Behavioral intention in revisiting hospital under the effect of expertise, reputation and service quality

Behavioral Intention In Revisiting Hospital Under The EffectOf Expertise, Reputation And Service Quality Pham Bao Duy International University, Vietnam National University HCMC, Vietnam

Behavioral Intention In Revisiting Hospital Under The Effect

Of Expertise, Reputation And Service Quality

Pham Bao Duy

International University, Vietnam National University HCMC, Vietnam

Nguyen Tan Loi

Eastern International University, Vietnam

the retained problems for hospitals in Vietnam

Keywords: Vietnam Healthcare, Service Quality, Expertise, Behavioral Intention in Revisiting, Hospital in Vietnam, Sustainable Development.

1 Introduction

Healthcare has long been the initial service for human, which provides significant purposes

in examination, prediction, treatment and control the health According to the formerresearches, it is considered as the high level of association services (Hogg, Laing, & Newholm,2004) In some emergency situation, the hospital is not only considered as the place for health

improvement and examination but also become the crucial place for saving a life Therefore,the high level in emotional vulnerable following with the hazard is not deniable (Jadad, 1998).

According to General Statistic Office in Vietnam, there are 1,101 hospitals in 2012 and higher36% compared with the statistics in 2007 In addition, the number and scale of corporation andorganization operating in medical and health care field such as Hoan My, VinMec and TMMC hasbeen increased in recent years It

621

provides the proof that the importance and attention of medical industry in Vietnam However,with the interesting figures demonstrated in the recent report, the fundamental right – basichealthcare would be not considered as the right in developing countries included Vietnamwhere people from rural areas, even the government spend hundreds of million dollars inmedical industries which mostly focus on facilities’ expansion and improvement in suburban.

In other sides, according to Vietnam 2035 general report has been posted by World Bank andMinistry of Planning and Investment in Vietnam, it shows directly that the proportion of GDP shares6% for medical and health care over 2 decades from 2015 to 2035 While GDP and the growth ratehave been reported outstanding positively increasing whereas the out-of-pocket spending inmedical still appeared with 49%, it shows the importance of medical fields among people even thetotal expenditure must be paid by their money

According to WHO, the bed occupancy rate should not be over 80% of the hospitals’ capacity.Vietnam, however, witnessed a high occupancy rate especially in large cities A research of “Study

on Current Situation of Overcrowding, Under-Crowding in Hospitals at Levels and RecommendedSolutions for Improvement” of Ministry of Health in 2011 demonstrates that central and provincialhospitals always in overcrowding situation It is in the ranged from 120-150% of the hospital bedsused and some special cases over 200% in big central hospital in Ho Chi Minh city and Ha Noicapital According to the research of PricewaterhouseCoopers (Vietnam) Ltd Company called “TheVietnamese healthcare industry: moving to next level”, it mentioned the overload services in largeand popular hospitals in Vietnam while remote area hospital and regional polyclinic in suburban islack of patient Moreover, it agreed that Vietnamese tends to approach national hospital instead ofprovincial hospital due to the mindset in lack of quality in medical staff and medical equipment

Following the article “The poor still miss out on healthcare in Vietnam” published in 2015 onJoint Learning Network – The global community of health systems practitioners andpolicymakers in 27 countries including Vietnam, it stated that “Health Care Fund for the Poor”

is signed in 2002 under the Decision 139 signed by Prime Minister of Vietnam in order tosupport the healthcare service Vietnam especially people live in communes However, thisprogram was not appreciated by World Bank, the research “Health Insurance for the Poor:Initial Impacts of Vietnam’s Health Care Fund for the Poor” found that the reduction of out-of-pocket spending has not happened

According to a recent survey by the Ministry of Health, every year around 40,000Vietnamese go abroad for health treatment purpose and spend $1 billion in 2010 and nearly $2billion for total expenditures in early 2016 It raises the problem that whether hospitals inVietnam still not meet the needs of domestic demand in health care purpose even 6% of GDP

in Vietnam spend for medical as mentioned above In addition, in Vietnam, the average peoplemake the out-of-pocket payment for health care is almost accounted for 75% the totalspending in health care (Knowles et al 2005) According to the research of Gludner and Rifkin

in 1993, private healthcare provider appealing the demand of people who have intend inhealthcare service as the public service is deficient and imperfect, the case of Vietnam andUganda

2 Literature Reviews

2.1 Service Quality

Service quality is a measurement on the matching between services delivered andcustomer’s expectation Service quality must be delivered that match with customerexpectation on a reliable basic (Lewis and Booms, 1983)

Unfortunately, the evaluation for service quality in the scale that built-up through previousstudy for healthcare industry has been on the rocks Instead of the value comes from the result

of health care, patients do not completely evaluate the comprehensive problem in servicequality through their perspective In addition, some sectors found many difficulties todetermine whether it will be added on the service quality

622

assessment or not such as the emergency affected to the probability in survival or vegetableexistence, the question is not able to figure out people who responsible to assess theevaluation In addition, the lack of skill also expertise to define the service whether it wasconducted following the process or not (Newcome, 1997; Williams, 1994) As a result, hospitalstake their advantages in the evaluation of patient with the misleading in technical servicequality aspect (Bowers et al., 1994; Ettinger, 1998; Donabedian, 1988), focus on the interactionbetween patients and physicians and approach with potential customer with the misleading offormer evaluation.

According to Bowers et al in 1994, they suggest that the scale of service quality in patient’sdeterminant take important role in their satisfaction through SERVQUAL model Before theBower and his partners’ findings, a former study also used SERVQUAL in implication in theantecedent of service quality in satisfying patient (Reidenbach and Sandifer-Smallwood, 1990)

It is explained from another study in health care service industry that “As a construct,customer satisfaction has been noted as a special form of consumer attitude; it is a post-purchase phenomenon reflecting how much the consumer likes or dislikes the service afterexperiencing it” (Woodside, AG Frey, LL and Daly, RT., 1989) It comes to the first hypothesis:

Hypothesis 1 A service quality of hospital is positively related to patient’s (customer’s) satisfaction

In health care research, SERVQUAL scale is the precursor model for evaluating the outcomesbehavioral intention comes from service quality (Reidenbach and Sandifer-Smallwood, 1990),and other variant model with the same result, for example, Headley and Miller developed 6-dimensional based on primitive SERVQUAL model in 1990 It can be seen obviously that theservice quality is a significant dimension not only satisfy customer but also attract customer inrepurchasing service or product

Hypothesis 5 A service quality of hospital is positively related to patient’s (customer’s) behavioral intention in revisiting hospital.

2.2 Satisfaction

In 1980, Oliver built the definition that “In brief, customer satisfaction is a summary cognitiveand affective reaction to a service incident (or sometimes to a long-term service relationship).Satisfaction (or dissatisfaction) results from experiencing a service quality encounter and comparingthat encounter with what was expected”

To analyze the level of satisfaction that customer measured based on service, product thatprovided by an organization through figures based on questionnaires and feedback from thefrontline staff It could be the positive judgments’ outcome from using a product or servicefrom customer perspectives (Westbrook, 1980) Related to the definition, it suggests thatsatisfaction is the emotional evaluation, it is a chain of individuals’ assessment rather than anindividual perspective (Cronin and Taylor, 1994; Hunt, 1977) The scale of satisfaction isdefined from dissatisfying to satisfying where other arguments implicate that the customersatisfaction assessment proves a comprehensive evaluation than the specific outcome of atransaction

According to Singh and Sirdeshrnukh (2000), customer’s experiences is defined as thedirectly evaluation on some cues which included satisfaction Based on implicit and explicitcues, customer can gradually formulate the trustworthiness with firm (Doney and Cannon1997) If build up a strongly satisfaction from customer, customer may have more confidencewith the firm, which is the basic for increasing their trust on service provider Thus,

Hypothesis 4 A patient’s (customer’s) satisfaction is positively related to their trust in hospital.

Satisfaction is the factor that combine many antecedent elements, when customer’ssatisfaction increased, it leads to the last variable, repurchasing intention or it can beconsidered as sub-dimensions of customer loyalty (Kitapci, Akdogan, & Dortyol, 2014) Inmedical industry, there are varied study that mentioned this relationship which shows theimpact of satisfaction on behavioral intention (Anderson and Sullivan, 1993; Bitner, 1990;Reichheld, 1996; Woodside and Shinn, 1988; Woodside et al., 1989) Considering customer’s

satisfaction as the intermediate variable, majority of studies suggests that there were theindirect influences

623

between the behavioral intention and service quality where using value and satisfaction as themediate factor (e.g., Anderson and Sullivan, 1993; Gotlieb, Grewal, and Brown, 1994; Pattersonand Spreng, 1997; Roest and Pieters, 1997; Taylor, 1997) Hence,

Hypothesis 6 A patient (customer’s) satisfaction is positively related to their behavioral intention in revisiting hospital.

2.3 Trust

Trust comes from the belief of a party’s promise or sentence is reliable and the obligationthat party need to be fulfilled in vice versa for relationship purpose (Schurr and Ozanne, 1985).Based on the trust, the interaction of a buyer’s perception future and service provider (seller) isanticipated (Doney and Cannon, 1997) It creates a long-term orientation of a relationship B2C

in positive ways (Ganesan, 1994) The trust’s advantages which create strong relationship inbusiness has been researched in the literature review of Morgan and Hunt in 1994 Theindividual experience is considered as the trustworthy source rather than the referral fromrelatives or friends which is explained as the second-hand trust referral or the popular

Building trust efforts is core value of all business in general and hospital service in specific,the results from this long journey is the substantial development where customer loyalty andattraction are not deniable There are some evidences show the behavioral intention inrepurchasing services, products are the origin of trust (Morgan and Hunt, 1994; Chaudhuri andHolbrook, 2001) As trust shows confidence in looking for new customer as the reliability andintegrity has been prepared, it is the main component for long-term relationship orientation as

it moves the focus in present to continuity and future conditions (Doney and Cannon, 1997;Ganesan, 1994) Therefore, it results in a hypothesis that:

Hypothesis 7 A patient (customer’s) trust is positively related to their behavioral intention in revisiting hospital.

2.4 Expertise

Knowledge and experience of service providers in the main services are two terms thattypically measure in expertise (Crosby el at., 1990) In Medicine and Surgery perspectives, theexpertise requires a mastery in relevant skills also the diversity of knowledge in many aspects.Unlike other fields, physicians require the diverse knowledge such as biology, chemistry,physics as the basement and up-to-date their specialization that they pursuit from thebeginning Besides, ethics, cognitive and motor must be consistent interpersonally according totheir leaning in behavior and responsibility Moreover, clinicians require higher level in theirenormous knowledge not only in their specialization but also conduct the relevant field frompharmacist to the surgeon Considering medical diagnosis is the general skill of the physicians,the expertise of the doctors is defined through the accuracy of medical diagnosis because thecombination of higher experience and knowledge are deeply and varied (Feltovich et al., 1984;Neufeld et al., 1981)

A study found that the source of credibility and trustworthiness is the results of individual’sperception on level of expertise, it implicates a positively effects on trust (Busch and Wilson,1976) In other words, the level of experts creates the trust’s foundation According to theresearch of Crosby, Evans and Cowles in 1990, trust signal was founded from the expertise’sperception of customer It can be related to the trustworthy company where the appearance ofrelationship between expertise and trust create positively effects (Newell and Goldsmith,2001) In specific of hospital service, the expertise is the undeniable role which contribute tothe decision and recommendation on customer’s health The enhancements in trust aredepending in the major of the expertise which provide the skilled-set learned from theperennial experience and qualifications or highly achievements in their professional career.Therefore,

Hypothesis 2 A worker’s expertise in hospital is positively related to patient’s (customer’s) trust.

624

In previous research, it implicated that the customer’s evaluation on reputation of a serviceprovider will positively impact on the acknowledgement on firm’s trustworthiness throughinformation transference process (Doney and Canon, 1997) A study of Devon Johnson and KentGrayson in 2005 suggested that firm reputation is the antecedent of both affective andcognitive trust, “customer who is not yet sufficiently familiar with a service provider mayextrapolate his/her opinions directly from the reputation of the firm” Hence, the hypothesis isbuilt,

Hypothesis 3 A hospital’s reputation is positively related to patient’s (customer’s) trust.

2.6 Behavioral Intention

The decision that intend to perform in a specific way is considered as intention (Fishbein andAjzen, 1975) A person who have their subjective perception ability that he or she will enjoy in agiven behavior is defined as behavioral intention (Committee on Communication for BehaviorChange in the 21st Century, 2002) Inother way, it can be the level that a person has built self-conscious intention to engage or not engage with some specified future behavior, it is a signalabout the customer future’s behaviors (Venkatesh et.al., 2003; Lai andChen, 2011)

Through previous research, it was definite to believe the important role of conceptualframework in study The model was prompted and changed by related empirical studies in ahealth care service provider which can apply in Vietnam context

625

H3(+)

ReputationFigure 6: Conceptual Model

3 Methodology

3.1 Research Method

Qualitative and quantitative methods are considered two main method in processing theresearch for various purpose, especially in achieving knowledge from the study (Ritchie andO’Connor, 2004) The quantitative research is supported from the statistics where it canretrieve from the primary or the secondary data such as survey, questionnaires or previousdata Meanwhile, the qualitive research method based on the evaluation of themes which isretrieved from the observation or interview In other words, it is the unmathematical method

In 2001, Soguno suggested that the objectives of the study were able to express clearly whichcould bring back to the society the enhancement in general views in many aspects also theeffect of each other

In this study, quantitative research was selected to go further With the same goals thatqualitative research delivering, the goals focus on the solution, recommendation based onsociety problems, concerns or the supporting in further research for other developingquantitative potential approach Besides, the quantitative methods delivered a deeper insight

or different aspects the problem that the study concerns which support for sociologist or theexperts in various industry In other words, it could not be rejected that it provided thecomprehensive conclusion and recommendation for social problems or concerns especially.Meanwhile, it went further with other research that give a deeper knowledge in the phenomenafollowing the research of Strauss and Corbin; Lundahl and Skärvad in 1998 and 1999respectively It can be pointed out the common collecting data in quantitative method such asdeliver survey through paper form, online form, telephone interview or face-to-face interview.Moreover, the collection can be assessed through email, pop-ups website ads In other words,there are various ways to conduct the data for quantitative research On other views, due tothe various ways in collecting data, it tended to apply popular with a significant sample size atthe short period comparing to the qualitative research method

is delivered in operation There are 350 questionnaires had been delivered to the patients, andthere are 316 valid respondents accounted at 90.3% The sample size included age range from

18 to over 55 where the outcome placed mostly in the 26-35 age group Over 316 validrespondents, 52.85% of them are female accounted for 167 people Patients in the final samplefocused on the income level from 10 to 20 million VND at 42.72%

3.3 Sample Size

According to the research of Gorsuch; Hatcher in 1983 and 1994 respectively, the ratioshould be allocated in 1:5 where 1 items is answered by 5 respondents in EFA analysis which isalso tested in this study for further validating In other words, with 40 items, the samples size

is required to approach at 200 units Moreover, supporting from the research of Comfrey andLee in 1992, he found that by assessing the sample size higher than 300 units, it can result inthe great research outcomes, meanwhile, the lower one is not quite appreciated Hence, itcomes to the decision that the valid sample size must be 316 Some data was eliminated due

to the invalid data, the paper survey must be higher than the number mentioned above

3.4 Measures

In scaled question, it cannot be denied that the Likert Scale is the most appropriate method

to apply for conducting the survey purpose Which is raised and promoted through theresearch of Rensis Likert in 1932 However, the Liker Scale provided the various ofmeasurement scale from 2-10, it results in the complicated decision to determine which scale

is better for this research Although, most researches apply 5-point scales for assessing theirdata through questioner, there are some evidences show that 7-point measurement scaleswhich could provide stronger correlations between one another items in t-test outcomes(Lewis, 1993) Applying the Theory Planned of Behavior (TPB) in 2002, Ajzen not only providedthe instruction in applying the behavioral intention item in the study but also point out that 7-point scales are preferable when constructing the factors around behavioral intention Besides,the demographic data giving the general information for the receiver to have a comprehensiveevaluation about the sample

627

Construct Sub-scale Item Measurement

SQCP1 There were many signboards in hospitalService The process for taking queue number for

healthQuality of The SQCP2 examination was quick and simpleProcess I did not have to wait long for medical

examination

physician(SQCP) SQCP4 The lab test was done in a prompt way

SQCP5 The payment procedure was quick and

simple

,

nurses and doctors

areSQHC1 friendly

Quality of The

SQHC2 They are willing to help me as much as they

could

HospitalConcerns SQHC3 They explained medication process well(SQHC)

Service Quality SQHC4 They were really cared about my health

Service The doctor gave an explanation sufficiently of

myQuality of The SQDC1 problem, lab test’s result and treatment

processDoctor The doctor was willing to answer many

questions,Concerns SQDC2 enough to understand everything(SQDC) SQDC3 The doctor made me feel comfortable

The waiting areas for examination and treatment

Service SQT1 were wide and pleasant

SQT2 It was easy to access amenities (e.g., canteen,

ATM)Quality of The

The parking lots wer

e

always available forTangible

stakeholders (e.g.,

hospital’s employee,

nurses,Concerns

SQT3 doctors, patients,

relatives)(SQT)

The hospital was equipped with the latest care

SQT4 equipment and facilities (e.g lifts, air

conditioners)The physicians were knowledgeable and highly

EXP1 educated

The physician instructed and explained fully clear

EXP2 and understandable about concerns

The hospital applied latest research, techniques and

Expertise (Exp) EXP3 methods in medical examination and

treatment

The hospital’s employee and nurses were well-

EXP4 educated in responding any situation

The hospital’s employee, nurses and physicians

were well-known about his/ her responsibilitiesand

EXP5 obligations

REP1 The hospital was highly regarded in

VietnamThe hospital was known as the one of the mostREP2 capable hospital in Vietnam

onmedia (e.g journals, news, television, scientific

REP3 conference, social networks)

My friends, families and relatives positively know

REP4 about this

hospitalTRS1 I had no reason to doubt about physician’s

advice

andTRS2 examination’s

I feel the physician understand and respond caringly

TRS4 and specifically my condition

I feel more comfortable and safe when I was taken

TRS5 care of nurses in this hospital

I satisfied about facilities and equipment inthe

SAS1 hospital

I satisfied about the hospital’s staff behavior (e.g

SAS3 I satisfied about the hospital’s expertise

I satisfied with my experience in treatmentand

SAS4 examination that I received in the hospital

SAS5 I satisfied with my decision to choose the

hospital

I will recommend friends; family members and

BEI1 relatives should use service in this hospital

If I needed medical services in the future, I would

BEI2 consider this hospital as my first choice

I will tell other people good things about this

I do not care about the distance between my home

and this hospital if I needed medical services

in theBEI4 future

Even price increased, I still choose this hospital

as theBEI5 primary medical services

Table 16: Measurement Scales

3.5 Process of Data Analysis

In this study, AMOS (version 20.0) and SPSS (version 21.0) are two tool-kit has been appliedfor extracted the raw data collected from the respondents through the survey on-site.Particularly, SPSS support in figure out the descriptive statistics not only for demographic databut also for the scaled questions For ensuring the validity and reliability of the study also themodel, this research is verified from SPSS to AMOS In specific, the reliability of this researchwould be tested through the Cronbach’s Alpha and Corrected Item – Total Correlation Beforemoving the model and data to AMOS, the testing in EFA is required for validation purposewhere it test the validation of items and group of items called factors in Promax methods, thisoutput was used as the default model purpose in Pattern Matrix Model Builder of AMOS’splugin The default model is built to understand whether the validation and reliability isaccepted on this first testing in the AMOS – called CFA, also checking the application of model

in population between factors including observed and latent After conducting the CFA, themodel was formulated in SEM where the test is conducted for checking the complicatedrelationship among unobserved and latent variables

4 Data Analysis and Results

4.1 Sample Characteristics

Following the methodology, the survey has been delivered on-site among 4 hospitalsmentioned above As online survey has not been used, the paper surveys have beentransferred to Excel where allow writer to analyze the data Unfortunately, there are 316among 350 surveys have been conducted is valid Invalid questionnaires are come from mostlypeople misunderstanding in scaling question also the routine in not

629

following the instruction has been implemented before conducting In short, 90.3% data isanalyzed in deeper testing.

Table 17: Response Rate

It can be observed directly that the proportion of Female is higher than Male at nearly52.85% while another computed at 47.15% Particularly, it can be seen from the pie chart thatwomen tend to concern about these problems rather than men Continually, it can be seen thatpeople in the two ages group: 26-35 and 36-45 accounted for more than 55% of therespondents It means that people in those age quite concern about their health rather thanother age group People with the higher age group is lower as they are unwilling to conduct thetest while their relatives are responsible to handle it In general, about the income level, twothose income levels group below 10 million and 10 – 20 million accounted more than 83%where half of them belongs to each other It can be explained that the vary of income levelapproach this study

46

Quality in Health Care's Provider Concern, Service Quality in Tangibles and Service Quality inDoctor’s Concern are

630

0.920, 0.912, 0.913, 0.901, 0.898, 0.893, 0.891, 0.876, 0.871 and 0.833 in respectively Aboveall, evaluation tools including the Cronbach’s Alpha and Corrected Items – Total Correlationshow that the need for removing items to enhance the reliability and consistence of theresearch are not appeared.

[Table 4 in here]

Besides, factors analysis is a diagnostic tool that combine the diversity techniques in term ofstatistic for estimating the level of population structure purpose which basically based on thevariation of variables through observation and defined the correlation among these In this section,Principal Axis Factoring (PAF) is based on the raw data and constructs new dimensional space forthe accessible displays purpose while maintain variability and reduce the weak connection into afewer number of components (Fabrigar et al., 1999) The tables applying PAF as the extractionmethods in this stage especially in the Total Variance Explained table which focus on the last row inCumulative Extraction Sums of Squared Loadings which means how variables can explain thedependent variable with the requirement over 50% while Eigenvalue represents for the varianceexplained by each variable, according to Kaiser’s research in 1960, the additional evaluation toolwhich based on the Eigenvalue > 1 The rule for Eigenvalue > 1 is consistently applied in manyresearches as Thompson and Daniel mentioned in their research According to previous studies,Kaiser-Meyer-Olkin and Bartlett’s Test would be analyzed in this section, based on the output, theKMO ratio and Sig at 0.901 and 0.000 in respectively, the KMO coefficient is qualified when it is over0.6, meanwhile, the sig at 0.00 < 0.05 which means that the items have a significantly correlationamong others At this stage, “Promax” is applied as the rotation methods for analyzing confirmatoryfactor analysis (CFA) rather than “Varimax” which is rather applicable for EFA analysis purpose Thedefault option in SPSS - “Varimax”, however, has some problems in analysis due to the uncorrelationamong dimensions which cause the error or mislead figures in CFA step (Pett, Lackey, & Sullivan,2003) In the pattern matrix which applied extraction method as PAF and rotation method as

“Promax” Other requirements implement that factor loading which illustrate the meaningfulpracticality of EFA in research, the item’s factor loading must be greater than 0.3 or the value would

be refused

[Table 5,6,7 in here respectively]

4.3 Confirmatory Factor Analysis (CFA)