Set in the UK’s end-of-life care (EOLC) system, research by Management School’s Marketing experts examines how vulnerable consumers navigate support services following an unusual, unwelcome and catastrophic event.
The investigation explores how vulnerability shapes consumer journeys for terminally ill patients and those accompanying them.
The findings indicate biophysical vulnerability is exacerbated by the emotional distress, mental blockage and looming unwanted life changes derived from the diagnosis.
However, consumer vulnerability fluctuates in response to positive and negative experiences with hospice care services and the wider healthcare system, offering invaluable insights to improve EOLC.
The study provides a comprehensive picture of how vulnerable consumers navigate negative services1 nested within a complex system and highlights the fundamental role of travelling companions.
The investigation not only provides important lessons for organisations involved in EOLC, but also to services where the user journey is marked by a substantial loss of control and ability to make decisions.
Does the path-to-purchase logic apply to vulnerable consumers?
People regularly embark on “solo travel journeys” to buy products or services following more or less complex decision-making processes.
In most journeys, consumers are normally in control, as they actively evaluate available choices and select options that best fit their needs.
But this is not always the case. A terminal diagnosis is catastrophic for patients and those close to them.
The heightened fear, stress and uncertainty over a soon approaching death reduces agency, leaving patients and their loved ones more vulnerable.
Making the right decisions is also difficult, despite having access of services designed to help users deal with a problem they hoped to never experience.
EOLC (aka hospice care) encompasses all the services that provide medical, physical, emotional and spiritual support to those facing the final months or weeks of their lives and their families.
In the UK, hospice care is highly fragmented, making it a particularly complex service system for users to navigate.
EOLC can be delivered at home, in a hospital or hospice. It involves a multidisciplinary team, including general healthcare staff (eg GPs, hospital staff, social workers) and specialist providers (eg hospice nurses).
While most care services seek to heal, EOLC focuses on maximising comfort and dignity, prioritising patient preferences and wishes.
Most journey research to date focuses on agentic, solo travellers making rational single-purchase decisions, in relatively familiar settings.
In contrast, EOLC presents an opportunity to examine a journey where vulnerable consumers must navigate an unfamiliar and complex system, alongside a companion.
Mapping the journey for vulnerable consumers
To better understand how vulnerability influences EOLC consumers, the research team looked at the lived experiences of patients and their caregivers2, by using a storytelling method called pathographies.
Spanning from diagnosis to bereavement, the pathographies comprised narratives of illness that focused on key touchpoints3 that influenced the journeys, to identify examples of good and bad institutional practices.
Problems in complex systems can arise from embedded dynamics that result in poor communication, coordination and inter-collaboration.
To complete the picture, the team interviewed staff from several hospices care suppliers and healthcare professionals from the wider system4.
The analysis confirmed the journey for EOLC primary and secondary consumers is marked by levels of vulnerability that don’t exist in most path-to-purchase journeys.
The start of an unwelcome journey: stress responses, cognitive limitations and identity threats
After the diagnosis that kick-started their journeys, consumers experienced heightened levels of emotional and cognitive vulnerability.
Negative reactions to a stressful and unfamiliar situation (eg shock, fear, sorrow) left people struggling to cope and “not knowing which way to turn”.
Their ability to grasp facts and information also diminished, which rendered traditional marketing materials and oral communication ineffective.
Overwhelmed by the emotional blockage and “brain-fog”, most consumers failed to take decisive action, delaying considerations over available EOLC services.
Importantly, this was the case for patients and their travelling companions, with vulnerability experience by the latter being on par with that of primary consumers.
This initial state of inertia progressed to a realisation of the new journey entailing unwelcome and frightening new roles, which were perceived as threats to their current identities, especially for traveling companions.
Resistance to new role can take two forms: fear of it (eg feeling unprepared to become a caregiver) and dread of role loss (eg transitioning from spouse to widow/er, fearing to lose one’s role as a parent).
This imposed transition pushed consumers to a “betwixt and between” period that delayed effective decisions even longer, as they faltered to come to terms with their new identities.
The ebb and flow of consumer vulnerability: the impact of system- and brand-owned touchpoints
While EOLC consumers are exposed to experiences with a variety of agents, the analysis confirmed they don’t differentiate between those controlled by hospices, home hospice care and EOLC hospital units (ie brand-owned), from others across the system.
Touchpoints are any form of interaction or point of contact between a person and a brand. These can be tangible or intangible, shaping the experiences of consumers throughout the journey and influencing their decisions.
System-owned touchpoints played a critical role in increasing vulnerability, presenting a system that (although unintentionally) excludes the people it exists to serve:
- Power imbalances in service encounters that leave consumers feeling small, powerless and/or angry
- A complex – often uncoordinated – system lacking normative guidance, that is hard to navigate by already cognitively vulnerable consumers
- Entrenched institutional logics that deprioritise consumer choice and further delay the move to EOLC services.
Zooming into EOLC, the analysis revealed widespread resistance to the hospice brand among those who had not experienced it, with people describing as “the death house” or “an old person’s home”.
While this finding has managerial implications for the brand ‘hospice’ itself, it also indicates a more complex trigger for vulnerability, as services designed to help consumers can make them feel powerless and threaten their identities.
In stark contrast, when consumers directly experienced hospice care, they were impressed by staff professionalism and therapeutic qualities of the facilities.
Highly skilled in calming anxiety, offering choices and making people feel safe, frontline staff alleviated feelings of vulnerability, conveying a sense of serenity and reassurance, unaccomplished in earlier communications.
However, while the physical servicescape5 helped to soothe and restore feelings of safety, its design unintentionally let people witness others very close to death, intensifying again fear and vulnerability.
This illustrates the ebb and flow of consumer vulnerability and how consumers can regain agency when exposed to the correct touchpoints.
In this respect, the role of travelling companions was found to be of utmost importance, as they - not the primary consumers - act as project managers, making things happen in three ways:
- Individual agency, eg relinquishing care to professionals, looking for information
- Proxy agency, eg dealing with system barriers, processes and agents
- Collective agency, eg collaborating with hospice staff to find solutions
Ultimately, collaboration between staff and traveling companions is what restores agency to primary consumers; hence, they must be considered as primary stakeholders in future strategy development.
Addressing service gaps for vulnerable consumers
The satisfactory service provided by EOLC staff offers opportunities for its specialists to train agents in the wider system.
The highly effective consumer focus among hospice staff, means training can help strengthen the emphasis on the wishes of the consumer.
From a brand perspective, addressing misconceptions around hospice care goes beyond changing the brand’s name, as death remains taboo in Western society and words don’t change without cultural input.
As many people have never experienced EOLC, the authors stress the need for a mainstream communications campaign to challenge current myths.
This requires prior understanding of how hospice care sits in the mind of consumers, so it can be repositioned as a service which enables people, provides choice and restores agency.
As having a private room is not always possible, to limit exposure to other people dying, the authors suggest bifold doors and concertina screens can be an easy way to alleviate a difficult problem.
From a wider strategic perspective, the authors stress journey mapping must include system-owned touchpoints due to their major impact on consumer vulnerability and satisfaction.
While consumers can point out service gaps, staff from the wider system provide invaluable insight into the dominant logics and practices behind those problems.
Finally, the authors underline journey mapping exercises must incorporate traveling companions and suggest they’re so crucial that managers who identify a solo traveller, should appoint a relevant friend to ride with them.
Important lessons for organisations outside EOLC
Although extreme, a terminal diagnosis is not the only situation that triggers consumer vulnerability in a substantial way.
Fear and stress are normal reactions in the aftermath of a disaster, such as floods, house fires or car accidents, so the study offers relevant insights for emergency services aimed at supporting these consumers.
Similar emotions are also prevalent among refugees and asylum seekers, or children in care who are approaching adulthood, and not terminally ill patients are often more emotional and dependent than consumers in other markets.
Even in less catastrophic scenarios, complex service systems can feel emotionally and cognitively overwhelming for users with poor literacy skills or inadequate digital literacy.
Resistance is also prevalent in a variety of support services, such as financial assistance, mental health, weight loss or drug rehabilitation, with already vulnerable consumers rejecting available help to protect their identities.
The research highlights important lessons for organisations nested within complex service systems, such as homelessness services which involve government agencies, welfare systems, local charities, social shelters, etc.
Finally, the study offers a useful frame of reference for service journeys that involve a companion or where someone else is likely to become vulnerable (eg drug/alcohol/gambling addiction, children in foster, domestic abuse).
1 Negative services deal with non-routine problems that arise from catastrophe and are perceived as risky, invasive and/or psychologically stressful.
2 The final sample included pathographies from 88 primary consumers (patients) and 169 travelling companions (family caregivers).
3 To aid pathographies, the research team used the trajectory touchpoint technique, a service design methodology that harnesses customer experiences for enriched understanding of value throughout multilevel service components to ultimately increase innovativeness (Sudbury-Riley et al., 2020).
4 The final sample comprised semi-structured interviews with professionals working in 9 organisations across the UK. 44 from hospices and EOLC units and 22 from the wider system, including hospital inpatient and outpatient units and a specialist cancer unit.
5 The physical servicescape refers to the tangible, built environment where service transactions and consumption occur, shaping customer emotions, perceptions, and behaviours.
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Chair in Marketing |
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Professor Philippa Hunter-Jones Chair in Marketing |
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Senior Lecturer in Marketing |
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Chair in Responsible Research in Marketing |
