An integrative model of customers' perceptions of health care services ...

The Service Industries Journal Vol. 28, No. 9, November 2008, 1307 –1319

An integrative model of customers’ perceptions of health care services in Taiwan Hsiu-Lan Wua , Chang-Yung Liub and Wen-Hsin Hsuc a

Department of Information Management, Fortune Institute of Technology, Kaohsiung County, Taiwan, Republic of China; bDepartment of Business Administration, I-Shou University, Kaohsiung County, Taiwan, Republic of China; cDepartment of Accounting, National Taiwan University, Taipei, Taiwan, Republic of China As the health care service gets more competitive, health care practitioners and academic researchers are increasingly interested in exploring how patients perceive the quality and value of their care before building up their satisfaction levels and generating behavioural intentions. Drawing some theories from marketing and health care service literature, this study tries to propose an integrative model of customers’ perceptions of health care services based on the established relationship among four key constructs (service quality, perceived value, satisfaction, and behavioural intentions). Structural equation modelling is then used to validate the model. As Taiwan’s universal health insurance offers every citizen equal financial access to all health care providers, Taiwan offers a good opportunity to study how the patients’ perception model is structured. The findings reveal both perceived quality and value as antecedent variables in this model illustrating direct and indirect paths from perceived quality and value to patient satisfaction and behavioural intentions. Keywords: service quality; patient satisfaction; perceived value; behavioural intentions

Introduction Over the past decade, customer-oriented service has emerged the pre-eminent model for service delivery across various disciplines. Past research, particularly in marketing, has linked service quality to customer satisfaction (Cronin & Taylor, 1992; Oliver, 1993; Taylor & Baker, 1994) and purchase intentions (Boulding, Kalra, Staelin, & Zeithaml, 1993; Zeithaml, Berry, & Parasuraman, 1996). At the same time, some researchers also attempted to apply related theories and methods in health care settings (Cronin & Taylor, 1992; Fullerton & Taylor, 2002). They suggested that patients’ perception of service quality is a key determinant of a health care organisation’s success due to its primary role in achieving patient satisfaction and hospital profitability (Donabedian, 1996). Conceptualising and measuring patient satisfaction and service quality in health care settings continue to be of particular interest to practitioners and academic researchers. However, in reviewing the health service literature, the relationship between service quality

Corresponding author. Email: [email protected]

ISSN 0264-2069 print/1743-9507 online # 2008 Taylor & Francis DOI: 10.1080/02642060802230130 http://www.informaworld.com

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and satisfaction in the process of forming patients’ loyal intentions and subsequent behaviour is still poorly understood (Baker & Taylor, 1997). Furthermore, perceived value is an important concept, as it is believed to have an influence upon customer satisfaction (Cronin, Brady, & Hult, 2000) and behavioural intentions (Cronin, Brady, Brand, Hightower, & Shemwell, 1997). As customers become more demanding, competition further intensifies. Woodruff (1997) contends that customers’ perception of value is the next underlying source for a competitive advantage. Despite its significance in business marketing literature, perceived value has rarely been mentioned in the health care settings. As a consequence, to develop a more pragmatic picture of the underlying relationships among service quality, perceived value, satisfaction, and behavioural intentions is important. The use of an integrative model to study customers’ perceptions of health care services and develop a marketing strategy for health care systems should be explored. In 1995, Taiwan established a national health insurance (NHI) program to guarantee all Taiwanese equal financial access to comprehensive health care service. NHI, a form of mandatory socialised health care, is based on the principle of mutual assistance of the people. While the government and employers contribute parts of the premium, citizens who have joined NHI program should pay premium per month, at less than 5% of the average monthly wage. By the end of 2005, more than 97% of the total population had enrolled in the insurance program. NHI covers comprehensive benefits, including inpatient care, ambulatory care, laboratory tests, diagnostic imaging, prescription drugs, dental care, traditional Chinese medicine, day care for the mentally ill, limited home health care, certain preventive medicine, etc. Furthermore, NHI has no restrictions on patients’ choices of the health care providers, hospitals and physicians. Patients are entitled to choose freely from 92% of all health care providers in Taiwan, who have been contracted in the NHI program. Unlike the managed care models in the USA or other western countries, the absence of a referral system and the completely free choice of providers in Taiwan has provided great incentives for patients to go ‘doctor shopping’. Between 1994 and 2000, total hospital outpatient visits increased by 16.6%. This has resulted in high health care use rates, especially outpatient care. Outpatient visits averaged 14.4 per capita in 2001, compared with 5.8 for the United States (1996), 6.4 in Canada (1998), 6.5 in Germany (1996), and 16 in Japan (1996) (Cheng, 2003). The increasing usage of health services and the ‘doctor shopping’ pattern have made the health care industry competitive. In the face of such an impetus, hospital administrators realise that to maintain and enhance their competitive advantage, they must provide customer-oriented care, as in other service settings. Studies documenting the importance of patients’ perceptions of care are drawn primarily from western countries. A review of the broader literature reveals a limited number of health care studies in developing non-western countries. Given that cross-cultural research in this area is relatively recent, the present study tries to clearly depict the relationships among service quality, perceived value, patient satisfaction, and behavioural intentions in the context of Taiwan’s competitive health care system. The framework of this analysis is first to review the literature that supports the development of the four constructs followed by the theoretical support for hypothesised causal paths. Next, the survey instrument and data collection are described. Once the reliability and validity of the four constructs are documented, the structural model fit statistics are presented. The article ends with a discussion of the results and implications.

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Theoretical background and research model Service quality Quality of care is often defined differently among stakeholders, such as employers, insurance companies, health care managers, physicians, and patients. The assessment of service quality poses some challenges on the issue of who will assess quality and on what criteria (Andaleeb, 2001). Donabedian (1982) provided an early guide to identify three approaches to assess the quality of health care as structure, process, and outcome. Structure is the resources used to deliver care; process is the delivery of the health services; and outcome is the result of the health care experience. She described the process of health care as comprising two components – technical and medical care, and management of the interpersonal relationship between the practitioner and the client. Historically, the establishment of quality standards was delegated to the medical profession. Not surprisingly, quality was traditionally defined by clinicians in terms of technical delivery of care. The recent literature, however, emphasises the importance of the patient’s perspective (Andaleeb, 2001). To date, most patients lack sufficient expertise and skills to evaluate whether the delivered medical service was performed properly or was even necessary (Gabbott & Hogg, 1995; Newcome, 1997). As a consequence, patients rely greatly on non-technical processrelated dimensions such as the patient–practitioner relationship and the surroundings of the service encounter in evaluating service quality (Bowers, Swan, & Koehler, 1994). Parasuraman, Zeithaml, and Berry (1988) developed a 22-item scale, called SERVQUAL, which comprises five dimensions including tangibles, reliability, responsiveness, assurance, and empathy for measuring service quality. The SERVQUAL scale has been widely adopted across service industries. It is based on the expectancy disconfirmation model, which states that evaluation of service quality results from comparing the perceptions of service received with prior expectations of what the service should provide. A number of researchers have criticised the SERVQUAL approach. Carman (1990) suggested that in specific service situations, it may be necessary to redesign SERVQUAL dimensions. Measuring the gap between expectations and performance can be problematic. Cronin and Taylor (1994) argued that service quality can be predicted adequately by using perceptions alone. Brown, Churchill, and Peter (1993) observed that difference scores produced theoretically poorer reliabilities than their component scores. Teas (1993) contended that the SERVQUAL scale of expectations induced several different types of expectations; the participants were not able to differentiate among different types of expectations when they provided evaluations. Thus, for the purpose of explaining variance in dependent constructs, the weight of the evidence in the extant literature supports the use of performance perceptions in measures of service quality (Parasuraman, Zeithaml, & Berry, 1994). Satisfaction Satisfaction reflects the degree to which a customer believes that the use of a service evokes positive feelings (Rust & Oliver, 1994). The general service literature suggests that service quality and satisfaction are distinct constructs. The distinction appears to revolve around the arguments that (1) service quality is a form of attitude representing a long-run overall evaluation, (2) satisfaction represents a more short-term, transaction-specific measure (Taylor & Cronin, 1994), and (3) service quality evaluations as cognitive antecedents to the affective construct of satisfaction

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(Oliver, 1997). Oliver (1993) first suggested that service quality would be an antecedent to customer satisfaction, and several researchers have found empirical support for this model. The importance of patient satisfaction has continued to grow such that patient satisfaction is now viewed as a vital component of health care services. Donabedian (1982) suggested that patient satisfaction should be indispensable to the assessment of service quality. Goldstein and Schweikhart (2002) argued that service quality is an indicator of patient satisfaction levels. Many researchers revealed that service quality is positively related to patient satisfaction (DeMan, Gemmel, Vlerick, VanRijk, & Dierckx, 2002; O’Connor & Shewchuk, 1989). This leads to the following hypothesis: H1: Perceived service quality is significantly related to satisfaction.

Perceived value Perhaps customers do not always consume the best quality service and they might instead purchase on the basis of their assessment of the value of a service (Cronin & Taylor, 1992). Perceived value is the consequence of a mental weighing of perceived benefits versus sacrifices. That is, customers may cognitively perceive what they get and what they have to give up for receiving services (Gronroos, 1984; Zeithaml, 1988). Previous value studies consistently showed that quality was an antecedent of perceived value (Cronin et al., 2000; Fornell, Johnson, Anderson, Cha, & Bryant, 1996; Oh, 2000; Zeithaml, 1988). Surprisingly, there is a scarcity of findings on the functional relationship between perceived value and satisfaction. Service quality has typically been viewed as the sole determinant of customer satisfaction, and the notion of trade-off in service evaluation has not received due attention. Even in health care settings, perceived value has been neglected. However, the role of perceived value in service contexts is important to investigate. It is well established in the marketing literature that higher value perceptions lead to higher repurchase intentions. Customers, who think that what they have received was worth what they have given up, have been found to be more likely to purchase from the same provider. Zeithaml (1988) provided evidence supporting an influential role of value in customers’ purchase decision-making. According to the means-end model proposed by Zeithaml (1988), perceived value is a direct antecedent of a purchase decision and a direct consequence of perceived service quality. Cronin and Taylor (1992) contended that marketers need to consider perceived value to enhance the predictive power of service quality. Satisfaction is influenced by the value of the services that customers have received (Heskett, Jones, Loveman, Sasser, & Schlesinger, 1994). The American customer satisfaction index model in Fornell et al.’s (1996) study supported a positive influence of perceived value on customer satisfaction. Cronin et al. (2000) further argued that perceived value is a significant predictor of satisfaction. Bojanic (1996) demonstrated the relationship among perceived value, price, quality, and satisfaction, and noted that price and quality determine perceived value, which correlates positively with satisfaction. Oh (1999) conducted an experimental study of the hotel industry, exploring the relationship among service quality, value, and satisfaction. He found that service quality is an antecedent of perceived value and value is significantly related to satisfaction and repurchase intentions. Thus, the following hypotheses can be formulated: H2: Perceived service quality is positively related to perceived value.


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H3: Perceived value is positively related to behavioural intentions. H4: Perceived value will have an influence upon satisfaction.

Behavioural intentions To date, most of the work in service industries has focused on repurchase intentions as the focal dependent variable (Cronin & Taylor, 1992; Taylor, 1997; Taylor & Baker, 1994). There are multiple behavioural intentions, including customer loyalty, positive recommending behaviour, and repurchase intentions (Cronin et al., 2000; Zeithaml et al., 1996). This study will adopt these distinct consequences of behaviour in which loyal customers engage. Several studies have modelled service quality as an antecedent to behavioural intentions and found a significant link (Bitner, 1990; Boulding et al., 1993; Zeithaml et al., 1996). Much evidence has also been gathered in the field of health care marketing for the direct impact of quality perception on patient behavioural intentions (Gooding, 1995). From the above, the hypothesis is as follows: H5: Perceived service quality is positively related to behavioural intentions.

Organisations that focus on customer satisfaction are able to build loyal clients who, then, serve to promote the organisation further through vital word-of-mouth advertising referrals (Zeithaml & Bitner, 2003). Word-of-mouth recommendations from satisfied customers lower the cost of attracting new customers and enhance the firm’s overall reputation, while that of dissatisfied customers naturally have the opposite effect (Anderson, 1998; Fornell, 1992). Under the circumstances, it is proposed that: H6: Satisfaction will have an impact upon behavioural intentions.

The conceptual model which integrates the hypothesised relationships (H1–H6) appears in Figure 1. Arrows in the model indicate causal directions. The relationships among the four constructs depicted in this model were empirically tested based on outpatient data collected in Taiwan. Methodology Data collection The goal of the survey was to capture patients’ perceptions of health services. Due to resource and time constraints, one of the most famous hospitals in Taiwan was chosen. The sample hospital, XYZ Hospital with 1626 beds founded in 1957, is one of Taiwan’s leading medical centres. Trained personnel interviewed a random sample of outpatients in the area where outpatients waited for medication after visiting physicians during the period from November 2005 to December 2005. In all, 350 patients were asked to participate in the survey. For each question, participants had to circle the response which best described their degree of agreement. A total of 322 valid replies, a response rate of 92%, was used for the data analysis. Respondents ranged from 18 to 65 years of age with a mean age of 39, and females outnumbered males (representing 56.9% of the sample). The theoretical constructs of interest in the study were not correlated with age or gender demographic variables. Questionnaire design The measures were developed via successive stages of scale development. All of the items were measured on 7-point Likert-type scales (1 ¼ very disagree strongly and 7 ¼ very agree

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Figure 1. Model of customers’ perceptions of services.

strongly). Instead of limiting the measures of service quality to the theoretical structure suggested by the SERVQUAL framework, the development of a service quality scale was based on a focus group of both patients and health care providers to generate insights into how Taiwan patients viewed the health care services they received. Four dimensions of perceived service quality comprising 14 items were developed based on the results of the interviews (see Appendix A, items 1 – 14). The dimensions are as follows: (1) tangible assets (e.g., hospital facilities), (2) the speed of the responsiveness to patients’ demands, (3) the interaction between medical staff and patients, and (4) the mental assurance from medical staff. The values of these four manifest variables are determined by calculating the averages in the dimensional questions. A three-item behavioural intention scale reflects the multiple dimensions of behavioural intentions, including ‘willingness to recommend’, ‘intention to repurchase’, and ‘compliance’. The corresponding items for each respective dimension were: (1) ‘I am willing to recommend this hospital to others who seek my advice’, (2) ‘if I need medical service in the future, I would consider this hospital as my first choice’, and (3) ‘I will follow what the doctor advised (e.g., took prescribed medication, engage in recommended behaviour, etc.)’. Perceived value was assessed with three items to reflect the conceptualisation of value as relative ‘gets’ versus ‘gives up’, the measure of which includes monetary price and non-monetary price (such as time, effort, and search costs) (Zeithaml, 1988). Specifically, perceived value was measured as a form of subjective trade-off. We asked for responses such as ‘This visit is worthy of money that I have spent’, ‘The benefits of health service I received are worth all the costs related with the searching information, psychological turmoil and the waiting time for this visit’, and ‘if the hospital raised the price of out-of-pocket expenses relative to other hospitals, I would consider this hospital as my first choice’. Customer satisfaction is often defined as overall feelings of satisfaction that immediately follows a service encounter. The items we develop attempts to capture the conceptualisation of patient satisfaction by exploring patients’ affective response to the overall service experience. The items are: (1) ‘I am satisfied with the health care service’, and (2) ‘The overall feelings about the service of care in this hospital is better than what I expected’.


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The questionnaire was reviewed by hospital managers and management researchers for relevance, clarity, and ease of use. We also conducted a pre-test of the survey instrument on a representative set of 30 respondents selected from our target population to modify the language suitably. Analysis The proposed model in Figure 1 was analysed via maximum likelihood estimator of LISREL 8.7 by using the variance – covariance matrix of the measured variables as input (Joreskog & Sorbom, 1993). The analysis followed a two-step procedure based on Anderson and Gerbing (1988) recommendations. First, we conduct a confirmatory factor analysis to develop a measurement model that achieves an acceptable fit to the data. In the second step, we test the structural model by path analysis to demonstrate a meaningful theoretical model.

Results Confirmatory factor analysis Analysis of the measurement part of the structural models before that of the structural parts is commonplace in customer behaviour research, and was suggested by structural equation modelling theoreticians (Anderson & Gerbing, 1988). A confirmatory factor analysis was run for the measurement model including the four latent constructs. The measurement model had a x2 value of 190.64 (48 degrees of freedom), and the x2/df ratio value of 3.972 was unsatisfactory. It is documented in the literature that x2 statistic is sensitive to sample size and large sample sizes frequently result in the rejection of a well-fitting model. Furthermore, the model fit also used the following indices: goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), comparative-fit-index (CFI), normed-fit-index (NFI), and standardised root mean square residual (SRMR). As shown in Table 1, all the model-fit indices exceeded the respective common acceptance levels suggested by previous research, demonstrating that the measurement model exhibited a good fit with the data collected. Therefore, we proceeded to evaluate the psychometric properties of the measurement model in terms of reliability and convergent validity. The reliability of the measure is assessed using composite reliability and variance extracted estimates, as listed in Table 1. The composite reliabilities were calculated as: {square of the summation of the factor loadings/(square of the summation of the factor loadings þ summation of error variables)}. The interpretation of the resultant coefficient is similar to that of Cronbach’s alpha, except that it takes into account the actual factor loadings rather than assuming that each item is equally weighted in the composite load determination. The composite reliability of each construct exceeded 0.6 in this study, satisfying the minimally acceptable level. On the other hand, the average extracted variances were all above the recommended 0.5 level, which meant that more than one-half of the variances observed in the items were accounted for by their hypothesised factors. As can be seen in Table 1, the t-values for all indicators range from 13.085 to 21.697, indicating that all factor loadings are highly significant at the 0.001 level. This fact provides evidence supporting the convergent validity of all indicators which effectively measure the same construct. Thus, all factors in the measurement model had adequate reliability and convergent validity.

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Table 1. Summary measurement statistics.

Factor Behavioural intentions (BI) O1 O2 O3 Patient satisfaction (PS) S1 S2 Perceived value (PV) V1 V2 V3 Service quality (SQ) Q1 Q2 Q3 Q4

Standardised factor loadings

t-value

0.779 0.738 0.824

16.120 14.943 17.474

0.776 0.954

16.059 21.697

0.690 0.823 0.700

13.251 16.796 13.524

0.662 0.670 0.903 0.931

13.085 13.280 20.585 21.655

Reliability

Average extracted variance

0.760a 0.607b 0.545 0.678 0.634 0.602 0.911 0.689 0.475 0.677 0.490 0.701 0.438 0.449 0.815 0.866

0.610

0.757 0.547

0.642

Notes: Goodness-of-fit indices (n ¼ 322) – CFI ¼ 0.974, NFI ¼ 0.967, GFI ¼ 0.910, AGFI ¼ 0.854, SRMR ¼ 0.0456. Composite reliability. b 2 R -value (square of factor loadings). p , 0.001. a

Structural model results The second step in the analytical process was to form the structural model by specifying the causal relations in accordance with the hypotheses. Table 2 summarises the result of path analysis. A similar set of fit indices was used to examine the structural model. The results of the proposed model fitting exceeded or were close to standard criteria, as indicated by the GFI, AGFI, CFI, and SRMR values of 0.910, 0.854, 0.974, and 0.0456, respectively. Good structural model fit exists when there is reasonably high explanatory power (measured by R2), indicating the ability of the proposed model to explain variation in the endogenous variables. In the present study, R2 values for behavioural intentions, satisfaction, and perceived value are 0.911, 0.754, and 0.562. The proposed model achieves a fairly good fit. Table 2. Structural model: standardised coefficient estimates and fit indices.

Path SQ ! PS SQ ! PV PV ! BI PV ! PS SQ ! BI PS ! BI

Standardised coefficient estimate

t-value

Result

0.543 0.750 0.467 0.383 0.336 0.227

7.344 10.536 5.310 5.042 4.235 2.527

H1 is supported H2 is supported H3 is supported H4 is supported H5 is supported H6 is supported

Notes: Goodness-of-fit indices (n ¼ 322) – CFI ¼ 0.974, NFI ¼ 0.967, GFI ¼ 0.910, AGFI ¼ 0.854, SRMR ¼ 0.0456. p , 0.05. p , 0.001.

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The Service Industries Journal Table 3. Standardised total and indirect effects.

Standardised coefficient estimate

t-value

Path (total effects) PS ! BI PV ! BI PV ! PS SQ ! BI SQ ! PS SQ ! PV

0.227 0.554 0.383 0.874 0.830 0.750

2.527 6.699 5.042 14.034 12.973 10.536

Path (indirect effects) PV ! BI SQ ! BI SQ ! PS

0.087 0.539 0.287

2.460 7.056 4.943

p , 0.05. p , 0.001.

We use the standardised path coefficient, which provides a comparison among variables of the magnitude of the association with the dependent variable in the model. Service quality had a positive impact upon behavioural intentions (g ¼ 0.336, p , 0.001) in H5, satisfaction (g ¼ 0.543, p , 0.001) in H1, and value (g ¼ 0.750, p , 0.001) in H2. Perceived value was found to exert a positive influence upon behavioural intentions (b ¼ 0.467, p , 0.001) in H3, and satisfaction (b ¼ 0.383, p , 0.001) in H4. Patient satisfaction was a significant predictor in behavioural intentions (b ¼ 0.227, p , 0.05), thereby confirming H6. All path coefficients in the current model are statistically significant and are as hypothesised. In addition to the direct effect, we further examined service quality and perceived value to determine whether they were indirectly related to behavioural intentions. That is, the indirect effect of service quality on behavioural intentions via both perceived value and satisfaction was tested. The indirect relationship between perceived value and behavioural intentions was also examined, as listed in Table 3. Again, the results indicate that these indirect relationships proved significant. Perceived value, despite showing a weaker total effect than service quality on behavioural intentions, exhibited a stronger direct effect on behavioural intentions than that of service quality. Service quality exerted a greater impact upon satisfaction than perceived value. More specifically, service quality emerged as a more important antecedent to patient satisfaction than perceived value.

Discussions and implications We empirically validated an integrative model within the context of health care services, investigating the direct and indirect effects of both service quality and perceived value on patient satisfaction and behavioural intentions. The integration of these perspectives advances our understanding of these constructs. The above results have a number of implications and give valuable insight into the patients’ perceptions within health care settings for research and management. First, this study expands current knowledge by establishing a relationship between service quality and satisfaction.

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A confirmatory factor analysis showed that service quality and satisfaction were, in this case, distinct, and structural equation modelling showed that they have different antecedents and consequents. Secondly, although some parts of the literature indicate that service quality influences behavioural intentions only through perceived value and satisfaction (Gotlieb, Grewal, & Brown, 1994; Taylor, 1997), others argue for a direct effect (Boulding et al., 1993; Taylor & Baker, 1994; Zeithaml et al., 1996). This study supports the latter perspective; that is, the relationship between service quality and behavioural intentions is direct. Thirdly, in recent years, even though numerous marketing studies have been conducted on the relationships among service quality, satisfaction, and behavioural intentions, perceived value has largely been neglected in the related research. This study has empirically demonstrated a positive relationship between perceived value and patient satisfaction. Findings from this study lend empirical support to the assertion that enhancing service quality is clearly not the only means of increasing patient satisfaction; perceived value is essential. The first determinant of overall customer satisfaction is perceived quality, and the second determinant is perceived value in accordance with the previous research (Cronin et al., 2000; Fornell et al., 1996). Meanwhile, perceived value exhibits a significant impact upon behavioural intentions, in accordance with the previous research (Cronin et al., 1997). Thus, perceived value can offer greater competitive leverage as it not only contributes to patient satisfaction, but also encourages favourable behavioural intentions. Finally, more importantly, this study makes a unique contribution by positioning the perceived quality and value as antecedent variables in an integrative model illustrating direct and indirect paths from quality and value perceptions to patient satisfaction and behavioural intentions. Our findings indicate that both service quality and perceived value lead to satisfaction, which justify Bagozzi’s (1992) argument that cognitive evaluations (quality and value) precede an emotional response (satisfaction), and in turn, drive behaviour. The model reveals both the influence of service quality and value perceptions on satisfaction and behavioural intentions in health care settings. That is to say, patients who perceived high quality and value while visiting a particular hospital are more likely to form favourable satisfaction and form intentions to visit this hospital. Although perceived quality of health care services has a relatively greater influence upon patient behaviour (referrals, revisit, etc.) and satisfaction compared with perceived value, the models of patients’ evaluations of services that consider direct effects and individual constructs are likely to result in incomplete assessments. Health care providers are operating in an increasingly competitive environment. Few studies have investigated multiple direct links between service quality, perceived value, satisfaction, and behavioural intentions. Hospital managers should attempt to determine the extent to which patient behaviour is influenced by service quality, perceived value, and satisfaction before embarking on service improvement programs. The practical contributions of this study include implications for designing an integrative patient perception model. Such integration is likely to enable managers to undertake more detailed analysis of relationships among antecedents, satisfaction, and desirable intentions.

Conclusions By modelling service quality and patient satisfaction as distinct but related constructs, managers can more closely monitor and respond to changes in patients’ perceptions. In a state of quality


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and value perceptions, a patient is more likely to engage in a perceived process from quality and value towards purchasing. Therefore, in order to improve patients’ perceptions, hospital administrators should make efforts to improve quality, value and satisfaction simultaneously. The findings indicate a partially mediated effect with perceived value having both a direct effect on behavioural intentions as well as an indirect effect via satisfaction. It reflects that perceived value is important in understanding patient behaviour. From a managerial standpoint, this emphasises the importance of perceived value as a strategic objective. Positive behavioural intentions can be increased through valuable services that patients can perceive. Consequently, health care providers should consider improving not only service quality and patient satisfaction but also perceived value in their offerings, and determine the components that constitute value for their customers. The literature to date does not provide a clear definition of most constructs in this study; in particular, ambiguity in the definition of perceived value is another critical subject for extensive health service studies. Future researchers may use a qualitative approach to gain a richer picture of the relationship between patients’ perceptions of care and the consequences of these constructs. Depth interviews and phenomenological approaches have the ability to offer deep insight into patients’ perceptions, attitudes, and intentions. In addition, another limitation can arise when our model fails to take into account the antecedent factors for the construct of ‘perceived value’. As perceived value results from comparing perceived benefits and perceived costs, the model would be more elaborate if future researchers could explore other antecedents of perceived value related to patients’ behavioural intentions. For example, intangible costs such as physical and psychic costs are highly relevant in services that are complex and professional such as health services. It would therefore be worthwhile to examine how these costs affect the behavioural intentions and subsequent post-visit evaluations (Tam, 2004).

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Appendix A. Items used in service quality

Factor

Item label

Description

Tangibles Q1 Q2 Q3 Q4

It was convenient to use amenities (e.g., parking plot, ATM, cafeteria, etc.) for me The hospital provided clear guide board (e.g., floor sign, building’s layout, lab, etc.) The hospital had up-to-date equipment and technology The surrounding of this hospital was pleasant (e.g., cleanliness, comfort, lighting, temperature, sanitation, etc.)

Q5 Q6 Q7

It was easy to schedule appointments for me Waiting time for medication and payment was short for me Waiting time for the physician’s examination was short for me

Q8 Q9 Q10 Q11

The physician paid attention to my concerns Medical staff clearly examined and explained illness for me I felt medical staff were friendly and polite The pharmacist clearly explained the medication for me (e.g., usage, side effects, etc.)

Q12 Q13 Q14

I felt medical staff were skillful and competent I felt safe during examination and treatment I trusted the process of service care

Responsiveness

Interaction

Assurance