The Vulnerable Consumer in the High Blood Pressure Drug Market: Bothered But Satisfied?

ABSTRACT - Patient satisfaction in the prescription drug industry has remained an under-researched area. Public policy concerns with access and pricing questions suggest that such research is urgently warranted. This paper reports the findings of a study that examines post-exchange phenomena in the high blood pressure prescription drug market, with regard to the elderly consumer. Since the decision making of consumers involved in exchange relationships in this market is highly restricted due to factors beyond their control, they can be classified as "vulnerable". In line with the vulnerable consumer hypothesis, the elderly in this study reported a high level of satisfaction. However, the relationship between demographic varaibles and level of satisfaction provided partial support for the vulnerable consumer hypothesis. The use of a self-reported measure such as "bothered" in place of "dissatisfied" revealed that a majority of the patients were experiencing some extent of negative post-exchange feelings. Finally, alternative influences on post-exchange behavior were examined.


Dev S. Pathak, Suzan Kucukarslan, Deepak Sirdeshmukh, and Richard Segal (1993) ,"The Vulnerable Consumer in the High Blood Pressure Drug Market: Bothered But Satisfied?", in NA - Advances in Consumer Research Volume 20, eds. Leigh McAlister and Michael L. Rothschild, Provo, UT : Association for Consumer Research, Pages: 245-252.

Advances in Consumer Research Volume 20, 1993      Pages 245-252


Dev S. Pathak, Ohio State University

Suzan Kucukarslan, Ohio State University

Deepak Sirdeshmukh, Ohio State University

Richard Segal, University of Florida


Patient satisfaction in the prescription drug industry has remained an under-researched area. Public policy concerns with access and pricing questions suggest that such research is urgently warranted. This paper reports the findings of a study that examines post-exchange phenomena in the high blood pressure prescription drug market, with regard to the elderly consumer. Since the decision making of consumers involved in exchange relationships in this market is highly restricted due to factors beyond their control, they can be classified as "vulnerable". In line with the vulnerable consumer hypothesis, the elderly in this study reported a high level of satisfaction. However, the relationship between demographic varaibles and level of satisfaction provided partial support for the vulnerable consumer hypothesis. The use of a self-reported measure such as "bothered" in place of "dissatisfied" revealed that a majority of the patients were experiencing some extent of negative post-exchange feelings. Finally, alternative influences on post-exchange behavior were examined.


It is now generally acknowledged by consumer researchers that post-purchase feelings and actions of consumers represent an important area of examination (Westbrook 1987, Oliver and Swan 1989, Day and Landon 1977). The concept of consumer satisfaction has also gained wide acceptance in industry(Andreasen and Best 1977, Swan and Mercer 1981). While substantial research has been conducted into satisfaction and post-purchase behaviors in the areas of consumers goods, patient satisfaction remains an under-researched field. While some attention has been directed at understanding patient satisfaction in the hospital care context (Singh, 1989), research examining the post-purchase outcomes of prescription drug consumers is still needed. This paper represents an effort in that direction.

The high blood pressure market is the area being examined in this study. It represents an important area of concern for two chief reasons, namely the age group which makes up this market and the size of the market. A majority of hypertensive patients are from the elderly segment (persons over the age of 65) which represents the fastest growing segment in the U.S. The elderly are expected to make up about 20% of the population of the country by the year 2010 (Tootelian, 1991). It has also been suggested that the elderly may be open to potential exploitation by marketers since they are less likely to police the market (Deshpande and Zaltman, 1978).

The prescription drug market also represents a very large sector of the health care industry. Retail sales for high-blood pressure drugs made up 7% of a 4.3 billion dollar market for cardiac drugs in 1990 (Glaser, 1991).The U.S. pharmaceutical industry has been subject to intense federal regulations in the past designed to protect the consumer from unsafe and ineffective products. Much of the current public concern, however, is centered around the pricing and promotional practices of pharmaceutical manufacturers (Waldholz, 1991). The Pryor Committee reported to the Senate that prescription prices had multiplied at three times the rate of the CPI in the 1980s (Majority Staff Report of the Special Committee on Aging, U.S. Senate, 1989,1990). As a result of the concern expressed, there have been several calls for public policy intervention to protect the prescription drug consumer from unfair practices.

Traditionally, the level of dissatisfaction in a market and the extent of complaints generated from the market have been taken as signals for external intervention. Also, dissatisfied consumers have the option of self-policing the market by exiting the market or by voicing their complaints (Hirschman, 1970). However, the high-blood pressure prescription drug market has certain unique characteristics. First, the patient does not have direct control on the choice of the drug. Next, the product is technologically complex and patients do not have adequate knowledge in order to evaluate outcomes. Finally, the patient is involved in interpersonal relationships with the pharmacist and the physician and these may affect their ability to objectively evaluate the nature of their transactions. This situation suggests that the patient may be involved in transactions in a "loose monopoly" (Hirschman, 1970) where the consumer may not have recourse to exit or voice and is thus unable to police the market. In a loose monopoly situation the extent of dissatisfaction is typically under-reported by the customer and may not be an appropriate signal of market failure. Consequently, public policy intervention may be required even in the face of high reported satisfaction. Andreasen (1985) found that the physician market, with high levels of reported satisfaction, fit the description of a loose monopoly. This study examines whether the high blood pressure prescription drug market fits the description of a "loose monopoly".

Next, it has been suggested that groups who are at a disadvantage due to demographic characteristics tend to over-report their satisfaction given that they are unable to judge the performance characteristics of the service or product domain under investigation (Andreasen and Manning, 1990). These consumers are referred to as the "vulnerable consumer" and they represent a group who may need pro-active public policy initiatives in order to protect them. The post-exchange behavior of vulnerable consumers is another area that has not been adequately examined. This study examines the relationships between patient demographics such as age, income and education and reported satisfaction in the pharmaceutical drug market.

An alternative for identifying dissatisfied consumers in a "loose monopoly" who may not otherwise be identified, is explored in this study. Woodruff, Schumann, and Clemons (1990) suggest that rather than using constructs and their operationalizations derived by the researcher, it may be more appropriate to use terminology derived from the consumers themselves. Consequently, in addition to assessing "dissatisfaction," we also assessed the extent to which patients were "bothered" by specific elements of their transaction. "Bother" was a term that patients were found to use with some frequency in a focus group conducted earlier (Sirdeshmukh, Pathak, Kucukarslan, Segal, Kier, and Aversa, 1991). Further, along with global measures of overall satisfaction, consumers were asked to indicate their feelings with respect to specific attributes of the exchange process with respect to the drug manufacturer, the pharmacist, and the physician. In fact, the study deals with "post-exchange" as opposed to traditional post-purchase actions which may be a narrower conceptualization in this context. Finally, the nature of patients' post-exchange reactions including voice and behavior were examined along with reasons for such behavior. These reactions were examined using the framework suggested by Andreasen (1991).


The pharmaceutical market has been criticized for its promotional and pricing practices by policy makers who argue that its consumers are being exploited for commercial gains. Research has suggested that there is increasing public concern with rising drug prices and inadequate justification for such prices in the consumer's perception (Waldholz, 1991). The high-blood pressure market is particularly liable to public policy concern given that it represents a fairly large proportion of the prescription drug market and the elderly make up a large part of this market. Researchers have suggested that the elderly may be prone to exploitation by marketers and are less likely to take recourse to self policing behaviors (Deshpande and Zaltman, 1978). Further,the complex nature of high-blood pressure therapy further puts the elderly at a disadvantage. In sum, the post-exchange feelings and behavior of the elderly patient in the high-blood pressure market warrant further research.

According to traditional market theory, there would not be any concern about public policy intervention since the market would be expected to police itself. Economists maintain that consumers vote in the marketplace through the brand choices they make. A marketer not providing satisfaction would not be able to survive and eventually the market would eventually drive out the inefficient and reward those providing value. Hirschman (1970) states that when a market fails, consumers may use two mechanisms to initiate correction - voice and exit. Voice is defined as any attempt to change, rather than to escape from, an objectionable state of affairs, whether through individual or collective petition to the management directly in charge, through appeal to a higher authority with the intention of forcing a change in management, or through various types of actions and protests, including those that are directed toward mobilizing public opinion (Hirschman, 1970, p.30). Voicing is expected to occur when there is consumer recognition that voice is an option to exit and an expectation that the performance of the product/service will improve. Exit refers to the process of switching to other brand/product markets.

Hirschman (1970), however, suggests that there may be some markets which may be characterized as "loose monopolies" where a majority of the consumers may not have recourse to either exit or voice. Loose monopolies are those markets which are not true monopolies but ones where a majority of the consumers do not perceive exit as a viable option due to loyalty or high exit costs. Thus, exiting the market is no longer an avenue for market policing by consumers. Further, Andreasen (1985) suggests that a small number of "quality elites" or quality conscious consumers will exit the market. These consumers are also those who would have been most likely to voice, had they stayed in the market. The exit of the potential voicers among the quality elite and/or the lack of availability of exit as a viable option may lead to a market that is most liable to exploitation and is consequently one that could be classified as a "loose monopoly".

Andreasen (1985) tested Hirschman's industry-level evaluation of consumer satisfaction/dissatisfaction and complaining in the physician services market. He hypothesized that, based on the characteristics of the physician "industry", including the limited supply of physicians, limited consumer knowledge about alternative medical treatments, and the loyalty that patients feel toward their physicians, the physician "industry" would fit the description of a loose monopoly. He predicted that patients would be less likely to take actions when dissatisfied and providers would be less responsive to complaints. Results suggested that over a period of time, only about 17% of the patients experienced any dissatisfaction and took any action. There was very little evidence of any voicing on the part of the dissatisfied patients. On the basis of his study, Andreasen (1985) concluded that there was very little evidence of self-policing in the health-care industry.

Little research has been aimed at examining "loose monopoly" situations in the health-care industry since Andreasen's (1985) study of the physician market. As suggested above, the elderly consumer in the high blood-pressure market represents a potentially exploitable segment of the population. Further, there are reasons to believe that the prescription drug market may, as a whole, be characterized as a loose monopoly. First, the demand for pharmaceuticals is largely derived from the prescriber and not the consumer and thus the consumer has very little control over product choice. Second, prescription drugs represent a technologically sophisticated product that is difficult for the elderly patient to understand. Also, information about pharmaceuticals may not be accessible to the average consumer in a comprehensive and usable form. Finally, the process of exchange involves interpersonal relationships with the pharmacist and the physician and may be characterized by loyalty on behalf of the patient. In fact, an earlier analysis of focus group protocols revealed that "trust" and "loyalty" were frequently mentioned with respect to pharmacists and physicians and patients tended to ignore negative characteristics of the transaction in the face of strong loyalty ( Sirdeshmukh et al. 1991). Thus, one important objective of this study was to examine whether based on the above characteristics, the high blood-pressure market may fit the description of a "loose monopoly".

Another concern of public policy research has been in terms of the possible exploitation of the "vulnerable" consumer. Vulnerable consumers may be defined as "those who are at a disadvantage in exchange relationships where that disadvantage is attributable to characteristics that are largely not controllable by them at the time of the transaction" (Andreasen and Manning, 1990). Andreasen and Manning (1990) further suggest that "this definition would include: children, the elderly, the uneducated, the structurally poor, the physically handicapped, ethnic and racial minorities and those with language problems". It is expected that vulnerable consumers perceive less problems, voice less complaints or take fewer actions, and it is argued that the "invisible hand" of the market may not be able to function as a form of market correction. Also, a market comprised of "vulnerable" consumers may not be able to signal market failure through voice and exit and thus pro-active public policy actions may be required and justified in such markets. This study will examine the relationship between demographic factors such as education, income, and poverty level and reported satisfaction. It is expected that demographically disadvantaged consumers will report higher levels of satisfaction, in accordance with the vulnerable consumer hypothesis.

Past research has chiefly examined consumer satisfaction using constructs developed by researchers. Woodruff et al. (1990) suggest that this practice stems from the researcher-specific definition of constructs which in turn gives rise to scale operationalizations whose meaning to the consumer may not match their intended meaning. The focus group interviews conducted for this study revealed that patients included the term "bother" frequently to describe a negative exchange experience either with the physician or pharmacist, or about the prescription product (Sirdeshmukh et al. 1991). Consequently, we hypothesized that the use of the term "bothered" in addition to "dissatisfied" may be a useful method of identifying consumers experiencing negative post-exchange feelings who may not otherwise be identified. Further, along with global measures of overall satisfaction, consumers were asked to indicate their feelings with respect to specific attributes of the exchange process.

Research has suggested that even when dissatisfied, not all consumers are likely to complain or take other action (Day and Bodur, 1978). They found that about 25% of the respondents in their study who were dissatisfied reported taking no action. Andreasen (1991) proposes that the relationship between dissatisfaction and post-exchange behavior could be explained within the framework of four "models": (1) cost/benefit; (2) personality; (3) learning; and (4) restraints. The cost/benefit model suggests that consumers objectively evaluate the extent of their dissatisfaction, the costs and benefits of complaining and the probability of success (perceived likelihood of channel member resolving the problem). The personality model suggest that a person's likelihood of engaging in some sort of post-exchange action is a function of their inherent drives and self-concept. The learning model states that complaining is a learned response to dissatisfaction. The nature of the outcome from past actions will in some way shape subsequent responses to dissatisfaction. Finally, physical constraints that may prohibit people from complaining describe the restraint model. No empirical research has been reported, to date, that compares the explanatory power of the four models. In this study, a first step has been taken toward operationalizing measures meant to tap the essential elements of each model. While we do not compare the relative explanatory power of each model, we provide a descriptive examination.

The equity-restoration model may also be used to explain the voicing behavior of dissatisfied consumers (Swan and Mercer, 1981). The process of equity is applicable to any social exchange when a focal person invests inputs in a transaction and receives outcomes. If that person feels that the relative gains (outcome minus inputs) are unequal to his exchange partner (i.e. retailer, manufacturer, etc.), inequity is said to have occurred. The result of the equity process is the feeling of fairness by the focal person if an equitable exchange has been experienced. Conversely, if the exchange between the focal person and the partner was perceived by the focal person as inequitable, a feeling of distress is expected (Oliver and Swan, 1989, Swan and Mercer, 1981). The equity-restoration model indicates that consumers who perceive inequity during the exchange process are expected to act to regain equity or their sense of fairness with the exchange by either minimizing the percieved imbalance in equity or by taking actions meant to achieve the same ends.


The key objectives of this study were as follows:

(1) To examine the extent of reported patient satisfaction in the high blood pressure drug market.

(2) To test the "vulnerable" consumer hypothesis by examining the relationship between patient demographics and reported satisfaction.

(3) To compare the operationalization of the satisfaction construct on the basis of subjects' self-reports ("bothered")with a researcher generated construct ("dissatisfied").

(4) To examine the nature of post-exchange behaviors of prescription drug patients in response to being bothered by elements of the exchange process and to examine factors that may moderate the relationship between being bothered and taking an action in response.


The Elderly Population

The elderly population was chosen because it purchases prescription drugs more frequently than other age groups. Although the elderly represent approximately 12 % of the total U.S. population, they accounted for approximately 34 % of the 1988 retail expenditures on prescription drugs (Drug Topics, 1990). High blood pressure (HBP) drug therapy was chosen because its treatment is chronic, and the type of prescription drug treatments vary in terms of active ingredient, dosage form, and price. Consumers of high blood pressure may be on prescription medication which may cost $10.00 per month to over $100.00 per month. Subjects were recruited from elderly resident homes in Ohio and Florida. The study was conducted in Ohio and Florida and 200 patients were surveyed in each state. Subjects were selected based on age (greater than or equal to 55 years) and current use of HBP prescription drug therapy. Each respondent was paid $10.00 for participating in the study and a total of 367 usable responses were collected.

Survey Instrument

The survey instrument consisted of a questionnaire that was developed on the basis of focus groups conducted with a sample of patients and expert opinion. Subjects were asked several questions regarding their level of overall satisfaction with the drug therapy, and satisfaction with the drug, manufacturer, physician, and pharmacist. Questions were also posed to identify issues about patients prescription drug exchange experience that bothered them and to identify actions taken in response. The perceived likelihood that some action would be taken in response to complaints about prescription prices by various channel members was also evaluated. Reasons why consumers did not complain about issues that bothered them were also identified. These reasons were included to represent the models of complaining behavior proposed by Andreasen (1991) as well as the equity-restoration model. Most items were on a seven point scale. The last section of the questionnaire consisted of background information such as gender, age, employment status, education, insurance, out-of-pocket costs for prescription drugs and health care costs, sources of income, number of persons in the household, and estimated annual income.


A total of 367 persons, 55 years of age and older provided usable responses. A majority of the respondents were female (82 %), had at least a high school education (67 %), and reported an annual income of less than $11,140. A majority of the respondents had been taking their prescription drugs for high blood pressure for more than one year. Although almost 80% of the subjects had insurance for hospitalization, about half did not have insurance for prescription drugs. Therefore, one would expect price to be one of the issues of concern. Finally, a majority of the elderly purchase their prescription drugs from either a chain or independent drug store and pick up their prescription drugs themselves.

Satisfaction was measured on a 7-point scale (1=Very dissatisfied, 7=Very satisfied). Subjects were divided into satisfied, dissatisfied, and neither by collapsing across categories, as shown in Table 1. The majority of the respondents indicated that they were satisfied with all of the components of their high blood pressure therapy. This result may seem contradictory in the face of several reports in the lay press regarding the high concern with rising prescription prices. However, the high satisfaction reported by a the majority of the respondents is consistent with the predictions associated with the "loose monopoly" markets (Andreasen, 1985).



Next, the relationship between two demographic variables, income and education and reported satisfaction was examined. Persons with income greater than $13,400 and above the poverty level (established by the government standard combining the level of income and number of persons in a household) had significantly lower satisfaction scores (p<.05) for pharmacists (6.41 vs. 6.69), manufacturer (5.64 vs. 6.13) and overall satisfaction (6.01 vs. 6.41). Also, those with a college degree had a significantly lower overall satisfaction score (5.93 vs. 6.38, p<.05). However, there were no differences in the mean overall satisfaction scores on any of the five items reported between the three groups with income lower than $13,400 or between college graduates and non-college graduates. This data provides partial support for the hypothesis that demographically disadvantaged consumers (vulnerable consumers) tend to report higher satisfaction. Again, this would suggest that self reports of satisfaction obtained from vulnerable consumers may be an insufficient indicator of market performance.

Next, using respondent generated terminology, the term "bothered" was used to identify specific exchange issues that were negatively perceived by the respondents. Table 2 summarizes the frequency of respondents identifying issues that bothered them about their high blood pressure therapy. When compared with the number of persons dissatisfied witha particular aspect of their prescription drug therapy (2.0 to 4.4 %), the number of persons bothered by at least one attribute of the prescription drug therapy (70.2 %) is significantly greater. Figure 1 summarizes the post-exchange actions of consumers in the HBP drug market. It appears that using operationalizations with which respondents were familiar led to greater reports of negative post-exchange feelings. This finding also supports the proposition that using specific issues yields a greater number of respondents with negative exchange experiences rather than using a global exchange construct.

An analysis of the specific issues that bothered consumers revealed that greater than 20% of the respondents were bothered by four issues related to price of drugs and a fifth issue that was related to waiting time at the physician's office. The four price related issues were, cost of the drug, price variability between pharmacies, manufacturer's profit margins, and price variability between generic and brand name drugs. In sum, these results suggest that low levels of dissatisfaction with the prescription drug market discussed above, and past findings using the term "dissatisfied" may be artifacts of the measurement methodology.

Next, an analysis of the extent of behavioral action and voicing in response to being bothered was conducted. Table 3 suggests that consumers' behavioral actions in response to being bothered by the price of the drug may be classified into two categories: reduce expense or reduce consumption. The frequency of subjects reporting such actions is displayed in the table. It appears a that reduction in expense was the more common response. However, it is important to recognize that despite the small incidence of consumers reducing consumption in response to drug prices, such a response is cause for concern. Health care practitioners would be alarmed by the noncompliance of elderly patients in a market such as high blood pressure drugs. The societal cost of such noncompliance has been clearly documented in several studies (Ulmer 1987, Sullivan, Kreling, and Hazlet, 1990). Public policy makers would also be concerned about such responses from patients since ensuring access to optimal therapy has always been a concern, more so in the case of the indigent.

In terms of voicing, it was again found that price related aspects were key reasons for voicing complaints. However, even with reference to drug cost, which was bothered 40.8% of respondents, only about 21% voiced their complaints. It appears that in line with Day and Landon (1977),and Andreasen (1985), a small minority in this market seem to experience negative post-exchange feelings and complain about them. This further suggests that this market may be classified as "loose monopoly".

Next, consumers' reasons for not complaining were analyzed, according to the five models used. The data indicate that various reasons explain the non-complaining behavior of bothered consumers. These reasons may be categorized under the (1) cost-benefit model, (2) the personality model, (3) the restraint model, (4) the learning model, and (5) the equity-restoration model. Table 4 presents the results. The four key reasons for not complaining that were selected by more than 40% of the bothered patients were: "It wouldn't accomplish anything" (54.9%), "It wasn't worth the effort" (47.5%), "I did not think I could get any one to do anything about it" (51.5%) and "I didn't like the hassle of complaining' (50.0%). These reasons fall into three models: the cost-benefit model, the personality model, and the restraint model.

Taken together, they suggest that perception of apathy from channel member may be an important reason that these patients do not voice. As Hirshman (1970) suggests, the lack of adequate voicing may lead to disregard for consumer welfare on the part of the market. Also, as Fornell and Wernerfelt (1987) suggest, at a time when firms are attempting to retain market share as a defensive strategy, marketers should attempt to encourage voicing from consumers. In this market it appears that perceived lack of responsiveness on the part of channel members may be leading to a reduction in voicing behaviors. Table 5 further bears out such an assertion. Patients seem to believe that consumer groups and government agencies are more likely to take action in response to their complaints, compared to the manufacturer and pharmacist. However, the mean value associated with the perceived responsiveness to complaints on the part of any channel member is dissapointingly low, with the highest mean value being only 4.43 on a seven-point scale.






The prescription drug market has criticized by public policy makers and citizen groups for its pricing and promotional practices. The need for regulations may be warranted if consumers are unable to police the market. This study found that a very large proportion of the patients in market indicated that they were satisfied with all components of their drug therapy. As Andreasen suggests(1985), such high reports of satisfaction in a market characterized by patient loyalty may lead to the conclusion that this market may be a "loose monopoly". This would further imply, that there may be the need for public policy intervention in order to regulate the market even in the absence of market generated signals for such intervention.

Next, it was found, in line with Andreasen and Manning's (1990) conceptualization of the vulnerable consumer that patients with lower levels of education and income seem to report higher levels of satisfaction. The vulnerable consumer, once identified may need to be educated and protected from possible exploitation. In fact, this study also suggests a methodology for identifying consumers who may be experiencing negative post-exchange feelings, but who would not be identified using traditional operationalizations of satisfaction. Using the term "bothered", it was found that in contrast to high levels of dissatisfaction reported earlier, almost 70% of the respondents were bothered by one or more issues. This suggests that marketers may be better off developing measurement scales on the basis of language used by consumers when examining post-exchange actions. Also, the relationship between being bothered and being dissatisfied bears future examination.







Finally, it was found that a large proportion of bothered consumers did not voice their concerns. It appears that consumers in this market perceive that channel members would not act in response to their complaints and as a result they did not feel that complaining was worth the effort. Also, patients bothered by drug cost seemed to reduce their expenses or reduce consumption of the drug. The latter actions not only represent a potentially negative economic impact on manufacturers (lost sales), but suggest a compromise in the quality of therapy. Sub-optimal therapy may trigger the need for public policy to protect consumers from making such decisions.

Taken together these findings suggest that educating the public on how to express their concerns and dissatisfaction with the prescription drug market may be more valuable than implementing further regulation on an already heavily regulated industry. Hirschman (1970) proposes that the consumer's ability to articulate their complaints determines if he/she will exit the market or voice a complaint. Advertising or educational programs that provide product information to consumers may enable them to communicate their complaints or concerns to the manufacturer before they are expressed to third parties such as consumer groups or before the consumer exits the market. The role of product information on the consumer complaining process should be the subject of future research.

Also, health care practitioners, particularly physicians and pharmacists, must take a proactive position in communicating with their patients to identify issues that bother them so that complaints may be directed to the manufacturer. Future research should also include an assessment of the channel member's role in information flow from consumer to manufacturer.


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Dev S. Pathak, Ohio State University
Suzan Kucukarslan, Ohio State University
Deepak Sirdeshmukh, Ohio State University
Richard Segal, University of Florida


NA - Advances in Consumer Research Volume 20 | 1993

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