FROM "NO WAY" TO "EVERY DAY" –How Liminal Phase Shapes Medication Adherence in Chronic Disease
Authors:   , Kun Zsuzsanna 
Published: December 2024

This doctoral dissertation investigates how the liminal phase impacts medication adherence among chronic disease patients. The study is grounded in the concept of liminality, which denotes the transitional state, and explores its application in the context of chronic health conditions. The research employs a comprehensive mixed-methods approach, combining both quantitative and qualitative data. The initial quantitative phases utilise PLS-SEM modelling. The preliminary phase incorporates INAS Resiting Illness as a moderator to comprehend non-adherent behaviour. This is followed by a qualitative phase involving in-depth interviews to gain a deeper understanding of patient experiences along the medication adherence continuum. The final, primary quantitative phase tests additional moderators like the 'Acceptance and Action Diabetes Questionnaire' (AADQ) and 'time since diagnosis' to determine their impact on adherence behaviours. The findings underscore the practical implications of the liminal phase in medication adherence. Patients' liminal experience, characterised by a state of 'betwixt and between', significantly influences their adherence behaviours, highlighting the necessity for healthcare strategies that acknowledge the temporal dimensions of living with chronic disease. This dissertation not only integrates the theory of liminality with chronic disease management but also provides actionable insights for healthcare professionals and individuals involved in chronic disease management. Measurement tool results: The research identified a three-dimensional structure in the Acceptance and Action Diabetes Questionnaire (AADQ) as: ‘Disease Denial’, ‘Liminal Disengagement’, and ‘Controlled Illness Consciousness’, which capture different psychological processes affecting disease acceptance and adherence. The study confirmed the reliability of the Intentional Non-Adherence Scale (INAS) through Confirmatory Factor Analysis. This validation adds depth to the theoretical understanding of intentional non-adherence. Direct effects on non-adherence (MARS5): Financial constraints significantly and strongly impact non-adherence. This broadens the theoretical models of medication non-adherence to encompass economic challenges. The study found that non-adherence is often influenced by a conscious decision (INAS) rather than a passive response influenced by beliefs about medications (BMQ). This suggests a paradigm shift towards incorporating intentional behaviours in adherence interventions. Moderating effects on non-adherence: The research uncovered that 'Resisting Illness' has a complex role in medication adherence, interacting with other psychological factors like concerns about medication to influence non-adherent behaviours. Additionally, time since diagnosis was found to moderate the impact of 'Testing Treatment' and ‘Necessity’ on non-adherence, highlighting the dynamic aspect of adherence behaviour over time. Pathways Toward Medication Adherence: The dissertation explores dual pathways to medication adherence: naturally adherent patients and those who are non-adherent after diagnosis and become adherent after a significant health crisis or symptom escalation. The 'threshold' is where the initial resistance to medication starts to follow the medication regimen. Overcoming this threshold involves a substantial psychological adjustment from denial to acceptance, indicating that the initial resistance is a pivotal barrier that needs to be crossed once and after additional medication is accepted easily.