Consumer Perceptions of Health Care - Hongkong

Consumers’ Perceptions of Health Care:The Case of Hong Kong

Sandra S. LiuAlan J. Dubinsky

ABSTRACT. The health care industry in Hong Kong has undergonemajor changes in organization as well as philosophy of operation sincethe 1970s. During this period, the Hong Kong government has alsoexperienced a political transition from colonial status to a special ad-ministrative region of Mainland China. Because of the economic down-turn in East Asia, including Hong Kong, contraction of public spendinghas compelled the government to reconsider the alternatives for healthcare provision in Hong Kong. A number of multinational health careproviders have entered this market and operate mainly in the privatesector, including solely-owned clinics and alliances with existing hospi-tals. This paper provides an understanding of the evolution and devel-opment of the health care industry in Hong Kong and, on that basis,suggests elements of quality health care from the findings of a survey ofpatients. [Article copies available for a fee from The Haworth Document Deliv-ery Service: 1-800-342-9678. E-mail address: <[email protected]>Website: <http://www.haworthpressinc.com>]

INTRODUCTION

Health care tends to be a major concern of many people. In fact, thesignificance of receiving adequate medical care will likely rise

Sandra S. Liu is Associate Professor, Department of Marketing, School of Busi-ness, Hong Kong Baptist University, 6th floor, Business Studies Building, RenfrewRoad, Kowloon Tong, Kowloon, Hong Kong (E-mail: [email protected]).At the time this article was written, Sandra S. Liu was a visiting scholar at the J. L.Kellogg Graduate School of Management, Northwestern University.

Alan J. Dubinsky is Editor, Journal of Personal Selling and Sales Management,and Professor of Marketing, Minnesota State University System-Minneapolis, Col-lege of Management, 730 Hennepin Avenue, Minneapolis, MN 55403 (E-mail: [email protected]).

Health Marketing Quarterly, Vol. 17(4) 2000E 2000 by The Haworth Press, Inc. All rights reserved. 1

HEALTH MARKETING QUARTERLY2

throughout the world, as the average age in most nations will increase.This ‘‘age accretion’’ will have serious implications for governmentskeen on providing effective and efficient medical care for their citi-zens (Peterson, 1999).

Without good health, all the money in the world alone won’t serveas a nostrum for the ailment or an anodyne for the sufferer. As philoso-pher Ralph Waldo Emerson opined: ‘‘The first wealth is health.’’People, like a car, do get into disrepair and require medical treat-ment--be it preventative, acute, chronic, or emergency. And whenmedical problems surface, the aggrieved await a medical provider’sincantation for wellness.

By and large, health care can be considered a ‘‘credence good,’’which is an offering that the ‘‘consumer’’ will never be able to evalu-ate effectively owing to his or her lack of medical knowledge (Bloomand Reeve, 1990). For instance, perhaps a child’s chickenpox wereeradicated within two weeks; the formerly discomfited parents mayfeel satisfied, but perhaps had they gone to a different doctor, thatphysician’s treatment may have reduced the healing process to oneweek. Their lack of medical knowledge, though, does not allow themto make this assessment. Or, for example, maybe a patient’s brokenarm totally heals within six months. Had the patient seen another careprovider, though, perhaps the arm would have been totally healedwithin three months. Again, the lack of medical knowledge precludesthe patient’s making such an evaluation.

Given the ‘‘credence’’ feature of health care, patients are likely tolook for cues or ‘‘signals’’ (Bloom and Reeve, 1990) that are redolentof the quality of treatment they are likely to receive (or do receive)from a given provider (be it a clinic or hospital). The aesthetics of theoffice, the appearance of the staff, the rapport between the patient andthe staff, and the speed of service, among other features, may beutilized as indicants of the adequacy of the medical care received.These surrogate indicators of service quality afford a patient relativecognitive ease with which to assess the efficaciousness of the serviceprovider.

Patients are consumers. They seek medical care (the offering) inorder to receive a bundle of benefits (the utilities derived from receiptof the care: good health). And just like consumers, irrespective of themedical attention sought, they have certain perceptions of the offer-ing--be they favorable, unfavorable, or even neutral--vis-à-vis the ex-

Sandra S. Liu and Alan J. Dubinsky 3

pected versus the actual quality level received. Much academic re-search (conceptual and empirical) has focused on consumerperceptions of health care in the United States (e.g., Furse et al., 1994;Fusilier and Simpson, 1995; Ostasiewske and Fugate, 1994; Raju,Lonial, and Gupta, 1995; Reidenbach and Sandffer-Smallwood,1995). Considering perceptions of consumers in non-U.S. countries,though, is important for at least one major reason.

Presupposing that perceptions of health care are equable irrespective ofcountry appears dubious. Several recent investigations, for instance,found that such issues as food shopping behavior (Brunso and Grunert,1998); the attributes, consequences, and values of perfumes (Valette-Flor-ence, 1998); and attitudes toward television advertisements (Witkowskiand Kellner, 1998) differ across cultures. Moreover, Rossiter and Chan(1998) promulgate that an individual’s ethncity (broadly defined to in-clude biological and physical characteristics, personality traits, and cultur-al values and norms) influences consumer behavior. Furthermore, Reis-inger and Turner (1998) briefly review the literature regarding differencesbetween Eastern and Western values and discern that such differentiaaffect the nature of the interaction between Eastern tourists and theirWestern hosts. Thus, this extant work suggests that trying to apply U.S.-based findings in non-U.S. polities is indeed questionable.

In light of this situation, a study was conducted regarding consum-ers’ perceptions of health care in Hong Kong. Specifically, the inves-tigation sought answers to the following two questions: (a) what dimen-sions of quality are perceived to be important by patients in hospitalinpatient, outpatient, and emergency room segments, and (b) what is therelationship between these dimensions of quality and patients’ percep-tions of overall satisfaction of the services.

The import of employing the Hong Kong context is discussed sub-sequently. Then, the method of the study is described. Next, studyresults are presented. Finally, managerial and future research implica-tions are provided.

HONG KONG HEALTH CARE

The global trends of consumerism and democratic movement haveinfluenced the behavior of consumers in Hong Kong since the early1980s (Hill 1988). Hong Kong consumers currently are not at thesame stage as patients in the United States (Ostasiewski and Fugate,


1994), where consumers of health care have an unprecedented oppor-tunity to express their views on various aspects of the health caresystem. Nonetheless, there has been increasing media exposure ofmedical mishaps occurring in Hong Kong hospitals. Under increasingpressure from the public, providing good quality health care in HongKong has been on the government’s agenda (Hospital Authority,1991). In fact, since the mid-1970s, a number of factors have adverse-ly affected the quality of health care service in Hong Kong (see Table1). Among these factors are rising costs of health care provision,increasing community expectations of health care quality, and lowmorale among medical staff in subvented hospitals. These inimicalphenomena led to the W. D. Scott report in 1985, which called for acomprehensive reform in the Hong Kong health care industry.

The health care industry in Hong Kong encompasses both publicand private systems. As there is only a nominal fee required for com-prehensive health care, the majority of Hong Kong people utilize the

TABLE 1. Development of Health Care in Hong Kong Since 1970s

Year Major Events in the Health Care Sector

Before 1974 S Overcrowding in government hospitalS Inefficient use of beds in sub-vented hospital

1974 S Publication of the White Paper ‘‘The Further Development of Medical and Health Service in Hong Kong”S Regional approach to hospital management was implemented; regional hospitals were established

Mid 1970s S Rapid expansion of hospital servicesS Rapid increase in the costs of providing health care servicesS Rising community expectations of health care service qualityS Low morale among staff in sub-vented hospitalsS Overcrowding of and long queues in hospitals

1983 S Legislative Council called for a review of medical services

1984-1985 S The management consultancy W. D. Scott Pty Co. conducted an investigation into the health careservices in Hong Kong

1986 S Public consultation on health care services

1988 S The establishment of the Provisional Hospital Authority

1990s S Establishment of the Hospital AuthorityS Staff functions were created to support medical staff; these staff functions provided continuous

improvement in health care servicesS A Hospital Complaint System was createdS A Patient Opinion Feedback System was createdS The importance of high quality services was emphasized

Extracted from the Hospital Authority Report, 1996.


services from hospitals that are within the public system (HospitalAuthority, 1991). Following the recommendation in the W. D. Scottreport, the government established the Hospital Authority in 1995 tooversee and coordinate the activities in public hospitals. Its inceptionwas predicated on the idea that the Hospital Authority could deployresources in a more efficient manner, and hence help raise the qualityof health care service. As of December 31, 1996, it managed 41 publichospitals and institutions (out of 60 hospitals in Hong Kong) and25,500 hospital beds, accounting for 85.2 percent of all hospital bedsin Hong Kong, or 4.05 public hospital beds per 1000 population (Hos-pital Authority, 1996).

Health care services in Hong Kong are classified into primary (thepatient’s first point of contact with the health care system), secondary(the more specialised and complex medical care which is usuallyprovided in a hospital setting), and tertiary levels (care catered to asmall proportion of patients requiring highly complex and specialisedcare), with acute and extended care (rehabilitation and long stay)components (http://www.ha.org.hk--Web site of Hospital Authority).The latter two levels are, in general, provided in a hospital setting, andover 90 percent of them are under the auspices of the Hospital Author-ity. In other words, while the private sector is providing 70 percent ofthe primary medical care, the Hospital Authority is almost exclusivelyresponsible for extended and long-term care for the disabled, chroni-cally ill, and elderly (http://www.ha.org.hk--Web site of Hospital Au-thority). In addition to a new management structure, which aims atefficient and effective resource deployment, the Hospital Authorityalso implements customer-concern mechanisms. For instance, a staff-function section is created to provide continuous improvement formeeting rising expectations in health care service. Also, the HospitalComplaint System and the Patient Opinions Feedback System are setup to collect comments and suggestions from citizens. Despite suchconsumer-oriented efforts, recently a number of serious accidents(e.g., incorrect drug therapy, incorrect kidney dialysis) have occurredin some public hospitals, thus conducing to an image of worseninghealth care quality (The Hong Kong Standard, 1998).

In line with the consumerism movement in Hong Kong, publichospitals should be adopting a market-driven approach to developingand implementing health care quality. Doing so requires health careadministrators in Hong Kong to understand the perceptions of their


external customers and, then, recommend areas for improvement. Ac-cordingly, the authors seek to identify aspects of health care qualitythat are vital to overall customer satisfaction in the public health caresector in Hong Kong.

JUSTIFICATION FOR EXAMININGTHE HONG KONG CONTEXT

Hong Kong was selected as the population of interest for severalreasons. First, Hong Kong’s population size (6.6 million in 1998) andits geographical proximity to the demographic behemoth MainlandChina betoken a substantial financial attraction for domestic and mul-tinational health care organizations interested in pursuing this market.Second, more and more service organizations are moving into theHong Kong and Mainland Chinese markets, thus garnering an increas-ing proportion of their revenues from these foreign sources; similarpursuits may well prove propitious for multinational health care pro-viders. Third, health care organizations, like traditional manufacturingcompanies, are seeking ways to enhance efficiency while simulta-neously satisfying customers adequately. A merger with or an acquisi-tion of a host country health care provider may offer such a solution.Given the economic declension pervading Hong Kong (that will alsoprobably soon envelop Mainland China), host country health careorganizations may be especially amenable to such moves by multina-tional providers. Finally, attendant with the Asian financial debaclehas been increasing caution regarding.how the Mainland Chinese gov-ernment allocates resources to industry (Lawrence, 1998). ‘‘Prudentbeneficence’’ has become the watchword of those mandarins responsi-ble for dispensing government monies to business. Those health careorganizations demonstrating skilled husbandry are more likely to re-ceive government resources than their less fiscally successful counter-parts. With the government’s fiscal conservatism, host country healthcare organizations are likely to pursue multinational alliances to fosterfuture business success.

METHOD

Sample

A structured questionnaire was administered face-to-face to patientsof inpatient, outpatient, and emergency room services in the general


public hospital of each district across the territory, a total of eightdistricts according to the classification of the Hospital Authority(1997). Sizes of the hospitals ranged from 300 to 1,000 beds. A totalof 320 subjects were interviewed during the period from February toApril in 1998.

The profile of subjects is shown in Table 2. There are 126 subjectsin the inpatient, 91 in the outpatient, and 97 in the emergency roomsub-sample. The education level, employment status, and income levelare indicative of the general population using health care services ofpublic hospitals (http://www.ha.org.hk--Web site of Hospital Author-ity). Among the respondents, 57.6 percent are male and 42.4 percentare female, but they are mostly under the age of 49, which constitutes78 percent of the total sample.

Measurement

A number of studies (Kleinsorge and Koenig 1991; Soliman 1992)have adopted SERVQUAL (Parasuraman, Zeithaml, and Berry, 1985;1988) to assess patient perceptions of service quality of health care.Reidenbach and Sandifer-Smallwood (1990) adopted SERVQUALand expanded it into forty-one service evaluative criteria based on tendimensions (see Table 3). The ten included Tangibles, Accessibility,Understanding, Courtesy, Reliability, Security, Credibility, Respon-siveness, Communication, and Competence. The present study slight-ly modified these items to reflect the situation in Hong Kong.

Independent Variables. Five items of Reidenbach and Sandifer-Smallwood’s (1990) questionnaire, as indicated in Table 3, were notsuitable for the Hong Kong health care environment. Thus, a thirty-sixitem scale taken from their work was used to measure patients’ per-ceived quality (from 1 = ‘‘very good’’ to 5 = ‘‘very bad’’) of variousaspects of hospital health care services. Separate factor analyses (us-ing varimax rotation) were employed to determine the underlyingdimensions of these 36 items for each sub-sample (inpatient, outpa-tient, and emergency patients). The screen test criterion was utilized toascertain the number of extracted factors for each sub-sample (Cattell,1996). An item was assigned to a factor if its factor loading was atleast 0.5, as suggested by Hair et al. (1995). If the item cross-loaded onat least two factors, it was eliminated from subsequent analyses. Re-maining items were summed and divided by the number of itemswithin the factor to arrive at a mean score for each service dimension


TABLE 2. Profile of Respondents

Characteristics No. of %Respondents

Sub-sample Inpatient 126 40.1%Outpatient 91 29.0%Emergency Room 97 30.9%

Sex Male 181 57.6%Female 133 42.4%

Age 15-19 5 1.6%20-29 72 22.9%30-39 93 29.6%40-49 75 23.9%50-59 48 15.3%60 or above 21 6.7%

Household $4,999 or below 199 63.4%income $5,000-$9,999 36 11.5%

$10,000-$14,999 66 21%$15,000-$24,999 9 2.9%$25,000-$29,999 1 0.3%$30,000-$34,999 1 0.3%$35,000-$39,999 1 0.3%$40,000-$49,999 1 0.3%

Career Worker 34 10.8%Clerk 59 18.8%Professional 20 6.4%Student 38 12.1%Housewife 50 15.9%Unemployed/Retired 110 35.0%Others 3 1.0%

Education No formal education 66 21%Primary education 88 28%Secondary education 113 36%Matriculation 13 4.1%Post secondary/University 26 8.3%Above university 8 2.5%

for each sub-sample. Coefficient alpha was computed to discern thereliability of each dimension.

The 36 service dimension items were subsumed by four factors inthe inpatient subsample, constituting 54 percent of the variance (seeAppendix 1A). The four are ‘‘care and concern’’ (coefficient alpha =0.95), ‘‘responsiveness’’ (alpha = 0.80), ‘‘appearance’’ (alpha = 0.73),and ‘‘comfort’’ (alpha = 0.62).

The factor analysis of the outpatient sub-sample yielded five fac-tors, comprising 55 percent of the variance (see Appendix 1B). Theunderlying dimensions were as follows: ‘‘medical staff’ (alpha =0.94), ‘‘time and convenience’’ (alpha = 0.79), ‘‘environment’’ (alpha =


TABLE 3. Service Evaluative Criteriaa

Tangibles

Cleanliness of the hospitalPleasantness and appeal of the hospital roomProfessional appearance of hospital staffProfessional appearance of other hospital employeesTemperature of the foodTaste of the foodTiming of the mealsPhysical appearance of your room

Accessibility

Availability of visitor parkingAvailability of information about your conditionEase of getting hold of hospital personnel on the phoneAvailability of meals for the familyAvailability of sleeping accommodations for your familyb

Understanding

Concern for family and visitorsConcern for your particular needsAmount of time spent by staff getting to know and understand your needs

Courtesy

Politeness of physiciansPoliteness of the nursesPoliteness of other hospital staff

Reliability

Performance of services when they were supposed to be performedPerformance of services the way you were told they would be performed

Security

Sense of security from physical harm that you felt in the hospitalSense of wellbeing you felt in the hospital

Credibility

Ability of the hospital to deliver what was promised in their advertisingb

Ability of the hospital to treat you the way you expected to be treated

Responsiveness

Responsiveness of the nurses to your needsResponsiveness of the physicians to your needsWaiting time for testsSpeed and ease of admissionsSpeed and ease of dischargeWaiting time for refund (if due)b

Waiting time for educationTime between admission and getting into your room

Communication

Adequacy of instructions given at time of release on how to care for yourselfAdequacy of explanation about your condition and treatment by hospital staffInstructions about billing procedures

Competence

Skill of the nurses attending youSkill of the physicians attending youSkill of those who performed the testsb

Accuracy of the billing proceduresCompetence of the staff in filing insurance claimsb


TABLE 3 (continued)

Dependent Variables

How would you rate the overall level of service you received as a patient in the hospital?Very Good _____ Good _____ Neutral _____ Bad _____ Very Bad _____

How satisfied were you with the treatment you received in the hospital?Very Satisfied ____ Satisfied ____ Neutral ____ Dissatisfied ____ Very Dissatisfied ____

How willing would you be to recommend this hospital to a friend of yours?Very Willing ____ Somewhat Willing ____ Neither _____ Somewhat Unwilling ____ Very Unwilling _____

As a result of your visit, how willing would you be to complain to your family and friends about the care received?Very Willing _____ Somewhat Willing _____ Neither _____ Somewhat Unwilling _____ Very Unwilling _____

a Operationalized as a 5-point scale in the following form:

Very Good ______ Good ______ Neutral ______ Bad ______ Very Bad ______

b Item removed from the questionnaire designed because it is not germane to public hospitals in Hong Kong.

0.72), ‘‘ancillary staff’’ (alpha = 0.60), and ‘‘billing procedure’’ (alpha =0.73).

Four factors were generated in the emergency sub-sample, explain-ing 71 percent of the variance (see Appendix 1C). The four werecomprised of ‘‘emotional comfort’’ (alpha = 0.91), ‘‘speed and accura-cy’’ (alpha = 0.93), ‘‘competency’’ (alpha = 0.86), and ‘‘auxiliaryservices’’ (alpha = 0.34). Because of the low reliability of the ‘‘auxil-iary services’’ dimension, it was omitted from subsequent analyses ofthe emergency sub-sample.

Dependent Variable. The dependent variable--satisfaction with hos-pital health care services--was taken from the same study as the inde-pendent variables (Reidenbach and Sandifer-Smallwood, 1990). Re-spondents were asked to rate the following items: (a) perception of theservices they received (1 = ‘‘very good’’ and 5 = ‘‘very bad’’), (b) thelevel of satisfaction with their treatment (1 = ‘‘very satisfied’’ and 5 =‘‘very dissatisfied’’), (c) willingness to recommend the hospital to theirfriends (1 = ‘‘very willing’’ and 5 = ‘‘very unwilling’’), and (d) willing-ness to complain to their family and friends about the health care thatthey had received (1 = ‘‘very willing’’ and 5 = ‘‘very unwilling’’).

Separate factor analyses (using varimax rotation) were employed todetermine the underlying dimensions of these four items for eachsub-sample. Factor analyses revealed that for all sub-samples, the fouritems comprised one overridden dimension and that one item (regard-ing the respondent’s likelihood of complaining to relatives about thehospital service) was below the 0.50 factor loading cutoff point. Thus,the final satisfaction measure consisted of three items (after omitting


the ‘‘complaints’’ item); for each sub-sample, this measure wassummed and divided by three to yield an average score. Coefficientalpha for this measure for each sub-sample was as follows: inpatient,0.88; outpatient, 0.80; and emergency, 0.71. Although previous stud-ies examined each of the four satisfaction items separately in theirwork, we chose to utilize an aggregate measure of service satisfactionbecause one-item measures have unknown reliability.

Data Analysis

Each sub-sample’s data were analyzed separately using multipleregression. All underlying service dimensions (factors) were ‘‘forced’’into the regression model to ascertain the percent of variance ex-plained in patient satisfaction from the entire matrix of independentvariables as well as the strength and direction of each dimension’srelationship with satisfaction. Prior to conducting multiple regression,variance inflation factors (VIFs) were computed to assess multicollin-earity among the independent variables. All VIF’s were less than 3.0,which are within an acceptable range (Montgomery and Peck, 1982).

FINDINGS

Shown in Table 4 are the findings of the study for each sub-sample.Depicted for each sub-sample are the F value for the overall model andits concomitant significance level and adjusted R square, as well as thebeta coefficients and their respective significance levels.

Inpatient Results. The overall regression model for public hospitalinpatient respondents is significant (F = 60.56, p < .000) and explains66 percent of the variance in patient satisfaction. Also, all four hospitalservice dimensions are significantly related (p < .01) to satisfaction.‘‘Care and concern,’’ ‘‘appearance,’’ and ‘‘comfort’’ are positivelyrelated to inpatient satisfaction with hospital services. Interestingly,however, ‘‘responsiveness’’ is inversely associated with inpatient sat-isfaction toward the hospital’s services. These results imply that whena hospital evidences increased levels of concern for the patient, pro-vides aesthetically appealing surroundings, and bestows a feeling ofcomfort on its patients, inpatient satisfaction augments. When thehospital staff is expeditious in its efforts, though, such responsivenesscan conduce to a decrement in inpatient satisfaction.

Outpatient Results. Twenty-four percent of public hospital outpa-


TABLE 4. Service Dimensions Affecting Perceptions of Service Quality

Subsample R2/Sig. F Dimension Beta Sig.

Inpatient .656/.000 Care and Concern .735 .000Responsiveness .224 .001Appearance .173 .006Comfort .212 .000

Outpatient .238/.000 Hospital Staff .263 .025Time and Convenience .321 .001Other Hospital Staff .179 .083Environment .112 .242

Emergency Room .674/.000 Emotion and Comfort .883 .000Speed and Accuracy .068 .647Competency .100 .554

tient satisfaction with the hospital is explained by the five servicedimensions (F = 6.42, p < .000) (see Table 4). ‘‘Medical staff’’ and‘‘time and convenience’’ are significantly and positively related (p <.05) to outpatient satisfaction; moreover, there is tentative evidencethat ‘‘ancillary staff’’ is positively associated (p < .10) with outpatientsatisfaction. Two of the five dimensions, though, are unrelated (p >.05) to outpatient satisfaction with hospital services; the two are ‘‘en-vironment’’ and ‘‘billing procedure.’’ These findings suggest that out-patient satisfaction can be enhanced to the extent that ‘‘medical staff’’(namely, physicians and nurses) evince competence, that services areadministered in a timely and commodious fashion, and that ‘‘ancillarystaff’’ (chiefly, employees other than physicians or nurses) manifest anappropriate appearance and bedside manner.

Emergency Room Patient Results. The overall model for publichospital emergency room patient satisfaction explains 67 percent ofthe variance (F = 12.70, p < .000), yet only one of the three factors issignificantly associated with satisfaction. More specifically, ‘‘emo-tional comfort’’ is positively related (p < 0.000) to emergency roompatient satisfaction. ‘‘Speed and accuracy’’ and ‘‘competence,’’ how-ever, are unrelated (p > .05) to satisfaction with hospital service.

DISCUSSION

The national health system in Hong Kong allows all citizens toenjoy basically free care, if they so choose. The demographic profileof the subjects in our study reflects a possible reality that, while


privately-owned for-profit clinics/hospitals provide good care for thewealthier patients (based on market-driven principles), they seeminglyshunt the poor to more crowded public hospitals. For instance, 63.4percent of the sample has a household income of below $5000, and 85percent only has achieved a secondary school level. This cohort ofcitizens seemingly is unable to afford relatively expensive privatehealth care and therefore must utilize services from public hospitals.Public hospital patients are well aware of the protracted waiting timefor treatment in the outpatient section, which is a common phenome-non for this type of health-care system (Weber, 1998). However, whenadmitted to the inpatient section, patients are being attended to in afashion that is similar to an assembly line--and even in some cases arecared for mainly by nurses and/or ancillary staff.

In addition, it should be noted that different types of patients per-ceive service dimensions for quality health care differently. Forinstance, those with inpatient needs mainly focus on the ‘‘care andconcern’’ of the staff, those in the outpatient segment emphasize ‘‘timeand convenience,’’ and emergency room patients stress ‘‘emotion andcomfort.’’ Moreover, factors contributing to service satisfaction of thethree segments of patients are also variegated.

Patients in the inpatient segment are satisfied when hospital staffshows ‘‘care and concern,’’ the ‘‘appearance’’ of the hospital is pleas-ant, and they are made to feel ‘‘comfortable.’’ However, as mentionedpreviously, those who utilize services from these hospitals have hadnegative experiences in terms of their medical care at the hospital. Thehuge number of patients per room in a ward (8 to 10 is commonplace[http://www.ha.org.hk--Web site of Hospital Authority]) and the largepatient to medical staff ratio make the medical care similar to anassembly line operation. It is, therefore, reasonable to observe a nega-tive relationship between the dimension of ‘‘responsiveness’’ and pa-tient satisfaction in this category. Patients may perceive ‘‘responsive-ness’’ (à la ‘‘expedience’’) as the possibility of not being attended withcare. (In contrast, those in the outpatient segment consider ‘‘time andconvenience’’ to be an important factor contributing to their satisfac-tion. This is consistent with Hui and his colleagues’ [1998] findingsthat the satisfaction of customers in the inservice stage is not so muchaffected adversely by waiting than the satisfaction of customers in thepre-service stage.) Furthermore, ‘‘responsiveness’’ in service may beseen by the inpatient subjects as a reflection of disengagement of the


hospital staff. Thus, when coupled with the effect of ‘‘care and con-cern,’’ our findings suggest that hospital staff should spend sufficienttime communicating with the patients in the inpatient segment andunderstanding their needs, even when such activity may slow downthe administrative process.

Providing patients with care and comfort by the hospital staff is acore concern regardless of which segment of hospital care the patientutilizes. The elements entail such characteristics as professionalism ofthe staff and business operations of the hospital. This finding is consis-tent with that of Reidenbach and Sandifer-Smallwood (1990) and corre-sponds to the original conceptual service dimensions of reliability, com-petence, and tangibles (Parasuraman, Zeithaml, and Berry, 1985).

In fact, the manner of hospital staff (in providing emotional care) isthe sole important contributor to the satisfaction of the patients in theemergency room segment. In Hong Kong, there frequently are longwaiting lists for patients to be examined in the hospital for their sus-pected medical problem; so, many utilize emergency room servicesfor immediate medical check-ups (The Hong Kong Standard, 1997).Patients visiting the emergency room are mainly looking for initialdiagnosis of the nature of their illness and attaining some preliminarytreatment, in addition to other regular emergency functions (e.g., trau-ma and sudden attacks of some diseases). Consequently, speed ofadministration and competence of staff are not so critical. Rather, themanner of the staff and comfort provided reflect to patients the im-pression that the hospital is well managed and resourceful and that thestaff is certainly willing to help. Otherwise, the patient may not havethe confidence that the hospital will have the necessary employeeresources to provide satisfactory services.

POLICY IMPLICATIONS

Public hospitals have been considered as the choice of health-carefor citizens in the lower income bracket in Hong Kong. These hospi-tals have suffered a negative image over the years. The status of beingthe teaching hospitals for major medical schools in Hong Kong uni-versities has, however, provided an opportunity for these public hospi-tals to promote themselves as technically more innovative and ad-vanced. The quality-circle concept suggested by Ostasiewske andFugate (1994) allows hospitals to enhance communication between


staff and patients and, in turn, helps hospitals anticipate as well assolve problems.

Owing to limited channels through which public hospitals gatherpatients’ opinions, such as leaflets informing people what sort ofservice hospital provided. It, however, is not enough and this is just aone-way communication. Thus, considering use of the Patient Circleseems beneficial. This tool uses the conventional quality circle in asmall group which numbers between 4 and 15, subordinated by em-ployees who voluntarily meet on a regular basis to discuss commonwork-related problems, identify causes, develop solutions, and makeremedial proposals to management. Accepted proposals are expectedto contribute to production efficiency and quality control as well ashave enthusiastic employee support.

Techniques for enhancing patients’ service include marketing researchto determine the wants and demands of patients and their satisfactionlevels. Recruitment, retention, and promotion programs focusing on per-sonnel having a strong service orientation are recommended. Each de-partment should define its role or mission in patient service terms. Health-care providers, especially the ancillary staff, should be trained tounderstand patient perceptions and, in turn, respond to them accordingly.As health-care requires specialized knowledge, in-house customer de-signed training and educational programs are recommended to focus onpatient service, empowerment of employees, and recognition and rewardfor employees with outstanding performance in customer services.

As there is a contraction of public spending recently and continuedreform of health care system in Hong Kong (http://www.ha.org.hk--Web site of Hospital Authority), an opportunity is therefore createdupon which multinational health care providers can capitalize. Thecurrent problem of long waiting lists and the lack of personal attentiongiven to patients utilizing inpatient services could be rectified bycustomer-oriented services provided by these private companies. Ofcourse, how to strike the balance of cost-effectiveness and quality ofservices would be a major challenge to these new comers. The find-ings of this study will, however, provide important indicators for thecompanies to plan for their ventures in Hong Kong.

FUTURE RESEARCH

This study seeks to understand patients’ evaluation of service quali-ty of health care during their encounter with hospitals. This is in line


with the recent view in services marketing that promulgates the ser-vice encounter is the ‘‘moment of truth,’’ and the evaluation of servicequality at these specific time intervals is important. However, Hui andhis colleagues’ (1998) study suggests that the stage of the serviceprocess is also important. Future research should therefore examinepatients’ perceptions of service quality of the three segments of hospi-tal care in different service stages, and hence provide further policyimplications on how quality health care service can be delivered.

REFERENCES

Bloom, Paul N. and Reeve, Torger (1990), ‘‘Transmitting Signals to Consumers forCompetitive Advantage,’’ Business Horizons, 33 (July-August), 58-66.

Brunso, Karen and Grunert, Klaus G. (1998), ‘‘Cross-Cultural Similarities and Dif-ferences in Shopping for Food,’’ Journal of Business Research, 42 (June),145-150.

Cattell, R. B. (1966), ‘‘The Screen Test for the Number of Factors,’’ MultivariateBehavioral Research, 1 (April), 245-276.

Furse, David H., Burcham, Michael R., Rose, Robin L., and Oliver, Richard W.(1994), ‘‘Leveraging the Value Customer Satisfaction Information,’’ Journal ofHealth Care Marketing, 14(3), 16-20.

Fusilier, Marcelline R. and Simpson, Penny M. (1995), ‘‘AIDS Patients’ Perceptionsof Nursing Care Quality,’’ Journal of Health Care Marketing, 10(4), 49-53.

Hair, J. F. Jr., Anderson, R. E., Tatham, R., and Black, W. C. (1995), MultivariateData Analysis with Readings, Prentice Hall: London.

Hill, J. S. (1988). ‘‘International Profiles: Asia’s Little Dragons,’’ Advertising Age,59(48), 104,106.

Hospital Authority (1996), Planning for 1997 to 1998, Hong Kong.Hospital Authority (1997), Introduction of Services Provided by Public Hospitals,

Hong Kong.http:// www.ha.org.hk (Web site of Hospital Authority).Hui, M. K., Thakor, M. V., and Gill, R. (1998), ‘‘The Effect of Delay Type and

Service Stage on Consumers’ Reactions to Waiting,’’ Journal of Consumer Re-search, 24(4), 469-479.

Lawrence, S.V. (1998), ‘‘Agent of Change,’’ Far Eastern Economic Review, (July23), 10-12.

Kleinsorge, I. K., and Koenig, H. F. (1991), ‘‘The Silent Customers: MeasuringCustomer Satisfaction in Nursing Homes.’’ Journal of Health Care Marketing,11(4), 2-13.

Montgomery, D., and Peck, E. (1982), Introduction to Linear Regression Analysis.New York: Wiley.

Ostasiewske, Paul and Douglas L. Fugate (1994), ‘‘Implementing the PatientCircle,’’ Journal of Health Care Marketing, 14(4), 20-26.

Parasuraman, A., Zeithaml, Valarie A., and Berry, L. L. (1985), ‘‘A Conceptual


Model of Service Quality and Its Implications for Future Research.’’ Journal ofMarketing, 49 (Fall), 41-50.

Parasuraman, A., Zeithaml, V. A., and Berry, L. L. (1988), ‘‘SERVQUAL: A Multi-ple Item Scale for Measuring Customer Perceptions of Service Quality,’’ Journalof Retailing, 64 (Spring), 12-40.

Peterson, Peter G. (1999), ‘‘Gray Dawn: The Global Aging Crisis,’’ Foreign Affairs,78 (January/February), 42-55.

Raju, P. S., Lonial, Subhash C., and Gupta, Yash P. (1995), ‘‘Market Orientation andPerformance in the Hospital Industry,’’ Journal of Health Care Marketing, 15(4),34-41.

Reidenbach, R. Eric and Sandffer-Smallwood, Beverly (1990), ‘‘Exploring Percep-tions of Hospital Operations by a Modified SERVQUAL Approach,’’ Journal ofHealth Care Marketing, 10(4), 47-55.

Reisinger, Yvette and Turner, Lindsay (1998), ‘‘Cultural Differences Between Man-darin Speaking Tourists and Australian Hosts and Their Impact on Cross-CulturalTourist-Host Interaction,’’ Journal of Business Research, 42 (June), 175-187.

Rossiter, John R. and Chan, Alvin M. (1998), ‘‘Ethnicity in Business and ConsumerBehavior,’’ Journal of Business Research, 42 (June), 127-134.

Soliman, A. A. (1992), ‘‘Assessing the Quality of Health Care: A ConsumeristApproach.’’ Health Marketing Quarterly, 10(1/2), 121-141.

The Hong Kong Standard (1997). ‘‘A&E Influx May Highlight Ward Misuse SaysCouncil,’’ (October 14).

The Hong Kong Standard (1997). ‘‘Witch-Hunts Not Part of Health Care Profession-al’s Role,’’ (February 2).

Valette-Florence, Pierre (1998), ‘‘A Causal Analysis of Means-End Hierarchies in aCrossCultural Context: Methodological Refinements,’’ Journal of Business Re-search, 42 (June), 161-166.

Weber, Joseph (1998), ‘‘Canada’s Health-Care System Isn’t a Model Anymore,’’Business Week, (August 31), 36.

Witkowski, Terrence H. and Kellner, Joachim (1998), ‘‘Convergent, Contrasting, andCountry-Specific Attitudes Toward Television Advertising in Germany and theUnited States,’’ Journal of Business Research, 42 (June), 167-174.


APPENDIX 1A. Factor Structure for Inpatient Sub-Sample

FACTOR % Variance Reliability

Item Factor Loading Explained

1: Care and Concern 35.826 0.9499concern for your particular needs 0.812bedside manner of physicians 0.801amount of time spent by staff getting to

know and understand your needs 0.798performance of services when they were

supposed to be performed 0.765responsiveness of the nurses to your needs 0.734skill of the physicians attending you 0.730responsiveness of the physicians

to your needs 0.728sense of wellbeing you felt in the hospital 0.715bedside manner of the nurses 0.706skill of the nurses attending you 0.698ability of the hospital to treat you the way

expected to be treated 0.695bedside manner of other hospital staff 0.591adequacy of instructions given at time of

release on how to care for yourself 0.542

2: Responsiveness 6.744 0.8004ease of getting hold of hospital personnel

on the phone 0.685accuracy of the billing procedure 0.666speed and ease of discharge 0.629speed and ease of admissions 0.625waiting time for medication 0.510

3: Appearance 6.132 0.7339pleasantness and appeal 0.788cleanliness of the hospital 0.747physical appearance of the room 0.655professional appearance of hospital staff 0.548

4: Comfort 5.347 0.6249timing of the meals 0.768temperature of the food 0.624


APPENDIX 1B. Factor Structure for Outpatient Sub-Sample

FACTOR % Variance Reliability

Item Factor Loading Explained

1: Medical Staff 25.952 0.9371bedside manner of physicians 0.891responsiveness of the physicians to your needs 0.824responsiveness of the nurses to your needs 0.789skill of the physicians attending you 0.787bedside manner of the nurses 0.775concern for your particular needs 0.774performance of services the way you were

told they would be performed 0.702amount of time spent by staff getting to

know and understand your needs 0.680sense of wellbeing you felt in the hospital 0.671adequacy of explanation about your condition

and treatment by hospital staff 0.591performance of services when they were

supposed to be performed 0.513ability of the hospital to treat you the way

expected to be treated 0.512

2: Time and Convenience 9.930 0.7914waiting time for medication 0.823time between admission and getting

in your room 0.790waiting time for tests 0.744speed and ease of admissions 0.610availability of meals for the family 0.557ease of getting hold of hospital personnel

on the phone 0.504

3: Environment 7.987 0.7155physical appearance of the room 0.845pleasantness and appeal 0.693availability of visitor parking 0.617sense of security from physical harm that

you felt in the hospital 0.586

4: Ancillary Staff 5.758 0.5991physical appearance of other hospital

employees 0.762bedside manner of other hospital staff 0.753skills of the nurses attending youa 0.564

5: Billing Procedure 5.145 0.7320instructions about billing procedures 0.857accuracy of the billing procedure 0.644

a The item was eliminated in the subsequent analysis because it is cross-loaded.


APPENDIX 1C. Factor Structure for Emergency Room Sub-Sample

FACTOR % Variance ReliabilityItem Factor Loading Explained

1: Emotional Comfort 33.241 0.9076bedside manner of physicians 0.900ability of the hospital to treat you the way

expected to be treated 0.895sense of security from physical harm that

you felt in the hospital 0.858sense of wellbeing you felt in the hospital 0.799bedside manner of other hospital staff 0.757performance of services when they were

supposed to be performed 0.742bedside manner of the nurses 0.738amount of time spent by staff getting to

know and understand your needs 0.729performance of services the way you were

told they would be performed 0.649adequacy of explanation about your

condition and treatment by hospital staff 0.550physical appearance of the room a 0.511

2: Speed and Accuracy 19.124 0.9330

speed and ease of admissions 0.933speed and ease of discharge 0.923instructions about billing procedures 0.914accuracy of the billing procedure 0.905taste of the food 0.696

3: Competency 11.267 0.8561

skill of the nurses attending you 0.870skill of the physicians attending you 0.870responsiveness of the nurses to your needs 0.793professional appearance of hospital staff 0.727responsiveness of the physicians

to your needs 0.685

4: Auxiliary Services 6.960 0.3406

timing of the meals 0.896availability of visitor parking 0.733adequacy of instructions given at time of

release on how to care for yourself 0.621temperature of the food 0.589

a The item was eliminated in the subsequent analysis because it is cross-loaded.

Consumer Perceptions of Health Care - Hongkong

Documents

Transcript of Consumer Perceptions of Health Care - Hongkong