequently, the role of the physician changes from thatof care (therapy) provider and value co-creator to a referee of care (therapy) and a valuefacilitator (Grönroos and Voima, 2013). This required logic change is presented in Figure 1.This also means that acceptance in this context does not mean merely acceptance oftechnology but refers an acceptance of the transformation from value co-creation to enablepatient independent value self-creation. Within this study, this is operationalized asphysicians’ intention to prescribe cCBT.

2.2 Understanding barriers to the acceptance of digital self-service (cCBT)Health-care professionals operate in specific settings involving factors at different levelsthat influence their decision making. Chau and Hu (2002) developed a framework suggestingtechnology acceptance is influenced by three contexts that should be seen as different layers,with each having a direct influence on acceptance. Those layers are:

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� the implementation context (organizational and social factors of where technology isimplemented);

� the technological context (perceived usefulness of innovation); and� the individual context (including factors such as attitude and knowledge).

Within this study, the technological context in labelled as the innovation context to bettercapture the idea of this layer.

Several studies examining physicians’ acceptance of cCBT have identified knowledge atthe individual level as the main barrier to acceptance (Du et al., 2013; Donovan et al., 2015;Vigerland et al., 2014). In general, greater knowledge and a positive attitude toward digitaltreatment options is associated with advanced e-mental health delivery (Topooco et al.,2017). Within this study, the individual context factors are captured by measuring attitudeand knowledge, which leads to the following hypothesis:

H1a. Attitude (Individual context) has a direct positive effect on physicians’ intention toprescribe cCBT.

H1b. Knowledge (Individual context) has a direct positive effect on physicians’ intentionto prescribe cCBT.

Studies examining clinicians’ use of health IT for patient care have consistently found theinnovation context (specifically perceived usefulness/performance expectancy) affectsclinicians’ acceptance of technology (Holden and Karsh, 2010), and some studies declare it tobe the most powerful factor affecting behavioral intention (Liu et al., 2015). Studiesexamining cCBT acceptance specifically among physicians express concerns over theeffectiveness and efficiency of treatment (Bruno and Abbott, 2015; Du et al., 2013; Vigerlandet al., 2014). The absence of a therapeutic relationship is an additional concern related to theinnovation context and has been identified as a factor hindering acceptance (Bruno andAbbott, 2015; Fleming and Merry, 2013; Vigerland et al., 2014). Within this study, theinnovation context is captured by measuring performance expectancy, referring to theperception that using the system will help the user to achieve certain goals, such aseffectively treating patients. Accordingly, the following hypotheses are proposed:

Figure 1.A framework tounderstand the

digital self-servicevalue creation logic

Consumer’s value sphere:Value self-creation

Provider’s value sphere: value production Joint value sphere:

Value co-creation

Acceptance of transformation to move from value co-creation to enable patient

independent value self-creation

Physician role: Active value co-creator

Patient role: Active value co-creator

Physician role: Value facilitatorPatient role: Active and

independent value creator

Physician role: Value facilitator

Patient role: n/a

Source: Modified from Grönroos and Voima (2013)

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H2. Performance expectancy (Innovation context) has a direct positive effect onphysicians’ intention to prescribe cCBT.

Factors related to the implementation context, such as facilitating conditions, can bemeaningful. However useful and easy to use health IT is, consumers will not accept it if it isnot possible to use, as occurs when usage is prohibited by policy, for example (Holden andKarsh, 2010). A multi-stakeholder study in the EU also identified low feasibility of deliverywithin existing care services as the primary barrier to the acceptance of digital treatment(Topooco et al., 2017). The implementation context has attracted little research attention,although concerns related to the implementation context, such as who is responsible for thepatient when they are undergoing cCBT, have been raised and identified as a barrier tocCBT acceptance (Bruno and Abbott, 2015). Following Chau and Hu (2002), theimplementation context is captured by measuring facilitating conditions (referring to theperception the organizational and technological infrastructure exists to support usingthe system) and social influence (referring to the perception important others support the useof the system). Accordingly, we hypothesize:

H3a. Facilitating conditions (the Implementation context) has a direct positive effect onphysicians’ intentions to prescribe cCBT.

H3b. Social influence (the Implementation context) has a direct positive effect onphysicians’ intentions to prescribe cCBT.

3. Method3.1 Context of the studyData for this study were collected from physicians in Finland via an e-mail survey. InFinland, health care is provided through a decentralized, three-level, public health-caresystem and a partly publicly reimbursed private sector. Most of the physicians areemployed by public or private health centers. The Finnish health-care system is based onthe Nordic welfare model that aims to offer equal access to health-care services for allresidents, and general practitioners are well equipped to offer a wide range of medicalservices and are often gatekeepers of specialized public services (Eide et al., 2017). Currently,mental health services are administered as specialized health care (a secondary level of care)at psychiatric clinics and psychiatric hospitals (Ministry of Social Affairs and Health, 2017)for which general practitioners act as gatekeepers (Kaipio et al., 2017). Recently, developedforms of cCBT have been up-scaled for provision in health care around the country inresponse to a shortage of available therapists and to provide more flexible and accessiblesolutions to provide mental health care especially at the primary care level (Johnson, 2017).Similar aims and progress can be observed around the EU in recent years (Topooco et al.,2017; Vis et al., 2015).

3.2 Data collection and sample characteristicsAn invitation to participate in the survey was sent by e-mail to 2,565 physicians who wererandomly selected using a simple random sample from each of two clusters supplied by TheFinnishMedical Association. These two clusters weremade up of unspecialized physicians andspecialized physicians (either specialized in general medicine or psychiatry). The total numberof working-age physicians in Finland is 20,970 (The Finnish Medical Association, 2016), and

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the register covers approximately 91 per cent of physicians registered in Finland. Theinvitation produced 412 responses, equating to a 16 per cent response rate (those whoanswered/those to whom the survey was sent), and the effective response rate (those whoanswered/those who opened the link) was 69 per cent. Response rates are in line with similarstudies conducted among the same target group (Groenewegen et al., 2016; Hyppönen et al.,2015; Kivekäs et al., 2014).

Approximately one-third of respondents (32.5 per cent) were 51-60 years old with 21-30years’work experience. In terms of main specialization, 41.4 per cent (n= 170) reported workingin psychiatric medicine; 35.4 per cent (n = 146) in general medicine; 11.4 per cent (n = 47) inoccupational health; and the remaining 11.9 per cent (n = 49) in other fields of medicine. Thismeans within the data set, those specializing in psychiatric medicine is overrepresented incomparison to the number of physicians specializing in the psychiatric field in Finland, but thiswas intentional given the context of the study. In Finland, physicians working in thepsychiatric, general medicine or occupational health fields should make the decisions related tocCBT usage, but currently, it is often a physician specialized in mental health making decisionson the care provided, such as cCBT. The majority of respondents worked in the public healthsector (73.5 per cent, n = 303), which is in line with the general situation in Finland as 70 percent of medical professionals work in the public sector (The Finnish Medical Association, 2016).Despite the limited sample size, the data represent the intended target groupwell.

3.3 Questionnaire development and measuresTo better understand the factors influencing physicians’ intention to prescribe cCBT,variables from technology adoption literature were identified among the previous literatureon health care (Chau and Hu, 2002; Holden and Karsh, 2010; Lazuras and Dokou, 2016; Liuet al., 2015). Items to measure intention to prescribe cCBT (three items), attitude (four items),facilitating conditions (four items), social influence (four items) and performance expectancy(four items) were all adopted from Venkatesh et al. (2003) and modified to fit the context ofthis study. Tomeasure knowledge, three items were adopted from Vigerland et al. (2014). Allitems were measured using a seven-point Likert scale. To better understand generalconcerns related to cCBT prescription, physicians were requested to describe any suchconcerns verbally following the process advocated by Stallard et al. (2010) and Vigerlandet al. (2014).

The next section presents the preliminary results of the quantitative data analysis andqualitative data analysis. This is followed by an integrative analysis of the qualitative andquantitative findings in the results section to answer RQ1 andRQ2.

3.4 Quantitative data analysis and preliminary resultsThe study analyzes the quantitative data using the two-step approach of structural equationmodeling (Anderson and Gerbing, 1988) and AMOS software. First, scale reliability andvalidity were examined using confirmatory factor analysis (CFA). The study’s initialmeasurement model had six multi-item constructs with 22 items. Owing to discriminantvalidity, two items were removed from the measurement model (PE3 and FC3), resulting insix multi-item constructs with 20 items. These modifications did not compromise theoriginal theoretical considerations and improved the model. Composite reliabilities (CRs)ranged from 0.83 to 0.96, demonstrating good internal reliability. The average varianceextracted (AVE) values exceeded the cut-off of 0.50, supporting the acceptable internalconsistency. Furthermore, AVEs greater than 0.50 and CR equal to or higher than 0.70indicates good convergent validity (Fornell and Larcker, 1981). All factor loadings wereequal to or greater than 0.532 (p< 0.001) Fornell and Larcker’s (1981) AVEmethodwas used

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to test discriminant validity. This showed acceptable discriminant validity, as thecorrelations between the constructs were below the square roots of the AVEs (Table I). Themodel indicated adequate model fit (x 2 = 403.29, df= 153, x 2/df = 2.64, p= 0.000; RMSEA=0.063, TLI = 0.96 CFI = 0.97 and IFI = 0.097) (Byrne, 2001).

Furthermore, survey studies are always subject to common method bias. In the presentstudy, this was minimized by carefully designing the questionnaire. In addition, to controlfor common method variance ex post, a Harman single factor test was performed, whichconfirmed the majority of variance could not be attributed to one factor (Fuller et al., 2016).

The second step involved estimating a structural model using the maximum likelihoodbootstrap method to examine the hypotheses. Table II presents the relationship betweenindividual factors and the intention to direct patients to use cCBT.

3.5 Qualitative data analysis and preliminary resultsAlmost 40 per cent of the physicians surveyed (38.8 per cent, n = 160) reported having noconcerns about prescribing cCBT for their patients, while the rest were either unsure (35.4per cent, n = 146) or had concerns (25.7 per cent, n = 106). The qualitative descriptions (n =240) covering the 381 concern that physicians had described verbally were coded andthematically analyzed to reveal potential barriers and the required value creation logic. Asimilar approach was used by Stallard et al. (2010) and Vigerland et al. (2014). Thisqualitative analysis followed the processes outlined by Corley and Gioia (2004) as explainedbelow:

Table I.AVE, constructcorrelations (CR),square root of AVEs(on the diagonal),mean andstandard deviations

Construct CR AVE INT ATT SI PE FC KNOW

Intention to prescribe cCBT (INT) 0.964 0.898 0.948*Attitude (ATT) 0.934 0.781 0.479* 0.884*Social Influence (SI) 0.828 0.562 0.480* 0.358* 0.749*Performance expectancy (PE) 0.91 0.771 0.561* 0.860* 0.423* 0.878*Facilitating conditions (FC) 0.85 0.657 0.575* 0.325* 0.709* 0.359* 0.81*Knowledge (KNOW) 0.92 0.793 0.492* 0.325* 0.580* 0.369* 0.787* 0.891*Mean 3.4 5.4 3.6 4.4 3.7 2.8SD 1.80 1.39 1.47 1.36 1.67 1.40

Note: *p = 0.01

Table II.Testing theconceptual modeland the hypotheses

Direct effects b Hypothesis test results

Individual contextH1a: Attitude –> Intention to prescribe cCBT �0.04ns H1a: Not supportedH1b: Knowledge –> Intention to prescribe cCBT 0.01ns H1b: Not supported

Innovation contextH2: Performance expectancy –> Intention to prescribe cCBT 0.44* H2: Supported

Implementation contextH3a: Facilitating conditions –> Intention to prescribe cCBT 0.418* H3a: SupportedH3b: Social influence –> Intention to prescribe cCBT 0.005ns H3b: Not supported

Notes: *p = 0.001; ns = not significant

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� The initial concepts were first identified in the data and then grouped intocategories (open coding) using simple descriptive phrases from the original surveyresponses (first-order themes).

� Next, axial coding was performed by grouping similar first-order themes. Thecurrent research primarily adopts an inductive approach, meaning the researcherstook account of themes identified in similar previous studies analysis (Stallard et al.,2010; Vigerland et al., 2014), a process that facilitated the identification of relevantthemes.

� After the first author concluded axial coding, the second author evaluated theinterpretations of the first author item by item to enhance intercoder reliability(Lombard et al., 2002). The level of agreement between the two authors was 94.5per cent, indicating highly acceptable agreement on coding.

� Finally, the authors discussed and negotiated over their different interpretationsand subsequently refined the coding manual and reassessed the second-orderthemes to form higher-order themes. The identified higher-order themes were alsolinked with the contextual levels to which each was related.

The final data structure is illustrated in Table III, revealing 7 higher-order themes and 15second-order themes. The table also details the context level (individual, innovation andimplementation) to which each theme is related.

4. ResultsThe results show physicians’ perceptions of cCBT are quite positive (attitude x� = 5.4 SD =1.39; performance expectancy x� = 4.4 SD = 1.36). This indicates that physicians agree thatsuch forms of separated services can serve to meet rather complex goals such as assistingthe physicians to treat their patients. Despite the recognized potential of cCBT, the intentionto guide patients to use them was low (x� = 3.4 SD = 1.80). This indicates there are somebarriers to be overcome to enable greater utilization. Linking the identified barriers with anenhanced understanding of the logic of value creation helps to understand how digital self-services can be incorporated to contribute to integrated mental health care.

4.1 Enhancing understanding of value creation logic in the context of digital self-services(cCBTs)First, the value creation logic within the health-care context as modified by enhancedempirical understanding is presented to answer RQ1: How can value creation logic beextended to incorporate digital self-service (cCBT) into integrated mental health-caredelivery? The qualitative analysis of the physicians’ concerns highlighted the current valuecreation issues and identified ways in which value creation logic might be extended toincorporate digital self-services in the form of cCBT into an integrated mental health-caredelivery process. The key additions to the current framework identified are summarized inFigure 2 (additions highlighted in italics) and described in detail below.

A service provider committed to delivering integrated health would ideally identify aform of cCBT (the value production) that allows value self-creation through a digitalinterface. Then the physician should evaluate the situation with the patient (value co-creation) and decide whether to use cCBT. The qualitative results of this study establish thatthis phase is critical to successful value self-creation. Physicians viewed the selection ofapplicable patient profiles along with patient willingness and the ability to self-create valueas aspects requiring careful consideration. They also expressed concern as to whether this

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Higher-order

them

esSecond

-orderthem

esFirsto

rder

them

esRepresentativequ

otation

Individu

alcontext

Lack

ofkn

owledg

e(n

=60,25%

)

Patient

selection(n

=22,9%)

Lack

ofun

derstand

ingofwhich

patientswill

benefit

from

thetreatm

ent

“Who

benefitsfrom

therapy/forw

hom

isitnever

applicableinanycircum

stances”

(ID269)

Content(n=23,10%

)Exp

ressed

theneed

form

oreinform

ationaboutthe

programsandtheirc

ontents

“Idon’tk

nowthecontentoftherapies

wellenoug

hthat

Iwould

feelconfi

dent

todirectmypatientsto

them

”(ID

112)

Serviceprovider

competence

(n=19,8%)

Challeng

esanddifficulties

inidentifying

competent

serviceproviders

“How

toidentifyreliableprovidersfrom

thosewhose

efficiency

isnotconfirm

ed/validated?”(ID

65)

Innovatio

ncontext

Efficiency

(n=124,52%)

Lack

ofhu

man

contact

(n=70,29%

)Reflectstheim

portance

ofhu

man/face-to-fa

ce(f2

f)interactioninprovidingtherapy,concernthat

thisis

lacking.(cf.them

eslack

oftherapeutic

relatio

nship,

Stallard

etal.,2010;and

human

supportV

igerland

etal.,

2014)

“Therapy

isso

muchmorethan

justwords”(ID

389)

Lack

ofhu

man

contact

subtheme1:Isolatio

n(n

=9,

4%)

Concerns

that

cCBTcouldexacerbatesocialisolation

(Stallard

etal.,2010)

“They(cCB

Tprocesses)don’tencourage

patientsto

leavehome”

(ID235)

Lack

ofhu

man

contact

subtheme

2:Riskman

agem

ent

(n=17

,7%)

Concerns

over

whether

itispossibleto

fully

understand

thepatient

andidentifyrisk

factorsdu

ring

thetherapy

(cf.risk

man

agem

ent,Stallard

etal.,2010

andredu

ced

clinicalinformation,Vigerland

etal.,2014).La

ckoff2f

monito

ring

during

theprocesswas

seen

asrisky

“Ifthe

patient’scond

ition

worsens,doesanyone

notice?”(ID

51)

Generalconcerns

aboutthe

efficacy

ofcCBT

(n=30,13%

)

Reflectsconcerns

relatedtoefficacy,efficiency,concerns

over

tailoring

“Isittoomuchofaone-size-fits-alltype?”(ID

217)

Concerns

ofpatient

engagement(n=39,16%

)Co

ncerns

relatedto

patient

engagement:Co

mmitm

ent,

motivation,ability

toexpressher/himselfin

written

form

at

“Iwonder,ifthereareeasy

drop-outs.Doesapatient

committo

therapy?”(ID

201)

Internetsecurity

(n=7,3%

)Co

ncerns

relatedto

internetsecurity

“Patient

recordsending

upinthewrong

hand

s,or

possiblehackingofpatient

data”(ID

133)

(contin

ued)

Table III.Data structure ofthemes of physicians’concerns with cCBT

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Higher-order

them

esSecond

-order

them

esFirsto

rderthem

esRepresentativequ

otation

Nonapplicablepatient

profi

le(n

=26,11%

)Co

ncerns

relatedtospecialg

roup

swho

arenotelig

ibleto

benefitfrom

cCBTsuch

aschild

ren,theelderly,patients

with

severe

issues

etc.

“Itreatm

entally

disabled

persons.Fo

rthemthere

should

bedifferentservices”

(ID212)

Implem

entatio

ncontext

Responsibility

androle

(n=47,20%

)

Care

responsibility(n

=36,

15%)

Who

takesresponsibilityforthe

patient

during

andafter

thecCBTcare;w

hoisresponsibleform

onito

ring

the

patient

andmakingnecessarychanges,especiallyifthe

patient

does

notfeelb

ettero

rdiscontinuesthetreatm

ent?

“Who

isresponsiblefortreatmenta

ndmonito

ring

ofthepatient?”(ID

406)

Patient

leftdrifting(n

=16,

7%)

Concerns

that

thepatient

isleftalonewith

thecond

ition

and/or

concerns

over

whetherthepatient

isgettingthe

requ

ired

supp

ort

“Inmyopinion,monito

ring

during

therapy,and

evaluatin

gtreatm

entresponseisnoto

ptim

ally

actualized,and

thus

patientsaresomew

hatleft

with

outcare”

(ID286)

Practicalmatters

(n=37,15%

)Unclear

practices

(n=19,8%)La

ckof

understand

ingofhowtodirectpatient

touse

cCBT,how

toreportetc.

“Idon’tk

nowhowto

directpatientsto

web-based

therapy”

(ID80)

Costcoverage

(n=12,5%)

Lack

ofclarity

onwho

pays

forthe

treatm

ent,thebilling

process,andhowthemoney

isdividedbetw

eenservice

providerandprescriber

“Allocatin

gthecostsoftheprescribercouldbe

complicated”(ID

256)

Rigid

cond

itions(n

=8,3%

)Cu

rrentp

ractices

that

preventedor

caused

problemsif

thepatient

was

directed

into

cCBT,suchas

guidelines

that

prohibitdirectingpatientsinto

cCBT,insomeareas

prescribingcCBTruledouto

ther

optio

nstoprovidecare

ortriggeredpatients’removalfrom

awaitin

glistfor

face-

to-fa

cetherapy

“Myem

ployerdoes

nota

llowpatientsto

bedirected

into

web-based

therapy”

(ID137)

Ideological

concerns

(n=26,11%

)

cCBTas

replacem

ent

(n=15,6%)

Concerns

over

cCBTbeingprom

oted

asan

inexpensive

optio

nandasolutio

nto

inadequateresourcestoprovide

care

“I’vegotanim

agethat

cCBTisprovided

for

econom

icreasonsandthehu

man

side

issecond

ary”

(ID28)

Importance

ofdiagnosis

(n=13,5%)

Concerns

that

cCBToffers

tooeasy

asolutio

nand

patientswill

notg

etaproper

diagnosisbefore

being

directed

onward

“Patientstreatedwith

outd

iagn

osis”(ID

260)

Table III.

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phase is feasible without meeting the patient face-to-face. The physicians believed a digitalinterface would condense too much clinical information. Once patients had been declaredsuitable for cCBT, they would then be advised to follow the instructions for the form ofcCBT (value self-creation). Importantly, the results of this study demonstrate the self-creation of value should not be the end of the process, which should extend to the physicianre-evaluating the situation with the patient (value co-creation). Accordingly, value creationshould be seen as an intertwined process where value co-creation and self-creation shouldoccur seamlessly at different stages. Physicians were concerned that using these types ofservices might leave the patient without support and saw their role as safeguarding patientcare. For the physicians, there also seemed to be a need to monitor patient value self-creation. Accordingly, the physicians felt the role of the service provider should nottransform from being a value co-creator to being only a value facilitator (Grönroos andVoima, 2013) but should also incorporate being a value self-creation supervisor.

4.2 Understanding and overcoming barriersUnderstanding of three different contexts provided a key to combine the quantitativehypotheses tested (Table II) and qualitative findings (Table III) systematically to furtherunderstand barriers and address factors that would facilitate self-service (cCBT)incorporation into integrated mental health care. This enabled RQ2 to be addressed: Whatare the barriers to digital self-service (cCBT) acceptance in mental health-care delivery andhow can they be overcome?

A summary of the identified key barriers for acceptance and aspects needed to beovercome is presented in Table IV.

The quantitative findings do not indicate individual level factors directly influenceintention (H1a; H1b); however, such factors do relate closely to the innovation context. Thequalitative findings indicate physicians need more information about suitable patientprofiles, the content of cCBT and help with selecting suitable cCBT service providers.Consistent with a market segmentation approach (Rundle-Thiele et al., 2015), the qualitativeresults suggest that guidelines on the severity of patients’ conditions and the suitability forself-service programs of different patient profiles should be developed. Increasing theunderstanding of the applicability of cCBT for different patient profiles might helpphysicians to see the benefits of cCBT for their patients, and hence increase the performanceexpectancy that in turn positively influences acceptance.

Figure 2.A framework tounderstand digitalself-service valuecreation logic

Consumer’s value sphere:Value self-creation

Provider’s value sphere: value production Joint value sphere:

Value co-creation

Physician role: Active value co-creator

Patient role: Active value co-creator

Physician role: Value facilitator AND value creation supervisor

Patient role: Active and independent value

creator

Physician role: Value facilitator

Patient role: n/a

Value creation supervisor as a necessary new role.

Value creation should be seen as anintertwined process where value co-creation and self-creation should occur seamlessly at different stages.

Source: Developed from Grönroos and Voima (2013)

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In relation to the innovation context, performance expectancy was found to be the primaryfactor influencing intention (H2). Themes related to efficiency also arose as the mainconcerns in the qualitative findings. The comments represent the feeling of physicians that adigital interface is not a suitable replacement for real interaction. The physicians viewed realinteraction as an important part of therapy both to promote efficiency and to ensure patientsare correctly monitored. This introduces the question of how to design an innovation in away that a digital interface does not replace but instead enhances face-to-face interaction.Another question is how the patient is to be safely monitored during the self-creation ofvalue. These modifications in the context of innovation itself are required to provide safeand efficient care delivery from the physicians’ perspective.

In relation to the implementation context, facilitating conditions had a significantinfluence on intention to prescribe (H3a). However, social influences did not have asignificant influence on intention to prescribe (H3b). Among the qualitative findings, thethemes responsibility and role, practical matters and ideological concerns were alsorecognized as capturing issues related to this context. Physicians’ intentions appear to behighly dependent on their employers’ policies. These aspects are crucial because often thefocus is on individual decision making, but in the case of clinical settings, institutionalfactors seem to play an important role. As the qualitative findings suggest, the currentpractices and facilitating conditions should support usage and a flexible transformationwithin the care chain between different levels of care and service provider (such as a cCBTservice provider). This requires careful process and policy development, as well as flexiblestructures and well-defined guidelines, on how these services can be organizationally tied tocurrent care practices.

Table IV.Summary of key

barriers foracceptance and

aspects needed tobe overcome

Context level

Barriers(Quantitativefindings) Barriers (Qualitative)

Key aspects needed to be overcome tobetter incorporate cCBT withinintegrated care

Individualcontext

Attitude(insignificantinfluencer)Knowledge(insignificantinfluencer)

Lack of knowledgePatient selectionContentService provider competence

Better knowledge of the applicability ofcCBT for different patient profiles

Innovationcontext

Performanceexpectancy(significantinfluencer)

EfficiencyLack of human contact(isolation, risk management)General concernsPatient engagementInternet securityNon-applicable patient profile

Product design to serve the needs ofthe physician to enable value self-creation monitoringProduct design that allows movingbetween value co-creation and valueself-creation

Implementationcontext

Facilitatingconditions(significantinfluencer)Socialinfluence(insignificantinfluencer)

Responsibility and roleCare responsibilityPatient left driftingPractical mattersUnclear practicesCost coverageRigid conditionsIdeological concernsCCBT as replacementImportance of diagnosis

Policies and practices that wouldenable value self-creation monitoringBetter integration of practices andstructures, possibility to move backand forth within value co-creation andself-creation

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5. Discussion5.1 Theoretical implicationsThe purpose of this paper was to enhance the current understanding of digital self-servicesas a form of cCBTs and of how they could be incorporated into integrated mental health-careprovision from the physicians’ perspective. The current research addressed its researchgoals by adopting a multidisciplinary perspective drawing on service marketing andinformation systems literature in the context of integrated mental health care.

The paper described the value creation logic of digital self-services and presented a newrole – value self-creation supervisor – under value creation in a health-care context; andaccordingly, this paper has extended the understanding of separated service delivery (Greenet al., 2016; Keh and Pang, 2010; Paluch and Blut, 2013). The results indicate value creationshould be seen as a simultaneous process where value co-creation and self-creation occurseamlessly at different stages in the service consumption process. Furthermore, these typesof digital services should not be seen as replacing co-creation, but as complementing it,highlighting the need for the solid integration of digital services within the care chain. Theresults suggest separated services can also serve more complex goals in the health-caresetting, in contrast to previous literature where self-services are suggested to serve routineactivities (Keh and Pang, 2010).

Second, this paper contributes to the current discussion about cCBT acceptance (Lazurasand Dokou, 2016; Montero-Marin et al., 2015; Topooco et al., 2017), identifying the innovationcontext together with the implementation context as the main barriers to greater utilization.The results suggest physicians would benefit from having a better understanding of theapplications of cCBT within their profession and from having access to facilitatingconditions to provide these kinds of solutions as part of the care chain. Consistent withprevious research (Topooco et al., 2017), this study found that current care systems are notyet ready for the integration of cCBT. Individual context factors (knowledge and attitude)were not found to be significant in influencing utilization, although in many previousstudies, lack of knowledge in particular has been highlighted as the main barrier to it(Du et al., 2013; Donovan et al., 2015; Vigerland et al., 2014).

Third, this paper has extended the understanding of the logic of value creation within themental health-care context and illustrated how digital self-services could serve asintegrators supporting the goal of integrated care. The current research has provided furtherevidence of the relevance of service theories within the health-care context (Hardyman et al.,2015; McColl-Kennedy et al., 2012; McDermott and Pedersen, 2016).

5.2 Managerial implicationsTaking a marketing approach to the development of service offerings for integrated carebrings the consumer into focus. In this context, there are two target groups of consumers;the patient and the physician, who each have different requirements. From the physicians’perspective, there are problems in both the service design and service delivery chain. Theseissues are also intertwined with the physicians’ ethical responsibility to provide the bestpossible care for their patients. Patients are often also vulnerable and therefore rely on theirphysicians to make treatment option decisions for them. This highlights that there are arange of ethical issues that need to be addressed for the physician as a consumer of cCBT asa separated service.

Although it is important to better understand how organizations can support thepatients’ role as active actors instead of passive recipients (McDermott and Pedersen, 2016),the results of this study emphasize that it is also important to understand when it is ethicaland appropriate to encourage an active role. Thus, to ensure these types of self-service

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programs are compatible for both groups, that is, the physician and their patients, it isimportant to also give due consideration to the patients’ specific needs and condition. Forexample, as part of the program design, physicians seem to require a mechanism or toolwhich allows them to monitor their patient’s progress. Guidelines should also be developedto address issues around the severity of patients’ conditions and their suitability for self-services such as cCBT. Further, the development of practices to choose the right patientsalong with incorporating and enabling monitoring has the potential to assist in overcomingsome of these important ethical concerns and enable physicians to fulfill their ethicalresponsibilities.

In addition, processes for moving the patient between digital and non-digital treatmentinterfaces need to be resolved at the policy level before such services can be fully integratedinto the care chain. The focus should be directed from individual-level factors to theimplementation-level factors that enable physicians to fully exploit these services withintheir work. Insights into the value creation logic and the related barriers from this study willprovide a foundation for discussion at the governing body level to enable the effectiveimplementation of these types of digital services as integrators in integrated care.

5.3 Limitations and future researchHealth-care systems vary across countries, which naturally also influence the interpretationand generalizability of the results of this study. Nevertheless, the study does provide adetailed description of the relevant health-care system and study context. Leveragingunderstanding through studying different health-care systems and countries should becentral aspects of future research. The service studied here, cCBT, also sets limits onthe interpretation of the results. This study was conducted in the context of mental healthwhere the patients are likely to be particularly vulnerable, which might be reflected in thephysicians’ responses. Future research should therefore study self-services in differenthealth-care contexts to test the extent of the universality of the concerns identified.Furthermore, the self-service type studied here is intended to deliver treatment, not to offerprevention or chronic condition management. This is important because there might bedifferences depending on which part of the care chain the self-service is incorporated within.Comparing self-services with different goals and positions in the integrated care chainwould improve understanding of their potential. Furthermore, as the results of this studyreveal, facilitating conditions is a major concern. A heightened understanding of thestructures within integrated care could assist in overcoming these concerns.

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Corresponding authorHeini Sisko Maarit Taiminen can be contacted at: heini.taiminen@jyu.fi

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PRACTITIONER COMMENTARYIncorporating digital self-servicesinto integrated mental healthcare:

a physician’s perspective

There is a common sense appeal about a therapeutic approach that can be accessed at all hourswithout leaving your home, especially where social anxiety, phobia, physical limitations or caringresponsibilities limit participation in traditional forms of therapy. But health professionals haveconcerns, and it is appealing that the authors suggest that digital interaction could be anenhancement rather than a replacement. This is certainly attractive for two reasons, first thatsome mental health practitioners are concerned about patient dependency and that theythemselves are perceived as the “active ingredient” in the patient’s recovery rather than thepatient recognising their agency. Second, patients need to be able to apply the cognitive andbehavioural changes they achieve in therapy into their day-to-day life. It is intriguing to considerhow that embedding process could be more likely when treatment is something that is itselfembedded into their daily routines, i.e. through digital sessions in their own home.

Taking a hands-off approach may challenge a physician about patients: How will theycope? Will they be motivated? What if they get worse and from a physician’s ownperspective? Is there input devalued? Does this threaten my role/contract? Will I be replacedby a digital interaction in the future? The concept of physician as a value self-creationsupervisor is helpful here, as it can help mitigate against resistance about a hands offapproach by instead suggesting a new facilitative role. Some physicians may already havebegun to shift to this mindset, for example, through recommending a self-help group thatthey may trust but that is outside their direct control.

In order to build both physician confidence and competence in this role, post-qualification training needs to be developed. It could be argued that incorporatingawareness of cCBT into basic training would help build an early appreciation of integratedhealthcare provision. This raises the potential for an early consideration of not if I willconsider cCBT as a treatment option but instead questions like: When would I introduce it?Howwould I introduce it? What would be my role in monitoring? Additional questions couldbe: To what extent would I engage the patient as an active consumer with autonomy overtreatment options? At what points in the process would I use face-to-face contact? Whatwould the function of this contact with me? Would I be most effective as a risk assessor,motivator and ambassador of cCBT, or extra support during a relapse or crises?

This shift in thinking could lead physicians to seek out informed advice on these questionsand present valuable questions for future research and maximising the voice of the pioneersalready working with integrating cCBT. For example, many of the respondents’ questionscould be answered by peers who have already wrestled with these issues, doubts could beaddressed and there could be a knowledge bank of best practice in operationalising cCBTwithin the therapeutic consultation. In essence the next step is taking this paper’s idea a stepfurther, i.e. how can I be themost effective value self-creation supervisor for my patients.

Rachel DaviesIndependent Researcher, Doncaster, UK

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European Journal of MarketingVol. 52 No. 11, 2018

p. 2251© Emerald Publishing Limited

0309-0566DOI 10.1108/EJM-11-2018-896

A paradoxical dynamic in aservice labyrinth: insights

from HIV careAngela Gracia B. Cruz, Elizabeth Snuggs and Yelena Tsarenko

Department of Marketing, Monash Business School,Monash University, Melbourne, Australia

AbstractPurpose –While theories of complex service systems have advanced important insights about integrated care,less attention has been paid to social dynamics in systems with finite resources. This paper aims to uncover aparadoxical social dynamic undermining the objective of integrated care within an HIV care service system.Design/methodology/approach – Grounded in a hermeneutic analysis of depth interviews with 26people living with HIV/AIDS (PLWHA) and drawing on Bourdieu’s (1984) theory of capital consumption tounpack dynamics of power, struggle and contestation, the authors introduce the concept of the servicelabyrinth.Findings – To competently navigate the service labyrinth of HIV care, consumers adopt capital consumptionpractices. Paradoxically, these practices enhance empowerment at the individual level but contribute to thefragmentation of the HIV care labyrinth at the system level, ultimately undermining integrated care.Research limitations/implications – This study enhances understanding of integrated care in threeways. First, the metaphor of the service labyrinth can be used to better understand complex care-relatedservice systems. Second, as consumers of care enact capital consumption practices, the authors demonstratehow they do not merely experience but actively shape the care system. Third, fragmentation is expectedlypart of the human dynamics in complex service systems. Thus, the authors discuss its implications. Furtherresearch should investigate whether a similar paradox undermines integrated care in better resourcedsystems, acute care systems and systems embedded in other cultural contexts.Originality/value – Contrasted to provider-centric views of service systems, this study explicates acustomer-centric view from the perspective of heterosexual PLWHA.

Keywords Integrated care, Capital consumption, Complex service systems, HIV care,Service fragmentation, Service labyrinth

Paper type Research paper

IntroductionThe provision and management of care in service contexts such as aged care, childcare andchronic conditions involve interwoven “configurations of people, technologies, and otherresources that interact with other service systems” (Patrício et al., 2011, p. 180). HIV care, forexample, requires not only integration across multiple disciplines in primary, secondary andtertiary clinical sites but also integration with social workers, community supportorganisations, providers of optional support services and providers of public funding. Insuch “complex human-centred service systems” (Breidbach et al., 2016, p. 458), theachievement of integrated care – defined as a patient-centred philosophy aimed at providingquality, comprehensiveness and continuity of care across a range of care-related needsthrough collaboration between multiple service providers and service systems (Bunger,2010; Danaher and Gallan, 2016) – represents a significant and on-going concern forconsumers, service providers and policymakers.

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Received 29 December 2016Revised 18May 201725 August 201714 November 201713 December 2017Accepted 19 June 2018

European Journal of MarketingVol. 52 No. 11, 2018pp. 2252-2265© EmeraldPublishingLimited0309-0566DOI 10.1108/EJM-12-2016-0822

The current issue and full text archive of this journal is available on Emerald Insight at:www.emeraldinsight.com/0309-0566.htm

While important insights about integrated care have been offered through the lens ofcomplex human-centred service systems from organisational perspectives (Bunger, 2010)and with particular attention to the role of service orchestrators (Breidbach et al., 2016),resource integration mechanisms (Bunger, 2010) and information and communicationtechnologies (Green et al., 2016), the social dynamics of complex service systems require adeeper understanding (Tien and Goldschmidt-Clermont, 2009). The very idea of integratedcare elides issues of power, struggle and contestation, representing salient considerationsparticularly within systems with finite resources. Attention to these issues offers insight onthe roots of systemic fragmentation, which continues to undermine the objective ofintegrated care.

To redress this asymmetry and capture these salient dynamics, we use Bourdieu’s (1984)capital consumption theory to elicit HIV service system dynamics that emerged through ahermeneutic analysis of depth interviews with 26 people living with HIV/AIDS (PLWHA).Specifically, we introduce the concept of the service labyrinth and explore how capitalconsumption practices of marginalised HIV-positive consumers are shaped by, andmaintain, fragmentation within the service labyrinth of HIV care. While the complexity ofthis service labyrinth drives capital consumption practices which contribute to consumerempowerment at the individual level, these same practices paradoxically contribute to thefragmentation of the service labyrinth at the system level.

Our first contribution is to demonstrate how the metaphor of the service labyrinth can beused to better understand complex care-related service systems. Second, as consumers ofcare enact capital consumption practices, we demonstrate how they do not merelyexperience but actively shape the care system. Our third contribution shows howfragmentation is expectedly part of the human dynamics in complex service systems. Thus,we discuss its implications. We conclude that more considered attention to complexasymmetries and flows of capital should inform the design of integrated care.

ABourdieusian lens on complex service systemsScholars have acknowledged the challenge of integrated care due to the complex nature ofhuman-centred service delivery systems (Breidbach et al., 2016; Bunger, 2010; Danaher andGallan, 2016). However, where complexity theories have been applied in shaping health-caresystems (Mowles et al., 2010), such approaches hold that the techno-rational assumptions ofsystems theory can be transposed into fundamentally human systems. Hence, theapproaches to care reform, to date, have been “insufficiently social” (Mowles et al., 2008,p. 818). To clarify this social dimension, we use Bourdieu’s (1984) capital consumptiontheory as an analytical lens for understanding the complex dynamics of care-related servicesystems.

This theoretical approach, pioneered by Bourdieu (1984) and developed by consumerculture theorists (Brei and Tadajewski, 2015; Mamali and Nuttall, 2016; Tapp and Warren,2010), emphasises an analytical focus on social practice. Here, practices within a given socialfield are fuelled by a drive for symbolic capital, referring to both material and non-materialassets which enable individuals to establish social identification and distinction in relationto other individuals in that field (Bourdieu, 1984). Social practices are regarded as“micropolitical acts of status claiming in which individuals constantly negotiate theirreputational positions” (Holt, 1998, p. 4).

Bourdieu (1986) underlined three types of capital which consumers continually acquire inthis “multidimensional status game” (Holt, 1998, p. 3): social capital, referring to the accessenabled by the “possession of a durable network [. . .] of mutual acquaintance andrecognition” (Bourdieu, 1986, p. 214); economic capital, referring to the aggregate of one’s

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actual and prospective financial, occupational and material resources; and cultural capital,referring to the embodied internalisation of distinctive practices which enable claims tolegitimised identities within a given field. These forms of capital are not only acquired, butmay be converted into other forms of capital (Coskuner-Balli and Thompson, 2013; Tappand Warren, 2010) or legitimised in the face of cultural forces which threaten theirdevaluation (Arsel and Thompson, 2011). For example, being socially connected toknowledgeable actors in a service system (i.e. social capital) can be converted into enhancedaccess to information about appropriate grants and application tactics (i.e. economic capital)or better knowledge about the “right” ways of interacting with care providers (i.e. culturalcapital).

Hence, capital consumption theory (Bourdieu, 1984) is particularly relevant forunderstanding the dynamics of service systems for two reasons. First, it moves from anactor-centric to a practice-centric analytical approach, focussing on the practices themselves,rather than the agents performing them. Care-related consumption behaviours are thus notanalysed as a result of individuals’ attitudes, values and characteristics, but seen asthoroughly entwined within the dynamic requirements of the complex service system inwhich such practices are embedded. Second, Bourdieu (1984) sensitises us to issues of powerand contestation, particularly intensified in consumption fields with finite resources.Bourdieu’s (1984) capital consumption theory has also been used in the interdisciplinaryspace of social and health policy research to understand the ideologically, institutionally andsocially contextualised, power-laden dynamics of public service provision (MacEachen et al.,2013; McDonough, 2006). In essence, a Bourdieusian theoretical approach underscores howan iterative play for access to important resources – including relevant information, “best”care providers, inclusion and respect amongst important reference groups and priority infinite public funding –might unfold in a care-related service system.

MethodResearch contextThe chosen research context was the HIV care service system as experienced by PLWHA inAustralia who identified as heterosexual, a less visible (Tsarenko and Polonsky, 2011) butgrowing segment of the PLWHA population (Persson et al., 2014). HIV care epitomises acomplex human-centred service system because it involves multiple service actors includingclinicians, social workers, peer-based community support groups, providers of optionalsupport services and gatekeepers of public funding. HIV consumers of care not only seekresources in the form of clinical care but also support services such as mental healthcare,childcare, massage, housing support and financial support through unemployment phases.The uncertainty and tension of these journeys are exacerbated by the stigmatisation of HIVand consequent discrimination of PLWHA (Gagnon, 2015; Mahajan et al., 2008).Additionally, the constantly shifting nature of this service system is fuelled by individualcase complexities and changing profiles of PLWHA. HIV/AIDS is no longer viewed as aterminal illness, but a chronic lifelong condition (Deeks et al., 2013; Dockrell, 2017;Zimmerman and Kirschbaum, 2017). Consumers navigating this service system often facesignificant confusion, struggling with where to start and what support is available. Thechronic and unique nature of their illness compels consumers to navigate a personalpathway into andwithin this system.

Data collectionGiven the complex, multifaceted and sensitive nature of the HIV service system, aqualitative approach is justified because it does not presuppose the parameters of a

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phenomenon (Lincoln and Guba, 1985), allowing latitude to explore further dimensions ofpractice and experience not immediately apparent to researchers. While we did not hold an apriori concept of the service labyrinth at the start of this research, we were quicklysensitised to issues of service system fragmentation and competition for resources throughfield conversations with multiple actors, including medical practitioners, service systemproviders and participants themselves. The theme of fragmentation was further reinforcedin our reading of health-care and services literature (Bunger, 2010; Danaher and Gallan,2016). Our Bourdieusian theoretical lens and emergent concept of the service labyrinthsubsequently evolved through a dialectical back-and-forth between emic and eticperspectives, in line with hermeneutic philosophy (Thompson, 1997).

Data generation occurred over a period of two years, involving depth interviews with 26heterosexual PLWHA in two metropolitan areas in Australia. Permission to conduct thestudy was granted by the University Ethics Committee. Participants were recruited throughpersonal approaches, snowballing and information flyers via HIV community-basedsupport organisations, medical practitioners, social workers and government agencies.Given the relative invisibility of heterosexual PLWHA and the sensitivities surroundingdisclosure (Nelms and Zeigler, 2008), considerable time was spent building trust withorganisations to gain access to participants, extending the data generation period.Participants embodied a range of characteristics including gender, age, family status,occupation, employment status and years since diagnosis (Table I).

Interviews followed a semi-structured approach and ranged between 1 and 2 h. Eachinterview began with “grand tour” questions about each individual’s life story and howthey came to be diagnosed with HIV (McCracken, 1988). Interviewees’ experiences ofpost-diagnosis life were inextricably intertwined with the dynamics of the broader caresystem, often involving personal stories regarding the complexities and strategies fornavigating access to care. The data collection process generated over 30 h’ audiorecordings and over 500 pages of transcripts ranging from 3,694 to 23,589 words(averaging 9,482 words).

Data analysisAnalysis of transcripts was guided by a hermeneutic interpretive approach (Thompson,1997), characterised by a dialectical iteration between text, interpretation and literature thatevolved over time. In addition to the use of open, axial and selective coding (Strauss andCorbin, 1998), trustworthiness of the emergent interpretive framework was enhancedthrough several methods. These included triangulation of interviews through directengagement with, and informal observation of, local HIV community-based supportorganisations; extensive discussions of coding decisions with experienced qualitativeresearchers; member checks to minimise distortions in interpretation; and regulardebriefings during and after data collection to facilitate data immersion and constantcomparison of emerging interpretations between the authors. The hermeneutic approach isin line with our Bourdieusian conceptual framework: over and above a focus on individualexperience, the hermeneutic approach takes individual narratives as social texts, offering awindow into the “unspoken background” (Thompson et al., 1994, p. 432), which informsindividual consumers’ practices and experiences.

FindingsOur analysis led to the concept of the service labyrinth as an informing metaphor forunderstanding the social dynamics of an HIV care service system. We define a servicelabyrinth as a service system characterised by complex, inter-related and frequently shifting

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maze-like networks of service actors and social, financial, material and technologicalresources, requiring consumers to navigate through nonlinear, uncertain and potentiallypuzzling service consumption experiences. The service labyrinth emphasises severalproperties already identified in the literature relating to complex service systems: theirinvolvement and integration of multiple actors and resources (Patrício et al., 2011), theiradaptive and dynamic nature (Chandler and Chen, 2016) and a degree of uncertainty (Tienand Goldschmidt-Clermont, 2009). What is less explicit, however, are notions of tension,conflict and contestation.

Navigating a service labyrinth requires consumers to overcome obstacles and makechoices about which direction to turn. For example, HIV patients regularly confrontdilemmas about whether to disclose their illness (Nelms and Zeigler, 2008), renderingthemselves vulnerable to potential service providers. Moreover, because service labyrinthsare dynamic and frequently shifting fields of practice unfolding in concert with multipleinter-related actors, they comprise hidden layers of knowledge and meaning. Essentially, aservice labyrinth is less of a “map” and more of a continually emerging series of puzzles.Each actor can only enjoy a partial and temporally situated view of their immediateinterests, networks and available choices. Consequently, the service labyrinth can bothexacerbate vulnerability and enable empowerment: while consumers may easily “get lost” ina complex labyrinth of service actors and resources, successfully carving a path through aservice labyrinth could lead to an empowering experience. The use of the term labyrinth

Table I.Participant profiles

Pseudonym Sex and age Family status Occupation Employment statusYears sincediagnosis

Sarah F, 38 Married Family support officer Part-time 21Alison F, 37 Engaged Transcriber Self-employed 8Stephen M, 33 Married Social worker Part-time 23Claire F, 40 Married Clerical DSP 11Christian M, 51 Divorced Chef DSP; volunteer 11Andrew M, 53 Single Taxi driver Volunteer 20George M, 47 Divorced Truck driver Part-time 10Matthew M, 45 Divorced Resort manager DSP; volunteer 9Laura F, 46 Single Crafting DSP 2Kerry F, 35 Married Photography DSP; maternity leave 8Mary F, 41 Single Part-time student DSP; volunteer 18Paul M, 58 Married Baker Retired 10Robert M, 41 Married Driver Part-time 7 weeksDebra F, 29 Single Women’s activist Part-time 16Jacqui F, 50 Divorced Health worker Part-time 17Sally F, 45 Single Casual DSP 10Evelyn F, 42 Single Arts DSP 18Ashley F, 38 Single Nurse DSP 19Martha F, 50 Married Casual DSP 24Deidre F, 47 Married Casual DSP 15Sophie F, 35 Married Casual DSP 7Nina F, 44 Single Casual DSP 20Conrad M, 53 Married Drama Volunteer 25Cecelia F, 48 Married Casual DSP 24Anabel F, 38 Married Social worker Part-time 20Simon M, 35 Married Retail manager DSP 17

Note: DSP – disability support pension

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highlights issues of consumer marginalisation and empowerment, underscoring tacitmechanisms for successful navigation.

Our analysis further reveals three intersecting elements: HIV service system complexity,capital consumption practices and individual consumer empowerment (Figure 1).Understanding the dynamics between these elements sheds light on how the HIV care-related service system has evolved into a labyrinth for PLWHA. Three themes highlight thethoroughly human dynamics of the HIV care service system. First, the complex nature of theHIV service system resonates with the concept of a service labyrinth. Second, consumersadopt capital consumption practices in response to HIV service system complexity. Finally,a paradoxical dynamic emerges: the practices which facilitate empowerment at theindividual level simultaneously produce the disempowering outcome of fragmentation atthe system level.

The complexity of the HIV service systemParticipants entering the HIV care service system for the first time found it confusing andoverwhelming. Because of its labyrinthine character, the accepted practice was to find aninformal guide, purposely or accidentally, setting them on the right path to access resourcesand support (Patrício et al., 2011):

There’s a lot out there but unless you know or get told, you don’t know they are there [. . .] Whensomeone is newly diagnosed I know how to talk to them, I know how to help them find the rightsupport. (Matthew)

Figure 1.A paradoxical

dynamic in a servicelabyrinth

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Participants revealed several issues underlying the complexity of the HIV care servicesystem. First, the lack of education about HIV within the service labyrinth is a prominentcontributor, where disclosure of HIV status often led to judgment and discrimination fromhealth-care professionals (Gagnon, 2015; Mahajan et al., 2008). As indicated by Christian’sprotracted search for non-discriminatory care, the limited choice of HIV-friendly serviceproviders emerged as a daunting, recurrent barrier to care:

I’ve been discriminated against by nurses, by doctors, nurses coming into my home wearinggloves [. . .] I went through eight personal carers in eight months because I had HIV [. . .] And Isaid this is not going to happen anymore and [they should] tell whoever comes to work with methat I’m HIV-positive. If they don’t want to work with me because I’m HIV-positive, then don’tsend them. (Christian)

Another contributor to the complexity of the HIV care labyrinth at a system level is limitedtransparency, visibility and accessibility due to funding constraints and system instability.Because services evolve and adapt based on changing resources, consumers were oftenuncertain about their availability and rules of access. Minimal tweaks to services couldcompel participants to modify their practices. Given this recurring issue, consumers need tomaintain current knowledge or risk experiencing reduced system access:

It’s a matter of knowing the system and being able to navigate the system, use it to my bestadvantage [. . .] It’s all kept under layers of paperwork and big secrets [. . .] Finding support ishard [. . .] Often they’re not advertised as for positive people, so you can’t just look it up in thephone book, you need to know somebody that knows what’s going on that can then tell you.(Nina)

Both a lack of education and resource allocation are critical contributors to the servicesystem’s complexity. Combined with the emotional, mental and physical states ofconsumers trying to access the system, this could lead to compromised outcomes fortreatment and support or the consumer choosing to exit the service labyrinth altogether.

Adopting capital consumption practicesGiven the confusing and complex nature of the service labyrinth, consumers are required toadopt capital consumption practices. Such practices encompass participants’ on-goingattempts to:

� acquire and convert field-dependent social capital into improved access to care-related resources;

� convert field-dependent social capital into economic capital; and� acquire, legitimise and convert field-dependent cultural capital into improved access

to care-related resources.

These inter-related processes of capital acquisition, conversion and legitimisation areenabled through service consumption practices, referring to consumers’ investments in field-specific skills, knowledge and dispositions as enacted through iterative interactions withmultiple actors in the service labyrinth.

Social capital was the most common type of consumption capital nurtured, confirmingprevious studies (Derose and Varda, 2009). Notions of credibility and trust were particularlyimportant, as confirmation of “insider” status and connection to key knowledgestakeholders facilitated more effective “follow through”, improving access to care within theservice system:

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The women there [in Service Provider D] know me, and they know I’m credible and they arecredible, and they will follow through. I find with any other government organisation orcommunity organisation, you could ring them and talk to them on the phone, but they don’tnecessarily follow up and they don’t always do what they say they’re going to do. (Nina)

Given the role of support groups in pooling knowledge and experiences in navigating the servicelabyrinth, acquiring social capital emerged as a necessary prerequisite for participants:

You have to be linked into one of them. Whether it be [Service Provider A], [Service Provider B],[Service Provider C], or [Service Provider D], because they’ll link you into everything. (Sarah)

In addition to social capital acquisition, participants consumed two additional types ofcapital: economic and cultural. With economic capital consumption practices, participantsused the HIV service system to improve their aggregate financial standing. A ripple-effect ofopportunity leading to further pecuniary outcomes was observed. In one instance, Sarahbegan volunteering with one of the support groups, leading her to further employmentopportunities. In another, more typical instance, Matthew’s access to one service allowedhim to discover unrelated opportunities, converting social capital into more financialsupport andmaterial resources for his son’s education based on his HIV status:

[Service Provider E] introduced me to an organisation through the government where they helpthe children, like they can help pay for the school uniforms. He [my son] got a grant and he got alaptop because of my [HIV] status [. . .] There are things out there but you have to be involvedbefore you actually find out these things. (Matthew)

With cultural capital consumption practices, participants claimed distinct identities andreputations (Bourdieu, 1986) through their individual ownership of their HIV status(Tsarenko and Polonsky, 2011) and an assertion of the unique knowledge they possess fromtheir experiences within the service labyrinth. Moreover, in the face of government-drivenpressures toward professionalisation of services, some participants’ insider status as long-standing community advocates needed to be constantly legitimised, defended and reasserted:

I think that we always need to be involved in the decision-making process because we are theones who understand what it is to live with it. We’re the ones who can help talk about things likehow to stop transmission and talk to our own community. (Kerry)

Legitimising identity within the HIV service labyrinth often involved intense personaldilemmas about disclosing HIV status, thereby exposing an individual’s vulnerability or, ata minimum, resulting in a reduction in privacy. In most instances, an internal evaluation ofimpact occurred prior to disclosure (Nelms and Zeigler, 2008):

I totally respect why someone doesn’t disclose however there are benefits that you need toconsider. It’s still a really hard decision, you may make it and get it wrong. (Anabel)

Overall, the practice of acquiring, converting and/or legitimising social, economic andcultural capital enabled individual consumer empowerment. By improving the flow ofresources and reducing the barriers to access, these practices enabled participants to betternavigate the HIV service labyrinth and steer it to their benefit. Notably, volunteering, boardmembership or employment within the HIV care service system enabled successfulnavigation by consumers who engaged in such practices. This is evidenced by Sarah, who isemployed as a community worker in an HIV peer support organisation:

I am aware of everything that is available, if I need help with something. I know where to go if Ineed legal advice. Same with dental. I know where to go that is HIV friendly or HIV educated(Sarah).

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In short, capital consumption emerges as a prerequisite for brokering access to care andachieving positive health outcomes at an individual level.

The fragmentation of the HIV service systemAt the system level, however, capital consumption practices within the HIV servicelabyrinth are influenced by, and contribute to, power struggles, tensions and rivalries.Illustrating Bourdieu’s (1984) assertion that actors in a given social field draw on multiplematerial and symbolic resources in their struggle to maintain and defend their positions, on-going rivalries between multiple actors such as service providers and consumers wereevident in the HIV service labyrinth:

[Service Provider D] started fighting [Service Provider B] for funds and they still do today. Theyfight each other: “I am bigger. I am better.” [. . .] I find at times it’s a big competition to see who’sgoing to get in the paper for recognition on something. (Matthew)

Kerry raised another point of competitive tension, where resource asymmetries areperpetuated over time:

At [Service Provider D] the [HIV-positive] director before this one was very good at gettingmoney. And so now they’ve got it, they just keep on getting it because they’ve got a goodreputation. (Kerry)

It was apparent that some service providers were perceived as insular, advancing only theirown agenda while defending their allocation of resources to the detriment of others and thebroader HIV service system. Most notably, rivalry between service providers shifted thefocus from meeting the needs of HIV care consumers to maintaining and enhancing theirposition within the broader service system.

With multiple agendas and protectionist practices in place, the service system canfracture, resulting in fragmentation. These tensions transpire in different ways, withparticipants forming diametrically opposed views about the ideal structure of the servicesystem. On one hand, participants such as Christian called for a merger of care to createholistic management of resources:

We have three lots of organisations who are resourced to do one thing and that is support peoplewith HIV and educate the community. If we pooled all our resources and we came together as oneorganisation [. . .] how much more powerful education, information and awareness programscould be developed with such power [. . .] It can no longer be fragmented. If it stays fragmentedthings won’t change, but if we come together it will change. (Christian)

In contrast, Martha expressed concern that conglomerating services would reduce supportavailable to consumers not perceived as “typical” consumers:

We’ve heard that in [Australian state], they’re talking about amalgamating all the differentservices and it’s something here we really fought against because [. . .] women’s needs are often alittle bit extraordinary, particularly with kids [. . .] The government has their picture of what aHIV-positive client should be and you have to fit within their parameters – almost like a one-size-fits-all. Most HIV services are geared towards the infected person themselves and maybe theirpartners, but there’s very little geared towards HIV-positive people that have non-HIV children. Itdoesn’t fit within their funding. I tried to look up places where [my child] may have sought somecounselling or support but there was nothing there. (Martha)

Another layer of competition transpired along dimensions of gender, sexual orientation, ageand mental health, with participants defending their distinct identities. Some participants

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felt that more resources should be allocated to their personal situation, even if it underminedother services:

The gay community through [Service Provider B] seem to be getting more than heterosexualpeople [. . .] [Service Provider C] is small and non-profit, but if you go up the other end of town to[Service Provider A] which [Service Provider B] run, they’ve got the money. (Paul)

In these ways, consumers and service providers’ practices of corralling material andsymbolic resources helped maintain divisions in the HIV service labyrinth. While theexisting service system nurtures capital consumption practices to enhance individualconsumer empowerment and positive outcomes, these same practices protect and supportsystem-level fragmentation.

DiscussionThis research contributes to the growing dialogue on the importance of services integrationto improve patient-centred care (Bunger, 2010; Danaher and Gallan, 2016) and ultimately thewell-being of PLWHA. Our exploration of an existing HIV care service system highlightsthe important role of marketing theory in advancing the agenda of integrated care. Notably,our Bourdieusian practice-based focus on the social dynamics of the HIV service labyrinthencourages theorists, policymakers and managers to reframe their assumptions of, andapproaches to, integrated care in the following ways.

First, this paper introduces the concept of the service labyrinth. While integrated careaspires for all services and resources to be available and easily accessible to consumers, ourfindings present an alternative perspective, recognising conflicting goals and agendas thatexist within a complex care system through the introduction of the service labyrinthmetaphor. While passing references to service labyrinths appear in the interdisciplinaryliterature on social services (Cooper, 2015; Sullivan and McCabe, 2015), this is the first studyto develop this concept in depth. This metaphor facilitates the recognition of key elementsthat actively contribute to creating the labyrinth through the interactions and inherenttensions that occur between them. To better deal with social stigma and discriminationassociated with HIV, the service system was populated by services catering separately forthe unique needs of homosexual people, heterosexual people, families and women. Theseservice providers position and define themselves as distinct organisations competing forfinite material and symbolic resources, contributing to the on-going fragmentation.

Second, our study shows how consumers of care do not merely experience the caresystem but actively shape the system through practices of capital consumption. Thesepractices fuel a paradoxical dynamic, facilitating empowerment at the individual level whilesimultaneously producing the disempowering outcome of fragmentation at the system level.Even though the proliferation of multiple services (in response to the diversity of individualcircumstances) is aimed at facilitating equal access to care, the on-going dynamics ofcompetition among actors in this field paradoxically fuel a service system characterised byfragmentation, constraint and asymmetrical access to care.

This study advances extant research from social and health policy by drawing onBourdieu to understand the importance of social and cultural capital in reinforcingadvantage and disadvantage in the context of public service provision (Falzer, 2007;McDonough, 2006). While the idea of social capital consumption is well established in theliterature (Derose and Varda, 2009), we show that acquiring, converting and/or legitimisingeconomic and cultural capital are equally essential for individual consumer empowerment.Apparent from the narratives, access to a continuum of services addressing health-careneeds requires consumers to immerse themselves in the service system so as to navigate

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services and ensure sustained, positive outcomes. Finite resources and contests for capitalprotect the fragmented nature of the service system and pose additional challenges tointegration within this context. The inherent dynamics and relationships betweenindividual- and system-level elements create a paradox in the HIV care labyrinth.

Third, policymakers are encouraged to consider how system complexities, combinedwith the unintended effects of capital consumption practices, may result in a fragmentedcare system. This insight highlights the critical limits of integrated care within an existingservice labyrinth. In such contexts, more considered attention to complex resourceasymmetries and flows of capital should inform the design of integrated care. Particularly,policymakers should be cognisant of institutional struggle and competition within the HIVcare system. The HIV service system in this study has evolved organically andspontaneously with benevolent intentions. However, its historical trajectory has created pre-conditions for the on-going fragmentation.

To mitigate inherent challenges of the fragmented service system, HIV support serviceproviders should undergo ideological and systemic shifts in the way they operate. Thisaligns with recent arguments by marketing theorists that service system design wouldbenefit from enhanced attention to “social structures and forces and not only resources”(Edvardsson et al., 2015, p. 80). Public policy theorists have similarly argued that a focus on“capacity building” and client empowerment (Newholm et al., 2006) can construct a “contextin which disadvantaged groups could build the skills and experience necessary to ‘play thegame’ effectively” (Hastings and Matthews, 2015, p. 554). Policymakers can support thisshift by emphasising not only metrics focussed on resources and efficiency (e.g. grantdollars obtained and number of clients served) but also qualitative indicators of clientempowerment (e.g. client confidence in accessing the services they need and improvementsin their subjective well-being).

Furthermore, our findings suggest the importance of policies which not only incentivisecompetition but also incentivise collaboration. This could be implemented throughformalising and sharing best practices in the broader care system, leadership skills trainingand establishing both formal and informal relations with organisations outside the sector. Inaddition to allocating funding to service providers based on their membership numbers,funding could also be weighted towards the sharing of best practices and the establishmentof knowledge sharing platforms between service providers in this complex service system.

Limitations and future researchWhile our study was conducted with PLWHA, it would be beneficial to compare the types ofcare accessed by populations with other chronic conditions. In particular, do paradoxicaldynamics permeate health service delivery systems for people with chronic conditions suchas cancer, diabetes or heart disease? Further research could also investigate whether similarparadoxes undermine integrated care in better resourced systems, acute care systems andsystems embedded in other cultural contexts. Future research can additionally explore howservice labyrinths could be better designed and managed to support consumer navigationand enhance positive outcomes. There is particular potential to investigate how individuals’variegated positionalities with respect to a service labyrinth may shape divergent well-beingoutcomes. For example, consumers with high levels of capital in other fields may not be asdependent on the HIV service system because they can access alternative support systems,while advances in medical treatments for younger and more recently diagnosed PLWHAhave also enabled less dependence on the HIV service system (Deeks et al., 2013; Dockrell,2017). Conversely, consumers with more years of diagnosis may be better socialised intotacit field dynamics and hence be better equipped to accumulate, convert and legitimise

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various forms of capital. Overall, this paper provides a critical perspective on the socialdynamics of an existing service system, which ultimately undermine integrated care. Wecall for further interdisciplinary research building on these insights to investigate andpromote the goal of integrated care.

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About the authorsAngela Gracia B. Cruz is a Senior Lecturer in Marketing at Monash University. Her research isfocussed on theories of consumption, marketing communication and branding at the boundaries ofmarkets – referring to liminal market spaces where complexities, ambivalences and transformationsabound. Her research has appeared in the European Journal of Marketing, International MarketingReview, Qualitative Market Research and Journal of Business Research, among others. Angelafrequently draws on cross-disciplinary, critical and poststructuralist modes of theorising in line withthe consumer culture theory paradigm. Angela Gracia B. Cruz is the corresponding author and can becontacted at: angela.cruz@monash.edu

Elizabeth Snuggs is a Lecturer in Marketing at Monash Business School. Her research isqualitative-based with dual interest within the fields of business education and consumer culturetheory.

Yelena Tsarenko is an Associate Professor in the Department of Marketing at Monash University.Her primary research interests are in consumer psychology and services marketing. Yelena haspublished her research in journals such as Journal of Service Research, European Journal ofMarketing, Journal of Business Research and several other journals. Her paper in the Journal ofServices Marketing has received the best commended paper by Emerald Literati Award 2008.

For instructions on how to order reprints of this article, please visit our website:www.emeraldgrouppublishing.com/licensing/reprints.htmOr contact us for further details: permissions@emeraldinsight.com

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COMMENTARY

Practitioner commentary on: aparadoxical dynamic in a servicelabyrinth: insights from HIV care

The French city of Chartres, south of Paris, is home to the famous cathedral Notre Dame deChartres, which was built around 1300. It has beautiful stained-glass windows andexuberant sculpture work, and in crypt the sancta camisa is kept. These are the robes thatMaria is said to have worn during the birth of Christ. Because of this relic, the cathedral is aplace of pilgrimage for many pilgrims, and also because Jacob’s route to Santiago deCompostella starts there. Pertinent to this commentary, the cathedral has a labyrinthembedded in the floor of the church’s midship. The labyrinth is composed of 11 circularwalkarounds that lead to its midpoint. Pilgrims who visit the cathedral walk the labyrinthas part of their pilgrimage, some do it on their knees. The labyrinth’s geometric structurehas had spiritual significance for eons and appears in many cultures and religions. Thepremise is that by walking the route through the labyrinth one contemplates one’s walk oflife. Arriving at the midpoint will lead to introspection and being in touch with the divineprinciple. The fact that this introspection is not easy appears from another characteristic ofthe labyrinth: one does not go straight to the central point but maximizes one’s route. Timeand again one is pulled away from the centre to arrive at the edge. The goal seems furtheraway than ever but it is essential to keep moving and pull through for eventually thedestination will be reached, according to the labyrinth’s premise.

In a similar vein, patients try to find their way through the labyrinth of integrated care,where an imagined destination would be better health and quality of life. En route in thisservice labyrinth, patients encounter doctors, caretakers, social workers and people invarious supporting roles. However, in contrast to the Chartres labyrinth, the route does notalways automatically lead to the central destination. In the service labyrinth the route issometimes unclear or filled with obstacles, and wrong choices can be made as a result ofwhich there is a chance of getting lost. The labyrinth can turn into a maze with wrong turnsand obstacles. The question is how to navigate the service labyrinth in such a way thatbetter health and quality of life can be reached.

It is very likely that the situation is even more complex than described in the research byCruz, Snuggs and Tsarenko (this issue). In addition to carers from the regular care circuit,patients often also use complementary and alternative cures (CAC). As a naturopathicpractitioner and provider of CAC, I meet these patients on a daily basis. Their decision to optfor complementary treatments is often not based on dissatisfaction with regular careoptions; they choose to combine regular and alternative care and cure. They want the bestfrom both worlds, as a recent study conducted in The Netherlands reveals (Jong et al., 2012).A study among HIV patients in Trinidad also bears witness to such an outlook;approximately a third use CAC, driven by the motivation to “try everything that could help”and also “take control themselves” (Bahall, 2017).

Patient-centric care only fully emerges when such findings are taken seriously andcomplementary and alternative care are acknowledged as elements of integrated care.

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Unfortunately, this will only make the service labyrinth more complex and it will make thequestion of how to navigate more pressing. A guide by one’s side, in whatever form andclear signage are essential. Possibly, the Chartres labyrinth with its implied significance ofintrospection can show us the way. In my work as CAC therapist, I have noticed howimportant it is for patients that they fit their (chronic) condition with their self-image and lifein a positive manner. In order to achieve this, one has to know oneself and one’s own needsand learn how to use one’s health creatively and optimally. This type of introspectionincreases the capacity to make better use of one’s internal compass. In turn, this will enablepatients to navigate through life and through the service labyrinth.

Marilène DolsIndependent Researcher, Maastricht, Netherlands

ReferencesBahall, M. (2017), “Prevalence, patterns, and perceived value of complementary and alternative

medicine among HIV patients: a descriptive study”, BMC Complementary and AlternativeMedicine, Vol. 17 No. 1, p. 422.

Jong, M.C., van de Vijver, L., Busch, M., Fritsma, J. and Seldenrijk, R. (2012), “Integration ofcomplementary and alternative medicine in primary care: what do patients want?”, PatientEducation and Counseling, Vol. 89 No. 3, pp. 417-422.

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