Forthcoming IJRM Volume 31 #3 (2014)

Transcription

1 The Effet of Customer Empowerment on Adherene to Expert Advie Nuno Camaho 1,* Martijn De Jong 2 Stefan Stremersh 3 Marh 30 th, 2014 ========================================================== ARTICLE INFO Artile history: First reeived in September 20, 2012 and was under review for 6 months Area Editor: Russell S. Winer ============================================================ 1 Nuno Camaho (amaho@ese.eur.nl) is Assistant Professor of Marketing at the Erasmus Shool of Eonomis, Erasmus University Rotterdam, the Netherlands. 2 Martijn De Jong (mgdejong@ese.eur.nl) is Professor of Marketing at the Erasmus Shool of Eonomis, Erasmus University Rotterdam, the Netherlands. 3 Stefan Stremersh (stremersh@ese.eur.nl) is Chaired Professor of Marketing and the Desiderius Erasmus Distinguished Chair of Eonomis, at the Erasmus Shool of Eonomis, Erasmus University Rotterdam, the Netherlands, and Professor of Marketing, at IESE Business Shool, University of Navarra, Spain. * Corresponding author. Tel.: ; Fax: Address: Burg. Oudlaan 50, room H15-09, 3062 PA Rotterdam, the Netherlands. We thank the Marketing Siene Institute for finanial support. We are also indebted to Bas Donkers, Benedit Dellaert and Gerry Tellis for their insightful omments and suggestions. We also thank partiipants at the 2010 Marketing Siene and 2011 EMAC Conferenes and seminar partiipants at Groningen University, Tilburg University and Católia Lisbon Shool of Business and Eonomis for all their valuable suggestions. The usual dislaimer applies.

2 The Effet of Customer Empowerment on Adherene to Expert Advie Abstrat Customers often reeive expert advie related to their health, finanes, taxes or legal proedures, to name just a few. A noble stane taken by some is that experts should empower ustomers to make their own deisions. In this artile, we distinguish informational from deisional empowerment and study whether empowerment leads ustomers to adhere more or less to expert advie. We empirially test our model using a unique dataset involving 11,735 respondents in 17 ountries on four ontinents. In the ontext of onsumer adherene to dotors therapy advie (patient non-adherene to dotor advie may ost about $564 billion globally to the pharmaeutial industry every year), we find that deisional empowerment lowers adherene to expert advie. The effet of informational empowerment varies preditably aross ultures and is only universally benefiial when initiated by the ustomer. These findings have important impliations for professional servie providers. Keywords: Relationship; servies marketing; expert servies; professional servies; advietaking, advie-giving, adherene to expert advie; empowerment; delegation; international marketing researh; ross-ultural studies; health marketing; onsumer behavior.

3 1 1. Introdution Customers often rely on experts, suh as aountants, onsultants, lawyers and physiians to make omplex deisions (Bove & Johnson, 2006). Expert advie dereases deision omplexity (Brehmer & Hagafors, 1986) and may improve deision quality (Yaniv, 2004). There is a rih literature, in marketing and psyhology, on ustomer-expert interations. One stream of literature fouses on how experts use ustomers input and feedbak to update their beliefs and deisions (e.g. Camaho, Donkers, & Stremersh, 2011; Narayanan & Manhanda, 2008). For instane, Camaho, Donkers and Stremersh (2011) show that, when learning about a new drug, physiians plae more emphasis on feedbak from patients who swith to alternative treatments than on feedbak from patients who ontinue their therapy. A seond stream of literature fouses on expert advie and ustomer adherene to suh advie (Bonaio & Dalal, 2006; Bowman, Heilman, & Seetharaman, 2004; Fitzsimons & Lehmann, 2004; Shwartz, Lue & Ariely, 2011; Tost, Gino, & Larrik, 2012; Usta & Häubl, 2011). The present paper fouses on the effets of ustomer empowerment during an advising interation on ustomer adherene to expert advie. In a typial ustomer-expert interation, a ustomer reeives an advie from the expert and subsequently deides whether to adhere to suh advie 1. A robust finding from this literature is that people do not suffiiently adhere to expert advie (Bonaio & Dalal, 2006). The traditional view of ustomer-expert interations is that the expert should hoose a partiular ourse of ation on behalf of the ustomer (e.g. I would advise you to do X, see Bonnaio & Dalal, 2006, p.128), a deision-making style we all paternalisti (e.g. Charles, Gafni & Wheelan, 1999). For example, a paternalisti lawyer-lient interation proeeds with a lient 1 We assume a setting where the ustomer seeks the advie of a single expert and that ustomer adherene to the expert s advie improves deision quality for the ustomer. This assumption builds upon the advie-taking literature (Bonaio & Dalal, 2006; Yaniv & Kleinberger, 2000; Yaniv, 2004).

4 2 exposing a legal problem to her lawyer who then reommends a partiular ourse of ation to the lient (Mafarlane, 2008). The lawyer then expets the lient to follow her advie to maximize hanes of suessful litigation. This traditional view of ustomer-expert deision-making stands in sharp ontrast to the inreasing influene or empowerment of the ustomer (Camaho, 2014; Camaho, Landsman, & Stremersh, 2010; Fuhs, Prandelli & Shreier, 2010; Mafarlane, 2008; Rapp et al. 2006). Empowerment refers to strategies or mehanisms that equip people with suffiient knowledge and autonomy to allow them to exert ontrol over a ertain deision (Ozer & Bandura, 1990). Empowerment ours when, instead of merely sharing diagnosti information i.e. information that allows the expert to understand the ustomer s problem - the expert and the ustomer disuss additional solution-relevant information. That is, information about alternative ourses of ation (e.g. there are two possible ourses of ation: option X and option Y ), their pros and ons (e.g. the downside of option X is ) or their fit with the ustomer s own preferenes ( I believe option Y may fit you well beause ). Finally, empowerment also ours when instead of reommending a single ourse of ation the expert onludes the interation by leaving the final hoie of a ourse of ation in the hands of the ustomer (e.g. we disussed options X and Y, please make your informed hoie ). Therefore, we distinguish between two different forms of ustomer empowerment. Informational empowerment ours when the ustomer and the expert share solution-relevant information. Deisional empowerment ours when the expert leaves the final deision to the

5 3 ustomer 2. We organize ustomer-expert deision-making models, aording to these dimensions of empowerment, whih is new to the literature. Reent views suggest that ustomer empowerment leads to better outomes beause it satisfies ustomers need for autonomy and self-esteem (Usta & Häubl, 2011). One of these aredited outomes is inreased ustomer adherene to expert advie (Loh et al., 2007; Mafarlane, 2008). However, despite an inreasing number of advoates of ustomer empowerment in ustomer-expert interations (Epstein, Alper & Quill, 2004; Mafarlane, 2008), there is limited empirial researh on how ustomer empowerment influenes ustomer adherene to expert advie. The present paper develops theoretial expetations on the relationship between empowerment and adherene, grounded in two theoretial traditions: dual models of information proessing (Chaiken, 1980; Petty, & Caioppo, 1986) and ustomer overonfidene (See et al., 2011; Tost, Gino, & Larrik, 2012; Yaniv & Kleinberger, 2000). Conneted to these two theoretial mehanisms, we distinguish between two different forms of non-adherene to expert advie, namely unintentional and reasoned non-adherene. Unintentional non-adherene ours when a ustomer inadvertently fails to follow the expert s advie (e.g. due to forgetfulness or misunderstanding of the advie). Reasoned non-adherene ours when a ustomer deliberately deides to deviate from the expert s advie. We hallenge the view that ustomer empowerment may only inrease adherene to expert advie and provide rih empirial evidene in support of this view. We argue that empowerment may derease, rather than inrease, adherene for two reasons. First, informational 2 In line with the advie-taking literature (see e.g. Bonaio & Dalal, 2006), the expert advisor merely provides a reommendation, so effetively the final deision always lies with the ustomer. Even if the ustomer has the legal right and responsibility to make the final deision, the expert an still deide to advise a single ourse of ation.

6 4 empowerment, when not expliitly requested by the ustomer, may inrease the ognitive and emotional burden for ustomers (Quill & Brody, 1996), and impair information proessing, whih results in higher unintentional non-adherene. Similarly, deisional empowerment may magnify the ognitive and emotional osts of the deision task (Botti & MGill, 2011), resulting in worse information proessing and higher unintentional non-adherene. Seond, deisional empowerment, and to a lesser extent unrequested informational empowerment, may trigger ustomer overonfidene. Customer overonfidene may inrease both unintentional and reasoned non-adherene. On the one hand, overonfident ustomers tend to listen less arefully to expert advie (Tost, Gino, & Larrik, 2012), whih inreases unintentional non-adherene. On the other hand, overonfident ustomers tend to egoentrially disount the expert s advie (See et al. 2011, Yaniv, 2004), whih inreases reasoned nonadherene. Using a multi-sample Bayesian strutural equation model, we show that deisional empowerment is assoiated with higher unintentional and reasoned non-adherene to expert advie and that informational empowerment is only able to redue unintentional and reasoned non-adherene when the ustomer expliitly requests the exhange of additional solutionrelevant information. We empirially validate our expetations in the highly relevant domain of healthare deisions. Consumer non-adherene to dotor advie ontributes to disease progression and inreased mortality rates, resulting in annual diret and indiret healthare osts of at least $290 billion in the U.S. alone (New England Healthare Institute, 2009) and lost revenue for pharmaeutial firms of $564 billion a year globally (Forissier & Firlik, 2012) 3. 3 See

7 5 Our sample inludes 11,735 respondents in 17 ountries on four ontinents. To the best of our knowledge, this is by far the largest and geographially most diverse test of the relationship between ustomer empowerment and adherene to date. Prior empirial researh on the relationship between empowerment and adherene to expert advie has foused on the U.S. or a seleted set of Western nations, while ustomers reation to empowerment may be vastly different aross ultures (Botti, Orfali & Iyengar, 2009; Charles et al., 2006). We build upon Shwartz s (1994) ultural values theory, to explain systemati rossountry differenes in the relationship between ustomer empowerment and adherene to expert advie. Our analyses revealed that, in line with our expetations, ulture matters. We find that ulture moderates the effets of deisional empowerment and, to a lesser extent, of informational empowerment on non-adherene in systemati and preditable ways. These findings have important impliations for marketers and poliy makers. 2. Theoretial Bakground: Customer Empowerment and Adherene to Expert Advie The expert advie literature typially distinguishes between advie-giving and advie-taking (Bonaio & Dalal, 2006; Yaniv, 2004). We first organize advie-giving styles aording to ustomer empowerment. Next, we disuss advie-taking, whih, in our ontext, is the ustomer s deision to adhere or deviate from the expert s advie Organizing Advie-Giving Styles Aording to Customer Empowerment Figure 1 organizes different advie-giving styles, aording to informational empowerment, through expert failitation (x-axis) or ustomer initiative (y-axis), and deisional empowerment (the z-axis). Expert failitation of informational empowerment happens when the expert proatively exhanges solution-relevant information with the ustomer (i.e. takes the initiative of sharing solution-relevant information even if it is not requested by the ustomer). Customer-

8 6 initiated informational empowerment happens when the ustomer requests solution-relevant information from the expert. Under deisional empowerment, the ustomer retains autonomy over the deision, whih is the opposite of deision delegation by the ustomer to the expert (see Usta & Häubl, 2011). The advie-giving styles at the bottom of Figure 1 are haraterized by low deisional empowerment (i.e. hoie delegation), while those at the top are haraterized by high deisional empowerment (i.e. hoie autonomy). --- Insert Figure 1 around here --- In the bottom left of the graph, we depit the traditional paternalisti model whih is haraterized by low deisional empowerment and by low informational empowerment (Charles, Gafni & Wheelan, 1999). In a paternalisti model, the expert deides on behalf of the ustomer in a paternalisti manner and hene only needs to exhange the information needed to identify and understand the ustomer s problem (diagnosti information). In informed delegation models, ustomers and experts also exhange solution-relevant information. Conditional on the information olleted, the expert then applies her knowledge to hoose an option that maximizes the ustomer s utility (Phelps, 1992). At the top of Figure 1, we depit onsumerist and informed autonomy models. In onsumerist models (Coulter, 1999), the ustomer demands that the expert helps her exeute a self-hosen ourse of ation and there is no exhange of solution-relevant information. Examples of onsumerism inlude requests for a speifi litigation strategy by lients to their lawyers (Mafarlane, 2008) and branded request by patients to their dotors (Venkataraman & Stremersh, 2007), a phenomenon that has steadily inreased in reent years (Stremersh, Landsman, & Venkataraman, 2013). To the extent that the ustomer takes initiative in

9 7 exhanging solution-relevant information during her interation with the expert, onsumerism an yield ustomer-driven informed autonomy (Charles, Gafni & Whelan, 1999). In the expertdriven informed autonomy model (Quill & Brody, 1996), the expert failitates the exhange of solution-relevant information, but leaves the final hoie of a ourse of ation to the ustomer Advie-Taking: Customer Adherene to Expert Advie We oneptualize adherene to expert advie as the propensity of a ustomer to follow an expert s advie (Bonaio & Dalal, 2006; DiMatteo et al., 1993). Adherene to expert advie requires an effortful ommitment of the ustomer to implement the behaviors reommended by the expert during the advising interation. If ustomers have diffiulty to understand or reall some of the information transmitted by the expert (e.g., the different steps a tax advisor reommended his lient to minimize her tax payments), they may unintentionally non-adhere to the advie. If ustomers do not aept and deliberately deviate from the expert s advie (and rely more on their own opinion than on the expert s opinion), we speak of reasoned non-adherene (Bonaio & Dalal, 2006; Yaniv & Kleinberger, 2000). 3. Hypotheses Development In developing hypotheses about the effets of ustomer empowerment on adherene to expert advie, we rely on two key psyhologial mehanisms: (1) dual models of information proessing (Chaiken, 1980; Petty, & Caioppo, 1986) and (2) ustomer overonfidene (See et al., 2011; Tost, Gino, & Larrik, 2012; Yaniv & Kleinberger, 2000). Dual models of information proessing, suh as the heuristi systemati model (HSM; Chaiken, 1980; Chaiken, Liberman, & Eagly, 1989) and the elaboration likelihood model (ELM; Petty & Caioppo, 1986) posit that ustomers possibly engage in two modes of information proessing, whih involve different levels of thought and ognitive effort. Heuristi (or

10 8 peripheral) proessing is relatively effortless and quik while systemati (or entral) proessing requires ustomers to devote more ognitive resoures to proess information. A good example, in a healthare ontext, is provided by Steginga and Ohipinti (2004) who show, for patients with prostate aner, that ustomers may either use an expert opinion heuristi (e.g. experts an be trusted, p.574) or more systemati information proessing strategies (e.g. weighing all pros and ons of different reommended options). For these reasons, dual-proess models have speial relevane for the effets of informational empowerment on unintentional non-adherene. Reent researh in soial psyhology suggests that empowerment may lead people to feel more powerful in a relationship and beome overonfident about their abilities (See et al., 2011). Overonfident ustomers tend to overweight their own knowledge and opinions and therefore: (i) listen less arefully to expert advie (Tost, Gino, & Larrik, 2012) and (ii) egoentrially disount expert advie (Bonaio & Dalal, 2006; See et al. 2011, Yaniv, 2004). Moreover, when given power in a ertain deision task, people tend to generalize their overonfidene to tasks outside the original sope of empowerment (Weitlauf et al., 2001). Hene, ustomer overonfidene has speial relevane for the effets of deisional empowerment on nonadherene and for the effets of informational empowerment on reasoned non-adherene Expert Failitation of Informational Empowerment and Customer Non-Adherene Expert failitation ours when an expert proatively exhanges solution-relevant information with the ustomer during an advising interation (e.g. a dotor asks a hild whether she likes strawberries or herries to deide on a drug s flavor to presribe, or a lawyer disusses with a lient whih expert witness to appoint in a patent litigation ase). Experts often exhange unrequested solution-relevant information with ustomers in order to inrease the ustomer s involvement and responsibility in a given deision-making task (Epstein, Alper & Quill, 2004).

11 9 Dual-proess models predit that elevated responsibility inreases task importane and thus motivates ustomers to use systemati, rather than heuristi, information proessing (Bohner et al. 1995; Chaiken, 1980). However, systemati proessing of unrequested piees of information may inrease ustomers ognitive and emotional burden and eventually obsure other relevant piees of information (Epstein, Korones, & Quill, 2010). Thus, when ompared with a paternalisti model, expert failitation of informational empowerment requires the ustomer to systematially proess additional solution-relevant information. Suh additional information will ompete, in the ustomer s memory, with other key piees of information in the expert s advie (e.g. dosing instrutions in a patient-physiian interation or advie on speifi litigation steps in a lawyer-lient interation), making the latter less salient and the advie harder to reall 4 (Raaijmakers & Shiffrin, 1992), as ompared to a paternalisti interation. Forgetting, in turn, is one of the key reasons why ustomers do not adhere to expert advie (Osterberg & Blashke, 2005). Thus, we expet that: H 1 : Expert failitation of informational empowerment inreases unintentional non-adherene. Customers often suffer, in their relationship with advisors, from egoentri bias, i.e. from a tendeny to overweight their own opinion and egoentrially disount the expert s advie (Bonnaio & Dalal, 2006; Yaniv & Kleinberger, 2000). This means that even when a ustomer aepts that the expert s advie is orret, she may still depart from this advie and maintain her own prior attitudes and beliefs, resulting in reasoned non-adherene (Bonnaio & Dalal, 2006). Expert failitation of informational empowerment may inrease this tendeny. When ompared 4 Experts may write down their advie to failitate ustomer reall. Still, ustomers often unintentionally deviate from written advie. Morris and Halperin (1979), for example, find that written dotor advie inreases adherene to short-term, but not long-term, therapy advie and only if the written advie is suffiiently attrative, easy-to-read, and diretive (p.48). Similarly, Weinman (1990) argues that, on top of the adequay of the written information, patients are only more likely to reall written dotor advie when suh advie meets their needs.

12 10 with a paternalisti model, expert failitation of informational empowerment may elevate ustomers pereived power in the ustomer-expert relationship, i.e. the belief in their own ability to deide and ontrol the problem being disussed (Tost, Gino, & Larrik, 2012). Customers with an elevated pereived power tend to beome overonfident, whih leads them to plae more weight in their own beliefs and less weight in the expert s advie (Bonaio & Dalal, 2006; See et al. 2011, Yaniv, 2004). Therefore, expert failitation of informational empowerment may trigger ustomers to egoentrially disount the expert' advie more than a paternalisti ustomer-expert interation. Therefore, we hypothesize the following: H 2 : Expert failitation of informational empowerment inreases reasoned non-adherene Customer-Initiated Informational Empowerment and Customer Non-Adherene Customer-initiated informational empowerment results in the disussion of solution-relevant information that the ustomer finds self-relevant and meaningful. Prior researh in dual-proess models shows that high self-relevane triggers systemati information proessing (Chaiken, 1980). Systemati proessing of self-relevant information should inrease ustomers motivation to arefully listen to the advie (Ryan & Dei, 2000), whih, in turn, failitates understanding and reall of the information exhanged. For instane, Kreuter et al. (1999) show that ognitive elaboration foused on self-relevant information failitates understanding and future reall of health-related advie. Similarly, Brug et al. (1996) find that people who reeive nutrition advie ustomized to their personal dietary behavior pereive suh advie as self-relevant and adhere more to advie than people who reeive non-tailored advie. In line with this logi, Abele and Gendolla (2007) show that ative exerisers proess health information fousing on physial exerise more deeply, and reall it better, than non-ative exerisers. Thus, we expet that: H 3 : Customer-initiated informational empowerment dereases unintentional non-adherene.

13 11 Customer-initiated informational empowerment may also affet reasoned non-adherene. When ompared with a paternalisti model, ustomer-initiated informational empowerment may affet the distribution of pereived power between the ustomer and the expert in different ways. The effet thereof on reasoned non-adherene is unlear. On the one hand, it may be possible that the ustomer gains power in the ustomer-expert relationship. This happens if the ustomer disovers, in the expert s response to her request for solution-relevant information, evidene that ontradits the expert s advie (Chaiken, Liberman, & Eagly, 1989). Contraditory information enables the ustomer to hallenge the validity of the expert advie, whih may inrease the ustomer s pereived power relative to the expert. On the other hand, it may also be oneivable that the expert gains power in the ustomer-expert relationship. For instane, the expert may push bak the ustomer s initiative and refuse to disuss solution-relevant information. When ompared with a paternalisti interation, an expert s refusal to respond to a ustomer s requests for additional information avoids the inrease in pereived power, and subsequent ustomer overonfidene, disussed above (Izraeli & Jik, 1986). Alternatively, the expert may, through skillfully answering the questions posed by the ustomer, inrease her expert status and undermine ustomer overonfidene. Hene, when ompared to a paternalisti interation, ustomer-initiated informational empowerment may inrease, or derease, the ustomer s tendeny to egoentrially disount the expert s advie (Yaniv & Kleinberger, 2000). Given these onfliting expetations, the ultimate effet of ustomer-initiated informational empowerment on reasoned non-adherene will depend on whih of these two fores dominates and is, thus, an empirial question.

14 Deisional Empowerment and Therapy Non-Adherene Deisional empowerment may inrease unintentional non-adherene in two main ways. First, deisional empowerment may trigger ustomer overonfidene and worse information proessing. Deisional empowerment allows ustomers to feel in ontrol of their deisions, and inreases their power in the ustomer-expert relationship (Botti & MGill, 2011). As disussed above, power may trigger overonfidene (See et al., 2011). Hene, when ompared with a paternalisti model, deisional empowerment should lead ustomers to overestimate the auray of their beliefs and opinions, whih leads them to listen and proess the expert advie less arefully (Tost, Gino, & Larrik, 2012). Less areful proessing of the advie inreases the likelihood that the ustomer forgets omponents of the advie. Seond, deisional empowerment inreases the ustomer s responsibility in deisionmaking, potentially magnifying the emotional and ognitive osts of the deision task (Botti & MGill, 2011; Botti, Orfali & Iyengar, 2009). These effets may inrease ustomer anxiety (Botti, Orfali & Iyengar, 2009), whih, in turn, has been shown to impair information proessing (Sengupta & Johar, 2001). Consequently, deisional empowerment impairs the quality of the ustomer-expert ommuniation and redues the saliene of the expert s advie making it harder to reall later. We thus hypothesize: H 4 : Deisional empowerment inreases unintentional non-adherene. Deisional empowerment may also inrease the likelihood of reasoned non-adherene. When ompared with expert failitation of informational empowerment, deisional empowerment represents a stronger departure from the traditional paternalisti ustomer-expert relationship (Charles, Gafni & Whelan, 1999; Quill & Brody, 1996). In addition, deisional empowerment entails patient partiipation in the deision-making without neessarily allowing

15 13 the ustomer to learn more about the problem under disussion. Hene, as disussed above, deisional empowerment may elevate ustomer power and trigger overonfidene, whih should lead ustomers to plae less weight on the expert s opinion and egoentrially disount the expert advie (See et al., 2011; Yaniv & Kleinberger, 2000). In addition, overonfident ustomers tend to generalize their self-effiay pereptions from a foal deision domain to deision domains outside the original sope of empowerment (Weitlauf et al., 2001). Aordingly, deisional empowerment during an advising interation (e.g. partiipating in the hoie of one out of several alternative ourses of ation) may lead ustomers to beome overonfident about their apaity to deide when to alter or stop their adherene to expert advie, inreasing reasoned non-adherene. In the words of Bowman, Heilman and Seetharaman (2004), in the ontext of physiians empowering patients to make their own treatment hoies, the pereption of empowerment and ontrol should persist suh that the onsumer also believes that he or she is apable of hanging dosage or stopping usage altogether without physiian onsultation (p. 325). Therefore, we hypothesize that: H 5 : Deisional empowerment inreases reasoned non-adherene Cultural Effets Behavioral responses to ustomer empowerment may be vastly different aross different national ultures (Charles et al., 2006). In partiular, we expet national-ultural values to shape expetations about the role of experts and to trigger positive or negative soial reinforement mehanisms that moderate the effets of ustomer empowerment on non-adherene. This fits the tradition in international marketing of onsidering national-ultural values as moderators of ustomer behavior (Burgess & Steenkamp, 2006; Steenkamp & De Jong, 2010; Steenkamp &

16 14 Geyskens, 2013; Stremersh & Tellis, 2004; Stremersh & Lemmens, 2009; Tellis, Stremersh, & Yin, 2003; Van den Bulte & Stremersh, 2004; van Everdingen, Fok, & Stremersh, 2009). We adopt Shwartz s (1994) framework of national-ultural values, instead of alternative frameworks of Hofstede, Inglehart and Baker, or Triandis (see Vinken, Soeters & Ester, 2004, for an overview), for three key reasons. First, Shwartz derived his ultural dimensions from his individual-level theory of human value priorities (Shwartz, 1992), whih is one of the most widely validated theories in soial sienes (Shwartz et al., 2001). For this reason, Shwartz s (1994) ultural framework is oneptually the most pure among existing theories of nationalultural values (Burgess & Steenkamp, 2006; Bond et al., 2004). Seond, this framework is robust in terms of its measurement properties. The different value dimensions in this framework form an integrated and interdependent system, in ontrast to other frameworks in whih ultural dimensions are orthogonal to eah other (e.g. Hofstede, 2001; Inglehart & Baker, 2000). The ultural dimensions in Shwartz s (1994) framework are also learly defined and operationalized a priori, in ontrast to other frameworks that, ex post, infer ultural dimensions from orrelations among diverse items and exploratory analyses (e.g. Inglehart & Baker, 2000). Third, Shwartz s values theory expliitly addresses the distintion between the individual and nation-ultural levels of analysis. Sholars have reently hallenged the notion of ulture as a set of meanings and priniples shared by most members of a ertain soiety (Fisher & Shwartz, 2011). In ontrast with other ultural theories, Shwartz s oneption of ultural values as a normative system that is external to individuals (but underlies the funtioning of soietal institutions) does not assume a high level of within-ountry onsensus (Fisher & Shwartz, 2011; Shwartz, 2009, 2011).

17 15 All the reasons above suggest that Shwartz s framework fits well with the topi of ustomer empowerment. Its bipolar dimensions apture opposing hoies to three ritial needs that onfront most soieties (Burgess & Steenkamp, 2006; Shwartz, 2006). The first dimension relates to the need to organize the relations between the individual and the group. Highautonomy ultures emphasize individuality, independene and self-expression. Affetive autonomy ultures enourage individuals to at aording to their own preferenes. Intelletual autonomy ultures enourage individuals to develop their own opinions. In ontrast, highembeddedness ultures emphasize soial relationships, group identifiation, respet for tradition and obediene. The seond dimension represents the need to guarantee responsible behaviors that protet the soial fabri. There are two opposing ways to reah this goal. Egalitarian ultures tend to instill soially responsible behavior by induing people to see eah other as moral equals and emphasizing equality and equal distribution of power. People in suh soieties tend to internalize ooperation and onern with others as a life-guiding priniple. Hierarhial ultures rely on an unequal distribution of power and roles as a legitimate mehanism to guarantee behaviors that protet the soial fabri. The third dimension relates to the need to manage the relations of people to soiety and the environment. High-mastery ultures emphasize suess, daring and ompetene. Highharmonious ultures emphasize the need to fit into the soial and natural world and the importane of behaving in a way that is ongruent with the soial and natural environment. We expet ulture to intensify or attenuate our hypothesized relationships for the effets of ustomer empowerment on non-adherene in three ways. First, as ustomers in high intelletual autonomy ultures are more inlined to pursue their own opinions independently, as

18 16 ompared with ustomers in low intelletual autonomy ultures (Shwartz, 2006), they should be more likely to beome overonfident when exposed to expert failitation of informational empowerment or deisional empowerment. In high-embeddedness ultures, in ontrast, ustomers are less likely to engage in ations that may disrupt traditional roles and in-group solidarity (Burgess & Steenkamp, 2006). Thus, we expet ustomers in soieties that emphasize embeddedness to be less likely to disount the expert s advie, in order to avoid disrupting the ustomer-expert relationship, as ompared to ustomers in soieties that emphasize autonomy. Seond, when ompared with ustomers in egalitarian soieties, ustomers in hierarhial soieties should be more likely to asribe power to the expert beause of her presumed aess to superior knowledge and information (Burgess & Steenkamp, 2006). When ustomers asribe more power to an expert, they are more likely to invest additional effort to understand and reall the expert s advie (Tost, Gino, & Larrik, 2011). We also expet ustomers in hierarhial soieties to be less likely to beome overonfident and more likely to omply with the obligations and rules attahed to their roles and status (Burgess & Steenkamp, 2006, p. 343). Hene, we expet the detrimental effets of ustomer empowerment (espeially of expert failitation of informational empowerment and deisional empowerment) on non-adherene to be less pronouned in hierarhial ultures. Finally, we expet ustomers in high-mastery soieties suh as the U.S. - to be more likely to pereive ustomer empowerment as a legitimate mehanism to enable them to ontrol their own destiny and deisions (Markus & Shwartz, 2010). Therefore, we expet the effets of ustomer empowerment on non-adherene to be less detrimental, or more benefiial, in highmastery ultures, as ompared to the high-harmony ultures.

19 17 4. Data and Method 4.1. Institutional Context Healthare deisions provide a highly relevant ontext in whih to study ustomer adherene to expert advie (Shwartz, Lue & Ariely, 2011; Stremersh, 2008). In this domain, expert advie may be a therapy plan presribed or reommended by the physiian to a onsumer, or patient. As stated in the introdution, therapy non-adherene generates enormous osts for soiety and lost sales for pharmaeutial firms, triggering signifiant attention in the marketing literature (Stremersh & Van Dyk, 2009; Wosinska, 2005). Dellande, Gilly and Graham (2004) show that onsumer-nurse homophily is an important anteedent of therapy adherene in weight-linis. Kahn and Lue (2003) find that false-positive results redue planned adherene among women in mammography waiting rooms. Bowman, Heilman and Seetharaman (2004) find that therapy non-adherene dereases around a dotor visit. Wosinska (2005) shows that diret-to-onsumer advertising (DTCA) modestly dereases onsumer non-adherene using a 4-year panel of presription laims. Neslin, Rhoads and Wolfson (2009) introdue a method to identify onsumers with high risk of non-adherene. We also ontrol for other domain-speifi drivers of unintentional and reasoned nonadherene to therapy advie, inspired by prior literature and befitting our theory above. In partiular, we ontrol for soiodemographis (DiMatteo, 2004), onsumer-physiian homophily (Dellande, Gilly & Graham, 2004), relationship quality (Palmatier et al., 2006), duration, frequeny of interation and time sine last enounter (Doney & Cannon, 1997), onsumer s pereived dotor expertise (given the role of expert power in our theory), onsumer health status (DiMatteo, 2004), health motivation (Moorman & Matulih, 1993), and onsumer medial knowledge (World Health Organization, 2003). Figure 2 summarizes our oneptual framework.

20 Insert Figure 2 About Here Data Colletion Method We surveyed 11,735 onsumers in Belgium, Brazil, Canada, Denmark, Estonia, Frane, Germany, India, Italy, Japan, the Netherlands, Poland, Portugal, Singapore, Switzerland, the UK and the US. Medial sholars have established the effetiveness of self-reports of onsumers on therapy adherene (Gehi et al., 2007), whih orrelates highly with biologial measures like plasma viraemia (Walsh, Mandalia & Gazzard, 2002). Reverse ausality and ommon method variane are two well-known onerns with ross-setional survey researh (Rindfleish et al., 2008). Setion 6 provides proess evidene to establish diretionality. Regarding ommon method variane, we onduted Harmon s one-fator test (Podsakoff et al. 2003), and the single fator hypothesis was rejeted in all ountries. We also relied on different response sales and anhors (e.g. never to very often for non-adherene, and strongly disagree to strongly agree for informational empowerment), whih has been shown to be an effetive strategy to redue ommon method bias (Rindfleish et al., 2008). Our estimated effets also show opposite signs (e.g. deisional empowerment versus relationship quality), whih is also inompatible with similar response behavior aross items. To the best of our knowledge, this is the largest study of the relationship between onsumer empowerment and therapy non-adherene to date. We ontrated SSI (Survey Sampling International) to exeute our survey on their online panels. Reruiting and rewarding proedures for SSI panels are onstantly evaluated in terms of sample representativeness and respondent s attention and motivation. We seleted this sample of ountries, beause: (1) it ontains suffiient ross-ultural variation; (2) onsumers are free to hoose their physiian and typially develop repeated

21 19 interations with the same physiian in eah sampled ountry; (3) survey osts per ountry were not greater than $10,000. We exluded respondents that were younger than 25 or that had less than three visits with their urrent general pratitioner, in order to guarantee respondent ability to assess the interation with her physiian and therapy non-adherene. We onstruted the original survey in English, whih native speakers translated to Danish, Duth, English, Estonian, Frenh, German, Italian, Japanese, Polish and Portuguese. Another native speaker (the bak-translator) translated the survey from his native tongue bak to English. The translators and bak-translators were dotoral students in soial sienes, fluent in English, attending a large European and a large Amerian university. We disussed the translated surveys with both translators and bak-translators, iteratively, until we were sure that the final survey retained exatly the same meaning in all languages. The vast majority of these graduate students were familiar with survey researh methods, often through their oursework, whih allowed us to disuss survey items, and their meanings, in detail Measurement: Individual-Level Construts In Tables A1-A4 (see Appendix) we provide our measures, their respetive soures, their reliabilities, and desriptive statistis for eah foal onstrut and for eah ountry. To ensure the validity of our measures, we disussed, ex ante, all items in the survey with researhers in marketing and two dotoral students in mediine to guarantee that the items were understandable and showed ontent validity. We typially asked the olleague to define the onstrut in his own words before showing her or him our proposed items and then ask for their agreement with the proposed operationalization. We pretested our purified measures in Singapore (186 subjets), The Netherlands (114 subjets) and the US (102 subjets). The pattern of answers in this pretest inreased our onfidene on the validity of our measures. We disarded these data and rolled-out

22 20 the final survey simultaneously in all ountries. In the full sample, all sales had a reliability of at least.7, with the two-item measure for onsumer health motivation as only exeption (ρ=.60). We used, five-point, multi-item sales for all onstruts with the following exeptions. We used a single-item for deisional empowerment, beause the measurement objet (treatment hoie) and its assoiated attribute (who is in harge of treatment hoie) an both be easily envisioned by respondents (Bergkvist & Rossiter, 2007). This is also onsistent with Usta and Häubl s (2011) measurement of involvement of self in deision onstrut. We also used single items for health status (see Safran et al., 1998), age, eduation, gender, inome, soioeonomi status, gender homophily, age homophily, relationship duration, interation frequeny and time sine last visit. Unless indiated otherwise (see Appendix), we used demeaned sores for these exogenous observed onstruts Measurement: Country-Level National Culture We obtained ountry-speifi sores of national ulture for all 17 ountries from Shalom Shwartz, whih are based on equally weighting sores of ollege students of varied majors and of shoolteahers of varied topis. These sores are similar to Shwartz (1994), but differ somewhat from these original teaher and student sores, beause of the addition of new samples and updated measures (see Shwartz, 2009 for more details). Shwartz s (1994) ultural values theory relies on the onept of soietal means for different ultural values, whih are obtained by aggregating individual value priorities. These soietal means apture the latent ultural orientations to whih all individuals are exposed and, espeially in soial ontexts (like ustomer-expert interations), to whih they tend to adapt (Fisher & Shwartz, 2011). Yet, Shwartz s oneptualization of ulture as external to the

23 21 individual allows for substantial variation of individual values around these soietal means and avoids the assumption of high within-soiety value onsensus (Shwartz, 2011). These ultural dimensions are therefore appropriate for ross-ountry omparisons but not for haraterizing the values of individuals, whih fits our researh purposes. In rossultural analyses, it is important to avoid the problem of eologial fallay. Eologial fallay ours when researhers assume that nation-level variables diretly apply to individuals (Bond, 2002). In our ase, the usage of national-level ultural dimensions is appropriate beause we are interested in the role of ulture as a moderator of the ountry-level effets of ustomer empowerment on non-adherene Model Speifiation In our models, i indexes respondents (i=1,,n; N=11,735), indexes ountries (=1,...,C; C=17), p indexes response items measuring latent onstruts (p=1,,p; P=28), q indexes latent endogenous onstruts (q=1,..,q; Q=2), and r indexes latent exogenous onstruts (r=1,,r; R=6). We speify our measurement equations relating the latent endogenous onstruts - unintentional non-adherene (UNA) and reasoned non-adherene (RNA) to the observed responses as follows: y y ip ip And for the latent exogenous onstruts as follows: UNA, for 1 p 4. (1) ip ip p p i i ip RNA, for 5 p 9. (2) yip ip p ir ip, for p > 9. (3) Where ir denotes an exogenous latent variable (i.e. expert failitation of informational empowerment (EFIE), onsumer-initiated informational empowerment (CIIE), relationship ip

24 22 quality, onsumer medial knowledge, health motivation and pereived dotor expertise). individual-speifi random interepts that aount for systemati differenes in sale usage ip are aross individuals and ountries. We extend a model by Maydeu-Olivares and Coffman (2006), and partition the individual-speifi random interepts into a fixed omponent p, ommon to all respondents in ountry but speifi for item p, and a sale usage heterogeneity omponent, i, whih varies from respondent to respondent but is ommon to all items: ip, for all p. (4) p i The mean and variane of the sale usage heterogeneity omponent in Equation 4 ( ) are ountry-speifi ( and 2,, =1,,17). Note that, in Equation 4, aptures eah respondent s baseline tendeny to sore high (or low) in eah of the onstruts we measure. For instane, baseline tendenies for non-adherene are aptured by, where 1 p 9. For model identifiation, we assume that the s are unorrelated with the error terms and with the latent i fators, whih implies that differenes in the usage of response sales are not related to respondents sores in the onstruts being measured (see Maydeu-Olivares & Coffman, 2006). i We ollet the error terms in Equations 1-3 in a single (P 1) random vetor of residuals, ε, whih we assume to be normally distributed as N(0, ), where is a (P P) diagonal ovariane matrix. The error terms are orthogonal to the latent fators. Our strutural model is defined as: ip ip i *, i UNAi EFIE UNA EFIE i CIIE UNA CIIEi DE UNA DEi Γ1 ' δ1,i Xi ξ (5)

25 23 *, i RNAi EFIE RNA EFIE i CIIE RNA CIIEi DE RNA DEi Γ 2 ' δ2,i Xi ξ (6) Where the β parameters 5 are ountry-speifi parameters apturing the effets of ustomer empowerment on unintentional and reasoned non-adherene. *, ξ i is a vetor where we ollet all exogenous latent variables besides the ustomer empowerment onstruts (i.e. relationship quality, onsumer medial knowledge, health motivation and pereived dotor expertise), X i is a vetor where we ollet all remaining ontrol variables (i.e. all observed independent variables). Consequently, Γ, for q=1,2, ontain the strutural paths orresponding to the ontrol variables, q pooled aross ountries. We ollet all exogenous latent variables in a (R 1) vetor ξ i [ EFIE CIIE DE ξ ]' distributed aording to N(0,Φ ), where Φ is a (R R) full i i i *, ' i ovariane matrix 6 and we assume the residuals, distributed N(0, 4.6. Estimation,q ), for q=1,2. δ q,i, are independent of the latent variables and We use Bayesian estimation, whih is a more flexible approah to the estimation of theorydriven strutural equation models than maximum likelihood (Muthén & Asparouhov, 2012). We speify the posterior distribution of the parameters of interest aross all respondents and estimate the model simultaneously aross all ountries. We sample the model parameters from their posterior distributions using the Gibbs sampler (Casella & George, 1992) with data 5 That is,,,,, EFIE UNA,, for all. CIIE UNA DE UNA EFIE RNA CIIE RNA DE RNA 6 A full ovariane matrix allows us to ontrol for ovariation among exogenous latent onstruts (Lee, 2007).

26 24 augmentation, whih allows sampling the latent onstruts alongside the model parameters (Tanner & Wong, 1987). Bayesian estimation also failitates our task of assessing the moderating effets of ulture in our model. In partiular, at eah iteration of our Gibbs sampler, we store the orrelations between eah of the ountry-speifi paths in our strutural model (i.e. the β parameters) and Shwartz s (1994) ulture dimensions. We use standard diffuse priors for our parameters (normal distributions for measurement interepts, loadings and strutural parameters and inverse-wishart distributions for variane ovariane matries) Identifiation and measurement invariane In addition to the standard distributional assumptions, disussed above, for the residuals, for the random interepts ( τ, in line with Maydeu-Olivares & Coffman, 2006) and for ξ (whih ip identify the item interepts), we follow the normal pratie of setting the fator loading of one item per onstrut (the marker item) to unity (whih identifies the sale of the latent onstruts). In addition, for meaningful ross-national omparisons, we need a suffiient degree of metri invariane aross ountries. Following Steenkamp and Baumgartner (1998), we test the hypothesis of full metri invariane by onstraining the matrix of fator loadings to be invariant aross ountries. The onfigural model has a smaller DIC (DIC onfig = 611,998) than the metri invariane model (DIC minv = 613,385), whih means that we do not find support for full metri invariane (DIC: deviane information riterion; see Spiegelhalter et al., 2002). Full metri invariane is very unlikely (Steenkamp & Baumgartner, 1998, p.81) and Byrne, Shavelson & Muthén (1989) have established that partial metri invariane is suffiient for ross-ultural equivalene and meaningful ross-national omparison. In order to understand the lak of full metri invariane, we ompared the fator loadings from the measurement i

27 25 invariane model with those of the onfigural model. We first stored, at eah draw, the 20 fator loadings aross the 17 ountries in our sample obtained from the onfigural model. Next, we omputed the 95% redible intervals for eah of these 340 loadings aross the posterior draws from our MCMC hain. We then examined whether the 95% redible interval for eah of the ountry-speifi loadings from the onfigural model ontained the posterior median of the orresponding fator loading estimated using the metri invariane model. This was the ase in 243 out of the 340 loadings (i.e. 71.5% of the loadings; see Table A3 in the Appendix for a ross-ountry omparison). More importantly, when omparing the strutural path estimates between the metri invariane and the onfigural models we saw no meaningful differenes. The orrelation between the foal strutural paths (apturing the effets of ustomer empowerment on non-adherene) in the onfigural and metri invariane models is.99 and we do not find any signifiant differene aross paths. In other words, in all ases, the 95% redible intervals of the strutural paths in the metri invariane model ontained the posterior mean of the same path aording to the onfigural model and vie versa. Overall, these results provide strong evidene that we have suffiient ross-ountry equivalene to make ross-national inferenes. 5. Results 5.1. Non-Adherene to Expert Advie aross Countries Figure 3 plots the mean levels of unintentional and reasoned non-adherene aross ountries in our sample, omputed by averaging, aross the MCMC draws, the measurement interepts ( ). We do not restrit the measurement interepts aross ountries, sine the latent means are onstrained to be equal, whih ensures meaningful ross-national omparison. The dashed lines in Figure 3 represent the median levels. While there is a positive relationship between unintentional and reasoned non-adherene, the relationship is not perfet (ρ=.80 and a linear ip

28 26 regression of RNA on UNA has an R 2 of.64). Consumers in Estonia, Japan, India and Singapore exhibit onsiderably higher levels of non-adherene than onsumers in Denmark and the Netherlands. --- Introdue Figure 3 about here Customer Empowerment and Non-Adherene to Expert Advie Table 1 presents the estimated oeffiients from our multi-sample strutural equation model with ountry-speifi random effets in the measurement model apturing sale usage heterogeneity. We let all hains onverge by running our models for 25,000 iterations, disarding the first 10,000 for burn-in, and using the subsequent 1,500 thinned draws (we used every 10 th draw to redue autoorrelation) for posterior inferene. The estimates are the posterior ross-ountry medians obtained from the MCMC hains from our Gibbs-sampler 7. Bolded figures represent estimates for whih the 95% redible interval (the interval between the 2.5 th and the 97.5 th perentiles of the distribution of MCMC draws) does not ontain zero. --- Insert Table 1 about here --- Even though we find a positive relationship between expert failitation of informational empowerment (EFIE) and non-adherene, the relationship was neither signifiant 8 for unintentional non-adherene ( EFIE UNA =.04; 95% CI = [-.01;.09]) nor for reasoned nonadherene ( =.04; 95% CI = [-.02;.09]). These initial results do not support H 1 and H 2. EFIE RNA 7 We obtain these posterior ross-ountry medians by averaging, at eah draw, the beta parameters -,,,,,, for all - aross ountries and then obtaining the EFIE UNA CIIE UNA DE UNA EFIE RNA CIIE RNA DE RNA posterior median of these averages. 8 We use the term signifiant whenever the 95% redible interval of a ertain parameter does not ontain zero.