International Conference on Technology and Business Management
March 23-25, 2015
The Healthscape as an Antecedent to Service Quality and Behavioral Intentions
Yogesh Pai P
School of Management, Manipal University
([email protected])
Satyanarayana Chary T
Telangana University
([email protected])
The demand for healthcare is increasing and thus service quality in a healthcare setting is being measured. This paper
presents the relationship of healthscape on service quality and behavioral intentions using PLS-SEM.
1. Introduction
A service has been defined as, „any activity or benefit that one party can offer to another that is essentially intangible and does
not result in the ownership of anything…‟ (P.Kotler, K.L.Keller, A.Koshy, M. Jha; 2013 p.322). The characteristics of
services such as intangibility, inseparability, heterogeneity and perishability make services distinct when compared to goods
(V.A. Zeithaml, A.Parasuraman, L.L.Berry; 1985). Although customers cannot grasp a service per se, they can grasp the
various tangibles associated with the service, which are clues for the „invisible‟ service. During a consumer‟s visit to a service
outlet, the service environment is the first characteristic of the service that is perceived by the customer. This stage is
important as the consumers are likely to form impressions of the level of service they would receive in the service outlet. It is
said that the first impression is the best impression. It is identified that the customers see more and process more informat ion
than managers and service providers in the selection and usage of services (L.L.Berry, K.D. Seltman; 2008).
The importance of service environment was first recognized by Kotler (1973-74, p.61) who stated that the servicescape
“may [in the future] become the chief form of competition”. Thus, Kotler initiated and declared the idea of the physical
environment as an important part of the service experience. However, the researchers Booms and Bitner (1981) advanced to
the concept of servicescape, defining „servicescape‟ as „the environment in which the service is assembled and in which seller
and consumer interact, combined with tangible commodities that facilitate performance or communication of service‟ (p.36).
The concept was further narrowed to healthcare facilities and coined the term „Healthscape‟ (J.D.Hutton, L.D.Richardson;
1995).
The behavioral intention is defined as a signal of whether customers will remain or exit the relationship with the service
provider (V.A.Zeithaml, L.L.Berry, A. Parasuraman; 1996). Though there are numerous definitions for behavioral intention
defined by numerous researchers, the primary interest as recognized in the literature is that of predictor of the profitability of
service firms (E.W.Anderson, C.Fornell, D.R. Lehmann; 1994; F.F.Reichheld, W.E. Sasser; 1990). It is incredible to note that
both costs and revenue of firms are affected by repeat purchases, positive word-of-mouth recommendation, and customer
feedback.
The service quality has gained a lot of attention after the SERVQUAL model (A. Parasuraman, V.A.Zeithaml, L.L.Berry;
1985, 1988). They put forth their model consisting of five dimensions for measuring service quality. Among the five
dimensions one is termed as „tangible‟. There are numerous studies that have measured service quality concepts across
industries and countries. Healthcare is no exception. The researchers Y.P.Pai and S.T. Chary (2013) identified that different
terminologies are used for stating „tangibles‟ by various researchers for measuring hospital service quality from the patient‟s
perspective.
Although there are varieties of studies conducted to demonstrate the impact of servicescape on emotion, customer
satisfaction (L.Johnson, K.J.Mayer, E.Champaner; 2004), service quality (R.Hightower, M.K.Brady, T.L.Baker; 2002),
behavioral intention (L.C.Haris, C.Ezeh; 2008), there are limited studies conducted in the servicescape of healthcare i.e.
healthscapes. From the literature it is found that most studies are conducted to explore the causal relationship among the
constructs: service quality, satisfaction and behavioral intentions (G.C.Saha, Theingi; 2009, H.Qin, V.R.Prybutok; 2009).
Studies have also identified the effect of hospital service quality on patient satisfaction and behavioral intentions (M.Amin,
S.Z.Nasharuddin; 2013). However not much of work has been conducted on healthscape, one study have explored the impact
of healthscape on service quality and behavioral intentions (Y.P.Pai and S.T.Chary; 2014). However, this present papers
explores to identify the relationship among healthscape along with another dimension personnel quality on the overall service
quality and behavioral intentions.
2. Focus of the Study
In the present times, there is an increased attention given to hospital services due to improved standard of living and demand
for better medical care to improve the lifestyles. From the literature, it is identified that the relationship of servicescape along
with other elements of quality using SERVQUAL indicated that the tangible factor (servicescape) was more important than
the four intangible factors in determining quality (A.Reimer, R.Kuehn; 2005) whereas, researchers A.Parasuraman,
V.A.Zeithaml, and L.L.Berry (1988) point out that the intangible factors were significantly more important than the tangible
factor. Therefore the nature of this relationship is interesting to explore in healthcare. Recently, D.Hooper, J.Coughlan and
M.R.Mullen (2013) explored the relationship among servicescape(S), employee service quality (ESQ), overall service quality
561
International Conference on Technology and Business Management
March 23-25, 2015
(OSQ) and behavioral intention (BI), as shown in figure 1. In the present study the healthscape is servicescape, as the study is
in a hospital setting, and personnel quality signifying the employee service quality is considered in the framework as shown
in the figure 2. Thus, the present study has applied similar framework of D.Hooper, J.Coughlan and M.R.Mullen (2013) in a
healthcare context, as shown in the figure 2, exploring the relationship among healthscape (H), personnel quality (PQ),
overall service quality (OSQ) and behavioral intentions (BI).
S
OSQ
BI
ESQ
Figure 1 Relationship among Servicescape, Employee Service Quality, Overall Service Quality and Behavioral Intentions
Source: D.Hooper, J.Coughlan and M.R.Mullen (2013, p.274)
H5
H
OSQ
H1
H4
BI
H2
PQ
H3
Figure 2 Relationship among healthscape, Personnel Quality, overall Service Quality and Behavioral Intentions
Source: Authors
The following hypotheses reflect this supposition
H1. Healthscape perceptions will have a direct and positive effect on personnel quality.
H2. Healthscape perceptions will have a direct and positive effect on overall service quality.
H3. Personnel quality will have a direct and positive effect on overall service quality.
H4. Overall service quality will have a direct and positive impact on behavioral intentions.
H5. Healthscape perceptions will have a direct and positive effect on behavioral intentions.
3. Study Methodology
A questionnaire was developed in English that was pre-tested to arrive at appropriate format. A sample of 602 patients are the
respondents for the present study, among those there are 300 inpatients and 302 outpatients. The respondents were chosen
from 11 hospitals among different teaching, corporate and public hospitals from the districts of Karnataka State in India.
There were 6 items for measuring healthscape, 8 items for measuring personnel quality, 4 items for measuring overall service
quality and 7 items for measuring behavioral intentions which were considered from the previous study. All items were in
statement form and were rated by respondents on five-point Likert scales from Strongly Disagree to Strongly Agree. Further a
pilot study revealed that respondents had no difficulty in understanding the questionnaire items indicating and confirming the
face validity of the instrument scale measurement as conducted by H.Arasli, E.E.Haktan, K.S.Turan (2008).
4. Results and Discussions
Data collected from respondents was analyzed with partial least squares structural equation modelling (PLS-SEM) using
Smart PLS 2.0 M3 (C.M. Ringle, S.Wende, S.Will; 2005). In the present study we have reflective measurement models and
assessment includes composite reliability, internal consistency, individual indicator data and average variance extracted to
evaluate convergent validity and the Fornell-Lacker criterion and cross loadings to assess discriminant validity (J.F.Hair, G.T.
M. Hult, C.M. Ringle, M.Sarstedt; 2014). Thus, in order to check the properties of the measurement scales, we assessed
internal consistency reliability through Cronbach‟s alpha and composite reliability; convergent validity through average
variance extracted (AVE) as shown in table 1 and discriminant validity through the Fornell Lacker criterion as shown in
Table 2. The results in the table 1 indicate that AVE and CR of all constructs are either equal to or exceed respectively 0.50
and 0.70 cut off values (J.F.Hair, G.T. M. Hult, C.M. Ringle, M.Sarstedt; 2014). Then, we ensured convergent validity, as all
the PLS indicators load much higher on their hypothesized factor than on other factors (own loading are higher than cross
loadings). In addition, in Table 2, we calculated the square root of the AVE that exceeds the inter correlations of the construct
with the other constructs in the model in order to ensure discriminant validity (C. Fornell, D.F. Larcker; 1981). Thus, the
measurement model was considered satisfactory with the evidence of adequate reliability, convergent validity and
discriminant validity and was employed for hypothesis testing and research model validation.
562
International Conference on Technology and Business Management
March 23-25, 2015
Table 1 Psychometric Properties of the Constructs
Constructs
Healthscape
Personnel Quality
Service Quality
Behavioral Intentions
AVE
0.5197
0.5003
0.7245
0.5870
CR Cronbachs Alpha
0.8655
0.8122
0.8883
0.8556
0.9130
0.8725
0.9084
0.8821
Table 2 Inter Correlations of the Latent Variables
Constructs Healthscape Personnel Quality Service Quality Behavioral Intentions
0.721†
Healthscape
-†
--
--
Personnel Quality
0.6518
0.7073
--
--
Service Quality
0.4949
0.539
0.8512†
--
Behavioral Intentions
0.4324
0.5402
0.6523
0.7662†
†Square Root of the AVE on the Diagonal
Table 3 Results of Significance Testing of Structural Path Coefficients
Path
Path Coefficients t values Significance levels
Healthscape -> Service Quality
0.2496
1.830
*
Healthscape -> Personnel Quality
0.6518
7.251
***
Personnel Quality -> Service Quality
0.3763
2.2995
**
Service Quality-> Behavioral Intentions
0.5805
5.3658
***
Healthscape -> Behavioral Intentions
0.1452
1.3411
NS
*p<0.10, **p<0.05, ***p<0.01
Thus the four hypothesis H1, H2, H3, H4 are supported in the present study. The hypothesis H5 is not supported.
5. References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
P.Kotler, K.L.Keller, A.Koshy, M.Jha (2013), Marketing Management, 14th ed., Pearson Education, New Delhi.
V.A. Zeithaml, A.Parasuraman, L.L.Berry (1985), „Problems and Strategies in Services, Marketing‟, Journal of
Marketing, Vol. 49, pp.33-46.
L.L. Berry, K. D. Seltman (2008), Management lessons from Mayo Clinic, McGraw Hill Companies, USA.
P.Kotler (1973), „Atmospherics as a marketing tool‟, Journal of Retailing, Vol. 49, pp. 48-64.
B. Booms, M.Bitner (1981), „Marketing strategies and organization structures for service firms‟, in J.H. Donnely, W.R.
George (Ed.), Marketing of Services, American Marketing Association, Chicago, USA, pp.47-52.
J.D.Hutton, L.D. Richardson (1995), „Healthscapes: the importance of place‟, Journal of Health Care Marketing, Vol.15
No.1, pp.10-11.
V.A.Zeithaml, L.L.Berry, A. Parasuraman (1996), „The behavioural consequences of service quality‟, Journal of
Marketing, Vol. 60 No. 2, pp.31-46.
E.W.Anderson, C.Fornell, D.R. Lehmann (1994), „Customer satisfaction, market share, and profitability: findings from
Sweden‟, Journal of Marketing, 58, pp.53-66.
F.F.Reichheld, W.E. Sasser (1990), „Zero defections: quality comes to services‟, Harvard Business Review, SeptemberOctober, pp.105-11.
A.Parasuraman, V.A.Zeithaml, L.L.Berry (1985), „A conceptual model of service quality and its implication for future
research‟, Journal of Marketing, Vol.49 No.4, pp.441-450.
A.Parasuraman, V.A.Zeithaml, L.L.Berry (1988), „SERVQUAL: A Multiple-item scale for measuring consumer
perceptions of service quality‟, Journal of Retailing, Vol.64 No.1, pp.12-40.
Y.P.Pai, and S.T.Chary (2013), „Dimensions of Hospital Service Quality: A Critical Review - Perspective of patients
from global studies‟, International Journal of Healthcare Quality Assurance, Vol.26 No.4, pp.308-340.
L.Johnson, K.J.Mayer, E.Champaner (2004), „Casino atmospherics from a customer‟s perspective a re-examination‟,
UNLV Gaming Research and Review Journal, Vol.8 No.2, pp.1-10.
R.Hightower, M.K.Brady, T.L.Baker (2002), „Investigating the role fo the physical environment in hedonic service
consumption: an exploratory study of sporting events‟, Journal of Business Research, Vol.55 No.9, pp.697-707, 2002.
L.C.Haris, C.Ezeh (2008), „Servicescape and loyalty intentions: an empirical investigation‟, European Journal of
Marketing, Vol. 42 No.3/4, pp.390-422.
G.C.Saha, Theingi (2009), „Service quality, satisfaction, and behavioural intentions: A study of low-cost airline carriers
in Thailand‟, Managing Service Quality, Vol.19 No.3, pp. 350- 72.
563
International Conference on Technology and Business Management
March 23-25, 2015
17. H.Qin, V.R.Prybutok (2009), „Service quality, customer satisfaction, and behavioral intentions in fast-food restaurants‟,
International Journal of Quality and Service Sciences, Vol.1 No.1, pp.78- 95.
18. M. Amin, S.Z.Nasharuddin (2013), „Hospital service quality and its effects on patient satisfaction and behavioural
intention‟, Clinical Governance: An International Journal, Vol. 18 No.3 pp. 238-254.
19. Y.P.Pai and S.T.Chary (2014), „The impact of healthscape on service quality and behavioral intentions‟, International
Journal of Conceptions on Management and Social Sciences, Vol. 2 No. 2, pp.18-22.
20. A.Reimer, R.Kuehn (2005), „The impact of servicescape on quality perception‟, European Journal of Marketing, Vol. 39
No.7/8, pp.785-808.
21. D.Hooper, J.Coughlan, M.R.Mullen (2013), „The servicescape as an antecedent to service quality and behavioral
intentions‟, Journal of services marketing, Vol.27 No.4, pp.271-80.
22. H.Arasli, E.E.Haktan, K.S.Turan (2008), „Gearing service quality into public and private hospitals in small islands
Empirical evidence from Cyprus‟, International Journal of Health Care Quality Assurance, Vol.21 No.1, pp.8-23.
23. C.M. Ringle, S.Wende, S.Will (2005), SmartPLS 2.0 (M3) Beta, Hamburg 2005.
24. J.F.Hair, G.T. M. Hult, C.M. Ringle, M.Sarstedt (2014), A Primer on Partial Least Squares Structural Equation Modeling
(PLS-SEM), Sage Publication, New Delhi.
25. C. Fornell, D.F. Larcker (1981), „Evaluating Structural Equation Models with Unobservable Variables and Measurement
Error‟, Journal of Marketing Research, Vol.18 No.1, pp. 39-50.
564