Behavioral intention in revisiting hospital under the effect of expertise, reputation and service quality

Behavioral Intention In Revisiting Hospital Under The Effect Of Expertise, Reputation And Service Quality Pham Bao Duy International University, Vietnam National University HCMC, Vietnam Nguyen Tan Loi Eastern International University, Vietnam Ho Nhut Quang International University, Vietnam National University HCMC, Vietnam Abstract The well-noted extensive solution for strengthening the hospital’s obstacles from various perspectives are seeking in Vietnam context Considering the foothold of medical industry formulated by government, the medical industry grants as sustainable fundamental development observed through FDI and governmental equity with shaky restriction As strikingly demands in healthcare services, private and public hospitals in Vietnam, however, divulge the noticeable missing pieces are service quality, trust and satisfaction in arousing rehash visitors whom reveal the disavowal through pursuing highly experience expectation in comprehensive alternatives Consequently, the deeply understanding in the rehash patients’ behavioral intention, especially, with further with appealing unfamiliar one is envisaged vital pharmaceutical to intensify specifically hospitals’ aspects Methodically, quantitative research spread out the study in advance, the sample size accounted at 316 processing in Explanatory Factors Analysis and deeply exploiting by Structural Equation Modeling method The outcomes spotlight the significant initial effect of independent dimensions in reputation and expertise toward trust, service quality toward satisfaction as well as towards behavioral intention in revisiting the hospital Undoubtedly, there are some recommendations toughen up specifically the retained problems for hospitals in Vietnam Keywords: Vietnam Healthcare, Service Quality, Expertise, Behavioral Intention in Revisiting, Hospital in Vietnam, Sustainable Development 1.Introduction Healthcare has long been the initial service for human, which provides significant purposes in examination, prediction, treatment and control the health According to the former researches, it is considered as the high level of association services (Hogg, Laing, & Newholm, 2004) In some emergency situation, the hospital is not only considered as the place for health improvement and examination but also become the crucial place for saving a life Therefore, the high level in emotional vulnerable following with the hazard is not deniable (Jadad, 1998) According to General Statistic Office in Vietnam, there are 1,101 hospitals in 2012 and higher 36% compared with the statistics in 2007 In addition, the number and scale of corporation and organization operating in medical and health care field such as Hoan My, VinMec and TMMC has been increased in recent years It provides the proof that the importance and attention of medical industry in Vietnam However, with the interesting figures demonstrated in the recent report, the fundamental right – basic healthcare would be not considered as the right in developing countries included Vietnam where people from rural areas, even the government spend hundreds of million dollars in medical industries which mostly focus on facilities’ expansion and improvement in suburban In other sides, according to Vietnam 2035 general report has been posted by World Bank and Ministry of Planning and Investment in Vietnam, it shows directly that the proportion of GDP shares 6% for medical and health care over decades from 2015 to 2035 While GDP and the growth rate have been reported outstanding positively increasing whereas the out-ofpocket spending in medical still appeared with 49%, it shows the importance of medical fields among people even the total expenditure must be paid by their money According to WHO, the bed occupancy rate should not be over 80% of the hospitals’ capacity Vietnam, however, witnessed a high occupancy rate especially in large cities A research of “Study on Current Situation of Overcrowding, Under-Crowding in Hospitals at Levels and Recommended Solutions for Improvement” of Ministry of Health in 2011 demonstrates that central and provincial hospitals always in overcrowding situation It is in the ranged from 120-150% of the hospital beds used and some special cases over 200% in big central hospital in Ho Chi Minh city and Ha Noi capital According to the research of PricewaterhouseCoopers (Vietnam) Ltd Company called “The Vietnamese healthcare industry: moving to next level”, it mentioned the overload services in large and popular hospitals in Vietnam while remote area hospital and regional polyclinic in suburban is lack of patient Moreover, it agreed that Vietnamese tends to approach national hospital instead of provincial hospital due to the mindset in lack of quality in medical staff and medical equipment Following the article “The poor still miss out on healthcare in Vietnam” published in 2015 on Joint Learning Network – The global community of health systems practitioners and policymakers in 27 countries including Vietnam, it stated that “Health Care Fund for the Poor” is signed in 2002 under the Decision 139 signed by Prime Minister of Vietnam in order to support the healthcare service Vietnam especially people live in communes However, this program was not appreciated by World Bank, the research “Health Insurance for the Poor: Initial Impacts of Vietnam’s Health Care Fund for the Poor” found that the reduction of out-ofpocket spending has not happened According to a recent survey by the Ministry of Health, every year around 40,000 Vietnamese go abroad for health treatment purpose and spend $1 billion in 2010 and nearly $2 billion for total expenditures in early 2016 It raises the problem that whether hospitals in Vietnam still not meet the needs of domestic demand in health care purpose even 6% of GDP in Vietnam spend for medical as mentioned above In addition, in Vietnam, the average people make the out-of-pocket payment for health care is almost accounted for 75% the total spending in health care (Knowles et al 2005) According to the research of Gludner and Rifkin in 1993, private healthcare provider appealing the demand of people who have intend in healthcare service as the public service is deficient and imperfect, the case of Vietnam and Uganda 2.Literature Reviews 2.1 Service Quality Service quality is a measurement on the matching between services delivered and customer’s expectation Service quality must be delivered that match with customer expectation on a reliable basic (Lewis and Booms, 1983) Unfortunately, the evaluation for service quality in the scale that built-up through previous study for healthcare industry has been on the rocks Instead of the value comes from the result of health care, patients not completely evaluate the comprehensive problem in service quality through their perspective In addition, some sectors found many difficulties to determine whether it will be added on the service quality assessment or not such as the emergency affected to the probability in survival or vegetable existence, the question is not able to figure out people who responsible to assess the evaluation In addition, the lack of skill also expertise to define the service whether it was conducted following the process or not (Newcome, 1997; Williams, 1994) As a result, hospitals take their advantages in the evaluation of patient with the misleading in technical service quality aspect (Bowers et al., 1994; Ettinger, 1998; Donabedian, 1988), focus on the interaction between patients and physicians and approach with potential customer with the misleading of former evaluation According to Bowers et al in 1994, they suggest that the scale of service quality in patient’s determinant take important role in their satisfaction through SERVQUAL model Before the Bower and his partners’ findings, a former study also used SERVQUAL in implication in the antecedent of service quality in satisfying patient (Reidenbach and SandiferSmallwood, 1990) It is explained from another study in health care service industry that “As a construct, customer satisfaction has been noted as a special form of consumer attitude; it is a post-purchase phenomenon reflecting how much the consumer likes or dislikes the service after experiencing it” (Woodside, AG Frey, LL and Daly, RT., 1989) It comes to the first hypothesis: Hypothesis A service quality of hospital is positively related to patient’s (customer’s) satisfaction In health care research, SERVQUAL scale is the precursor model for evaluating the outcomes behavioral intention comes from service quality (Reidenbach and Sandifer-Smallwood, 1990), and other variant model with the same result, for example, Headley and Miller developed 6dimensional based on primitive SERVQUAL model in 1990 It can be seen obviously that the service quality is a significant dimension not only satisfy customer but also attract customer in repurchasing service or product Hypothesis A service quality of hospital is positively related to patient’s (customer’s) behavioral intention in revisiting hospital 2.2 Satisfaction In 1980, Oliver built the definition that “In brief, customer satisfaction is a summary cognitive and affective reaction to a service incident (or sometimes to a long-term service relationship) Satisfaction (or dissatisfaction) results from experiencing a service quality encounter and comparing that encounter with what was expected” To analyze the level of satisfaction that customer measured based on service, product that provided by an organization through figures based on questionnaires and feedback from the frontline staff It could be the positive judgments’ outcome from using a product or service from customer perspectives (Westbrook, 1980) Related to the definition, it suggests that satisfaction is the emotional evaluation, it is a chain of individuals’ assessment rather than an individual perspective (Cronin and Taylor, 1994; Hunt, 1977) The scale of satisfaction is defined from dissatisfying to satisfying where other arguments implicate that the customer satisfaction assessment proves a comprehensive evaluation than the specific outcome of a transaction According to Singh and Sirdeshrnukh (2000), customer’s experiences is defined as the directly evaluation on some cues which included satisfaction Based on implicit and explicit cues, customer can gradually formulate the trustworthiness with firm (Doney and Cannon 1997) If build up a strongly satisfaction from customer, customer may have more confidence with the firm, which is the basic for increasing their trust on service provider Thus, Hypothesis A patient’s (customer’s) satisfaction is positively related to their trust in hospital Satisfaction is the factor that combine many antecedent elements, when customer’s satisfaction increased, it leads to the last variable, repurchasing intention or it can be considered as sub-dimensions of customer loyalty (Kitapci, Akdogan, & Dortyol, 2014) In medical industry, there are varied study that mentioned this relationship which shows the impact of satisfaction on behavioral intention (Anderson and Sullivan, 1993; Bitner, 1990; Reichheld, 1996; Woodside and Shinn, 1988; Woodside et al., 1989) Considering customer’s satisfaction as the intermediate variable, majority of studies suggests that there were the indirect influences between the behavioral intention and service quality where using value and satisfaction as the mediate factor (e.g., Anderson and Sullivan, 1993; Gotlieb, Grewal, and Brown, 1994; Patterson and Spreng, 1997; Roest and Pieters, 1997; Taylor, 1997) Hence, Hypothesis A patient (customer’s) satisfaction is positively related to their behavioral intention in revisiting hospital 2.3 Trust Trust comes from the belief of a party’s promise or sentence is reliable and the obligation that party need to be fulfilled in vice versa for relationship purpose (Schurr and Ozanne, 1985) Based on the trust, the interaction of a buyer’s perception future and service provider (seller) is anticipated (Doney and Cannon, 1997) It creates a long-term orientation of a relationship B2C in positive ways (Ganesan, 1994) The trust’s advantages which create strong relationship in business has been researched in the literature review of Morgan and Hunt in 1994 The individual experience is considered as the trustworthy source rather than the referral from relatives or friends which is explained as the second-hand trust referral or the popular Building trust efforts is core value of all business in general and hospital service in specific, the results from this long journey is the substantial development where customer loyalty and attraction are not deniable There are some evidences show the behavioral intention in repurchasing services, products are the origin of trust (Morgan and Hunt, 1994; Chaudhuri and Holbrook, 2001) As trust shows confidence in looking for new customer as the reliability and integrity has been prepared, it is the main component for long-term relationship orientation as it moves the focus in present to continuity and future conditions (Doney and Cannon, 1997; Ganesan, 1994) Therefore, it results in a hypothesis that: Hypothesis A patient (customer’s) trust is positively related to their behavioral intention in revisiting hospital 2.4 Expertise Knowledge and experience of service providers in the main services are two terms that typically measure in expertise (Crosby el at., 1990) In Medicine and Surgery perspectives, the expertise requires a mastery in relevant skills also the diversity of knowledge in many aspects Unlike other fields, physicians require the diverse knowledge such as biology, chemistry, physics as the basement and up-to-date their specialization that they pursuit from the beginning Besides, ethics, cognitive and motor must be consistent interpersonally according to their leaning in behavior and responsibility Moreover, clinicians require higher level in their enormous knowledge not only in their specialization but also conduct the relevant field from pharmacist to the surgeon Considering medical diagnosis is the general skill of the physicians, the expertise of the doctors is defined through the accuracy of medical diagnosis because the combination of higher experience and knowledge are deeply and varied (Feltovich et al., 1984; Neufeld et al., 1981) A study found that the source of credibility and trustworthiness is the results of individual’s perception on level of expertise, it implicates a positively effects on trust (Busch and Wilson, 1976) In other words, the level of experts creates the trust’s foundation According to the research of Crosby, Evans and Cowles in 1990, trust signal was founded from the expertise’s perception of customer It can be related to the trustworthy company where the appearance of relationship between expertise and trust create positively effects (Newell and Goldsmith, 2001) In specific of hospital service, the expertise is the undeniable role which contribute to the decision and recommendation on customer’s health The enhancements in trust are depending in the major of the expertise which provide the skilled-set learned from the perennial experience and qualifications or highly achievements in their professional career Therefore, Hypothesis A worker’s expertise in hospital is positively related to patient’s (customer’s) trust 2.5 Reputation The customer’s belief and trust that the firm is truthful and equitable is defined as firm reputation (Doney and Cannon, 1997) In widely views, it is a general overview measurement of a corporate or a firm in level whether it is “good” or “bad” (Weiss, Anderson, & MacInnis, 1999; Roberts & Dowling, 2002) In the sense of reliability, reputation is defined as the collective opinions which evaluate positively the trustworthiness and it results in the individual’s perspective in what they believed or positive said about the firm’s character (Freeman, 1979) Hospital’s reputation could be directly affected by concrete financial problems, even the professional pride is highly attracted by a motivating factor In specific, the sponsor and investment from corporate and individuals are founded as the huge amount to maintain the operation Especially in human health service sector, it is necessary to concentrate on the corporate reputation due to the dense of customer relation which is the most problematic affected customer perspectives to the hospital (Chase, 1978) In previous research, it implicated that the customer’s evaluation on reputation of a service provider will positively impact on the acknowledgement on firm’s trustworthiness through information transference process (Doney and Canon, 1997) A study of Devon Johnson and Kent Grayson in 2005 suggested that firm reputation is the antecedent of both affective and cognitive trust, “customer who is not yet sufficiently familiar with a service provider may extrapolate his/her opinions directly from the reputation of the firm” Hence, the hypothesis is built, Hypothesis A hospital’s reputation is positively related to patient’s (customer’s) trust 2.6 Behavioral Intention The decision that intend to perform in a specific way is considered as intention (Fishbein and Ajzen, 1975) A person who have their subjective perception ability that he or she will enjoy in a given behavior is defined as behavioral intention (Committee on Communication for Behavior Change in the 21st Century, 2002) In other way, it can be the level that a person has built self-conscious intention to engage or not engage with some specified future behavior, it is a signal about the customer future’s behaviors (Venkatesh et.al., 2003; Lai and Chen, 2011) Through previous research, it was definite to believe the important role of conceptual framework in study The model was prompted and changed by related empirical studies in a health care service provider which can apply in Vietnam context Service Quality H1(+) H5(+) Satisfaction Behavioral Intention H6(+) H4(+) H2(+) Expertise Trust H7(+) H3(+) Reputation Figure 6: Conceptual Model 3.Methodology 3.1 Research Method Qualitative and quantitative methods are considered two main method in processing the research for various purpose, especially in achieving knowledge from the study (Ritchie and O’Connor, 2004) The quantitative research is supported from the statistics where it can retrieve from the primary or the secondary data such as survey, questionnaires or previous data Meanwhile, the qualitive research method based on the evaluation of themes which is retrieved from the observation or interview In other words, it is the unmathematical method In 2001, Soguno suggested that the objectives of the study were able to express clearly which could bring back to the society the enhancement in general views in many aspects also the effect of each other In this study, quantitative research was selected to go further With the same goals that qualitative research delivering, the goals focus on the solution, recommendation based on society problems, concerns or the supporting in further research for other developing quantitative potential approach Besides, the quantitative methods delivered a deeper insight or different aspects the problem that the study concerns which support for sociologist or the experts in various industry In other words, it could not be rejected that it provided the comprehensive conclusion and recommendation for social problems or concerns especially Meanwhile, it went further with other research that give a deeper knowledge in the phenomena following the research of Strauss and Corbin; Lundahl and Skärvad in 1998 and 1999 respectively It can be pointed out the common collecting data in quantitative method such as deliver survey through paper form, online form, telephone interview or face-to-face interview Moreover, the collection can be assessed through email, pop-ups website ads In other words, there are various ways to conduct the data for quantitative research On other views, due to the various ways in collecting data, it tended to apply popular with a significant sample size at the short period comparing to the qualitative research method Standardized Regression Weights SAS1 SAS2 SAS3 SAS4 SAS5 SQCP1 SQCP2 SQCP3 SQCP4 SQCP5 BEI1 BEI2 BEI3 BEI4 BEI5 EXP1 EXP2 EXP3 EXP4 EXP5 REP1 REP2 REP3 REP4 TRS1 TRS2 TRS3 TRS4 TRS5 SQHC1 SQHC2 SQHC3 SQHC4 SQT1 SQT2 SQT3 SQT4 SQDC1 SQDC2 SQDC3 < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < < - SAS SAS SAS SAS SAS SQCP SQCP SQCP SQCP SQCP BEI BEI BEI BEI BEI EXP EXP EXP EXP EXP REP REP REP REP TRS TRS TRS TRS TRS SQHC SQHC SQHC SQHC SQT SQT SQT SQT SQDC SQDC SQDC Estimate 0.793 0.806 0.823 0.806 0.783 0.792 0.791 0.773 0.853 0.751 0.819 0.798 0.804 0.776 0.797 0.784 0.754 0.748 0.818 0.843 0.874 0.841 0.884 0.843 0.834 0.804 0.806 0.822 0.840 0.819 0.794 0.810 0.774 0.864 0.867 0.860 0.591 0.791 0.815 0.764 Table 21: Standardized Regression Weights (Group number 1-Default model) Considering data from the table 23 the p-value displays as the encryption *** which represents for the number that lower than 0.01 Hence, it must be lower than the requirement at 0.05 In addition, by focusing on the estimation of Standardized Regression Weights, all values are higher than the threshold at 0.5 4.3.4 Discriminant Validity Checking According to the research of Fornell and his partner – Larcker in 1981, the discriminant validity is assessed by computing the Average Variance Extracted (AVE) of the variables in the construct, then comparing to the squared of correlation ration or r squared (r2), both AVEs of these must be higher than the r squared, or root squared of AVEs greater than the involved correlation ratio Estimate �� Both AVEs > �� SAS SAS < > < > SQCP BEI 0.361 0.776 0.130 0.602 Valid Valid SAS < > EXP 0.045 0.002 Valid SAS < > REP 0.464 0.215 Valid SAS < > TRS 0.614 0.377 Valid SAS < > SQHC -0.217 0.047 Valid SAS < > SQT 0.483 0.233 Valid SAS < > SQDC 0.042 0.002 Valid SQCP < > BEI 0.442 0.195 Valid SQCP < > EXP -0.080 0.006 Valid SQCP < > REP 0.289 0.084 Valid SQCP < > TRS 0.372 0.138 Valid SQCP < > SQHC -0.185 0.034 Valid SQCP < > SQT 0.277 0.077 Valid SQCP < > SQDC 0.239 0.057 Valid BEI < > EXP -0.065 0.004 Valid BEI < > REP 0.483 0.233 Valid BEI < > TRS 0.676 0.457 Valid BEI < > SQHC -0.067 0.004 Valid BEI < > SQT 0.478 0.228 Valid BEI < > SQDC 0.071 0.005 Valid EXP < > REP 0.021 0.000 Valid EXP < > TRS -0.015 0.000 Valid EXP < > SQHC -0.024 0.001 Valid EXP < > SQT 0.116 0.013 Valid EXP < > SQDC -0.079 0.006 Valid REP < > TRS 0.571 0.326 Valid REP < > SQHC -0.169 0.029 Valid REP < > SQT 0.439 0.193 Valid REP < > SQDC -0.045 0.002 Valid TRS < > SQHC -0.067 0.004 Valid TRS < > SQT 0.458 0.210 Valid TRS < > SQDC 0.197 0.039 Valid SQHC < > SQT -0.012 0.000 Valid SQHC < > SQDC -0.255 0.065 Valid SQT < > SQDC 0.125 0.016 Valid Table 22: Correlations (CFA) By applying the criteria which AVEs > � 2, it is founded that the outputs show the AVEs of both constructs is higher than �2 in any correlation Hence, it can not be deniable that the model is valid with discriminant validity assessment 4.4 Structural Equation Modeling (SEM) In the previous section, CFA was used in the AMOS application at the first step to evaluate the correlation between the observed variables and latent variables Then, it was upgraded in SEM with the framework model where it is the extension of general linear model and allowed researcher It is considered as the powerful and argil technique to analyze the framework, also pointed out particularly the relationship between unobserved and observed items The outcomes of first SEM have been showed in the diagram below Figure 3: First Structural Equation Model 4.4.1 First SEM Model Fit Similarly, to conduct the Model Fit assessment of CFA, the results illustrate straightforwardly comparing to the criteria have been implemented in the CFA section Chi-square over degree of freedom or CMIN/df at 1.499 where it demonstrates the great outcome where it need to be lower than Goodness-ofFit Index (GFI) and Adjusted-Goodness-of-Fit Index (AGFI) reach at 0.858 and 0.837 respectively where it leads to a good outcome following the thresholds Assessing the Comparative Fit Index (CFI), the result produce positively where it shows the great outcome at 0.956 In addition, TLI is considered as the confidently model fit which reaches at 0.952 The close fit to the population is confirmed where the outcome after evaluating RMSEA where it reaches at 0.040 SRMR is calculated through plugin at 0.0541 which is qualified in the requirement of theory (0.09) To sum-up, the information will be provided in short below: Measurement Chi-square/DF (CMIN/DF) Current Indices Threshold < Good; s< Acceptable > 0.95: Great CFI (Comparative Fit Index) 1.499 (Good Result) 0.956 (Great Result) 0.95 – 0.9: Good 0.9 – 0.8: Sometimes Acceptable > 0.95: Great 0.95 – 0.9: Good 0.9 – 0.8: Sometimes Acceptable ≥ 0.9 GFI (Goodness-of-Fit Index) TLI (Tucker Lewis Index) AGFI SRMR 0.858 (Acceptable Result) 0.952 (Good Result) 0.837 (Good Result) (Good 0.0541 Result) > 0.8 < 0.09 < 0.01: excellent fit 0.01 – 0.05: close fit 0.05 – 0.80: good fit 0.08 – 0.10: mediocre fit RMSEA (Root Mean Squared Error of Approximation) 0.040 (Close Fit) >= 0.1: poor fit Table 23: Model Fit Assessment in first round Correlation Observed Variables Testing Estimate S.E C.R P SQHC < > SQT -0.014 0.076 -0.186 0.853 SQHC < > SQDC -0.246 0.067 -3.693 *** SQCP < > SQHC -0.228 0.08 -2.842 0.004 REP < > SQHC -0.234 0.091 -2.588 0.01 EXP < > SQHC -0.031 0.078 -0.392 0.695 SQT < > SQDC 0.141 0.074 1.916 0.055 SQCP < > SQDC 0.277 0.079 3.517 *** SQCP < > SQT 0.396 0.095 4.184 *** REP < > SQT 0.745 0.115 6.497 *** EXP < > SQT 0.159 0.09 1.76 0.078 REP < > SQDC -0.044 0.086 -0.514 0.607 EXP < > SQDC -0.095 0.075 -1.258 0.208 SQCP < > REP 0.513 0.112 4.568 *** SQCP < > EXP -0.126 0.093 -1.355 0.176 EXP < > REP 0.036 0.105 0.345 0.73 Label Table 24: Covariances (Group number 1: Default model) (First Round) According to the figure above, p-value promote weak correlations among relationship between Service Quality in Hospital Concerns and Service Quality in Tangible Concerns; Expertise and Service Quality in Hospital Concerns; Service Quality in Tangible Concerns and Service Quality in Doctor Concerns; Expertise and Service Quality in Tangible Concerns; Reputation and Service Quality in Doctor Concerns; Expertise and Service Quality in Doctor Concerns; Service Quality in Process Concerns and Expertise; Expertise and Reputation where p-value assessments are over 0.05 Hence, those correlations should be eliminated in the second SEM Hypothesis Testing According to the Business Statistic Textbook 7th Edition, p-value is defined as the assessment whether it is considered as the statistically significant when the value is lower 0.05 (p