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Health Marketing Quarterly Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whmq20

The Role of Affect in Consumer Evaluation of Health Care Services a

Sandy Ng & Rebekah Russell-Bennett

b

a

School of Economics, Finance and Marketing, RMIT University, Melbourne, Australia b

School of Advertising, Marketing and Public Relations, Queensland University of Technology, Brisbane, Australia Published online: 09 Mar 2015.

Click for updates To cite this article: Sandy Ng & Rebekah Russell-Bennett (2015) The Role of Affect in Consumer Evaluation of Health Care Services, Health Marketing Quarterly, 32:1, 31-47, DOI: 10.1080/07359683.2015.1000708 To link to this article: http://dx.doi.org/10.1080/07359683.2015.1000708

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Health Marketing Quarterly, 32:31–47, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0735-9683 print=1545-0864 online DOI: 10.1080/07359683.2015.1000708

The Role of Affect in Consumer Evaluation of Health Care Services SANDY NG Downloaded by [University of Nebraska, Lincoln] at 13:42 03 April 2015

School of Economics, Finance and Marketing, RMIT University, Melbourne, Australia

REBEKAH RUSSELL-BENNETT School of Advertising, Marketing and Public Relations, Queensland University of Technology, Brisbane, Australia

Health care services are typically consumed out of necessity, typically to recover from illness. While the consumption of health care services can be emotional given that consumers experience fear, hope, relief, and joy, surprisingly, there is little research on the role of consumer affect in health care consumption. We propose that consumer affect is a heuristic cue that drives evaluation of health care services. Drawing from cognitive appraisal theory and affect-as-information theory, this article tests a research model (N ¼ 492) that investigates consumer affect resulting from service performance on subsequent service outcomes. KEYWORDS consumer affect, service performance, general practitioners, satisfaction, value perceptions, intentions

INTRODUCTION Health services, such as hospitals and general practice, can be classified as an unsought product that consumers use reactively when they get sick. The stress created by the uncertainty and trauma of illness elicits a variety of affective responses, including negative emotions of fear and anxiety along with the positive emotions of hope and joy (Dube & Morgan, 1998; Vinagre & Neves, 2008). Despite evidence that emotions are part of the health care setting and evidence that service performance evaluations drive outcomes, such as satisfaction, consumer value, and repeat patronage (Dagger, Sweeney, & Johnson, 2007), there has been little research that has investigated the Address correspondence to Sandy Ng, PhD, School of Economics, Finance and Marketing, RMIT University, Melbourne, VIC 3000, Australia. E-mail: [email protected] 31

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central roles of affect in this process. Prior research in understanding consumer judgments of health care services reflects the classic cognitive models of evaluation (e.g., Baker & Taylor, 1997; Dagger & Sweeney, 2006), yet this perspective is limiting (Edvardsson, 2005). The need to go beyond cognitive influences has been identified as an area of further research in health care services (Mattila & Enz, 2002), yet the call has largely gone unheeded. This article, thus, seeks to address this gap by addressing the research question: Does service performance influence consumer affect and, if so, how does affect influence the service outcomes of satisfaction, value, and behavioral intentions? This question is investigated within the context of general practice. It is reasonable to expect that in a high contact, intimate service setting like these, the general practitioner (GP) service performance will have a direct influence on consumer feelings. While GPs need to demonstrate that they are clinically competent and possess the expertise to deliver appropriate care to their consumers (Bendapudi, Berry, Frey, Parish, & Rayburn, 2006), research has showed that consumers are also concerned with ‘‘the bedside manner’’ and the interpersonal skills of the GP as an indication of the service performance (Bendapudi et al., 2006). The article, thus, makes three contributions. First, the role of consumer affect on service outcomes is demonstrated as important and central. Second, the emotions that consumers experience during health care service encounters are identified. Third, the effect of GP service performance on consumer affect is identified. The next section presents the research frameworks that underpin this study followed by the development of the research hypotheses. After which, the methodology and results findings are shown and to end, suggestions for future research are discussed.

RESEARCH FRAMEWORK The development of the research model (Figure 1) is underpinned by cognitive appraisal theory (Bagozzi, Gopinath, & Nyer, 1999) and affect-asinformation theory (Schwarz & Clore, 1988). The left side of the conceptual model (service performance and affect) uses cognitive appraisal theory and the right side uses affect as information theory (affect, satisfaction, value, and behavioral intentions). Cognitive appraisal theory purports that the critical determinant of consumer feelings is the evaluation and interpretations that arise after comparing an actual service encounter with a desired service encounter (Bagozzi et al., 1999). In other words, the consumer elicits an affective response after evaluating the service performance of the doctor. Affect-as-information theory explains that consumer affective states lead to judgments of a service (Schwarz & Clore, 1988). People often rely on their affective states in a heuristic fashion to make complex judgments as long as

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FIGURE 1 Research model.

the experienced feelings are perceived as relevant to the object of judgment (Schwarz, 1990). Essentially, consumers’ rely on their feelings because they perceive these feelings to contain valuable judgmental information (Pham, Cohen, Pracejus, & Hughes, 2001). Therefore, consumer affect experienced in a health care setting is expected to influence if they are satisfied with the service, whether the service is valuable, and whether they intend to see the doctor again in the future. The term affect represents the superordinate level of the hierarchy of consumption affect (Laros & Steenkamp, 2005) and is a valenced approach that has positive or negative affective states (Hightower, Brady, & Baker, 2002; Lin & Liang, 2011). Consumer affect is comprised of a combination of the basic emotions in the hierarchy of consumption emotions, such as pleased, happy, irritated, or discontent (Laros & Steenkamp, 2005; Richins, 1997).

HYPOTHESIS DEVELOPMENT Service Performance and Consumer Affect Service performance is an important construct and has gained widespread attention due to the vital role service plays in gaining competitive advantage (Chahal & Kumari, 2012). In this research, interaction and expertise have been identified as two service elements that are central to the consumer’s evaluation of a health service’s performance (Bendapudi et al., 2006). Interaction refers to the empathetic, understanding and caring nature of the service provider, and the ability of the provider to communicate clearly with the consumer, while expertise refers to the provider’s competence,

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knowledge, and skill in diagnosing, treating and caring for the consumer (Dagger, Sweeney, & Johnson, 2007). Interaction demonstrates GP professionalism through their communication skills, for example, their bedside manner (Gaur, Xu, Quazi, & Nandi, 2011). Good interactions can enhance relationships between doctors and patients. Positive interaction behavior has been found to boost patients’ confidence in their doctors and enhance loyalty (Guar et al., 2011). Expertise demonstrates the doctor’s efficiency (i.e., the appropriate medical knowledge) in solving a patients’ medical problem. As a credence service, health care is difficult to evaluate even after purchase and consumption (Darby & Karni, 1973; Nelson, 1970), therefore the level of expertise demonstrated by the GP is an important service element to assess as it forms a quality cue for patients. These two service elements reflect the overall service performance of a doctor. While prior research has focused on identifying and examining relationships between service performance, satisfaction, and intention (O’Neil, Wright, & Fitz, 2001; Trocchia & Janda, 2003), little is known about the possible intervening influence of consumer affect. Drawing upon cognitive appraisal theory and affect-as-information theory, this research tests whether service performance (reflecting the core service elements of the doctor’s expertise and interaction) has an influence on consumer affect in an emotion-laden context such as health care. Consider this: If a GP presents as being knowledgeable, competent, approachable, and emphatic while treating the patient, this is likely to create positive affirmation of the service being relevant to the patient’s well-being. The result would be positive cognitive appraisals, which trigger positive affective reactions (Lazarus & Folkman, 1984). Conversely, if a GP’s bedside manners are poor and the GP appears to be unsure of which medical procedure is appropriate, the lack of empathy or credibility may create stress for the consumer and therefore generate negative cognitive appraisals, which in turn trigger negative affective reactions (Bagozzi et al., 1999). Therefore, it is hypothesized that: H1: Service performance will be positively associated with positive affect. H2: Service performance will be negatively associated with negative affect.

Consumer Affect and Service Evaluation Service evaluation consists of factors, such as satisfaction and perceived value, which lead to behavioral intentions such as repeat patronage and word-of-mouth. Consumer satisfaction is a postconsumption outcome of consumers’ judgments of product consumption-related fulfillment (Oliver 1999). Prior studies have found support for the relationship between affect

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and satisfaction (Alford & Sherrell, 1996; Grace & O’Cass, 2004). In particular, affect as information theory has been used to identify the reliance consumers have on their affective states to make judgments in the consumption of credence based high contact services, such as medical service (Alford & Sherrell, 1996). Thus, when consumers feel positive emotions such as happiness or joy after seeing their GP, they are more likely to feel satisfied. In contrast, if consumers experience negative emotions such as anxiety or fear, they are more likely to be dissatisfied. Therefore, it is hypothesized that:

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H3: Positive affect will be positively associated with satisfaction. H4: Negative affect will be negatively associated with satisfaction.

How consumers form value judgments of any service is a critical piece of information for service organizations (Zeithaml, 1988). Value refers to consumer’s perceived preference for and evaluation of those service attributes and performances, and consequences arising from service encounters that facilitate (or block) achieving the consumer’s goals and purposes in situations (Woodruff, 1997; Sweeney & Soutar 2001). Obtaining value is a fundamental purchase goal and pivotal to successful service transactions (Holbrook, 1994). Prior research has shown that consumer affect is a critical driver of value perceptions in consumers’ experience of services (Shaw, 2007). Interestingly the influence of consumer affect on perceived value remains underresearched in credence service contexts (Garry, 2008; Murray & Howat, 2002) and not been examined in the health care service context. As such it is hypothesized that: H5: Positive affect will be positively associated with perceived value. H6: Negative affect will be negatively associated with perceived value.

The relationship between perceived value and consumer satisfaction has received substantial attention in the literature (e.g., Brady et al., 2005; Cronin, Brady, Tomas, & Hult, 2000; Eggert & Ulaga, 2002). Cronin et al. (2000) confirmed the positive relationship between perceived value and satisfaction across industry contexts. Specifically, this relationship has been examined in Korean health care context in and the result supports the impact of value on satisfaction (Choi, Cho, Lee, Lee, & Kim, 2004). This causal link between value and satisfaction is therefore expected to hold in our study. It is expected that this causal link will hold in our study. Hence: H7: Perceived value will be positively related with satisfaction.

Satisfaction has been to shown to influence behavioral intentions (Cronin et al., 2000). A satisfied consumer is less likely to switch, less likely to yield to competitor overtures, and less resistant to deepening relationship

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bonds with their existing service provider (R. E. Anderson & Srinivasan, 2003). Further, satisfied consumers do not partake in negative word-ofmouth and have higher repurchase intentions (Szymanski & Henard, 2001). Future intentions are also determined by perceived value (Bolton & Drew, 1991). A higher perceived value translates into increased intention to repeat behavior (Goetzinger, Park, Lee, & Widdows, 2007). Given that the value creation is crucial to achieving long term financial and market success (Gremler & Brown, 1999), and that consumer satisfaction is necessary for reducing consumer churn (Oliver, 1999), understanding the influence that satisfaction and value has on behavioral intentions is important to health care services. A recent study has shown that when patients feel satisfied with their GP and perceive value in the service, they are likely to exhibit behavioral intentions such as repeat patronage (loyalty), and positive word-of-mouth (Rundle-Thiele & Russell-Bennett, 2010). Thus: H8: Satisfaction will be positively associated with behavioral intentions. H9: Perceived value will be positively associated with behavioral intentions.

METHOD Using a commercially available mailing list, a random national sample of 2,000 consumers over the age of 18 who visited their GP in the previous 6 months was contacted. Over a period of 6 weeks, 492 usable questionnaires were returned, resulting in a response rate of 25%, which is the upper end range of mail response rate typical of service research (Dillman, 2007). There was no evidence of nonresponse bias (Armstrong & Overton, 1977). The demographic composition of the sample was spread across gender, age, and education groups (Table 1), with a skew towards women in the 31 to 49 age range. The majority of respondents were under the age of 50, and 99% had received at least a high school education. Approximately 68% of the sample population was working either part or full time and of the respondents 96% were skilled workers. Of the sample population, approximate 87% visited their GP at least once every six months with the majority of the population consulting at least two doctors. This polygamous loyalty to a GP is not surprising given that it is common consumer practice in Australia to seek a second opinion from another doctor when consuming a credence service, such as health care, or having a GP close to home and one close to work for the sake of convenience.

Measures Existing scales were used for the purpose of this study. Service performance was operationalized as interaction and expertise, adapted from Dagger,

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The Role of Affect TABLE 1 Sample Demographics (N ¼ 492)

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Demographics Gender Male Female Age 18–30 31–49 50–64 65þ Education Primary school High school Technical college=TAFE University, undergraduate University, postgraduate Other Work status of consumer Working full time Working part time Full-time student Retired Unemployed Occupation Unskilled Trades Administrators and managers Semiprofessional Professional No. of GPs visited One doctor Two doctors Three doctors Doctor visit frequency Quarterly Twice Every 6 months Once a year Once every 2 years

Medical service (%) 39.8 60.2 26.3 47.4 25.7 0.6 1 36.1 31.2 15.4 11.9 4.3 45.5 22.9 3.9 6.9 20.8 3.9 13.5 25.8 25.8 30.9 34.7 42.1 23.3 56.5 0.2 30.0 10.8 2.5

Sweeney, and Johnson (2007). The emotions that reflect items in the positive affect and negative affect scales were drawn from Richins (1997) and Laros and Steenkamp (2005). The satisfaction and perceived value scale items were from Cronin et al. (2000) while behavioral intentions were measured with items from Zeithaml, Berry, and Parasuraman (1996). Scale items can be found in the Appendix.

Statistical Procedures Structural equation modeling (SEM) using AMOS 6.0 (Bryne, 2001) was used to assess the research model. In particular, the maximum likelihood

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TABLE 2 Correlation Matrix, Discriminant Validity, and Descriptive Statistics SP

PA

NA

Sat

Val

BI

SP PA NA Sat Val BI

0.75 0.25 0.19 0.81 0.78 0.80

0.07 0.53 0.21 0.24 0.26 0.24

0.04 0.06 0.51 0.21 0.19 0.16

0.69 0.05 0.05 0.92 0.88 0.85

0.64 0.07 0.04 0.79 0.88 0.81

0.65 0.06 0.02 0.71 0.65 0.78

M SD R2

5.51 1.37 n=a

3.46 1.69 0.08

2.21 1.18 0.05

5.46 1.59 0.87

5.28 1.67 0.15

5.49 1.53 0.84

Note. Discriminant validity is presented in the upper triangle of the top matrix. Correlations are presented in the lower triangle. Average variance extracted for each construct is presented in bold. The descriptive statistics (mean and standard deviation) and R2 is presented in this table as well. SP ¼ service performance; PA ¼ positive affect; NA ¼ negative affect; SAT ¼ satisfaction; Val ¼ value, and BI ¼ behavioral intentions.

estimation method of SEM was applied to the analysis, as it is robust to minor variations of normality (Hoyle, 1995). A two-step approach to SEM was utilized (Anderson & Gerbing, 1988). The measurement model was first specified, evaluated, and validated, through confirmatory factor analysis (Garver & Mentzer, 1999). Following this, the structural relationships between the latent constructs in the research model were examined, which completed the two-step approach (J. C. Anderson & Gerbing, 1988; Garver & Mentzer, 1999).

Reliability and Validity of Measures The correlation matrix and descriptive statistics of the constructs in the model is provided in Table 2. An analysis of the measurement model resulted in adequate fit and all items were found to serve as strong measures of their respective constructs, v2 (50) ¼ 88.7, p < .01, CFI ¼ 0.99, IFI ¼ 0.99, RMSEA ¼ 0.04. Convergent validity was established with all t-values being significant (p < .01) and the average variances extracted were greater than 0.50. Fornell and Larcker’s (1981) test was then used to examine discriminant validity. As shown in Table 2, all pairs of constructs passed the stringent test (Fornell & Larcker, 1981) and discriminant validity was achieved. Further measurement analysis revealed adequate levels of construct reliability. Construct reliability exceeded 0.80 and average variance extracted exceeded the criterion value of 0.50. Table 3 presents Cronbach’s alpha, scale reliability, and average variance extracted results.

RESULTS Fit and structural estimates of our model are presented in Table 4. The testing of the research model (Figure 1) revealed fit statistics that are of an acceptable

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The Role of Affect TABLE 3 Scale Reliability, Construct Reliability, and Average Variance Extracted EFA SEM scale reliability for unobserved structural path constructs

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Service performance Positive affect Negative affect Satisfaction Value Behavioral intention

CFA

Cronbach’s alpha

CFA loadings

Construct reliability

Average variance extracted

0.96 0.85 0.89 0.97 0.95 0.95

0.81–0.94 0.65–0.81 0.64–0.82 0.92–0.99 0.90–0.97 0.77–0.97

0.96 0.85 0.89 0.97 0.96 0.95

0.75 0.53 0.51 0.92 0.88 0.78

level, v2 (54) ¼ 229.5, p < .01, CFI ¼ 0.97, IFI ¼ 0.97, RMSEA ¼ 0.08. An examination of the statistical significance and direction of the parameter estimates indicated that seven of the nine hypotheses were supported. Service performance was found to have a moderate effect on positive affect (b ¼ 0.28, p < .05) and negative affect (b ¼  0.22, p < .05), supporting H1 and H2. Positive and negative affect had no significant effect on satisfaction, thus not supporting H3 and H5. Positive (b ¼ 0.29, p < .05), and negative affect (b ¼  0.23, p < .05) were found to have a significant effect on perceived value, supporting H4 and H6. Perceived value was found to have a significant effect on satisfaction (b ¼ 0.93, p < .05), supporting H7. Finally, satisfaction was found to have a significant effect on behavioral intentions (b ¼ 0.69, p < .05), whilst value (b ¼ 0.24, p < .05) was found to have a significant effect on behavioral intentions, supporting H8 and H9. In terms of the specific emotions that reflected positive and negative affect, pleased, happy, relieved, peaceful, and fulfilled, reflected positive affect while negative affect was represented by tense, nervous, panicky, irritated, unfulfilled, discontent, depressed, and sad, as shown in Table 5.

TABLE 4 Results Hypotheses H1: H2: H3: H4: H5: H6: H7: H8: H9:

Service Performance! Positive Affect Service Performance! Negative Affect Positive Affect ! Satisfaction Positive Affect ! Perceived Value Negative Affect ! Satisfaction Negative Affect ! Perceived Value Perceived Value ! Satisfaction Satisfaction! Behavioral Intentions Value ! Behavioral Intentions

b

Critical ratio

Results

0.28 0.22 0.00 0.29 0.03 0.23 0.93 0.69 0.24

5.35 4.36 0.05 5.48 1.22 4.97 31.68 8.00 2.82

Supported Supported Not supported Supported Not supported Supported Supported Supported Supported

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TABLE 5 Emotional Responses to GP Service Performance Emotion Pleased Happy Relieved Peaceful Fulfilled

M Positive affect 3.80 3.89 3.34 3.48 3.52

SD 2.192 2.193 2.093 2.197 2.050

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Negative affect Tense Nervous Panicky Irritated Unfulfilled Discontent Depressed Sad

2.30 2.35 2.10 2.23 2.11 2.23 2.11 1.97

1.613 1.627 1.425 1.534 1.580 1.500 1.409 1.379

DISCUSSION The purpose of this study was to examine the role of consumer affect in consumer evaluation of health care services. This article draws on cognitive appraisal (Bagozzi et al., 1999) and affect-as-information theory (Schwarz & Clore, 1988) to put forth a model that investigates the service elements that influence consumer affect and subsequently, how consumer affect influences key service outcomes such as satisfaction, value, and behavioral intentions. In addition, this study also uncovered the range of positive and negative emotions experienced by consumers in health care services. Although there were more negative emotions experienced than positive emotions, the mean levels for positive emotions were higher than that of the negative emotions. Given that visits to a GP are utilitarian rather than hedonic, and are consumed out of necessity, these emotions are not surprising. The interesting aspect of these results is that negative emotions, while low in intensity, are still present as a result of GP service performance. Interestingly, whilst a high level of variance is explained in satisfaction and behavioral intentions by the antecedents, only a small level of variance is explained in affect by service performance. This means that important service decisions such as whether to return to the doctor, or not, are being made on the basis of affect and other factors are contributing to affect beyond the GP’s service performance. This study extends past studies of service performance on service outcomes, such as satisfaction and behavioral intentions (Tih & Ennis, 2006), to demonstrate that service performance (GP-based attributes namely interaction and expertise) has a significant influence on consumer affect. The findings show that service performance influences both positive and negative

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affect, although the effect on positive affect appears to be stronger. Service performance has a moderate influence on positive affect and a small effect on negative affect. One plausible explanation for these results is that consumers typically visit general practitioners for the initial diagnosis of a presented illness, such as non-life-threatening medical issues such as colds and flu, immunization, and other general health checks, which are treatable, rather than complex chronic diseases such as cancer and diabetes, which may become terminal. As such, visitation to the doctor is likely to elicit stronger positive emotions than negative emotions given that the presenting illnesses are generally curable. While prior research has established the relationship between affect and satisfaction (Alford & Sherrell, 1996; Grace & O’Cass, 2004), this research found no support for this relationship. At first, the lack of relationship between affect and satisfaction seem surprising and counterintuitive. However the significant relationships of affect–value and value–satisfaction provide an explanation. Value appears to be a critical intervening variable between affect and satisfaction and thus to achieve satisfaction, value needs to be generated. This is consistent with prior research on the role of value and satisfaction (Brady et al., 2005; Cronin et al., 2000). The important role of affect in driving value, which in turn drives satisfaction, demonstrates the need for ensuring that the health care service acknowledges the consumer need that the effort of going to the GP is worthwhile. Finally, the interrelationships between satisfaction, value, and behavioral intentions show support for prior marketing research (Cronin et al., 2000; Brady et al., 2005). Satisfaction has a significant influence on behavioral intentions while value has a significant but smaller influence on behavioral intentions. Thus the role of value in generating satisfaction, which in turn generates positive behavioral intentions, has been shown. As such, it is clear that health care services need to ensure that they provide valuable service to consumers and also need to satisfy needs and wants to ensure consumers will reuse the medical service.

IMPLICATIONS FOR MEDICAL PRACTICE The results of this study indicate the importance of understanding consumers’ emotional reactions to GPs and the effect this has on their continued use of the service. The influence of GP service performance on consumer affect highlights the importance of hiring GPs with more than just credentials. It is necessary to train doctors to demonstrate their expertise effectively to consumers and to professionally develop their emphatic communication skills. Acknowledging the pressure and challenges that medical practitioners face on a daily basis, it is not surprising that they may be less than empathetic as they face emotional stress and fatigue as a direct consequence of their job. Building positive

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emotional rapport with consumers is also more likely to build long-term relationships, which are important in a competitive health care environment. A key concern for medical practices is the increase in the number of complaints that Australians are willing to lodge in relation to the perceived poor delivery of medical services (Australian Health Practitioner Regulation Agency, 2011). In 2011 of 8,139 complaints (termed notifications), 3,672 related to the conduct of health practitioners and 1,306 related to performance. As complaints stem from dissatisfactory service experiences (Ozborne, 1995), a preventative managerial approach to reducing complaints and possible litigation or regulatory intervention is necessary. As demonstrated in this research, the role of consumer affect is instrumental in consumers’ perceptions of service performance and subsequent decision-making. Therefore, in an effort to deliver good service experiences in medical services, it is necessary to pay attention to the service elements that can impact consumer affect and to ensure that consumer is happy (and not unhappy) with the medical service experience. Feelings have an important bearing on consumer value perceptions, satisfaction levels, and intentions to consume the medical service in the future.

LIMITATIONS AND FUTURE RESEARCH This research has both limitations and opportunities for further research. The cross-sectional design of this study is a limitation as all measures were collected simultaneously. Therefore, a need exists for longitudinal studies to aid in establishing causal relationships between the constructs studied in this research. This research presents a static model of medical service evaluation, taken in a single service medical category (GP health care), and in one country. Therefore, to enhance generality, future research could replicate this study in other health service environments, such as oncology, physiotherapy, dentistry, and so on, to further increase confidence in the research model. Given that the consumer experience in a medical setting is more than just contact with the general practitioner, future research is required to uncover other service elements that should be accounted for in the performance of the holistic service delivery in a medical practice. Researchers could use satisfier–dissatisfier theory (Cadotte & Turgeon, 1988) to determine which service elements are central to the consumer experience. This then provides managerial implications to service providers, which in turn allows them to direct resources appropriately to manage the important service elements that consumers perceived. Future research could also draw from relationship marketing literature and investigate the moderating influence of relationship duration and strength on the research model. Finally, more research is required to examine the role of consumer affect in health care settings.

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CONCLUSION

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GPs are an important first step in the health care system performing both preventative and treatment roles. As such encouraging patients to develop a long-term relationship with their GP is fundamental to an effective health care system. As quality of life can be either enhanced or threatened by health services, the management of the emotional response to GP performance has been found to be an important indicator of repeat usage. This research shows the importance of managing these emotional responses to ensure that customers receive value, feel satisfied, and continue to seek medical assistance from their GP.

FUNDING The authors would like to acknowledge the financial assistance for this study by National Seniors Productive Ageing Centre and the manuscript assistant of the Service Innovation Research Program at the Queensland University of Technology.

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APPENDIX: SURVEY ITEMS Construct General practitioner service performance

Positive affect

Negative affect

Scale items Interaction: I can count on my GP being friendly My GP gives me personal attention My GP gives me individual attention Expertise: My GP has the knowledge to answer my questions My GP knows what they are talking about I can rely on my GP being well qualified and trained My GP keeps up-to-date with developments in their area of expertise My GP is courteous Pleased Happy Relieved Peaceful Fulfilled Tense Nervous Panicky Irritated Unfulfilled Discontent Depressed Sad

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Construct Satisfaction

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Perceived value

Behavioral intentions

Scale items My choice to use the service provided by this GP was a wise one I think that I did the right thing when I chose to use the services provided by this GP The services provided by this GP are exactly what I needed The services provided by this GP are worth the costs The services provided by this GP represent good value Overall the value of the services provided by my GP is high I say positive things about my GP to other people I recommend my GP to someone who seeks my advice I encourage friends and relatives to go and see my GP I consider my GP to be my first choice for general medical services I intend to continue seeing my GP

The role of affect in consumer evaluation of health care services.

Health care services are typically consumed out of necessity, typically to recover from illness. While the consumption of health care services can be ...
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