THE 2009 NAPLES FORUM ON SERVICES:
SERVICE-DOMINANT LOGIC, SERVICE SCIENCE,
AND NETWORK THEORY
CAPRI, JUNE 16-19, 2009
DOCTORAL WORKSHOP
“Usage of affective and cognitive feelings in high credence service…”
Name: Iraz (Raziye) Kilic
Affiliation: Department of Marketing, Maastricht University, the Netherlands.
E-mail address: [email protected]
Phone: +31 43 38 83 861
Fax: +31 43 38 84 918
Homepage: www.marketingsite.nl
Brief professional biography:
Since January 2008 Iraz Kilic is working as a PhD student at the department of
marketing at Maastricht University, the Netherlands.
Her main research interests are relationship and services marketing concerning high
credence based services.
“Usage of feelings in high credence service…”
Abstract
Purpose: The main purposes are: (1) to assess the link between the communication
behaviors, type of feelings evoked and desired outcomes (e.g. compliance). Thereby,
feeling-as-information serves as the underlying mechanism; and (2) to show that before
ones cognition tunes to the environment, ones feelings already do so.
Methodology: A quasi experiment will be conducted, whereby the communication
behavior will be manipulated. This is done to measure which types of feelings – affective
and/or cognitive feelings – are activated and consequently which outcome variables
result from these feelings.
Practical Implications: Since the main focus of this research is on the impact of
communication on feelings as well as attitudinal and behavioral outcomes in general, its
implications contribute to understanding the relationship between customer and service
providers. The results will help a service provider to understand how his / her
communication style influences certain types of outcome.
Originality: Until now, much research has been conducted about the patient-physician
interaction without providing a theoretical explanation why certain communication
behaviors of the physician lead to certain responses by the patient such as compliance
(see Ong et al., 1995). With the feelings-as-information concept (Schwarz, 1990) as an
underlying mechanism, the authors’ aim is to provide a theoretical foundation for the
established literature. Furthermore, the development of the cognitive tuning
phenomenon introduced by Schwarz (2002) is intended. Last but not least, this study will
examine affective and cognitive feelings simultaneously in order to assess the weight of
each type on the outcome variables.
Key words: communication, compliance, affective / cognitive feelings, high-credence
service
Category: research paper
1. Introduction
Two recent developments are very striking: First, the development of the health care
industry towards consumerism (Sharf, 1988) with an increasing intensity of competition.
Besides medical and psychological scholars, more and more marketing and business
scholars have begun to pay attention to the health care sector and in particularly to
health communication (Keller & Lehmann, 2008; Moorman & Luce, 2008). Second, the
costs of non-compliance are increasing tremendously. Besides financial costs, noncompliance also causes physiological, psychological and social costs. In the USA alone
the annual financial costs can excel 100 billion US Dollars (Showalter, 2006). Therefore,
It is crucial to gain more insight and understand why individuals do not comply.
The paper at hand focuses on the micro-level and considers patient-physicianinteraction from a services and relationship marketing perspective. Thereby, the focal
point is on the communication behavior of the physician towards the patient and
consequently, its influence on satisfaction and especially on patients’ compliance. In this
context, compliance is defined as patients’ adherence to the advices and suggestions
(e.g. medication or changing eating habit) of the physician.
A service encounter in the health care setting is characterized by “(1) one-on-one
interaction, (2) frequent encounters with the same physician, (3) intimate exchanges, (4)
substantial variability across encounters, and (5) require patient co-operation to achieve
successful health outcomes” (Hausman 2004, p. 403). These health service encounters
are an illustration of the service dominant logic (Vargo and Lusch, 2004). Vargo and
Lusch define service as “application of the specialized competences … for the benefit of
another entity…” (Vargo and Lusch, 2008, p.26). Furthermore, the authors (2004, 2008)
mention the role of the customer as a co-creator of value, the inherent relationship
aspect, and the unique and phenomenological determination of value by the recipient in
their ten foundational premises of service-dominant logic (2008). These elements are
clearly portrayed in the high credence based medical services.
This project will contribute to existing research in several ways: 1) Until now, research
delivers contradicting findings regarding the influence of the different communication
styles of the physician on patients satisfaction and compliance (Ong et al., 1995). With a
more comprehensive definition of communication, the objective is to shed light on
existing findings; 2) Furthermore, an underlying mechanism will support existing papers
with a theoretical foundation and explanation (Arora, 2003). This will be accomplished by
applying the feelings-as-information concept from Schwarz (1996); 3) As Jacobson et al.
(2008) point out, the main focus within this area is on affective feelings and mostly
disregards cognitive feelings. For that reason, the authors will explicitly include both
types of feelings in the model and measure them simultaneously; 4) An additional aim is
the application and refinement of the cognitive tuning phenomenon, which is the
adoption of our processing style to a given situation, by Schwarz (2002). The reasons for
the application and further refinement are multiple: (a) the potential of the cognitive
tuning phenomenon is not yet fully exploited, especially within marketing, (b) in most
studies the authors focused on affective feelings and they exclusively considered the
prefix of the feeling (positive or negative). Whereas, this study will explicitly consider the
type of feeling – affective or cognitive – and its effect on the processing strategy of an
individual. An interesting question to look at is the following: is there a tuning of feelings
before a cognitive tuning takes place?; 5) Last but not least, the applicability of the
conceptual model for other high credence based services will be validated by testing it
for other business relevant settings.
The practical implications of the findings will lie in the information the service provider
gets about how to change his / her communication behavior most efficiently, so that
results can be improved.
For instance, if the main aim is to achieve compliance then preferably the customers
should have strong positive cognitive feelings (such as the feeling of understanding,
comprehension). But if the main aim is to achieve a high level of preference / liking, then
the service provider should concentrate on the elicitation of affective feelings. Another
benefit would be to know that the elicitation of certain types of feelings will already
influence the desired processing strategy.
2. Literature Review
Decades ago, many researchers already identified and described different
communication behaviors by physicians (Roter et al., 1987; Ben-Sira, 1980; Bensing,
1991; Buller and Buller, 1987). Two main groups of communication behaviors became
apparent: instrumental (also known as task oriented or cure oriented) vs. affective (also
known as socio-emotional or care oriented). Many definitions have been used for the
above mentioned communication behaviors. However, for this study the instrumental
communication of the doctor is defined as the patient’s perception of all verbal and nonverbal behavioral cues of the physician that signals his technical skills and expertise to
the patient. His / her affective communication is defined in this study as the patient’s
perception of all verbal and non-verbal behavioral cues that contain a socio-emotion
aspect and anything else said or done by the physician to establish, maintain, and
enhance a relationship with the patient. The current study only considers the perspective
of the patient such that, communication is any cue that the patient perceives consciously
or subconsciously during the interpersonal face-to-face interaction with the physician
(Rosengren, 2000; Kreps & Thornton, 1984).
Several researchers conducted studies to assess the influence of the communication
behavior on important outcome variables such as patients’ satisfaction with the physician
or patients’ compliance with the suggestions of the physician (Buller and Buller, 1987;
Arora, 2003; Roter et al., 1987; Hausmann, 2004). However, an explanation why certain
behaviors lead to certain outcomes is still not adequately explored.
In a high credence based service, like a medical visit, patients do not possess the
knowledge to judge the quality of a service (Garry, 2007; Alford & Sherrel, 1996).
Moreover, Schwarz (1990) mentions the affective nature of the judgment at hand, lack of
other information, the complexity of the given situation and also time constraints as
enhancing conditions for a heuristic approach. Under these circumstances the likelihood
of using ones feelings to judge the service increases. Hence, the feelings-as-information
model from Schwarz (1990, 2002) is proposed as a theoretical explanation for the
current project.
Schwarz (1996, 2007) distinguished between affective and cognitive feelings which are
of particular importance for the high credence based services. Affective feelings have a
fixed valence and are immediate evaluations of ones environment (e.g. joy, anger,
sadness, and happiness). They inform us about how much and in what way something is
good or bad. They are also termed emotional feelings (Schwarz, 1996, 2002; Schwarz
and Clore, 2006; Clore and Parott, 1994; Ortony and Turner, 1990; Stepper and Strack,
1993). Cognitive feelings on the other hand, have no fixed valence and more importantly
reflect ones state of knowledge (e.g. surprise, confusion and familiarity) (Pham, 2004;
Schwarz, 2002, Ortony & Turner, 1990). These feelings are also termed non-emotional
feelings (Schwarz, 1996, 2002; Schwarz and Clore, 2006; Clore and Parott, 1994;
Ortony and Turner, 1990). Besides their use for service judgment, an additional function
of feelings is that they tune individuals’ processing style to the requirements of the
environment or task at hand. The feelings signal, which kind of environment – benign or
problematic – the individual is in. For instance, a positive affective feeling informs the
person that everything is all right in his environment. Therefore, there is no need for
detailed and more effortful systematic information processing. Contrasting this, a
problematic environment reveals negative affective feelings. In that case, the individual
engages in a systematical processing style. Schwarz (2002) called this phenomenon
cognitive tuning.
3. Conceptual model and Hypotheses
This section mainly consists of two sub-sections. In the first part, the general conceptual
model with its underlying mechanism will be introduced. The second part, delves into
cognitive tuning and tuning of feelings.
General conceptual model
The following visualization illustrates the general conceptual model of the intended
project:
Take in figure 1: conceptual model
The straight line in the middle of the graph indicates that there is rough division between
the constructs of the upper part – instrumental communication  cognitive feelings 
compliance – and the lower part – affective communication  affective feelings 
satisfaction. The upper part is more “factual”, whereas the lower part can be seen as
more “emotional”. However, there is no clear cut between the upper and lower part of
the model. We are expecting some interrelations but these should not be very strong.
Resulting from the general conceptual model, the following hypotheses are formulated:
H1: Instrumental communication will lead to more task-oriented outcomes such as
compliance than to affective outcomes.
H2: Affective communication will lead to more affective outcomes such as satisfaction
than to task-oriented outcomes.
H3: Instrumental communication will evoke more cognitive feelings than affective
feelings.
H4: Affective communication will evoke more affective feelings than instrumental
feelings.
H5: Cognitive feelings have a higher chance of influencing task-oriented outcomes such
as compliance than affective outcomes.
H6: Affective feelings have a higher chance of influencing affective outcomes such as
satisfaction than task-oriented outcomes.
Cognitive Tuning and tuning of feelings
Below, the graph shows the difference between cognitive tuning and tuning of feelings.
Take in figure 2: Comparison of cognitive tuning and tuning of feelings
As shown above, the main difference is that the cognitive tuning phenomenon states that
the prefix of the feeling – positive or negative feeling – influences the processing
strategy. However, the tuning of feelings states that it is not only the prefix, but already
the type of feeling – affective or cognitive –influences the adoption of our cognition.
The graphs below, illustrate the details of cognitive tuning and the tuning of feelings
separately.
Take in figure 3: Cognitive tuning
Take in figure 4: Tuning of feelings
The thickness of the arrows of the latter graph illustrates that in a benign situation more
positive affective feelings will be evoked than cognitive positive feelings. In a problematic
situation, however, more negative cognitive feelings will be evoked than negative
affective feelings.
4. Methodology
Study 1
To support our ideas, we will conduct a series of studies. The aim of the first study will
be to verify the utilization of affective as well as cognitive feelings by the patient during
the service encounter. An additional aim is to identify a clear link between the type of
communication and the type of feeling evoked by the communication behavior of the
physician. And also a clear link is expected between the type of feeling and the outcome
variable. This will be achieved by conducting a quasi experiment. The communication
behavior will be manipulated and the feelings and outcome variables will be measured
with a survey.
Manipulation
The study will have a 2*2 experimental design. The two factors are the communication
style of the physician: instrumental versus affective. Each of the styles will be
furthermore manipulated on two levels: positive and negative. Positive instrumental
would be for example when the doctor explains extensively what the consequences of
the medication are, whereas a negative instrumental would not give this information.
Positive affective communication would be if the doctor looks in the eyes of the patient
while he talks, whereas a negative affective communication would be when he looks at a
PC screen. Resulting from these manipulations, four scenarios are prepared. The
respondents will receive one of the four written scenarios and will afterwards fill out a
questionnaire.
Measurement
From a pre-test we first analyzed the most common affective – like afraid, happy, and
worried – and cognitive feelings – like feeling uncertain or skeptical – in a medical
consultation and then we chose the top three feelings of each type. We will use already
established scales to measure each of the top feelings with at least three items. For the
outcome variables, satisfaction and compliance, we will also use established scales.
Study 2
A second study will concentrate on cognitive tuning. It is known that affective feelings
need less vigilance and effort, because they are immediate reactions with a fixed
valence. But this does not hold for cognitive feelings. They do not have fixed valence
and furthermore, the experience of cognitive feeling interacts and therefore depends on
the content recalled. The purpose is to empirically prove that even though benign and
problematic situations evoke both types of feelings (affective and cognitive), a benign
situation will evoke more affective than cognitive feelings. Whereas, a problematic
situation will evoke more cognitive feelings than affective ones. As already mentioned, in
a high credence based service an individual may not have any knowledge and therefore
has to rely on his/her feelings. Even though the reliance on feelings is usually
considered a heuristic approach, one will use them and still have a high vigilance and
effort level, which is considered as systematic approach and not a heuristic – like
feelings-as-information – in the literature.
One possibility to measure the tuning of feelings would be to gradually manipulate the
cue (communication) from one extreme (benign) to another extreme (problematic) and
then measure which kind of feelings are evoked more. After evoking these feelings
respondents should do a psychological test (e.g. thought listing) which reveals
information about the processing strategy used by them.
Study 3
In a third study the robustness of the conceptual model for other high credence based
services like financial consultant will be confirmed.
5. Results
Until now, only a pre-test has been conducted with 25 respondents. They were asked to
think about their medical consultation and then to write down all the feelings they have
had during the stay at the doctors’ office. The intention was to find out what feelings are
evoked during their visit. Later all the feelings were coded as affective or cognitive by
three independent coders. The coders were provided with the definitions of each feeling
type and then asked to categorize the written feeling of the respondents independently
from each other. Soon after, the frequency was counted in order to identify the most
common feelings. The most common feelings will then serve the following studies to
measure the evoked feelings by the communication behavior.
6. Main Issues and Problems
The authors would appreciate any constructive feedback that supports a refinement of
the project.
Figures
Instrumental
communication of
physician
+H
1
Feelings
evoked in the
patient:
Outcome
variables:
+H3
cognitive
compliance
+H5
+H6
affective
satisfaction
+H4
Affective
communication of
physician
+H
2
Figure 1: Conceptual model
Cognitive
Tuning
cue
benig
n
Positive Feeling
(affective & cognitive.)
Heuristic
Processing
problematic
Negative
Feeling
Affective
Feeling
(positive)
(affective &
cognitive.)
benign
Systematic
Processing
Cognitive
Feeling
(negative)
problematic
cue
Tuning of
Feelings
Figure 2: Comparison of cognitive tuning and tuning of feelings
Only Positive
Feelings
+A
Benign
Cue
Heuristic
Processing
+C
-A
Problematic
Cue
Systematic
Processing
-C
Only Negative
Feelings
Benign or problematic cue evokes positive or negative feelings, and if it is positive then the individual
approaches heuristic processing and if it is negative the individual approaches systematic processing.
Figure. 3: Cognitive tuning
Mainly Affective
Feelings
+A
Benign
Cue
Heuristic
Processing
+C
-A
Problematic
Cue
Systematic
Processing
-C
Mainly Cognitive
Feelings
Note:
The thickness of the arrow indicates the
weight (strength)
Benign cues will evoke more affective feelings than cognitive which will therefore lead to heuristic
processing.
Problematic cues will evoke more cognitive feelings than affective which will lead to systematic
processing.
Figure 4: Tuning of feelings
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