Consumer Perceived Value and Consumer Loyalty in ...

Consumer Perceived Value and Consumer Loyalty in Health Care Sector

Dr Hardeep Chahal (Associate Professor, Dept. of Commerce, University of Jammu) [email protected] Ms Neetu Kumari (Research Scholar, Dept. of Commerce, University of Jammu) [email protected]

1

Abstract Purpose: This study provides conceptual as well as empirical investigation of consumerperceived value (CPV) and consumer loyalty (CL) measures in healthcare sector. It also offers an insight regarding the role of CPV in influencing the consumer loyalty (CL).

Methodology: The data is collected from 515 hospitalized patients of two tertiary hospitals namely Government Medical College and Hospital (public) and ASCOMS (private) sector operating in Jammu, North India, during July 2009 to October 2009. The exploratory factor analysis ( SPSS) and confirmatory factor analysis ( AMOS) are used to analyse CPV and CL.

Results : The results suggest that CPV is a function of acquisition value (AV), transaction value (TV), efficiency value (EV), esthetic value (ESV), social interaction value (SI) and self gratification value (SG). Similarly CL is related to preference loyalty (i.e. using provider again for services (UPAS), using provider again for different services (UPAD)), recommending provider to others (RP), price indifference loyalty and dissatisfaction response (DR). The study confirms that delivering superior consumer value enables service provider to associate consumers for long –term through their favourable behavioural intentions or loyalty.

Value: The study underscores significant dimensions of consumer value and consumer loyalty and validates the relationship between value and loyalty in healthcare service sector. . Implications: The CPV and CL instruments include important aspects of patients’ perceptions of healthcare services. The scales are psychometrically adequate and

recommended for

evaluating patients’ experiences of the quality of healthcare services. With proper focus on value and loyalty dimensions, service providers can strengthen relationship with patients and sustain competitive advantage.

Limitations: The study is theoretically limited to assess relationship between CPV and CL. Their relationship with other measures such as consumer experiences, quality, satisfaction, service dominant logic, and image need to be assessed in further works. Key words: Consumer – Perceived Value (CPV), Consumer Loyalty (CL), Healthcare Services 2

INTRODUCTION During the last decade, the interest of both marketing practitioners and scholars regarding the notion of consumer value has increased (Cronin, Brady and Hult, 2000). The researchers acknowledge the importance of superior consumer value and consumer loyalty as an important factor for company’s success to improve customer relationship (Day, 1994) and to achieve sustainable competitive performance ( Grönroos, 1994; Zeithaml et al., 1996; Parasuraman, 1997) Specifically, studies on value and satisfaction relationship (Lovelock 2006; Sweeney, Soutar and Johnson 1999; Sweeney and Soutar, 2001; Parasuraman 1997; Gallarza and Saura 2004) are available in the literature but studies on value and loyalty (Parasuraman and Grewal 2000, Zeithaml 1988, Rust and Oliver 1994) are rare and relationship between the two is yet to be explored. Further, the conceptualization of the notion of consumer perceived value also remains quite divergent and unclear in the literature. The lack of empirical investigation impedes the comprehension of the relationship between the value the company offers to its consumers and the relational outcomes, such as consumer loyalty, that is, subsequent consumer behavioural intentions. Thus, the purpose of this study is to build and empirically test an integrated framework between consumer perceived value, and consumer loyalty, in addition to focussing on significant dimensions of the value and loyalty in healthcare sector.

The paper is organized as follows. First we present the conceptual framework underpinning our study. Then we discuss and develop research hypotheses based on the reviewed literature. Next, we present the methodology of research we followed to conduct the study. This is followed by data analysis and testing of the hypotheses. And finally results, limitations of the study and suggestions for future research are discussed.

RESEARCH GAP AND JUSTIFICATION OF STUDY The studies reviewed highlight the need to work on the relationship between Consumer Perceived Value and Consumer Loyalty ( Choi et. al. 2004;Cronin, Brady and Hult, 2000; Gallarza, Martina and Saura, 2004; Gounaris, Tzempelikos and Chatzipanagiotou, 2007; Lam, Shakar and Murthy, 2004). Most of the studies are focused on limited relationship strengths, for instance service quality and loyalty (Parasuraman, Zeithaml and Berry, 1988; Cronin and Taylor, 1994; Choi et.al. 2004, Gross 2003, Sweeney, Soutar and Johnson, 1999 and Vyas and Thakkar, 2005), satisfaction and loyalty (Corbin et. al., 2001 and Ruyter et. al., 1998), service quality and value (Choi et.al. 2004, Cronin et. Al. 1997, and Sweeney, Soutar and Johnson, 3

1999). Further few studies such as Cronin, Brady and Hult (2000), Ruyter and Bloemer (1999) and Gounaris, Tzempelikos, and Chatzipanagiotou, (2007), Sweeney and Soutar (2001), Parasuraman (1997) and Gallarza and Saura (2004) although worked on value, satisfaction and loyalty relationship but direct relationship between value and loyalty are assessed by very rare (Parasuraman and Grewal 2000, Zeithaml 1988, and Rust and Oliver 1994). There are few published instruments for evaluating the CPV and CL in healthcare sector but cannot be used because consumer value and loyalty are context specific concepts and perceptions of consumers may vary from place to place and time to time. Hence our research proposes mult-dimensional concept to measure consumer perceived value and loyalty in health care sector to fill the research gap.

LITERATURE REVIEW AND RESEARCH HYPOTHESES CONSUMER PERCEIVED VALUE Consumer value in literature refers to consumers’ overall assessment based on benefits and sacrifices, about product /services utility (Zeithaml, 1988). This aspect has been well accepted by number of researchers such as Fernandez and Bonillo (2007), Ekrem (2007), Rust and Oliver (1994), Caruana and Berthon (2000). This concept of value is also well accepted for health care services. Ekrem (2007), Choi et al. (2004) and Corbin et al. (2001) consider value as a difference between benefits and sacrifices. Benefits in the healthcare sector are primarily the outcome of good service quality ( i.e. CV, satisfaction, loyalty, and image) (Choi et al. 2004). On the other side, both non - monetary cost such as time spent, mental and physical stress, and monetary cost are elements of sacrifice component of perceived quality. Besides cost-benefit analysis concept so discussed, CPV has been defined from different perspectives. For instance Gronroos (1997) considers value in terms of emotional and cognitive features. Sweeney and Soutar (2001) emphasized on emotional, social, quality, performance and price/ value for money dimensions to define CPV. Grewal et al. (1988) and Dodds, Monroe and Grewal (1991) consider transaction and acquisition values to conceptualize perceived value. According to Sheth, Newman and Gross (1991) CPV is a function of social, emotional, functional, epistemic and emotional value. Later Arnold and Reynolds (2003) added aesthetic as another important driver to enhance the perceived value of customer. Burnis (1993) has considered CPV dimensions in terms of product value, value – in – use, possession value and overall value. Ruyter et al. (1997) use emotional, functional and logical dimensions of CPV. Mathwick, Malhotra and Rigdeon (2002) and Gallarza and Saura (2004) consider CPV quite 4

comprehensively. For instance, Mathwick, Malhotra and Rigdeon (2002) identify economic, efficiency, enjoyment, escapism, entertainment, visual appeal and service excellence dimensions to explain. Gallarza and Saura (2004), on the other hand, use efficiency, service quality, social value, play, aesthetics, perceived monetary cost, perceived ride, time and effort spent to define CPV. However, Sweeney, Soutar and Johnson (1999), Sweeney and Soutar (2001) and Sanchez et al. (2006) find value as a compound of three dimensions namely, functional value, social value and emotional value. Ekrem (2007) support these dimensions for healthcare services. More recently Gounaris, Tzempelikos and Chatzipanagiotouslim, (2007) consider CPV as a function of six elements, namely product value, procedural value, personnel value, emotional value, social value and perceived sacrifice.

Since different scholars define CPV from different aspects, we consider CPV in healthcare sector to be function of six latent dimensions namely transaction value, efficiency value, aesthetic, social value, self gratification value and acquisition value. Acquisition value refers to the perceived net gains accrued when products or services are acquired, which is commonly referred to as the trade – off between benefits and sacrifices (Mathwick et. al., 2002). Past acquisition value based model (Zeithaml, 1988) considers CPV as the perceived net gains associated with the products or services acquired. That is, the perceived acquisition value of the product is positively influenced by the benefits patients’ believe they are getting by acquiring and using the services of hospital and negatively influenced by the money given up to acquire the service. The transaction value, relates to psychological satisfaction or pleasure or relief gained from getting a “services performed” (Grewal et al. 1998 and Parasuraman and Grewal 2000). The service users assess the value of a deal by comparing the selling value to internal reference prices (Grewal, Monroe and Krishnan 1998). For example, in healthcare setting transaction value for a patient is feeling safe in hand of doctors, post- medical treatment, personal care and good medical advice. Therefore, a patient on examining the financial transaction the price offer, might perceive additional value beyond provided by acquisition value. Hence, perceived transaction value is the perception of psychological satisfaction or obtained from taking advantage of the financial transaction of the price deal (Grewal, Monroe and Krishnan, 1998). Efficiency value refers to how efficiently and effectively the treatment process is completed (Mathwick et al. 2002). Keeping other things controlled, consumer, selects the hospital ( i.e. is, public or private) which is best or efficient in comparison to other. Since the consumer is not from medical background, he judges service delivery process based 5

on interaction with service provider to know the efficiency value. The evaluation may relate with things such as staff is well equipped with necessary training, doctors explain reasons for tests, they always diagnose the medical problem accurately, technical supporting staff are careful while making tests, administering injections etc., nurses regularly discharge their duties relating to dressing, drips, administering injections and giving medicine. Further, aesthetic value refers to visual appeal that is driven by the design, physical attractiveness and beauty inherent in the hospital setting (Arnold and Reynold 2003). The conducive internal environment, neat and clean wards and corridors, hygienically clean clothing, clean and functional bathroom and proper ventilation in wards etc. contribute to aesthetic value of the hospital. The social interaction value refers to patient’s interaction with friends, family, staff as well as with other patients during hospitalization (Sweeney et al. 2001). Social interaction theory focuses on people being altruistic, cohesive and seeking acceptance and affection in interpersonal relationships. The last dimension that is, self gratification refers to improvement of personal well – being, relief from stress, alleviation of negative mood, elimination of loneliness and giving oneself a special “treat” (Arnold and Reynolds 2003). The gratification dimension suggests that human is motivated to act in such a way so as to reduce tension, thereby maintaining inner equilibrium and returning the self to a state of homeostasis. .In the present study treatment is acknowledged as a form of emotional – focused coping in response to stressful events or simply to get one’s mind off a problem.

Based on aforesaid discussion, the study proposed the following hypothesis:

Hypothesis 1: The CPV is significantly affected by transaction value, efficiency value, esthetic value, social value, self gratification value and acquisition value.

CONSUMER LOYALTY Consumer loyalty is approached both as an attitudinal and behavioural concept. As an attitudinal concept, it denotes the degree to which consumer’s disposition towards a service is favorably inclined. This is reflected, for instance, in the willingness to recommend a service provider to other consumers consistently over period. Similarly as behavioural concept, it reflects consumer’s commitment to use a preferred service provider despite existence of financial and location barriers (Ruyter, Wetzels and Bloemer, 1998). 6

Peltier, Boyt and

Sehibrowsky (2000) consider using provider again for same services ( UPAS), using provider again for different services ( UPAD) and recommending provider to other ( RPO) as three elements of patient loyalty. On the other hand, Ruyter et al. (1998) recognize preference loyalty, price indifference loyalty and dissatisfaction response as important determinants of patient loyalty. The preference loyalty includes UPAS, and UPAD. Dissatisfaction response (DR) and price indifference loyalty another two elements that relate to loyalty. Hirschman (1982) argue that a dissatisfied consumer has three options to a negative (service) experience: communicate dissatisfaction (voice) or continue using services without communicating to the concerned authority or discontinue the relationship (exit). Consumers who voice dissatisfaction may complain to the service provider, its employees, or external agencies such as consumer organizations and may remain with the organization if the problem is solved. In the healthcare sector especially in public healthcare unit, with regard to dissatisfaction response, it is observed that the majority of consumers simply remain inactive and do not undertake any action following a negative service experience (Day 1984). Furthermore, it is argued that actually responding to dissatisfaction (e.g. complaining directly to the company or complaining to a third party) is negatively related to the level of service quality (Ruyter, Wetzels and Bloemer, 1998) and also affects later loyalty. Lastly, price indifference loyalty is willingness to pay a premium price for the service to be availed (Ruyter, Wetzels and Bloemer, 1998). Zeithaml et al. (1988) report positive relationship between service quality and the willingness to pay a higher price and the intention to remain loyal in case of a price increase. In the healthcare sector, particularly, private healthcare organization, price indifference loyalty is preferred for same hospital over competitors even if fee of medical services/ treatment is high. The four factor model comprising preference loyalty), price indifference loyalty dissatisfaction response and recommending provider is used to measure patient loyalty in the present study. The study as such hypothesized that Hypothesis 2: Preference loyalty (UPAS and UPAD), price indifference loyalty dissatisfaction response and recommending provider significantly affects consumer loyalty.

CONSUMER PERCEIVED VALUE AND CONSUMER LOYALTY The importance of consumer loyalty in achieving business goals and its impact on business performance is widely acknowledged (Anderson, Fornell and Lehmann 1994). Consumer loyalty is an outcome of consumer perceived value, and is a fundamental indicator of the firm’s past, current, and future performance (Lam, Shakar and Murthy, 2004). which has an impact on 7

development of sustainable competitive edge (Ruyter et

al., 1998). According to the

disconfirmation paradigm, the consumer’s degree of overall loyalty is a function of the value the consumer expects in relation to the value actually received (Gounaris, Tzempelikos, and Chatzipanagiotou, 2007). Although the disconfirmation paradigm is heavily criticized, particularly when it comes to methodology and measurement issues (Teas, 1993 and Cronin and Taylor, 1994), its theoretical value and contribution in conceiving the impact of value upon consumer satisfaction and loyalty remains unquestioned. The consumer first forms specific expectations regarding the value he wishes and anticipates to receive from the product. Consumers become satisfied when receiving “adequate doses” of value from the products/services they buy. Post-purchase experiences reveal the level of value each individual accumulates from the choice he made (CPV). When CPV exceeds the individual’s expectancy, the consumer is satisfied (Anderson, Fornell and Lehmann., 1994 and Oliver 1981), the same over a period of time leads to loyalty (Ravald and Grönroos, 1996). Wang et al., (2004) Gallarza and Saura, (2004) findings show that satisfaction and loyalty are related to CPV. However, since

CPV comprises elements that carry positive and negative utility for the consumer, it follows that the former (positive utility elements) will serve as satisfaction drivers, while the latter (negative utility element) will reduce the overall level of consumer’s satisfaction with a product. The study thus hypothesized that Hypothesis 3: Consumer perceived value directly and positively affect consumer loyalty in healthcare services..

METHODOLOGY Scale Development: The reviewed literature helped in the generation of scale items. The consumer perceived value items ( 32 in number) are spread over of six sub dimensions namely acquisition value (AV), transaction value (TV), efficiency value (EV), esthetic value (ESV), social interaction value (SI), self gratification value (SG). Loyalty of the patient ( 21 items) is gauged using

five sub-dimensions namely preference loyalty (UPAS and UPAD),

recommending provider to others (RP), dissatisfaction response (DR) and price indifference loyalty (PI).

Pretesting: Pretesting of the scales were conducted on 70 inpatients. At the outset, inter-item analysis is conducted to identify items that are least correlated with respective value and loyalty dimensions. Such items were later deleted for final scale. Further, reliability test for the overall 8

scale and sub scales of CPV and CL yielded a high Cronbach alpha score ranging between 0.601 to 0.935, indicating moderate to excellent reliability.

Sample Size: The final sample size for inpatients is identified on the basis of pre - testing results. The total sample frame including public and private hospitals came out to be 515. The public hospital sample (280) comprised of 90 patients from medicine, 126 from surgery, 36 from orthopedics and 28 from ophthalmology. The sample size for private hospital (235) included 72 patients from medicine, 72 from surgery, 72 from orthopedics, and 30 from ophthalmology.

Data Collection: The data were collected from patients availing services from two big referral public and private hospitals using personal contact approach from four specialties namely, medicine, surgery, orthopedics and ophthalmology departments during ………………. Further, the hospitalized patients willing to participate in the survey and with minimum 4 days stay were considered for the sample.

Assessment of Measurement Scales: The measurement scale is purified in three stages that is, exploratory factor analysis (EFA), inter – item correlation and confirmatory factor analysis (CFA). In the first step, EFA using VARIMAX rotation with eigenvalue ≥ 1 was applied to each of the two scales (CPV and CL) under investigation. The main purpose of this step is to see whether the scale for each construct under investigation is multidimensional as expected. Items with low factor loadings (< 0.50) and cross loadings items were eliminated because they did not converge properly with the latent construct they were designed to measure (Hair et al., 1995). In addition, MSA ( Measure of Sampling Adequacy) (< 0.50) is also considered for deletion of statements. After applying EFA next step is to apply additional item analysis in which items having low item-to-total correlation coefficients (1.98), SRW (>0.5)and SMC (> than AVE) for both the two the two scales. The CR values and SRW values for all the constructs of the two scales are well above the threshold value. The SMC values ranged between 0.268 to 0.910 for CPV scale and 0.328 to 0.715 for CL scale . The majority of the values are well within the criterion value. The items with below .3 SMC values are however retained because of two reasons. Firstly all such items are found to be significant with CR above 1.98 . Secondly the items contribute significantly to the respective scales.

ANALYSIS OF CONSUMER PERCEIVED VALUE AND CONSUMER LOYALTY This section examines individually CPV and CL scales on the basis of dimensions emerged after the application of EFA using CFA.

12

Consumer Perceived Value

Efficiency Value (Factor 1) - The efficiency value relates to how effectively and efficiently the service provider delivers health care service product. In health care sector it is found to be function of 5 items that include ‘well equipped staff with necessary training’(SRW = 0.757), ‘doctors explain reasons for test’ (C.R =24.552, SRW =0.890 ), ‘doctor always diagnosis medical problem accurately’ (C.R = 22.806, SRW =0.847), ‘technical supportive staff are careful while making tests’ (C.R =27.289, SRW = 0.954) and ‘nurses regularly discharge their duties regarding injection, dressing’(C.R = 17.051, SRW =0.684 ). Aesthetic Value (Factor 2) - The application of CFA came with five significant items namely ‘visual appealing physical facilities’ (C.R = 21.479, SRW =0.766), ‘neat & clean corridors’ (SRW =0.544), ‘clean & functional bathroom’ (C.R =23.344, SRW =0.805), ‘proper ventilation in wards’( SRW =0.831) and ‘fresh & clean bedding (C.R = 31.040, SRW =0.944) in aesthetic value. Self – gratification Value (Factor 3) - The third factor self – gratification value contains 4 statements, all of them have significant CR and SRW values which include ‘relief from stress’ ( C.R =17.817 , SRW = 0.662), ‘easing of negative mood’ (C.R =30.553 , SRW = 0.895), ‘elimination of pain’ (C.R = 23.127, SRW =0.775 ) and

‘personalized attention’ (SRW

=0.925). Social Interaction Value (Factor 4) - The social interaction value is important as it is the overall experience which consumer perceive during interaction during hospitalization. It contains 3 items namely ‘feel relaxed during socializing with other patients’ (C.R = 25.629, SRW =0.806), ‘comfort zone with physician interaction’ (C.R = 33.320, SRW =0.915)

and ‘nursing

interaction’ (SRW =0.940). Transaction Value (Factor 5) - The factor 5 namely transaction value contains 6 items with respect to ‘staff is quick in serving patients’ ( C.R =10.592, SRW =0.582), ‘post – medical treatment’ ( C.R =13.207, SRW =0.826), ‘personal care of patients’ (C.R = 13.643, SRW =0.890), ‘good medical advice’ ( C.R = 10.820, SRW =0.600), ‘feel safe in hand of medical staff’ ( C.R =8.061, SRW =0.510), ‘psychological satisfaction’ ( SRW =0.567) all of them indicate towards the psychological satisfaction gain from service encounter. Acquisition Value (Factor 6) - The last factor acquisition value that is overall net value contains 4 statements i.e ‘getting your money worth’ (C.R = 8.233, SRW =0.506), ‘good services at reasonable price’ (C.R =8.685, SRW = 0.550) and ‘availability of latest technology’ 13

( SRW =0.543) and ‘high quality low price requirement’ (C.R = 9.764, SRW =0.691) all of them having significant CR and SRW values.

Consumer Loyalty Using Provider Again for Different Services (Factor 1) – The factor 1 that is, using provider again for different services contains three statements, all of which have significant CR and SRW values i.e ‘nursing care’ (C.R = 18.888 , SRW = 0.793), ‘cleanliness’ (SRW = 0.535), and ‘ physician care’ (C.R = 20.954, SRW =0.802). Using Provider Again for Same Services (Factor 2) – The second factor namely using provider again for same services includes ‘nursing care’ (SRW = 0.526), ‘physician care’ (C.R = 22.142 , SRW = 0.824) and ‘good technical services’ ( SRW = 0.508). Price Indifference Loyalty (Factor 3) - The factor 3 namely price indifference loyalty is preferring service of the hospital over the other. In the present study two statements i.e ‘same hospital prefer over competitor’ (C.R = 11.054, SRW = 0.845) and ‘visit other hospital’ (C.R = 5.767, SRW =0.530) are found to be signicant to predict price indifference loyalty.

Dissatisfaction Response (Factor 4) - The factor 4 namely dissatisfaction response is very important in services sector because if the problem of the consumer is known to the service provider it can be taken care at the right time. The two statements that is, ‘prefer to go to concerned authorities’ (C.R =16.261, SRW =0.838) and ‘discuss to other consumers’ ( SRW =0.647) reflect dissatisfaction response.

Recommendation (Factor 5) - The factor 5 namely recommendation includes 2 statements i.e. ‘recommend physician’ (C.R = 6.085, SRW =0.530) and ‘recommend hospital’ (SRW = 0.637). Recommendation shows the loyalty of the consumer because if patient is referring physician or hospital to others, it means that consumer is satisfied.

14

Relationship between Consumer Perceived Value and Consumer Loyalty The relationship between consumer value and consumer loyalty reveals that CPV affect CL (CR = 11.051, SRW = 0.772) in healthcare sector. Further the relationship is also validated on public healthcare consumers assessed in public healthcare sector. Similar result came out for public hospital, consumer loyalty showed positive and significant relationship with loyalty (CR = 7.223, SRW = 0.556, SMC = 0.352). Same results are also found in private healthcare organization (CR = 5.000, SRW = 0.724, SMC = 0.524). The result indicate that consumer value have significant relationship with loyalty in both public health care and private health care sector. The study contribute to health care literature by considering value as important antecedent leads to consumer loyalty.

DISCUSSION The Structural Equational Modeling results indicate that acquisition value (AV), transaction value (TV), efficiency value (EV), esthetic value (ESV), social interaction value (SI), self gratification value (SG) are six antecedents of consumer perceived value. The RMSEA value of 0.050 indicates good fit and other measures suggested a well fit model with CFI (0.887), TLI (0.867), NFI (0.963), RFI (0.941) were all above the desired level. So our first hypothesis is accepted. The second hypothesis pertains to Loyalty, is that its affected by preference loyalty (using provider again for services (UPAS), Using provider again for different services (UPAD)), recommending provider to others (RP) and dissatisfaction response (DR) is also accepted. The RMSEA value of 0.072 indicates good fit and other measures suggested a well fit model with CFI (0.800), TLI (0.891), NFI (0.862), RFI (0.820) were all above the desired level. Further the relationship between consumer value and consumer loyalty is assessed in health care sector. In overall data RMSEA value of 0.090 indicates good fit and other measures suggested a well fit model with CFI (0.929), TLI (0.894), NFI (0.914), RFI (0.872). The relationship among consumer value and loyalty is also assessed in GMC (RMSEA = 0.103, CFI = 0.909, TLI 0.868, NFI = 0.883, RFI = 0.673) and ASCOMS (RMSEA = 0.095, CFI = 0.824, TLI = 0.752, NFI = 0.768, RFI = 0.673). The result indicates that consumer value and loyalty have significant relationship. The study came out with antecedents of consumer value and consumer loyalty and in addition the relationship between value and loyalty is also verified which is less found in literature. 15

MANAGERIAL IMPLICATION Service performance remains significant research topic for both practitioners and academicians from last four decades. Since the concepts such as satisfaction, quality, value and loyalty are context specific, their definition and

measurement remained been an issue of primary

importance in healthcare. The present study helps in understanding patients’ behaviour and their needs, which can be used for providing quality of care in healthcare organizations. The quality in healthcare sector can only be implemented by due focus of service providers on consumer –savvy managerial policy. Theoretically, the study proposes multi-dimension scale of measuring consumer perceived value (acquisition value, transaction value, efficiency value, esthetic value, social interaction value, self gratification value) and consumer loyalty (preference loyalty, indifference loyalty and dissatisfaction response). In addition relationship between consumer’s perceived value and consumer loyalty provide new insight into the healthcare literature. The proper focus on these relationships can help in strengthening the relationship with patients and through delivering value to retain them vis-à-vis to achieve competitive advantage over competitors. Basically, loyalty is an outcome of the process in which service provider can access the actual performance of the health care services against their consumer expectation.

FUTURE RESEARCH The study provides new and broader perspective to measure direct relationship between consumer perceived value and loyalty measures which provide a roadmap for the future researcher. Since the study is theoretically limited to assess relationships between loyalty and value, future research that would replicate the study in different cultural contexts is necessary before we can generalize the findings of this study. Such type of study at national or global levels could come with different and useful results Further, the relationships need to be extended to include quality, satisfaction and image. from both patients and employees perspectives, to establish theoretical framework. The healthcare sector also pose constraints on our ability to generalize our findings for the credence services. Hence, future research in different service areas should be examined to generalize the relationship between consumer value and consumer loyalty using identified dimensions.

16

REFERENCES

Anderson, E.W., C. Fornell and R.R. Lehmann (1994), “Customer Satisfaction, Market Share, and Profitability: Findings from Sweden,” Journal of Marketing, 58, January, 53-66. Arnold, Mark J. and Kristy E. Reynolds (2003), “Hedonic Shopping Motivations”, Journal of Retailing, 79, 77 – 95. Caruana, Albert and Pierre R. Berthon (2000), “Service Quality and Satisfaction – The Moderating Role of Value”, European Journal of Marketing, 34, (11), 1338 – 1353. Choi, Kui-son, Woo-hyun Cho, Sunhee Lee, Hanjoon Lee and Chankon Kim (2004), “The Relationship Among Quality, Value, Satisfaction and Behavioral Intention in Health Care Provider Choice: A South Korean Study”, Journal of Business Research, 57, 913-921. Corbin, Christopher L. Scott W. Kelley and Richard W. Schwartz (2001), “Concepts in Service Marketing for Healthcare Professionals”, The American Journal of Surgery, 189, 1 – 7. Cronin Jr. J. Joseph, Michael K. Brady and G. Thomas M. Hult (2000), “Assessing the Effects of Quality, Value and Customer Satisfaction on Consumer Behavioral Intentions in Service Environments”, Journal of Retailing, 76 (2), 193 – 218. Cronin, J. Joseph and Steven A. Taylor (1994), “SERVPERF versus SERVQUAL: Reconciling Performance – Based and Perceptions – Minus – Expectations Measurement of Service Quality”, Journal of Marketing, 58, 125 – 131. Dabholkar, P.A., D.I.Thorpe and J.O.Rentz (1996), “A Measurement of Service Quality for Retail Stores: Scale Development and Validation”, Journal of the Academy of Marketing Science, 24, 3-16. Day, G. (1994), “The capabilities of Market-driven Organizations,” Journal of Marketing, 58, 4, 37-52. Ekrem, Cengiz (2007), “Customer Perceived Value: The Development of a Multiple Item Scale in Hospitals”, Problem and Perspectives in Management”, http://find articles.com/p/articles/miqa 5417/is – 200701/ai-n21298075, accessed on Januray 18, 2010 Fernandez, Raquel Sanchez and M. Angeles Iniesta Bonillo (2007), “The Concept of Perceived Value: A Systematic Review of the Research”, 7 (4), 427 – 451. Gallarza, Martina G and Irene Gil Saura (2004), “Value Dimensions, Perceived Value, Satisfaction and Loyalty: An Investigation of University Students Travel Behaviour”, Tourism Management,www.elsevier.com/locate/tourman.

17

Gounaris, Spiros P., Nektarios A. Tzempelikos and Kalliopi Chatzipanagiotou (2007), “The Relationships of Customer-Perceived Value, Satisfaction, Loyalty and Behavioral Intentions”, Journal of Relationship Marketing, 6, 1 ,63 — 87. Grewal, Dhruv, Kent B. Maroe and R. Krishan (1988), “The Effects of Price – Comparison Advertising on Buyers’ Perceptions of Acquisition Value, Transaction Value and Behavioral Intentions”, Journal of Marketing, 62, 46 – 59. Grönroos, C. (1994), “From Marketing Mix to Relationship Marketing. Towards a ParadigmShift in Marketing,” Management Decision, 32, 2, 4-32. Gross, Revital (2003), “A Consumer Based Tool for Evaluating the Quality of Health Services in the Isaraeli Health Care System Following Reform”, Health Policy, 68, 143 – 158. Hair, J.J., R.E.Anderson, R.L. Tatham and W.C Black (1995), “Multivariate Data Analysis with Readings”, Prentice Hall, New Jersey, pp 87 - 135. Hirschman, E.C and M.B. Holbrook (1982), “Hedonics Consumptions: Emerging Concepts”, Journal of Marketing, 46, 92 – 101. Lam, S.Y., V. Shakar, and M.K.E.B. Murthy (2004), “Customer Value, Satisfaction, Loyalty and Switching Costs: An Illustration from a Business-to-Business Service Context,” Journal of the Academy of Marketing Science, 32, 3, 293-311. Lovelock, Christopher and Jochen Wirtz (2006), “Services Marketing – People, Technology and Strategy “, Dorling Kindersley (India). Mathwick, Charla, Naresh K. Malhotra and Edward Rigdon (2002), “The Effect of Dynamic Retail Experiences on Experiential Perceptions of Value: An Internet and Catalog Comparison”, Journal of Retailing, 78, 51 – 60. MC Guire, William (1974), “Psychological Motives and Communication Gratification”, In J.F. Blumer & Katz(eds.), The Use of Mass Communication: Current Perspectives on Gratification Research, Beverly Hills: Sage,106 – 167.

Oliver, R.L. (1981), “Measurement and Evaluation of Satisfaction Processes in Retail Settings,” Journal of Retailing, 57, 25-48. Oliver, R.L. and W.S. DeSarbo (1988), “Response Determinants in Satisfaction Judgments,” Journal of Consumer Research, 14, 4, 495-507. Parasuraman, A., and Dhruv Grewal (2000), “The Impact of Technology on the Quality – Value – Loyalty Chain: A Research Agenda”, Journal of Academy of Marketing Science, 28, 1, 168 – 174. Parasuraman, A., Valarie A. Zeithaml and Leonard L. Berry (1988), “SERVQUAL: A Multiple – item Scale for Measuring Customer Perceptions of Service Quality”, Journal of Retailing, spring, 64 (1), 12 – 40. 18

Parasuraman, A. (1997), “Reflections on Gaining Competitive Advantage through Customer Value,” Journal of the Academy of Marketing Science, 25, 2, 154-161. Peltier, James W, Thomas Boyt and John A. Sehibrowsky (2000), “Obstetrical Care and Patient Loyalty, Marketing Health Services”, 18( Fall) 5 – 12. Ravald, A. and C. Gronroos (1996), “The value Concept and Relationship Marketing,” European Journal of Marketing, 30, 2, 19-30. Rust, Roland T. and Richard L. Oliver (1994), “Service Quality: Insights and Managerial Implications from the Frontlines, in Service Quality: New Directions in Theory and Practice”, Sage Publications, 1 – 19. Ruyter, Kode, Martin Wetzels, Josee Blomer (1998), “On the Relationship Between Perceived Service Quality, Service Loyalty and Switching Costs”, International Journal of Service Industry Management, 9 (5), 436 – 453. Ruyter, Ko de and Jose Ae Bloemer (1999), “Customer Loyalty in Extended Settings: The Interaction Between Value Attainments and Positive Mood,” International Journal of Service Industry Management, 10 (3), 320 – 336. Stone, Gregory (1954), “City Shoppers and Urban Identification : Observation on the Social Psychology o City Life”, American Journal of Sociology, 60, 36 – 45. Sweeney, Jillan C. and Geoffrey N. Soutar (2001), “Consumer Perceived Value: The Development of a Multiple Item Scale”, Journal of Retailing, 77, 203 – 220. Sweeney, J.C., G. N. Soutar and L.W. Johnson (1999), “The Role of Perceived Risk in the Quality - Value Relationships : A Study in a Retail Environment”, Journal of Retailing, 75 (1), 77 – 105. Tauber E.M. (1972), “Why Do People Shop?”, Journal of Marketing, 36, 46 – 59. Teas, R.K. (1993), “Expectations, Performance Evaluation and Consumers’ Perception of Quality,” Journal of Marketing, 57, 4, 18-34. Wang, Y., H.P. Lo, R. Chi and Y. Yang (2004), “An Integrated Framework for Customer Value and Customer-Relationship-Management Performance: A Customer – based Perspective from China,” Managing Service Quality, 14, 2/3, 169-182. Westbrook, R. and Oliver, R. (1981), “Developing Better Measures of Consumer Satisfaction: Some Preliminary Results,” Advances in Consumer Research, 8, 1, 94-100. Zeithaml, V.A. (1988), “Consumer Perceptions of Price, Quality and Value: A Means – End Model and Synthesis of Evidence”, Journal of Marketing, 52, 2-22.

19

Zeithaml, V.A, L.L Berry and A. Parasuraman (1996), “The Behavioral Consequences of Service Quality”, Journal of Marketing, 60, 31 – 46.

20

Table 1 Cronbach alpha value and Split half Reliability of Consumer Perceived Value and Consumer Loyalty Scale

Overall Split – half 1 Split – half 2 Overall Split – half 1 Split – half 2

Consumer Perceived Value – Scale-items Respondent - Wise Respondent 1 Respondent 2 (1 - 257) (258 - 515) 0.933 0.935 0.848 0.868 0.871 0.787 0.916 0.921 0.808 Consumer Loyalty 0.787 0.677 0.635 0.715 0.678 0.683 0.654 0.601 0.683

Table 2 Convergent Validity & Variance Extracted Values of Consumer Perceived Value and Consumer Loyalty Scales Average Squared Composite Inter - item Variance Multiple Reliability Correlation KMO & Extracted Correlation Sig. Value 0.928 0.943 1.000 0.884 Efficiency Value 0.828 0.603 0.852 0.739 .000 Esthetic Value 0.934 0.496 0.985 0.764 .000 Self -Gratification 0.957 0.368 0.988 0.831 .000 Value Social Value 0.856 0.415 0.922 0.753 .000 Transaction Value 0.866 0.662 0.931 0.782 .000 Acquisition Value 0.865 0.597 0.890 0.655 .000 Loyalty 0.846 0.991 1.000 0.793 Using provider 0.908 0.444 0.931 0.768 .000 again for different services Using provider 0.813 0.416 0.869 0.674 .000 again for same services Price indifference 0.831 0.547 0.932 0.704 .000 loyalty Dissatisfaction 0.841 0.533 0.879 0.511 .000 Response Recommending 0.734 0.328 0.825 0.708 .000 Provider 21

Table 3 Critical Ratio, Standardised Regression Weight, Squared Mulitiple Correlation Values with Hospital – wise Mean Scores of Consumer Perceived Value Scale Statements AV